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1.  A new method to quantify male pelvic floor displacement from 2D transperineal ultrasound images 
Urology  2013;81(3):685-689.
To develop a method to quantify displacement of pelvic structures during contraction of the pelvic floor muscles from transperineal ultrasound images in men and investigate the reliability of the method between days.
Ten healthy male volunteers (aged 28 – 41 years) attended two separate data collection sessions. Ultrasound images were recorded during voluntary pelvic floor muscle contractions in cine-loop (video) format with the transducer aligned in the mid-sagittal plane on the perineum. Five anatomical points were defined to represent contraction from striated urethral sphincter (SUS), levator ani (LA) and bulbocavernosus (BC) muscles. Displacement of each point was calculated between the relaxed and contracted-state images. Intra-class correlation coefficient (ICC) values were calculated from displacement data to assess reliability of the method between days.
Displacements of the five anatomical points closely matched predictions based on anatomical considerations of the male pelvic musculature. ICC values for displacement data calculated from 1, 2 and 3 repetitions ranged between 0.82–0.95 for ICC (2,1), 0.85–0.97 for ICC (2,2) and 0.86–0.97 for ICC (2,3), respectively.
The new method reliably calculates displacements of points previously validated for females (Ano-rectal junction and bladder base) in addition to new measures of muscle actions (SUS and BC) specific to men. Future use might include assessment of clinical populations to understand how these displacements relate to symptoms of incontinence.
PMCID: PMC4123322  PMID: 23332998
Perineal ultrasound imaging; male continence; striated urethral sphincter; urinary incontinence
2.  Activation of the striated urethral sphincter to maintain continence during dynamic tasks in healthy men 
Neurourology and urodynamics  2011;31(1):36-43.
Function of the striated urethral sphincter (SUS) in men is debated. Current evidence is limited to electromyographic (EMG) recordings made with concentric needle electrodes in supine. Understanding of SUS function requires investigation of SUS EMG activity using new recording techniques in dynamic tasks. The aim of this study was to evaluate timing and amplitude of SUS EMG at rest and during dynamic tasks that challenge continence by increasing intra-abdominal pressure (IAP).
Investigative study of five healthy men aged 25–39 years. Measurements included SUS, anal sphincter (AS) and transversus abdominus (TrA) EMG, and IAP (recorded with a naso-gastric pressure catheter). Participants performed four tasks that challenged postural control in standing (single and repetitive arm movement, stepping and load catching).
IAP amplitude and SUS activity were linearly correlated during repetitive arm movement (R2: 0.67–0.88). During stepping SUS EMG onset preceded the IAP increase, but followed it with rapid arm movements. When the trunk was loaded unpredictably onset of SUS generally followed the increase in IAP. The modest sample size meant only younger men were tested. Future studies might investigate healthy older men or those with certain pathologies.
Data show that SUS activity increases proportionally with IAP. This provided evidence that SUS contributes to continence when IAP is increased, and that postural control of the trunk involves activation of this muscle.
PMCID: PMC4118456  PMID: 21780175
activity; continence; electromyography; electrode; function; male; sphincter; urinary incontinence
3.  Novel insight into the dynamics of male pelvic floor contractions through transperineal ultrasound imaging 
The Journal of urology  2012;188(4):1224-1230.
Transperineal ultrasound imaging (US) enables minimally invasive assessment of pelvic floor muscle function. Although commonly used in females, the approach has not been reported in males. This approach has advantages because the mid-sagittal view visualises a bony landmark and the entire urethral length. This allows investigation of displacement of multiple points along the urethra and the unique mechanical actions of multiple muscles that could influence continence. We used a new transperineal US technique to compare relative displacement of urethra-vesical junction, ano-rectal junction, and distal urethra during voluntary pelvic floor muscle contractions in continent men.
Materials and Methods
Measurement and comparison of urethral displacement at specific urethral regions in ten continent males (28-41 years). Measures made on 2D mid-sagittal plane ultrasound images included the displacements of specific points along the urethra. Anatomic considerations suggest that these are caused by contraction of the levator ani, striated urethral sphincter and bulbocavernosus muscles. Pearson's correlation coefficient was used in investigate the relationship between displacements of pairs of points.
Data show individual variation in displacement of the distal urethra (striated urethral sphincter contraction) and urethra-vesical junction (levator ani contraction). A strong inverse linear relationship (0.723) between displacements of these points indicates two alternative strategies of urethral movement.
Transperineal US imaging allows simultaneous investigation of multiple pelvic floor muscles by measurement of urethral displacement. Data provide evidence of different but coordinated strategies of urethral displacement in males.
PMCID: PMC4106154  PMID: 22902016
perineal; ultrasound imaging; male continence; striated urethral sphincter; urinary incontinence
4.  Measuring the Lifespace of People With Parkinson’s Disease Using Smartphones: Proof of Principle 
JMIR mHealth and uHealth  2014;2(1):e13.
