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Objectives The purpose of this study was to assess the use of computer-aided combined movement examination (CME) to measure change in low back movement after neurosurgical intervention for lumbar spondylosis and to use a CME normal reference range (NRR) to compare and contrast movement patterns identified from lumbar disk disease, disk protrusion, and nerve root compression cases. Methods A test-retest, cohort observational study was conducted. Computer-aided CME was used to record lumbar range of motion in 18 patients, along with pain, stiffness, disability, and health self-report questionnaires. A minimal clinically important difference of 30% was used to interpret meaningful change in self-reports. z Scores were used to compare CME. Post hoc observation included subgrouping cases into 3 discrete pathologic conditions—disk disease, disk protrusion, and nerve root compression—to report intergroup differences in CME. Results Self-report data indicated that 11, 7, and 10 patients improved by ≥30% in pain, stiffness, and function, respectively. Three patients experienced clinically significant improvement in health survey. A CME pattern reduced in all directions suggested disk disease. Unilaterally restricted movement in side-flexed or extended directions suggested posterolateral disk protrusion with or without ipsilateral nerve root compression. Bilateral restrictions in extension suggested posterior disk protrusion with or without nerve root compression. In 11 of the 18 cases, CME converged toward the NRR after surgery. Conclusion We described the use of CME to identify atypical lumbar movement relative to an NRR. Data from this short-term postoperative study provide preliminary evidence for CME movement patterns suggestive of disk disease, disk protrusion, and nerve root compression.

Objective A test-retest cohort study was conducted to assess the use of a novel computer-aided, combined movement examination (CME) to measure change in low back movement after pain management intervention in 17 cases of lumbar spondylosis. Additionally we desired to use a CME normal reference range (NRR) to compare and contrast movement patterns identified from 3 specific structural pathologic conditions: intervertebral disc, facet joint, and nerve root compression. Methods Computer-aided CME was used before and after intervention, in a cohort study design, to record lumbar range of movement along with pain, disability, and health self-report questionnaires in 17 participants who received image-guided facet, epidural, and/or rhizotomy intervention. In the majority of cases, CME was reassessed after injection together with 2 serial self-reports after an average of 2 and 14 weeks. A minimal clinically important difference of 30% was used to interpret meaningful change in self-reports. A CME NRR (n = 159) was used for comparison with the 17 cases. Post hoc observation included subgrouping cases into 3 discrete pathologic conditions, intervertebral disc, facet dysfunction, and nerve root compression, in order to report intergroup differences in CME movement. Results Seven of the 17 participants stated that a “combined” movement was their most painful CME direction. Self-report outcome data indicated that 4 participants experienced significant improvement in health survey, 5 improved by ≥30% on low back function, and 8 reported that low back pain was more bothersome than stiffness, 6 of whom achieved the minimal clinically important difference for self-reported pain. Subgrouping of cases into structure-specific groups provided insight to different CME movement patterns. Conclusion The use of CME assists in identifying atypical lumbar movement relative to an age and sex NRR. Data from this study, exemplified by representative case studies, provide preliminary evidence for distinct intervertebral disc, facet joint, and nerve root compression CME movement patterns in cases of chronic lumbar spondylosis.

Wenn wir uns ganz normal bewegen, finden unsere Bewegungen in der Regel auf mehreren Bewegungsebenen gleichzeitig statt. Es macht daher Sinn, kombinierte Bewegungen auch im manualtherapeutischen Setting zu untersuchen. Die Untersuchung kombinierter Bewegungen (Combined Movement Examination – CME) geht auf Brian Edwards zuruck, der dieses Konzept bekannt machte. Seitdem wird die CME stetig weiterentwickelt. Die Autoren stellen die aktuelle Forschung zu CME und ihren Nutzen fur die tagliche Praxis vor.

Consensus guidelines for the management of low back pain recommend that the clinician use contemporary best practice for assessment and treatment, consider biopsychosocial factors and, if chronic, use a multimodal and multi-disciplinary approach. Where guidelines are not followed and basic assessment is inadequate the diagnosis may be compromised and the sequelae of errors compounded. Factors such as a lack of knowledge or recognition of the common structure specific pain referral patterns, poor clinical reasoning, inappropriate referral and predilection for popular management approaches also contribute to mis-diagnosis and mis-management. This report describes two cases of chronic low back pain with lengthy histories of multiple failed interventions to highlight the consequences of focussing on a singular approach to the exclusion of evidence based pathways and the resulting risk of a missed diagnosis. The eventual management to mitigate these problems is reported with the aid of low back pain outcome measures, computer-aided combined movement examination, disability and pain questionnaires and health quality of life surveys.

Objectives The aim of this study is to report the development and validation of a low back computer-aided combined movement examination protocol in normal individuals and record treatment outcomes of cases with symptomatic degenerative lumbar spondylosis. Design Test–retest, following intervention. Background Self-report assessments and combined movement examination were used to record composite spinal motion, before and following neurosurgical and pain medicine interventions. Methods 151 normal individuals aged from 20 years to 69 years were assessed using combined movement examination between L1 and S1 spinal levels to establish a reference range. Cases with degenerative low back pain and sciatica were assessed before and after therapeutic interventions with combined movement examination and a battery of self-report pain and disability questionnaires. Change scores for combined movement examination and all outcome measures were derived. Findings Computer-aided combined movement examination validation and intraclass correlation coefficient with 95% confidence interval and least significant change scores indicated acceptable reliability of combined movement examination when recording lumbar movement in normal subjects. In both clinical cases lumbar spine movement restrictions corresponded with self-report scores for pain and disability. Post-intervention outcomes all showed significant improvement, particularly in the most restricted combined movement examination direction. Interpretation This study provides normative reference data for combined movement examination that may inform future clinical studies of the technique as a convenient objective surrogate for important clinical outcomes in lumbar degenerative spondylosis. It can be used with good reliability, may be well tolerated by individuals in pain and appears to change in concert with validated measures of lumbar spinal pain, functional limitation and quality of life.

Viele Symptome, viele Therapieansatze – Mit einer vielfaltigen Symptomkonfiguration assoziierte interskapulare Schmerzen bezeichnet die Manuelle Therapie als T4-Syndrom. Das kritische Auseinandersetzen mit der Klinik und Pathophysiologie des Syndroms tragt dazu bei, eine rationalere Diagnose und einen neuen Behandlungsansatz fur die Patienten zu entwickeln.

