Scott F. Farrell

Can physiotherapists contribute to care in the emergency department

Throughout the history of healthcare practice, controversy has often surrounded instances of non-medical clinicians, such as allied health practitioners, undertaking roles traditionally performed by doctors. While this blurring of professional boundaries may occur in response to a need to enhance the efficiency of health service delivery, concerns invariably arise regarding the quality of care delivered by non-medical clinicians and the potential negative implications for patient safety.1 In recent years, physiotherapists have begun to practice in Australia’s emergency departments (EDs) as autonomous, primary contact clinicians responsible for many duties traditionally solely within the domain of the medical profession. Some controversy does exist around this development, and as such, gives rise to the following questions: Do physiotherapists deliver quality care in the ED? Has the introduction of physiotherapists to ED improved service delivery as intended? Decreasing waiting times and improving efficiency of patient management in EDs is a significant goal of modern healthcare delivery. Patients presenting with mechanical musculoskeletal pathologies can experience long waiting times in busy departments, as medical staff must prioritise higher triage category patients with more urgent medical issues. The use of suitably trained and experienced physiotherapists as primary contact clinicians has been implemented in EDs in the United Kingdom, Australia, and the United States, in an attempt to reduce waiting times for such patients, and to reduce clinical loads placed upon medical staff. Emergency department physiotherapists (EDPs) are responsible for the management of patients with semiurgent and non-urgent (Australian triage categories 4 and 5) musculoskeletal complaints. Their role includes undertaking patient interviews and examinations, ordering investigations such as X-rays, making a diagnosis, implementing suitable interventions, referring for ongoing management, and arranging patient discharge.2 EDPs may also contribute to the care of patients with acute respiratory conditions (e.g. secretion clearance interventions) or facilitate the discharge of patients from ED into the community to reduce preventable hospital admissions. Such clinicians practice autonomous to medical staff in the management of presentations within their scope of practice, such as ankle or knee sprains and mechanical back pain, in a similar capacity as a physiotherapist working in a private clinic. EDPs may also practice in collaboration with medical staff in the management of simple limb fractures, or as a secondary practitioner providing physiotherapy input to respiratory conditions or an opinion regarding musculoskeletal injuries. In Australia, as this role is outside the traditional duties of physiotherapists, this is termed “advanced practice”.3

Sensorimotor control in individuals with idiopathic neck pain and healthy individuals: a systematic review and meta-analysis

OBJECTIVES (1) To identify reported tests used to assess sensorimotor control in individuals with idiopathic neck pain and (2) to investigate whether these tests can quantify differences between individuals with idiopathic neck pain and healthy individuals. DATA SOURCES Allied and Complementary Medicine Database, CINAHL, Cochrane Central Register of Controlled Trials, Embase, MEDLINE, Physiotherapy Evidence Database, Scopus, and SPORTDiscus. STUDY SELECTION Studies reporting sensorimotor outcomes in individuals with idiopathic neck pain or healthy individuals were identified. There were 1,677 records screened independently by 2 researchers for eligibility: 43 studies were included in the review, with 30 of these studies included in the meta-analysis. DATA EXTRACTION Methodologic quality was determined using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data were extracted using a standardized extraction table. DATA SYNTHESIS Sensorimotor control was most commonly assessed by joint position error and postural sway. Pooled means for joint position error after cervical rotation in individuals with neck pain (range, 2.2°-9.8°) differed significantly (P=.04) compared with healthy individuals (range, 1.66°-5.1°). Postural sway with eyes open ranged from 4.85 to 10.5cm2 (neck pain) and 3.5 to 6.6cm2 (healthy) (P=.16), and postural sway with eyes closed ranged from 2.51 to 16.6cm2 (neck pain) and 2.74 to 10.9cm2 (healthy) (P=.30). Individual studies, but not meta-analysis, demonstrated differences between neck pain and healthy groups for postural sway. Other test conditions and other tests were not sufficiently investigated to enable pooling of data. CONCLUSIONS The findings from this review suggest sensorimotor control testing may be clinically useful in individuals with idiopathic neck pain. However, results should be interpreted with caution because clinical differences were small; therefore, further cross-sectional research with larger samples is needed to determine the magnitude of the relation between sensorimotor control and pain and to assess any potential clinical significance.

Cervical spine meniscoids: an update on their morphological characteristics and potential clinical significance

PurposeCervical spine meniscoids are intra-articular folds of synovial membrane that have been theorised to have potential clinical significance in neck pain. Recent anatomical and clinical research has re-visited the pathoanatomical capacity of these structures. The purpose of this review is to discuss cervical spine meniscoid morphology in light of recently published work, to provide an update on the plausible relevance of these structures to clinical practice.MethodsNarrative review critically discussing basic science and clinical research regarding cervical spine meniscoids, with focus upon implications for clinical practice.ResultsBasic science research indicates that cervical spine meniscoids can be innervated and appear to vary in morphology in the presence of articular degeneration. In a clinical population, associations have been observed between cervical spine meniscoid morphology and presence of cervical spine symptoms.ConclusionsRecent studies regarding cervical spine meniscoid morphology provide further evidence of pathoanatomical capacity of these structures. Further research is required, however, in clinical populations to empirically investigate specific theorised mechanisms of cervical spine meniscoid involvement in neck pain.

