Inter-rater Accuracy and Reliability of a Palpation Protocol of the C7 Spinous Process Comprising a Combination of 3 Traditional Palpation Techniques

ObjectiveThe purpose of this study was to determine the accuracy and intrarater reliability of a palpatory protocol based on a combination of 3 palpatory methods to identify both the C7 spinous process (C7 SP) and the factors that affect the errors and inaccuracy of palpation.MethodsTwenty-five women between the ages of 18 and 60 years were submitted to a palpation protocol of the C7 SP, and a radiopaque marker was fixed on the skin at the possible location of the vertebrae. A radiograph and a photograph of the cervical spine were obtained in the same posture by a first rater. A second rater performed the same palpation protocol and took a second photograph. The accuracy and measurement error of the palpation protocol of C7 SP were assessed through radiographic images. The inter-rater reliability was estimated by the interclass correlation coefficient and assessed using photographs of each rater. The Pearson's correlation coefficients (r), the Fisher exact test, and the χ² test were used to identify the factors associated with the error and inaccuracy of palpation.ResultsAccuracy of the C7 palpation was 76% with excellent reliability (interclass correlation coefficient = 0.99). There was a moderate correlation between weight and the measurement of palpation error (r = –0.6; P = .003). One hundred percent of inaccuracy palpation was related to the increased soft-tissue thickness (P = .005) in the cervical region.ConclusionThe palpation protocol described in this study was accurate and presented excellent reliability in identifying the C7 SP. Increased weight and dorsocervical fat pad were associated to error and palpation inaccuracy, respectively.     

Sonographically Guided Proximal Tibiofibular Joint Injection

Objective. The purpose of this investigation was to describe a technique for sonographically guided proximal tibiofibular joint (PTFJ) injections and compare its accuracy with that of palpation guided injections in a cadaveric model. Methods. A single experienced operator completed 12 sonographically guided and 12 palpation guided PTFJ injections in unembalmed cadavers. The injection order was randomized, and all injections were completed with diluted colored latex. Coinvestigators blinded to the injection technique dissected each specimen and graded the colored latex location as accurate (in the PTFJ), accurate with overflow (within the PTFJ but also in other regions), or inaccurate (no latex in the joint). For statistical analysis, all injections placing latex within the PTFJ were considered “accurate,” whereas “inaccurate” injections resulted in no PTFJ latex. Results. All 12 sonographically guided PTFJ injections accurately placed latex into the PTFJ (100% accuracy), whereas only 7 of 12 palpation guided injections (58%) placed latex within the PTFJ (P = .01). All 5 inaccurate palpation guided injections were superficial and inferior to the PTFJ. Four of 12 accurate sonographically guided PTFJ injections (33%) showed some overflow into the adjacent anterior musculature, whereas 5 of the accurate palpation guided injections (42%) resulted in overflow into the anterior musculature (1), knee joint (2), or both (2). Conclusions. This cadaveric investigation suggests that sonographic guidance can be used to inject the PTFJ with a high degree of accuracy and should be considered superior to palpation guidance. Clinicians should consider using sonographic guidance to inject the PTFJ for diagnostic or therapeutic purposes when clinically indicated.     

Accuracy of rib palpation for dry needling of deep periscapular musculature,measured with ultrasound

IntroductionDry needling of the periscapular musculature is a procedure commonly performed by physical therapists. Needling of the deep musculature may be challenging, and use of a thoracic rib as a “backstop” is often applied to prevent inadvertent puncture of the pleura. The aim of this study was to: 1) To examine the accuracy rate of experienced physical therapists in identifying a mid-scapular thoracic rib using palpation, 2) to understand patient characteristics that affect the accuracy rate, and 3) to examine if therapist confidence levels were associated with palpatory accuracy.MethodsTwo experienced physical therapists attempted to palpate a thoracic rib in the mid-scapular region of healthy participants (n = 101 subjects, 202 ribs), and self-reported their level of confidence in an accurate palpation. Their accuracy was verified with ultrasonography.ResultsThe two physical therapists were accurate on 73.3% of palpations and did not differ in accuracy (72.0% vs. 75.0%, p = 0.747). The only ultrasonographic or subject characteristic measurement that correlated with improved accuracy was a reduced muscle thickness (p = 0.032). Therapists’ self-reported confidence levels did not correlate to actual accuracy (p = 0.153).DiscussionPhysical therapists should be aware that palpation of a thoracic rib may not be as accurate as it may seem. The greater thickness of muscle in the area reduces the accuracy of accurate palpation.ConclusionDry needling of the periscapular muscles should be done with caution if using a rib as a “blocking” technique.     

