Reliability of the Knee Examination in Osteoarthritis: Effect of Standardization

Objective. To assess the reliability of physical examination of the osteoarthritic (OA) knee by rheumatologists, and to evaluate the benefits of standardization. Methods. Forty-two physical signs and techniques were evaluated using a 6 X 6 Latin square design. Patients with mild to severe knee OA, based on physical and radiographic signs, were examined in random order prior to and following standardization of techniques. For those signs with dichotomous scales, agreement among the rheumatologists was calculated as the prevalence-adjusted bias-adjusted kappa (PABAK), while for the signs with continuous and ordinal scales, a reliability coefficient (R-c) was calculated using analysis of variance. A PABAK of >0.60 and an Re of >0.80 were considered to indicate adequate reliability. Results. Adequate poststandardization reliability was achieved for 30 of 42 physical signs/techniques (71%). The most highly reliable signs identified by physical examination of the OA knee included alignment by goniometer (R-c = 0.99), bony swelling (R-c = 0.97), general passive crepitus (R-c = 0.96), gait by inspection (PABAK = 0.78), effusion bulge sign (R-c = 0.97), quadriceps atrophy (R. = 0.97), medial tibiofemoral tenderness (R-c = 0.94), lateral tibiofemoral tenderness (R-c = 0.85), patellofemoral tenderness by grind test (R-c = 0.94), and flexion contracture (R-c = 0.95). The standardization process resulted in substantial improvements in reliability for evaluation of a number of physical signs, although for some signs, minimal or no effect of standardization was noted. After standardization, warmth (PABAK = 0.14), medial instability at 30degrees flexion (PABAK = 0.02), and lateral instability at 30degrees flexion (PABAK = 0.34) were the only 3 signs that were highly unreliable. Conclusion. With the exception of physical examinations for instability, a comprehensive knee examination can be performed with adequate reliability. Standardization further improves the reliability for some physical signs and techniques. The application of these findings to future OA studies will contribute to improved outcome assessments in OA.

Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients

There has been little investigation into whether or not differences exist in the nature of physical impairment associated with neck pain of whiplash and insidious origin. This study examined the neck flexor synergy during performance of the cranio-cervical flexion test, a test targeting the action of the deep neck flexors. Seventy-five volunteer subjects participated in this study and were equally divided between Group 1, asymptomatic control subjects, Group 2, subjects with insidious onset neck pain and Group 3, subjects with neck pain following a whiplash injury. The cranio-cervical flexion test was performed in five progressive stages of increasing cranio-cervical flexion range. Subjects' performance was guided by feedback from a pressure sensor inserted behind the neck which monitored the slight flattening of the cervical lordosis which occurs with the contraction of longus colli. Myoelectric signals (EMG) were detected from the muscles during performance of the test. The results indicated that both the insidious onset neck pain and whiplash groups had higher measures of EMG signal amplitude (normalized root mean square) in the sternocleidomastoid during each stage of the test compared to the control subjects (all P

Neck flexor muscle fatigue is side specific in patients with unilateral neck pain

Despite the evidence of greater fatigability of the cervical flexor muscles in neck pain patients, the effect of unilaterality of neck pain on muscle fatigue has not been investigated. This study compared myoelectric manifestations of sternocleidomastoid (SCM) and anterior scalene (AS) muscle fatigue between the painful and non-painful sides in patients with chronic unilateral neck pain. Myoelectric signals were recorded from the sternal head of SCM and the AS muscles bilaterally during sub-maximal isometric cervical flexion contractions at 25% and 50% of the maximum voluntary contraction (MVC). The time course of the mean power frequency, average rectified value and conduction velocity of the electromyographic signals were calculated to quantify myoelectric manifestations of muscle fatigue. Results revealed greater estimates of the initial value and slope of the mean frequency for both the SCM and AS muscles on the side of the patient's neck pain at 25% and 50% of MVC. These results indicate greater myoelectric manifestations of muscle fatigue of the superficial cervical flexor muscles ipsilateral to the side of pain. This suggests a specificity of the effect of pain on muscle function and hence the need for specificity of therapeutic exercise in the management of neck pain patients. (C) 2003 European Federation of Chapters of the International Association for the Study of Pain. Published by Elsevier Ltd. All rights reserved.

