Karen McCreesh

Ultrasound measurement of subcutaneous adipose tissue thickness accurately predicts total and segmental body fat of young adults.

This study evaluated the ability of ultrasound measurement of subcutaneous adiposity to accurately determine whole body and segmental body fat in young adults aged 18-29 years. Subcutaneous adipose tissue (SAT) thickness was measured by ultrasound at five body sites in 135 subjects (83 men, 52 women) and compared with the corresponding segmental fat mass measured by dual energy X-ray absorptiometry (DXA). Ultrasound measures of SAT thickness were strongly correlated to segmental fat mass and total percentage (%) body fat (r = 0.697-0.907, p < 0.01). Prediction equations generated using quantile regression found SAT thickness at the abdomen and thigh to accurately predict % body fat in men (standard error of the estimate, SEE = 1.9%, 95% limits of agreement (LoA); -3.6% to +3.8%) and SAT thickness at the abdomen and medial calf to accurately predict % body fat in women (SEE = 3.0%, LoA; -6.5% to +5.4%). These data indicate that ultrasound measurement of SAT thickness proportionally reflects segmental fat mass and accurately predicts % body fat in young adults.

Acromiohumeral distance measurement in rotator cuff tendinopathy: is there a reliable, clinically applicable method? A systematic review

Abstract Background Narrowing of the subacromial space has been noted as a common feature of rotator cuff (RC) tendinopathy. It has been implicated in the development of symptoms and forms the basis for some surgical and rehabilitation approaches. Various radiological methods have been used to measure the subacromial space, which is represented by a two-dimensional measurement of acromiohumeral distance (AHD). A reliable method of measurement could be used to assess the impact of rehabilitation or surgical interventions for RC tendinopathy; however, there are no published reviews assessing the reliability of AHD measurement. Objectives The aim of this review was to systematically assess the evidence for the intrarater and inter-rater reliability of radiological methods of measuring AHD, in order to identify the most reliable method for use in RC tendinopathy. Study appraisal and synthesis An electronic literature search was carried out and studies describing the reliability of any radiological method of measuring AHD in either healthy or RC tendinopathy groups were included. Eighteen studies met the inclusion criteria and were appraised by two reviewers using the Quality Appraisal for reliability Studies checklist. Results Eight studies were deemed to be of high methodological quality. Study weaknesses included lack of tester blinding, inadequate description of tester experience, lack of inclusion of symptomatic populations, poor reporting of statistical methods and unclear diagnosis. There was strong evidence for the reliability of ultrasound for measuring AHD, with moderate evidence for MRI and CT measures and conflicting evidence for radiographic methods. Overall, there was lack of research in RC tendinopathy populations, with only six studies including participants with shoulder pain. Conclusions The results support the reliability of ultrasound and CT or MRI for the measurement of AHD; however, more studies in symptomatic populations are required. The reliability of AHD measurement using radiographs has not been supported by the studies reviewed.BACKGROUND Narrowing of the subacromial space has been noted as a common feature of rotator cuff (RC) tendinopathy. It has been implicated in the development of symptoms and forms the basis for some surgical and rehabilitation approaches. Various radiological methods have been used to measure the subacromial space, which is represented by a two-dimensional measurement of acromiohumeral distance (AHD). A reliable method of measurement could be used to assess the impact of rehabilitation or surgical interventions for RC tendinopathy; however, there are no published reviews assessing the reliability of AHD measurement. OBJECTIVES The aim of this review was to systematically assess the evidence for the intrarater and inter-rater reliability of radiological methods of measuring AHD, in order to identify the most reliable method for use in RC tendinopathy. STUDY APPRAISAL AND SYNTHESIS An electronic literature search was carried out and studies describing the reliability of any radiological method of measuring AHD in either healthy or RC tendinopathy groups were included. Eighteen studies met the inclusion criteria and were appraised by two reviewers using the Quality Appraisal for reliability Studies checklist. RESULTS Eight studies were deemed to be of high methodological quality. Study weaknesses included lack of tester blinding, inadequate description of tester experience, lack of inclusion of symptomatic populations, poor reporting of statistical methods and unclear diagnosis. There was strong evidence for the reliability of ultrasound for measuring AHD, with moderate evidence for MRI and CT measures and conflicting evidence for radiographic methods. Overall, there was lack of research in RC tendinopathy populations, with only six studies including participants with shoulder pain. CONCLUSIONS The results support the reliability of ultrasound and CT or MRI for the measurement of AHD; however, more studies in symptomatic populations are required. The reliability of AHD measurement using radiographs has not been supported by the studies reviewed.

Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum

Synopsis The hallmark characteristics of rotator cuff (RC) tendinopathy are pain and weakness, experienced most commonly during shoulder external rotation and elevation. Assessment is complicated by nonspecific clinical tests and the poor correlation between structural failure and symptoms. As such, diagnosis is best reached by exclusion of other potential sources of symptoms. Symptomatic incidence and prevalence data currently cannot be determined with confidence, primarily as a consequence of a lack of diagnostic accuracy, as well as the uncertainty as to the location of symptoms. People with symptoms of RC tendinopathy should derive considerable comfort from research that consistently demonstrates improvement in symptoms with a well-structured and graduated exercise program. This improvement is equivalent to outcomes reported in surgical trials, with the additional generalized benefits of exercise, less sick leave, a faster return to work, and reduced costs to the health care system. This evidence covers the spectrum of conditions that include symptomatic RC tendinopathy and atraumatic partial- and full-thickness RC tears. The principles guiding exercise treatment for RC tendinopathy include relative rest, modification of painful activities, an exercise strategy that initially does not exacerbate pain, controlled reloading, and gradual progression from simple to complex shoulder movements. Evidence also exists for a specific exercise program being beneficial for people with massive inoperable tears of the RC. Education is an essential component of rehabilitation, and attention to lifestyle factors (smoking cessation, nutrition, stress, and sleep management) may enhance outcomes. Outcomes may also be enhanced by subgrouping RC tendinopathy presentations and directing treatment strategies according to the clinical presentation and the patients response to shoulder symptom modification procedures outlined herein. There are substantial deficits in our knowledge regarding RC tendinopathy that need to be addressed to further improve clinical outcomes. J Orthop Sports Phys Ther 2015;45(11):923-937. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5941.

Continuum model of tendon pathology - where are we now?

Chronic tendon pathology is a common and often disabling condition, the causes of which remain poorly understood. The continuum model of tendon pathology was proposed to provide a model for the staging of tendon pathology and to assist clinicians in managing this often complex condition (Br. J. Sports Med., 43, 2009, 409). The model presents clinical, histological and imaging evidence for the progression of tendon pathology as a three‐stage continuum: reactive tendinopathy, tendon disrepair and degenerative tendinopathy. It also provides clinical information to assist in identifying the stage of pathology, in addition to proposed treatment approaches for each stage. The usefulness of such a model is determined by its ability to incorporate and inform new and emerging research. This review examines the degree to which recent research supports or refutes the continuum model and proposes future directions for clinical and research application of the model.

Ultrasound measurement of the size of the anterior tibial muscle group: the effect of exercise and leg dominance.

BackgroundKnowledge of normal muscle characteristics is crucial in planning rehabilitation programmes for injured athletes. There is a high incidence of ankle and anterior tibial symptoms in football players, however little is known about the effect of limb dominance on the anterior tibial muscle group (ATMG). The purpose of this study was to assess the effect of limb dominance and sports-specific activity on ATMG thickness in Gaelic footballers and non-football playing controls using ultrasound measurements, and to compare results from transverse and longitudinal scans.MethodsBilateral ultrasound scans were taken to assess the ATMG size in 10 Gaelic footballers and 10 sedentary controls (age range 18-25 yrs), using a previously published protocol. Both transverse and longitudinal images were taken. Muscle thickness measurements were carried out blind to group and side of dominance, using the Image-J programme.ResultsMuscle thickness on the dominant leg was significantly greater than the non-dominant leg in the footballers with a mean difference of 7.3%, while there was no significant dominance effect in the controls (p < 0.05). There was no significant difference between the measurements from transverse or longitudinal scans.ConclusionsA significant dominance effect exists in ATMG size in this group of Gaelic footballers, likely attributable to the kicking action involved in the sport. This should be taken into account when rehabilitating footballers with anterior tibial pathology. Ultrasound is a reliable tool to measure ATMG thickness, and measurement may be taken in transverse or longitudinal section.

