Dawn T. Gulick

Influence of instrument assisted soft tissue treatment techniques on myofascial trigger points

OBJECTIVE The purpose of this study was to examine the influence of instrument assisted soft tissue techniques (IASTT) on myofascial trigger points (MTrP). DESIGN Randomized, controlled study with the researcher assessing the MTrP sensitivity blinded to the treatment rendered. PARTICIPANTS Phase 1 = 27; Phase 2 = 22. INTERVENTION MTrPs were identified in the upper back. In phase 1, two MTrPs (right & left) were identified. One was treated with IASTT, the other was a control. In phase 2, one MTrP was identified in a treatment and a control group. In each phase, the treatment groups received six treatments of IASTT. OUTCOME MEASURES Sensitivity threshold of the MTrP was assessed with a dolorimeter. RESULTS There was a significant improvement in both groups over time but there was no difference between the treatment and control groups. CONCLUSIONS The use of a pressure dolorimeter may have served as a form of ischemic compression treatment. This assessment tool may have been a mitigating factor in the over-shadowing any potential influence of the IASTT on the MTrP. Thus, another assessment tool needs to be identified for MTrP assessment. Until that technique is identified, the effect of IASTT on MTrPs in inconclusive.

Validity and Reliability of 2 Goniometric Mobile Apps: Device, Application, and Examiner Factors

CONTEXT Smartphones are being used in a variety of practice settings to measure joint range of motion (ROM). A number of factors can affect the validity of the measurements generated. However, there are no studies examining smartphone-based goniometer applications focusing on measurement variability and error arising from the electromechanical properties of the device being used. OBJECTIVE To examine the concurrent validity and interrater reliability of 2 goniometric mobile applications (Goniometer Records, Goniometer Pro), an inclinometer, and a universal goniometer (UG). DESIGN Nonexperimental, descriptive validation study. SETTING University laboratory. PARTICIPANTS 3 physical therapists having an average of 25 y of experience. MAIN OUTCOME MEASURES Three standardized angles (acute, right, obtuse) were constructed to replicate the movement of a hinge joint in the human body. Angular changes were measured and compared across 3 raters who used 3 different devices (UG, inclinometer, and 2 goniometric apps installed on 3 different smartphones: Apple iPhone 5, LG Android, and Samsung SIII Android). Intraclass correlation coefficients (ICCs) and Bland-Altman plots were used to examine interrater reliability and concurrent validity. RESULTS Interrater reliability for each of the smartphone apps, inclinometer and UG were excellent (ICC = .995-1.000). Concurrent validity was also good (ICC = .998-.999). Based on the Bland-Altman plots, the means of the differences between the devices were low (range = -0.4° to 1.2°). CONCLUSIONS This study identifies the error inherent in measurement that is independent of patient factors and due to the smartphone, the installed apps, and examiner skill. Less than 2° of measurement variability was attributable to those factors alone. The data suggest that 3 smartphones with the 2 installed apps are a viable substitute for using a UG or an inclinometer when measuring angular changes that typically occur when examining ROM and demonstrate the capacity of multiple examiners to accurately use smartphone-based goniometers.

Effect of visual feedback and verbal encouragement on eccentric quadriceps and hamstrings peak torque

Biofeedback may be a valuable tool in the rehabilitation of musculoskeletal injury whenever a maximal contraction is desired. The purpose of this study was to investigate the effect of visual feedback (VF) and verbal encouragement (VE) on eccentric quadriceps and hamstrings peak torque of males and females. Fifteen males and 15 females performed eccentric knee flexion/extension at 60°/s on the Biodex B‐2000. Four data collection sessions included one of the following randomly ordered conditions: VF via a bar graph display, VE via a tape recording, VF and VE together, and a control situation (no feedback). Analyses of variance with repeated measured and Tukey post‐hoc tests revealed a significant difference in the results with regard to gender regardless of condition and a significant difference with regard to condition regardless of gender. Males generated more eccentric peak torque than females. VF and combined VF and VE resulted in a higher peak torque value than VE alone and the control condition for b...

