Effect of Different Neurodynamic Mobilization Techniques on Knee Extension Range of Motion in the Slump Position

Abstract

Mobilization of the nervous system has emerged as a significant adjunct to the treatment of musculoskeletal injuries. Clinical studies have shown that neurogenic symptoms can be resolved by treatment techniques directed at restoring normal neural biomechanics and physiology. Two alternate mobilization techniques have been proposed: the slider and tensioner techniques. A search of the literature revealed no peer-reviewed studies comparing the effects of these two treatment techniques, although a number of studies have investigated these techniques in isolation and found them to have positive effects on range of motion and other outcome measures. The aim of this study was to investigate the effects of these two techniques on knee range of motion of normal subjects (30 females [mean age 21.4+/?1.2 years, range 19-24]) in the slump position. Knee flexion angle of the right leg was measured using a universal 360° goniometer while in a fully slumped position, prior to and after the application of the respective mobilization technique. The tensioner technique brought about a significant decrease in knee flexion angle (P=0.003) with a mean percentage change of 14.7+/?11.8%(3.4+/?2.5°). The slider technique brought about a significant decrease in knee flexion angle (P<0.001) with a mean percentage change of 19.9+/?15%(4.3+/?2.6°). There was a non-significant between-group difference for the effect of the two techniques on range of motion (P=0.075). The findings of this study indicate that in normal female subjects, both the tensioner and slider techniques have a positive and significant effect on improving knee extension range of motion in the slump position. This could decrease the sensitivity of the sciatic nerve and the neuromeningeal structures to mechanical load. The clinical significance of changes of this magnitude on neural tissue and of these techniques in a symptomatic population requires further investigation.     

Reliability and Measurement error of Active Knee extension Range of Motion in a Modified slump Test Position: A Pilot study

Abstract

The slump test is a tool to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. While some studies have investigated the reliability of aspects of this test within the same day, few have assessed the reliability across days. Therefore, the purpose of this pilot study was to investigate reliability when measuring active knee extension range of motion (AROM) in a modified slump test position within trials on a single day and across days. Ten male and ten female asymptomatic subjects, ages 20–49 (mean age 30.1, SD 6.4) participated in the study. Knee extension AROM in a modified slump position with the cervical spine in a flexed position and then in an extended position was measured via three trials on two separate days. Across three trials, knee extension AROM increased significantly with a mean magnitude of 2° within days for both cervical spine positions (P>0.05). The findings showed that there was no statistically significant difference in knee extension AROM measurements across days (P>0.05). The intraclass correlation coefficients for the mean of the three trials across days were 0.96 (lower limit 95% CI: 0.90) with the cervical spine flexed and 0.93 (lower limit 95% CI: 0.83) with cervical extension. Measurement error was calculated by way of the typical error and 95% limits of agreement, and visually represented in Bland and Altman plots. The typical error for the cervical flexed and extended positions averaged across trials was 2.6° and 3.3°, respectively. The limits of agreement were narrow, and the Bland and Altman plots also showed minimal bias in the joint angles across days with a random distribution of errors across the range of measured angles. This study demonstrated that knee extension AROM could be reliably measured across days in subjects without pathology and that the measurement error was acceptable. Implications of variability over multiple trials are discussed. The modified set-up for the test using the Kincom dynamometer and elevated thigh position may be useful to clinical researchers in determining the mechanosensitivity of the nervous system.     

Complex Regional Pain Syndrome I: Management through the Use of Vertebral and Sympathetic Trunk Mobilization

Abstract

The purpose of this study was to describe the clinical differential diagnostic process and effective management of an individual presenting with lower-extremity complex regional pain syndrome I (CRPS I). A 50-year-old female 8-weeks status post ORIF right tibia/fibula presented with a warm, red, edematous, hyperhidrotic right lower extremity. She also exhibited hyperalgesia, allodynia, and a positive slump test on the right. The patient satisfied clinical diagnostic criteria for a diagnosis of CRPS I. The subject was treated for 10 sessions over a 3-month period using progressive desensitization, weight-bearing activities, thoracolumbar mobilizations, and a neural mobilization technique referred to as slump long sitting with sympathetic emphasis (SLSSE). An analysis of outcome measures at the time of discharge and at a one-year follow-up demonstrated a significant improvement in both pain and function. Effective management was achieved by addressing both the patient's proximal and distal impairments including thoracolumbar segmental lesions and positive neurodynamic tests. It is speculated that the influence of neural mobilizations to the ipsilateral sympathetic ganglia directly affected the pathophysiology associated with autonomic dysregulation and pain in this subject. This case report provides initial evidence that the SLSSE may be an effective neural mobilization technique in reducing the magnitude of symptoms and improving function in patients with CRPS.     

