Neurophysiological basis of rehabilitation of adolescent idiopathic scoliosis

Background. Knowledge on mechanisms of neurophysiological control of trunk movement and posture could help in the development of rehabilitation programs and brace treatment in adolescent idiopathic scoliosis (AIS).

Aims. Reviewing up-to-date research on neurophysiology of movement and posture control with the aim of providing basis for new researches in the field of AIS rehabilitation and background understanding for clinicians engaged in management of AIS.

Methods. Review of literature.

Results. We considered several neurophysiological issues relevant for AIS rehabilitation, namely, the peculiar organization of patterns of trunk muscle recruitment, the structure of the neural hardware subserving axial and arm muscle control, and the relevance of cognitive systems allowing mapping of spatial coordinates and building of body schema.

Discussion and conclusion. We made clear the reason why trunk control is generally carried out by means of very fast, feedforward or feedback driven patterns of muscle activation which are deeply rooted in our neural control system and very difficult to modify by training. We hypothesized that augmented sensory feedback and strength exercises could be an important stage in a rehabilitation program aimed at hindering, or possibly reversing, scoliosis progression. In this context we considered bracing not only as a corrective biomechanical device but also as a tool for continuous sensory stimulation that could help awareness of body misalignment. Future research aimed at developing strategies of trunk postural control learning is essential in the rehabilitation of adolescent idiopathic scoliosis.     

Conservative management of neuromuscular scoliosis: personal experience and review of literature

Purpose. The principles of conservative management of neuromuscular scoliosis in childhood and adolescence are presented.

Methods. Analysis of personal experience and literature review. The topic is discussed separately for patients with flaccid or spastic paresis.

Results. These demonstrate that conservative management might be proposed for patients with neuromuscular scoliosis in many clinical situations. In spastic disorders, it maintains the symmetry around the hip joints. Bracing is technically difficult and often is not tolerated well by cerebral palsy children. In patients with flaccid paresis, the fitting and the use of brace is easier than in spastic patients. The flexibility of the spinal curvature is more important. Functional benefits of conservative management of neuromuscular scoliosis comprise stable sitting, easier use of upper limbs, discharge of the abdomen from the collapsing trunk, increased diaphragm excursion, and, not always, prevention of curve progression.

Conclusions. Specific natural history and multiple medical problems associated with the disease make the treatment of children with neuromuscular scoliosis an extremely complex issue, best addressed when a team approach is applied. Continuously improving techniques of conservative management, comprising bracing and physiotherapy, together with correctly timed surgery incorporated in the process of rehabilitation, provide the optimal care for patients.     

Effect of bilateral reaching on affected arm motor control in stroke--with and without loading on unaffected arm

Purpose. To investigate the effect of bilateral reaching, with/without inertial loading on the unaffected arm, on hemiparetic arm motor control in stroke.

Methods. Twenty unilateral stroke patients were recruited. A three-dimensional optical motion capture system was used to measure the movement trajectory of the hemiparetic arm while performing three tasks: affected limb reaching forward; two-limb reaching forward; and two-limb reaching forward with inertia loading of 25% upper limb weight on the unaffected limb, respectively. Kinematical parameters were utilized to quantify the reaching performance of the affected arm.

Results. No matter whether loading was applied on the unaffected arm or not, the bilateral reaching task did not significantly facilitate smoother and faster movement. Furthermore, during bilateral reaching task with/without loading on the unaffected arm, stroke patients showed slower movement, lower maximal movement velocity, feedback control dominant and discontinuous movements in the affected arm than the same task with unilateral reaching. Subjects showed the greatest active upper extremity range of motion in proximal joints during the bilateral reaching task without unaffected arm loading. The amount of trunk movement also increased during bilateral reaching either with or without loading on the unaffected arm. Patients with moderate upper extremity motor impairment performed more discontinuous movements and less active elbow range of motion during bilateral reaching tasks; however, those with mild upper extremity motor impairment performed smoother movements and demonstrated greater active elbow range of motion during bilateral reaching tasks.

Conclusions. Bilateral reaching tasks with/without loading on the unaffected arm could be considered as adding challenges during motor control training. Training with bilateral arm movements may be considered as a treatment strategy, and can be incorporated in stroke rehabilitation to facilitate greater arm active movement and improve motor control performance in the affected arm.     

Adolescent idiopathic scoliosis (AIS) - an indication for surgery? A systematic review of the literature

Purpose. Historically, the treatment options for AIS, the most common form of scoliosis are: Exercises, in-patient rehabilitation, braces and surgery. While there is evidence in the form of prospective controlled studies that Scoliosis Intensive Rehabilitation (SIR) and braces can alter the natural history of the condition, there is no review on prospective controlled trials for surgical treatment. The aim of this review was to perform a systematic search of the Pub Med literature to reveal the evidence on scoliosis surgery.

