Reliability of physical examination tests used in the assessment of patients with shoulder problems: a systematic review

Background

Shoulder pain is a common clinical problem, and numerous tests are used to diagnose structural pathology.

Objectives

To systematically review the reliability of physical examination procedures used in the clinical examination of patients with shoulder pain.

Data sources

MEDLINE, PEDro, AMED, PsychInfo, Cochrane Library (2009) and CINAHL were searched from the earliest record on the database to June 2009.

Study eligibility criteria

Reliability studies that included any patients with shoulder pain were analysed for their quality and reliability results.

Study appraisal and synthesis methods

Pre-established criteria were used to judge the quality of the studies (high quality >60% methods score) and satisfactory levels of reliability (kappa or intraclass correlation coefficient ≥0.85, sensitivity analysis 0.70). A qualitative synthesis was performed based on levels of evidence.

Results

Thirty-six studies were included with a mean methods score of 57%. Seventeen studies were deemed to be of high quality; high-quality studies were less likely to meet the pre-agreed level of reliability. The majority of studies indicated poor reliability for all procedures investigated.

Limitations

Overall, the evidence regarding reliability was contradictory.

Conclusions and implications

There is no consistent evidence that any examination procedure used in shoulder assessments has acceptable levels of reliability. Alternate methods of classification which are reliable should be used to classify patients with shoulder problems.     

Balance-Based Torso-Weighting May Enhance Balance in Persons With Multiple Sclerosis: Preliminary Evidence

Widener GL, Allen DD, Gibson-Horn C. Balance-based torso-weighting may enhance balance in persons with multiple sclerosis: preliminary evidence.

Objective

To determine whether weight placed on the trunk in response to directional balance loss would enhance function and stability in people with multiple sclerosis (MS).

Design

Quasi-experimental study in which subjects served as their own controls.

Setting

Research laboratory.

Participants

Subjects (N=16) age 20 to 65 years with MS recruited through the Northern California Chapter of the National Multiple Sclerosis Society.

Interventions

Balance-based torso-weighting where up to 1.5% body weight was placed in a garment on the trunk. Subjects were tested at baseline and then in randomly ordered balance-based torso-weighting and nonweighted garment conditions.

Main Outcome Measures

Sharpened Romberg, eyes open (SREO) and Sharpened Romberg, eyes closed, computerized dynamic platform posturography (CDPP), Timed Up & Go (TUG), and 25-foot timed walk.

Results

Significant improvement (P<.014) was found with SREO in the balance-based torso-weighting compared with nonweighted conditions. CDPP eyes open and TUG showed improvements (P<.03) from baseline to balance-based torso-weighting and nonweighted conditions.

Conclusions

Improved performance in a group of adults with MS was seen when light weights were placed on the torso to counteract balance loss. Placement of weights may have the potential to produce immediate improvements in balance in this population.     

The expression of fucose isoforms of amniotic and plasma alpha-1-acid glycoprotein derived from 2nd and 3rd trimester normal pregnancies

Objectives

To analyse modifications in AGP fucosylation in relation to different stages of human pregnancy.

Design and methods

The relative amounts of three fucosyl-glycotopes on AGP were analysed by lectin-ELISA using fucose-specific biotinylated lectins in 169 plasma and 178 amniotic fluid samples from normal pregnancies with gestational ages of 14 to 42 weeks.

Results

The plasma AGPs of all the pregnant women and amniotic AGPs from the 2nd trimester lacked fucoses. In contrast, in the 3rd trimester the amniotic AGPs were highly decorated by the innermost α1,6-fucose as well as α1,2- and α1,3-fucoses of the outer arms, reaching the highest expression around the perinatal period. At delivery the relative amounts of the α1,3- and α1,2-AGP isoforms, but not the α1,6 isoform, significantly decreased.

Conclusions

The highly fucosylated amniotic AGP isoforms could be implicated in regulatory processes to ensure homeostasis during pregnancy and to protect the fetus. They have the potential of becoming laboratory markers in obstetrics to monitor pregnancy.     

Weight-Bearing Asymmetry in Relation to Measures of Impairment and Functional Mobility for People With Knee Osteoarthritis

Christiansen CL, Stevens-Lapsley JE. Weight-bearing asymmetry in relation to measures of impairment and functional mobility for people with knee osteoarthritis.

