Manual Therapy Journal - Volume 14, Supplement (October 2009)

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Author: Editors: Ann Moore and Gwen Jull

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Welcome On behalf of Kinetic Control and the MACP, we welcome you to Edinburgh for this 3rd International Conference on Movement Dysfunction. Since launching in 2001 the conference has established itself as a key conference for therapists using movement, exercise and other strategies to rehabilitate movement dysfunction. Further developing our themes from 2001 and 2005 the theme for 2009 is integrating hard research and science and the art of clinical practice. This will link the science behind biomechanics, neurophysiology and biopsychosocial influences on movement and pain, into clinical practice. Based on feedback from the second conference we have introduced a clinical focus which will run throughout the sessions, as well as during the clinical seminars running each afternoon. We have also introduced some ‘hands on’ sessions alongside sponsored sessions running over the lunch breaks, as well as interactive poster sessions. Please do support these sessions as well as interacting with our exhibitors in the Cromdale Hall during the breaks. This year we are pleased to welcome delegates from over 36 countries and a range of professions. We have been overwhelmed by the support of speakers and presenters, delegates and exhibitors during this period of global recession; we appreciate the commitment you have all shown to making this third conference a great success. Each conference is a challenge for us to provide the best conference experience we can, whilst trying to keep the delegate fees at an acceptable rate and we really welcome your feedback on your experience at this third conference. Some of you may be wondering ‘why Edinburgh again?’ - the accessibility, hospitality and historic appeal of Scotland’s capital city and the overwhelming positive feedback from past conferences had made this the city of choice for the third venue. The EICC is a fabulous world class conference facility. 2009 is also the year of ‘Homecoming Scotland’ celebrating the 250th anniversary of Robert Burns’ birth and some of Scotland’s great contributions to the world: golf, whisky, great minds and innovations and Scotland’s rich culture and heritage. We hope you will also have the opportunity to experience some if not all of these during your stay! Finally, we are pleased once again to have partnered with Elsevier and Manual Therapy journal as our conference organisers and sponsors, building on the success of our collaboration in 2005. Thank you for giving us the opportunity to host you at this international conference and welcome once again! Sarah Mottram Kinetic Control

Chris Mercer Chair, MACP

Co-Chairs, Planning Committee 3rd International Conference on Movement Dysfunction

xvii

ORAL PROGRAMME

FRIDAY 30 OCTOBER 2009 Notes:

All Plenary Sessions will take place in PENTLAND AUDITORIUM Level 3 For Parallel Sessions the PENTLAND AUDITORIUM breaks into three sections: PENTLAND, SIDLAW and FINTRY Rooms – Level 3 Numbers in [ ] indicate abstract book references

07:00 – 08:45

Conference Registration Strathblane Hall ~ Level 0

08:45

CONFERENCE OPENING AND WELCOME ADDRESS: M. Comerford, Kinetic Control UK, Performance-Rehab, Australia Pentland Auditorium ~ Level 3

PLENARY SESSION 1 Chair: A. Moore, University of Brighton, UK; Executive Editor, Manual Therapy 09:00

KEYNOTE [K1] Low back pain: Isolated or degenerative problem - What are the implications? S. Sahrmann, Washington University School of Medicine, USA

09:35

KEYNOTE [K2] Chronic low back pain patients –unravelling pieces of the puzzle W. Dankaerts, K.U.Leuven; AUHL-PHL, Belgium

10:10

GUEST LECTURE [GL1] Pain-induced changes in motor control revealed by muscle imaging D. Falla, Aalborg University, Denmark

10:30

COFFEE BREAK, EXHIBITION AND POSTER VIEWING Cromdale Hall ~ Level ņ2

PLENARY SESSION 2 Chair: A. Moore, University of Brighton, UK; Executive Editor, Manual Therapy 11:00

KEYNOTE [K3] Manipulating neural plasticity to enhance functional recovery after damage to the motor system J. Rothwell, University College London, UK

11:35

GUEST LECTURE [GL2] Shoulder girdle control; some mechanisms of function to dysfunction C. Alexander, Imperial College Healthcare NHS Trust, UK

11:55

GUEST LECTURE [GL3] Rehabilitative ultrasound imaging: Technology to improve assessment and treatment of those with musculoskeletal conditions D. Teyhen, Academy of Health Sciences, USA

12:15

GUEST LECTURE [GL4] What does proprioception testing tell us about patellofemoral pain? M. Callaghan, University of Manchester, UK

12:35

PANEL DISCUSSION – Speakers from Plenary Sessions 1 and 2

xviii

13:00 – 14:30

LUNCH, EXHIBITION and POSTER SESSIONS Cromdale Hall ~ Level ņ2 13:45 – 14:30

13:45 – 14:15

General Poster Session

Interactive Poster Session Chairs: L. Finucane, Surrey PCT, UK and M. Daly, MACP, UK

SPONSORED INTERACTIVE SESSIONS Lomond Suite ~ Level 0 13:45 – 14:15

TINTO ROOM

MOORFOOT ROOM

KILSYTH ROOM

Imotek International Ltd Demonstration of ultrasound by Jackie Whittaker, University of Southampton

Sels Instruments Demonstration of SPMD by K.O’Sullivan, University of Limerick

L. McLaughlin Demonstration of Capnograph

AFTERNOON SESSIONS – PENTLAND AUDITORIUM ~ LEVEL 3 CLINICAL SEMINARS

14:30 – 15:15

PENTLAND ROOM Chair: M. Comerford, Kinetic Control UK, Perform -ance-Rehab, Australia [CS1] Demonstration of an examination for movement system low back syndrome S. Sahrmann, Washington University School of Medicine, USA

SIDLAW ROOM Chair: E. Thoomes, SOMT, Netherlands

FINTRY ROOM Chair: A. Rushton, University of Birmingham, UK

[CS2] Sub-classification of non-specific CLBP patients: Integrating pieces of the evidence into clinical practice W. Dankaerts, KUL-PHL, Belgium

[CS3] Training the brain: principles, pitfalls and pearls L. Moseley, Prince of Wales Medical Research Institute, Australia

SUBMITTED ORAL PRESENTATIONS PENTLAND ROOM Chair: G.M. Homstøl, NHP, Norway

SIDLAW ROOM Chair: C. Mercer, MACP, UK

FINTRY ROOM Chair: Y. Coldron, ICMD 2009 Scientific Committee Chair, UK

15.20 – 15.35

[O1] Is back pain a problem for people with a stoma? A postal survey in Northern Ireland I.M. Wilson1, D.P. Kerr1, S. Lennon2, 1School of Health Sciences, University of Ulster, UK, 2 School of Health Sciences, Health & Rehabilitation Sciences Institute, University of Ulster, UK

[O9] Does stabilising the scapula change glenohumeral movements in healthy subjects? M.C. Cairns1, G. Neal2, 1University of Hertfordshire, UK, 2Devon PCT, UK

15.35 – 15.50

[O2] Respiratory dysfunction in neck pain patients. A pilot study Z. Dimitriadis2,1, E. Vourazanis1, J.A. Oldham2, N. Strimpakos1,2, L. Komnianou1, E. Kapreli1, 1TEI Lamia, Greece, 2University of Manchester, UK

[O5] Exercise reduces work disability in patients with nonacute non-specific low back pain: systematic review and meta-analysis of randomised controlled trials J. Kool1, P. Oesch2,3, K.B. Hagen4, S. Bachmann2,3, 1Zurich University of Applied Science, Switzerland, 2Research Dept, Rehabilitation Centre Valens, 3 Switzerland, Dept of Rheumatology, Rehabilitation Centre Valens, Switzerland, 4 University of Oslo, Norway [O6] Change in lumbar lordosis during prone knee flexion test in subjects with and without low back pain A.M. Arab, A. Talimkhani, S Emdadi, University of Social Welfare & Rehabilitation Sciences, Iran

15.50 – 16.05

[O3] Multidisciplinary rehabilitation or surgery for chronic low back pain – 7 year follow up of a randomised controlled trial K. Barker, H. Frost, J. Wilson MacDonald, J. Fairbank, Nuffield Orthopaedic Centre NHS Trust, UK

[O7] Ultrasound imaging transducer motion during clinical lumbopelvic manoeuvres J.L. Whittaker1,2, M.B. Warner1, M.J. Stokes1, 1University of Southampton, UK, 2Whittaker Physiotherapy Consulting, Canada

[O10] Tactile thresholds are preserved yet cortical sensory function is impaired in chronic nonspecific low back pain patients B.M. Wand1, F. Di Pietro2, P. George1, N. O'Connell1, 1The University of Notre Dame, Australia, 2Bunbury Hospital, Australia, 3Brunel University, UK [O11] The assessment of vibration sense in a healthy population: a study to assess the inter-rater reliability and validity of the tuning fork E.M. O' Conaire1,2, A.B. Rushton1, 1 University of Birmingham, UK, 2 Westminster Primary Care Trust, UK

xix PENTLAND ROOM

SIDLAW ROOM

FINTRY ROOM

16.05 – 16.20

[O4] Decrease in postural sway and trunk stiffness during cognitive dual-task in nonspecific chronic low back pain patients, performance compared to healthy control subjects. U. Van Daele1,2, F. Hagman2, S. Truijen1, P. Vorlat3, B. Van Gheluwe2, P. Vaes2,4, 1Artesis University College of Antwerp, Belgium, 2Faculty of Physical Education & Physical Therapy, Vrije Universiteit Brussel, Belgium, 3Universitair Ziekenhuis 4 Manual Brussel, Belgium, Therapy Dept, Vrije Universiteit Brussel, Belgium

[O8] An investigation into hip muscle strength of previously injured and non-injured Gaelic footballers O. Kelly, A. Clifford, K.O.'Sullivan, University of Limerick, Ireland

[O12] Reliability of the median neurodynamic test 1: A painful response analysis in healthy subjects M. Barbero1, E. Castelli2, A. Piatti3, M. Egloff1, R. Gatti2, 1Dept of Health Sciences, University of Applied Sciences of Southern Switzerland, Switzerland, 2Vita-Salute University, 3 Italy, Dept of Innovative Technologies, University of Applied Sciences of Southern Switzerland, Switzerland

16.20 – 16.30

Q&A

Q&A

Q&A

16.30 – 17.00

TEA BREAK, EXHIBITION AND POSTER VIEWING Cromdale Hall ~ Level ņ2 PENTLAND ROOM Chair: J.L. Whittaker, University of Southampton, UK; Whittaker Physiotherapy Consulting, Canada

SIDLAW ROOM Chair: R. Sephton, Knowsley PCT, UK

FINTRY ROOM Chair: O. Crummey, NHS Lothian, UK

17.00 – 17.15

[O13] Reduced head steadiness in whiplash compared to nontraumatic neck pain patients A. Woodhouse, O. Vasseljen, Norwegian University of Science & Technology, Norway

[O21] Proposed classification system for peripheral nerve disorders with a musculoskeletal underlying mechanism P. Moulaert, W. Dankaerts, K.U.Leuven, Belgium

17.15 – 17.30

[O14] Randomised clinical trial for primary care patients with neck pain: manual therapy versus electrical stimulation E. Escotrell1, Y. Perez2, R. Riesgo1, S. Garrido1, A. Asunsolo2, I. Fuentes1, 1Servicio Madrileño de Salud, Spain, 2 Universidad Alcalá, Spain

17.30 – 17.45

[O15] The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects E. Willett, C. Hebron, University of Brighton, UK

[O17] Specific motor control exercise for lumbo-pelvic pain of articular origin: A systematic review S.G.T. Gibbons1,2, J. Clark1,3, 1 Neuromuscular Rehabilitation Institute, Canada, 2Memorial University of Newfoundland, 3 Canada, Manchester Metropolitan University, UK [O18] An unstable base of support decreases Serratus Anterior muscle activity during push-up plus exercise in patients with chronic shoulder pain H. Fredriksen1,2, M.A. Risberg2,5, 1 Norwegian Olympic & Paralympic Committee & Confederation of Sports, Norway, 2Norwegian School of Sport Science, Norway, 3NAR, Norway, 4Ullevaal University Hospital, Norway, 5Hjelp24NIMI, Norway [O19] The effect of exercise position on trapezius activity during a scapular setting exercise T. Crowley, K. McCreesh, University of Limerick, Ireland

17.45 – 18.00

[O16] Factors affecting the safety of cervical manipulation L.C. Thomas1, D.A. Rivett1, C. 1 The University of Levi1,2, 2 John Newcastle, Australia, Hunter Hospital, Newcastle, Australia

[O20] An advanced cervical neuromuscular task performed by Whiplash and chronic nontraumatic neck pain patients A. Woodhouse, O. Vasseljen, Norwegian University of Science & Technology, Norway

18.00 – 18.10

Q&A

Q&A

18:10 – 19:30

WELCOME DRINKS RECEPTION Cromdale Hall ~ Level ņ2

[O22] A combination of constraintinduced therapy and motor control retraining in the treatment of focal hand dystonia in musicians - Case studies of a guitarist and flautist P. Berque1, H. Gray2, C. Harkness1, A. McFadyen2, 1Glasgow Royal Infirmary, Glasgow, UK, 2Glasgow Caledonian University, Glasgow, UK

[O23] Comparison of the energy cost of walking between patients with Charcot-Marie-Tooth IA and healthy individuals F. Menotti1, F. Felici1, A. Damiani2, R. F. Mangiola2, A. Vannicelli2, Macaluso1, 1University of Rome Foro 2 Italico, Italy, UILDM Sezione Laziale, Italy [O24] Neurological soft signs are present more often and to a greater extent in adults with chronic low back pain with cognitive learning deficits S.G.T. Gibbons1,2, 1Neuromuscular Rehabilitation Institute, Canada, 2 Memorial University of Newfoundland, Canada

Q&A

xx

SATURDAY 31 OCTOBER 2009 SPONSORED INTERACTIVE SESSIONS Lomond Suite ~ Level 0 08:00 – 08:45

MOORFOOT ROOM

KILSYTH ROOM

Pilates ~ E. Ellis

Gyrokinesis ~ S. Scott

PLENARY SESSION 3 Chair: W. Dankaerts, K.U.Leuven; AUHL-PHL, Belgium 09:00

KEYNOTE [K4] Shoulder impingement: Biomechanical considerations in rehabilitation P.M. Ludewig, The University of Minnesota, USA