‘Sympathetic Slump’: The Effects of a Novel Manual Therapy Technique on Peripheral Sympathetic Nervous System Function

Abstract

The present study examined the physiological effects of the ‘sympathetic slump’ on measures of peripheral sympathetic nervous system (SNS) function in normal volunteers. ‘Sympathetic slump’ has been proposed (1) as a technique to load the sympathetic trunk (ST). It is suggested that mechanical stimulation of the ST will result in alterations in peripheral SNS function and/or target tissue sensitivity. This technique forms part of an overall examination and treatment protocol for patients with features of sympathetically maintained pain (2 = 13). The present study evaluated the effect of ‘sympathetic slump’ on two measures (skin conductance and skin temperature) of peripheral SNS function.

Twenty-two normal, asymptomatic subjects with no previous experience of manual therapy participated in the study. A randomised, repeated measures, double-blind, placebo controlled protocol was used to evaluate the effects of ‘sympathetic slump’, placebo and control conditions on skin conductance and skin temperature in the upper limbs.

‘Sympathetic slump’ produced a significantly greater increase in skin conductance than either placebo or control. A greater increase in skin conductance was observed in the right upper limb compared to the left upper limb, in keeping with the fact that the technique used in this study was intended to bias the right ST. Significant changes in skin temperature occurred for both ‘sympathetic slump’ and placebo compared to control, however there was no significant difference between ‘sympathetic slump’ and placebo. ‘Sympathetic slump’ did however appear to exert a greater differential effect between sides (R < L) than did the placebo technique.

The results of this study demonstrate that the ‘sympathetic slump’ technique influences peripheral SNS function. The technique has the capacity to differentially increase sympathetic activity in the ipsilateral upper limb.     

Reliability and Measurement Error of Active Knee Extension Range of Motion in a Modified Slump Test Position: A Pilot Study

