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Background: There is a need to validate the reliability and validity of Direct Observation of Procedural Skills (DOPS) of knee joint mobilization for providing immediate feedback on the procedure. Additionally, it is crucial to examine whether the tools developed for on-site use can be applied off-site to prepare for future practice. The purpose of this study is to describe the implementation and clinimetric properties of a DOPS for knee joint mobilization evaluation (DOPSknee) on-site and off-site and to determine the pre-clinical competencies of physical therapy (PT) students at school. Methods: After the DOPSknee had been developed, 42 pre-clinical students from a single PT program were videotaped performing knee joint mobilization. Their performance was assessed in the standard manner by two clinical instructors using the DOPSknee. Assessments were conducted on-site and then off-site using the recorded videos after a time gap ranging from 1.5 months to 4.5 months. Results: The DOPSknee demonstrated a good level of on-site inter-rater reliability (intraclass correlation coefficient [ICC] = 0.78). It had a poor level of off-site inter-rater reliability (ICC = 0.37) and a poor to good level of intra-rater reliability between on-site and off-site evaluations (evaluator 1: ICC = 0.42; evaluator 2: ICC = 0.88). However, the DOPSknee was shown to have good reliability average measures between the on-site and off-site evaluations (average on-site vs. average off-site: ICC = 0.84). Average total DOPSknee scores were significantly correlated with the average global rating scores on-site and off-site (r= 0.47 and 0.75) and in cross-over conditions (r = 0.54 and 0.71). The cut-off score for the DOPSkneewas determined to be 14 points, and the construct validity analysis of both on-site and off-site evaluations from the average DOPSknee total scores demonstrated that the average global rating scores of the students who passed were significantly higher (p< 0.05). Conclusions: The clinimetric properties of the DOPSknee protocol revealed generally good results for on-site validity and reliability in assessing student performance and a need to be interpreted and applied with care off-site. The average measures may help improve the results from the two evaluators.

Carl PC Chen,1 Chih-Chin Hsu,2 Chih-Hsiu Cheng,3 Shu-Chun Huang,1 Jean-Lon Chen,1 Shin-Yi Lin1 1Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, Taoyuan City, Taiwan; 2Department of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Keelung and College of Medicine, Chang Gung University, Taoyuan City, Taiwan; 3School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan City, TaiwanCorrespondence: Carl PC ChenDepartment of Physical Medicine & Rehabilitation, Chang Gung Memorial Hospital at Linkou and College of Medicine, Chang Gung University, 5, Fu-Hsin Street, Guishan, Taoyuan 333, TaiwanTel +886-909396196Fax +886-3-3281320Email carlchendr@gmail.comBackground: To investigate whether body mass index (BMI) and changes in body positioning have any correlation with the distance from the pleura to the inferior trunk of the supraclavicular brachial plexus.Patients and Methods: Twenty stroke patients with upper limb spasticity and complex regional pain syndrome were recruited for this study. Distance from the pleura to the inferior trunk was measured in the supine position, body turned sideways at 45 °, and in the lateral decubitus position. Correlations between BMI and measured distances in these body positions were evaluated. A linear musculoskeletal ultrasound transducer was used to conduct these distance measurements.Results: The distance from the pleura to the inferior trunk in the supine position was calculated to have an average of 0.42 ± 0.06 cm (D1), 0.44 ± 0.05 (D2) when lying sideways at 45 °, and 0.87 ± 0.08 cm (D3) in the lateral decubitus position. The Kruskal–Wallis test revealed significant differences when comparing D3 with D1, and D3 with D2 (p < 0.001). Positive correlations were observed between BMI and D1 (Spearman’s rho = 0.62, p = 0.004, two-tailed), and between BMI and D2 (Spearman’s rho = 0.61, p = 0.005, two-tailed). The strongest positive correlation was observed between BMI and D3 (Spearman’s rho = 0.78, p < 0.001, two-tailed).Discussion: In the lateral decubitus body position, the distance from the pleura to the inferior trunk increased significantly by 2-fold and was positively correlated with BMI. The increased distance may improve the safety of the nerve block procedure. As a result, it is recommended that patients be placed in the lateral decubitus body position when performing ultrasound-guided supraclavicular brachial plexus nerve block of the inferior trunk.Keywords: body mass index, ultrasound-guided, brachial plexus, nerve block, inferior trunk, lateral decubitus, corner pocket, complex regional pain syndrome

This study aimed to investigate the biomechanical impact of laminectomy on cervical intersegmental motion and load sharing using a parametric patient-specific finite element (FE) model towards providing clinicians with a viable quantitative tool for informed decision-making and improved surgical planning. Ten subject-specific nonlinear osteo-ligamentous cervical spine (C3–C7) FE models were developed using X-ray image-based algorithms. The models were used to evaluate the effect of laminectomy on lower cervical spine biomechanics for two-level (C3–C4) and three-level (C3–C5) laminectomy procedures. The average cervical spine ranges of motion (ROM) for the pre-op models were 24.09 (± 8.65), 18.08 (± 7.48), 27.86 (± 6.82), and 33.18 (± 10.81) degrees, during flexion, extension, lateral bending, and axial rotation, respectively, in alignment with the literature. Post laminectomy increased the intersegmental ROM, disc stress, and intradiscal pressure at the upper cervical levels during sagittal plane motion and axial rotation, while the lower levels experienced the opposite trend, as compared with intact models. No significant changes were observed in facet joint forces after surgery. The current study used a parametric personalized FE modeling technique as a practical, clinically-applicable approach to predict cervical spine biomechanics post-surgical laminectomy. Altered biomechanical responses, both in terms of kinematics and kinetics, were observed, although more pronounced in models with fewer levels of laminectomy. Overall, a higher degree of motion compensation was observed at the higher levels of the cervical spine, regardless of the laminectomy level, which suggests increased spinal instability, potential risk of post-laminectomy kyphosis, and axial neck pain.