To examine long-term outcomes of Botulinum toxin type A (BoNT-A) injection to vastus lateralis (VL) for refractory anterior knee pain (AKP).Two cohorts (private clinic referrals and previous research participants) injected with BoNT-A for AKP by one neurologist were surveyed retrospectively. Primary outcomes were self-reported benefit, duration of symptom relief, and knee surgery post-injection. Secondary outcomes were changes in utilization of medication/physiotherapy treatment, AKP symptoms and activity limitation.Overall, average symptom duration was 76 months (SD 98). Responses were available from 46 of 53 private patients. Thirty-eight reported benefit from injection, which was ongoing in 29. Average benefit was 25 months (SD 21). Nine individuals reported symptom recurrence after an average of 14 months (SD 21). Ten had knee surgery post-injection; six of whom had not benefitted from BoNT-A injection. Nineteen of 23 previous research participants were contactable. Initially, all responded favorably to injection. Symptomatic benefit, with an average duration of 44 months (SD 20), persisted in 15. Two subjects proceeded to surgical intervention.A single BoNT-A treatment to VL led initially to improved function and relief of knee-related symptoms in 57 of 65 individuals. Improvements were sustained at follow-up, with an average benefit of 34 months (SD 25) post-injection, in 44 of 57 cases.

Objectives This randomised controlled crossover trial examined the efficacy of botulinum toxin type A (BoNT-A) injection, plus an exercise programme, to remediate chronic anterior knee pain (AKP) associated with quadriceps muscle imbalance. Methods 24 individuals with refractory AKP received either BoNT-A (500 U Dysport) or the same volume saline injection to the vastus lateralis (VL) muscle and performed home exercises focusing on re-training the vastus medialis (VM) muscle. All subjects were offered open-label injection at 12 weeks. Knee-related disability (anterior knee pain scale; AKPS) and activity-induced pain (10 cm visual analogue scale) at 12 weeks were the primary outcomes. Peak isometric extensor force was recorded and normalised VL:VM ratios were derived from simultaneous surface electromyography. Selfreported pain and disability measures were collected at six time points to a mean of 20±8 months. Results 14 subjects received BoNT-A and 10 placebo injection. Improvement at 12 weeks was significantly greater for BoNT-A compared with placebo-injected subjects for the AKPS (p

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non-injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT-A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

Interspinous implants (ISP) represent a contemporary non-fusion surgical option in the treatment of lumbar segment disease. Several devices have been developed within the last two decades and have been variously supported by investigations into their clinical and biomechanical efficacy. Spinal stenosis and facet arthropathy are reported as the primary clinical indications for their use, with degenerative disc disease and segmental instability recently extending their application. The principle common to all interspinous systems is an induced distraction of the interspinous space, resulting in reduced approximation of pain-sensitive and space-occupying tissue. Collectively, these devices are considered to prevent adjacent segment overload by restoring physiologic load transmission. This review article summarizes existing published literature, describes four different interspinous implants — the DIAM, Wallis, X-Stop and Coflex systems, and outlines clinical trials in progress. The design and surgical technique characteristics, mechanism of action, and clinical indications for interspinous implants are reviewed. Recommendations for future research of interspinous implants in the treatment of lumbar segment disease are made.

Interspinous process implants, used to augment lumbar spine surgery, putatively induce a local segmental lumbar kyphosis yet few investigations outline the effect in vivo on thoracolumbar sagittal curvature. Changes in lumbar skeletal alignment and posture have traditionally relied upon radiographic and back surface spinal curvature measurements, respectively.Lumbar lordosis curvature in 10 healthy subjects (6F, 4M; mean age 36 years) and 10 interspinous implant lumbar surgery patients (5F, 5M; mean age 51 years) was assessed with rasterstereography at baseline and at 6 weeks. Skeletal lumbar lordosis in standing was measured from lateral erect radiography pre- and 6 weeks post-operatively in the surgical cohort, and compared to angulation obtained for surface lordosis curvature derived from rasterstereography.Repeatable measurement of standing lumbar lordosis from rasterstereographic back shape imaging in healthy volunteers and lumbar surgery cases was demonstrated. Reductions of 0.6 (NS) in healthy and 3.1 (significant, P0.001) in surgical subjects were recorded for surface lumbar lordosis angle between the 6 week time-points. Slight flattening of the segmental angle and regional lordosis after DIAM surgery was revealed by radiography. Skeletal and surface lumbar lordosis changes were uncorrelated preoperatively (rho=0.28) and postoperatively (rho=0.26).Rasterstereography is sensitive in assessing lumbar lordosis changes in healthy and lumbar surgical individuals over time. Surgery with DIAM for lumbar pathology may result in an initial mild flattening of lordosis. Serial investigations of spinal curvature after surgery with DIAM interspinous implant are warranted in order to better understand the time-course of spinal posture changes of such cases.

Posterior interspinous dynamic stabilization is used increasingly in the treatment of lumbar degenerative spinal conditions, with preliminary evidence for its clinical and biomechanical efficacy emerging. The need remains to define patients who respond best to this form of surgery. This study examined clinical outcomes in 39 patients (21 females) with defined lumbar spinal pathologies, for two years after lumbar surgery augmented with the Device for Intervertebral Assisted Motion (DIAM). Anatomical patient categorization revealed involvement of disc (n=25/39) and facet (n=14/39) lumbar pathology, with clinical indications for surgery being: segmental instability (n=21/39); nerve root compression (n=11/39); and facet joint pain syndrome (n=7/39). Pain, function and satisfaction data were derived from MODEMS self-report questionnaires, which were collected prospectively over a two-year post-operative period. Results showed that L4-5 and L5-S1 were the most common DIAM-implanted spinal levels. Clinically significant post-operative improvement in pain (23.4%) and function (13.5%) occurred between three and twenty-four months. Eleven (of 39) required further lumbar surgery. Nineteen (of 28) were more satisfied at 24 months post-operatively compared to baseline. Disc involvement and segmental instability were the most common presenting lumbar segmental pathologies, yet the least successful in response to surgery augmented with DIAM. Patients with facet involvement reported superior improvement post-operatively compared with those with disc involvement. Patients with facet joint disease demonstrate better outcomes at 24 months following lumbar surgery augmented with DIAM posterior interspinous dynamic stabilization, compared with those presenting with disc pathology.