The slump test is a tool to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. While some studies have investigated the reliability of aspects of this test within the same day, few have assessed the reliability across days. Therefore, the purpose of this pilot study was to investigate reliability when measuring active knee extension range of motion (AROM) in a modified slump test position within trials on a single day and across days. Ten male and ten female asymptomatic subjects, ages 20–49 (mean age 30.1, SD 6.4) participated in the study. Knee extension AROM in a modified slump position with the cervical spine in a flexed position and then in an extended position was measured via three trials on two separate days. Across three trials, knee extension AROM increased significantly with a mean magnitude of 2° within days for both cervical spine positions (P>0.05). The findings showed that there was no statistically significant difference in knee extension AROM measurements across days (P>0.05). The intraclass correlation coefficients for the mean of the three trials across days were 0.96 (lower limit 95% CI: 0.90) with the cervical spine flexed and 0.93 (lower limit 95% CI: 0.83) with cervical extension. Measurement error was calculated by way of the typical error and 95% limits of agreement, and visually represented in Bland and Altman plots. The typical error for the cervical flexed and extended positions averaged across trials was 2.6° and 3.3°, respectively. The limits of agreement were narrow, and the Bland and Altman plots also showed minimal bias in the joint angles across days with a random distribution of errors across the range of measured angles. This study demonstrated that knee extension AROM could be reliably measured across days in subjects without pathology and that the measurement error was acceptable. Implications of variability over multiple trials are discussed. The modified set-up for the test using the Kincom dynamometer and elevated thigh position may be useful to clinical researchers in determining the mechanosensitivity of the nervous system.Key Words: Modified Slump Test, Knee Extension, Within-Trial Reliability, Reliability across Days, Measurement ErrorMaitland¹ proposed the slump test as a tool to assess the mechanosensitivity of the neuromeningeal structures within the vertebral canal. This test and other tests of neuromeningeal structures, such as the upper limb tension tests have been described as “neurodynamic” or “neural provocation” tests^2–4. A neural provocation test is a sequence of movements designed to assess the mechanics and physiology of that part of the nervous system by elongation of the nerve⁴. Physical therapists have found the slump test both a useful test and intervention in patients who present with spinal or lower limb pain^3,5,6. However, in these neurodynamic tests, a number of structures may be responsible for the pain elicited during the test sequence. Many of these nerve tissues interface or run alongside various mono- and poly-articular joint structures that may be mechanically stressed with neural provocation tests, so the sequence and order of the loading components needs to be well controlled in order to differentiate between these structures⁴.While trying to control all the elements of this test or treatment procedure, clinicians may ask the patient to actively extend the knee to increase tension to the neural components⁵. Knee extension range of motion (ROM) has been used as a dependent variable to quantify the slump test^1,8–12. Values of 16–35.4° short of full knee extension have been observed in the slump position^7–9,11,12; these restrictions in knee extension ROM decreased when the neck was extended. From a treatment perspective, some authors have modified the slump position and have placed the patient in long sitting in order to control the knee extension range of motion and have then used cervical flexion as the variable to be altered⁶. It could be argued that this position places significant stress through the neural components of the test and is more useful as a progression towards the end stages of treatment. However, patients who cannot tolerate this position may require an alternative position. One possible alternative position might be to increase the amount of hip flexion and combine this with knee extension. Whereas some patients might be unable to even assume the long sitting position due to other bi-articular influences, using knee extension in a modified slump sitting position with increased hip flexion as described above would reduce the influence that the other polyarticular structures (most notably limitations in hamstring muscle length) have on the outcomes of the test sequence. With those subjects unable to attain full knee extension, this position also eliminates the effect that mono-articular (mainly capsuloligamentous) restraints might have on the amount of knee extension.Coppieters et al⁴ have commented that high reliability and small measurement error is required to render a test (such as neuromeningeal tests) suitable for clinical practice and experimental studies. Two earlier studies have assessed the reliability of the slump test. Phillips et al⁵ studied interrater agreement for the slump test in patients with low back and leg symptoms. These authors reported a κ-value of 0.89 (95% CI: 0.81-0.97) for mean pair-wise interrater agreement on a positive or negative test finding when defining a positive slump test as symptom reproduction and subsequent decrease with cervical extension, whereas adding increased knee extension ROM as a criterion for a positive slump test yielded a mean κ = 0.83 (95% CI: 0.75–0.91). More similar to the current study, Yeung et al¹¹ studied the reliability of instrumented goniometric measurement of knee extension AROM limited by symptom response during slump sitting, but they did not clarify if the measures for this pilot reliability study were taken from asymptomatic controls or subjects with post-whiplash syndrome. They reported excellent intrarater (r = 0.940) and, for one pair of raters, good interrater agreement (r = 0.854). However, neither of these studies undertook testing of the respective slump test parameters across more than one day. Therefore, the purpose of this pilot study was to investigate the measurement error and the reliability of measurements within trials on a single day and across days of knee extension AROM in a modified slump test position involving increased hip flexion. We hypothesized that this position would be reliable as a test procedure in that it would have small measurement error and that it would show little variation within and across days.     

The Effects of Footwear on Postural Sway: A Pilot Study

Abstract

Aims: This pilot study provides a methodology to measure differences in velocity of postural sway of older adults while barefoot, with non-slip socks, and in athletic shoes during a simulated fall. Methods: Postural sway was measured during a simulated fall on 14 ambulatory adults over 50?years of age using computerized posturography. Hierarchical linear modeling statistics determined the difference in velocity of sway wearing different types of randomly applied footwear with p?≤?.05. Results: Velocity of sway while wearing socks was significantly lower compared to barefoot (p?=?0.0132). Velocity of sway while being barefoot compared to wearing shoes did not significantly differ (p?=?0.1460). Velocity of sway while wearing socks is significantly lower compared to wearing shoes (p?=?0.0001). Conclusions: This pilot study indicates postural sway is lowest during a simulated fall while wearing non-slip socks.     

