Musculoskeletal Field Research Articles

Short-term effects of high-intensity laser therapy on frozen shoulder: A prospective randomized control study

BackgroundFrozen shoulder, which is characterized by shoulder pain and limitation of the range of motion (ROM), is a common disorder. High-intensity laser therapy (HILT) was recently introduced in the musculoskeletal therapeutic field. ObjectiveThe objective of this study is to evaluate the clinical efficacy of HILT in patients with frozen shoulder. DesignA prospective randomized controlled study. MethodPatients with frozen shoulder were randomly divided into 2 groups: a HILT group (n = 33) and a placebo group (n = 33). The treatment was administered 3 times per week on alternate days for 3 weeks. For all patients, the visual analog scale (VAS) for pain, VAS for satisfaction, and passive ROM were measured at baseline and 3, 8, and 12 weeks after the treatment. ResultsThe HILT group had a lower pain VAS score at 3 weeks (3.2 ± 1.7 vs. 4.3 ± 2.2, p = 0.033) and 8 weeks (2.2 ± 2.0 vs. 3.4 ± 2.7, p = 0.042), however, no statistically significant difference in the pain VAS was observed between the two groups at the final follow-up (12 weeks). No statistical difference in the ROM and the satisfaction VAS was observed between the 2 groups at serial follow-ups. ConclusionsIn management of frozen shoulder, HILT provided significant pain relief at 3 and 8 weeks, but not at the final follow-up time point. HILT is a noninvasive adjuvant treatment that can reduce pain in frozen shoulders. Further study is needed in order to optimize the dose and duration of HILT.

MRgFUS in the treatment of MSK lesions: a review based on the experience of the University of L’Aquila, Italy

The magnetic resonance guided focused ultrasound surgery (MRgFUS) is a promising and rapidly developing tecnique in the bone applications. To achieve therapeutic success, however, is necessary the correct selection of the lesion to be treated and of the patient. The purpose of this review is to describe the technical aspects of the treatment, to identify the principles for proper patient selection and to illustrate the main applications in the musculoskeletal (MSK) field of MRgFUS in our department in the light of some years of experience.

Updated Method Guidelines for Cochrane Musculoskeletal Group Systematic Reviews and Metaanalyses

The Cochrane Musculoskeletal Group (CMSG), one of 53 groups of the not-for-profit, international Cochrane Collaboration, prepares, maintains, and disseminates systematic reviews of treatments for musculoskeletal diseases. It is important that authors conducting CMSG reviews and the readers of our reviews be aware of and use updated, state-of-the-art systematic review methodology. One hundred sixty reviews have been published. Previous method guidelines for systematic reviews of interventions in the musculoskeletal field published in 2006 have been substantially updated to incorporate methodological advances that are mandatory or highly desirable in Cochrane reviews and knowledge translation advances. The methodological advances include new guidance on searching, new risk-of-bias assessment, grading the quality of the evidence, the new Summary of Findings table, and comparative effectiveness using network metaanalysis. Method guidelines specific to musculoskeletal disorders are provided by CMSG editors for various aspects of undertaking a systematic review. These method guidelines will help improve the quality of reporting and ensure high standards of conduct as well as consistency across CMSG reviews.

Evolving Strategies in Mechanobiology to More Effectively Treat Damaged Musculoskeletal Tissues

In this paper, we had four primary objectives. (1) We reviewed a brief history of the Lissner award and the individual for whom it is named, H.R. Lissner. We examined the type (musculoskeletal, cardiovascular, and other) and scale (organism to molecular) of research performed by prior Lissner awardees using a hierarchical paradigm adopted at the 2007 Biomechanics Summit of the US National Committee on Biomechanics. (2) We compared the research conducted by the Lissner award winners working in the musculoskeletal (MS) field with the evolution of our MS research and showed similar trends in scale over the past 35 years. (3) We discussed our evolving mechanobiology strategies for treating musculoskeletal injuries by accounting for clinical, biomechanical, and biological considerations. These strategies included studies to determine the function of the anterior cruciate ligament and its graft replacements as well as novel methods to enhance soft tissue healing using tissue engineering, functional tissue engineering, and, more recently, fundamental tissue engineering approaches. (4) We concluded with thoughts about future directions, suggesting grand challenges still facing bioengineers as well as the immense opportunities for young investigators working in musculoskeletal research. Hopefully, these retrospective and prospective analyses will be useful as the ASME Bioengineering Division charts future research directions.