The healthcare cost of managing osteoporotic fractures is projected to rise because of the change in population demographics. To reduce the fracture epidemic, strategies are needed to identify those at risk early to allow preventative intervention to be implemented. The aim of this study was to investigate if low-cost community-based assessments, such as calcaneal ultrasound and falls risk assessments, can discriminate a group of elderly women at risk of osteoporotic fracture from those at lower risk. Over the period of 2002-2003, 104 community-dwelling women (mean age 71.3, standard deviation 5.8) were recruited via various modes including advertisements in community newspaper and community centres. These women underwent dual-energy X-ray absorptiometry bone mineral density (BMD) and calcaneal quantitative ultrasound (QUS) measurements; spinal radiography; and performance-based assessment of strength, mobility and balance. The women were classified into a 'high risk' (osteoporotic) group, based on low BMD (T-score of

Areal bone mineral density (aBMD), derived from dual-energy X-ray absorptiometry (DXA) scanners is used routinely to infer bone strength. With DXA hip scans there is growing acceptance of the advantages of also measuring bone structural geometric variables, that complement conventional aBMD to improve understanding of bone modelling, remodelling and processes of metabolic bone disease. However, phantoms for assessing structural geometric variables from DXA scans are not widely available, unlike those for aBMD. This study describes the development of such a phantom, simulating the cortical shell of the human femoral neck, using dental plaster as a material radiologically similar to cortical bone. The mass attenuation coefficient of the dental plaster differed by < 1% from cortical bone, over the relevant energy range. Performance testing was carried out with DXA, to determine accuracy and precision of the phantom structural geometry, using its dimensions and composition as 'gold standards'. Accuracy and precision of cortical structural geometry were poor when measured in a simulated 1 mm-thick osteoporotic cortex (5.5% precision and 50% accuracy errors), but improved with increasing cortical thickness. This study demonstrates the limitations of DXA-based Hip Structure Analysis when applied to femora with thin cortices, and indicates improvements in the design of a phantom to better simulate such cortical structures.

Background: Hallux abducto valgus and hallux limitus are two commonly encountered foot deformities causing altered structure and function of the first metatarsophalangeal joint and subsequent compensatory mechanisms. This study was undertaken to determine the relationships between these two deformities and transverse plane position of the foot, or angle of gait, and several radiographic angular and linear parameters with established reliability. Methods: A convenience sample of 23 subjects with hallux abducto valgus, 22 subjects with hallux limitus, and 20 control subjects was used. Radiographic parameters were standardized weightbearing views and included lateral stressed dorsiflexion of the first metatarsophalangeal joint, composite, dorsoplantar, and lateral views. Angle of gait was obtained from powdered footprints recorded on paper. Two left and two right footprints identified on each trial were used to calculate angle of gait. Results: The findings of the study suggest that an association between angle of gait and the presence of hallux abducto valgus or hallux limitus does not exist. Possible explanations may relate to the large variability of normal angle of gait, the need to identify factors extrinsic to the foot capable of affecting transverse plane orientation of the foot, and the addition of information relating to symptoms. Conclusions: In this study, the presence of hallux abducto valgus or hallux limitus did not correspond to an association with a particular angle of gait. Length and elevation of the first metatarsal were associated in subjects with hallux abducto valgus and hallux limitus. (J Am Podiatr Med Assoc 97(3): 175–188, 2007)

To assess the reliability and validity of the Neck Pain and Disability Scale (NPAD) translated into Hindi.Following a pilot study to ascertain uncertainties with existing terminology in the NPAD scale, a cervical radiculopathy patient cohort (n = 63) was assessed with the translated NPAD. Reliability was assessed by regression analysis for test-retest and by item-factor and factor-total score correlations. Face validity was compared in a cross-sectional design study with an asymptomatic group (n = 38). Convergent and divergent validity were investigated by correlating the NPAD scores with the Numerical Pain Rating Scale (NPRS) for neck and arm pain, and 10 cm long VAS Activity and VAS Depression scales.ICC values for test-retest NPAD total and factor scores were0.92 and R2 values0.912. Pearson product moment correlation of item vs. factor scores varied from 0.17 - 0.91 and for factor vs. total scores 0.72 - 0.91. Differences in NPAD scores between the patient and the asymptomatic group were significant (t = 30.90, p0.05). Convergent validity was explained when Factor 2 (minus item 20) was correlated (r = 0.67) with NPRS maximum value scores. Divergent validity was illustrated by low correlation with VAS Activity (r = 0.15) and negative correlation with VAS Depression (r = -0.80) scores.Based on the results of this study, the Hindi version of the NPAD is a reliable and valid instrument for the assessment of pain and disability in cervical radiculopathy patients.

To examine the effect of intramuscular injection of botulinum toxin type A [Dysport] to reduce relative overactivity of the vastus lateralis [VL] muscle, in conjunction with re-training of vastus medialis [VM] muscle as an adjunct to rehabilitation for chronic anterior knee pain.Eight females with chronic (6 months) history of anterior knee pain, who had failed conservative management, were studied in this open label pilot study. Intramuscular Dysport injection [300 - 500 units] to the distal third of VL muscle was followed by a 12-week customized home exercise programme to improve recruitment of VM muscle and functional knee control. VL and VM muscle cross sectional area from a standardized spiral CT sequence, isometric quadriceps strength (dynamometry), timed stair task, self-reported pain and disability were assessed.Subjects reported reduced knee pain and brace dependency and increased participation in sporting and daily living activities. Isometric quadriceps muscle strength was maintained or improved despite significant atrophy, evident on CT, of the distal component of VL in the treated limb. Time taken to ascend and descend a flight of stairs improved in all subjects. Subjective and objective improvements were maintained at 24-week follow-up.These pilot data provide preliminary support for the role of Dysport as an adjunct to non-surgical management of individuals with chronic anterior knee pain. Larger double blind, randomized, placebo-injection controlled studies of this novel approach to improving patellofemoral mechanics are needed to establish the efficacy of this intervention.

To test the validity of the Spin-T goniometer for the assessment of cervical range of movement.A linear regression analysis for paired neck movements using first a foam head model and then human subjects was performed to quantify the differences between the measurements obtained from the MotionStar, a movement-tracking device, and the Spin-T. A within-subject repeated measures design using simultaneous data acquisition was completed.The coefficient of determination (R2) for all planes of cervical range of motion for both model and human data sets was higher than 0.99. The regression equations for the model data showed no significant (P.05) intercept for flexion-extension and lateral rotation. Human data showed statistically significant intercept for flexion-extension (mean, -0.52 degrees) and lateral flexion (mean, 0.81 degrees) at P.05.This study quantifies the difference between the MotionStar and the Spin-T goniometer and documents the systematic error between the measures. Where the error reached statistical significance, the magnitude of the error was very small (1.5 degrees). The results of this study suggest that the Spin-T goniometer may be used as a valid measuring instrument for cervical range of movement.