Head control ability assessed by the cervicocephalic kinesthetic sensibility test has been widely used as an important indicator for the diagnosis or treatment of cervical disorders. However, a reliable and handy device to measure head control has not been developed. This study aimed to compare the capability to quantify the cervicocephalic kinesthetic sensibility between an ultrasound-based motion capture system and an inertial measurement unit-based (IMU-based) mobile device with the ultimate goal of developing a clinically-useful assessment tool. Thirty-five young healthy volunteers were recruited in this study. The subjects were asked to perform the clinical cervicocephalic kinesthetic sensibility test in a head-to-neutral reposition procedure. The maximal range of motion and the reposition test in the cervical flexion, extension, right rotation, and left rotation directions were analyzed. After 5–7 days, the experimental procedure was repeated for the between-day retest measurement. No significant differences in cervical maximal range of motion and head reposition errors between the two devices were found. The intra-rater reliability of both ranged from good to excellent for the within-day and between-day measurements. The correlation between the two devices was also high, with r-values higher than 0.7 in all movement directions. The IMU-based mobile device shows the potential to be a reliable and feasible head assessment device. Further study is warranted to extend its applications for clinical examination.

The prolonged head forward and neck flexion posture associated with tablet computer use is a known risk factor for neck pain. Neck pain related dysfunction may cause proprioceptive errors and deficits in balance control. Thus, this study aimed to investigate the impact of prolonged tablet computer use with head forward and neck flexion posture on the pain intensity, cervical position sense and balance control in mechanical neck pain patients. The prolonged head forward and neck flexion posture associated with tablet computer use is a known risk factor for neck pain. Neck pain related dysfunction may cause proprioceptive errors and deficits in balance control. Thus, this study aimed to investigate the impact of prolonged tablet computer use with head forward and neck flexion posture on the pain intensity, cervical position sense and balance control in mechanical neck pain patients.The prolonged head forward and neck flexion posture associated with tablet computer use is a known risk factor for neck pain. Neck pain related dysfunction may cause proprioceptive errors and deficits in balance control. Thus, this study aimed to investigate the impact of prolonged tablet computer use with head forward and neck flexion posture on the pain intensity, cervical position sense and balance control in mechanical neck pain patients. Twenty subjects with mechanical neck pain (24.1 ± 3.4 years) and 20 healthy controls (23.7 ± 3.3 years) were recruited from a university environment. A neck pain inducing protocol simulating prolonged tablet computer usage with neck flexion posture was performed by the mechanical neck pain subjects until the point of moderate pain. The neck pain related scores, cervical range of motion and neck tissue hardness were evaluated in both the healthy controls and the neck pain subjects before the neck pain inducing protocol. Differences in the cervical joint position sense, neck tissue hardness and static standing balance performance of the healthy controls and mechanical neck pain subjects were investigated after the neck pain inducing protocol. The mechanical neck pain subjects demonstrated a lower cervical range of motion and a harder neck tissue status than the control subjects. The pain intensity reported by the neck pain subjects after the neck pain inducing protocol was similar to that experienced by the subjects in previous pain attacks. Significant differences in the absolute neck joint positioning error were observed between the mechanical neck pain group and the control group. Prolonged tablet computer use with head forward and neck flexion posture did not significantly increase the joint positioning error in the mechanical neck pain group. However, prolonged tablet computer use with head forward and neck flexion posture resulted in a poorer static standing balance performance in the subjects with mechanical neck pain than in the healthy controls. The subjects with mechanical neck pain exhibited a decreased cervical range of motion, a harder neck tissue status and greater neck joint position errors than the healthy controls. In addition, prolonged tablet computer use with head forward and neck flexion posture reproduced the neck pain severity and reduced the balance control ability of the mechanical neck pain subjects.

BACKGROUND CONTEXT Multisensory afferent inputs to the cervical spine affect the generation of neck muscle control. Chronic neck pain (CNP) and muscle fatigue are factors that disturb somatosensory function. Whether they affect postural control under self-initiated perturbation in daily activities is still unclear. PURPOSE To investigate the effect of CNP and neck flexor muscle fatigue on muscle control strategy and postural control in young patients performing voluntary shoulder flexion movements. STUDY DESIGN Cross-sectional case-control study. PATIENT SAMPLE Twenty-five patients with CNP and 25 age-matched asymptomatic controls. OUTCOME MEASURES The postural sway, muscle onset time, and activation level of the erector spinae, rectus abdominal, semispinalis capitis (SSC), and sternocleidomastoid (SCM) muscles were recorded and analyzed using two-way ANOVA to evaluate the interaction of CNP and muscle fatigue on standing balance and muscle control upon self-initiated perturbations. METHODS All participants were instructed to perform shoulder flexion movements in the standing position before and after a neck flexor muscle fatigue exercise under either the eyes-open or eyes-closed condition. RESULTS The CNP group exhibited significantly larger body sway, greater neck muscle activation (SCM and SSC), and longer onset time of neck flexor muscle (SCM) compared with the control group. The CNP group also demonstrated a trend of greater postural sway and shorter muscle onset under the eyes-closed condition than those under the eyes-open condition. After muscle fatigue, the CNP group further exhibited (1) greater body sway during the eyes-open condition but decreased body sway during the eyes-closed condition, (2) higher activation of the neck flexor (SCM) and lower activation of the trunk extensor (erector spinae), and (3) early onset of the neck muscles (SCM and SSC). CONCLUSIONS CNP causes poor postural control and altered neck muscle control patterns. The addition of neck flexor muscle fatigue further decreases balance stability and provokes a protective neck muscle control strategy during the shoulder flexion movement. Those findings facilitate the understanding of the strategies adopted by patients and suggest that neck endurance training programs may be beneficial to improve whole postural control in patients with CNP.

