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1.  Trunk isometric force production parameters during erector spinae muscle vibration at different frequencies 
Vibration is known to alter proprioceptive afferents and create a tonic vibration reflex. The control of force and its variability are often considered determinants of motor performance and neuromuscular control. However, the effect of vibration on paraspinal muscle control and force production remains to be determined.
Twenty-one healthy adults were asked to perform isometric trunk flexion and extension torque at 60% of their maximal voluntary isometric contraction, under three different vibration conditions: no vibration, vibration frequencies of 30 Hz and 80 Hz. Eighteen isometric contractions were performed under each condition without any feedback. Mechanical vibrations were applied bilaterally over the lumbar erector spinae muscles while participants were in neutral standing position. Time to peak torque (TPT), variable error (VE) as well as constant error (CE) and absolute error (AE) in peak torque were calculated and compared between conditions.
The main finding suggests that erector spinae muscle vibration significantly decreases the accuracy in a trunk extension isometric force reproduction task. There was no difference between both vibration frequencies with regard to force production parameters. Antagonist muscles do not seem to be directly affected by vibration stimulation when performing a trunk isometric task.
The results suggest that acute erector spinae muscle vibration interferes with torque generation sequence of the trunk by distorting proprioceptive information in healthy participants.
PMCID: PMC3750832  PMID: 23919578
Muscle vibration; Muscle spindle; Low back; Neuromuscular responses; Isometric force; Proprioception; Erector spinae muscles
2.  Changes in flexion-relaxation phenomenon and lumbo-pelvic kinematics following lumbar disc replacement surgery 
A single group prospective study. Disc prostheses are believed to contribute to the restoration of the segmental movement and the preservation of the adjacent segments. The study’s main objective was to determine if changes in neuromuscular patterns assessed using the flexion-relaxation phenomenon (FRP) can be observed following disc replacement surgery.
Fifteen subjects participated in this study; they were evaluated before and after lumbar disc replacement surgery. Both assessments included ten repetitions of a trunk flexion and extension movement (with and without a load), where the surface electromyography (EMG) and kinematic data were recorded.
Following the disc replacement procedure (17.3 weeks ± 8.4), participants reported a significant reduction in their ODI and FABQ - physical activity scores. Increases in pelvic flexion as well as in erector spinae (ES) muscle activity at L5 in the flexion phase were observed. Following the disc replacement surgery, ES activity at L2 decreased during the quiet standing position.
The results of this study suggest that although improvements in disability scores and fear-avoidance related to physical activities scores were noted after a disc replacement surgery, the lumbar ROM was not modified. Nevertheless, a significant increase in the hip ROM during the flexion-extension task as well as an increase in ES muscle activity in flexion was observed following surgery. The VAS, FABQ I and ODQ scores were positively correlated with change in the muscular activities during the FRP.
PMCID: PMC3710487  PMID: 23842284
Low back pain; Disc prosthesis; Degenerative disc disease; Flexion-relaxation phenomenon; Lumbar kinematics
3.  Short term modulation of trunk neuromuscular responses following spinal manipulation: a control group study 
Low back pain (LBP) is one of the most frequent musculoskeletal conditions in industrialized countries and its economic impact is important. Spinal manipulation therapy (SMT) is believed to be a valid approach in the treatment of both acute and chronic LBP. It has also been shown that SMT can modulate the electromyographic (EMG) activity of the paraspinal muscle. The purpose of this study was to investigate, in a group of patients with low back pain, the persistence of changes observed in trunk neuromuscular responses after a spinal manipulation (SMT).
Sixty adult participants with LBP performed a block of 5 flexion-extension movements. Participants in the experimental group (n=30) received lumbar SMT whereas participants in the control group (n=30) were positioned similarly for the treatment but did not receive SMT. Blocks of flexion-extension movements were repeated immediately after the manipulation as well as 5 and 30 minutes after SMT (or control position). EMG activity of paraspinal muscles was recorded at L2 and L5 level and kinematic data were collected to evaluate the lumbo-pelvic kinematics. Pain intensity was noted after each block. Normalized EMG, pain intensity and lumbo-pelvic kinematics were compared across experimental conditions.
Participants from the control group showed a significant increase in EMG activity during the last block (30 min) of flexion-extension trials in both flexion and full-flexion phases at L2. Increase in VAS scores was also observed in the last 2 blocks (5 min and 30 min) in the control group. No significant group x time interaction was seen at L5. No significant difference was observed in the lumbo-pelvic kinematics.
Changes in trunk neuromuscular control following HVLA spinal manipulation may reduce sensitization or muscle fatigue effects related to repetitive movement. Future studies should investigate short term changes in neuromuscular components, tissue properties and clinical outcomes.
