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Purpose Pulmonary rehabilitation (PR) including exercise training improves muscle strength, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD). However, the evidence of the effect of upper limb exercise training (ULET) on activities of daily living (ADL) is sparse. This study investigated the effect of two different types of ULET on ADL in addition to standard PR. Methods Patients were randomly assigned to a strength or a combined ULET group. Both groups exercised 2 d/wk for 12 wk. Outcome measures were handgrip strength and muscle strength of biceps and triceps muscles. Moreover, health-related quality of life was assessed through the COPD assessment test (CAT) and Saint George Respiratory Questionnaire. Ability to perform ADL was evaluated through an ADL simulation test. Dyspnea was evaluated by a modified Medical Research Council scale, whereas dyspnea and fatigue perception during strength and ADL tests were measured through a modified Borg scale. Results Thirty-six patients with COPD (67.4 ± 5.3 yr) participated in the study. Significant improvements in upper limb strength and CAT were found within both groups. At the end of the study period, patients in the combined group improved time of the ADL test (P = .02) with reduced perception of fatigue (P = .03) compared with patients in the strength group. Conclusions In addition to standard PR of patients with COPD, the combined endurance and resistance ULET program improved ADL and muscle strength, whereas resistance training only increased strength.

Background/purpose Cervical and thoracic spine manipulation has been found to reduce tendon pain and disability in lateral epicondylalgia and rotator cuff tendinopathy. Based on these findings, the application of lumbar spine manipulation may also provide similar improvements in Achilles tendinopathy (AT). Therefore, the purpose of this study was to evaluate the effect of lumbar spine manipulation on pain and disability in a patient experiencing AT. Case description A 44 years old male ex-football player presented with a 20-year history of persistent Achilles tendon pain (ATP) consistent with AT diagnosis. The patient attended 12 treatment sessions receiving a high-velocity, low amplitude lumbar spine manipulation. Outcome measures were collected at baseline, 2 weeks, 4 weeks, 3 months and 6 months and included pain in visual analogue scale, the American Orthopedic Foot and Ankle Score, the 36-Item Short Form Health Survey and the Victorian Institute of Sport Assessment-Achilles questionnaire. Pressure pain threshold was also assessed using an electronic pressure algometer. Outcomes Improvement in all outcome measures was noted 6-months post intervention. Outcome measures indicated substantial improvements in both the patient's pain and disability. The patient was able to perform activities of daily living without difficulties, suggesting higher level of function and quality of life at 6-months post initial evaluation. Conclusion These findings have demonstrated the positive effects of lumbar spine manipulation on ATP and disability. Further studies, specifically clinical trials investigating the effect of lumbar spine manipulation or combining this technique with exercises and functional activities are suggested.

Background Although both neural mobilization (NM) and cervical traction (CT) are widely used interventions in cervical radiculopathy (CR), there is limited clinical data to support their use. Objective To evaluate the effects of CT, with or without the addition of NM, on pain, function, and disability in patients with CR. Design A randomized, double-blinded, placebo-controlled clinical trial. Methods 66 patients with CR were randomly allocated to: a group (n = 22) received CT combined with NM (CT + NM), a group (n = 22) received CT combined with sham NM (CT + shamNM) and a wait-list control (WLC) group (n = 22). The Neck Disability Index (NDI), the Patient-Specific Functional Scale, the Numeric Pain Rating Scale (NPRS), grip strength and cervical spine mobility were used as outcome measures. A two-way analysis of variance was used to evaluate differences between the three groups at baseline and at 4-week follow-up. Results Statistically and clinically significant between-group differences at 4-week follow-up were found between CT + NM and WLC groups in favor of CT + NM group in NDI scores (d = 1.30), NRPS (d = 1.94), and active cervical rotation towards the opposite arm (d = 1.18) and between CT + NM and CT + shamNM groups in favor of CT + NM group in NRPS (d = 1.21). No significant differences were observed between CT + shamNM and WLC groups in all outcome measures. Clinically significant within-group improvements were found only for the CT + NM group. Conclusion At 4-week follow-up, CT in combination with NM resulted in improved outcomes in pain, function and disability in patients with CR.