Objectives

To compare weight-bearing asymmetry (WBA) for people with unilateral knee osteoarthritis (OA) with that for healthy adults of similar age. In addition, associations between WBA and clinical measures of knee impairment and functional mobility were evaluated.

Design

Cross-sectional design with age-matched control (CTL) group.

Setting

Clinical research laboratory.

Participants

People with end-stage unilateral knee OA (n=50) (OA group) and healthy people (n=17) (CTL group) were enrolled in the study (N=67).

Interventions

Not applicable.

Main Outcome Measures

WBA during a Five Times Sit-to-Stand Test (FTSST) based on average vertical ground reaction force under each foot, self-reported knee pain assessed using a Numerical Pain Rating Scale, knee extensor strength asymmetry based on peak isometric knee extension torque, knee motion asymmetry based on maximum passive knee extension and flexion angles, FTSST time, six-minute walk test distance, and Stair Climbing Test time.

Results

The OA group demonstrated greater WBA than the CTL group during transitions between sitting and standing as measured by an absolute symmetry index (P=.015). No correlation was found between WBA and knee motion asymmetry, but comparisons of WBA with all the other outcome variables indicated fair relationships (range, r=.29-.44).

Conclusions

Weight-bearing asymmetry during transitions between sitting and standing can serve as a clinically relevant measure related to both knee impairment and functional mobility for people with unilateral knee OA.     

Self-Report of Missteps in Older Adults: A Valid Proxy of Fall Risk?

Srygley JM, Herman T, Giladi N, Hausdorff JM. Self-report of missteps in older adults: a valid proxy of fall risk?

Objective

To evaluate the relationship between missteps and falls and to identify factors associated with missteps, potentially to generate a broader picture of fall risk.

Design

Prospective, observational cohort.

Setting

General community.

Participants

A sample of healthy, community-living older adults (N=266; age, 70-90y) who were cognitively intact and walked independently.

Interventions

Not applicable.

Main Outcome Measures

Baseline testing of gait, motor function, cognitive function, affect, and balance confidence was followed by a 12-month period in which subjects completed a daily log documenting the number of falls and missteps (defined as a trip, slip, or other loss of balance in which recovery occurred to prevent a fall).

Results

Mean ± SD participant age was 76.4±4.3 years. Of all the participants, 20.7% reported at least 1 misstep, and 25.6% of the participants reported at least 1 fall during the 12 months. Among subjects who had multiple falls, missteps were more common than falls by a ratio of 3:1 (P<.001). Subjects who reported multiple missteps were more likely to fall prospectively (relative risk=3.89). Missteps were associated with higher scores on the Geriatric Depression Scale (P=.009) and increased anxiety (P=.014), but were not associated with other known risk factors for falls, including gait and cognitive function.

Conclusions

The self-report of missteps may be a valuable tool in the research of falls and fall risk and may provide a way to identify patients at risk for falls before they fall.     

Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests

Nijs J, Roussel N, Vermuelen K, Souvereyns G. Scapular positioning in patients with shoulder pain: a study examining the reliability and clinical importance of 3 clinical tests.

Objective

To examine the interobserver reliability, internal consistency, and clinical importance of 3 clinical tests for the assessment of scapular positioning in patients with shoulder pain.

Design

Prospective repeated-measures design.

Setting

Private practices for physical therapy and hospital outpatient physical therapy divisions.

Participants

Twenty-nine patients with shoulder pain who were diagnosed by a physician as having a shoulder disorder.

Interventions

Not applicable.

Main Outcome Measures

Study participants filled in a visual analog scale for pain and the Shoulder Disability Questionnaire. Next, 2 assessors performed the following tests: measurement of the distance between the posterior border of the acromion and the table, measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and the lateral scapular slide test.

Results

The interobserver reliability coefficients were greater than .88 (intraclass correlation coefficients) for the measurement of the distance between the posterior border of the acromion and the table, were greater than .50 for the measurement of the distance from the medial scapular border to the fourth thoracic spinous processes, and were greater than .70 for the lateral scapular slide test. The Cronbach α coefficient for internal consistency for all tests was .88. No associations between the outcome of the tests and self-reported pain severity or disability were found.

