Specific Clinical Tests Research Articles

Learning of musculoskeletal ligament stress testing in a gross anatomy laboratory

Human anatomy in physical therapy programs is a basic science course serving as a foundation for subsequent clinical courses. Integration of anatomy with a clinical emphasis throughout a curriculum provides opportunities for reinforcement of previously learned material. Considering the human cadaver laboratory as a fixed cost to our program, we sought opportunities to add value to the resource via vertical integration into a clinical skills course taught later in the curriculum. We designed an opportunity for second-year physical therapy students to revisit the human anatomy laboratory to study select clinical musculoskeletal tests and the associated anatomy in a clinically relevant context. Students performed select orthopedic ligament test on human cadavers, then incised specific structures and repeated the tests. Students were able to feel and visualize the function of pertinent anatomy associated with the clinical tests. Ninety-five percent of respondents reported that the ligament stress testing experience enhanced their understanding of orthopedic clinical tests with 91% reporting an enhanced understanding of anatomy related to specific clinical tests. Likewise, the experience was perceived as enjoyable and valuable with 86% of respondents reporting the experience as enjoyable and 100% responding the experience should continue as part of the curriculum.

July 2011 Letters to the Editor-in-Chief

July 2011 Letters to the Editor-in-Chief

The assessment of function: How is it measured? A clinical perspective

Testing for outcome or performance can take many forms; including multiple iterations of self-reported measures of function (an assessment of the individual’s perceived dysfunction) and/or clinical special tests (which are primarily assessments of impairments). Typically absent within these testing mechanisms is whether or not one can perform a specific task associated with function. The paper will operationally define function, discuss the construct of function within the disablement model, will overview the multi-dimensional nature of ‘function’ as a concept, will examine the current evidence for functional testing methods, and will propose a functional testing continuum. Limitations of functional performance testing will be discussed including recommendations for future research.

Subscapularis Function and Structural Integrity After Arthroscopic Repair of Isolated Subscapularis Tears

Background: Results of arthroscopic repair of isolated subscapularis tendon tears have not been widely studied. A detailed evaluation of subscapularis function with subscapularis strength quantification has not been performed to date. Purpose: To evaluate postoperative subscapularis muscle function and to assess the clinical outcome and structural tendon integrity with postoperative magnetic resonance imaging after arthroscopic repair of isolated subscapularis tears. Study Design: Case series; Level of evidence, 4. Methods: In a prospective study, isolated subscapularis tendon tears in 21 patients were treated with an all-arthroscopic repair. The average age of the study population was 43 years. The mean interval between trauma and surgery was 5.8 months. In 19 patients, a traumatic event caused the onset of symptoms. Subscapularis muscle function was assessed with specific clinical tests and the Constant scoring system. Postoperative subscapularis strength was evaluated with a custom-made electronic force measurement plate. All patients underwent postoperative magnetic resonance imaging to assess structural integrity of the repair. Results: The average duration of follow-up was 27 months. The Constant score increased from 50 points preoperatively to 82 points postoperatively (P < .01). Most positive preoperative lift-off and belly-press tests were reversed by surgery, with a rate of 5 (24%) persistent positive tests after surgery. In operated shoulders, subscapularis strength in the belly-press (65 vs 87 N; P < .05) and the lift-off position (44 vs 68 N; P < .05) was significantly reduced compared with the contralateral shoulder. Magnetic resonance imaging revealed an intact repair in 20 patients. Atrophy of the upper subscapularis muscle portion was present in about one-fourth of the patients and in all patients with a positive postoperative belly-press test. Conclusion: Arthroscopic repair of isolated subscapularis tendon tears achieves substantial improvement of shoulder function and a low rerupture rate. Despite excellent clinical results, a significant postoperative subscapularis strength deficit compared with the contralateral shoulder persists that can be quantified with use of the force measurement plate. Atrophy of the upper subscapularis muscle is present in 25% of the patients in the postoperative course.

Acute respiratory distress syndrome definition: do we need a change?

