Search

Background: Fluid therapy plays a major role in the management of critically ill patients. Yet assessment of intravascular volume in these patients is challenging. Different invasive and non-invasive methods have been used with variable results. The passive leg raise (PLR) maneuver has been recommended by international guidelines as a means to determine appropriate fluid resuscitation. We performed this systematic review and meta-analysis to determine if using this method of volume assessment has an impact on mortality outcome in patients with septic shock. Methods: This study is a systematic review and meta-analysis. We searched available data in the MEDLINE, CINAHL, EMBASE, and CENTRAL databases from inception until October 2020 for prospective, randomized, controlled trials that compared PLR-guided fluid resuscitation to standard care in adult patients with septic shock. Our primary outcome was mortality at the longest duration of follow-up. Results: We screened 1,425 article titles and abstracts. Of the 23 full-text articles reviewed, 5 studies with 462 patients met our eligibility criteria. Odds ratios (ORs) and associated 95% confidence intervals (CIs) for mortality at the longest reported time interval were calculated for each study. Using random effects modeling, the pooled OR (95% CI) for mortality with a PLR-guided resuscitation strategy was 0.82 (0.52 -1.30). The included studies were not blinded and they ranged from having low to high risk of bias using the Cochrane Risk of Bias Tool. Conclusion: Our analysis showed there was no statistically significant difference in mortality among septic shock patients treated with PLR-guided resuscitation vs. those with standard care.

Background: Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking. Methods: A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg−1 or intermediate-dose dexamethasone 0.3 mg kg−1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications. Results: Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P−1 i.v., dexamethasone 1 mg kg−1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects. Clinical trial registration: NCT03763734.

Background. Regular physical activity plays an important role in the treatment of patients with cystic fibrosis (CF). This study is aimed at investigating the effects of a 12-month partially supervised exercise program on attributes of health-related and motor performance fitness, lung function (ppFEV1), BMI, and habitual physical activity (HPA, steps/day) in adults with CF. Methods. Attributes of health-related and motor performance fitness were examined at the beginning (T0), after 6 (T1), and 12 months (T2) on the basis of five test items: forward bend (FB), bent knee hip extension (HE), plank leg raise (PLR), standing long jump (SLJ), and standing on one leg (OLS). Additionally, we recorded HPA by accelerometry, peak exercise performance ( W peak ) by an incremental cycle test, ppFEV1, and BMI. During the first six months, there was close supervision by an experienced sport therapist. Results. 26 CF patients (8 female, mean age 26.5 ± 7.9 years; ppFEV1 53.7 ± 21.0 ) completed the exercise program. Significant improvements were recorded from T0 to T1 (FB: p ≤ 0.05 ; PLR, OLS: p ≤ 0.01 ) and from T0 to T2 (FB, PLR: p ≤ 0.01 and HE, OLS: p ≤ 0.05 ). W peak , ppFEV1, BMI, and HPA showed no significant improvement between the single test points and over the entire study period (all p > 0.05 ). Conclusion. Our results show trainability of adults with CF in aspects of health-related and motor performance fitness during a partially supervised exercise program. Close supervision positively influences the results. Using a simple test setup seems to be a promising tool for evaluating the effects of exercise programs in CF and could serve as an additional outcome parameter in future clinical trials. Trial registration: ClinicalTrials.gov (retrospectively registered May 8, 2018).

Rectus abdominis diastasis is regarded as a risk factor for abdominal muscle dysfunction and reduced quality of life postpartum. It is thought that specific exercises and additional physical support might reduce the diastasis, with a need to establish efficacy in doing so.Determine the effect of four abdominal exercises as well as Tubigrip or taping in reducing rectus abdominis diastases three weeks postpartum.Cross-sectional repeated measures comparison.32 women undertook a single session of ultrasound imaging. Ultrasound measurements of inter-rectus distance were taken at rest and during: 1) crook lying abdominal "drawing in" exercise; 2) crook lying trunk curl-up; 3) early Sahrmann level leg raise; 4) McGill side lying plank. The curl-up and abdominal "drawing in" exercises were assessed under two further conditions: a) wearing Tubigrip, b) taping across the diastasis. Data analyses involved repeated measures ANOVA.At rest the mean inter-rectus distance above and below the umbilicus was 3.5 cm (SD:1.1) and 2.6 cm (SD:1.2) respectively. A significant decrease (19%, p 0.05) was observed at both measurement points during the curl-up exercise. No other exercises elicited a significant difference compared to resting. At rest, wearing Tubigrip reduced the inter-rectus distance (7%, p 0.05). During exercise, there was no additional change in the inter-rectus distance (p 0.05) with supports.The curl-up exercise was most effective in reducing inter-rectus distance. As no exercises invoked an increase in the rectus diastasis, they could not be regarded as potentially detrimental. Tubigrip and taping did not add to the effects of these exercises.

OBJECTIVES:Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN:Prospective, noninterventional study. SETTING:ICU at a large academic center. PATIENTS:Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS:Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS:Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1 ± 18.7 ms versus -4.0 ± 8 ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7 ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS:Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.

Objectives The aim of this study was to investigate the value of bedside echocardiography with a passive leg raise as a noninvasive marker of volume responsiveness. Methods This work was a prospective observational study of patients with end-stage renal disease presenting to the emergency department. The left ventricular outflow tract (LVOT) velocity time integral (VTI) was obtained. Measurements before and after dialysis as well as before and after the passive leg raise were recorded. Results Fifty-four patients were enrolled, in whom the mean volume of fluid removed ± SD was 3.89 ± 0.91 L. In the predialysis cohort, the mean LVOT VTI was 28.05 cm (95% confidence interval [CI], 26.55-29.55 cm). After the passive leg raise, the mean VTI was 28.52 cm (95% CI, 26.98-30.07 cm). In the postdialysis cohort, the mean VTI was 30.31 cm (95% CI, 28.92-31.69 cm), and it increased to 34.91 cm (95% CI, 33.11-36.72 cm) after the passive leg raise. The Δ VTI values were 1.83% (95% CI, 0.12%-3.55%) in the predialysis group and 15.05% (95% CI, 12.76%-17.34%) in the postdialysis cohort. When stratified by fluid removal, the mean Δ VTI values after hemodialysis were 12.64% (95% CI, 9.79%-15.49%) and 16.84% (95% CI, 13.47%-20.22%) for patients who had less than 4 L and 4 L or greater removed, respectively. In patients without congestive heart failure, the Δ VTI was 15.28% (95% CI, 12.25%-18.32%), whereas for those with congestive heart failure, the mean change was 14.63% (95% CI, 10.91%-18.35%). Conclusions The LVOT VTI in conjunction with a passive leg raise seems to correlate with the volume status and volume responsiveness.