A Pilot Study Examining the Effects of Tolvaptan on Residual Renal Function in Peritoneal Dialysis for Diabetics

♦ Background:

For patients with end-stage renal disease (ESRD), peritoneal dialysis (PD) serves as a possible renal replacement therapy. However, most PD patients, particularly those with ESRD and diabetes mellitus, reportedly discontinue PD early, resulting in shorter survival periods and poorer prognosis because of overhydration. Recently, the vasopressin-2 receptor antagonist tolvaptan was approved for volume control in patients with heart failure. The present study aimed to identify the effects of tolvaptan in diabetic PD patients.

♦ Methods:

In this pilot study, the tolvaptan group (n = 12) were treated with 15 mg/day of tolvaptan 2 weeks after PD initiation and were prospectively analyzed for 1 year, and patients in the control group (n = 12) did not receive tolvaptan and were retrospectively analyzed for 1 year. In addition to the biochemical tests, echocardiograms, serum atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels, peritoneal Kt/V, and creatinine clearance (CCr) were examined at baseline and at 6 and 12 months after PD initiation.

♦ Results:

In the control group, the urine volume, renal Kt/V, and renal CCr levels consistently decreased; however, these parameters were stably maintained during the study period in the tolvaptan group. Atrial natriuretic peptide, CRP levels and the left ventricular mass index of the tolvaptan-treated group were significantly lower than those in the control group, whereas total protein and albumin levels were significantly higher at 6 and 12 months in the tolvaptan group. There were no obvious adverse effects.

♦ Conclusions:

These data suggest that tolvaptan may preserve residual renal function and improve volume control in PD patients with diabetes mellitus.     

Effects of High Intensity Training on Elderly Women: A Pilot Study

The objective of this study was to evaluate the safety and effectiveness of a high-intensity program of muscular strength combined with aquatic exercise. Thirty-two older completed three strength sessions and two aquatic sessions, 5 days a week during 5 months. Anthropometric and Strength (1RM upper and lower-body strength) measures were taken. Significant differences were found for 1RM strength, the fat tissue percent and the summation of corporal folds. Older women can take part in high-intensity training combined with aquatic exercise with no risk to their health while experiencing improvements to their muscular performance.     

Spirometric Assessment of Pulmonary Function in Road-side Vendors: A Pilot Study

Although much is known about the chronic effects of air pollution on pulmonary function, short-term changes in response to pollution levels over days, weeks and months have been less well documented. Such investigation requires field studies using portable equipment. Therefore, we studied forced vital capacity (FVC), forced expiratory volume in 1 second, and peak expiratory flow rate using a conventional hand-held spirometer, in a sample of Hong Kong roadside vendors (n = 21; age, 48.7 ± 13.4 yr) across 2 days (n = 14), 4 weeks (n = 10), and 3 months (n = 7). In addition, exhaled carbon monoxide was measured, and percent carboxyhemoglobin derived. There was no difference in pulmonary function between a weekday and the weekend. Only FVC decreased over 4 weeks and 3 months compared with initial testing, but this was not associated with pollution level. Our results support that the technology of hand-held spirometry needs to be advanced to detect potential short-term changes in the real world context, in pulmonary function including small airway reactivity and airway closure. Future generations of this technology need to provide the capacity for more detailed spirometry suitable for field studies.     

Relationship between the Duplex Doppler Ultrasound and a Questionnaire Screening for Positional Tolerance of the Cervical Spine in Subjects with Suspected Vascular Pathology: A Case Series Pilot Study

Abstract

Manual therapy healthcare practitioners routinely perform the vertebral artery test (VAT) to determine cervical positional tolerance and to screen for vertebrobasilar insufficiency (VBI) prior to manipulating the cervical spine. Because the safety and validity of the VAT has been questioned in the literature, the purpose of this study was to determine if a relationship existed between a new tool, the cervical positional tolerance questionnaire (CPTQ), and the duplex Doppler ultrasound findings for patients with suspected VBI. Subjects were 39 consecutive patients referred by their physician for a duplex Doppler ultrasound with suspicion of VBI. On the CPTQ, patients reported whether they avoided certain cervical positions due to symptoms consistent with VBI prior to undergoing the ultrasound. The CPTQ had a sensitivity = 1.00 (95% CI: 0.34–1.00); specificity = 0.78 (95% CI: 0.64–0.92); negative likelihood ratio = 0.00 (95% CI: 0.02–2.73); and positive likelihood ratio = 4.50 (95% CI: 1.67–7.89). The results of this case series study, while preliminary, are encouraging. Further research with larger sample sizes is warranted in the development of the CPTQ regarding pre-cervical manipulation clinical decision-making. Inclusion of subjects from a cohort including asymptomatic people (no suspicion of VBI) would also strengthen the screening ability of the CPTQ. In addition to duplex Doppler ultrasound, using a gold standard test of vertebral artery testing by way of magnetic resonance angiography (MRA) would further improve data on the diagnostic utility of the CPTQ.     