09:35

KEYNOTE [K5] What is our baseline for movement? The clinical need for movement screening and assessment G. Cook, Averett University, Gray Cook Physical Therapy, Functional Movement Systems, USA

10:10

GUEST LECTURE GL5] Breathing evaluation and retraining as an adjunct to manual therapy L. McLaughlin, NAIOMT, Canada

10:30

COFFEE BREAK, EXHIBITION AND POSTER VIEWING Cromdale Hall ~ Level ņ2

PLENARY SESSION 4 Chair: W. Dankaerts, K.U.Leuven; AUHL-PHL, Belgium 11:00

11:35

KEYNOTE [K6] Skeletal muscle fibres. What types have we got? Can we change them and does it matter? S.D.R. Harridge, King’s College London, UK KEYNOTE [K7] Diagnostic utility of clinical tests for spinal dysfunction C. Cook, Duke University, USA

12:10

GUEST LECTURE [GL6] Recurrence of injury and pain in sport – What’s missing M. Comerford, Kinetic Control, UK; Performance-Rehab, Australia

12:25

PANEL DISCUSSION – Speakers from Plenary Sessions 3 and 4

13:00 – 14:30

LUNCH, EXHIBITION and POSTER SESSIONS Cromdale Hall ~ Level ņ2 13:45 – 14:30

13:45 – 14:15

General Poster Session

Interactive Poster Session Chair: C. Hebron, University of Brighton, UK

SPONSORED INTERACTIVE SESSIONS Lomond Suite ~ Level 0

13:30 – 14:15

TINTO ROOM

MOORFOOT ROOM

Try Kangoo Jumps boots

Pilates ~ E. Ellis

KILSYTH ROOM

The Foundation Matrix with Mark Comerford and Suzanne Scott SIDLAW ROOM ~ Level 3 Get Read! Get Writing! Writing for publication workshop A.Moore, Editor, Manual Therapy

xxi

AFTERNOON SESSIONS – PENTLAND AUDITORIUM ~ LEVEL 3 CLINICAL SEMINARS

14:30 – 15:15

PENTLAND ROOM Chair: S. Mottram, Kinetic Control, UK [CS4] Treatment of shoulder impingement: Targeted intervention strategies P.M. Ludewig, The University of Minnesota, USA

SIDLAW ROOM Chair: G.M. Homstøl, NHP, Norway [CS5] Demonstration of the Selective Functional Movement Assessment (SFMA) G. Cook, Averett University, Gray Cook Physical Therapy, Functional Movement Systems, USA

FINTRY ROOM Chair: C. Small, Pure Sports Medicine, UK [CS6] Specificity in assessment and management of hip abductor muscle dysfunction A. Grimaldi, University of Queensland, Australia

SUBMITTED ORAL PRESENTATIONS

15.20 – 15.35

15.35 – 15.50

15.50 – 16.05

16.05 – 16.20

PENTLAND ROOM Chair: C. Barrett, Imperial College Healthcare Trust, UK

SIDLAW ROOM Chair: O. Aranko, Physiotherapist, Finland

FINTRY ROOM Chair: K. Schoolmeesters, Katholic University Louvain KUL, Belgium

[O25] Impaired control of scapular rotation during a clinical dissociation test in people with a history of shoulder pain S. Mottram1, M. Warner1, P. Chappell2, D. Morrissey3, M. Stokes1, 1Schools of Health Sciences, University of Southampton, UK, 2Electronics and Computer Science, University of Southampton, UK, 3University of London, UK [O26] Validating recruitment of posterior gluteus medius fibres during two muscle tests and exploration of the kinetic control rating system for these tests N.V. Jeal, P. Browning, University of Hertfordshire, UK

[O29] Induced transducer orientation during ultrasound imaging: Effects on abdominal muscle thickness and bladder position J.L. Whittaker1,2, M.B. Warner1, M.J. Stokes1, 1University of Southampton, UK, 2Whittaker Physiotherapy Consulting, Canada

[O33] Primitive reflex inhibition and sensory motor training improves cognitive learning function and symptoms in chronic disabling low back pain: A case series S.G.T. Gibbons1,2, 1Neuromuscular Rehabilitation Institute, Canada, 2 Memorial University of Newfoundland, Canada

[O30] Factors influencing the use of standardised outcome measures in daily practice: a survey in Dutch physiotherapists R.A.H.M. Swinkels1, R.P.S. van Peppen2, H. Wittink2, A.J.H.M. Beurskens1, 1Zuyd University, 2 Netherlands, University of Applied Sciences, Netherlands [O31] Positioning of elbow flexion versus elbow extension for measuring grip strength and muscle activation in lateral epicondylitis M.I. Arik1, F. Can1, 1Hacettepe University, Turkey

[O34] The graduated return to activity for low back pain: Exploring the patient’s perspective of physiotherapy M. Perry1, S. Dean2, S. Hudson2, L. Hale1, D. Baxter1, 1Centre for Physiotherapy Research, University of Otago, New Zealand, 2Rehabilitation Teaching and Research Unit, University of Otago, New Zealand [O35] Talking function: Personal accounts of acute non-specific low back pain experiences C.A. McCrum1,2, A.P. Moore1, V. Hall3, 1 Clinical Research Centre for Health Professions, University of Brighton, UK, 2East Sussex Hospitals NHS Trust, UK, 3School of Nursing and Midwifery, University of Brighton, UK [O36] Prediction of functional disability in patients with stiff shoulder: Posterior shoulder muscle stiffness and rotation deficit J.-J. Lin1,2, J.-l. Yang3, C.-J. Hung1, P.-L. Yang1, 1School of Physical Therapy, 2Center of Physical Therapy, 3 Department of Physical Medicine & Rehabilitation; National Taiwan University Hospital, Taiwan

[O27] The development, initial reliability and construct validity of the motor control abilities questionnaire S.G.T. Gibbons1,2, 1 Neuromuscular Rehabilitation 2 Memorial Institute, Canada, University of Newfoundland, Canada [O28] Motor control and physical fitness training prevent musculoskeletal injuries in professional dancers 1 N.A. Roussel , L. Daenen1, D. Vissers1, A. Schutt1, A. Van Moorsel1, S. Mottram3, 1Artesis University College Antwerp, 2 Belgium, Vrije Universiteit Brussel, Belgium, 3Kinetic Control, UK

[O32] The reliability of a wireless monitor for measurement of lumbar spine posture K. O'Sullivan1, L. Galleotti1,2, W. Dankaerts2,3, L. O'Sullivan1, P 1 University of O'Sullivan4, 2 Limerick, Ireland, Catholic 3 University, Belgium, Association 4 University, Belgium, Curtin University of Technology, Australia

16.20 – 16.30

Q&A

16.30 – 17.00

TEA BREAK, EXHIBITION AND POSTER VIEWING Cromdale Hall ~ Level ņ2

Q&A

Q&A

xxii

17.00 – 17.15

17.15 – 17.30

17.30 – 17.45

17.45 – 18.00

18:00 – 18:15

PENTLAND ROOM Chair: J. Napper, MACP, UK

SIDLAW ROOM Chair: E. Thoomes, SOMT, Netherlands

FINTRY ROOM Chair: N. Petty, University of Brighton, UK

[O37] Scapular positioning in overhead athletes with and without shoulder pain: A casecontrol study F. Struyf1,2, J. Nijs1,2, J. De S. Mottram3, R. Graeve1, Meeusen2, 1Artesis University College Antwerp, Belgium, 2Vrije Universiteit Brussel, Belgium, 3 Kinetic Control, UK [O38] Muscle recruitment of the scapula in patients with traumatic and insidious onset neck pain H. Helgadottir1, E. Kristjansson2, E. Einarsson3, H. Jonsson4, 1 University of Iceland, Iceland, 2 Bakstofan Physical Therapy Clinic, Iceland, 3Efling Physical 4 Therapy Clinic, Iceland, Lanspitali University Hospital, Iceland [O39] An investigation into the effects of a simulated effusion in healthy subjects on knee kinematics and lower limb muscle activity during a single leg drop landing G.F. Coughlan1, R.McLoughlin2, U.J. McCarthy Persson1, B.M. 1 School of Caulfield1, Physiotherapy and Performance Science, University College Dublin, Ireland, 2O’Neill’s Sports Injury Clinic, Sports Centre, University College Dublin, Ireland [O40] Patients with chronic low back pain exhibit altered breathing patterns during motor control assessment 1,2 1,3 N.A. Roussel , J. Nijs , S. S. Mottram4, L. Truijen1, Vervecken1, G. Stassijns2, 1 Artesis University College Antwerp, Belgium, 2University of 3 Antwerp, Belgium, Vrije Universiteit Brussel, Belgium, 4 Kinetic Control, UK [O41] Hypermobility (HM) Influence of passive and active tone C. Mebes1, U. Stutz1, G. Luder1, H. Ziswiler2, M. Stettler3, L. 1 Institute of Radlinger3, Physiotherapy, Inselspital, University Hospital Bern, 2 RIA University Switzerland, Hospital of Bern, Switzerland, 3 Bern University of Applied Sciences Health, Switzerland

[O42] Reliability of real-time ultrasound measurement of supraspinatus size in normal subjects and subjects with unilateral shoulder pain A. Roche, K. McCreesh, University of Limerick, Ireland

[O47] Effects of manual therapy followed by specific active exercises on the improvement of functional disability of chronic low back pain patients P. Balthazard1, P. Demeulenaere1, P. De Goumoens2, O. Dé riaz3, 1 HECVSanté , Switzerland, 2CHUV, Switzerland, 3Clinique Romande de Ré adaptation, Switzerland [O48] The effect of cetylated fatty esters and physical therapy on myofascial pain syndrome of the neck D. Sharan1, B.N. Jacob1, P.S. Ajeesh1, R. Barathur2, J. Bookout2, 1 RECOUP Neuromusculoskeletal Rehabilitation Centre, India, 2 Cymbiotics Inc, USA

[O43] Two clinical tests are highly accurate when diagnosing unilateral shoulder tendinopathy: An ultrasonography study 1,2 3 J. Joensen , C. Couppe , J.M. Bjordal1,2, 1Bergen University College, Norway, 2University of Bergen, Norway, 3University of Copenhagen, Denmark [O44] The multiple hop test: a discriminative or evaluative instrument for chronic ankle instability? C.J. Eechaute, P.H .Vaes, The Physical Therapy Dept of the Vrije Universiteit Brussel, Belgium

[O49] The relationship between change in function and change in psychosocial parameters in individuals with chronic low back pain C.G. Ryan1, W. MacLaren1, M.H. 1 Glasgow Caledonian Granat1, University, UK

[O45] Support for modifications to the anteromedial reach test (an anterior cruciate ligament rehabilitation outcome measure) N.P. Bent1, A.B. Rushton1, C.C. Wright1, M.E. Batt2, 1University of Birmingham, UK, 2Nottingham University Hospitals, UK

[O50] Research priorities for postgraduate theses in manipulative physiotherapy 1 2 1 A. Rushton , A. Moore , University of Birmingham, UK, 2University of Brighton, UK

[O46] Ultrasound measurement of the anterior tibial muscle group: reliability and dominance effects S. Egan, K. McCreesh, University of Limerick, Ireland

[O51] Cognitive learning and sensorimotor function provide a protective effect from disability in low back pain S.G.T. Gibbons1,2, 1Neuromuscular Rehabilitation Institute, Canada, 2 Memorial University of Newfoundland, Canada

Q&A

Q&A

18.15 – 18.25

Q&A

18:30 – 19:30

MACP AGM (members only) Pentland Auditorium – Level 3

xxiii

SUNDAY 1 NOVEMBER 2009 SPONSORED INTERACTIVE SESSIONS Lomond Suite ~ Level 0 08:00 – 08:45

MOORFOOT ROOM

KILSYTH ROOM

Pilates ~ E. Ellis

Gyrokinesis ~ S. Scott

PLENARY SESSION 5 Chair: C. McCarthy, St Mary’s Hospital, London 09:00

KEYNOTE [K8] The eyes have it – recent developments in training the brain for chronic pain L. Moseley, Prince of Wales Medical Research Institute, Australia

09:35

KEYNOTE [K9] Subgrouping patients with low back pain in primary care: Are we getting any better at it? N.E. Foster, Keele University, UK

10:10

GUEST LECTURE [GL7] Outcome following treatment for chronic low back pain. processes of change? S. Woby, North Manchester General Hospital, UK

10:30

10:50

What are the

GUEST LECTURE [GL8] Pre-season screening of professional footballers – The role of movement assessment W. Diesel, Tottenham Hotspur Football Club, UK COFFEE BREAK, EXHIBITION AND POSTER VIEWING Cromdale Hall ~ Level ņ2

PLENARY SESSION 6 Chair: C. McCarthy, St Mary’s Hospital, London 11:20

KEYNOTE [K10] Understanding the lateral stability mechanism of the hip and pelvis A. Grimaldi, University of Queensland, Australia

11:55

GUEST LECTURE [GL9] Evidence from cognitive neuroscience supports action observation as part of an integrated approach to stroke rehabilitation P. Holmes, Institute for Performance Research, Cheshire Faculty, MMU, UK

12:15

GUEST LECTURE [GL10] “What if”: the use of biomechanical models for understanding and treating upper extremity musculoskeletal disorders D.J. (H.E.J.) Veeger, VU University Amsterdam, Delft University of Technology, The Netherlands

12:35

GUEST LECTURE [GL11] Rehabilitating Achilles Tendonopathy J. Fearn, Reading Football Club, UK

12:55

PANEL DISCUSSION

13:10

Closing remarks and presentation of Elsevier Sponsored Awards A. Moore, University of Brighton, UK; Executive Editor, Manual Therapy CLOSE OF CONFERENCE

We would like to thank Mindy Cairns, University of Hertfordshire, for her role as Chair of Chairs, and all those who have agreed to Chair Sessions for their support.

xxiv

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2WPS2^^Z3dZTD]XeTabXchDB0 Chad Cook, PT, PhD, MBA, OCS, FAAOMPT is an Associate Professor and the Director of Outcomes Measurement at Duke University with a dual appointment in Department of Community and Family Medicine and the Department of Surgery. Dr. Cook received his Bachelors of Science in Physical Therapy at Maryville University in 1990, a Masters of Business Administration in 1999, and a Doctorate of Philosophy (PhD) at Texas Tech University in 2003. He was certified as an orthopedic manual therapist in 2001, obtained fellowship status with AAOMPT in 2007, and is an APTA board certified orthopedic specialist (2002). Dr. Cook has published over 70 peer reviewed research papers in journals such as acW^_TSXR CaPd\P9^da]P[^U>acW^_TSXRATbTPaRW2>AA9>B?CB_X]T9 ?PX] ?aPRcXRT 9^da]P[ ^U acW^_TSXR acW^_TSXR ?WhbXRP[ 4gP\X]PcX^] CTbcb)0]4eXST]RT1PbTS0__a^PRW as well as book chapters and orthopedic monographs. He is currently the Editor in Chief of the 9^da]P[ ^U
6aPh2^^Z0eTaTccD]XeTabXch6aPh2^^Z?WhbXRP[ CWTaP_h5d]RcX^]P[<^eT\T]cBhbcT\bDB0 Gray Cook MSPT, OCS, CSCS, a practicing physical therapist, has spent his entire career refining and developing functional evaluation and exercise techniques. He has taken the Functional Movement Screen (a system he developed) and his advanced assessment practices and combined them with reactive-based exercises that enhance motor learning for both rehabilitation and performance. These two components were the pillars of the Reebok Core Training System which he developed in 2000. Gray’s ability to teach at many different professional levels is the result of his diverse background as both a sports medicine and conditioning expert. Gray has lectured nationally and internationally in the fields of physical therapy, sports medicine, fitness and performance enhancement. He has served as a consultant to numerous universities and professional sports teams as well as Reebok University and the Titleist Performance Institute. His is author of the book titled Athletic Body in Balance which serves as a working example to trainers, coaches and athletes of the unique way Cook looks at assessment, movement, and exercise.