Lifespace is a multidimensional construct that describes the geographic area in which a person lives and conducts their activities, and reflects mobility, health, and well-being. Traditionally, it has been measured by asking older people to self-report the length and frequency of trips taken and assistance required. Global Positioning System (GPS) sensors on smartphones have been used to measure Lifespace of older people, but not with people with Parkinson’s disease (PD).
The objective of this study was to investigate whether GPS data collected via smartphones could be used to indicate the Lifespace of people with PD.
The dataset was supplied via the Michael J Fox Foundation Data Challenge and included 9 people with PD and 7 approximately matched controls. Participants carried smartphones with GPS sensors over two months. Data analysis compared the PD group and the control group. The impact of symptom severity on Lifespace was also investigated.
Visualization methods for comparing Lifespace were developed including scatterplots and heatmaps. Lifespace metrics for comparison included average daily distance, percentage of time spent at home, and number of trips into the community. There were no significant differences between the PD and the control groups on Lifespace metrics. Visual representations of Lifespace were organized based on the self-reported severity of symptoms, suggesting a trend of decreasing Lifespace with increasing PD symptoms.
Lifespace measured by GPS-enabled smartphones may be a useful concept to measure the progression of PD and the impact of various therapies and rehabilitation programs. Directions for future use of GPS-based Lifespace are provided.
PMCID: PMC4114414  PMID: 25100206
Parkinson's disease; community; telemedicine; mHealth
5.  Combined exercise and transcranial direct current stimulation intervention for knee osteoarthritis: protocol for a pilot randomised controlled trial 
BMJ Open  2015;5(8):e008482.
Osteoarthritis (OA) is a major health problem and a leading cause of disability. The knee joint is commonly affected, resulting in pain and physical dysfunction. Exercise is considered the cornerstone of conservative management, yet meta-analyses indicate, at best, moderate effect sizes. Treatments that bolster the effects of exercise, such as transcranial direct current stimulation (tDCS), may improve outcomes in knee OA. The aims of this pilot study are to (1) determine the feasibility, safety and perceived patient response to a combined tDCS and exercise intervention in knee OA, and (2) provide data to support a sample size calculation for a fully-powered trial should trends of effectiveness be present.
Methods and analysis
A pilot randomised, assessor-blind and participant-blind, sham-controlled trial. 20 individuals with knee OA who report a pain score of 40 or more on a 100 mm visual analogue scale on walking, and meet a priori selection criteria will be randomly allocated to receive either: (1) active tDCS plus exercise, or (2) sham tDCS plus exercise. All participants will receive 20 min of either active or sham tDCS immediately prior to 30 min of supervised muscle strengthening exercise twice a week for 8 weeks. Participants in both groups will also complete unsupervised home exercises twice per week. Outcome measures of feasibility, safety, pain, disability and pain system function will be assessed immediately before and after the 8-week intervention. Analyses of feasibility and safety will be performed using descriptive statistics. Statistical analyses will be used to determine trends of effectiveness and will be based on intention-to-treat as well as per protocol.
Ethics and dissemination
This study was approved by the institutional ethics committee (H10184). Written informed consent will be obtained from all participants. The results of this study will be submitted for peer-reviewed publication.
Trial registration number
PMCID: PMC4550738  PMID: 26297371
6.  Organisation of the motor cortex differs between people with and without knee osteoarthritis 
The aim of this study was to investigate possible differences in the organisation of the motor cortex in people with knee osteoarthritis (OA) and whether there is an association between cortical organisation and accuracy of a motor task.
fMRI data were collected while 11 participants with moderate/severe right knee OA (6 male, 69 ± 6 (mean ± SD) years) and seven asymptomatic controls (5 male, 64 ± 6 years) performed three visually guided, variable force, force matching motor tasks involving isolated isometric muscle contractions of: 1) quadriceps (knee), 2) tibialis anterior (ankle) and, 3) finger/thumb flexor (hand) muscles. fMRI data were used to map the loci of peak activation in the motor cortex during the three tasks and to assess whether there were differences in the organisation of the motor cortex between the groups for the three motor tasks. Root mean square of the difference between target and generated forces during muscle contraction quantified task accuracy.
A 4.1 mm anterior shift in the representation of the knee (p = 0.03) and swap of the relative position of the knee and ankle representations in the motor cortex (p = 0.003) were found in people with knee OA. Poorer performance of the knee task was associated with more anterior placement of motor cortex loci in people with (p = 0.05) and without (p = 0.02) knee OA.
Differences in the organisation of the motor cortex in knee OA was demonstrated in relation to performance of knee and ankle motor tasks and was related to quality of performance of the knee motor task. These results highlight the possible mechanistic link between cortical changes and modified motor behavior in people with knee OA.