坐姿矫正系统对脑瘫患儿卧与坐位功能的影响

目的：研究脑瘫患儿配备坐姿矫正系统对卧位与坐位功能的影响。方法：坐姿功能异常的脑瘫患儿34例，随机分为矫正组和对照组各17例，均采用Bobath、Vojta和Rood等神经生理学疗法，矫正组同时配备坐姿矫正系统。治疗前后采用粗大运动功能评价量表（GMFM）对卧位、翻身、坐位等项进行功能评定。结果：治疗3个月后，2组GMFM得分均较治疗前明显提高（均P〈0．001），矫正组得分高于对照组（P〈0．05）。结论：配备坐姿矫正系统辅以神经生理学疗法更利于提高脑瘫患儿卧位与坐位功能。     

A Pilot Study of Ultrasound Analysis before Pediatric Peripheral Vein Cannulation Attempt

Objectives To determine whether peripheral veins can be detected by ultrasound (US) and to determine vein characteristics, as measured by US, that are associated with successful peripheral venous (PV) catheterization in young children. Methods The authors conducted an observational study in the pediatric emergency department (ED), with a convenience sample of children younger than 7 years. They evaluated attempts at PV catheterization in two groups on the basis of the visibility and palpability of the patients' veins: 1) clinically apparent (visible or palpable) and 2) not clinically apparent (nonvisible and nonpalpable). The authors obtained sonographic measurements in a transverse view (vertical diameter, circumference, and area) and in a longitudinal view (maximal uninterrupted length). Practitioners blinded to the US images then attempted to catheterize veins in the usual manner. The proportion of clinically apparent veins and the proportion of veins that were successfully catheterized that were identified by US were assessed, and the association between ultrasonographic vein measurements and success at catheterization, controlling for possible confounders, was determined. Results The authors assessed 120 attempts (90 clinically apparent and 30 not clinically apparent) at PV catheterization in 83 patients. US detected all 90 clinically apparent veins, and cannulation success rate was 62/90 (69%). In the not clinically apparent vein group, the rate of success was only 3/30 (10%), and US detected all successfully catheterized veins. In no instance was cannulation successful when the vein was not detected by US. Maximal vein length in longitudinal view was an independent predictor of cannulation success in multivariate analysis. Conclusions Ultrasound appears to be capable of detecting peripheral veins in children younger than 7 years of age, with lack of US vein visualization likely leading to unsuccessful PV placement. Greater vein length visualization may be a useful predictor of successful PV catheterization.     

Effects of a Multimodal Pain Rehabilitation Program: A Pilot Study

The purpose of this pilot study was to examine the effects of a multimodal pain rehabilitation program on pain perceptions, opioid usage, activity, down time, sleep, and role function status of 23 chronic pain patients. Data were collected at the start of the program, at the program's completion, and again during a follow-up period (3–11 months afterwards). At the end of the program, patients reported a significant reduction in pain levels, opioid usage, and hours of disturbed sleep. During the follow-up period, patients continued to report significant improvements in activity and role functions as well as significant reductions in opioid usage, sleep disturbance, and down time. These findings provided encouraging preliminary evidence that multimodal pain rehabilitation programs for chronic pain patients may be effective in pain management and functional restoration.     