Conclusions

These data provide evidence favoring the interobserver reliability of 2 of 3 tests for the assessment of scapular positioning in patients with shoulder pain. The clinical importance of the tests’ outcomes, however, is questionable.     

Pulsed Electromagnetic Fields to Reduce Diabetic Neuropathic Pain and Stimulate Neuronal Repair: A Randomized Controlled Trial

Weintraub MI, Herrmann DN, Smith AG, Backonja MM, Cole SP. Pulsed electromagnetic fields to reduce diabetic neuropathic pain and stimulate neuronal repair: a randomized controlled trial.

Objective

To determine whether repetitive and cumulative exposure to low-frequency pulsed electromagnetic fields (PEMF) targeting painful feet can reduce neuropathic pain (NP), influence sleep in symptomatic diabetic peripheral neuropathy (DPN), and influence nerve regeneration.

Design

Randomized, double-blind, placebo-controlled parallel study.

Setting

Sixteen academic and clinical sites in 13 states.

Participants

Subjects (N=225) with DPN stage II or III were randomly assigned to use identical devices generating PEMF or sham (placebo) 2 h/d to feet for 3 months.

Interventions

Nerve conduction testing was performed serially.

Main Outcome Measures

Pain reduction scores using a visual analog scale (VAS), the Neuropathy Pain Scale (NPS), and the Patient's Global Impression of Change (PGIC). A subset of subjects underwent serial 3-mm punch skin biopsies from 3 standard lower limb sites for epidermal nerve fiber density (ENFD) quantification.

Results

Subjects (N=225) were randomized with a dropout rate of 13.8%. There was a trend toward reductions in DPN symptoms on the PGIC, favoring the PEMF group (44% vs 31%; P=.04). There were no significant differences between PEMF and sham groups in the NP intensity on NPS or VAS. Twenty-seven subjects completed serial biopsies. Twenty-nine percent of PEMF subjects had an increase in distal leg ENFD of at least 0.5 SDs, while none did in the sham group (P=.04). Increases in distal thigh ENFD were significantly correlated with decreases in pain scores.

Conclusions

PEMF at this dosimetry was noneffective in reducing NP. However neurobiological effects on ENFD, PGIC and reduced itching scores suggest future studies are indicated with higher dosimetry (3000-5000 G), longer duration of exposure, and larger biopsy cohort.     

Mental Health and Posttraumatic Stress Symptoms 2 Years After Severe Multiple Trauma: Self-Reported Disability and Psychosocial Functioning

Soberg HL, Bautz-Holter E, Roise O, Finset A. Mental health and posttraumatic stress symptoms 2 years after severe multiple trauma: self-reported disability and psychosocial functioning.

Objectives

To describe mental health and posttraumatic stress symptoms (PTSS) for patients with severe multiple trauma at 2 years postinjury. Further, objectives were to examine relationships between PTSS and factors related to the person, injury, and postinjury physical and psychosocial functioning from the time of return home to 2 years after injury. The final aim was to identify predictors of PTSS and mental health at 2 years.

Design

Prospective cohort study with a 2-year follow-up.

Setting

Hospital and community setting.

Participants

Patients (N=99) age 18 to 67 years with multiple trauma and a New Injury Severity Score (NISS) greater than 15 treated at a regional trauma referral center. Mean age ± SD was 35.3±14.2 years; 83% were men. Mean NISS ± SD was 34.9±12.7.

Intervention

Not applicable.

Main Outcome Measures

Postinjury psychologic distress associated with depression on the Medical Outcomes Study 36-Item Short-Form Health Survey Mental Health scale and PTSS on the Post-Traumatic Symptom Scale 10 (PTSS-10) at 2 years post injury. Self-reported physical, mental, and cognitive functioning at the return home and 1 and 2 years, and coping strategies.

Results

Mean PTSS-10 score ± SD at 2 years was 25.6±12.2. Twenty percent had a PTSS-High score, indicating posttraumatic stress disorder (PTSD). Twenty-seven percent had Mental Health scores indicating depression. Predictors of PTSS were sex (female), younger age, avoidant coping, pain, mental health, and cognitive functioning on the return home, which explained 70% of the variance in PTSS-10 score.

