Flexion Rotation Research Articles

Intrarater and Interrater Reliability of the Flexion Rotation Test and Cervical Range of Motion in People With Migraine

ObjectiveThe aim of this study was to determine the reliability, standard error of measurement (SEM), and smallest detectable change (SDC) of the flexion rotation test (FRT) and cervical range of motion (CROM) assessed with the CROM device in individuals with and without migraine. MethodsTwenty-five women with migraine (mean age, 35 years; standard deviation, 10 years) and 25 comparable headache-free women (mean age, 32 years; standard deviation, 11 years) participated in this study. C1/C2 mobility was assessed with the FRT, whereas global cervical range of motion was calculated using a CROM device. To assess the interrater reliability, tests were conducted on the same day at 20-minute intervals, by 2 independent assessors, and they were repeated after a 1-week interval by the same assessor to evaluate the intrarater reliability. The mean value of 3 repetitions was used to calculate the intraclass correlation coefficient ICC(2,k), SEM, and SDC. ResultsThe intrarater reliability was excellent (ICC > 0.83), and interrater reliability ranged from substantial to excellent (ICC > 0.77) for the FRT. The SEM ranged from 2.44° to 2.85°, and the SDC from 6.78° to 7.9°. Intrarater and interrater reliability for cervical range of motion was substantial to excellent (ICC > 0.65), with the SEM ranging from 2.03° to 5.46° and the SDC from 5.6° to 15.14°. ConclusionThe results demonstrate that FRT and global cervical range of motion with a CROM device show high reliability in individuals with migraine. In addition, the SEM and SDC were relatively small. Both assessments can be used for clinical evaluation of the cervical spine in individuals with migraine.

Concurrent validity and reliability of measuring range of motion during the cervical flexion rotation test with a novel digital goniometer

BackgroundHeadache is a common and costly health problem. Although the pathogenesis of headache is heterogeneous, reported contributing factors are dysfunctions of the upper cervical spine. The flexion rotation test (FRT) is a commonly used diagnostic test to detect upper cervical movement impairment. A digital goniometer may support precise measurement of movement impairment in the upper cervical spine. However, its reliability and validity is not assessed, yet. The aim of this study was to investigate the reliability and validity of the digital goniometer compared to an ultrasound-based movement analysis system.MethodsTwo separate cross-sectional studies were conducted using the digital goniometer EasyAngle (Meloq AB, Stockholm, Sweden) for a) investigating the concurrent validity of upper cervical range of motion (ROM) during the FRT and b) determining the inter- and intra-rater reliability in the target population of patients with head and neck pain. Sixty-two participants, 39 with and 23 without head and neck pain, were recruited for the concurrent validity study. For the reliability study, a total of 50 participants were recruited. Intraclass correlation coefficients (ICC) and Bland Altmann plots were used to assess validity and ICC values, Bland Altmann plots as well as Kappa coefficients were used for estimating intra-rater and inter-rater reliability.ResultsConcurrent validity was strong with an ICC (2,1) of 0.97 for ROM to either side (95%CI = 0.95–0.98). Bland Altman Plots revealed a mean difference between measurement systems of 0.5° for the left and 0.11° for the right side.The inter-rater ICC (2,1) was 0.66 (95%CI 0.47–0.79, p < 0.001, SEM 6.6°), indicating good reliability. The limits of agreement were between 10.25° and − 11.89°, the mean difference between both raters was − 0.82°. Intra-rater reliability for the measurement of ROM during the FRT was between 0.96 (ICC 3,1) for rater 1 and 0.94 (ICC 3,1) for rater 2.ConclusionsThe digital goniometer demonstrated strong concurrent validity and good to strong reliability and can be used in clinical practice to accurately determine movement impairment in the upper cervical spine.Trial registrationGerman Registry of Clinical Trials DRKS00013051.

Reciprocal roles of joint position error, visual dependency and subjective perception in cervicogenic dizziness

