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BACKGROUND: The cranio-cervical flexion exercise and sub-occipital muscle inhibition technique have been used to improve a forward head posture among neck pain patients with straight leg raise (SLR) limitation. However, little is known about the cranio-vertebral angle (CVA) and cervical spine range of motion (CROM) after applying stretching methods to the hamstring muscle. OBJECTIVE: To compare the immediate effects of static stretching and proprioceptive neuromuscular facilitation stretching on SLR, CVA, and CROM in neck pain patients with hamstring tightness. METHODS: 64 subjects were randomly allocated to the static stretching (n1= 32) or proprioceptive neuromuscular facilitation (n2= 32) stretching group. The SLR test was performed to measure the hamstring muscle’s flexibility and tightness between the two groups, with CROM and CVA also being measured. The paired t-test was used to compare all the variables within each group before and after the intervention. The independent t-test was used to compare the two groups before and after the stretching exercise. RESULTS: There were no between-group effects for any outcome variables (P> 0.05). However, all SLR, CVA, and CROM outcome variables were significantly improved within-group (P< 0.05). CONCLUSIONS: There were no between-group effects for any outcome variable; however, SLR, CVA, and CROM significantly improved within-group after the one-session intervention in neck pain patients with hamstring tightness.

BACKGROUND: Electrotherapy is part of a physician’s toolbox for treating various musculoskeletal conditions, including radicular pain, but the preferred modality is yet unclear. OBJECTIVE: To compare the short-term efficacy of three electrotherapeutic modalities in relieving lumbar disc herniation (LDH)-induced radicular pain. METHODS: Fourteen patients with LDH-induced radicular pain attended a single session of electrotherapy, which included four 10-min consecutive treatments: transcutaneous electrical nerve stimulation (TENS), interferential (IF) stimulation, a combined treatment with pulsed ultrasound and IF current (CTPI), and a sham control. Treatments were randomized and the straight leg raise (SLR) degree was measured immediately before and after each treatment. RESULTS: Each of the three active modalities significantly improved the SLR score. The most prominent improvement was observed in the CTPI condition, followed by IF and, finally, TENS. The sham stimulation did not affect the SLR scores. CONCLUSIONS: A single session with either TENS, IF current or CTPI is sufficient to improve the range of motion and degree of radicular pain associated with LDH. CTPI appears to be the most effective modality of the three, possibly due to greater penetration efficiency of the induced current. The effects of a long-term treatment schedule are yet to be identified.

Background Controversy remains over what and how many analgesic techniques are required as the most effective multimodal pain regimen in total knee arthroplasty (TKA). This study aimed to evaluate the effect of additional analgesic methods combined with periarticular injection (PAI) analgesia for TKA. Methods Using retrospective cohort data, patients undergoing TKA with spinal anesthesia and PAI were divided into 4 groups. Group A (control) comprised 66 patients; group B (73 patients) had additional adductor canal block; group C (70 patients) obtained additional femoral nerve block, and group D (73 patients) received additional adductor canal block and intrathecal morphine. Propensity score matching was applied to compare visual analog scale (VAS) for pain intensity, cumulative morphine use (CMU), knee flexion angle, straight leg raise, length of hospital stay, and postoperative nausea and vomiting. Results There was no significant difference regarding VAS and morphine use, when either group B or C was compared with group A. Group D had significantly lower VAS than groups A, B, and C during the first 24 hours after surgery and required significantly less CMU than groups A and B. However, the pain score of group D increased afterward, with significantly longer length of hospital stay than groups A and B. There was no difference in straight leg raise among the groups. Conclusion Additional peripheral nerve block to PAI provides no benefit for patients undergoing TKA. Adjuvant intrathecal morphine could significantly reduce the VAS and CMU in the acute postoperative period; however, rebound pain with prolonged hospital stays was observed.

BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) for chronic low back pain (CLBP) requires a treatment period of ⩾ 6 weeks to decrease pain and disability and is ineffective as sole treatment. Instrument-assisted soft tissue mobilization (IASTM) has rapid effects in musculoskeletal disorders. OBJECTIVE: This study aimed to investigate the effects of a 3-week combined TENS and IASTM treatment (TICT) on CLBP. METHODS: Thirty-two young men with CLBP were randomly divided into the TICT and control groups (n= 16 each). Patients were evaluated with the visual analog (VAS) and face pain-rating scales (FPRS) for pain, the Oswestry Disability Index (ODI) and passive straight leg raise (PSLR) test for flexibility, and the supine bridge test (SBT) for endurance before and after the treatment course. The TICT group received TICT on the lower back, glutes, and hamstrings, six times in 3 weeks. RESULTS: Group, time, and group × time interaction effects on pain were significant (VAS and FPRS, all p< 0.001). Group × time interaction (ODI, p< 0.001; PSLR, p< 0.05; SBT, p< 0.01) and group (ODI, p< 0.05) and time main effects (ODI, p< 0.001; PSLR, p< 0.01; SBT, p< 0.001) on motor function were significant. CONCLUSION: Thus, short-term TICT decreased pain level and increased motor function in CLBP patients, yet further investigation is needed on different age and gender groups.

With the advent of high-resolution esophageal manometry, it is recognized that the antireflux barrier receives a contribution from both the lower esophageal sphincter (intrinsic sphincter) and the muscle of the crural diaphragm (extrinsic sphincter). Further, an increased intra-abdominal pressure is a major force responsible for an adaptive response of a competent sphincter or the disruption of the esophagogastric junction resulting in gastroesophageal reflux, especially in the presence of a hiatal hernia. This review describes how the pressure dynamics in the lower esophageal sphincter were discovered and measured over time and how this has influenced the development of antireflux surgery.

Chemonucleolysis with condoliase, which degrades chondroitin sulfate, could be a new, minimally invasive therapeutic option for patients with lumbar disc herniation (LDH). The purpose of this study was to analyze prognostic factors for clinical outcomes in LDH patients subjected to chemonucleolysis with condoliase.Inclusion criteria for this procedure were 1) 18-70 years of age; 2) unilateral leg pain and positive straight leg raise (SLR) (70°) or femoral nerve stretching test; 3) subligamentous extrusion verified on magnetic resonance imaging; 4) neurological symptoms consistent with a compressed nerve root on magnetic resonance imaging (MRI) images; and 5) minimum six months of follow-up. In total, 82 patients (55 men, 27 women; mean age, 47.2 ± 15.5 years; mean follow-up, 9.1 ± 3.0 months) who underwent chemonucleolysis with condoliase for painful LDH were included. An improvement of 50% or more in the Visual analogue scale (VAS) of leg pain was classified as effective.Seventy patients (85.4%) were classified into the effective (E) group and 12 patients (14.6%) into the less-effective (L) group. Surgical treatment was required in four patients. No severe adverse complications were reported; 41.3% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level. Univariate analysis revealed that young age (p = 0.036), without history of epidural or nerve root block (p = 0.024), and injection into the central portion of the intervertebral disc (p = 0.014) were significantly associated with clinical effectiveness. A logistic regression analysis revealed that injection into the central portion of the intervertebral disc (p = 0.049; odds ratio, 4.913; 95% confidence interval, 1.006-26.204) was significantly associated with clinical effectiveness.Chemonucleolysis with condoliase is a safe and effective treatment for painful LDH; 85.4% of the patients showed improvement after the treatment without severe adverse events. To obtain the best outcome, condoliase should be injected into the center of the intervertebral disc.

Objective To investigate the short-term outcomes at discharge of patients who receive additional postoperative rehabilitative exercises by peer volunteers after total knee arthroplasty (TKA). Design Retrospective cohort study. Setting Tertiary teaching hospital. Participants A total of 476 adult patients who had undergone a primary elective unilateral TKA (N=467). Interventions An intervention group received a standardized postoperative rehabilitative exercise protocol taught and supervised by peer volunteers in additional to standard physiotherapy (n=309) compared with a control group receiving standard physiotherapy alone (n=167). Main Outcome Measures Discharge outcomes were the pain score using the Numeric Rating Scale pain score, passive knee flexion and extension range of motion (ROM), length of hospitalization, ability to perform an unassisted straight leg raise of the operated leg, ambulation distance, ability in independent walking, walking aids required, discharge destination, and adverse events. Results On multivariate analysis, patients in the intervention group had an increased discharge passive knee flexion ROM of 7.89 degrees (95% confidence interval, 5.47-10.33; P Conclusions A rehabilitative exercise program by peer volunteers is feasible and safe after TKA in addition to standard physiotherapy and is associated with improved knee flexion ROM on discharge.