PMCID: PMC4494800  PMID: 26080802
7.  Interventions to prevent back pain and back injury in nurses: a systematic review 
A systematic literature review was undertaken to assess the effectiveness of interventions that aim to prevent back pain and back injury in nurses. Ten relevant databases were searched; these were examined and reference lists checked. Two reviewers applied selection criteria, assessed methodological quality and extracted data from trials. A qualitative synthesis of evidence was undertaken and sensitivity analyses performed. Eight randomised controlled trials and eight non‐randomised controlled trials met eligibility criteria. Overall, study quality was poor, with only one trial classified as high quality. There was no strong evidence regarding the efficacy of any interventions aiming to prevent back pain and injury in nurses. The review identified moderate level evidence from multiple trials that manual handling training in isolation is not effective and multidimensional interventions are effective in preventing back pain and injury in nurses. Single trials provided moderate evidence that stress management programs do not prevent back pain and limited evidence that lumbar supports are effective in preventing back injury in nurses. There is conflicting evidence regarding the efficacy of exercise interventions and the provision of manual handling equipment and training. This review highlights the need for high quality randomised controlled studies to examine the effectiveness of interventions to prevent back pain and injury in nursing populations. Implications for future research are discussed.
PMCID: PMC2078392  PMID: 17522134
nurses; back pain; back injuries; intervention studies; review
8.  Trunk Muscle Activity Is Modified in Osteoporotic Vertebral Fracture and Thoracic Kyphosis with Potential Consequences for Vertebral Health 
PLoS ONE  2014;9(10):e109515.
This study explored inter-relationships between vertebral fracture, thoracic kyphosis and trunk muscle control in elderly people with osteoporosis. Osteoporotic vertebral fractures are associated with increased risk of further vertebral fractures; but underlying mechanisms remain unclear. Several factors may explain this association, including changes in postural alignment (thoracic kyphosis) and altered trunk muscle contraction patterns. Both factors may increase risk of further fracture because of increased vertebral loading and impaired balance, which may increase falls risk. This study compared postural adjustments in 24 individuals with osteoporosis with and without vertebral fracture and with varying degrees of thoracic kyphosis. Trunk muscle electromyographic activity (EMG) associated with voluntary arm movements was recorded and compared between individuals with and without vertebral fracture, and between those with low and high thoracic kyphosis. Overall, elderly participants in the study demonstrated co-contraction of the trunk flexor and extensor muscles during forwards arm movements, but those with vertebral fractures demonstrated a more pronounced co-contraction than those without fracture. Individuals with high thoracic kyphosis demonstrated more pronounced alternating flexor and extensor EMG bursts than those with less kyphosis. Co-contraction of trunk flexor and extensor muscles in older individuals contrasts the alternating bursts of antagonist muscle activity in previous studies of young individuals. This may have several consequences, including altered balance efficacy and the potential for increased compressive loads through the spine. Both of these outcomes may have consequences in a population with fragile vertebrae who are susceptible to fracture.
PMCID: PMC4186857  PMID: 25285908
9.  Concurrent Validity of Accelerations Measured Using a Tri-Axial Inertial Measurement Unit while Walking on Firm, Compliant and Uneven Surfaces 
PLoS ONE  2014;9(5):e98395.
Although accelerometers are extensively used for assessing gait, limited research has evaluated the concurrent validity of these devices on less predictable walking surfaces or the comparability of different methods used for gravitational acceleration compensation. This study evaluated the concurrent validity of trunk accelerations derived from a tri-axial inertial measurement unit while walking on firm, compliant and uneven surfaces and contrasted two methods used to remove gravitational accelerations; i) subtraction of the best linear fit from the data (detrending); and ii) use of orientation information (quaternions) from the inertial measurement unit. Twelve older and twelve younger adults walked at their preferred speed along firm, compliant and uneven walkways. Accelerations were evaluated for the thoracic spine (T12) using a tri-axial inertial measurement unit and an eleven-camera Vicon system. The findings demonstrated excellent agreement between accelerations derived from the inertial measurement unit and motion analysis system, including while walking on uneven surfaces that better approximate a real-world setting (all differences <0.16 m.s−2). Detrending produced slightly better agreement between the inertial measurement unit and Vicon system on firm surfaces (delta range: −0.05 to 0.06 vs. 0.00 to 0.14 m.s−2), whereas the quaternion method performed better when walking on compliant and uneven walkways (delta range: −0.16 to −0.02 vs. −0.07 to 0.07 m.s−2). The technique used to compensate for gravitational accelerations requires consideration in future research, particularly when walking on compliant and uneven surfaces. These findings demonstrate trunk accelerations can be accurately measured using a wireless inertial measurement unit and are appropriate for research that evaluates healthy populations in complex environments.
PMCID: PMC4035289  PMID: 24866262
10.  Does Stress within a Muscle Change in Response to an Acute Noxious Stimulus? 
PLoS ONE  2014;9(3):e91899.