Methods. A systematic review has been performed using the Pub Med database. Literature has been searched for the outcome parameter; 'rate of progression' and only prospective controlled studies that have considered the treatment versus the natural history have been included.

Results. No controlled study, not in the short, mid or long term, searched within the review, has been found to reveal evidence to support the hypothesis that the effects of surgery as a treatment option for AIS is superior to natural history.

Conclusions. No evidence has been found in terms of prospective controlled studies to support surgical intervention from the medical point of view. In the light of the unknown long-term effects of surgery and in concluding on the lack of evidence already found that surgery might change the signs and symptoms of scoliosis, a randomized controlled trial (RCT) is long overdue. Until such a time that such evidence exists, there can be no medical indication for surgery. The indications for surgery are limited for cosmetic reasons in severe cases and only if the patient and the family agree with this.     

Bracing adolescent idiopathic scoliosis: a systematic review of the literature of effective conservative treatment looking for end results 5 years after weaning

Purpose. The purpose of this study is to investigate long-term radiological and clinical outcomes of brace treatment, comparing to those of the natural history or surgical treatment.

Method. Review of literature.

Results. Most of the ling-term follow-up study of brace treatment showed initial improvement with use of the brace, slight improvement compared with the original curve at the time of the brace discontinuation, and an additional loss of correction at the time of the follow-up. The rate of loss of correction was comparable to the progression rate observed in the natural history after skeletal maturity, and the effect of the brace treatment remained even with some loss of correction after the treatment. Clinical outcomes investigated were pain, function, and activity of the patients, including marital status, child bearing, and job performance. Most of the studies concluded that quality of life of the patients treated by brace was comparable to that of the control, with some exception reported regarding back pain and some kind of activities.

Conclusion. Brace treatment is effective even in the long-term for the treatment of adolescent idiopathic scoliosis. Curve progression after the treatment was equivalent to that in the natural history. Quality of life of the patients treated by brace was comparable to that of the normal control.     

Usefulness of BFB/EMG in facial palsy rehabilitation

Objective. To analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bell's palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG).

Study design. Retrospective cases - series review.

Methods. Seventy-four patients with Bell' palsy were clinically evaluated within 1 month from onset of palsy and at 12 months after palsy (House scale and synkinesis evaluation). Electromyography (EMG) and Electroneurography (ENG) were performed about 4 weeks after palsy to better evaluate functional abnormalities due to facial nerve lesion. The patients followed two different protocols for rehabilitation: the first 32 patients were treated with therapeutic exercises performed by therapists (KT group), the latter 42 patients were treated using BFB/EMG methods (BFB group) with inhibition of synkinetic movement as the primary goal.

Results. KT and BFB patients were evaluated for clinical and neurophysiological characteristics before rehabilitative treatment. BFB patients showed better clinical recovery and minor synkinesis than KT patients.

Conclusions. BFB/EMG seems to be more useful than KT in Bell's palsy treatment. This could be due to the fact that BFB/EMG gives more accurate information than KT on muscle activation with better modulation in voluntary recruitment of motor unit.     

Interception of moving objects while walking in children with spastic hemiparetic cerebral palsy

Purpose. The purpose of the study was to examine the coordination of reaching and walking behaviour when children with Spastic Hemiparetic Cerebral Palsy (SHCP) intercept an approaching and hence externally-timed object.

Method. Using either the impaired or non-impaired arm, children intercepted a ball approaching from a fixed distance with one of three velocities. Each participant's initial starting position was scaled to their maximum walking velocity determined prior to testing; for the medium ball velocity, participants would arrive at the point of interception at the correct time if they walked with their maximum velocity.

Results. Children with SHCP adapted their reaching and walking behaviour to the different ball approach velocities. These adaptations were exhibited when using the impaired and non-impaired arm, and resulted in similar outcome performance irrespective of which arm was used. Still, children with SHCP found it necessary to increase trunk movement to compensate for the decreased elbow excursion and a decreased peak velocity of the impaired arm.

Conclusion. Children with SHCP exhibited specific adaptations to their altered movement capabilities when performing a behaviourally-realistic task. The provision of an external timing constraint appeared to facilitate both reaching and walking movements and hence could represent a useful technique in rehabilitation.     

A clinical model for the assessment of posture and balance in people with stroke

Purpose : The lack of models to define and describe rehabilitation processes have often been identified as limiting research and the development of clinical practice. This study describes the development of a clinical model to address a key aspect of stroke physiotherapy--the assessment of posture and balance.

Method : Twenty seven experienced neurological physiotherapists (PT) in six focus groups were used. Participants were shown photographs of a typical stroke patient in sitting and standing positions and were asked 'What would you note if you were assessing the posture and balance of this patient?' Answers were displayed on flip charts to allow immediate feedback about the accuracy and completeness of data. Thematic content analysis was then used.