Craniocervical Posture Assessed With Photogrammetry and the Accuracy of Palpation Methods for Locating the Seventh Cervical Spinous Process: A Cross-sectional Study

ObjectiveThe purpose of this study was to compare craniocervical posture assessed by photogrammetry using 2 distinct palpation methods for locating the spinous process of the seventh cervical vertebra (C7SP).MethodsThis cross-sectional study was conducted in 2 phases. In phase I (n = 42), the assessor's accuracy in locating the C7SP using the flexion-extension and the modified thorax-rib static methods was compared to radiography. In phase II (n = 68), the craniocervical posture was analyzed with photogrammetry after palpation using the 2 methods. Neck pain intensity and disability were also determined.ResultsThe accuracy in locating the C7SP was higher using the modified thorax-rib static method (67%, 95% confidence interval [CI], 55-79) compared to the flexion-extension method (38%, 95% CI, 26-50, P = .016). Lower values of the craniocervical angle were obtained with the flexion-extension method than the modified thorax-rib static method (mean difference = ?1.1°, 95% CI, ?1.6 to ?0.6, P < .001). However, both palpation methods resulted in similar classifications of participants as with or without forward head posture (P = .096). Weak correlations were observed between the craniocervical angle and neck pain intensity (ρ = ?0.088 and ?0.099, respectively) and disability (ρ = ?0.231 and ?0.249, respectively).ConclusionCraniocervical angles obtained using palpation methods with different accuracies were different, although the magnitude of the difference was insufficient to lead to different classifications of a forward head posture in adults with mild neck pain and disability. Craniocervical posture was weakly correlated with neck-pain intensity and disability.     

Accuracy of Palpation Procedures for Locating the C1 Transverse Process and Masseter Muscle as Confirmed by Computed Tomography Images

ObjectiveThe purpose of this study was to examine the accuracy of palpation methods for locating the transverse processes of the first cervical vertebra and masseter muscle using radiographic images as the gold-standard method and the association between personal characteristics with the observed accuracy.MethodsThis was a single-blinded, diagnostic accuracy study. Ninety-five participants (49 women, 58 ± 16 years of age) were enrolled in this study. A single examiner palpated the neck and face region of all participants to identify the transverse processes of the first cervical vertebra and masseter muscles bilaterally. In sequence, participants underwent a multislice computed tomography scan for assessment of the superimposed inner body structure. Two radiologists assessed the computed tomography images using the same criteria and were blinded regarding each other's assessment and the anatomic landmarks under investigation. The palpation accuracy was calculated as the proportion of the correctly identified landmarks in the studied sample. The correlation of the palpation outcome (correct = 1; incorrect = 0) with age, sex (male = 1; female = 0), and body mass index was investigated using the point-biserial correlation coefficient.ResultsThe right and left transverse processes were correctly located in 76 (80%) and 81 (85%) participants, respectively, and bilaterally in 157 events (83%), as evaluated by the consensus of the 2 radiologists. The masseter muscles were correctly localized bilaterally in 95 of 95 (100%) participants. Body mass showed statistical evidence of a weak, positive correlation with the correct location of the transverse processes of the first cervical vertebra at the right body side (r = .219; 95% confidence interval, 0.018-0.403; P = .033).ConclusionPalpation methods used in this study accurately identified the location of the first cervical vertebra spinous processes and the masseter muscles.     