Conclusions

Twenty percent had a PTSS-High score indicating PTSD at 2 years postinjury. The personal factors sex (female), younger age, and avoidant coping and the functional factors pain, mental health, and cognitive functioning predicted PTSS at 2 years.     

Relationship Among Shoulder Proprioception, Kinematics, and Pain After Stroke

Niessen MH, Veeger DH, Meskers CG, Koppe PA, Konijnenbelt MH, Janssen TW. Relationship among shoulder proprioception, kinematics, and pain after stroke.

Objective

To identify a possible relationship among chronic poststroke shoulder pain (PSSP), scapular resting pose, and shoulder proprioception.

Design

Case-control study.

Setting

Rehabilitation center.

Participants

A total of 21 inpatients with stroke and 10 healthy control subjects.

Interventions

Not applicable.

Main Outcome Measures

Orientations of both the contralateral and ipsilateral (ie, paretic and nonparetic) shoulders during rest in degrees, angular displacement (degrees) for threshold to detection of passive motion (TDPM) tests, and absolute error (degrees) for passive reproduction of joint position (PRJP) tests.

Results

The contralateral shoulder of patients with PSSP showed more scapular lateral rotation and larger TDPM and PRJP scores than both patients without PSSP and control subjects. Additionally, the contralateral shoulder of patients with deteriorated proprioception showed more scapular lateral rotation than control subjects, whereas their ipsilateral shoulder showed more scapular lateral rotation than both control subjects and patients with good proprioception.

Conclusions

A clear relation among affected shoulder kinematics, affected proprioception, and PSSP was found. In determining the risk of developing PSSP, attention should be paid to a patients shoulder proprioception and kinematics. If both are altered after stroke, this could worsen the initial pathology or cause secondary pathologies and thus initiate a vicious circle of repetitive soft tissue damage leading to chronic PSSP. Additionally, more attention should be paid to the ipsilateral (ie, nonparetic) shoulder because it could be used in determining the risk of developing PSSP in the contralateral (ie, paretic) shoulder.     

Learning to Control Opening and Closing a Myoelectric Hand

Bouwsema H, van der Sluis CK, Bongers RM. Learning to control opening and closing a myoelectric hand.

Objective

To compare 3 different types of myoelectric signal training.

Design

A cohort analytic study.

Setting

University laboratory.

Participants

Able-bodied right-handed participants (N=34) randomly assigned to 1 of 3 groups.

Interventions

Participants trained hand opening and closing on 3 consecutive days. One group trained with a virtual myoelectric hand presented on a computer screen, 1 group trained with an isolated prosthetic hand, and 1 group trained with a prosthetic simulator. One half of the participants trained with their dominant side, and the other half trained with their nondominant side. Before and after the training period, a test was administered to determine the improvement in skill. Participants were asked to open and close the hand on 3 different velocities at command.

Main Outcome Measures

Peak velocity, mean velocity, and number of peaks in the myoelectric signal of hand opening and closing.

Results

No differences were found for the different types of training; all participants learned to control the myoelectric hand. However, differences in learning abilities were revealed. After learning, a subgroup of the participants could produce clearly distinct myoelectric signals, which resulted in the ability to open and close the hand at 3 different speeds, whereas others could not produce distinct myoelectric signals.

Conclusions

Acquired control of a myoelectric hand is irrespective of the type of training. Prosthetic users may differ in learning capacity; this should be taken into account when choosing the appropriate type of control for each patient.     

Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were proposed

Objective

Results of reliability and agreement studies are intended to provide information about the amount of error inherent in any diagnosis, score, or measurement. The level of reliability and agreement among users of scales, instruments, or classifications is widely unknown. Therefore, there is a need for rigorously conducted interrater and intrarater reliability and agreement studies. Information about sample selection, study design, and statistical analysis is often incomplete. Because of inadequate reporting, interpretation and synthesis of study results are often difficult. Widely accepted criteria, standards, or guidelines for reporting reliability and agreement in the health care and medical field are lacking. The objective was to develop guidelines for reporting reliability and agreement studies.