PMCID: PMC3602072  PMID: 23496876
Spinal manipulation; Electromyography; Kinematics; Flexion-relaxation phenomenon
4.  The effect of spinal manipulative therapy on spinal range of motion: a systematic literature review 
Spinal manipulative therapy (SMT) has been shown to have an effect on spine-related pain, both clinically and in experimentally induced pain. However, it is unclear if it has an immediate noticeable biomechanical effect on spinal motion that can be measured in terms of an increased range of motion (ROM).
To assess the quality of the literature and to determine whether or not SMT is associated with an immediate increase in ROM.
A systematic critical literature review.
Systematic searches were performed in Pubmed, the Cochrane Library and EMBASE using terms relating to manipulation, movement and the spine. Selection of articles was made according to specific criteria by two independent reviewers. Two checklists were created based on the needs of the present review. Articles were independently reviewed by two reviewers. Articles were given quality scores and the data synthesized for each region treated in the literature. Findings were summarized in tables and reported in a narrative fashion.
Fifteen articles were retained reporting on experiments on the neck, lumbar spine, hip and jaw. The mean quality score was 71/100 (ranges 33/100 - 92/100). A positive effect of SMT was reported in both studies where mouth opening was assessed after cervical manipulation. In five of the nine studies on cervical ROM a positive effect was reported, whereas the remaining four studies did not show improvement. None of the three studies of the lumbar spine showed an effect of SMT on lumbar ROMs and one study of sacroiliac manipulation reported no effect on the ROM of the hip joint.
In relation to the quality score, the seven highest ranked studies, showed significant positive effects of SMT on ROM. Continuing down the list, the other studies reported no significant differences in the outcomes between groups.
SMT seems sometimes to have a small effect on ROM, at least in the cervical spine. Further research should concentrate on areas of the spine that have the potential of actually improving to such a degree that a change can be easily uncovered.
PMCID: PMC3487906  PMID: 22866816
5.  Trunk muscle fatigue during a lateral isometric hold test: what are we evaluating? 
Side bridge endurance protocols have been suggested to evaluate lateral trunk flexor and/or spine stabilizer muscles. To date, no study has investigated muscle recruitment and fatigability during these protocols. Therefore the purpose of our study was to quantify fatigue parameters in various trunk muscles during a modified side bridge endurance task (i.e. a lateral isometric hold test on a 45° roman chair apparatus) and determine which primary trunk muscles get fatigued during this task. It was hypothesized that the ipsilateral external oblique and lumbar erector spinae muscles will exhibit the highest fatigue indices.
Twenty-two healthy subjects participated in this study. The experimental session included left and right lateral isometric hold tasks preceded and followed by 3 maximal voluntary contractions in the same position. Surface electromyography (EMG) recordings were obtained bilaterally from the external oblique, rectus abdominis, and L2 and L5 erector spinae. Statistical analysis were conducted to compare the right and left maximal voluntary contractions (MVC), surface EMG activities, right vs. left holding times and decay rate of the median frequency as the percent change from the initial value (NMFslope).
No significant left and right lateral isometric hold tests differences were observed neither for holding times (97.2 ± 21.5 sec and 96.7 ± 24.9 sec respectively) nor for pre and post fatigue root mean square during MVCs. However, participants showed significant decreases of MVCs between pre and post fatigue measurements for both the left and right lateral isometric hold tests. Statistical analysis showed that a significantly NMFslope of the ipsilateral external oblique during both conditions, and a NMFslope of the contralateral L5 erector spinae during the left lateral isometric hold test were steeper than those of the other side’s respective muscles. Although some participants presented positive NMFslope for some muscles, each muscle presented a mean negative NMFslope significantly different from 0.
Although the fatigue indices suggest that the ipsilateral external oblique and contralateral L5 erector spinae show signs of muscle fatigue, this task seems to recruit a large group of trunk muscles. Clinicians should not view this task as evaluating specifically lateral trunk flexors, but rather as providing an indication of the general endurance and stabilisation capacity of the trunk.
PMCID: PMC3418569  PMID: 22515489
Side bridge test; Muscle fatigue; Trunk muscle; Functional testing
8.  Learning Spinal Manipulation 
The goal of the present study was to quantify the high-velocity, low-amplitude spinal manipulation biomechanical parameters in two cohorts of students from different teaching institutions. The first cohort of students was taught chiropractic techniques in a patient–doctor positioning practice setting, while the second cohort of students was taught in a “complete practice” manipulation setting, thus performing spinal manipulation skills on fellow student colleagues. It was hypothesized that the students exposed to complete practice would perform the standardized spinal manipulation with better biomechanical parameters.
Participants (n = 88) were students enrolled in two distinct chiropractic programs. Thoracic spine manipulation skills were assessed using an instrumented manikin, which allowed the measurement of applied force. Dependent variables included peak force, time to peak force, rate of force production, peak force variability, and global coordination.