3.0 T磁共振3D-DESS与3D-SPACE对腰骶神经成像的临床应用价值比较

目的：比较3.0 T磁共振3D-DESS与3D-SPACE在腰骶丛神经(sacral plexus,SP)成像中的临床应用价值。材料与方法(1)正常志愿者组：采用男女各5名健康志愿者行3D-DESS与3D-SPACE在骶丛神经根成像,选取L5神经评价影像图像,并采用2名医师采用5分法分别主观评价两序列图像质量,测量L5神经最大长度和L5神经节长径大小,采用配对t检验比较同一序列下左右侧SP是否存在差异,其次比较两序列是否存在差异。(2)病例组：前瞻性纳入98例SP占位患者,并利用两序列行SP成像;采用与志愿者相同方法分析病灶特征和正常神经解剖结构特征评价两序列的优劣并独立评分,采用Mann-Whitney U检验,比较两序列在显示SP病变特征差异,设定P＜0.05差异有统计学意义。结果10名志愿者年龄范围为20～27岁;3D-DESS序列与3D-SPACE序列在左右侧L5神经节大小配对t检验中均无统计学差异;3D-DESS能显示粗大的神经根,3D-SPACE对神经长度的显示优于3D-DESS,且具有统计学差异(t值分别为5.45和9.481, P=0.000),但两序列比较双侧L5神经节的大小时无明显统计学差异(P=0.79, P=0.70);98例患者18～74岁,平均(62.8±7.52)岁;3D-DESS与3D-SPACE对正常神经解剖评分中,3D-SPACE[(4.41±0.67)分]明显高于DESS[(3.75±0.75)分],DESS显示神经根细节较好,差异具有统计学意义(P=0.036);对于神经根病变的评价,DESS[(4.07±0.83)分]较SPACE[(3.57±0.65)分]高,且无统计学差异(P=0.099)。结论3D-SPACE与3D-DESS联合应用能清晰显示SP病灶细节,3D-DESS在神经泌尿学方面相对更实用、更准确。     

Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials

ObjectiveThis study aimed to evaluate whether ultrasound-guided techniques are superior compared to traditional palpation techniques in patients undergoing radial artery catheterization (RAC).MethodsElectronic databases of PubMed, Embase, and the Cochrane Library were systematically searched to identify randomized controlled trials (RCTs). The relative risks (RRs) or weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to calculate the pooled effect estimates using the random effects model for categories and continuous data, respectively.ResultsA total of 19 RCTs comprising a total of 3220 individuals were selected for final analysis. The pooled RR suggested that ultrasound-guided techniques were associated with higher incidence of first attempt success than traditional palpation techniques (RR, 1.39; 95% CI, 1.21–1.59; P < 0.001). Moreover, we noted that ultrasound-guided techniques were associated with fewer mean attempts to success (WMD, −0.80 s; 95% CI, −1.35 to −0.25; P = 0.004) and a shorter mean time to success (WMD, −41.18 s; 95% CI, −75.43 to −6.93; P = 0.018) than traditional palpation techniques. Furthermore, individuals using ultrasound-guided techniques had a reduced risk of hematoma (RR, 0.40; 95% CI, 0.22–0.72; P = 0.003).ConclusionsThis study indicated that ultrasound-guided techniques were superior compared to traditional palpation techniques for RAC in terms of efficacy and complications.     

Predictive role of PI-RADSv2 and ADC parameters in differentiating Gleason pattern 3 + 4 and 4 + 3 prostate cancer

Purpose

To compare the predictive roles of qualitative (PI-RADSv2) and quantitative assessment (ADC metrics), in differentiating Gleason pattern (GP) 3 + 4 from the more aggressive GP 4 + 3 prostate cancer (PCa) using radical prostatectomy (RP) specimen as the reference standard.

Methods

We retrospectively identified treatment-naïve peripheral (PZ) and transitional zone (TZ) Gleason Score 7 PCa patients who underwent multiparametric 3T prostate MRI (DWI with b value of 0,1400 and where unavailable, 0,500) and subsequent RP from 2011 to 2015. For each lesion identified on MRI, a PI-RADSv2 score was assigned by a radiologist blinded to pathology data. A PI-RADSv2 score ≤ 3 was defined as “low risk,” a PI-RADSv2 score ≥ 4 as “high risk” for clinically significant PCa. Mean tumor ADC (ADC_T), ADC of adjacent normal tissue (ADC_N), and ADC_ratio (ADC_T/ADC_N) were calculated. Stepwise regression analysis using tumor location, ADC_T and ADC_ratio, b value, low vs. high PI-RADSv2 score was performed to differentiate GP 3 + 4 from 4 + 3.