Purpose The purpose of this double-blind, randomized, controlled trial was to evaluate the use of intravenous (IV) tranexamic acid (TXA) in patients undergoing primary bone–patellar tendon–bone (BPTB) anterior cruciate ligament reconstruction (ACLR) regarding postoperative hemarthrosis, pain, opioid consumption, and quadriceps atrophy and activation. Methods A controlled, randomized, double-blind trial was conducted in 110 patients who underwent ACLR with BPTB autograft. Patients were equally randomized to the control and experimental groups. The experimental group received two 1-g boluses of IV TXA, one prior to tourniquet inflation and one prior to wound closure; the control group did not receive TXA. If a clinically significant hemarthrosis was evident, the knee was aspirated and the volume of blood (in milliliters) was recorded. Additionally, we recorded perioperative blood loss (in milliliters); visual analog scale scores on postoperative days 1, 4, and 7 and at postoperative weeks 1, 6, and 12; postoperative opioid consumption on postoperative days 1, 4, and 7; range of motion (ROM) and ability to perform a straight leg raise at postoperative weeks 1, 6, and 12; and preoperative and postoperative thigh circumference ratio. Results There was no significant difference in perioperative blood loss between the TXA and control groups (32.5 mL vs 35.6 mL, P = .47). In the TXA group, 23 knees were aspirated; in the control group, 26 knees were aspirated (P = .56). No significant difference in postoperative hemarthrosis volume was seen in patients who received IV TXA versus those who did not (26.7 mL vs 37.3 mL, P = .12). There was no significant difference in visual analog scale scores between the 2 groups (P = .15); in addition, there was no difference in postoperative opioid consumption (P = .33). No significant difference in ROM, ability to perform a straight leg raise, or postoperative thigh circumference ratio was observed (P > .05 for all). Conclusions IV TXA in patients who undergo ACLR with BPTB autograft does not significantly impact perioperative blood loss, postoperative hemarthrosis, or postoperative pain levels. Additionally, no significant differences were seen in early postoperative recovery regarding ROM or quadriceps reactivation. Level of Evidence Level I, randomized controlled trial.

INTRODUCTION Pelvic girdle pain (PGP) is the most common musculoskeletal concern in pregnancy. The Active Straight Leg Raise (ASLR) test is diagnostic. Sacroiliac joint (SIJ) belts are included in multimodal therapy, but there is no established predictive measure to determine which pregnant women will benefit. OBJECTIVE To determine if the ASLR score is immediately reduced by SIJ belt application and whether PGP pain and function improves after 4 weeks of belt use. DESIGN Prospective observational cohort study. SETTING Academic medical center. PARTICIPANTS Pregnant women at least 18 years of age in the second or third trimester of pregnancy with posterior PGP and ASLR score of 2 to 10. INTERVENTIONS Four-week SIJ belt use. MAIN OUTCOME MEASURES ASLR, Numerical Rating Scale (NRS), Pelvic Girdle Questionnaire (PGQ), Perceived Global Impression of Improvement (PGII). RESULTS Sixty-three women enrolled. On multivariable analysis, immediate belted ASLR score was -2.70 points lower than the non-belted ASLR score (P

Context: It has been recently demonstrated that tissue flossing around the ankle joint can be effectively used to improve ankle range of motion, jump, and sprint ability. However, there is a lack of studies investigating the acute effects of tissue flossing applied using different wrapping pressures. Objective: To investigate the acute effects of tissue flossing and the degree of floss band pressure, around the upper thigh on knee range of motion, strength, and muscle contractile characteristics. Design: Crossover design in 3 distinct sessions. Setting: University laboratory. Participants: A total of 19 recreationally trained volunteers (age 23.8[4.8] y) participated in this study. Intervention: Active knee extension and flexion performed for 3 sets of 2 minutes (2-min rest between sets with wrapped upper thigh). Individualized wrapping pressures were applied to create conditions of high and moderate vascular occlusion, while a loose band application served as a control condition. Main Outcome Measures: Participants were assessed for active straight leg raise test; tensiomyography displacement and contraction time for rectus femoris, vastus medialis, and biceps femoris muscles; and maximum voluntary contractions for knee extensors and flexors for pre, after, and 30 minutes after applying the floss band. Results: There was a statistically significant increase in maximum voluntary contractions for knee extensors and a significant shortening in rectus femoris contraction time for the moderate condition, which was associated with small to medium effects in favor of the moderate condition. There were no statistically significant changes observed between control and high conditions. The active straight leg raise test was unaffected regardless of intervention. Conclusions: The results of this study suggest that tissue flossing around the upper thigh might have a localized as well as pressure-sensitive response, thereby improving neuromuscular function of the knee extensors.

Delayed onset of muscle soreness (DOMS) is a common finding in trained and untrained individuals post high intensity exercises which can lead to injuries. Foam rolling (FR) and neurodynamic therapy (NDT) are types of active cool-down which provides effective for treatment of DOMS. But their role in reduction of intensity of the same in cool down is not established.Crossover study.Total 60 healthy individuals participated in the study. Pre intervention readings were taken of strength and tightness by Range of motion. Subjects performed both the types of cool-down separated by 4 weeks interval with random allocation. Post intervention readings of hamstring and quadriceps tightness, grade of tenderness and stand to sit VAS score was taken post 24 h and 48 h and strength post 48 h.Analysis was done for using repeated measures ANOVA and Friedman's test. The difference of values for Straight Leg Raise and Prone knee Flexion between NDT and FR post 24 h were statistically significant (p 0.05) while that of NDT post 24 h being similar to FR post 48 h (p 0.05). There was a significant difference between strength, tenderness and VAS in NDT and FR (p 0.05). With the mean of post 24 h as well as post 48 h being less in the FR intervention.Foam rolling is a better option than Neurodynamic therapy for reduction of intensity of DOMS.

Background There are no clear indicators for predicting return to work for patients with chronic low back pain (LBP). We aim to report the outcomes of a 14-week multidisciplinary programme targeting patients with chronic LBP who failed conventional physiotherapy to provide functional rehabilitation. Also, this study will identify factors predicting successful return to work (RTW). Methods A collected cohort of patients with chronic LBP was consecutively enrolled into the programme from 1996 to 2014. All recruited patients failed to RTW despite at least 3 months of conservative treatment. Patient underwent weekly multidisciplinary sessions with physiotherapists, occupational therapists and clinical psychologists. Patient perceived function was considered the primary outcome of the programme. Patients were assessed for their sitting, standing and walking tolerance. Oswestry Disability Index (ODI) and Spinal Function Sort Score (SFSS) were used to assess patient perceived disability. Results One hundred and fifty-eight patients were recruited. After the programme, statistically significant improvement was found in ODI (47.5 to 45.0, p = 0.01) and SFSS (98.0 to 109.5, p p 2 = 59.5%, χ2 (9) = 85.640, p Conclusion The results of this study may support the use of this multidisciplinary programme to improve patient function and return to work.

The modified Functional Movement Screen™ (mFMS) has been used to screen for mobility, stability, motor control, and balance in older adults, yet, its relationship to measures of physical fitness is not fully understood. The purpose of this study was to determine the association between mFMS scores and measures of physical fitness in older adults. A secondary aim was to determine physical fitness differences depending on mFMS Lower Body Motor Control Screen scores.One hundred and eight older adults completed this cross-sectional study. Measurements of physical fitness included: Handgrip Strength (HG), Back-Leg Strength Dynamometer (BLS), 8 foot Up and Go (8UG), Vertical Jump (VJ), Medicine Ball Throw (MBT), Chair Stand (CST), Arm Curl (AC), and 6-Minute Walk test (6 MW). The mFMS consisted of four screens: Shoulder Mobility Screen (SMS), Deep Squat (DS), Active Straight Leg Raise (ASLR), and a Lower Body Motor Control Screen (LB-MCS). Spearman's R correlations determined associations between physical fitness tests and mFMS scores (DS, SMS, ASLR). Independent t-tests or Mann Whitney U tests determined whether individuals who passed the LB-MCS displayed higher physical fitness scores.The DS was significantly correlated with all fitness measures (p 0.05). Higher DS scores were associated with better HG (r = 0.31), BLS (r = 0.49), VJ height (r = 0.54), MBT (r = 0.41), CST (r = 0.57), AC (r = 0.30), 6 MW (r = 0.50), and 8UG (r = -0.61) performance. Individuals who passed the LB-MCS displayed superior BLS, 8UG test, and 6 MW test performance (p 0.05).Higher DS scores are associated with higher physical fitness scores. Individuals who passed the LB-MCS displayed better physical fitness scores. Practitioners may desire to use the mFMS to measure physical fitness in older adults.

