James R. Beazell

Effects of lumbopelvic joint manipulation on quadriceps activation and strength in healthy individuals

Lumbopelvic joint manipulation has been shown to increase quadriceps force output and activation, but the duration of effect is unknown. It is also unknown whether lower grade joint mobilisations may have a similar effect. Forty-two healthy volunteers (x+/-SD; age=28.3+/-7.3 yr; ht=172.8+/-9.8 cm; mass=76.6+/-21.7 kg) were randomly assigned to one of three groups (lumbopelvic joint manipulation, 1 min lumbar passive range of motion (PROM), or prone extension on elbows for 3 min). Quadriceps force and activation were measured using the burst-superimposition technique during a seated isometric knee extension task before and at 0, 20, 40, and 60 min following intervention. Collectively, all groups demonstrated a significant decrease (p<0.001) in quadriceps force output without changes in activation (p>0.05) at all time intervals following intervention. The group that received a lumbopelvic joint manipulation demonstrated a significant increase in quadriceps force (3%) and activation (5%) (p<0.05) immediately following intervention, but this effect was not present after the 20 min interval. Since participants in this study were free of knee joint pathology, it is possible that they did not have the capacity to allow for large changes in quadriceps muscle activation to occur.

Neuromuscular consequences of low back pain and core dysfunction.

Recurring episodes of low back pain present a dilemma for patients and clinicians. Patients who experience disability caused by repeated low back pain episodes are limited in their activities of daily living and may experience inappropriate neuromuscular adaptations to maintain and/or preserve function. Unfortunately, it is likely that these changes create an environment where lower extremity and spine joints are exposed to unusual and possibly excessive forces while attenuating impact from walking, running, or other activities. Individuals who want to maintain a healthy lifestyle may be restricted because of recurring and disabling nonspecific low back pain. Individuals who must continue with normal and necessary activities of daily living may choose an adaptive mechanism to preserve functional gait. Some individuals may use an adaptive strategy that is unfavorable, possibly exposing muscles and joints to further injury or long-term degenerative processes.

Immediate effects of a tibiofibular joint manipulation on lower extremity H-reflex measurements in individuals with chronic ankle instability

Persistent muscle inhibition of the fibularis longus and soleus muscles and altered joint arthrokinematics may play a role in chronic ankle instability (CAI). Joint mobilization has been shown to improve ankle joint motion, but effects on surrounding musculature is unknown. The purpose of this study was to determine the change in fibularis longus and soleus activation following tibiofibular joint manipulation in individuals with CAI. Forty-three subjects were randomized to one of three groups (proximal tibiofibular manipulation, distal tibiofibular manipulation, or control). A two-way mixed model ANOVA was used to compare changes in the ratio of the maximum H-reflex and maximum M-wave measurements (H/M ratio) of the fibularis longus and soleus between groups over time (pre, post 0, 10, 20, 30 min). The distal tibiofibular joint manipulation group demonstrated a significant increase (P<.05) in soleus H/M ratio at all post-intervention time periods except 20 min post-intervention (P=.48). The proximal tibiofibular joint manipulation and control groups did not demonstrate a change in soleus H/M ratios. All groups demonstrated a decrease (P<.05) from baseline values in fibularis longus (10-30 min post-intervention) and soleus (30 min post-intervention) H/M ratios. Interventions directed at the distal tibiofibular joint acutely increase soleus muscle activation.

Effects of a proximal or distal tibiofibular joint manipulation on ankle range of motion and functional outcomes in individuals with chronic ankle instability.

STUDY DESIGN Randomized clinical trial. OBJECTIVES To determine whether manipulation of the proximal or distal tibiofibular joint would change ankle dorsiflexion range of motion and functional outcomes over a 3-week period in individuals with chronic ankle instability. BACKGROUND Altered joint arthrokinematics may play a role in chronic ankle instability dysfunction. Joint mobilization or manipulation may offer the ability to restore normal joint arthrokinematics and improve function. METHODS Forty-three participants (mean ± SD age, 25.6 ± 7.6 years; height, 174.3 ± 10.2 cm; mass, 74.6 ± 16.7 kg) with chronic ankle instability were randomized to proximal tibiofibular joint manipulation, distal tibiofibular joint manipulation, or a control group. Outcome measures included ankle dorsiflexion range of motion, the single-limb stance on foam component of the Balance Error Scoring System, the step-down test, and the Foot and Ankle Ability Measure sports subscale. Measurements were obtained prior to the intervention (before day 1) and following the intervention (on days 1, 7, 14, and 21). RESULTS There was no significant change in dorsiflexion between groups across time. When groups were pooled, there was a significant increase (P<.001) in dorsiflexion at each postintervention time interval. No differences were found among the Balance Error Scoring System foam, step-down test, and Foot and Ankle Ability Measure sports subscale scores. CONCLUSIONS The use of a proximal or distal tibiofibular joint manipulation in isolation did not enhance outcome effects beyond those of the control group. Collectively, all groups demonstrated increases in ankle dorsiflexion range of motion over the 3-week intervention period. These increases might have been due to practice effects associated with repeated testing. LEVEL OF EVIDENCE Therapy, level 2b-.