Evaluation of Clinical Methods for Peroneal Muscle Testing

Manual muscle testing of the peroneal muscles is well accepted as a testing method in musculoskeletal physiotherapy for the assessment of the foot and ankle. The peroneus longus and brevis are primary evertors and secondary plantar flexors of the ankle joint. However, some international textbooks describe them as dorsi flexors, when instructing peroneal muscle testing. The identified variability raised a question whether these educational texts are reflected in the clinical field. The purposes of this study were to investigate what are the methods commonly used in the clinical field for peroneal muscle testing and to evaluate their compatibility with functional anatomy. A cross-sectional study was conducted, using an electronic questionnaire sent to 143 Israeli physiotherapists in the musculoskeletal field. The survey questioned on the anatomical location of manual resistance and the combination of motions resisted. Ninety-seven responses were received. The majority (69%) of respondents related correctly to the peronei as evertors, but asserted that resistance should be located over the dorsal aspect of the fifth metatarsus, thereby disregarding the peroneus longus. Moreover, 38% of the respondents described the peronei as dorsi flexors, rather than plantar flexors. Only 2% selected the correct method of resisting plantarflexion and eversion at the base of the first metatarsus. We consider this technique to be the most compatible with the anatomy of the peroneus longus and brevis. The Fisher-Freeman-Halton test indicated that there was a significant relationship between responses on the questions (P = 0.0253, 95% CI 0.0249-0.0257), thus justifying further correspondence analysis. The correspondence analysis found no clustering of the answers that were compatible with anatomical evidence and were applied in the correct technique, but did demonstrate a common error, resisting dorsiflexion rather than plantarflexion, which was in agreement with the described frequencies. Inconsistencies were identified between the instruction method commonly provided for peroneal muscle testing in textbook and the functional anatomy of these muscles. Results reflect the lack of accuracy in applying functional anatomy to peroneal testing. This may be due to limited use of peroneal muscle testing or to inadequate investigation of the existing evaluation methods and their validity. Accordingly, teaching materials and clinical methods used for this test should be re-evaluated. Further research should investigate the value of peroneal muscle testing in clinical ankle evaluation.

Use of Contrast-Enhanced Ultrasonography in Musculoskeletal Medicine

Ultrasound contrast agents enhance blood flow signals and allow assessment of microcirculation. The objective of this review is to systematically identify and summarize the literature on the use of contrast-enhanced ultrasonography in the musculoskeletal field. A literature search was conducted using the following keywords: ultrasound, contrast agent, and relevant musculoskeletal terms (muscle, tendon, joint, or bone). Only articles devoted to human research were reviewed. Information about each study, including category, subject, site, type of contrast agent, imaging technique, and contribution, was summarized. We reviewed 44 of the 260 retrieved articles. The associated categories were muscle (21 articles), tendon (4 articles), joint (17 articles), and bone (2 articles). Contrast-enhanced ultrasonography has been widely applied to the clinical evaluation of rheumatoid arthritis (n = 12) and research of muscle perfusion (n = 20). SonoVue (n = 20) was the most commonly used contrast agent, followed by Levovist (n = 17), Definity (n = 6), and Sonazoid (n = 1). Gray scale sonography (n = 3), color Doppler sonography (n = 4), power Doppler sonography (n = 15), and nonlinear imaging techniques specific for the existence of microbubbles (n = 22) were used according to different protocols. Contrast-enhanced ultrasonography has emerged as a promising diagnostic and research tool in musculoskeletal systems. Its application in bony structures is limited, owing to poor ultrasound penetration; however, development of nonlinear imaging techniques may promote advanced research on microcirculation in tendons.

Valedictory Editorial

Valedictory Editorial

The place of ultrasonography in knee joint osteoarthritis: an update

Ultrasound is gaining ground over conventional imaging methods in the assessment of musculoskeletal changes in osteoarthritis. Systematic ultrasound scanning following established guidelines enables the detection of even minimal and early abnormalities of cartilage, synovial tissue and subchondral bone. Thus far, ultrasound has shown to be extremely sensitive in the detection of soft tissue changes in knee osteoarthritis, including synovial proliferation and synovial fluid. Such abnormalities are correlated with symptomatic flares and have associated prognostic implications. Although there has been some progression, there is still a lack of standardization and validation over the definition and scoring of ultrasound signs that are thought to reflect structural damage affecting different joint structures. Meanwhile, exciting developments are expanding the applications of ultrasound in the musculoskeletal field; the application of technologies such as sonoelastography, imaging coupling, 3D ultrasound and ul...