ObjectivesThe aim of this study was to evaluate the efficacy of local infiltration anaesthesia (LIA) during primary total hip arthroplasty (THA) via a posterolateral approach under general anaesthesia and to compare the efficacy of LIA in all layers with LIA in the deep and superficial fascia.Patients and methodsOne hundred twenty patients were randomised into three groups: LIA in the deep and superficial fascia (group A), LIA in all layers (group B) and the control (group C). The primary outcomes were the visual analogue scale (VAS) pain scores at rest and on movement within 72 h (h) postoperatively. The secondary outcomes included opioid consumption, patient satisfaction, range of motion (ROM), straight leg raise completion rate, length of hospital stay, opioid-related side effects and wound complications. We followed the patients until 6 months after discharge.ResultsAt 2 and 6 h, groups A and B had lower resting VAS scores than group C (p< 0.01); at 12 h, group B had a lower resting VAS score than group C (p< 0.05). At 6 and 12 h, the movement VAS scores in groups A and B were lower than those in group C (p< 0.01). Groups A and B had similar VAS scores during the observation period. Groups A and B had higher levels of patient satisfaction than group C (p= 0.03 andp= 0.018, respectively). Opioid consumption was similar in the three groups. There were no significant differences in the other secondary outcomes amongst the three groups. No difference was found in hip rehabilitation or chronic pain during the follow-up period.ConclusionSingle-shot LIA with ropivacaine alone reduces the pain score during the first 12 postoperative hours and improves patients’ satisfaction with THA. LIA in the deep and superficial fascia and LIA in all layers have similar analgesic effects. LIA in the deep and superficial fascia may be an alternative method to LIA in all layers.

BACKGROUND: Low back pain (LBP) is a common problem that causes pain, disability, and gait and balance problems. Neurodynamic techniques are used in the treatment of LBP. OBJECTIVE: The aim of this study was to compare the effects of electrotherapy and neural mobilization on pain, functionality, gait, and balance in patients with LBP. MATERIALS AND METHODS: A total of 41 patients were randomly assigned to either the neural mobilization group (NMG, n= 20) or electrotherapy group (ETG, n= 21). Assessment tools used were Visual Analogue Scale (VAS) for pain, Oswestry Disability Index (ODI) for functionality, straight leg raise test (SLRT) for neural involvement, and baropedographic platform (Zebris FDM-2TM) for gait and static balance measurements. RESULTS: Both groups showed a significant decrease in pain and functional disability, while only the NMG group showed a significant increase in SLRT scores (p< 0.05). However, there were no statistically significant pre- to post-treatment changes in gait or static balance parameters in either group (p< 0.05). CONCLUSION: Neural mobilization was effective in reducing pain and improving functionality and SLRT performance in patients with LBP, but induced no change in gait and static balance parameters. Neural mobilization may be used as self-practice to supplement standard treatment programs.

Objectives This study aimeded to examine acute and late effects of five consecutive sessions of Swedish massage on hamstring flexibility and agility of players.Methods: Arandom sample of 34 female players having bilateral tight hamstrings [passive straight leg raise ≤70° and active knee extension test ≥ 30°] was randomly allocated to two equal groups. Study design involved 7 minute massage given on each posterior thigh for 5 continuous days; followed by 5 days of no massage. Experimental group received classical Swedish massage whereas control group received only superficial stroking. Outcome measures were Passive straight leg raise [PSLR], Active knee extension test [AKET], Passive knee extension test [PKET], Back saver sit and reach test [BSSR] for flexibility and 5-0-5 change of direction test for agility measured pre and post intervention on each days of massage and also on 10th day. Two way ANOVA with post hoc t-test was the tool of statistical analysis with significance level 0.05.Results: Significant [p ≤ 0.05] post intervention increase in all parameters of flexibility was observed each day in experimental group within PSLR (8%–12% ↑), AKET (10%24% ↓) and PKET (12%–30% ↓) and highly significant (p ≤ 0.001) increase on 5th and 10th day in BSSR (4%–21% ↑) for both legs. Pre and post intervention values for control group were not significantly different. No significant changes were observed in agility performance of both groups.Conclusion: Swedish massage of posterior thigh appears to acutely increase flexibility of hamstrings in female athletes, which persisted for 5 days even after cessation of massage.

Background Police officer use of Individual Light Armour Vests (ILAVs) is increasing due to potential occupational hazards that include blunt trauma, stabbing, and light calibre bullets. It is unclear how addition of this extra load will affect the officer's mobility or postural control. Objectives The aim of this study was to determine the effects of various ILAVs on the mobility and postural control of police officers when compared to wearing their normal station wear. Methods A prospective, within-subjects, repeated measures study was conducted in which officers wore one of three different ILAV variants or normal station wear (N) and acted as their own controls. Officer mobility was assessed via the Functional Movement Screen (FMS) and postural sway (including total sway, average sway velocity, medial-lateral velocity, anterior-posterior velocity, and total excursion area) via force plate. Results Significant differences were found between ILAV or N conditions in various components of the FMS, including right Straight Leg Raise, left shoulder mobility, and both right and left quad rotary stability. No significant differences were found in any of the balance measures between these conditions. Conclusion It appears ILAVs can significantly affect police officer mobility and therefore may contribute to injury risk and decreased ability to complete occupational tasks, though this should be weighed against protective benefits. ILAVs should therefore be carefully selected to minimise injury risk without detracting from occupational performance.

Catheter-based adductor canal blocks are an effective pain management strategy for total knee arthroplasty. Nevertheless, catheter-based techniques may fail if the tip migrates because of leg movement. This observational study used ultrasound to measure the distance from the skin to the adductor canal (SAC). We tested the hypothesis that leg movements mimicking those occurring during postoperative physiotherapy change the SAC distance.Following total knee arthroplasty under spinal anesthesia, the SAC distance was measured using ultrasound in 40 patients. The leg was passively moved into five standardized positions: neutral, neutral position with manual lateral displacement of the skin, 30° external rotation, straight leg raised to 30°, and knee and hip flexed to 90°.The mean (standard deviation) SAC distance change from the neutral position was +1.0 (0.6) cm with manual displacement, +0.3 (0.4) cm with external rotation, +0.4 (0.4) cm with straight leg raise, and +0.6 (0.5) cm with leg flexion (P0.001 for all positions). SAC distance changes did not correlate with height, body mass index, or leg circumference.Passive leg movements in five standardized positions increase the SAC distance. We speculate that the altered SAC distance associated with passive leg movement may contribute to catheter tip dislodgement and adductor canal block failure.www.clinicaltrials.gov , NCT03562559; registered 19 June, 2018.RéSUMé: OBJECTIF: Les blocs du canal des adducteurs utilisant un cathéter constituent une stratégie efficace du contrôle de la douleur pour l’arthroplastie totale de genou. Néanmoins, les techniques reposant sur des cathéters peuvent échouer si leur extrémité migre du fait d’un mouvement de la jambe. Cette étude observationnelle a utilisé l’échographie pour mesurer la distance séparant la peau du canal des adducteurs (P-CA). Nous avons testé l’hypothèse que des mouvements de la jambe imitant ceux qui surviennent au cours de la physiothérapie postopératoire modifient la distance P-CA. MéTHODES: Après une arthroplastie totale de genou sous rachianesthésie, la distance P-CA a été mesurée par échographie chez 40 patients. La jambe a été mobilisée passivement dans cinq positions standardisées : position neutre, position neutre avec déplacement latéral manuel de la peau, rotation latérale de 30°, jambe tendue soulevée à 30° et, enfin, genou et hanche fléchis à 90°. RéSULTATS: La modification de la distance P-CA moyenne (écart-type) à partir de la position neutre a été +1,0 (0,6) cm avec le déplacement manuel, +0,3 (0,4) cm avec la rotation latérale, +0,4 (0,4) cm avec la jambe tendue soulevée et +0,6 (0,5) cm avec la jambe fléchie (P0,001 pour toutes les positions). Les modifications de la distance P-CA n’étaient pas corrélées à la taille, l’indice de masse corporelle ou la circonférence de la jambe du patient. CONCLUSION: Les mouvements passifs de la jambe dans cinq positions standardisées augmentent la distance P-CA. Nous pensons que la modification de la distance P-CA associée à un mouvement passif de la jambe peut contribuer au déplacement de l’extrémité du cathéter et à l’échec du bloc du canal des adducteurs. ENREGISTREMENT DE L’ESSAI CLINIQUE: www.clinicaltrials.gov, NCT 03562559; Enregistré le 19 juin 2018.

Introduction Alternatives to the classical medial parapatellar (MPP) approach for total knee arthroplasty (TKA) include the mini-medial parapatellar (MMPP), mini-subvastus (MSV), mini-midvastus (MMV) and quadriceps-sparing (QS) approaches. The best approach has been not fully clarified. The purpose of the present study was to conduct a Bayesian network meta-analysis comparing these approaches. Materials and methods The present analysis was carried out according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. The databases search was performed in October 2019. All clinical trials comparing two or more approaches for primary TKA were considered for inclusion. The baseline comparability was evaluated through the analysis of variance (ANOVA) test. The statistical analysis was performed through the STATA software/MP. A Bayesian hierarchical random-effects model analysis was adopted in all the comparisons. Results Data from 52 articles (4533 patients) were collected. The mean follow-up was 20.38 months. With regard to diagnosis, gender, age and BMI, adequate baseline comparability was detected. The MSV approach ranked better concerning clinical scores (the lowest visual analogic scale, the higher KSS and KSFS) and functional outcomes (the shortest straight leg raise, the greatest degree of flexion and range of motion). Concerning perioperative data, the MSV evidenced the shortest hospital stay, while the MPP the shortest surgical duration and lowest estimated blood loss. Conclusion According to the main findings of the present study, the mini-subvastus approach for total knee arthroplasty demonstrated superior overall compared to the other approaches. Orthopaedic surgeons should consider this approach in the light of the evidence and limitations of this Bayesian network meta-analysis.

