Computer-aided combined movement examination of the lumbar spine and manual therapy implications: Case report.

Combined movement examination (CME) of the lumbar spine has been recommended for clinical examination as it confers information about mechanical pain patterns. However, little quantitative study has been undertaken to validate its use in manual therapy practice. This study used computer aided CME to develop a normal reference range, and to guide provisional diagnosis and management. Two cases were assessed, before and after manual therapy using CME, a pain Visual Analogue Scale, the Roland Morris Low Back Pain and Disability Questionnaire and the Short Form (SF-12) Health Survey. Diagnosis and management were guided by comparing each CME pattern with the age and gender matched reference range. Self-reports data and CME total change scores were markedly improved for both cases, particularly for the most painful and restricted CME directions. This report describes how computer-aided CME and a normal reference range may be used objectively to inform a diagnosis and as an outcome measure in cases of mechanical LBP. Future investigations of cases with specific lumbar pathologies are required to validate this concept.

Low back pain misdiagnosis or missed diagnosis: Core principles.

Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, inappropriate referral and predilection for popular management approaches also contribute to mis-diagnosis and mis-management. This report describes two cases of chronic low back pain with lengthy histories of multiple failed interventions to highlight the consequences of focussing on a singular approach to the exclusion of evidence based pathways and the resulting risk of a missed diagnosis. The eventual management to mitigate these problems is reported with the aid of low back pain outcome measures, computer-aided combined movement examination, disability and pain questionnaires and health quality of life surveys.

Assessing the clinical utility of combined movement examination in symptomatic degenerative lumbar spondylosis.

OBJECTIVES: The aim of this study is to report the development and validation of a low back computer-aided combined movement examination protocol in normal individuals and record treatment outcomes of cases with symptomatic degenerative lumbar spondylosis. DESIGN: Test-retest, following intervention. BACKGROUND: Self-report assessments and combined movement examination were used to record composite spinal motion, before and following neurosurgical and pain medicine interventions. METHODS: 151 normal individuals aged from 20 years to 69 years were assessed using combined movement examination between L1 and S1 spinal levels to establish a reference range. Cases with degenerative low back pain and sciatica were assessed before and after therapeutic interventions with combined movement examination and a battery of self-report pain and disability questionnaires. Change scores for combined movement examination and all outcome measures were derived. FINDINGS: Computer-aided combined movement examination validation and intraclass correlation coefficient with 95% confidence interval and least significant change scores indicated acceptable reliability of combined movement examination when recording lumbar movement in normal subjects. In both clinical cases lumbar spine movement restrictions corresponded with self-report scores for pain and disability. Post-intervention outcomes all showed significant improvement, particularly in the most restricted combined movement examination direction. INTERPRETATION: This study provides normative reference data for combined movement examination that may inform future clinical studies of the technique as a convenient objective surrogate for important clinical outcomes in lumbar degenerative spondylosis. It can be used with good reliability, may be well tolerated by individuals in pain and appears to change in concert with validated measures of lumbar spinal pain, functional limitation and quality of life.

Referrer and service provider beliefs and attitudes towards rehabilitation in the home; factors related to utilisation of Early Supported Discharge.

PURPOSE: To investigate the attitudes and beliefs held by referrers and service providers of an Australian Early Supported Discharge (ESD) service called "Rehabilitation in the Home" (RITH); with particular consideration of factors that may influence referral to RITH. METHODS: A cross-sectional online survey based on the Theory of Planned Behaviour was undertaken. RESULTS: There were 113 respondents; 90 referrers and 23 service providers. Referrers and RITH staff had a moderately favourable attitude towards RITH. The majority of referrers, and, to a greater degree, RITH staff members, understood and appreciated the advantages ascribed to ESD. However, views varied with regard to some of the factors upon which the decision to refer to RITH rests. Two-fifths of referrers did not think that RITH provided hospital equivalent therapy intensity and over one-fifth of referrers had concerns about the capability of the RITH service to provide specialist stroke rehabilitation. Opinion of RITH staff was also varied on these topics. CONCLUSIONS: This study provides evidence that there was a level of uncertainty amongst referrers and RITH service providers regarding issues directly and indirectly related to patient eligibility and RITH service capability. This uncertainty needs to be explored in future research. IMPLICATIONS FOR REHABILITATION: Differences in views held by referrers and ESD service providers were identified in this study that could lead to inconsistencies in patient selection for, and under-utilization of, ESD services. Improved communication between referrers and ESD service providers, for instance attendance of RITH staff at inpatient team meetings, could ameliorate some of these misconceptions. On-going education of referrers about service capability is essential to ensure timely transfer of appropriate clients to ESD services.

