A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain Annals of Internal Medicine, 07/11/2011 Cherkin DC et al. – Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.Methods

Parallel–group randomized, controlled trial. Randomization was computer–generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual

care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. An integrated health care delivery system in the Seattle area. 401 persons 20 to 65 years of age with nonspecific chronic low back pain. Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133).

Results The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the

relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage.

The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small

Cherkin DC et al. A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain. Annals of Internal Medicine. July 2011. (Entered July 2011) Category: Misc Bib- Massage

Reliability and Validity of a New Objective Tool for Low Back Pain Functional Assessment Spine, 07/12/2011 Clinical Article Sánchez–Zuriaga D et al. – It is possible to distinguish low back pain (LBP) patients from healthy subjects by means of the biomechanical analysis of everyday tasks. This kind of analysis can produce objective and reliable indexes about the patients' degree of functional impairment.

Methods Sixteen controls and 39 LBP patients performed a sit–to–stand task, and lifted three different

weights from a standing position. The vertical forces exerted and the relative positions of the lower limb and the cervical,

thoracic, lumbar, and sacroiliac regions were recorded. Reliability was determined from repetitions of the tests performed by the control group. Binary logistic regression analyses were computed. The results of the selected regression equation were correlated to the Oswestry Disability

Index scale results, to check the validity of the procedure for the measurement of functional disability.

Results Reliability of the parameters was good. The selected regression model used two variables, and correctly classified 97.3% of the

patients. High correlations were found between the results of this regression equation and the

Oswestry Disability Index scale.

Sanchez-Zuriaga D et al. Reliability and Validity of a New Tool for Low Back Pain Functional Assessment. Spine. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Functional Tests

A brief comparison of the pathophysiology of inflammatory versus neuropathic pain Current Opinion in Anesthesiology, 07/11/2011 Xu Q et al. – Recognition of mechanisms common to both inflammatory pain and neuropathic pain might shed light on the understanding of the transition from acute pain to persistent pain.AbstractPurpose of review: The causes of inflammatory pain and neuropathic pain are fundamentally different. There are, however, common mechanisms underlying the generation of each pain state. We will discuss some specific elements observed in both tissue and nerve injury pain states and consider the hypothesis that these two states actually demonstrate a convergence over time.Recent findings: The increased pain sensation following tissue and nerve injury results from several mechanisms, including altered ion channel expression in dorsal root ganglion neurons, enhanced dorsal horn glutamate release from primary afferents, enhanced glutamate receptor function in second-order neurons, disinhibition in the dorsal horn and glia cell activation. The role of specific subtypes of receptors, ion channels and glutamate transporters is revealed at peripheral and central sites. Importantly over time, a number of changes, in the dorsal root ganglion and in dorsal horn observed after tissue injury resemble changes observed after nerve injury.Summary: Recognition of mechanisms common to both inflammatory pain and neuropathic pain might shed light on the understanding of the transition from acute pain to persistent pain

Xu Q et al. A brief comparison of the pathophysiology of inflammatory versus neuropathic pain. Current Opinion in Anesthesiology. Jul 2011. (Entered July 2011)

Category: Misc Bib- Pain

Dysfunctional coping in headache: Avoidance and endurance is not associated with chronic forms of headache European Journal of Pain, 07/05/2011 Wieser T et al. – Dysfunctional coping was seen with high prevalence in the entire patient sample (66%). Against the hypothesis, it was not confined to chronic forms of headache. In respect to the data, authors discuss the role of avoidance and endurance coping in headache and its possible role in chronicity.Methods

Authors performed a cross sectional study on pain coping behaviour in 211 patients with migraine and tension type headache.

Pain–related cognition and coping was investigated using the Kiel Pain Inventory. Prevalence of depression, medication intake and headache characteristics were analysed in

regard to chronicity of headache. Results

Overall pain intensity was high in the patient sample. The level of depression increased with headache frequency. Dysfunctional coping, characterized by fear and avoidance is frequently used by headache

patients. As in low back pain, also endurance is highly prevalent. Other features known to be associated with chronic headache, like depression and medication

overuse, could be confirmed. Discussion

Dysfunctional coping was seen with high prevalence in the entire patient sample (66%). Against our hypothesis, it was not confined to chronic forms of headache. In respect to our data, we discuss the role of avoidance and endurance coping in headache and its possible role in chronicity.

Wieser T et al. Dysfunctional coping in headache: Avoidance and endurance is not associated with chronic forms of headaches. European Journal of Pain. Jul 2011. (Entered July 2011)Category: Upper Quarter Bib- Headaches

Associations between proinflammatory cytokines in the synovial fluid and radiographic grading and pain-related scores in 47 consecutive patients with osteoarthritis of the knee Full Text BMC Musculoskeletal Disorders, 07/13/2011 Pain S et al. – Background One of the sources of knee pain in osteoarthritis (OA) is believed to be related to local chronic inflammation of the knee joints, which involves the production of inflammatory cytokines such as tumor necrosis factor alpha (TNF-alpha), interleukin (IL)-6, and nerve growth factor (NGF) in the synovial membrane, and these cytokines are believed to promote pathological OA. In the present study, correlations between proinflammatory cytokines in knee synovial fluid and radiographic changes and functional scores and pain scores among OA patients were examined.Methods Synovial fluid was harvested from the knees of 47 consecutive OA patients, and the levels of TNF-alpha, IL-6, and NGF were measured using enzyme-linked immunosorbent assays. Osteoarthritic knees were classified using Kellgren-Lawrence (KL) grading (1-4). The Western Ontario and McMaster University Osteoarthritis Index (WOMAC) was used to assess self-reported physical function, pain, and stiffness. Results TNF-alpha and IL-6 were detectable in knee synovial, whereas NGF was not. TNF-alpha was not correlated with the KL grade, whereas IL-6 had a significantly negative correlation. We observed differences in the correlations between TNF-alpha and IL-6 with WOMAC scores and their subscales (pain, stiffness, and physical function). TNF-alpha exhibited a significant correlation with the total score and its 3 subscales, whereas IL-6 exhibited a moderately significant negative correlation only with the subscale of stiffness.ConclusionsThe present study demonstrated that the concentrations of proinflammatory cytokines are correlated with KL grades and WOMAC scores in patients with knee OA. Although TNF-alpha did not have a significant correlation with the radiographic grading, it was significantly associated with the WOMAC score. IL-6 had a significant negative correlation with the KL grading, whereas it had only a weakly significant correlation with the subscore of stiffness. The results suggest that these cytokines play a role in the pathogenesis of synovitis in osteoarthritic knees in different ways: TNF-alpha is correlated with pain, whereas IL-6 is correlated with joint function.

Pain S et al. Associations between proinflammatory cytokines in the synovial fluid and radiographic grading and pain-related scores in 47 consecutive patients with osteoarthritis of the knee. BMC Musculoskeletal Disorders. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Knee Osteoarthritis

Vastus Medialis Obliquus Atrophy: Does It Exist in Patellofemoral Pain Syndrome American Journal of Sports Medicine, 07/13/2011 Pattyn E et al. – This is the first study to examine vastus medialis obliquus (VMO) size in patellofemoral pain syndrome (PFPS) patients by MRI. Patients with patellofemoral problems exhibited atrophy of the VMO. Although it is not clear whether this atrophy is a result or a cause of PFPS, the results of this study do show that atrophy of the VMO is a contributing factor in PFPS. Longitudinal, prospective studies are needed to establish the cause–effect relation of VMO atrophy and PFPS.Background: Quadriceps atrophy and in particular atrophy of the vastus medialis obliquus (VMO) muscle have been frequently related with patellofemoral pain syndrome (PFPS), despite very little objective evidence. Hypothesis: Patients with PFPS exhibit atrophy of the VMO in comparison with healthy controls. Study Design: Case-control study; Level of evidence, 3. Methods: Forty-six patients with PFPS and 30 healthy control persons with similar age, gender, body mass index, and activity index distributions underwent magnetic resonance imaging (MRI) of the quadriceps. The muscle size was determined by calculating the cross-sectional area of the total quadriceps and its components. Results: The cross-sectional area (CSA) of the VMO was significantly smaller in the PFPS group than in the control group (16.67 ± 4.97 cm2 vs 18.36 ± 5.25 cm2) (P = .040). A tendency was noted for a smaller total quadriceps CSA for the PFPS patients at midthigh level (66.99 ± 15.06 cm2 vs 70.83 ± 15.30 cm2) (P = .074). Conclusion: This is the first study to examine VMO size in PFPS patients by MRI. Patients with patellofemoral problems exhibited atrophy of the VMO. Although it is not clear whether this atrophy is a result or a cause of PFPS, the results of this study do show that atrophy of the VMO is a contributing factor in PFPS. Longitudinal, prospective studies are needed to establish the cause-effect relation of VMO atrophy and PFPS.

Pattyn E et al. Vastus Medialis Obliquus Atrophy: Does It Exist in Patellofemoral Pain Syndrome. American Journal of Sports Medicine. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Patellofemoral Pain

Illness beliefs, treatment beliefs and information needs as starting points for patient information-Evaluation of an intervention for patients with chronic back pain Patient Education and Counselling, 07/14/2011 Glattacker M et al. – The intervention group assessed their back pain as personally controllable and their information needs at the end of rehabilitation as being met to a greater extent than did patients who received care as usual.

Methods The intervention was evaluated in a sequential control group design (control group N=105;

intervention group N=96). Changes with respect to illness and treatment beliefs, satisfaction with information, and

health status at the end of rehabilitation were selected as outcome measures. Analyses of covariance were used to assess differences between control and intervention

group. Results

Significant time–by–group interactions were shown for causal beliefs, personal control, satisfaction with information about illness and rehabilitation, and for general health.

All time–by–group interactions indicated superiority of the intervention group.

Conclusion The intervention group assessed their back pain as personally controllable and their information

needs at the end of rehabilitation as being met to a greater extent than did patients who received care as usual.

Practice implications The extended Common Sense Model seems promising as a frame for discussing illness and

treatment perceptions as well as information needs in patients with chronic back pain.

Glattacker M et al. Illness beliefs, treatment beliefs and information needs as starting points for patient information-Evaluation of an intervention for patients with chronic back pain. Patient Education and Counselling. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Low Back Pain

Fatigue in knee and hip osteoarthritis: The role of pain and physical function Rheumatology, 07/14/2011 Snijders GJ et al. – Important levels of fatigue are common in knee and hip OA patients. After evidence-based tailored conservative treatment targeted to improve pain and physical function, a small decrease in fatigue levels was found. Reduction in levels of different fatigue dimensions were related to the change in physical function and pain. Methods

Observational cohort study Levels of different dimensions of fatigue measured in knee and/or hip OA patients before and

after 12 weeks of conservative treatment Cross-sectional and longitudinal relations between (change in) fatigue dimensions and

(change in) pain or physical function studied using association models, controlling for predefined possible confounders

Results 231 patients was included, with 47% experiencing severe fatigue A small decrease in levels of fatigue was seen after standardized treatment Level of fatigue severity was cross-sectionally and longitudinally associated with physical

function Level of physical fatigue cross-sectionally and longitudinally associated with pain and

physical function No confounders identified

Results. A total of 231 patients was included, with 47% experiencing severe fatigue. A small decrease in levels of fatigue was seen after standardized treatment. The level of fatigue severity was cross-sectionally and longitudinally associated with physical function, whereas the level of physical fatigue was cross-sectionally and longitudinally associated with pain and physical function. No confounders were identified.

Conclusions. Important levels of fatigue are common in knee and hip OA patients. After evidence-based tailored conservative treatment targeted to improve pain and physical function, a small decrease in fatigue levels was found. Reduction in levels of different fatigue dimensions were related to the change in physical function and pain.

Snijders GJ et al. Fatigue in knee and hip osteoarthritis: The role of pain and physical function. Rheumatology. Jul 2011. (Entered July 2011)

Category: Lower Quarter Bib- Knee Osteoarthritis

Health-Related Quality of Life in Subjects With Low Back Pain and Knee Pain in a Population-Based Cohort Study of Japanese Men: The Research on Osteoarthritis Against Disability StudyMuraki, Shigeyuki MD, PhD*; Akune, Toru MD, PhD*; Oka, Hiroyuki MD†; En-yo, Yoshio MD‡; Yoshida, Munehito MD, PhD‡; Saika, Akihiko MD, PhD‡; Suzuki, Takao MD, PhD§; Yoshida, Hideyo MD, PhD§; Ishibashi, Hideaki MD, PhD§; Tokimura, Fumiaki MD, PhD§; Yamamoto, Seizo MD, PhD§; Nakamura, Kozo MD, PhD¶; Kawaguchi, Hiroshi MD, PhD¶; Yoshimura, Noriko MD, PhD†Spine: 15 July 2011 - Volume 36 - Issue 16 - p 1312–1319doi: 10.1097/BRS.0b013e3181fa60d1EpidemiologyStudy Design. Cross-sectional surveys of health-related quality of life (QOL) in subjects with low back pain and knee pain using a population-based cohort.Objective. The purpose of the present study was to clarify the impact of low back pain and knee pain on QOL in men. In addition, we analyzed the impacts of vertebral fracture (VFx), lumbar spondylosis, and knee osteoarthritis (OA) on the magnitude of QOL loss in men with low back pain and knee pain.Summary of Background Data. Low back pain and knee pain are major public health issues causing disability among the elderly men, but there were no population-based studies to compare the impact of low back pain on QOL with that of knee pain in Japanese men.Methods. From 3040 participants in the Research on Osteoarthritis Against Disability study, data from 767 men older than 40 years who completed questionnaires (mean age = 69.7 years) were examined. To carry out the QOL assessment, the Medical Outcomes Study Short Form 8 (SF-8) and EuroQol (EQ-5D) were used. We examined the association of low back pain and knee pain with QOL. Furthermore, we also examined the presence of VFx and the severity of lumbar spondylosis and knee OA with the magnitude of QOL loss in men with low back pain and knee pain, respectively.Results. The impact of low back pain on QOL was larger than that of knee pain. In men with low back pain, there were few associations between Kellgren-Lawrence grade and QOL, whereas VFx was associated with physical QOL. For men with knee pain, Kellgren-Lawrence grade equal to 4 knee OA was associated with QOL.Conclusion. This study revealed that low back pain has a larger impact than knee pain on QOL. Furthermore, low back pain with VFx is strongly associated with physical QOL loss.

Muraki S et al. Health-Related Quality of Life in Subjects With Low Back Pain and Knee Pain in a Population-Based Cohort Study of Japanese Men: The Research on Osteoarthritis Against Disability Study. Spine. Jul 2011;36(16):1312-1319. (Entered July 2011)Category: Lower Quarter Bib- Low Back Pain

Influence of Low Back Pain Status on Pelvis-Trunk Coordination During Walking and Running Spine, 07/14/2011 Seay JF et al. Study Design. Two-way repeated-measures analysis of variance.Objective. To assess pelvis and trunk three-dimensional segmental excursions and coordination differences during walking and running between runners with low back pain (LBP), runners with resolved LBP, and a control group with no history of LBP.Summary of Background Data. Studies have documented differences in pelvis and trunk coordination between those with moderate to severe LBP during walking. Few studies document pelvis and trunk mechanics in those with low to moderate LBP and individuals who recover from LBP even though these individuals comprise 80% of LBP cases and are at increased risk for re-injury.Methods. Recreational runners walked and ran on a treadmill at speeds including 0.8 to 3.8 m/s at 0.5 m/s increments. Pelvis and trunk kinematic data were collected during the last 20 s of each stage. Coordination analysis quantified the portion of gait cycle each group spent in trunk only motion, pelvis-only motion, in-phase, and antiphase relationships.Results. During walking, the LBP group spent more of the gait cycle in-phase in the frontal plane (P = 0.030). During running, the LBP group showed greater pelvis axial rotation than the control group (P = 0.014) and spent more of the gait cycle in-phase in the transverse plane (P = 0.019). Also during running, the LBP (P = 0.035) and the resolved LBP (P = 0.037) groups demonstrated reduced antiphase coordination compared to controls.Conclusion. Coordination analysis demonstrates a reduction in relative motion between the pelvis and trunk despite low disability levels in our LBP group and no pain in our group with a history of LBP.