Aim Since cervical joint position error (JPE) and visual dependency (VD) may reflect altered ascending inputs from the neck receptors, the aim of the present study was to test how these parameters may be impacted by those clinical parameters in cervicogenic dizziness (CGD) patients when compared with healthy subjects participants. Materials and methods 93 subjects participants fulfilling inclusion criteria for CGD and 98 age- and gender-matched healthy subjects volunteers – undergoing cervical relocation and rod and disc test to evaluate JPE and VD, respectively – were compared to each other. Cervical range of motion (CROM), Dizziness Handicap Inventory (DHI), Neck Disability Index (NDI), Neck pain intensity (NPI), Tampa Scale for Kinesiophobia (TSK-17) and Hospital Anxiety and Depression Scale (HADS) were also collected in both groups Results When compared to healthy participants, CGD patients were found to have a higher degree of JPE in right (p = 0.008, mean difference, MD: 2.88) and left (p = 0.006, MD: 2.55) rotation as well as in extension (p = 0.011, MD: 2.31), flexion (p = 0.009, MD: 2.35) and mean value (p = 0.001, MD: 2.53) and higher degrees of error in CCW at +40° and −40° (p = 0.012, MD: 0.85 and p = 0.016, MD: 0.82, respectively) and CW at +40° and −40° (p = 0.018, MD: 0.83 and p = 0.015 MD: 0.81, respectively). CGD patients also demonstrated a significant reduction in degrees of CROM in active flexion (p = 0.011, MD: −34.63), extension (p = 0.018, MD: −21.67), left (p = 0.012, MD: −28.29) and right (p = 0.009, MD: −28.52) rotation, and left (p = 0.02, MD: −7.29) and right (p = 0.021, MD: −5.05) lateral flexion. Furthermore, these patients demonstrated higher scores in total DHI (p = 0.007, MD: 25.17) (and relative DHI-P, DHI-F, DHI-E; p = 0.009, MD: 11.4; p = 0.014, MD: 8.73 and p = 0.018, MD: 5.03, respectively), in TSK-17 (p = 0.017, MD: 17.56), and HADS, both in anxiety (p = 0.022, MD: 4.62) and depression (p = 0.02, MD: 7.31) subscale. Conclusions A possible common physiopathological background may impact on processes involved in both the JPE and VD behaviour, entangled in a vicious circle with the impaired subjective clinical and quality of life perception.

Field hockey sport-specific postures during unanticipated sidestepping: Implications for anterior cruciate ligament injury prevention

ABSTRACT Much research has investigated whole-body postures and associated knee joint loading during unanticipated sidestepping (UnSS). However, no research has considered sport-specific postures in field hockey. The purpose of this study was to investigate differences in trunk and lower limb angle and lower extremity joint moment waveforms during UnSS while holding a hockey stick in a flexed posture (HS-UnSS) and traditional UnSS. Additionally, we aimed to determine if differences in posture during HS-UnSS were associated with changes in knee joint moments. Twelve elite female field hockey athletes underwent 3D motion analysis during UnSS and HS-UnSS. Athletes increased trunk (0–100% of stance phase, hip (0–15%), knee (12–29%; 39–59%; 78–100%) and ankle (41–57%) flexion angles, and increased hip flexion (19–24%; 42–45%; 75–84%) and external rotation moments (75–80%) during HS-UnSS compared with UnSS (p < 0.05). Flexed postures observed during HS-UnSS did not influence knee flexion and valgus moments when compared with UnSS (p > 0.05), however knee external rotation moments reduced. Changes in trunk flexion were positively associated with peak knee internal rotation moments from UnSS to HS-UnSS (r = 0.779, p = 0.005). These findings indicate that field hockey players sidestep with significantly different techniques when holding a hockey stick, which should be considered in injury prevention training protocols.

Biomechanical comparison of noncontiguous cervical disc arthroplasty and noncontiguous cervical discectomy and fusion in the treatment of noncontinuous cervical degenerative disc disease: a finite element analysis

BackgroundBiomechanical characteristics of noncontinuous ACDF and noncontinuous CDA in the treatment of noncontinuous cervical degenerative disc disease were still unclear. The aim of this research is to compare the differences between these two kinds of treatment methods and to verify the effectiveness of Prodisc-C in noncontinuous CDA.MethodsEight FEMs of the cervical spine (C2–C7) were built based on CT images of 8 mild CDDD volunteers. In the arthroplasty group, we inserted Prodisc-C at C3/4 and C5/6. In the fusion group, CoRoent® Contour and NuVasive® Helix ACP were implanted at C3/4 and C5/6. Initial loads of 75 N were used to simulate the head weight and muscle forces. The application of 1.0 N m moment on the top on the C2 vertebra was used to create motion in all directions. Statistical analyses were performed using STATA version 14.0 (Stata Corp LP, College Station, Texas, USA). Statistical significance was set at P < 0.05.ResultsThe IDPs in C2/3 (P < 0.001, P = 0.005, P < 0.001, P < 0.001), C4/5 (P < 0.001), and C6/7 (P < 0.001) of the intact group were significantly less than that in the fusion group in flexion, extension, lateral bending, and axial rotation, respectively. In addition, the IDPs in C2/3 (P < 0.001, P = 0.001, P < 0.001, P < 0.001), C4/5 (P < 0.001), and C6/7 (P < 0.001) of the arthroplasty group were significantly less than that in the fusion group in flexion, extension, lateral bending, and axial rotation, respectively. Contact forces of facet joints in C2/3 (P = 0.010) in the arthroplasty group was significantly less than that in the intact group. Contact forces of facet joints in C2/3 (P < 0.001), C4/5 (P < 0.001), and C6/7 (P < 0.001) in the arthroplasty group was significantly less than that in the fusion group. Contact forces of facet joints in C2/3 (P < 0.001), C4/5 (P < 0.001), and C6/7 (P < 0.001) in the intact group were significantly less than that in the fusion group.ConclusionsNoncontinuous CDA could preserve IDP and facet joint forces at the adjacent and intermediate levels to maintain the kinematics of cervical spine near preoperative values. However, noncontinuous ACDF would increase degenerative risks at adjacent and intermediate levels. In addition, the application of Prodisc-C in noncontinuous CAD may have more advantages than that of Prestige LP.