Altered muscle activation during pain is thought to redistribute stress within muscles and ultimately decrease the load on painful structures. However, change in muscle stress during pain has not been directly tested. The aim of the present study is to determine whether stress within muscle tissue is reduced during local acute experimental pain.
Methods and Results
Ten participants attended 2 experimental sessions that each involved isometric knee extension tasks in 2 series of control trials and 1 series of test trials at ∼10%MVC. Shear elastic modulus was measured from vastus lateralis using a shear wave elastographic technique (Supersonic Shear Imaging). Prior to the test contractions, a bolus of hypertonic (Pain) or isotonic saline (No-pain) was injected into vastus lateralis. Pain intensity was 5.2±1.0 during the painful contractions. The intra-session repeatability of the shear elastic modulus determined between control trials was good (ICC: 0.95 and 0.99; SEM: 5.1 and 9.3 kPa for No-pain and Pain, respectively). Muscle shear elastic modulus did not change systematically during Pain or No-pain contractions (all main effects and interaction P>0.14). Examination of data for individual participants showed that stress either increased or decreased. If the absolute change in modulus is considered between the control and the test trials, the change during Pain (16.2±9.5 kPa) was double that observed with No pain (7.9±5.9 kPa; P = 0.046).
This is the first study to directly determine the change in stress within a muscle (change in shear elastic modulus) during pain. We conclude that experimental pain induced by hypertonic saline does not induce a systematic reduction in muscle stress during a single-joint isometric task. Therefore, the changes in muscle activity reported previously during similar tasks are unlikely to systematically reduce load in the painful region. Whether the individual-specific increase and decrease are physiologically relevant or purposeful requires further investigation.
PMCID: PMC3953640  PMID: 24626150
11.  Texting and Walking: Strategies for Postural Control and Implications for Safety 
PLoS ONE  2014;9(1):e84312.
There are concerns about the safety of texting while walking. Although evidence of negative effects of mobile phone use on gait is scarce, cognitive distraction, altered mechanical demands, and the reduced visual field associated with texting are likely to have an impact. In 26 healthy individuals we examined the effect of mobile phone use on gait. Individuals walked at a comfortable pace in a straight line over a distance of ∼8.5 m while; 1) walking without the use of a phone, 2) reading text on a mobile phone, or 3) typing text on a mobile phone. Gait performance was evaluated using a three-dimensional movement analysis system. In comparison with normal waking, when participants read or wrote text messages they walked with: greater absolute lateral foot position from one stride to the next; slower speed; greater rotation range of motion (ROM) of the head with respect to global space; the head held in a flexed position; more in-phase motion of the thorax and head in all planes, less motion between thorax and head (neck ROM); and more tightly organized coordination in lateral flexion and rotation directions. While writing text, participants walked slower, deviated more from a straight line and used less neck ROM than reading text. Although the arms and head moved with the thorax to reduce relative motion of the phone and facilitate reading and texting, movement of the head in global space increased and this could negatively impact the balance system. Texting, and to a lesser extent reading, modify gait performance. Texting or reading on a mobile phone may pose an additional risk to safety for pedestrians navigating obstacles or crossing the road.
PMCID: PMC3898913  PMID: 24465402
12.  Fear of Movement Is Related to Trunk Stiffness in Low Back Pain 
PLoS ONE  2013;8(6):e67779.
Psychological features have been related to trunk muscle activation patterns in low back pain (LBP). We hypothesised higher pain-related fear would relate to changes in trunk mechanical properties, such as higher trunk stiffness.
To evaluate the relationship between trunk mechanical properties and psychological features in people with recurrent LBP.
The relationship between pain-related fear (Tampa Scale for Kinesiophobia, TSK; Photograph Series of Daily Activities, PHODA-SeV; Fear Avoidance Beliefs Questionnaire, FABQ; Pain Catastrophizing Scale, PCS) and trunk mechanical properties (estimated from the response of the trunk to a sudden sagittal plane forwards or backwards perturbation by unpredictable release of a load) was explored in a case-controlled study of 14 LBP participants. Regression analysis (r2) tested the linear relationships between pain-related fear and trunk mechanical properties (trunk stiffness and damping). Mechanical properties were also compared with t-tests between groups based on stratification according to high/low scores based on median values for each psychological measure.
Fear of movement (TSK) was positively associated with trunk stiffness (but not damping) in response to a forward perturbation (r2 = 0.33, P = 0.03), but not backward perturbation (r2 = 0.22, P = 0.09). Other pain-related fear constructs (PHODA-SeV, FABQ, PCS) were not associated with trunk stiffness or damping. Trunk stiffness was greater for individuals with high kinesiophobia (TSK) for forward (P = 0.03) perturbations, and greater with forward perturbation for those with high fear avoidance scores (FABQ-W, P = 0.01).
