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Objectives We investigated whether a specific exercise program for the neck–shoulder region reduces headache intensity, frequency, and duration, and how it influences neck disability among women with chronic headache compared to a control group. Design Two-center randomized controlled trial. Subjects 116 working-age women. Intervention The exercise group (n = 57) performed a home-based program with six progressive exercise modules, over 6 months. The control group (n = 59) underwent six placebo-dosed transcutaneous electrical nerve stimulation sessions. Both groups performed stretching exercises. Main measures The primary outcome was pain intensity of headache, assessed using the Numeric Pain Rating Scale. Secondary outcomes were frequency and duration of weekly headaches, and neck disability assessed using the Neck Disability Index. Generalized linear mixed models were used. Results Mean pain intensity at baseline was 4.7 (95% CI 4.4 to 5.0) in the exercise group and 4.8 (4.5 to 5.1) in the control group. After 6 months the decrease was slight with no between-group difference. Headache frequency decreased from 4.5 (3.9 to 5.1) to 2.4 (1.8 to 3.0) days/week in the exercise group, and from 4.4 (3.6 to 5.1) to 3.0 (2.4 to 3.6) in the control group (between-group p = 0.017). Headache duration decreased in both groups, with no between-group difference. Greater improvement in the Neck Disability Index was found in the exercise group (between-group change −1.6 [95% CI −3.1 to −0.2] points). Conclusion The progressive exercise program almost halved headache frequency. The exercise program could be recommended as one treatment option for women with chronic headache.

Objectives: To evaluate the association of thoracic spine (TS) posture and mobility with TS pain. Methods: Participants with TS pain reported maximum, average, and night pain in TS area, and pain summary score was calculated. Upright and sitting TS postures were evaluated by inspection. TS posture and mobility (flexion and extension) were recorded using an inclinometer and a tape measure, respectively. Correlations between posture and mobility assessments were calculated using Spearman rank correlation, the association of TS posture and mobility with TS pain by logistic regression analysis. Results: The participants’ (n = 73, 52 females, age range 22–56) TS pain duration was 12 weeks on average. The correlations for measurements of TS posture and flexion mobility were higher than correlations of other TS measurements being between 0.53 and 0.82. Decreased extension mobility of the upper (from 1st to 6th TS segments; Th1–Th6) TS was associated with higher worst pain (OR 1.04, 95% CI 1.00–1.07) and whole TS with pain sum score (OR 1.05, 95% CI 1.01– 1.08). Less kyphotic whole TS was associated with lower pain sum score (OR 0.96, 95% CI 0.92– 1.00). Greater flexion mobility of upper and lower (Th6–Th12) TS were associated with lower pain sum score (OR 0.96, 95% CI 0.91–1.00, and OR 0.96, 95% CI 0.91–1.00, respectively). Conclusions: Reduced thoracic extension mobility was associated with higher pain scores and the greater flexion mobility with lower pain scores. Future research is warranted to evaluate if treatments geared toward TS extension mobility improvements would result in lower TS pain. peerReviewed

Observational cohort study.To measure and compare the structural validity of the Oswestry Disability Index (ODI) and the Scoliosis Research Society-30 (SRS-30) questionnaire in an adult population with prolonged degenerative thoracolumbar disease.The ODI and the SRS-30 are commonly used patient-reported outcome instruments to assess back-specific disability and symptoms related to scoliosis. Still, these instruments have not been validated for degenerative spinal disease with different stages of deformity.Altogether, 637 consecutive adult patients with degenerative spinal pathologies were included. The patients completed the ODI (version 2.0), the 23 preoperative items of the SRS-30, a general health survey, the Kasari Frequency Intensity Time (FIT) index, the Depression Scale (DEPS), the RAND-36, and visual analog scales for leg and back pain instruments. Psychometric statistical and illustrative analyses were conducted. Deformity groups were analyzed to assess how well the two instruments reflect deformity-related back problems.Both instruments reflected good coverage and targeting. Correlation between the ODI and the SRS-30 was high (r = 0.70; p .001). Both measures could distinguish between different general health states. The SRS-30 strongly reflected mental state and social well-being. The SRS-30 was less sensitive for pain and function. Furthermore, the principal component of pain/function explained more variance in the SRS-30 compared with the ODI score. The ODI was more sensitive for variance of disability among different age and deformity groups.Both the ODI and the the SRS-30 provide valid scores in evaluating health-related quality of life and/or level of disability among patients with prolonged degenerative thoracolumbar disease. The ODI has slightly higher correlation with physical functioning. The SRS-30 seems to be better when evaluating the emotional and psychological functions.Level III.

This was a cross-sectional, observational study.The main objectives of this study were to observe the prevalence of a true L6 among patients with symptomatic adult spinal degeneration, and to evaluate similarities of their radiographic spinopelvic parameters to L5 patients.Spinopelvic parameter values used for diagnosis and surgical planning are different between individuals with 5 or 6 lumbar vertebrae. The difference has not been studied in patients with symptomatic spinal degenerative conditions.A total of 775 consecutive symptomatic patients with degenerative spinal disorders were classified as having 5 or 6 lumbar vertebrae in full spine radiographs. Pelvic incidence minus lumbar lordosis (PI-LL), sagittal vertical axis (SVA), pelvic tilt, and T1 pelvic angle were measured in 3 groups: sacral (L5 and L6s) and L6 upper endplate (L6e). Oswestry Disability Index (ODI) was obtained.In total, 715 (92.3%) patients had L5 and 60 (7.7%) had L6. LL values were comparable between the L5 and L6s (P=0.355) and SVA between all groups (P=0.869). Only SVA had excellent concordance correlation (ρc=0.91) between the L6s and L6e groups. PI-LL had significantly different values (P0.001 all groups) and distributions between L5 and L6s (P=0.038), and L6s and L6e (P0.001) groups. In patients with severe disability (ODI40%) the parameters that deteriorate with increasing degeneration (pelvic tilt, T1 pelvic angle, SVA, LL, PI-LL) were not significantly different between L5 and L6s groups unlike patients with ODI40% while PI remained similarly different (P0.001). PI and LL had a multivariate relationship in L6 patients computable as regression model equation: PI (sacrum)=-0.92×LL (L6e)+0.91×LL (sacrum) +1.11×PI (L6e)+10.81 (R=0.88).L6 variant is fairly common. The radiographic L6 parameters were different from L5 except for SVA and values of patients with severe disability measured from sacrum. PI and LL have a mathematic relationship in L6 patients. The cutoff values for radiographic modifiers need further studies combining radiology and clinical outcome.Level III.