Mechanical stability study of three techniques used in the fixation of transverse and oblique metaphyseal-diaphyseal junction fractures of the distal humerus in children: a finite element analysis

BackgroundManagement of distal humerus metaphyseal-diaphyseal junction (MDJ) region fractures can be very challenging mainly because of the higher location and characteristics of the fracture lines. Loss of reduction is relatively higher in MDJ fractures treated with classical supracondylar humerus fractures (SHFs) fixation techniques.MethodsThree different fracture patterns including transverse, medial oblique and lateral oblique fractures were computationally simulated in the coronal plane in the distal MDJ region of a pediatric humerus and fixated with Kirschner Wires (K-wires), elastic stable intramedullary nails (ESIN), and lateral external fixation system (EF). Stiffness values in flexion, extension, valgus, varus, internal, and external rotations for each fixation technique were calculated.ResultsIn the transverse fracture model, 3C (1-medial, 2-lateral K-wires) had the best stiffness in flexion, varus, internal, and external rotations, while 3L (3-divergent lateral K-wires) was the most stable in extension and valgus. In the medial oblique fracture model, EF had the best stiffness in flexion, extension, valgus, and varus loadings, while the best stiffness in internal and external rotations was generated by 3MC (2-medial, 1-lateral K-wires). In the lateral oblique fracture model, 3C (1-medial, 2-lateral K-wires) had the best stiffness in flexion and internal and external rotations, while ESIN had the best stiffness in extension and valgus and varus loadings.ConclusionThe best stability against translational forces in lateral oblique, medial oblique, and transverse MDJ fractures would be provided by ESIN, EF, and K-wires, respectively. K-wires are however superior to both ESIN and EF in stabilizing all three fracture types against torsional forces, with both 2-crossed and 3-crossed K-wires having comparable stability. Depending on the fracture pattern, a 3-crossed configuration with either 2-divergent lateral and 1-medial K-wires or 2-medial and 1-lateral K-wires may offer the best stability.

Comparison of Gait Pattern in Athletes with ACL Deficiency and Healthy Individual using an Accelerometer

Background: In athletes with anterior cruciate ligament (ACL) deficiencies could assess functional capabilities with different instruments such as use of a camera in vivo situation. However, these methods have suffered from a large number of limitations such as inability to be repeatable and complexity in technique. Objective: The main purpose of this study was to compare gait pattern of the athletes with ACL injury and able-bodied subjects using an accelerometer. Method: A three-dimensional accelerometer was placed over the tibia tuberosity of 20 healthy and 20 individuals with ACL-deficiencies (ACLD). After walking on the treadmill, the principal components of the acceleration data were calculated using MATLAB software. Results: In this study, Principle Component analysis was used for statistical analysis. The results indicated that subjects with ACL deficiency have different gait pattern compared to the control group. The major differences between stride trajectories of the two groups were at the end of mid-swing and the beginning of terminal swing phases in vertical axis. ACL deficient subjects exhibited different gait patterns during mid and terminal stance phases in anterior- posterior axis compared with normal controls. Conclusions: The difference in gait between subjects with ACL deficiency and healthy subjects are depends on variation in the amount of knee flexion and tibia rotation that could be altered to motor recruitment.

Physiotherapy Program for Managing Adhesive Capsulitis in Patients with Diabetes: A Protocol for a Pilot Randomized Trial

Background: Adhesive capsulitis (AC) occurs five times more often in people with diabetes and leads to prolonged disability. Exercises and joint mobilization are usually used to manage AC. However, the recovery is slow and often incomplete. Aerobic exercises improve hyperglycemia and insulin sensitivity. Currently, no research has formally assessed the benefits of incorporating an aerobic training program into the treatment plan of AC in patients with diabetes. This single blind pilot randomized trial will compare the preliminary effect of a regular physiotherapy program (PT), to a regular PT program combined with a progressive walking program (PT+) in patients with and without diabetes who have AC. Methods: Patients (n= 40) will be recruited from St. Joseph's HealthCare Centre and associated primary care practices. Patients will be randomly assigned into either the regular PT program or regular PT combined with a progressive walking program. Patients will be referred to physical therapy facilities and the intervention will be chosen by the treating physical therapist. In the PT+ group, patients will be asked to perform free walking at their own pace for 30-45 minutes, five days per week, for six consecutive weeks. The primary outcome will be testing the functional performance of the shoulder using the Functional Impairment Test- Hand and Neck/ Shoulder/Arm (FIT-HaNSA) test. Secondary outcomes will include shoulder pain and function using the Shoulder Pain and Disability Index (SPADI) questionnaire; shoulder range of motion in flexion, abduction, and external rotation; muscles strength of shoulder flexors and abductors; and physical activity level using an accelerometer and the Rapid Assessment of Physical Activity (RAPA) questionnaire. The primary outcome will be evaluated at baseline and after six weeks. Secondary outcomes will be evaluated at baseline, and after three, six and 12 weeks from enrolment. Discussion: The novel approach taken in this pilot trial will establish the preliminary effect of a regular PT program combined with a progressive walking program and will evaluate a study design prior to the performance of a full-scale research project that may lead to better outcomes for managing adhesive capsulitis in people with diabetes.

