Integrative Physiotherapy Management of Cervical Radiculopathy and Concurrent Tarlov Cysts

Tarlov cysts, also known as perineural cysts, are usually associated with lumbar discomfort and neurological deficits, with an uncertain etiology that may involve genetic predisposition and collagen disorders, possibly influenced by traumatic events and hemorrhagic episodes. Diagnostic methods such as magnetic resonance imaging or computed tomography myelography are commonly employed and treatment approaches range from conservative measures to more invasive interventions. This case involves a 42-year-old female with cervical pain and upper limb symptoms; a comprehensive assessment, including diagnostic imaging and physiotherapeutic interventions, resulted in significant improvements in pain intensity, range of motion, manual muscle testing, and functional scale scores after a two-week physiotherapy intervention. These findings contribute to advancing our understanding of managing Tarlov cysts associated with cervical radiculopathy, highlighting the potential efficacy of physiotherapeutic interventions in enhancing patient outcomes.

Improving Strength and Fatigue Resistance in Post-Polio Syndrome Individuals with REAC Neurobiological Treatments

Post-Polio Syndrome (PPS) is a chronic condition characterized by the emergence of new symptoms and functional decline in individuals who previously had polio. Despite advances in medical understanding, management of PPS remains challenging. This study aimed to evaluate the use of neurobiological modulation treatments using Radio Electric Asymmetric Conveyer (REAC) technology on fatigue and muscle strength. An open-label study was conducted with 17 patients submitted to four neuromodulation protocols: Neuro Postural Optimization (NPO), Neuro Psycho Physical Optimization (NPPO), Neuro Psycho Physical Optimization-Cervico Brachial (NPPO-CB), and Neuromuscular Optimization (NMO). The Time Up and Go (TUG) test, Handgrip Strength Test, and Revised Piper Fatigue Scale (RPFS) were used to assess participants' fatigue and muscle strength, being applied at the beginning and end of each protocol. The results obtained from the improvement in strength, physical endurance, and particularly the RPFS behavioral dimension, affective dimension, and psychological sensory dimension, through the utilization of REAC neurobiological modulation treatments, highlight this correlation. These results suggest that these treatments could be considered as a potential therapeutic approach for PPS.

Structured Manual Muscle Testing of the Lower Limbs

An accurate and reliable neurological examination is pivotal in diagnosing patients with neurological and neurosurgical conditions. Despite the advancement of neuroscientific knowledge and the ever-progressing technologies and modalities that are being adopted to help achieve the challenge of accurate diagnosis, the neurologic examination is still crucial in both ambulatory and emergency settings. It provides the physician a tool to recognise neurologic involvement in certain disease states, and thereby allow proper work-up and treatment for patients. A basic neurologic examination can be performed rapidly with practice. Manual muscle testing of the lower limbs was carried out in accordance with a bedside clinical examination involving a clinical personnel examiner and a patient. This testing was performed in a rostro-caudal manner, starting from the hip and progressing to the toes. The neurological exam can be intimidating to perform for a lot of physicians. Deficiencies in accurate muscle testing have always presented a challenge for medical students and clinicians. By referring to the examination methods mentioned in our text and with the help of related video, it is our aim to improve the quality of neurological examination among medical personnel so that diseases may be recognised and managed earlier in their course.

CDX2-positive Cancer of Unknown Primary With Upper-body Paralysis Was Dramatically Improved by Colorectal Cancer Chemotherapy

BACKGROUND

Caudal-related homeobox transcription factor 2 (CDX2) is expressed in intestinal epithelial cells. CDX2 is a very sensitive marker for the identification of small and large intestine tumors, which is expressed in 85.7-100% of colorectal cancer (CRC) cases.