Muscle strength imbalances and poor flexibility are frequently described as risk factors for hamstring injury. Preventive strategies include eccentric exercises, but the influence of field eccentric exercises on these risk factors remains unclear. We investigated the influence of a field hamstring eccentric program on hamstring strength and flexibility. Twenty-seven amateur athletes were randomly assigned to an intervention (n=13) or control group (n=14). In the intervention group, participants were involved in 15 sessions of four eccentric exercises. Peak torque, hamstring-to-quadriceps ratios, passive and active flexibility were analyzed. No significant modifications of strength, passive or active flexibility were observed in the control group (p>0.05). Hamstring eccentric peak torque (+7.1%) and functional hamstring-to-quadriceps ratios (9.3%) were significantly increased (p0.05). In conclusion, a 6-week eccentric program, including four field exercises for hamstring muscles, is an effective method of improving eccentric strength, functional ratios and, especially, passive flexibility. As this program may be easily implemented in a real-world context, this association of multiple eccentric exercises might be useful in an injury prevention strategy.

Background: Clinical assessment of sagittal plane hip mobility is usually performed using the Modified Thomas Test (for extension) and the Straight-Leg-Raise (for flexion) with a goniometer. These tests have limited reliability, however. An active swinging leg movement test (the SWING test), assessed using 3D motion analysis, could provide an alternative to these passive clinical tests.Research question: Is the SWING test a more reliable alternative to evaluate hip mobility, in comparison to the clinical extension and flexion tests?Methods: Ten asymptomatic adult participants were evaluated by two investigators over three sessions. Participants performed 10 maximal hip extensions and flexions, with both legs straight and no trunk movement (the SWING test). Hip kinematics was assessed using a 3D motion analysis system. Maximal and minimal hip angles were calculated for each swing and represented maximal hip flexion (SWING flexion) and extension (SWING extension), respectively. The Modified Thomas Test and Straight-Leg-Raise were repeated 3 times for each leg. On the first day, both investigators performed all the tests (SWING + Modified Thomas Test + Straight-Leg-Raise). A week later, a single investigator repeated all the tests. Inter-rater, intra-rater, within-day and between-day reliability were evaluated using intra-class correlation.Results: Intra-class correlation coefficients for all the tests were superior to 0.8, except for the Modified Thomas Test's intra-rater, between-day (intra-class correlation 0.673) and the Straight-Leg-Raise's inter-rater, within-day (intra-class correlation 0.294). The SWING test always showed a higher intra-class correlation coefficient than the passive clinical tests. The only significant correlation found was for the Straight-Leg-Raise and SWING flexion (r = 0.48; P < 0.001).Significance: The SWING test seems to be an alternative to existing passive clinical tests, offering better reliability for assessing sagittal plane hip mobility.

Purpose The aim was to compare active heel-slide exercise (AHSE) + standard physiotherapy (PT) to continuous passive motion (CPM) + standard PT during inpatient rehabilitation of total knee arthroplasty (TKA) patients in terms of postoperative outcomes. Methods Patients were randomly assigned into AHSE or CPM groups. Both groups received standard PT (range of motion and strengthening exercises, and ambulation) during hospital stay. Patients were evaluated regarding functional outcomes, knee proprioception, pain intensity, active range of motion, knee circumference, length of hospital stay, time for achieving straight leg raise actively, time for achieving 70 degrees knee flexion. Results Groups were similar at baseline (n.s.). At discharge, AHSE group was better in terms of pain intensity (p < 0.001), Hospital for Special Surgery knee score (p = 0.001), rise from sitting (p = 0.015), ascend/descend stairs (p = 0.038), and timed up and go test (p = 0.028) compared to CPM group. AHSE group was able to perform the straight leg raise earlier than CPM group during inpatient period (p = 0.001) and demonstrated improved proprioception at discharge and at 3-month follow-up (p < 0.05). No statistical differences were detected between groups in other evaluation parameters (n.s.). Conclusion Our findings support AHSE therapy offers a more functional rehabilitation and leads beneficial results for patients following TKA. Therefore, active exercise approach encouraging patients to participate in their rehabilitation should be first choice in acute postoperative rehabilitation following TKA rather than CPM.

Objective To provide detailed information on the effectiveness of neurodynamic treatment on hamstrings flexibility. Methods Systematic review in the following databases: PubMed, Google Scholar, and ScienceDirect. Articles were included if the intervention followed a neurodynamic treatment and the study was a randomized clinical trial including at least one measurement related to hamstrings flexibility. Articles were independently screened for inclusion and data were extracted by two researchers. It was registered in the PROSPERO database (CRD42015020707). Results Finally, 6 articles (n = 294 participants) were included. Neurodynamic treatment was compared with no treatment, placebo, and with other manual therapy techniques such as active and passive stretching, muscle inhibition and proprioceptive neuromuscular facilitation. Meta-analysis shows benefits of neurodynamic treatment for knee-extension range of motion (1 trials compared with no intervention, MD = −2.23, 95% CI = −3.02 to −1.44, and 4 trials compared to other techniques, MD = −0.40, 95% CI = −1.09 to 0.29, I2 = 81.55%) and passive straight leg raise test measures (2 trials compared with no intervention, MD = 2.26, 95% CI = 1.78 to 2.74, I2 = 0%, and 3 trials compared with other techniques MD = 2.26, 95% CI = 1.78 to 2.74, I2 = 0%). Conclusions This review and meta-analysis shows the effectiveness of neurodynamic treatment on hamstrings flexibility compared with no intervention and other techniques.

In hamstrings injuries, sciatic nerve and muscle disorders can coexist. Therefore, differential diagnosis to include or exclude nerve involvement is an important aspect of evaluation. The objective of this paper is to investigate the mechanical behaviour of the sciatic nerve and biceps femoris muscle in the proximal thigh with the ankle dorsiflexion manoeuvre at different degrees of hip flexion during the straight leg raise in cadavers.A cross-sectional study was carried out. Linear displacement transducers were inserted into the sciatic nerve and the biceps femoris muscle of 11 lower extremities from 6 fresh cadavers to measure potential strain of both structures during ankle dorsiflexion at 0°, 30°, 60° and 90° of hip flexion during the straight leg raise. Excursion was also measured with a digital calliper.Ankle dorsiflexion resulted in significant strain and distal excursion of the sciatic nerve at all ranges of hip flexion during the straight leg raise (p 0.05). In contrast, the ankle movement did not affect the strain in biceps femoris at any position of the hip (p 0.05).Ankle dorsiflexion at different degrees of hip flexion during the straight leg raise produces changes in the strain and excursion of the sciatic nerve in the upper thigh. In contrast, the biceps femoris muscle at the same location was not affected by ankle movement. These findings show differential behaviour between the nerve and muscle with ankle dorsiflexion at this location that could be used as differential diagnosis in posterior hip pain.

Patellofemoral pain syndrome (PPS) is characterized by anterior knee pain and affects young female adults. Physiotherapy is the most indicated treatment. The objective of the study was to analyze electromyographic activity of the quadriceps and gluteus medius muscles during different open and closed kinetic chain exercises in women with PPS. Twenty-two clinically healthy women and 24 women with symptomatic PPS were assessed through surface electromyography of the quadriceps and gluteus medius during the following exercises: straight leg raise with and without lateral hip rotation; squats; squats with adduction and hip abduction; and squats combined with lateral hip rotation. When comparing the groups, only the quadriceps muscle showed higher activity in the PPS group. In the comparisons between the exercises, in relation to gluteus medius and quadriceps muscle activity, the straight leg raise and straight leg raise with lateral hip rotation exercises showed more activity than squats in both groups. Among the squats, squats with adduction generated more gluteus medius activity in both groups, and no difference was noted among the squats for the quadriceps muscle. Therefore, rehabilitation programs that include exercises such as straight leg raises, straight leg raises with lateral hip rotation, and squats with adduction may be used for PPS patients.