The Traces of Sound: Taking the Road to Skin

In the latest years there has been an explosive growth in the use of ultrasound for exploring the soft tissues. Thus, the utility of sonography in the musculoskeletal field is now very well supported in literature. Moreover, this sonographic expansion has continued through the dermatologic field. The aim of this article is to review the recent advances in dermatologic ultrasound considering last-generation equipment, and assess the potential of ultrasound on rheumatic disorders that may present concomitant and challenging skin or nail lesions at some point during their clinical course.

Regenerative medicine in the field of pain medicine: Prolotherapy, platelet-rich plasma therapy, and stem cell therapy—Theory and evidence

The concept of “regenerative medicine” (RM) has been applied to musculoskeletal injuries dating back to the 1930s. Currently, RM is an umbrella term that has been used to encompass several therapies, namely prolotherapy, platelet-rich plasma therapy (PRP), and stem cell therapy, which are being used to treat musculoskeletal injuries. Although the specific treatments share similar concepts, the mechanism behind their reparative properties differs. Recently, treatments that possess a regenerative quality are resurfacing and expanding into the musculoskeletal field as potential therapeutic treatment modalities. RM, in the form of prolotherapy, was first used to treat tendon and ligament injuries. With the advancement of technology, RM has expanded to PRP and stem cell therapy. The expansion of different RM treatments has lead to its increase in the application for ligament and tendon injuries, muscle defects, as well as pain associated with osteoarthritis and degenerative disks. Recently, the use of ultrasound has been added to these therapies to guide the solution to the exact site of injury. We review 3 forms of RM injection: prolotherapy, PRP therapy, and stem cell therapy.

Ultrasound and Magnetic Resonance Imaging of the Peripheral Nerves: Current Techniques, Promising Directions, and Open Issues

High-resolution ultrasound (US) and magnetic resonance (MR) imaging are the two imaging methods of choice for the study of peripheral nerves. The many advances that have been made in recent years, either by US or MR imaging, including diffusion tensor imaging and tractography, offer new perspectives for the assessment of many pathological processes affecting peripheral nerves such as entrapment syndromes, tumors and tumor-like lesions, and traumatic disorders. Most of these improvements have especially increased the spatial resolution of nerve imaging. US and MR imaging are complementary, each having advantages and disadvantages. Tractography is still emerging in the musculoskeletal field, particularly for the analysis of peripheral nerves, but this technique seems promising.

Is Sonoelastography of Value in Assessing Tendons?

Sonoelastography is a newly introduced ultrasound technique that evaluates tissue elasticity and thus provides additional information to that offered by conventional ultrasound images. In the musculoskeletal field, sonoelastography can help improve estimation of tendon stiffness. In this article, the principles and future developments of sonoelastography are discussed using the strongest and thickest tendon of the human body, the Achilles tendon, for illustrative purposes. Preliminary findings of sonoelastography in healthy and pathological Achilles tendons, technical considerations, examination technique and several limitations are addressed. The usefulness of elastography can be expected to increase rapidly in the musculoskeletal field, as soon as we learn to interpret elastographic artifacts as well as to take advantage of the new information provided by sonoelastography.

Cells and Biomaterials for Intervertebral Disc Regeneration

Abstract Disorders related to the intervertebral disc (IVD) are common causes of morbidity and of severe life quality deterioration. IVD degeneration, although in many cases asymptomatic, is often the origin of painful neck and back diseases. In Western societies IVD related pain and disability account for enormous health care costs as a result of work absenteeism and thus lost production, disability benefits, medical and insurance expenses. Although only a small percentage of patients with disc disorders finally will undergo surgery, spinal surgery has been one of the fastest growing disciplines in the musculoskeletal field in recent years. Nevertheless, current treatment options are still a matter of controversial discussion. In particular, they hardly can restore normal spine biomechanics and prevent degeneration of adjacent tissues. While degeneration affects all areas of the IVD, the most constant and noticeable changes occur in the gel-like central part, the nucleus pulposus (NP). Recent emphasis ha...

