A multi-modal treatment approach for the shoulder: A 4 patient case series

BACKGROUND: This paper describes the clinical management of four cases of shoulder impingement syndrome using a conservative multimodal treatment approach. CLINICAL FEATURES: Four patients presented to a chiropractic clinic with chronic shoulder pain, tenderness in the shoulder region and a limited range of motion with pain and catching. After physical and orthopaedic examination a clinical diagnosis of shoulder impingement syndrome was reached. The four patients were admitted to a multi-modal treatment protocol including soft tissue therapy (ischaemic pressure and cross-friction massage), 7 minutes of phonophoresis (driving of medication into tissue with ultrasound) with 1% cortisone cream, diversified spinal and peripheral joint manipulation and rotator cuff and shoulder girdle muscle exercises. The outcome measures for the study were subjective/objective visual analogue pain scales (VAS), range of motion (goniometer) and return to normal daily, work and sporting activities. All four subjects at the end of the treatment protocol were symptom free with all outcome measures being normal. At 1 month follow up all patients continued to be symptom free with full range of motion and complete return to normal daily activities. CONCLUSION: This case series demonstrates the potential benefit of a multimodal chiropractic protocol in resolving symptoms associated with a suspected clinical diagnosis of shoulder impingement syndrome

Detecting changes in the basin of attraction of a dynamical system: Application to the postural restoring system

A method that provides athree-dimensional representation ofthe basin ofattraction of a dynamical system from experimen tal data was applied tothe problem ofdynamic balance restoration. The method isbased onthe density ofthe data onthe phase space ofthe system under study and makes use ofmodeling and numerical curve fittingtools.For the dynamical system ofbalance restora tion,the shape and the size of the basin of attraction depend on the dynamics of the postural restoring mechanisms and contain important information regarding the biomechanical,as well as the neuromuscular condition of the individual. The aim ofthis work was toexamine the ability ofthe method todetect, through the observed changes inthe shape and/or the size ofthe calculated basins of attraction, (a)the inherent differences between different systems (in the current application, postural restoring systems of different individuals)and (b)induced chan ges in the same system (thepostural restoring system of an individual).The results ofthe study confirm the validity of the method and furthermore justify its robustness

The effectiveness of different minimally invasive epiphysiodesis techniques in the management of paediatric leg length discrepancies: a systematic review

Paediatric leg length discrepancies (LLDs) are more common than might be expected with the literature reporting that between 0.1 and 7% of the paediatric population has a LLD of >2 cm. Causes can be subdivided into congenital and acquired aetiologies. LLDs greater than 2 cm can lead to functional complications such as altered gait kinetics and abnormal loading of joints. For children predicted to have a LLD of 2-5 cm, minimally invasive epiphysiodesis (MIE) is the current management of choice. Presently, there are four MIE techniques commonly used throughout the world, however, no systematic reviews have compared these techniques. The objective of this thesis was to conduct a systematic review to synthesise the best available evidence on the use of MIE for the management of paediatric LLD. The effectiveness of four different techniques was compared: percutaneous epiphysiodesis using transphyseal screws (PETS); physeal drilling and curettage (PDC); physeal stapling; and guided growth with eight-Plates. Studies that evaluated two or more of the interventions or those that investigated a single intervention were considered for inclusion. Primary outcomes for the review included absolute LLD at skeletal maturity; rate of correction; percentage of correction; and incidence of long term complications. This review found that all techniques were sufficient at reducing the burden of a LLD with the mean final LLD of each being calculated to be <2 cm. Despite this, the rate of complications was higher in the eight-Plates and staples groups than the PDC and PETS groups. The PETS cohort had a reported failure of growth plate arrest (GPA) of 2.5% compared with 6% in the PDC and staples groups and 14% in the eight-Plate groups. The rate of inadequate correction (i.e. over or under correction), were also higher in the eight-Plate and staples groups (15% and 23%, respectively) than the PETS and PDC groups (8% and 13%, respectively). The incidence of angular deformities was much higher in the staples cohort (33%) than in the other groups (PDC 2%; PETS 9%; and eight-Plates 5%). The incidence of acute complications, such as haematoma, infection and acute knee pain, was similar across all techniques. Unfortunately, the overall level of evidence was low, due to the suboptimal and heterogeneous nature of the study designs included in this systematic review, and thus, treatment guidelines could not be developed. Notwithstanding this, the available evidence showed that all the evaluated techniques can adequately reduce a LLD, although PDC and PETS appear to be more effective at this. Further research is required to substantiate these claims; for now, all techniques remain an acceptable technique for addressing LLDs of 2-5 cm.Thesis (MClinSc) -- University of Adelaide, Adelaide Medical School, 201