Seay JF et al. Influence of Low Back Pain Status on Pelvis-Trunk Coordination During Walking and Running. Spine. Jul 2011. (Entered July 2011)Category: Lower Quarter- Gait

Violent Patient Behavior Is Associated with Bodily Pain and a High Burden on Informal Caregivers Journal of General Internal Medicine, 07/13/2009 Yamamoto Y et al. – BACKGROUND There have been no studies of the relationship between violent behavior by older patients and the physical and mental health of caregivers. OBJECTIVE To evaluate the influence of violent behavior in vulnerable elderly patients on bodily pain and caregiver burden in their informal caregivers. DESIGN Cross-sectional study. SUBJECTS One hundred thirty-seven patients aged ≥40 years old with limited activity and mobility in ten facilities providing home-care services in Japan. MEASUREMENTS Degree of caregiver-perceived violent patient behavior and caregivers’ bodily pain derived from a self-administered questionnaire, and caregiver burden assessed using scores from both the Burden Index of Caregivers and the Zarit Burden Interview. RESULTS The mean age of the 137 patients enrolled in this study was 80.9 years. Of these patients, 31.4% were men, and 34.3% had violent behavior. The mean caregiver age was 65.0 years, and 29.2% were men. Caregivers who looked after violent patients experienced significantly higher odds of having bodily pain [AOR = 3.51; 95% confidence interval (CI): 1.81 to 6.85]. Caregivers of violent patients also reported significant caregiver burden as assessed by the Burden Index of Caregivers (β-coefficient = 4.92; 95% CI: 1.95 to 7.88) and the Zarit Burden Interview (β-coefficient = 5.81; 95% CI: 2.92 to 8.70). CONCLUSIONS Violent behavior among older patients is associated with significant increases in both physical and psychological burden in their informal caregivers.

Yamamoto Y et al. Violent Patient Behavior Is Associated with Bodily Pain and a High Burden on Informal Caregivers. Journal of General Internal Medicine. Jul 2011. (Entered July 2011)Category: Misc Bib- Pain

three Steps to Gallbladder Health[Editor’s Note: Dr. Williams wrote this article on gallbladder health in the September 1996 issue of Alternatives, and his recommendations on how to keep this often underappreciated organ healthy still ring true to this day.]Your red blood cells have a life span of about 120 days. At that time, they become so fragile they rupture. The pigmented part of the red blood cell is then broken down into several components, one of which is eventually converted to the yellow pigment, bilirubin. Bilirubin travels through your bloodstream and is absorbed by cells in your liver. Some bilirubin returns to the bloodstream and some is mixed with other components to form bile. Bile consists of water, bile salts, bilirubin, cholesterol, fatty acids, lecithin, and minerals. It is formed in the liver and stored in the gallbladder—a small sac directly below the liver. Once inside the gallbladder, water is reabsorbed from the mixture and the bile becomes more and more concentrated. Compared to the liver bile, gallbladder bile has roughly six times more bile salts, over seven times more bilirubin and lecithin, and as much as 10 times more fatty acids and cholesterol. The concentration of bile allows it to function more effectively in a number of different tasks. For one, when fat enters the small intestine, a hormone is released (cholesystokinin) that triggers the gallbladder to contract and release bile. Bile first acts like a detergent or an emulsifier. It reduces the surface tension of the fats and helpsbreak them down into smaller particles. Next, the bile salts attach to the smaller fat particles and pull them out of the intestinal tract so they are properly absorbed. The liver also uses bile to get rid of excess cholesterol in the blood. Bile is also one of the avenues used by the liverto remove toxins from the body. It takes toxins out of the bloodstream and releases them through the bile. Overloading the liver with toxins from conditions like constipation; persistent drug, alcohol, or hormone use; or contaminated or highly processed foods will have a tendency to “thicken” the bile. Thickened bile flows from the gallbladder at a much slower rate. This not only affects digestion, but also causes the bileto become extremely concentrated, which can lead to the formation of gallstones. Inadequate amounts of bile, thickened bile, or a sluggishgallbladder can have a negative effect on your overall health. But these techniques will benefit the health of practically everyone’s gallbladder. Those who have had their gallbladder removed will also benefit.ArtichokesLeaves from the artichoke plant contain caffeylquinic acids, which promote bile flow and also promote a degree of regeneration within the liver itself. The simplest and least expensive way to benefit from these compounds is to eat the artichoke leaves.Sauerkraut and Sauerkraut JuiceWhen used regularly, sauerkraut and its juice will promote bile output. A cup of the juice by itself taken once or twice a week before breakfast can work wonders.

Joint Pain and DehydrationQuestion: As I’ve gotten older, I’ve noticed that I’m beginning to have more joint pain and stiffness. I’ve recently started taking the joint product you developed and I’ve seen a very noticeable improvement, but my problems haven’t totally gone away. X-rays I’ve had takenof the joints that give me the most problems don’t show any serious arthritis. Is there anything else you can suggest that might help?—W.M., Houston, TexasAnswer: One of the factors you also need to consider is dehydration. For numerous reasons, dehydration is one of the most common underlying causes of countless health issues—everything from headaches and constipation to blood pressure problems. But most people don’t associate dehydration with joint pain and stiffness.Many of the fluids we consume nowadays act as diuretics.These include things like soft drinks, tea, coffee, and alcohol.Lots of drugs also exhibit a diuretic effect. And, a diet rich in protein and fat promotes fluid loss, as well. (Urea,a byproduct of protein, is a well-known diuretic.) Some of the primary ingredients in joint products are carbohydrate and protein complexes known as glycosaminoglycans (called GAGs for short). Along with sulfur compounds, these GAGs form a thick gel-like liquid thatsupplies cushioning, lubrication, shock absorption, and nutrition to the cartilage in our joints. But keep in mind, they are primarily only the matrix or framework, much like a sponge. For the sponge to be “full” and “cushiony,” it needs to be filled with water. As we age, these matrixes begin to break down and the ability to keep our joints hydrated lessens. Taking the compounds in the joint product will help, but you also need to rehydrate your joints. You can start to do this by eliminating or cutting back on the drinks I mentioned earlier that act as diuretics. And, many drugs used these days, particularly the diuretics or “water pills” given to control blood pressure, can be contributing to the problem. And obviously, you need to be drinking plenty of water every day. Regardless of what you may hear, 1/2 gallon a day isnot unreasonable for most people.At first, increasing the amount of water you drink may not seem like it’s doing much good. In the beginning, it may just make you go to the bathroom more often, but as the matrixes begin to swell again and regain their ability to retain water, that will subside. It’s like trying to water a plant when the surrounding soil has dried up. When you first water it, it takes a few times before it dehydrates and begins to retain that much-needed water. A similar thing happens with your joints. Consuming foods rich in complex carbohydrates will also speed up the process. Beans, legumes, and whole grains absorb and retain water. Pretty much any high-fiber foodwill help tremendously, like vegetables (particularly raw), whole fruits (the pectin content in apples makes them especially helpful), and sprouted seeds. As they move through the intestinal tract, they provide a “reservoir” from which the body can pull water as it is needed. By the time most foods reach the large intestine, about the only thing being absorbed at that point is water. If you avoid these kinds offoods, it will be far more difficult to remain hydrated. Finally, if you really want to jumpstart the process, then start adding meat broth to your diet. I’ve mentioned this in the past and also have provided recipes. The gelatin from animal bones and joints provides the GAGs, sulfurcompounds, and necessary minerals in a form that’s easily digested and used by the body. [Editor’s Note: You can find these recipes on Dr. Williams’ subscriber center at drdavidwilliams.com.]

Sleeping Pills Increase the Risk of FallsThis shouldn’t come as any surprise but apparently it required a study to verify it. Zolpidem, a sedative drug found in many prescription sleeping pills like Ambien, causes balance problems and unsteadiness which continues for several hours after waking. The result could be an increased risk of falling. Around 58% of the elderly and 27% of young users were found to experience a significant loss of balance while taking the drug. (J Am Geriatr Soc 11;59:73-81)Falling is one of the biggest fears (and causes for disability) among our older population. Sleeping aids like Ambien are being promoted aggressively on television and in print, but the public isn’t being told that they may be trading a night’s sleep for a broken hip or worse. Apparently this balance problem wasn’t seen in earlier studies…go figure. I’m not sure if this was the case with this particular drug, but most new drug studies are performed on younger groups even though the target market is the elderly. Drug companies obviously are aware that younger individuals generally tolerate medications betterwith fewer side effects. This “cherry picking” of the test group certainly speeds up the approval process. Only later, after widespread use in the elderly, do the many side effects begin to surface. A study out of the University of Michigan that evaluated 109 clinical trials found that only one in four studies included elderly participants and in those, rarely was there any evaluation on how the drug affected quality of life.

Than Guideline-Based Drug Management: Results of a Pilot, Randomized, Controlled Trial Journal of Pain and Symptom Management, 07/18/2011 Clinical Article Marineo G et al. – In this pilot randomized trial, Scrambler therapy appeared to relieve chronic neuropathic pain better than guideline–based drug management.Neuropathic pain is common, disabling, and often difficult to treat.Objectives To compare guideline-based drug management with Scrambler therapy, a patient-specific electrocutaneous nerve stimulation device.Methods A clinical trial with patients randomized to either guideline-based pharmacological treatment or Scrambler therapy for a cycle of 10 daily sessions was performed. Patients were matched by type of pain including postsurgical neuropathic pain, postherpetic neuralgia, or spinal canal stenosis. Primary outcome was change in visual analog scale (VAS) pain scores at one month; secondary outcomes included VAS pain scores at two and three months, pain medication use, and allodynia.Results Fifty-two patients were randomized. The mean VAS pain score before treatment was 8.1 points (control) and 8.0 points (Scrambler). At one month, the mean VAS score was reduced from 8.1 to 5.8 (−28%) in the control group, and from 8 to 0.7 points (−91%) in the Scrambler group (P < 0.0001). At two and three months, the mean pain scores in the control group were 5.7 and 5.9 points, respectively, and 1.4 and 2 points in the Scrambler group, respectively (P < 0.0001). More relapses were seen in polyradicular pain than monoradicular pain, but retreatment and maintenance therapy gave relief. No adverse effects were observed.Conclusion In this pilot randomized trial, Scrambler therapy appeared to relieve chronic neuropathic pain better than guideline-based drug management.

Marineo G et al. Than Guideline-Based Drug Management: Results of a Pilot, Randomized, Controlled Trial. Journal of Pain and Symptom Management. Jul 2011. (Entered July 2011)Category: Misc Bib- Pharmacology

Current Analysis of Women Athletes with Pelvic Pain Medicine and Science in Sports and Exercise, 07/18/2011 Meyers WC et al. – In this series of patients, most pelvic pain in women athletes was identifiable and treatable. Most had benign musculoskeletal causes, and surgery played an important role in treatment of those causes. Still, the authors found a large number of other causes that required longer specialized care. Health care professionals seeing such patients need to be alert to the new concepts of pelvic injury and the various roles for surgery and the broad list of other considerations.Methods

One hundred fourteen females, 14% of the total male/female cohort, were referred for treatment of suspected musculoskeletal injury.

Results On the basis of history and physical and radiological examinations, 74 (64.9% of females) turned

out to have injuries of the hip (group A) and/or soft tissues surrounding the hip (group B), and 40 (35.1%) had other sometimes more threatening diagnoses.

In groups A and B, 40 (90.1%) of 44 patients who chose surgery achieved previous performance levels within 1 yr compared with only 4 (13.8%) of 29 who did not have surgery.

Factors such as sport type, competitive status, and age did not affect the outcomes. Most diagnoses in group C, e.g., inflammatory bowel disease, reflex sympathetic dystrophy, and

malignancy, usually eclipsed the potential musculoskeletal diagnoses in terms of long–term importa

Background and Methods: Accurate diagnosis and effective management of pelvic pain in women have become more challenging now that the number of women athletes and the number of diagnostic possibilities are increasing. We conducted a prospective study of women athletes with pelvic pain seen during a 2-yr period within a large well-defined clinical practice to clarify some of the current causes and treatment possibilities.Results: One hundred fourteen females, 14% of the total male/female cohort, were referred for treatment of suspected musculoskeletal injury. On the basis of history and physical and radiological examinations, 74 (64.9% of females) turned out to have injuries of the hip (group A) and/or soft tissues surrounding the hip (group B), and 40 (35.1%) had other sometimes more threatening diagnoses. In groups A and B, 40 (90.1%) of 44 patients who chose surgery achieved previous performance levels within 1 yr compared with only 4 (13.8%) of 29 who did not have surgery. Factors such as sport type, competitive status, and age did not affect the outcomes. Most diagnoses in group C, e.g., inflammatory bowel disease, reflex sympathetic dystrophy, and malignancy, usually eclipsed the potential musculoskeletal diagnoses in terms of long-term importance.Conclusions: In this series of patients, most pelvic pain in women athletes was identifiable and treatable. Most had benign musculoskeletal causes, and surgery played an important role in treatment of those causes. Still, we found a large number of other causes that required longer specialized care. Health care professionals seeing such patients need to be alert to the new concepts of pelvic injury and the various roles for surgery and the broad list of other considerations.

Meyers WC et al. Current Analysis of Women Athletes with Pelvic Pain. Medicine and Science in Sports and Exercise. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Pelvic Pain

Patellofemoral Pain Syndrome and Its Association with Hip, Ankle, and Foot Function in 16- to 18-Year-Old High School Students Journal of the American Podiatric Medical Association, 07/22/2011 Mølgaard C et al.Background: An increased pronated foot posture is believed to contribute to patellofemoral pain syndrome (PFPS), but the relationship between these phenomena is still controversial. The objectives of this study were to investigate the prevalence of PFPS in high school students and to compare passive internal and external hip rotation, passive dorsiflexion, and navicular drop and drift between healthy high school students and students with PFPS. Methods: All 16- to 18-year-old students in a Danish high school were invited to join this single-blind case-control study (N = 299). All of the students received a questionnaire regarding knee pain. The main outcome measurements were prevalence of PFPS, navicular drop and drift, passive ankle dorsiflexion, passive hip rotation in the prone position, and activity level. The case group consisted of all students with PFPS. From the same population, a randomly chosen control group was formed. Results: The prevalence of knee pain was 25%. Of the 24 students with knee pain, 13 were diagnosed as having PFPS. This corresponds to a PFPS prevalence of 6%. Mean navicular drop and drift were higher in the PFPS group versus the control group (navicular drop: 4.2 mm [95% confidence interval (CI), 3.2–5.3 mm] versus 2.9 mm [95% CI, 2.5–3.3 mm]; and navicular drift: 2.6 mm [95% CI, 1.6–3.7 mm] versus 1.4 mm [95% CI, 0.9–2.0 mm]). Higher passive ankle dorsiflexion was also identified in the PFPS group (22.2° [95% CI, 18°–26°] versus 17.7° [95% CI, 15°–20°]). Conclusions: This study demonstrated greater navicular drop, navicular drift, and dorsiflexion in high school students with PFPS compared with healthy students and highlights that foot posture is important to consider as a factor where patients with PFPS diverge from healthy individuals. (J Am Podiatr Med Assoc 101(3): 215–222, 2011)

Molgaard C et al. Patellofemoral Pain Syndrome and Its Association with Hip, Ankle, and Foot Function in 16- to 18-Year-Old High School Students. Journal of the American Podiatric Medical Association. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Patellofemoral Pain

Is there a relationship between pain intensity and postural sway in patients with non-specific low back pain BMC Musculoskeletal Disorders, 07/21/2011 Ruhe A et al. – COP mean velocity and sway area are closely related to self–reported pain scores. This relationship may be of clinical use as an objective monitoring tool for patients under treatment or rehabilitation.Methods

Seventy-seven patients with non-specific low back pain and a matching number of healthy controls were enrolled.

Center of pressure parameters were measured by three static bipedal standing tasks of 90sec duration with eyes closed in narrow stance on a firm surface.

The perceived pain intensity was assessed by a numeric rating scale (NRS-11), an equal number of patients (n=11) was enrolled per pain score.

Results Generally, these results confirmed increased postural instability in pain sufferers compared to

healthy controls. In addition, regression analysis revealed a significant and linear increase in postural sway

with higher pain ratings for all included COP parameters. Statistically significant changes in mean sway velocity in antero-posterior and medio lateral

direction and sway area were reached with an incremental change in NRS scores of two to three points.

Results Generally, our results confirmed increased postural instability in pain sufferers compared to

healthy controls. In addition, regression analysis revealed a significant and linear increase in postural sway with higher pain ratings for all included COP parameters. Statistically significant changes in mean sway velocity in antero-posterior and medio lateral direction and sway area were reached with an incremental change in NRS scores of two to three points.