The results revealed that students exposed to complete practice demonstrated lower time to peak force values, higher peak force, and a steeper rate of force production compared with students in the patient–doctor positioning scenario. A significant group by gender interaction was also noted for the time to peak force and rate of force production variables.
The results of the present study confirm the importance of chiropractic technique curriculum and perhaps gender in spinal manipulation skill learning. It also stresses the importance of integrating spinal manipulation skills practice early in training to maximize the number and the quality of significant learner–instructor interactions.
PMCID: PMC3204948  PMID: 22069337
Chiropractic; Education; Manipulation; Spinal; Motor Skills
9.  A randomised controlled trial of preventive spinal manipulation with and without a home exercise program for patients with chronic neck pain 
Evidence indicates that supervised home exercises, combined or not with manual therapy, can be beneficial for patients with non-specific chronic neck pain (NCNP). The objective of the study is to investigate the efficacy of preventive spinal manipulative therapy (SMT) compared to a no treatment group in NCNP patients. Another objective is to assess the efficacy of SMT with and without a home exercise program.
Ninety-eight patients underwent a short symptomatic phase of treatment before being randomly allocated to either an attention-group (n = 29), a SMT group (n = 36) or a SMT + exercise group (n = 33). The preventive phase of treatment, which lasted for 10 months, consisted of meeting with a chiropractor every two months to evaluate and discuss symptoms (attention-control group), 1 monthly SMT session (SMT group) or 1 monthly SMT session combined with a home exercise program (SMT + exercise group). The primary and secondary outcome measures were represented by scores on a 10-cm visual analog scale (VAS), active cervical ranges of motion (cROM), the neck disability index (NDI) and the Bournemouth questionnaire (BQ). Exploratory outcome measures were scored on the Fear-avoidance Behaviour Questionnaire (FABQ) and the SF-12 Questionnaire.
Our results show that, in the preventive phase of the trial, all 3 groups showed primary and secondary outcomes scores similar to those obtain following the non-randomised, symptomatic phase. No group difference was observed for the primary, secondary and exploratory variables. Significant improvements in FABQ scores were noted in all groups during the preventive phase of the trial. However, no significant change in health related quality of life (HRQL) was associated with the preventive phase.
This study hypothesised that participants in the combined intervention group would have less pain and disability and better function than participants from the 2 other groups during the preventive phase of the trial. This hypothesis was not supported by the study results. Lack of a treatment specific effect is discussed in relation to the placebo and patient provider interactions in manual therapies. Further research is needed to delineate the specific and non-specific effects of treatment modalities to prevent unnecessary disability and to minimise morbidity related to NCNP. Additional investigation is also required to identify the best strategies for secondary and tertiary prevention of NCNP.
Trial registration NCT00566930
PMCID: PMC3045999  PMID: 21303529
10.  Conservative care of temporomandibular joint disorder in a 35-year-old patient with spinal muscular atrophy type III: a case study☆ 
Journal of Chiropractic Medicine  2009;8(4):187-192.
This article describes the chiropractic clinical management and therapeutic benefits accruing to a patient with temporomandibular joint (TMJ) disorder and spinal muscular atrophy type III.
Clinical Features
A 35-year-old white man presented at the university chiropractic outpatient clinic with a complaint of masseter muscle pain and mouth-opening restriction. Temporomandibular joint range of motion evaluation revealed restricted opening (11 mm interincisival), and pain was rated by the patient at an intensity of 5 on a pain scale of 0 to 10.
Intervention and Outcome
Chiropractic care was provided and included TMJ mobilization, myofascial therapy, trigger point therapy, and light spinal mobilizations of the upper cervical vertebrae. Final evaluation of TMJ range of motion showed active opening of 12 mm with absence of pain and muscle tenderness of the jaw.
This case suggests that a patient with musculoskeletal disorders related to underlying neurodegenerative pathologies may benefit from chiropractic management adapted to their condition. In the present case, chiropractic treatment of the TMJ represented a viable, low-cost approach with limited adverse effects compared with surgery.
PMCID: PMC2786227  PMID: 19948309
Temporomandibular joint disorders; Chiropractic; Muscular atrophy, Spinal; Musculoskeletal manipulations
11.  A randomized controlled (intervention) trial of ischemic compression therapy for chronic carpal tunnel syndrome 
Study Design:
Randomized clinical trial.
The aim of this study was to evaluate the effect of ischemic compression therapy in the treatment of chronic carpal tunnel syndrome.