The effect of interspinous implant surgery on back surface shape and radiographic lumbar curvature.

BACKGROUND: Interspinous process implants, used to augment lumbar spine surgery, putatively induce a local segmental lumbar kyphosis yet few investigations outline the effect in vivo on thoracolumbar sagittal curvature. Changes in lumbar skeletal alignment and posture have traditionally relied upon radiographic and back surface spinal curvature measurements, respectively. METHODS: Lumbar lordosis curvature in 10 healthy subjects (6F, 4M; mean age 36 years) and 10 interspinous implant lumbar surgery patients (5F, 5M; mean age 51 years) was assessed with rasterstereography at baseline and at 6 weeks. Skeletal lumbar lordosis in standing was measured from lateral erect radiography pre- and 6 weeks post-operatively in the surgical cohort, and compared to angulation obtained for surface lordosis curvature derived from rasterstereography. FINDINGS: Repeatable measurement of standing lumbar lordosis from rasterstereographic back shape imaging in healthy volunteers and lumbar surgery cases was demonstrated. Reductions of 0.6 (NS) in healthy and 3.1 (significant, P<0.001) in surgical subjects were recorded for surface lumbar lordosis angle between the 6 week time-points. Slight flattening of the segmental angle and regional lordosis after DIAM surgery was revealed by radiography. Skeletal and surface lumbar lordosis changes were uncorrelated preoperatively (rho=0.28) and postoperatively (rho=0.26). INTERPRETATION: Rasterstereography is sensitive in assessing lumbar lordosis changes in healthy and lumbar surgical individuals over time. Surgery with DIAM for lumbar pathology may result in an initial mild flattening of lordosis. Serial investigations of spinal curvature after surgery with DIAM interspinous implant are warranted in order to better understand the time-course of spinal posture changes of such cases.

The short term effect of cyclic passive stretching on plantarflexor resistive torque after acquired brain injury.

BACKGROUND: Increased calf muscle stiffness is a common impairment following acquired brain injury. This study examined the immediate effects of cyclic ankle stretching at two stretch velocities on calf stiffness in individuals with hemiparesis (n=17) and control subjects (n=10). METHODS: Cyclic ankle stretching was applied for 3min at velocities of 5 degrees s(-1) and 25 degrees s(-1) using a purpose-built dynamometer. Surface electromyography was employed to ensure stretches were passive. Peak plantarflexor resistive torque was derived from torque-angle curves. Comparisons were made between groups, velocities, and between limbs for hemiparetic subjects. FINDINGS: At baseline, mean peak plantarflexor resistive torque was greater in the affected limbs of hemiparetic subjects than their contralateral limbs (P<0.001), however there was no significant difference between groups. Plantarflexor resistive torque was reduced in all limbs following cyclic stretching regardless of stretch velocity (P<0.005). Two distinct patterns of response were observed in hemiparetic subjects. In nine cases the affected limb responses did not differ from the contralateral limb or control data. In the remaining eight cases mean peak plantarflexor resistive torque in the affected limb was greater than the contralateral limb and control values. In this subgroup, peak plantarflexor resistive torque was significantly affected by stretch velocity and showed the greatest reduction following cyclic stretching. INTERPRETATION: Cyclic stretching has been shown to produce a short term reduction in calf stiffness in a subgroup of individuals with hemiplegia. Further investigation is required to elaborate the characteristics of those most likely to respond optimally to this intervention.

