Ian Fulton

Virtual reality as a pediatric pain modulation technique: a case study.

Post-surgical pain has been consistently reported in pediatrics as being difficult to manage and limiting to surgical outcomes. Pain management of children is not ideal, and some children unable to tolerate traditional pharmacological agents. Virtual reality (VR) is a new and promising form of non-pharmacologic analgesia. This case study explored the use of VR analgesia with a 16-year-old patient with cerebral palsy participating in a twice-daily physiotherapy program following Single Event Multi-Level Surgery. Over 6 days, the patient spent half of his physiotherapy sessions using VR and the other half without (order randomized). Traditional pharmacological pain management was administered throughout the trial. Using a subjective pain scale (five faces denoting levels of pain), the patients overall pain ratings whilst in the VR (experimental) condition were 41.2% less than those in the no-VR (control) condition. This case report provides the first evidence that VR may serve as a powerful non-pharmacologic analgesic for children following surgery.

Motor Imagery in People With a History of Back Pain, Current Back Pain, Both, or Neither

Introduction:There is mounting evidence that cortical maps are disrupted in chronic limb pain and that these disruptions may contribute to the problem and be a viable target for treatment. Little is known as to whether this is also the case for the most common and costly chronic pain—back pain. Objectives:To investigate the effects of back pain characteristics on the performance of left/right trunk judgment tasks, a method of testing the integrity of cortical maps. Methods:A total of 1008 volunteers completed an online left/right trunk judgment task in which they judged whether a model was rotated or laterally flexed to the left or right in a series of images. Results:Participants who had back pain at the time of testing were less accurate than pain-free controls (P=0.027), as were participants who were pain free but had a history of back pain (P<0.01). However, these results were driven by an interaction such that those with current back pain and a history of back pain were less accurate (mean [95% CI]=76% [74%-78%]) than all other groups (>84% [83%-85%]). Discussion:Trunk motor imagery performance is reduced in people with a history of back pain when they are in a current episode. This is consistent with disruption of cortical proprioceptive representation of the trunk in this group. On the basis of this result, we propose a conceptual model speculating a role of this measure in understanding the development of chronic back pain, a model that can be tested in future studies.

Effects of chronic low back pain, age and gender on vertical spinal creep.

This study investigated the effect of chronic low back pain, age, gender, and time of measurement on the magnitude of vertical spinal creep (VSC) and its recovery. A mixed design, involving three independent variables (chronic low back pain, age, and gender) and one repeated variable (time), was used. One hundred and six subjects of both genders, with and without chronic low back pain, aged between 20 and 60 years, participated in the study. The measurement of VSC and its recovery was performed using a seated stadiometer that allowed continuous measurement of VSC without changing the subjects posture over 25 min. Unloaded VSC was measured during the initial 5 min, followed by 10 min with an additional load of 15% of the subjects body weight and then for a further 10 min after the removal of the load. Subjects were grouped into one of eight categories according to the presence of chronic low back pain, age (20–39 years or 40–60 years) and gender. Repeated measures analysis of variance was computed. A significant increase in VSC with time of measurement was observed (p<0.001). No significant main effects for chronic low back pain, age, or gender were found at any time during the 25-min VSC testing protocol. Significant interactions were found between age and gender during the loaded (p = 0.02) and unloaded (p = 0.02) phases. A significant interaction was found between chronic low back pain and gender at the end of the unloaded phase (p = 0.04). These findings suggest a combined influence of chronic low back pain, age, and gender on VSC and its recovery and that the dominance of each variable changed with the time of the measurement. Thus, subjects who differ in the presence of chronic low back pain, age, and gender should not be combined for statistical analysis of VSC and its recovery.

Left/right neck rotation judgments are affected by age, gender, handedness and image rotation.

Understanding motor imagery of the hands and feet has led to promising new treatments for neurological and chronic pain disorders. We aimed to extend this line of research to the neck with a view to developing the definitive platform study upon which clinical and experimental studies can be based. In a cross-sectional experiment with a convenience sample, volunteers were shown 40 photographs of a model with their head turned to the left or right. Images were presented in random order and orientation. Participants judged the direction of neck rotation. They also completed a left/right hand judgment task. 1361 pain-free participants volunteered. Mean ± standard deviation response time (RT) for making left/right judgments of neck rotation was 1.621 ± 0.501 s. Median accuracy was 92.5%. RT was related to age, gender, and handedness (p < 0.001). That is, RT increased with age, was greater in females than in males and was greater in left-handers than in right-handers. Accuracy reduced with age (p < 0.001), but was unaffected by gender or handedness. Judgments were more accurate when images showed a neck rotated to the right than when they showed a neck rotated to the left (p < 0.001). The magnitude of image rotation affected both response time and accuracy (p < 0.001). In general, the performance parameters established for left/right limb judgments also apply for left/right neck rotation judgments. The current work establishes the definitive normative values against which clinical and experimental groups can be compared and reveals unpredicted effects of the direction neck rotation and the orientation of the image.

Reliability of the vertical spinal creep response measured in sitting (asymptomatic and low-back pain subjects).