Fifty-five patients suffering from carpal tunnel syndrome were randomized to two groups. Thirty-seven patients received 15 experimental treatments which consisted of ischemic compressions at trigger points located in the axilla of the shoulder, the length of the biceps muscle, at the bicipital aponeurosis and at the pronator teres muscle in the hollow of the elbow. Eighteen patients received the control treatment involving ischemic compression on trigger points located in the deltoid muscle, supraspinatus muscle and infraspinatus muscle. Of the 18 patients forming the control group, 13 agreed to receive the experimental treatments after the 15 control treatments. Outcome measures included a validated 18-question questionnaire to assess the severity of symptoms and functional status in carpal tunnel syndrome, and a quantification of the patients’ perceived improvement, using a scale from 0% to 100%. Outcome measures evaluations were completed at baseline, after 15 treatments, 30 days following the last treatment, and 6 months later.
For the disability questionnaire, a significant reduction of symptoms was noted only in the experimental group. In the experimental group the outcome at baseline was 33.5 (SD, 10.3); after 15 treatments it was 18.6 (SD, 7.0). The control group outcome at baseline was 36.3 (SD, 15.2); after 15 treatments it was 26.4 (SD, 9.9) and after the crossover (15 control treatments plus 15 experimental treatments) 20.2 (SD, 12.2). A significant between group difference (P < 0.021) was noted in the patients’ perceived improvement after 15 treatments: 67 (SD, 26) percent and 50 (SD, 25) percent respectively for the experimental and control groups.
This practice-based clinical trial suggests that myofascial therapy using ischemic compression the length of the biceps, at the bicipital aponeurosis, at the pronator teres and at the subscapularis muscles could be a useful approach to reduce symptoms associated with the carpal tunnel syndrome. Patients’ perceived improvement in functional capacities persisted over a 6-month period.
PMCID: PMC2921781  PMID: 20808615
chiropractic; myofascial trigger points; ischemic compression; carpal tunnel syndrome; randomized clinical trial; chiropratique; point gâchette myofascial; compressions ischémiques; syndrome du canal carpien; essai clinique randomisé
12.  Changes in the flexion-relaxation response induced by hip extensor and erector spinae muscle fatigue 
The flexion-relaxation phenomenon (FRP) is defined by reduced lumbar erector spinae (ES) muscle myoelectric activity during full trunk flexion. The objectives of this study were to quantify the effect of hip and back extensor muscle fatigue on FRP parameters and lumbopelvic kinematics.
Twenty-seven healthy adults performed flexion-extension tasks under 4 different experimental conditions: no fatigue/no load, no fatigue/load, fatigue/no load, and fatigue/load. Total flexion angle corresponding to the onset and cessation of myoelectric silence, hip flexion angle, lumbar flexion angle and maximal trunk flexion angle were compared across different experimental conditions by 2 × 2 (Load × Fatigue) repeated-measures ANOVA.
The angle corresponding to the ES onset of myoelectric silence was reduced after the fatigue task, and loading the spine decreased the lumbar contribution to motion compared to the hip during both flexion and extension. A relative increment of lumbar spine motion compared to pelvic motion was also observed in fatigue conditions.
Previous results suggested that ES muscles, in a state of fatigue, are unable to provide sufficient segmental stabilization. The present findings indicate that, changes in lumbar-stabilizing mechanisms in the presence of muscle fatigue seem to be caused by modulation of lumbopelvic kinematics.
PMCID: PMC2896348  PMID: 20525336
13.  Chiropractic management of patients post-disc arthroplasty: eight case reports 
When conservative therapies for low back pain (LBP) are not effective, elective surgery may be proposed to these patients. Over the last 20 years, a new technology, disc replacement, has become increasingly popular because it is believed to maintain or restore the integrity of spinal movement and minimize the side-effects compared to fusion. Although disc replacement may relieve a patient from pain and related disability, soreness and stiffness of the lumbopelvic region seem to be common aftermaths of the surgery. This prospective case series was undertaken to identify and describe potential adverse events of lumbar spinal manipulation, a common therapy for low back pain, in a group of patients with symptoms after disc prostheses.
Cases presentation
Eight patients who underwent lumbar spine total disc replacement were referred by an orthopaedic surgeon for chiropractic treatments. These patients had 1 or 2 total lumbar disc replacements and were considered stable according to the surgical protocol but presented persistent, post-surgical, non-specific LBP or pelvic pain. They were treated with lumbar spine side posture manipulations only and received 8 to 10 chiropractic treatments based on the clinical evolution and the chiropractor's judgment. Outcome measures included benign, self-limiting, and serious adverse events after low back spinal manipulative therapy. The Oswestry Disability Index, a pain scale and the fear avoidance belief questionnaire were administered to respectively assess disability, pain and fear avoidance belief about work and physical activity. This prospective case series comprised 8 patients who all had at least 1 total disc replacement at the L4/L5 or L5/S1 level and described persistent post-surgical LBP interfering with their daily activities. Commonly-reported side-effects of a benign nature included increased pain and/or stiffness of short duration in nearly half of the chiropractic treatment period. No major or irreversible complication was noted.
