Assessing risks for bovine and zoonotic tuberculosis through spatial analysis and a questionnaire survey in Fiji - A pilot study.

Mycobacterium bovis causes tuberculosis in cattle and when transmitted to humans typically causes extra-pulmonary tuberculosis (EPTB). Bovine tuberculosis (bTB) has a global distribution and is controlled in most countries to protect animal and public health. Recent studies revealed that bTB is established on dairy farms in Fiji where EPTB cases have been reported in people. The aims of this pilot investigation were to look for putative zoonotic TB (EPTB) cases in people and to evaluate practices that might contribute to the persistence and transmission of M. bovis between cattle and to humans. Existing data sets were shared between the Fiji Ministry of Agriculture and Ministry of Health and a questionnaire-based survey was implemented using One Health principles. Statistically significant co-location and close proximity of EPTB cases and bovine TB affected farms were identified. The bTB infection status of farms was significantly associated with unfenced water sources where cattle grazed. Of 247 households, 65 % shared drinking water sources with cattle and 36 % consumed raw milk without boiling, while 62 % of participants reported backyard slaughter of cattle. Several participants reported current symptoms potentially suggestive of TB (chronic cough) but the impact of smoking and history of previous TB treatment could not be evaluated. Farmers had limited understanding of the practices required to prevent bTB at farm level. Further study is recommended and should include an assessment of lifetime EPTB diagnoses, classification of farms based on more recent bTB test data and molecular typing of mycobacterial isolates from humans, cattle and the environment. A targeted awareness and education approach is required to reduce the future risk of zoonotic TB and to help ensure uptake of recommendations and practices aimed at controlling and preventing bTB.

Strategic Planning for Tuberculosis Control in the Republic of Fiji.

The tuberculosis (TB) health burden in Fiji has been declining in recent years, although challenges remain in improving control of the diabetes co-epidemic and achieving adequate case detection across the widely dispersed archipelago. We applied a mathematical model of TB transmission to the TB epidemic in Fiji that captured the historical reality over several decades, including age stratification, diabetes, varying disease manifestations, and incorrect diagnoses. Next, we simulated six intervention scenarios that are under consideration by the Fiji National Tuberculosis Program. Our findings show that the interventions were able to achieve only modest improvements in disease burden, with awareness raising being the most effective intervention to reduce TB incidence, and treatment support yielding the highest impact on mortality. These improvements would fall far short of the ambitious targets that have been set by the country, and could easily be derailed by moderate increases in the diabetes burden. Furthermore, the effectiveness of the interventions was limited by the extensive pool of latent TB infection, because the programs were directed at only active cases, and thus were unlikely to achieve the desired reductions in burden. Therefore, it is essential to address the co-epidemic of diabetes and treat people with latent TB infection.

Tuberculosis, Fiji, 2002-2013.

During 2002-2013, a total of 1,890 tuberculosis cases were recorded in Fiji. Notification rates per 100,000 population increased from 17.4 cases in 2002 to 28.4 in 2013. Older persons were most affected, but tuberculosis also increased sharply in persons 25-44 years of age.

Eccentric Exercise Versus Eccentric Exercise and Soft Tissue Treatment (Astym) in the Management of Insertional Achilles Tendinopathy.

BACKGROUND: Eccentric exercise is commonly used in the management of Achilles tendinopathy (AT) but its effectiveness for insertional AT has been questioned. Soft tissue treatment (Astym) combined with eccentric exercise could result in better outcomes than eccentric exercise alone. HYPOTHESIS: Soft tissue treatment (Astym) plus eccentric exercise will be more effective than eccentric exercise alone for subjects with insertional AT. STUDY DESIGN: Prospective randomized controlled trial. LEVEL OF EVIDENCE: Level 2. METHODS: Sixteen subjects were randomly assigned to either a soft tissue treatment (Astym) and eccentric exercise group or an eccentric exercise-only group. Intervention was completed over a 12-week period, with outcomes assessed at baseline, 4, 8, 12, 26, and 52 weeks. Outcomes included the Victorian Institute of Sport Assessment Achilles-Specific Questionnaire (VISA-A), the numeric pain rating scale (NPRS), and the global rating of change (GROC). RESULTS: Significantly greater improvements on the VISA-A were noted in the soft tissue treatment (Astym) group over the 12-week intervention period, and these differences were maintained at the 26- and 52-week follow-ups. Both groups experienced a similar statistically significant improvement in pain over the short and long term. A significantly greater number of subjects in the soft tissue treatment (Astym) group achieved a successful outcome at 12 weeks. CONCLUSION: Soft tissue treatment (Astym) plus eccentric exercise was more effective than eccentric exercise only at improving function during both short- and long-term follow-up periods. CLINICAL RELEVANCE: Soft tissue treatment (Astym) plus eccentric exercise appears to be a beneficial treatment program that clinicians should consider incorporating into the management of their patients with insertional AT.