Epidemiological and clinical studies show that the magnitude and scope of cervical disease are on the rise, along with the world's rising aging population. From a biomechanical perspective, the cervical spine presents a wide inter-individual variability, where its motion patterns and load sharing strongly depend on the anatomy. This study aimed to first develop and validate a geometrically patient-specific model of the lower cervical spine for clinical applications, and secondly to use the model to investigate the spinal biomechanics associated with typical cervical disorders. Based on measurements of 30 parameters from X-ray radiographs, the 3D geometry of the vertebrae and intervertebral discs (IVDs) were developed, and detailed finite element models (FEMs) of the lower ligamentous cervical spine for 6 subjects were constructed and simulated. The models were then used for the investigation of different grades of IVD alteration. The multi directional range of motion (ROM) results were in alignment with the in-vitro and in-Silico studies confirming the validity of the model. Severe disc alteration (Grade 3) presented a significant decrease in the ROM and intradiscal pressure (flexion, extension, and axial rotation) on the C5-C6 and slightly increase on the adjacent levels. Maximum stress in Annulus Fibrosus (AF) and facet joint forces increased for Grade 3 for both altered and adjacent levels. The novel validated geometrically-personalized FEM presented in this study potentially offers the clinical community a valuable quantitative tool for the noninvasive analyses of the biomechanical alterations associated with cervical spine disease towards improved surgical planning and enhanced clinical outcomes.

Frailty is one of the most important geriatric syndromes, which can be associated with increased risk for incident disability and hospitalization. Developing a real-time classification model of elderly frailty level could be beneficial for designing a clinical predictive assessment tool. Hence, the objective of this study was to predict the elderly frailty level utilizing the machine learning approach on skeleton data acquired from a Kinect sensor. Seven hundred and eighty-seven community elderly were recruited in this study. The Kinect data were acquired from the elderly performing different functional assessment exercises including: (1) 30-s arm curl, (2) 30-s chair sit-to-stand, (3) 2-min step, and (4) gait analysis tests. The proposed methodology was successfully validated by gender classification with accuracies up to 84 percent. Regarding frailty level evaluation and prediction, the results indicated that support vector classifier (SVC) and multi-layer perceptron (MLP) are the most successful estimators in prediction of the Fried’s frailty level with median accuracies up to 97.5 percent. The high level of accuracy achieved with the proposed methodology indicates that ML modeling can identify the risk of frailty in elderly individuals based on evaluating the real-time skeletal movements using the Kinect sensor.

Study Design: Prospective study. Objective: Minimally-invasive lumbar fusion surgery (MIS) is a viable alternative to conventional open surgery (COS) for spinal disorders. Although MIS seems to be associated with less para-spinal muscle trauma, the actual back muscle performance after MIS and COS remain controversial. This study investigated post-operative para-spinal muscle performance, and the correlation between muscle dysfunction and clinical outcome. Methods: In this prospective, non-randomized control study, 50 patients were enrolled and split into 2 groups: COS and MIS. We established a biomechanical model of the para-spinal muscle in the lumbar spine using electromyography (EMG) and specific muscle function tests. Functional outcomes were also reviewed and analyzed. All patients underwent EMG pre-operatively, and at 3 months and 1 year post-operatively. The para-spinal muscle performance was investigated by comparing the back muscle co-contraction ratio and the load transmission zone to the pre-operative data. Results: Twenty-one patients in the COS group and 25 in the MIS group completed the study. Both groups showed a significant improved functional score. The abdominal and back muscle strengths were decreased post-operatively, and were then increased at 12 months post-operatively in both groups. During the perturbed balance task and static task, the MIS group exhibited a trend of recovery in comparison with the COS group. But, the back muscle performance at 12 months was poorer than the pre-op performance in both groups. Conclusions: There was no significant difference in clinical outcome and para-spinal muscle performance between groups. In both methods, the global muscle function had declined post-operatively.

Laminotomy and transforaminal lumbar interbody fusion (TLIF) is usually used to treat unstable spinal stenosis. Minimally invasive surgery (MIS) can cause less muscle injury than conventional open surgery (COS). The purpose of this study was to compare the degree of postoperative fatty degeneration in the paraspinal muscles and the spinal decompression between COS and MIS based on MRI. Forty-six patients received laminotomy and TLIF (21 COS, 25 MIS) from February 2016 to January 2017 were included in this study. Lumbar MRI was performed within 3 months before surgery and 1 year after surgery to compare muscle-fat-index (MFI) change of the paraspinal muscles and the dural sac cross-sectional area (DSCAS) change. The average MFI change at L2–S1 erector spinae muscle was significantly greater in the COS group (27.37 ± 21.37% vs. 14.13 ± 19.19%, P = 0.044). A significant MFI change difference between the COS and MIS group was also found in the erector spinae muscle at the caudal adjacent level (54.47 ± 37.95% vs. 23.60 ± 31.59%, P = 0.016). DSCSA improvement was significantly greater in the COS group (128.15 ± 39.83 mm2 vs. 78.15 ± 38.5 mm2, P = 0.0005). COS is associated with more prominent fatty degeneration of the paraspinal muscles. Statically significant post-operative MFI change was only noted in erector spinae muscle at caudal adjacent level and L2–S1 mean global level. COS produces a greater area of decompression on follow up MRI than MIS with no statistical significance on clinical grounds.