Developments in musculoskeletal ultrasound and clinical applications

Ultrasound (US) technologies are rapidly advancing, offering several refined transducer technologies as well as soft and hardware facilities. The aim of this article is to outline US developments, from B-mode technologies over Doppler advances to more sophisticated technologies, and their potential clinical impact in the field of musculoskeletal (MSK) imaging. When using B-mode ultrasound, compound imaging and beam-steering are of help to decrease anisotropy in tendons and ligaments, that are less well depicted due to their oblique course. Doppler imaging has become sensitive in the detection of flow in small vessels, which is of particular value in rheumatologic conditions, tumour and overuse assessment. The use of US microbubble contrast agents improves detection of low-volume blood flow in smaller vessels by increasing the signal-to-noise ratio and thereby facilitating detection of angiogenetic vessels in inflammatory conditions or tumours. The use of US blood pool contrast agents enables molecular imaging in real-time, and thus the diagnostic potential of US is expanded, opening up a new field of US applications. Objective quantification of altered tissue (e.g., synovial proliferation, tumours) is still demanding and might be improved by the use of three-dimensional imaging and software tools as parametric evaluation. Real-time sonoelastography (EUS) is a new development for visualization of tissue elasticity by measurement of tissue displacement in terms of tissue stiffness changes, promising new insights into tendon disorders. Image fusion is an exciting development that enables superimposition of CT/MRI data sets on real-time US scanning. This technique might be helpful in guiding injections under real-time conditions even in regions less easily accessible by US as, for instance, the axial skeleton, and can additionally provide an interesting tool for teaching MSK imaging and ways to guide interventions. In summary, exciting developments are expanding the applications of US in the MSK field, offering the advantages of real-time performance, high tissue resolution and relative speed at a reasonable cost.

Adult Stem Cells in Bone and Cartilage Tissue Engineering

The progressive increase in life expectancy within the last century has led to the appearance of novel health related problems, some of those within the musculoskeletal field. Among the latter, one can find diseases such as osteoporosis, rheumatoid arthritis and bone cancer, just to mention some of the most relevant. Other related problems are those that arise from serious injuries, often leading to non-recoverable critical size defects. The therapies currently used to treat this type of diseases/injuries are based on the use of pharmaceutical agents, auto/allotransplant and synthetic materials. However, such solutions present a number of inconveniences and therefore, there is a constant search for novel therapeutic solutions. The appearance of a novel field of science called Tissue engineering brought some hope for the solution of the above mentioned problems. In this field, it is believed that by combining a 3D porous template--scaffold--with an adequate cell population, with osteo or chondrogenic potential, it will be possible to develop bone and cartilage tissue equivalents that when implanted in vivo, could lead to the total regeneration of the affected area. This ideal cell population should have a series of properties, namely a high osteo and chondrogenic potential and at the same time, should be easily expandable and maintained in cultures for long periods of time. Due to its natural and intrinsic properties, stem cells are one of the best available cell types. However, after this sentence, the readers may ask, "Which Stem Cells?". During the last 10/15 years, the scientific community witnessed and reported the appearance of several sources of stem cells with both osteo and chondrogenic potential. Therefore, the present review intends to make an overview of data reported on different sources of adult stem cells (bone marrow, periosteum, adipose tissue, skeletal muscle and umbilical cord) for bone and cartilage regenerative medicine, namely those focusing on the differentiation potential of the latter as well as in vivo proof of concept of their applicability. Simultaneously novel aspects of adult stem cells biotechnology such as their immunogenic characteristics and cell expansion methodologies will also be put forward. The present review also points out on issues such as the bone and cartilage regenerative market, and gives a brief description on bone and cartilage bone biology, so the readers can have a true idea of the current state of the art, and how adult stem cells can be an added value to this field.