Aim To evaluate the activity of knee stabilizing muscles while using custom-made biomechanical footwear (BF) and to compare it when walking barefoot and with a knee brace (Unloader®). Methods Seventeen healthy working-aged (mean age: 29 years; standard deviation: 8 years) individuals participated. The knee brace was worn on the right knee and BF in both legs. Surface electromyography (sEMG) data was recorded bilaterally from vastus medialis (VM), semitendinosus (ST), tibialis anterior (TA) and lateral gastrocnemius (LG) muscles during walking, and repeated-measures ANOVA with a post-hoc t-test was used to determine differences between the different walking modalities (barefoot, brace and BF). Results Averaged sEMG was significantly higher when walking with BF than barefoot or knee brace in the ST muscles, in the right LG, and left TA muscle. It was significantly lower when walking with the brace compared to barefoot in the right ST and LG muscles, and left TA muscle. Analysis of the ensemble-averaged sEMG profiles showed earlier activation of TA muscles when walking with BF compared to other walking modalities. Conclusion BF produced greater activation in evaluated lower leg muscles compared to barefoot walking. Thus BF may have an exercise effect in rehabilitation and further studies about its effectiveness are warranted.

Background Rotator cuff disease (RCD) causes prolonged shoulder pain and disability in adults. RCD is a continuum ranging from tendinopathy to full-thickness tendon tear. Recent studies have shown that subacromial decompression and non-surgical treatments provide equivalent results in RCD without a full-thickness tendon lesion. However, the importance of surgery for full-thickness tendon tears remains unclear. Methods In a pragmatic, randomised, controlled trial, 417 patients with subacromial pain underwent 3-month initial rehabilitation and MRI arthrography (MRA) for the diagnosis of RCD. Of these, 190 shoulders remained symptomatic and were randomised to non-surgical or surgical treatments. The primary outcomes were the mean changes in the Visual Analogue Scale for pain and the Constant Murley Score for shoulder function at the 2-year follow-up. Results At the 2-year follow-up, both non-surgical and surgical treatments for RCD reduced pain and improved shoulder function. The scores differed between groups by 4 (95% CI −3 to 10, p=0.25) for pain and 3.4 (95% CI −0.4 to 7.1, p=0.077) for function. Among patients with full-thickness ruptures, the reduction in pain (13, 95% CI 5 to 22, p=0.002) and improvement in function (7.0, 95% CI 1.8 to 12.2, p=0.008) favoured surgery. Conclusions Non-surgical and surgical treatments for RCD provided equivalent improvements in pain and function. Therefore, we recommend non-surgical treatment as the primary choice for patients with RCD. However, surgery yielded superior improvement in pain and function for full-thickness rotator cuff rupture. Therefore, rotator cuff repair may be suggested after failed non-surgical treatment. Trial registration details ClinicalTrials.gov, NCT00695981 and NCT00637013.

BACKGROUND: The Depression Scale (DEPS) is a commonly used screening tool for major depression in studies investigating low back pain, yet it has not been validated for patients with back-specific problems. OBJECTIVE: To assess the psychometric properties of the DEPS in patients with degenerative spinal disease. METHODS: Six hundred and thirty-seven patients with a degenerative spinal disease completed the DEPS instrument. The Rasch Measurement Theory was applied to analyze the measurement properties of the DEPS. The main hypothesis-driven approach was whether the DEPS would meet relevant psychometric criteria for assessing depressive symptoms among patients with degenerative spinal disease. RESULTS: The Mean (SD) DEPS score was 9.2 (6.6). Scale minimum or maximum points among participants were 2.4% and 0.8%, respectively. Cronbach’s alpha for internal consistency was 0.92. Person Separation Index for reliability was 0.88. All items had ordered thresholds and seven of the 10 items had good item fit. Unidimensionality of the DEPS was supported (proportion of significant t-tests, 4.5%). CONCLUSIONS: This study supports the validity of the DEPS for screening depressive symptoms in patients with degenerative spinal disease.

Objective: To compare the effects of a 12-month home-based exercise program to usual care in patients after arthroscopic capsulolabral repair of the shoulder. Design: Randomized controlled trial. Setting: Outpatient physical and rehabilitation medicine clinic. Subjects: Forty-five patients (mean age: 35 years; standard deviation (SD): 10 years) who underwent arthroscopic capsulolabral repair due to labral lesion were randomized into an exercise group (EG) or a control group (CG). Intervention: The EG received a 12-month home-based additional exercise program with four physiotherapy follow-up visits, while the CG received standard postoperative exercise instructions. Main measures: Self-reported shoulder disability was assessed with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and quality of life with the Short-Form (SF)-36 Health Survey. The function of the operated shoulder was evaluated with strength and range of motion measurements. Results: No between-group differences were observed in any of the outcomes at the follow-up. Mean ASES score improved by 16 (95% confidence interval (CI): 10–23) points from the baseline 78 (SD: 17) in the EG and 13 (95% CI: 7–19) points from the baseline 79 (SD: 17) in the CG. Both groups achieved a significant improvement in the dimensions of Physical Functioning, Role-Physical, and Bodily Pain of the SF-36 and in every aspect of strength and range of motion measures. In EG, exercise adherence was moderate (52%) during the first six months and poor (22%) during the last six months. Conclusion: Home-based additional exercises with four outpatient follow-up visits did not improve outcome after arthroscopic capsular repair of the shoulder.

