Intra- and intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with knee restrictions

OBJECTIVE: To examine the intra- and intertester reliability of the universal goniometer (UG) and parallelogram goniometer (PG), and to assess the criterion validity of the same instruments on subjects with knee restrictions. DESIGN: Reliability and validation study. SETTING: Radiology department at university hospital. PARTICIPANTS: Sixty subjects (34 men, 26 women; mean age, 52yr) with various knee restrictions. INTERVENTIONS: Sixteen goniometric measurements were collected per patient by 2 physical therapists. Subjects were evaluated in knee flexion and knee extension positions. To serve as a gold standard, radiographs were taken in both positions. MAIN OUTCOME MEASURES: Active knee flexion and knee extension on 2 goniometers, radiographs. Maximum active range of motion (AROM). RESULTS: The UG intratester reliability (intraclass correlation coefficients [ICCs]) was .997 in flexion and .972 to .985 in extension. The results were also high with the PG (ICC =.996,.953-.955) for flexion and extension, respectively. The intertester reliability was high for flexion (ICC =.977-.982) and for extension (ICC =.893-.926) when using the UG. For the PG, ICC results ranged from .959 to .970 for flexion and from .856 to .898 for extension. Criterion validity (r) varied from .975 to .987 for flexion and from .390 to .442 for extension with the UG, and from .976 to .985 for flexion and .423 to .514 for extension with the PG. CONCLUSION: Intra- and intertester reliability were high for both goniometers. The results for the criterion validity varied. Our study also revealed that it is preferable to use goniometry rather than visual estimations when measuring AROM. It is recommended that the same therapist take all the measurements when assessing AROM for UG and PG goniometric measurements on patients with knee restrictions.     

屈伸检查在颈椎病X线诊断中的应用

目的探讨前屈-后伸位功能摄片在颈椎病X线诊断中的应用价值.方法对本院100例颈椎病患者进行前屈及后伸颈椎侧位片检查,测量其前屈角、后伸角及相对角(前屈角-后伸角=相对角),观察椎体向前及/或向后滑移情况和棘突分离或相互靠近情况.结果前屈角为85°～154°,平均130°.后伸角为42°～87°,平均62°.相对角32°～98°,平均67°.前屈位见颈椎椎体前移者71例,后移者5例,部分椎体前移部分椎体后移者2例;后伸位见颈椎椎体后移者82例;前屈位见局部棘突不能分离者13例;后伸位见局部棘突不能靠近者51例.结论屈伸检查能发现常规颈椎正侧斜位片所未能显示的颈椎失稳和功能改变;有时还能发现常规片中未能显示或显示不清楚的解剖结构性改变;对X线观察颈椎运动,记录局部韧带损害,颈椎失稳及用以估计治疗后功能恢复的程度有重要作用.     

Mobility of the cervical spine after anterior interbody fusion for spondylotic myelopathy—a radiographic study

To study the influence of anterior body fusion on the adjacent vertebral discs, the radiographs of 101 patients with cervical spondylotic myelopathy (CSM) were analysed, and cervical mobility and intersegmental mobility were determined. Single level fusions were carried out in 29 patients, double level fusions in 45 patients and triple level fusions in 27 patients. Cervical mobility after surgery was inversely proportional to the number of fused discs. Angles were reduced by fusion in proportion to the number of fused discs. The compensatory increase in motion at the disc adjacent to the fusion was slight, and the number of fused discs had little influence on the compensatory increase in motion. Regarding cervical motion, extension and flexion were limited to the same extent in single level fusions, flexion was more limited in double level fusions and limitation of extension was much larger in triple level fusions.Seven patients underwent a second operation after a double level fusion, and one patient underwent a second operation after a single level fusion. In all five patients whose radiographs before the second operation were available, flexion was adequately limited, but extension was not limited at all. These results suggest that the failure to limit extension is responsible for the recurrence of CSM.     