Normalizing to a reference signal is essential when analysing and comparing electromyography signals across or within individuals. However, studies have shown that MVC testing may not be as reliable in persons with acute and chronic pain.The purpose of this study was to compare the test-retest reliability of the muscle activity in the biceps femoris and gluteus maximus between a novel sub-MVC and standard MVC protocols.This study utilized a single individual repeated measures design with 12 participants performing multiple trials of both the sub-MVC and MVC tasks on two separate days. The participant position in the prone leg raise task was standardised with an ultrasonic sensor to improve task precession between trials/days. Day-to-day and trial-to-trial reliability of the maximal muscle activity was examined using ICC and SEM.Day-to-day and trial-to-trial reliability of the EMG activity in the BF and GM were high (0.70-0.89) to very high (≥0.90) for both test procedures. %SEM was5-10% for both tests on a given day but higher in the day-to-day comparisons. The lower amplitude of the sub-MVC is a likely contributor to increased %SEM (8-13%) in the day-to-day comparison.The findings show that the sub-MVC modified prone double leg raise results in GM and BF EMG measures similar in reliability and precision to the standard MVC tasks. Therefore, the modified prone double leg raise may be a useful substitute for traditional MVC testing for normalizing EMG signals of the BF and GM.

The pulse amplitude ratio, the ratio of pulse pressure at the end of a Valsalva maneuver to before the onset of Valsalva, correlates with filling pressure. This study aimed to noninvasively estimate cardiac filling pressure in patients with heart failure. We developed a noninvasive handheld device to measure pulse amplitude ratio using finger photoplethysmography. In 69 patients who underwent right heart catheterization, photoplethysmography waveforms were recorded during a standardized Valsalva maneuver, and in 60 of these patients, pulse amplitude ratio was able to be calculated. Pulse amplitude ratio correlated with pulmonary capillary wedge pressure (PCWP) (r = 0.58, p 15 mm Hg was statistically significant (p 15 mm Hg with 73% sensitivity and 77% specificity. Pulse amplitude ratio also increased by an average of 0.03 with a leg raise maneuver (p = 0.05, n = 36). In conclusion, we demonstrate that noninvasively measured response to the Valsalva maneuver in patients with HF can estimate PCWP and also detect changes within a single patient.

Objective Assessment of Corrected Flow Time (FTc) in carotid artery has been suggested recently as a measure of intravascular volume status. This study aimed to determine the reference values of FTc in carotid artery in a normal population. Methods A total number of 142 healthy volunteers (73 females and 69 males) with a mean age of 36.65 ± 10.52 years were included. Results The mean FTc in carotid artery was 325.18 ± 22.15 ms0.5. The mean value of FTc differed significantly between females and males both before and after passive leg raise (PLR) (330.18 ± 21.61 ms0.5 vs. 319.88 ± 21.62, P = 0.005 before PLR, and 336.89 ± 22.95 ms0.5 vs. 326.51 ± 21.21, P = 0.006 after PLR). Conclusion This study would potentially pave the way to determine clinically significant cutoff points in order to assess the diagnostic accuracy of FTc in predicting intravascular volume status and fluid therapy responsiveness.

Introduction: Preoperative fasting was long regarded as an important cause of fluid depletion, leading to hemodynamic instability during surgery should replenishment is not promptly instituted. Lately, this traditional point of view has been progressively challenged, and a growing number of authors now propose a more restrictive approach to fluid management, although doubt remains as to the true hemodynamic influence of preoperative fasting. Methods: We designed an observational, analytic, prospective, longitudinal study in which 31 ASA 1 and ASA 2 volunteers underwent an echocardiographic examination both before and after a fasting period of at least 6 hours (h). Data from both static and dynamic preload indices were obtained on both periods, and subsequently compared. Results: Static preload indices exhibited a markedly variable behaviour with fasting. Dynamic indices, however, were far more consistent with one another, all pointing in the same direction, i.e., evidencing no statistically significant change with the fasting period. We also analysed the reliability of dynamic indices to respond to known, intentional preload changes. Aortic velocity time integral (VTI) variation with the passive leg raise manoeuvre was the only variable that proved to be sensitive enough to consistently signal the presence of preload variation. Conclusion: Fasting does not appear to cause a change in preload of conscious volunteers nor does it significantly alter their position in the Frank–Starling curve, even with longer fasting times than usually recommended. Transaortic VTI variation with the passive leg raise manoeuvre is the most robust dynamic index (of those studied) to evaluate preload responsiveness in spontaneously breathing patients. Resumo: Introdução: O jejum no pré-operatório é há muito tempo considerado como uma importante causa de depleção de líquidos, levando à instabilidade hemodinâmica durante a cirurgia, caso a reposição não seja prontamente instituída. Recentemente, esse ponto de vista tradicional vem sendo progressivamente desafiado, e um número crescente de autores agora propõe uma abordagem mais restritiva para o controle de líquidos, embora permaneçam dúvidas quanto à verdadeira influência hemodinâmica do jejum no pré-operatório. Métodos: Estudo observacional, analítico, prospectivo e longitudinal, no qual 31 voluntários ASA I e II foram submetidos a exame ecocardiográfico antes e após um período de jejum de no mínimo 6 horas. Os dados dos índices de pré-carga tanto estáticos quanto dinâmicos foram obtidos em ambos os períodos e, subsequentemente, comparados. Resultados: Os índices estáticos de pré-carga mostraram um comportamento acentuadamente variável com o jejum. Os índices dinâmicos, entretanto, foram bem mais consistentes entre si, todos apontando na mesma direção; isto é, não evidenciando nenhuma alteração estatisticamente significativa com o período de jejum. Analisamos também a confiabilidade dos índices dinâmicos para responder a alterações pré-carga intencionais conhecidas. A variação da integral de velocidade-tempo (VTI) aórtica com a manobra de elevação passiva dos membros inferiores foi a única variável que mostrou sensibilidade suficiente para sinalizar de forma consistente a presença de variação na pré-carga. Conclusão: O jejum não pareceu causar uma alteração na pré-carga de voluntários conscientes nem alterou substancialmente a sua posição na curva de Frank-Starling, mesmo com tempos de jejum mais prolongados que o normalmente recomendado. A variação do VTI transaórtico com a manobra de elevação passiva dos membros inferiores foi o índice dinâmico mais robusto (dos estudados) para avaliar a capacidade de resposta a variações da pré-carga em pacientes respirando espontaneamente. Keywords: Fasting, Echocardiography, Fluid therapy, Hemodynamics, Palavras-chave: Jejum, Ecocardiografia, Fluidoterapia, Hemodinâmica