Fear of movement is positively (but weakly) associated with trunk stiffness. This provides preliminary support an interaction between biological and psychological features of LBP, suggesting this condition may be best understood if these domains are not considered in isolation.
PMCID: PMC3694850  PMID: 23826339
13.  The effect of electrical stimulation on corticospinal excitability is dependent on application duration: a same subject pre-post test design 
In humans, corticospinal excitability is known to increase following motor electrical stimulation (ES) designed to mimic a voluntary contraction. However, whether the effect is equivalent with different application durations and whether similar effects are apparent for short and long applications is unknown. The aim of this study was to investigate whether the duration of peripheral motor ES influenced its effect on corticospinal excitability.
The excitability of the corticomotor pathway to abductor pollicis brevis (APB) was measured in fourteen health subjects using transcranial magnetic stimulation before, immediately after and 10 minutes after three different durations (20-, 40-, 60-min) of motor ES (30Hz, ramped). This intervention was designed to mimic a voluntary contraction in APB. To control for effects of motor ES on the peripheral elements (muscle fibre, membrane, neuromuscular junction), maximum compound muscle actions potentials (M-waves) were also recorded at each time point. Results were analysed using a repeated measures analysis of variance.
Peripheral excitability was reduced following all three motor ES interventions. Conversely, corticospinal excitability was increased immediately following 20- and 40-min applications of motor ES and this increase was maintained at least 20-min following the intervention. A 60-min application of motor ES did not alter corticospinal excitability.
A 20-min application of motor ES that is designed to mimic voluntary muscle contraction is as effective as that applied for 40-min when the aim of the intervention is to increase corticospinal excitability. Longer motor ES durations of 60-min do not influence corticospinal excitability, possibly as a result of homeostatic plasticity mechanisms.
PMCID: PMC3688368  PMID: 23758902
Electrical stimulation therapy; Homeostatic plasticity; Transcranial magnetic stimulation; Physical therapy modalities; Rehabilitation
14.  Primary Sensory and Motor Cortex Excitability Are Co-Modulated in Response to Peripheral Electrical Nerve Stimulation 
PLoS ONE  2012;7(12):e51298.
Peripheral electrical stimulation (PES) is a common clinical technique known to induce changes in corticomotor excitability; PES applied to induce a tetanic motor contraction increases, and PES at sub-motor threshold (sensory) intensities decreases, corticomotor excitability. Understanding of the mechanisms underlying these opposite changes in corticomotor excitability remains elusive. Modulation of primary sensory cortex (S1) excitability could underlie altered corticomotor excitability with PES. Here we examined whether changes in primary sensory (S1) and motor (M1) cortex excitability follow the same time-course when PES is applied using identical stimulus parameters. Corticomotor excitability was measured using transcranial magnetic stimulation (TMS) and sensory cortex excitability using somatosensory evoked potentials (SEPs) before and after 30 min of PES to right abductor pollicis brevis (APB). Two PES paradigms were tested in separate sessions; PES sufficient to induce a tetanic motor contraction (30–50 Hz; strong motor intensity) and PES at sub motor-threshold intensity (100 Hz). PES applied to induce strong activation of APB increased the size of the N20-P25 component, thought to reflect sensory processing at cortical level, and increased corticomotor excitability. PES at sensory intensity decreased the size of the P25-N33 component and reduced corticomotor excitability. A positive correlation was observed between the changes in amplitude of the cortical SEP components and corticomotor excitability following sensory and motor PES. Sensory PES also increased the sub-cortical P14-N20 SEP component. These findings provide evidence that PES results in co-modulation of S1 and M1 excitability, possibly due to cortico-cortical projections between S1 and M1. This mechanism may underpin changes in corticomotor excitability in response to afferent input generated by PES.
PMCID: PMC3515545  PMID: 23227260
15.  The effects of neuromuscular exercise on medial knee joint load post-arthroscopic partial medial meniscectomy: ‘SCOPEX’ a randomised control trial protocol 
Meniscectomy is a risk factor for knee osteoarthritis, with increased medial joint loading a likely contributor to the development and progression of knee osteoarthritis in this group. Therefore, post-surgical rehabilitation or interventions that reduce medial knee joint loading have the potential to reduce the risk of developing or progressing osteoarthritis. The primary purpose of this randomised, assessor-blind controlled trial is to determine the effects of a home-based, physiotherapist-supervised neuromuscular exercise program on medial knee joint load during functional tasks in people who have recently undergone a partial medial meniscectomy.