Low-energy pulsed electromagnetic field (PEMF) therapy has been suggested as a promising therapy to increase microcirculation, which is of great concern in patients with fibromyalgia. This study evaluated the effectiveness of PEMF therapy on the treatment of fibromyalgia. A group of 108 women with fibromyalgia were allocated to a 12-week treatment period with an active Bio-Electro-Magnetic-Energy-Regulation (BEMER) device and a similar treatment period with an inactive device. Each patient received active and sham treatments in a random order. Pain and stiffness were assessed on a visual analog scale (VAS, scale 0-100 mm), and functional status was assessed by the Fibromyalgia Impact Questionnaire (FIQ). Mean VAS pain scores before the active and sham treatment periods were 66 (SD 22) and 63 (SD 22), respectively. After treatment periods, mean VAS pain scores had decreased significantly in active treatment, -12, 95% CI [-18, -6], and in sham treatment, -11, 95% CI [-17, -5]. Similarly, the decrease in stiffness and FIQ index after both treatments was statistically significant. However, per-protocol analysis showed no differences between active and sham treatments at any of the outcomes. This study demonstrated that low-energy PEMF therapy was not efficient in reducing pain and stiffness or in improving functioning in women with fibromyalgia. Bioelectromagnetics. 39:405-413, 2018. © 2018 Wiley Periodicals, Inc.

Study design A prospective clinical study to test and adapt a Finnish version of the Scoliosis Research Society 30 (SRS-30) questionnaire. Objective The aim of this study was to perform cross-cultural adaptation and evaluate the validity of the adapted Finnish version of the SRS-30 questionnaire. Summary of background data The SRS-30 questionnaire has proved to be a valid instrument in evaluating health-related quality of life (HRQoL) in adolescent and adult population with spine deformities in the United States. Multinational availability requires cross-cultural and linguistic adaptation and validation of the instrument. Methods The SRS-30 was translated into Finnish using accepted methods for translation of quality-of-life questionnaires. A total of 274 adult patients with degenerative radiographic sagittal spinal disorder answered the questionnaire with sociodemographic data, RAND 36-item health survey questionnaire (RAND Corp. Health, Santa Monica, CA, US), Oswestry disability index, DEPS depression scale, and Visual Analog Scale (VAS) back and leg pain scales within 2 weeks' interval. The cohort included patients with and without previous spine surgery. Internal consistency and validity were tested with Cronbach α, intraclass correlation (ICC), standard error of measurement, and Spearman correlation coefficient with 95% confidence intervals (CIs). Results The internal consistency of SRS-30 was good in both surgery and nonsurgery groups, with Cronbach α 0.853 (95% CI, 0.670 to 0.960) and 0.885 (95% CI, 0.854 to 0.911), respectively. The test-retest reproducibility ICC of the SRS-30 total and subscore domains of patients with stable symptoms was 0.905 (95% CI, 0.870-0.930) and 0.904 (95% CI, 0.871-0.929), respectively. The questionnaire had discriminative validity in the pain, self-image, and satisfaction with management domains compared with other questionnaires. Conclusion The SRS-30 questionnaire proved to be valid and applicable in evaluating HRQoL in Finnish adult spinal deformity patients. It has two domains related to deformity that are not covered by other generally used questionnaires. Level of evidence 3.

Objective To evaluate the effects of surgery and a postoperative progressive home exercise program on gait parameters among individuals operated with total knee arthroplasty. Design Single blinded randomized controlled trial. Subjects 108 patients (84 females, 24 males, mean age 69 years). Interventions Patients were equally randomized into an exercise group (EG) and control group (CG). The 12-months progressive home exercise program starting two months postoperatively was compared to usual care. Methods Gait analysis was performed using the Gaitrite electronic walkway system. In addition, knee extension and flexion strength were measured by a dynamometer preoperatively, and pain on visual analog scale (VAS) at two months and 14 months postoperatively. Results At the 12–month follow-up, maximal gait velocity (p = 0.006), cadence (p = 0.003) and stance time (p = 0.039) showed a greater increase among EG than CG. All the other gait parameters improved among both groups, but with not statistically discernible difference between groups. Weak correlations were found between changes in maximal gait velocity and the knee extension (r = −0.31, p = 0.002), flexion strength (r = 0.28, p = 0.004) and pain during loading (r = −0.27, p = 0.005) values. Conclusion The intervention produced statistically significant changes in maximal gait velocity, cadence and stance times in the exercise group compared to controls. Although the average change was small it is of importance that biggest changes occurred in those with low performance.

Purpose The Scoliosis Research Society (SRS-30) questionnaire proved valid in measuring health-related quality of life (HRQoL) in adult patients with spinal deformity or degenerative disease. This study further assesses the validity of the SRS-30 by comparing its results with other HRQoL instruments, such as Oswestry disability index (ODI) and the RAND-36, among unselected adult patients with degenerative spinal disorder. Materials and methods 628 consecutive patients completed the SRS-30, the ODI, the pain visual analog scale (VAS), and RAND-36 questionnaires. Using a 9 mm minimal important difference threshold of the VAS, patients were divided into three groups of symptom location: back pain (n = 226), lower extremity pain (n = 161), and combination of both (n = 241). Statistical and illustrative tests using beta coefficients, Rasch measurement analytics, and score distributions were used for analysis. Results The SRS-30 functioned well for all three subgroups. There were small differences in convergent validity of the SRS-30 compared to the ODI and the RAND-36 between the three subgroups. The SRS-30 performed similarly in different pain groups independent of age, gender, or deformity severity. The scale displayed good coverage and targeting for all three subgroups. Conclusions The SRS-30 proved to provide valid HRQoL scores for all adult patients with degenerative spinal disorders. Implications for Rehabilitation Degenerative spinal conditions associated with spinal deformities are common in patients over 60 years. Low back pain is globally the leading cause of disability. The applicability of the Scoliosis Research Society (SRS-30) questionnaire has not been tested in relation to different pain origins. The SRS-30 proved to provide valid health-related quality of life assessment among patients with degenerative spinal disease independent of pain location. The SRS-30 questionnaire can be used to assess the level of disability and rehabilitation of patients with degenerative spinal disease.

