A simulated passive intervertebral motion task: observations of performance in a cross-sectional study

Introduction:

Passive motion palpation is an integral component in examination, diagnosis or classification, and treatment of persons with mechanical disorders of the cervical spine. If the magnitude of force application during passive movement assessment is associated with greater palpatory accuracy has not been established.

Methods:

This investigation used a novel mechanical model as a basis for assessing the palpatory force of students and clinicians. The model included multiple palpable resistance and displacement levels similar to that observed in humans. The ability of the subjects to discriminate the various levels of resistance and displacement offered by the model was concurrently measured.

Results:

Large variability occurred in the amount of force applied by the subjects in completing the palpatory examination. The data indicated no major differences in palpatory accuracy across the student and clinician groups with different training and experience levels beyond basic competency. Those subjects applying less force in the palpatory exam demonstrated greater accuracy of palpatory assessment with one measure.

Discussion:

The data indicate training and experience had minimal relationship to palpatory interpretation precision beyond the basic level and individual natural discriminatory ability may be a factor in accuracy of palpatory skill. The results demonstrate remarkable inconsistency in palpatory force among examiners and suggest that palpatory accuracy may be related to less force application.     

Barriers to implementation of a pelvic examination among family doctors in primary care clinics

Objective: although the pelvic examination of female patients should be an integral part of the physical examination in family medicine there are many barriers to the conduct of this intimate examination by family doctors. the objective: an assessment of the attitudes and barriers reported by family doctors on conducting a pelvic examination.

Methods: An anonymous, self-administered questionnaire.

Results: Two hundred thirty doctors participated in the study, of who 157 were males (68.9%). The mean age was 42.2 ± 9.6 years. 179 family doctors (77.8%) thought that the pelvic examination should be an important part of their work as a family doctor, 100 (43.9%) said that they had conducted a pelvic examination in the past, but the majority (85.2%) had not done a pelvic examination over the previous year. Senior doctors did more pelvic examinations than younger doctors (P = 0.007). Graduates of Israeli medical schools were more likely than those who graduated elsewhere to state that family doctors should do pelvic examinations (P = 0.032). Graduates of non-Israeli medical schools cited less experience (P = 0.002) and less motivation (P = 0.006) as reasons for not doing pelvic examinations.

Conclusions: Although most family doctors believe that pelvic examinations are an important part of their work, only a small percentage actually do a pelvic examination. Among the reasons for not doing the examination are lack of knowledge, lack of experience, and work burden.     

A new perspective for Somatic Dysfunction in Osteopathy: the Variability Model

IntroductionOsteopathy uses manipulative techniques to support physiological function and adaptation. These conditions are modified by the presence of Somatic Dysfunction (SD), an altered function of the components of the body's framework system. Despite SD's widespread use in clinical practice and education, research has previously shown poor results in terms of reliability and validity.In this theoretical article, the authors’ proposal is to argue for a new clinical perspective for SD, which suggests a different palpatory assessment of its clinical signs: the “Variability Model”.MethodsA double simultaneous literature search was performed between January and March 2019 in Medline's electronic database. The first one critically analysed the clinical signs most used to detect SD. The second one informed authors' hypothesis related to movement variability assessment in the Neutral Zone (NZ).DiscussionThe Variability Model explains how the assessment of the range of motion in the NZ is essential to detect SD, its motion asymmetry and its relative restriction.The Variability Model explains SD semeiotics which could be related to “body adaptability”, thus having implications with the concept of health. Finally, this paradigm aims to establish new developments in research, especially regarding SD reliability and clinical relevance.ConclusionsMovement variability allows to interpret SD clinical signs as an attempt by the body to maintain a healthy condition. This paradigm should be included in the future context of osteopathy which could better explain SD's pathophysiological mechanism, without ignoring the accuracy of its physical examination.     

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.     

The reliability of the cervical relocation test on people with and without a history of neck pain

Background: Physical therapy intervention is often sought to treat cervical spine conditions and a comprehensive physical therapy examination has been associated with more favourable outcomes. The cervical relocation test (CRT) is one method used to assess joint position sense (PS) integrity of the cervical spine. Previous research has found significant differences in the CRT between symptomatic and asymptomatic subjects. Impaired kinaesthetic awareness in the cervical spine may be associated with degenerative joint disease, chronicity of the complaint and increased susceptibility to re-injury.

