Gaetane Stassijns

Reliability of the Assessment of Lumbar Range of Motion and Maximal Isometric Strength in Patients With Chronic Low Back Pain

OBJECTIVE To examine the interobserver reliability of the assessment of lumbar range of motion (ROM) and maximal isometric strength in patients with chronic low back pain (CLBP) using commercially available equipment. DESIGN A prospective repeated-measures design. SETTING Ambulatory care in a university hospital. PARTICIPANTS Twelve patients (5 men, 7 women; age range, 20-52y) with CLBP, with a mean visual analog scale score of 31.5+/-25.8mm, volunteered for the study. The duration of their symptoms was 63+/-115 months and the mean Oswestry Disability Index score was 31%. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Movements of the lumbar spine were assessed with commercially available equipment. Both the range of motion (ROM) and the maximal isometric strength for flexion, extension, lateroflexion, and rotation of the lumbar spine were evaluated twice to analyze the interobserver reliability. The same test procedure was performed on 2 separate days by 2 investigators who were blinded to the outcome of the assessment of their colleague. The order of investigator was balanced, so that each investigator tested the same number of patients as first investigator. RESULTS The intraclass correlation coefficient varied between .91 and .98 for the measurements of the lumbar ROM and was between .93 and .97 for all the strength measurements. Post hoc power analysis confirmed previous power analysis, that is, despite the small sample size, an excellent power was found for the observed interobserver reliability coefficients (power range, 0.93-1.00). No learning effect was found when comparing the results of the second measurement with the first measurement (P>.05). CONCLUSIONS The interobserver reliability is excellent for the measurement of the ROM of the lumbar spine and for the maximal isometric strength using specific devices in patients with CLBP.

Bilateral ulnar nerve entrapment by the M. anconeus epitrochlearis. A case report and literature review

Ulnar neuropathy at the elbow is the second most common entrapment neuropathy. Ulnar nerve entrapment has several causes. A case report is presented with the presence of the M. anconeus epitrochlearis at both sides. The patient contacted our department with chronic, diffuse bilateral elbow pain irradiating into both forearms. She experienced typical nocturnal paresthesias involving digit IV and V of both hands. Tinel’s sign was present just proximal to the medial epicondyle. A bilateral ulnar nerve entrapment was clinically suspected. An electromyographic (EMG) investigation revealed slowing of the motor conduction velocity in the ulnar nerve across the elbow. An ultrasound and MRI investigation demonstrated the presence of an anomalous muscle, called the M. anconeus epitrochlearis, at both sides. Treatment consisted of bilateral surgical excision of the muscle and retinacular release, followed by physical therapy. The outcome was favourable.

Identification of Preliminary Prognostic Indicators for Back Rehabilitation in Patients With Nonspecific Chronic Low Back Pain: A Retrospective Cohort Study.

Study Design. Retrospective Cohort. Objective. Our aim was to identify prognostic indicators for success after a back rehabilitation program (BR) in patients with nonspecific chronic low back pain (CLBP). Summary of Background Data. Exercise therapy is recommended for patients with nonspecific CLBP. Consensus on the type of exercises is lacking, largely due to heterogeneity in the studied patient samples. The identification of subgroups through the identification of prognostic indicators is therefore needed. To our knowledge, no specific prognostic indicators for BR are described in the literature. Methods. We retrospectively analyzed the patient files of 49 nonspecific CLBP patients who followed a BR. Patients were selected based on predefined in- and exclusion criteria. All underwent 43 therapy sessions, two times per week. Primary outcome measure and dependent variable was the change in Oswestry Disability Questionnaire (ODI) score. Potential predictive variables were tested for association with the primary outcome and consequently entered in a logistic regression model. Results. In this study, the posthoc calculated power was 91%. Based on the change in ODI scores, 24 patients were considered as therapy success (eight points or 50% improvement on change in ODI score) and 25 as therapy failure. Univariate and multiple regression analysis revealed only one significant prognostic indicator: higher scores on the physical function subscale of the SF36 (PF-SF36) corresponded with high risk of therapy failure (odds ratio of 0.791 (95% CI = 0.662–0.945); sensitivity of 0.79, and specificity of 0.68). Conclusion. Potentially, the preset exercises of the BR in this study design were not appropriate for the identified subgroup. The results of this study should be replicated in a RCT design that conforms to the necessary methodological steps in the identification of prognostic indicators and clinical prediction rules (CPRs). Level of Evidence: 3

Efficacy of Different Types of Mobilization Techniques in Patients With Primary Adhesive Capsulitis of the Shoulder: A Systematic Review