BackgroundClinicians nominate the distribution of leg pain as being important in diagnosing nerve root involvement. This study aimed to identify: (i) common unisegmental radicular pain patterns and whether they were dermatomal, and (ii) whether these radicular pain patterns assisted clinician discrimination of the nerve root level involved.MethodsA cross-sectional diagnostic accuracy study of adult patients with radicular leg pain at a hospital in Denmark. All patients had positive neurological signs (average 2.8 signs - hypoalgesia, diminished reflexes, muscle weakness, positive Straight Leg Raise test).Part 1 (pain patterns) was a secondary analysis of baseline pain pattern data collected during a clinical trial. The pain charts of 93 patients with an MRI and clinically confirmed single-level disc herniation with nerve root compression were digitised and layered to form a composite picture of the radicular patterns for the L5 and S1 nerve roots, which were then compared to published dermatomes.In Part 2 (clinical utility) we prospectively measured the discriminative ability of the identified pain patterns. The accuracy was calculated of three groups of six clinicians at classifying the nerve root affected in a randomized sequence of 53 patients, when not shown, briefly shown or continuously shown the composite pain patterns. In each group were two chiropractors, two medical doctors and two physiotherapists.ResultsThere was a wide overlap in pain patterns from compromised L5 and S1 nerve roots but some distinguishing features. These pain patterns had approximately 50 to 80% overlap with published dermatomes. Clinicians were unable to determine with any accuracy above chance whether an individual pain drawing was from a person with a compromised L5 or S1 nerve root, and use of the composite pain drawings did not improve that accuracy.ConclusionsWhile pain distribution may be an indication of radiculopathy, pain patterns from L5 or S1 nerve root compression only approximated those of sensory dermatomes, and level-specific knowledge about radicular pain patterns did not assist clinicians’ diagnostic accuracy of the nerve root impinged. These results indicate that, on their own, pain patterns provide very limited additional diagnostic information about which individual nerve root is affected.

Study design: A controlled radiologic follow-up study. Objective: The aim of this study was to ascertain whether changes in cord excursion with straight leg raise test (SLR) at 1.5-year follow- up time accompany changes in clinical symptoms. Summary of background data: Lumbar intervertebral disc herniation (LIDH) is known to be a key cause of sciatica. Previously, we found that a significant limitation of neural displacement (66.6%) was evident with the SLR on the symptomatic side of patients with subacute single level posterolateral LIDH. Methods: Fourteen patients with significant sciatic symptoms due to a subacute single-level posterolateral LIDH were reassessed clinically and radiologically at 1.5 years follow-up with a 1.5T MRI scanner. Displacement of the conus medullaris during the unilateral and bilateral SLR was quantified reliably with a randomized procedure and compared between SLRs and to data from baseline. Multivariate regression models and backward variable selection method were employed to identify variables more strongly associated with a decrease in low back pain (LBP) and radicular symptoms. Results: Compared with previously presented baseline values, the data showed a significant increase in neural sliding in all the quantified maneuvers (P ≤ 0.01), and particularly of 2.52 mm (P ≤ 0.001) with the symptomatic SLR.Increase in neural sliding correlated significantly with decrease of both radicular symptoms (Pearson = -0.719, P ≤ 0.001) and LBP (Pearson = -0.693, P ≤ 0.001). Multivariate regression models and backward variable selection method confirmed the improvement of neural sliding effects (P ≤ 0.004) as the main variable being associated with improvement of self- reported clinical symptoms. Conclusion: To our knowledge, these are the first noninvasive data to objectively support the association between increase in magnitude of neural adaptive movement and resolution of both radicular and LBP symptoms in in vivo and structurally intact human subjects. Level of evidence: 2.

Background Tuberculosis (TB) of the posterior spinal element is an uncommon condition. In a developed country its diagnosis is becoming difficult due to low incidence. Case Description A 60-year-old lady presented with low back pain and right leg pain for 6 months. On examination there was tenderness over L4 and L5, a positive straight leg raise test at 70 degrees on the right side and free on the left, and sensory involvement on the right L5 dermatome. Initial magnetic resonance imaging (MRI) showed an L4-5 ligamentum flavum cyst, high signal intensity in the right pedicle and facet joint. It was considered to be a degenerative spinal disorder. Later MRI showed increased size of the cyst, and computed tomography revealed erosion of the right pedicle of the L5 vertebrae, which raised the suspicion of the tubercular pathology. Initially the patient was managed for a degenerative spinal disorder. Later, when tubercular pathology was suspected, she underwent full endoscopic uniportal stenosis decompression and excision biopsy of the cyst. The histology of the cyst revealed chronic granulomatous inflammation with central necrosis. The diagnosis of a TB cyst was confirmed, and antitubercular therapy was started. Conclusion TB of the posterior elements of the spine is a diagnostic challenge in developed parts of the world. We describe the first likely case of tubercular ligamentum flavum cyst, which was managed by a full endoscopic uniportal approach.

Background The slump test is a type of neurodynamic test that is believed to evaluate the mechanosensitivity of the neuromeningeal structures within the vertebral canal. The objective of this review was to investigate the effectiveness of slump stretching on back pain and disability in patients with low back pain (LBP). Methods We searched eight electronic databases (PubMed/Medline, Scopus, Ovid, CINAHL, Embase, PEDro, Google Scholar, CENTRAL). The publication language was restricted to English, and we searched the full time period available for each database, up to October 2017. Our primary outcomes were pain and disability, and the secondary outcome was range of motion (ROM). Results We identified 12 eligible studies with 515 LBP patients. All included studies reported short-term follow-up. A large effect size (standardized mean difference [SMD] = -2.15, 95% confidence interval [CI] = -3.35 to -0.95) and significant effect were determined, favoring the use of slump stretching to decrease pain in patients with LBP. In addition, large effect sizes and significant results were also found for the effect of slump stretching on disability improvement (SMD = -8.03, 95% CI = -11.59 to -4.47) in the LBP population. A qualitative synthesis of results showed that slump stretching can significantly increase straight leg raise and active knee extension ROM. Conclusions There is very low to moderate quality of evidence that slump stretching may have positive effects on pain in people with LBP. However, the quality of evidence for the benefits of slump stretching on disability was very low. Finally, it appears that patients with nonradicular LBP may benefit most from slump stretching compared with other types of LBP.

Proper alignment in dancers is a pre-requisite for achieving aesthetic line and form and for efficient execution of movement. Pelvic alignment is a common deficit in dancers that results in faulty technique and impaired performance. Dancers must be able to obtain their personal neutral alignment to avoid injury and achieve ease of execution. This study was designed to examine the effects, qualitatively and quantitatively, of Pilates training on pelvic alignment, strength, and flexibility in dancers. Twenty female dancers, 17 to 22 years of age, participated in a screening that consisted of an AlignaBod posture screen, upper abdominal manual muscle test, double leg lower test, straight leg raise test, and modified Thomas test. Participants were screened, engaged in dance classes for 14 weeks without Pilates, and screened a second time. They then attended a 2-hour pelvic alignment workshop followed by two weekly Pilates classes, one mat and one apparatus, for 14 weeks. The study concluded with a final screening and collection of qualitative data regarding participant perceptions of their experience. Analysis demonstrated a decrease in the number of postural misalignments with Pilates intervention compared to no significant change in total misalignments when taking dance classes only. The prevalence of forward head posture, knee hyperextension, and foot-ankle pronation or supination all decreased significantly. After participating in the Pilates intervention, the prevalence of iliotibial band and hamstring inflexibility decreased and lower abdominal muscle strength improved significantly. All participants reported they felt that Pilates improved their core stability, pelvic alignment, strength, and body awareness. This study suggests that Pilates, when added to dance training, can improve postural alignment, flexibility, and abdominal strength in dancers. Additionally, it is well tolerated by dancers, making it a potentially valuable cross-training tool.

BACKGROUND Contractile segment impedance (CSI) obtained from high-resolution impedance manometry (HRIM) is a measure of mucosal integrity that predicts gastroesophageal reflux disease (GERD). While straight leg raise (SLR) maneuver augments esophageal peristaltic vigor, it remains unclear whether SLR affects CSI values. This study was aimed to evaluate whether CSI with SLR is feasible and useful to complement the diagnosis of GERD. METHODS We prospectively recruited 48 patients with typical GERD symptoms who underwent esophagogastroduodenoscopy, HRIM with SLR maneuver, and multichannel intraluminal impedance-pH (MII-pH) testing. The capability of mean nocturnal baseline impedance (MNBI), resting baseline impedance (RBI), CSI with or without SLR maneuver in predicting GERD was assessed using receiver operating characteristics (ROC) analysis. KEY RESULTS Among 20 GERD patients and 28 non-GERD patients, all values of impedance-based metrics were lower in GERD patients compared to non-GERD patients (p

Background The straight leg raise (SLR) is the most commonly applied physical tests on patients with sciatica, but the sensitivity and specificity ratings for disc hernia and neural compression leave areas for improvement. Hip internal rotation tensions the lumbosacral nerve roots and ankle dorsiflexion tensions the sciatic nerve along its course. We added these movements to the SLR (extended SLR = ESLR) as structural differentiators and tested inter-rater reliability in patients with LBP, with and without sciatica. Methods Forty subjects were recruited to the study by the study controller (SC), 20 in the sciatic group and in the control group. Two independent examiners (E1&E2) performed the ESLR and did not communicate to the subjects other than needed to determine the outcome of the ESLR. First, SLR was performed traditionally until first responses were evoked. At this hip flexion angle, a location-specific structural differentiation was performed to confirm whether the emerged responses were of neural origin. Cohen’s Kappa score (CK) for interrater reliability was calculated for ESLR result in detection of sciatic patients. Also, the examiners’ ESLR results were compared to the traditional SLR results. Results The interrater agreement between Examiner 1 and Examiner 2 for the ESLR was 0.85 (p p Conclusions ESLR with the addition of location-specific structural differentiation is a reliable and repeatable tool in discerning neural symptoms from musculoskeletal in patients with radiating low back pain. We recommend adding these movements to the standard SLR with aim of improving diagnostic ability.