Conclusions COP mean velocity and sway area are closely related to self-reported pain scores. This

relationship may be of clinical use as an objective monitoring tool for patients under treatment or rehabilitation.

Ruhe A et al. Is there a relationship between pain intensity and postural sway in patients with non-specific low back pain. BMC Musculoskeletal Disorders. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Posture

Evaluation of the McKenzie Intervention for Chronic Low Back Pain by Using Selected Physical and Bio-Behavioral Outcome Measures PM&R, 07/21/2011 Al–Obaidi SM et al. – McKenzie intervention reduced pain and related fear and disability beliefs and improved physical performances in individuals with chronic low back pain. Improvements in physical performances remained stable 10 weeks after treatment, regardless of the elevation in bio–behavioral factors.Methods

A prospective cohort study with assessment at baseline and 2 follow–ups after completion of the McKenzie intervention.

Outpatient orthopedic physical therapy clinics. 62 volunteers with chronic low back pain (28 men, 34 women; average ages 41.9 and 37.1 years,

respectively). The subjects completed pain and related fear and disability questionnaires, underwent McKenzie

mechanical assessment, and executed selected physical performances. They then received the McKenzie intervention. Outcomes measurements were repeated at the end of the 5th and 10th weeks after treatment

completion. Pain–related disability and fear beliefs were assessed by using the Disability Belief Questionnaire

and Fear Avoidance Belief Questionnaires, respectively. The time for repeated sit to stand, trunk forward bending, and customary and fast walking were

measured by stopwatch. Pain (anticipated versus actual reported) was measured before and immediately after a given

physical performance. Descriptive statistics, paired t–tests, and repeated measures analysis of variance were used.

Results Significant improvements peaked at the end of the 5th week for all outcome measures (P < .001),

with slight increase in bio–behavioral variables at the end of the 10th week. Conclusions

McKenzie intervention reduced pain and related fear and disability beliefs and improved physical performances in individuals with chronic low back pain. Improvements in physical performances remained stable 10 weeks after treatment, regardless of the elevation in bio-behavioral factors.

Al-Obaidi SM et al. Evaluation of the McKenzie Intervention for Chronic Low Back Pain by Using Selected Physical and Bio-Behavioral Outcome Measures. PM&R. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- McKenzie

Individuals with chronic low back pain have greater difficulty in engaging in positive lifestyle behaviours than those without back pain: An assessment of health literacy BMC Musculoskeletal Disorders, 07/21/2011Background Despite the large volume of research dedicated to understanding chronic low back pain (CLBP), patient outcomes remain modest while healthcare costs continue to rise, creating a major public health burden. Health literacy - the ability to seek, understand and utilise health information - has been identified as an important factor in the course of other chronic conditions and may be important in the aetiology of CLBP. Many of the currently available health literacy measurement tools are limited since they measure narrow aspects of health literacy. The Health Literacy Measurement Scale (HeLMS) was developed recently to measure broader elements of health literacy. The aim of this study was to measure broad elements of health literacy among individuals with CLBP and without LBP using the HeLMS.Methods Thirty-six community-dwelling adults with CLBP and 44 with no history of LBP responded to the HeLMS. Individuals were recruited as part of a larger community-based spinal health study in Western Australia. Scores for the eight domains of the HeLMS as well as individual item responses were compared between the groups.Results HeLMS scores were similar between individuals with and without CLBP for seven of the eight health literacy domains (p>0.05). However, compared to individuals with no history of LBP, those with CLBP had a significantly lower score in the domain 'Patient attitudes towards their health' (mean difference [95% CI]: 0.46 [0.11-0.82]) and significantly lower scores for each of the individual items within this domain (p<0.05). Moderate effect sizes ranged from d=0.47-0.65.Conclusions Although no differences were identified in HeLMS scores between the groups for seven of the health literacy domains, adults with CLBP reported greater difficulty in engaging in general positive health behaviours. This aspect of health literacy suggests that self-management support initiatives may benefit individuals with CLBP.

Individuals with chronic low back pain have greater difficulty in engaging in positive lifestyle behaviours than those without back pain: An assessment of health literacy. BMC Musculoskeletal Disorders. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- LBP and Emotional Attachments

Not Plantar Fasciitis: the differential diagnosis and management of heel pain syndrome Orthopaedics and Trauma, 07/20/2011 Hossain M et al. – Histological specimens show evidence of degeneration in the plantar aponeurosis but not inflammation. Seronegative arthritis should be excluded in cases of bilateral Plantar heel pain (PHP). A number of different treatment options have been tried but very few have been rigorously investigated. Indeed, the overwhelming majority of cases will improve on conservative treatment. Shock wave therapy and surgery may be of use in selected subsets of patients who do not respond to other modes of conservative treatment.Plantar heel pain (PHP) is a common orthopaedic presentation, but our understanding of this symptom is still limited. Multiple risk factors have been proposed but few substantiated. Obesity and foot pronation are known risk factors, whilst running or standing for long periods probably also contribute. There, however, is no relationship between heel spurs and PHP. As well as plantar fasciopathy, a number of different conditions can also give rise to PHP. It may be helpful to consider the differential diagnoses in terms of the structures that are symptomatic: the plantar aponeurosis, other soft tissues, the calcaneum and the peripheral nerves. The pathophysiology of PHP is still unclear but could be multi-factorial. Histological specimens show evidence of degeneration in the plantar aponeurosis but not inflammation. Seronegative arthritis should be excluded in cases of bilateral PHP. A number of different treatment options have been tried but very few have been rigorously investigated. Indeed, the overwhelming majority of cases will improve on conservative treatment. Shock wave therapy and surgery may be of use in selected subsets of patients who do not respond to other modes of conservative treatment.

Hossain M et al. Not Plantar Fasciitis: the differential diagnosis and management of heel pain syndrome. Orthopaedics and Trauma. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Plantar Heel Pain

The relationship between patient satisfaction with physical therapy care and global rating of change reported by patients receiving worker's compensation.Beattie PF, Nelson RM, Heintzelman M20110527(4):310-8Language: engCountry: EnglandClinical Associate Professor, Program in Physical Therapy, Department of Exercise Science, Arnold School of Public Health and the Department of Developmental Biology and Anatomy, School of Medicine, University of South Carolina, Columbia, South Carolina, USA.This study examined relationships between patient satisfaction with physical therapy care and global rating of change; 1,944 respondents completed the Medrisk Instrument for Measuring Patient Satisfaction with Physical Therapy Care (MR-12) and a nine-point Global Rating of Change Scale (GROC) following a course of physical therapy for a work-related musculoskeletal problem. Ninety percent of all respondents reported being satisfied or very satisfied with their overall care, whereas 70.1% of all respondents indicated they improved following treatment. Respondents who reported improvement had significantly higher scores for all measures of satisfaction (p<0.01) than did those who reported failure to improve; however, both of these groups had mean scores of greater than 4.0 on the MR-12, indicating that respondents were likely to be satisfied or very satisfied with care regardless of perceived change following treatment. Scores>4.0 from the MR-12 had high sensitivity to detect those respondents classified as "improved" (0.87-0.95), but low specificity to differentiate between those who were classified as "improved" and those who were classified as "did not improve" (0.22-0.30). Our findings support the hypothesis that patient satisfaction with care is primarily independent of perceived clinical change.

Beattie PF, Nelson RM, Heintzelman M. The relationship between patient satisfaction with physical therapy care and global rating of change reported by patients receiving worker's compensation. May 2011;27(4):310-318. (Entered July 2011)Category: Misc Bib- Physical Therapy Issues

The Neuropathic Components of Chronic Low Back Pain: A Prospective Multicenter Study Using the DN4 Questionnaire The Journal of Pain, 07/26/2011 Attal N et al. – The observation that neuropathic and nociceptive components of low back pain (LBP) vary in the back and lower limb probably accounts for the discrepancies of reported prevalence rates of NP in LBP. As this study was essentially based on a questionnaire, future studies combining standard clinical sensory testing, specific questionnaires, and more objective assessment of the sensory lesion are now required to further investigate the neuropathic component of chronic LBP.Abstract The present study investigated the neuropathic components of chronic low back pain (LBP) in patients with and without lower limb pain using the DN4 questionnaire and confirmed its psychometric properties. Patients (n = 132) from 11 French multidisciplinary pain or rheumatology centers were classified by a first investigator into 4 groups derived from the Quebec Task Force Classification of Spinal Disorders (QTFSD): group 1 (pain restricted to the lumbar area); group 2 (pain radiating proximally); group 3 (pain radiating below the knee without neurologic signs); and group 4 (pain radiating towards the foot in a dermatomal distribution, with neurological signs, corresponding to typical radiculopathy). A second investigator applied the DN4 questionnaire to the lower limb (groups 2 to 4) and lower back. A comparison of groups 1 and 4 confirmed the psychometric properties of DN4 (sensitivity 80%; specificity 92%, for a cutoff of 4/10, similar to other neuropathic conditions). In the lower limb, the proportion of patients with neuropathic pain (NP) was related to the distality of pain radiation (15, 39, and 80% in groups 2, 3 and 4, respectively; P < .0001). In the lower back, the proportion of patients with NP was higher for patients with typical radicular pain compared with the other groups (P = .006). Thus, typical radiculopathy has similar characteristics as other neuropathic conditions and is confirmed as the commonest neuropathic syndrome in LBP patients. The observation that neuropathic and nociceptive components of LBP vary in the back and lower limb probably accounts for the discrepancies of reported prevalence rates of NP in LBP. As this study was essentially based on a questionnaire, future studies combining standard clinical sensory testing, specific questionnaires, and more objective assessment of the sensory lesion are now required to further investigate the neuropathic component of chronic LBP.Perspective This study confirms the psychometric properties of the DN4 questionnaire to assess neuropathic pain in patients with low back pain. Neuropathic mechanisms largely contribute to pain in the lower limb as compared to the back, but neuropathic pain is not restricted to typical radiculopathy. This may have significant implications for the choice of treatment strategy in these patients

Attal N et al. The Neuropathic Components of Chronic Low Back Pain: A Prospective Multicenter Study Using the DN4 Questionnaire. The Journal of Pain. Jul 2011. (Entered July 2011).Category: Lower Quarter Bib- Low Back Pain

Relating Pelvic Pain Location to Surgical Findings of Endometriosis Obstetrics and Gynecology, 07/26/2011 Hsu AL et al. – In this group of women with biopsy–proven endometriosis, few had deeply infiltrating lesions or endometriomas. Dysuria and midline anterior pain were the only symptoms associated with the location of superficial endometriosis lesions. The lack of relationship between pain and superficial lesion location raises questions about how these lesions relate to pain.Methods

A secondary analysis was performed to compare self–reported pain location with recorded laparoscopy findings for location and characteristics of all visible lesions.

All lesions were excised. Endometriosis was diagnosed using histopathology criteria. The pelvic area was divided into three anterior and two posterior regions. Lesion depth, number of lesions or endometriomas, and disease burden (defined as sum of lesion

sizes, or single compared with multiple lesions) were determined for each region. Data were analyzed using t tests, Fisher exact tests, and logistic regression modeling, with P

values corrected for multiple comparisons using the step–down Bonferroni method. Results

Women with endometriosis (n=96) had lower body mass indexes, were more likely to be white, had more previous surgeries, and had more frequent menstrual pain and incapacitation than did chronic pain patients without endometriosis (n=37).

Overall, few patients had deeply infiltrating lesions (n=38). Dysuria was associated with superficial bladder peritoneal lesions.

Other lesions or endometriomas were not associated with pain in the same anatomic locations. Lesion depth, disease burden, and number of lesions or endometriomas were not associated with

pain.

Hsu AL et al. Relating Pelvic Pain Location to Surgical Findings of Endometriosis. Obstetrics and Gynecology. Jul 2011. (Entered July 2011).Category: Lower Quarter Bib- Pelvic Pain

Tensegrity II. How structural networks influence cellular information processing networksDonald E. IngberDepartments of Surgery and Pathology, Children’s Hospital and Harvard Medical School, Enders 1007, 300 Longwood Avenue, Boston, MA02115, USAe-mail: donald.ingber@tch.harvard.eduJournal of Cell Science 116, 1397-1408 © 2003 The Company of Biologists LtdThe major challenge in biology today is biocomplexity: the need to explain how cell and tissue behaviors emerge from collective interactions within complex molecular networks. Part I of this two-part article, described a mechanical model of cell structure based on tensegrity architecture that explains how the mechanical behavior of the cell emerges from physical interactions among the different molecular filament systems that form the cytoskeleton. Recent work shows that the cytoskeleton also orients much of the cell’s metabolic and signal transduction machinery and that mechanical distortion of cells and the cytoskeleton through cell surface integrin receptors can profoundly affect cell behavior. In particular, gradual variations in this single physical control parameter (cell shape distortion) can switch cells between distinct gene programs (e.g. growth, differentiation and apoptosis), and this process can be viewed as a biological phase transition. Part II of this article covers how combined use of tensegrity and solid-state mechanochemistry by cells may mediate mechanotransduction and facilitate integration of chemical and physical signals that are responsible for control of cell behavior. In addition, it examines how cell structural networks affect gene and protein signaling networks to produce characteristic phenotypes and cell fate transitions during tissue development.

Ingber DE. Tensegrity II. How structural networks influence cellular information processing networks. Journal of Cell Science. 2003;116:1397-1408. (Entered July 2011)Category: Misc Bib- Connective Tissue

Tensegrity I. Cell structure and hierarchical systemsbiologyDonald E. IngberDepartments of Surgery and Pathology, Children’s Hospital and Harvard Medical School, Enders 1007, 300 Longwood Avenue, Boston,MA 02115, USA(e-mail: donald.ingber@tch.harvard.edu)Journal of Cell Science 116, 1157-1173 © 2003 The Company of Biologists Ltd doi:10.1242/jcs.00359In 1993, a Commentary in this journal described how a simple mechanical model of cell structure based on tensegrity architecture can help to explain how cell shape, movement and cytoskeletal mechanics are controlled, as well as how cells sense and respond to mechanical forces (J.Cell Sci. 104, 613-627). The cellular tensegrity model can now be revisited and placed in context of new advances in our understanding of cell structure, biological networks and mechanoregulation that have been made over thepast decade. Recent work provides strong evidence to support the use of tensegrity by cells, and mathematical formulations of the model predict many aspects of cell behavior. In addition, development of the tensegrity theory and its translation into mathematical terms are beginning to allow us to define the relationship between mechanics and biochemistry at the molecular level and to attack the larger problem of biological complexity. Part I of this twopart article covers the evidence for cellular tensegrity at the molecular level and describes how this building system may provide a structural basis for the hierarchical organization of living systems – from molecule to organism. Part II, which focuses on how these structural networks influence information processing networks, appears in the next issue.

Ingber DE. Tensegrity I. Cell structure and hierarchical systems. Journal of Cell Science. 2003;116:1157-1173. (Entered July 2011)Category: Misc Bib- Connective Tissue

Tensegrity-Based Mechanosensing from Macro to MicroDonald E. IngberVascular Biology Program, Departments of Pathology and Surgery, Children’s Hospital and HarvardMedical School, Boston, MA, USA.Published in final edited form as:Prog Biophys Mol Biol. 2008 ; 97(2-3): 163–179. doi:10.1016/j.pbiomolbio.2008.02.005.AbstractThis article is a summary of a lecture on cellular mechanotransduction that was presented at asymposium on “Cardiac Mechano-Electric Feedback and Arrhythmias” that convened at Oxford,England in April 2007. Although critical mechanosensitive molecules and cellular components, suchas integrins, stretch-activated ion channels, and cytoskeletal filaments, have been shown to contributeto the response by which cells convert mechanical signals into a biochemical response, little is knownabout how they function in the structural context of living cells, tissues and organs to produceorchestrated changes in cell behavior in response to stress. Here, studies are reviewed that suggestour bodies use structural hierarchies (systems within systems) composed of interconnectedextracellular matrix and cytoskeletal networks that span from the macroscale to the nanoscale tofocus stresses on specific mechanotransducer molecules. A key feature of these networks is that theyare in a state of isometric tension (i.e., experience a tensile prestress), which ensures that variousmolecular-scale mechanochemical transduction mechanisms proceed simultaneously and produce aconcerted response. These features of living architecture are the same principles that governtensegrity (tensional integrity) architecture, and mathematical models based on tensegrity arebeginning to provide new and useful descriptions of living materials, including mammalian cells.This article reviews how the use of tensegrity at multiple size scales in our bodies guides mechanicalforce transfer from the macro to the micro, as well as how it facilitates conversion of mechanicalsignals into changes in ion flux, molecular binding kinetics, signal transduction, gene transcription, cell fate switching and developmental patterning.