Background Anticipatory postural adjustments (APAs) occur in the trunk during tasks such as rapid limb movement and are impaired in individuals with musculoskeletal and neurological dysfunction. To understand APA impairment, it is important to first determine if APAs can be measured reliably and which characteristics of APAs are task-invariant. Research question What is the test-retest reliability of latency, amplitude and muscle activation patterns (synergies) of trunk APAs during arm-raise and leg-raise tasks, and to what extent are these APA characteristics invariant across tasks at the individual and group levels? Methods 15 young adults (mean age: 23.7 (±3.2) years) performed six trials of a rapid arm raise task in standing and a leg raise task in supine on two occasions. Latency, amplitude and coactivation of APAs in the erector spinae and external/internal oblique musculature were measured, and APA synergies were identified with principle components analysis. Test-retest reliability across the two sessions was calculated with intraclass correlation coefficients. Task-invariance was assessed at the individual level with correlation and at the group level with tests of equivalence. Results Most variables demonstrated acceptable test-retest reliability. Synergies and many features of APA activation varied across tasks, although at the individual level, motor performance time and amplitude of lumbar erector spinae activation were significantly correlated across tasks. Average pre-motor reaction time, external oblique latency, contralateral oblique amplitude and internal oblique coactivation were equivalent across tasks. Significance Characteristics of trunk muscle APAs quantified during a single task may not be representative of an anticipatory postural control strategy that generalizes across tasks. Therefore, APAs must be assessed during multiple tasks with varying biomechanical demands to adequately investigate mechanisms contributing to movement dysfunction. The reliability analysis in this study facilitates interpretation of group differences or changes in APA behavior in response to intervention for the selected tasks.

BACKGROUND Various forms of trunk exercise have been used for increasing abdominal strength. The plank exercise and bilateral leg raise exercise are one of these trunk exercises. However, there are few studies that compared the effects of these exercise variations. OBJECTIVE The present study aimed to investigate how effectively the trunk muscles during plank and bilateral leg raise exercises are activated. METHOD Surface electromyography responses of the rectus abdominis, internal oblique, and erector spinae muscles were investigated during the plank and bilateral leg raise exercise with different hip position. A total of 18 healthy, physically active female volunteers completed the normal plank exercise, plank exercise with placing the lower leg in a horizontal condition, bilateral leg raise exercise, and bilateral leg raise with lower leg as horizontal condition. RESULTS The horizontal condition caused significant increases in activity of the internal oblique muscles compared with the general condition (p< 0.05). The bilateral leg raise exercise showed significantly greater activation in the rectus abdominis compared to the plank exercise (p< 0.05). CONCLUSION The present study showed that the horizontal condition had the advantage of activating the internal oblique muscles, and the leg raise exercise is effective in strengthening global muscle such as the rectus abdominis.

The purpose of this study was to determine the relation between posturally increased intra-abdominal pressure and lower/upper esophageal sphincter pressure changes in patients with gastroesophageal reflux disease. We used high resolution manometry to measure pressure changes in lower and upper esophageal sphincter during bilateral leg rise. We also examined whether the rate of lower and upper esophageal sphincter pressure would increase during leg raise differentially in individuals with versus without normal resting pressure. Fifty eight patients with gastroesophageal reflux disease participated in the study. High resolution manometry was performed in relaxed supine position, then lower and upper esophageal sphincter pressure was measured. Finally, the subjects were instructed to keep their legs lifted while performing 90-degree flexion at the hips and knees and the pressure was measured again. Paired t-test and independent samples t-test were used. There was a significant increase in both lower (P 0.001) and upper esophageal sphincter pressure (P = 0.034) during leg raise compared to the initial resting position. Individuals with initially higher pressure in lower esophageal sphincter (10 mmHg) exhibited a greater pressure increase during leg raise than those with initially lower pressure (pressure ≤10 mmHg; P = 0.002). Similarly individuals with higher resting upper esophageal sphincter pressure (44 mmHg) showed a greater pressure increase during leg raise than those with lower resting pressure (≤44 mmHg; P 0.001). The results illustrate the influence of postural leg activities on intraesophageal pressure in patients with gastroesophageal reflux disease, indicating by means of high resolution manometry that diaphragmatic postural and sphincter function are likely interrelated in this population.