A cortical-bone structural geometry phantom: dental plaster as a convenient and radiologically similar fabrication material.

Areal bone mineral density (aBMD), derived from dual-energy X-ray absorptiometry (DXA) scanners is used routinely to infer bone strength. With DXA hip scans there is growing acceptance of the advantages of also measuring bone structural geometric variables, that complement conventional aBMD to improve understanding of bone modelling, remodelling and processes of metabolic bone disease. However, phantoms for assessing structural geometric variables from DXA scans are not widely available, unlike those for aBMD. This study describes the development of such a phantom, simulating the cortical shell of the human femoral neck, using dental plaster as a material radiologically similar to cortical bone. The mass attenuation coefficient of the dental plaster differed by < 1% from cortical bone, over the relevant energy range. Performance testing was carried out with DXA, to determine accuracy and precision of the phantom structural geometry, using its dimensions and composition as 'gold standards'. Accuracy and precision of cortical structural geometry were poor when measured in a simulated 1 mm-thick osteoporotic cortex (5.5% precision and 50% accuracy errors), but improved with increasing cortical thickness. This study demonstrates the limitations of DXA-based Hip Structure Analysis when applied to femora with thin cortices, and indicates improvements in the design of a phantom to better simulate such cortical structures.

Botulinum toxin injection to facilitate rehabilitation of muscle imbalance syndromes in sports medicine.

Intramuscular injection of Botulinum toxin to produce reduction of focal muscle overactivity, and localized muscle spasm, has been utilized therapeutically for almost two decades. Muscle overactivity in neurologically normal muscle, where an imbalance exists between a relatively overactive muscle and its less active synergist or antagonist, can inhibit control of the antagonist producing a functional muscle imbalance. This brief review provides an overview of the role of muscle imbalance in sports-related pain and dysfunction, and outlines the potential for intramuscular injection of Botulinum toxin to be used as an adjunct to specific muscle re-education and functional rehabilitation in this patient group. A comprehensive understanding of normal movement and the requirements of the sporting activity are essential to allow accurate diagnosis of abnormal motor patterns and to re-educate more appropriate movement strategies. Therapeutic management of co-impairments may include stretching of tight soft tissues, specific re-education aimed at isolation of the non-dominant weak muscles and improvement in their activation, 'unlearning' of faulty motor patterns, and eventual progression onto functional exercises to anticipate gradual return to sporting activity. Intramuscular injection of Botulinum toxin, in carefully selected cases, provides short term reduction of focal muscle overactivity, and may facilitate activation of relatively 'inhibited' muscles and assist the restoration of more appropriate motor patterns.

An open label pilot investigation of the efficacy of Botulinum toxin type A [Dysport] injection in the rehabilitation of chronic anterior knee pain.

PURPOSE: To examine the effect of intramuscular injection of botulinum toxin type A [Dysport] to reduce relative overactivity of the vastus lateralis [VL] muscle, in conjunction with re-training of vastus medialis [VM] muscle as an adjunct to rehabilitation for chronic anterior knee pain. METHOD: Eight females with chronic (>6 months) history of anterior knee pain, who had failed conservative management, were studied in this open label pilot study. Intramuscular Dysport injection [300 - 500 units] to the distal third of VL muscle was followed by a 12-week customized home exercise programme to improve recruitment of VM muscle and functional knee control. VL and VM muscle cross sectional area from a standardized spiral CT sequence, isometric quadriceps strength (dynamometry), timed stair task, self-reported pain and disability were assessed. RESULTS: Subjects reported reduced knee pain and brace dependency and increased participation in sporting and daily living activities. Isometric quadriceps muscle strength was maintained or improved despite significant atrophy, evident on CT, of the distal component of VL in the treated limb. Time taken to ascend and descend a flight of stairs improved in all subjects. Subjective and objective improvements were maintained at 24-week follow-up. CONCLUSIONS: These pilot data provide preliminary support for the role of Dysport as an adjunct to non-surgical management of individuals with chronic anterior knee pain. Larger double blind, randomized, placebo-injection controlled studies of this novel approach to improving patellofemoral mechanics are needed to establish the efficacy of this intervention.

