Karen L. Newcomer

Differences in repositioning error among patients with low back pain compared with control subjects

Study Design. Trunk repositioning error was measured in 20 patients with chronic low back pain and 20 control subjects. Objectives. To measure trunk repositioning error as a method of measuring proprioception of the low back and to compare trunk repositioning error in patients with low back pain and in control subjects. Summary of Background Data. Although many current low back pain rehabilitation programs incorporate proprioceptive training, very little research has been performed on proprioception of the low back. Methods. While standing with the legs and pelvis immobilized, the subject bent the trunk to a predetermined target position and then attempted to replicate the position. Repositioning error was calculated as the absolute difference between the actual target position and the subject-perceived target position. The multiple target positions in the frontal and sagittal planes were tested. Trunk position was measured with a 3Space Tracker, which analyzes the three-dimensional position of the body. Results. Repositioning error in patients with low back pain was significantly higher than that of control subjects in flexion, and significantly lower than that of control subjects in extension. Conclusions. The increase in repositioning error of patients with low back pain during flexion implies that some aspects of proprioception are lost in patients with low back pain. The decrease in repositioning error in patients with low back pain in extension is not as easily explained, but could possibly be caused by increased activation of mechanoreceptors in facet joints.

Corticosteroid injection in early treatment of lateral epicondylitis.

ObjectiveTo analyze whether a corticosteroid injection in combination with rehabilitation early in the course of lateral epicondylitis (LE) alters the outcome up to 6 months after injection compared with a control injection and rehabilitation. DesignRandomized, controlled, double-blind study. SettingSports medicine center in a tertiary care center. Participantsubjects with a diagnosis of LE whose symptoms had been present less than 4 weeks were included. Subjects were recruited by word of mouth and through advertising. The 39 subjects who were recruited were 18 to 65 years old. Interventions19 subjects were randomized to receive rehabilitation and a sham injection, and 20 were randomized to receive rehabilitation and a corticosteroid injection. At 4 and 8 weeks, they were reevaluated and their treatment programs were modified, if indicated. Main Outcome MeasuresOutcome measurements were performed at baseline, 4 weeks, 8 weeks, and 6 months, and included a functional pain questionnaire and a visual analogue pain scale. Painless grip strength on the affected side and maximal grip strength bilaterally were measured at baseline, 4 weeks, and 8 weeks. ResultsThere were no significant differences in outcome between the two groups with the exception of an improvement in the visual analogue pain scale in the corticosteroid group from 8 weeks to 6 months. Outcome measurements in both groups improved significantly over time; more than 80% of subjects reported improvements from baseline to 6 months for all scales. ConclusionA corticosteroid injection does not provide a clinically significant improvement in the outcome of LE, and rehabilitation should be the first line of treatment in patients with a short duration of symptoms.

Repositioning error in low back pain: Comparing trunk repositioning error in subjects with chronic low back pain and control subjects

Study Design. Repositioning error of the trunk was tested in 20 subjects with chronic low back pain and in 20 control subjects. The 3Space Tracker (Polhemus, Colchester, VT), a device that measures three-dimensional position in space, was used to determine the subject’s trunk position. Objectives. To determine whether repositioning error is different in subjects with chronic low back pain than in control subjects. Summary of Background Data. Proprioception allows the body to maintain proper orientation during static and dynamic activities. In peripheral joint injuries, researchers have demonstrated a loss of some aspects of proprioception and improvement in outcome with retraining. Although the components of proprioception in subjects with low back pain have not been well studied, it is thought that these persons lose some elements of proprioception that can be measured in a quantifiable way. If so, then rehabilitation to improve these deficits is important. In this pilot study, one aspect of proprioception, repositioning error, was examined. Methods. The subjects attempted to replicate target positions of the trunk in flexion, extension, lateral bending, and lateral rotation. Repositioning error was calculated as the absolute difference between the actual and the subject-replicated target positions. Results. No significant difference was found in repositioning error between the control subjects and the persons with chronic low back pain. Conclusions. Because proprioception is complex and entails the use of many afferent receptors, it is difficult to measure any one afferent deficiency discretely. The authors believe that this study, in which one aspect of proprioception was measured in an indirect manner, provides important background information on low back position sense. Further studies analyzing aspects of proprioception in subjects with low back pain are recommended.