During the short treatment period, no major complication was encountered by the patients. Moreover, the benign side-effects reported after lumbar spine manipulation were similar in nature and duration to those frequently experienced by the general population.
PMCID: PMC2865461  PMID: 20409327
14.  Load and speed effects on the cervical flexion relaxation phenomenon 
The flexion relaxation phenomenon (FRP) represents a well-studied neuromuscular response that occurs in the lumbar and cervical spine. However, the cervical spine FRP has not been investigated extensively, and the speed of movement and loading effects remains to be characterized. The objectives of the present study were to evaluate the influence of load and speed on cervical FRP electromyographic (EMG) and kinematic parameters and to assess the measurement of cervical FRP kinematic and EMG parameter repeatability.
Eighteen healthy adults (6 women and 12 men), aged 20 to 39 years, participated in this study. They undertook 2 sessions in which they had to perform a standardized cervical flexion/extension movement in 3 phases: complete cervical flexion; the static period in complete cervical flexion; and extension with return to the initial position. Two different rhythm conditions and 3 different loading conditions were applied to assess load and speed effects. Kinematic and EMG data were collected, and dependent variables included angles corresponding to the onset and cessation of myoelectric silence as well as the root mean square (RMS) values of EMG signals. Repeatability was examined in the first session and between the 2 sessions.
Statistical analyses revealed a significant load effect (P < 0.001). An augmented load led to increased FRP onset and cessation angles. No load × speed interaction effect was detected in the kinematics data. A significant load effect (P < 0.001) was observed on RMS values in all phases of movement, while a significant speed effect (P < 0.001) could be seen only during the extension phase. Load × speed interaction effect was noted in the extension phase, where higher loads and faster rhythm generated significantly greater muscle activation. Intra-session and inter-session repeatability was good for the EMG and kinematic parameters.
The load increase evoked augmented FRP onset and cessation angles as well as heightened muscle activation. Such increments may reflect the need to enhance spinal stability under loading conditions. The kinematic and EMG parameters showed promising repeatability. Further studies are needed to assess kinematic and EMG differences between healthy subjects and patients with neck pain.
PMCID: PMC2850324  PMID: 20219131
15.  Back and hip extensor muscles fatigue in healthy subjects: task-dependency effect of two variants of the Sorensen test 
European Spine Journal  2008;17(12):1721-1726.
Paraspinal muscle fatigability during various trunk extension tests has been widely investigated by electromyography (EMG), and its task-dependency is established recently. Hip extensor muscle fatigability during the Sorensen test has been reported. The aim of the present experiments was to evaluate the task-dependency of back and hip extensor muscle fatigue during two variants of the Sorensen test. We hypothesized that the rate of muscular fatigue of the hip and back extensor muscles varies according to the test position. Twenty healthy young males with no history of low back pain volunteered to participate in this cross-sectional study. They were asked to perform two body weight-dependent isometric back extension tests (S1 = Sorensen test; S2 = modified Sorensen on a 45° Roman chair). Surface EMG activity of the paraspinal muscles (T10 and L5 levels) and hip extensor muscles (gluteus maximus; biceps femoris) was recorded, and muscular fatigue was assessed through power spectral analysis of the EMG data by calculating the rate of median power frequency change. We observed hip extensor muscle fatigue simultaneously with paraspinal muscle fatigue during both Sorensen variants. However, only L5 level EMG fatigue indices showed a task-dependency effect between S1 and S2. Hip extensor muscles appear to contribute to load sharing of the upper body mass during both Sorensen variants, but to a different extent because L5 level fatigue differs between the Sorensen variants. Our findings suggest that task-dependency has to be considered when EMG variables are compared between two types of lumbar muscle-fatiguing tasks.
PMCID: PMC2587667  PMID: 18813961
Erector spinae; Hip extensors; Sorensen test; Muscle fatigability; Task-dependency
16.  Rehabilitation program for traumatic chronic cervical pain associated with unsteadiness: a single case study 
Neck problems are often recurring or chronic. After pain, unsteadiness and balance problems are among the most frequent symptoms reported by chronic neck pain (CNP) patients. Altered sensorimotor control of the cervical spine and sensorimotor integration problems affecting postural control have been observed in CNP patients. Very few data are available regarding the post-intervention effects of rehabilitation programs on postural control in CNP.
Case presentation
This is a case study of a traumatic CNP patient (a 45-year old female) with postural unsteadiness who participated in an 8-week rehabilitation program combining therapeutic exercises with spinal manipulative therapy. Pre-intervention data revealed that the postural control system was challenged when postural control sensory inputs were altered, particularly during the head-extended-backward condition. Post-intervention centre of pressure measurements indicated a drastic reduction in postural sway during trials with changes in neck orientation.