Ingber DE. Tensegrity-Based Mechanosensing from Macro to Micro. Prog Biophys Mol Biol. 2008;97(2-3):163-179. (Entered July 2011)Category: Misc Bib- Connective Tissue

Architectural and functional features of human triceps surae muscles during contractionYASUO KAWAKAMI, YOSHIHO ICHINOSE, AND TETSUO FUKUNAGADepartment of Life Sciences (Sports Sciences), The University of Tokyo, Tokyo 153, JapanvJ Appl Physiol 85:398-404, 1998. Architectural and functional features of human triceps surae muscles during contraction. J. Appl. Physiol. 85(2): 398–404, 1998.— Architectural properties of the triceps surae muscles were determined in vivo for six men. The ankle was positioned at 15° dorsiflexion (215°) and 0, 15, and 30° plantar flexion, with the knee set at 0, 45, and 90°. At each position, longitudinal ultrasonic images of the medial (MG) and lateral (LG) gastrocnemius and soleus (Sol) muscles were obtained while the subject was relaxed (passive) and performed maximal isometric plantar flexion (active), from which fascicle lengths and angles with respect to the aponeuroses were determined. In the passive condition, fascicle lengths changed from 59, 65, and 43 mm (knee, 0°; ankle, 215°) to 32, 41, and 30 mm (knee, 90° ankle, 30°) for MG, LG, and Sol, respectively. Fascicle shortening by contraction was more pronounced at longer fascicle lengths. MG had greatest fascicle angles, ranging from 22 to 67°, and was in a very disadvantageous condition when the knee was flexed at 90°, irrespective of ankle positions. Different lengths and angles of fascicles, and their changes by contraction, might be related to differences in force-producing capabilities of the muscles and elastic characteristics of tendons and aponeuroses.

Kawakami Y, Ichinose Y, Fukunaga T. Architectural and functional features of human triceps surae muscles during contraction. J Appl Phsiol. 1998;85(2):398-404. (Entered July 2011)Category: Upper Quarter Bib- Shoulder

In vivo muscle fibre behaviour during counter-movement exercise in humans reveals a significant role for tendon elasticityY. Kawakami, T. Muraoka, S. Ito, H. Kanehisa and T. FukunagaDepartment of Life Science (Sports Science), University of Tokyo, Komaba, Tokyo 153-8902, JapanJournal of Physiology (2002), 540.2, pp. 635–646 DOI: 10.1113/jphysiol.2001.013459© The Physiological Society 2002Six men performed a single ankle plantar flexion exercise in the supine position with the maximaleffort with counter movement (CM, plantar flexion preceded by dorsiflexion) and without countermovement (NoCM, plantar flexion only) produced by a sliding table that controlled applied load tothe ankle (40% of the maximal voluntary force). The reaction force at the foot and ankle joint anglewere measured using a force plate and a goniometer, respectively. From real-time ultrasonography of the gastrocnemius medialis muscle during the movement, the fascicle length was determined.The estimated peak force, average power, and work at the Achilles’ tendon during the plantar flexion phase in CM were significantly greater than those in NoCM. In CM, in the dorsiflexion phase, fascicle length initially increased with little electromyographic activity, then remained constant while the whole muscle–tendon unit lengthened, before decreasing in the final plantar flexion phase. In NoCM, fascicle length decreased throughout the movement and the fascicle length at the onset of movement was longer than that of the corresponding phase in CM. It was concluded that during CM muscle fibres optimally work almost isometrically, by leaving the task of storing and releasing elastic energy for enhancing exercise performance to the tendon.

Kawakami Y, Muraoka T, Ito S, Kanehisa H, Fukunaga T. In vivo muscle fibre behaviour during counter-movement exercise in humans reveals a significant role for tendon elasticity. Journal of Physiology. 2002;540(2):635-646. (Entered July 2011)Category: Misc Bib- Connective Tissue

Fatigue responses of human triceps surae muscles during repetitive maximal isometric contractionsYASUO KAWAKAMI,1 KENJI AMEMIYA,2 HIROAKI KANEHISA,1SHIGEKI IKEGAWA,2 AND TETSUO FUKUNAGA11Department of Life Sciences, University of Tokyo, Komaba, Meguro, Tokyo 153-8902;and 2Laboratory for Exercise Physiology, Tokyo Metropolitan College, Akishima-shi, Tokyo 196, JapanKawakami, Yasuo, Kenji Amemiya, Hiroaki Kanehisa, Shigeki Ikegawa, and Tetsuo Fukunaga. J Appl Physiol 88:1969-1975, 2000.Fatigue responses of human triceps surae muscles during repetitive maximal isometric contractions. J Appl Physiol 88: 1969–1975, 2000.—Nine healthy men (22–45 yr) completed 100 repetitive maximal isometric contractions of the ankle plantar flexor muscles in two knee positions of full extension (K0) and flexion at 90° (K90), positions that varied the contribution of the gastrocnemii. Electromyographic activity wasrecorded from the medial and lateral gastrocnemii and soleus muscles by using surface electrodes. Plantar flexion torque in K0 was greater and decreased more rapidly than in K90. Theelectromyographic amplitude decreased over time, and there were no significant differences between muscles and knee joint positions. The level of voluntary effort, assessed by asupramaximal electrical stimulation during every 10th contraction, decreased from 96 to 70% (P , 0.05) with no difference between K0 and K90. It was suggested that a decrease in plantar flexion torque was attributable to both central and peripheral fatigue and that greater fatigability in K0 than in K90 would result from a greater contribution and hence more pronounced fatigue of the gastrocnemius muscle. Further support for this possibility was provided from changesin twitch torque. gastrocnemius and soleus muscles; plantar flexion; electrical stimulation; twitch interpolation; central and peripheral fatigue; fiber types

Kawakami Y, Ameniya K, Kaneshisa H, Ikegawa S, Fukunaga T. Fatigue responses of human triceps surae muscles during repetitive maximal isometric contractions. J Appl Physiol. 2000;88:1969-1975. (Entered July 2011)Category: Lower Quarter Bib: Shoulder

Intraoperativee Measurement of Length-force Relationship of Human Forearm Muscle MJ.C.. Smeulders \ M. Kreulen \ J.J. Hage \ P.AJ.B.M. Huijing 2>3, C.M.A.M.. Van der Horst111 Dept. of plastic, reconstructive and hand surgery, Academic Medical Center, Amsterdam22 Institute for Fundamental and Clinical Human Movement Sciences, VU, Amsterdam33IntegratedBiomedicalIntegratedBiomedical Engineering for Restoration of Human Function, TechnologischTechnologisch Instituut, Universiteit Twente, EnschedeAbstract The specific relationship between force and length is one of the most important characteristics of vertebrate muscle. The only accurate method to measure the length forcecharacteristics is to generate a set of isometric force-time plots at different muscle lengths.. In humans, such length-force characteristics mostly are based on indirect measurements that have their limitations. A method of direct, in-vivo measurement of length-forcee characteristics of the human flexor carpi ulnaris muscle using relativelysimplee equipment during transposition surgery is presented. The method is proven reproducible,, with an overall estimated error of 2.8 %.ClinicalClinical Orthopaedics & Related Research 2004; 418:237-

Smeulders MJC, Kreulen M, Hage JJ, Huijing BM, Van der Horst AM. Intraoperativee Measurement of Length-force Relationship of Human Forearm Muscle. Clinical Orthopaedics & Related Research. 2004;418:237. (Entered July 2011)Category: Upper Quarter Bib- Hand & Wrist

Overstretching of sarcomeres may not cause cerebral palsy muscle contractureM.J.C.. Smeulders \ M. Kreulen ', J.J. Hage ', P.A.J.B.M. Huijing w ,C.M.A.M.. Van der Horst1Dept.Dept. of plastic, reconstructive and hand surgery, Academic Medical Center, AmsterdamInstituteInstitute for Fundamental and Clinical Human Movement Sciences, VU, AmsterdamIntegratedIntegrated Biomedical Engineering for Restoration of Human Function, BiomedischTechnologischTechnologisch Instituut, Universiteit Twente, EnschedeAbstract Too answer the question whether the muscle contracture in patients with cerebral palsy is caused by overstretching of in-series sarcomeres we studied the active and passive length-force relationship of the flexor carpi ulnaris muscle (FCU) in relation to its operating length range in 14 such patients with a flexion deformity of the wrist. Length-force relationship was measured intraoperatively using electrical stimulation, a force transducer, and a data-acquisition system. Muscle length was measured in maximallyflexed and maximally extended position of the wrist. The spastic FCU was found to exert over 80% of its maximum active force at maximal extension of the wrist and this indicates abundant overlap of the sarcomeres. At maximal wrist extension, FCU passive force corresponded with only 0.7% to 18% of maximum active force. Both findings imply that the FCU sarcomeres are not overstretched when the wrist is extended. We conclude that the overstretching of in-series sarcomeress appears not to be the cause of contracture of the spastic FCU.Journal of Orthopaedic Research 2004; 22:1331

Smeulders MJC, Kreulen M, Hage JJ, Huijing PAJBM, Van der Horst CMAM. Overstretching of sarcomeres may not cause cerebral palsy muscle contracture. Journal of Orthopaedic Research.2004;22:1331. (Entered July 2011)Category: Misc Bib- Connective Tissue

Cerebral activation during unilateral clenching in patients with temporomandibular joint synovitis and biting pain: an functional magnetic resonance imaging study Chinese Medical Journal, 07/27/2011 Yan–ping Z et al. – The inferior frontal gyrus and precentral gyrus play essential roles during the unilateral clenching task. Activation of anterior cingulate cortex in the synovitis patients with biting pain was associated with higher levels of psychological distress.Methods

Fourteen TMD synovitis patients with unilateral biting pain and 14 controls were included in the study.

Contralateral biting pain was defined as right molar clenching causing left temporomandibular joint (TMJ) pain.

Ipsilateral biting pain was defined as right molar clenching causing right TMJ pain. Symptom Check List–90 (SCL–90) was administered to the patients and controls. Independent sample t–test was used to compare the SCL–90 subscales between the two

groups. Unilateral clenching tasks were performed by the patients and controls. Imaging data were analyzed using SPM99.

Results Patients were divided into contralateral TMD biting pain group (n=8) and ipsilateral TMD

biting pain group (n=6). The SCL–90 subscales were significantly different between the two groups for somatization,

depression, anxiety, phobic anxiety, and paranoid ideation. Group analysis of the controls demonstrated brain activations in the inferior frontal gyrus,

precentral gyrus, middle frontal gyrus, superior temporal gyrus, and insular. The areas of activation were different between right and left clenching task. In TMJ synovitis patients with contralateral or ipsilateral biting pain, the group analysis

showed activations in the inferior frontal gyrus, superior temporal gyrus, medium frontal gyrus, precentral gyrus, and anterior cingulate cortex.

Yan-ping Z et al. Cerebral activation during unilateral clenching in patients with temporomandibular joint synovitis and biting pain: an functional magnetic resonance imaging study. Chinese Medical Journal. Jul 2011. (Entered July 2011)Category: Upper Quarter Bib- TMJ

An eight-week yoga intervention is associated with improvements in pain, psychological functioning and mindfulness, and changes in cortisol levels in women with fibromyalgia Journal of Pain Research, 07/27/2011 Clinical Article Curtis K et al. – The results suggest that a yoga intervention may reduce pain and catastrophizing, increase acceptance and mindfulness, and alter total cortisol levels in women with Fibromyalgia (FM). The changes in mindfulness and cortisol levels may provide preliminary evidence for mechanisms of a yoga program for women with FM. Future studies should use an RCT design with a larger sample size.Methods

Participants (n = 22) were recruited from the community to participate in a 75 minute yoga class twice weekly for 8 weeks

Questionnaires concerning pain (intensity, unpleasantness, quality, sum of local areas of pain, catastrophizing, acceptance, disability), anxiety, depression, and mindfulness were administered pre–, mid– and post–intervention

Salivary cortisol samples were collected 3 times daily for each of 2 days, pre– and post–intervention

Results Repeated measures analysis of variance (ANOVA) revealed that mean ± standard deviation

(SD) scores improved significantly (p < 0.05) from pre– to post–intervention for continuous pain (pre: 5.18 ± 1.72; post: 4.44 ± 2.03), pain catastrophizing (pre: 25.33 ± 14.77; post: 20.40 ± 17.01), pain acceptance (pre: 60.47 ± 23.43; post: 65.50 ± 22.93), and mindfulness (pre: 120.21 ± 21.80; post: 130.63 ± 20.82).

Intention–to–treat analysis showed that median AUC for post–intervention cortisol (263.69) was significantly higher (p < 0.05) than median AUC for pre–intervention levels (189.46).

Mediation analysis revealed that mid–intervention mindfulness scores significantly (p < 0.05) mediated the relationship between pre– and post–intervention pain catastrophizing scores

Curtis K et al. An eight-week yoga intervention is associated with improvements in pain, psychological functioning and mindfulness, and changes in cortisol levels in women with fibromyalgia. Journal of Pain Research. Jul 2011. (Entered July 2011)Category: Misc Bib- Fibromyalgia

Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study Clinical Rehabilitation, 07/27/2011 Shih YF et al. – Immediately after wearing the foot orthosis, pain incidence reduced in the treatment group but not in the control group. The rearfoot medially–wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot.Objective: To examine the effects of foot orthosis intervention during a 60-minute running test in pronated-foot runners with overuse knee or foot pain during running. Design: A randomized, controlled design. Setting: Sports gym. Participants: Twenty-four runners with pronated foot who experienced pain over anterior knee or foot region during running were recruited and randomized into the treatment, or the control, group. Interventions: A soft insole with a semi-rigid rearfoot medial wedge was given to the treatment group, and a soft insole without corrective posting was applied to the control group. Outcome measures: The immediate and short-term effects of orthosis application on incidence of pain, pain intensity and onset time were evaluated using the 60-minutes treadmill test. Results: Immediately after wearing the foot orthosis, pain incidence reduced in the treatment group but not in the control group (P = 0.04). After two weeks, seven (58%) subjects in the treatment group and one (8%) in the control group were free of pain during the test (P = 0.01). The pain intensity score decreased significantly after orthosis application, from 35.5 to 17.2 (immediate effect, P = 0.014), then to 12.3 (short-term effect, P < 0.001). Conclusion: The rearfoot medially-wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot.