Comparison of tissue heating between manual and hands-free ultrasound techniques

ABSTRACT The objective of this single-factor repeated-measures design was to examine the effectiveness of tissue heating with a hands-free ultrasound (US) technique compared to a hand-held US transducer using the Rich-Mar AutoSoundTM unit. US is a therapeutic modality often used to provide deep tissue heating. Recently, a “hands-free” US unit was introduced by Rich-Mar Incorporated. This unit allows the clinician to choose the mode of US delivery, using either a handheld (manual) transducer or a hands-free device that pulses the US beam through the transducer. However, the Center for Medicare and Medicaid Services has deemed delivery of US via a hands-free unit to be investigational. Forty volunteers over 18 years of age participated. Treatment was provided at a 3-MHz US frequency. Muscle temperature was measured with 26-gauge, 4-cm Physiotemp thermistors placed in the triceps surae muscle. The depth of thermistor placement was at 1 - and 2-cm deep. One calf was treated with a manual transducer (5-cm2 US head at three times the effective radiating area [ERA]), and one calf was treated with the hands-free transducer (14-cm2 [ERA]). Both methods used a 1.5 W/cm2 intensity for 10 minutes. The manual technique used an overlapping circular method at 4 cm/sec, and the hands-free method used a sequential pulsing at 4 cm/sec. Tissue temperatures were recorded at baseline and every 30 seconds. The hands-free technique resulted in a tissue temperature increase from 33.68 to 38.7°C and an increase from 33.45 to 40.1°C using the manual technique at 1-cm depth. The tissue temperature increase at the 2-cm depth was from 34.95 to 35.44°C for the hands-free device and 34.44 to 38.42°C for the manual device. Thus, there was a significant difference between the hands-free and the manual mode of US delivery for the 3-MHz frequency (5.02°C vs. 6.65°C at 1 cm and 1.49°C vs. 3.98°C at 2 cm). In this study, the “hands-free” device did not result in the same level of tissue heating as the manual technique. The hands-free device has the advantage of not needing a clinician present to deliver the modality but a therapeutic level of heating was not achieved at the 2-cm tissue depth. Thus, the efficacy of the “hands-free” treatment is in question.

Reliability of peak torque values for concentric and eccentric shoulder internal and external rotation on the biodex, kinetic communicator, and lido dynamometers

The purpose of this study was to investigate the concentric and eccentric peak torque reliability of the Biodex B-2000, Kinetic Communicator, and Lido isokinetic dynamometers when testing the shoulder internal and external rotators. The subjects were 22 males with no previous shoulder pathology. Each subject completed two test sessions for each isokinetic dynamometer. The right upper extremity was tested at 1200 /s through a 1400 arc of motion with the shoulder in 900 of abduction. After a warm-up of three sub-maximal repetitions and 1 maximal repetition, five maximal repetitions were completed in either the concentric or eccentric mode. A 5-min rest period lapsed and then the second test mode was completed. Six days later, the subjects were tested in the reverse order. This procedure was completed for each isokinetic dynamometer. Four one-way analyses of variance with repeated measures were used to compare peak torque values of shoulder internal and external rotation in each test mode. The F-values indicated significant differences in concentric and eccentric internal rotation and eccentric external rotation. Therefore indicating that comparisons of peak torque values should not be made between different isokinetic dynamometers. Means, standard error of measurement (SEM), and intraclass correlations (ICC) were calculated for each dynamometer in each test mode. The ICCs for concentric peak torque were generally higher than those of eccentric peak torque, but lower than those reported by previous researchers. Of the many variables that can impact isokinetic testing, position may have been the most influential in this study. It is possible that impingement of the shoulder rotators occured with the shoulder in 90 of abduction. Perhaps another test position would have yielded more consistent results. The presence of delayed onset muscle soreness may have also influenced this study. Copyright

Effect of analgesic nerve block electrical stimulation in a patient with adhesive capsulitis

Although the pathophysiology of adhesive capsulitis is poorly understood, the primary goal of therapeutic intervention is to restore pain-free, functional range of motion (ROM) of the shoulder. Pain and muscle guarding, particularly of the subscapularis muscle, are common impairments that occur with adhesive capsulitis. The purpose of this case report is to describe a novel approach to help the pain-muscle guarding-pain cycle associated with pain and limited shoulder motion in a patient with a medical diagnosis of adhesive capsulitis. The patient was a 64-year-old female with adhesive capsulitis. Outcome variables were the Shoulder Pain and Disability Index (SPADI), internal rotation (IR) and external rotation (ER) ROM, and rotational lack. Twelve treatments of moist heat, analgesic nerve block electrical stimulation, contract/relax exercises for shoulder IR/ER, and Pendulum/Codman exercises were administered. After both 2 and 4 weeks of treatment, the patient demonstrated marked improvements in all areas. Overall, there was a 78–106% increase in ROM (IR and ER) and a 50–83% improvement in functional mobility (rotational lack & SPADI). It appears that analgesic electrical stimulation may have helped decrease the pain-muscle guarding cycle associated with adhesive capsulitis to enhance functional outcomes in a timely manner.