THE MINIMUM CLINICALLY IMPORTANT DIFFERENCE ON THE VISA-A AND LEFS FOR PATIENTS WITH INSERTIONAL ACHILLES TENDINOPATHY.

STUDY DESIGN: Cohort study of subjects with insertional Achilles tendinopathy (IAT). OBJECTIVES: The purpose of this study was to establish the minimum clinically important difference (MCID) on the Victorian Institute of Sport Assessment - Achilles Questionnaire (VISA-A) and the Lower Extremity Functional Scale (LEFS) for patients with IAT. BACKGROUND: The VISA-A and LEFS are two measures commonly utilized for patients with IAT. Previous authors have estimated the MCID for the VISA-A, but a MCID has not been formally established. The MCID for the LEFS has been established for patients with lower extremity conditions in general, but it is not clear if this MCID is applicable to patients with IAT. METHODS: Fifteen subjects participating in a randomized controlled trial studying the effectiveness of intervention for IAT over a 12-week period were included in this study. Subjects completed the VISA-A and LEFS forms at baseline and 12 weeks after the initiation of treatment. All subjects also completed a 15-point global rating of change (GROC) questionnaire at 12 weeks after the initiation of treatment. Subjects were classified as improved or stable based on their GROC scores. RESULTS: The area under the curve (AUC) for the VISA-A was 0.97 and a MCID of 6.5 points was identified. The AUC for the LEFS was 0.97 and a MCID of 12 points was identified. CONCLUSION: The VISA-A and LEFS are both useful outcome measures to assess response in patients with IAT. LEVEL OF EVIDENCE: 3.

Experimentally induced pain alters the EMG activity of the lumbar multifidus in asymptomatic subjects.

Lumbar musculature plays an important role in stabilization during functional movements such as walking, bending and overhead activities. Current research has focused on the lumbar multifidus (LM) muscle to determine if altered activity of the LM may contribute to low back pain (LBP). Therefore, the purpose of this study was to determine whether experimentally induced LBP affects deep LM muscle activity during functionally oriented tasks, weight shifting and upper extremity lifting. Intramuscular electromyography (EMG) activity of the LM at L4 was measured in 17 healthy adults during a dominant side shoulder flexion and extension task and during a staggered-stance weight shift task. Data were collected at baseline, after pain was induced with hypertonic saline and after the pain had subsided. Comparisons of within-subjects effects were performed with the use of a two-way repeated-measure ANOVA. A significantly higher magnitude of activity was found in the induced pain condition as compared to the baseline condition for the shoulder extension phase of the upper extremity task (p = 0.04). During forward weight shifting, lower values in both the induced pain (p = 0.02) and the recovery conditions (p = 0.01) were measured. During backward weight shifting, lower values were measured during the recovery condition as compared to baseline (p = 0.03). Across trials and subjects the EMG amplitudes were increased during the extension phase of the upper extremity task and decreased during the weight shifting task. These results suggest that the LM does not respond to induced pain in the same manner during different phases of functionally oriented tasks.

The reliability of an instrumented device for measuring components of the star excursion balance test.

BACKGROUND: The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception and has been used to assess physical performance, identify chronic ankle instability, and identify athletes at greater risk for lower extremity injury. In order to improve the repeatability in measuring components of the SEBT, the Y Balance Test™ has been developed. OBJECTIVE: The purpose of this paper is to report the development and reliability of the Y Balance Test™. METHODS: Single limb stance excursion distances were measured using the Y Balance Test™ on a sample of 15 male collegiate soccer players. Intraclass Correlation Coefficients (ICC) were used to determine the reliability of the test. RESULTS: The ICC for intrarater reliability ranged from 0.85 to 0.91 and for interrater reliability ranged from 0.99 to 1.00. Composite reach score reliability was 0.91 for intrarater and 0.99 for interrater reliability. DISCUSSION: This study demonstrated that the Y Balance Test™ has good to excellent intrarater and interrater reliability. The device and protocol attempted to address the common sources of error and method variation in the SEBT including whether touch down is allowed with the reach foot, where the stance foot is aligned, movement allowed of the stance foot, instantaneous measurement of furthest reach distance, standard reach height from the ground, standard testing order, and well defined pass/fail criteria. CONCLUSION: The Y Balance Test™ is a reliable test for measuring single limb stance excursion distances while performing dynamic balance testing in collegiate soccer players.