Since the first description of the acute respiratory distress syndrome (ARDS) in 1967, no specific clinical sign or diagnostic test has yet been described that identifies ARDS. Its diagnosis is based on a combination of clinical, hemodynamic, and oxygenation criteria. The purpose of this review is to examine the current definition for ARDS and to discuss why this definition may not be the most appropriate definition for this syndrome. We will briefly review our current understanding of ARDS, discuss the problems with its current diagnosis, and present clinical, pathological, and biochemical evidences supporting a more appropriate definition for ARDS. In addition, we will discuss recent efforts to identify biological markers for lung injury in pulmonary edema fluid and blood collected from critically ill patients. On the basis of current evidence, it is time for a change in the ARDS definition. A newer classification system that recognizes different severities of pulmonary dysfunction is needed. Such a system should be able to identify patients that would be most responsive to supportive therapies and those unlikely to benefit because of the severity of their disease.

Relationship between occlusal findings and orofacial myofunctional status in primary and mixed dentition

The aim of this study was to provide basic representative data on the prevalence of malocclusions involving space deficiency in both primary and early mixed dentition and to examine the relationship between these malocclusions and orofacial dysfunctions. The results should be viewed from an orthodontic prevention and early treatment perspective. Orthodontic findings in the maxilla and mandible as well as the myofunctional status of 766 children in primary dentition and 2,209 children in mixed dentition were examined clinically in a cross-sectional study. The following parameters from each jaw were subjected to orthodontic analysis: crowding in the anterior and posterior regions of the maxilla and mandible in primary and mixed dentitions, deviations from normal maxillary arch forms in the primary dentition, deviations from normal anterior maxillary arch width in mixed dentition and maxillary apical base morphology in mixed dentition. Static and dynamic orofacial dysfunctions were documented with reference to specific parameters and clinical tests. Crowding was observed in every tenth child in primary dentition (10.8%) and in every second child in mixed dentition (49.7%). Habitual open mouth posture, visceral swallowing, articulation disorders and oral habits were statistically significantly more frequent in children in primary dentition presenting a narrow maxillary arch. Reduced anterior maxillary arch width (compression) was statistically more frequent in children in early mixed dentitions with habitual open mouth posture. A narrow maxillary apical base correlated positively with all the orofacial dysfunctions analyzed. Deviations from a regular arch form become apparent very early during dentition development and coexist with specific orofacial dysfunctions. They are thus important indicators for the early detection of functional abnormalities, causing deviations from normal dentition development. In children with orofacial dysfunctions the development of a narrow maxillary dental arch should be prevented by myofunctional therapy and by educating the parents. Interceptive orthodontic measures to treat a narrow maxillary arch in primary and early mixed dentition should also focus on eliminating functional disturbing factors, such as orofacial dysfunctions. Interdisciplinary cooperation with specialists in other fields of medicine, e.g. otorhinolaryngology and speech therapy, is essential to achieve this goal.

Impaired Visual Performance in Patients with Dry Eye

Patients with dry eye disease (DED) often complain about poor vision, which is not easily quantifiable. This review assesses the current understanding of clinical evaluations of visual function in patients with DED. Several noninvasive techniques for the assessment of visual performance have been utilized in patients with DED, and these are critically reviewed in relation to the visual symptoms experienced by these patients. It is clear that none of the current techniques is ideal, and there is not one appropriate, simple, clinical test that can be used for assessing visual impairment in patients with DED. Evidence from a comprehensive literature search combined with clinical experience have been used to identify which tests are currently of most benefit and to highlight the future development of a more specific clinical test for visual impairment in the dry eye patient.

Surgical treatment of thoracic outlet syndrome in young adults: single centre experience with minimum three-year follow-up

Thoracic outlet syndrome is an often misdiagnosed syndrome which consists of a neurovascular compression at the upper thoracic outlet. The clinical presentation can be variable, ranging from mild symptoms to venous thrombosis and muscle atrophy. Many aetiologies, both congenital and acquired, related either to bony or soft tissue anomalies, have been associated with this syndrome. As a consequence, the diagnosis is often challenging and sometimes it can be obtained only with surgical exploration. Additionally, no specific clinical test is considered diagnostic of thoracic outlet syndrome. However, the recent advances in imaging techniques together with a careful clinical evaluation give the surgeon the chance to recognize the constricting anatomy before surgery in many cases. No standard surgical procedure has been identified; however, in literature the largest series have been treated with transaxillary first rib resection. Here we report our experience in the surgical treatment of this syndrome with a minimum follow-up of three years. Our approach consists of performing a supraclavicular decompression without routine first rib resection. This allows for identifying and removing the constricting anatomy in most cases, with satisfactory results in 96.9% of patients and a low complication rate.