He is also the author of numerous text book chapters and articles related to these topics. He holds a faculty and staff position at Averett University. Cook has also produced a complete product line of educational material for rehabilitation and exercise professionals. These products and publications represent a paradigm shift in the way we will look movement science in the future. He lives in Southwest Virginia with his wife and daughters and enjoys a wide variety of sports and outdoor activities.

FX\3P]ZPTacb :D;TdeT]*0D7;?7;1T[VXd\ Wim Dankaerts is an Associate Professor in Musculoskeletal Physiotherapy at the Catholic University Leuven and the Association University Hasselt Limburg-PHL, Belgium. He also works part-time in private practice in Tienen (Belgium) as a Musculoskeletal Physiotherapist. Wim graduated as a physiotherapist from the Catholic University Leuven, Belgium (1990) and received his Post Graduate Diploma in Manipulative Physiotherapy, from Curtin University, Perth, WA (1995). He completed his PhD at Curtin University (2005). Associate Professor Dr Peter O’Sullivan was his principal supervisor. During his doctoral studies Wim was a Lecturer at the prestigious Professional Masters in Musculoskeletal Physiotherapy program at Curtin University of Technology, Perth WA. His main interest of research is into mechanism-based classification for CLBP. He has published several papers and presented his research findings at many international conferences. He has also presented many clinical courses on the treatment of chronic low back pain internationally.

=PSX]T5^bcTa:TT[TD]XeTabXchD: One of the senior academic team in the Clinical Trials Unit of the Arthritis Research Campaign National Primary Care Centre at Keele University, Nadine is a physiotherapist by background whose research activity is focused on musculoskeletal pain in primary care. Her research includes clinical trials and other intervention studies for low back pain, knee pain and shoulder pain, and epidemiological studies of predictors of clinical outcome. Her portfolio of research includes studies of the effectiveness of interventions across the spectrum of physiotherapists, general practitioners, osteopaths and chiropractors. With more than £10 million research funding, she has contributed more than 50 full paper publications and supervises MSc/MMedSci and PhD students. She co-leads an annual short course ‘Practical introduction to running randomised clinical trials’ and contributes to MSc programmes at Keele University and elsewhere. She is a member of the HTA Clinical Evaluation and Trials Prioritisation Group, the West Midlands NIHR Research for Patient Benefit Committee and the Arthritis Research Campaign’s Clinical Studies Group on Musculoskeletal Pain. She is one of the international organising committee members for the International Forum for Research in Low Back Pain in Primary Care and secretary elect for the Society of Back Pain Research in the UK. Her post is funded by a Primary Care Career Scientist Award from the National Institute of Health Research (NIHR) in the UK, to deliver a programme of research on common musculoskeletal problems.

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0[Xb^]6aX\P[SX D]XeTabXch^U@dTT]b[P]S0dbcaP[XP Alison Grimaldi is an APA accredited Sports Physiotherapist with a Masters degree in Sports Physiotherapy and a Doctorate in Philosophy (Physiotherapy). Her PhD was completed through the University of Queensland, Australia, and was aimed at improving the understanding of function and dysfunction of the lateral stability mechanism of the hip and pelvis. Alison is the Principal Physiotherapist at PhysioTec Physiotherapy and Pilates in Brisbane. She has 18 years of clinical experience which over the last 10 years has focused primarily on management of hip, lumbopelvic and lower limb conditions. Alison is a visiting lecturer on Physiotherapy Masters programmes at the University of Queensland, has presented at many national and international conferences, and runs weekend educational programmes for other physiotherapists.

BcTeT7PaaXSVT :X]Vb2^[[TVT;^]S^]D: Steve Harridge is physiologist with a wide ranging (genes to muscle function) research interest in human skeletal muscle function and plasticity. He hast a particular interest in ageing muscle. He obtained his PhD from the University of Birmingham after which he spent three years at the Karolinska Institute in Stockholm and the Copenhagen Muscle Research, Denmark. He returned to the UK to take a Lectureship in the Department of Geriatric Medicine at the Royal Free Hospital School of Medicine, prior to spending 7 years in the Department of Physiology at University College London as a Wellcome Trust Research Fellow and Senior Lecturer. He was appointed Professor of Human and Applied Physiology at King’s College London 2005. Steve is currently Convenor of the Human Physiology Special Interest Group of The Physiological Society and a member of the Scientific Committee of the European College of Sports Science. He is on the Editorial Board of Experimental Physiology and the Scandinavian Journal of Medicine and Science in Sports. In addition to his research he is Director of the MSc programme in Human and Applied Physiology at King’s and contributes to the post-graduate programmes in Advanced Physiotherapy.

?Pd[P;dSTfXVCWTD]XeTabXch^U<X]]Tb^cPDB0 Paula Ludewig is an Associate Professor in the Program in Physical Therapy, Department of Physical Medicine & Rehabilitation at the University of Minnesota. She received her PhD in Exercise Science from the University of Iowa and her Physical Therapy degree from the College of St. Scholastica. Her research and teaching interests are in the area of orthopaedic biomechanics, with particular interest in mechanisms of injury and rehabilitation approaches for the shoulder. She has published numerous articles in the area of shoulder biomechanics and rehabilitation. Dr. Ludewig also serves as an Associate Editor for the Journal of Orthopaedic & Sports Physical Therapy.

;^aX\Ta<^bT[Th?aX]RT^UFP[Tb
9^W]A^cWfT[[D]XeTabXch2^[[TVT;^]S^]D: After receiving a PhD from the University of London, UK, in 1980, Professor Rothwell worked in London as a Royal Society University Research Fellow in the Neurology Department of the Institute of Psychiatry until 1988, before moving as a Senior scientist to the Medical Research Council Human Movement and Balance Unit at the Institute of Neurology. In that period he developed his current interests in the pathophysiology of human movement disorders, with a particular interest in Parkinson’s disease, dystonia, myoclonus and stroke. This was also a time of great expansion in the new technique of transcranial magnetic stimulation, which he and others developed for the study of the human cortical motor system. He was Acting Director of the Unit in 1998 before being appointed to be Head of the Sobell Department of Motor Neuroscience and Movement Disorders at the Institute of Neurology in London. He was elected a Fellow of the Academy of Medical Sciences in 1994. Professor Rothwell has extensive experience in as a journal editor, having served on the editorial boards of the Journal of Physiology and Clinical Neurophysiology. He was deputy editor of the journal Brain from 1997-2004 and is presently managing editor of Experimental Brain Research and a member of the editorial boards of Journal of Neurophysiology, Neurorehabilitation and Neural Repair and Brain Stimulation. With Dr Richard Greenwood he organised the recent Cumberland Consensus Conference on Stroke Rehabilitation in London 2007.

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BWXa[ThBPWa\P]]FPbWX]Vc^]D]XeTabXchBRW^^[ ^U
6D4BC;42CDA4AB 2Pa^[X]T0[TgP]STa8\_TaXP[2^[[TVT7TP[cWRPaT =7BCadbcD: Dr Alexander graduated as a Physiotherapist in 1987. She received an MSc in Advanced Neuro-Musculoskeletal Physiotherapy from University College London in 1994 when she became a member of the Manipulation Association of Chartered Physiotherapists. In December 2001 she was awarded a PhD from University College London after studying the reflex control of shoulder girdle muscles. She now works as a clinician and researcher for Imperial College Healthcare NHS Trust where she has a laboratory situated within the Department of Physiotherapy. Dr Alexander presents internationally and publishes work that explores the reflex and descending control of girdle and trunk muscles in both healthy individuals and people with various musculoskeletal and neurological problems.

<XRWPT[2P[[PVWP] Dr. Michael Callaghan qualified in 1983 at Salford School of Physiotherapy and is a Research Associate at Manchester University’s ARC epidemiology research group and a Clinical Specialist Physiotherapist in Emergency Medicine at Manchester Royal Infirmary. In the sports medicine context he has attended 4 Commonwealth Games and 4 Olympic Games as a physiotherapist and was physiotherapist to Everton Football club, Wigan Rugby League Club and the Great Britain Cycling Team.

His general area of research has been the assessment and rehabilitation of the lower limb. His research degrees of M.Phil awarded by Liverpool University and Ph.D. at Manchester University focussed the patellofemoral joint in particular. His recent work on patellofemoral pain syndrome has been the further development of functional joint and muscle evaluation and the use of both brain and knee MR imaging to monitor the effects of nonoperative treatment for the knee such as taping and bracing. His involvement with the ARC epidemiology unit at Manchester now includes the treatment of patellofemoral pain caused by osteoarthritis and he is involved in a 5 year study of patellofemoral bracing on synovitis and bone marrow oedema in patellofemoral OA. (152).

<PaZ2^\TaU^aS:X]TcXR2^]ca^[D:?TaU^a\P]RT ATWPQ0dbcaP[XP Mark Comerford (B.Phty. MCSP MAPA) graduated from the University of Queensland, Australia in 1980. He worked for seven years in the Public Health System, as a Senior Musculoskeletal Physiotherapist. In 1987 Mark started teaching in the Physiotherapy Department at the University of Queensland for the undergraduate and postgraduate programmes, lecturing in electrotherapy, sports physiotherapy and therapeutic exercise. During this time he also worked in private practice in Brisbane. In 1992 he moved to the U.K. and established postgraduate courses in dynamic stability and muscle balance. This process evolved into Kinetic Control Movement Dysfunction Courses. Kinetic Control Movement Dysfunction courses are now established worldwide, being taught in 16 countries and 4 languages. Mark Comerford is the senior director of KC International, is a part-time lecturer for the MSc programme at the Physiotherapy Dept, Keele University, UK and continues to work clinically. He also does consulting work for various sporting and professional organisations. With Sarah Mottram he has recently set up Performance Stability which offers movement and core stability training courses for those involved in sport and movement. These courses are based on the Performance Matrix - a method of stability assessment and retraining designed to ‘find weak links in the functional performance chain'. Mark has published several papers on the integration of local and global muscle retraining to enhance joint stability function. He has presented numerous conference papers and courses internationally on the area of assessment movement dysfunction and the use of exercise to treat mechanical stability dysfunction. He has moved back to Brisbane, Australia in 2003 to set up a private clinic. ‘Performance Rehab' is established with the aim of providing a multidimensional approach to the management of musculoskeletal pain, movement dysfunction and elite level functional performance. Mark continues to develop the Kinetic Control process. His current research interests include: v Measurement and validation of direction specific stability dysfunction v Investigation of the function and the stability role of psoas major v Investigation of the use of imaging ultrasound to determine the interaction of synergistic muscle function in the normal pain free state, the abnormal pain free state, the pain present state and analysis of retraining strategies for muscle re education. v He is also involved in the analysis of movement dysfunction relationships to alterations of the golf swing contributing to consistent slicing, hooking etc. Mark's special interest is in the development of clinically relevant models of mechanical stability dysfunction and the integration of local and global muscle assessment and training into clinical reasoning frameworks.

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FPh]T9^]PcWP]3XTbT[C^ccT]WP\7^cb_da 5^^cQP[[2[dQD: South African Physiotherapist who qualified in 1986. Completed a BSc (Med)(Hons) Sports Science in 1988. Awarded PhD in Exercise Physiology in 1994. In 1997 selected to start the Private Physiotherapy Practice at the Sports Science Institute of South Africa. Gained experience working with several National Teams including Women’s Gymnastics, Men’s Hockey, Football and Rugby as well as All African, Olympics and Commonwealth Games. Arrived in the UK in 2002 to work for Gloucester Rugby Football Club. Subsequently joined Charlton Athletic in 2003 where he worked for 4 seasons before joining Tottenham Hotspur Football Club in June 2007 as Head of Medical Services

3TQ^aPW5P[[P0P[Q^aVD]XeTabXch3T]\PaZ Deborah Falla received her PhD in Physiotherapy from The University of Queensland, Australia in 2003. In 2005 she was awarded Fellowships from the International Association for the Study of Pain and the National Health and Medical Research Council of Australia to undertake postdoctoral research at the Center for Sensory-Motor Interaction, Aalborg University, Denmark. Since 2007 she is an Associate Professor at the Faculty of Engineering, Science and Medicine, Department of Health Science and Technology of Aalborg University, Denmark. Her research focus involves the integration of neurophysiological and clinical research to evaluate neuromuscular control of the spine in people with chronic pain. In this field, she received the Delsys Prize for Electromyography Innovation in 2004. Her research interests also include investigation of the mechanisms that underpin the efficacy of therapeutic exercise for the rehabilitation of neck pain disorders.