Shih YF et al. Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study. Clinical Rehabilitation. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Orthotics

From NOI newsletter - We would like clinicians and patients to be aware of these philosophies as part of our contribution to National Pain Week.1. Pain as an outputIf you pinch yourself hard enough, it hurts and it is so intuitive to think that pain kind of goes into your body and brain. Biologically this is not correct. First, if pain was entirely an input it should be easy to stop it by turning off inputs such as the pinch or a thought. This may work for some pains but it clearly doesn’t work for most people with chronic pain. One billion plus people in the world can’t be wrong! Of course it is nociception* which goes in – it is up to the brain to weigh everything up and decide whether the nociception is worth a pain experience. So many health professionals still don’t get the difference between pain and nociception. (You can tell they don’t when they say things like “pain signals into the brain” and “pain nerve endings”.) If pain is regarded as a brain output experienced in a body part, it simply makes you take on the biology of the brain, all that is in it and all that can influence it.2. Pain is just one of many brain outputsThis is a precious neuroscience base to our teaching. When we are in trouble, threatened, injured, curious or learning, there are numerous brain outputs which could be constructed to protect, defend and help us. These include the immune, sympathetic, motor and endocrine systems, but also pain, language, emotions, cognitions, respiration, inflammation and many more. It is good to have some of these turned on for a short time to help us learn and to protect and defend us, (eg being anxious can protect us, cortisol level changes can help healing, pain makes us change behaviour) but if there is non-resolution of the inputs that set off these outputs, then the outputs may become pathological in their own right. If a tiger starts following you around the suburbs, you will turn on defence systems (outputs) which will become pathological if ‘the tiger’ continues to follow for months and months. For example – pathological sympathetic, endocrine and immune responses, pathological muscle changes and ‘pathological’ thoughts and emotions. Early intervention is obviously the key. The tiger might simply be a lack of knowledge.Freedom of the output systemsIf a person has numerous outputs turned on it can become taxing for the body. That is, it takes an enormous amount of energy to run multiple systems. A typical patient with chronic pain may have unusual cortisol levels, muscle tightness, a labile sympathetic nervous system, an unbalanced immune system, and produce inflammatory immune compounds. There is not much energy left for the rest of life.A patient, with a bit of knowledge, may be able to identify the outputs systems turned on and then perhaps the issues (could be body structures, thoughts, contexts etc) which need resolution to turn the outputs off. Just knowledge about why we hurt can give so much freedom to the output systems.'Control' is a bit of a buzz word out there – pain control, motor control, control of your emotions and on it goes. But there are problems with the control doctrine. Brains don’t construct by control, they construct by freedom, creativity, curiosity, testing the edges of homeostatic behaviour. 'Pain freedom' and 'motor freedom' sits better with our teaching (acknowledging that sometimes you need control to get freedom), but ultimately it is freedom and choice, much of it subconscious, of construction which is critical for brain health.Our aim here is to give patient freedom of choice of the output systems, essentially by movement and education so that they have brains that can weigh the world when challenged and not automatically default to a pain, motor, endocrine, language or other habit.Promoting awareness of these issues is our contribution to National Pain Week. - David*NociceptionThere are some neurones in your tissues that respond to all manner of stimuli, if those stimuli are sufficient to be dangerous to the tissue. Activation of these special neurones sends a prioritised alarm signal to your spinal cord, which may be sent on towards your brain. Activity of this type in these nerves is called ‘nociception’, which literally means ‘danger reception’. We all have nociception happening nearly all of the time – only sometimes does it end in pain.Butler DS, Moseley GL. Explain Pain. Adelaide, Noigroup Publications. 2003:32. (Entered July 2011)Category: Misc Bib- Pain

Current evidence for effectiveness of interventions to treat rotator cuff tearsBionka

M.A. Huisstedeab, Bart W. Koesb, Lukas Gebremariamb, Ellen Keijsersb, Jan A.N. VerhaarcReceived 1 April 2010; received in revised form 9 October 2010; accepted 25 October 2010. published online 13 December 2010.Abstract In this systematic review we assessed effectiveness of non-surgical and (post)surgical interventions for symptomatic rotator cuff tears (RotCuffTear). The Cochrane Library, PubMed, Embase, Cinahl, and Pedro were searched for relevant systematic reviews and randomized controlled trials (RCTs). Two reviewers independently selected relevant studies, extracted data and assessed the methodological quality.Three Cochrane reviews (7 RCTs) and 14 RCTs were included (3 non-surgery, 10 surgery, 8 post-surgery).For small or medium RotCufftears, moderate evidence was found in favour of surgery versus physiotherapy in mid- and long-term. In surgery, tendon-to-bone fixation with one metal suture anchor loaded with double sutures (TB) was more effective (moderate evidence) than a side-to-side repair with permanent sutures (SS) in the mid- and long-term; limited evidence for effectiveness was found in favour of debridement versus anchor replacement and suture repair of the type II SLAP tear in the long-term. Further, no evidence was found in favour of any non-surgical, surgical or post-surgical intervention.In conclusion, although surgery seems to give better results compared to non-surgery and TB is more effective than SS in rotator cuff repair (RCR), it remains hard to draw firm evidence-based conclusions for effectiveness of non-surgical or (post)surgical interventions to treat RotCuffTears. More research is clearly needed.Keywords: Rotator cuff, Shoulder, Therapy, Surgery

Bionka MA et al. Current evidence for effectiveness of interventions to treat rotator cuff tears. Manual Therapy. Jun 2011:217-230. (Entered July 2011)Category: Upper Quarter Bib- Rotator Cuff

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Extrinsic feedback and management of low back pain: A critical review of the literature

Daniel Cury Ribeiroa, Gisela Solea, J. Haxby Abbottb, Stephan MilosavljevicaReceived 5 May 2010; received in revised form 22 November 2010; accepted 13 December 2010. published online 27 January 2011.Manual Therapy Volume 16, Issue 3, Pages 231-239 (June 2011Abstract Effective intervention for low back pain (LBP) can include feedback in one form or other. Although extrinsic feedback (EF) can be provided in a number of ways, most research has not considered how different EF characteristics (e.g. timing and content) influence treatment outcomes. A systematic search related to feedback and LBP was performed on relevant electronic databases. This narrative review aims to describe the forms of feedback provision in the literature regarding management of LBP, and to discuss these in light of previously recommended principles for the use of extrinsic feedback. The present review found support for the provision of EF that focuses on content characteristics including program feedback, summary results feedback, and external focus of attention. Temporal characteristics should enhance the use of intermittent or self-selected feedback. The literature does not support the provision of concurrent or constant EF. As much of the literature related to EF in the management of LBP has not considered content and timing characteristics we have identified future research directions that will clarify the use of content and timing characteristics of EF relative to the management of LBP.

Ribeiroa DC, Solea G, Abbottb JH, Milosavljevica S. Extrinsic feedback and management of low back pain: A critical review of the literature. Manual Therapy. Jun 2011;16(3):231-239. (Entered July 2011)Category: Lower Quarter Bib- Low Back Pain

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Validity and reliability of clinical tests for assessing hip passive stiffnessViviane

Otoni do Carmo Carvalhais, Vanessa Lara de Araújo, Thales Rezende Souza, Gabriela Gomes Pavan Gonçalves, Juliana de Melo Ocarino, Sérgio Teixeira FonsecaReceived 6 April 2010; received in revised form 19 October 2010; accepted 25 October 2010. published online 06 January 2011.Manual therapy Volume 16, Issue 3, Pages 240-245 (June 2011)Abstract Inadequate levels of hip passive joint stiffness have been associated with the occurrence of movement dysfunction, development of pathologies and reduction in performance. Clinical tests, designed to evaluate hip joint stiffness, may allow the identification of improper stiffness levels. The purpose of this study was to determine the concurrent validity as well as the intra- and inter-examiners reliabilities of clinical measures used to assess hip passive stiffness during internal rotation. Fifteen healthy participants were subjected to test-retest evaluations by two examiners. Two clinical measures were performed: ‘position of first detectable resistance’ and ‘change in passive resistance torque’. The results of these tests were compared to the passive stiffness measured with an isokinetic dynamometer (gold standard measure). A significant correlation was found between the stiffness measured with the isokinetic dynamometer and the clinical measures of ‘position of first detectable resistance’ (r = −0.85 to −0.86, p <0.001) and ‘change in passive resistance torque’ (r = 0.78 to 0.84, p ≤ 0.001). The Intraclass Correlation Coefficients for intra- and inter-examiners reliabilities varied from 0.95 to 0.99. Thus, the results demonstrated that the clinical measures have adequate validity and reliability for obtaining information on hip passive stiffness during internal rotation.

Carvalhais VODC et al. Validity and reliability of clinical tests for assessing hip passive stiffness. Manual Therapy. Jun 2011;16(3):240-245. (Entered July 2011)Category: Lower Quarter Bib- Hip Tests

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Neck/shoulder pain is more strongly related to depressed mood in adolescent girls than in boys

C.M. Pollock, R.L. Harries, A.J. Smith, L.M. Straker, G.E. Kendall, P.B. O’SullivanReceived 19 May 2010; received in revised form 19 October 2010; accepted 25 October 2010. published online 22 November 2010.Manual Therapy Volume 16, Issue 3, Pages 246-251 (June 2011)Abstract A cross-sectional study of 1258, 14 year old girls and boys used self-report and physical examination measures to assess neck/shoulder pain in the last month, depressed mood, physical fitness, body composition, self-efficacy, global self-worth, family functioning and social advantage. The data was used to compare the relationship between depressed mood and neck/shoulder pain (NSP) in adolescent girls and boys.The prevalence of NSP in girls (34%, 211/621) was significantly greater than in boys (21%, 134/637; p < .001). After controlling for covariates, girls with medium (OR = 4.28; CI = 2.31–7.92; p < .001) and high depressed mood (OR = 8.63; CI = 4.39–16.98; p < .001) were significantly more likely to report NSP than girls with low depressed mood. Depressed mood was also a significant correlate of NSP in boys after controlling for covariates, although the association was substantially weaker (OR = 2.44; CI = 1.29–4.61; p < .001).After controlling for relevant biological, psychological and social covariates, depressed mood was a significant correlate of NSP in both sexes; but the association between depressed mood and NSP was significantly stronger for girls than for boys.

Pollack CM, Harries RL, Smith AJ, Straker LM, Kendall GE, O’Sullivan PB. Neck/shoulder pain is more strongly related to depressed mood in adolescent girls than in boys. Manual Therapy. Jun 2011;16(3):246-251. (Entered July 2011)Category: Upper Quarter Bib- Shoulder

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The slow and fast components of postural sway in chronic neck painUlrik

Röijezon, Martin Björklund, Mats DjupsjöbackaManual therapy Volume 16, Issue 3, Pages 273-278 (June 2011)Received 3 June 2010; received in revised form 26 October 2010; accepted 20 November 2010. published online 27 December 2010.Abstract Background Several studies have reported altered postural control in people with neck pain. The aim of this study was to increase the understanding of the nature of altered postural control in neck pain by studying the slow and fast components of body sway.Methods Subjects with whiplash associated disorders (WAD, n = 21) and chronic non-specific neck pain (NS, n = 24) were compared to healthy controls (CON, n = 21) in this cross-sectional study. The magnitudes of the slow and fast sway components were assessed in Rhomberg quiet stance for 30 s on a force plate with eyes closed. We also investigated associations between postural sway and symptoms, self-ratings of functioning and kinesiophobia.Results Increased magnitude of the slow sway component was found in WAD, but not in NS. Greater magnitude of the slow component in WAD was associated with poorer physical functioning, including balance disturbances, and more severe sensory symptoms.Conclusions Increased magnitude of the slow sway component implies an aberration in sensory feedback or processing of sensory information in WAD. The associations between postural sway and self-rated characteristics support the clinical validity of the test. Further investigation into NS, involving a longer test time is warranted.Roijezon U, Bjorklund M, Djupsjabacka M. The slow and fast components of postural sway in chronic neck pain. Manual Therapy. Jun 2011;16(3):273-278. (Entered July 2011)Category: Upper Quarter Bib- Cervical Spine

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Magnetic resonance imaging assessment of regional abdominal muscle function in elite AFL players with and without low back pain

Julie Hides, Brita Hughes, Warren StantonReceived 29 April 2010; received in revised form 12 November 2010; accepted 19 November 2010. published online 27 December 2010.Manual therapy Volume 16, Issue 3, Pages 279-284 (June 2011)Abstract Changes in the motor control of trunk muscles have been identified in people with low back pain (LBP) including elite football players. Previous research has found functional differences in the anatomical regions of abdominal muscles; however, this has not been examined in football players with LBP. The aim of this study was to investigate if the ability to draw-in the abdominal wall is altered among football players with LBP, and to determine if there are functional differences between the middle and lower abdominal regions in participants with and without LBP. Forty-three elite Australian Football League players were imaged using magnetic resonance imaging (MRI) as they drew in their abdominal walls, and the trunk cross-sectional area (CSA) was measured in relaxed and contracted states. At the lower region, participants with LBP (1.1%) reduced their trunk CSA to a lesser extent than those without LBP (3.2%) (P = 0.018). The results also showed that the draw-in of the abdominal wall was smaller in Region 1 (8.8%) compared to Region 2 (16.0%) and Region 3 (19.7%) (P < 0.001). This study provides evidence of regional differences in motor control and altered control of the lower region in participants with LBP. This may direct physiotherapists, especially those treating athletes, to focus on the lower abdominal region in those with LBP

Hides J, Hughes B, Stanton W. Magnetic resonance imaging assessment of regional abdominal muscle function in elite AFL players with and without low back pain. Manual Therapy. Jun 2011;16(3):279-284. (Entered July 2011)Category: Lower Quarter Bib- Posture

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Spino-pelvic postural changes between the standing and sitting human position: Proposal of a method for its systematic analysisE. Berthonnaud, R. Hilmi, H. Labelle, J. DimnetComputerized Medical Imaging and Graphics , 07/28/2011Abstract This study presents numerical tools, based on biplanar radiography, allowing to analyze the 3D changes in position and length of the various spinal segments with respect to the pelvis which occur between the standing and sitting positions. Three asymptomatic adult subjects and twelve adult patients with low back pain or scoliosis had biplanar calibrated radiographs in the erect posture and sitting position. The 3D points of the spinal curve were then reconstructed from their plane projections using a standard photogrammetric technique. A technical data form has been formulated to present and summarize the complex 3D spino-pelvic changes occurring between both postures. The spine and pelvis are displayed as a chain of linear articulated segments, in their plane of maximum curvature, allowing users to compare both postures and to assess the global and local spinal mobility between the two fixed postures. Examples of asymptomatic volunteers and of subjects with low back pain or scoliosis demonstrate that different strategies can be adopted to perform this simple task and are presented to illustrate these new techniques and their clinical potential to discriminate between and within normal and pathological conditions.

Berthonnaud E, Hilmi R, Labelle H, Dimnet J. Spino-pelvic postural changes between the standing and sitting human position: Proposal of a method for it s systematic analysis. Computerized Medical Imaging and Graphics. Jul 2011. (Entered July 2011)Category: Lower Quarter Bib- Posture

Headaches resolve at similar rates with and without drugs  The Clinical Advisor, 07/28/2011An analysis of 119 randomized controlled clinical trials showed that more than a third of subjects who received placebo or no treatment recovered from their headaches, although the recovery rate varied between types of intervention and patientsAn analysis of 119 randomized controlled clinical trials showed that more than a third of subjects who received placebo or no treatment recovered from their headaches, although the recovery rate varied between types of intervention and patients.Pharmacologic treatment of headaches typically starts when lifestyle changes, relaxation therapy, cognitive therapy and other nondrug approaches fail. Many of the prescribed or OTC drugs can lead to adverse events and even medication-overuse headaches. "The prescription of medication needs to be carefully considered and evaluated with each individual patient," investigators noted in the Journal of Manipulative and Physiological Therapeutics. "The question rises whether or not this way of prescription is always preferable over no treatment (wait and see), especially in the [tension-type headache] population."The trials centered on tension-type headaches and migraines, and involved 7,119 participants. The mean recovery rate in all control groups was 35.7%. More control subjects recovered in pharmacological vs. nonpharmacologic (behavioral) trials (38.5% vs. 15.0%, respectively), but adults were more likely to recover in nonpharmacologic studies and children in pharmacologic studies. de Groot FM et al.   J Manipulative Physiol Ther . 2011;34:297-305

de Groot FM et al. Headaches resolve at similar rates with and without drugs. J Manipulative Physiol Ther. Jul 2011;34:297-305. (Entered July 2011)Category: Upper Quarter Bib- Headaches 

Effects of light deprivation on visual evoked potentials in migraine without aura  BMC Neurology, 07/28/2011Coppola G et al. – Light deprivation is thought to decrease both excitatory and subsequent inhibitory processes in visual cortex, which is in line with these findings in healthy volunteers. The visual evoked potentials(VEP) results in migraine patients suggest that early excitation was adequately suppressed, but not the inhibitory mechanisms occurring during long term stimulation and habituation. Accordingly, deficient intracortical inhibition is unlikely to be a primary factor in migraine pathophysiology and the habituation deficit.Methods

Effects of light deprivation(LD) on VEP in migraine patients without aura between attacks (MO, n=17) and in healthy volunteers (HV, n=17) were compared.

6 sequential blocks of 100 averaged VEP at 3.1 Hz were recorded before and after 1 hour of LD. VEP P100 amplitude of the 1st block of 100 sweeps and its change over 5 sequential blocks of

100 responses were measured.Results

In HV, the consequence of LD was a reduction of 1st block VEP amplitude and of the normal habituation pattern.

By contrast, in MO patients, the interictal habituation deficit was not significantly modified, although 1st block VEP amplitude, already lower than in HV before LD, further decreased after LD

Coppola G et al. Effects of light deprivation on visual evoked potentials in migraine without aura. BMC Neurology. Jul 2011. (Entered July 2011)Category: Upper Quarter Bib- Headaches

Lumbar spinal stenosis-diagnosis and management of the aging spineKaren

Maloney Backstrom, Julie M. Whitman, Timothy W. FlynnReceived 1 October 2010; received in revised form 3 January 2011; accepted 22 January 2011. published online 03 March 2011.Manual Therapy Pages 308-317 (August 2011)Abstract Low back pain and lumbar spinal stenosis (LSS) is an extensive problem in the elderly presenting with pain, disability, fall risk and depression. The incidence of LSS is projected to continue to grow as the population ages. In light of the risks, costs and lack of long-term results associated with surgery, and the positive outcomes in studies utilizing physical therapy interventions for the LSS patient, a non-invasive approach is recommended as a first line of intervention. This Masterclass presents an overview of LSS in terms of clinical examination, diagnosis, and intervention. A focused management approach to the patient with LSS is put forward that emphasizes a defined four-fold approach of patient education, manual physical therapy, mobility and strengthening exercises, and aerobic conditioning.