Non-surgical management of ankle contracture following acquired brain injury.

BACKGROUND AND PURPOSE: The purpose of this study was to document the outcome of non-surgical management of equinovarus ankle contracture in a cohort of patients with acquired brain injury admitted to a specialist Neurosurgical Rehabilitation Unit. METHODS: This prospective descriptive study examined all patients with a new diagnosis of moderate to severe acquired brain injury (Glasgow Coma Scale score

Evaluation of extensibility, passive torque and stretch reflex responses in triceps surae muscles following serial casting to correct spastic equinovarus deformity.

PRIMARY OBJECTIVE: Spastic equinovarus deformity of the ankle in adults with acquired brain injury can severely limit the achievement of rehabilitation goals. This study examined changes in triceps surae muscle extensibility, passive resistive torque and soleus stretch reflex responses in 10 adult brain injured subjects undergoing serial casting to correct ankle equinovarus deformity. METHOD: Goniometric measurement of maximal passive dorsiflexion was used to evaluate extensibility of the triceps surae muscles. Computer controlled ankle dynamometry and surface electromyography were used to identify passive resistive torque and soleus stretch reflex onset angle in response to stretches at two velocities. RESULTS: The mean casting period was 5 weeks. Casting was discontinued in one subject due to failure to achieve measurable gain in ankle range over three consecutive cast changes. Median improvements in maximal ankle dorsiflexion, with the knee flexed or extended, of 30 degrees and 15 degrees, respectively, were achieved in the remaining nine subjects (p < 0.0001). The median passive ankle range in response to a displacing torque of 10 Nm increased 4.3 degrees over the intervention period (p < 0.0001). Consistent soleus reflex activity in response to passive stretches at 25 degrees x s(-1) was elicited in only four subjects. A trend for the stretch reflex onset to move further into the available range was demonstrated in these subjects. CONCLUSION: In the present study, serial casting contributed to significant change in triceps surae extensibility and passive resistive torque, corresponding with improved maximal passive ankle dorsiflexion range and an increase in the angle achieved with a displacing torque of 10 N.m. Increased stretch reflex threshold was observed in some subjects. The use of pre-determined outcome criteria and careful measurement of responses to this intervention were important to prevent premature discontinuation of casting when gains were slower than expected.

Velocity dependent passive plantarflexor resistive torque in patients with acquired brain injury.

OBJECTIVES: This study sought to determine whether factors other than stretch reflex excitability contribute to velocity dependent passive plantarflexor resistive torque following brain injury. BACKGROUND: In patients with acquired brain injury increased resistance to passive muscle lengthening commonly results from abnormal muscle contraction, secondary to disinhibition of descending motor pathways, in addition to rheologic changes within the musculo-tendinous unit. Hyper-excitable tonic stretch reflex responses (spasticity) have traditionally been considered to be the main factor influencing resistance that is velocity dependent. METHODS: Ten adults with brain injury and eighteen age matched controls were studied. A computer controlled torque measurement system was utilised to evaluate resistance to dorsiflexion stretches at two velocities (5 degrees and 25 degrees s(-1)). Only stretches which did not evoke muscle contraction were included in the data analysis. The mean difference and 95% confidence limits in passive plantarflexor resistive torque at two stretch velocities, measured over a defined portion of the test movement, were compared between subject groups. RESULTS: A velocity dependent increase in passive plantarflexor resistive torque was evident when the ankle was dorsiflexed past the neutral position in both subjects with brain injury and controls. However, the mean difference was approximately 10 times greater in neurologically impaired limbs compared with control values. CONCLUSIONS: These data indicate that an important component of velocity dependent resistance to passive muscle lengthening in adults with brain injury can be mechanical, and unrelated to stretch induced reflex muscle contraction. RELEVANCE: Increased resistive torque during rapid muscle lengthening may represent a compensatory adaptation for reduced distal motor control following brain injury. A velocity dependent increase in passive plantarflexor resistive torque has the potential to improve stability during gait and provide mechanical resistance to sudden external perturbations.