Study design and setting

Eight experts in reliability and agreement investigation developed guidelines for reporting.

Results

Fifteen issues that should be addressed when reliability and agreement are reported are proposed. The issues correspond to the headings usually used in publications.

Conclusion

The proposed guidelines intend to improve the quality of reporting.     

The effect of medial patellar taping on pain, strength and neuromuscular recruitment in subjects with and without patellofemoral pain

Objectives

Patellar taping is used by clinicians to reduce pain, increase strength and enhance neuromuscular recruitment in patients with patellofemoral pain. This study explored the effect of medial patellar taping on these parameters in physically active subjects with and without patellofemoral pain.

Study design

A placebo-controlled clinical trial with randomised interventions.

Setting

Sport Science Institute of South Africa.

Participants

Fifteen subjects with patellofemoral pain (experimental group) and 20 subjects without patellofemoral pain (healthy cohort).

Methods

Pain perception, quadriceps force output and electromyographic (EMG) data were collected during maximal quadriceps strength testing and submaximal step testing for each intervention.

Intervention

Subjects were tested during three different knee taping conditions: (1) no tape; (2) placebo tape; and (3) medial tape, in a randomised order.

Main outcome measures

Visual analogue scale (VAS), isokinetic and isometric force output, and EMG analysis.

Results

Medial patellar tape did not result in a significant reduction in pain during the step testing (step-up) in the group with patellofemoral pain (no tape condition: mean VAS 1.0, 95% confidence interval 0.30-1.70; taped condition: mean VAS 1.07, 95% confidence interval 0.22-1.91) or an increase in quadriceps force output. However, there was a significant decrease in EMG activity of the vastus medialis oblique in both groups during the closed chain step test (e.g. group with patellofemoral pain, no tape condition: mean 77%, 95% confidence interval 62-92%; taped condition: mean 64%, 95% confidence interval 53-75%, P < 0.05).

Conclusion

Although taping did not reduce pain in the patellofemoral pain group, it did enhance the efficiency of the vastus medialus oblique. Future studies should determine whether there are clinical benefits to these findings.     

Neuromuscular Electrical Stimulation Training: A Safe and Effective Treatment for Facioscapulohumeral Muscular Dystrophy Patients

Colson SS, Benchortane M, Tanant V, Faghan J-P, Fournier-Mehouas M, Benaïm C, Desnuelle C, Sacconi S. Neuromuscular electrical stimulation training: a safe and effective treatment for facioscapulohumeral muscular dystrophy patients.

Objective

To investigate the feasibility, safety, and effectiveness of neuromuscular electrical stimulation (NMES) strength training in facioscapulohumeral muscular dystrophy (FSHD) patients.

Design

Uncontrolled before-after trial.

Setting

Neuromuscular disease center in a university hospital and a private-practice physical therapy office.

Participants

FSHD patients (N=9; 3 women, 6 men; age 55.2±10.4y) clinically characterized by shoulder girdle and quadriceps femoris muscle weakness.

Interventions

Patients underwent 5 months of strength training with NMES bilaterally applied to the deltoideus, trapezius transversalis, vastus lateralis, and vastus medialis muscles for five 20-minute sessions per week.

Main Outcome Measures

Plasma creatine kinase (CK) activity; scores for pain and fatigue on visual analog scales (VAS), manual muscle testing (MMT), maximal voluntary isometric contraction (MVIC), 6-minute walking tests (6MWT), and self-reported changes in daily living activities.

Results

NMES strength training was well tolerated (CK activity and pain and fatigue scores on VAS were not modified). Most of the muscle functions (shoulder flexion and extension and knee extension) assessed by MMT were significantly increased. MVIC of shoulder flexion and abduction and the 6MWT distance were also improved.

Conclusions

In FSHD, NMES strength training appears to be safe with positive effects on muscle function, strength, and capacity for daily activities.     

Can four key psychosocial risk factors for chronic pain and disability (Yellow Flags) be modified by a pain management programme?: A pilot study

Objectives

To identify the extent to which an adapted pain management programme is successful in modifying pain beliefs, psychological distress, locus of control and self-efficacy using both qualitative and quantitative approaches.