A comparison of foot kinematics between pregnant and non-pregnant women using the Oxford foot model during walking

To investigate the effects between pregnant women (PW) and non-pregnant women (NW) on foot kinematics during walking using the Oxford foot model (OFM). Twenty women with last trimester of pregnancy and 23 non-pregnant women were involved in this study. Three-dimensional motion of the forefoot, hindfoot and tibia during walking were recorded by a Vicon motion analysis system. Two force platforms were used to record the ground reaction force. Compared with NW, PW demonstrated greater plantar flexion and internal rotation of hindfoot and internal tibial rotation during initial contact, greater forefoot eversion and hindfoot external rotation during push off. Moreover, PW showed greater external tibial rotation than NW during toe off and the centre of pressure (COP) trajectory moved to the 2nd to 3rd metatarsal at this stage. It appears that the altered foot kinematics of pregnant women may contribute to the redistribution of joints loads and the maintenance stability at a comfortable walking pace.

Cervicogenic Headache

Cervicogenic headache is a secondary headache that occurs due to referred pain from the cervical region, perceived in the trigeminal nerve distribution. It is a rare entity which is often seen in patients following whiplash injuries belonging to the early 30s age group. The pain generators are facet joints, atlanto-occipital joint, intervertebral discs, neck muscles, and cervical nerves from various pathologies. Clinically, it is a side-locked headache worsened by abnormal neck postures and neck strain. The flexion–rotation test is positive in most cases. Diagnosis is made based on the ICHD-3 criteria. The mainstay of treatment involves physical therapy for 6 weeks along with psychological therapy and pain medications. Interventional pain therapy options include cervical epidural steroid injections, trigger point injections, selective nerve root injections, and radiofrequency thermal neurolysis.

Posterior Cruciate Ligament

Improved understanding of the anatomy and biomechanics of the posterior cruciate ligament (PCL) has led to the evolution and improvement of anatomic-based reconstructions. The PCL is composed of the larger anterolateral bundle (ALB) and the smaller posteromedial bundle (PMB). On the femoral side, the ALB spans from the trochlear point to the medial arch point on the roof of the notch, while the PMB occupies the medial wall from the medial arch point to the most posterior aspect of the articular cartilage. Because of these broad and distinct attachments, the bundles have a load-sharing, synergistic and codominant relationship. Both restrict posterior translation; however, the ALB has a proportionally larger role in restricting translation throughout flexion, whereas the PMB has a role comparable to that of the ALB in full extension. In addition, the PMB resists internal rotational at greater flexion angles (> 90°). Consequently, it is difficult to restore native kinematics with a single graft. Biomechanical analysis of single- versus double-bundle PCL reconstructions (SB PCLR vs DB PCLR) demonstrates improved restoration of native kinematics with a DB PCLR, including resistance to posterior translation throughout flexion (15°-120°) and internal rotation in deeper flexion (90°-120°). Similarly, clinical research demonstrates excellent outcomes following DB PCLR, including functional outcomes comparable to those of anterior cruciate ligament reconstructions, with no significant differences between isolated and multiligament PCL injuries. Compared to SB PCLR, systematic review has demonstrated the superiority of DB PCLR based on objective postoperative stress radiography and International Knee Documentation Committee scores in randomized trials. In addition to reconstruction techniques, recent research has identified other factors that impact kinematics and PCL forces, including decreased tibial slope, which leads to increased graft stresses, and incidence of native PCL injuries. As the understanding of these other contributing factors evolves, so will surgical and treatment algorithms that will further improve patients’ outcomes.

Muscle loss in elderly patients - prevention effects of a multimodal therapy program for low back pain