We warmly thank Randelli and coworkers for their interest in our work.1 Our randomised, pragmatic, controlled trial compared surgical and non-surgical treatments for rotator cuff disease (RCD) with or without full-thickness tendon tears after unsuccessful initial rehabilitation.2 Randelli and coworkers commented that the power of our study lies in the fact that potential eligible patients underwent a systematic, adequately performed 3-month rehabilitation, after which only patients who remained symptomatic were randomised; we agree. Symptoms alleviated in 102 of the 417 shoulders with chronic RCD (mean duration of symptoms 9 months before recruitment) during the 3 month, pragmatic nonoperative treatment. This indicates that conservative management should be carried out in all patients with chronic RCD before considering surgical treatment for full-thickness rotator cuff tear. Randelli and coworkers criticised us for not reporting baseline characteristics of the prespecified subgroups (RCD with and without full-thickness tendon rupture). They also noted that while 25% …

Cervical dystonia (CD) is a focal dystonia causing involuntary activation of neck and shoulder muscles resulting in abnormal, sustained and painful posturing that may lead to physical disability and social withdrawal [1]. In recent years, botulinum neurotoxin (BoNT) has become the first line therapy for CD [2]. A subjective feeling of neck weakness has been reported as one of the most common localized adverse events of BoNT [2-7]. In clinical practice, this may sometimes be reported as having difficulty keeping the head upright. Although the effects of BoNT have been widely studied [2,5], there have been no prospective studies quantifying changes in maximal isometric neck muscle strength. Objective strength measurements may help identify patients with neck weakness after BoNT injections that causes difficulties in daily living and therefore need additional strength training. Additionally, even though CD patients have frequent complaints of neck tension, only one study [8] has provided quantitative data about the effects of initial BoNT injections on the passive mechanical properties of skeletal muscle in a clinical setting, despite that measurement devices have been developed for this purpose. Myotonometers may provide an objective, non-invasive tool to quantify changes in muscle properties after BoNT injections that were previously obtained using subjective methods. The aim of this study was to evaluate the changes in neck strength, the mechanical properties of neck muscles, and disability over a twelve-week period following BoNT injections in patients with CD who had a two-year history of BoNT treatment. We hypothesized that the mechanical properties of muscle fluctuate after BoNT injection, and this fluctuation is reflected in decreased muscle power and tension, as well as disability.

Fibromyalgia is a highly heterogeneous disorder occurring as widespread pain associated with general symptoms such as fatigue, depression, anxiety, insomnia, sexual dysfunction, and gastrointestinal conditions. This cross-sectional single tertiary medical center survey study aimed to investigate how multiple pain sites contribute to the construct of general pain in fibromyalgia. Altogether 266 women with fibromyalgia aged 18 to 60 years were included in the analysis. Confirmatory factor analysis of pain severity measured by a visual analogue scale (0 to 100 points) in seven major body regions. Headache, low back pain, and neck pain explained most of the total variance in general pain perceived across seven different body regions. Substantial correlations of 0.71, 0.68, and 0.61 were found between general pain and headache, low back pain, and neck pain, respectively. Pain reported for other four regions (chest, abdomen, upper extremity, and lower extremity) demonstrated fair correlations with general pain. When experiencing multi-site pain, women with fibromyalgia perceived headache, low back pain, and neck pain being subjectively more important than pain in other sites. While pain intensity and location commonly varies in fibromyalgia patients, it is important that one is aware of most common sites to be able to recognize fibromyalgia so that it can be managed properly.

Objective: The aim of this study was to investigate changes in trunk muscle strength 12 months after lumbar spine fusion (LSF) compared to preoperative strength. Methods: A total of 194 patients (mean ± standard deviation [SD] age, 61 ± 21 years) who underwent LSF participated in this prospective longitudinal study. Physical measurements of the participants were made before surgery and 12 months postoperatively. Isometric trunk extension and flexion strength was measured using a strain-gauge dynamometer in the standing position. Strength changes were calculated. Regression analysis was performed to explore which factors predicted strength levels at 12 months postoperatively. Results: The preoperative mean ± SD extension strength was 205 ± 144 N, which increased to 258 ± 142 N (p < 0. 001) at the 12-month follow-up. Flexion strength increased from 295 ± 172 N to 364 ± 164 N (p < 0. 001). The preoperative extension/flexion strength ratio was 0.75 ± 0.38 and remained similar (0.73 ± 0.26) at 12 months postoperatively (p = 0.39). Conclusion: Although trunk muscle strength increased by 26% for extension and 23% for flexion at the 12-month postoperative follow-up, both values remained objectively low. In addition, flexion strength remained higher than extension strength, which indicates an imbalance between those muscle groups. Age, severe back pain, and low trunk muscle strength before surgery predicted low trunk muscle strength at 1 year after spinal fusion.

Study design Cross-sectional, observational study. Objective To study the occurrence of sagittal malalignment, the adaptability of a simplified sagittal modifiers grading of the Scoliosis Research Society (SRS)-Schwab adult spinal deformity (ASD) classification, and the deformity-specific SRS questionnaire version 30 (SRS-30) in an unselected adult cohort with symptomatic degenerative spinal disorders. Summary of background data The sagittal modifiers of the SRS-Schwab ASD classification correlate with health-related quality of life (HRQoL) measures in patients with ASD. The deformities and disabilities caused by sagittal malalignment in patients with common degenerative spinal disorders of multiple etiologies are rarely studied. A simplified and categorizing version of the SRS-Schwab ASD classification in relation to the Oswestry Disability Index (ODI) and the SRS-30 outcomes has not yet been developed. Methods We recruited 874 consecutive patients with degenerative spinal disorders between March 2013 and February 2014. Full spine radiographs were taken and the patients divided into sagittal deformity severity groups: mild or none, moderate, and marked deformity. Participants completed the ODI, SRS-30, and a general health questionnaire. Results We included 637 patients in the analysis. The severity of sagittal deformity was mild or none in 407 (63.9%) patients, moderate in 159 (25.0%), and marked in 71 (11.1%). Linearity across the modifier grades and deformity classes was found for ODI total score (P = 0.033), and the function/activity (P = 0.004) and self-image/appearance (P = 0.030) domains of the SRS-30. Age, body mass index, duration of symptoms, and the use of painkillers increased while physical activity, working, and educational status decreased significantly with deformity severity. Conclusion Sagittal spinopelvic malalignment is significantly related to deterioration of the ODI and the SRS-30 in symptomatic adults with degenerative spinal disorders. The SRS-Schwab classification sagittal modifiers categorized into three groups is a practical tool to detect various clinically significant grades of deformity in a cohort with no recognized ASD. Level of evidence 3.