牵引位下影像学评价腰椎滑脱的垂直失稳及治疗策略

背景：腰椎滑脱一般通过影像学屈伸位片进行确认,通常用滑移距离和滑脱角表明滑脱的严重程度。目的：复制腰椎滑脱中的垂直失稳模式,寻求有效的影像学评价方式。方法：纳入37例腰椎滑脱患者,分别拍直立位、侧卧位、仰卧牵引位、俯卧牵引位腰骶段侧位X射线片。分别在X射线平片上测量间盘面积、滑脱角、滑移距离变化。结果与结论：在患者直立屈曲位片上可测量最大滑脱角、最大滑移距离百分比、最小的间盘面积百分比。俯卧牵引位和侧卧伸展位可测量最小滑脱角,仰卧和俯卧牵引位可测量最小滑移百分比。与其他体位相比俯卧牵引位下的间盘面积百分比最大。直立屈曲位和俯卧牵引位下滑脱角的变化与滑脱节段间盘面积百分比有关。直立屈曲位和俯卧牵引位分别复制了滑脱最严重的程度和复位最大程度。滑移距离的变化与间盘面积和滑脱角的变化有关,节段的垂直失稳是因间盘退变导致韧带和间盘纤维环松弛所致。间盘高度及周围软组织张力的恢复可使滑脱节段自动复位。因此可用植入椎间融合器或骨块行椎间融合治疗腰椎滑脱。峡部裂型滑脱因后柱成分缺失,可行后路椎弓根螺钉固定重建。     

The biomechanics of the lumbar multifidus

The possible actions of the lumbar multifidus were determined by plotting the points of attachment and orientation of each of its component fascicles on radiographs of 5 cadavers and 21 living subjects. Subsequent analysis revealed that the principal action of multifidus is posterior sagittal rotation (extension without posterior translation) of the lumbar vertebrae. It has no translatory action. Any axial rotation exerted by the lumbar multifidus is only a minor, secondary action which must be coupled with posterior sagittal rotation. This extension balances the flexion moment generated by the abdominal muscles which rotate the trunk. The constancy of the sites of attachment of the multifidus allows each of its fascicles to be plotted accurately on radiographs or computer diagrams which can be used to produce highly detailed analyses or models of the forces exerted by the multifidus on the lumbar spine.     

Differences of lumbosacral kinematics between degenerative and induced spondylolisthetic spine

OBJECTIVE: To investigate the differences of lumbosacral kinematics between degenerative and induced spondylolisthetic subjects. DESIGN: Translations and angulations of spondylolisthetic spine from L1-L2 to L5-S1 were documented by taking X-ray films at flexion, standing and extension positions. BACKGROUND: The unstable mechanism of spondylolisthesis leads to lower back pain. It is important to determine the kinematics and the process of spondylolisthesis. METHODS: Nineteen subjects with spondylolisthesis participated in this research, seven subjects with diagnosis of degenerative and 12 with induced spondylolisthesis, were taken lateral radiographs at three positions including flexion, standing and extension. RESULTS: The differences of angulation among three positions (flexion, standing, and extension) at different levels were statistically significant (P<0.05) in both spondylolisthetic groups. The differences of translation among three different positions in induced spondylolisthetic group had a statistical significance (P<0.05) except at the level of L5-S1 (P>0.05). CONCLUSIONS: Segmental total translation and angulation at each level of induced spondylolisthetic spine were greater than those of degenerative spondylolisthetic spine except L5-S1 level, which illustrated the evolution of spondylolisthesis from unstable to less unstable. RELEVANCE: The results showed induced spondylolisthesis may link to degenerative spondylolisthesis. It provided essential knowledge to detect the evolution of degenerative spondylolisthesis clinically earlier.     

The role of axial torque in disc herniation

Background

Epidemiological studies have found associations between lifting, lifting and twisting and twisting alone with increased incidence of disc herniation. This study investigated the role of repeated dynamic axial torque/twist combined with repeated flexion on the disc herniation mechanism.