Lumbopelvic Joint Manipulation and Quadriceps Activation of People With Patellofemoral Pain Syndrome

CONTEXT Quadriceps weakness and inhibition are impairments associated with patellofemoral pain syndrome (PFPS). Lumbopelvic joint manipulation has been shown to improve quadriceps force output and inhibition, but the duration of the effect is unknown. OBJECTIVE To determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with PFPS. DESIGN Randomized controlled clinical trial. SETTING University laboratory. PATIENTS OR OTHER PARTICIPANTS Forty-eight people with PFPS (age = 24.6 ± 8.9 years, height = 174.3 ± 11.2 cm, mass = 78.4 ± 16.8 kg) participated. INTERVENTION(S) Participants were randomized to 1 of 3 groups: lumbopelvic joint manipulation (grade V), side-lying lumbar midrange flexion and extension passive range of motion (grade II) for 1 minute, or prone extension on the elbows for 3 minutes. MAIN OUTCOME MEASURE(S) Quadriceps force and activation were measured using the burst superimposition technique during a seated isometric knee extension task. A 2-way repeated-measures analysis of variance was performed to compare changes in quadriceps force and activation among groups over time (before intervention and at 0, 20, 40, and 60 minutes after intervention). RESULTS We found no differences in quadriceps force output (F(5.33,101.18) = 0.65, P = .67) or central activation ratio (F(4.84,92.03) = 0.38, P = .86) values among groups after intervention. When groups were pooled, we found differences across time for quadriceps force (F(2.66,101.18) = 5.03, P = .004) and activation (F(2.42,92.03) = 3.85, P = .02). Quadriceps force was not different at 0 minutes after intervention (t(40) = 1.68, P = .10), but it decreased at 20 (t(40) = 2.16, P = .04), 40 (t(40) = 2.87, P = .01) and 60 (t(40) = 3.04, P = .004) minutes after intervention. All groups demonstrated decreased quadriceps activation at 0 minutes after intervention (t(40) = 4.17, P < .001), but subsequent measures were not different from preintervention levels (t(40) range, 1.53-1.83, P > .09). CONCLUSIONS Interventions directed at the lumbopelvic region did not have immediate effects on quadriceps force output or activation. Muscle fatigue might have contributed to decreased force output and activation over 1 hour of testing.

Lumbar instability: an evolving and challenging concept

Abstract Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.

Changes in Lateral Abdominal Muscle Thickness During an Abdominal Drawing-In Maneuver in Individuals With and Without Low Back Pain

The purpose of this study was to compare lateral abdominal muscle thickness changes in individuals with and without low back pain (LBP) during an abdominal drawing-in maneuver (ADIM) using ultrasound imaging. Twenty individuals (13 females and 7 males, average age 40.1 ± 13.4) with stabilization classification LBP and 19 controls (10 females and 9 males, average age 30.3 ± 8.7) participated in this study. Bilateral measurements were made using ultrasound imaging to determine changes in thickness of the transversus abdominus (TrA) and external and internal oblique (EO+IO) muscles during an ADIM. There were no significant differences in relaxed muscle thickness values or contraction ratios for the TrA or EO+IO between groups or side. Individuals with stabilization classification LBP demonstrated no difference in lateral abdominal muscle thickness during an ADIM when compared with controls without LBP when using a pressure biofeedback device to monitor stability.

Flexibility for Runners

Flexibility training, commonly referred to as stretching, has become a standard part of athletic training for nearly all sports. Athletes almost universally engage in some form of flexibility training because of the perception that it prevents injury and may enhance sports performance. With specific regard to running, controversy has arisen regarding these proposed benefits of stretching. In this article, the authors seek to define flexibility training and evaluate the evidence for its clinical benefit. They also describe the components of a general lower quarter flexibility program that they encourage their patients to follow at the University of Virginia Runners Clinic.

A Revisitation of Distractive-Extension Injuries of the Subaxial Cervical Spine : A Cadaveric and Radiographic Soft Tissue Analysis

Study Design. A biomechanical cadaveric and radiographic analyses. Objective. To identify and elaborate on specific anatomic soft tissue structures that are injured during various stages of a distractive-extension (DE) injury of the lower cervical spine and their role in angulation and posterior translation. Summary of Background Data. Two DE stages (DES) of injury to the cervical spine have been described as follows: DES-1 and DES-2. However, the role of the soft tissue structures involved in such injuries has not been clearly defined. Furthermore, the importance of the facet capsules in DES injuries has not been well-addressed. Methods. A total of 15 adult cadaveric motion segments of the lower cervical spine were isolated and tested. Motion segments were mounted, with the cervical spine in extension, such that a distractive load was applied through the cephalad body. Anatomic supporting structures were serially sectioned from anterior to posterior to simulate varying degrees of soft-tissue disruption as occurring with the DE mechanism. Specimens were loaded at each stage of injury and measurements of angulation and posterior translation were recorded from fluoroscopic images by 2 independent observers. Results. A strong correlation was noted between the 2 sets of independent measurements. A statistical significant difference was noted between the degree of soft-tissue injury to the change in angulation and posterior translation (P < 0.001). The mean change in angulation and posterior translation was significantly greatest following sectioning of the anterior aspect of the facet capsules and to a lesser extent following sectioning of the posterior longitudinal ligament (PLL) (P < 0.001). A greater mean percent change between sequential sectioning of soft tissue structures was largely associated with posterior translation rather than angulation. Conclusion. Sequentially greater angulation and posterior translation was seen after serial sectioning of the anterior facet capsule and to a lesser degree the PLL. This suggests that there are in fact 2 main “tethers” to angulation and posterior translation in the DE injury model, with the anterior facet capsule being the major stabilizer and to a lesser degree the PLL. Thus, based on our findings, it would appear that an expansion of the DE injury classification may be warranted, based on angulation and posterior translation, and regarded as DES-1, DES-2A, DES-2B, and DES-3. Such categorization based on the degree of angulation and posterior translation may prove advantageous in designing appropriate treatment strategies to address DE injuries of the lower cervical spine; however, further studies are needed to validate the clinical applications of such categorization.

Treatment of a female collegiate rower with costochondritis: a case report

Abstract Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale – VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.