OBJECTIVE To systematically review the literature for efficacy of isolated articular mobilization techniques in patients with primary adhesive capsulitis (AC) of the shoulder. DATA SOURCES PubMed and Web of Science were searched for relevant studies published before November 2014. Additional references were identified by manual screening of the reference lists. STUDY SELECTION All English language randomized controlled trials evaluating the efficacy of mobilization techniques on range of motion (ROM) and pain in adult patients with primary AC of the shoulder were included in this systematic review. Twelve randomized controlled trials involving 810 patients were included. DATA EXTRACTION Two reviewers independently screened the articles, scored methodologic quality, and extracted data for analysis. The review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. All studies were assessed in duplicate for risk of bias using the Physiotherapy Evidence Database Scale for randomized controlled trials. DATA SYNTHESIS The efficacy of 7 different types of mobilization techniques was evaluated. Angular mobilization (n=2), Cyriax approach (n=1), and Maitland technique (n=6) showed improvement in pain score and ROM. With respect to translational mobilizations (n=1), posterior glides are preferred to restore external rotation. Spine mobilizations combined with glenohumeral stretching and both angular and translational mobilization (n=1) had a superior effect on active ROM compared with sham ultrasound. High-intensity mobilization (n=1) showed less improvement in the Constant Murley Score than a neglect group. Finally, positive long-term effects of the Mulligan technique (n=1) were found on both pain and ROM. CONCLUSIONS Overall, mobilization techniques have beneficial effects in patients with primary AC of the shoulder. Because of preliminary evidence for many mobilization techniques, the Maitland technique and combined mobilizations seem recommended at the moment.

Biomechanical implications of walking with indigenous footwear

Abstract Objectives This study investigates biomechanical implications of walking with indigenous “Kolhapuri” footwear compared to barefoot walking among a population of South Indians. Materials and methods Ten healthy adults from South India walked barefoot and indigenously shod at voluntary speed on an artificial substrate. The experiment was repeated outside, on a natural substrate. Data were collected from (1) a heel‐mounted 3D‐accelerometer recording peak impact at heel contact, (2) an ankle‐mounted 3D‐goniometer (plantar/dorsiflexion and inversion/eversion), and (3) sEMG electrodes at the m. tibialis anterior and the m. gastrocnemius medialis. Results Data show that the effect of indigenous footwear on the measured variables, compared to barefoot walking, is relatively small and consistent between substrates (even though subjects walked faster on the natural substrate). Walking barefoot, compared to shod walking yields higher impact accelerations, but the differences are small and only significant for the artificial substrate. The main rotations of the ankle joint are mostly similar between conditions. Only the shod condition shows a faster ankle rotation over the rapid eversion motion on the natural substrate. Maximal dorsiflexion in late stance differs between the footwear conditions on an artificial substrate, with the shod condition involving a less dorsiflexed ankle, and the plantar flexion at toe‐off is more extreme when shod. Overall the activity pattern of the external foot muscles is similar. Discussion The indigenous footwear studied (Kolhapuri) seems to alter foot biomechanics only in a subtle way. While offering some degree of protection, walking in this type of footwear resembles barefoot gait and this type of indigenous footwear might be considered “minimal”.

Reliability of physical functioning tests in patients with low back pain: a systematic review.

PURPOSE The aim of this study was to provide a comprehensive overview of physical functioning tests in patients with low back pain (LBP) and to investigate their reliability. DATA SOURCES A systematic computerized search was finalized in four different databases on June 24, 2017: PubMed, Web of Science, Embase, and MEDLINE. STUDY SELECTION Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed during all stages of this review. Clinical studies that investigate the reliability of physical functioning tests in patients with LBP were eligible. The methodological quality of the included studies was assessed with the use of the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. To come to final conclusions on the reliability of the identified clinical tests, the current review assessed three factors, namely, outcome assessment, methodological quality, and consistency of description. DATA SYNTHESIS A total of 20 studies were found eligible and 38 clinical tests were identified. Good overall test-retest reliability was concluded for the extensor endurance test (intraclass correlation coefficient [ICC]=0.93-0.97), the flexor endurance test (ICC=0.90-0.97), the 5-minute walking test (ICC=0.89-0.99), the 50-ft walking test (ICC=0.76-0.96), the shuttle walk test (ICC=0.92-0.99), the sit-to-stand test (ICC=0.91-0.99), and the loaded forward reach test (ICC=0.74-0.98). For inter-rater reliability, only one test, namely, the Biering-Sörensen test (ICC=0.88-0.99), could be concluded to have an overall good inter-rater reliability. None of the identified clinical tests could be concluded to have a good intrarater reliability. CONCLUSIONS Further investigation should focus on a better overall study methodology and the use of identical protocols for the description of clinical tests. The assessment of reliability is only a first step in the recommendation process for the use of clinical tests. In future research, the identified clinical tests in the current review should be further investigated for validity. Only when these clinimetric properties of a clinical test have been thoroughly investigated can a final conclusion regarding the clinical and scientific use of the identified tests be made.