Evaluation of triceps surae muscle length and resistance to passive lengthening in patients with acquired brain injury.

OBJECTIVE: To examine changes in muscle length and resistance to passive lengthening in the triceps surae muscles in patients with recently acquired brain injury. BACKGROUND: Increased passive resistance in the triceps surae muscles is common following acquired brain injury. Adaptive shortening secondary to relative immobility, and increased stiffness due to rheologic changes within the musculo-tendinous unit, may be exacerbated by plantarflexor muscle overactivity related to the brain injury itself. DESIGN: Three variables representing resistance to passive lengthening and soleus muscle length were compared between subjects with recent brain injury and age matched normal controls. Comparison between limbs was made for subjects with unilateral neurological impairment. METHODS: Slow passive dorsiflexion stretches were performed using a computer controlled dynamometer. Muscle stiffness in the initial and latter portion of the range, and the angles achieved at torques of 5 and 10 N m were determined from torque-angle curves. Maximal ankle dorsiflexion with the knee flexed was considered to reflect soleus muscle length. RESULTS: Significant differences were demonstrated for all variables, except passive stiffness near the end of available range. The limb ipsilateral to unilateral brain injury differed from control limbs in that significantly less passive range of dorsiflexion was available and initial resistance to passive stretch was significantly less. CONCLUSIONS: The reduction in soleus muscle length evident in subjects with recent acquired brain injury, even in neurologically unaffected limbs, may reflect the influence of relative immobility. Although plantarflexor muscle overactivity was found to be associated with increased resistance to slow passive stretch, the mechanism was unable to be elucidated from these data. The limb ipsilateral to unilateral neurological impairment cannot be considered to be a 'normal' control for comparative purposes. RELEVANCE: Adaptive shortening and increased resistance to passive lengthening limit active ankle dorsiflexion, and alter ankle biomechanics. Tonic muscle overactivity has the potential to exacerbate these changes. Prophylactic management of inappropriate muscle activity and maintenance of muscle length may facilitate the achievement of rehabilitation goals and reduce subsequent disability following acquired brain injury.

Serial plaster casting to correct equino-varus deformity of the ankle following acquired brain injury in adults.

PURPOSE: Proposed mechanisms via which serial casting might effect increased joint range, muscle extensibility and reduced reflex excitability are outlined in this review. Support for these mechanisms stems largely from animal experimental studies. The applicability of these data to human muscle is unknown. ISSUES: Equino-varus deformity of the ankle is a common secondary complication of acquired brain injury. It results from a combination of sequelae of the brain injury and subsequent immobility, including hypertonia, reduced muscle length and increased stiffness. Some evidence exists for the efficacy of serial plaster casts in the treatment of equino-varus deformity, although most reported studies are uncontrolled and involve small numbers of subjects. Serial casting has been shown to result in decreased resistance to passive lengthening and a reduction in dynamic reflex excitability within the lengthened muscles in children with cerebral palsy. Currently documented effects of serial casting in brain injured adults are limited to changes in range of maximal passive dorsiflexion. CONCLUSION: Serial casting should be considered as an adjunct to therapy aimed at improving functional mobility. A variety of therapeutic interventions have been used to augment the effect of the casting regime. Factors that have been demonstrated to be associated with a favourable outcome from serial casting, and recommendations for future research are also discussed in this review.

MRI evaluation of lumbar spine flexion and extension in asymptomatic individuals.