Purpose: The purpose of this study was to determine the intertester and intratester reliability of cervical relocation using the cervical range of motion instrument (CROM) and an affixed laser (AL) device among subjects with and without a history of neck pain. In addition, it was hypothesised that those individuals with a history of neck pain would have greater difficulty on the CRT.

Methods: A total of 50 asymptomatic subjects (n?=?50) were assigned to two researchers. The CRT was performed for each tester by the subject rotating the cervical spine for three trials to the right and left for the CROM and AL.

Results: The results indicate a significant intertester reliability of the CROM (interclass correlation coefficient (ICC)?=?0.717[0.502–0.839]; 0.773[0.595–0.873]) for the subjects in this sample.

Conclusion: This study demonstrated that the CROM is a reliable device for measuring cervical relocation between different testers. Future research should investigate if the CRT is predictive of prognosis in patients with cervical pathology.     

Motor skill training in musculoskeletal pain: a case report in chronic low back pain

Purpose: Low back pain is a chronic condition that limits function. The chief reason individuals with low back pain seek care is difficulty performing functional activities. A novel approach to improving performance of painful and limited functional activities is motor skill training, defined as challenging practice of activities to learn or relearn a skill. The purpose of this report is to describe the design and application of a motor skill training intervention in a 26-year-old man with a 10-year history of low back pain.

Methods: A motor skill training intervention was implemented to modify the altered alignment and movement patterns he used during the performance of his painful and limited activities.

Results: The patient was seen for six visits in 12 weeks. The patient reported decreased pain and medication use, as well as improved function immediately, 3-, and 9-months post-intervention.

Conclusion: Individuals with low back pain report limitation in ability to perform everyday functions and demonstrate altered patterns of movement and alignment during these activities. This case report describes an innovative motor skill training intervention that directly addresses the performance of functional activities and the application of motor learning principles.

• Implications for rehabilitation

• Low back pain is a chronic condition that limits function.

• The chief reason individuals with chronic low back pain seek care is difficulty performing everyday functional activities.

• Motor skill training is a novel approach that directly addresses the performance of painful and limited functional activities through challenging practice to improve performance and decrease pain.

     

Directional preference constructs for patients’ neck pain in the absence of centralization

Objectives: We conducted a secondary analysis of a prospective, observational cohort study to (1) report the prevalence of Directional Preference (DP) constructs at first examination for patients with cervical spine challenges, and (2) determine the association between DP constructs and clinical outcomes at discharge from physical therapy.

Methods: We analyzed data collected from 718 consecutive patients who presented to outpatient, private practice clinics with primary complaints of non-specific neck pain; 200 patients met the inclusion criteria and completed first examination and discharge data. Statistical analysis determined the association between DP constructs at first examination and clinical outcomes at discharge.

Results: The findings in this investigation were that (1) the most prevalent DP constructs at first examination were related to ROM and pain intensity including Patient Reported Improvement in ROM (79.5%), Increase in Spine ROM (32.5%), and Pain Intensity Change (15.0%), (2) all DP groups improved and met the MCID for disability and pain intensity change at discharge except for the group that did not exhibit Increase in Spine ROM for pain intensity, (3) no clinically significant differences in pain intensity or disability existed between DP groups at discharge, and (4) 28.5% and 6.5% of patients exhibited a relative increase in cervical spine extension and flexion ROM, respectively, post-repeated movement testing on the first examination.

Discussion: The most prevalent DP constructs at first examination were related to ROM and pain intensity, and each was associated with a comparable clinical trajectory in terms of pain and disability outcomes at discharge. The findings of this study help Mechanical Diagnosis and Therapy (MDT) providers understand the common DP constructs encountered in routine clinical practice and their relation to pain and disability outcomes for patients with cervical spine challenges.