Low back ache (LBA) is a common musculoskeletal disorder sometimes associated with a positive limited Straight leg raise (SLR) test. Mulligan's bent leg raise (BLR) and Butler's neural tissue mobilization (NTM) are commonly used techniques for the treatment of low back ache where SLR is limited. The aim of this study was to evaluate the effect of both the techniques on pain and limited SLR in patients with LBA. Thirty one patients with LBA with radiculopathy were randomly allocated into 2 groups; BLR [n = 16] NTM [n = 15]. The outcome measures i.e. visual analogue scale (VAS) for pain and universal goniometer for measuring SLR range of motion (SROM) were assessed at the baseline, post intervention and after 24 h (follow up). Within group analysis using paired t-test revealed a significant difference between pre-treatment and post-treatment VAS and SROM score(p 0.05). However no difference was seen between pre-treatment and follow up (p 0.05). The study showed that both techniques produce immediate improvement in pain and SLR range but this effect was not maintained during the follow up period.

The purpose of this study was to investigate the effect of Abdominal Enhancement (AE) on the muscle activation of vastus medialis obliquus (VMO), vastus lateralis (VL) and rectus femoris (RF) muscle activation levels during eccentric, isometric and concentric phases of single leg raise (SLR), single leg wall squat (SLWS) and forward lunge (FL) exercises. Sixteen healthy individuals (Age: 24.6 ± 1.7 years) were included in the study. Internal Obliques/Transversus Abdominis (IO/TA), VMO, RF and VL muscle activation levels were measured by surface EMG during the exercises in two conditions: with and without AE. The abdominal drawing-in technique was used for AE. Repeated-measures analysis of variance was performed for statistical analysis. With AE, the average of IO/TA muscle activation level was 28.9%. VMO and VL muscle activation levels were significantly greater with AE during SLR (p = .02), SLWS (p .001) and FL (VMO, p = .008, VL, p = .04) exercises. The effect of AE on VMO muscle activation level ranged from 2.5% to 5% (Effect size range: 0.54 to 0.91) and VL muscle activation level ranged from 2.1% to 5.5% (Effect size range: 0.35-1.24). RF muscle activation level did not change with AE (p .05). The results of this study showed that AE increased VMO and VL muscle activities during SLR, SLWS and FL exercises but the corresponding changes were small. Even if this is not enough for muscle strengthening, exercises with AE may be used to enhance knee joint stability while controlling lumbopelvic stability.

Purpose: Passive leg raise (PLR), in combination with technologies capable of capturing stroke volume changes, has been widely adopted in the management of shock. However, dedicated evaluation of safety, feasibility, and receptiveness of patients and nursing staff to PLR maneuver is missing. Methods: A noninterventional, prospective trial recruited adult patients with onset of undifferentiated shock within 24 hours with persistent vasopressor requirements despite fluid resuscitation. A standardized PLR maneuver was used to compare two noninvasive hemodynamic monitoring systems, each without significant impact on the performance of the maneuver. Safety and efficacy of the PLR were evaluated via subjective and objective measures. Objective measures of patient comfort and tolerance were evaluated through changes in vital signs, sedation, and analgesia requirements. Nurses and awake patients completed surveys on their experience. Results: Seventy-nine patients were enrolled. Testing was aborted in 2 cases for medical reasons (one patient developed rapid atrial fibrillation, second had profound desaturation). Of all, 5.4% of patients required additional vasopressor support after completion of the PLR maneuver due to persistent hypotension and 4.1% of patients required additional sedation. Among awake patients (N = 35), 6% reported pain and 29% reported discomfort. A total of 11% of nurses reported minor technical difficulties with the maneuver. Conclusion: Passive leg raise maneuver leads to a few serious but reversible complications in a selected population of hemodynamically unstable patients. Although it provides relevant diagnostic information, it may impact patient care. Treating physician should be aware of infrequent but possible complications and appreciate the impact of the maneuver on patients’ comfort and nursing workload.

Purpose of the current study was to compare early effectiveness of pain relieve of 3 in 1 regional pain catheter to local infiltration anesthesia (LIA) in primary total knee arthroplasty (TKA). Secondary endpoint was quadriceps muscle strength after both procedures. A single-center, prospective, randomized controlled trial was performed. Patients eligible to TKA were either randomized into group 3 in 1 regional pain catheter (C), or group local infiltration anesthesia (L). Pain relieve was assessed by visual analogue scale (VAS) at rest and under physical activity (PA) prior to surgery (t0) and at days one through six. In addition, quadriceps muscle strength ( = straight leg raise) was tested according to the Manual Muscle Testing Scale. Functional outcome was measured using the Oxford Knee Score (OKS) preoperatively and 6 months postoperatively. 121 patients were included in the study. 59 (48.8%) patients were allocated to group C, 62 (51.2%) patients to Group L. No differences concerning pain level evaluated by VAS could be detected between the groups at any time. Comparing straight leg raise test group L was significantly superior over the complete postoperative period (p

Objectives In this study, the authors sought to obtain hemodynamic estimates across a wide age span and in both sexes for future reference and compare these estimates with current guideline diagnostic hemodynamic thresholds for abnormal filling pressure and pulmonary hypertension. Background At present, the influence of age on hemodynamic function is largely unknown. Because many diseases with proposed cardiac impact are more prevalent in the older population, it is pivotal to know how hemodynamic parameters are affected by age itself to discern the influence of disease from that of physiological aging. Methods Sixty-two healthy participants, evenly distributed with respect to age (20 to 80 years) and sex (32 women/30 men), were prospectively enrolled in the study. Participants were all deemed healthy by medical history, echocardiography, exercise test, spirometry, blood tests, and electrocardiogram. Participants had hemodynamic parameters measured using right heart catheterization during rest, passive leg raise, and incremental exercise. Results During rest, all hemodynamic parameters were similar between age groups, apart from blood pressure. During leg raise and incremental exercise, there was augmented filling pressure (p < 0.0001) and diminished cardiac output (p = 0.001) and hence a higher pressure:flow ratio (pulmonary artery pressure/capillary wedge pressure to cardiac output) with progressive age, evident from the earliest ages. All indexed hemodynamic measures were similar between sexes. The diagnostic threshold (pulmonary capillary wedge pressure ≥25 mm Hg) currently used during exercise testing to diagnose abnormal left ventricular filling pressure was measured in 30% of our healthy elderly participants. Conclusions Cardiac aging was progressive without sex differences in healthy participants. The hemodynamic reference values obtained suggest that the diagnostic threshold for abnormal filling pressure should be individually determined according to age of the patient.