Anxiety Levels, Fear-avoidance Beliefs, and Disability Levels at Baseline and at 1 Year among Subjects with Acute and Chronic Low Back Pain

To compare anxiety levels, fear‐avoidance beliefs, and disability levels over 1 year for patients with acute (≤3 months) and chronic (>3 months) low back pain (LBP).

Physical activity and four-year development of back strength in children.

Physical activity in children is important, both for its direct benefits and for establishing potentially lasting future behaviors. Understanding the development of back strength in children is also important, because decreased back strength is associated with low back pain in adults. We hypothesized the following: (1) a substantial percentage of children do not participate in adequate physical activity; (2) the development of back strength corresponds to the development of strength of appendicular muscles; (3) there is a positive relationship between physical activity and back strength. The study included 53 boys and 43 girls, aged 10 to 19 yr, who had undergone isometric strength testing 4 yr previously. From responses to a questionnaire, each childs level of physical and sedentary activity was calculated. Isometric back flexion and extension were measured with the same method used 4 yr previously. Statistical analyses were performed, including quadratic regressions to estimate the rate of increase in strength, height, and weight. The following results were found: (1) during the month before testing, 21 children participated in physical activity for less than 30 min/day; (2) the level of physical activity was significantly associated with back flexion and back extension (P = 0.03 for both); (3) the peak rate of increase in back strength occurred approximately 1 yr after the peak rate of increase in height. We conclude the following: (1) measures should be taken to increase the involvement of children in athletic activities; 2) physical activity may be important in the development of back strength; (3) the pattern of back strength development seems to be the same as that for development of muscles of the appendicular skeleton.

Musculoskeletal Education for Medical Students

Mayer RS, Baima J, Bloch R, Braza D, Newcomer K, Sherman A, Sullivan W: Musculoskeletal education for medical students.Musculoskleletal conditions comprise the second most common reason for physician visits and have the greatest negative impact on health-related quality of life in the industrialized world. Therefore, all medical schools should provide education for their students in these disorders. Physiatrists play a unique role in musculoskeletal care and hence, should play a leading role in medical student education. The Association of Academic Physiatrists formed a task force in 2007 to make recommendations as to how physiatrists could contribute to musculoskeletal education for medical students. This report contains those recommendations.

Sonographic Evaluation of the Extensor Carpi Ulnaris in Asymptomatic Tennis Players

To determine the prevalence of structural abnormalities and instability affecting the extensor carpi ulnaris (ECU) tendons of asymptomatic recreational tennis players by the use of high‐resolution ultrasonography.

The “Near-Peer” Approach to Teaching Musculoskeletal Physical Examination Skills Benefits Residents and Medical Students

The musculoskeletal physical examination (MSK PE) is an essential part of medical student training, and it is best taught in a hands‐on, longitudinal fashion. A barrier to this approach is faculty instructor availability. “Near‐peer” teaching refers to physicians‐in‐training teaching their junior colleagues. It is unknown whether near‐peer teaching is effective in teaching this important physical examination skill.

The physiatrists' crucial role in the development and implementation of a longitudinal musculoskeletal physical examination curriculum in a medical school.

The musculoskeletal physical examination (MSK PE) is a critical clinical skill that should be mastered by all medical students. The authors believe that physiatrists should have a crucial role in undergraduate musculoskeletal education. This article outlines the successful integration of an MSK PE curriculum taught by physiatrists into the first 2 yrs of medical school. During year 1, a basic MSK PE is taught concomitantly with the human anatomy course and focuses on anatomical correlation with physical examination maneuvers. In year 2, the MSK PE is taught concomitantly with the musculoskeletal didactic block. Special musculoskeletal tests, basic neurologic evaluation, and case correlation are also added to expand on the examination skills learned in the first year. At the end of the second year and before beginning third-year clinical rotations, students take a practical test to demonstrate their competency in the MSK PE. The authors believe that an important component of their MSK PE educational sessions is a low student-to-instructor ratio (4:1), with ample hands-on supervision of physical examination skills practice. Residents in the Department of Physical Medicine and Rehabilitation assist with the teaching. With their intensive training and clinical experience in musculoskeletal medicine, physiatric staff and residents are ideal faculty for teaching the MSK PE. The authors are hopeful that this article encourages other physiatrists to construct similar programs aimed to develop MSK PE skills in medical students.