Physical therapist compliance with electromyography guidelines.

PURPOSE: The purpose of this study was to determine compliance rates for following three electromyography (EMG) clinical practice guidelines and to determine the reliability of two performance measurement tools developed for this study. METHODS: This was a retrospective descriptive and correlation study of chart reviews of voluntary submissions of EMG reports performed by physical therapists (PTs). Chart reviewers included a PT, a neurologist, and a physiatrist. EMG reports leading to diagnosis of carpal tunnel syndrome (CTS) (n = 43), ulnar neuropathy at the elbow (n = 36), and cervical radiculopathy (n = 38) were collected. The performance measurement tools were analyzed for interrater reliability. RESULTS: The mean (median) score for CTS was 84% (89%), ulnar neuropathy at the elbow was 71% (72%), and cervical radiculopathy was 83% (85%). The reliability calculation (95% confidence interval) for the performance measurement tool for CTS was 0.74 (0.49-0.86), ulnar neuropathy at the elbow was 0.75 (0.56-0.86), and cervical radiculopathy was 0.57 (0.16-0.79). All three reliability calculations were statistically significant (P < 0.05). CONCLUSIONS: The EMG reports performed by PTs had high compliance rates for following the three clinical practice guidelines. The performance measurement tools developed for CTS, ulnar neuropathy at the elbow, and cervical radiculopathy were moderately reliable. They may be useful for quality improvement projects in individual EMG laboratories.

Rehabilitative ultrasound measurement of select trunk muscle activation during induced pain.

Rehabilitative ultrasound imaging (RUSI) is considered a valid method to measure muscle activation in key spinal muscles in asymptomatic subjects. Research measuring muscle activation with RUSI in painful subjects is limited. The aim of this study was to determine if changes in muscle activation from experimentally induced pain can be measured by RUSI. Six male subjects performed tasks known to activate the transverse abdominis (TrA) and lumbar multifidus (LM) while RUSI measurements of muscle thickness were obtained during control and hypertonic saline conditions. The abdominal draw-in maneuver was used to volitionally activate the TrA and a series of upper extremity lifting tasks were used to automatically activate the LM. Pain was induced by injecting 5% hypertonic saline into the longissimus muscle adjacent to the LM at the L4 level. The percent change in muscle thickness from rest to contraction represented muscle activation. Activation was significantly less (p<0.01) during the painful condition on 4 of the 5 tasks performed for the LM and on the task performed for the TrA. These results indicate that RUSI can be used to measure pain-related changes in deep trunk muscle activation. Future research should include a larger sample size and women.

A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls.

STUDY DESIGN: Cross-sectional descriptive. OBJECTIVES: To investigate if muscle thickness change, as measured with rehabilitative ultrasound imaging (RUSI), is different across subgroups of patients with low back pain (LBP), classified in the Treatment-Based Classification (TBC) system, when compared to controls. BACKGROUND: Researchers have demonstrated that subgroups of patients with LBP exist and respond differently to treatment, challenging the assertion that LBP is "nonspecific." The TBC system uses 4 categories (stabilization, mobilization, direction specific exercise, or traction) to subgroup patients. Recently, researchers have demonstrated impairments of the transverse abdominis (TrA) and lumbar multifidus (LM) in those with LBP, regardless of classification. Although distinct differences in impairments have been identified between subgroups, TrA and LM impairments have not been studied and may be present across categories of the TBC system. METHODS AND MEASURES: RUSI was utilized to measure percent thickness change from rest to contracted state during a voluntary task of the TrA and during an upper extremity task known to activate the LM in 56 subjects classified in the TBC system and 20 controls. RESULTS: During the prone upper extremity lifting task with a hand weight, there was a significant group difference for the LM at L4-L5 (P = .03) and at L5-S1 (P = .04), and during volitional activation for the TrA (P < .01). Post hoc testing revealed the differences were between controls and both the direction specific and stabilization categories at the L4-L5 level, between control and direction specific category for the L5-S1 level, and between controls and all 3 categories for the TrA. CONCLUSION: Deficits in the ability to generate muscle thickness changes in the TrA and LM occurred across categories of the TBC system. Intervention studies should be performed to determine if intervention can correct these deficits and if deficit corrections are related to outcomes.

Medial tibial stress syndrome in high school cross-country runners: incidence and risk factors.