Patients with cervical myelopathy may manifest impairments in functional activities and balance control caused by compression of the spinal cord. The objective of the current study was to determine long-term changes in the upright balance control of patients with cervical myelopathy who had undergone cervical decompression surgery. This is a prospective cohort study from the preoperative phase to 3 months, 6 months, and 1 year postsurgery. Fifty-three patients with cervical myelopathy were recruited for the cervical myelopathy group and 22 age-matched healthy controls were recruited for the control group. Functional assessments including Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire-Lower Extremity Function (JOACMEQ-LEF) and 10-second step test; as well as balance assessments including postural sway (center-of-pressure: COP) were performed for both groups. The JOACMEQ-LEF (p = 0.036) scores of the myelopathy group improved postoperatively, and a significant decrease in COP variables of postural sway was observed. The upright posture was less stable in the myelopathy group than in the control group (p

Background To investigate whether the addition of injecting 5% dextrose water to the genicular nerves can augment the effect of platelet rich plasma (PRP) injections in treating elderly patients with moderate degree of knee osteoarthritis (OA). Material and Methods Forty-six elderly patients with grade 3 on the Kellgren and Lawrence knee OA grading system were divided into control and genicular nerve block groups. Both groups received 4 milliliters (mL) of PRP injected into the knee joint and 2 mL of PRP to the pes anserinus complex. In the nerve block group, 2 mL of 5% dextrose water was also injected to each genicular nerve. In the control group, normal saline was used to inject the genicular nerves. Proteomic technique of 2-dimensional electrophoresis was used to detect the changes in synovial fluid (SF) protein concentrations. Lequesne Functional Index was used to evaluate knee functional status. Results After 3 monthly PRP injections, concentrations of SF total protein, and proteins associated with inflammation decreased. Protein concentrations associated with chelation increased. In the nerve block group, improvements in pain and in the functional status of the knee joint lasted up to a period of 6 months. At 1 month and 3 months after the injections, Lequesne Functional Index was less than 7 (a value of 7 or higher indicates knee OA). Conclusions The concept of combining 5% dextrose water injection to the genicular nerves, and PRP injection into the knee joint and to the pes anserinus complex can be a feasible non-operative conservative treatment option for elderly patients with knee OA.

Background Data on visuomotor performance in combat training and the effects of combat training on visuomotor performance are limited. This study aimed to investigate the effects of a specially designed combat sports (CS) training program on the visuomotor performance levels of children. Methods A pre–post comparative design was implemented. A total of 26 students aged 9–12 years underwent 40-min CS training sessions twice a week for 8 weeks during their physical education classes. The CS training program was designed by a karate coach and a motor control specialist. The other 30 students continued their regular activities and were considered as a control group. Each student’s eye movement was monitored using an eye tracker, whereas the motor performance was measured using a target hitting system with a program-controlled microprocessor. The measurements were taken 8 weeks before (baseline), 1 day before (pretest), and 1 week after (posttest) the designated training program. The task used for evaluating these students was hitting or tracking random illuminated targets as rapidly as possible. A two-way analysis of variance [group(2) × time(3)] with repeated measures of time was performed for statistical analysis. Results For the children who received combat training, although the eye response improvement was not significant, both the primary and secondary saccade onset latencies were significantly earlier compared to the children without combat training. Both groups of students exhibited improvement in their hit response times during the target hitting tasks. Conclusion The current finding supported the notion that sports training efforts essentially enhance visuomotor function in children aged 9–12 years, and combat training facilitates an earlier secondary saccade onset.

The success of lumbar interbody fusion, the key surgical procedure for treating different pathologies of the lumbar spine, is highly dependent on determining the patient-specific lumbar lordosis (LL) and restoring sagittal balance. This study aimed to (1) develop a personalized finite element (FE) model that automatically updates spinal geometry for different patients; and (2) apply this technique to study the influence of LL on post-fusion spinal biomechanics. Using an X-Ray image-based algorithm, the geometry of the lumbar spine (L1-S1) was updated using independent parameters. Ten subject-specific nonlinear osteoligamentous FE models were developed based on pre-operative images of fusion surgery candidate patients. Post-operative FE models of the same patients were consequently created. Comparison of the obtained results from FE models with pre- and post-operation functional images demonstrated the potential value of this technique in clinical applications. A parametric study of the effect of LL was conducted for cases with zero LL angle, positive LL angles (+6° and +12°) and negative LL angles (-3° and -6°) on fused level (L4-L5), resulting in a total of 50 fusion simulation models. The average range of motion, intradiscal pressure, and fiber strain at adjacent levels were significantly higher with decreased LL during different directions except axial rotation. This study demonstrates that the LL alters both the intersegmental motion and load-sharing in fusion, which may influence the initiation and rate of adjacent level degeneration. This personalized FE platform provides a practical, clinically applicable approach for the analyses of the biomechanical changes associated with lumbar spine fusion.

Background Cervical spondylotic myelopathy (CSM) is a degenerative cervical disease in which the spinal cord is compressed. Patients with CSM experience balance disturbance because of impaired proprioception. The weighting of the sensory inputs for postural control in patients with CSM is unclear. Therefore, this study investigated the weighting of sensory systems in patients with CSM. Method Twenty-four individuals with CSM (CSM group) and 24 age-matched healthy adults (healthy control group) were analyzed in this observational study. The functional outcomes (modified Japanese Orthopaedic Association Scale [mJOA], Japanese Orthopaedic Association Cervical Myelopathy Questionnaire [JOACMEQ], Nurick scale) and static balance (eyes-open and eyes-closed conditions) were assessed for individuals with CSM before surgery, 3 and 6 months after surgery. Time-domain and time–frequency-domain variables of the center of pressure (COP) were analyzed to examine the weighting of the sensory systems. Results In the CSM group, lower extremity function of mJOA and Nurick scale significantly improved 3 and 6 months after surgery. Before surgery, the COP mean velocity and total energy were significantly higher in the CSM group than in the control group for both vision conditions. Compared with the control group, the CSM group exhibited lower energy content in the moderate-frequency band (i.e., proprioception) and higher energy content in the low-frequency band (i.e., cerebellar, vestibular, and visual systems) under the eyes-open condition. The COP mean velocity of the CSM group significantly decreased 3 months after surgery. The energy content in the low-frequency band (i.e., visual and vestibular systems) of the CSM group was closed to that of the control group 6 months after surgery under the eyes-open condition. Conclusion Before surgery, the patients with CSM may have had compensatory sensory weighting for postural control, with decreased weighting on proprioception and increased weighting on the other three sensory inputs. After surgery, the postural control of the patients with CSM improved, with decreased compensation for the proprioceptive system from the visual and vestibular inputs. However, the improvement remained insufficient because the patients with CSM still had lower weighting on proprioception than the healthy adults did. Therefore, patients with CSM may require balance training and posture education after surgery. Trial registration Trial Registration number: NCT03396055 Name of the registry: ClinicalTrials.gov Date of registration: January 10, 2018 - Retrospectively registered Date of enrolment of the first participant to the trial: October 19, 2015