The purpose of this study was to investigate the activation of the hip flexor and abdominal muscles during an active straight leg raise (ASLR) to end range of hip flexion. Data were recorded from nine healthy men. Fine-wire electromyography (EMG) electrodes were inserted into psoas major (PM), and surface electrodes were placed over rectus femoris (RF), rectus abdominis, obliquus externus abdominis (OE), and obliquus internus abdominis/transversus abdominis (OI/TrA). EMG and kinematic data were obtained during concentric, hold (at end range) and eccentric phases of an ASLR. Concentric and eccentric movements were divided into three phases (early, mid, and late). Onsets of EMG relative to the onset of the ALSR movement and EMG amplitudes in each phase were compared between muscles. Onsets of the PM (–33 ± 245 ms) and RF (-3 ± 119 ms) EMG prior to leg elevation were significantly earlier than those of the OE and OI/TrA. PM EMG showed highest activation in the late concentric, hold, early eccentric phase, and was significantly higher than RF EMG. OI/TrA EMG was significantly greater in mid and late concentric, hold, and early eccentric phase than other phases. During the ASLR, unlike RF, PM EMG continues to increase towards the end range of hip flexion. Activation of OI/TrA muscle may be involved in control trunk and pelvic movement.

Background The straight leg raise test (SLR) is one of the most utilized and studied physical tests in patients with low back pain (LBP) for the detection of lumbar disc herniation (LDH), showing high sensitivity and heterogeneous or low specificity. The high incidence of asymptomatic ‘pathologic’ findings in the magnetic resonance imaging (MRI) scans may cause verification bias to these results. We studied an extended SLR (ESLR) by adding location-specific structural differentiation movements (hip internal rotation or ankle dorsiflexion) to the traditional SLR for it to better differentiate neural symptoms from musculoskeletal. Previously, the ESLR has shown almost perfect interrater reliability between examiners and ability to detect sciatic patients. In this study, we investigated whether a ’positive’ ESLR finding is associated with pathology seen on MRI. Methods Forty subjects comprised the study population, 20 in sciatic group and 20 in control group. The ESLR was performed ‘blinded’ to the subjects. After the ESLR, each subject’s lumbar MRI was evaluated. The MRIs were analyzed independently by 2 senior radiologists and a spine specialist clinician. The ESLR and MRI results were cross-tabulated. To obtain the odds ratio (OR) with positive ESLR or SLR results for LDH or nerve root compression (NC), a binary logistic regression analysis with subjects’ age, gender, height and weight was performed. ESLR’s validity was assessed by combination of interrater agreement and percentage prevalence of both LDH and NC. Results Of sciatic (ESLR+) patients, 85 % had LDH and 75 % NC in the MRI. Not surprisingly, MRI showed a very high incidence of ‘false-positive’ findings with the ESLR negative group. The ESLR showed 0.61 sensitivity and 0.75 specificity for LDH and 0.60 sensitivity and 0.67 specificity for NC when using MRI as a reference standard. A positive result in the ESLR was found to be strongly associated with for both LDH and NC: the OR was 8.0 (p = 0.028) and 5.6 (p = 0.041), respectively. Conclusions The ESLR shows high validity in detecting neural symptoms and is strongly associated with pathology seen in the MRI when judged positive. We suggest the use of ESLR in clinical practice as a part of clinical examination, where it may prove to be a valuable tool in detecting patients with sciatic symptoms.

Objectives: The aim of the present study was to assess the validity and trending ability of the bioreactance method in estimating cardiac output at rest and in response to stress in advanced heart failure patients and heart transplant candidates. Design: This was a prospective single-center study. Setting: This study was conducted at the heart transplant center at the Freeman Hospital, Newcastle upon Tyne, UK. Participants: Eighteen patients with advanced chronic heart failure due to reduced left ventricular ejection fraction (19 ± 7%), and peak oxygen consumption 12.3 ± 3.9 mL/kg/min. Interventions: Participants underwent right heart catheterization using the Swan-Ganz catheter. Measurements and Main Results: Cardiac output was measured simultaneously using thermodilution and bioreactance at rest and during active straight leg raise test to volitional exertion. There was no significant difference in cardiac index values obtained by the thermodilution and bioreactance methods (2.26 ± 0.59 v 2.38 ± 0.50 L/min, p > 0.05) at rest and peak straight leg raise test (2.92 ± 0.77 v 3.01 ± 0.66 L/min, p > 0.05). In response to active leg raise test, thermodilution cardiac output increased by 22% and bioreactance by 21%. There was also a strong relationship between cardiac outputs from both methods at rest (r = 0.88, p < 0.01) and peak straight leg raise test (r = 0.92, p < 0.01). Cartesian plot analysis showed good trending ability of bioreactance compared with thermodilution (concordance rate = 93%) Conclusions: `Cardiac output measured by the bioreactance method is comparable to that from the thermodilution method. Bioreactance method may be used in clinical practice to assess hemodynamics and improve management of advanced heart failure patients undergoing heart transplant assessment.

Objective To compare the effects of dynamic oscillatory stretch and static stretching techniques in order to improve hamstring extensibility in healthy individuals with asymptomatic hamstring tightness. Methods The single-blind randomised controlled trial was conducted from March to June 2018 at Sadiq Hospital, Sargodha Institute of Health Sciences, and District Headquarter Teaching Hospital,Sargodha, Pakistan, and comprised young healthy individuals with hamstring tightness who were randomly divided into groups 1 and 2, with the former getting exposure to oscillatory stretch technique and the latter to static stretching technique. Assessment of hamstring length was done using reliable clinical measurement test along with pain for stretch tolerance during passive straight leg raise using numeric pain rating scale. Measurements were taken at baseline, immediate (10min) and 1 hourpost-intervention. Data was analysed using SPSS 20. Results Of the 83 subjects, 42(%) were in group 1 with a mean age of 24.22±4.09 years, and 41(%) were in group 2 with a mean age of 25.85±6.09 years.Group1 showed significantly more improvement in all variables of hamstring flexibility and perceived pain at both post-intervention checkups compared to group 2 (p Conclusion Dynamic oscillatory stretch technique was found to be more effective in improving hamstring flexibility and perceived pain compared to static stretching technique.

Esophageal high-resolution manometry (HRM) assesses esophageal motor function and is indicated both for evaluation of esophageal symptoms and before antireflux interventions. HRM studies are interpreted and esophageal motor diagnoses made according to the Chicago Classification, version 3.0 algorithm, which is based on ten 5 mL supine water swallows. However, this practice of single liquid swallows performed in the supine position does not reflect typical "real-life" swallowing, and may not reproduce the patient's presenting symptoms. Therefore, provocative maneuvers at HRM-beyond these 10 standard swallows-can afford additional insights into esophageal motor function with clinically significant implications, and represent areas of exciting investigation and innovation. Accordingly, the 2020 American College of Gastroenterology Guidelines on Esophageal Physiologic Testing conditionally recommend their inclusion in the HRM protocol. In this clinical review, we discuss the supporting data for and clinical utility of provocative maneuvers at HRM that include changes in body position or accessories (upright swallows, "bridge" position, straight leg raise, abdominal compression), bolus consistency (solid swallows, test meals, postprandial high-resolution impedance manometry), bolus frequency (multiple rapid swallows), the volume of bolus (rapid drink challenge/multiple water swallows), and the use of pharmacological agents.