Shoulder function after latissimus dorsi transfer in breast reconstruction

Latissimus dorsi (LD) transfer in the case of breast reconstruction remains frequently used because this muscle provides a good size source of tissue in reconstructive surgery. Given that, the consequences of the LD removal on shoulder function and the actual loss of maximal strength developed must be investigated. Twenty women (50 ± 7.5 years old) were evaluated before surgery, 3 and 6 months after an unilateral transfer of a pedicle flap of LD muscle used for breast reconstruction. Women performed a bilateral shoulder isokinetic assessment [for the internal rotators (IRs) and external rotators and for the abductor and adductor (ADD) muscles] allowing the establishment of bilateral muscular deficit status and the study of agonist/antagonist muscle ratios. The algofunctional and clinical status of the shoulders was analysed by the means of Constant score and specific shoulder clinical tests. The women did not perform any specific strengthening of muscle shoulder after surgery. The isokinetic assessment showed a muscle weakness 3 and 6 months after LD transfer, mainly on the ADDs (33 ± 9% at 6 months) and on the IRs (16 ± 11% at 6 months). The Constant score significantly decreased after surgery on the operated shoulder. Women with a Constant score impairment showed pain during specific shoulder clinical tests. We also found a correlation between Constant score impairment and internal rotators weakness or rotator muscle imbalance. Given those results, we could advocate a specific shoulder strengthening after LD transfer, focused mainly on the IRs and ADDs.

Thoracic outlet syndrome: a controversial clinical condition. Part 1: anatomy, and clinical examination/diagnosis

Thoracic outlet syndrome (TOS) is a frequently overlooked peripheral nerve compression or tension event that creates difficulties for the clinician regarding diagnosis and management. Investigators have categorized this condition as vascular versus neurogenic, where vascular TOS can be subcategorized as either arterial or venous and neurogenic TOS can subcategorized as either true or disputed. The thoracic outlet anatomical container presents with several key regional components, each capable of compromising the neurovascular structures coursing within. Bony and soft tissue abnormalities, along with mechanical dysfunctions, may contribute to neurovascular compromise. Diagnosing TOS can be challenging because the symptoms vary greatly amongst patients with the disorder, thus lending to other conditions including a double crush syndrome. A careful history and thorough clinical examination are the most important components in establishing the diagnosis of TOS. Specific clinical tests, whose accuracy has been documented, can be used to support a clinical diagnosis, especially when a cluster of positive tests are witnessed.

Sensitivity and Specificity: A Review of Related Statistics and Controversies in the Context of Physical Therapist Education

Background and Purpose. Sensitivity and specificity are important factors to consider when evaluating the validity of a diagnostic test. The 2 measures can help to determine whether test results are indicative of the actual disease status during client assessment and evaluation. Their properties, however, can be misinterpreted in clinical settings. The purpose of this paper is three-fold: (1) to review the appropriate interpretation of sensitivity and specificity, positive and negative predictive values, likelihood ratios, posttest probabilities, and receiver operating characteristic (ROC) curves; (2) to discuss limitations of sensitivity and specificity as sole indicators of test validity; and (3) to offer recommendations for educators to improve related curricular content. Position and Rationale. The position adopted in this paper is that physical therapist education programs should cover the concepts of sensitivity and specificity in depth and in combination with other elements of test characteristics prior to discussing specific clinical tests and their applications to clinical decision making. Related content should include a review of the appropriate interpretation of sensitivity and specificity as well as an introduction to positive and negative predictive values, likelihood ratios, posttest probabilities, and ROC curves. The limitations of sensitivity and specificity as sole indicators of test validity should also be discussed. The rationale for this approach is based on the potential over-reliance of students and educators on sensitivity and specificity alone to establish the validity of clinical measures. Conclusion and Recommendations. Sensitivity and specificity will continue to be very important concepts in physical therapist education. Educators, however, should thoroughly discuss sensitivity and specificity prior to using them across the curriculum and emphasize limitations of these test properties in clinical diagnostic practice. Specific recommendations include a review of the 2 x 2 table, evaluation of specific studies on diagnostic tests, using related measures to evaluate validity, class exercises using interval estimates, and a review of the Standards for Reporting of Diagnostic Accuracy Studies (STARD) and Quality Assessment of Diagnostic Accuracy Studies (QUADAS) initiatives for research on diagnostic test validity. Key Words: Sensitivity, Specificity, Likelihood ratios, Predictive values. BACKGROUND AND PURPOSE Evidence-based practice (EBP) is an integral part of the Vision 2020 Statement of the American Physical Therapy Association (APTA).1,2 One vital component of EBP is the use of valid diagnostic tests. Sensitivity and specificity are important components of validity, providing estimates of the extent to which test results match the actual disease status. To assure that physical therapist (PT) students make grounded decisions in the test selection and application process, measurement validity, and the related concepts of sensitivity and specificity, should be introduced early in the curriculum. The inclusion of sensitivity and specificity estimates in commonly used physical therapy textbooks are evidence of this issue's increasing importance.3-5 Students are typically taught to apply these concepts in choosing a diagnostic test. Increasingly however, students must also learn to apply these concepts in treatment selection. Sensitivity and specificity can be used to help determine responses to interventions using clinical prediction rules or other criteria. In spite of the relevance of sensitivity and specificity to clinical practice, recent studies suggest that a large proportion of physicians lack adequate knowledge of these test properties.6,7 Reid et al,6 in a survey of 300 practicing physicians, reported that only 58% used sensitivity and specificity in the interpretation of test results, and just 5% of those interpreted them in the recommended manner. …