The Modified Low Back Pain Disability Questionnaire: Reliability, Validity and Responsiveness of a Dutch Language Version

Study design. Cross-sectional study. Objective. The goal of this study is to translate the English version of the Modified Low Back Pain Disability Questionnaire (MDQ) into a Dutch version and investigate its clinimetric properties for patients with nonspecific chronic low back pain (CLBP). Summary of Background Data. Fritz et al (2001) developed a modified version of the Oswestry Disability Questionnaire (ODI) to assess functional status and named it the MDQ. In this version, a question regarding employment and homemaking ability was substituted for the question related to sex life. Good clinimetric properties for the MDQ were identified but up until now it is not clear whether the clinimetric properties of the MDQ would change if it was translated into a Dutch version. Methods. Translation of the MDQ into Dutch was done in 4 steps. Test-retest reliability was investigated using the intraclass correlation coefficient (ICC) model. Validity was calculated using Pearson correlations and a 2-way analysis of variance for repeated measures. Finally, responsiveness was calculated with the area under the curve (AUC), minimal detectable change (MDC), and the standardized response mean (SRM). Results. A total of 80 completed questionnaires were collected in 3 different hospitals and a total of 43 patients finished a 9 weeks intervention period, completing the retest. Test-retest reliability was excellent with an ICC of 0.89 (95% confidence interval [CI], 0.74–0.95). To confirm the convergent validity, the MDQ answered all predefined hypothesises (r = −0.65–0.69/P = 0.01–0.00) and good results for construct validity were found (P = 0.02). The MDQ had an AUC of 0.64 (95% confidence interval [CI], 0.47–0.81), an MDC of 8.80 points, and a SRM of 0.65. Conclusion. The Dutch version of the MDQ shows good clinimetric properties and is shown to be usable in the assessment of the functional status of Dutch-speaking patients with nonspecific CLBP. Level of Evidence: 3

Letter to the editor concerning “Do we have the right PROMs for measuring outcomes in lumbar spinal surgery?” by O.M. Stokes et al. Eur Spine J (2017) 26:816–824

we wanted to provide some more insight in this matter and build a platform for further discussion. The sex life disability question of the ODI shows a poorer compliance to patients with low back pain (LBP) and is frequently found to be left blank due to several reasons [2, 3]. For example, Mousavi et al. reported that out of a patient sample of 100, a total of 19 patients failed to fill in the sex life disability question [3]. As O.M. Stokes and colleagues concluded, the ODI is used extensively in intervention studies as a primary outcome measure. However, if the ODI is used to determine success or failure of an intervention, it is extremely important that the entire questionnaire is applicable on all patients in that study. Stokes et al. reported that the minimal clinically important difference (MCID) of the ODI is set at 10% which means that there is certainly no room for systematic errors due to a non-applicable question. For example, one question can influence the final ODI score between 0 and 10% with 10% representing the MCID. To minimize missing data issues in studies, Fritz et al. [2] developed a modified version of the ODI and named it the Modified Low Back Pain Disability Questionnaire (MDQ). In this version, the sex life disability question was substituted by a question regarding employment and homemaking disability which is actually the most reported goal for rehabilitation by patients with LBP [4]. The MDQ shows good reliability, responsiveness, and validity in patients with LBP [2, 5]. Nowadays, the MDQ is used extensively both in the literature and in the clinic. For example, the study in which Fritz and colleagues [2] investigated the clinimetric properties on the MDQ has been cited 132 times according to the Pubmed database. The MDQ has some obvious advantages over the ODI, and therefore, it is important that authors report whenever a modified version is being used. In this review, the authors did not report when or if a modified version of the With great interest, we have read the narrative review written by O.M. Stokes and colleagues entitled “Do we have the right PROMs for measuring outcomes in lumbar spinal surgery?” [1]. The authors reviewed patient-reported outcome measures that are used to assess outcome in spinal surgery. One of their main findings was that the Oswestry Disability Index (ODI) is the most commonly used outcome measure for spinal conditions. Within the discussion section, the authors briefly mention the existence of a modified version of the ODI which removes the question regarding sex life disability, but they do not seem to report when and if such a modified version was used. This modified version has several advantages over the original ODI, and therefore,

Musculoskeletal Injuries in Dancers and Musicians

Both dancers and musicians present with specific injuries. Dancing is associated with a very high injury rate. Most injuries are soft tissue injuries such as sprains and tendinopathies. Dancers mainly present with injuries of the lower limb, usually localized at the ankle and foot such as dancer’s toe or dancer’s heel. Knee and back injuries are also common. Musicians on the other hand often suffer from injuries of the upper limb. Most frequent are the musculoskeletal problems of the wrist and hand. In this chapter an overview is given of the common injuries seen in dancers and musicians and their approach.

Walking on a natural substrate and on an artificial substrate: the effect of indigenous footwear

The influence of modern lifestyle, including the use of footwear, appears to effect foot function (Fong Yan et al., 2013; Hoffmann, 1905; Zipfel & Berger, 2007;). D’Aout et al. (2009) and Kandambande et al. (2006) have shown that unshod populations differ from habitually shod populations in their foot anatomy and function. However, not much research has been done on the effect of indigenous footwear. Kolhapuri footwear, a type of sandal (chappal) made entirely from buffalo skin, is regularly used in India. The chappal features a leather sole, two side flaps (kanwali), an instep band and a toe strap. Characteristic of the Kolhapuri chappal is the initial stiffness of the outsole. Only the parts touching the ground become more flexible. The other parts retain their stiffness and ensure protection of the foot on the clayish rocky terrain. The footwear does not constrain the feet, has no extra arch support and has a very thin heel. As part of a larger study on indigenous footwear, including design-related and anthropological aspects, we are studying the biomechanics of this type of footwear.