Maloney Bacstrom K, Whitman JM, Flynn TW. Lumbar spinal stenosis-diagnosis and management of the aging spine. Manual Therapy. Aug 2011:308-317. (Entered July 2011)Category: Lower Quarter Bib- Spinal Stenosis

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The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review

Roanna M. Burgess, Alison Rushton, Chris Wright, Cathryn DabornReceived 27 October 2010; received in revised form 4 January 2011; accepted 7 January 2011. published online 11 February 2011.Manual Therapy Volume 16, Issue 4, Pages 318-326 (August 2011)Abstract Acetabular labral tears are an area of increasing interest to clinicians involved in the diagnosis of musculoskeletal complaints of the hip. This review systematically evaluated the evidence for the diagnostic accuracy and validity of reported symptoms, physical examination and imaging in this complex population. Studies published in English prior to May 2010 were included. One reviewer searched information sources to identify relevant articles. Two reviewers independently assessed studies for inclusion, extracted data and evaluated quality using the Quality Assessment of Diagnostic Studies Tool.Twenty one studies were included. Meta-analysis was limited owing to heterogeneity between studies. Results showed Magnetic Resonance Arthrography to consistently outperform Magnetic Resonance Imaging. Computerised Tomography also showed high accuracy levels for the few studies identified. Studies investigating physical tests were of poor quality demonstrating a need for further research in this area. Symptoms likely to be present in patients presenting with acetabular labral tears were found to be anterior groin pain and mechanical hip symptoms; however, additional good quality studies are needed to consolidate findings.

Burgess RM, Rushton A, Wright C, Daborn C. The validity and accuracy of clinical diagnostic tests used to detect labral pathology of the hip: A systematic review. Manual Therapy. Aug 2011;16(4):318-326. (Entered July 2011)Category: Lower Quarter Bib- Acetabular Labral Tear

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Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain

Stephen Edmondston, Guðný Björnsdóttir, Thorvaldur Pálsson, Hege Solgård, Kasper Ussing, Garry AllisonReceived 3 September 2010; received in revised form 2 December 2010; accepted 14 December 2010. published online 21 January 2011.Manual Therapy Volume 16, Issue 4, Pages 332-338 (August 2011Abstract Sustained postural loading of the cervical spine during work or recreational tasks may contribute to the development of neck pain. The aim of this study was to compare neck muscle endurance and fatigue characteristics during sub-maximal isometric endurance tests in patients with postural neck pain, with asymptomatic subjects. Thirteen female patients with postural neck pain and 12 asymptomatic female control subjects completed timed sub-maximal muscle endurance tests for the neck flexor and extensor muscles. Muscle fatigue, defined as the time-dependent decrease in median frequency electromyography (EMG), was examined using surface EMG analysis during the tests. The median extensor test holding time was lower but not significantly different in the neck pain group (165 s) that the control group (228 s) (p = 0.17). There was no difference between groups in the flexor test holding time (neck pain = 36 s, controls = 38 s) (p = 0.96). The neck pain group was characterised by greater variability in neck flexor (p = 0.03) and extensor (p = 0.006) muscle endurance. For both tests, the rate of decrease in median frequency EMG was highly variable within and between groups with no significant difference between groups for the flexor or extensor test (p = 0.05–0.82). Patients with postural neck pain did not have significant impairment of neck muscle endurance or accelerated fatigue compared to control subjects. However, the greater variability in these indices of muscle function may reflect patient-specific changes in muscle function associated with neck pain disorder.

Edmondston S et al. Endurance and fatigue characteristics of the neck flexor and extensor muscles during isometric tests in patients with postural neck pain. Manual Therapy. Aug 2011;16(4):332-338. (Entered July 2011)Category: Upper Quarter Bib- Cervical BET

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The effect of neck torsion on postural stability in subjects with persistent whiplash

Li-Ju Yu, Raina Stokell, Julia TreleavenReceived 15 September 2010; received in revised form 22 November 2010; accepted 13 December 2010. published online 21 January 2011.Manual Therapy Volume 16, Issue 4, Pages 339-343 (August 2011Abstract Dysfunction of cervical receptors in neck disorders has been shown to lead to disturbances in postural stability. The neck torsion manoeuvre used in the smooth pursuit neck torsion (SPNT) test is thought to be a specific measure of neck afferent dysfunction on eye movement in those with neck pain. This study aimed to determine whether neck torsion could change balance responses in those with persistent whiplash-associated disorders (WADs). Twenty subjects with persistent WAD and 20 healthy controls aged between 18 and 50 years stood on a computerised force plate with eyes closed in comfortable stance under 5 conditions: neutral head, head turned to left and right and neck torsion to left and right. Root mean square (rms) amplitude of sway was measured in the anterior–posterior (AP) and medial–lateral (ML) directions. The whiplash group had significantly greater rms amplitude in the AP direction following neck torsion compared to the control group (p < 0.03). The results show that the neck torsion manoeuvre may lead to greater postural deficits in individuals with persistent WAD and provides further evidence of neck torsion to identify abnormal cervical afferent input, as an underlying cause of balance disturbances in WAD. Further research is warranted.

Yu LJ, Stokell R, Treleaven. The effect of neck torsion on postural stability in subjects with persistent whiplash. Manual Therapy. Aug 2011;16(4):339-343. (Entered July 2011)Category: Upper Quarter Bib- Whiplash Associated Disorders

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Risk factors and clinical features of craniocervical arterial dissectionLucy C.

Thomas, Darren A. Rivett , John R. Attia , Mark Parsons , Christopher Levi Received 18 May 2010; received in revised form 6 December 2010; accepted 15 December 2010. published online 21 January 2011.Manual Therapy Volume 16, Issue 4, Pages 351-356 (August 2011)Abstract Craniocervical arterial dissection is one of the most common causes of ischaemic stroke in young people and is occasionally associated with neck manipulation. Identification of individuals at risk will guide risk management. Early recognition of dissection in progress will expedite medical intervention. Study aims were to identify risk factors and presenting features of craniocervical arterial dissection. Medical records of patients from the Hunter region of New South Wales, Australia aged ≤55 years with radiographically confirmed or suspected vertebral or internal carotid artery dissection, were retrospectively compared with matched controls with stroke from some other cause. Records were inspected for details of clinical features, presenting signs and symptoms and preceding events. Records of 47 dissection patients (27 males, mean age 37.6 years) and 43 controls (22 males, mean age 42.6 years) were inspected. Thirty (64%) dissection patients but only three (7%) controls reported an episode of mild mechanical trauma, including manual therapy, to the cervical spine within the preceding three weeks. Mild mechanical trauma to the head and neck was significantly associated with craniocervical arterial dissection (OR 23.53). Cardiovascular risk factors for stroke were less evident in the dissection group (<1 factor per case) compared to the controls (>3).

Thomas LC, Rivett DA, Attia JR, Parsons M, Levi C. Risk factors and clinical features of craniocervical arterial dissection. Manual Therapy. Aug 2011; 16(4):351-356. (Entered July 2011)Category: Upper Quarter Bib- Vertebral Artery

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Hypoalgesic effect of a passive accessory mobilisation technique in patients with lateral ankle pain

Hwee Koon Yeo, Anthony WrightReceived 24 September 2010; received in revised form 17 December 2010; accepted 7 January 2011. published online 02 February 2011.Manual therapy Volume 16, Issue 4, Pages 373-377 (August 2011)Abstract A randomised, double blind, repeated measures study was conducted to investigate the initial effects of an accessory mobilisation technique applied to the ankle joint in 13 patients with a unilateral sub-acute ankle supination injury. Ankle dorsiflexion range of motion, pressure pain threshold, visual analogue scale rating of pain during functional activity and ankle functional scores were assessed before and after application of treatment, manual contact control and no contact control conditions. There were significant improvements in ankle dorsiflexion range of motion (p = 0.000) and pressure pain threshold (p = 0.000) during the treatment condition. However no significant effects were observed for the other measures. These findings demonstrate that mobilisation of the ankle joint can produce an initial hypoalgesic effect and an improvement in ankle dorsiflexion range of motion.

Yeo HK, Wright A. Hypoalgesic effect of a passive accessory mobilisation technique in patients with lateral ankle pain. Manual Therapy. Aug 2011;16(4):373-377. (Entered July 2011)Category: Lower Quarter Bib- Ankle Sprains

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Does cervical kyphosis relate to symptoms following whiplash injury?Mats

Peter Johansson, Martin Skogheim Baann Liane, Tom Bendix, Helge Kasch, Alice KongstedReceived 23 June 2010; received in revised form 4 January 2011; accepted 7 January 2011. published online 04 February 2011.Manual Therapy Volume 16, Issue 4, Pages 378-383 (August 2011Abstract The mechanisms for developing long-lasting neck pain after whiplash injuries are still largely unrevealed. In the present study it was investigated whether a kyphotic deformity of the cervical spine, as opposed to a straight or a lordotic spine, was associated with the symptoms at baseline, and with the prognosis one year following a whiplash injury. MRI was performed in 171 subjects about 10 d after the accident, and 104 participated in the pain recording at 1-year follow-up. It was demonstrated that postures as seen on MRI can be reliably categorized and that a straight spine is the most frequent appearance of the cervical spine in supine MRI. In relation to symptoms it was seen that a kyphotic deformity was associated with reporting the highest intensities of headache at baseline, but not with an increased risk of long-lasting neck pain or headache. In conclusion, a kyphotic deformity is not significantly associated with chronic whiplash associated pain. Moreover, it is a clear clinical implication that pain should not be ascribed to a straight spine on MRI. We suggest that future trials on cervical posture focus upon the presence of kyphotic deformity rather than just on the absence of lordosis.

Johansson MP, Laine MSB, Bendix T, Kasch H, Kongsted A. Does cervical kyphosis relate to symptoms following whiplash injury? Manual Therapy. Aug 2011;16(4):378-383. (Entered July 2011)Category: Upper Quarter Bib- Cervical Whiplash

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Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain

Omid Rasouli, Amir Massoud Arab, Mohsen Amiri, Shapour JaberzadehReceived 26 July 2010; received in revised form 11 January 2011; accepted 24 January 2011. published online 17 February 2011.Manual Therapy Volume 16, Issue 4, Pages 388-393 (August 2011)Abstract The purpose of this study was to investigate the changes in the thickness of the transversus abdominis (TrA) and internal oblique (IO) muscles in three sitting postures with different levels of stability. The technique of ultrasound imaging was used for individuals with and without chronic low back pain (LBP). A sample of 40 people participated in this study. Subjects were categorised into two groups: with LBP (N= 20) and without LBP (N = 20). Changes in the thickness of tested muscles were normalized under three different sitting postures to actual muscle thickness at rest in the supine lying position and were expressed as a percentage of thickness change. The percentage of thickness change in TrA and IO increased as the stability of the sitting position decreased in both groups. However, the percentages of thickness change in all positions were less in subjects with LBP. There was a significant difference in thickness change in TrA when sitting on a gym ball between subjects with and without LBP but no difference was found when sitting on a chair. There was no significant difference in thickness change in IO in all positions between the two groups.

Rasouli O, Arab AM, Amiri M, Jaberzadeh S. Ultrasound measurement of deep abdominal muscle activity in sitting positions with different stability levels in subjects with and without chronic low back pain. Manual Therapy. Aug 2011;16(4):388-393. (Entered July 2011)Category: Lower Quarter Bib- Posture

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Dynamic and functional balance tasks in subjects with persistent whiplash: A pilot trial

Raina Stokell, Annie Yu, Katrina Williams, Julia TreleavenReceived 2 August 2010; received in revised form 24 January 2011; accepted 31 January 2011. published online 02 March 2011.Manual Therapy Volume 16, Issue 4, Pages 394-398 (August 2011)Abstract Disturbances in static balance have been demonstrated in subjects with persistent whiplash. Some also report loss of balance and falls. These disturbances may contribute to difficulties in dynamic tasks. The aim of this study was to determine whether subjects with whiplash had deficits in dynamic and functional balance tasks when compared to a healthy control group.Twenty subjects with persistent pain following a whiplash injury and twenty healthy controls were assessed in single leg stance with eyes open and closed, the step test, Fukuda stepping test, tandem walk on a firm and soft surface, Singleton test with eyes open and closed, a stair walking test and the timed 10 m walk with and without head movement.Subjects with whiplash demonstrated significant deficits (p < 0.01) in single leg stance with eyes closed, the step test, tandem walk on a firm and soft surface, stair walking and the timed 10 m walk with and without head movement when compared to the control subjects.Specific assessment and rehabilitation directed towards improving these deficits may need to be considered in the management of patients with persistent whiplash if these results are confirmed in a larger cohort.

Stokell R, Yu A, Williams K, Treleaven J. Dynamic and functional balance tasks in subjects with persistent whiplash: A pilot trial. Manual Therapy. Aug 2011;16(4)394-398. (Entered July 2011)Category: Upper Quarter Bib- Whiplash Associated Disorders

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The Effects of Age, Sex, Ethnicity, and Spinal Level on the Rate of Intervertebral Disc Degeneration: A Review of 1712 Intervertebral Discs Spine; 01 August 2011 - Volume 36 - Issue 17 - p 1333–1339Age, sex, race, and lumbar level are among some of the factors that play a role in IVD degeneration. The rate at which IVDs degenerate is unknown. Methods: Complete lumbar spine segments (T11/T12 to S1) were received within 24 hours of death. The nucleus pulposus, anulus fibrosus, cartilaginous and bony endplate, and the peripheral vertebral body were assessed with magnetic resonance imaging and IVD degeneration was graded by two observers from grade 1 (nondegenerated) to grade 5 (severely degenerated) on the basis of a scale developed by Tanaka et al. The specimens were then sectioned and gross anatomic evaluation was per-formed according to Thompson et al. Results: A total of 433 donors and 1712 IVDs were analyzed. There were 366 whites, 47 Africans, 16 Hispanics, 4 Asian. There were 306 male and 127 female donors. The age range was 14 to 81 years, (average: 60.5 ± 11.3). For donors greater than age 40, the L5/S1 IVD degenerated at a significantly faster rate of 0.043 per year compared to 0.031, 0.034, 0.033, 0.027 for L1/L2, L2/L3, L3/L4, L4/L5, respectively. For donors younger than 40, L5/S1 IVD degenerated at a significantly faster rate of 0.141/y compared to 0.033, 0.021, 0.031, 0.050 for L1/L2, L2/L3, L3/L4, L4/L5, respectively. Multiple regression analysis revealed that sex had no significant effect on IVD degeneration whereas African ethnicity was associated with lower Thompson score at L1/L2, L2/L3, L3/L4, L4/L5 when compared with whites. Conclusion: The relatively early degeneration at L5–S1 in all races and lower Thompson grade in donors of African ethnicity needs further investigation. Factors such as sagittal alignment, facet joint arthritis, and genetics potentially play a role in IVD degeneration.

The Effects of Age, Sex, Ethnicity, and Spinal Level on the Rate of Intervertebral Disc Degeneration: A Review of 1712 Intervertebral Discs. Spine. Aug 2011;36(17):1333-1339. (Entered July 2011)Category: Lower Quarter Bib- Disc

Legal Sequelae of Occupational Back Injuries: A Longitudinal Analysis of Missouri Judicial Records Spine; 01 August 2011 - Volume 36 - Issue 17 - p 1402–1409Retrospective studies suggest that workers with occupational back injuries experience financial and personal duress after claim settlement. This study examined these issues by comparing financial and domestic court actions for the 5-year presettlement against 5-year postsettlement. Sociodemographic differences also were exam-ined. Methods: Missouri judicial records were reviewed for African American (n = 580) and non-Hispanic white (n = 892) worker's compensation (WC) claimants to determine the frequency with which four types of cases occurred: general financial, domestic financial, residence financial, and domestic behavior. Average annual level of judicial activity during the 5 years before claim settlement was compared to activity for each of five postsettlement years; significance of change was evaluated with univari-ate and multivariate repeated measures analyses.Results: Statistically significant postsettlement increases in legal cases were noted for each of the four categories of cases. There were significant interactions between race and time for general financial and domestic financial cases. A significant interaction between age and time occurred for general financial cases. Significant three-way interactions (race × income change × time) emerged for general and domestic financial cases. Conclusion: The results confirm that workers with occupational back injuries, especially African American and younger adults, encounter long-term financial and domestic duress that appears to escalate with each passing year after claim settlement. This pattern suggests that short-term studies underestimate post-settlement difficulties, particularly among selected demographic cohorts.