9^]5TPa]ATPSX]V5^^cQP[[2[dQD: Jon qualified as a Chartered Physiotherapist in 1991 from St Mary’s Hospital, Paddington. He then went on to work in numerous specialities in the NHS for 5 years. During this time he started working part-time in amateur sport with Richmond and London Welsh Rugby clubs and London Monarch and London Olympian American football teams. In 1997 he completed an MSc in Advanced Physiotherapy at University College London with clinical distinction. He then followed his ambition to work in sport full time working with the Professional squad at West Ham United Football Club together with developing a private practice. In 2001 Jon joined Reading Football club as First team physiotherapist and is now Head of Sports Medicine, dealing with all aspects of players’ healthcare with a team of 8 full-time staff. He also runs a physiotherapy practice based in Reading. Jon is also involved with lecturing and mentoring of MSc and MACP students and sometimes finds time to see his wife and 2 children!!

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xxviii

3ThSaTCThWT]2T]cTaU^a?WhbXRP[CWTaP_h ATbTPaRW0RPST\h^U7TP[cWBRXT]RTbDB0 Dr. Teyhen is an Associate Professor and Director of the Center for Physical Therapy Research in the U.S. Army-Baylor University Doctoral Program in Physical Therapy at Fort Sam Houston, TX. She also serves as a research consultant to the Spine Research Center and the Defense Spinal Cord and Column Injury Center at Walter Reed Army Medical Center, Washington D.C. and to the Military Performance Laboratory at Brooke Army Medical Center in San Antonio, TX. Dr. Teyhen completed her PhD in Biomechanics from the University of Texas in 2004. She received a Master of Physical Therapy from the U.S. Army-Baylor University in 1995 and a Bachelor of Arts in Sports Science from Ohio Wesleyan University in 1993. Dr. Teyhen’s professional experience and training have been primarily in orthopaedic physical therapy. She is a board-certified Orthopaedic Clinical Specialist from the American Board of Physical Therapy Specialties, a certified Health Fitness Instructor from the American College of Sports Medicine, and a certified Health Promotion Director through the Cooper Institute. Dr. Teyhen’s research has focused on the development of imaging tools that can enhance rehabilitation of spinal and shoulder dysfunctions. She has been developing a novel approach to measure spinal and shoulder kinematics in those with lumbar and shoulder instability using digital fluoroscopic video technique. Furthermore, she has been clinically examining the ability to use real-time ultrasound imaging as a measurement and biofeedback tool to enhance the delivery of medical care to those with spinal pain since 1999. She has lectured extensively on the examination and treatment of patients with lumbar instability, therapeutic exercise, injury prevention, digital fluoroscopic video, and real-time ultrasound imaging. Dr. Teyhen serves as a manuscript reviewer for rehabilitative and biomechanical journals and is currently an Editorial Review Board Member of the 9^da]P[^U>acW^_PTSXRP]S B_^acb?WhbXRP[CWTaP_h

3XaZ9P]ETTVTaEaXYTD]XeTabXcTXc0\bcTaSP\CWT =TcWTa[P]Sb 3a 749 ETTVTa (1958), Department of Human Movement Sciences, Vrije Universiteit Amsterdam & Faculty of Mechanical Engineering, section Biomedical Engineering, Delft University of Technology. After obtaining his masters in Human Movement Sciences in 1984, DirkJan Veeger continued his studies in London, where he obtained his MSc in Ergonomics from University College London. Since 1986, DirkJan Veeger has been affiliated to the Department of Human Movement Sciences, where he received his PhD in 1992 on Biomechanics of Wheelchair Propulsion. His main research interest lies in the field of musculoskeletal mechanics, and especially the upper extremity. Most profound research subject is the relationship between structure and function, which has been applied to the shoulder in wheelchair propulsion, the effect of surgical interventions such as tendon transfers on muscle function and ADL. Since 2000, Dr. Veeger also serves as Associate Professor at the Biomedical Engineering Department of Delft University of Technology, where he is responsible for research in the area of shoulder biomechanics. Dr. Veeger is chair of the International Shoulder Group, a technical group of the International Society of

Biomechanics and member of the editorial board of Clinical Biomechanics. Dr. Veeger has authored over 100 papers in SCIindexed journals.

BcTeTF^Qh=^acW
8=E8C43B?40:4A2[^bX]V2^\\T]cb 0]]<^^aTD]XeTabXch^U1aXVWc^]D: Ann qualified as a physiotherapist in 1973 and worked as a clinician until 1977 when she took up teacher training (PG Cert Ed at Wolverhampton Polytechnic and Coventry School of Physiotherapy). Ann later specialised as a musculoskeletal physiotherapist and worked in private practice for 11 years whilst also working as a full time lecturer/researcher at Coventry Polytechnic. She has been a member of the MACP since 1979. She completed her PhD in 1989 in musculoskeletal physiotherapy and then became Principal Lecturer in Physiotherapy at the then Brighton Polytechnic (later University of Brighton). At the University of Brighton she led postgraduate developments between 1994 and 1998 including the development of the first MSc in physiotherapy at the University an innovative Postgraduate Certificate in Clinical Education and The Professional Doctorate Programme in Health and Social Care. In 1994 she was also appointed as Head of Research and in 1998 became full time Head of the Clinical Research Centre for Health Professions where one of the key research groups focuses on applied pedagogic research. Ann has published widely in the field of musculoskeletal physiotherapy and her publications also include papers on clinical education. She is regularly invited to present keynote addresses at major national and international conferences. In 1998 she was awarded a Fellowship of the Chartered Society of Physiotherapy and in 2001 a Fellowship of the Manipulation Association of Chartered Physiotherapists. She is a Visiting Research Fellow at the University of Kent. She has been Executive Editor of Manual Therapy Journal since 1995. She is Research Lead for the Chartered Society of Physiotherapy, Chair of the National Physiotherapy Research Network, Chair of the National Council for Osteopathic Research and Chair of the National Association of Educators in Practice. She is currently Chair of the International Scientific Committee for WCPT 2011.

Manual Therapy 14 (2009) S1–S4

Contents lists available at ScienceDirect

Manual Therapy journal homepage: www.elsevier.com/locate/math

KEYNOTE ABSTRACTS

[K1] Low back pain: Isolated or degenerative problem - What are the implications?

5. Van Dillen LR, Sahrmann SA, Caldwell CA, McDonnell MK, Bloom N, Norton BJ. Trunk rotation-related impairments in people with low back pain who participated in 2 different types of leisure activities: a secondary analysis. J Orthop Sports Phys Ther. 2006 Feb;36(2):58-71.

S. Sahrmann, Washington University School of Medicine, USA Ninety percent of people are expected to experience low back pain during their life. The prevailing pattern for treatment of low back pain is to intervene during an acute episode of pain with the intention of alleviating the symptoms through application of various modalities or techniques designed to provide immediate relief. In some instances a program of exercise is provided but often with a rationale that is highly variable or poorly deﬁned. The recurrence rate of low back pain is known to be high, having been reported to range from 36 to 80%. This raises several questions about both the pattern of management and the emphasis of treatment. The high incidence and the recurrence rate are consistent with low back pain being associated with the degenerative process. Characteristic of the degenerative process is temporary dysfunction and 4 stages of hypermobility before the ﬁnal stage of hypomobility and spinal stenosis. If the ‘‘acute episodes’’ are part of the pattern of temporary dysfunction associated with segmental hypermobility then treatment should be directed toward control and prevention of the progressive hypermobility that at a minimum should slow the degenerative process. Other investigators have suggested that that ‘‘loading’’ of the spine is an important factor in the degenerative process. The presence of hypermobility and/or abnormal loading as causative factors is consistent with the need for long-term monitoring of movement patterns and appropriate recommendations for correction. This would mean that physical therapists should be periodically but continually monitoring the pattern of movement of the low back, designing and appropriately instructing the patient in corrective exercises and movement strategies rather than just providing episodic short-term treatment. This presentation will describe the best-available evidence regarding low back pain as part of the degenerative process and for the presence of segmental hypermobility. The exam to detect segmental hypermobility and treatment will be described. Evidence will be presented that detection of the movement direction associated with modiﬁcation of symptoms can be used to classify the patient. Such a classiﬁcation system provides a speciﬁc strategy for treatment rather than a generic, generalized stability program. Excessive loading associated with abdominal muscle overdevelopment will also be discussed as a contributing factor to low back pain. References 1. Gombatto SP, Norton BJ, Scholtes SA, Van Dillen LR. Differences in symmetry of lumbar region passive tissue characteristics between people with and people without low back pain. Clin Biomech (Bristol, Avon). 2008 Jun 28. 2. Scholtes SA, Van Dillen LR. Gender-related differences in prevalence of lumbopelvic region movement impairments in people with low back pain. J Orthop Sports Phys Ther. 2007 Dec;37(12):744-53. 3. Gombatto SP, Collins DR, Sahrmann SA, Engsberg JR, Van Dillen LR. Patterns of lumbar region movement during trunk lateral bending in 2 subgroups of people with low back pain. Phys Ther. 2007 Apr;87(4):441-54. 4. Van Dillen LR, Gombatto SP, Collins DR, Engsberg JR, Sahrmann SA. Symmetry of timing of hip and lumbopelvic rotation motion in 2 different subgroups of people with low back pain. Arch Phys Med Rehabil. 2007 Mar;88(3):351-60.

[K2] Chronic low back pain patients –unravelling pieces of the puzzle W. Dankaerts, K.U.Leuven; AUHL-PHL, Belgium Classiﬁcation of LBP disorders into homogeneous subgroups is considered one of the greatest challenges to enable the application of speciﬁc interventions effective in the management and prevention of recurrences of LBP. This invited talk presents an approach to classiﬁcation, for a subgroup of patients with non-speciﬁc chronic LBP and clinical signs of motor control impairment, proposed by O’Sullivan. This novel classiﬁcation system acknowledges the complex and multi-dimensional nature of these disorders. A biomechanical approach, linked to known pain provoking postures and movements, to quantify parameters of motor control is suggested. The presentation will discuss a series of studies investigating speciﬁc aspects of validity of the proposed mechanism-based classiﬁcation system. To evaluate the integration of sub-classiﬁcation strategies in randomized controlled trials (RCTs) for CLBP a systematic review of the literature was conducted. Clinical sub-groups of NS-CLBP patients with MCI can be discriminated from asymptomatic controls, and each other, using selected parameters of motor control. The data supports the concept of NS-CLBP patients presenting with maladaptive motor control. The differences in trunk muscle activation and lumbo-sacral kinematics in sub-groups of NS-CLBP found in these studies strengthens the hypothesis that there exist distinctly different underlying mechanisms of pain. The ﬁndings from these clinical studies lead to a better understanding of the mechanisms behind the LBP disorder. Improved understanding of the mechanisms is likely to lead to more targeted interventions, and subsequently enhance treatment efﬁcacy. The systematic review of the literature evaluating the integration of subclassiﬁcation strategies in randomized controlled trials (RCTs) for CLBP highlights subclassiﬁcation is lacking in the majority of all RCT on CLBP patients and leaves a vacuum for speciﬁc management. While evidence from recent research supports the need to sub-classify NSCLBP patients a systematic review highlights the lack of sub-classiﬁcation strategies into outcome research. Main references 1. Dankaerts W, O’Sullivan P, et al. - The inter-examiner reliability of a classiﬁcation method for Non Speciﬁc Chronic Low Back Pain patients with motor control impairment - Manual Therapy, 11(2006), 28-39 2. Dankaerts W. O’Sullivan P. Burnett A. Straker L. Altered patterns of superﬁcial trunk muscle activation during sitting in non-speciﬁc chronic low back pain patients: importance of subclassiﬁcation, Spine. 31(17): 2017-23, 2006 Aug 1. 3. Dankaerts W. O’Sullivan P. Burnett A. Straker L. Differences in sitting postures are associated with non-speciﬁc chronic low back pain disorders when patients are subclassiﬁed. Spine. 31(6): 698-704, 2006 Mar 15. 4. Dankaerts W, O’Sullivan P, Burnett A and Straker L, Discriminating healthy controls and two sub-groups of non-speciﬁc chronic low back pain

S2

Keynote Abstracts / Manual Therapy 14 (2009) S1–S4

patients using trunk muscle activation and lumbo-sacral kinematics of postures and movements – a statistical classiﬁcation model, International Society for the Study of the Lumbar Spine (ISSLS) Conference, Bergen Norway, June 2006. [K3] Manipulating neural plasticity to enhance functional recovery after damage to the motor system J. Rothwell, University College London, UK A large number of brain imaging studies have shown that the pattern of activity associated with a given movement may change after partial damage to the motor system (e.g. after stroke). It is thought that there are changes in the pattern of connectivity between motor areas as the system attempts to make optimal use of remaining anatomical pathways. However, there is also evidence that even in the chronic stage of recovery, optimality has not been achieved: for example, constraint induced movement therapy can improve movement in patients in chronic stroke and this is accompanied by further changes in connectivity in a system that must clearly have been suboptimal prior to therapy. The challenge of therapy is to achieve as near an optimal use of a damaged system as possible. It is also the therapist’s task to deﬁne optimality in the context of each individual patient’s needs and aspirations. However, I will argue that even if these objectives are achieved, the best they amount to is letting the brain repair itself. New lines of research using brain stimulation, pharmacological interventions, and even stem cell implants seek to increase the ability of the brain to reorganise, by inﬂuencing processes involved in synaptic plasticity and learning. To be maximally effective, these new methods need to operate in conjunction with targeted therapy to avoid maladaptive changes and improve recovery. [K4] Shoulder impingement: Biomechanical considerations in rehabilitation P.M. Ludewig, The University of Minnesota, USA There is a growing body of literature relating abnormal shoulder movement patterns with the presence of shoulder pain and dysfunction. During elevation of the am overhead, the scapula should upwardly rotate, posteriorly tilt, and internally or externally rotate to follow the thorax. In persons with impingement, alterations of reduced scapular posterior tilting and upward rotation, as well as increased scapular internal rotation have been identiﬁed. Several advances in the understanding of 3-dimensional shoulder complex function and dysfunction have occurred in recent scientiﬁc investigations. Thus abnormal mechanics may be contributing to the development or progression of subacromial impingement beneath the coracoacromial arch or internal shoulder impingement against the glenoid or glenoid labrum. This presentation will update current knowledge on normal and abnormal shoulder complex motion, including clavicular motion patterns. Altered muscle function identiﬁed in shoulder impingement has included excess upper trapezius activation and reduced serratus anterior activation. An overview of potential mechanisms contributing to abnormal movement patterns including soft tissue tightness, altered muscle activation, and thoracic posture will be provided. Scientiﬁcally based implications for shoulder evaluation and rehabilitation interventions will be presented, including sub-grouping of movement deviation types. Evidence for effectiveness of targeted exercise programs in cases of shoulder impingement will be reviewed. In particular, there is scientiﬁc support for the use of serratus anterior strengthening, pectoralis minor and posterior shoulder stretching, and thoracic extension exercises as adjuncts to traditional glenohumeral exercises for shoulder impingement. [K5] What is our baseline for movement? The clinical need for movement screening and assessment G. Cook, Averett University, Gray Cook Physical Therapy, Functional Movement Systems, USA

The strongest predictor of future injury is previous injury. Since it is known that injury adversely affects movement and that asymmetry and dynamic neuromuscular control are also predictors of injury, a systematic method is needed to screen active individuals for injury risk and identify potential weak links in performance. Additionally, the current best evidence suggests that movement changes after an injury and these changes occur at multiple joints away from the injury site. Pain adversely affects motor control and the results of pain related motor control changes are unpredictable and highly individualized. Thus, the health care professionals need a systematic method to clinically assess and train movement patterns during the rehabilitation process.