Στόχος της διδακτορικής διατριβής ήταν να διερευνήσει την αποτελεσματικότητα της αυχενικής έλξης σε συνδυασμό με την εφαρμογή των ασκήσεων κινητοποίησης του περιφερικού νευρικού ιστού στην αντιμετώπιση της αυχενικής ριζοπάθειας. Πιλοτικά η διερεύνηση του συγκεκριμένου θεραπευτικού πλάνου πραγματοποιήθηκε με μια περιπτωσιακή μελέτη ενώ αργότερα πραγματοποιήθηκε μια διπλά τυφλή τυχαιοποιημένη ελεγχόμενη δοκιμασία (συμμετοχή σαράντα δύο ασθενών που ισομερώς κατανεμήθηκαν στις ομάδες ελέγχου και θεραπείας) με σαφώς καλύτερο μεθοδολογικό σχεδιασμό σε σχέση με την προηγούμενη μελέτη. Για την αξιολόγηση του συγκεκριμένου θεραπευτικού πλάνου χρησιμοποιήθηκαν τα όργανα αξιολόγησης the Neck Disability Index, the Patient-Specific Functional Scale and the Numeric Pain Rating Scale. Επιπρόσθετα, αξιολογήθηκε η δύναμη της λαβής της άκρας χειρός αλλά και το εύρος κίνησης της αυχενικής μοίρας της σπονδυλικής στήλης. Σύμφωνα με τα ευρήματα της διατριβής αποδείχτηκε πως η εφαρμογή της αυχενικής έλξης και των ασκήσεων κινητοποίησης του περιφερικού νευρικού ιστού μπορεί να αντιμετωπίσουν τον νευρογενή πόνο αλλά και να αναβαθμίσουν το επίπεδο λειτουργικότητας των ασθενών με αυχενική ριζοπάθεια. Περισσότερες μελλοντικές ερευνητικές εργασίας θα πρέπει να διεξαχθούν έτσι ώστε να διερευνηθεί η μακροπρόθεσμη αποτελεσματικότητα του συγκεκριμένου θεραπευτικού πλάνου αλλά και να συγκριθεί η δράση του σε σχέση με την αποτελεσματικότητα άλλων θεραπευτικών εργαλείων όπως είναι ο θεραπευτικός υπέρηχος κτλ.

Objective: To summarize the available literature with regards to the potential analgesic effect and mechanism of joint mobilization and manipulation in tendinopathy. Results: The effect of these techniques in rotator cuff tendinopathy and lateral elbow tendinopathy, applied alone, compared to a placebo intervention or along with other interventions has been reported in some randomized controlled trials which have been scrutinized in systematic reviews. Due to the small randomized controlled trials and other methodological limitations of the evidence base, including short-term follow-ups, small sample size and lack of homogenous samples further studies are needed. Literature in other tendinopathies such as medial elbow tendinopathy, de Quervain's disease and Achilles tendinopathy is limited since the analgesic effect of these techniques has been identified in few case series and reports. Therefore, the low methodological quality renders caution in the generalization of findings in clinical practice. Studies on the analgesic mechanism of these techniques highlight the activation of the descending inhibitory pain mechanism and sympathoexcitation although this area needs further investigation. Conclusion: Study suggests that joint mobilization and manipulation may be a potential contributor in the management of tendinopathy as a pre-conditioning process prior to formal exercise loading rehabilitation or other proven effective treatment approaches.

Little attention has been given to support the use of slider and tensioner neural mobilization (NM) techniques for upper quadrant pain (UQP). The purpose of this study was to systematically review the effectiveness of these techniques in patients with UQP.The PubMed, Cochrane Library and EBSCOhost were searched without chronological restriction to identify randomized clinical trials (RCTs) that assessed pain changes following NM in the upper quadrant. Two researchers independently performed screening, full-text assessment, data extraction and risk of bias assessment of the studies.A total of 974 articles were identified, of which 25 were included in this systematic review. The score for methodological quality of studies included was between 5 and 10 with a mean score of 7.96 points. Results demonstrated that slider and tensioner NM techniques are considered beneficial in pain reduction of UQP in certain musculoskeletal conditions including carpal tunnel syndrome and cervical radiculopathy. Regarding other conditions such as subacromial impingement syndrome, lateral elbow tendinopathy and cubital tunnel syndrome, due to conflicting findings, various methodological limitations and/or inadequate information, the available evidence remains uncertain. Furthermore, slider NM was found to be more effective in acute conditions compared to tensioner NM that seems to provide further analgesic effect in chronic UQP.This systematic review revealed that NM slider and tensioner techniques can be used as analgesic modalities for managing UQP resulting from cervical radiculopathy and carpal tunnel. There remain unanswered questions concerning other conditions, and, therefore, further well-designed RCTs are needed to examine the analgesic response of NM techniques in UQP.