The Effects of Creative Reminiscing on Individuals with Dementia and Their Caregivers: A Pilot Study

ABSTRACT

Reminiscing is known to enhance well-being, increase social participation and provide opportunities for self-expression. However, while reminiscing activities have become standard in many memory care facilities, their outcomes have not been systematically evaluated. Aims: This research explored the effects of creative reminiscence activities on the quality of life of clients with memory loss and on caregivers' self-perceived burdens associated with caring for an individual with memory loss. Methods: Using time and attention control activities and creative reminiscing activities, the observed, self-reported, and caregivers' opinions of the quality of life of clients with moderate Alzheimer's disease was documented over the course of this study. Caregivers' perceptions of the burdens associated with caring for loved ones were also assessed. Result: Results of this pilot study showed significant increases in caregivers' perceptions of their loved ones' quality of life and decreases in the burdens they experienced during the intervention phase. No significant changes occurred in clients' self-reported or observed well-being during the study. Conclusions: While using a carefully considered creative reminiscence activity intervention for clients with dementia can cause a decrease in caregivers' perception of their own burden and an increase in their perceptions of the loved ones' quality of life, future research is needed to determine the subtle nuances in well-being of individuals with memory loss and their caregivers.     

Effects of Tai Chi Intervention on Dual-Task Ability in Older Adults: A Pilot Study

Hall CD, Miszko T, Wolf SL. Effects of Tai Chi intervention on dual-task ability in older adults: a pilot study.

Objective

To determine if a 12-week program of Tai Chi that has been shown to reduce falls incidence in older adults would improve the ability to allocate attention to balance under dual-task conditions.

Design

Pre-/posttest experimental research design.

Setting

Movement studies research laboratory.

Participants

Community dwelling older adults (N=15; range, 62-85y) participated in either Tai Chi training or health education classes (controls) for 12 weeks.

Interventions

Participants in the Tai Chi group attended a twice-weekly, 1.5-hour class taught by an experienced instructor. The control group attended a biweekly, 1-hour class for lectures on health-related topics.

Main Outcome Measures

Two cognitive tasks (responding to auditory or visual stimulus as quickly as possible) were performed concurrently while maintaining static balance during the Sensory Organization Test (SOT) and while avoiding obstacles while walking. The percent change in performance relative to the single-task condition was calculated and defined as the dual-task cost. The dual-task cost was calculated for both the postural and cognitive measures.

Results

There was no improvement in the performance of postural stability or cognitive task under dual-task conditions for the SOT for Tai Chi versus controls. There was no improvement in avoiding obstacles under dual-task conditions for Tai Chi versus controls.

Conclusions

Contrary to our hypothesis, the findings of this study did not support a benefit of Tai Chi on the ability to allocate attention to balance under dual-task conditions.     

A Pilot Study on the Effect of Functional Electrical Stimulation of Stroke Patients in a Sitting Position on Balance and Activities of Daily Living

[Purpose] This study investigated the effect of functional electrical stimulation (FES) of stroke patients in a sitting position on balance and activities of daily living. [Methods] FES was applied to stroke patients (six male, three female) while in a sitting and supine position. FES was applied six times for 30 minutes each for a total of six weeks. [Results] The timed up and go (TUG) values at weeks 2, 4, and 6 after FES treatment in a sitting position were noticeably decreased in a time-dependent manner, compared with controls. In the sitting, the functional reach test (FRT) values were significantly increased in a time-dependent manner. The same values in the supine position weakly showed a similar pattern to those in the sitting position. Furthermore, the functional independent measurement (FIM) values in the sitting position were markedly increased in a time-dependent manner. In the sitting position, the intensity of FES was markedly decreased in a time-dependent manner. The same values in the supine position weakly showed a similar pattern to those in the sitting position. [Conclusion] These results suggest that the conditions of stroke patients in both the sitting and supine positions after FES treatment were improved and that FES had a greater effect in the sitting position.Key words: Functional electrical stimulation, Sitting position, Stroke patients     

Preventive Effects of Renin-angiotensin System Inhibitors on Oxaliplatin-induced Peripheral Neuropathy: A Retrospective Observational Study

Purpose

Oxaliplatin-induced peripheral neuropathy has remained an unresolved issue in clinical practice. Our previous study hypothesized that inhibition of the renin-angiotensin system (RAS) may produce a preventive effect on oxaliplatin-induced neuropathy. The aim of this study was to clarify whether RAS inhibitors prevent oxaliplatin-induced peripheral neuropathy.