Technical considerations for accurate measurement of subcutaneous adipose tissue thickness using B-mode ultrasound

The search for valid, reliable and inexpensive methods of measuring body composition is an ongoing issue for many researchers. In particular, the measurement of subcutaneous adipose tissue (SAT) is carried out by numerous methods, each with its own drawbacks. Skinfold thickness measurement is the most common in-field method, but it is limited by its tendency to deform the adipose layer, by the limited caliper opening which prevents measurement of larger skinfolds, and the lack of correction for elastic properties of tissue between individuals. Therefore non-invasive field measures which overcome these limitations would be desirable. Ultrasound scanning provides such a device due to its portability and availability, allowing reduced tissue compression and on-screen views of the adipose tissue. Despite a number of papers referring to the use of ultrasound for measuring adipose tissue, the method of measurement has not been fully described. This paper describes our work in determining an accurate method for the measurement of SAT at different body sites, including a comparison of scanning directions and sites. We also describe our investigations into the degree to which compression force through the transducer affects adipose tissue measurement, and the reliability and sensitivity of our methods. We conclude with a recommended reliable scanning protocol for the measurement of SAT.

Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis

Background Ultrasound (US) imaging is commonly used to visualise tendon structure. It is not clear whether the presence of structural abnormalities in asymptomatic tendons predicts the development of future tendon symptoms in the Achilles or patellar tendon. Aim To perform a systematic review and meta-analysis investigating the ability of US imaging to predict future symptoms of patellar or Achilles tendinopathy. Methods Prospective studies that performed US imaging of Achilles OR patellar tendon structure among asymptomatic patients at baseline and a clinical measure of pain and/or function at follow-up were included. Study quality was assessed using the Critical Appraisal Skills Programme tool by two independent reviewers, and predictive ability of US was assessed using meta-analyses. Results The majority of participants in the review were from sporting populations. Meta-analysis revealed that tendon abnormalities on US are associated with future symptoms of both patellar and Achilles tendinopathy (RR=4.97, 95% CI 3.20 to 7.73). Subgroup analysis indicated that tendon abnormalities at baseline were associated with an increased risk of both Achilles (RR=7.33, 95% CI 2.95 to 18.24) and patellar (RR=4.35, 95% CI 2.62 to 7.23) tendinopathy. Conclusions This systematic review and meta-analysis indicates that tendon abnormalities visualised using US in asymptomatic tendons are predictive of future tendinopathy and are associated with at least a fourfold increased risk. Implications Identification of at-risk athletes using screening tools such as US may allow preventative programmes to be implemented. However, it is clear that other factors beyond tissue structure are involved in the development of lower limb tendinopathy.

Intrarater and Interrater Reliability of the Flexicurve Index, Flexicurve Angle, and Manual Inclinometer for the Measurement of Thoracic Kyphosis

Objective. This study aimed to describe the interrater and intrarater reliability of the flexicurve index, flexicurve angle, and manual inclinometer in swimmers. A secondary objective was to determine the level of agreement between the inclinometer angle and the flexicurve angle and to provide an equation to approximate one angle from the other. Methods. Thirty swimmers participated. Thoracic kyphosis was measured using the flexicurve and the manual inclinometer. Intraclass correlation coefficient, 95% confidence interval, and standard error of measurement were computed. Results. The flexicurve angle and index showed excellent intrarater (ICC = 0.94) and good interrater (ICC = 0.86) reliability. The inclinometer demonstrated excellent intrarater (ICC = 0.92) and interrater (ICC = 0.90) reliability. The flexicurve angle was systematically smaller and correlated poorly with the inclinometer angle (R 2 = 0.384). The following equations can be used for approximate conversions: flexicurve angle = (0.275 × inclinometer angle) + 8.478; inclinometer angle = (1.396 × flexicurve angle) + 8.694. Conclusion. The inclinometer and flexicurve are both reliable instruments for thoracic kyphosis measurement in swimmers. Although the flexicurve and inclinometer angles are not directly comparable, the approximate conversion factors provided will permit translation of flexicurve angle to inclinometer angle and vice versa.