Methods

Porcine cervical spines were tested in one of the following four testing protocols: flexion–extension only; axial torque/twist only; flexion–extension followed by axial torque/twist; or axial torque/twist followed by flexion–extension. Plane film radiographs and computed tomography with contrast in the nucleus were obtained at regular intervals during and following the mechanical testing process together with final dissection to determine the disc injury patterns.

Findings

Axial torque/twist in combination with repetitive flexion extension motion, regardless of order, encouraged radial delamination within the annulus (67.5% of specimens). Alternatively, repetitive flexion motion alone encouraged posterior or posterolateral nucleus tracking through the annulus. Axial torque/twist alone was unable to initiate a disc herniation. Both X-ray images with contrast and computed tomography were not good at detecting radial delamination observed during dissection.

Interpretation

The clinical relevance is that twisting may cause more radial delamination while repeated flexion causes more posterior tracking of the nucleus giving guidance for both prevention and rehabilitation decisions. In addition, X-ray images with contrast are not effective at detecting the radial delamination which was exacerbated by combined loading in flexion extension and axial torque/twist.     

Varus alignment after total knee arthroplasty results in greater axial rotation during deep knee bend activity

BackgroundsThe correlation between in vivo knee kinematics and alignment has not been fully elucidated. Recently, similar or better clinical outcomes have been reported by restoration of mild varus alignment after total knee arthroplasty for preoperative varus knees. The aim of this study was to evaluate the effect of postoperative alignment on knee kinematics during a deep knee bend activity.MethodsIn vivo knee kinematics of 36 knees (25 patients) implanted with tri-condylar total knee arthroplasty were analyzed with a three dimensional model fitting approach using fluoroscopy. Under fluoroscopic surveillance, individual video frames were digitized at 30° increments from full extension to maximum flexion. Postoperative coronal and sagittal alignments were assessed using radiographs, and rotational alignment was assessed with computed tomography. Pearson correlation coefficients were calculated to determine the correlations between the alignment data and kinematic factors.FindingsCorrelation analysis showed that coronal alignment was significantly correlated with knee kinematics. The varus alignment of the limb and tibial component led to a greater axial rotation from full extension to maximum flexion and more rotated position in the mid to deep flexion range. Neither the rotational alignment of the femoral nor tibial components showed significant correlation with axial rotation from full extension to maximum flexion.InterpretationVarus alignment resulted in greater axial rotation, which could represent near-normal knee kinematics. The current study can be a kinematic rationale reporting similar or better clinical and functional outcomes for the total knee arthroplasty with residual varus alignment.     

Agreement of measures obtained radiographically and by the OSI CA-6000 Spine Motion Analyzer for cervical spinal motion

The purpose of this study was to determine the agreement between angular measures of cervical spinal motion obtained from radiographs and from measures recorded by the OSI CA 6000 Spine Motion Analyzer (OSI SMA) in asymptomatic subjects. Fourteen subjects performed each of the following motions two times while wearing the OSI SMA: cervical flexion, extension, side bending to the right and left. Each motion was performed once for the cervical radiograph. The difference between the values obtained by the two methods was plotted against the average of those values for each subject to illustrate the level of agreement of the two methods. The plotted points were widely scattered, with a large range between the limits of agreement. Range of motion values taken from the OSI SMA were not similar to those obtained from radiographs for the motions of the cervical spine.     

Avulsion traumatique du tendon tricipital brachial : à propos d’un cas

The authors report the rare case of a socker having a complete avulsion of the triceps brachii tendon. The diagnosis was evoked on profil standard radiographs of the elbow. Treatment was surgical by reinsertion of the tendon through olecranon. Follow up at 24 months, the results were satisfactory with total recovery of the function of the triceps and elbow flexion extension perfect.     