This study examined anterior chain whole body linkage exercises, namely the body saw, hanging leg raise and walkout from a push-up. Investigation of these exercises focused on which particular muscles were challenged and the magnitude of the resulting spine load. Fourteen males performed the exercises while muscle activity, external force and 3D body segment motion were recorded. A sophisticated and anatomically detailed 3D model used muscle activity and body segment kinematics to estimate muscle force, and thus sensitivity to each individual's choice of motor control for each task. Gradations of muscle activity and spine load characteristics were observed across tasks. On average, the hanging straight leg raise created approximately 3000 N of spine compression while the body saw created less than 2500 N. The hanging straight leg raise created the highest challenge to the abdominal wall (>130% MVC in rectus abdominis, 88% MVC in external oblique). The body saw resulted in almost 140% MVC activation of the serratus anterior. All other exercises produced substantial abdominal challenge, although the body saw did so in the most spine conserving way. These findings, along with consideration of an individual's injury history, training goals and current fitness level, should assist in exercise choice and programme design.

International audience; Background: Assessment of circulating volume and the requirement for fluid replacement are fundamental to resuscitation but remain largely empirical. Passive leg raise (PLR) may determine fluid responders while avoiding potential fluid overload. We hypothesised that inferior vena cava collapse index (IVCCI) and carotid artery blood flow would change predictably in response to PLR, potentially providing a non-invasive tool to assess circulating volume and identifying fluid responsive patients.Methods: We conducted a prospective proof of concept pilot study on fasted healthy volunteers. One operator measured IVC diameter during quiet respiration and sniff, and carotid artery flow. Stroke volume (SV) was also measured using suprasternal Doppler. Our primary endpoint was change in IVCCI after PLR. We also studied changes in IVCCI after “sniff”, and correlation between carotid artery flow and SV.Results: Passive leg raise was associated with significant reduction in the mean inferior vena cava collapsibility index from 0.24 to 0.17 (p

Corrected carotid systolic flow time (CFTc) has been proposed as a measure of volume status in acutely ill patients. This study endeavors to determine whether the change in CFTc with passive leg raise (PLR) maneuver correlates with volume status changes. Dialysis patients at Kingston General Hospital (Kingston, Canada) underwent point-of-care carotid ultrasonography at the beginning and the end of dialysis. With each measurement, 2 values were recorded: the absolute CFTc, and the difference in CFTc before and after the PLR maneuver. A total of 49 measurements were collected during the study period. CFTc changed with PLR by 5 ± 22 milliseconds (2.0%) pre-dialysis and by 40 ± 19 milliseconds (13.0%) post-dialysis (P

A computational model was used to simulate the passive leg raising (PLR) maneuver during cardiopulmonary resuscitation (CPR).Cardiac output (CO), coronary perfusion pressure (CPP), and systematic perfusion pressure (SPP), were compared between PLR-CPR and CPR only.Hemodynamic effects improve during PLR-CPR compared to CPR only.An optimal angle for the PLR maneuver delivers the optimum hemodynamic effects. Background and objectiveThe passive leg-raising (PLR) maneuver has been used for patients with circulatory failure to improve hemodynamic responsiveness by increasing cardiac output, which should also be beneficial and may exert synergetic effects during cardiopulmonary resuscitation (CPR). However, the impact of the PLR maneuver on CPR remains unclear due to difficulties in monitoring cardiac output in real-time during CPR and a lack of clinical evidence. MethodsWe developed a computational model that couples hemodynamic behavior during standard CPR and the PLR maneuver, and simulated the model by applying different angles of leg raising from 0 to 90 and compression rates from 80/min to 160/min. ResultsThe simulation results showed that the PLR maneuver during CPR significantly improves cardiac output (CO), systemic perfusion pressure (SPP) and coronary perfusion pressure (CPP) by 4065% particularly under the recommended range of compression rates between 100/min and 120/min with 45 of leg raise, compared to standard CPR. However, such effects start to wane with further leg lifts, indicating the existence of an optimal angle of leg raise for each person to achieve the best hemodynamic responses. ConclusionsWe developed a CPR-PLR model and demonstrated the effects of PLR on hemodynamics by investigating changes in CO, SPP, and CPP under different compression rates and angles of leg raising. Our computational model will facilitate study of PLR effects during CPR and the development of an advanced model combined with circulatory disorders, which will be a valuable asset for further studies.

The aim of this study was to analyze trunk muscle activity during bridge style stabilization exercises, when combined with single and double leg support strategies. Twenty-nine healthy volunteers performed bridge exercises in 3 different positions (back, front and side bridges), with and without an elevated leg, and a quadruped exercise with contralateral arm and leg raise ("bird-dog"). Surface EMG was bilaterally recorded from rectus abdominis (RA), external and internal oblique (EO, IO), and erector spinae (ES). Back, front and side bridges primarily activated the ES (approximately 17% MVC), RA (approximately 30% MVC) and muscles required to support the lateral moment (mostly obliques), respectively. Compared with conventional bridge exercises, single leg support produced higher levels of trunk activation, predominantly in the oblique muscles. The bird-dog exercise produced greatest activity in IO on the side of the elevated arm and in the contralateral ES. In conclusion, during a common bridge with double leg support, the antigravity muscles were the most active. When performed with an elevated leg, however, rotation torques increased the activation of the trunk rotators, especially IO. This information may be useful for clinicians and rehabilitation specialists in determining appropriate exercise progression for the trunk stabilizers.

