Camilla Marie Larsen

Neuromuscular control of scapula muscles during a voluntary task in subjects with Subacromial Impingement Syndrome. A case-control study

Imbalance of neuromuscular activity in the scapula stabilizers in subjects with Subacromial Impingement Syndrome (SIS) is described in restricted tasks and specific populations. Our aim was to compare the scapular muscle activity during a voluntary movement task in a general population with and without SIS (n=16, No-SIS=15). Surface electromyography was measured from Serratus anterior (SA) and Trapezius during bilateral arm elevation (no-load, 1kg, 3kg). Mean relative muscle activity was calculated for SA and the upper (UT) and lower part of trapezius (LWT), in addition to activation ratio and time to activity onset. In spite of a tendency to higher activity among SIS 0.10-0.30 between-group differences were not significant neither in ratio of muscle activation 0.80-0.98 nor time to activity onset 0.53-0.98. The hypothesized between-group differences in neuromuscular activity of Trapezius and Serratus was not confirmed. The tendency to a higher relative muscle activity in SIS could be due to a pain-related increase in co-activation or a decrease in maximal activation. The negative findings may display the variation in the specific muscle activation patterns depending on the criteria used to define the population of impingement patients, as well as the methodological procedure being used, and the shoulder movement investigated.

Inter-examiner reproducibility of clinical tests and criteria used to identify subacromial impingement syndrome

Introduction A specific algorithm has been proposed for classifying impingement related shoulder pain in athletes with overhead activity. Data on the inter-examiner reproducibility of the suggested clinical tests and criteria and their mutual dependencies for identifying subacromial impingement symptoms (SIS) are not available. Objective To test the inter-examiner reproducibility of selected tests and criteria suggested for classifying SIS and the mutual dependencies of each of the individual tests and SIS. Method A standardised three-phase protocol for clinical reproducibility studies was followed, consisting of a training, an overall agreement and a study phase. To proceed to the study phase, an overall agreement of 0.80 was required. In total 10, 20 and 44 subjects were included in the three phases, respectively. The case prevalence in the study phase was 50%. The inclusion criterion for cases was ≥3, and for controls ≤1 positive test out of four. Cohens κ statistics were used for calculating agreement. Results In the overall agreement phase, an agreement of 0.90 was obtained, while in the study phase it was 0.98 with a κ of 0.95 for SIS. κ Values for the individual tests varied between 0.60 and 0.95. Mutual dependencies between each test and SIS showed Neers test with anterior pain to be most often used to determine SIS. Conclusions Inter-examiner reproducibility was moderate to almost perfect for the selected tests and criteria for SIS. The next challenge will be to establish reproducibility in clinical practice, as well as the validity of the tests and criteria for SIS.

Selective activation of intra-muscular compartments within the trapezius muscle in subjects with Subacromial Impingement Syndrome. A case-control study

Neuromuscular control of the scapular muscles is important in the etiology of shoulder pain. Electromyographical (EMG) biofeedback in healthy people has been shown to support a selective activation of the lower compartment of the trapezius muscle, specifically. The aim of the present paper was to investigate whether patients with Subacromial Impingement Syndrome (SIS) were able to selectively activate the individual compartments within the trapezius muscle, with and without EMG biofeedback to the same extent as healthy controls (No-SIS). Fifteen SIS and 15 No-SIS participated in the study. Sessions with and without visual biofeedback were conducted. Surface EMG was recorded from four compartments of the trapezius muscle. Selective activation was defined as activation above 12% with other muscle parts below 1.5% or activation ratio at or above 95% of the total activation. Without biofeedback significantly fewer SIS subjects than No-SIS achieved selective activation (p=0.02-0.03). The findings of the study show that without biofeedback No-SIS had a superior scapular muscle control. However, when provided with visual EMG feedback the SIS group performed equally well as the No-SIS group. This indicated that individuals with SIS may benefit from biofeedback training to gain control of the neuromuscular function of the scapular muscle.

Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies

Introduction The leading cause of erectile dysfunction (ED) is arterial dysfunction, with cardiovascular disease as the most common comorbidity. Therefore, ED is typically linked to a web of closely interrelated cardiovascular risk factors such as physical inactivity, obesity, hypertension, and metabolic syndrome. Physical activity (PA) has proved to be a protective factor against erectile problems, and it has been shown to improve erectile function for men affected by vascular ED. This systematic review estimated the levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or manifest cardiovascular diseases. Aim To provide recommendations of levels of PA needed to decrease ED for men with physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. Methods In accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was performed of research articles specifically investigating PA as a possible treatment of ED. The review included research on ED from physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. All available studies from 2006 through 2016 were checked for the predetermined inclusion and exclusion criteria to analyze the levels of PA needed to decrease ED. Results 10 articles met the inclusion criteria, all suggesting various levels of PA needed to decrease ED for men with relevant risk factors for ED. The results of the review provided sufficient research evidence for conclusions regarding the levels of PA necessary to decrease ED. Conclusion Recommendations of PA to decrease ED should include supervised training consisting of 40 minutes of aerobic exercise of moderate to vigorous intensity 4 times per week. Overall, weekly exercise of 160 minutes for 6 months contributes to decreasing erectile problems in men with ED caused by physical inactivity, obesity, hypertension, metabolic syndrome, and/or cardiovascular diseases. Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical Activity to Improve Erectile Function: A Systematic Review of Intervention Studies. Sex Med 2018;6:75–89.

Competitive swimmers with hypermobility have strength and fatigue deficits in shoulder medial rotation

Generalised Joint Hypermobility including shoulder hypermobility (GJHS) in swimmers is considered an intrinsic risk factor for shoulder injuries. The aim was to investigate the association of GJHS with shoulder strength, fatigue development and muscle activity during swimming-related shoulder rotations. Totally, 38 competitive swimmers (aged 13-17 years) participated, 19 were competitive swimmers with GJHS and 19 were age, sex and club matched swimmers without GJHS. Concentric isokinetic force in medial and lateral rotations were measured at 60°/s (5 repetitions) and 180°/s (10 repetitions). Electromyographic activity was measured from upper trapezius, lower trapezius, serratus anterior, infraspinatus and pectoralis major muscles. Swimmers with GJHS produced significantly lower peak torque (0.53 vs. 0.60 Nm/kg; p = .047) and maximum work (0.62 vs. 0.71 J/kg; p = .031) than controls during medial rotation (60°/s). Swimmers with GJHS showed significantly larger isokinetic fatigue at 180°/s (0.321 J/repetition; p = .010), and tendencies to lower levels of muscle activity in infraspinatus (20%, p = .066) and pectoralis major (34%, p = .092) at 60°/s during medial rotation. Young competitive swimmers with GJHS, despite no formal diagnosis, displayed strength and fatigue deficits in medial rotation, potentially inherent with greater risk of shoulder injury. Whether GJHS swimmers benefit from medial rotation strengthening is an important topic for future studies.

Intertester reliability of clinical shoulder instability and laxity tests in subjects with and without self-reported shoulder problems