Legal Sequelae of Occupational Back Injuries: A Longitudinal Analysis of Missouri Judicial Records. Spine. Aug 2011;36(17):1402-1409. (Entered July 2011)Category: Lower Quarter Bib- Low Back Pain

Factors Associated With the Thickness of the Ligamentum Flavum: Is Ligamentum Flavum Thickening Due to Hypertrophy or Buckling? Spine; 15 July 2011 - Volume 36 - Issue 16 - p E1093–E1097―Ligamentum flavum (LF) thickness‖ and ―LF hypertrophy‖ are used interchangeably in the literature, although they are not necessarily the same thing. Thickness may increase by buckling without a change in the mass of the LF, and whether LF thickening is due to tissue hypertrophy or buckling remains controversial. Methods: The thickness of 896 LFs at the L2–L3, L3–L4, L4–L5, and L5–S1 levels of 224 (mean age, 47.8 ± 16.7 yrs) patients was measured prospectively on axial T1-weighed magnetic resonance images, obtained at the facet joint level. The presence of disc degeneration, spinal stenosis, and disc herniation was evaluated. Results: At all of the levels investigated, LF thickness was significantly greater in patients with grades IV to V degeneration compared with the patients with grades I to III degeneration (P < 0.05). LF thickness at all levels increased significantly with age. Sex and the degree of pain were not correlated with the thickness of the LF. Patients with a BMI of 25 kg/m2 or greater had the thickest LF at the L3–L4 level. LF thickness was significantly greater at the L2–L3, L3–L4, and L4–L5 levels in subjects with LSS and significantly greater at all levels in subjects with disc herniation. Conclusion: Thickening of the LF is correlated with disc degeneration, aging, BMI, LSS, spinal level, and disc herniation. The authors concluded that thickening of the LF is due to buckling of the LF into the spinal canal secondary to disc degeneration more than to LF hypertrophy. Sex and the degree of pain were not correlated with the thickness of the LF.

Factors Associated With the Thickness of the Ligamentum Flavum: Is Ligamentum Flavum Thickening Due to Hypertrophy or Buckling? Spine. Jul 2011;36(16):E1093-E1097. (Entered July 2011)Category: Lower Quarter Bib- Lumbar Spine

Systematic review: Placebo response in drug trials of fibromyalgia syndrome and painful peripheral diabetic neuropathy—magnitude and patient-related predictors Pain; 152 (8); August 2011; Pages 1709-1717The magnitude of placebo response and its predictors in fibromyalgia syndrome (FMS) and painful peripheral diabetic neuropathy (DPN) had not been studied. We performed a systematic review by searching MEDLINE, CENTRAL, SCO-PUS, and the databases of the U.S. National Institutes of Health and the Pharmaceutical Research and Manufacturers of America until July 2010. We included randomised controlled trials of any pharmacological therapy compared with pharmacological placebo in patients with FMS and painful DPN. Pain values were converted to a 0 to 100 scale. We computed the pooled weighted mean difference (WMD) between pain baseline and end of treatment scores in placebo and active drug groups using a random effects model. A total of 72 studies (9827 patients) in FMS and of 70 studies in DPN (10,297 patients) were included. The pooled WMD in the FMS-placebo group was 7.69 (95% confidence interval [CI] 6.10 to 9.29) and 17.11 (95% CI 16.41 to 17.90) in painful DPN. The pooled WMD in the FMS-active drug group was 13.96 (95% CI 11.93 to 15.99) and in painful DPN was 22.54 (95% CI 20.49 to 24.58). The correlation between WMD in the placebo and active drug group in FMS was r = 0.69 and painful DPN r = 0.47. Placebo accounted for 45% of the response in the drug groups in FMS and for 62% in painful DPN. The placebo response was higher in painful DPN than in FMS (P < .001). The placebo response was not associated with age, sex, and race, but with year of study initiation, pain baseline, and effect size in active drug groups in both diseases.

Systematic review: Placebo response in drug trials of fibromyalgia syndrome and painful peripheral diabetic neuropathy—magnitude and patient-related predictors. Pain. Aug 2011;152(8):1709-1717. (Entered July 2011)Category: Misc Bib- Fibromyalgia

Long-Term Effects of Structured Home-Based Exercise Program on Functional Capacity and Quality of Life in Patients With Intermittent Claudication Archives of Physical Medicine and Rehabilitation; Volume 92 (7) Pages 1066-1073, July 2011 Objectives: To evaluate effects of a structured home-based exercise program on functional capacity and quality of life (QoL) in patients with intermittent claudication (IC) after 1-year follow-up, and to compare these results with those from a concurrent control group who received supervised exercise training (SET). Design: Comparative longitudinal cohort study. Participants: Patients (N=142) with IC. Interventions: Structured home-based exercise training or SET. Main Outcome Measures: The maximum (pain-free) walking distance and the ankle-brachial index (ABI) (at rest and postexercise) were measured at baseline and after 6 and 12 months' follow-up. Additionally, QoL was evaluated using a self-administered questionnaire consisting of the Euroqol-5D (scale 0–1), rating scale (scale 0–100), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36; scale 0–100), and the Vascular Quality of Life Questionnaire (VascuQol; scale 1–7). Comparison of the groups was performed with adjustment for the nonrandomized setting using propensity scoring. Results: One hundred forty-two patients with IC started the structured home-based exercise program, of whom 95 (67%) completed 12 months' follow-up. The mean relative improvement compared with baseline was statistically significant after 12 months' follow-up for the maximum and pain-free walking distance (342%, 95% confidence interval [CI], 169–516; P<.01 and 338%, 95% CI, 42–635; P=.03, respectively) and for the ABI postexercise (mean change, .06; 95% CI, .01–.10; P=.02). For the QoL outcomes, the improvement compared with baseline was statistically significant after 12 months for the VascuQol (mean change, .42; 95% CI, .20–.65; P<.01) and for the SF-36 physical functioning (mean change, 5.17; 95% CI, .77–9.56; P=.02). Compared with the structured home-based exercise program, patients in the control group showed significantly better results in the mean relative improvement of maximum and pain-free walking distance and change in the ABI at rest after 12 months' follow-up. Conclusions: Structured home-based exercise training is effective in improving both functional capacity and QoL in patients with IC and may be considered as a feasible and valuable alternative toSET, since supervised exercise programs are not often available.

Long-Term Effects of Structured Home-Based Exercise Program on Functional Capacity and Quality of Life in Patients With Intermittent Claudication. Archives of Physical Medicine and Rehabiliation. Jul 2011;92(7):1066-1073. (Entered July 2011)Category: Misc Bib- Intermittent Claudication

The impact of Alzheimer’s disease on the func-tional connectivity between brain regions under-lying pain perception European Journal of Pain; 15 (6); July 2011 Pages 568.e1-568.e11 Patients with Alzheimer’s disease (AD) are administered fewer analgesics and report less clinical pain compared with their cognitively-intact peers, prompting much speculation about the likely impact of neurodegeneration on pain perception and processing. This study used functional connectivity analysis to examine the impact of AD on the integrated functioning of brain regions mediating the sensory, emotional, and cognitive aspects of pain. Fourteen patients with AD and 15 controls attended two experimental sessions. In an initial psychophysical testing session, a random staircase procedure was used to assess sensitivity to noxious mechanical pressure applied to the thumbnail. In a subsequent brain imaging session, fMRI data were collected as participants received noxious or innocuous thumbnail pressure, delivered at intensities corresponding with previously identified subjective pain thresholds. Two approaches to functional connectivity analysis were utilized. A seed-based correlation method was first used to identify regions showing significant functional connectivity with the right dorsolateral prefrontal cortex (DLPFC). Functional connectivity between a network of 17 predefined pain processing regions was then assessed. Between-group comparisons revealed enhanced functional connectivity between the DLPFC and the anterior mid cingulate cortex, periaqueductal grey, thalamus, hypothalamus, and several motor areas in pa-tients with AD compared with control group. Likewise, inter-regional functional connectivity across most re-gions of the predefined pain network was shown to be greater in the patient group, with the enhanced functional connectivity centred on three nodes: the DLPFC-R, hypothalamus, and PAG. The results of this study support previous research suggesting an interplay between pain and cognitive processes in patients with AD.

The impact of Alzheimer’s disease on the func-tional connectivity between brain regions under-lying pain perception. European Journal of Pain. Jul 2011;15(6):568.e1-568.e11. (Entered July 2011)Category: Misc Bib- Alzheimer’s Disease

Activation of Selected Shoulder Muscles During Unilateral Wall and Bench Press Tasks Under Submaximal Isometric Effort Helga T. Tucci, Marcia A. Ciol, Rodrigo Cappato de Araújo, Rodrigo de Andrade, Jaqueline Martins, Kevin J. McQuade, Anamaria S. OliveiraDOI: 10.2519/jospt.2011.3418STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To assess the activation of 7 shoulder muscles under 2 closed kinetic chain (CKC) tasks for the upper extremity using submaximal isometric effort, thus providing relative quantification of muscular isometric effort for these muscles across the CKC exercises, which may be applied to rehabilitation protocols for individuals with shoulder weakness. BACKGROUND: CKC exercises favor joint congruence, reduce shear load, and promote joint dynamic stability. Additionally, knowledge about glenohumeral and periscapular muscle activity elicited during CKC exercises may help clinicians to design protocols for shoulder rehabilitation. METHODS: Using surface electromyography, activation level was measured across 7 shoulder muscles in 20 healthy males, during the performance of a submaximal isometric wall press and bench press. Signals were normalized to the maximal voluntary isometric contraction, and, using paired t tests, data were analyzed between the exercises for each muscle. RESULTS: Compared to the wall press, the bench press elicited higher activity for most muscles, except for the upper trapezius. Levels of activity were usually low but were above 20% maximal voluntary isometric contraction for the serratus anterior on both tasks, and for the long head triceps brachii on the bench press. CONCLUSIONS: Both the bench press and wall press, as performed in this study, led to relatively low EMG activation levels for the muscles measured and may be considered for use in the early phases of rehabilitation. J Orthop Sports Phys Ther 2011;41(7):520-525, Epub 2 February 2011. doi:10.2519/jospt.2011.3418

Tucci HT et al. Activation of Selected Shoulder Muscles During Unilateral Wall and Bench Press Tasks Under Submaximal Isometric Effort. JOSPT. 2011;41(7):520-525. (Entered July 2011)Category: Upper Quarter Bib- Shoulder

Analysis of Knee Flexion Angles During 2 Clinical Versions of the Heel Raise Test to Assess Soleus and Gastrocnemius Function Kim Hébert-Losier, Anthony G. Schneiders, S. John Sullivan, Richard J. Newsham-West, José A. García, Guy G. SimoneauDOI: 10.2519/jospt.2011.3489STUDY DESIGN: Controlled laboratory study, using a repeated-measures, counterbalanced design. OBJECTIVES: To provide estimates on the average knee angle maintained, absolute knee angle error, and total repetitions performed during 2 versions of the heel raise test. BACKGROUND: The heel raise test is performed in knee extension (EHRT) to assess gastrocnemius and knee flexion (FHRT) for soleus. However, it has not yet been determined whether select knee angles are maintained or whether total repetitions differ between the clinical versions of the heel raise test. METHODS: Seventeen healthy males and females performed maximal heel raise repetitions in 0° (EHRT) and 30° (FHRT) of desired knee flexion. The average angle maintained and absolute error at the knee during the 2 versions, and total heel raise repetitions, were measured using motion analysis. Participants’ kinematic measures were fitted into a generalized estimation equation model to provide estimates on EHRT and FHRT performance applicable to the general population. RESULTS: The model estimates that average angles of 2.2° and 30.7° will be maintained at the knee by the general population during the EHRT and the FHRT, with an absolute angle error of 3.4° and 2.5°, respectively. In both versions, 40 repetitions should be completed. However, the average angles maintained by participants ranged from –6.3° to 21.6° during the EHRT and from 22.0° to 43.0° during the FHRT, with the highest absolute errors in knee position being 25.9° and 33.5°, respectively. CONCLUSION: On average, select knee angles will be maintained by the general population during the select heel raise test versions, but individualized performance is variable and total repetitions do not distinguish between versions. Clinicians should, therefore, interpret select heel raise test outcomes with caution when used to respectively assess and rehabilitate soleus and gastrocnemius function. J Orthop Sports Phys Ther 2011;41(7):505-513, Epub 18 February 2011. doi:10.2519/jospt.2011.3489

Hebert-Losier K, Schneiders AG, Sullivan J, Newsham-West RJ, Garcia JA, Simoneau GG. Analysis of Knee Flexion Angles During 2 Clinical Versions of the Heel Raise Test to Assess Soleus and Gastrocnemius Function . JOSPT. 2011;41(7):505-513. (Entered July 2011)Category: Lower Quarter Bib- Knee

Total Number and Severity of Comorbidities Do Not Differ Based on Anatomical Region of Musculoskeletal Pain Rogelio A. Coronado, Meryl J. Alappattu, Dennis L. Hart, Steven Z. GeorgeDOI: 10.2519/jospt.2011.3686STUDY DESIGN: Secondary analysis, cross-sectional study. OBJECTIVES: To (1) compare differences in individual comorbidity rates among patients with cervical, lumbar, and extremity pain complaints and (2) compare rates based on total number and severity in these same patient groups. BACKGROUND: Comorbidities can impact recovery, prognosis, and potentially hinder participation in rehabilitation. Few studies have compared comorbidity rates among patients with different anatomical region of pain, to determine whether specific screening is warranted in physical therapy settings. METHODS: Included in the analyses were 2375 patients who reported complete demographic, clinical, and comorbidity information using Patient Inquiry software. Comorbidity data were collected from the Functional Comorbidity Index (18 items) and 6 additional comorbidities, to assess the presence of medical disease across multiple body systems. Comorbidities were further classified as “nonsevere” or “severe,” based on inclusion in the Charlson Comorbidity Index. Chi-square analyses investigated differences in the rates of total number and severe comorbidities. Odds ratios (OR) and 95% confidence intervals (CIs) were calculated on rates with statistically significant differences (P<.001), using the lumbar spine as the reference group. RESULTS: Of the 24 comorbid conditions included in this analysis, 3 nonsevere medical conditions (degenerative disc disease, obesity, and headache) had different rates among anatomical region. A lower rate for degenerative disc disease was associated with the extremity conditions (Χ2 = 66.3; OR = 0.40; 95% CI: 0.32, 0.50). Higher rate of headache (Χ2 = 115.3; OR = 3.01; 95% CI: 2.45, 3.70) and lower rate of obesity (Χ2 = 16.2; OR = 0.64; 95% CI: 0.51, 0.80) were associated with cervical conditions. There were no differences among the 3 anatomical regions for total number or severe comorbidities. CONCLUSION: Focused screening for degenerative disc disease, obesity, and headache may be warranted. However, the same strategy was not supported for total number or severe comorbidities, at least when considering comparative rates from this cohort. Physical therapists should consider the potential influence of total number and severe comorbidities equally for all anatomical regions of musculoskeletal pain. LEVEL OF EVIDENCE: Differential diagnosis/symptom prevalence, level 3b. J Orthop Sports Phys Ther 2011;41(7):477-485, Epub 7 June 2011. doi:10.2519/jospt.2011.3686

Coronado RA, Alappattu MJ, Hart DL, George SZ. Total Number and Severity of Comorbidities Do Not Differ Based on Anatomical Region of Musculoskeletal Pain. JOSPT. Jun 2011;41(7):477-485. (Entered July 2011)Category: Misc Bib- Pain

Conflicting Dermatome Maps: Educational and Clinical Implications Mary Beth Downs, Cindy LaPorteSYNOPSIS: Sensory testing is a common noninvasive method of evaluating nerve function that relies on the knowledge of skin dermatomes and sensory fields of cutaneous nerves. Research to determine the extent of the dermatomes was conducted in Europe during the late nineteenth and early twentieth centuries. Experiments performed on cadavers, monkeys, and human patients prior to 1948 resulted in the creation of similar but somewhat different dermatome maps. A radically different map with long, swirling dermatomes was produced by Keegan and Garrett in 1948. This map was derived largely by examining compression of dorsal nerve roots by vertebral disc herniation. The maps appearing in textbooks are inconsistent. Some books show a version of the early maps, some show the Keegan and Garrett map, and others show maps that are not consistent with either. The purpose of this paper is to discuss the history of dermatome maps, including the experimental procedures by which each was obtained, and to relate the early maps to those found in textbooks commonly used in healthcare education programs. The paper discusses the significance of these maps as used for clinical diagnosis and the need for further research. J Orthop Sports Phys Ther 2011;41(6):427-434. doi:10.2519/jospt.2011.3506KEY WORDS: anatomy, neck, nerves, sensation, skin, spine

Downs MB, LaPorte C. Conflicting Dermatome Maps: Educational and Clinical Implications. JOSPT. 2011;41(6):427-434. (Entered July 2011)Category: Misc Bib- Neurology

Asymmetrical Lower Extremity Loading After ACL Reconstruction: More Than Meets the EyeTerese L. ChmielewskiSports fans know that movement patterns are important for athletic performance. Similarly, clinicians know that addressing abnormal movement patterns after an anterior cruciate ligament (ACL) reconstruction is important for a successful return to sport. The kinematic (motion) component of movement patterns is more easily observed than the kinetic (forces) component, thus more commonly addressed in ACL reconstruction rehabilitation. Ignoring the kinetic component, though, could impede a successful return to sport. Asymmetrical lower extremity loading has been reported in a variety of activities following ACL reconstruction, and may contribute to both short- and long-term consequences. It is important that clinicians become aware of the potential for asymmetrical lower extremity loading to affect patient outcomes and for researchers to enlarge the body of knowledge.