Faults in postural alignment and movement of the pelvis are associated with non-specific low back pain. However, limited studies have investigated the differences in pelvic rotation angle in the transverse plane in the supine position and during active straight leg raise between subjects with and without non-specific low back pain.Thirty-one subjects with non-specific low back pain and 31 subjects without non-specific low back pain were examined. Angular measures of the pelvic rotation angle in the transverse plane were obtained in the supine position and during active straight leg raise using a Smart KEMA measurement system.The pelvic rotation angle in the transverse plane during active straight leg raise was significantly greater in subjects with non-specific low back pain than in healthy subjects (p 0.05). However, the pelvic rotation angle in the transverse plane in the supine position and asymmetry index of the pelvic rotation angle during active straight leg raise were not significantly different between subjects with and those without non-specific low back pain.This indicates that a greater pelvic rotation angle in the transverse plane during active straight leg raise could be contributing factors to the development of a non-specific low back pain related to lumbopelvic instability.

Background There is no validated sham neural mobilization (NM) intervention for lower quadrant conditions. A suitable sham NM comparator will allow to blind patients with low back pain (LBP) and reduce bias by limiting the confounding effects of expectations. Objective The primary aim was to develop a sham NM technique in patients with non-specific LBP and assess its validity in supplying a suitable blinding. Secondly, we compared the short-term effects of NM and the sham comparator on pain and the straight leg raise. Design A randomized placebo-controlled trial in which participants and assessors were blinded. Method Fifty one patients (20 men,31 women), aged 22–65 years (43 ± 12y) were allocated randomly to a NM group (n = 26) or a sham NM group (n = 25). The primary outcome of believability of the sham technique was measured one week after the intervention. Secondary outcomes of pain intensity and the straight leg raise range-of-motion were assessed at baseline, immediately after the intervention and one week after. Results The believability of the sham technique in terms of the frequencies of perceived group assignment showed no differences between groups. Eighteen participants believed they had received the experimental NM technique in the experimental group (69.2%) and 14 in the placebo NM group (56%). Pain and the straight leg raise changes did not show differences between groups. Conclusions The novel sham NM demonstrated to be a believable intervention, capable of supplying a suitable blinding. Both groups showed similar short term perceived effects on pain and the straight leg raise.

Background: Lumbar radiculopathy is a nerve root disorder whose correct diagnosis is essential. The objective of the present study was to analyze the reliability diagnostic validity of eight neurodynamic and/or orthopedic tension tests using magnetic resonance imaging as the Gold Standard. Methods: An epidemiological study of randomized consecutive cases which was observational, descriptive, transversal, double blinded and was conducted following the Standards for Reporting Diagnostic accuracy studies (STARD) declaration. The sample size was 864 participants. Internal and external validity (CI = 95%) and reliability, were calculated for all tests performed independently. The diagnostic validity of the combined and multiple tests in parallel was also calculated. Results: The analysis indicated that only two tests performed independently had external validity, but neither had reliability or precision. The Straight Leg Raise test and the Bragard test performed in a multiple parallel way showed high sensitivity (97.40%), high negative predictive value (PV&minus, 96.64%) and external validity (Likelihood Ratio&minus, 0.05). The combined test of the Slump test and the Dejerine&rsquo, s triad had internal and external validity. Conclusions: The Straight Leg Raise test and the Bragard test performed in a multiple parallel way and the combined test of the Slump Test and the Dejerine&rsquo, s triad have clinical validity to discard lumbar or lumbar-sacral radiculopathy.

This study aimed to determine effects of lymphatic drainage therapy (LDT) on autonomic nervous system (ANS) responses by comparing including Hoffmann reflex (H reflex), heart rate variability (HRV), salivary alpha-amylase (sAA) and muscle tone (via straight leg raise (SLR)) in healthy participants.A single blind randomized controlled trial evaluating sixty-six healthy participants including 58 females and 8 males aged between 40 and 65 years. All participants were blinded and randomized to either experimental group (EXP: LDT) or control group (CT: rest). LDT was applied to participants 45 min in experimental group. The LDT is light movement applied by an experienced physical therapist, starting from neck, deep abdomen, and along to the leg. While for the control group, participants received 45 min supine on the treatment table. Tests for evaluating ANS such as Hoffmann reflex (H reflex), heart rate variability (HRV), salivary alpha-amylase (sAA) and straight leg raise (SLR) were assessed at pre and post intervention.The findings demonstrated that H reflex decreased significantly after applying LDT; within and between groups (p 0.05). Whereas, it increased significantly in control group. First tension (R1) indicated by participants during SLR significantly improved within both groups. However, there were no significant differences of HRV and sAA in either LDT or control groups.This study demonstrated that LDT decreased autonomic activity via decreased spinal reflex excitability and tension in healthy participants.

The flexibility and proper functioning of all myofascial chains are crucial for athletes, especially for long-distance runners. Due to the continuity of the myofascial structures, restrictions in one part of the body may cause excessive tension in others. The aim of our study was to evaluate the influence of short foot muscle exercises on muscle flexibility and the quality of movement patterns in amateur runners. Eighty long-distance runners, aged 20&ndash, 45, were randomly divided into two groups: Group 1 (n = 48) and Group 2 (n = 32). Participants in Group 1 performed foot exercises daily for six weeks. Subjects in Group 2 were without any intervention. At baseline and after six weeks, the quality of movement patterns with the Functional Movement Screen and muscle flexibility was evaluated. In Group 1, significantly higher Functional Movement Screen values in individual tasks and in the total score were noted after six weeks. The total score increased from 17 to 18 points (Median (Me) &plusmn, half of interquartile range (IQR/2) (Standard Error of Measurement - SEM) 17 &plusmn, 1.5 (0.23) at baseline and 18 &plusmn, 1.5 (0.24) after six weeks) (p &lt, 0.01), whereas in Group 2, its level remained at 16 points (Me &plusmn, IQR/2 (SEM) 16 &plusmn, 1.5 (0.31) at baseline and 16 &plusmn, 1.25 (0.31) after six weeks). In Group 1, the significant improvement in muscle flexibility was noted (e.g., results for external rotation muscles: (Mean &plusmn, SD (SEM) 60.3 &plusmn, 0.4 (1.50) at baseline and 62.4 &plusmn, 10.3 (1.49) after six weeks) (p = 0.005). In Group 2, significant improvement was observed only for one task in the Active straight leg raise test (p = 0.005 and 0.02). During the measurement of external rotation muscles, a significant decrease in flexibility was observed (Mean &plusmn, SD (SEM) 60.1 &plusmn, 9.0 (1.60) at baseline and 58.0 &plusmn, 8.5 (1.51) after six weeks) (p = 0.001). Plantar short foot muscle exercises may improve muscle flexibility in the upper parts of the body within myofascial chains and influence the quality of fundamental movement patterns. Such exercises may be beneficial for all physically active people and can be performed as part of overall fitness programmes. Moreover, including such exercises in daily training routines of long-distance runners, as well as by athletes in other sport disciplines is also recommended.

BACKGROUND: Piriformis syndrome (PS) is a neuro-muscular condition, which is often underdiagnosed in clinical settings. This study will determine the effects of myofascial stretching Elongation Longitudinaux Avec Decoaption Osteo Articulaire (ELDOA) and post-facilitation stretching of the piriformis muscle in patients with PS. OBJECTIVE: We aimed to compare the effects of ELDOA and post-facilitation stretching of the piriformis muscle on pain, muscle length and functional performance in patients with PS. METHODS: A randomized clinical trial was conducted with 40 PS patients including both males and females, between the ages of 30–70. Patients were randomly assigned to the ELDOA or post-facilitation group after assessments with the Numeric Pain Rating Scale (NPRS), Lower Extremity Functional Scale (LEFS), Piriformis Length Test and Straight Leg Raise (SLR). The assessments were done at baseline and at the end of the sixth week of treatment. RESULTS: The patients treated with ELDOA demonstrated significant improvement in pain (pre = 7.00 ± 2.75, post = 3.00 ± 1.75), piriformis length (pre = 27.6 ± 5.54, post = 36.8 ± 3.13), SLR (pre = 36.40 ± 7.24, post = 67.5 ± 8.36) and LEFS (pre = 26.90 ± 12.24, post = 58.10 ± 8.62), as compared with the group treated with post-facilitation stretching: pain: pre = 6.00 ± 1.00, post = 2.00 ± 1.50; piriformis length: pre = 28.55 ± 4.03, post = 38.8 ± 2.70; SLR: pre = 40.60 ± 7.48, post = 74.25 ± 5.19, and LEFS: pre = 25.20 ± 7.66, post = 66.30 ± 7.27). CONCLUSION: It can be concluded that the post-facilitation stretching technique shows more improvement in pain, muscle length, SLR, and LEFS in patients with PS as compared to ELDOA.