The Functional Movement Screen – The predictive system The Functional Movement Screen (FMS) is a reliable5 screening system created to rank movement patterns that are fundamental to normal function. By screening these patterns, movement limitations and asymmetries are readily identiﬁed and measured. Basic movement pattern limitation and asymmetry are thought to reduce the effects of functional training and physical conditioning and recent data suggest these factors may be related to injury in sport.3, 4 One goal of the FMS is to identify those athletes with movement pattern limitations so individualized correct exercise can be prescribed to normalize movement prior to an increase in physical training or a competitive sports season.2 The FMS is a screen and therefore designed for, applied to, those individuals who do not have a known musculoskeletal injury.

The Selective Functional Movement Assessment – The diagnostic system The Selective Functional Movement Assessment (SFMA) is a series of 7 full body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain.1 When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contributing to the associated disability. This concept, known as Regional Interdependence,6 is the hallmark of the SFMA which guides the clinician to the most dysfunctional non-painful movement pattern which is then assessed in detail. By addressing the most dysfunctional non-painful pattern, the applications of targeted therapeutic exercise choices are not adversely affected by pain. The SFMA serves as a clinical model for the musculoskeletal healthcare professional to address regional interdependence. This approach is designed to complement the existing exam and should serve as a model to efﬁciently integrate the concepts of posture, muscle balance and the fundamental patterns of movement into musculoskeletal practice. Selected References 1. Cook E, Kiesel K. Impaired Patterns of Posture and Function In: Prentice B, Voight M, eds. Techniques in Musculoskeletal Rehabilitation. 2nd ed. Chicago: McGraw-Hill; 2006. 2. Kiesel K, P P, R B, Burton L, Cook E. Functional Movement Test Scores Improve following a Standardized Off-season Intervention Program Scand J Med Sci Sports. 2009; In Review. 3. Kiesel K, Plisky P, Kersey P. Functional Movement Test Score as a Predictor of Time-loss during a Professional Football Team’s Pre-season Paper presented at: American College of Sports Medicine Annual Conference, 2008; Indianapolis, IN. 4. Kiesel K, Plisky P, Voight M. Can serious injury in professional football be predicted by a preseason Functional Movement Screen? North American Journal of Sports Physical Therapy. August 2007;2(3):147-158. 5. Minick K, Burton L, Butler R, Kiesel K. A Reliability Study of the Functional Movement Screen. National Journal of Strength and Conditioning Research. 2009;In Press. 6. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. Nov 2007;37(11):658-660.

Keynote Abstracts / Manual Therapy 14 (2009) S1–S4

[K6] Skeletal muscle ﬁbres. What types have we got? Can we change them and does it matter? S.D.R. Harridge, King’s College London, UK Our muscles are machines that allow us to convert the chemical energy stored in food into mechanical work, enabling us to undertake all the necessary activities for daily living. Our muscles are made up of hundreds and thousands of long cells, our ﬁbres, and nature has produced a system by which differences in these ﬁbres allow us to produce great feats of strength and power on the one hand and great feats of endurance on the other. Fibres can crudely be classiﬁed on their basis of their colour (red or white), or on the basis of twitch contraction time (slow twitch and fasttwitch). There are however, traditionally considered to be three types of ﬁbre which can be identiﬁed on the basis of their ATPase activity (type 1, type IIa and type IIx), their metabolic properties (slow oxidative, fast oxidative or fast glycolytic) or different isoforms of myosin, the molecular motors, (myosin heavy chain (MHC)-I, MHC-IIa and MHC-IIx). Whilst the nomenclature of these classiﬁcations is based on the speciﬁc characteristic measured, there is a general agreement between classiﬁcations. For example, slow oxidative ﬁbres are those that normally contain MHC-I isoforms and are classiﬁed as type I by ATPase histochemistry. However, it should be noted that even these classiﬁcations are somewhat crude, in that ﬁbres can also represent a continuum between types, with some containing more than one type of MHC isosform (i.e. they are hybrid). In contrast to type I ﬁbres, type II ﬁbres have a higher velocity of shortening and as a consequence have a greater potential for power generation than type I ﬁbres. However, the compromise is the lesser ability of type II (particularly type IIx ﬁbres) to sustain power over a prolonged period of time. In other words they fatigue more easily. Type I ﬁbres are slow to contract, but are highly resistant to fatigue. Unlike some animal muscles, human muscles are not made up of exclusively one or other type, but are mixed with varying proportions of fast and slow ﬁbres. However, it makes sense that muscles with a postural function, such as the soleus, are dominated by type I, fatigue-resistant ﬁbres. It also comes as little surprise that athletes who excel in different events have muscles with compositions that reﬂect the demands of particular events. Sprinters tend to have a high proportion of high-power generating type II ﬁbres, whilst endurance runners tend to have with a higher proportion of fatigue resistant type I ﬁbres. The question is to what extent can, through changes in activity, a ﬁbre be switched? We know from animal studies, that have used cross-innervation or chronic low-frequency stimulation techniques, that it is possible to effectively change fast muscles into slow muscles. However, under more normal physiological conditions, such as voluntary exercise, such a switch is difﬁcult to demonstrate. This is the case in both humans and animals. In contrast to increased activity, we know that disuse, associated with prolonged bed rest or cast immobilisation, results not only in ﬁbre atrophy, but also a switch towards the fast type. This is exempliﬁed in the muscles of spinal chord injured individuals who demonstrate a dominance of type II ﬁbres in the affected muscles distal to the sire of lesion. This lecture will address the extent to which human muscles can alter their type within the context of athletic performance, rehabilitation and ageing. It will also address the question as to whether a drive towards making ﬁbres become ‘‘type I’’, is a desirable outcome. Indeed it may be preferable for fast ﬁbres to be conditioned so as to increase their fatigue resistance, but retain their ability to generate power. [K7] Diagnostic utility of clinical tests for spinal dysfunction C. Cook, Duke University, USA In clinical practice, physical therapists use spine-related tests and measures daily and frequently associate all tests equally. Use of diagnostic accuracy values such as sensitivity, speciﬁcity, and positive likelihood ratios has improved our ability to discriminate tests’ strengths. Recent advances in diagnostic accuracy research have allowed physical therapists

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to progress beyond simple unadjusted accuracy measures; to categorize tests and measures based on the tests’ strengths in the spectrum of differential diagnosis. Differential Diagnosis is designed to provide the beginning and experienced physical therapist with parameters for analyzing elements of differential diagnosis and Prognosis (e.g. diagnostic accuracy values, checklists for quality scores for tests and measures, and guidelines for accuracy of prognosis studies). The foci of this presentation include essential parameters for effective screening, differentiation, and conﬁrmation of spine-related tests and measures, used by physiotherapists. Strengths and weakness of each test and measure are discussed and tests are either viliﬁed or advocated depending on each test’s value. Upon completion, the learner will have knowledge of a battery of useful diagnostic tests (as well as those that have limited use) but most importantly, will have knowledge on how to critique study designs to determine future values of tests and measures. References 1. Cook C, Hegedus E. Orthopedic clinical special tests. Upper Saddle River; Prentice Hall: 2008. 2. Jaeschke R, Meade M, Guyatt G, Keenan SP, Cook DJ. How to use diagnostic test articles in the intensive care unit: diagnosing weananability using f/vt. Crit Care Med. 1997;25:1514-1521. 3. Garbuz et al. Classiﬁcation systems in orthopaedics. J Am Acad Orthop Surg. 2002;10:290-297 4. Obuchowski et al. Ten Criteria for Effective Screening. Am J Roent. 2001;176:1357-62 5. Kleinstuck et al. Are structural abnormalities on MRI a contraindication to the successful conservative treatment of chronic nonspeciﬁc low back pain? Spine. 2006;31:2250-2257. 6. Jarvik et al. Three-year incidence of low back pain in an initially asymptomatic Cohort. Spine. 2005;30:1541-8. [K8] The eyes have it – recent developments in training the brain for chronic pain L. Moseley, Prince of Wales Medical Research Institute, Australia In this lecture, I will outline some important developments in the way chronic pain is understood and treated. I will present fundamental research that has clear implications for the treatment of people in pain for example, studies that show a two way relationship between the state and regulation of our body and the way our body feels, and studies that show high-order cognitive processes have implications for blood ﬂow, brain processing of sensory input, immune function and immune-related tissue inﬂammation. These exciting ﬁndings are more exciting than they are intimidating - I will contend that we can harness the complexity of the human brain to help people in pain. I will provide examples of the use of visual input to trick and train the brain of people with chronic painful disorders. I will discuss studies that are at the forefront of this new line of enquiry and suggest that we are obliged as clinicians to begin integrating these new ﬁndings within our current clinical reasoning paradigms.

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Keynote Abstracts / Manual Therapy 14 (2009) S1–S4

[K9] Subgrouping patients with low back pain in primary care: Are we getting any better at it?

[K10] Understanding the lateral stability mechanism of the hip and pelvis A. Grimaldi, University of Queensland, Australia

N.E. Foster, Keele University, UK Low back pain is a common, disabling condition with high personal and economic costs. Despite available guidelines for practice, there have not been tangible reductions in the population prevalence of back pain or its serious long-term consequences. One reason for this, that has received increasing research attention, is that the ‘‘one size ﬁts all approach’’ advocated by many guidelines fails to target treatments at patients who might beneﬁt from them most, thus diluting their potential beneﬁts. Systematic identiﬁcation of key obstacles to recovery in primary care back pain patients from high quality epidemiological studies can inform the development of early, targeted interventions. Indeed, maximising the potential for optimally targeted interventions is predicated on better understanding of the prognostic factors that are causally related to clinical outcome and identifying which are a) most predictive of outcome and b) most likely to be modiﬁable in primary care. Only then can closer matching of treatments to patient characteristics be a clinical reality. Using speciﬁc examples drawn from recent research within the Arthritis Research Campaign National Primary Care Centre at Keele University in the UK, and other studies, this presentation will provide an overview of subgrouping approaches under investigation, provide new evidence about the predictive strength of obstacles to recovery and share experience from studies that focus on translating subgrouping approaches into workable systems in primary care clinical practice. Acknowledgements: Research support from the Arthritis Research Campaign (arc), the National Institute of Health Research (NIHR) and the Health Foundation. Nadine Foster is funded by a Primary Care Career Scientist Award from the NIHR in the UK.

The lateral stability mechanism of the hip consists of a complex arrangement of muscles with variable function and differing responses to the presence of joint pathology, or to unloading in the absence of pathology. Clearer understanding of the function and dysfunction of this system will be important for the development of more speciﬁc and effective management programmes not only for hip pathologies, but for optimal alignment and function of the lumbopelvic region and the whole lower kinetic chain. The hip abductor synergy primarily responsible for lateral stability can be divided into 3 layers – the superﬁcial layer consisting of the tensor fascia lata muscle, the upper portion of the gluteus maximus muscle, and their connections with the iliotibial band, the intermediate layer including the piriformis and the gluteus medius muscles, with the gluteus minimus muscle the deepest member of the abductor synergy. This presentation will provide evidence from recent research to suggest that our approach to assessment and therapeutic exercise prescription for lateral pelvic stability may need to be re-evaluated. Exercise prescription should address all parts of the abductor synergy in a manner consistent with their normal functional role. Real time ultrasound in assessment and re-education of the hip abductors may be a valuable tool, while higher level exercise progressions should consider the importance of weightbearing stimulus and pelvic-femoral alignment for optimal muscle balance within the abductor synergy.