Results

119 out of 645 cases initially identified met eligibility requirements. 76 lesions were GP 3 + 4, 43 were 4 + 3. ADC_ratio was significantly different between the two GP groups (p = 0.001). PI-RADSv2 score (“low” vs. “high”) was not significantly different between the two GP groups (p = 0.17). Regression analysis selected ADC_T (p = 0.03) and ADC_ratio (p = 0.0007) as best predictors to differentiate GP 4 + 3 from 3 + 4. Estimated sensitivity, specificity, and accuracy of the predictive model in differentiating GP 4 + 3 from 3 + 4 were 37, 82, and 66%, respectively.

Conclusions

ADC metrics could differentiate GP 3 + 4 from 4 + 3 PCa with high specificity and moderate accuracy while PI-RADSv2, did not differentiate between these patterns.

     

Auslösung von Phantomschmerzen und -sensationen durch muskuläre Stumpftriggerpunkte nach Beinamputationen

Objectives

The aim of the study was to examine whether/how myofascial stump trigger points (TPs) after lower leg amputations are able to produce stump pain (SP), phantom pain (PP), and sensations (PS) in the phantom limb.

Methods

Palpation of the 5 most striking stump TPs of 30 leg amputees (12 transfemoral, 18 transtibial) was documented in a standardized manner. Patients were asked to localize SP, PP, and PS.

Results

Of 150 TPs, 14 produced involuntary stump movements and 10 stump fasciculations. Dorsal PP after ventral TP palpation occurred as well as PP in the toes from TPs near the hip. Of 30 patients, 20 reported PS and 8 PP; 60 of 150 TPs produced PS and 17 PP. Phantom phenomena were localized in 62.8% in the toes (1st toe 19.8%, toes 2–5 about 10% each), 17.9% midfoot, and the rest were more proximal. TPs were localized more in the lateral/dorsal stump than medial/ventral. About 70% of the TPs were found between 3 and 7 cm from the stump end, those with toe projections more distal than those with tibial projections.

Conclusions

Myofascial TPs in amputation stumps are common and able to produce sensations and pain in the phantom limb. Most reported experiences were localized in the toes, as phantom pain usually is. There seems to be a “stump representation” and it seems possible that “referred TP pain” and “phantom pain” may develop from similar origin.     

Reliability of intra- and inter-rater palpation discrepancy and estimation of its effects on joint angle measurements

This study presents data on the intra- and inter-rater reliability of palpation on normal and overweight subjects and shows the influence of palpation discrepancy on angular variability for a collected data set, using computer simulation. Thirty healthy males were recruited. Two physiotherapists identified 12 anatomical landmarks that enabled measurement of eight joint angles. Palpation discrepancy was determined by photographic recordings under ultraviolet light. Angular discrepancies were determined from photos of the subject's orthostatic posture. A computer simulation was developed to predict expected angular variation according to observed palpation discrepancy. The results showed that the inter-rater reliability was lower than the intra-rater reliability for both palpation and angle measurements. Palpation of the greater trochanter (GT), anterior superior iliac spine (ASIS), seventh cervical vertebra (C7) and femoral epicondyle (FE) showed larger discrepancies. The overweight group presented a significant difference in palpation discrepancy for ASIS (P<0.03). Angular variations were associated with palpation discrepancies for trunk flexion (TF), hip flexion (HF) and pelvic inclination (PI). Therefore, measurements should be performed by a single rater, rather than by different raters, if reliable angular measurements are intended. Specific anatomical landmarks require careful identification. Simulation was useful for providing estimates of variations due to palpation discrepancy.     

A self-determination theory-based self-myofascial release program in older adults with myofascial trigger points in the neck and back: A pilot study

Purpose: To examine the effectiveness and adherence to a self-determination theory (SDT)-based self-myofascial release (SMR) program in older adults with myofascial trigger points (MTrPs), and to investigate the factors that influence participant behavioral change while conducting the program in a home setting. Methods: An explanatory mixed-method design was used to evaluate a 12-week SDT-based SMR program, including a 4-week group-based education and practice (EP) phase and an 8-week home-based self-management (SM) phase. Pain intensity on palpation and sensitivity to pain were assessed at baseline and the post EP and post SM phase. Focus group interviews were conducted at the post SM phase. Findings: Fifteen participants completed the study. Pain intensity and sensitivity to pain significantly improved at the post SM phase compared with the baseline. Adherence increased during the SM phase compared with that during the EP phase. Four main themes emerged as factors that influenced participant behavioral change: 1) “awareness of the effectiveness”; 2) “a sense of duty to perform the exercise”; 3) “obedience to expert instruction”; and 4) “lack of friendship.” Conclusions: These results support the effectiveness of an SDT-based SMR program for the treatment of MTrPs and in motivating older adults to participate in the program.     