This case report indicates that an 8-week rehabilitation program combining therapeutic exercises with spinal manipulative therapy may have had an effect on improvement of postural control in a trauma CNP patient with unsteadiness. These results warrant further studies to investigate the relationships between pain amelioration, sensorimotor control of the cervical spine, muscle fitness and postural steadiness.
PMCID: PMC2600629  PMID: 19014706
17.  Urinary incontinence in women treated by ischemic compression over the bladder area: a pilot study 
Journal of Chiropractic Medicine  2007;6(4):132-140.
The purpose of this study was to determine if ischemic compression therapy over the bladder area results in clinically important changes among female patients with stress and mixed (stress and urge) incontinence.
One group of patients (n = 24) received ischemic compression therapy directed over the bladder area (experimental group). The control group (n = 9) received ischemic compression therapy directed toward structures of the hip joint. Changes in urinary incontinence symptoms were monitored using a 2-part questionnaire: the urogenital distress inventory and the incontinence impact questionnaire. Patients' perceived amelioration (improvement) was quantified using a scale divided from 0% to 100%.
Mean scores for the first questionnaire (urogenital distress inventory + incontinence impact questionnaire, 19 questions) were 23.3 vs 25.3 at baseline and 10.2 vs 22.2 after 15 treatments for the experimental and control group, respectively. The experimental group scores were 6.9 at 30 days after the last treatment and 11.3 at the 6-month follow-up. The perceived percentages of amelioration after 15 treatments were 69% vs 32% for the experimental and control group, respectively. The experimental group scores were 73% at 30 days after the last treatment and 60% at the 6-month follow-up.
In this study, ischemic compression directed toward elicited trigger points over bladder area was found to be an effective treatment of patients presenting symptoms of urinary incontinence. Improvement in symptoms was still present in follow-up at 6 months.
PMCID: PMC2647099  PMID: 19674707
Urinary incontinence; Chiropractic; Myofascial pain syndromes
18.  Changes in the flexion relaxation response induced by lumbar muscle fatigue 
The flexion relaxation phenomenon (FRP) is an interesting model to study the modulation of lumbar stability. Previous investigations have explored the effect of load, angular velocity and posture on this particular response. However, the influence of muscular fatigue on FRP parameters has not been thoroughly examined. The objective of the study is to identify the effect of erector spinae (ES) muscle fatigue and spine loading on myoelectric silence onset and cessation in healthy individuals during a flexion-extension task.
Twenty healthy subjects participated in this study and performed blocks of 3 complete trunk flexions under 4 different experimental conditions: no fatigue/no load (1), no fatigue/load (2), fatigue/no load(3), and fatigue/load (4). Fatigue was induced according to the Sorenson protocol, and electromyographic (EMG) power spectral analysis confirmed that muscular fatigue was adequate in each subject. Trunk and pelvis angles and surface EMG of the ES L2 and L5 were recorded during a flexion-extension task. Trunk flexion angle corresponding to the onset and cessation of myoelectric silence was then compared across the different experimental conditions using 2 × 2 repeated-measures ANOVA.
Onset of myoelectric silence during the flexion motion appeared earlier after the fatigue task. Additionally, the cessation of myoelectric silence was observed later during the extension after the fatigue task. Statistical analysis also yielded a main effect of load, indicating a persistence of ES myoelectric activity in flexion during the load condition.
The results of this study suggest that the presence of fatigue of the ES muscles modifies the FRP. Superficial back muscle fatigue seems to induce a shift in load-sharing towards passive stabilizing structures. The loss of muscle contribution together with or without laxity in the viscoelastic tissues may have a substantial impact on post fatigue stability.
PMCID: PMC2259346  PMID: 18218087
19.  Diagnosis and management of “an apparent mechanical” femoral mononeuropathy: a case study 
This report describes an apparent case of femoral nerve mononeuropathy in a 58-year-old equestrian due to mechanical stress. A woman presented at a chiropractic office complaining of right buttock pain radiating to the right groin and knee. A treatment plan, consisting of chiropractic adjustments in addition to stretching and myofascial therapy, was initiated. The goal was to reduce pain and inflammation in the sacroiliac articulation by restoring normal biomechanical function. A rehabilitation program to alleviate tension in the musculature was initiated to reduce mechanical stresses exerted on the femoral nerve. The patient received five treatments over a period of three weeks and became asymptomatic. Even though peripheral nerve entrapment is an uncommon condition, clinicians must not overlook the possibility of a femoral mononeuropathy as it can produce a complex presentation and lead to ineffective patient management.
PMCID: PMC2077874  PMID: 18060007
femoral nerve entrapment; mononeuropathy; chiropractic; peripheral nerve compression; iliopsoas muscle
20.  Three dimensional evaluation of posture in standing with the PosturePrint: an intra- and inter-examiner reliability study 
Few digitizers can measure the complexity of upright human postural displacements in six degrees of freedom of the head, rib cage, and pelvis.