Consensus Statement on Shoulder Instability

The understanding and treatment of shoulder instability comprise a rapidly evolving area of interest in orthopaedics. Evaluation methods are becoming more specific in showing the exact pathologies causing the symptoms. Magnetic resonance arthrography and arthroscopy have contributed to this development. The patient with an unstable shoulder should be thoroughly evaluated through their history and specific clinical tests of the shoulder as well as the scapulothoracic joint. Often, shoulder instability can be classified after this primary evaluation. Magnetic resonance arthrography and arthroscopy are the gold standards in soft-tissue evaluation, whereas specialized radiographic examinations and computed tomography scans are used to assess bony defects. Patients are treated according to the pathology found on preoperative or pretreatment evaluation. Multiple factors need to be considered before the treatment program is instituted, including the patient's age, activity demands, associated pathology and dysfunction, soft-tissue pathology, degree of instability, direction, frequency, and etiology. Treatment can be nonoperative or arthroscopic or open repair. Soft-tissue pathology and bony defects should be addressed, and the surgeon's preferred method and skills are important in choosing the right treatment for the patient. The patient should be informed about possible complications, restrictions during the treatment period, and the prognosis for the particular type of instability. To improve progress in shoulder orthopaedics, one of the most important factors can be a universal agreement on an outcome measurement tool that is well designed and validated.

Reliability and Diagnostic Accuracy of Clinical Special Tests for Myelopathy in Patients Seen for Cervical Dysfunction

Case control study. Myelopathy is a clinical diagnosis based largely on initial examination findings during a clinical screen, followed by imaging verification of cord injury or compression. At present, few studies have examined the reliability and diagnostic accuracy of clinical examination measures. To determine the reliability and diagnostic accuracy of neurological tests associated with the diagnosis of myelopathy. Reliability and diagnostic accuracy of 7 frequently used tests and measures and subjective findings associated with myelopathy were examined on consecutive patients with cervical pain. Interrater reliability and diagnostic accuracy values, including posttest probability, based on a pretest probability of 40%, were calculated for each test and for combinations of tests and measures. Four of the 7 diagnostic tests were found to have a substantial interrater reliability. None of the single or clusters of tests yielded low negative likelihood ratios. Of the individual tests, the Babinski sign demonstrated the highest positive likelihood ratio (LR+, 4.0; 95% CI: 1.1-16.6) and posttest probability (73%) for diagnosis, but yielded only a moderate negative likelihood ratio (LR-, 0.7; 95% CI: 0.6-0.9). Combinations of tests did not yield improved accuracy values over single test results. This study demonstrated that 4 of 7 tests used to screen for myelopathy offered substantial levels of interrater agreement when used on individuals with cervical dysfunction. None of the tests when performed individually or in combinations are effective for screening; however, the Babinski sign did alter posttest probability more significantly than combinations of test findings. Diagnosis, Level 2b.