Objective First, to investigate the intertester reliability of clinical shoulder instability and laxity tests, and second, to describe the mutual dependency of each test evaluated by each tester for identifying self-reported shoulder instability and laxity. Methods A standardised protocol for conducting reliability studies was used to test the intertester reliability of the six clinical shoulder instability and laxity tests: apprehension, relocation, surprise, load-and-shift, sulcus sign and Gagey. Cohen’s kappa (κ) with 95% CIs besides prevalence-adjusted and bias-adjusted kappa (PABAK), accounting for insufficient prevalence and bias, were computed to establish the intertester reliability and mutual dependency. Results Forty individuals (13 with self-reported shoulder instability and laxity-related shoulder problems and 27 normal shoulder individuals) aged 18–60 were included. Fair (relocation), moderate (load-and-shift, sulcus sign) and substantial (apprehension, surprise, Gagey) intertester reliability were observed across tests (κ 0.39–0.73; 95% CI 0.00 to 1.00). PABAK improved reliability across tests, resulting in substantial to almost perfect intertester reliability for the apprehension, surprise, load-and-shift and Gagey tests (κ 0.65–0.90). Mutual dependencies between each test and self-reported shoulder problem showed apprehension, relocation and surprise to be the most often used tests to characterise self-reported shoulder instability and laxity conditions. Conclusions Four tests (apprehension, surprise, load-and-shift and Gagey) out of six were considered intertester reliable for clinical use, while relocation and sulcus sign tests need further standardisation before acceptable evidence. Furthermore, the validity of the tests for shoulder instability and laxity needs to be studied.

Interrater Reliability of the 6-Minute Walk Test in Women With Hip Fracture

Background and Purpose: The 6-minute walk test (6MWT) is widely used as a clinical outcome measure. However, the reliability of the 6MWT is unknown in individuals who have recently experienced a hip fracture. The aim of this study was to evaluate the relative and absolute interrater reliability of the 6MWT in individuals with hip fracture. Methods: Two senior physical therapy students independently examined a convenience sample of 20 participants in a randomized order. Their assessments were separated by 2 days and followed the guidelines of the American Thoracic Society. Hip fracture-related pain was assessed with the Verbal Ranking Scale. Results: Participants (all women) with a mean (standard deviation) age of 78.1 (5.9) years performed the test at a mean of 31.5 (5.8) days postsurgery. Of the participants, 10 had a cervical fracture and 10 had a trochanteric fracture. Excellent interrater reliability (intraclass correlation coefficient [ICC2.1] = 0.92; 95% confidence interval, 0.81-0.97) was found, and the standard error of measurement and smallest real difference were calculated to be 21.4 and 59.4 m, respectively. Bland-Altman plots revealed no significant difference (mean of 3.2 [31.5] m, P = .83) between the 2 raters, and no heteroscedasticity was observed (r = −0.196, P = .41). By contrast, participants walked an average of 21.7 (22.5) m longer during the second trial (P = .002). Participants with moderate hip fracture-related pain walked a shorter distance than those with no or light pain during the first test (P = .04), but this was not the case during the second test (P = .25). Conclusion: The interrater reliability of the 6MWT is excellent, and changes of more than 21.4 m (group level) and 59.4 m (individual participants with hip fracture) indicate a real change in the 6MWT. Measuring hip fracture-related pain during testing is recommended for individuals with hip fracture who undergo the 6MWT.

73 Methods for teaching evidence-based practice: a scoping review

Background EBP skills are essential requirements in clinical practice among health professionals. Further knowledge about teaching Professional Bachelor Degree healthcare students evidence-based practice at undergraduate level is however needed. This scoping review aims to gather recommendations for teaching evidence-based practice across Professional Bachelor’s Degree healthcare programmes by mapping literature describing teaching methods for undergraduate healthcare students including the five steps suggested by the Sicily Statement. Methods Three databases covering health, education and grey literature were searched. Full-text articles were screened by four reviewers and data extracted to two data extraction tools: Study characteristics and key methods of teaching evidence-based practice. Study characteristics were described narratively. Thematic analysis identified key methods for teaching evidence-based practice while full-text revisions identified the use of the Sicily Statement’s five steps and context. Results The database search identified 1908 records. 181 records were eligible for full-text assessment and 73 studies were included. Studies were conducted from 2010–2016. Seven key methods for teaching evidence-based practice were identified. Research courses and workshops, collaboration with clinical practice and IT technology were the key methods most frequently identified. Journal clubs and embedded librarians were referred to the least. The majority of the methods included 2–4 of the Sicily Statement five steps, while few methods referred to all five steps. Conclusions Collaboration with clinical practice is an advantageous method for teaching undergraduate healthcare students evidence-based practice; incorporating many of the Sicily Statements steps. Journal clubs and embedded librarians should be further investigated as methods to fortify existing methods of teaching.

