Architectural Ultrasound Pennation Angle Measurement of Lumbar Multifidus Muscles: A Reliability Study

The pennation angle has been shown to be a relevant parameter of muscle architecture. This parameter has not previously been measured in the lumbar multifidus musculature, and it is for this reason that it has been considered of great interest to establish an assessment protocol to generate new lines of research in the future. Objective: The objective of this study was to establish a protocol for measuring the pennation angle of the multifidus muscles, with a study of intra-rater and interrater reliability values. Design: This was a reliability study following the recommendations of the Guidelines for Reporting Reliability and Agreement Studies (GRRAS). Setting: The study was carried out at University of Alcalá, Department of Physiotherapy. Subjects: Twenty-seven subjects aged between 18 and 55 years were recruited for this study. Methods: Different ultrasound images of the lumbar multifidus musculature were captured. Subsequently, with the help of ImageJ software, the pennation angle of this musculature was measured. Finally, a complex statistical analysis determined the intra- and interrater reliability. Results: The intra-rater reliability of the pennation angle measurement protocol was excellent for observer 1 in the measurement of the left-sided superficial multifidus 0.851 (0.74, 0.923), and for observer 2 in the measurement of the right-sided superficial 0.711 (0.535, 0.843) and deep multifidus 0.886 (0.798, 0.942). Interrater reliability was moderate to poor, and correlation analysis results were high for thickness vs. pennation angle. Conclusions: The designed protocol for ultrasound measurement of the pennation angle of the lumbar multifidus musculature has excellent intra-rater reliability values, supporting the main conclusions and interpretations. Normative ranges of pennation angles are reported. High correlation between variables is described

Health-status outcomes with invasive or conservative care in coronary disease

BACKGROUND In the ISCHEMIA trial, an invasive strategy with angiographic assessment and revascularization did not reduce clinical events among patients with stable ischemic heart disease and moderate or severe ischemia. A secondary objective of the trial was to assess angina-related health status among these patients. METHODS We assessed angina-related symptoms, function, and quality of life with the Seattle Angina Questionnaire (SAQ) at randomization, at months 1.5, 3, and 6, and every 6 months thereafter in participants who had been randomly assigned to an invasive treatment strategy (2295 participants) or a conservative strategy (2322). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate differences between the treatment groups. The primary outcome of this health-status analysis was the SAQ summary score (scores range from 0 to 100, with higher scores indicating better health status). All analyses were performed in the overall population and according to baseline angina frequency. RESULTS At baseline, 35% of patients reported having no angina in the previous month. SAQ summary scores increased in both treatment groups, with increases at 3, 12, and 36 months that were 4.1 points (95% credible interval, 3.2 to 5.0), 4.2 points (95% credible interval, 3.3 to 5.1), and 2.9 points (95% credible interval, 2.2 to 3.7) higher with the invasive strategy than with the conservative strategy. Differences were larger among participants who had more frequent angina at baseline (8.5 vs. 0.1 points at 3 months and 5.3 vs. 1.2 points at 36 months among participants with daily or weekly angina as compared with no angina). CONCLUSIONS In the overall trial population with moderate or severe ischemia, which included 35% of participants without angina at baseline, patients randomly assigned to the invasive strategy had greater improvement in angina-related health status than those assigned to the conservative strategy. The modest mean differences favoring the invasive strategy in the overall group reflected minimal differences among asymptomatic patients and larger differences among patients who had had angina at baseline

Initial invasive or conservative strategy for stable coronary disease

BACKGROUND Among patients with stable coronary disease and moderate or severe ischemia, whether clinical outcomes are better in those who receive an invasive intervention plus medical therapy than in those who receive medical therapy alone is uncertain. METHODS We randomly assigned 5179 patients with moderate or severe ischemia to an initial invasive strategy (angiography and revascularization when feasible) and medical therapy or to an initial conservative strategy of medical therapy alone and angiography if medical therapy failed. The primary outcome was a composite of death from cardiovascular causes, myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. A key secondary outcome was death from cardiovascular causes or myocardial infarction. RESULTS Over a median of 3.2 years, 318 primary outcome events occurred in the invasive-strategy group and 352 occurred in the conservative-strategy group. At 6 months, the cumulative event rate was 5.3% in the invasive-strategy group and 3.4% in the conservative-strategy group (difference, 1.9 percentage points; 95% confidence interval [CI], 0.8 to 3.0); at 5 years, the cumulative event rate was 16.4% and 18.2%, respectively (difference, 121.8 percentage points; 95% CI, 124.7 to 1.0). Results were similar with respect to the key secondary outcome. The incidence of the primary outcome was sensitive to the definition of myocardial infarction; a secondary analysis yielded more procedural myocardial infarctions of uncertain clinical importance. There were 145 deaths in the invasive-strategy group and 144 deaths in the conservative-strategy group (hazard ratio, 1.05; 95% CI, 0.83 to 1.32). CONCLUSIONS Among patients with stable coronary disease and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years. The trial findings were sensitive to the definition of myocardial infarction that was used