Normal range of motion of the cervical spine

To evaluate the normal range of motion of the cervical spine, 70 healthy subjects were studied using radiography and clinical examination. An equal number of men and women were studied; age ranged from 12 to 79 years. Radiographs were taken in the lateral projection during maximal flexion and extension. In the frontal projection, radiographs were taken during maximal bending to the left and right. The radiographs were analyzed on a digitizing tablet linked to a computer, using preset points to indicate the motion between the vertebrae. The intraobserver error of measurement was +/- 1.8 degrees. The range of axial rotation was measured with the aid of a compass placed on the subject's head. The intraobserver error of measurement with this technique was +/- 6 degrees. The largest intersegmental flexion-extension motion occurred between C4/C5 and C5/C6. A linear decrease of motion in all directions, except in flexion, was found with age. There was no statistically significant difference in motion for men and women. The reliability of methods is discussed.     

Occult ligamentous injury of the cervical spine

Evaluating the cervical spine for injury is an essential part of the assessment of a traumatized patient. Clinical examination and radiographs are the traditional techniques used for this evaluation. Often, however, a reliable clinical examination is not possible because of head injury, altered mental status, or "distracting" injuries. In such cases, cervical spine injury that is not apparent on radiographs may be missed. This case report illustrates a purely ligamentous cervical spine injury resulting in cervical instability. We describe our method of screening for and evaluating these types of injuries using physician-controlled stretch, flexion, and extension examination under fluoroscopy.     

Intersegmental sagittal motion in the lower cervical spine and discogenic spondylosis: a preliminary study.

OBJECTIVE: The object of this investigation was to identify any correlation between discogenic spondylosis and the type of motion (normal, hypomobility, hypermobility, paradoxical motion) found in the sagittal plane of the intervertebral motion units of the lower cervical spine. DESIGN AND SETTING: A case control study was performed from the files of 100 patients (ages 15-73) with cervical spine-related symptomatology at the Anglo-European College of Chiropractic Clinic. PATIENTS: The cases were randomly selected from a cohort of patients with normal radiographic anatomy who attended the clinic from 1987-1990 and were known to have cervical spine neutral, flexion and extension lateral radiographs taken. MAIN OUTCOME MEASURES: Extended chi 2 was used to test the observed data. RESULTS: The findings from both the flexion and extension films suggested that intervertebral motion units with and without varying severities of discogenic spondylosis did differ with respect to the type of motion exhibited there (flexion: chi 2 = 39.399, p < .001; extension: chi 2 = 45.7424, p < .001). Intervertebral motion units which had discogenic spondylosis had a greater likelihood of exhibiting motion abnormalities (flexion: chi 2 = 5.665, p < .01; extension: chi 2 = 6.178, p < .01), and all types of motion seemed to be dependent on its severity (flexion: chi 2 = 16.464, p < .01; extension: chi 2 = 15.954, p < .02). In general, normal motion occurred approximately 60% of the time when there was absent or mild discogenic spondylosis and decreased precipitously as moderate and severe amounts of discogenic spondylosis appeared. In global cervical flexion, when there was either little or no discogenic spondylosis and abnormal motion was present, intersegmental hypermobility was predominant. Hypomobility became predominant overall as moderate and severe discogenic spondylosis was found. In global cervical extension, for all severities of discogenic spondylosis when there was abnormal motion, intersegmental hypomobility was predominant. Also of note was the presence of paradoxical motion, which occurred in 11% of the intervertebral motion units without discogenic spondylosis [usually at the C7-T1 intervertebral motion unit (86%)]. CONCLUSIONS: From the data it can be concluded that there are trends which occur with differing amounts of discogenic spondylosis when considering intersegmental cervical sagittal motion. However, additional detailed study is required to corroborate the findings and determine what their clinical significance is.     