Voluntary activation of the trapezius muscle in cases with neck/shoulder pain compared to healthy controls

Subjects reporting neck/shoulder pain have been shown to generate less force during maximal voluntary isometric contractions (MVC) of the shoulder muscles compared to healthy controls. This has been suggested to be caused by a pain-related decrease in voluntary activation (VA) rather than lack of muscle mass. The aim of the present study was to investigate VA of the trapezius muscle during MVCs in subjects with and without neck/shoulder pain by use of the twitch interpolation technique. Ten cases suffering from pain and ten age and gender matched, healthy controls were included in the study. Upper trapezius muscle thickness was measured using ultrasonography and pain intensity was measured on a 100mm visual analog scale (VAS). VA was calculated from five maximal muscle activation attempts. Superimposed stimuli were delivered to the accessory nerve at peak force and during a 2% MVC following the maximal contraction. Presented as mean±SD for cases and controls, respectively: VAS; 16.0±14.4mm and 2.1±4.1mm (P=0.004), MVC; 545±161N and 664±195N (P=0.016), upper trapezius muscle thickness; 10.9±1.9mm and 10.4±1.5mm (P=0.20), VA; 93.6±14.2% and 96.3±6.0% (P=0.29). In spite of significantly eight-fold higher pain intensity and ∼20% lower MVC for cases compared to controls, no difference was found in VA. Possible explanations for the reduction in MVC could be differences in co-activation of antagonists and synergists as well as muscle quality.

499 NEUROMUSCULAR FUNCTION OF THE SCAPULAR STABILIZING MUSCLES WITH AND WITHOUT ELECTROMYOGRAFICAL BIOFEEDBACK

then analysed per block. The final model was made using the enter method (p<0.05). The data was analysed using 3 different approaches to define progression: 1) a change of more than 0.5 SD of the mean WOMAC pain score at baseline, 2) a shift to a higher quintile-group, or remaining in the 3 highest quintiles of WOMAC pain scores as proposed by Sharma et al., 3) any deterioration in WOMAC pain score. The first 2 approaches were analysed with logistic regression analyses. The third approach was analysed with linear regression analyses. Results: Of the 1002 patients in the CHECK cohort, the majority were female (79%). Mean age was 56 years. 82.7% of all patients had knee pain, while 58.7% had hip pain at baseline. Almost half of the patients (41.4%) consulted for hip and knee pain. On average the pain of the CHECK patients declined slightly over the first two years. However, after two years 40.1% of the patients had a higher WOMAC pain score than at baseline. For the approach based on change >0.5 SD we found for hip complaints that moderate alcohol use and a higher WOMAC pain score at baseline protected against an increase, while a painful hip flexion led to more pain after two years. While the Sharma method only found a relation between a painful hip flexion and more pain. The linear regression analysis yielded that having paid employment and more pain at baseline (WOMAC) and a better health (SF 36) protected against more pain, while having concomitant complaints of arm, neck and shoulder led to more pain. For knee complaints the SD method yielded that moderate alcohol use, more pain at baseline and a better vitality (SF 36) protected against an increase in pain, while hip stiffness and a Kellgren & Lawrence (KL) score of 2 or more was related to more pain after two years. Using the Sharma method we found that moderate alcohol use and a better physical functioning score (SF 36) protected against more pain, while hip stiffness and a KL ≥ 2 led to more pain after two years. Finally the linear regression showed that more pain at baseline (WOMAC) and a better physical functioning score (SF 36) protected against an increase in pain. Conclusions: We were able to identify several predictors on progression of pain in early osteoarthritis. However the predictors for the 3 definitions of deterioration of pain are very different. Not one factor was found in all 3 methods for one joint. This indicates that the choice of what is regarded as deterioration is essential.