Design

Prospective, observational study with questionnaires at baseline and following completion of a pain management programme.

Setting

Outpatient pain management programme in a district general hospital.

Participants

Fifteen participants experiencing chronic pain, referred from pain and rheumatology clinics within the hospital.

Outcome measures

Pain beliefs, self-efficacy, locus of control and psychological distress.

Results

Wilcoxon signed ranks tests demonstrated significant improvements in pain beliefs, self-efficacy and psychological distress. However, changes in locus of control were not found to be significant. The qualitative data supported these findings.

Conclusions

The pilot study suggested that the pain management programme successfully modified three out of four of the psychosocial risk factors (Yellow Flags) in a population with established pain and disability. A larger scale project replicating this pilot study including a comparison group, and further research to assess the extent to which modifying Yellow Flags generalises to affect quality of life and disability, are underway.     

Weight Lifting in Patients With Lower-Extremity Lymphedema Secondary to Cancer: A Pilot and Feasibility Study

Katz E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study.

Objective

To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.

Design

Before-after pilot study with a duration of 5 months.

Setting

University of Pennsylvania.

Participants

Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.

Intervention

Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months.

Main Outcome Measures

The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.

Results

Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life.

Conclusions

Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.     

The Effects of Foot Position on the Performance of the Sit-To-Stand Movement With Chronic Stroke Subjects

Camargos AC, Rodrigues-de-Paula-Goulart F, Teixeira-Salmela LF. The effects of foot position on the performance of the sit-to-stand movement with chronic stroke subjects.

Objective

To investigate the effects of different foot positions during the sit-to-stand (STS) movements with stroke subjects.

Design

Cross-sectional.

Setting

Research laboratory.

Participants

Twelve chronic stroke subjects (N=12).

Interventions

Not applicable.

Main Outcome Measures

Differential latency and electromyography (EMG) activity of the tibialis anterior, soleus, quadriceps, and hamstring muscles of the affected leg as well as the movement time, time of seat-off, weight symmetry, and rising index were obtained while the subjects performed the STS movements by using 4 different strategies: spontaneous; symmetric; asymmetric-1, with the affected foot behind; and asymmetric-2, with the unaffected foot behind.

Results

Compared with the spontaneous strategy, the soleus showed the greatest differential latency in the asymmetric-2 strategy, the hamstrings had lower EMG activity in the symmetric strategy, and the movement time was greater in the asymmetric strategies.

Conclusions

The asymmetric 2 strategy appeared to be the least favorable, whereas the spontaneous and the symmetric strategies appeared to be more favorable in improving the STS performance. Based on these findings, allowing the subjects to adopt the spontaneous strategy or training of the symmetric strategy could result in greater benefits for subjects with higher chronicity and higher functional levels, such as those evaluated in the present study.     

Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study

Lew HL, Lee EH, Castaneda A, Klima R, Date E. Therapeutic use of botulinum toxin type A in treating neck and upper-back pain of myofascial origin: a pilot study.

Objective

To determine the efficacy of botulinum toxin type A (BTX-A) in treating neck and upper-back pain of myofascial origin.

Design

A randomized, double-blind, placebo-controlled pilot study.

Setting

Outpatient physical medicine and rehabilitation clinic of a university-affiliated tertiary hospital.

Participants

A total of 29 subjects enrolled from among 45 screened patients. No subject withdrawal due to serious adverse events occurred.

Intervention

Subjects were evaluated at baseline, received a 1-time injection of either BTX-A (treatment group) or saline (control group), and were followed up at 2 weeks and at months 1, 2, 3, 4, and 6.

Main Outcome Measures

Visual analog scale (VAS) for pain, the Neck Disability Index (NDI), and the Medical Outcome Study 36-Item Short-Form Health Survey (SF-36).

Results

Improvements in the VAS and NDI scores were seen in the treatment group but were not significant when compared with the controls. Statistically significant improvements for the treatment group were seen in the SF-36 bodily pain (at months 2 and 4) and mental health (at month 1) scales but not in the other scales, nor in the summary measures. No serious adverse events were reported.