Results : A complex reasoning process emerged to answer three main questions: What can the patient do? How does s/he do it? Why does s/he do it that way? To answer these questions physiotherapists established balance disability (by observing the patient's ability to perform a series of increasingly demanding balance tasks), identified postural and movement impairments (by observing alignment and movement of body segments relative to each other and to the expected norm for that patient) and assessed muscle activity (by observation and palpation).

Conclusions : Focus groups have been used to elicit a clinical model for the assessment of posture and balance, the content of which will be used to inform a new outcome measure.     

The potential for utilizing inter-limb coupling in the rehabilitation of upper limb motor disability due to unilateral brain injury

Purpose. Symmetry tendencies in human movement have generally been regarded as a constraint to upper limb motor performance. However, several recent studies have suggested that this phenomenon might be utilized in the rehabilitation of individuals with motor disability due to unilateral brain injury. In this paper the efficacy of such a rehabilitative approach is explored by reviewing: (i) examples of symmetry tendencies in healthy individuals, (ii) the potential neurophysiological mechanisms responsible for inter-limb coupling, and (iii) recent studies which have directly assessed the effects of inter-limb coupling on individuals with unilateral brain injury.

Method. A thorough review of current published evidence was conducted utilizing various electronic search engines (Medline, PreMedline, Embase and Cinahl). Studies included those that focused on symmetry tendencies and/or inter-limb coupling in the upper limbs with a particular emphasis placed on studies of individuals with unilateral brain injury.

Results. Based on the current literature it seems that motor function of the affected upper limb in individuals with unilateral brain injury can be improved through a rehabilitation approach that incorporates inter-limb coupling.

Conclusion. This approach should be considered as an adjunct to more common rehabilitation strategies with future research aimed at determining the most effective means of employing this paradigm.     

Time for a shift in Australian rehabilitation?

Purpose. Tertiary rehabilitation, particularly in Australia, still costs a significant amount of money each year. Turnover in the rehabilitation industry is extremely high and rehabilitation professionals report being dissatisfied in their work. These ironic findings can be attributed to the state of tension in which rehabilitation finds itself. A decade ago, it was noted that tertiary rehabilitation counselling was facing the challenge of managing several conflicting forces and constantly shifting priorities. In the last decade, this challenge has intensified.

Method. A review of current data was undertaken to identify the primary tensions that have influenced rehabilitation over the last decade.

Results. Tensions were attributed to three sets of opposing forces related to the philosophy of rehabilitation, the economic imperative and the role of privatisation of the industry.

Conclusion. This paper argues the need for a fundamental shift in thinking if the rehabilitation discipline is to continue growing. Precedents exist that can assist rehabilitation to make a significant shift to a new model of thinking, but a great deal of attention must be focused on the legal, economic and medical barriers to that movement.     

A nursing perspective on the relationship between nursing and allied health in inpatient rehabilitation

Purpose. To generate a deeper understanding of contextual factors influencing nursing's contribution to inpatient rehabilitation units in Australia.

Method. Grounded theory informed by the theoretical perspective of symbolic interactionism. Data were generated by interviews with nurses and observation of their everyday practice.

Results. Nursing and allied health work in inpatient rehabilitation was segregated by divided and dividing work practices. Several contextual conditions contributed to the segregation. These were 'limited acknowledgment of nursing's complex role', 'divisive work practices' and 'discontinuous teamwork'. Segregation limited the extent to which nurses could contribute to patient rehabilitation.

Conclusion. The delivery of multi-professional inpatient rehabilitation is complex. By focusing efforts to ameliorate segregation, progress can be made towards optimizing the contribution of all disciplines to patient rehabilitation.     

Predictors for successful vocational rehabilitation for clients with back pain problems

Purpose. The aim of this study was to identify predicting factors for successful vocational rehabilitation for people with back pain problems.

Method. The study was based on data from 347 long-term sick-listed clients collected at the onset of vocational rehabilitation. The outcome was measured 6 months after the conclusion of rehabilitation.

Results. In a first bi-variate analysis, a considerable number of variables were associated with the rehabilitation outcome. In a second multivariate analysis, only four associations remained. These were age, general health, vitality and internal locus of control. Young vital clients in good general health, with a high internal locus of control were more likely than others to return to work.

Conclusion. The findings regarding age, general health and vitality are well in line with previous studies. The findings regarding internal locus of control are more unique.     

Force production and EMG activity of neck muscles in adolescent headache

Purpose. This study compared the maximal force, EMG/force ratio and co-activation characteristics of the neck-shoulder muscles between 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls.

Method. Force was measured with surface electromyography (EMG) from the cervical erector spinae (CES), the sternocleidomastoid (SCM) and trapezius muscles during the maximal isometric neck flexion, neck extension and shoulder flexion.