CASE REPORT

A 61-year-old female had been suffering from left shoulder pain for one month. Computed tomography showed osteolytic masses extending to the vertebral arch in the C5, C6, C7, and Th3 vertebral bodies. In addition, a thickening of the sigmoid colon was observed from the rectal-sigmoid colon, suggesting CRC. A colon biopsy revealed poorly differentiated adenocarcinoma and the vertebra excision was metastatic adenocarcinoma. However, immunohistochemically, the vertebra tumor was negative for CK7 and CK20 but positive for CDX2. Therefore, we made the diagnosis of CRC with bone metastasis and decided to start treatment for CRC. Posterior stabilization was performed for the spinal tumor 6 days after admission. About one month after admission, she started treatment with chemotherapy. Initially, her left hand could not move, and she could barely hold the pen with her right hand. After adding cetuximab for the third time, she became able to bend the dorsiflexion of her right wrist joint, grasp a stick with her right hand, and move the fingertips of her left hand a little.

CONCLUSION

The presented case could not be diagnosed as CRC unless CDX2 was examined. Upper body paralysis due to CRC bone metastasis was improved by chemotherapy.

Inter-rater reliability of the Rasch-modified medical research council scoring criteria for manual muscle testing in neuromuscular diseases

It was argued that researchers and clinicians are not able to make judgments between most categories of the original Medical Research Council (MRC) scale and that a modified short version would reach higher agreement levels. We aimed to assess the inter-rater reliability for both the original and the Rasch-modified MRC scoring criteria of Manual Muscle Strength tests (MMSt) in patients with neuromuscular diseases. Two MRC scoring criteria were used to score muscle strength using MMSt in 40 muscle groups of the upper and lower limbs in patients with neuromuscular disorders. Three investigators performed the evaluations; the order of the MMSt and the use of the scales were performed according to the preferences of the investigators. The agreement coefficient (Gwet's AC₂ ) was used to compute the reliability. Sixty patients (mean age of 39.3 years ± 15.2) with neuromuscular diseases were included. The mean AC₂ for the muscle groups of the upper limbs ranged from 0.82 to 0.96 using the modified MRC scale and from 0.86 to 0.96 using the original MRC scale. The AC₂ for the lower limb muscle groups ranged from 0.80 to 0.91 (modified MRC scale) and from 0.87 to 0.93 (original MRC scale). These values might be interpreted as "almost perfect agreement" with no significant differences between the scales. The results indicate that both MRC scoring criteria have significant reliability among trained observers. Moreover, the Rasch-modified MRC scale is as reliable as the original MRC scale and can be used in future clinical studies.

Manual Muscle Testing of the Scapula and the Upper Limb through Bedside Examination

Neurological examination is an important tool in diagnosing patients with neurological and neurosurgical conditions. As the complexity and knowledge of neurological and neurosurgical conditions increases, we are now required to learn and indoctrinate our peers and students with the correct skills and methods of examination. Emphasis on the correct techniques of testing muscle strength is essential to avoid errors in recording muscle power and in testing specific muscles which may have overlapping functions. The manual muscle testing of muscles of scapula and upper limbs was performed as to mimic a bedside clinical examination and involved an examiner, a patient and a videographer. The manual muscle testing has been performed in rostrocaudal manner starting from the scapula and ending with the thumbs. A reliable and consistent method of manual muscle testing is lacking among students and clinicians. By adhering to the methods delineated in our text and accompanying video, we hope to reduce inter-examiner variability and increase the reliability and validity of this important examination.

[Monomelic amyotrophy]

Monomelic amyotrophy, also known as Hirayama disease, is a rare neurological disorder characterized by focal and latent onset of upper limb weakness and atrophy in the absence of sensory deficits, bulbar or pyramidal signs. It usually occurs in young patients. The disease usually begins unnoticeably and progresses slowly, and can manifest itself as unilateral or asymmetrical weakness, as well as atrophy of the distal upper limb. Sensory disturbances, reflex changes and signs of lesions of lower motor neurons are rare. This article describes a case of a patient with complaints of weakness not only in the upper but also in the lower extremities.