Traumatic Knee Pain

[Ann Emerg Med. 2009;53:403.] A 19-year-old man presented after riding a 125-cc dirt bike. While accelerating, the bike slipped out from underneath him, and he fell onto his left side. He presented with pain in his left knee after his flexed knee went into extreme varus alignment. His physical examination result was notable for diffuse left knee swelling, ecchymosis of medial knee, and a large intraarticular knee effusion. Patellar apprehension test result was negative, and the Lachman's test result was positive. Knee motion was limited from –8 to 60 degrees of flexion. There was a firm endpoint with posterior drawer testing at the above mentioned flexion angle. The remainder of the ligamentous knee examination was limited as a result of pain and guarding. Radiographs were obtained (Figure 1). The Segond fracture is a small vertical avulsion injury of the lateral aspect of the proximal tibia immediately distal to the tibial plateau. The mechanism of injury is an axial load on a semiflexed knee, with internal rotation and varus stress.1Davis D.S. Post W.R. Segond fracture: lateral capsular ligament avulsion.J Orthop Sports Phys Ther. 1997; 25: 103-106Crossref PubMed Scopus (35) Google Scholar, 2Irvine G.B. Dias J.J. Finlay D.B.L. Segond fractures of the lateral tibial condyle: brief report.J Bone Joint Surg. 1987; 69-B: 613-614Google Scholar The fracture has a strong association with an anterior cruciate ligament tear (75% to 100%), as well as meniscal injury (67% to 75%)3Dietz G.W. Wilcox D.M. Montgomery J.B. Segond tibial condyle fracture: lateral capsular ligament avulsion.Radiology. 1986; 159: 467-469PubMed Google Scholar, 4Goldman A.B. Pavlov H. Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous damage.AJR Am J Roentgenol. 1988; 151: 1163-1167Crossref PubMed Scopus (172) Google Scholar, 5Bathala E.A. Bancroft L.W. Ortiguera C.J. et al.Radiologic case study Segond fracture.Orthopedics. 2007; 30 (688): 689PubMed Google Scholar, 6Weber W.N. Neumann C.H. Barakos J.A. et al.Lateral tibial rim (Segond) fractures: MR imaging characteristics.Radiology. 1991; 180: 731-734PubMed Google Scholar (Figure 2). A hemarthrosis is commonly present.3Dietz G.W. Wilcox D.M. Montgomery J.B. Segond tibial condyle fracture: lateral capsular ligament avulsion.Radiology. 1986; 159: 467-469PubMed Google Scholar Clinically, signs of anterior instability such as a positive pivot-shift test result, Lachman's test, and anterior draw sign may be present.5Bathala E.A. Bancroft L.W. Ortiguera C.J. et al.Radiologic case study Segond fracture.Orthopedics. 2007; 30 (688): 689PubMed Google Scholar The most specific clinical test is the pivot-shift test, but false-negative results may occur from a locked knee or guarding.4Goldman A.B. Pavlov H. Rubenstein D. The Segond fracture of the proximal tibia: a small avulsion that reflects major ligamentous damage.AJR Am J Roentgenol. 1988; 151: 1163-1167Crossref PubMed Scopus (172) Google Scholar Furthermore, physical examination (Lachman's and anterior draw test) to evaluate the function of the anterior cruciate ligament may be unreliable as result of pain, hamstring resistance, or effusion.7Kerr H.D. Segond fracture, hemarthrosis, and anterior cruciate ligament disruption.J Emerg Med. 1990; 8: 29-33Abstract Full Text PDF PubMed Scopus (10) Google Scholar Radiographically, the bone fragment is located on the lateral edge of the tibial condyle and is best visualized on the anterior-posterior view. The Segond fragment, seen on plain radiograph, is identified by magnetic resonance imaging only in one third of cases.6Weber W.N. Neumann C.H. Barakos J.A. et al.Lateral tibial rim (Segond) fractures: MR imaging characteristics.Radiology. 1991; 180: 731-734PubMed Google Scholar Although magnetic resonance imaging is not sensitive in the detection of the Segond fracture fragment, it is useful in demonstrating associated ligamentous and meniscal injuries.6Weber W.N. Neumann C.H. Barakos J.A. et al.Lateral tibial rim (Segond) fractures: MR imaging characteristics.Radiology. 1991; 180: 731-734PubMed Google Scholar Management entails elevation, ice application, crutches, knee immobilization, and prompt orthopedic referral.7Kerr H.D. Segond fracture, hemarthrosis, and anterior cruciate ligament disruption.J Emerg Med. 1990; 8: 29-33Abstract Full Text PDF PubMed Scopus (10) Google Scholar Consideration should be given to drainage of tense effusions for pain relief.