Background: In recent years, the functional movement screen (FMS) and FMS training have attracted attention as a means of preventing injury, but no studies have examined the effect of such training in high-school baseball players. The aim of this study was to clarify the effect of FMS training on FMS score, physical function and baseball performance in high-school baseball players. Methods: Subjects in this randomized controlled clinical trial were high-school male baseball players assigned to either an FMS training group (intervention group) or a control group. The intervention group performed FMS training 4 times per week for 12 weeks. FMS ability, physical function, and baseball performance were measured prior to the intervention, 8, 12, and 24 weeks after the intervention in the subjects’ school environment. Results: A total of 71 baseball players aged 15 to 17 years were recruited and assigned to either an intervention group (n = 37) or control group (n = 34). There was no significant difference in the characteristics of participants between the 2 groups. Most FMS scores improved to 12 weeks after continued training. In the intervention group compared with the control group, deep squat, hurdle step, inline lunge, active straight leg raise, trunk stability push-up and rotary stability FMS score, total FMS score and eyes closed single leg stance time significantly increased after 8 weeks of training. While hurdle step, inline lunge, active straight leg raise, trunk stability push-up, total FMS score, and eyes closed single leg stance time significantly increased, pitching ball speed significantly decreased at the end of the 12 week training period. Eyes closed single leg stance time and feeling of fatigue significantly improved 12 weeks after training. The number of subjects who scored less than 14 for the total FMS score in the intervention group compared with control group were significantly less after 8 and 12 weeks of FMS training. Conclusion: FMS training for 8 weeks contributes to improving FMS scores for high-school baseball players, but FMS scores go down if FMS training is not continued. Trial registration: University Hospital Medical Information Network Center, Tokyo, Japan: UMIN000027553. Registered on May 30, 2017.

BACKGROUND: The straight leg raise test (SLR) is one of the most performed physical tests for mechanosensitivity and impairment of the nervous system. According to the anatomy of the tibial nerve, ankle dorsiflexion and eversion movements could be used to perform the tibial neurodynamic test (TNT). To date, no study has documented the normal responses of the TNT. OBJECTIVE: To document normal responses of the TNT in asymptomatic individuals and to investigate influences from sex and leg dominance. METHODS: A cross-sectional study with 44 asymptomatic volunteer subjects, a total of 88 lower limbs, was carried out. The range of motion (ROM), quality, and distribution of sensory responses were recorded. The hip flexion ROM was measured when subjects reported an intensity of their symptoms of 2/10 (P1) and 8/10 (P2). RESULTS: The mean ROM for hip flexion at P1 was 44.22 ± 13.13∘ and 66.73 ± 14.30∘ at P2. Hip flexion was significantly greater at P2 than P1 (p< 0.001). However, it was not different between sex or limbs (p> 0.05). The descriptor of the quality of sensory responses most often used by participants was stretching (88.6% and 87.5% for P1 and P2, respectively) in the popliteal fossa and posterior calf. CONCLUSIONS: This study describes the sensory responses of asymptomatic subjects resulting from the TNT. Our findings indicate that TNT responses are independent of the influence of sex or leg dominance.

Background Dry needling (DN) has been consistently shown to decrease pain sensitivity and increase flexibility local to the site of treatment, however it is unclear whether these effects are limited to the region of treatment or can be observed remote to the area of treatment. Objective To determine the immediate, short-term effects of DN to the thoracolumbar junction on regional and remote flexibility, and to observe if changes in pain sensitivity can occur remote to site of treatment. Design Double-blind randomized clinical trial. Methods Fifty-four subjects with low back pain and decreased length in at least one hamstring were randomized to receive either DN or sham DN to the T12 and L1 multifidi. Participants underwent regional (fingertip-to-floor) and remote flexibility (passive knee extension, passive straight leg raise) and pressure pain threshold (PPT) testing of the upper and lower extremity before, immediately after and 1 day after treatment. ANCOVAs were used to analyze flexibility data, with the covariate of pre-treatment values. Paired t-tests were used for difference in remote pain sensitivity. Results Statistically larger improvements in regional flexibility, but not remote flexibility, were observed immediately post-treatment in those who received DN than in those receiving sham DN (p = .0495; adjusted difference 1.2, 95% CI 0.002–2.3). Differences between upper and lower extremity PPT were not significant. Conclusion DN can potentially have immediate changes in regional flexibility, but effects are not sustained at 24-h follow-up. DN may not affect remote flexibility or segmental pain sensitivity.

OBJECTIVE: Explore challenges associated with implementing a home-based strengthening exercise program for people with knee osteoarthritis and comorbid obesity. METHODS: Qualitative study embedded within a randomised controlled trial comparing two home-based strengthening programs (weight bearing functional exercise versus non-weight bearing quadriceps strengthening exercise) for people with knee osteoarthritis and comorbid obesity. Patients in both exercise programs attended five consultations with a physiotherapist and undertook a home-based exercise program for 12 weeks. Semi-structured individual telephone interviews were conducted with 22 patients after trial completion, and all seven physiotherapists who delivered trial interventions. Interviews were recorded, transcribed verbatim, and thematically analysed using an inductive approach. RESULTS: Three themes arose: i) psychological challenges (false assumptions about exercise; fear of pain; disliking exercise; mental effort of weight bearing functional program; underestimating capability) ii) physical challenges (complexity of weight bearing functional program; cuff weights and straight leg raise problematic in non-weight bearing quadriceps program; other health conditions), and; iii) overcoming challenges (incentives to exercise; accountability; education and reassurance; tailoring the exercise program). CONCLUSION: Patients and physiotherapists experienced numerous psychological and physical challenges to exercise, including a fear of pain, having false assumptions about exercise, difficulties with exercise performance, application of cuff weights, and adverse impacts of other health conditions.

BACKGROUND The time course of passive stiffness responses following an acute bout of static stretching has received little research attention, particularly in older adults. OBJECTIVE To determine the time course of the acute effects of static stretching on passive stiffness of the hamstrings in healthy, elderly men. METHODS Fifteen elderly men (age = 70 ± 7 years) underwent two randomized conditions that included a control treatment and an experimental treatment of four, 15-s straight-leg raise static stretches. Passive stiffness was calculated as the slopes of the initial and final phases of the angle-torque curve at pre-treatment (Pre) and post-treatment time points of zero (Post0), five (Post5), and ten (Post10) minutes. RESULTS Passive stiffness collapsed across phase was lower at Post0 (P= .029, d= 0.64) and Post5 (P= .042, d= 0.54) but not Post10 (P> .999, d= 0.15) compared to Pre for the stretching treatment. There were no significant differences in passive stiffness (collapsed across phase) between any of the time points (P> .999, d≤ 0.14) for the control. CONCLUSIONS An acute bout of static stretching produced significant decreases in the passive stiffness characteristics of elderly men; however, these decreases returned to baseline values within 5 to 10 minutes.

BACKGROUND: Lumbar vertebrae carry the greatest load from the spinal column, often leading to several pathologies, including degenerative disc disease (DDD), potentially disturbing spinal movement patterns. Mobilisation increases hypomobile segment mobility, however there is little evidence on mobilisation in patients suffering from different types of DDD. OBJECTIVE: To assess the efficacy of mobilisation in young patients with DDD, as diagnosed by MRI. METHODS: Thirty patients (24–35 years) participated in this study, and were divided into two groups, based on progression levels of DDD diagnosed by MRI (protrusion-PRO/extrusion-EXT). Twenty sessions of sustained stretch mobilisation (grade III) were applied to both groups over four weeks. Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), straight leg raise (SLR), passive lumbar extension (PLE) and lumbar range of motion (ROM) assessed outcome variables. Three trial stages were investigated: pre-therapy (1), post-therapy (2) and follow-up (3). RESULTS: Age (p= 0.007) and NRS (p= 0.002) were significantly different before therapy. Patient outcomes were significantly improved for all parameters in both groups, except SLR which improved in the EXT group only (p= 0.043). CONCLUSIONS: Applied treatments improved patient outcomes and were statistically significant in both groups, however, better outcomes were observed in the EXT group during follow-up. Mobilisation was a safe and effective procedure for the treatment of DDD.

The percentage of spine misalignment increases during the childhood and adolescence stages. The Pilates method has been associated with an improvement in the sagittal spine disposition, but no studies have been conducted on adolescents. Therefore, the present study aimed to evaluate the effectiveness of a 9-month Pilates exercise program (PEP) on hamstring extensibility and sagittal spinal curvatures on adolescents. This randomised controlled trial included 236 adolescents. The experimental group (EG) received a PEP (9 months, 2 sessions/week, 15 minutes/session). The control group (CG) did not receive any intervention. Hamstring extensibility was measured with the passive and active straight leg raise and toe-touch tests. Sagittal spinal curvatures and pelvic tilt was assessed in relaxed standing, active alignment and toe-touch test positions. The EG had significant changes in hamstring extensibility, lumbar curvature and pelvic tilt in standing sagittal curvature. The CG became significantly worse in thoracic kyphosis in standing. This study provides evidence of nine-months of a PEP increased the hamstring extensibility; averted the increase of the thoracic curvature, and decreased the curvature of the lumbar lordosis and pelvic tilt in standing position; avoided a greater increase of thoracic curvature in active alignment in standing position; and avoided the increase of thoracic curvature in trunk flexion.