Comparison between laryngeal handshake and palpation techniques in the identification of cricothyroid membrane: a meta-analysis

Because the use of conventional digital palpation technique for the identification of cricothyroid membrane (CTM) has been widely believed to be unreliable, the ‘laryngeal handshake’ technique (LH) has been introduced for CTM identification in the event of cricothyroidotomy. To provide evidence for clinical practice, this pilot meta-analysis aimed at investigating whether identification of CTM with the LH is superior to that with the palpation technique. Studies that evaluated the accuracy of CTM identification by using LH or palpation techniques (i.e., LH group vs. Palpation group) were identified from electronic databases including PubMed, Embase, Medline, google scholar, Cochrane Central Register of Controlled Trials from inception to July 5, 2020. The primary outcome was the accuracy of both techniques. Four studies published from 2018 to 2020 were considered relevant and were read in full. We found no significant difference in success rate of CTM identification [Risk Ratio (RR) 1.09, 95% CI 0.89–1.34, p?=?0.41] between the two groups. These preliminary results of the current study demonstrated no significant differences in success rate between the laryngeal handshake and conventional palpation techniques in cricothyroid membrane identification.

     

Palpation identification of spinous processes in the lumbar spine

The purpose of this study was to determine the accuracy of manipulative physiotherapists in palpating radiologically identified lumbar spinous processes (SPs). Five experienced manipulative physiotherapists were each allocated a cohort of 15 consecutive low back pain (LBP) patients presenting for X-rays and were asked to use surface palpation to identify the L1, L3 and L5 SPs. Spherical radio-opaque markers were taped to the skin over these palpated points and standard lateral radiographs taken. Measurements were made to determine the proximity of these nominated markers to identified SPs. Seventy-two percent of markers were either placed accurately over the nominated SP or consistently within one SP of the nominated level. Forty-seven percent were accurately placed over the nominated SPs. A greater SP height at L3 and L5, and decreased soft tissue thickness over L5, were associated with an increase in palpation accuracy levels, yet the patient variables of age, sex and body mass index (BMI) had no effect. The strongest effect on accuracy was between-therapist variability. The manipulative physiotherapists used in this study appear to be moderately successful in either palpating a nominated SP or being no more than one spinal level in error. Further research will focus on the choice of palpation procedure and a larger sample.     

ASSESSMENT OF HUMERAL TORSION BY PALPATION IN BASEBALL PITCHERS: A VALIDATION STUDY

Background/Purpose:Greater humeral retroversion has been associated with shoulder and elbow injuries. Methods for measuring torsion include radiography, computed tomography (CT) and sonography (US) which may be costly or unavailable. A palpation method might be a reliable alternative to imaging techniques. The purpose of the current study was to examine the construct validity of the palpation technique for humeral torsion by (1) determining if a side‐to‐side difference in humeral torsion (HT) could be detected in a cohort of baseball pitchers using the palpation technique and (2) compare the side‐to‐side difference in HT obtained through the palpation method to the US method.Hypothesis:Clinical assessment of HT by palpation is reliable and is as accurate as sonographic HT measurements among overhead athletes.Methods:Twenty collegiate and high school pitchers were assessed. Bilateral shoulder passive external rotation (ER) and internal rotation (IR) range of motion were measured. Humeral torsion was indirectly measured using sonographic and palpatory methods. Paired t‐tests were used to determine HT side‐to‐side difference measured by US versus palpation. Pearson''s correlation coefficient (r) was used to determine the relationship between HT side‐to‐side difference detected by palpation and US, and relationships among IR and ER of the shoulder and HT side to‐side difference measurements.Results:There was significantly greater HT in dominant versus nondominant arm assessed by both palpation (5°±5, p=0.0004) and ultrasound (9°±11, p=0.0007). There was a positive correlation between both methods of HT measurement (r = 0.522, p=0.018). Palpation significantly underestimated HT as compared to US measurements (difference 4°±9, p=0.048). Difference in IR between shoulders correlated with HT measured by palpation (r=‐0.651, p=0.002) and US (r=0.569, p=0.009). Increased ER in the dominant versus nondominant arm correlated with the side‐to‐side difference in HT measured by both palpation (r = 0.509, p=0.02) and US (r = 0.602, p=0.005).Conclusion:Greater HT on the dominant versus nondominant shoulder via palpation indicated this method can be used to assess HT in pitchers. HT assessed by palpation correlated with HT assessed by US. However, the magnitude of side‐to‐side difference in HT was smaller with palpation compared to US, and the two techniques should not be used interchangeably. Nevertheless, assessment of HT via palpation is a reliable and practical method and its use should be encouraged.Level of Evidence:Level 3, measurement study.     