The purpose of this study was to evaluate the standard field tests of flexibility of the lower extremity through their (a) intratrial and test-retest reliability, (b) concurrent validity with respect to a high-precision 3D system for kinematic recording, and (c) factorial validity. Physically active men (n = 84) were tested over 2 separate sessions by means of standard simple devices (kinanthropometry, ruler, and protractor) on the following flexibility tests: leg raise in a supine position, hip abduction test, single-legged knee bend (SLKB), sideward leg splits (SdLS), sit and reach (SR), sideways leg splits, and lengthwise leg splits. Additionally, 17 participants were simultaneously tested by means of a laboratory 3D kinematic analysis system. Most of the tests demonstrated high intratrial and test-retest reliability and concurrent validity. The exceptions were SLKB and SR tests that revealed not only a somewhat lower reliability but also a lower concurrent validity. For estimation of factorial validity, we applied a principal component analysis of the intercorrelations among the evaluated flexibility tests that revealed a single extracted principal component. Strong mutual relationships among them also suggest that very few of them, if not a single one, should be applied within the standard batteries of physical performance tests. We particularly recommend using SdLS over the most frequently used SR not only because of its relatively high reliability and validity but also because of its postural properties. Finally, we conclude that most of the standard field tests of flexibility of the lower extremity based on using inexpensive field equipment could be both reliable and valid and, therefore, justified for use in routine testing.

Pregnancy-related low back and pelvic pain (PLBP) is a frequent complication of pregnancy. Although pathological mechanisms underlying PLBP are obscure, dysfunction of the sacroiliac joints (SI-joints) seems to play an important role. A cross-sectional study was performed on 24 pregnant women with and without PLBP. The objective was to determine muscle activation patterns of trunk and leg muscles during the active straight leg raising test (ASLR) and static hip flexion, and to determine maximal hip flexion force at 0 and 20 cm leg raise height. Moreover, the effort to raise the leg was scored. The measurements resulted in several significant differences between the patients and healthy controls; among others (a) patients scored subjectively more effort during ASLR, (b) at both 0 and 20 cm leg raise height patients had less hip flexion force, and (c) patients developed more muscle activity during ASLR. Since pregnant women with PLBP developed a higher muscle activity during ASLR with a significantly lower output at 0 and 20 cm than healthy pregnant women, it could be proposed that the ASLR demonstrates a disturbed load transfer across the SI-joints in this population. (c) 2006 Elsevier Ltd. All rights reserved.

Background and Purpose The aim of this study was to compare the trunk muscle activities and the local/global activity ratios of the abdominal, back and trunk muscles during stabilization exercises such as one arm raise (AR), one leg raise (LR), and opposing arm/leg raise (ALR) in patients with chronic low back pain (LBP). Method Ten individuals with chronic LBP (five men and five women) participated in this study. The external oblique abdominis, internal oblique abdominis, multifidus, thoracic part of the lumbar iliocostalis and the local/global activity ratio were assessed, while quadruped stabilization exercises were performed (AR, LR, and ALR); each exercise was carried out three times. Result One-way repeated ANOVA was used to measure the differences in the trunk muscle activity and the local/global activity ratio. Post hoc analyses were performed (α = 0.05/3 = 0.017). In the right internal oblique, muscle activity during LR was significantly greater than that during AR. In the bilateral multifidus and lumbar iliocostalis, each ALR muscle activity was significantly greater than those of AR and LR. In addition, the local/global activity ratios of the back and trunk muscle in LR and ALR were significantly greater compared with AR. Conclusions LR should be recommended over AR for individuals with chronic LBP. Moreover, the application of ALR should be approached carefully on the basis of progress and ability to stabilize the spine in this patient population. Copyright © 2014 John Wiley & Sons, Ltd.

10.1186/1471-227X-14-15 Background It is estimated that about 275,000 inhabitants experience an out-of-hospital cardiac arrest (OHCA) every year in Europe. Survival in out-of-hospital cardiac arrest is relatively low, generally between five per cent and 10%. Being able to explore new methods to improve the relatively low survival rate is vital for people with these conditions. Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) has been found to improve cardiac preload and blood flow during chest compressions. The aim of our study is to evaluate whether early PLR during CPR also has an impact on one-month survival in sudden and unexpected out-of-hospital cardiac arrest (OHCA). Method/Design A prospective, randomized, controlled trial in which all patients (=18 years) receiving out-of hospital CPR are randomized by envelope to be treated with either PLR or in the flat position. The ambulance crew use a special folding stool which allows the legs to be elevated about 20 degrees. Primary end-point: survival to one month. Secondary end-point: survival to hospital admission to one month and to one year with acceptable cerebral performance classification (CPC) 1¿2. Discussion PLR is a simple and fast maneuver. We believe that the greatest benefit with PLR is when performed early in the process, during the first minutes of CPR and before the first defibrillation. To reach power this study need 3000 patients, we hope that this method article will encourage other sites to contact us and take part in our study. Trial registration ClinicalTrials.gov NCT01952197. Keywords: Passive leg raise; Cardiopulmonary resuscitation; Out-of-hospital cardiac arrest; Emergency medical service (EMS)

A model of the knee in the sagittal plane was developed to study the forces in the ligaments induced by isometric contractions of the extensor and flexor muscles. The geometry of the distal femur was obtained from cadaver data. The tibial plateau and patellar facet were modeled as flat surfaces. Eleven elastic elements were used to describe the mechanical behavior of the anterior and posterior cruciate ligaments (ACL and PCL), the medial and lateral collateral ligaments (MCL and LCL), and the posterior capsule. The model knee was actuated by 11 musculotendinous units, each muscle represented by a Hill-type contractile element, a series-elastic element, and a parallel-elastic element. Tendon was assumed to be elastic. The response of the model to anterior-posterior drawer suggests that the geometrical and mechanical properties of the model ligaments approximate the behavior of real ligaments in the intact knee. Calculations for a simulated quadriceps leg raise indicate further that the two-dimensional model reproduces the response of the three-dimensional knee under similar conditions of loading and constraint. During maximum isometric contractions of the quadriceps, the model ACL is loaded from full extension to 80 degrees C of flexion; the model PCL is loaded at 70 degrees of flexion and greater. For maximum isometric extension, ACL forces in the range 0-20 degrees of flexion depend most heavily upon the force-length properties of the quadriceps. At flexion angles greater than 20 degrees, cruciate ligament forces are determined by the geometry of the articulating surfaces of the bones. During isolated contractions of the hamstrings and gastrocnemius muscles, the model ACL is loaded from full extension to 10 degrees of flexion; the model PCL is loaded at all flexion angles greater than 10 degrees. Isolated contractions of the flexor muscles cannot unload the ACL near full extension, as the behavior of the ACL in this region is governed by the shapes of the bones. At 10 degrees of flexion or greater, the overall pattern of PCL force is explained by the force length properties of the hamstrings and by the geometrical arrangement of the flexor muscles about the knee.