Local delivery of bisphosphonate from coated orthopedic implants increases implants mechanical stability in osteoporotic rats

Patients with osteoporosis and joint disabilities represent a constant growing and challenging population to be treated in the musculoskeletal clinical field. Especially in the case of total hip arthroplasty, new solutions should be developed to compensate for the double negative factors, peri-implant osteolysis, and osteoporotic bone loss, affecting the quality of implant outcome. The goal of this study was then to establish a proof of concept for orthopedic implant used as Zoledronate delivery in osteoporotic rats, and in particular, to verify if this approach could increase the initial implant stability. Twenty-five female 6-month-old Wistar rats were ovariectomized 6 weeks before the implantation to induce osteoporosis. The animals were randomly separated in five groups representing the different Zoledronate concentrations in the HA coating: 0, 0.2, 2.1, 8.5, and 16 microg/implant. Histomorphometric measures and peri-implant bone volume fraction were assessed and mechanical stability tests were performed. Bone volume fraction and biomechanical results clearly illustrate the positive effect of Zoledronate coated implants in the osteoporotic rats. A remarkable result was to show the existence of a window of Zoledronate content (0.2 to 8.5 microg/implant) in which the mechanical fixation of the implant increased. We were able to establish the proof of concept for orthopedic implants used as a drug delivery system in osteoporotic rats. The local bisphosphonate delivery from a calcium phosphate coating allowed increase of the mechanical fixation of an orthopedic implant. This study shows that orthopedic implants containing bisphosphonates could be beneficial for osteoporotic patients in need of a total joint replacement.

Do Physical Therapists in the United Kingdom Recognize Psychosocial Factors in Patients With Acute Low Back Pain?

A cross-sectional, descriptive vignette survey of practicing, musculoskeletal physical therapists. The aim of this study was to determine if musculoskeletal physical therapists, in the United Kingdom, recognize when patients with low back pain (LBP) are at risk of chronicity due to psychosocial factors. A secondary aim was to explore the advice they give to patients about work and activities. Psychosocial factors have been shown to be important in the progression from acute LBP to chronic disability. Early identification of individuals at risk of developing chronic disability is important to enable targeted intervention. Three vignettes were written based on acute LBP patients attending for physical therapy and incorporated into a self-completed postal questionnaire sent to a simple random sample of musculoskeletal physical therapists in the United Kingdom (n = 900). After one reminder, 20% of nonresponders were sent a further questionnaire (n = 80). Data were analyzed using the Statistical Package for the Social Sciences (SPSS version 11). The response rate was 57.7% (n = 518) with 453 meeting all inclusion criteria. The sample consisted of physical therapists working in the musculoskeletal field across all practice settings. Most correctly rated the chronicity risk of the low- and high-risk patient vignettes. Advice to restrict work and activity was common. Most physical therapists recognize when patients are at high risk of developing chronicity, yet many recommend the patient limit their activity levels and not work. Advice to "not work" is associated with more severe perceived spinal pathology, suggesting persistence of the biomedical model for LBP.

The toughness of cortical bone and its relationship with age.

Toughness is a quantitative measure of bone quality in terms of its susceptibility to fracture. Thus, to elucidate the underlying mechanisms of age-related bone fractures, it is necessary to understand age-related changes in the toughness of bone. The objective of this review is to provide current understanding on the structure-function relationships of cortical bone and its correlation with the toughness of the tissue from the perspective of basic engineering principles. The review is written for the readers in the musculoskeletal research field, who may not have a strong engineering background. For better understanding of toughening mechanisms, this review intends to focus on correlations of the toughness of cortical bone with its constituents and microstructural characteristics. In addition, a special emphasis is placed on age-related changes in the toughness of bone.

Therapeutic Ultrasound: Clinician Usage and Perception of Efficacy

A mailed questionnaire, employing both open- and closed-ended questions, was distributed to all members of the Australian Physiotherapy Association (South Australian branch) registering an interest in the musculoskeletal field. Questions were asked regarding the usage and perception of the effectiveness of therapeutic ultrasound. A response rate of 55% was achieved, with a total of 210 questionnaires available for statistical analysis. The results demonstrated that ultrasound is frequently used as an electrotherapy modality by South Australian musculoskeletal physiotherapists. Most physiotherapists perceived ultrasound to be effective in treating localized, superficial conditions, especially when used in conjunction with other treatment techniques and at suitable dosages. However, ultrasound was thought to be most effective in producing a placebo effect. These findings suggest that ultrasound is perceived as an effective treatment tool when applied appropriately. Its placebo quality may contribute to its effectiveness. Further scientific research is warranted to confirm the results. Randomized controlled trials investigating ultrasound's usefulness for muscle strains, scar tissue, bursitis and tendinitis are indicated. The results of this study will be useful for educators and researchers, and suggest that more research into ultrasound applied as part of a treatment package is needed.