Functional level of lesion scale: Validating fourteen years of research with the national spina bifida patient registry

PURPOSE

Functional level of lesion (FLOL) is a grading of the level of neurological function in patients with myelomeningocele and other forms of spina bifida. It has been widely used as an independent variable in studies of spina bifida, but its inter-rater reliability has not previously been tested. The purpose of this study was to measure inter-rater reliability of FLOL testing and compare testing performed by a non-medically trained research associate to testing performed by a pediatric rehabilitation medicine specialist.

METHODS

Children in a multi-disciplinary spina bifida clinic underwent FLOL grading by a non-medically trained research associate. On the same day, these children were also graded by a pediatric rehabilitation medicine specialist. Cohen's weighted kappa statistic was used to compare grading, with the rehabilitation medicine specialist considered the gold standard.

RESULTS

A total of 71 patients participated. FLOL was graded for left and right leg for each participant, resulting in 142 measurements. Cohen's weighted kappa was κ= 0.809, with a standard error of 0.034 and 95% confidence interval 0.723-0.875, indicating substantial agreement.

CONCLUSION

FLOL as measured according to the instructions of the National Spina Bifida Patient Registry by a non-medically trained researcher is a reliable method to grade lower extremity function in spina bifida.

Intermittent versus daily regimen of prednisolone in ambulatory boys with Duchenne muscular dystrophy: A randomized, open-label trial

INTRODUCTION/AIMS

Corticosteroids prolong ambulation and improve muscle power among boys with Duchenne muscular dystrophy (DMD). However, the optimal steroid regimen remains unclear. Hence, this study was undertaken to compare the efficacy of daily- versus intermittent-steroid regimens in ambulatory boys with DMD.

METHODS

In this single-center, open-label randomized trial, 72 children were randomized to receive either daily prednisolone (0.75 mg/kg/day) or intermittent prednisolone (0.75 mg/kg/day, for first 10 days of every month). The primary outcome measure was the difference in average score on manual muscle testing (MMT) at baseline and after 6 mo of steroids. A difference of >0.2 was hypothesized to be significant. Secondary outcomes included changes in timed functions, muscular dystrophy-specific functional-rating scale score, peak torque, average power, and pulmonary function.

RESULTS

In the intention-to-treat analysis, the mean (SD) change in MMT scores was 0.17 (0.15) and 0.08 (0.10) for the daily and intermittent steroid groups, respectively. The mean difference between the two interventions was 0.10 (95% confidence interval [CI] = 0.04-0.16; P = .003), which although significant was less than the predefined value of 0.2. Statistically significantly improvements were observed with daily-steroid regimen in the Gowers time (P = .01), nine-metre walk test (P = .02) and average power (P = .02) as compared to intermittent-steroid regimen. A total of 19/32 (52.8%) children in the daily-steroid group and 8/29 (27%) children in the intermittent-steroid group experienced some form of adverse effect (P = .02).

DISCUSSION

Over a short-term period, the intermittent-steroid regimen was non-inferior to the daily-steroid regime in preserving muscle strength among children with DMD. However, better improvement of functional measures was observed with daily-steroid administration. The frequency of individual side effects was similar between the two groups.

Manual Muscle Testing-Force Profiles and Their Reproducibility

The manual muscle test (MMT) is a flexible diagnostic tool, which is used in many disciplines, applied in several ways. The main problem is the subjectivity of the test. The MMT in the version of a "break test" depends on the tester's force rise and the patient's ability to resist the applied force. As a first step, the investigation of the reproducibility of the testers' force profile is required for valid application. The study examined the force profiles of n = 29 testers (n = 9 experiences (Exp), n = 8 little experienced (LitExp), n = 12 beginners (Beg)). The testers performed 10 MMTs according to the test of hip flexors, but against a fixed leg to exclude the patient's reaction. A handheld device recorded the temporal course of the applied force. The results show significant differences between Exp and Beg concerning the starting force (padj = 0.029), the ratio of starting to maximum force (padj = 0.005) and the normalized mean Euclidean distances between the 10 trials (padj = 0.015). The slope is significantly higher in Exp vs. LitExp (p = 0.006) and Beg (p = 0.005). The results also indicate that experienced testers show inter-tester differences and partly even a low intra-tester reproducibility. This highlights the necessity of an objective MMT-assessment. Furthermore, an agreement on a standardized force profile is required. A suggestion for this is given.