In a University laboratory, three examiners performed delayed repeated postural measurements on forty subjects over two days. Three digital photographs (left lateral, AP, right lateral) of each of 40 volunteer participants were obtained, twice, by three examiners. Examiners placed 13 markers on the subjects before photography and chose 16 points on the photographic images. Using the PosturePrint® internet computer system, head, rib cage, and pelvic postures were calculated as rotations (Rx, Ry, Rz) in degrees and translations (Tx, Tz) in millimeters. For reliability, two different types (liberal = ICC3,1 & conservative = ICC2,1) of inter- and intra-examiner correlation coefficients (ICC) were calculated. Standard error of measurements (SEM) and mean absolute differences within and between observers' measurements were also determined.
All of the "liberal" ICCs were in the excellent range (> 0.84). For the more "conservative" type ICCs, four Inter-examiner ICCs were in the interval (0.5–0.6), 10 ICCs were in the interval (0.61–0.74), and the remainder were greater than 0.75. SEMs were 2.7° or less for all rotations and 5.9 mm or less for all translations. Mean absolute differences within examiners and between examiners were 3.5° or less for all rotations and 8.4 mm or less for all translations.
For the PosturePrint® system, the combined inter-examiner and intra-examiner correlation coefficients were in the good (14/44) and excellent (30/44) ranges. SEMs and mean absolute differences within and between examiners' measurements were small. Thus, this posture digitizer is reliable for clinical use.
PMCID: PMC2077332  PMID: 17892559
21.  Postural development in school children: a cross-sectional study 
Little information on quantitative sagittal plane postural alignment and evolution in children exists. The objectives of this study are to document the evolution of upright, static, sagittal posture in children and to identify possible critical phases of postural evolution (maturation).
A total of 1084 children (aged 4–12 years) received a sagittal postural evaluation with the Biotonix postural analysis system. Data were retrieved from the Biotonix internet database. Children were stratified and analyzed by years of age with n = 36 in the youngest age group (4 years) and n = 184 in the oldest age group (12 years). Children were analyzed in the neutral upright posture. Variables measured were sagittal translation distances in millimeters of: the knee relative to the tarsal joint, pelvis relative to the tarsal joint, shoulder relative to the tarsal joint, and head relative to the tarsal joint. A two-way factorial ANOVA was used to test for age and gender effects on posture, while polynomial trend analyses were used to test for increased postural displacements with years of age.
Two-way ANOVA yielded a significant main effect of age for all 4 sagittal postural variables and gender for all variables except head translation. No age × gender interaction was found. Polynomial trend analyses showed a significant linear association between child age and all four postural variables: anterior head translation (p < 0.001), anterior shoulder translation (p < 0.001), anterior pelvic translation (p < 0.001), anterior knee translation (p < 0.001). Between the ages of 11 and 12 years, for anterior knee translation, T-test post hoc analysis revealed only one significant rough break in the continuity of the age related trend.
A significant linear trend for increasing sagittal plane postural translations of the head, thorax, pelvis, and knee was found as children age from 4 years to 12 years. These postural translations provide preliminary normative data for the alignment of a child's sagittal plane posture.
PMCID: PMC1781952  PMID: 17204148
22.  Kinetic analysis of expertise in spinal manipulative therapy using an instrumented manikin 
The goals of this study were to measure the kinetic profile of thrust in different groups of subjects with various levels of expertise and to quantify general coordination while performing thoracic spine manipulation.
A total of 43 students and chiropractors from the Chiropractic Department of the Université du Québec à Trois-Rivières participated in this study.
Participants were asked to complete ten consecutive thoracic spine manipulations on an instrumented manikin. Peak force, preload force, time to peak force, time to peak force variability, peak force variability, rate of force production and unloading time were compared between groups. Hand-body delay obtained by calculating the temporal lag between the onset of unloading and the onset of peak force application was also compared between groups.
No group difference was observed for the peak force, peak force variability and preload force variables. However, group differences were present for variables like time to peak force, time to peak force variability, rate of force production, unloading time and hand-body delay.
This study demonstrates clear differences between groups of subjects with different levels of expertise in thoracic spine manipulation. This study also demonstrates the usefulness of a simple, instrumented manikin to analyze spinal manipulation and identify important parameters related to expertise.
PMCID: PMC2647034  PMID: 19674647
Manipulation, Spinal; Professional Competence; Task Performance and Analysis; Education
23.  Repositioning accuracy and movement parameters in low back pain subjects and healthy control subjects 
European Spine Journal  2004;14(2):185-191.