Immunohistochemical investigation of nerve fiber presence and morphology in elderly cervical spine meniscoids

BACKGROUND CONTEXT Innervation of anatomical structures is fundamental to their capacity to generate nociceptive impulses. Cervical spine meniscoids are hypothesized to be contributors to neck pain; however, their innervation is not comprehensively understood. PURPOSE This study aimed to examine the presence and morphology of nerve fibers within cervical spine meniscoids and adjacent joint capsules. STUDY DESIGN This is a cross-sectional study. PATIENT SAMPLE The sample consists of cervical hemispines of 12 embalmed cadavers (mean [standard deviation] age 82.9 [6.5] years, six female, six left). Either the right or the left half of the cervical spine (hemispine) of each cadaver was included in the sample. So six left sides and six right sides of the cadaver cervical spines made up the 12 hemispines that formed the sample. METHODS Cervical spine meniscoids and adjacent joint capsules were excised from lateral atlantoaxial and cervical zygapophyseal (C2-C3 to C6-C7) joints (n=67), then paraffin embedded. Meniscoids were sectioned sagittally (5 µm), slide mounted, and immunohistochemistry was performed using primary antibodies to neurofilament heavy (NF-H) and pan-neurofilament (Pan-NF) to identify nerve tissue. The study was supported by institutional graduate student funding. The authors have no conflicts of interest to declare. RESULTS Seventy-seven meniscoids (23 lateral atlantoaxial, 54 cervical zygapophyseal) were extracted and processed (154 sections in total). Sixty-four individual nerve fiber bundles were identified (26 NF-H positive, 38 Pan-NF positive) from 14 meniscoids. Nerves immunoreactive to both NF-H and Pan-NF were identified in 13 of 77 meniscoids (10 of 14 lateral atlantoaxial joint) from 11 joints (eight cadavers). Nerves were always located in joint capsules except three exclusively Pan-NF immunoreactive nerve fiber bundles from two adipose meniscoids. CONCLUSIONS The low nerve prevalence in elderly cervical spine meniscoids, with nerves only found in two adipose type meniscoids, suggests these structures may play a minimal role in cervical nociception generation in this demographic. The joint capsules, which were more frequently innervated, appear to be more likely generators of nociception in the elderly. Joint capsule nerves were mostly NF-H positive, indicating potential Aδ-fiber presence.

The influence of isometric exercise on endogenous pain modulation: comparing exercise-induced hypoalgesia and offset analgesia in young, healthy adults

Abstract Background and aims Impairment of endogenous analgesia has been associated with the development, maintenance and persistence of pain. Endogenous analgesia can be evaluated using exercise-induced hypoalgesia (EIH) and offset analgesia (OffA) paradigms, which measure temporal filtering of sensory information. It is not clear if these paradigms are underpinned by common mechanisms, as EIH and OffA have not previously been directly compared. A further understanding of the processes responsible for these clinically relevant phenomena may have future diagnostic and therapeutic utility in management of individuals with persistent pain conditions. The primary aim of this study was to investigate if there is a correlation between the magnitudes of EIH and OffA. The secondary aim of the study was to examine whether exercise influences OffA. Methods Thirty-six healthy, pain-free participants were recruited. EIH was evaluated using pressure pain thresholds (PPT) and pain ratings to suprathreshold pressure stimuli over tibialis anterior and the cervical spine. OffA evaluation utilised a three-step protocol, whereby individualised heat pain thermal stimuli [Numerical Rating Scale (NRS)=50/100] were applied (T1), before increasing 1 °C (T2), followed by 1 °C reduction (T3). The magnitude of OffA was calculated as the percentage reduction in the NRS from T2 to T3. PPT/suprathreshold pain ratings and OffA measures were recorded, before and after 5 min of isometric quadriceps exercise performed at 20–25% maximum voluntary contraction (MVC); and following a 15 min rest period. Data were analysed using repeated measures (RM) ANCOVA and correlational analyses. Results There was no correlation between EIH measures (PPTs or pain ratings to suprathreshold pressure stimuli over tibialis anterior or the cervical spine) and OffA (p>0.11 for all). OffA was induced and not modulated by exercise (p=0.28). Conclusions Five minutes of 20–25% MVC lower limb isometric exercise provided non-pharmacological pain modulation in young, active adults. Magnitude of EIH was not correlated with that of OffA, and exercise did not influence magnitude of OffA. Implications These results suggest that in young, pain-free individuals, separate testing of these two paradigms is required to comprehensively evaluate efficacy of endogenous analgesia. If these results are replicated in patient populations, alternative or complementary methods to exercise interventions may be required to modulate impaired OffA.