Objective: To investigate the efficacy of upper limb exercise training (ULExT) in improving the performance of activities of daily living (ADL) that involve the upper limbs (UL) in patients with COPD. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in this systematic review. PubMed and EBSCOhost databases were searched to identify randomized controlled trials involving adults with COPD who underwent ULExT, compared with those who underwent other types of exercise or no exercise, in order to assess the performance of ADL that involve the UL. The methodological quality of the selected studies was assessed using the Physiotherapy Evidence Database scale. Results: Five studies, with a total sample of 173 subjects, met the inclusion criteria. The results of the selected studies showed that ULExT is safe and can significantly improve the performance of ADL that involve the UL in patients with COPD. However, there were inconsistencies in the results, especially regarding the perception of symptoms during ADL. The small number of studies included and their methodological quality do not allow for firm conclusions. Conclusions: The findings of this review revealed that ULExT is a safe therapeutic approach and can improve the performance of ADL that involve the UL in patients with COPD, but the results are unclear. Further investigation through well-designed randomized trials is warranted to determine the effectiveness of ULExT in improving the performance of ADL that involve the UL in patients with COPD. RESUMO Objectivo: Investigar a eficácia do treinamento de membros superiores (MMSS) na melhora na execução de atividades da vida diária (AVD) que envolvem os MMSS em pacientes com DPOC. Métodos: Nesta revisão sistemática foram utilizadas as diretrizes do Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Os bancos de dados PubMed e EBSCOhost foram pesquisados para identificar ensaios controlados randomizados envolvendo adultos com DPOC submetidos a treinamento de MMSS, comparados àqueles submetidos a outros tipos de exercício ou a nenhum exercício, a fim de avaliar a execução de AVD que envolvem os MMSS. A qualidade metodológica dos estudos selecionados foi avaliada por meio da escala do Physiotherapy Evidence Database. Resultados: Cinco estudos, com uma amostra total de 173 indivíduos, preencheram os critérios de inclusão. Os resultados dos estudos selecionados mostraram que o treinamento de MMSS é seguro e pode melhorar significativamente a execução de AVD que envolvem os MMSS em pacientes com DPOC. No entanto, houve inconsistências nos resultados, especialmente em relação à percepção de sintomas durante as AVD. O pequeno número de estudos incluídos e a qualidade metodológica desses estudos não permitem conclusões firmes. Conclusões: Os achados desta revisão revelaram que o treinamento de MMSS é uma abordagem terapêutica segura e pode melhorar a execução de AVD que envolvem os MMSS em pacientes com DPOC, mas os resultados não são claros. São necessárias mais investigações, por meio de ensaios aleatorizados bem desenhados, para determinar a eficácia do treinamento de MMSS na melhora na execução de AVD que envolvem os MMSS em pacientes com DPOC.

The purpose of this study was to investigate the intra-rater reliability and agreement of handgrip strength (HGS) measurement using a hydraulic hand dynamometer in patients with chronic obstructive pulmonary disease (COPD). A sample of 19 COPD patients (18 males and 1 female; mean ± SD age, 66.9 ± 6.3 years) was evaluated using a hand dynamometer by the same rater in two different testing sessions with a 7-d interval. During each session, patients were asked to exert three maximal isometric contractions on the dominant hand and the mean value of the 3 efforts (measured in kilogram-force [Kgf]) was used for data analysis. The intraclass correlation coefficient (ICC

Background Eccentric (ECC) exercise is an “economical” type of exercise with low energy requirements and does not cause early fatigue. Therefore, it is used for cardiac patients, who have low physical activity and exercise intolerance, as an easier kind of training. Objective This systematic review aimed to investigate the efficacy of ECC exercise for functional capacity (FC) in patients with ischemic heart disease. Design Systematic review. Methods MEDLINE via PubMed and EBSCO databases were searched for articles of randomized controlled trials of adults with ischemic heart disease who underwent ECC training as compared with other forms of exercise (concentric exercise) or no exercise and assessed FC. The methodologic quality of studies was assessed by the PEDro scale. A meta-analysis was performed with sufficient homogeneity between at least 2 studies in the pre-defined comparisons. Results Four studies, investigating a total of 99 subjects, met the inclusion criteria. The results of the studies did not clearly indicate whether ECC exercise could improve FC better than traditional forms of exercise. However, the small number of studies and their methodologic weaknesses do not allow for drawing firm conclusions. Conclusions We found contradictory results about the effectiveness of ECC as compared with concentric exercise in terms of FC in ischemic cardiac patients. Further investigation with well-designed randomized trials is needed to determine the effectiveness of this kind of exercise for FC in such patients.