Manual Therapy 14 (2009) S5–S8

Contents lists available at ScienceDirect

Manual Therapy journal homepage: www.elsevier.com/locate/math

GUEST LECTURE ABSTRACTS

[GL1] Pain-induced changes in motor control revealed by muscle imaging D. Falla, Aalborg University, Denmark Take Home Message: 1. Although neuromuscular impairments are well documented in patients with musculoskeletal pain, the relationship between pain, altered motor strategies and changes in muscle properties are not fully understood. 2. High-density surface EMG (muscle imaging) has shown that muscles with complex architecture display variations in activity among different regions. For example, during fatiguing contractions, the relative activity of the cranial region of the upper trapezius muscle increases more with respect to the caudal muscle region. 3. Variation in activation within regions of the same muscle seems an efﬁcient strategy for avoiding accumulation of metabolites within the same muscle region; accordingly, this strategy is associated with a reduction in fatigue. 4. In contrast, in the presence of acute and chronic pain, patients perform sustained contractions with negligible changes in the relative activation of different muscle regions. 5. A long term consequence of this strategy is an overload of muscle ﬁbers and as a further consequence, alterations in the biochemical status of the muscle. This knowledge provides new insight into the development of altered muscle properties which may play a key role in the chronicity and recurrence of pain. [GL2] Shoulder girdle control; some mechanisms of function to dysfunction C. Alexander, Imperial College Healthcare NHS Trust, UK Fast conducting, group I muscles afferents originating in the forearm and hand evoke long latency, facilitatory reﬂexes to the scapulothoracic muscles, trapezius and serratus anterior in healthy subjects (Alexander and Harrison 2003). These transcortical reﬂexes are facilitated during tasks that require precise use of the hand (Alexander et al. 2005). Presumably this is in order to assist the stabilisation and appropriate positioning of the scapula upon the chest wall whilst doing a task with the hand. Interestingly these reﬂexes are similarly modulated by observation of this hand task alone (Alexander et al. 2004). In contrast to healthy subjects, these reﬂexes are delayed or in the main absent in people with various shoulder dysfunctions. In order to investigate why this might be the case, we examined this reﬂex pathway in 11 subjects suffering with non-traumatic shoulder instability (NTSI) and compared the results to a healthy population (n ¼ 15). The subjects with NTSI had a low to moderate degree of disability (Oxford Instability Shoulder Score ¼ 25.1/60 9.7). With ethical approval and informed consent, we attempted to evoke this reﬂex using electrical stimulation of the ulna nerve at the elbow. Secondly, the conduction velocity of the effective afferents was recorded by additional stimulation of the ulna nerve at the level of the wrist. Thirdly, the descending control of trapezius was investigated using magnetic

stimulation of the contralateral motor cortex to record the latency and threshold of the motor evoked potential (MEP) of trapezius. Finally, the motor response and H reﬂex of trapezius were recorded by electrically stimulating the spinal accessory nerve and the cervical nerve of C3/4 (Alexander and Harrison 2002). The long latency reﬂex from ulna nerve afferents to the lower ﬁbres of trapezius had a longer latency (p < 0.01) and was less frequently evoked (p < 0.002) in subjects with NTSI when compared to the healthy group. However, this was not the case for this reﬂex evoked in upper trapezius (p ¼ 0.23 and 0.41 respectively). When we examined the reﬂex pathway, the conduction of the peripheral part of the pathway was not different to the healthy group. However, the corticospinal part of the reﬂex pathway did differ. The threshold to evoke an MEP in the lower ﬁbres of trapezius was greater (p < 0.006) and the latency of the lower trapezius MEP was longer (p < 0.003). However, the threshold and latency of the upper trapezius MEP did not differ (p ¼ 0.21 and 0.11 respectively). How these physiological differences relate to the patient’s problems will be discussed. These results suggest that feedback mechanisms, some of which may assist scapula stability are not as proﬁcient in subjects with NTSI. These changes seem to be due, at least in part, to an alteration in the corticospinal control of lower trapezius. This suggests that there are also implications for the voluntary action of this muscle (Alexander 2007). Reference List 1. Alexander CM (2007) Altered control of the trapezius muscle in subjects with non-traumatic shoulder instability. Clin Neurophysiol 118:2664-2671. 2. Alexander, C. M., Chase, H., Reynolds, C., and Harrison, P. J. The effect of mental effort on the amplitude of shoulder girdle reﬂexes? Proceedings of the 34nd Annual meeting of the Soc.for neuroscience , 417.12. 2004. 3. Alexander CM, Harrison PJ (2002) The bilateral reﬂex control of the trapezius muscle in humans. Exp Brain Res 142:418-424. 4. Alexander CM, Harrison PJ (2003) Reﬂex connections from forearm and hand afferents to shoulder girdle muscles in humans. Exp Brain Res 148:277-282. 5. Alexander CM, Miley R, Harrison PJ (2005) Functional modulation of shoulder girdle stability. Exp Brain Res 161:417-422. [GL3] Rehabilitative ultrasound imaging: Technology to improve assessment and treatment of those with musculoskeletal conditions D. Teyhen, Academy of Health Sciences, USA Over the past decade, researchers have identiﬁed associations between neuromusculoskeletal disorders such as low back pain and underlying neuromuscular control deﬁcits.2 However, reliable and valid non-invasive measurement strategies that could be employed in a clinical setting have been scarce. Evidence for the use of ultrasound imaging as a strategy to assist with these patient populations is growing. The use of ultrasound technology for medical applications began in the 1950s and it has proven to be an effective, safe, and relatively inexpensive tool for assessing morphologic characteristics and structural integrity of visceral organs and soft tissues. Speciﬁcally related to physical therapy practice, the use of

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Guest Lecture Abstracts / Manual Therapy 14 (2009) S5–S8

ultrasound to assess muscle morphology and guide rehabilitation decision-making can be traced back to the late 1960s.6 Over the last decade there has been rapid development of this technique, with reliable and valid non-invasive measurement procedures that can be employed in a clinical setting. The use of ultrasound imaging in the rehabilitation of neuromusculoskeletal disorders has been coined ‘‘rehabilitative ultrasound imaging’’ (RUSI). RUSI has been deﬁned as ‘‘a procedure used by physical therapists to evaluate muscle and related soft tissue morphology and function during exercise and physical tasks.and is used to assist in the application of therapeutic interventions aimed at improving neuromuscular function.’’4 RUSI has been advocated to improve the understanding of the relationship between motor control and function, determine which patients may beneﬁt from a speciﬁc exercise treatment approach, enhance treatment efﬁcacy via augmented feedback, and document the beneﬁts of speciﬁc exercise treatment approaches. Early RUSI research has been promising. This presentation will provide an overview of how RUSI has been applied in both clinical and research settings to assess underlying muscular dysfunction and exercise prescription for the abdominal wall,5 posterior spine,3 and pelvic ﬂoor,7 and the potential of RUSI as a biofeedback tool to help with rehabilitation.1 References 1. Henry SM, Teyhen DS. Ultrasound imaging as a feedback tool in the rehabilitation of trunk muscle dysfunction for people with low back pain. J Orthop Sports Phys Ther. 2007;37:627-634. 2. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J Electromyogr Kinesiol. 2003;13:361-370. 3. Stokes M, Hides J, Elliott JM, Kiesel KB, Hodges P. Rehabilitative ultrasound imaging of the posterior paraspinal muscles. J Orthop Sports Phys Ther. 2007;37:581-595. 4. Teyhen D. Rehabilitative ultrasound imaging symposium San Antonio, TX, May 8-10, 2006. J Orthop Sports Phys Ther. 2006;36:A1-3. 5. Teyhen DS, Gill NW, Whittaker JL, Henry SM, Hides JA, Hodges P. Rehabilitative ultrasound imaging of the abdominal muscles. J Orthop Sports Phys Ther. 2007;37:450-466. 6. Whittaker JL, Teyhen DS, Elliott JM, et al. Rehabilitative ultrasound imaging: understanding the technology and its applications. J Orthop Sports Phys Ther. 2007;37:434-449. 7. Whittaker JL, Thompson JA, Teyhen DS, Hodges P. Rehabilitative ultrasound imaging of pelvic ﬂoor muscle function. J Orthop Sports Phys Ther. 2007;37:487-498. [GL4] What does proprioception testing tell us about patellofemoral pain? M. Callaghan, University of Manchester, UK Proprioception has become an increasingly common measure of joint function. Various techniques have been used to detect differences between healthy knee joints and those with OA(8), ACL deﬁciency(3) and PF pain(1,4). Proprioception testing has also been used as an outcome measure after therapeutic interventions. This allows researchers to show an association between symptom changes and proprioception status after treatment with braces(7), taping(2) and rehabilitation programmes(5). Methods to assess proprioception commonly involve perception of movement (TDPM) active and passive joint position sense (JPS). A more recent technique of assessing proprioception using vibratory perception threshold (VPT) can distinguish between healthy and OA knees(6). This method may have advantages over the TDPM and JPS techniques in terms of reliability and reproducibility, but this has yet to be fully established. Finally, fMRI techniques provide an exciting opportunity to examine neural activity the areas of the brain associated with proprioception and coordination during a simple knee joint JPS task. fMRI techniques can also note the activity changes that occur when patellar tape is applied. References 1. Baker V, Bennell K, Stillman B, Cowan SM, Crossley K: Abnormal knee joint position sense in individuals with patellofemoral pain syndrome. J Orthop Res 20:208-214, 2002.

2. Callaghan MJ, Selfe J, McHenry A, Oldham JA: Effects of patellar taping on knee joint proprioception in patients with patellofemoral pain syndrome. Man Ther 13:192-199, 2008. 3. Corrigan JP, Cashman WF, Brady MP: Proprioception in the cruciate deﬁcient knee. J Bone Joint Surg (Br) 74(B):247-250, 1992. 4. Kramer J, Handﬁeld T, Keifer G, Forwell L, Birmingham TB: Comparisons of weight bearing and non weight bearing tests of knee joint proprioception performed by patients with PFPS and asymptomatic. Clin J Sport Med 7:113-118, 1997. 5. Panics G, Tallay A, Pavlik A, Berkes I: Effect of proprioception training on knee joint position sense in female team handball players. Brit J Sports Med 42:472-476, 2008. 6. Shakoor N, Agrawal A, Block JA: Reduced lower extremity vibratory perception in osteoarthritis of the knee. Arthritis & Rheumatism (Arthritis Care & Research) 59:117-121, 2008. 7. Van Tiggelen D, Coorevits P, Witvrouw E: The Effects of a Neoprene Knee Sleeve on Subjects With a Poor Versus Good Joint Position Sense Subjected to an Isokinetic Fatigue Protocol. Clin J Sport Med 18:259-265, 2008. 8. Wegener L, Kisner C, Nichols D: Static and dynamic balance responses in persons with bilateral knee osteoarthritis. J Orthop Sports Phys Ther 25:1318, 1997. [GL5] Breathing evaluation and retraining as an adjunct to manual therapy L. McLaughlin, NAIOMT, Canada Back and neck pain are extremely common health problems comprising a substantial portion of patients seeking manual therapy treatment. Meta Analyses regarding spinal pain management state that best practice includes manual therapy, education and exercise but suggests there is substantial room for improvement. Epidemiological evidence supports a link between breathing difﬁculties and back pain. Since trunk muscles perform both postural and breathing functions, it is theorized that disruption in one function can negatively impact the other. Altered breathing mechanics can change respiratory chemistry and therefore pH causing smooth muscle constriction, altered electrolyte balance and decreased tissue oxygenation. These changes can profoundly impact any body system leading to a wide range of possible symptoms. Increased excitability in the muscular and nervous systems may be most relevant to a manual therapist. Respiratory function can be tested via capnography which measures CO2 at the end of exhale known as End Tidal CO2 or ETCO2. ETCO2 closely reﬂects arterial CO2 in people with normal cardiopulmonary function. Capnography is used in critical care settings and is considered an accurate, time sensitive arterial CO2 measure. To investigate breathing as a possible contributor to musculoskeletal pain a pilot study was undertaken. A case series of twenty nine outpatients with neck or back pain who had plateaued with manual therapy and exercise were identiﬁed to determine whether poor respiratory chemistry was present and whether biofeedback training could improve chemistry, pain and function. All were found to have low ETCO2. Breathing retraining improved ETCO2, pain and function in all patients with 93% achieving a clinically important change in at least one of the measures of pain or function. Screening for breathing dysfunction using capnography can be easily integrated into a manual therapy approach providing access to this very relevant physiological information. Incorporating breathing management may improve patient outcomes in those patients where manual therapy, exercise and education do not provide full resolution of symptoms.

Guest Lecture Abstracts / Manual Therapy 14 (2009) S5–S8

[GL6] Recurrence of injury and pain in sport – What’s missing M. Comerford, Kinetic Control, UK; Performance-Rehab, Australia Screening of athletes for musculo-skeletal factors is commonplace in elite, professional and competitive sport. This screening is promoted as part of an injury risk management strategy to prevent recurrence of pain or reinjury. To date, musculo-skeletal screening has focused on testing joint range, muscle strength (both power and endurance) and testing muscle extensibility (Bennell et at 1998 1999, Garrick 2004, Leetun et al 2004, Gabbe et al 2005, Kibler et al 2006). Assessing these parameters invariably tends to isolate the individual joints or muscles in non-functional ‘standard’ situations. All have been relatively unsuccessful at predicting risk of re-injury or recurrence of pain. There is almost no reliable evidence base to support the use of screening for these physical factors to either predict risk of injury to prevent re-injury in the systematic review or meta-analysis databases (Chalmers 2002, Wingﬁeld et al 2004). Currently, the research and review evidence points to a history of previous injury being the single most consistent and reliable predictor of high risk of re-injury (Van Mechelen et al 1992 1996, Watson 2001, Locke 2003, Reed 2004, Joy et al 2004, Fuller & Drawer 2004). If this is the case, then clearly there is a problem in the way that we are managing the original or previous injury. It seems that the acceptable outcomes of asymptomatic function, normal range of joint motion (isolated testing) and normal muscle strength (isolated testing) are not adequate rehabilitation end points to prevent recurrence. The process of assessing the control of ‘real’ function, that is, the inﬂuence of the multiple muscle interactions acting on multiple joints in functionally orientated tasks has not be promoted because it has universally been put in the ‘too hard basket’. This is the missing piece of the screening puzzle. [GL7] Outcome following treatment for chronic low back pain. What are the processes of change? S. Woby, North Manchester General Hospital, UK Determining the processes that underpin outcome from treatment could facilitate reﬁnement of theoretical models and the development of more effective treatments. Chronic low back pain (CLBP) is a complex condition and therefore multiple factors are often targeted during treatment. However, the speciﬁc processes that determine successful outcome from treatment are still unclear. This presentation will review the existing literature that has investigated processes of change within CLBP. [GL8] Pre-season screening of professional footballers – The role of movement assessment W. Diesel, Tottenham Hotspur Football Club, UK Traditionally pre-season physiotherapy screening exams of footballers have in the main revolved around joint speciﬁc clinical tests. However, more recently medical staff at Tottenham Hotspur Football Club has started looking at screening tools that are functional; require little or no equipment; don’t take long to complete and hopefully prevent either the onset or recurrence of intrinsic injuries. The National Academy of Sports Medicine’s [NASM] approach to functional screening met all of these objectives. The functional movements used include an Overhead Squat [OHS] and Single–Legged Squat [SLS]; requires only a postural grid; digital camera and can be completed inside of 15 minutes. Overactive muscle groups that require inhibition and lengthening as well as underactive muscle groups that need isolated strengthening can then easily be identiﬁed and incorporated into the player’s individual Injury Prevention [IP] programmes. Historically all players, irrespective of differing movement dysfunction patterns, participated in identical IP programmes.