Reliability of pulse palpation by healthcare personnel to diagnose paediatric cardiac arrest

AimTo determine the reliability of pulse palpation to diagnose paediatric cardiac arrest.Materials and methodsWith all cardiovascular information obscured, 209 doctors and nurses (rescuers) were requested once each to determine if a pulse was present in 1 of 16 infants and children (average age 1.8 years, range 1 week–13 years) provided with non-pulsatile circulation with veno-arterial extracorporeal membrane oxygenation or left ventricular assistance for cardiac arrest or failure. Rescuers did not know the stage of recovery of the heart and did not if a true pulse was present or absent. Rescuer decisions “pulse absent” or “pulse present” were compared with concurred decisions of investigators and bedside nurse who knew cardiovascular data and had unlimited time to palpate pulses.ResultsRescuer pulse palpation accuracy was 78% (95% CI 70–82), sensitivity 0.86 (95% CI 0.77–0.90) and specificity 0.64 (95% CI 0.53–0.74). When investigators diagnosed cardiac arrest pulse pressure was 6 ± 5 mmHg (range 0–20) compared with 9 ± 8 mmHg (range 0–29) with rescuers (p = 0.0004). With pulse pressure zero, rescuer accuracy was 89% and sensitivity 0.89. Sixty per cent of rescuers chose a brachial pulse, 33% a femoral pulse with respective accuracies of 78% and 77%, sensitivities 0.86 and 0.85 and specificities 0.67 and 0.56.ConclusionsPulse palpation is unreliable to diagnose paediatric cardiac arrest. Rescuers misdiagnose on 22% of occasions and which may lead them to withhold external cardiac compression on 14% of occasions when needed and on 36% to give it when not needed. Brachial palpation is slightly more reliable than femoral palpation.     

Manual landmark identification and tracking during the medial rotation test of the shoulder: an accuracy study using three-dimensional ultrasound and motion analysis measures

Palpation of movement is a common clinical tool for assessment of movement in patients with musculoskeletal symptoms. The purpose of this study was to measure the accuracy of palpation of shoulder girdle translation during the medial rotation test (MRT) of the shoulder. The translation of the gleno-humeral and scapulo-thoracic joints was measured using both three-dimensional ultrasound and palpation in order to determine the accuracy of translation tracking during the MRT of the shoulder. Two movements of 11 normal subjects (mean age 24 (SD=4), range 19-47 years) were measured. The agreement between measures was good for scapulo-thoracic translation (r=0.83). Gleno-humeral translation was systematically under estimated (p=0.03) although moderate correlation was found (r=0.65). These results indicate that translation of the measured joints can be tracked by palpation and further tests of the efficacy of palpation tracking during musculoskeletal assessment may be warranted.     