Vertical spinal creep (or change in stature) has been used as an index of spinal loading, yet reliability of the testing protocol has not been fully examined. This study investigated the reliability of a vertical spinal creep response in 10 asymptomatic and five low-back pain subjects. Each subject performed the 25-min testing protocol, which consisted of three phases (5-min preload, 10-min loaded and 10-min unloaded), at the same time on two separate days. Good reliabilities in vertical spinal creep response between two days of testing were demonstrated for both asymptomatic and low-back pain subjects.

Contribution of soft tissue deformation below the sacrum to the measurement of total height loss in sitting

This study investigated the contribution of soft tissue deformation below the sacrum (S) and vertical spinal creep to total height loss (THL) measured in sitting. Eight asymptomatic subjects (four males, four females) aged between 21 and 51 years were measured. Simultaneous measurement of THL and S were commenced after the subjects had been sitting for 5 min. THL was recorded while subjects were positioned in a seated stadiometer, which controlled their spinal posture. S was measured by placing an ultrasound transducer at the level of the top of the subjects sacrum. Over 25 min of sitting with loaded and unloaded interventions applied to their spine, different response characteristics between S and THL were noted. This study demonstrated that soft tissues below the sacrum could contribute up to 30% on average of total height loss. This suggests that researchers should take into account the soft tissue deformation outside the spine when studying vertical creep in sitting.

Adolescent versus adult responses to vertical spinal loading.

This study compared the vertical spinal creep response between adolescent and adult males. Thirty healthy male subjects, 15 adolescents (aged 12 to 16 years) and 15 adults (aged 30 to 57 years) were measured. Spinal creep was measured continuously over 25 min under loaded and unloaded conditions using a seated stadiometer that controlled spinal posture. Both adolescent and adult subjects showed significant increase in vertical spinal creep with time but the magnitude of vertical spinal creep was significantly greater in adolescent than in the adult subjects.

Effect of time of day on the vertical spinal creep response.

Vertical spinal creep (VSC) is height loss during sustained postures over a set period of time. While total stature has been demonstrated to decrease throughout the day, whether a diurnal effect applies to the VSC response has not been reported. The aim of this study was to investigate whether time of day had an effect on the magnitude of the VSC response in young subjects asymptomatic for musculoskeletal pathologies. The VSC response was recorded over 25 min while subjects remained seated on the stadiometer, at three times (morning, midday and afternoon) on the same day, in 48 asymptomatic volunteers aged 20-39 years. While no significant differences were calculated for the magnitude of the VSC responses on the three occasions of testing, differences in magnitude of VSC response may have been confounded by preloading activities. Where magnitude of the VSC response is the primary outcome measure, measurement protocols should control preloading activities and continue to conduct measurements at the same time of day, until further studies conclusively refute the existence of a diurnal effect.

Transversus abdominis: Changes in thickness during an incremental upper limb exercise test

The aim of this study was to measure transversus abdominis (TrA) during an incremental fatiguing task. Using real-time ultrasound, TrA thickness was measured in 26 healthy subjects (18–25 years, 9 male) during an unsupported upper limb exercise test (UULEX). Repeatability of changes in TrA thickness during the UULEX was established by using a test-retest process (n=9, intraclass correlation coefficient=0.62 (95% CI 0.38–0.82), standard error of measurement ∼1 (95% CI 0.87–1.08)). Using mixed model analysis with time as an independent variable, TrA thickness changed significantly throughout the UULEX (p < 0.05). Measures of TrA thickness at minutes 10, 11, and 12 were significantly greater than at baseline (p=0.006 (95% CI 0.23–1.35), 0.001 (95% CI 0.45–1.61), and <0.0001 (95% CI 0.77–2.03), respectively). Transversus abdominis was shown to be continuously and increasingly active over the 12 minutes of an incremental bilateral upper limb test in young healthy adults. As increases in TrA thickness occurred at the points of greatest postural and ventilatory demands, these findings may have implications for subjects with musculoskeletal or respiratory impairments who are often challenged by upper limb tasks.

Transversus abdominis: Changes in thickness during the unsupported upper limb exercise test in older adults

Novel, short-lived upper limb tasks performed by young adults have been used to investigate the role of transversus abdominis (TrA) in maintaining postural stability. Little information exists concerning the behaviour of TrA in older adults during protracted postural challenges. The primary aim of this study was to describe the change in thickness of TrA during an incremental upper limb exercise test in older adults. A secondary analysis was undertaken to compare the results between younger and older subjects. Healthy subjects aged between 40 and 70 years performed the Unsupported Upper Limb Exercise Test (UULEX) while activity of TrA was continuously monitored by using rehabilitative ultrasound imaging. Changes in muscle dimensions were measured every minute during the test. The thickness of TrA increased significantly and exponentially between minutes 8 and 13 of the UULEX. Although there was a significant difference between older and younger subjects in absolute measures of TrA thickness, the change in TrA thickness as a percentage of resting thickness during the UULEX demonstrated an identical pattern between younger and older subjects. This study suggests that TrA is continually and increasingly active during an upper limb task in both younger and older asymptomatic subjects.