RESPONSE TO "LACK OF DIAGNOSTIC VALUE OF HIGH-PASS NOISE MASKING OF AUDITORY BRAINSTEM RESPONSES IN MÉNIÈRE'S DISEASE BY CLAUDIA F. J. DE VALCK, GERD M. E. CLAES, FLORIS L. WUYTS, AND PAUL H. VAN DE HEYNING. OTOLOGY &amp; NEUROTOLOGY 2007;28:700-7"

In the recent paper “Lack of Diagnostic Value of High-Pass Noise Masking of Auditory Brainstem Responses in Meniere’s Disease” by De Valck et al. (2007), the authors concluded that, due to its low sensitivity (31%) and low specificity (28%), the ABR high-pass noise masking technique (Don et al., 2005), commercially known as CHAMP (Natus/Bio-logic Corp.), had “…no discriminative value in differentiating Meniere’s from non-MD subjects with otovestibular symptoms” (p. 706). In reviewing their data and analyses, we found errors that led to misleading and inappropriate conclusions. This response will briefly review the errors and suggest that once these errors are corrected, the revised values of 100% sensitivity and 80% specificity are consistent with the excellent sensitivity and specificity described in the original paper (Don et al., 2005). Before discussing the errors, it is important to note that the authors state, “…when only definite MD patients were included, and only the interpretable tests were used, a 100% sensitivity was obtained as in the study of Don et al. (11).” (p.705) In addition, they state, “…none of our definite MD patients had a test within normal ranges.” (p. 706) Thus, as in our study (Don et al., 2005), these authors found that in all the patients with definite Meniere’s disease (MD) and measurable responses, the test results were abnormal. So, what errors led De Valck et al. (2007) to their erroneous conclusion about the value of the CHAMP test?

Posterior shoulder pain and anterior instability: a preliminary clinical study

Different clinical tests have been suggested in the literature as significant indicators of anterior shoulder instability. Sometimes patients with recurrent anterior shoulder instability may show some muscular guarding thus making the evaluation of specific clinical tests very difficult. These patients may also report a medical history with posterior shoulder pain that can be also elicited during some clinical manoeuvres. From September 2005 to September 2006 we prospectively studied patients who underwent an arthroscopic anterior capsuloplasty. Shoulder clinical examination was performed including anterior shoulder instability tests (drawer, apprehension and relocation tests). Furthermore the exam was focused on the presence of scapular dyskinesia and posterior shoulder pain. The patients were also evaluated with ASES, Rowe, SST (Simple Shoulder Test), Constant and UCLA (University of California at Los Angeles) scoring system preoperatively and at the latest follow-up time. In the period of this study we observed 16 patients treated for anterior gleno-humeral arthroscopic stabilisation, who preoperatively complained also of a posterior scapular pain. The pain was referred at the level of lower trapezium and upper rhomboids tendon insertion on the medial border of the scapula. It was also reproducible upon local palpation by the examiner. Four of these patients also referred pain in the region of the insertion of the infraspinatus and teres minor. After arthroscopic stabilisation the shoulder was immobilised in a sling with the arm in the neutral rotation for a period of 4 weeks. A single physician supervised shoulder rehabilitation. After a mean time of 6.8 months of follow-up, all the shoulder scores were significantly improved and, moreover, at the same time the patients referred the disappearance of the posterior pain. Posterior scapular shoulder pain seems to be another complaint and sign that can be found in patients affected by anterior shoulder instability. It can also be related to eccentric work of posterior stabilising muscles of scapula during the altered biomechanics observed in case of anterior shoulder instability. This pain responds positively to surgical intervention showing that re-centring the humeral head probably also re-establishes the periscapular muscle-firing pattern with a mechanism mediated by the proprioceptive system.