The Influence of Age, Sex, and Posture on the Measurement of Atlantodental Interval in a Normal Population

OBJECTIVE The atlantodental interval (ADI) is used in assessing atlantoaxial stability. This measurement may potentially be affected by several features encountered during patient examination. This study examined the influence of 3 features: age, sex, and posture, on the measurement of ADI in a normal population. METHODS The ADI was measured sequentially on 269 lateral cervical radiographs of adults with no demonstrated bony injury. Images were stratified by age and sex with equal representation in each age group. A further 25 asymptomatic adults were assessed for posture using craniovertebral angle measured from digital lateral photographs. The ADI was then measured from a lateral radiograph. The data were examined for correlation between age, craniovertebral angle, and ADI using Spearman rank correlation. The ADI of age groups was compared by Kruskal-Wallis test. The relationship between ADI and sex was examined using Wilcoxon rank sum test. Interaction between age and sex was explored using an interaction term in regression analysis. RESULTS The ADI decreased with age, median measurements reducing from 2.07 to 0.85 mm across age groups (P < .01). No significant relationship was demonstrated between ADI and sex. No significant interaction was demonstrated between age and sex. Measurements of craniovertebral angle did not correlate with ADI (ρ = 0.03, P = .90). CONCLUSION The magnitude of ADI decreases with advancing age. Age should be considered a modifying factor when interpreting measurement of ADI, particularly in consideration of potential minor instabilities. Patient sex does not appear to influence ADI, either independently or in interaction with age. Craniocervical posture variation does not influence ADI in an asymptomatic adult population.

Shoulder Taping and Neuromuscular Control

CONTEXT   Scapular taping can offer clinical benefit to some patients with shoulder pain; however, the underlying mechanisms are unclear. Understanding these mechanisms may guide the development of treatment strategies for managing neuromusculoskeletal shoulder conditions. OBJECTIVE   To examine the mechanisms underpinning the benefits of scapular taping. DESIGN   Descriptive laboratory study. SETTING   University laboratory. PATIENTS OR OTHER PARTICIPANTS   A total of 15 individuals (8 men, 7 women; age = 31.0 ± 12.4 years, height = 170.9 ± 7.6 cm, mass = 73.8 ± 14.4 kg) with no history of shoulder pain. INTERVENTION(S)   Scapular taping. MAIN OUTCOME MEASURE(S)   Surface electromyography (EMG) was used to assess the (1) magnitude and onset of contraction of the upper trapezius (UT), lower trapezius (LT), and serratus anterior relative to the contraction of the middle deltoid during active shoulder flexion and abduction and (2) corticomotor excitability (amplitude of motor-evoked potentials from transcranial magnetic stimulation) of these muscles at rest and during isometric abduction. Active shoulder-flexion and shoulder-abduction range of motion were also evaluated. All outcomes were measured before taping, immediately after taping, 24 hours after taping with the original tape on, and 24 hours after taping with the tape removed. RESULTS   Onset of contractions occurred earlier immediately after taping than before taping during abduction for the UT (34.18 ± 118.91 milliseconds and 93.95 ± 106.33 milliseconds, respectively, after middle deltoid contraction; P = .02) and during flexion for the LT (110.02 ± 109.83 milliseconds and 5.94 ± 92.35 milliseconds, respectively, before middle deltoid contraction; P = .06). These changes were not maintained 24 hours after taping. Mean motor-evoked potential onset of the middle deltoid was earlier at 24 hours after taping (tape on = 7.20 ± 4.33 milliseconds) than before taping (8.71 ± 5.24 milliseconds, P = .008). We observed no differences in peak root mean square EMG activity or corticomotor excitability of the scapular muscles among any time frames. CONCLUSIONS   Scapular taping was associated with the earlier onset of UT and LT contractions during shoulder abduction and flexion, respectively. Altered corticomotor excitability did not underpin earlier EMG onsets of activity after taping in this sample. Our findings suggested that the optimal time to engage in rehabilitative exercises to facilitate onset of trapezius contractions during shoulder movements may be immediately after tape application.

An ectopic intramedullary hematopoietic niche in a cervical spine meniscoid: a case report

We present the first documented case of an ectopic intramedullary hematopoietic niche within a cervical zygapophyseal joint intra-articular meniscoid. The meniscoid was identified in the cervical spine of an 81-year-old male cadaver, located at the dorsal aspect of the right C4-5 zygapophyseal joint, and was noted to be larger and more dense than other meniscoids during disarticulation and dissection of the joint. Histologically, the meniscoid contained hematopoietic cells surrounded by lamellar bone, and was lined with articular cartilage on the surface protruding into the joint cavity. Radiologically, the structure was hypointense on both T1- and T2-weighted magnetic resonance imaging sequences. The potential mechanisms underpinning development of this novel finding and the possible clinical implications are discussed in this report.

Vertebral haemangioma compared to bony metastasis on magnetic resonance imaging

Vertebral haemangiomas (VHs) are benign vascular lesions of vertebral bodies, and are common incidental findings in imaging, occurring in approximately 10–12% of the adult population.1 These lesions consist of thin-walled blood vessels that pervade the medul-lary cavity between trabecula.2 Typically, VHs are asymptomatic and do not require intervention unless causing neurological compromise.