Functional radiographs of the craniocervical region and the cervical spine. A new computer-aided technique

Disabilities of the articulations of the head and cervical spine can often be detected only by exact measurement of functional radiographs. From two radiographs, one in flexion and one in extension, not only can the total mobility of the head be measured, but also the mobility of the individual articulations can be evaluated by taking exact measurements of the position of each vertebra. A method for semi-automatic measuring of such pairs of radiographs is presented. Edges and structures of the bones that are clearly visible in both radiographs are digitized on a graphics tablet. Then, by computer program, each vertebra of the first radiograph is shifted and rotated until it fits best to the respective vertebra of the second radiograph. Thus, for each articulation, the mobility angle and the location of the mobility axis relative to the adjacent vertebra, can be computed. First experiences with this method are presented.     

Radiological and magnetic resonance imaging of cervical spine instability: a case report

Hypermobility and instability following injury and degenerative joint disease is poorly understood and often not recognized as the cause of the patients symptoms. Routine radiographs should be complemented by flexion/extension studies. Magnetic resonance imaging has been found useful in demonstrating degenerative disc disease, disc herniations, cord impingements and instabilities that are not amenable to diagnosis by myelograms and computed tomography.     

Transverse Ultrasound Assessment of Median Nerve Deformation and Displacement in the Human Carpal Tunnel during Wrist Movements

The symptoms of carpal tunnel syndrome, a compression neuropathy of the median nerve at the wrist, are aggravated by wrist motion, but the effect of these motions on median nerve motion are unknown. To better understand the biomechanics of the abnormal nerve, it is first necessary to understand normal nerve movement. The purpose of this study was to evaluate the deformation and displacement of the normal median nerve at the proximal carpal tunnel level on transverse ultrasound images during different wrist movements, to have a baseline for comparison with abnormal movements. Dynamic ultrasound images of both wrists of 10 asymptomatic volunteers were obtained during wrist maximal flexion, extension and ulnar deviation. To simplify the analysis, the initial and final shape and position of the median nerve were measured and analyzed. The circularity of the median nerve was significantly increased and the aspect ratio and perimeter were significantly decreased in the final image compared with the first image during wrist flexion with finger extension, wrist flexion with finger flexion and wrist ulnar deviation with finger extension (p < 0.01). There were significant differences in median nerve displacement vector between finger flexion, wrist flexion with finger extension and wrist ulnar deviation with finger extension (all p's < 0.001). The mean amplitudes of median nerve motion in wrist flexion with finger extension (2.36 ± 0.79 normalized units [NU]), wrist flexion with finger flexion (2.46 ± 0.84 NU) and wrist ulnar deviation with finger extension (2.86 ± 0.51 NU) were higher than those in finger flexion (0.82 ± 0.33 NU), wrist extension with finger extension (0.77 ± 0.46 NU) and wrist extension with finger flexion (0.81 ± 0.58 NU) (p < 0.0001). In the normal carpal tunnel, wrist flexion and ulnar deviation could induce significant transverse displacement and deformation of the median nerve.     

Muscular endurance and wheelchair propulsion in children with cerebral palsy or myelomeningocele.

Bivariate correlations between muscular endurance or resistance used during six-repetition maximum (6-RM) for eight upper body exercises (shoulder flexion, extension, abduction, internal and external rotation, elbow flexion, extension and shoulder flexion/elbow extension (bench press), 50-meter dash, and 12-minute wheelchair propulsion tests were examined in six children with diagnoses of cerebral palsy or myelomeningocele. Correlations were determined before and after resistance training. Before training, only elbow extension correlated significantly with the 12-minute test. Following training, significant correlations (p less than or equal to 0.05) were found between all 6-RM exercises and 12-minute test scores. Additionally, significant correlations were found between all 6-RM exercises (except elbow flexion, which approached significance) and 50-meter dash scores. The results of this clinical case investigation indicate that the relationship between muscular endurance (6-RM) and wheelchair propulsion improves as muscular endurance increases.     