To examine the intratester reliability of the Spin-T goniometer, a cervical range of motion device, in a normal Indian population.Subjects comprised 30 healthy adults with mean age of 34 years (range, 18-65 years). The subjects were stabilized in the sitting position and the Spin-T goniometer mounted on the head of the subject. The study design was a within-subject repeated intratester reliability trial conducted for cervical range of motion in 6 directions of movement. Three measurements were taken in each direction (flexion, extension lateral flexion, and lateral rotation) per participant. Reliability coefficients, intraclass correlation coefficients, and 95% confidence interval were derived from repeated-measures analysis of variance (ANOVA). Where differences in ANOVA were detected, a paired t test was conducted and the typical error values and coefficient of variance were calculated.All repeated measures showed high intraclass correlation coefficients (all0.96, P.01). The ANOVA detected no differences between trials for all movements except rotation. The typical error values for the rotation trials did not exceed 2.5 degrees and the coefficient of variance did not exceed 4%, which is clinically acceptable considering the normally variable cervical range of movement.In this study, the Spin-T goniometer proved to be a reliable measuring instrument for cervical range of movement in an Indian population. The use of a laser pointer fixed to the instrument ensured a consistent neutral start position.

Hip structural analysis (HSA) is a technique for extracting strength-related structural dimensions of bone cross-sections from two-dimensional hip scan images acquired by dual energy X-ray absorptiometry (DXA) scanners. Heretofore the precision of the method has not been thoroughly tested in the clinical setting. Using paired scans from two large clinical trials involving a range of different DXA machines, this study reports the first precision analysis of HSA variables, in comparison with that of conventional bone mineral density (BMD) on the same scans. A key HSA variable, section modulus (Z), biomechanically indicative of bone strength during bending, had a short-term precision percentage coefficient of variation (CV%) in the femoral neck of 3.4-10.1%, depending on the manufacturer or model of the DXA equipment. Cross-sectional area (CSA), a determinant of bone strength during axial loading and closely aligned with conventional DXA bone mineral content, had a range of CV% from 2.8% to 7.9%. Poorer precision was associated with inadequate inclusion of the femoral shaft or femoral head in the DXA-scanned hip region. Precision of HSA-derived BMD varied between 2.4% and 6.4%. Precision of DXA manufacturer-derived BMD varied between 1.9% and 3.4%, arising from the larger analysis region of interest (ROI). The precision of HSA variables was not generally dependent on magnitude, subject height, weight, or conventional femoral neck densitometric variables. The generally poorer precision of key HSA variables in comparison with conventional DXA-derived BMD highlights the critical roles played by correct limb repositioning and choice of an adequate and appropriately positioned ROI.

This study investigated intra- and inter-rater reliability of several radiographic angular and linear parameters using 6 subjects. Using standard weight-bearing radiographs, the following measurements were performed: first metatarsal protrusion distance, hallux abductus, first intermetatarsal, calcaneal inclination and lateral intermetatarsal angles. Measurement of lateral stressed dorsiflexion of the first metatarsophalangeal joint and the rearfoot-to-forefoot-axis angle taken using a composite view were also obtained. All parameters were measured independently by 2 raters, and measurements were repeated on 3 separate occasions at weekly intervals. Intrarater reliability of radiographic measurements ranged between R = 0.65–1.00 for lateral stressed dorsiflexion, and between R = 0.91 and 0.99 for the rearfoot to forefoot axis angle. Inter-rater reliability of radiographic measurements ranged from R = 0.82–0.99. Specifically, lateral stressed dorsiflexion showed R = 0.87 with a mean difference of −1.47 (confidence interval [CI]: −3.42, 0.47), indicating no significant difference ( t = 1.54, P = 0.13). The rearfoot-to-forefoot-axis angle showed R = 0.92 with a mean difference of −0.15 (CI: −1.05, 0.74), indicating no significant difference ( t = 0.35, P = 0.73). The 7 angular and linear measurements chosen demonstrated high inter- and intrarater reliability. These results indicate that weight-bearing radiographic first metatarsophalangeal joint dorsiflexion using the lateral stressed dorsiflexion view, and measurement of the rearfoot-to-forefoot-axis angle using a composite view could be measured reliably within and between raters.

Background:Gait analysis using footprint impressions is a simple and inexpensive method of obtaining valuable information relating to foot dynamics. Objectives: To assess the reliability and comparability of two different measurement techniques to quantify angle of gait (AOG). Method: Part 1. Two observers measured angle of gait (AOG), in six asymptomatic adult subjects, three times at weekly intervals. Part 2. A comparison of AOG from powdered footprints, and foot progression angle (FPA), the equivalent to AOG, derived from the EMED-SF ® force platform were simultaneously compared using 11 asymptomatic adult subjects. Results: A Pearson’s product moment correlation of 0.94 for rater 1 and 0.93 for rater 2 was observed between trials 1 and 2. Between trials 2 and 3, a Pearson’s product moment correlation of 0.95 was observed for rater 1 and rater 2. The mean difference was 0.26 (CI: −0.06, 0.57), indicating no significant difference (t =− 1.63, P = 0.108). A Pearson’s product moment correlation of 0.98 for AOG from powdered footprints and FPA from EMED-SF ® was observed with a mean difference of 0.03 (CI: −0.54, 0.59), indicating no significant difference ( t = 0.09, P = 0.93). Assessment of agreement using the Bland and Altman statistical model reflected moderate differences between raters and techniques of measuring AOG. Conclusions: Calculation of AOG from powdered footprints is a reliable and repeatable method, also demonstrating comparability to the FPA derived from the EMED-SF ® platform.

Singer BJ, Jegasothy GM, Singer KP, Allison GT, Dunne JW. Incidence of ankle contracture after moderate to severe acquired brain injury. Arch Phys Med Rehabil 2004;85:1465–9. Objective To examine an adult population undergoing rehabilitation after brain injury to determine the incidence of ankle contracture and factors contributing to the development of this deformity. Design Descriptive study Setting Specialist inpatient neurosurgical rehabilitation unit in Australia. Participants Patients (N=105) admitted with a new diagnosis of moderate to severe brain injury over a 12-month period. Interventions Not applicable. Main outcome measures Maximal ankle dorsiflexion range and the presence of abnormal muscle tone affecting the lower limb(s) were evaluated at weekly intervals. Ankle contracture was defined as maximal passive range of less than 0° dorsiflexion with the knee in extension. Patients were grouped into 3 muscle tone categories: normal, predominantly spastic, or predominantly dystonic. Age, sex, mechanism and severity of brain injury, time to onset of ankle contracture, total length of hospital stay, and discharge mobility status data were also recorded. Results Muscle tone was designated as normal in 68 (64.7%), as spastic in 14 (13.3%), and as dystonic in 23 (21.9%) patients. The incidence of ankle contracture was 16.2% (17/105 cases). Ankle deformity correlated closely with muscle tone category. Of 23 cases with dystonic muscle overactivity, 17 developed contracture at some point between 1 and 16 weeks after brain injury, although no subject with normal tone or spasticity developed the deformity. There was a weak association between the severity of brain injury and development of ankle contracture. Conclusions The incidence of ankle contracture was much lower than previously reported. Dystonic overactivity of the plantarflexor and invertor muscles is a major predisposing factor to ankle contracture.