Age-related changes of gait performance have been evidenced by the altered kinetic coordination of the lower extremity. However, a systematic approach to explore the gait control in terms of the mechanical energy transfer across multiple segments throughout the gait phases is still not well documented. Ten healthy elderly and ten young adults were asked to walk along a 10-meter walkway at the self-selected and fast walking speeds. The visualized energy flow model of the swing leg was established and the factor analysis was then applied to extract the high-dimensional energy flow characteristics of the swing leg. The results showed that the young adults have similar energy flow characteristics of the swing leg for both fast and self-selected walking speeds, while the elderly showed an opposite energy flow pattern especially at the fast walking speed. The hip power and the knee power were also found to mainly correspond to the swing acceleration and deceleration, respectively. This study demonstrated a valuable tool to explore the change of the gait characteristics in the elderly and could help to facilitate the understanding of the neuromuscular adaptation due to aging.

STUDY DESIGN A prospective, time series design. OBJECTIVE The purpose of this study is two-fold: firstly, to investigate the impact of altered cervical alignment and range of motion (ROM) on patients' self-reported outcomes after anterior cervical discectomy and fusion (ACDF), and secondly, to comparatively differentiate the influence of single- and two-level ACDF on the cervical ROM and adjacent segmental kinematics up to 12-month postoperatively. SUMMARY OF BACKGROUND DATA ACDF is one of the most commonly employed surgical interventions to treat degenerative disc disease. However, there are limited in vivo data on the impact of ACDF on the cervical kinematics and its association with patient-reported clinical outcomes. METHODS Sixty-two patients (36 males; 55.63 ± 11.6 yrs) undergoing either a single- or consecutive two-level ACDF were recruited. The clinical outcomes were assessed with the Pain Visual Analogue Scale (VAS) and the Neck Disability Index (NDI). Radiological results included cervical lordosis, global C2-C7 ROM, ROM of the Functional Spinal Unit (FSU), and its adjacent segments. The outcome measures were collected preoperatively and then at 3, 6, and 12-month postoperatively. RESULTS A significant reduction of both VAS and NDI was found for both groups from the preoperative to 3-month period (P

To investigate the presence of head control deficits and its course of recovery after anterior cervical discectomy and fusion (ACDF) surgery in cervical spondylotic myelopathy (CSM) patients. Thirty-seven CSM patients were assessed for their C2–C7 cervical lordosis, neck Range of Motion (ROM), repositioning accuracy, neck strength as well as surface electromyography of the neck muscle activities during slow head motions. Assessments were performed preoperatively and then at 3- and 6-month postoperatively. No significant difference was found for the C2–C7 cervical lordosis postoperatively at 6-month. ROM was restricted immediately after surgery but recovered over time, however, neck strength remained significantly reduced postoperatively. Reposition accuracy improved immediately after surgery but declined again at 6-month follow-up. In addition, muscle activities required to control head motions showed a continuous reduction postoperatively. Adequate C2–C7 cervical lordosis was maintained in the current study with improvement of slow head motion control and ROM at 6-month. However, improvement in head position sense was not maintained and neck strength showed continuous declination overtime. Assessment and monitoring of head control deficits should be routinely considered in CSM patients.

Background Degenerative lumbar diseases (DLDs) are characterized by motor functional deficits and postural instability. In this study, we investigated the differences in the trunk muscle responses to postural control between the presurgical DLD patients and healthy individuals while performing the static and perturbed balance tasks. Methods Thirty-five DLD patients (aged 61.1 ± 8.0 years) and thirty-five asymptomatic controls (aged 62.9 ± 3.7 years) participated in this study. All participants stood on a force plate and performed the quiet standing (QS) and in situ weight-lifting (WL) tasks. The participants’ performance in the QS task was tested under the eyes-open, eyes-closed, wide-base, and narrow-base conditions. Center of pressure (CoP) movements and electromyography of the erector spinae (ES) were recorded. The Mann–Whitney U test was applied for statistical analysis. Results The DLD group showed a significantly greater CoP movements and muscle activations during the QS task. Nevertheless, smaller CoP movements were noted during the WL task in the DLD group. Under the eyes-closed and narrow-base conditions, the DLD group showed even higher muscle activations and CoP movements. Significance The DLD patients demonstrated a poor postural control ability and tended to rely on the visual feedback and wide-base standing posture. A rigid and restricted posture was also adopted during the perturbed WL task. A high level of ES activation was required to maintain their postural steadiness. This study reveals an aberrant pattern of postural control and trunk muscle activations in symptomatic DLD patients which potentially contributes to the development of beneficial rehabilitation programs.