Aim The aim was to assess the level of lower body pain among people with previous femoral neck fracture, and whether the type of surgery was associated with pain and physical function a mean of 2 years after surgery. Methods The study included 115 community-dwelling older adults aged 60 years and older with previous femoral neck fracture, and 31 reference subjects without previous lower limb injuries. A total of 30 patients had internal fixation surgery, 70 had hemiarthroplasty and 15 had total hip replacement. All patients had surgery in the same hospital and received typical inpatient rehabilitation. From 1.6 months to 7.5 years after the fracture, the patients underwent examination including clinical evaluation, measurements of pain in the lower body (visual analog scale), physical function (maximal walking speed, Timed Up & Go, Berg Balance Scale) and self-reported walking difficulties. Results Hip fracture patients reported more pain (81 ± 88 mm) compared with the reference group (25 ± 39 mm, P = 0.004). Patients with internal fixation reported significantly more pain than the other study groups. Significantly more patients with internal fixation (53%) reported walking difficulties compared with patients who had hemiarthroplasty (29%, P = 0.028) or total hip replacement (13%, P = 0.018). No significant difference was observed in performance-based physical function between the fracture groups, but participants in the reference group had better physical function than any of the fracture groups. Conclusions Hip fracture patients treated with internal fixation experienced more pain and walking difficulties than the hemiarthroplasty and total hip replacement groups. Different types of surgical fixation might require different rehabilitation and pain management strategies after hip fracture. Geriatr Gerontol Int 2015; ●●: ●●–●●.

Objective: To study the effectiveness of a 12-month exercise therapy on kinesiophobia and physical activity in patients with spondylolisthesis after lumbar spine fusion. Design: Randomized controlled trial. Subjects: Patients (n = 98) with spondylolisthesis who had undergone lumbar spine fusion. Methods: All patients (mean age 59 years) had received lumbar spine fusion surgery and identical postoperative instructions. Three months postoperatively, they were randomized into an exercise group (n = 48) or usual care group (n = 50). The exercise group received 12-month progressive home-based training with regular booster sessions, and the usual care group a single session of physiotherapy instruction. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) and physical activity by the International Physical Activity Questionnaire (IPAQ) preoperatively, 3 months after lumbar spine fusion, and at the end of the 12-month intervention. Results: Before the intervention, the median (first quartile; third quartile) of TSK was 32.5 (29.0; 37.0) in the exercise group and 30.0 (25.8; 36.0) in the usual care group, changing to 30.0 (25; 36) in the exercise group and to 30.5 (24; 36.3) in the usual care group (between-group p = 0.17). IPAQ metabolic equivalent minutes per week increased from 1,863 (1,040; 3,042) to 3,190 (1,634; 6,485) in the exercise group and from 2,569 (1,501; 4,075) to 3,590 (1,634; 6,484) in the usual care group (between-group p = 0.92). Conclusion: Progressive 12-month home-exercise starting 3 months postoperatively was not superior to usual care in decreasing kinesiophobia or increasing physical activity in spondylolisthesis.

Low-energy pulsed electromagnetic field (PEMF) therapy has been suggested as a promising therapy to increase microcirculation, which is of great concern in patients with fibromyalgia. This study evaluated the effectiveness of PEMF therapy on the treatment of fibromyalgia. A group of 108 women with fibromyalgia were allocated to a 12-week treatment period with an active Bio-Electro-Magnetic-Energy-Regulation (BEMER) device and a similar treatment period with an inactive device. Each patient received active and sham treatments in a random order. Pain and stiffness were assessed on a visual analog scale (VAS, scale 0-100 mm), and functional status was assessed by the Fibromyalgia Impact Questionnaire (FIQ). Mean VAS pain scores before the active and sham treatment periods were 66 (SD 22) and 63 (SD 22), respectively. After treatment periods, mean VAS pain scores had decreased significantly in active treatment, -12, 95% CI [-18, -6], and in sham treatment, -11, 95% CI [-17, -5]. Similarly, the decrease in stiffness and FIQ index after both treatments was statistically significant. However, per-protocol analysis showed no differences between active and sham treatments at any of the outcomes. This study demonstrated that low-energy PEMF therapy was not efficient in reducing pain and stiffness or in improving functioning in women with fibromyalgia. Bioelectromagnetics. 39:405-413, 2018. © 2018 Wiley Periodicals, Inc.

Objective: To compare a 12-month home-based exercise programme with usual care for disability and health-related quality of life after rotator cuff repair. Design: Randomized controlled trial. Setting: Outpatient physical and rehabilitation medicine clinic. Subjects: Consecutive patients ( n = 67, mean age 54 years) who underwent rotator cuff repairs were randomized into an experimental group (EG) or a usual care group (UCG). Interventions: The UCG received ordinary postoperative instructions, while the EG were given advice and instructions on a shoulder muscle strengthening programme to be undertaken at home. Main measures: Disability was assessed with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and quality of life with the Short-Form 36 Health Survey (SF-36). Results: At the follow-up, no between-group differences were observed in any of the outcomes. The mean (SD) ASES score improved by 21 points (95% CI, 16 to 26, p Conclusions: The home exercise programme and usual care were equally effective in improving disability and quality of life after rotator cuff repair. The extra time involved in teaching the home exercise programme is not warranted.

Lumbar spine fusion (LSF) has been reported to change the biomechanics of the spine and therefore the rehabilitation after LSF is important. In this study, the effect of selected neutral spine control exercises on activation of trunk muscles after LSF was evaluated. Muscle activity was measured by surface electromyography of the rectus abdominis, external oblique, longissimus, and multifidus muscles during 6 exercises in 22 LSF patients (mean age = 59 years; age range = 25-84 years; 50% women). Muscle activity concurrent with trunk flexion and extension during maximal voluntary isometric contraction (MVIC) was used as a reference value. Pain during the effort was assessed with a visual analog scale (VAS). The highest activity in the rectus abdominis muscles was measured during bilateral shoulder extension (51% of MVIC), and in the external oblique, it occurred during unilateral shoulder horizontal adduction (48% of MVIC) and unilateral hip extension (46% of MVIC) exercises. The highest activation of the multifidus and longissimus muscles (60-104%) was measured during bilateral shoulder flexion and modified Roman chair exercises. The mean (SD) self-reported back pain VAS scores during exercises varied from 3 (7) to 16 (26). Neutral spine control exercises activate trunk muscles and cause minimal pain and are therefore feasible exercises for home-based training to improve muscle endurance and postural control after LSF. In addition, the level of muscle activity during bilateral shoulder flexion and modified Roman chair exercises was over 60% of MVIC, justifying their use in training for strength of the trunk extensor muscles.