Human thoracic discs were analyzed for collagen and collagen cross-links to determine the distribution due to segmental, age, and gender influences. Thoracic discs from 26 cadaveric spines (1 to 90 years old) were graded macroscopically, then separated into anular and nuclear samples. Only grade I (i.e., normal) disc samples were selected (n ¼ 209). Pyridinoline and deoxypyridinoline cross-links were initially separated by column chromatography and analyzed by reverse-phase high-pressure liquid chromatography. The collagen content was lower and the extent of pyridinoline and deoxypyridinoline were significantly higher in the nucleus compared with the anulus (p , .001). The collagen content and extent of pyridinoline were significantly lower with increasing age in the anulus and nucleus (p , .001). Young male discs had a significantly higher extent of pyridinoline compared with females (p , .001). Age, gender, and disc region differences were found to have a significant influence on the biochemical composition of the normal disc extracellular matrix.

Objective. This study sought to determine whether factors other than stretch reflex excitability contribute to velocity dependent passive plantarflexor resistive torque following brain injury. Background. In patients with acquired brain injury increased resistance to passive muscle lengthening commonly results from abnormal muscle contraction, secondary to disinhibition of descending motor pathways, in addition to rheologic changes within the musculo-tendinous unit. Hyper-excitable tonic stretch reflex responses (spasticity) have traditionally been considered to be the main factor influencing resistance that is velocity dependent. Methods. Ten adults with brain injury and eighteen age matched controls were studied. A computer controlled torque measurement system was utilised to evaluate resistance to dorsiflexion stretches at two velocities (5° and 25° s−1). Only stretches which did not evoke muscle contraction were included in the data analysis. The mean difference and 95% confidence limits in passive plantarflexor resistive torque at two stretch velocities, measured over a defined portion of the test movement, were compared between subject groups. Results. A velocity dependent increase in passive plantarflexor resistive torque was evident when the ankle was dorsiflexed past the neutral position in both subjects with brain injury and controls. However, the mean difference was approximately 10 times greater in neurologically impaired limbs compared with control values. Conclusion. These data indicate that an important component of velocity dependent resistance to passive muscle lengthening in adults with brain injury can be mechanical, and unrelated to stretch induced reflex muscle contraction. Relevance Increased resistive torque during rapid muscle lengthening may represent a compensatory adaptation for reduced distal motor control following brain injury. A velocity dependent increase in passive plantarflexor resistive torque has the potential to improve stability during gait and provide mechanical resistance to sudden external perturbations.

Spastic equinovarus deformity of the ankle in adults with acquired brain injury can severely limit the achievement of rehabilitation goals. This study examined changes in triceps surae muscle extensibility, passive resistive torque and soleus stretch reflex responses in 10 adult brain injured subjects undergoing serial casting to correct ankle equinovarus deformity.Goniometric measurement of maximal passive dorsiflexion was used to evaluate extensibility of the triceps surae muscles. Computer controlled ankle dynamometry and surface electromyography were used to identify passive resistive torque and soleus stretch reflex onset angle in response to stretches at two velocities.The mean casting period was 5 weeks. Casting was discontinued in one subject due to failure to achieve measurable gain in ankle range over three consecutive cast changes. Median improvements in maximal ankle dorsiflexion, with the knee flexed or extended, of 30 degrees and 15 degrees, respectively, were achieved in the remaining nine subjects (p0.0001). The median passive ankle range in response to a displacing torque of 10 Nm increased 4.3 degrees over the intervention period (p0.0001). Consistent soleus reflex activity in response to passive stretches at 25 degrees x s(-1) was elicited in only four subjects. A trend for the stretch reflex onset to move further into the available range was demonstrated in these subjects.In the present study, serial casting contributed to significant change in triceps surae extensibility and passive resistive torque, corresponding with improved maximal passive ankle dorsiflexion range and an increase in the angle achieved with a displacing torque of 10 N.m. Increased stretch reflex threshold was observed in some subjects. The use of pre-determined outcome criteria and careful measurement of responses to this intervention were important to prevent premature discontinuation of casting when gains were slower than expected.

Objective. To define the post-mortem cervicothoracic spinal curvature relative to age. Design. Spinal curvature assessment of lateral cervicothoracic radiographs. Background. A late consequence of age is the progressive accentuation of spinal curvatures, particularly the thoracic kyphosis. Little is known about the influence of the kyphosis on the alignment of the cervical spine. Method. One hundred and seventy two lateral spinal radiographs (113 males, 59 females) were analysed using two procedures: (1) sagittal curve deformation angles were derived, according to the method of Cobb, for thoracic (T1–T12), cervical (C2–C7) and cervicothoracic junctional regions (C6–T4); and (2) the cervicothoracic curvatures were digitised (C2–T12), to derive the apex of both curves and the inflexion point. Results. A significantly increasing thoracic spinal curvature was determined for both genders, with the mean apex of the kyphosis close to T6. The cervical lordosis tended to flatten with increasing age, particularly in males, with the cervical apex location shifting cranially. This association was significant in older males and females. The mean location of the cervicothoracic curve inflexion point moved from T3 towards C7–T1 with increasing age. Conclusion. The cervicothoracic spinal curvature undergoes progressive change through the lifespan with a subsequent cranial migration of the inflexion point between the thoracic kyphosis and cervical lordosis, accompanied by a similar shift in the cervical apex. Relevance Sensitive measures of spinal curvature have utility in determining changes attributed to age, deformity or trauma on cervicothoracic spinal alignment. The value of assessing the location of curve inflexion lies in the ability to quantify changes in the relationship between different regions of the human spine without problems associated with identifying specific vertebral landmarks.

The collagen and elastin content and extent of collagen crosslinks were determined in human formalin-fixed and unfixed intervertebral discs and ligamentum flava. Tissue samples from cadaveric spinal discs (n = 77) and ligamentum flava (n = 364) were obtained from 24 formalin-fixed and 2 fresh spines. The mean age of all cases was 57±26 years. Spinal ligament and disc samples were harvested and analyzed for collagen, and crosslinks of pyridinoline, deoxypyridinoline, and elastin crosslinks isodesmosine and desmosine. Collagen and elastin crosslinks were extracted from hydrolyzed samples by cellulose partition chromatography, and analyzed by reverse-phase HPLC. Elastin crosslinks were only detected in 4 lumbar discs (mean 0.04±0.01 nmol/mg dry wt) but yielded results for all ligamentum flavum samples (mean 20.2±6.4 nmol/mg dry wt). For ligamentum flavum, the collagen and collagen crosslinks increased significantly with age (p < 0.05), whereas elastin content decreased significantly with age but only for the lumbar region (p < 0.05). Collagen and elastin content were significantly higher in females (p < 0.01) and collagen, pyridinoline and isodesmosine were significantly higher in the lumbar region (p < 0.01). Elastin detected in lumbar discs was significantly less than that found in ligamentum flavum. The collagen and elastin content and extent of collagen crosslinks in ligamentum matrix varied significantly depending on the age, gender and spinal region.