The relationship of femoral torsion and lower limb injury

Research about femoral torsion has existed since the late 1980’s with the focus on developing a method to measure femoral torsion. Identifying the degree of femoral torsion has become important because excessive antetorsion of the femur has been associated with hip pathology. In addition, it is important to identify the degree of femoral torsion prior to placement of a hip prosthesis and prior to derotational osteotomy for children with congenital excessive femoral antetorsion, which is seen in cerebral palsy, hip dysplasia and Blount’s disease. The gold standard for measuring femoral torsion is a CT scan, which is invasive therefore limiting its usage especially in children. While research on femoral torsion has been narrowed to hip pathology and correcting deformity, excessive femoral antetorsion is thought to impact structures distal to the hip therefore increasing the risk of developing lower limb injury. Since the relationship between femoral torsion and lower limb injury is unknown, a systematic review is presented in Chapter 2 that looked at the relationship between femoral torsion and other hip characteristics as a risk factor for lower limb injury. Excessive range of external rotation and increased strength may increase the risk of lower limb stress fracture and patellofemoral pain. Weaker hip external rotators and stronger hip abductors were found to significantly increase the risk of developing patellofemoral pain. Greater range of hip external rotation was also found to be a factor in increasing the risk of lower limb stress fracture however the figure is too small to be considered a clinically worthwhile effect. Although hip strength and hip range of motion were found to be risk factors for lower limb injury, no prospective study investigating the relationship between femoral torsion and lower limb injury was found. Therefore, one of the aims of this thesis was to provide preliminary data to uncover this relationship. Another aim of the work presented in this thesis was to develop a new ultrasound imaging protocol to assess femoral shaft torsion utilising a new landmark on the greater trochanter, ‘the ridge’. The protocol showed excellent intra-rater reliability (ICC2,1 = 0.98; 95% CI 0.97 to 0.99), and inter-rater reliability (ICC2,1 = 0.97; 95% CI 0.95 to 0.98). Fifty per cent of the measurements were within 1o both within and between raters and within 2.7o for 80% of the measurements. The largest difference between raters was 9.3o. Standard error of measurement (SEM) was 0.5 degrees and 0.6 degrees respectively for intra-rater and inter-rater reliability measurements. The excellent reliability supports its usage in the clinical setting. This work is presented in chapter 3. Consequently, using the newly developed reliable method, the relationship between femoral torsion and hip proprioception was examined in healthy adults (n=40). Hip proprioceptive acuity was measured using an active reproduction of movement in three different angles; 10% of neutral, 50% or mid-range and 90% of maximum external rotation. Greater range of medial shaft torsion was found to be associated with better hip proprioceptive acuity only at the angle near the end of maximum external rotation (r=-0.325, p=0.04) not at 10% (r=0.019, p=0.909) and 50% (r=0.116, p=0.478). The detail of this study is described in chapter 4 of this thesis. A cross-sectional study investigated the relationship between femoral shaft torsion and lower limb injury in dancers (n=80). No difference was found in the magnitude of femoral shaft torsion between injured and non-injured dancers (p = 0.94). The relationship between femoral shaft torsion and eight other hip measures was also investigated. Femoral shaft torsion was found to have a very weak, negative correlation with range of hip external rotation (r = -0.034, p=0.384) and turnout (r = -0.066, p=0.558). The association between femoral shaft torsion with all other variables was also found to be very weak. This study is described in detail in Chapter 5. Overall the results of the studies documented in this thesis: describe the development of a novel femoral torsion measurement tool, identify femoral shaft torsion as a measurable component of femoral torsion, and provide preliminary data and inferences regarding the relationship between femoral torsion, distal lower limb injury and lower limb proprioceptive acuity in a high risk population of dancers. It is proposed that future research will determine the extent to which femoral torsion poses a lower limb injury risk, which will inform the modification of screening protocols. The findings of this thesis will also assist clinicians to direct their prophylactic management to joints and soft tissues at risk. If a time-frame for development of FT can be identified, modified training loads may be investigated to enhance optimal FT and determine whether this minimises injury risk. This new information therefore will also provide a basis for future research that would likely be in longitudinal studies establishing relationships, hence providing useful information for coaches and clinicians regarding designing alternative methods of training in preventing lower limb injuries. The body of knowledge provided by this thesis will also inform researchers in determining the measures of the hip to be used in future research which might be worthwhile investigating in relation to lower limb injury