This study aimed to identify the muscle synergies during standing under various sensory contexts in healthy young adults.Sixteen healthy young adults participated in this study. The 4-min stance task was conducted under vision (eyes open or eyes closed) and proprioception (standing on ground or narrowed blocks) manipulated contexts. Electromyography (EMG) of 8 muscles around the right side of the trunk and leg were recorded and submitted to principal component analysis (PCA) to extract the muscle synergies. Two-way ANOVA with repeated measures was employed to test the effect of sensory contexts on the muscle synergies.PCA extracted three muscle synergies that accounted for the variance of standing EMG, including the push-back (composed of medial gastrocnemius, vastus medialis and biceps femoris), push-forward (composed of tibialis anterior and rectus femoris) and proximal mixed (composed of rectus abdominis, rector spinae, rectus femoris and biceps femoris) synergies. Block-standing increased the contribution of the push-back synergy while decreased the contribution of the push-forward synergy. In addition, contribution of the proximal mixed synergy was higher under ground-standing with eyes open than under block-standing with eyes open.Three muscle synergies were identified during standing in healthy young adults, and the synergies were affected by proprioception but not visual disturbance. The push-back and push-forward synergies showed the opposite response to proprioceptive disturbance, which may result from their antagonism role. Whether this control regime is used for elderly adults or patient populations with movement disorder needs to be further investigated.

A B S T R A C T Purpose: Previous studies have identified sensorimotor disturbances and greater fatigability of neck muscles in patients with neck pain. The purpose of this study was to investigate the effect of neck pain and neck flexor fatigue on standing balance following postural perturbations. Methods: Twenty patients with chronic neck pain (CNP) (24.7 3.6 year-old) and 20 age-matched asymptomatic subjects (22.1 2.2 year-old) were recruited. Subjects stood barefoot on a force plate and experienced backward perturbations before and after neck flexor fatigue. Center of pressure, electromyography of cervical and lumbar muscles, and head/trunk accelerations were recorded. Two-way ANOVA (pain fatigue) was used for statistical analysis. Results: CNP group showed larger body sway during quiet standing but not during perturbed standing compared with asymptomatic adults. In both groups, neck flexor fatigue resulted in greater body sway during the quiet standing but smaller body sway during perturbed standing, increased neck muscle activations and decreased lumbar muscle activations, as well as increased time to maximal head acceleration. Conclusions: Disturbed balance control was observed in CNP patients during the quiet standing. However, a rigid strategy was used to minimize the postural sway and to protect the head against backward perturbations in both CNP and asymptomatic young adults after neck flexor fatigue. The results facilitate the understanding of how the subjects with chronic neck pain and with neck muscle fatigue deal with the challenging condition. Further studies are needed to verify if such phenomenon could be changed after the intervention of specific flexor muscle retraining and balance control exercises.

[Purpose] This study aimed to determine the effectiveness of joystick-controlled video console games in enhancing subjects’ ability to control power wheelchairs. [Subjects and Methods] Twenty healthy young adults without prior experience of driving power wheelchairs were recruited. Four commercially available video games were used as training programs to practice joystick control in catching falling objects, crossing a river, tracing the route while floating on a river, and navigating through a garden maze. An indoor power wheelchair driving test, including straight lines, and right and left turns, was completed before and after the video game practice, during which electromyographic signals of the upper limbs were recorded. The paired t-test was used to compare the differences in driving performance and muscle activities before and after the intervention. [Results] Following the video game intervention, participants took significantly less time to complete the course, with less lateral deviation when turning the indoor power wheelchair. However, muscle activation in the upper limbs was not significantly affected. [Conclusion] This study demonstrates the feasibility of using joystick-controlled commercial video games to train individuals in the control of indoor power wheelchairs.

[Purpose] Nonspecific neck pain is a common musculoskeletal disease. Therapeutic exercise has been shown to improve pain and disability in short-term and midterm follow-ups. This study performed a literature review of the long-term effects of therapeutic exercise on subjects with nonspecific chronic neck pain. [Subjects and Methods] The databases of the CINAHL, MEDLINE, PEDro and PubMed were used. Randomized controlled trials (RCT) published from January 2000 to January 2014 and explicitly including a one-year follow-up were identified. [Results] Only six articles were included in this review. They had scores of 5 to 8 points on the PEDro scale, and the level of evidence was grade I. The study results show that the main exercises used were cervical strengthening and endurance training exercise. Short-term exercises (10 to 12 weeks) helped to improve the body function, structure, activity and participation immediately after the intervention, but not at the long-term follow-up. On the other hand, long-term interventions (1 year) resulted in improvements in body function and structure at the 3 year follow-up. [Conclusion] The results of the six high-quality studies suggest that long-term exercise have long-term benefits for patients with nonspecific neck pain in terms of body function and structure.

[Purpose] Cervical radiculopathy is a clinical condition associated with pain, numbness and/or muscle weaknesses of the upper extremities due to a compression or irritation of the cervical nerve roots. It is usually managed conservatively but surgical intervention is sometimes required for those who fail to respond adequately. This study performed a literature review to determine the effects of exercise on non-operative and post-operative cervical radiculopathy patients. [Methods] The PubMed, MEDLINE, CINAHL and Scopus databases were searched to identify relevant articles published from January 1997 to May 2014, which explicitly stated that an exercise program was employed as an intervention for cervical radiculopathy. The therapeutic effectiveness and outcomes were then classified based on the International Classification of Functioning, Disability and Health (ICF) model. [Results] Eleven studies were identified and included in the final analysis. In these studies, the main forms of exercise training were specific strengthening and general stretching exercises. Levels of evidence were graded as either I or II for all studies according to the Oxford Centre for Evidence-based Medicine. The PEDro Scale score of these studies ranged from 5 to 8. [Conclusion] A review of eleven high-level evidence and high-quality studies revealed that, based on the ICF model, exercise training is beneficial for improving the body function as well as activity participation of cervical radiculopathy patients.