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Finally, in the event of injury thought to result from dysfunction in their movement patterns, the restoration of correct movement patterns will follow a speciﬁc sequence of events. The NASM have developed a Corrective Exercise Strategy that will be discussed during the presentation. [GL9] Evidence from cognitive neuroscience supports action observation as part of an integrated approach to stroke rehabilitation P. Holmes, Institute for Performance Research, Cheshire Faculty, MMU, UK Recent advances in brain imaging have led to a greater understanding of the mechanisms of post-stroke recovery. This knowledge has been essential for optimizing the efﬁcacy of interventions aimed at promoting motor recovery. All forms of brain plasticity are possible following stroke. Therefore, any functional post-stroke intervention should attempt to enrich neural stimulation in order to promote plasticity. This paper will report ﬁndings from electroencephalographic, transcranial magnetic stimulation and applied research that provides evidence to support the use of action observation in stroke rehabilitation. Data will be presented that show: (i) a functional equivalence between central markers of action execution and action observation; and (ii) increased MEP amplitude during action observation. The application of these ﬁndings to a longitudinal study of individuals with stroke will reveal how action observation can support physical therapies to improvements in motor function and affective behaviour.

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Guest Lecture Abstracts / Manual Therapy 14 (2009) S5–S8

[GL10] ‘‘What if’’: the use of biomechanical models for understanding and treating upper extremity musculoskeletal disorders D.J. (H.E.J.) Veeger, VU University Amsterdam, Delft University of Technology, The Netherlands The structure of the shoulder is an ingenious compromise between stability and mobility that allows the hand to be moved within almost 2/3 of a sphere. In addition to the truly three-dimensional mobility of the upper extremity, the hand is capable of exerting forces in almost any direction. This versatility is enabled by mobile joints and controlled by mono-, bi- and tri-articular muscles. Given the 3D structure of the shoulder, muscles will not only generate joint moments to meet external forces, but will also generate considerable undesired joint moment components, which must be compensated by other muscles. Also, the mechanical effect of each muscle is highly dependent on arm posture and can even change sign completely. We developed a musculoskeletal model of the shoulder and elbow to aid understanding the working of the upper extremity. The model comprises the thorax, scapula, clavicle, humerus and forearm and all muscles controlling these. The model uses musculoskeletal parameters from one specimen and works on the assumption of the existence of a general control principle (or cost function) based on the minimization of energy cost. The model can, and has been used for several clinical applications, of which a selection will be discussed: 1. prevention of muscle overload: to be able to prevent overload injuries in wheelchair users the magnitude of muscle strains and joint loading should be quantiﬁed so that decisions on training and overuse prevention can be made (Van Drongelen et al, 2005); 2. ‘‘what if’’: The decision on what tendon transfer to perform to restore function is dependent on its functional gain, f.i. in terms of Activities of Daily Living (Magermans et al, 2004), on the newly constructed moment balance around a joint (Veeger et al., 2004); 3. understanding muscle control in pathological cases: in patients sometimes muscle activation patterns can be seen that conﬂict with their primary function (Steenbrink et al., 2006) Understanding this requires insight in the mechanical balance of the system, including all interactions between muscles; Any modeling result is only as good as the model itself. Recently, the model has been validated with the use of an instrumented endoprosthesis (Asadi Nikooyan, 2008). Validation has included the effect of scaling, but still two issues remain, namely the extent to which patient data can be related to model results in which a general control principle is assumed and second, to what extent models can, or should be individualized. References 1. Van Drongelen et al, Archives of Physical Medicine & Rehabilitation 2005;1434-1440. 2. Magermans et al, Clinical Biomechanics 2004; 116-122. 3. Veeger et al., Journal of Hand Surgery 2004; 259-264. 4. Steenbrink et al., Manual Therapy 2006; 231-237. 5. Asadi Nikooyan et al, 2008, Proceedings 16th ESB Conference, Lucerne, Switzerland.

[GL11] Rehabilitating Achilles Tendonopathy J. Fearn, Reading Football Club, UK This lecture will review rehabilitation strategies involved in managing Achilles Tendonopathy (AT). A brief overview of current evidence is given initially to update delegates on the latest physiology, pathology, assessment and diagnosis of AT. The core of the lecture will discuss the many suggested aetiological factors, both extrinsic and intrinsic, and go onto discuss options for conservative intervention. Areas that will be discussed in more detail include load management, exercise progression, eccentric training methods, manual therapy techniques, electrotherapy and scrutinise the numerous injection therapies available to the clinician. Treatment strategies for the two fundamental types of AT, Proliferative and Degenerative, will be suggested. The author’s background in the rehabilitation of elite athletes allows him to offer some useful practical rehabilitation guidelines from early to late stage, stressing the essential aspect of the functional demand of the target tissue and of the athlete.

Manual Therapy 14 (2009) S9–S10

Contents lists available at ScienceDirect

Manual Therapy journal homepage: www.elsevier.com/locate/math

CLINICAL SEMINARS

[CS1] Demonstration of an examination for movement system low back syndrome

[CS3] Training the brain: principles, pitfalls and pearls Lorimer Moseley, Prince of Wales Medical Research Institute, Australia

Shirley Sahrmann, University School of Medicine, USA This seminar will use either a video or a volunteer subject to demonstrate the complete examination for a low back syndrome. The examination consists of a series of tests of movements of the lumbar spine of the limbs and how they affect the lumbar spine. The primary test is one in which the patient performs the movement in his/her preferred manner while both the symptoms and the precision of performance is noted. The secondary test is one in which the patient is shown how to perform the movement correctly and the effect on the symptoms is noted. The tests are performed in standing, supine, sidelying, prone, quadruped and sitting. The tests are used to indicate the movement direction that most consistently causes pain and when corrected decreases or eliminates the pain. The identiﬁed movement direction is designated as the patient’s movement system diagnosis. The examination not only provides the diagnosis but also identiﬁes the contributing factors, tissue adaptations, and the speciﬁc exercises that will be the basis of the patient’s treatment. The examination also enables the patient to learn the movements that cause pain and how to minimize or eliminate the pain. The results of the examination also provide indicators of the way the patient performs his daily activities that are contributing to his/her pain problem. Correction of the way the patient performs his daily activities is an important part of the treatment program. Upon completion of this seminar the participant will be able to describe the 1) examination for movement system low back syndromes, 2) development of the diagnosis, 3) contributing factors and 4) treatment program. [CS2] Sub-Classiﬁcation of non-speciﬁc CLBP patients: integrating pieces of the evidence into clinical practice Wim Dankaerts, KUL-PHL, Belgium Major focus of this clinical seminar will be on integrating novel research ﬁndings into clinical practice for pain disorders of the lumbo-pelvic region, where motor control has been compromised and is deemed to be an underlying basis for disorder. This clinical seminar draws together current knowledge as well as ongoing clinical work investigating the classiﬁcation and management of CLBP disorders. It includes case studies and equips physiotherapists to develop skills in diagnostics as well as the design of motor learning interventions.

This clinical seminar delves deeper into clinical strategies for people in pain. Principles of brain plasticity will be presented in clinically accessible terms. Pitfalls and problems that have been faced by various clinical research groups will be discussed, as well as practical pearls of wisdom. Participants will be encouraged to offer, on the basis of their clinical experiences, their own pitfalls and pearls (although contributions must be succinct - the chairperson will not tolerate wafﬂe!) Pitfalls and problems will be discussed in the hope of possible solutions, as time permits. [CS4] Treatment of shoulder impingement: Targeted intervention strategies Paula M. Ludewig, University of Minnesota, USA Exercise programs for shoulder impingement have generally been show to have signiﬁcant positive effects. However, treatment programs vary widely and are often non-speciﬁc. This clinical seminar will present examples of potential sub-categories of movement based diagnoses for persons with shoulder impingement. An overview of patient clinical and movement presentation for each category will be provided. Biomechanical implications for the rotator cuff will be identiﬁed. Capabilities of speciﬁc shoulder muscle groups to contribute to or reduce deviations will be described. Integration of the clinical and biomechanical factors to direct targeted intervention strategies for each sub-category will be illustrated with case examples. It is proposed that sub-grouping based on movement deviation categories and subsequent targeted intervention can improve overall long term outcomes for the treatment of shoulder impingement pain and dysfunction.

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Clinical Abstracts / Manual Therapy 14 (2009) S9–S10

[CS5] The Selective Functional Movement Assessment G. Cook, Averett University, Gray Cook Physical Therapy, Functional Movement Systems, USA The Selective Functional Movement Assessment (SFMA) is a series of 7 full body movement tests designed to assess fundamental patterns of movement such as bending and squatting in those with known musculoskeletal pain.1 When the clinical assessment is initiated from the perspective of the movement pattern, the clinician has the opportunity to identify meaningful impairments that may be seemingly unrelated to the main musculoskeletal complaint, but contributing to the associated disability. This concept, known as Regional Interdependence, 2 is the hallmark of the SFMA, which guides the clinician to the most dysfunctional non-painful movement pattern that is then assessed in detail. By addressing the most dysfunctional non-painful pattern, the applications of targeted therapeutic exercise choices are not adversely affected by pain. The SFMA serves as a clinical model for the musculoskeletal healthcare professional to address regional interdependence. This approach is designed to complement the existing exam and should serve as a model to efﬁciently integrate the concepts of posture, muscle balance and the fundamental patterns of movement into musculoskeletal practice. This seminar will include a short introductory lecture and the remaining time will be spent demonstrating the clinical application of the SFMA. Selected References 1. Cook E, Kiesel K. Impaired Patterns of Posture and Function In: Prentice B, Voight M, eds. Techniques in Musculoskeletal Rehabilitation. 2nd ed. Chicago: McGraw-Hill; 2006. 2. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. Nov 2007;37(11):658-660.

[CS6] Speciﬁcity in assessment and management of hip abductor muscle dysfunction Alison Grimaldi, University of Queensland, Australia The hip abductor muscle synergy may not be most effectively assessed or managed as a single entity in those with musculoskeletal dysfunction. This seminar will provide ideas for improving the speciﬁcity of our assessment and exercise approaches with the aim of optimising treatment outcomes in both the short and long term. Assessment techniques will cover functional movement patterns, muscle tests and real time ultrasound evaluation. Exercise approaches discussed will include real time ultrasound retraining and progressions to weightbearing – movement retraining, strengthening, and perturbation training.

Manual Therapy 14 (2009) S11–S30

Contents lists available at ScienceDirect

Manual Therapy journal homepage: www.elsevier.com/locate/math

ORAL ABSTRACTS

[O01] Is back pain a problem for people with a stoma? A postal survey in Northern Ireland I.M. Wilson 1, D.P. Kerr 1, S. Lennon 2. 1 School of Health Sciences, University of Ulster, UK; 2 School of Health Sciences, Health and Rehabilitation Sciences Institute, University of Ulster, UK Study Design: A postal questionnaire sent to people in Northern Ireland with an ileostomy or colostomy. Introduction: The abdominal muscles play a vital role in lumbar stability. The stoma surgery creates a permanent ﬂaw in the abdominal wall and this may increase the risk of low back pain for people with a stoma. The aims were (i) to determine whether back pain was a problem for people with stoma, and if so, to investigate the characteristics of the back pain and related disability, and (ii) whether there was a difference in back pain experience between the two stoma groups: ileostomy and colostomy. Methods: The questionnaire was mailed to two groups in Northern Ireland: the entire membership of the Ileostomy Association of Northern Ireland (IA) (n ¼ 402), and to people who had either an ileostomy or colostomy who were on the stoma care nurses databases in various Trusts in Northern Ireland (n ¼ 920).

Results: Over half (56.7%, n ¼ 417) had back pain in the last 6 months and the primary perceived cause was the stoma surgery. This perception was supported by a statistically signiﬁcant ﬁnding (p < 0.001) of ﬁrst onset back pain being related to the time of stoma surgery. There was a statistically signiﬁcant deterioration in functional activities in those with back pain when ‘today’ was compared with ‘before surgery’, and those with a colostomy had generally poorer outcomes in respect of pain and disability, than those with an ileostomy. Discussion: This novel work has demonstrated that low back pain in people with a stoma is a real and complex issue. Many factors are likely to contribute to a person developing low back pain, not least, the underlying reason for the surgery and the surgical procedure itself. Keywords: low back pain, stoma, ileostomy, colostomy [O02] Respiratory dysfunction in neck pain patients. A pilot study Z. Dimitriadis 2,1, E. Vourazanis 1, J.A. Oldham 2, N. Strimpakos 1, 2, L. Komnianou 1, E. Kapreli 1. 1 TEI Lamia, Greece; 2 University of Manchester, UK Introduction: Neck pain is one of the most common musculoskeletal disorders with a tremendous impact on the quality of life and social activities of the sufferers. The management of neck pain is mostly related

Figure 1: Neck pain and respiratory dysfunction (Kapreli et al. (2008), with permission). This ﬁgure refers to [O02].