65 Immediate response of the Supraspinatus Tendon to Loading in Rotator Cuff Tendinopathy.

Introduction Loading leads to multiple changes in tendon morphological and mechanical properties, which can be altered in tendinopathy. Reductions in tendon thickness are generally reported after loading in lower limb tendons, with some studies suggesting a reduced response in painful tendons. However, no such studies exist for the rotator cuff (RC) tendons. Therefore, the aim of this research was to examine the short-term effect of loading on thickness of the supraspinatus tendon (SsT) and acromiohumeral distance (AHD) in people with and without RC tendinopathy. Abstract 65 Figure 1 Supraspinatus tendon thickness at baseline (0hr) and 3 subsequent time points of 1, 6 and 24 hrs post-exercise for A) Controls and B) RC tendinopathy Methods participants Painfree controls (n = 20, 10 Males, Mean age = 43) and people with unilateral RC tendinopathy (n = 22, 12 males, Mean age = 47), were recruited. People with full thickness RC tears, bilateral shoulder pain and those with a history of surgery, were excluded. Both groups provided demographic data, and the shoulder pain group also completed a Numerical Rating Scale (NRS) for average shoulder pain intensity and the Shoulder Pain and Disability Index (SPADI) to assess shoulder disability. Ethical approval was obtained and all participants provided written informed consent. Measurements: Ultrasound images were used to measure acromiohumeral distance (AHD) and SsT thickness. A pilot study indicated excellent inter-rater reliability of these measures (ICC > 0.9), and minimal detectable difference (MDD) values of 0.7 mm for AHD and 0.6 mm for SsT thickness. Measures of AHD and SsT thickness were carried out immediately before, and at 3 intervals after the loading protocol (1 h, 6 h and 24 h). Loading protocol: Following a 5-minute shoulder warm-up, participants were seated on a Biodex 3 isokinetic dynamometer. The painful shoulder was exercised in the RC tendinopathy group, while coin toss determined the exercised side for controls. The exercise protocol involved one bout each of concentric and eccentric shoulder abduction, and external rotation, order randomly determined. Speed was set at 120°/sec, range of motion was from 20º internal rotation to at least 25 external rotation, and from neutral to as close as 90º abduction as was tolerable. Three sets of 10 repetitions of each movement direction were undertaken, ceasing once a fatigue level of 35% of overall torque was reached, or if pain beyond resting level was reported. Results For the RC tendinopathy group, there was a significant increase in SsT thickness at the one and six-hour time points, however only the six hour difference (0.6 mm, 11%) reached the MDD. There was a small statistically significant reduction (0.2 mm, 4%) in SsT thickness in the control group six hours after exercise, however the mean difference less than the MDD. The AHD reduced significantly in both groups at one hour (exceeding MDD), with recovery to normal by 6 h in controls, and 24 h in the pain group. Discussion Painful RC tendons showed an altered response to loading and slower return to normal compared to pain-free tendons. The coincidence of reduced subacromial space and thickened SsT in the RC tendinopathy group may provide evidence for an interaction between intrinsic and extrinsic mechanisms of RC tendinopathy.

Are group-based and individual physiotherapy exercise programmes equally effective for musculoskeletal conditions? A systematic review and meta-analysis

Background Musculoskeletal pain is common and its treatment costly. Both group and individual physiotherapy interventions which incorporate exercise aim to reduce pain and disability. Do the additional time and costs of individual physiotherapy result in superior outcomes? Objective To compare the effectiveness of group and individual physiotherapy including exercise on musculoskeletal pain and disability. Methods Eleven electronic databases were searched by two independent reviewers. Randomised controlled trials (RCTs) including participants with musculoskeletal conditions which compared group and individual physiotherapy interventions that incorporated exercise were eligible. Study quality was assessed using the PEDro scale by two independent reviewers, and treatment effects were compared by meta-analyses. Results Fourteen RCTs were eligible, including patients with low back pain (7 studies), neck pain (4), knee pain (2) and shoulder pain (1). We found no clinically significant differences in pain and disability between group and individual physiotherapy involving exercise. Conclusions Only small, clinically irrelevant differences in pain or disability outcomes were found between group and individual physiotherapy incorporating exercise. Since all but one study included other interventions together with exercise in either the group or individual arm, deciphering the unique effect of the way in which exercise is delivered is difficult. Group interventions may need to be considered more often, given their similar effectiveness and potentially lower healthcare costs.