This study aims to compare the head control ability in terms of the cervicocephalic kinesthetic sensibility between the elderly with and without cervical spondylotic myelopathy (CSM). Thirty CSM patients and thirty healthy elderly were recruited to perform the maximal neck extension as well as the maximal cervical range of motion (ROM) and head reposition tasks in neck flexion, extension, right and left rotation. Three measurements of the reposition accuracy were analyzed, including the constant error (CE), variable error (VE) and root mean square error (RMSE) of the reposition movements. Independent t test was used to investigate the difference of all measurements between the groups. CSM group showed less maximal neck strength and smaller cervical ROM compared with the healthy group with significant difference in cervical extension (p < 0.001) and right rotation (p < 0.05). During the reposition task, the CE of all movements showed significant difference between groups. The CSM group trended to show greater VE in all directions. The RMSE were greater in CSM group with significant difference in cervical extension and right rotation (p < 0.05). This study demonstrated that the CSM patients suffer from poor head control compared with that in the age-matched elderly. Those findings could help to facilitate the rehabilitation program targeting on the treatment of cervical problem in CSM patients.

Background Mechanomyography (MMG) has been used to investigate mechanical characteristics of muscle contraction in clinical and experimental settings. Objective The aim of this study was to determine the test-retest reliability of mechanomyographic amplitude (MMGRMS) measurements as a tool for measuring the maximal voluntary isometric contractions (MVICs) of trunk muscles in healthy participants. Methods There were ten young adults participating in this study. Accelerometers were used to detect surface MMG signals from three trials of 5-s MVICs of the rectus abdominis, external obliques, erector spinae, and multifidus in the vertical, transverse, and longitudinal directions. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and minimum detectable change were calculated. Results Good to excellent test-retest reliability of mechanomyographic amplitude (MMGRMS) measurements was achieved for all MVICs of trunk muscles in healthy participants, as indicated by ICCs ranging from 0.99 to 0.64 for MMGRMS of the trunk muscles during MVIC. Conclusions This study demonstrates that MMG is a reliable measurement to detect the activation amplitudes of trunk muscles during MVIC.

Background. The measurement of the functional range of motion (FROM) of lower limb joints is an essential parameter for gait analysis especially in evaluating rehabilitation programs.Aim. To develop a simple, reliable, and affordable mechanical goniometer (MGR) for gait analysis, with six-degree freedom to dynamically assess lower limb joint angles.Design. Randomized control trials, in which a new MGR was developed for the measurements of FROM of lower limb joints.Setting. Reliability of the designed MGR was evaluated and validated by a motion analysis system (MAS).Population. Thirty healthy subjects participated in this study.Methods. Reliability and validity of the new MGR were tested by intraclass correlation coefficient (ICC), Bland-Altman plots, and linear correlation analysis.Results. The MGR has good inter- and intrarater reliability and validity withICC≥0.93(for both). Moreover, measurements made by MGR and MAS were comparable and repeatable with each other, as confirmed by Bland-Altman plots. Furthermore, a very high degree of linear correlation (R≥0.92for all joint angle measurements) was found between the lower limb joint angles measured by MGR and MAS.Conclusion. A simple, reliable, and affordable MGR has been designed and developed to aid clinical assessment and treatment evaluation of gait disorders.

Knee pain is commonly seen in orthopedic and rehabilitation outpatient clinical settings. Patients with knee osteoarthritis (OA) are often complicated with joint soreness, swelling, weakness, and pain. These complaints are often caused by the excessive amount of synovial fluid (SF) accumulated in the bursae around the knee joint. This study was aimed to evaluate the effectiveness of platelet rich plasma (PRP) in treating patients with minor to moderate knee osteoarthritis (OA) combined with supra-patellar bursitis using a proteomic approach and clinical evaluation tool. In this study, 24 elderly patients with minor to moderate knee OA combined with supra-patellar bursitis were recruited. Musculoskeletal ultrasound was used for accurate needle placement for the aspiration of SF followed by subsequent PRP injections. Three monthly PRP injections were performed to the affected knees for a total of 3months. Approximately after the 2nd PRP injection, significant decreases in SF total protein concentrations, volumes, and Lequesne index values were observed. SF proteins associated with chelation and anti-aging physiological functions such as matrilin, transthyretin, and complement 5 increased at least 2-fold in concentrations. Proteins associated with inflammation, such as apolipoprotein A-I, haptoglobin, immunoglobulin kappa chain, transferrin, and matrix metalloproteinase decreased at least 2-fold in concentrations. Therefore, at least two monthly PRP injections may be beneficial for treating patients with minor to moderate knee OA combined with supra-patellar bursitis.

[Purpose] Muscle co-contraction is important in stabilizing the spine. The aim of this study was to compare cervical muscle co-contraction in adults with and without chronic neck pain during voluntary movements. [Subjects and Methods] Surface electromyography of three paired cervical muscles was measured in fifteen young healthy subjects and fifteen patients with chronic neck pain. The subjects performed voluntary neck movements in the sagittal and coronal plane at slow speed. The co-contraction ratio was defined as the normalized integration of the antagonistic electromyography activities divided by that of the total muscle activities. [Results] The results showed that the co-contraction ratio of patients was greater during flexion movement, lesser during extension movement, slightly greater during right lateral bending, and slightly lesser during left lateral bending compared with in the controls. [Conclusion] The results suggested that neck pain patients exhibit greater antagonistic muscle activity during flexion and dominate-side bending movements to augment spinal stability, while neuromuscular control provides relatively less protection in the opposite movements. This study helps to specify the changes of the stiffness of the cervical spine in neck pain patients and provides a useful tool and references for clinical assessment of neck disorders.