Muscle loss with an increasing loss of muscle mass, muscle strength and muscle function is a disease in elderly individuals. Along with the severity of muscle loss, an increased frailty is evident. The consequences of an increased frailty are age-related reduced resilience and reduced strength conditions, and following this substantial loss of quality of life. The onset and progression of aging processes can be positively influenced by physical training, which helps to prevent the decline in neuromuscular capacity. There is consensus that hypertrophy training focusing on the training of situation specific movement tasks of the individual muscle groups is recommended. In this study we demonstrated that multimodal therapy is an efficient alternative intervention to strengthen the back muscles and by this to increase muscle growth in the areas of extension and flexion as well as lateralization and rotation on both sides. 52 patients aged between 50 and 65 with a main diagnosis of back disease were examined prospective. They completed a 3-week inpatient multimodal therapy program. Effects of the program were assessed by applying two isometric strength measurements of the back muscles. Baseline measurement (T0) was done on the first day of the program and post measurement (T1) on the last day of therapy. The results were described by means of SPSS as mean (M) and standard deviation (SD). The normal distribution was verified (Kolmogorov-Smirnov test). Data indicates that there are significant improvements in extension force, right lateral and right rotation force. Strength gains in flexion, left lateral and left rotation could also be demonstrated, but compared to the other three directions with reduced strength. It could be shown that even a multimodal therapy program leads to an increase in strength. Since pure hypertrophy training is a great challenge, especially for the elderly, the multimodal therapy concepts promising approach to facilitate the often difficult start to the treatment of muscle loss. The significant higher power increase concerning extension, rotation and lateralization on the right side compared to the left side is remarkable. Here further research is needed to obtain explanations. A significant weakness of the study is the lack of a control group. Further research with more sophisticated study designs (e.g. RCT) is necessary in order to learn more about this alternative intervention to treat muscle loss.

Usefulness of Soft Tissue Therapy in Patients with Shoulder Pain Syndrome

Shoulder pain is among the most common musculoskeletal pain syndromes. This study aimed to compare the effectiveness of the worldwide renowned Kaltenborn and Evjenth manual therapy and the innovative concept of Fascial Distortion Model (FDM) in the treatment of patients suffering from shoulder pain. The study group consisted of 100 patients treated for shoulder pain (SP), who were randomly assigned to two groups: Group A, whose therapy involved FDM (51), and Group B, treated with Kaltenborn and Evjenth method (49). Exclusion criteria comprised age &lt; 30 years, low threshold of sensitivity to pain, participation in another rehabilitation programme, uncontrolled arterial hypertension, neurological conditions associated with sensory impairment, connective tissue conditions and presence of 'red flags'. The tools used in the study included a digital inclinometer to measure the range of joint mobility and a NeuroTrack device to assess neuromuscular conductivity. Statistical analysis used the non-parametric Mann-Whitney U test and non-parametric Wilcoxon signed rank test. The significance threshold was accepted as p ≤ 0.05. Both groups showed significant improvement (p&lt;0.05) in the range of motion in the upper limb in all direc-tions (flexion, abduction and external rotation) and change in the function of the infraspinous muscle. The only significant difference between the groups was found for external rotation (p&lt;0.05), with Group A displaying a superior range of motion. 1. A single session of the Kaltenborn and Evjenth method and FDM in patients suffering from shoulder pain may increase their range of motion in the shoulder as well as improve the function of the infraspinous muscle. 2. Cur-rently there is insufficient evidence to warrant stronger recommendation of one of the study therapies over the other. 3. There is a need for further prospective randomised studies involving larger groups of patients and assessing long-term effec-tiveness of the therapies.

The measurement and clinical significance of the rotation angles of head-neck fragments after cephalomedullary nail fixation in intertrochanteric fractures

To measure the rotation angle of the head-neck fragment of intertrochanteric fracture after cephalomedullary nail fixation by three-dimensional CT imaging, and to explore its clinical significance. The clinical data of 68 patients with unstable intertrochanteric fracture of AO/Orthopaedic Trauma Association (AO-OTA) type 31-A2 treated with cephalomedullary nail fixation and with complete intraoperative fluoroscopy and postoperative three-dimensional CT imaging data between July 2016 and October 2018 were retrospectively analyzed. Among them, there were 21 males and 47 females, aged 68-93 years, with an average age of 81.8 years. There were 31 cases of AO/OTA type 31-A2.2 and 37 cases of 31-A2.3. Fracture reduction quality was evaluated according to Baumgaertner et al. and Chang et al. criteria. The anteromedial cortical contact or not of each patient was observed by three-dimensional CT imaging on T3DView software after operation. The rotation of head-neck fragments were divided into three types: non-rotation, flexion rotation, and hyperextension rotation. The rotation angles of each type were measured and the relationship between the rotation type of the head-neck fragments and the contact of the anteromedial cortex was analyzed. The reduction and fixation of the small trochanter were not performed in 68 patients. According to Baumgaertner et al. criteria, the quality of fracture reduction was excellent in 15 cases (22.1%), acceptable in 50 cases (73.5%), and poor in 3 cases (4.4%). According to Chang et al. criteria, 31 cases were excellent (45.6%), 33 cases were acceptable (48.5%), and 4 cases were poor (5.9%). Thirty-nine cases (57.4%) received anteromedial cortical support and 29 cases (42.6%) did not receive cortical support. Three-dimensional CT imaging showed non-rotation in 12 cases (17.6%), flexion rotation in 39 cases (57.4%), and hyperextension rotation in 17 cases (25.0%). There were 7 cases (58.3%), 30 cases (76.9%), and 2 cases (11.8%) of cortical support in non-rotation group, flexion rotation group, and hyperextension rotation group, respectively. The rotation angles were (1.05±0.61), (13.96±6.17), (8.21±3.88)°, respectively. There were significant differences between groups ( P<0.05). In the unstable intertrochanteric fracture after cephalomedullary nail fixation, the rotation of head-neck fragment exists in most patients, and the types of flexion rotation and non-rotation can easily obtain cortical support reduction.