Objective. To examine changes in muscle length and resistance to passive lengthening in the triceps surae muscles in patients with recently acquired brain injury. Background. Increased passive resistance in the triceps surae muscles is common following acquired brain injury. Adaptive shortening secondary to relative immobility, and increased stiffness due to rheologic changes within the musculo-tendinous unit, may be exacerbated by plantarflexor muscle overactivity related to the brain injury itself. Design. Three variables representing resistance to passive lengthening and soleus muscle length were compared between subjects with recent brain injury and age matched normal controls. Comparison between limbs was made for subjects with unilateral neurological impairment. Methods. Slow passive dorsiflexion stretches were performed using a computer controlled dynamometer. Muscle stiffness in the initial and latter portion of the range, and the angles achieved at torques of 5 and 10 N m were determined from torque–angle curves. Maximal ankle dorsiflexion with the knee flexed was considered to reflect soleus muscle length. Results. Significant differences were demonstrated for all variables, except passive stiffness near the end of available range. The limb ipsilateral to unilateral brain injury differed from control limbs in that significantly less passive range of dorsiflexion was available and initial resistance to passive stretch was significantly less. Conclusions. The reduction in soleus muscle length evident in subjects with recent acquired brain injury, even in neurologically unaffected limbs, may reflect the influence of relative immobility. Although plantarflexor muscle overactivity was found to be associated with increased resistance to slow passive stretch, the mechanism was unable to be elucidated from these data. The limb ipsilateral to unilateral neurological impairment cannot be considered to be a `normal' control for comparative purposes. Relevance Adaptive shortening and increased resistance to passive lengthening limit active ankle dorsiflexion, and alter ankle biomechanics. Tonic muscle overactivity has the potential to exacerbate these changes. Prophylactic management of inappropriate muscle activity and maintenance of muscle length may facilitate the achievement of rehabilitation goals and reduce subsequent disability following acquired brain injury.

Combined movement examination (CME) of the lumbar spine has been recommended for clinical examination as it confers information about mechanical pain patterns. However, little quantitative study has been undertaken to validate its use in manual therapy practice. This study used computer aided CME to develop a normal reference range, and to guide provisional diagnosis and management. Two cases were assessed, before and after manual therapy using CME, a pain Visual Analogue Scale, the Roland Morris Low Back Pain and Disability Questionnaire and the Short Form (SF-12) Health Survey. Diagnosis and management were guided by comparing each CME pattern with the age and gender matched reference range. Self-reports data and CME total change scores were markedly improved for both cases, particularly for the most painful and restricted CME directions. This report describes how computer-aided CME and a normal reference range may be used objectively to inform a diagnosis and as an outcome measure in cases of mechanical LBP. Future investigations of cases with specific lumbar pathologies are required to validate this concept.

The interest in electro-motor stimulation as a strengthening modality has prompted many recent studies. Unfortunately, ambiguity rather than clear directions for future research and clinical practice have emerged. Problems are identified with strength testing methods, and in non-standardized training programmes and stimulus parameters, suggesting the need for minimum requirements when reporting these studies. It is hoped that suggestions presented in this paper will result in more careful research designs, improved inter-study comparison and more appropriate clinical protocols.

To investigate the attitudes and beliefs held by referrers and service providers of an Australian Early Supported Discharge (ESD) service called "Rehabilitation in the Home" (RITH); with particular consideration of factors that may influence referral to RITH.A cross-sectional online survey based on the Theory of Planned Behaviour was undertaken.There were 113 respondents; 90 referrers and 23 service providers. Referrers and RITH staff had a moderately favourable attitude towards RITH. The majority of referrers, and, to a greater degree, RITH staff members, understood and appreciated the advantages ascribed to ESD. However, views varied with regard to some of the factors upon which the decision to refer to RITH rests. Two-fifths of referrers did not think that RITH provided hospital equivalent therapy intensity and over one-fifth of referrers had concerns about the capability of the RITH service to provide specialist stroke rehabilitation. Opinion of RITH staff was also varied on these topics.This study provides evidence that there was a level of uncertainty amongst referrers and RITH service providers regarding issues directly and indirectly related to patient eligibility and RITH service capability. This uncertainty needs to be explored in future research.Differences in views held by referrers and ESD service providers were identified in this study that could lead to inconsistencies in patient selection for, and under-utilization of, ESD services. Improved communication between referrers and ESD service providers, for instance attendance of RITH staff at inpatient team meetings, could ameliorate some of these misconceptions. On-going education of referrers about service capability is essential to ensure timely transfer of appropriate clients to ESD services.

The present retrospective study reviewed and examined the prevalence of thoracic disc degeneration, end-plate lesions and osteophytes in the thoracic spine using T2-weighted sagittal magnetic resonance images (MRI). The sample comprised 216 thoracic spine cases (101 males and 115 females), aged from 1 to 85 years (mean age = 42±19.7 years). Nuclear and anular degeneration, end-plate lesions and osteophytes were graded using a 3-point scale. The prevalence of degeneration was highest in the nucleus (86%) and lowest in the end-plates (63%). Males had a higher prevalence of degeneration in the nucleus, anulus and end-plates, and a lower prevalence of osteophytes compared to females. Increasing cranio-caudal trends in the prevalence of degeneration in the nucleus, anulus and end-plates were observed, and these trends were statistically significant (p

There are limited data detailing the pattern of age and gender-related changes to the thoracic vertebral bodies and intervertebral discs. A retrospective MR investigation, involving T1-weighted midsagittal images from 169 cases, was undertaken to examine age influences on the anterior wedge (anteroposterior height ratio or Ha/Hp), biconcavity (midposterior height ratio or Hm/Hp), and compression indices (posterior height/anteroposterior diameter or Hp/D) of the thoracic vertebral bodies. Disc degenerative changes in the annulus, nucleus, end-plate and disc margin were noted on T2-weighted sagittal images for the 169 cases, based on a 3-level grading system. A linear age-related decline in the Ha/Hp and Hm/Hp indices was noted. The Hp/D index increased during the first few decades of life, then decreased gradually thereafter. The prevalence of abnormal findings in the annuli, nuclei and disc margins increased with increasing age, particularly in the mid and lower thoracic discs. Greater disc degenerative changes were observed in males. These findings provide further insight into the nature of thoracic vertebral shape changes across the lifespan, and the typical patterns of degeneration of the thoracic intervertebral discs.