A novel method in assessing lower limb motor function

PURPOSE

To propose a novel, accurate, and easy to perform test replacing the manual muscle testing. Our target is to develop a valuable tool for identification of patients with neurological motor impairment precisely, rapidly, and easily.

METHODS

We have randomly selected patients presenting to the clinic complaining of back pain with or without lower limb symptoms. These patients were asked to walk on their heels and on their toes. Being unable to walk on heels and/or toes, the patient is considered to have positive test result (abnormal finding). After that, a full and thorough neurological examination was performed on every patient by an orthopedic resident doctor. We looked specifically to the correlation between the ability to do toe-heel walking with the results of the detailed neurological examination.

RESULTS

Toe-heel walking test was able to detect all patients with weakness in their lower limb musculature. The results from the current investigation indicate a very high Pearson correlation of 0.95 ( p = 0.001) between the toe-heel test and manual muscle testing.

CONCLUSION

Toe-heel walking test is superior to detailed neurological examination in identification of patients with weakness, sphincter problem, and/or positive straight leg raising test. This test is both simple and rapidly performed test, which can be easily done by any health-care provider. Owing to its ease, this test is not restricted to medical doctors, but it could be accurately performed by any health-care provider such as nurses and physiotherapists. This will enable us to decrease the referral to the specialty clinic and to decrease the overall cost.

Comparison of Shoulder Protraction Strength and Electromyography Activity of Serratus Anterior and Pectoralis Major in Subjects With or Without a Winged Scapula

CONTEXT

A winged scapula (WS) is associated with faulty posture caused by weakness of the serratus anterior (SA), which mainly acts as a scapular stabilizer muscle. It is important to accurately assess and train the SA muscle with a focus on scapula stabilizers during musculoskeletal rehabilitation of individuals with a WS.

OBJECTIVE

The authors examined muscle activity in the SA and pectoralis major (PM), upper trapezius (UT), and anterior deltoid (AD) as well as shoulder protraction strength during isometric shoulder protraction in individuals with and without a WS.

DESIGN

Cross-sectional study.

SETTING

A clinical biomechanics laboratory.

PARTICIPANTS

In total, 27 males with no shoulder, neck, or upper-extremity pain participated.

MAIN OUTCOME MEASURES

Isometric shoulder protraction strength was collected and surface electromyography used to measure the activity of the SA, PM, UT, and AD muscles and selective SA activity ratio to other shoulder muscles.

RESULTS

Electromyography activity of the SA muscle and shoulder protraction strength were significantly lower in individuals with a WS compared with the non-WS group (P < .05). In contrast, PM muscle activity and the PM-to-SA, UT-to-SA, and AD-to-SA ratios were significantly greater in individuals with a WS than in individuals without winging (P < .05).

CONCLUSIONS

Isometric shoulder protraction for measuring SA strength in individuals with a WS should focus on isolated muscle activity of the SA, and SA strengthening exercises are important for individuals with a WS.

Quantitative assessment of elbow flexion by handheld dynamometry in brachial plexus palsy

The purpose of this study was to assess the relative and absolute reliability of a handheld dynamometer when used for examining elbow flexion power in patients with brachial plexus palsy. The assessment of the intra-rater and inter-rater reliability coefficients for the handheld dynamometer was done using the stationary Kin-Com® dynamometer as the reference standard. We determined the measurement errors and checked the systematic biases of the handheld dynamometer. The inter-rater and intra-rater reliabilities of the handheld dynamometer had a very high intraclass correlation coefficient. The values of handheld dynamometer readings had a high correlation to Kin-Com® readings. The Medical Research Council grading was a comparatively inaccurate method for quantitative assessment of motor power. We conclude that a handheld dynamometer measurement is more precise and reliable than the Medical Research Council grading for measuring recovery of elbow flexion in patients with brachial plexus palsy. Level of evidence: III.