Anticipatory postural adjustments (APAs) stabilize potential disturbances to posture caused by movement, impaired APAs are common with disease and injury. Brain functions associated with generating APAs remain uncertain due to a lack of paired tasks that require similar limb motion from similar postural orientations, but differ in eliciting an APA while also being compatible with brain imaging techniques (e.g., functional magnetic resonance imaging; fMRI). This study developed fMRI-compatible tasks differentiated by the presence or absence of APAs during leg movement. Eighteen healthy subjects performed two leg movement tasks, supported leg raise (SLR) and unsupported leg raise (ULR), to elicit isolated limb motion (no APA) versus multi-segmental coordination patterns (including APA), respectively. Ground reaction forces under the feet and electromyographic (EMG) activation amplitudes were assessed to determine the coordination strategy elicited for each task. Results demonstrated that the ULR task elicited a multi-segmental coordination that were either minimized or absent in the SLR task, indicating that it would serve as an adequate control task for fMRI protocols. A pilot study with a single subject performing each task in an MRI scanner demonstrated minimal head movement in both tasks and brain activation patterns consistent with an isolated limb movement for the SLR task versus multi-segmental postural coordination for the ULR task.

To assess whether the passive leg raising (PLR) test can predict fluid responsiveness in pediatric patients.This was a prospective observational study in a tertiary care pediatric center. Hemodynamic parameters including heart rate, stroke volume and cardiac output were assessed at baseline, after passive leg raising (PLR), at second baseline, and after volume loading (10 mL/kg normal saline in 10 min). Cutoff values of 7.5 and 10 % increase in cardiac index (CI) with passive leg raising were explored as predictors of volume loading response.Overall, the changes in CI with passive leg raising varied widely and was a poor predictor of response to volume loading in children under 5 years of age. Of 40 patients, 23 had greater than 10 % increase in CI with PLR which predicted fluid responsiveness with a sensitivity of 94 % (95 % confidence interval 71,100) and specificity of 26 % (95 % confidence interval 10,48). Sensitivity was higher (100 % vs. 91 %) and specificity similar (27 % vs. 25 %) in predicting CI for those over 5 as compared to under 5 y, respectively. In patients over 5 y, simple linear regression revealed a positive correlation (R(2) = 21) while R(2) values were much lower (0-0.07) for those under 5 y.Cardiac index changes after PLR varies widely in children and may be a poor predictor to volume loading in children under 5-y-old. However, in those over 5 y, PLR may be helpful in predicting fluid responsiveness in pediatric patients.

It was hypothesized that patients who are preload dependent, as demonstrated by a12% increase in cardiac output in response to a passive leg raise test, would be more likely to exhibit hypotension during spinal anesthesia for cesarean delivery.Cardiac output response to the passive leg raise test was measured in 40 women before spinal anesthesia with a noninvasive, continuous cardiac output monitor (NICOM®). Patients were divided into two groups based on their performance on the passive leg raise test; those who increased cardiac output12% following passive leg raise test were considered fluid responsive. NICOM® hemodynamic values were collected from the onset of spinal anesthesia until 10min after delivery of the fetus. The incidence of hypotension, defined as mean arterial blood pressure70% of the patient's baseline value was compared between the two groups. Vasopressor use, umbilical cord blood gases and Apgar scores were also compared between the groups.Nine patients were fluid responsive and 31 were fluid non-responsive. The groups had similar demographics and baseline hemodynamic parameters. No significant differences were seen between the groups in the incidence of spinal hypotension, vasopressor use, or neonatal outcome. At the time of delivery, fluid responsive patients had larger cardiac outputs compared to fluid non-responsive patients.In this pilot study, non-invasive assessment of the hemodynamic response to a volume load was not predictive of hypotension or vasopressor use during cesarean delivery under spinal anesthesia. Fluid responsiveness was related to hemodynamic responses at delivery.

Cross-sectional design.To investigate lumbar multifidus (LM) thickness differences, using ultrasound imaging in people during remission from recurrent low back pain (LBP) and healthy participants, during the following lower extremity movements: (1) active straight leg raise (ASLR), (2) crook-lying active leg raise (CLR), and (3) prone straight leg raise (PSLR).ASLR, CLR, and PSLR are used clinically to challenge the ability of the trunk muscles to control spinal motion in people with LBP, and it is believed that decreased LM activity is related to altered spinal control in this population. However, it is unclear whether LM behavior differs between healthy individuals and people with recurrent LBP during symptom remission in such tasks.The present study used ultrasound imaging to measure LM percentage thickness change parasagitally at the L4-5 and L5-S1 levels in people with recurrent LBP during symptom remission and in healthy participants, during the ASLR, CLR, and PSLR tasks.LM percentage thickness change was greater in the recurrent LBP group than in healthy participants during the PSLR task (P.01) and greater in both groups during the PSLR than the ASLR and CLR tasks (P.01). LM percentage thickness change was greatest at L4-5 in both groups (P.01) and during all tasks (P≤.02). No difference was found in LM percentage thickness change between groups in either the ASLR (P = .70) or CLR (P = .69) task.These data suggest that, during symptom remission, individuals with recurrent LBP, compared to healthy individuals, may have greater activity in at least some parts of the LM. Further investigation is required to determine whether the LM percentage thickness change observed in this study may be explained by differential changes in deep and/or superficial fibers of LM activity. This observation may have implications for clinical practice, but requires further investigation.