Objective: To evaluate the efficacy of a delayed home exercise programme compared with normal care after primary total knee arthroplasty. Design: Single-blind, prospective, randomized, controlled trial. Participants: A total of 108 participants (61% females, mean age 69 years [standard deviation 8.7]), were randomized to a home-based exercise group (EG, n=53) or to a control group (CG, n=55). Methods: Two months post-operatively, the EG received a home exercise programme, while the CG received no additional guidance. The outcome measurements were: pain and disability, measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC); healthrelated quality of life (HRQoL), measured using the Short Form-36 questionnaire (SF-36); maximal walking speed; isometric knee muscle strength; and the Timed Up and Go (TUG) test. Measurements were made at baseline and at 12 months thereafter. Results: At the 12-month follow-up, maximal walking speed (p

To analyze trunk muscle function pre- and postoperatively in patients undergoing lumbar spine fusion. Associations between changes in trunk muscle strength and disability were also studied.A total of 114 patients undergoing lumbar spine fusion participated in the study. The flexion and extension strength of the trunk was measured preoperatively and 3 months after surgery using a strain-gauge dynamometer. Disability and pain during the past week was evaluated with the Oswestry disability index (ODI) and visual analog scale (VAS), respectively.Preoperative trunk extension and flexion strength levels were 319 N and 436 N in males, respectively, and 160 N and 214 N in females, respectively. In females 3 months postoperatively, the trunk extension strength increased by 39 N (p0.001) and flexion by 38N (p0.001), whereas it remained unchanged in males. The preoperative extension/flexion strength ratio was 0.79 in females and 0.76 in males. Three months postoperatively, the strength ratio decreased to 0.66 in males (p = 0.02). The mean ODI improved by 47% and back pain decreased by 65% (both p0.001). The changes in the ODI correlated with changes in trunk extension (r = -0.38) and flexion (r = -0.43) strength.Patients undergoing lumbar spine fusion had low trunk muscle strength and strength imbalance. Back fusion surgery leads to considerable relief of pain and disability, but patients still have low trunk extension and flexion strength levels 3 months postoperatively. Therefore, there is need for a proper progressive strength training protocols to normalize back function.

Objective To obtain reference values for the isometric endurance test (IET) of the cervical flexor muscles, investigate its reproducibility, and compare the results with the maximal isometric strength test (MIST) of the cervical flexor muscles. Design Cross-sectional non-comparative study with single group repeated measurements. Methods Altogether 219 healthy females aged 20–59 years volunteered to participate in the study. The IET was performed in the supine position and MIST seated. The reproducibility was evaluated by the intraclass correlation coefficient (ICC) and an analysis described by Bland and Altman. The relationship between the two measuring methods was evaluated by Pearson's correlation coefficient. Results The mean (SD) IET time was 60 (33) seconds with no significant differences between the age groups of each decade. The ICC for intrarater repeatability was 0.80. However, the Bland-Altman analysis suggested moderate variation in repeated measurements. Pearson's correlation coefficient between the IET and MIST was 0.56. Conclusion Normative reference values for the IET are presented. Although the ICC showed good repeatability, one should consider that the change at follow-up visits has to be considerable to be clinically relevant. The correlation between the endurance time and maximal flexion strength was moderate. Thus IET of the cervical flexor muscles may be used in the clinic like the Biering-Sorenson test has been used to assess fatigue of the trunk extensor muscles.

Study design Follow-up study. Objective To study whether neck muscle strength or cervical spine mobility values could serve as predictors for future neck pain among originally pain-free working-age subjects during a long period. Summary of background data Neck pain has been associated with weaker neck muscle strength and lower cervical spine mobility in several studies. However, causality between physical capacity and neck pain has not been shown. Methods Isometric neck muscle strength and passive range of motion of the cervical spine of 220 healthy female volunteers, aged 20 to 59 years, were measured. A postal survey was conducted 6 years later to determine whether any volunteers had experienced neck pain. The receiver operator characteristics curve was used to study how well the neck strength and mobility values in different movement planes at baseline served as predictors of future neck pain. Results Of the 192 (87%) responders, 37 (19%) reported neck pain for 7 days during the past year. In predicting neck pain, areas under the receiver operator characteristics curves (95% confidence intervals) in different movement planes were 0.52 to 0.56 (0.41-0.66) for isometric neck strength and 0.54 to 0.56 (0.44-0.76) for passive mobility of the cervical spine. Conclusion The results suggest that neither isometric neck muscle strength nor passive mobility of cervical spine has predictive value for later occurrences of neck pain in pain-free working-age women. Thus, screening healthy subjects for weaker neck muscle strength or decreased mobility of the cervical spine may not be recommended for preventive purposes.

To determine the relationship between functional disability and health-related quality of life (HRQoL) in rotator cuff tear (RCT) patients.In 67 RCT patients (mean age, 54 years; 57% males), functional disability was self-reported with the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), HRQoL with the Short-Form 36 Health Survey (SF-36), and pain by visual analogue scale. ASES results were divided into tertiles (12-38, 39-51, and 52-82).Mean ASES score was 48 (range, 12-82). Patients with the highest functional disability and highest pain level had the lowest HRQoL. For the highest, middle, and lowest ASES categories, respectively, mean SF-36 Physical Component Summary (PCS) scores were 35 SD 5, 36 SD 8, and 41 SD 6 (p0.001) (r = 0.47 for ASES vs. PCS; p0.001), and Mental Component Summary (MCS) scores were 50 SD 13, 56 SD 10, and 58 SD 8 (p = 0.011) (r = 0.37 for ASES vs. MCS; p= 0.003).Patients with higher functional disability had lower HRQoL. RCT extensively affects patients' lives; therefore, capturing both generic and shoulder-specific measures of RCT problems is recommended.