Characterization of acute whiplash-associated disorders

Study Design. An experimental study of motor and sensory function and psychological distress in subjects with acute whiplash injury. Objectives. To characterize acute whiplash injury in terms of motor and sensory systems dysfunction and psychological distress and to compare subjects with higher and lesser levels of pain and disability. Summary of Background Data. Motor system dysfunction, sensory hypersensitivity, and psychological distress are present in chronic whiplash associated disorders ( WAD), but little is known of such factors in the acute stage of injury. As higher levels of pain and disability in acute WAD are accepted as signs of poor outcome, further characterization of this group from those with lesser symptoms is important. Materials and Methods. Motor function ( cervical range of movement [ ROM], joint position error [JPE]; activity of the superficial neck flexors [EMG] during a test of craniocervical flexion), quantitative sensory testing ( pressure, thermal pain thresholds, and responses to the brachial plexus provocation test), and psychological distress (GHQ-28, TAMPA, IES) were measured in 80 whiplash subjects ( WAD II or III) within 1 month of injury, as were 20 control subjects. Results. Three subgroups were identified in the cohort using cluster analysis based on the Neck Disability Index: those with mild, moderate, or severe pain and disability. All whiplash groups demonstrated decreased ROM and increased EMG compared with the controls ( all P < 0.01). Only the moderate and severe groups demonstrated greater JPE and generalized hypersensitivity to all sensory tests ( all P < 0.01). The three whiplash subgroups demonstrated evidence of psychological distress, although this was greater in the moderate and severe groups. Measures of psychological distress did not impact on between group differences in motor or sensory tests. Conclusions. Acute whiplash subjects with higher levels of pain and disability were distinguished by sensory hypersensitivity to a variety of stimuli, suggestive of central nervous system sensitization occurring soon after injury. These responses occurred independently of psychological distress. These findings may be important for the differential diagnosis of acute whiplash injury and could be one reason why those with higher initial pain and disability demonstrate a poorer outcome.

Early alterations in serum creatine kinase and total cholesterol following high intensity eccentric muscle actions

Aim. The purpose of this experiment was to assess the levels of muscle soreness, serum total cholesterol (TC) and creatine kinase (CK) in the first 48 hours following fatiguing eccentric exercise performed with the triceps brachii. Methods. Eleven untrained male college students performed a total of 50 eccentric elbow extensions in 8 sets (6x7 and 2x4) with a load equal to 85% of their maximal concentric elbow extension strength. Isometric elbow extension strength, muscle soreness and circumference, and serum CK and TC concentrations were measured before, immediately after, and 2, 24 and 48 hours after the exercise. Results. Statistically reliable changes in isometric strength, serum CK and TC, muscle soreness and upper arm circumference occurred within the first 48 hours following eccentric exercise. Serum TC concentrations exhibited a very rapid (within 2 hours) reduction from pre-exercise values after eccentric exercise to a relatively stable concentration of approximately 85% of baseline. Conclusion. These results suggest that serum TC concentration may follow the time-course of reductions in force generating capacity more closely than other biochemical markers of muscle damage.

Bimanual coordination: constraints imposed by the relative timing of homologous muscle activation

It has often been supposed that patterns of rhythmic bimanual coordination in which homologous muscles are engaged simultaneously, are performed in a more stable manner than those in which the same muscles are activated in an alternating fashion. In order to assess the efficacy of this constraint, the present study investigated the effect of forearm posture (prone or supine) on bimanual abduction-adduction movements of the wrist in isodirectional and non-isodirectional modes of coordination. Irrespective of forearm posture, non-isodirectional coordination was observed to be more stable than isodirectional coordination. In the latter condition, there was a more severe deterioration of coordination accuracy/stability as a function of cycling frequency than in the former condition. With elevations in cycling frequency, the performers recruited extra mechanical degrees of freedom, principally via flexion-extension of the wrist, which gave rise to increasing motion in the vertical plane. The increases in movement amplitude in the vertical plane were accompanied by decreasing amplitude in the horizontal plane. In agreement with previous studies, the present findings confirm that the relative timing of homologous muscle activation acts as a principal constraint upon the stability of interlimb coordination. Furthermore, it is argued that the use of manipulations of limb posture to investigate the role of other classes of constraint (e.g. perceptual) should be approached with caution because such manipulations affect the mapping between muscle activation patterns, movement dynamics and kinematics.

