Carol A. Courtney

Heightened Flexor Withdrawal Responses in Subjects With Knee Osteoarthritis

UNLABELLED Patients with osteoarthritic (OA) knee pain often present with impaired muscle activation and function that may be attributed in part to hyperexcitability of flexion withdrawal reflexes (FWRs). The aim of this study was to investigate alterations in the excitability of FWR in individuals with knee OA and its potential associations with impaired quadriceps activation (QA) and subjective reports of pain. Twenty subjects with and 20 without knee OA (age, 45 to 75 years) participated. Impaired QA was determined in OA subjects during maximal volitional contraction of the quadriceps. FWRs were tested in isometric conditions using electrocutaneous stimulation applied at the medial foot at 1x and 2x FWR threshold and surface electromyographic recordings obtained from tibialis anterior (TA) and biceps femoris (BF). Joint torques at the hip, knee, and ankle were calculated and normalized to body mass. FWR threshold was significantly diminished in OA versus the control group (P < .01). In addition, FWR latencies were consistent with spinally mediated responses, with significantly earlier responses in OA versus control subjects of TA at threshold (P = .002) and BF at suprathreshold stimulation (P = .0006). Impaired QA was found in 4 of 20 OA subjects but was not correlated to FWR threshold or pain levels. Peak joint torques were diminished in the OA versus the control group (P < .0006). PERSPECTIVE Increased excitability of FWRs was evident in subjects with chronic knee osteoarthritis, including those subjects without resting pain, but was not associated with impaired QA. Management strategies for this patient population must consider altered pain processing in addition to addressing impairments found at the knee.

Heightened Flexor Withdrawal Response in Individuals With Knee Osteoarthritis Is Modulated by Joint Compression and Joint Mobilization

UNLABELLED Patients with chronic pain often present with hyperalgesia, possibly due to hyperexcitability of nociceptive pathways. The aim of the present study was to investigate alterations in flexor withdrawal reflex (FWR) excitability in individuals with knee osteoarthritis (OA) and the potential effect of specific physical inputs or therapeutic interventions (ie, joint compression and mobilization) on these behaviors. Ten subjects with and 10 without knee OA (age 45-75) were recruited. The FWR was examined utilizing suprathreshold, noxious electrocutaneous stimuli applied at the medial foot. Surface electromyographic (EMG) was recorded from the tibialis anterior (TA) and biceps femoris (BF), and peak joint torques recorded at the hip, knee, and ankle. FWR threshold was ascertained and responses at 2x threshold recorded after the following conditions: a maximal, volitional, joint-compression task, a sham hands-on intervention, and a Grade III oscillatory joint-mobilization intervention. A decreased threshold-to-flexor withdrawal response was found in the OA vs control group (P < .01). EMG and joint-torque FWR responses were further augmented in the OA group following the maximal joint-compression task (P < .05), yet remained unchanged or diminished in controls. Joint mobilization, but not sham intervention, reduced reflex responses significantly, although primarily by decreasing BF activity and knee torques (P < .05). PERSPECTIVE Application of specific physical inputs to individuals with knee OA similar to those encountered during activity of daily living or during therapeutic interventions appear to modulate involuntary, nociceptive reflex responses. Routine weight-bearing activities such as walking may potentially enhance heightened FWR responses, while joint mobilization, a commonly used clinical intervention, may diminish reflex excitability.

Interpreting Joint Pain: Quantitative Sensory Testing in Musculoskeletal Management

SYNOPSIS Pain is a common complaint among clients seeking physical therapy services, yet interpretation of associated sensory changes can be difficult for the clinician. Musculoskeletal injury typically results in nociceptive pain due to noxious stimuli of the damaged muscle or joint tissues. However, with progression from acute to chronic stages, altered nociceptive processing can give rise to an array of sensory findings. Specifically, patients with chronic joint injury may present with signs and symptoms typically associated with neuropathic injury, due to changes in nociceptive processing. Clinical presentation may include expansion of hyperalgesia into adjacent and remote areas, allodynia, dysesthesias, and perceptual deficits. Quantitative sensory testing (QST) may provide an objective method of examining sensation and, thereby, of recognizing potential changes in the nociceptive pathways. The purpose of this paper is to provide an overview of altered nociceptive processing and somatosensory changes that may occur following a musculoskeletal injury without associated neural injury. Recommendations are made on clinical uses of quantitative sensory testing in orthopaedic physical therapy practice, and supporting clinical and laboratory evidence are presented. Examples related to joint injury are discussed, specifically, osteoarthritis of the knee and low back pain. Quantitative sensory testing may be a useful clinical tool to aid clinical decision making and for determination of prognosis.