STUDY DESIGN: Prospective cohort. OBJECTIVE: To determine (1) the cumulative seasonal incidence and overall injury rate of medial tibial stress syndrome (MTSS) and (2) risk factors for MTSS with a primary focus on the relationship between navicular drop values and MTSS in high school cross-country runners. BACKGROUND: MTSS is a common injury among runners. However, few studies have reported the injury rate and risk factors for MTSS among adolescent runners. METHODS AND MEASURES: Data collected included measurement of bilateral navicular drop and foot length, and a baseline questionnaire regarding the runner's height, body mass, previous running injury, running experience, and orthotic or tape use. Runners were followed during the season to determine athletic exposures (AEs) and occurrence of MTSS. RESULTS: The overall injury rate for MTSS was 2.8/1000 AEs. Although not statistically different, girls had a higher rate (4.3/1000 AEs) than boys (1.7/1000 AEs) (P = .11). Logistic regression modeling indicated that only gender and body mass index (BMI) were significantly associated with the occurrence of MTSS. However, when controlled for orthotic use, only BMI was associated with risk of MTSS. No significant associations were found between MTSS and navicular drop or foot length. CONCLUSIONS: Our findings suggest that navicular drop may not be an appropriate measure to identify runners who may develop MTSS during a cross-country season; thus, additional studies are needed to identify appropriate preseason screening tools.

Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging.

Rehabilitative Ultrasound Imaging (RUSI) has been validated as a noninvasive method to measure activation of selected muscles. The purpose of this study was to determine the relationship between muscle thickness change, as measured by ultrasonography, and electromyography (EMG) activity of the lumbar multifidus (LM) muscle in normal subjects. Bipolar fine wire electrodes were inserted into the LM at the L4 level of five subjects. Simultaneous EMG and RUSI data (muscle thickness) were collected while subjects performed increasingly demanding postural response tasks thought to activate the LM muscle. To determine the relationship between muscle thickness change and EMG activity, the normalized EMG data were correlated to normalized RUSI data. To determine if the tasks increased the demand on the LM, the mean EMG data were compared over each of the four tasks. Muscle thickness change as measured by RUSI was highly correlated with EMG activity of LM in asymptomatic subjects (r=.79,P<.001). Mean EMG data showed increasing levels of activation across tasks (19-34% of maximum voluntary isometric contraction (MVIC)). The results of the repeated measures ANOVA demonstrated theses differences were significant (F(3,12)=25.39,P<.001). Measurement of muscle thickness change utilizing RUSI is a valid and potentially useful method to measure activation of the LM muscle in a narrow range (19-34% of MVIC) in an asymptomatic population.

Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players.

STUDY DESIGN: Prospective cohort. OBJECTIVE: To determine if Star Excursion Balance Test (SEBT) reach distance was associated with risk of lower extremity injury among high school basketball players. BACKGROUND: Although balance has been proposed as a risk factor for sports-related injury, few researchers have used a dynamic balance test to examine this relationship. METHODS AND MEASURES: Prior to the 2004 basketball season, the anterior, posteromedial, and posterolateral SEBT reach distances and limb lengths of 235 high school basketball players were measured bilaterally. The Athletic Health Care System Daily Injury Report was used to document time loss injuries. After normalizing for lower limb length, each reach distance, right/left reach distance difference, and composite reach distance were examined using odds ratio and logistic regression analyses. RESULTS: The reliability of the SEBT components ranged from 0.82 to 0.87 (ICC3,1) and was 0.99 for the measurement of limb length. Logistic regression models indicated that players with an anterior right/left reach distance difference greater than 4 cm were 2.5 times more likely to sustain a lower extremity injury (P<.05). Girls with a composite reach distance less than 94.0% of their limb length were 6.5 times more likely to have a lower extremity injury (P<.05). CONCLUSIONS: We found components of the SEBT to be reliable and predictive measures of lower extremity injury in high school basketball players. Our results suggest that the SEBT can be incorporated into preparticipation physical examinations to identify basketball players who are at increased risk for injury.

The effect of repeated bouts of backward walking on physiologic efficiency.

Previous studies have demonstrated an increased energy expenditure with novel tasks. With practice, the energy cost decreases as the body more efficiently recruits motor units. This study examined whether one becomes more efficient after repeated bouts of backward walking. The subjects were 7 healthy subjects between the ages of 23 and 49 years. A backward walking speed was calculated to elicit a VO(2) equal to 60% of the VO(2)max. There were 18 training sessions at the prescribed walking speed 3 d x wk(-1) for 20 min x d(-1). The backward walking speed required to elicit a fixed VO(2) increased between weeks 4 and 6 of the training period. This finding suggests that backward walking is indeed a novel task and that motor learning occurs as a result of practice, leading to a more efficient recruitment of motor units.