Study Design: A control group study with repeated measures. Objective: To compare trunk repositioning parameters in chronic low back pain (LBP) and healthy subjects. Summary and background data: Recent evidence suggests that chronic LBP patients exhibit deficits in trunk proprioception and motor control. Trunk repositioning and the various spatio-temporal parameters related to it can be used to evaluate sensori-motor control and movement strategies. Methods: Fifteen control subjects and 16 chronic LBP subjects participated in this study. Subjects were required to reproduce different trunk position in flexion (15°, 30° and 60°) and extension (15°). In the learning phase preceding each condition, visual feedback was provided. Following these learning trials, subjects were asked to perform ten consecutive trials without any feedback. Movement time, movement time variability and peak velocity were obtained and a temporal symmetry ratio was calculated. Peak angular position variability and absolute error in peak angular position were also calculated to evaluate spatial accuracy. Results: Two subgroups of LBP patients were identified. One subgroup of LBP subjects demonstrated longer movement time and smaller peak velocities and symmetry ratios than normal subjects. No group difference was observed for peak angular position variability and absolute error in peak angular position. Conclusion: Chronic LBP patients, when given a sufficient learning period, were able to reproduce trunk position with a spatial accuracy similar to control subjects. Some LBP subjects, however, showed modifications of movement time, peak velocity and acceleration parameters. We propose that the presence of persistent chronic pain could induce an alteration or an adaptation in the motor responses of chronic LBP subjects.
PMCID: PMC3476690  PMID: 15759173
Trunk positioning; Low back pain; Motor control; Sensori-motor deficits
24.  Biomechanical effects of a lumbar support in a mattress 
For many patients with chronic low back pain, the lack of sleep and sufficient rest period that allows some relaxation is a major obstacle to a good quality of life. During sleep periods, neuromuscular activity is at a minimal level. The major factor influencing the forces on the body, and particularly the spine, is gravity. The force of gravity is sufficient to deform soft tissues when the body is resting on a mattress. Thus, the goal of this study is to measure the contact pressure forces acting on the spine with and without an inflatable support in various experimental conditions. Our hypothesis is that a lumbar support will distribute the force of gravity more uniformly over the pelvic, lumbar and thoracic areas, maintaining the lumbar lordosis, in a supine posture.
In this study, 10 participants were tested when lying supine in six separate experimental conditions. These conditions varied according to the surface (no mattress, foam, mattress) and the fact that the support was inflated or not. The dependent variable measured was the contact pressure. It was measured using a pressure sensor mat (Tekscan™). When the cushion was inflated the distribution of contact pressure in the different areas (pelvic, lumbar and thoracic) was modified. The comparison of the mean forces revealed that when the cushion was not inflated, the pressure distribution was mainly localized in the pelvic area. After the cushion was inflated, a significant decrease of contact pressure in the pelvic region and a significant increase in the lumbar area were observed. Our results confirm the hypothesis that a lumbar support inserted in a mattress allows a more homogenous distribution of contact pressure over the pelvic, lumbar and thoracic areas during supine posture. The use of an inflatable cushion favouring a transition of the contact pressure from the pelvic to the lumbar region could potentially limit unfavourable compressive and shearing forces acting on the lumbar spine.
PMCID: PMC1840018  PMID: 17549199
lumbar support; mattress; lying posture; contact pressure
25.  Isometric force production parameters during normal and experimental low back pain conditions 
The control of force and its between-trial variability are often taken as critical determinants of motor performance. Subjects performed isometric trunk flexion and extension forces without and with experiment pain to examine if pain yields changes in the control of trunk forces. The objective of this study is to determine if experimental low back pain modifies trunk isometric force production.
Ten control subjects participated in this study. They were required to exert 50 and 75% of their isometric maximal trunk flexion and extension torque. In a learning phase preceding the non painful and painful trials, visual and verbal feedbacks were provided. Then, subjects were asked to perform 10 trials without any feedback. Time to peak torque, time to peak torque variability, peak torque variability as well as constant and absolute error in peak torque were calculated. Time to peak and peak dF/dt were computed to determine if the first peak of dF/dt could predict the peak torque achieved.
Absolute and constant errors were higher in the presence of a painful electrical stimulation. Furthermore, peak torque variability for the higher level of force was increased with in the presence of experimental pain. The linear regressions between peak dF/dt, time to peak dF/dt and peak torque were similar for both conditions. Experimental low back pain yielded increased absolute and constant errors as well as a greater peak torque variability for the higher levels of force. The control strategy, however, remained the same between the non painful and painful condition. Cutaneous pain affects some isometric force production parameters but modifications of motor control strategies are not implemented spontaneously.
It is hypothesized that adaptation of motor strategies to low back pain is implemented gradually over time. This would enable LBP patients to perform their daily tasks with presumably less pain and more accuracy.
PMCID: PMC549631  PMID: 15703067

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