Association between altered somatosensation, pain, and knee stability in patients with severe knee osteoarthrosis

Objective: To examine the relationship between knee pain, altered somatosensation, and self-reported instability in individuals with knee osteoarthrosis (OA) during a step-up-and-over task. Methods: Quantitative sensory testing, including mechanical detection threshold (MDT), allodynia, vibration perception threshold, and pressure pain threshold (PPT), was assessed in 16 individuals (mean age, 52±7 y) with knee OA and in 16 age-matched and sex-matched controls. Pain intensity ratings and subjective reports of instability/buckling were recorded at rest and while performing a step-up task, and these findings were correlated with somatosensory measures. Results: In the OA group, all participants reported allodynia on MDT testing. Compared with healthy controls, MDT was significantly increased (P<0.001), and vibration perception threshold was increased (P=0.02) at the medial knee, indicating hypoesthesia. PPT was significantly decreased at the medial joint line (P=0.03) and 12 cm distal (P=0.02). Comparing participants with OA having severe versus mild radiographic changes, PPT was lower at the medial joint line (P<0.01) but not at 12 cm distal. Fourteen (87.5%) participants with knee OA reported pain and instability during the step task as compared with none or 1 (6%) of the controls. On the step task, longer duration of symptoms was associated with increased pain (P=0.02). A moderate correlation between greater self-reported instability and increased vibratory hypoesthesia at the knee (r=−0.633; P=0.01) was demonstrated, suggesting a potential relationship between somatosensory changes and functional deficits. Conclusions Severe OA may result in both hyperalgesia and hypoesthesia at the affected knee. Perceived instability during functional tasks may be mediated in part by pain in individuals with knee OA.

Water versus land-based multimodal exercise program effects on body composition in breast cancer survivors: a controlled clinical trial

Goals of workOur aim was to compare the effects of land versus water multimodal exercise programs on body composition and breast cancer-specific quality of life in breast cancer survivors.Patients and methodsNinety-eight breast cancer survivors were assigned to three groups: control, land exercise, and water exercise. Both exercise groups participated in an 8-week multimodal program. Adiposity was measured by anthropometry (body mass index, waist circumference) and bioelectrical impedance (body fat and muscle lean body mass). Incidence of clinically significant secondary lymphedema was also assessed. Finally, specific quality of life was assessed using the European Organization for Research and Treatment of Cancer Quality of Life BR-23.Main ResultsUsing ANCOVA, significant group × time interactions for body fat percentage (F = 3.376; P = 0.011) and lean body mass (F = 3.566; P = 0.008) were found. Breast cancer survivors in the land exercise group exhibited a greater decrease in percentage of body fat than those in the water exercise (P < 0.001) and control (P = 0.002) groups. The ANCOVA revealed a significant group × time interaction for waist circumference (F = 4.553; P = 0.002): breast cancer survivors in the control group showed a greater waist circumference when compared to water (P = 0.003) and land (P < 0.001) exercise groups. A significant group × time interaction was also found for breast symptoms (F = 9.048; P < 0.001): participants in the water exercise group experienced a greater decrease of breast symptoms than those in the land exercise (P < 0.01) and control (P < 0.05) groups.ConclusionLand exercise produced a greater decrease in body fat and an increase in lean body mass, whereas water exercise was better for improving breast symptoms.

Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee

STUDY DESIGN An experimental laboratory study with a repeated-measures crossover design. BACKGROUND Treatment effects of joint mobilization may occur in part by decreasing excitability of central nociceptive pathways. Impaired conditioned pain modulation (CPM) has been found experimentally in persons with knee and hip osteoarthritis, indicating impaired inhibition of central nociceptive pathways. We hypothesized increased effectiveness of CPM following application of joint mobilization, determined via measures of deep tissue hyperalgesia. OBJECTIVE To examine the effect of joint mobilization on impaired CPM. METHODS An examination of 40 individuals with moderate/severe knee osteoarthritis identified 29 (73%) with impaired CPM. The subjects were randomized to receive 6 minutes of knee joint mobilization (intervention) or manual cutaneous input only, 1 week apart. Deep tissue hyperalgesia was examined via pressure pain thresholds bilaterally at the knee medial joint line and the hand at baseline, postintervention, and post-CPM testing. Further, vibration perception threshold was measured at the medial knee epicondyle at baseline and post-CPM testing. RESULTS Joint mobilization, but not cutaneous input intervention, resulted in a global increase in pressure pain threshold, indicated by diminished hyperalgesic responses to pressure stimulus. Further, CPM was significantly enhanced following joint mobilization. Diminished baseline vibration perception threshold acuity was enhanced following joint mobilization at the knee that received intervention, but not at the contralateral knee. Resting pain was also significantly lower following the joint intervention. CONCLUSION Conditioned pain modulation was enhanced following joint mobilization, demonstrated by a global decrease in deep tissue pressure sensitivity. Joint mobilization may act via enhancement of descending pain mechanisms in patients with painful knee osteoarthritis.