Chmielewski TL. Asymmetrical Lower Extremity Loading After ACL Reconstruction: More Than Meets the Eye. JOSPT. 2011;41(6). (Entered July 2011)Category: Lower Quarter Bib- Anterior Cruciate Ligament

Association Between Changes in Abdominal and Lumbar Multifidus Muscle Thickness and Clinical Improvement After Spinal ManipulationShane L. Koppenhaver, Julie M. Fritz, Jeffrey J. Hebert, Greg N. Kawchuk, Maj John D. Childs, Eric C. Parent, Norman W. Gill, Deydre S. TeyhenSTUDY DESIGN: Prospective case series. OBJECTIVE: To examine the relation between improved disability and changes in abdominal and lumbar multifidus (LM) thickness using ultrasound imaging following spinal manipulative therapy (SMT) in patients with low back pain (LBP). BACKGROUND: Although there is a growing body of literature demonstrating physiologic effects following the application of SMT, few studies have attempted to correlate these changes with clinically relevant outcomes. METHODS: Eighty-one participants with LBP underwent 2 thrust SMT treatments and 3 assessment sessions within 1 week. Transversus abdominis (TrA), internal oblique (IO), and LM muscle thickness was assessed during each session, using ultrasound imaging of the muscles at rest and during submaximal contractions. The Modified Oswestry Disability Index was used to quantify participants’ improvement in LBP-related disability. Stepwise hierarchical multiple linear regression and repeated-measures analysis of variance were performed to examine the multivariate relationship between change in muscle thickness and clinical improvement over time. RESULTS: After controlling for the effects of age, sex, and body mass index, change in contracted LM muscle thickness was predictive of improved disability at 1 week (P = .02). As expected, larger increases in contracted LM muscle thickness at 1 week were associated with larger improvements in LBP-related disability. Contrary to our hypothesis, significant decreases in both contracted TrA and IO muscle thickness were observed immediately following SMT; but these changes were transient and unrelated to whether participants experienced clinical improvements. CONCLUSION: These findings provide evidence that clinical improvement following SMT is associated with increased thickening of the LM muscle during a submaximal task. LEVEL OF EVIDENCE: Prognosis, level 4. J Orthop Sports Phys Ther 2011;41(6):389-399, Epub 6 April 2011. doi:10.2519/jospt.2011.3632KEY WORDS: low back pain, muscle contraction, transversus abdominis, ultrasound

Koppenhaver SL et al. Association Between Changes in Abdominal and Lumbar Multifidus Muscle Thickness and Clinical Improvement After Spinal Manipulation. JOSPT. 2011;41(6):389-399. (Entered July 2011)Category: Lower Quarter Bib- Lumbar Manipulation

Diagnostic Accuracy of Clinical Tests and Signs of Temporomandibular Joint Disorders: A Systematic Review of the LiteratureJennifer Reneker, Jaime Paz, Christopher Petrosino, Chad E. CookSTUDY DESIGN: Systematic review. OBJECTIVE: To summarize the research on accuracy of individual clinical diagnostic signs and tests for the presence of temporomandibular disorder (TMD), and for the subclassifications affiliated with TMD. BACKGROUND: Diagnosis of TMD through clinical diagnostic measures has been reported in many studies; however, few of these studies have identified individual clinical tests or signs that can aid in the diagnosis of TMD or differentiate between the subclassifications of TMD. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. Computerized and hand searches were completed to locate articles on the diagnostic accuracy of clinical tests and signs. To be considered for review, the study required (1) an assessment of individual clinical measures of TMD, (2) a report of the diagnostic accuracy of these measures, and (3) an acceptable reference standard for comparison. Quality assessment of studies of diagnostic accuracy (QUADAS) scores were completed on each selected article. Sensitivity and specificity and negative and positive likelihood ratios were calculated for each diagnostic test described. RESULTS: The search strategy identified 131 potential articles, which were narrowed down to 7 that met the criteria for this review. After assessment using the QUADAS score, 3 of the 7 articles were of high quality. All 7 studies used tests to differentiate subclassifications of TMD. The 7 studies included (1) diagnostic tests/signs of joint sounds, (2) joint movements, or (3) clinically oriented pain measures. There were no studies that investigated TMD versus a competing, non-TMD condition. CONCLUSION: Only 3 studies presented in this literature review were of high quality. Because all of the included studies assessed diagnostic accuracy among subclassifications of individuals suspected of having TMD, the ability of any of these tests to distinguish between patients with TMD versus patients without TMD remains unknown. Because of the lack of clear findings indicating compelling evidence for clinical diagnosis of TMD, and because of the low quality of most of these studies, the data are insufficient to support or reject these tests. LEVEL OF EVIDENCE: Diagnosis, level 2a–. J Orthop Sports Phys Ther 2011;41(6):408-416, Epub 18 February 2011. doi:10.2519/jospt.2011.3644Reneker J, Paz J, Petrosino C, Cook CE. Diagnostic Accuracy of Clinical Tests and Signs of Temporomandibular Joint Disorders: A Systematic Review of the Literature. JOSPT. 2011;41(6):408-416. (Entered July 2011)Category: Upper Quarter Bib- TMJ

The Relationships Between Inter-recti Distance Measured by Ultrasound Imaging and Abdominal Muscle Function in Postpartum Women: A 6-month Follow-up StudyLih-Jiun Liaw, Miao-Ju Hsu, Chien-Fen Liao, Mei-Fang Liu, Ar-Tyan HsuSTUDY DESIGN: A prospective longitudinal study. BACKGROUND: Diastasis recti abdominis (DRA) is defined as an increase in the inter-recti distance (IRD), or width of the linea alba. It is a common occurrence in women postpartum. Little information exists on the short- and long-term recovery of IRD and the relationship between changes in IRD and the functional performance of the abdominal muscles. OBJECTIVES: To investigate the natural recovery of IRD and abdominal muscle strength and endurance in women between 7 weeks and 6 months postpartum, and to examine the relationship between IRD and abdominal muscle function. METHODS: Forty postpartum (25-37 years of age) and 20 age-matched, nulliparous females participated. IRD was measured at 4 locations (upper and lower margin of the umbilical ring, and 2.5 cm above and below the umbilical ring) with a 7.5-MHz linear ultrasound transducer. Trunk flexion and rotation strength and endurance were measured with manual muscle testing and curl-ups. Evaluation was conducted at 4 to 8 weeks and 6 to 8 months after childbirth in postpartum women, and only once for the nulliparous female controls. RESULTS: During follow-up, the IRD at 2.5 cm above the umbilical ring and at the upper margin of the umbilical ring decreased (P = .013 and P = .002, respectively). The strength and static endurance of the abdominal muscles improved over time (P<.05). A negative correlation between IRD and abdominal muscle function at 7 weeks and 6 months postpartum was found (r = 0.34 to 0.51; P<.05, except for trunk flexion strength at 6 months postpartum [P = .064]). In addition, IRD changes between 7 weeks and 6 months postpartum were correlated with improvement in trunk flexion strength (Spearman rho = 0.38, P = .040). At 6 months after childbirth, postpartum women had greater mean ? SD IRDs at all 4 locations (from cranial to caudal: 1.80 ± 0.72, 2.13 ± 0.65, 1.81 ± 0.62, and 1.16 ± 0.58 cm) than those of nulliparous females (0.85 ± 0.26, 0.99 ± 0.31, 0.65 ± 0.23, and 0.43 ± 0.17 cm) (all P<.001). All abdominal strength and endurance measurements were less than those of nulliparous females (all P<.001). CONCLUSIONS: The IRD and abdominal muscle function of postpartum women improved but had not returned to normal values at 6 months after childbirth. Future research is essential to explore the need for intervention and, if needed, the effectiveness of specific intervention to reduce the size of IRD in postpartum women. J Orthop Sports Phys Ther 2011;41(6):435-443, Epub 2 February 2011. doi:10.2519/jospt.2011.3507

Liaw LJ, Hsu MJ, Liao CF, Liu MF, Hsu AT. The Relationships Between Inter-recti Distance Measured by Ultrasound Imaging and Abdominal Muscle Function in Postpartum Women: A 6-month Follow-up Study. JOSPT. 2011;41(6):435-443. (Entered July 2011)Category: Lower Quarter Bib- Pregnancy

Occult Hypermobility of the Craniocervical Junction: A Case Report and ReviewK. Sean Mathers, Michael Schneider, Michael TimkoSTUDY DESIGN: Resident’s case problem. BACKGROUND: Patients often present to physical therapists with chief complaints of neck pain, occipital headache, and dizziness associated with a past history of cervical spine injury. These symptoms may be associated with various cervical spine conditions, including craniocervical junction (CCJ) hypermobility. DIAGNOSIS: This report reviews the history, physical exam, and diagnostic imaging findings of a patient with the above symptoms. This patient, who had a history of multiple cervical spine injuries, was examined with 2 manual therapy provocative tests: the Sharp-Purser test, which is intended to stress the transverse ligament and odontoid, and the modified lateral shear test, which is intended to stress the alar ligaments. The lateral shear test was perceived as demonstrating excessive mobility and a soft end feel, with a “shift” of C1 on C2. Stress cervical radiographs, obtained using open-mouth projections in neutral, left, and right cervical lateral flexion, revealed a 3-mm lateral offset of the right lateral mass of C1 on C2. MRI evaluation of the lower cervical spine did not reveal any significant disc derangement; however, images of the soft tissues of the craniocervical junction were not obtained. Based on the examination and imaging studies, the patient was determined to have a previously undiagnosed hypermobility of the atlantoaxial joint. DISCUSSION: The patient was advised to avoid rotational manipulation and end range lateral flexion stretching exercises. Axial traction manipulation techniques, midrange stabilization exercises, and postural advice appeared to provide good relief of symptoms. Physical therapists should consider the possibility of CCJ hypermobility in the frontal plane when examining the cervical spine in patients with chronic neck pain, headache, and a past history of trauma. The lateral shear test and stress radiography may provide simple screening tests for occult CCJ hypermobility; however, the reliability and validity of these tests is lacking. Further research on diagnosis and management of CCJ hypermobility is warranted. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther 2011;41(6):444-457. doi:10.2519/jospt.2011.3305KEY WORDS: alar ligament, cervical spine, manual therapy, transverse ligament

Mathers KS, Schneider M, Timko M. Occult Hypermobility of the Craniocervical Junction: A Case Report and Review. JOSPT. 2011;41(6):444-457. (Entered July 2011)Category: Upper Quarter Bib- Upper Cervical Spine

Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical TrialHsiu-Chuan Hung, Sheng-Mou Hsiao, Shu-Yun Chih, Ho-Hsiung Lin and Jau-Yih TsauoBackground Pelvic-floor muscle (PFM) strengthening has been widely used to treat people with urinary incontinence (UI). However, its effect on bladder neck position and stiffness is unknown. Objective The aim of the study was to investigate the effect of PFM strengthening on bladder neck mobility for women with stress UI (SUI) or mixed UI (MUI). Design This study was conducted as a single-group pretest-posttest design. Setting This study was conducted mainly at the Life Quality & Health Promotion Laboratory at National Taiwan University and partly in the Ultrasonography Room of the Department of Obstetrics and Gynecology at National Taiwan University Hospital. Patients Twenty-three patients (mean age=51.9 years, SD=6.1) participated in the study. Intervention and Measurements Each participant underwent a PFM strengthening program for 4 months. Bladder neck position at rest and during a cough, the Valsalva maneuver, and a PFM contraction was assessed by transperineal ultrasonography before and after the intervention. Severity Index score, self-reported improvement, PFM strength (force-generating capacity), and vaginal squeeze pressure were assessed for treatment effect. Results The position of the bladder neck at PFM contraction and bladder neck mobility for maximal incursion from rest to PFM contraction were elevated, with effect sizes of 0.48 and 0.84, respectively. Bladder neck position and bladder neck mobility were not changed during a cough and the Valsalva maneuver. All participants reported diminution of incontinence, and PFM strength and maximal vaginal squeeze pressure were improved after the intervention. Limitations The limitations of the present trial included the pretest-posttest design and the absence of intra-abdominal pressure measuring and exercise adherence recording. Conclusions Four months of daily PFM strengthening can significantly improve the ability of the PFM to elevate the bladder neck voluntarily, but may not improve its stiffness during a cough and the Valsalva maneuver for women with SUI and MUI.

Hung HC, Hsiao SM, Chih SY, Lin HH, Tsauo JY. Effect of Pelvic-Floor Muscle Strengthening on Bladder Neck Mobility: A Clinical Trial. PT Journal. 2011;91(7):1030. (Entered July 2011)Category: Lower Quarter Bib- Strengthening Pelvic Floor

The Pelvic Girdle Questionnaire: A Condition-Specific Instrument for Assessing Activity Limitations and Symptoms in People With Pelvic Girdle PainBritt Stuge, Andrew Garratt, Hanne Krogstad Jenssen and Margreth Grotle

AbstractBackground No appropriate measures have been specifically developed for pelvic girdle pain (PGP). There is a need for suitable outcome measures that are reliable and valid for people with PGP for use in research and clinical practice. Objective The objective of this study was to develop a condition-specific measure, the Pelvic Girdle Questionnaire (PGQ), for use during pregnancy and postpartum. Design This was a methodology study. Methods Items were developed from a literature review and information from a focus group of people who consulted physical therapists for PGP. Face validity and content validity were assessed by classifying the items according to the World Health Organization's International Classification of Functioning, Disability and Health. After a pilot study, the PGQ was administered to participants with clinically verified PGP by means of a postal questionnaire in 2 surveys. The first survey included 94 participants (52 pregnant), and the second survey included 87 participants (43 pregnant). Rasch analysis was used for item reduction, and the PGQ was assessed for unidimensionality, item fit, redundancy, and differential item functioning. Test-retest reliability was assessed with a random sample of 42 participants. Results The analysis resulted in a questionnaire consisting of 20 activity items and 5 symptom items on a 4-point response scale. The items in both subscales showed a good fit to the Rasch model, with acceptable internal consistency, satisfactory fit residuals, and no disordered threshold. Test-retest reliability showed high intraclass correlation coefficient estimates: .93 (95% confidence interval=0.86–0.96) for the PGQ activity subscale and .91 (95% confidence interval=0.84–0.95) for the PGQ symptom subscale. Limitations The PGQ should be compared with low back pain questionnaires as part of a concurrent evaluation of measurement properties, including validity and responsiveness to change. Conclusions The PGQ is the first condition-specific measure developed for people with PGP. The PGQ had acceptably high reliability and validity in people with PGP both during pregnancy and postpartum, it is simple to administer, and it is feasible for use in clinical practice.

Stuge B, Garrett A, Jenssen HK, Grotle M. The Pelvic Girdle Questionnaire: A Condition-Specific Instrument for Assessing Activity Limitations and Symptoms in People With Pelvic Girdle Pain. PT Journal. 2011;91(7):1096. (Entered July 2011)Category: Lower Quarter Bib-Pelvic Tests