Learning and knowing bodies: Norwegian psychomotor physiotherapists’ reflections on embodied knowledge

Background: The lived experience is irreducible, and can give access to pre-reflective and implicit, embodied knowledge. There is a lack of research concerning how specialists in Norwegian Psychomotor physiotherapy (NPMP) utilize their patients’ embodied knowledge. Aim: The aim of this study was to explore if the NPMP therapists experience the phenomenon “listening to the body” as a useful source of personal knowledge and motivation in the patient’s process of’ recovery, and if there could be too much “listening to the body”? Design and methods: A qualitative study based on empirical data from the interviews with 12 specialists in NPMP. The research data were analyzed using systematic text condensation as analyzing method. Results: Four themes emerged: (1) “The negative imperative of the body”; (2) “The embodied traumatic experiences”; (3) “The process of creating meaning”; and (4) “The embodied person emerges—who am I and what choice do I have?” The results revealed the importance of becoming aware of embodied experiences, which might represent different aspects of the patients’ lives. Conclusion: Embodied knowledge can support the physiotherapists in their clinical practice. The learning and knowing body represents resources of empowerment for the patients.     

The role of ultrasound in front-of-neck access for cricothyroid membrane identification: A systematic review

PurposeConventional palpation techniques for cricothyroid membrane (CTM) identification are inaccurate and unreliable. Ultrasound plays a multi-faceted role in airway management, however there is limited literature around its use for CTM identification prior to cricothyrotomies. This review sought to compare ultrasound to palpation in the general population, identify its indications in subjects with ill-defined neck anatomy, and determine its role in defining neck anatomy.MethodsTwo reviewers independently assessed titles, abstracts and full-text English articles through the Ovid Medline and EMBASE databases. Studies related to ultrasound for CTM assessment and/or cricothyrotomy in subjects older than 12 years were included.ResultsFourteen studies were selected. Compared to palpation, ultrasound has greater accuracy, but longer CTM identification times in those with normal airway anatomy. Interestingly, ultrasound offers comparable times to palpation in patients with difficult airways. Ultrasound also helps define anatomical parameters in the neutral and extended neck positions thereby underscoring the importance of neck positioning during cricothyrotomies and confirming consensus-based incision recommendations set by the Difficult Airway Society.ConclusionUltrasound appears to be superior to palpation for CTM localization especially in those with difficult airway anatomy and objectively defines neck anatomy. Its pre-emptive use should be incorporated during difficult airway management.     

Expression of Toll‐like receptors 2 and 4 on innate immunity cells modulated by cardiac surgical operation

Objective. This study aimed to follow‐up on the changes in the expression of Toll‐like receptors (TLRs) on monocytes and granulocytes in venous blood of patients undergoing cardiac surgical operation. Material and methods. TLR2 and TLR4 expression on blood cells was determined by flow cytometry in 40 patients undergoing cardiac surgery performed either with cardiopulmonary bypass (CPB) (“on‐pump”) or without it (“off‐pump”). Results. Intensity of the expression of TLR2 on both monocytes and granulocytes, expressed as median fluorescence intensity, is significantly reduced during CPB, being lower in both groups at the finish of surgery. These changes are not so remarkable in the case of TLR4 expression. Compared to “on‐pump” patients, there is a higher relative number of TLR2⁺ granulocytes in “off‐pump” patients at the finish of surgery and of TLR4⁺ granulocytes on the first postoperative day. Conclusions. We found characteristic patterns in the expression of TLR2 and TLR4 on monocytes and granulocytes in venous blood of patients undergoing cardiac surgery with or without CPB.     

Imaging procedures in diagnosis of laryngeal cancer with special reference to high resolution ultrasound]

Sonography was compared with operative and histological results in 42 patients with advanced laryngeal cancer. Sonography was accurate in the imaging of supraglottic tumours. Infiltration of the base of the tongue (n = 4) and of the pre-epiglottic space (n = 12), as well as of the thyroid cartilage (n = 8) and subglottic extensions (n = 3) were visualized too. Infiltration of the piriform sinus was correctly assessed sonographically in 8 patients. Endoscopy was superior to sonography in endolaryngeal delineation of the tumour, with in exception of paraglottic tumours. In cervical lymph node staging sonography was more accurate than palpation (86% versus 69%). The diagnostic capabilities of sonography were compared with computed tomography and magnetic resonance imaging (MRI). Due to its widespread availability and high accuracy in the delineation of supraglottic and extralaryngeal extensions and in cervical lymph node staging, sonography can be performed as primary imaging modality in advanced laryngeal cancer. If it is not possible to obtain complete delineation of the tumour by sonography, MRI must be undertaken.