To evaluate whether long-term neck and upper body exercises conducted in economical community-based outpatient clinic and home-based settings could improve health-related quality of life (HRQoL)for individuals affected by chronic neck pain. The effect of baseline HRQoL and neck pain values on training adherence was also studied.Subjects (n = 101, 91 women/10 men, mean age 41.0 ± 9.5 years) with chronic non-specific neck pain were randomized to a combined strength-training and stretching-exercise group (CSSG, n = 49) or to a stretching exercise group (SG, n = 52). HRQoL was assessed at baseline and after 12 months using the RAND-36 questionnaire. Comparisons between groups were performed using bootstrap-type analysis of covariance. The impact of HRQoL and neck pain values on training adherence, determined using participants' exercise logs, was studied using generalized estimating equations.CSSG showed significant improvements in five and SG in four of eight of the HRQoL dimensions. There were no significant differences between the groups. Adherence to long-term training was only slightly affected by baseline-assessed HRQoL and neck pain values.The two training protocols were feasible and equally effective in improving HRQoL. Baseline HRQoL and pain values had only a minor effect on training adherence.• Long-term strength training and stretching are effective in improving HRQoL in people with chronic neck pain. • Baseline HRQoL and neck pain values have little effect on training adherence.

The active manual straight leg raise (ASLR) and passive manual straight leg raise (MSLR) tests are commonly used in clinical settings to assess hamstring tightness. However, to our knowledge, the validity and sensitivity of these tests have not been compared with the instrumental straight leg raise (ISLR). The aim of the present study was to assess the intrarater reproducibility of the ISLR and compare the sensitivity of the ASLR, MSLR, and ISLR to change. Twelve men with hamstring tightness underwent the ASLR, MSLR, and ISLR tests at baseline and after a 4-week home-based right leg stretching program with the left leg serving as a control. The ISLR measurements were repeated consecutively at baseline to assess reproducibility. The intraclass correlation coefficient for the ISLR was 0.94, and the coefficient of reproducibility was 6. Significant differences in the range of motion emerged between all testing methods (p0.05). In the stretched legs, the mean +/- SD increases were 17 +/- 5 degrees for ISLR, 10 +/- 8 degrees for ASLR, and 6 +/- 5 degrees for MSLR, whereas the control legs showed a significant mean change only for ASLR (5 +/- 4 degrees ). The mean standard response with the ASLR and MSLR tests did not differentiate between the treated and control legs, but it was almost 10-fold higher in the treated leg than the control leg for the ISLR, clearly differentiating between them. The ISLR had good reproducibility and sensitivity to changes, whereas ASLR and MSLR showed a poor ability to detect changes. Thus, the ISLR test is recommended for use in research evaluating the effectiveness of stretching.

OBJECTIVE To compare the efficacy of three 12-month training programmes on headache and upper extremity pain in patients with chronic neck pain. METHODS A total of 180 female office workers, with chronic, non-specific neck pain were randomly assigned to 3 groups. The strength group performed isometric, dynamic and stretching exercises. The endurance group performed dynamic muscle and stretching exercises. The control group performed stretching exercises. Pain was assessed with a visual analogue scale. Each group was divided into 3 subgroups according to headache intensity. RESULTS At the 12-month follow-up headache had decreased by 69% in the strength group, 58% in the endurance group and 37% in the control group compared with baseline. Neck pain diminished most in the strength group with the most severe headache (p < 0.001). In the dose analysis, one metabolic equivalent per hour of training per week accounted for a 0.6-mm decrease in headache on the visual analogue scale. Upper extremity pain decreased by 58% in the strength group, 70% in the endurance group and 21% in the control group. CONCLUSION All of the training methods decreased headache. However, stretching, which is often recommended for patients, was less effective alone than when combined with muscle endurance and strength training. Care must be taken in recommending the type of training to be undertaken by patients with severe cervicogenic headache.

In all studies in which the strength of the neck extensor muscles has been measured, the level of thoracic support has been adjusted differently so direct comparison of the results is not possible.To measure and compare the isometric force and isometric torque of neck extensor muscles at different levels of thoracic support.Twenty healthy women volunteered for the study. The maximum isometric force of the neck extensor muscles was measured with the thoracic support located at five different levels. The highest level was set at the level of the spine of the scapula (level I) and the other levels were located 2.5 cm lower than the previous one, with the lowest level set 10 cm below the highest level. The maximum isometric torque for each level was calculated by multiplying the isometric force by the length of the lever arm measured from the upper tip of the thoracic support to the centre point of the cell load at the occiput.The maximum isometric force and maximum isometric torque of the neck extensor muscles were increased step by step from 130.5 N to 138.9 N, 141.9 N, 147.9 N and 155.4 N and from 33.7 Nm to 38.7 Nm, 42.5 Nm, 47.2 Nm and 52.7 Nm, respectively. Except for the isometric force of the cervical extensor muscles measured at levels II and III, the differences between the other levels were significant (p0.05). There was a significant correlation between isometric force and isometric torque measurements of the neck extensor muscles at different levels (0.81r0.96).Maximum isometric force and maximum isometric torque measurements of the neck extensor muscles vary with the length of the lever arm. It is recommended that a specific level of thoracic support should be used in follow-up and intervention studies. Setting the level of thoracic support at a specific level will make it possible to compare the strength of the neck extensor muscles in different studies. Measurements at the level of the spine of the scapula were easier and less time consuming.

Tarnanen SP, Ylinen JJ, Siekkinen KM, Malkia EA, Kautiainen HJ, Hakkinen AH. Effect of isometric upper-extremity exercises on the activation of core stabilizing muscles. Objective To evaluate whether isometric exercises for the upper extremities could sufficiently activate core stabilizing muscles to increase muscle strength. Design Cross-sectional study. Setting Department of physical medicine and rehabilitation at a Finnish hospital. Participants Healthy adult women (N=20). Interventions Not applicable. Main Outcome Measures Peak isometric strength of the back and abdominal muscles was measured and relative loading in 5 test exercises was evaluated by surface electromyography. Results The rectus abdominis and obliquus externus abdominis were activated to the greatest degree in a bilateral shoulder extension exercise and the average surface electromyographic activity was 114% and 101% compared with the amplitude elicited during the maximal isometric trunk flexion exercise. Horizontal shoulder extension elicited the greatest activation of the longissimus and multifidus muscles. In this exercise, the activity levels of the left side multifidus and longissimus muscles were 84% and 69%, respectively, compared with the level of activity elicited during trunk extension. Conclusions Of all the exercises studied, bilaterally performed isometric shoulder extension and unilaterally performed horizontal shoulder extension elicited the greatest levels of activation of the trunk musculature. Thus, it can be assumed that these exercises elicit sufficient levels of contraction of the trunk muscles for the development of their endurance and strength characteristics in rehabilitation.