Force Coordination in Object Manipulation

Force Coordination in Object Manipulation Purpose: The purpose of this review is to present our recent findings related to the studies of hand function based on the coordination of forces exerted against hand-held objects. Basic procedures: A novel device has been developed for recording grip (GF; acting perpendicularly at the hand-object contact) and load force (LF; acting tangentially) during uni- and bimanual manipulation tasks performed under either static or dynamic conditions. Both healthy participants and neurological patients were tested. The outcome measures were obtained from the task performance (i.e., the ability to exert accurate LF profiles), GF-LF coordination and GF modulation. Main findings: The method applied proved to not only to be both reliable and valid, but also sufficient to detect differences between the dominant and non-dominant hand, as well as between healthy participants and mildly involved neurological patients. Marked differences in most of the depended variables were also detected between unidirectional and bi-direction tasks (i.e., in the tasks where LF acts in one and in two alternating directions). The later finding could not be based neural mechanisms known for their role in manipulative actions, such as on employing ad hoc muscle synergies or on the afferent activity of skin mechanoreceptors. Conclusions: The employed methodological approach can be applied not only to explore various manipulation activities, but also to serve as a basis for future development of specific clinical tests for populations that demonstrate impaired hand function.

Osseous Metaplasia In Adenocarcinomo Of The Rectum: A Case Report

Osseous metaplasia is a rare feature to be seen in any type of tumor. Very few cases of osseous metaplasia in benign or malignant tumors of the gastrointestinal tract have been reported. Majority of these cases are mucin secreting adenocarcinomas. In all these cases osseous metaplasia is an incidental finding on microscopic examination and there are no specific clinical features or tests which will indicate osseous metaplasia. Etiopathogenesis of osseous metaplasia is not well known but Bone morphogenic proteins(BMP) are known to play an important role in the pathogenesis of this condition. Awareness of this condition is necessary to avoid overdiagnosis of bone invasion in malignant tumors.

The Evaluation of Various Physical Examinations for the Diagnosis of Type II Superior Labrum Anterior and Posterior Lesion

Background Many types of physical examinations have been used to diagnose superior labrum anterior and posterior lesions; no decisive clinical test is available for confirming the diagnosis. Hypothesis A selection from 10 well-established physical tests, alone or in combination, can be used to differentiate lesions with biceps anchor detachment from those with an intact biceps anchor with arthroscopic correlation. Study Design Case control study (diagnosis); Level of evidence, 3. Methods Among 297 patients who underwent shoulder arthroscopy between January 2004 and July 2005, 146 patients were enrolled in the study as a type II superior labrum anterior and posterior lesion group and an age-matched control group. Sensitivity, specificity, and predictive values of each test and all possible combinations of 2 and 3 tests were analyzed. The same procedures were repeated in patients younger than and older than 40 years. Results The sensitivities of the Whipple, O'Brien, apprehension, and compression-rotation tests and the specificities of the Yergason, biceps load II, and Kibler tests were relatively high. No single physical examination was found to be simultaneously highly sensitive and specific for the diagnosis of a type II superior labrum anterior and posterior lesion. When 2 of the 3 relatively sensitive tests (O'Brien, apprehension, or compression-rotation test) were combined with 1 of the 3 relatively specific tests (Speed, Yergason, or biceps load II test), sensitivity and specificity reached approximately 70% and 95%, respectively. Similar trends were noted in the younger and older patient groups and in the isolated type II superior labrum anterior and posterior lesion group. Conclusion The data suggest that some combinations of 2 relatively sensitive clinical tests and 1 relatively specific clinical test increase the diagnostic efficacy of superior labrum anterior and posterior lesions. Requiring 1 of the 3 chosen tests to be positive will result in a sensitivity of about 75%, whereas requiring all 3 to be positive will result in a specificity of about 90%.

Die isolierte Subskapularissehnenruptur

Isolated subscapularis tendon tears are rare and often of traumatic origin. Despite specific clinical tests and exact radiological tools (ultrasound, magnetic resonance imaging), these tendon ruptures are often overlooked. For restoration of normal biomechanical joint function, immediate operative reconstruction is recommended. Tears of the upper subscapularis and partial articular-side tendon can be safely managed arthroscopically. The biceps tendon is often involved, and adequate treatment with tenotomy or tenodesis must be given to prevent postoperative pain. Complete subscapularis tendon avulsions should be reconstructed with an open repair technique. Immediate surgical management provides better results than delayed repair.