Background The effectiveness of both neural mobilization and intermittent cervical traction (ICT) has been previously explored in some studies of generally low methodological quality. However, the effect of simultaneous application of these techniques in people with cervical radiculopathy (CR) has not been previously investigated. Aim To investigate the effect of neural mobilization with simultaneously applied ICT on pain, disability, function, grip strength and cervical range of motion in patients with CR. Design Randomized, controlled, assessor-blinded, clinical trial. Methods Participants (n = 42) diagnosed with unilateral CR were randomly allocated to intervention (neural mobilization combined with ICT, n = 21) or control (n = 21) groups. Participants in the intervention group were asked to attend for 12 treatment sessions to receive 6 sets of 60s grade II–IV ICT with simultaneously applied ‘slider' neural mobilizations with median nerve bias. Participants randomized to the control group did not receive any type of treatment and were asked to avoid prescription or over-the-counter analgesia or anti-inflammatory medication. The Neck Disability Index (NDI), the Patient-Specific Functional Scale (PSFS), the Numeric Pain Rating Scale (NPRS), and measures of grip strength (GS) and cervical spine active range of motion (CSAROM) were administered at baseline and at 4-weeks. Results The intervention group demonstrated significant improvements in NDI scores (mean difference = −16.95; 95% CI = −22.47 to −11.43, ES = 0.42), PSFS scores (mean difference = 2.88; 95% CI = 2.33 to 3.43, ES = 0.66), NPRS scores (mean difference = −3.74; 95% CI = −4.92 to −2.96, ES = 0.37), GS (mean difference = 1.87 kg; 95% CI = 0.51 to 3.23; ES = 0.07), and CSAROM (except for lateral flexion), compared to the control group where significant changes were not detected. Conclusion Neural mobilization with simultaneous ICT can improve, pain, function, disability, grip strength and cervical range of motion in people with CR. Further clinical trials comparing neural mobilization with cervical traction to other standard interventions are justified.

Objective The purpose of this study was to investigate the degree of test-retest reliability of grip strength measurement using a hand dynamometer in patients with shoulder impingement syndrome. Methods A total of 19 patients (10 women and 9 men; mean ± standard deviation age, 33.2 ± 12.9 years; range 18-59 years) with shoulder impingement syndrome were measured using a hand dynamometer by the same data collector in 2 different testing sessions with a 7-day interval. During each session, patients were encouraged to exert 3 maximal isometric contractions on the affected hand and the mean value of the 3 efforts (measured in kilogram-force [Kgf]) was used for data analysis. The intraclass correlation coefficient (ICC2,1) as well as the standard error of measurement (SEM) and Bland-Altman plot were used to estimate the degree of test-retest reliability and the measurement error, respectively. Results Grip strength data analysis revealed an ICC2,1 score of 0.94, which, based on the Shrout classification, is considered as excellent test-retest reliability of grip strength measurement. The small values of SEMs reported in both sessions (SEM1, 2.55 Kgf; SEM2, 2.39 Kgf) and the small width of the 95% limits of agreement in the Bland-Altman plot (ranging from −7.39 Kgf to 7.03 Kgf) reflected the measurement precision and the narrow variation of the differences during the 2 testing sessions. Conclusions Results from this study identified excellent test-retest reliability of grip strength measurement in shoulder impingement syndrome, indicating its potential use as an outcome measure in clinical practice.

BACKGROUND: Although the antinociceptive effect of high-velocity, low amplitude thrust manipulation (HVLAM) has been recognized by numerous systematic reviews, the underlying mechanism for manipulation-related pain relief remains poorly understood. An increasing number of studies have explored its analgesic mechanism suggesting that the excitation of the descending inhibitory pain mechanism (DIPM) might play the most important role for musculoskeletal pain relief. OBJECTIVE: The objective of this review is to investigate the role of the DIPM in musculoskeletal pain following HVLAM as well as to identify the pain-relieving importance of this technique within clinical practice. METHODOLOGY: English literature databases were searched to find studies related to the objective of the present review. RESULTS AND CONCLUSIONS: Findings from current literature support that HVLAM has a profound influence on nociceptive stimulus via the possible activation of the DIPM. It seems that the application of this technique activates the periaqueductal gray region area of the midbrain, stimulates the noradrenergic descending system and at the level of the spinal cord, the nociceptive afferent barrage is reduced and mechanical hypoalgesia is induced. However, the literature on HVLAM induced-analgesia is still problematic regarding the methodological design of the existing research. Despite these limitations, the clinical importance of the activation of the DIPM should not be ignored since the resulted analgesic effect of this technique can provide a window of opportunity to restore impaired physical performance and disability.

