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1.  Humeral Lateral Epicondylitis Complicated by Hydroxyapatite Dihydrite Deposition Disease: A Case Report 
The aim of this case report is to differentiate the recovery timeline expected for patients with simple lateral epicondylitis from an abnormal recovery period, in which case an underlying condition should be suspected.
Clinical features
A 49-year-old woman presented to a chiropractic clinic with posterolateral right elbow pain. The history included chronic recurrent lateral elbow pain, followed by a traumatic event leading to sustained pain and disability.
Intervention and outcomes
Following a trial of conservative therapy including activity restrictions, soft tissue therapy, joint mobilizations, and therapeutic ultrasonography that led to no significant improvement, the patient was referred for diagnostic imaging that revealed hydroxyapatite dihydrite deposition disease.
This report describes a case for which lateral epicondylitis symptoms failed to resolve because of an underlying condition (hydroxyapatite dihydrite deposition disease). This case emphasizes that primary care practitioners treating lateral epicondylitis should consider referral for further investigations when positive results are not achieved.
PMCID: PMC3976492  PMID: 24711788
Tennis elbow; Therapy; Chronic pain; Prognosis; Chiropractic
2.  Assessment of musculoskeletal symptoms and their impacts in the adolescent population: adaptation and validation of a questionnaire 
BMC Pediatrics  2014;14:173.
Valid and reliable instruments measuring musculoskeletal symptoms prevalence and their impacts in the adolescent population are scarce. The Extended Nordic Musculoskeletal Questionnaire (NMQ-E) is a reliable instrument that measures the prevalence, severity and impact of musculoskeletal symptoms. The purpose of this study was: (1) to develop a musculoskeletal symptom screening tool for younger populations derived from the NMQ-E and NMQ French versions and (2) to assess the validity and reliability of the adapted version of the instrument.
Based on the results of a translated (French) and adapted NMQ-E administered to 61 adolescents, a final 27-item dichotomous questionnaire was developed. The questionnaire measured the 6-month prevalence of musculoskeletal symptoms and the impact of these symptoms on school attendance as well as on sports and leisure activity participation. Among the adolescents who agreed to participate, thirty-nine (mean age: 13.7 ± 1.8) formed the reliability cohort and thirty-four (mean age: 14.2 ± 2.3) formed the criterion validity cohort. Reliability was measured by test-retest with a mean time interval of 28 hours. Criterion validity was assessed by comparing the answers to the questionnaires to the participants’ clinical records. Statistical tests used were proportions of observed agreement (Po) and the Cohen kappa statistic (k).
The mean Po for the test-retest was 0.92 for the 6-month symptom prevalence items, 0.99 for the impact of symptoms on school items and 0.96 for the impact on sports and leisure activities items. Kappa values for the reliability assessment ranged between 0.57 and 1.00 for the 27 dichotomous variables. The criterion validity kappa obtained for the agreement between participants’ clinical records and questionnaires was k = 0.76.
Kappa values for the reliability and the criterion validity are of moderate to perfect agreement beyond chance, indicating that there are only minor variations between tests, and good agreement between questionnaire items and clinical records. These results indicate that the adapted version of the NMQ-E is an appropriate self-administered musculoskeletal symptom screening tool for the adolescent population. Items related to the impacts of symptoms would benefit from additional validation using school and sport attendance records.
PMCID: PMC4107588  PMID: 24992817
Musculoskeletal symptoms; Adolescents; Musculoskeletal disorders; Validation
4.  The effect of spinal manipulation impulse duration on spine neuromechanical responses 
Spinal manipulation therapy (SMT) is characterized by specific kinetic and kinematic parameters that can be modulated. The purpose of this study is to investigate fundamental aspects of SMT dose-physiological response relation in humans by varying SMT impulse duration.
Twenty healthy adults were subjected to four different SMT force-time profiles delivered by a servo-controlled linear actuator motor and differing in their impulse duration. EMG responses of the left and right thoracic paraspinal muscles (T6 and T8 levels) and vertebral displacements of T7 and T8 were evaluated for all SMT phases.
Significant differences in paraspinal EMG were observed during the “Thrust phase” and immediately after (“Post-SMT1”) (all T8 ps < 0.01 and T6 during the thrust ps < 0.05). Sagittal vertebral displacements were similar across all conditions (p > 0.05).
Decreasing SMT impulse duration leads to a linear increase in EMG response of thoracic paraspinal during and following the SMT thrust.
PMCID: PMC4025084  PMID: 24932018
spine; manipulation; dose; impulse duration; chiropractic; colonne vertébrale; manipulation; dose; durée de l’impulsion; chiropratique
5.  Is performance in goal oriented head movements altered in patients with tension type headache? 
Head repositioning tasks have been used in different experimental and clinical contexts to quantitatively measure motor control performance. Effects of pain on sensorimotor control have often been described in various musculoskeletal conditions and may provide relevant information with regard to potential mechanisms underlying tension-type headaches. The purpose of the current study was to compare the performance of patients with tension-type headache and healthy participants in a cervical aiming task using the Fitts’ task paradigm.
Patients with tension-type headache and healthy controls were compared in a cervical aiming task. Participants were asked to move their head as quickly, and precisely as possible to a target under various experimental conditions. Dependent variables included movement time, variable error, constant error and absolute error.
As predicted by Fitts’ law, decreasing target size and increasing head rotation amplitudes yielded longer movement times in both groups. Participants with tension-type headache, when compared to healthy participants showed a significant increase in both constant and absolute errors for each of the four conditions.
Decreased motor performance was observed in participants with tension-type headache, likely due to altered motor control of the neck musculature. Future research is warranted to investigate the clinical aspect related to decrease in motor performance.
PMCID: PMC4049425  PMID: 24884672
Tension type headaches; Motor control; Cervical spine; Kinesthetic sense
6.  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
7.  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
8.  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
9.  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
10.  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
13.  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
14.  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
15.  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
16.  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
17.  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
18.  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
19.  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
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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