TESTING INFRASPINATUS AND DELTOID MUSCLES WITH NEW TECHNIQUE TO DECREASE DELTOID ACTIVITY DURING TESTING USING EMG ANALYSIS

BACKGROUND

Muscle strength testing of an injured infraspinatus muscle (IM) is confounded by actions of synergistic muscles such as the posterior deltoid (PD).

HYPOTHESIS/PURPOSE

The purpose of this study was to describe a condition for testing of the IM that results in less EMG activity of the PD musculature. The researchers hypothesized that greater inhibition of the PD could be achieved through active adduction (AA), creating reciprocal inhibition of the PD.

STUDY DESIGN

Prospective cohort descriptive study.

METHODS

Thirty-four (19 females and 15 males) right-handed subjects between the ages of 22- 31 (mean 24.2 years + /- 6.2) with no previous history of shoulder surgery or pathology participated. Surface electrodes were placed over the muscle bellies of the IM and PD of the right shoulder along with a ground electrode over the C7 spinous process. EMG activity was recorded during resisted external rotation in four different testing conditions (seated active and passive adduction, and side-lying active and passive adduction). The order of test positions was randomly assigned, and each subject completed all four positions with appropriate rest. During AA conditions, subjects were asked to adduct the humerus against a sphygmomanometer (using 80% maximum force output) while maximal effort external rotation was manually resisted.

RESULTS

PD activity was significantly less during AA than with no AA (p<0.05) in both test positions. No significant difference occurred between IM EMG activity in the various test conditions.

CONCLUSION

The results of this study suggest that clinicians can reduce activity of the PD without reducing activity of the IM by using AA of the humerus before applying manual resistance to test the IM during manual muscle testing.

LEVELS OF EVIDENCE

1b.

Eversion Strength and Surface Electromyography Measures With and Without Chronic Ankle Instability Measured in 2 Positions

BACKGROUND

Individuals with chronic ankle instability (CAI) have demonstrated strength deficits compared to healthy controls; however, the influence of ankle position on force measures and surface electromyography (sEMG) activation of the peroneus longus and brevis has not been investigated. The purpose of this study was to compare sEMG amplitudes of the peroneus longus and brevis and eversion force measures in 2 testing positions, neutral and plantarflexion, in groups with and without CAI.

METHODS

Twenty-eight adults (19 females, 9 males) with CAI and 28 healthy controls (19 females, 9 males) participated. Hand-held dynamometer force measures were assessed during isometric eversion contractions in 2 testing positions (neutral, plantarflexion) while surface sEMG amplitudes of the peroneal muscles were recorded. Force measures were normalized to body mass, and sEMG amplitudes were normalized to a resting period.

RESULTS

The group with CAI demonstrated less force when compared to the control group ( P < .001) in both the neutral and plantarflexion positions: neutral position, CAI: 1.64 Nm/kg and control: 2.10 Nm/kg) and plantarflexion position, CAI: 1.40 Nm/kg and control: 1.73 Nm/kg). There were no differences in sEMG amplitudes between the groups or muscles ( P > .05). Force measures correlated with both muscles' sEMG amplitudes in the healthy group (neutral peroneus longus: r = 0.42, P = .03; plantarflexion peroneus longus: r = 0.56, P = .002; neutral peroneus brevis: r = 0.38, P = .05; plantarflexion peroneus longus: r = 0.40, P = .04), but not in the group with CAI ( P > .05).

CONCLUSIONS

The group with CAI generated less force when compared to the control group during both testing positions. There was no selective activation of the peroneal muscles with testing in both positions, and force output and sEMG activity was only related in the healthy group.