62 people aged 30–50 years who have undergone an arthroscopic partial medial meniscectomy within the previous 3 to 12 months will be recruited and randomly assigned to a neuromuscular exercise or control group using concealed allocation. The neuromuscular exercise group will attend 8 supervised exercise sessions with a physiotherapist and will perform 6 exercises at home, at least 3 times per week for 12 weeks. The control group will not receive the neuromuscular training program. Blinded assessment will be performed at baseline and immediately following the 12-week intervention. The primary outcomes are change in the peak external knee adduction moment measured by 3-dimensional analysis during normal paced walking and one-leg rise. Secondary outcomes include the change in peak external knee adduction moment during fast pace walking and one-leg hop and change in the knee adduction moment impulse during walking, one-leg rise and one-leg hop, knee and hip muscle strength, electromyographic muscle activation patterns, objective measures of physical function, as well as self-reported measures of physical function and symptoms and additional biomechanical parameters.
The findings from this trial will provide evidence regarding the effect of a home-based, physiotherapist-supervised neuromuscular exercise program on medial knee joint load during various tasks in people with a partial medial meniscectomy. If shown to reduce the knee adduction moment, neuromuscular exercise has the potential to prevent the onset of osteoarthritis or slow its progression in those with early disease.
Trial Registration
Australian New Zealand Clinical Trials Registry reference: ACTRN12612000542897
PMCID: PMC3529104  PMID: 23181415
16.  Physiotherapy movement based classification approaches to low back pain: comparison of subgroups through review and developer/expert survey 
Several classification schemes, each with its own philosophy and categorizing method, subgroup low back pain (LBP) patients with the intent to guide treatment. Physiotherapy derived schemes usually have a movement impairment focus, but the extent to which other biological, psychological, and social factors of pain are encompassed requires exploration. Furthermore, within the prevailing 'biological' domain, the overlap of subgrouping strategies within the orthopaedic examination remains unexplored. The aim of this study was "to review and clarify through developer/expert survey, the theoretical basis and content of physical movement classification schemes, determine their relative reliability and similarities/differences, and to consider the extent of incorporation of the bio-psycho-social framework within the schemes".
A database search for relevant articles related to LBP and subgrouping or classification was conducted. Five dominant movement-based schemes were identified: Mechanical Diagnosis and Treatment (MDT), Treatment Based Classification (TBC), Pathoanatomic Based Classification (PBC), Movement System Impairment Classification (MSI), and O'Sullivan Classification System (OCS) schemes. Data were extracted and a survey sent to the classification scheme developers/experts to clarify operational criteria, reliability, decision-making, and converging/diverging elements between schemes. Survey results were integrated into the review and approval obtained for accuracy.
Considerable diversity exists between schemes in how movement informs subgrouping and in the consideration of broader neurosensory, cognitive, emotional, and behavioural dimensions of LBP. Despite differences in assessment philosophy, a common element lies in their objective to identify a movement pattern related to a pain reduction strategy. Two dominant movement paradigms emerge: (i) loading strategies (MDT, TBC, PBC) aimed at eliciting a phenomenon of centralisation of symptoms; and (ii) modified movement strategies (MSI, OCS) targeted towards documenting the movement impairments associated with the pain state.
Schemes vary on: the extent to which loading strategies are pursued; the assessment of movement dysfunction; and advocated treatment approaches. A biomechanical assessment predominates in the majority of schemes (MDT, PBC, MSI), certain psychosocial aspects (fear-avoidance) are considered in the TBC scheme, certain neurophysiologic (central versus peripherally mediated pain states) and psychosocial (cognitive and behavioural) aspects are considered in the OCS scheme.
PMCID: PMC3395852  PMID: 22348236
17.  Comparison of neuromuscular and quadriceps strengthening exercise in the treatment of varus malaligned knees with medial knee osteoarthritis: a randomised controlled trial protocol 
Osteoarthritis of the knee involving predominantly the medial tibiofemoral compartment is common in older people, giving rise to pain and loss of function. Many people experience progressive worsening of the disease over time, particularly those with varus malalignment and increased medial knee joint load. Therefore, interventions that can reduce excessive medial knee loading may be beneficial in reducing the risk of structural progression. Traditional quadriceps strengthening can improve pain and function in people with knee osteoarthritis but does not appear to reduce medial knee load. A neuromuscular exercise program, emphasising optimal alignment of the trunk and lower limb joints relative to one another, as well as quality of movement performance, while dynamically and functionally strengthening the lower limb muscles, may be able to reduce medial knee load. Such a program may also be superior to traditional quadriceps strengthening with respect to improved pain and physical function because of the functional and dynamic nature. This randomised controlled trial will investigate the effect of a neuromuscular exercise program on medial knee joint loading, pain and function in individuals with medial knee joint osteoarthritis. We hypothesise that the neuromuscular program will reduce medial knee load as well as pain and functional limitations to a greater extent than a traditional quadriceps strengthening program.
100 people with medial knee pain, radiographic medial compartment osteoarthritis and varus malalignment will be recruited and randomly allocated to one of two 12-week exercise programs: quadriceps strengthening or neuromuscular exercise. Each program will involve 14 supervised exercise sessions with a physiotherapist plus four unsupervised sessions per week at home. The primary outcomes are medial knee load during walking (the peak external knee adduction moment from 3D gait analysis), pain, and self-reported physical function measured at baseline and immediately following the program. Secondary outcomes include the external knee adduction moment angular impulse, electromyographic muscle activation patterns, knee and hip muscle strength, balance, functional ability, and quality-of-life.