To study the feasibility of predicting fluid responsiveness (FR) by passive leg raising (PLR) using a Bioreactance-based noninvasive cardiac output monitoring device (NICOM).This prospective, two-center study included 75 consecutive intensive care unit (ICU) adult patients immediately after cardiac surgery. NICOM was used to continuously record cardiac output (CO) at baseline, during a PLR, and then during a 500 ml i.v. rapid colloid infusion. We estimated the precision of NICOM at baseline to derive the least minimum significant change (LMSC) in CO. We studied the predictability of PLR for FR by systematic analysis of different categorizations of PLR and FR, based on percentage change in CO (from 0 to 20%).The LMSC was 8.85%. CO was 4.17 ± 1.04 L min⁻¹ at baseline, 4.38 ± 1.14 L min⁻¹ during PLR, 4.16 ± 1.08 L min⁻¹ upon return to baseline, and 4.85 ± 1.41 L min⁻¹ after fluid infusion. The change in CO following fluid bolus was highly correlated with the change in CO following PLR: y = 0.91x + 4.3, r = 0.77. The Pearson correlation coefficient showed that the best pair of thresholds was found for PLR ≥ 0% predicting FR ≥ 0%. Using this pair of thresholds, PLR had 88% sensitivity and 100% specificity for predicting FR. When we restricted the analysis to change in COLMSC, the best pair of thresholds was obtained for PLR9% predicting FR9%. Using this pair of thresholds, PLR sensitivity was reduced to 68% and specificity to 95%.In this specific population of patients, it is clinically valid to use the bioreactance-based NICOM system to predict FR from changes in CO during PLR.

The aim of this study was to demonstrate the usefulness of leg raise in identifying lower diastolic functional reserve to exercise.One hundred fifty-four patients with abnormal left ventricular relaxation on Doppler mitral inflow with preserved left ventricular ejection fractions were enrolled. After resting evaluations, Doppler echocardiographic measurements were repeated during passive leg raise and graded supine bicycle exercise.Patients were divided into 3 groups according to resting E/e' ratio and its response to leg raise: group IA (persistent E/e'15 [n = 112]), group IB (change to E/e'or = 15 after leg raise [n = 19]), and group II (persistent E/e'or = 15 [n = 23]). Group II had lower S', e', and diastolic reserve index values during exercise compared with group IA but not with group IB. Group IB had higher E/e' ratios during exercise and lower diastolic functional reserve index values accompanied by lower exercise capacity compared with group IA.Passive leg raise might be helpful in identifying a subgroup with lower diastolic functional reserve and lower exercise capacity among patients with abnormal relaxation.

BACKGROUND We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy. METHODS Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue i.v. fentanyl (25 microg) was administered to achieve a visual analog scale score of

PURPOSE: We investigated the reproducibility of passive leg raise (PLR) and fluid bolus (BOLUS) using the Non-Invasive Cardiac Output Monitor (NICOM; Cheetah Medical, Tel Aviv, Israel) for assessment of fluid responsiveness (FR) in spontaneously breathing emergency department (ED) patients.METHODS: Prospective, observational study of a convenience sample of adult ED patients receiving intravenous fluid bolus. We assessed stroke volume (SV) using NICOM and obtained results from PLR, where the head of the bed was changed from semirecumbent to supine while the patients' legs raised to 45° for 3 minutes. Fluid bolus was defined as 5 mL/kg normal saline infusion. Maximal increase in SV was recorded. Fluid responsiveness was defined as an increase of SV greater than 10% from baseline. We obtained 4 consecutive responses for each patient; PLR1, PLR2, BOLUS1 separated each by 10 minutes, and BOLUS2 initiated immediately after the end of BOLUS1. We calculated κ statistics, correlation coefficients, and odds ratios with 95% confidence interval and Bland-Altman plots.RESULTS: We enrolled 109 patients enrolled in this study. The 2 PLRs were significantly correlated (r = 0.78, P < .001) with κ = 0.46 for FR (P < .001). The 2 BOLUSES less strongly correlated (r = 0.14, P = .001) and κ = 0.06 for FR (P < .001). Patients who were responsive to PLR1 had 9.5 (3.6-25) odds of being FR for PLR2, whereas those responsive to BOLUS1 had a 1.8 (0.76-4.3) increased odds of FR for BOLUS2.CONCLUSION: In conclusion, we have found PLR as measured by the NICOM to be a promising tool for the evaluation of SV responsiveness. It was feasible for use in the ED, and the data suggest that the PLR technique may be more reproducible than the fluid bolus technique for assessing volume responsiveness.

The aim of this study was to investigate the effects over 24h, on range of motion and pain, of a single intervention of Mulligan's bent leg raise (BLR) technique in subjects with limited straight leg raise (SLR) and low back pain (LBP). Mulligan techniques are frequently used in practice but their effectiveness has not been adequately researched. Ninety-four subjects were contacted by telephone and 46 volunteered for assessment. Of these, 24 fulfilled inclusion criteria of unilateral SLR limitation and LBP. All subjects were naive to physiotherapy, blinded, and randomly allocated to either a BLR (n=12) or placebo group (n=12). Range of SLR was measured by an assessor blind to group allocation, prior to, immediately following, and 24h after the intervention. Similarly pain was assessed prior to, and 24h after the intervention. After adjusting for differences in baseline values of SLR range, there was no difference between the two groups immediately after the intervention. However, 24h later, there was a significant increase in the range by 7 degrees in the BLR group, which may be clinically important. In addition there was a one-point reduction in pain, but no difference between groups. This preliminary study provides limited support for the use of the BLR technique; however, further research is required.

This study was designed to determine the intensity and duration of EMG muscle action potentials in the upper and lower segments of the rectus abdominis (RA) muscle during four abdominal exercises: the conventional sit-up, the hook sit-up, the arched back sit-up, and the double leg raise. Integrated