Based on an IMU motion sensitive device, a dynamic time warping (DTW) to detect risky activities of people under healthcare has been devised and implemented. DTW, beneficial by matching time sequences with nonlinear dynamic alignment of the sample points to optimize the similarity, is especially a candidate for such a kind of activity detection because that the discrete activity signal sequence would be investigated with various time or speed, and often be unequally lengthened. DTW shows potentially an excellence in dealing straightforward with this kind of unequal-length sequence matching problem. In this study, we clarify the use of DTW for such an application in both theory and application aspects. Besides, a related neural network mapping development, often used in solving the same kind of problem, is intentionally introduced in the paper for comparison. A performance investigation in both developments arise to seek an excellent methodology to deal effctively and efficiently with the activity detection. The comparison causally confirms the direct template matching based method DTW is superior in detecting temporally a matched activity from a continuous signal sequence source. DTW has thus been recommended to incorporate with the electronically assistive IMU device for monitoring specifically risky motions of the people who are under remote healthcare.

Background: Identifying disability early in life confers long-term benefits for children. The Taipei City Child Development Screening tool, second version (Taipei II) provides checklists for 13 child age groups from 4 months to 6 years. However, the usability of a text-based screening tool largely depends on the literacy level and logical reasoning ability of the caregivers, as well as language barriers caused by increasing numbers of immigrants. Objective: The objectives of this study were to (1) design and develop a Web-based multimedia version of the current Taipei II developmental screening tool, and (2) investigate the measurement equivalence of this multimedia version to the original paper-based version. Methods: To develop the multimedia version of Taipei II, a team of experts created illustrations, translations, and dubbing of the original checklists. The developmental screening test was administered to a total of 390 primary caregivers of children aged between 4 months and 6 years. Results: Psychometric testing revealed excellent agreement between the paper and multimedia versions of Taipei II. Good to excellent reliabilities were demonstrated for all age groups for both the cross-mode similarity (mode intraclass correlation range 0.85-0.96) and the test-retest reliability (r=.93). Regarding the usability, the mean score was 4.80 (SD 0.03), indicating that users were satisfied with their multimedia website experience. Conclusions: The multimedia tool produced essentially equivalent results to the paper-based tool. In addition, it had numerous advantages, such as it can facilitate active participation and promote early screening of target populations. ClinicalTrial: Clinicaltrials.gov NCT02359591; https://clinicaltrials.gov/ct2/show/NCT02359591 (Archived by WebCite at http://www.webcitation.org/6l21mmdNn) [J Med Internet Res 2016;18(10):e277]

Cervical spinal loads are predominately influenced by activities of cervical muscles. However, the coordination between deep and superficial muscles and their influence on the spinal loads is not well understood. This study aims to document the changes of cervical spinal loads and the differential contributions of superficial and deep muscles with varying head postures. Electromyography (EMG) of cervical muscles from seventeen healthy adults were measured during maximal isometric exertions for lateral flexion (at 10°, 20° and terminal position) as well as flexion/extension (at 10°, 20°, 30°, and terminal position) neck postures. An EMG-assisted optimization approach was used to estimate the muscle forces and subsequent spinal loads. The results showed that compressive and anterior-posterior shear loads increased significantly with neck flexion. In particular, deep muscle forces increased significantly with increasing flexion. It was also determined that in all different static head postures, the deep muscle forces were greater than those of the superficial muscle forces, however, such pattern was reversed during peak efforts where greater superficial muscle forces were identified with increasing angle of inclination. In summary, the identification of significantly increased spinal loads associated with increased deep muscle activation during flexion postures, implies higher risks in predisposing the neck to occupationally related disorders. The results also explicitly supported that deep muscles play a greater role in maintaining stable head postures where superficial muscles are responsible for peak exertions and reinforcing the spinal stability at terminal head postures. This study provided quantitative data of normal cervical spinal loads and revealed motor control strategies in coordinating the superficial and deep muscles during physical tasks.

This study investigated center-of-pressure (COP) characteristics during volitional stepping in forward, backward, and sideways directions, along with the behavioral performance measures and COP measures of volitional stepping in these directions, and the relationships between these two types of measures in healthy older and young adults. Fifteen older and 15 young adults performed rapid stepping in the three directions using each leg. Behavioral performance measures included reaction time (RT), movement time (MT), step length, and step velocity in the MT phase. COP measures included the maximum anteroposterior (COPAP) and mediolateral COP displacement (COPML) in the RT phase. Stepping in each direction demonstrated unique COP characteristics. The older adults presented slower RT, MT, step velocity, and smaller COPAP in all three stepping directions (p < 0.05), as well as smaller COPML in the sideways stepping direction (p < 0.017), compared to the young adults. Step velocity correlated with COPAP and/or COPML in all three stepping directions for both groups (r = 0.42–0.77, p < 0.05), suggesting that stepping performances during the movement execution phase correlated with COP control during the postural preparation phase. Results suggest that stepping training prescribed to older adults to improve their balance control may include multi-directional stepping.

The head reposition test is traditionally used to examine the proprioceptive sensitivity of the neck. The aim of this study was to investigate the position accuracy and corresponding cervical electromyographic (EMG) responses of the neck pain subjects during sagittal head-to-neutral tasks. Twelve young subjects with chronic neck pain and twelve young healthy subjects were recruited. The position accuracy was measured by the constant error, variable error, and root mean square error of joint angles during head-to-neutral tasks in flexion and extension directions. Surface EMG of neck flexors and extensors were analyzed by the voluntary response index, including the similarity index (SI) and electromyographic magnitude (MAG) of muscle groups. The normalized average integration of EMG activity (NAIEMG) of individual muscle was also calculated. The results showed: (1) significantly larger constant error and root mean square error but similar variable error in patients compared with controls, (2) smaller SI but similar MAG in patients compared with controls, (3) greater synergistic/antagonistic NAIEMG in patients than controls. The findings suggested that young adults with chronic neck pain exhibit proprioceptive dysfunction and altered EMG pattern during voluntary sagittal neck motions. This study provides guidelines which could lead to the development of therapeutic exercise programs.