Flexion and extension movements or positions have been advocated in the treatment of various forms of low back dysfunction due to the potential pain relieving effects attributed to displacements of the intervertebral disc (IVD). Objective in vivo determination of the segmental behaviour of the disc to contrasting positions has until recently been difficult. Magnetic resonance imaging (MRI) was used in this study to evaluate the influence of sagittal plane positions on lumbar IVD height and nucleus displacement in a small asymptomatic population.T2-weighted sagittal plane images from L1 to S1 were obtained from 10 subjects (mean age: 30+/-5 years) positioned supine in lumbar flexion, followed by extension. Changes in disc height and localization of nucleus position (determined by peak MRI signal intensity) between the two positions were calculated. Discs were classified for degenerative changes using a semi-quantitative grading scale. The mean range of lumbar sagittal movement achieved in the MRI was 44 degrees (range: 22-77 degrees ). Between flexion and extension, a significant increase in measured anterior disc height of 1.1 mm (P<0.0001) and anterior displacement of the nucleus of 6.7% (P<0.0001) was observed. Despite the anterior displacement of the nucleus in extension observed in the pooled analysis, 30% of discs did not follow this trend. Nucleus degeneration was observed in at least one disc in nine subjects and in 26% of all discs examined. Lumbar spine position was found to be associated with small measured changes in anterior disc height and nucleus position, however, this response was variable within and between individuals. The theoretical concept of a stereotypical effect of spinal position on the lumbar IVD is challenged by these initial data. Since the health of the disc is often unknown in clinical practice, manual therapy treatment for lumbar spine pain should be based on the symptomatic response to movement and position rather than biomechanical theory.

Navigating the internet maze.

The 'internet-driven information age' is a term in common usage, implying that everyone can access all the information they need, when they need it. The purpose of this brief paper is to outline some web sources that highlight the possibilities and potential for accessing web-based knowledge. From this the clinician will be encouraged to follow leads along the labyrinth of links to a greater appreciation of how this resource can be used to shape their practice. Examples of web links are provided for: search engines; library-based sources, including medical databases and electronic journals; evidence-based practice databases, mail-groups; electronic conferences; research centres; and general health sources. Importantly, this review does not aspire to be all-inclusive, for the web changes, chameleon-like, to the seasons. The web is here to stay. It will provide the framework for much education and will guide clients to a greater appreciation of their disease or disability than ever before. It may ultimately be the tool through which health fund agents will promote best practice, including self-help to clients, and therefore direct discriminating individuals to select health practitioners who have been endorsed by professional and fund agencies as providing a contemporary service which conforms to evidence-based practice.

Normal values of plantar pressure measurements determined using the EMED-SF system.

Plantar pressure-measurement technology is being increasingly used by podiatric physicians and surgeons in both clinical practice and research. The authors present normal reference-range values for peak pressure, mean pressure, and pressure-time integral obtained from 30 healthy subjects using a two-step recording technique and the EMED-SF system, as background for proposed clinical trials. Normative data of this type are essential for clinical practice in the comparison of plantar pressure-measurement values of individual patients with those of normal, asymptomatic feet.

A comparison of three methods for measuring thoracic kyphosis: implications for clinical studies.

OBJECTIVES: To compare the Cobb technique for measuring kyphosis with an alternative Cobb method and a computer-assisted curve assessment technique, and to examine the influence of vertebral body and disc shape on kyphosis. METHODS: Kyphosis measurements were derived from 93 lateral spinal radiographs or sagittal computed tomography images of cadaveric spines, using: (i) a computer-assisted method for estimating radius of curvature; (ii) the traditional Cobb method; and (iii) an alternative Cobb method. Regression models were applied for agreement analyses, and to examine the relative contribution of vertebral body and disc shape on the extent of curvature. Results and conclusions. Strong associations existed between curvature and angle data derived from the three methods, confirming the clinical utility of these techniques for the quantification of thoracic kyphosis. However, the traditional Cobb method tended to overestimate kyphosis in the presence of vertebral body end-plate deformation. The degree of kyphosis was strongly reflective of the extent of deformity of the vertebral bodies, and to a lesser extent the shape of the thoracic discs.