The effects of marathon running on three-dimensional knee kinematics during walking and running in recreational runners

BackgroundRunning-related musculoskeletal injuries are common. Knee injuries are most frequent, and often occur during or shortly after marathons. Research questionThe effects of a marathon on runners’ knee kinematics remain unclear. No studies have shown comprehensive three-dimensional (3D) knee kinematic changes following a marathon. This study aimed to observe the effects of running a marathon on 3D knee kinematics and identify the phases of walking and running gait in which significant changes occur. MethodsBased on an electronic survey, 10 healthy, recreational runners (20 knees) with similar running experience were included. Their 3D knee kinematics (during treadmill walking and running) were collected using a portable, optical motion capture system within 24 h before and within 6 h after running a marathon. ResultsAll measurements after the marathon were compared with pre-marathon measurements. (1) For walking post-marathon: varus rotation increased by 1.8° [95% confidence interval (CI) 0.1–3.4, P = 0.036] at peak knee extension during stance; anterior translation increased by 2.2 mm (95% CI 0.3–4.1, P = 0.025) at initial contact; range of motion (ROM) in internal-external rotation increased less than 1°, P = 0.023; ROM in anteroposterior translation increased by 3.8 mm, P = 0.048. (2) For running post-marathon: flexion rotation increased by 1.6° (95% CI 0.2–2.9, P = 0.025) at initial contact; varus rotation increased by 2.0° (95% CI 0.2–3.8, P = 0.031) at peak knee extension during stance. SignificanceSignificant differences in varus rotation and anterior translation were identified following a marathon, which could potentially contribute to injury. These results provide important information for runners and coaches about knee kinematic alterations following a marathon.

295. Comparison of the biomechanical performances among PLF, TLIF, OLIF and XLIF: a finite element analysis

BACKGROUND CONTEXT Posterolateral fusion (PLF) and lumbar interbody fusion (LIF) are the commonly used techniques for the treatment of lumbar degenerative diseases. Although the superiority of PLF or LIF remains controversial, LIF technique provides the potential advantages of anterior column supports and 360° arthrodesis. The most commonly used LIF technique is transforaminal LIF (TLIF). Lateral approaches including extreme LIF (XLIF) and the subsequent oblique LIF (OLIF), have been accepted by an increasing number of spine surgeons due to their unique advantages. Previous studies revealed that radiological outcomes significantly varied among PLF, TLIF, XLIF and OLIF, suggesting their different biomechanical properties. PURPOSE To compare the biomechanical differences among PLF, TLIF, XLIF and OLIF construct and determine which surgical construct was most beneficialto the segmental stability and cage subsidence resistance. STUDY DESIGN/SETTING a finite element (FE) analysis. OUTCOME MEASURES The ranges of motion (ROMs) and stress peaks in the cortical endplate, cancellous bone and posterior instrumentations were compared among the five constructs. METHODS An intact FE model of the L3-L5 lumbar spine was constructed. After validation, the PLF, TLIF with a banana-shaped cage, TLIF with a straight cage, XLIF and OLIF procedures were simulated at the L4/5 level. A bilateral pedicle screw fixation was added in each construct. The TLIF banana-shaped cage was placed on the anterior one-third portion of the endplate. The TLIF straight cage was placed around the midpoint of the endplate and was diagonally positioned at an angle of 45° . The XLIF cage was placed at the mid-endplate and the OLIF cage was placed more anteriorly. An axial preload of 400 N was imposed on the superior surface of L3 to simulate the corresponding physiologic compression. Another 8 Nm was applied on L3 to simulate flexion, extension, bending and axial rotation. RESULTS The PLF construct has much higher ROMs than the LIF constructs (0.44° to -1.05° vs 0.29° to -0.72°). TLIF with a straight cage induces the highest stress peak in the endplate and cancellous bone (23.2-63.7 MPa and 0.69-2.03 MPa, respectively), followedby TLIF with a banana-shaped cage (23.7-44.8 MPa and 0.6-1.36 MPa, respectively). OLIF (16.76-32.41 MPa and 0.54-1.07 MPa, respectively) and XLIF (17.01-35.34 MPa and 0.56-1.12 MPa, respectively) constructs induces much lower stress peaks in the endplate and cancellous bone. In the PLF construct, the stress peaks in the posterior instrument range from 244.6 MPa to 377.4 MPa, which are significantly higher than those in the LIF constructs (123.9-237.4 MPa). CONCLUSIONS The PLF construct had\s less stability than the LIF construct due to the higher ROMs and stress peaks in the posterior instrument. TLIF with a banana-shaped cage outperforms TLIF with a straight cage in decreasing the stress peaks in the endplate and cancellous bone, as the banana-shaped cage is ideally located more anteriorly and placed on the strong cortical rim of the endplate. Compared with TLIF constructs, the much larger cages used in the OLIF and XLIF constructs induce significantly fewer stress peaks and increase homogeneous stress distributions in the endplate cancellous bone, which was beneficial to the subsidence resistance and maintenance of disc height and segmental angle. FDA DEVICE/DRUG STATUS XLIF (Approved for this indication), OLIF (Approved for this indication)