Evidence-based myofascial trigger point interventions

H is the only known mammalian endoglycosidase capable of degrading the heparan sulfate (HS) glycosaminoglycan, both in extracellular space and within the cell. HS is reported to control inflammatory responses at multiple levels, including the sequestration of cytokines/chemokines in the extracellular space, the modulation of the leukocyte interaction with the endothelium and ECM and the initiation of innate immune responses. We have reported heparanase expression in synovium of rheumatoid arthritis (RA) patients and this new finding may offer a new insight of the potential regulatory role of heparanase in the disease activity of RA. However, the precise mode of action by heparanase in inflammatory reactions of RA remains largely unknown. The aim of this project was to examine the heparanase activity, its expression and correlation with the inflammatory mediatory and angiogenic gene expression in plasma and synovium of RA patients, with an ultimate goal of developing heparanase as a potential predictor of RA progression and a new therapeutic target. We have found thata highly significant increase of heparanase activity and expression in synovial fluid and synovial tissue of RA patients, and an increase of the heparanase activity positively correlate with the inflammatory and angiogenic gene expression. We also have some evidence to support a postulation that the involvement of heparanase in gene regulation in the development of pannus in RA may be reflected in a patient’s blood, thus heparanase can be a potential predictor of RA progression and a novel therapeutic target.Materials & Methods: Nineteen subjects with recurrent low back pain (LBP) and 19 age-matched control subjects who are all right limb dominant participated in this study. All participants were asked to perform axial trunk rotation activities at a self-selected speed to the end of maximum range in standing position. The outcome measures included ROM, angular velocity, and RP on the shoulder and pelvis in the transverse plane and were analyzed based on the demographic characteristics between groups.M trigger points (MTrP) are a focus of hyperirritability in muscle or fascia. MTrPs can be a significant source of pain. A large percentage of patients with shoulder dysfunction, patellofemoral pain and medial longitudinal arch pain present with MTrPs. Ingraham described MTrP as a “clump of contracted sarcomeres living in a swamp of garbage molecules and waste metabolites.” There are histochemical milieus of eight substances in MTrP’s that are not in normal, pain-free muscle. MTrPs are known to be in a vicious cycle of increased contractile activity with an increase in metabolic rate that leads to an increase in metabolites that fire the nociceptors to produce local and referred pain. Furthermore, sustained contractions decrease blood flow and ATP availability which interferes with the effectiveness of the calcium pump. This cyclic response begs the question, “How do we treat MTrPs?” Interventions geared towards restoring blood flow, removing metabolites and restoring ATP availability would be most efficacious. This presentation addresses numerous modalities. Topical agents such as lidocaine and diclofenac have been found to reduce pain (30-40%). Ischemic compression (30-60 seconds) has been found to increase the pain pressure threshold (PPT). Given the depth of MTrPs, 3 MHz ultrasound is the most appropriate mode. Class IV LASER has been shown to significantly increase tissue heating and enhance ATP levels. Last but not least, instrument-assisted soft tissue techniques (IASTT) using techniques such as sweeping, swiveling and fanning have been shown to reduce PPT. Yet, a multi-modal approach may be most efficacious.Background: Both the Barcelona Scoliosis Physical Therapy School (BSPTS)/Schroth Method and the Wood Cheneau Rigo (WCR) brace focus on the individual curvature pattern by applying 3D corrections according to the original Schroth curve classification and Dr. Rigo Manuel’s new classification with particular attention to the following principles: 1. Axial elongation (deflexion and derotation), 2. Asymmetric sagittal straightening, 3. Frontal plane corrections, 4. Rotational/corrective breathing, 5. Muscle activation. The aim of this study was to examine the efficacy of both the WRC brace and the BSPTS/Schroth method on two adolescent girls with AIS.

Comparison of muscle activation of hip belt squat and barbell back squat techniques

BACKGROUND: Hip belt squats are believed to have been introduced in 1970. By removing the load from the shoulders and upper trapezius, the hip belt squat places emphasis on the legs with less load on the spine. No peer-reviewed research exists on the muscle recruitment patterns of a hip belt squat, or how it compares in muscle activation to other squatting activities. OBJECTIVE: The purpose of the study was to determine lower extremity muscle activation in a hip belt squat (SquatMax = MD) in comparison with a barbell back squat. METHODS: Thirteen participants performed four repetitions of an 8-RM squat using three different techniques: hip belt squat without a band, hip belt squat with a band, and barbell back squat. Electromyographic data were collected from six muscles: quadriceps, biceps femoris, hip adductors, hip abductors, gluteus maximus, and gastrocnemius. RESULTS: ANOVA revealed no significant difference in muscle activity between devices. The only muscle group statistically different between genders was the gastrocnemius (p = 0.04). Hip adductor activity was lowest and hip abductor activity was highest when performing a hip belt squat with the band for both genders. Likewise, the adductor to hamstring ratio was lowest with the hip belt squat. CONCLUSIONS: Given the lack of significant difference in the muscle activity between the squat techniques, one needs to look at other attributes to determine both the scientific and, consequently, the practical value. Given the placement of the belt around the pelvis, one positive attribute for the hip belt squat is the ability to unload the shoulders and spine. Another positive attribute for the hip belt squat is the higher hip abductor to adductor ratio. This could be very important for injury prevention and patella tracking. While the back squat has slightly higher hamstring recruitment, which is important in ACL injury prevention, the hip belt squat may address this by offsetting the free weight with the use of an additional band. If a free weight hip belt squat device is available, it may be a better alternative to the traditional barbell squat technique.