The study aimed to investigate the variability in interpreting magnetic resonance imaging (MRI) films for thoracic disc degeneration, using a 5-point MRI disc grading scale and a modified 3-point scale. Forty-six T2-weighted sagittal thoracic MRI films, comprising 18 males and 28 females, aged 7 to 73 years, (mean age =41±16.3 years), were randomly selected from 318 archived cases. Nuclear and anular degeneration, end-plate lesions and osteophytes were graded on the first 30 cases using a modified 3-point grading scale. The next 30 cases were evaluated using the 5-point grading scale. Repeat evaluations for both scales were conducted after a three- to six-month interval. The intra-rater kappa coefficient was higher using the 3-point scale (0.71 to 0.87, p < 0.001) compared to the 5-point scale (0.57 to 0.78, p < 0.001) for the end-plate–disc–end-plate components. The lowest intra-rater reliability was for osteophytes and the highest was for the nucleus. The intra-rater reliability was generally higher in the upper thoracic region compared to the mid and lower thoracic regions.

The ‘internet-driven information age’ is a term in common usage, implying that everyone can access all the information they need, when they need it. The purpose of this brief paper is to outline some web sources that highlight the possibilities and potential for accessing web-based knowledge. From this the clinician will be encouraged to follow leads along the labyrinth of links to a greater appreciation of how this resource can be used to shape their practice. Examples of web links are provided for: search engines; library-based sources, including medical databases and electronic journals; evidence-based practice databases, mail-groups; electronic conferences; research centres; and general health sources. Importantly, this review does not aspire to be all-inclusive, for the web changes, chameleon-like, to the seasons. The web is here to stay. It will provide the framework for much education and will guide clients to a greater appreciation of their disease or disability than ever before. It may ultimately be the tool through which health fund agents will promote best practice, including self-help to clients, and therefore direct discriminating individuals to select health practitioners who have been endorsed by professional and fund agencies as providing a contemporary service which conforms to evidence-based practice.

Objective. The aim of this study was to examine age, gender, and segmental trends in thoracic vertebral body shape, utilising thoracic spine magnetic resonance images involving an age range spanning the life span. Design. A quantitative, cross-sectional, retrospective study design involving a sample of convenience. Background. Thoracic vertebral shape data are commonly derived from radiographic resources. The non-ionising properties of magnetic resonance imaging and availability of digital data for image analysis suggest potential for MR-based morphometric studies. For the thoracic spine, there is limited vertebral shape data on males, while few studies have examined the pattern of age-related changes across the life span. Methods. Morphometry was performed on 220 mid sagittal T1-weighted MR images using image analysis software. Three indices of vertebral shape were utilised: the antero-posterior height ratio or anterior wedge index, mid-posterior height ratio or biconcavity index, and ratio of posterior vertebral height to mid antero-posterior diameter or compression index. Results. Different segmental patterns were noted for the vertebral shape indices. Significantly lower mean values were noted in males for the compression index. Age trends were significant, with a linear age-related decline demonstrated for the anterior wedge and biconcavity indices, and a quadratic trend noted for the compression index. Conclusions. Thoracic vertebral body shape may be uniquely described using specific shape indices, for examining various segmental, gender and age-associated changes. Relevance These results suggest the importance of defining specific reference criteria for thoracic vertebral body shape indices, particularly age-related data encompassing a wide age range. Magnetic resonance studies enable interpretation of vertebral shape data in relation to the wide spectrum of pathologies afflicting the thoracic spine, without the concerns of ionising radiation.

This study investigated the relationship between static osseous radiographic foot measurements and mean peak pressure recordings of 10 selected regions of the foot in 30 normal subjects and in 30 subjects with hallux valgus or hallux limitus. The results suggest that dynamic peak pressure distribution beneath the foot is unrelated to those static weight-bearing radiographic parameters tested, in normal subjects and those with hallux valgus or hallux limitus. Other intrinsic or extrinsic biomechanical or physiological factors, which may have an influence on foot function, must be responsible for variation of pressure distribution within the foot.

Selected dynamic plantar pressure measurements of 30 control, 30 hallux valgus and 30 hallux limitus subjects, using an EMED-SF system and a two-step method of data collection, were analysed for significant differences, with a one-way analysis of variance being performed with P

Summary There have been no reports describing the pattern of degenerative changes of spinal segments within the cervicothoracic (CT) transitional junction. To address this deficiency, intervertebral disc degenerative changes in this region were studied between the C6 to T4 vertebrae, using hemisected spinal columns from 96 individuals (69 male and 27 female). Sagittally sectioned spinal columns were inspected macroscopically by one observer and graded using previously reported grading scales. In addition, endplate irregularity, intervertebral disc degenerative changes, discal splitting and vertebral body marginal osteophytes were recorded. Combining all classifications of degeneration, the frequency of disc degeneration at C6–C7 was 49%, C7−T1 = 42%, T1−T2 = 40%, T2−T3 = 50% and T3−T4 = 44%. Significant age trends were noted, with 25% of all discs showing degeneration in the youngest group, compared to 58% in the oldest group. The incidence of disc degenerative changes through this transition declined from the C6–C7 to the T1–T2 segments but increased slightly for the more severe changes at the T2–T3 and T3–T4 segments. In one third of cases demonstrating degenerative discal changes no evidence of osteophyte formation was present. The manual therapist should not exclude the possibility of discal pathology in patients presenting with cervicothoracic pain, particularly if the patient is over 30 years of age.

The ability to transfer in tetraplegia is a focal point of rehabilitation. Many factors have been associated with independence in transferring, yet the majority of these are anecdotal reports. The purpose of this paper is to report preliminary findings of the study of movement strategies of individuals with spinal cord injury attempting a long sitting transfer. Analyses were made from the lateral and posterior views. Pattern recognition techniques show two distinct movement strategies in both views. These were a lift and forward flexion technique from the lateral perspective and a translatory and rotatory technique when viewed from behind. It would seem that the posterior view provides more discriminative information. It is recommended that intervention techniques, such as Functional Electrical Stimulation or orthotic devices be developed within fundamental motion analysis constructs to optimize functional outcome.