4. Lumbosacral TLIF but not ALIF increases proximal junction motion in long-segment constructs

BACKGROUND CONTEXT Proximal junctional kyphosis and lumbosacral (LS) pseudoarthrosis/instrumentation failure are relatively common complications following long instrumentation constructs to the sacrum. Methods to improve fusion rates and decrease instrumentation failure include LS anterior column support (ALIF or TLIF), iliac screw fixation, and accessory rods. The impact of these lumbosacral augmentation strategies on the proximal junction is not clear. PURPOSE The purpose of this study was to investigate the impact of various lumbosacral constructs on proximal junction biomechanics. STUDY DESIGN/SETTING Human biomechanical cadaveric study. PATIENT SAMPLE Twelve (L1-Pelvis) cadaveric spines were studied. OUTCOME MEASURES Proximal junction range of motion (ROM) at L1-2 was measured. METHODS Fourteen human cadaveric spine (L1-Ilium) specimens were prepared and potted at L1 and Ilium. Specimens were equally divided into either an L5-S1 ALIF or TLIF group. 4R conditions consisted of accessory rods spanning the L3-L4 and S1-Ilium levels. Compression (400 N) in combination with 7.5 Nm of flexion (FL), extension (EX), lateral bending (LB), or axial rotation (AR) was applied to all conditions. Specimens underwent testing in the following conditions: (1) intact, (2) L2-S1 pedicle screw fixation (PSR), (3) L2-ilium (PSR-I), (4) PSR+ALIF (ALIF-S) or TLIF (TLIF-S), (5) PSR-I + ALIF (ALIF-I) or TLIF (TLIF-I), and (6) ALIF-I + 4R or TLIF-I + 4R. Statistical comparisons were performed using one-way (RM) ANOVA (p RESULTS PSR-I did not significantly change proximal junction ROM in any direction compared to PSR-S (p>.069). However, TLIF-I and TLIF+4R resulted in significant increase in L1-2 ROM in FL and Right LB (p .095). ALIF-I did not significantly change ROM in any direction compared to ALIF+4R or PSR-I (p>.069). CONCLUSIONS In cadavers with pelvic fixation, lumbosacral TLIF results in increased ROM at the proximal junction while ALIF does not. Further augmentation of either ALIF or TLIF constructs with lumbosacral accessory rods does not impact proximal junctional ROM. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

245. Comprehensive biomechanical profile of anterior column realignment for minimally invasive deformity correction

BACKGROUND CONTEXT To achieve clinical success in minimally invasive spinal approaches to deformity correction, the optimal construct should provide sound biomechanics without limiting lordotic correction. Anterior column realignment (ACR) is a powerful, but highly destabilizing minimally invasive technique for sagittal realignment with growing popularity; however, the biomechanics of this construct have never been previously investigated in a biomechanical study. In particular, it is unclear to what degree lateral plate fixation across the ACR construct constrains segmental lordosis and promotes improved biomechanics, nor whether supplemental rod fixation provides additional biomechanical benefit. PURPOSE The purpose of this study was to comprehensively evaluate the effect of ACR design on radiographic lordosis, range of motion (ROM) stability, and rod strain (RS) in a cadaveric model. We hypothesized that anterolateral fixation and four-rod (4R) supplementation would decrease rod strain (RS) and improve segmental stability (ROM) in a cadaveric ACR model. STUDY DESIGN/SETTING In vitro biomechanical study using human cadaveric specimens. PATIENT SAMPLE Seven fresh-frozen lumbar spine cadaveric specimens (T12–sacrum) were selected for this study (2F/5M, 52±13yrs, DEXA 1.02g/cm2). OUTCOME MEASURES Primary outcome measure of interest was maximum segmental lordosis measured using lateral radiograph. Secondary outcomes were range of motion (ROM) stability and posterior rod strain (RS) at L3/4. METHODS Standard nondestructive flexibility tests (7.5 Nm) were performed following 30° ACR at L3/4 and pedicle screw fixation from L1 to S1. First, maximum lordosis was measured after no osteotomies (G0), grade 1 (G1), and grade 2 (G2) osteotomies with either single screw lateral fixation (ACR+1XLP) or screws into both L3 and L4 (ACR+2XLP). Uni-axial strain gauges were placed midway between L3/L4 pedicle screws on the posterior surface of right rod. ROM and RS were recorded during applications of continuous dynamic loads in a 6DOF robot in flexion (FL), extension (EX), compression (C), lateral bending (LB), and axial rotation (AR). Conditions included: 1) intact, 2) intact+pedicle screws and 2 rods (PSR+2R), 3) ACR+1XLP+2R, 4) ACR+2XLP+2R, 5) ACR+1XLP+4 rods, 6) ACR+2XLP+4R. Data were analyzed using RM-ANOVA (p RESULTS Mean segmental lordosis increased from G0 (14.9°), to G1(18.7°), to G2(29.7°). There were no differences between 1XLP or 2XLP(p>.15). ACR+1XLP+2R was less stable than all other ACR conditions in FL, EX, and AR (p .48). Adding extra rods to ACR+1XLP and ACR+2XLP reduced primary rod strain in all directions of loading (p .16). There was no difference in strain between ACR+2XLP+2R and ACR+2XLP+4R (p>.48). CONCLUSIONS The ACR is a highly destabilizing procedure. For maximum stability, ACR constructs should contain either 2-screw fixation or 4 rods. Anterolateral fixation with two screws can be used without compromising the maximal achievable lordosis, but do not provide the same RS reduction as 4 rods. Combining these two techniques did not provide any additional benefit. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Defining subgroups of patients with a stiff and painful shoulder: an analytical model using cluster analysis