CLINICAL RELEVANCE

Clinicians should assess eversion strength and implement strength training exercises in different sagittal plane positions and evaluate for other pathologies that may contribute to reduced eversion strength in patients with CAI.

LEVEL OF EVIDENCE

Level III, cross-sectional.

[Anti-NXP2-positive dermatomyositis associated with ulcerative colitis and celiac disease]

The authors discuss a rare case of a 25-year-old female patient having dermatomyositis associated with celiac disease and ulcerative colitis. The idiopathic inflammatory myopathies are systemic, chronic, immune-mediated diseases characterized by proximal, symmetrical muscle weakness. Many examples from the literature refer that celiac disease occurs more often in patients with myositis than in the general population, but its association with ulcerative colitis is a real rarity in the international literature.

Association with isokinetic ankle strength measurements and normal clinical muscle testing in sciatica patients

BACKGROUND

Sensitive muscle strength tests are needed to measure muscle strength in the diagnosis and management of sciatica patients.

OBJECTIVE

The aim of this study was to assess the isokinetic muscle strength in sciatica patients' and control subjects' ankles that exhibited normal ankle muscle strength when measured clinically.

METHODS

Forty-six patients with L5 and/or S1 nerve compression, and whose age, sex, weight, and height matched 36 healthy volunteers, were recruited to the study. Heel-walking, toe-walking, and manual muscle testing were used to perform ankle dorsiflexion and plantar flexion strengths in clinical examination. Patients with normal ankle dorsiflexion and plantar flexion strengths assessed by manual muscle testing and heel-and toe-walking tests were included in the study. Bilateral isokinetic (concentric/concentric) ankle plantar-flexion-dorsiflexion measurements of the patients and controls were performed within the protocol of 30°/sec (5 repetitions). Peak torque and peak torque/body weight were obtained for each ankle motion of the involved limb at 30°/s speed.

RESULTS

L5 and/or S1 nerve compression was evident in 46 patients (76 injured limbs). Mean disease duration was two years. The plantar flexion muscle strength of the patients was found to be lower than that of the controls (p=0.036). The dorsiflexion muscle strength of the patients was found to be the same as that of the controls (p=0.211).

CONCLUSIONS

Isokinetic testing is superior to clinical muscle testing when evaluating ankle plantar flexion torque in sciatica patients. Therefore, isokinetic muscle testing may be helpful when deciding whether to place a patient into a focused rehabilitation program.

Reference for the 2011 revision of the International Standards for Neurological Classification of Spinal Cord Injury

The latest revision of the International Standards for the Neurological Classification of Spinal Cord Injury (ISNCSCI) was available in booklet format in June 2011, and is published in this issue of the Journal of Spinal Cord Medicine. The ISNCSCI were initially developed in 1982 to provide guidelines for the consistent classification of the neurological level and extent of the injury to achieve reliable data for clinical care and research studies. This revision was generated from the Standards Committee of the American Spinal Injury Association in collaboration with the International Spinal Cord Society's Education Committee. This article details and explains the updates and serves as a reference for these revisions and clarifications.

Fair as a percentage of normal using manual muscle testing of knee extensor strength

We explored the extent to which fair knee extensors might be judged to be weaker than the normal knee extensors of healthy young adults. To obtain quantitative data for normal strength of knee extensors, we recorded knee torque in 20 healthy young subjects using an isokinetic dynamometer, and calculated muscle strength equivalent to fair, including the effect of inertial force, using a rigid body model. The results showed that fair torque as a percentage of actual normal torque at 60 degrees per second was 4.8 ± 1.2% (mean ± standard deviation) among the men and 4.6 ± 1.0% among the women. This difference in per cent strength was not statistically significant between men and women. In manual muscle testing, the grade of fair for knee extensors is thus very far below the midpoint of the scale from no activity to normal. This means that the good range between grade fair and normal is too wide to connote one particular state of strength. We believe that other methods are needed, for example using a dynamometer, to evaluate intermediate muscle weakness in detail.