The findings will help determine whether neuromuscular exercise is superior to traditional quadriceps strengthening regarding effects on knee load, pain and physical function in people with medial knee osteoarthritis and varus malalignment.
Trial Registration
Australian New Zealand Clinical Trials Registry reference: ACTRN12610000660088
PMCID: PMC3247187  PMID: 22141334
18.  Is the psoas a hip flexor in the active straight leg raise? 
European Spine Journal  2010;20(5):759-765.
Psoas function is a topic of considerable relevance in sports and clinical science. However, the literature on psoas function is not sufficiently consistent. Questions are, amongst others, if during hip flexion the psoas always has the same function as the iliacus, and if the psoas affects the hip more than the lumbar spine. In the present study, 17 healthy women, 20–40 years, performed the active straight leg raise (ASLR), with the right or the left leg (“Side”), and without or with weight added above the ankle (“Condition”). Electromyographic (EMG) activity of psoas and iliacus were recorded with fine-wire electrodes, and of rectus femoris and adductor longus with surface electrodes, all on the right side. Movements of the leg were recorded with active markers and a camera system. During ASLR, the iliacus, rectus femoris, adductor longus and psoas were active ipsilaterally, but psoas was also active contralaterally. All muscles started to contract before movement onset, the iliacus, rectus femoris, and adductor longus largely at the same time, before the psoas. There was no significant difference between the amplitude or time of onset of ipsilateral and contralateral psoas EMG activity, nor was there a significant interaction between Side and Condition for the psoas. Although ipsilateral psoas activity is consistent with the psoas being a hip flexor, contralateral activity is not. The most simplest explanation of the pattern found is that the psoas is bilaterally recruited to stabilize the lumbar spine, probably in the frontal plane.
PMCID: PMC3082678  PMID: 20625774
M. psoas; Hip flexion; Fine-wire EMG; Lumbar spine stability; Active straight leg raise
19.  An investigation of the reproducibility of ultrasound measures of abdominal muscle activation in patients with chronic non-specific low back pain 
European Spine Journal  2009;18(7):1059-1065.
Ultrasound (US) measures are used by clinicians and researchers to evaluate improvements in activity of the abdominal muscles in patients with low back pain. Studies evaluating the reproducibility of these US measures provide some information; however, little is known about the reproducibility of these US measures over time in patients with low back pain. The objectives of this study were to estimate the reproducibility of ultrasound measurements of automatic activation of the lateral abdominal wall muscles using a leg force task in patients with chronic low back pain. Thirty-five participants from an existing randomised, blinded, placebo-controlled trial participated in the study. A reproducibility analysis was undertaken from all patients using data collected at baseline and after treatment. The reproducibility of measurements of thickness, muscle activation (thickness changes) and muscle improvement/deterioration after intervention (differences in thickness changes from single images made before and after treatment) was analysed. The reproducibility of static images (thickness) was excellent (ICC2,1 = 0.97, 95% CI = 0.96–0.97, standard error of the measurement (SEM) = 0.04 cm, smallest detectable change (SDC) = 0.11 cm), the reproducibility of thickness changes was moderate (ICC2,1 = 0.72, 95% CI 0.65–0.76, SEM = 15%, SDC 41%), while the reproducibility of differences in thickness changes from single images with statistical adjustment for duplicate measures was poor (ICC2,1 = 0.44, 95% CI 0.33–0.58, SEM = 21%, SDC = 66.5%). Improvements in the testing protocol must be performed in order to enhance reproducibility of US as an outcome measure for abdominal muscle activation.
PMCID: PMC2899591  PMID: 19415347
Ultrasound; Abdominal muscles; Reproducibility; Agreement; Reliability
20.  Paraspinal muscle control in people with osteoporotic vertebral fracture 
European Spine Journal  2007;16(8):1137-1144.
The high risk of sustaining subsequent vertebral fractures after an initial fracture cannot be explained solely by low bone mass. Extra-osseous factors, such as neuromuscular characteristics may help to explain this clinical dilemma. Elderly women with (n = 11) and without (n = 14) osteoporotic vertebral fractures performed rapid shoulder flexion to perturb the trunk while standing on a flat and short base. Neuromuscular postural responses of the paraspinal muscles at T6 and T12, and deep lumbar multifidus at L4 were recorded using intramuscular electromyography (EMG). Both groups demonstrated bursts of EMG that were initiated either before or shortly after the onset of shoulder flexion (P < 0.05). Paraspinal and multifidus onset occurred earlier in the non-fracture group (50–0 ms before deltoid onset) compared to the fracture group (25 ms before and 25 ms after deltoid onset) in the flat base condition. In the short base condition, EMG amplitude increased significantly above baseline earlier in the non-fracture group (75–25 ms before deltoid onset) compared to the fracture group (25–0 ms before deltoid onset) at T6 and T12; yet multifidus EMG increased above baseline earlier in the fracture group (50–25 ms before deltoid) compared to the non-fracture group (25–0 ms before deltoid). Time to reach maximum amplitude was shorter in the fracture group. Hypothetically, the longer time to initiate a postural response and shorter time to reach maximum amplitude in the fracture group may indicate a neuromuscular contribution towards subsequent fracture aetiology. This response could also be an adaptive characteristic of the central nervous system to minimise vertebral loading time.