Purpose The primary purpose of this research was to develop a classification system for patients with stiff and painful shoulders using hierarchical cluster analysis. Methods Medical charts of 52 patients treated for stiff and painful shoulders were reviewed for descriptive and clinical data after completion of their rehabilitation. A clinician-reported outcome was derived from ratings of three members of the American Society of Shoulder and Elbow Therapists. Data were subjected to cluster analysis using the hierarchical method. Analysis of difference tests was performed to determine if differences between clusters could be found with either initial examination or outcome data. Results Two clusters emerged from the clustering process: a healthy, strong, and mobile group of 32 patients, and an unhealthy, weak, and immobile groups consisting of 20 patients. Significant differences in initial examination measures between clusters were found for the presence of co-morbidities, range of motion for shoulder flexion, abduction, external rotation, and internal rotation, and strength of the shoulder external rotators and in the empty can position. Significant differences between clusters were found for shoulder flexion, abduction, and external rotation range of motion, and clinician-reported outcome at the time of patient discharge. Conclusion Patients with stiff and painful shoulders in this study were classified into two distinct subgroups using hierarchical cluster analysis based on demographic attributes and initial examination findings. The findings from this study also suggest that patients who may be at risk for a poorer outcome can be identified based on initial examination measures. By identifying these patients early in rehabilitation who have a poorer prognosis, improved patient education, alternative interventions or diagnostic tests may be utilized on their behalf. Implications for rehabilitation Patients with stiff and painful shoulders were classified into two subgroups using hierarchical cluster analysis based on demographic attributes and initial examination findings. Significant differences in mean clinician-reported outcome was also noted between clusters, with the patients who were healthier, stronger, and more mobile having a significantly better outcome than those patients who were more unhealthy, weak, and immobile. The findings from this study suggest that patients can be identified on initial examination who may be at risk for a poorer outcome. By identifying these patients early in rehabilitation who have a poorer prognosis, improved patient education, alternative interventions, or diagnostic tests may be utilized on their behalf sooner in the course of care.

EFEITOS DO DEEP RUNNING SOBRE A AMPLITUDE DE MOVIMENTO E A CAPACIDADE FUNCIONAL DOS MEMBROS SUPERIORES DE MULHERES MASTECTOMIZADAS: RELATO DE CASOS

Introduction: Breast cancer is the most common type of cancer among women in Brazil and in the worl. The surgical treatment procedure may cause severe morbidity in the upper limb homolateral to surgery, including the reduction of the range of motion, with consequent impairment of function. A physiotherapeutic approach has an important role in the recover range of motion and the functionality of these women, guaranteeing the occupational, domestestic, familiar and conjugated activities, and, in this way, also improving the quality of life. Objectives: To analyse chances in the shoulder's range of motion and the functional capacity of the upper limbs, promoted by the deep running procedure in women with late postoperative mastectomy. Methods: All the patients were submitted to an evaluation in the beginning and end of the treatment, including: goniometry of flexion, extension, abduction, adduction, internal and external rotation of the shoulder joint; and function capacity analysis in activities that involve the upper members by DASH questionnaire. The treatment protocol includes twelve sessions of deep running, realized twice a week, in deep pool, for 20-minute during six weeks. Results: Were submitted to treatment a total of 4 patients. Despite the improvement in the numerical values, statistically significant differences were not found on the range of movements and in the functional capacity of upper members before and after the deep running sessions in post-mastectomy women. Conclusion: Deep running had effects on the numerical values of range of movement and upper limb functionality in women in the late postoperative period of the mastectomy procedure, but without statistically significant differences.