Prolotherapy injections, saline injections, and exercises for chronic low-back pain: A randomized trial

Objectives. To assess the efficacy of a prolotherapy injection and exercise protocol in the treatment of chronic nonspecific low back pain. Design. Randomized controlled trial with two- by- two factorial design, triple- blinded for injection status, and single- blinded for exercise status. Setting. General practice. Participants. One hundred ten participants with nonspecific low- back pain of average 14 years duration were randomized to have repeated prolotherapy ( 20% glucose/ 0.2% lignocaine) or normal saline injections into tender lumbo- pelvic ligaments and randomized to perform either flexion/ extension exercises or normal activity over 6 months. Main outcome measures: Pain intensity ( VAS) and disability scores ( Roland- Morris) at 2.5, 4, 6, 12, and 24 months. Results. Follow- up was achieved in 96% at 12 months and 80% at 2 years. Ligament injections, with exercises and with normal activity, resulted in significant and sustained reductions in pain and disability throughout the trial, but no attributable effect was found for prolotherapy injections over saline injections or for exercises over normal activity. At 12 months, the proportions achieving more than 50% reduction in pain from baseline by injection group were glucose- lignocaine: 0.46 versus saline: 0.36. By activity group these proportions were exercise: 0.41 versus normal activity: 0.39. Corresponding proportions for > 50% reduction in disability were glucose- lignocaine: 0.42 versus saline 0.36 and exercise: 0.36 versus normal activity: 0.38. There were no between group differences in any of the above measures. Conclusions. In chronic nonspecific low- back pain, significant and sustained reductions in pain and disability occur with ligament injections, irrespective of the solution injected or the concurrent use of exercises.

The Effect of Wrist Rests and Forearm Support during Keyboard and Mouse Use

Supporting the forearm on the work surface during keyboard operation may increase comfort, decrease muscular load of the neck and shoulders, and decrease the time spent in ulnar deviation. Wrist rests are used widely in the workplace and are more commonly being incorporated in keyboard design. The aim of this study was to examine the effect of wrist rest use on wrist posture during forearm Support. A laboratory based, experimental study was conducted (subjects n = 15) to examine muscle activity and wrist Postures during keyboard and mouse tasks in each of' two conditions; wrist rest and no wrist rest. There were no significant differences for right wrist flexion/extension between use of a wrist rest and no wrist rest for keyboard or mouse use. Left wrist extension was significantly higher without a wrist rest than with a wrist rest during keyboard use (df = 14; t = 2.95; p = 0.01; d = 0.38). No differences with respect to use of a wrist rest were found for the left or right hand for ulnar deviation For keyboard or mouse use. There were no differences in muscle activity between the test conditions for keyboard use. Relevance to industry Wrist rests are used widely in the workplace and are more commonly being incorporated in keyboard design. Use of a wrist rest in conjunction with forearm support when using a conventional desk does not appear to have any impact on wrist posture or muscle activity during keyboard use. (C) 2004 Elsevier B.V. All rights reserved.

Incorporating nerve-gliding techniques in the conservative treatment of cubital Tunnel syndrome

Objective: To discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The rationale for the addition of nerve-gliding techniques will be highlighted. Clinical Features: Two months after onset, a 17-year-old female nursing student who had a traumatic onset of cubital tunnel syndrome still experienced pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were present which were regarded as contributing factors hindering natural recovery. Intervention and Outcomes: After 6 sessions consisting of nerve-gliding techniques and segmental joint manipulation and a home exercise program consisting of nerve gliding and light free-weight exercises, a substantial improvement was recorded on both the impairment and functional level (pain scales, clinical tests, and Northwick Park Questionnaire). Symptoms did not recur within a 10-month follow-up period, and pain and disability had completely resolved. Conclusions: Movement-based management may be beneficial in the conservative management of cubital tunnel syndrome. As this intervention is in contrast with the traditional recommendation of immobilization, comparing the effects of both interventions in a systematic way is an essential next step to determine the optimal treatment of patients with cubital tunnel syndrome.

Effects of experimentally-induced anterior knee pain on knee joint position sense in healthy individuals

Purpose. The ability to sense the position of limb segments is a highly specialised proprioceptive function important for control of movement. Abnormal knee proprioception has been found in association with several musculoskeletal pathologies but whether nociceptive Stimulation can produce these proprioceptive changes is unclear. This study evaluated the effect of experimentally induced knee pain on knee joint position sense (JPS) in healthy individuals. Study design. Repeated measures, within-subject design. Methods. Knee JPS was tested in 16 individuals with no history of knee pathology under three experimental conditions: baseline control, a distraction task and knee pain induced by injection of hypertonic saline into the infrapatellar fat pad. Knee JPS was measured using active ipsilateral limb matching responses at 20degrees and 60degrees flexion whilst non-weightbearing (NWB) and 20degrees flexion single leg stance. During the tasks, the subjective perception of distraction and severity of pain were measured using 11-point numerical rating scales. Results. Knee JPS was not altered by acute knee pain in any of the positions tested. The distraction task resulted in poorer concentration, greater JPS absolute errors at 20degrees NWB, and greater variability in errors during the WB tests. There were no significant correlations between levels of pain and changes in JPS errors. Changes in JPS with pain and distraction were inversely related to baseline knee JPS variable error in all test positions (r = -0.56 to -0.91) but less related to baseline absolute error. Conclusion. Knee JPS is reduced by an attention-demanding task but not by experimentally induced pain. (C) 2004 Orthopaedic Research Society. Published by Elsevier Ltd. All rights reserved.