Level of Evidence: 2b     

Manual examination in the diagnosis of cervicogenic headache: a systematic literature review

ObjectiveTo evaluate the diagnostic validity of manual examination techniques used to diagnose cervicogenic headache (CGH).BackgroundCervicogenic headache is a specific type of headache that originates from the cervical spine and is typically chronic in nature. Diagnostic criteria for CGH have been established by the International Headache Society (IHS) and are cited extensively in the literature. Diagnosis of CGH through manual examination is a more recent practice. To our knowledge, no systematic review of manual diagnosis of CGH has been performed.MethodsSearches of electronic databases (CINAHL, Cochrane Library, Medline, PEDro, Scopus, and SPORTDiscus) were conducted for research studies from July 2003 to February 2014. The GRADE approach was used to determine the quality of each paper.ResultsTwelve papers that fulfilled the inclusion and exclusion criteria were identified (12 observational studies). The level of evidence ranged from very low to low, and recommendations for use of specific manual techniques ranged from weak to strong.ConclusionsDespite low levels of evidence, manual examination of the cervical spine appears to aid the diagnostic process related to CGH and can be implemented by both experienced and inexperienced examiners.     

Changes in wheelchair biomechanics within the first 120 minutes of practice: spatiotemporal parameters,handrim forces,motor force,rolling resistance and fore-aft stability

Abstract

Purpose: During manual wheelchair (MWC) skill acquisition, users adapt their propulsion technique through changes in biomechanical parameters. This evolution is assumed to be driven towards a more efficient behavior. However, when no specific training protocol is provided to users, little is known about how they spontaneously adapt during overground MWC locomotion. For that purpose, we investigated this biomechanical spontaneous adaptation within the initial phase of low-intensity uninstructed training.

Materials and methods: Eighteen novice able-bodied subjects were enrolled to perform 120?min of uninstructed practice with a field MWC, distributed over 4?weeks. Subjects were tested during the very first minutes of the program, and after completion of the entire training protocol. Spatiotemporal parameters, handrim forces, motor force, rolling resistance and fore-aft stability were investigated using an instrumented field wheelchair.

Results: Participants rapidly increased linear velocity of the MWC, thanks to a higher propulsive force. This was achieved thanks to higher handrim forces, combined with an improved fraction of effective force for startup but not for propulsion. Despite changes in mechanical actions exerted by the user on the MWC, rolling resistance remained constant but the stability index was noticeably altered.

Conclusion: Even if no indication is given, novice MWC users rapidly change their propulsion technique and increase their linear speed. Such improvements in MWC mobility are allowed by a mastering of the whole range of stability offered by the MWC, which raises the issue of safety on the MWC.

• Implications for rehabilitation

• The learning process of manual wheelchair locomotion induces adaptations for novice users, who change their propulsion technique to improve their mobility.

• Several wheelchair biomechanical parameters change during the learning process, especially wheelchair speed, handrim forces, motor force, rolling resistance and fore-aft stability.

• Fore-aft stability on the wheelchair rapidly reached the tipping limits for users. Technical solutions that preserve stability but do not hinder mobility have to beimplemented, for instance by adding anti-tipping wheels rather than moving the seat forwards with respect to the rear wheels axle.

     

Lack of transfer of skills after virtual reality simulator training with haptic feedback

Background and objective: Virtual reality (VR) simulators enrich surgical training and offer training possibilities outside of the operating room (OR). In this study, we created a criterion-based training program on a VR simulator with haptic feedback and tested it by comparing the performances of a simulator group against a control group.

Material and methods: Medical students with no experience in laparoscopy were randomly assigned to a simulator group or a control group. In the simulator group, the candidates trained until they reached predefined criteria on the LapSim^® VR simulator (Surgical Science AB, Göteborg, Sweden) with haptic feedback (Xitact^TM IHP, Mentice AB, Göteborg, Sweden). All candidates performed a cholecystectomy on a porcine organ model in a box trainer (the clinical setting). The performances were video rated by two surgeons blinded to subject training status.

Results: In total, 30 students performed the cholecystectomy and had their videos rated (N?=?16 simulator group, N?=?14 control group). The control group achieved better video rating scores than the simulator group (p?Conclusions: The criterion-based training program did not transfer skills to the clinical setting. Poor mechanical performance of the simulated haptic feedback is believed to have resulted in a negative training effect.     

Inter-rater reliability of the McKenzie System of Mechanical Diagnosis and Therapy in the examination of the knee

Objective: The McKenzie System of Mechanical Diagnosis and Therapy (MDT) is a widely used method of classification and management of musculoskeletal problems. Although MDT has been investigated for its reliability and efficacy in the management of spinal pain, few studies have evaluated the system when applying it to musculoskeletal problems in the extremities, in particular the knee. The purpose of this study was to investigate the inter-rater reliability of MDT when classifying clinical vignettes describing patients with musculoskeletal knee pain.