Relationship between knee range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis

OBJECTIVE: To investigate the relationships between the joint range of motion and Kellgren-Lawrence radiographic scores of knee joint compartments in patients with knee osteoarthritis. DESIGN: Forty knees of 20 consecutive bilateral, primary knee osteoarthritis patients were examined in the study. Maximal flexion, extension, and internal and external rotation were assessed using a goniometer. Kellgren-Lawrence radiographic scores were determined for medial tibiofemoral, lateral tibiofemoral, and patellofemoral compartments of the knee joint on lateral, tangential, and standing anteroposterior radiographs. RESULTS: Statistically significant negative correlations were found between the range of motion and radiographic scores. Specifically, internal rotation was correlated with lateral compartment scores (r = -0.439, P < 0.01), and external rotation and flexion were correlated with medial compartment scores (r = -0.361, P < 0.05; r = -0.338, P < 0.05; respectively) [corrected]. Extension values were correlated with patellofemoral ( = -0.533, < 0.01), medial (r = -0.456, P < 0.01), and lateral (r = -0.327, P < 0.05) compartment scores. CONCLUSIONS: A clear relationship is present between joint range of motion and Kellgren-Lawrence radiographic scores in knee osteoarthritis patients. Examination of the joint range of motion can give information about the compartmental distribution of the disease and help the physician focus on the compartment or compartments involved when performing diagnostic and therapeutic procedures. Evaluation of the compartments of the knee joint in radiographs can be informative about the joint range of motion in knee osteoarthritis.     

不同年龄与不同位置下进行远端指间关节活动度的测量研究

摘要 目的：使用通用量角器测量远端指间关节活动度,探讨不同年龄和不同姿势对测量结果的影响。 方法：选取40名健康志愿者（20名年轻人和20名老年人）,对其在四个姿势下（即姿势1近端指间关节屈曲并主动屈曲远端指间关节、姿势2近端指间关节屈曲并被动屈曲远端指间关节,姿势3近端指间关节伸直并主动屈曲远端指间关节,姿势4近端指间关节伸直并被动屈曲远端指间关节）分别进行远端指间关节活动度的测量。 结果：在同一年龄组,近端指间关节屈曲和伸直位可对远端指间关节的活动度产生明显的影响。即使保持近端指间关节在同一姿势,远端指间关节主动活动度和被动活动度值间差异具有显著性。另外,近端指间关节伸直位时远端指间关节主动屈曲的活动度明显小于近端指间关节屈曲位时远端指间关节被动屈曲的活动度。在同一姿势下,年轻人与老年人的远端指间关节活动度也存在显著性差异。 结论：不同年龄和不同姿势可明显影响远端指间关节活动度的测量结果。     

Cervical muscle co-activation in isometric contractions is enhanced in chronic tension-type headache patients

The purpose of the study was to compare the co-activation of cervical agonist and antagonist muscles between people with chronic tension-type headache (CTTH) and healthy controls during brief isometric cervical flexion and extension contractions. Nine women with CTTH and 10 matched controls participated. Surface electromyographic (EMG) signals were detected from the sternocleidomastoid and splenius capitis muscles bilaterally during cervical flexion and extension contractions of linearly increasing force from 0% to 60% of the maximum voluntary contraction (MVC) in 3 s. Sternocleidomastoid and splenius capitis EMG average rectified values (ARV) were estimated at 10% MVC force increments. During cervical extension contraction, sternocleidomastoid (i.e. antagonist muscle) ARV was greater for patients than for controls in the force range 20–60% MVC ( P  = 0.029). During cervical flexion, the left splenius capitis (i.e. antagonist muscle) ARV was greater for CTTH patients regardless of the force level ( P  = 0.02). Maximum cervical flexion and extension force was lower for the CTTH patients compared with controls ( P  = 0.001). In conclusion, women with CTTH demonstrated greater co-activation of antagonist musculature during cervical extension and flexion contractions compared with healthy women. Increased co-activation of antagonist musculature may reflect reorganization of the motor control strategy in CTTH patients, potentially leading to muscle overload and increased nociception.