An investigation into the ultrastructural parameters of abdominal muscles in children and adolescents with spastic type cerebral palsy and the effect on postural muscle performance

Includes bibliographical references.Cerebral palsy (CP) is an abnormality in motor function and postural tone that usually occurs at an early age. Spastic type cerebral palsy (STCP) - the most common type of motor disorder - involves increased muscle tone, a rigid posture in the limbs and muscle weakness resulting in impairment of gross motor function, trunk instability and co-ordination. The management of CP cases includes a broad spectrum of therapeutic interventions, therefore involving a large multi-professional team, and providing an ideal opportunity for collaboration amongst professionals. The primary determinants of muscle function are the architectural parameters (MAP's) of the muscle which determine the macroscopic arrangement of muscle fibres relative to the axis of force generation. Ultrasonography was used to quantify these MAP's while the NORAXAN® electromyograph was used to monitor neuromuscular activity in children and adolescents with STCP (N = 63) and the results were compared with the findings from aged-matched individuals with typical development (TD), (N = 82). All the muscles - external oblique (EO), internal oblique (IO), transversus abdominis (TrA) and rectus abdominis (RA) - were thicker in the STCP group than in the TD group. The EO, IO and TrA muscles in the STCP group were thicker at rest than in individuals with TD. The MAP's of EO, IO and TrA in the STCP group decreased when the muscles changed from the resting to an active state, as opposed to increasing in the TD group. The four muscles of individuals with TD and the RA of the STCP group showed significant changes (p < 0.001) in the frequency of EMG activity between the resting and active states. With regards to pennation, the abdominal muscles could be regarded as a transition group of muscles, lying somewhere between pennated and non-pennated muscle bellies. The findings from this study revealed that the RA may be targeted during rehabilitation regimens in the provision of stability for the bony pelvis, however, the force generated by this muscle may not be sufficient for the maintenance of trunk stability without optimal support from the EO and IO. An elevated tone at rest in the EO and IO, coupled with unilateral activity of the RA may lead to mal-rotation of the bony pelvis. The gross motor function measure (GMFM), which tested the five main domains of activity in individuals with STCP was well aligned with the gross motor function classification system (GMFCS) Levels (disability status) but did not correlate with changes in MAP's or with changes in the frequency of EMG activity between resting and active states. The performance of daily activities by individuals with STCP may not be a reflection of the activity of a muscle. The physiological cost index (PCI) was performed as an outcome measure to determine and compare the level of energy consumption between the two groups. The participants with STCP consumed significantly more (p < 0.001) energy than the TD group. However, this test showed no association with MAP, EMG activity and the changes in these muscle parameters from resting to active states (rho ranged from -0.009 to 0.27 in the STCP group; rho ranging from - 0.423 to 0.199 in the TD group). The PCI may not be a useful test in determining the morphological transformation taking place in a muscle or muscle groups. The MAP's of the unaffected side of the abdominal muscles of the STCP individuals with hemiplegia showed similar characteristics to those of TD individuals. The STCP adversely affects the trunk musculature in a similar fashion to the limbs. Knowledge of the macroscopic arrangement of the abdominal muscles is important in the management of pelvic stability in individuals with STCP