Temporomandibular disorders. Part 1: anatomy and examination/diagnosis

Abstract Temporomandibular disorders (TMD) are a heterogeneous group of diagnoses affecting the temporomandibular joint (TMJ) and surrounding tissues. A variety of methods for evaluating and managing TMD have been proposed within the physical therapy profession but these sources are not peer-reviewed and lack updates from scientific literature. The dental profession has provided peer-reviewed sources that lack thoroughness with respect to the neuromusculoskeletal techniques utilized by physical therapists. The subsequent void creates the need for a thorough, research informed, and peer-reviewed source regarding TMD evaluation and management for physical therapists. This paper is the first part in a two-part series that seeks to fill the current void by providing a brief but comprehensive outline for clinicians seeking to provide services for patients with TMD. Part one focuses on anatomy and pathology, arthro- and osteokinematics, epidemiology, history taking, and physical examination as they relate to TMD. An appreciation of the anatomical and mechanical features associated with the TMJ can serve as a foundation for understanding a patient’s clinical presentation. Performance of a thorough patient history and clinical examination can guide the clinician toward an improved diagnostic process.

Temporomandibular disorders. Part 2: conservative management

Abstract Appropriate management of temporomandibular disorders (TMD) requires an understanding of the underlying dysfunction associated with the temporomandibular joint (TMJ) and surrounding structures. A comprehensive examination process, as described in part 1 of this series, can reveal underlying clinical findings that assist in the delivery of comprehensive physical therapy services for patients with TMD. Part 2 of this series focuses on management strategies for TMD. Physical therapy is the preferred conservative management approach for TMD. Physical therapists are professionally well-positioned to step into the void and provide clinical services for patients with TMD. Clinicians should utilize examination findings to design rehabilitation programs that focus on addressing patient-specific impairments. Potentially appropriate plan of care components include joint and soft tissue mobilization, trigger point dry needling, friction massage, therapeutic exercise, patient education, modalities, and outside referral. Management options should address both symptom reduction and oral function. Satisfactory results can often be achieved when management focuses on patient-specific clinical variables.

Clinical reasoning for manual therapy management of tension type and cervicogenic headache

Abstract In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.

Enhanced Proprioceptive Acuity at the Knee in the Competitive Athlete

STUDY DESIGN Controlled laboratory study: cross-sectional. OBJECTIVE To determine if proprioception, measured by the threshold to detection of passive motion (TDPM), differed in individuals who regularly participate in moderate-intensity exercise for fitness as compared to individuals involved in high-intensity skilled exercise. BACKGROUND Previous research has been equivocal as to whether exercise training is associated with superior proprioceptive acuity, in particular, exercise that includes dynamic postural challenges such as cutting and pivoting. METHODS Two groups of 25 healthy individuals (18-32 years old) were recruited. One group consisted of individuals who performed moderate-activity level exercises for 5 to 10 hours per week. Participants in the other group performed high-activity level exercises, including high-speed cutting and pivoting activities, at least 10 hours per week. Proprioception was determined using TDPM, in which the knee was slowly extended or flexed at an angular velocity of 0.5°/s or less from a starting position of 40° of knee flexion. RESULTS Individuals participating in competitive, high-intensity skilled exercise demonstrated better acuity (average of both limbs) of TDPM (mean ± SD, 0.81° ± 0.38°; P<.001) than those participating in moderate-intensity exercise for fitness (1.53° ± 0.58°). A low but statistically significant association (r = -0.38, P = .006) was found between weekly duration of exercise and proprioceptive threshold as measured by TDPM. CONCLUSION These results suggest that perceptual thresholds of passive movement may be enhanced, depending on activity level and associated postural challenge, and that higher level and increased amount of exercise may promote enhanced neurosensory processing in these individuals. Consequently, high-intensity skilled training may deserve further emphasis in orthopaedic rehabilitation.