Methods: This study was divided into two phases. First, 10 clinicians experienced in the use of MDT were recruited to write a total of 60 clinical vignettes based upon the initial assessment of their past patients with knee pain. Second, six different MDT raters were recruited to rate 53 selected vignettes and reliability was determined using Fleiss Kappa.

Results: There was ‘substantial agreement’ among six MDT raters classifying the clinical vignettes into one of four categories (κ = 0.72). There was no statistically significant difference between therapists with different levels of training.

Discussion: MDT demonstrated acceptable reliability among trained raters to classify clinical vignettes describing patients with musculoskeletal knee pain. To generalize the use of the system to more users, future research should continue to investigate the reliability of MDT using raters with lower levels of training and experience and assess reliability in real patients.

Level of Evidence: 5.     

The effectiveness of cervical versus thoracic thrust manipulation for the improvement of pain,disability, and range of motion in patients with mechanical neck pain

Background:

Many patients present to physical therapy with mechanical neck pain. Cervical and thoracic manipulations are being utilized in treating this impairment, but minimal evidence as to which technique is superior exists in the literature.

Objective:

The purpose of this systematic review is to identify whether cervical or thoracic manipulation is more effective at improving pain, range of motion (ROM), and disability in patients with mechanical neck pain.

Methods:

A comprehensive search of published literature from seven search engines (PubMed, ProQuest, PEDro, CINAHL, Healthsource, Cochrane Library, SPORTDiscus) yielded 13 studies that examined the effectiveness of either cervical manipulations, thoracic manipulations, or cervical and thoracic manipulations to relieve the effects of mechanical neck pain. Eleven of the studies included were randomized controlled trials (RCTs), while two were secondary analyses of RCTs. Each study was assessed using the PEDro scale and found to be of fair to high research quality.

Results:

The studies included in this systematic review produced both positive clinical and statistical differences in pain, disability, and ROM following manipulations of the cervical or thoracic spine.

Conclusion:

There is limited high-quality research directly comparing the two interventions, so determining whether cervical or thoracic thrust manipulation is superior cannot be concluded from this systematic review alone. However, based on the results found in this review, cervical and thoracic thrust manipulations are equally valuable in relieving pain, disability, and improving ROM for a patient with mechanical neck pain in the short term.     

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.     

Knowledge translation from continuing education to physiotherapy practice in classifying patients with low back pain

Abstract

Objectives:

Physical therapists have used continuing education as a method of improving their skills in conducting clinical examination of patients with low back pain (LBP). The purpose of this study was to evaluate how well the pathoanatomical classification of patients in acute or subacute LBP can be learned and applied through a continuing education format. The patients were seen in a direct access setting.

Methods:

The study was carried out in a large health-care center in Finland. The analysis included a total of 57 patient evaluations generated by six physical therapists on patients with LBP. We analyzed the consistency and level of agreement of the six physiotherapists’ (PTs) diagnostic decisions, who participated in a 5-day, intensive continuing education session and also compared those with the diagnostic opinions of two expert physical therapists, who were blind to the original diagnostic decisions. Evaluation of the physical therapists’ clinical examination of the patients was conducted by the two experts, in order to determine the accuracy and percentage agreement of the pathoanatomical diagnoses.

Results:

The percentage of agreement between the experts and PTs was 72–77%. The overall inter-examiner reliability (kappa coefficient) for the subgroup classification between the six PTs and two experts was 0·63 [95% confidence interval (CI): 0·47–0·77], indicating good agreement between the PTs and the two experts. The overall inter-examiner reliability between the two experts was 0·63 (0·49–0·77) indicating good level of agreement.

Discussion:

Our results indicate that PTs’ were able to apply their continuing education training to clinical reasoning and make consistently accurate pathoanatomic based diagnostic decisions for patients with LBP. This would suggest that continuing education short-courses provide a reasonable format for knowledge translation (KT) by which physical therapists can learn and apply new information related to the examination and differential diagnosis of patients in acute or subacute LBP.