Spinal radiculopathy (SR) is a multifactorial nerve root injury that can result in significant pain, psychological stress and disability. It can occur at any level of the spinal column with the highest percentage in the lumbar spine. Amongst the various interventions that have been suggested, neural mobilization (NM) has been advocated as an effective treatment option. The purpose of this review is to (1) examine pathophysiological aspects of spinal roots and peripheral nerves, (2) analyze the proposed mechanisms of NM as treatment of injured nerve tissues and (3) critically review the existing research evidence for the efficacy of NM in patients with lumbar or cervical radiculopathy.

Necrotic enteritis toxin B (NetB) is a β-pore-forming toxin produced by Clostridium perfringens and has been identified as a key virulence factor in the pathogenesis of avian necrotic enteritis, a disease causing significant economic damage to the poultry industry worldwide. In this study, site-directed mutagenesis was used to identify amino acids that play a role in NetB oligomerisation and pore-formation. NetB K41H showed significantly reduced toxicity towards LMH cells and human red blood cells relative to wild type toxin. NetB K41H was unable to oligomerise and form pores in liposomes. These findings suggest that NetB K41H could be developed as a genetic toxoid vaccine to protect against necrotic enteritis.

Objective The purpose of this study was to evaluate the test-retest reliability of handgrip strength measurement using a hydraulic hand dynamometer in patients with cervical radiculopathy (CR). Methods A convenience sample of 19 participants (14 men and 5 women; mean ± SD age, 50.5 ± 12 years) with CR was measured using a Jamar hydraulic hand dynamometer by the same rater on 2 different testing sessions with an interval of 7 days between sessions. Data collection procedures followed standardized grip strength testing guidelines established by the American Society of Hand Therapists. During the repeated measures, patients were advised to rest their upper limb in the standardized arm position and encouraged to exert 3 maximum gripping efforts. The mean value of the 3 efforts (measured in kilogram force [Kgf]) was used for data analysis. The intraclass correlation coefficient, SEM, and the Bland-Altman plot were used to estimate test-retest reliability and measurement precision. Results Grip strength measurement in CR demonstrated an intraclass correlation coefficient of 0.976, suggesting excellent test-retest reliability. The small SEM in both testing sessions (SEM1, 2.41 Kgf; SEM2, 2.51 Kgf) as well as the narrow width of the 95% limits of agreements (95% limits of agreement, − 4.9 to 4.4 Kgf) in the Bland-Altman plot reflected precise measurements of grip strength in both occasions. Conclusions Excellent test-retest reliability for grip strength measurement was measured in patients with CR, demonstrating that a hydraulic hand dynamometer could be used as an outcome measure for these patients.

The objective of this study was to investigate the test–retest reliability of measurement of grip strength in full elbow extension. The grip strengths of 19 healthy participants were measured using the Jamar dynamometer by the same rater on two occasions with an interval of 7 days between measures. Test–retest reliability of grip strength measurement was excellent in full elbow extension and associated with low values of standard error of measurement and small variations in the differences between the two measurements in both testing sessions.

Cervical radiculopathy is the result of cervical nerve root pathology that may lead to chronic pain and disability. Although manual therapy interventions including cervical traction and neural mobilization have been advocated to decrease pain and disability caused by cervical radiculopathy, their analgesic effect has been questioned due to the low quality of research evidence. The purpose of this paper is to present the effect of cervical traction combined with neural mobilization on pain and disability in a patient experiencing cervical radiculopathy. A 52-year-old woman presented with a 2 month history of neurological cervico-brachial pain and whose presentation was consistent with cervical radiculopathy. Cervical traction and a slider neural mobilization of the medial nerve were applied simultaneously to reduce the patient's pain and disability measured at baseline and at 2 and 4 weeks using the Numeric Pain Rating Scale, the Neck Disability Index and the Patient-Specific Functional Scale. Improvements in all outcome measures were noted over a period of four weeks. Scores in all outcome measures revealed that the patient's pain had almost disappeared and that she was able to perform her household chores and job tasks without difficulties and limitations. In conclusion, the findings of this study support that the application of cervical traction combined with neural mobilization can produce significant improvements in terms of pain and disability in cervical radiculopathy.