Results. Girls with migraine-type headache had higher EMG/force ratios between the EMG of the left agonist SCM muscle and the corresponding maximal neck flexion (p = 0.030) and neck rotation force to the right side (p = 0.024) than the girls with tension-type headache. Migrainous girls had more co-activation of right antagonist CES muscle during maximal neck flexion force than the girls without headache (p = 0.015). Neck force production showed no significant differences between girls. Girls with tension-type headache displayed lower left shoulder flexion force than girls with migraine-type headache (p = 0.005) or with no headache (p = 0.005). In boys, no significant differences were observed.

Conclusions. Girls with tension-type headache and migraine-type headache have differences in neuromuscular function in the neck-shoulder muscles. The data amplify our knowledge of the neck-shoulder muscle dysfunction in adolescent headache, and may encourage the use of specific rehabilitation methods in the management of different types of headache.     

Cervicogenic dizziness - musculoskeletal findings before and after treatment and long-term outcome

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.     

Is there a relationship between light touch-pressure sensation and functional hand ability?

Purpose. To investigate and compare the level of light touch-pressure sensation as tested via the Semmes Weinstein monofilament (SWM) test with the level of functional hand ability.

Methods. Twenty-seven persons with isolated sensory deficit due to leprosy and 31 healthy controls were tested in the Occupational Therapy department of a hospital for patients with Hansen's disease. Palmar light touch thresholds were determined by SMW testing. Functional hand ability was tested via the Jebsen-Taylor Hand Function Test (JTHFT) and the Functional Dexterity Test (FDT). All participants were measured by manual muscle testing (MMT) to exclude any motor impairment. Data analysis compared sensory thresholds and level of functional hand ability between the two groups and examined the relationship between the variables.

Results. In the group with sensory deficit, the sensory thresholds were significantly higher than in the control group. Significant correlations were found between the sensory thresholds measured by the SWM test and the FDT and JTHFT scores, with higher correlations found for tasks entailing manipulation of small objects.

Conclusions. The findings support the existence of a relationship between sensory light touch thresholds tested by the Semmes Weinstein monofilaments (SWMs) and hand function. However, the SWM test alone is not sufficient as an indicator of hand function and must therefore be supplemented with other hand function tests.     

Range of motion of the scoliotic spine in adults]

OBJECTIVE: To describe the movement of the trunk in adults with untreated adolescent idiopathic scoliosis (AIS) and to evaluate their relationship with the age of the patients, the location and angle of the curve, and the number of involved intervertebral segments. MATERIALS AND METHODS: Two hundred adult subjects with untreated AIS, without associated signs, were analyzed with rachimetry. The flexion, extension, bending, and rotation of the trunk were determined for each patient. The results were compared with a different sample: healthy subjects without spinal disease/other groups with more severe scoliosis (treated). RESULTS: In the absence of discopathy, regardless of the angle, location of the curve, or age of the patient, adults with untreated AIS demonstrated a 24% increase in truncal flexion, and a 30% decrease in hip flexion. The other movements studied with rachimetry were comparable to normal subjects. Lesions of the intervertebral segments increased in number and severity with age. These lesions progressively limited the mobility of the spine, initially in extension; and then in bending and flexion. CONCLUSIONS: The measurement of the mobility of the spine and the pelvis is part of the systematic examination of patients with adult scoliosis. This information can be used to improve the patients' health and spinal function; independent of their age and degree of spinal deformity.     

Predictors of assistive technology use: the importance of personal and psychosocial factors

Objective. To validate an assistive technology (AT) baseline and outcomes measure and to quantify the measure's value in determining the best match of consumer and AT considering consumer ratings of their subjective quality of life, mood, support from others, motivation for AT use, program/therapist reliance, and self-determination/self-esteem.

Design. Prospective multi-cohort study.

Setting. Vocational rehabilitation offices and community.

Participants. Over 150 vocational rehabilitation counselors in 25 U.S. states with one consumer each receiving new AT.

Interventions. Counselor training in the Matching Person and Technology (MPT) Model and consumer completion of the MPT measure, Assistive Technology Device Predisposition Assessment (ATD PA).

Main outcome measures. Total and subscale scores on the ATD PA as well as counselor-completed questionnaires.

Results. ATD PA items differentiated consumer predispositions to AT use as well as AT and user match. There were no significant differences due to gender, physical locality, or age within this sample of working-age adult consumers. Vocational rehabilitation counselors exposed to training in the MPT Model achieved enhanced AT service delivery outcomes.

Conclusions. The ATD PA is a valid measure of predisposition to use an AT and the subsequent match of AT and user. Rehabilitation practitioners who use the ATD PA will achieve evidence-based practice and can expect to see enhanced AT service delivery outcomes.