Purpose. This study compared the maximal force, EMG/force ratio and co-activation characteristics of the neck-shoulder muscles between 30 adolescents with migraine-type headache, 29 with tension-type headache, and 30 headache-free controls. Method. Force was measured with surface electromyography (EMG) from the cervical erector spinae (CES), the sternocleidomastoid (SCM) and trapezius muscles during the maximal isometric neck flexion, neck extension and shoulder flexion. Results. Girls with migraine-type headache had higher EMG/force ratios between the EMG of the left agonist SCM muscle and the corresponding maximal neck flexion (p ¼ 0.030) and neck rotation force to the right side (p ¼ 0.024) than the girls with tension-type headache. Migrainous girls had more co-activation of right antagonist CES muscle during maximal neck flexion force than the girls without headache (p ¼ 0.015). Neck force production showed no significant differences between girls. Girls with tension-type headache displayed lower left shoulder flexion force than girls with migraine-type headache (p ¼ 0.005) or with no headache (p ¼ 0.005). In boys, no significant differences were observed. Conclusions. Girls with tension-type headache and migraine-type headache have differences in neuromuscular function in the neck-shoulder muscles. The data amplify our knowledge of the neck-shoulder muscle dysfunction in adolescent headache, and may encourage the use of specific rehabilitation methods in the management of different types of headache.

The aim was to evaluate the tone and electric activity of the quadriceps muscle at rest and different torque levels. The second aim was to study whether thickness of soft tissues and change in the joint position would affect muscle tone. Eighteen healthy subjects participated. Computerized muscle tonometer (CMT) and surface electromyography (sEMG) measurements were performed: seated, first at rest with leg straight and then with the knee at 60 degrees . Thereafter measurements were obtained at levels of 80, 60, 40 and 20% of the maximum isometric torque at the same knee angle. Thickness of skin, subcutis and muscle was measured by ultrasound. The CMT values taken were the depth the indenter travelled and the work it did while compressing the right rectus femoris and vastus intermedius muscles. Expressed as mean (SD) depth the change in muscle tone changed from 29.2 (3.6) mm in the relaxed position to 16.9 (5.2) mm at 80% of maximal torque, and expressed as work the values were from 1589 (150) mJ to 739 (149) mJ respectively. The correlation between CMT, sEMG and torque measurements varied from r = -0.52 to -0.71 (p < 0.01). CMT was able to detect a change of 20% in torque production and 4% in tone. Tone values, at each torque level, were significantly separate from the values at the other force levels (p < 0.001-0.04). Soft tissue thickness explained most of the tone results at rest (57%). The repeatability of the CMT measures was good (ICCs 0.75-0.99). Both depth and work correlated with electric activity and muscle torque, but the correlation with work was higher. In conclusion, muscle activity, length and thickness have to be taken into account when evaluating muscle tone.

Background Rotator cuff repair incidence rates have reportedly increased in the United States and England. Here we analyzed nationwide data relating to rotator cuff repairs recorded in the Finnish National Hospital Discharge Register (NHDR). Methods The NHDR was reviewed to identify adult patients who underwent rotator cuff repair between 1998 and 2011. Incidence rates per 10 5 person-years were calculated using the annual adult population size. Results During the 14-year time period, 50,646 rotator cuff repairs were performed on subjects aged 18 years or older. The incidence of rotator cuff repair showed an almost linear increase of 204 %, from 44 per 10 5 person-years in 1998 to 131 per 10 5 person-years in 2011. The most common concomitant procedure was acromioplasty, which was performed in approximately 40 % of rotator cuff repairs in 2011. Other common concomitant procedures included tenodesis (7 %) and tenotomy (6 %) of the long head of the biceps tendon, and resection of the acromioclavicular joint (3 %). Conclusions This nationwide analysis revealed a remarkable increase in the incidence of rotator cuff repair from 1998 to 2011 in Finland. This progress can be questioned, since there are not convincing data of the superiority of the operative treatment over non-operative management in all rotator cuff tears. BioMed Central open access

Background Cervicogenic headache and migraine are common causes of visits to physicians and physical therapists. Few randomized trials utilizing active physical therapy and progressive therapeutic exercise have been previously published. The existing evidence on active treatment methods supports a moderate effect on cervicogenic headache. Objective The aim of this study is to investigate whether a progressive, group-based therapeutic exercise program decreases the intensity and frequency of chronic headache among women compared with a control group receiving a sham dose of transcutaneous electrical nerve stimulation (TENS) and stretching exercises. Design A randomized controlled trial with 6-month intervention and follow-up was developed. The participants were randomly assigned to either a treatment group or a control group. Setting The study is being conducted at 2 study centers. Patients The participants are women aged 18 to 60 years with chronic cervicogenic headache or migraine. Intervention The treatment group's exercise program consisted of 6 progressive therapeutic exercise modules, including proprioceptive low-load progressive craniocervical and cervical exercises and high-load exercises for the neck muscles. The participants in the control group received 6 individually performed sham TENS treatment sessions. Measurements The primary outcome is the intensity of headache. The secondary outcomes are changes in frequency and duration of headache, neck muscle strength, neck and shoulder flexibility, impact of headache on daily life, neck disability, fear-avoidance beliefs, work ability, and quality of life. Between-group differences will be analyzed separately at 6, 12, and 24 months with generalized linear mixed models. In the case of count data (eg, frequency of headache), Poisson or negative binomial regression will be used. Limitations The therapists are not blinded. Conclusions The effects of specific therapeutic exercises on frequency, intensity, and duration of chronic headache and migraine will be reported.