The effect of anticoagulation on the restoration of range of motion after total knee arthroplasty: Enoxaparin versus aspirin

Anticoagulation used for thromboembolic prophylaxis following total knee arthroplasty (TKA) could interfere with movement. This study compares the effect of 2 anticoagulants, enoxaparin and aspirin, on restoration of range of motion (ROM) after TKA. Two groups of 75 consecutive patients, matched for age, arthritic severity, and preoperative ROM, underwent TKA. Flexion and extension milestone measures were recorded daily. Results show a highly statistically significant difference (P

Sagittal movement of the medial longitudinal arch is unchanged in plantar fasciitis

Background: Although a lowered medial longitudinal arch has been cited as a causal factor in plantar fasciitis, there is little experimental evidence linking arch motion to the pathogenesis of the condition. This study investigated the sagittal movement of the arch in subjects with and without plantar fasciitis during gait. Methods: Digital fluoroscopy was used to acquire dynamic lateral radiographs from 10 subjects with unilateral plantar fasciitis and 10 matched control subjects. The arch angle and the first metatarsophalangeal joint angle were digitized and their respective maxima recorded. Sagittal movement of the arch was defined as the angular change between heel strike and the maximum arch angle observed during the stance phase of gait. The-thickness of the proximal plantar fascia was determined from sagittal sonograms of both feet. ANOVA models were used to identify differences between limbs with respect to each dependent variable. Relationships between arch movement and fascial thickness were investigated using correlations. Results: There was no significant difference in either the movement or maximum arch angle between limbs. However, subjects with plantar fasciitis were found to have a larger metatarsophalangeal joint angle than controls (P < 0.05). Whereas the symptomatic and asymptomatic plantar fascia were thicker than those of control feet (P < 0.05), significant correlations were noted between fascial thickness and peak arch and metatarsophalangeal joint angles (P < 0.05) in the symptomatic limb only. Conclusions: Neither abnormal shape nor movement of the arch are associated with chronic plantar fasciitis. However, arch mechanics may influence the severity of plantar fasciitis once the condition is present. Digital flexion, in contrast, has a protective role in what might be a bilateral disease process.

A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia

A systematic review of the literature on the effectiveness of physical interventions for lateral epicondylalgia ( tennis elbow) was carried out. Seventy six randomised controlled trials were identified, 28 of which satisfied the minimum criteria for meta-analysis. The evidence suggests that extracorporeal shock wave therapy is not beneficial in the treatment of tennis elbow. There is a lack of evidence for the long term benefit of physical interventions in general. However, further research with long term follow up into manipulation and exercise as treatments is indicated.

A new method of isometric dynamometry for the craniocervical flexor muscles

Background and Purpose. A new method of dynamometry has been developed to measure the performance of the craniocervical (CC) flexor muscles by recording the torque that these muscles exert on the cranium around the CC junction. This report describes the method, the specifications of the instrument, and the preliminary reliability data. Subjects and Methods. For the reliability study, 20 subjects (12 subjects with a history of neck pain, 8 subjects without a history of neck pain) performed, on 2 occasions, maximal voluntary isometric contraction (MVIC) tests of CC flexion in 3 positions within the range of CC flexion and submaximal sustained tests (20% and 50% of MVIC) in the middle range of CC flexion (craniocervical neutral position). Reliability coefficients were calculated to establish the test-retest reliability of the measurements. Results. The method demonstrated good reliability over 2 sessions in the measurement of MVIC (intraclass correlation coefficient [ICC] =.79-.93, SEM=0.6-1.4 N-m) and in the measurement of steadiness (standard deviation of torque amplitude) of a sustained contraction at 20% of NMC (ICC=.74-.80, SEM=0.01 N-m), but not at 50% of MVIC (ICC=.07-.76, SEM=0.04-0.13 N-m). Discussion and Conclusion. The new dynamometry method appears to have potential clinical application in the measurement of craniocervical flexor muscle performance.