Conclusions

Trends toward improvements in VAS and NDI scores of the BTX-A group are encouraging, but they were possibly due to a placebo effect and were not statistically significant. The BTX-A subjects, at certain time points, showed statistically significant improvements in the bodily pain and mental health scales of the SF-36 compared with controls. Our study had limited power and population base, but the results could be used to properly power follow-up studies to further investigate this topic.     

Intraobserver reliability of angular and linear measurements of scapular position in subjects with and without symptoms

Lewis JS, Valentine RE. Intraobserver reliability of angular and linear measurements of scapular position in subjects with and without symptoms.

Objective

To assess intraobserver reliability of angular and linear clinical measurements of scapular position.

Design

Test-retest analyses.

Setting

Outpatient department in National Health Service teaching hospital in the United Kingdom.

Participants

Subjects (n=45) without symptoms (21 men, 24 women; age range, 23-56y) and 45 subjects (22 men, 23 women; age range, 19-84y) with shoulder symptoms (defined as pain in the C5-6 dermatome reproduced by shoulder movement and not reproduced with cervical movement).

Interventions

Not applicable.

Main Outcome Measures

Intraclass correlation coefficient (ICC) models 2,1 and 2,3, 95% confidence intervals (CIs), and SE of measurements for 68% confidence and 2 SEs of measurement (for the 95% CI) for the bilateral angular measurements of scapular rotation and tilt, and the bilateral linear measurements of lateral scapular displacement (protraction) and vertical displacement (elevation).

Results

For subjects without symptoms, ICC_2,3 results ranged from .75 to .98. The 2 SE results for the angular movements ranged from 1.8° to 2.4° and from 0.4 to 1.0cm for the direct linear measurements. Subjects with symptoms: ICC_2,3 results ranged from .61 to .98. The 2 SE results for the angular movements ranged from 1.4° to 2° and from 0.6 to 1cm for the direct linear measurements.

Conclusions

Repeated-measure (ICC_2,3) results were more reliable than single-measure (ICC_2,1) results. Very good to excellent intraobserver reliability was demonstrated for the angular and linear measurements of interest in both shoulders of subjects with and without symptoms. The 2 SE results provide guidance about the error associated with the individual measurements and will assist the clinician determining whether a change in the static position of the scapula has occurred as a result of intervention or over time. (National Research Register identifier N0060148286.)     

Trunk Muscle Activity During Wheelchair Ramp Ascent and the Influence of a Geared Wheel on the Demands of Postural Control

Howarth SJ, Polgar JM, Dickerson CR, Callaghan JP. Trunk muscle activity during wheelchair ramp ascent and the influence of a geared wheel on the demands of postural control.

Objectives

To quantify levels of torso muscular demand during wheelchair ramp ascent and the ability of a geared wheel to influence trunk muscle activity.

Design

Repeated-measures design. Each participant completed manual wheelchair ramp ascents for each combination of 4 ramp grades (1:12, 1:10, 1:8, and 1:6) and 3 wheel conditions (in gear, out of gear, and a standard spoked wheel) in a block randomized order by wheel condition.

Setting

Biomechanics laboratory.

Participants

Healthy novice wheelchair users (N=13; 6 men) from a university student population.

Interventions

Not applicable.

Main Outcome Measures

Peak electromyographic activity, expressed as a percentage of maximal voluntary isometric contraction (MVIC) of the abdominals, latissimus dorsi, and erector spinae during ramp ascent. Temporal location of peak electromyographic activity (EMG) within a propulsive cycle and integrated electromyographic activity for a single propulsive cycle.

Results

Abdominal peak activity increased 13.9% MVIC while peak posterior trunk muscle activity increased 4.9% MVIC between the shallowest and steepest ramp grades (P<.05). The geared wheel prevented increased peak activity of the rectus abdominis and external oblique (P>.05). Only peak electromyographic timing of the erector spinae was influenced during the push phase by increasing ramp slope.

Conclusions

Increased trunk muscular demand as a result of increasing ramp slope is required to enhance stiffness of the spinal column and provide a stable base during manual propulsion. Manual wheelchair users with compromised activity capacity, compromised abdominal muscle strength, or both, may be able to navigate more difficult terrains while using a geared wheelchair wheel because of reduced demands from the abdominal musculature in the geared wheel condition.