PMCID: PMC2200788  PMID: 17203276
Osteoporosis; Vertebral fracture; Paraspinal muscle; Electromyography; Neuromuscular control
21.  Motor control or graded activity exercises for chronic low back pain? A randomised controlled trial 
Chronic low back pain remains a major health problem in Australia and around the world. Unfortunately the majority of treatments for this condition produce small effects because not all patients respond to each treatment. It appears that only 25–50% of patients respond to exercise. The two most popular types of exercise for low back pain are graded activity and motor control exercises. At present however, there are no guidelines to help clinicians select the best treatment for a patient. As a result, time and money are wasted on treatments which ultimately fail to help the patient.
This paper describes the protocol of a randomised clinical trial comparing the effects of motor control exercises with a graded activity program in the treatment of chronic non specific low back pain. Further analysis will identify clinical features that may predict a patient's response to each treatment. One hundred and seventy two participants will be randomly allocated to receive either a program of motor control exercises or graded activity. Measures of outcome will be obtained at 2, 6 and 12 months after randomisation. The primary outcomes are: pain (average pain intensity over the last week) and function (patient-specific functional scale) at 2 and 6 months. Potential treatment effect modifiers will be measured at baseline.
This trial will not only evaluate which exercise approach is more effective in general for patients will chronic low back pain, but will also determine which exercise approach is best for an individual patient.
Trial registration number
PMCID: PMC2409320  PMID: 18454877
22.  Differential activity of regions of transversus abdominis during trunk rotation 
European Spine Journal  2004;14(4):393-400.
The role of the abdominal muscles in trunk rotation is not comprehensively understood. This study investigated the electromyographic (EMG) activity of anatomically distinct regions of the abdominal muscles during trunk rotation in six subjects with no history of spinal pain. Fine-wire electrodes were inserted into the right abdominal wall; upper region of transversus abdominis (TrA), middle region of TrA, obliquus internus abdominis (OI) and obliquus externus abdominis (OE), and lower region of TrA and OI. Surface electrodes were placed over right rectus abdominis (RA). Subjects performed trunk rotation to the left and right in sitting by rotating their pelvis relative to a fixed thorax. EMG activity was recorded in relaxed supine and sitting, and during an isometric hold at end range. TrA was consistently active during trunk rotation, with the recruitment patterns of the upper fascicles opposite to that of the middle and lower fascicles. During left rotation, there was greater activity of the lower and middle regions of contralateral TrA and the lower region of contralateral OI. The upper region of ipsilateral TrA and OE were predominately active during right rotation. In contrast, there was no difference in activity of RA and middle OI between directions (although middle OI was different between directions for all but one subject). This study indicates that TrA is active during trunk rotation, but this activity varies between muscle regions. These normative data will assist in understanding the role of TrA in lumbopelvic control and movement, and the effect of spinal pain on abdominal muscle recruitment.
PMCID: PMC3489203  PMID: 15940481
Transversus abdominis; Trunk rotation; Regional recruitment; Abdominal muscles; Electromyography
23.  The effect of motor control exercise versus placebo in patients with chronic low back pain [ACTRN012605000262606] 
While one in ten Australians suffer from chronic low back pain this condition remains extremely difficult to treat. Many contemporary treatments are of unknown value. One potentially useful therapy is the use of motor control exercise. This therapy has a biologically plausible effect, is readily available in primary care and it is of modest cost. However, to date, the efficacy of motor control exercise has not been established.
This paper describes the protocol for a clinical trial comparing the effects of motor control exercise versus placebo in the treatment of chronic non-specific low back pain. One hundred and fifty-four participants will be randomly allocated to receive an 8-week program of motor control exercise or placebo (detuned short wave and detuned ultrasound). Measures of outcomes will be obtained at follow-up appointments at 2, 6 and 12 months after randomisation. The primary outcomes are: pain, global perceived effect and patient-generated measure of disability at 2 months and recurrence at 12 months.
This trial will be the first placebo-controlled trial of motor control exercise. The results will inform best practice for treating chronic low back pain and prevent its occurrence.
PMCID: PMC1291370  PMID: 16271149

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