Background Spinal rotation couples with lateral flexion as a composite movement. Few data report the in vivo mechanical deformation of the nucleus pulposus following sustained rotation. MRI provides a non-invasive method of examining nucleus pulposus deformation by mapping the hydration signal distribution within the intervertebral disc. Methods T1 weighted coronal and sagittal lumbar images and T2 weighted axial images at L1–2 and L4–5 were obtained from 10 asymptomatic subjects (mean age 29, range: 24–34 years) in sustained flexed and extended positions plus combined positions of left rotation with flexion and extension. Nucleus pulposus deformation was tracked by mapping the change in hydration profiles from coronal and sagittal pixel measurements. Findings An average sagittal change in position of 44° (SD 14.5°) from flexion to extension was recorded between L1 and S1 (range: 18°– 60°) resulting in a mean anterior nucleus pulposus deformation of 16% of disc hydration profile (range: 3.5%–19%) in 19/20 discs. When rotation was combined with either flexion or extension, mean coronal deformation was 4.8% (SD—5.1%; range: 0.4%–15%). Lateral nucleus pulposus deformation direction varied in rotation (44% deformed left and 56% deformed right). Intersegmental lateral flexion direction more strongly predicted nucleus pulposus deformation direction with 75% deforming contralaterally. Interpretation Nucleus pulposus deformation direction in young subjects was more predictable following sagittal position change than in rotation combined with flexion or extension. Deformation magnitude was reduced in rotated positions. Intersegmental lateral flexion was a stronger predictor of nucleus pulposus deformation direction.

Segmental variations in vertebral body cancellous bone architecture throughout the thoracolumbar spine were examined using histomorphometry and microradiography, and compared to bone mass measured using dual energy X-ray absorptiometry. In six human vertebral columns (T1 to L5) bone mineral content (BMC) and bone mineral density (BMD) of each vertebral body was determined in the lateral projection. Sagittal plane cancellous bone architecture was assessed from two-dimensional surface stained images and microradiographs of two 1 mm thick sections at each vertebral level. Computer-assisted image analysis was used to measure the total bone area (TBA), mean trabecular width (MTW) and trabecular number (TbN) from the stained images, and the skeletonized network length (SNL) from the radiographic images. Consistent segmental trends were observed for all structural parameters across the six columns examined. Higher TBA and TbN values were observed in the upper thoracic segments and decreased caudally. The MTW was relatively constant in the thoracic vertebrae before increasing in the lumbar spine. Pooled correlations between TBA and the bone density measurements were poor (BMC: r = 0.17, BMD: r = 0.25), while the TBA and SNL were only moderately correlated (r = 0.42). In conclusion, histomorphometric and radiological measurements appear to provide different information about cancellous bone structure. Bone structure is poorly correlated to integral measurements of bone mass. The consistent segmental variations in bone architecture appear to reflect a skeletal response to the relative extent of habitually applied loads in different regions of the spine.

Lateral scanning with dual energy X-ray absorptiometry (DXA) was undertaken on 153 thoracic and lumbar vertebral bodies from nine individuals (mean age 67; range 34–92 years) to establish their bone mineral content (BMC). All specimens were subsequently de-fatted and ashed to compare ash weight with BMC of the Tl to L5 segments. Linear regression analysis indicated a higher correlation between BMC and measured ash weights for each vertebral column (range: r = 0.97 0.99), with error analysis for all vertebrae tested showing a standard error of 0.40 g, or 10.8%. For the L2 4 segments the accuracy error was 0.50 g or 7.9%. In both cases there was a mean trend towards underestimation of ash weight. Mean BMC values of the T1 to T5 segments were similar before a progressive increase caudally. These data affirm the utility of DXA for determining bone mineral content in the vertebral column across wide ranges of age, and segmental and bone density.

Whilst there are numerous studies examining aspects of sagittal plane motion in the lumbar spine, few consider coronal plane range of motion and there are no in vivo reports of nucleus pulposus (NP) displacement in lateral flexion. This study quantified in vivo NP deformation in response to side flexion in healthy volunteers. Concomitant lateral flexion and axial rotation range were also examined to evaluate the direction and extent of NP deformation. Axial T2- and coronal T1-weighted magnetic resonance images (MRI) were obtained from 21 subjects (mean age, 24.8 years) from L1 to S1 in the neutral and left laterally flexed position. Images were evaluated for intersegmental ranges of lateral flexion and axial rotation. A novel methodology derived linear pixel samples across the width of the disc from T2 images, from which the magnitude and direction of displacement of the NP was determined. This profiling technique represented the relative hydration pattern within the disc. The NP was displaced away from the direction of lateral flexion in 95/105 discs (p

Intramuscular injection of botulinum toxin (BoNT) produces reversible blockade of neuromuscular transmission. In animal experimental models, recovery begins within four weeks and is usually complete by twelve weeks. We present evidence of prolonged denervation following BoNT injection of the vastus lateralis (VL) muscle to correct quadriceps muscle imbalance in patients with chronic anterior knee pain. Needle electromyography data were obtained from 10 subjects who had received a single BoNT treatment 5 to 19 months earlier as part of a clinical trial. Insertional and spontaneous activity, recruitment, and motor unit action potentials were examined. Clear differences between the injected and non-injected VL muscles, which correlated with the time since injection, were identified in all subjects. All 10 subjects studied with needle EMG showed evidence of persisting denervation in the BoNT-A injected VL muscle beyond the period of neuromotor recovery expected from animal experimental studies.

The healthcare cost of managing osteoporotic fractures is projected to rise because of the change in population demographics. To reduce the fracture epidemic, strategies are needed to identify those at risk early to allow preventative intervention to be implemented. The aim of this study was to investigate if low-cost community-based assessments, such as calcaneal ultrasound and falls risk assessments, can discriminate a group of elderly women at risk of osteoporotic fracture from those at lower risk. Over the period of 2002-2003, 104 community-dwelling women (mean age 71.3, standard deviation 5.8) were recruited via various modes including advertisements in community newspaper and community centres. These women underwent dual-energy X-ray absorptiometry bone mineral density (BMD) and calcaneal quantitative ultrasound (QUS) measurements; spinal radiography; and performance-based assessment of strength, mobility and balance. The women were classified into a 'high risk' (osteoporotic) group, based on low BMD (T-score of/= -2.5) and/or a history of a fragility fracture, or a 'low risk' (non-osteoporotic) group. Multiple stepwise logistic regression identified decreased speed of sound (SOS), a QUS variable, and poor mobility [slower performance in the timed 'up and go' (TUG) task], as significant discriminators, adjusted for age [SOS: adjusted odds ratio (OR) = 2.96, 95% confidence interval (CI) = 1.64-5.12, P0.001; TUG: adjusted OR = 1.69, 95% CI = 1.04-2.73, P = 0.031]. This result suggests that there may be a potential role for primary healthcare practitioners to use calcaneal QUS and functional mobility assessment (TUG) to screen for post-menopausal women at risk of osteoporotic fracture in community settings.