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[003] Multidisciplinary rehabilitation or surgery for chronic low back pain – 7 year follow up of a randomised controlled trial K. Barker 1, H. Frost 1, 2, J. Wilson MacDonald 1, J. Fairbank 1. Orthopaedic Centre NHS Trust, UK; 2 University of Warwick, UK

Figure 2: Regression model for the prediction of Pimax from the Forward Head Posture

Figure 3: Regression model for the prediction of Pemax from the Forward Head Posture

to the musculoskeletal deﬁcits of the disease. However, other systems such as the respiratory may be also affected. Changes in endurance, strength, range of movement, proprioception, pain and psychosocial impairments have been all stipulated to lead to respiratory dysfunction (Figure 1). The aim of this study was to investigate whether patients with neck pain present respiratory dysfunction. Methods: Twelve patients with chronic neck pain (5 males, 7 females) and twelve healthy age, height, weight and activity level-matched control subjects were recruited. Subjects’ perceived impairments were assessed by using the Neck Disability Index. A 11-point Numeric Rating Scale was used for assessing the average weekly pain intensity. Physical activity level was assessed by using the Baecke Questionnaire. The Forward Head Posture (FHP) was assessed by recording the craniovertebral angle through a camera. Spirometry and a mouth pressure meter were used for recording the pulmonary volumes and maximal mouth pressures respectively. Results: Patients with chronic neck pain were found to have signiﬁcantly decreased Maximal Inspiratory Pressure (Pimax), Maximal Expiratory Pressure (Pemax) and Maximal Voluntary Ventilation (p < 0.05). Regression analysis showed that FHP is signiﬁcantly correlated with Pimax (R2 ¼ 0.75, p < 0.01) (Figure 2) and Pemax (R2 ¼ 0.43, p < 0.05) (Figure 3). All the other differences and correlations were found to be no signiﬁcant (p > 0.05) Discussion: The ﬁndings of this study indicate that the respiratory system of patients with neck pain is also affected. This conclusion could have a great impact on various clinical aspects notably patient assessment, rehabilitation and consumption of pharmacological agents. Therapists are strongly advised to focus their assessment and intervention not only on musculoskeletal deﬁcits, but also on respiratory dysfunction. References Kapreli E., Vourazanis E. and Strimpakos N. (2008). Neck pain causes respiratory dysfunction. Medical Hypotheses. 70, pp. 1009-1013 Keywords: maximal inspiratory pressure, maximal expiratory pressure, spirometry, neck pain, forward head posture

1

Nufﬁeld

Introduction: The MRC sponsored Spine Stabilisation Trial (SST) 1 was a landmark study of 349 patients with chronic low back pain considered candidates for spinal fusion surgery. It suggested that intensive rehabilitation can produce similar results to spinal fusion surgery at 2 years at about half the cost. However there remained a need to ascertain the longer term outcome of patients managed by the rehabilitation and the surgical strategies. Methods: At 2 years there were 329 subjects remaining in the SST. These subjects were followed for a further 5 years. Subjects were contacted by postal questionnaire and completed the Oswestry Disability Index (primary outcome), SF-36 and Euroqol-5 questionnaire. They also completed a question about whether they had received either surgery or rehabilitation since completion of the original trial intervention that they were allocated. An intention to treat ANCOVA analysis was carried out. Results: At the 7 year follow up 235 (67%) subjects completed the ODI (109 rehab and 126 surgery groups). There was a non signiﬁcant difference of 2.29 (CI -7.9 – 3.2) between the groups in favour of rehabilitation (rehabilitation mean ODI 32.7 (std error 2.03, 95% CI 28.7-36.7); surgery mean ODI 35 (std error 1.98, 95% CI 31.1-38.9). There were no statistically signiﬁcant differences in the outcomes for the two intervention strategies for SF-36 and Euroqol. Overall there were only small changes in ODI values between the 2 and 7 year follow up. Discussion: This research suggests that rehabilitation including a cognitive behavioural approach is as beneﬁcial as surgery in the longer term (7 years after randomisation). Whilst subjects in both groups remained moderately disabled, rehabilitation was less invasive and cheaper. It is impossible to rule out the chance that subjects would have improved without either intervention, but rehabilitation should be seriously considered prior to fusion surgery. 1. Fairbank J, Frost H, Wilson-MacDonald J, Yu LM, Barker K, Collins R. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. Bmj 2005;330(7502):1233. Keywords: back pain, surgery, rehabilitation, fusion [O04] Decrease in postural sway and trunk stiffness during cognitive dualtask in non-speciﬁc chronic low back pain patients, performance compared to healthy control subjects U. Van Daele 1,2, F. Hagman 2, S. Truijen 1, P. Vorlat 3, B. Van Gheluwe 2, P. Vaes 2, 4. 1 Artesis University College of Antwerp, Belgium; 2 Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel, Belgium; 3 Universitair Ziekenhuis Brussel, Belgium; 4 Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Belgium Introduction: The purpose of the study was to investigate the effect of a cognitive dual-task on postural sway of pelvis and trunk during unstable sitting in non-speciﬁc chronic low back pain patients (CLBP) compared to healthy control subjects. Higher cognitive systems as well as sensory processes contribute to postural control. An increase in postural sway due to a cognitive dual task could mean more need of cognitive systems to control balance. Methods: Twenty-one CLBP patients and twenty-one control subjects were included based on detailed clinical criteria. Every subject was submitted to two postural control tests in an unstable sitting position (easy test position: two feet on the ground and difﬁcult test position: one foot lifted). Both tests were performed with and without cognitive dual-task. A three-dimensional motion analysis system was used measure angular displacement of trunk and pelvis in the 3 cardinal planes. Results: In the most difﬁcult balance position postural sway increases in the control group when the cognitive dual-task is added, for 50% of the variables the increase is signiﬁcant (p between .02 and .05). On the contrary postural sway decreases, not signiﬁcantly, in the CLBP group

Oral Abstracts / Manual Therapy 14 (2009) S11–S30

when the dual-task is added. These ﬁndings are the same for trunk as for pelvis deviations. The Pearson correlation coefﬁcient between trunk and pelvis movement from the CLBP group are lower for all three movement directions in the dual-task condition (r between .441 and .988) compared to the single task condition (r between .982 and .995). Discussion: In non-speciﬁc CLBP patients a cognitive dual-task reduces both postural sway and trunk stiffness due to the distracting effect of the dual-task. This effect is only visible when the balance task is difﬁcult. The automatic processes of balance keeping are probably increasing due to the dual-task. Keywords: chronic low back pain, postural control, cognitive dual task, trunk stiffness [O05] Exercise reduces work disability in patients with non-acute nonspeciﬁc low back pain: systematic review and meta-analysis of randomised controlled trials J. Kool 1, P. Oesch 2, 3, K.B. Hagen 4, S. Bachmann 2, 3. 1 Zurich University of Applied Science, Switzerland; 2 Research Department, Rehabilitation Centre Valens, Switzerland; 3 Department of Rheumatology, Rehabilitation Centre Valens, Switzerland; 4 University of Oslo, Norway Background and objective: Reviews based on studies published until 2002 found strong evidence that exercise compared to usual care reduces work disability in patients with non-speciﬁc non-acute Low Back Pain (LBP). New studies have been published. It remains unclear which type of exercise is most effective. Methods: We included RCT’s published in English, German or Dutch reporting on work disability. Data sources: MEDLINE, EMBASE, PsycLIT, PsycINFO, PEDro, Cochrane Library and NIOSHTIC-2 (until Aug. 2008). Study quality was assessed for selection bias, attrition bias, and detection bias. Publication bias was assessed using funnel plots. Work disability data were converted to odds ratios. Random effects meta-analyses were conducted. Results: 21 trials were included; 18 comparisons of exercise interventions with usual care and 13 comparisons between different exercise interventions. Overall treatment effect of exercise intervention in comparison with usual care (18 comparisons) with a total of 3275 patients was in favour of exercise (OR ¼ 0.67, 95% CI 0.53-0.86). Pooled effect estimates for the four low and 10 high quality trials were comparable (OR ¼ 0.55, 95% CI 0.320.94 and OR ¼ 0.72, 95% CI 0.54-0.93). In comparisons between exercise interventions and usual care (eight trials, 10 comparisons) short and intermediate term (4 weeks and 6 months) results revealed no effect whereas long term follow up (1 year) showed statistically signiﬁcant beneﬁts for work disability (OR 0.66, 95% CI 0.48-0.92). All differences between different types of exercise were non-signiﬁcant: Effects were slightly higher for shorter compared to longer treatment duration (OR 0.51, 95% CI 0.35-0.73 and OR ¼ 0.76, 95%CI 0.56-1.05), for home exercises then for supervised exercise (OR ¼ 0.38, 95%CI 0.17-0.84 and OR ¼ 0.70 95% CI 0.58 – 0.85), and for exercises with a behavioural treatment approach then for exercises without (OR ¼ 0.52, 95% CI 0.34- 0.80 and OR ¼ 0.72, 95% CI 0.57 – 0.91). The effect of exercise interventions with > 17 contact hours compared to exercise interventions with less contact hours (six trials) was not signiﬁcant. Conclusion: Exercise interventions have a long term effect on work disability in patients with LBP. We can expect a 33% improvement of work disability if an exercise intervention is used instead of usual care. No recommendations can be made for speciﬁc exercise types. Home exercises seem to be at least as effective as supervised programs. Keywords: exercise, low back pain, meta-analysis, disability [O06] Change in lumbar lordosis during prone knee ﬂexion test in subjects with and without low back pain A.M. Arab, A. Talimkhani, S. Emdadi. University of Social Welfare and Rehabilitation Sciences, Iran During the past decades the main focus in the evaluation of musculoskeletal disorders has been placed on the assessment of movement

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patterns. Prone knee ﬂexion is one of the most common tests which is used to asses the movement pattern of the lumbar-pelvic-hip complex. It is assumed that considerable increase in lumbar lordosis during this test is due to instability in lumbopelvic region. Trunk instability has been also associated with development of low back pain (LBP). However, no study that has directly evaluated the change in lordosis during prone knee ﬂexion test in patients with LBP. The purpose of this study was to investigate the change lumbar lordosis in prone knee ﬂexion test in subjects with and without LBP and to determine if this change varies between two groups. Convenience sample of 30 subjects participated in the study. Subjects were categorized into two groups: with LBP (n ¼ 15) and without LBP (n ¼ 15). A standard ﬂexible ruler was used to measure the size of lumbar lordosis. Lordosis was measured ﬁrst in prone position and then, after prone knee ﬂexion test in each group. The amount of change in lordosis between two measurements was calculated and compared in two groups. A two-way mixed-design ANOVA was used to determine the change in lordosis during the prone knee ﬂexion test in both groups. There was no signiﬁcant difference in lumbar lordosis between prone position and after prone knee ﬂexion test (P ¼ 0.08). There was no significant interaction between health status of subjects (having or not having LBP) and test position (P ¼ 0.69). In overall, the lumbar lordosis was not signiﬁcantly changed during prone knee ﬂexion test compared to prone position in both subjects with and without LBP. The amount of change in lordosis during prone knee ﬂexion test was not signiﬁcant between two groups (P ¼ 0.84). Keywords: Movement pattern, Low back pain, Lordosis, Prone knee ﬂexion [O07] Ultrasound imaging transducer motion during clinical lumbopelvic manoeuvres J.L. Whittaker 1, 2, M.B. Warner 1, M.J. Stokes 1. 1 University of Southampton, UK; 2 Whittaker Physiotherapy Consulting, Canada Introduction: Clinical use of ultrasound imaging (USI) by physiotherapists is increasing but its use in clinical settings may be problematic due to variability inherent in the environment. As transducer motion interferes with accurate measurement, this study aimed to measure transducer motion, relative to the pelvis, during a clinical simulation involving typical test manoeuvres on normal subjects. Methods: Transducer and pelvis motion about three axes (x, anterior/ posterior; y, medial/lateral; z, inferior/superior), was monitored (Vicon, Oxford, UK) on 11 subjects during three clinical manoeuvres (respiration, RESP; active straight leg raise, ASLR; abdominal drawing in, ADIM) at four imaging sites (lateral abdominal wall, LAW; linea alba, LA; sagittal and transverse supra-pubic, SSP and TSP respectively). Data were grouped and means used to determine discrepancies in transducer and pelvis motion for each condition (i.e. imaging site / manoeuvre combination). Results: None of the manoeuvres produced large transducer motions relative to the pelvis (Table 1). Table 1: Ultrasound Transducer Motion during a Clinical Simulation (degrees, Mean S.D, range)

CONDITION

X AXIS

Y AXIS

Z AXIS

RESP

LAW

2.3 0.8, (0.3 – 5.2)

3.3 1.4, (0.8 – 7.2)

ADIM LAW ASLR LAW LA SSP TSP

1.4 0.8, (0.2 – 3.8) 2.1 0.7, (0.7 – 3.3) 2.1 1.4, (0.5 – 6.1) 5.2 4.0, (0.8 – 19.3) 3.7 2.2, (1.0 – 8.9)

2.7 1.5, (0.5 – 6.9) 2.7 1.1, (1.0 – 6.5) 3.3 1.6, (1.0 – 10.3) 2.8 2.2, (0.7 – 9.9) 4.2 2.8, (1.2 – 10.1)

2 .2 1.1, (0.6 – 4.6) 1.4 0.7, (0.5 – 3.4) 4.1 1.4, (2.3 – 7.1) 4.8 2.4, (2.1 – 11.0) 7.1 4.5, (2.2 – 23.2) 5.6 2.6, (1.5 – 11.0)

Discussion: A previous study showed that no statistically signiﬁcant (p < 0.05) changes in measurements of transversus abdominis thickness or bladder base position occur if transducer motion is kept to less than approximately 5 – 10 degrees respectively1. The ﬁndings of the current study are within these guidelines suggesting that a transducer can be held

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Oral Abstracts / Manual Therapy 14 (2009) S11–S30

relatively stationary in a clinical setting for the manoeuvres tested in the hands of an experienced operator. Acknowledgments We thank Ion Medical Solutions, USA and Vicon, Oxford UK for funding. References 1. Whittaker JL, Warner MB, Stokes MJ, Induced Transducer Orientation during Ultrasound Imaging: Effects on Abdominal Muscle Thickness and Bladder Position, Ultrasound Med Biol (accepted), 2009. Keywords: Bladder Position, Transversus Abdominis, Ultrasound Imaging, Ultrasound Transducer, Validity [O08] An investigation into hip muscle strength of previously injured and non-injured gaelic footballers O. Kelly, A. Clifford, K. O’Sullivan. University of Limerick, Ireland Introduction: Hip muscle weakness and asymmetry can exist in subjects with a variety of lower-limb injuries, and within a variety of activity levels. However, there is a gap in the literature in studies involving Gaelic footballers, despite the high injury rate of 2.2 injuries per player per year (Wilson et al 2007). The purpose of this pilot study was to determine if a difference in hip muscle strength exists between dominant (preferred kicking) and non-dominant limbs of male Gaelic footballers, and if this difference also exists between previously injured (at knee and above) and non-injured limbs. Methods: A sample of convenience of 11 members of a University male senior Gaelic football team volunteered to participate, following ethical approval. Peak-torque, average peak-torque and peak-torque per kilogram body weight was measured isometrically for hip abductors, adductors, ﬂexors, extensors, internal and external rotators in all subjects, using the Biodex System 3 dynamometer. Data was analysed using paired t-tests (for comparisons between dominant and non-dominant limbs) and independent t-tests (for comparisons between previously injured and non-injured limbs). Results: The non-injured group had signiﬁcantly stronger hip abduction values for peak-torque to body weight (p ¼ 0.049), and signiﬁcantly stronger external rotation values for peak-torque to body weight (p ¼ 0.04), compared to the previously injured group. No statistically signiﬁcant difference was found between hip muscle strength of dominant and non-dominant limbs, however there was a trend towards signiﬁcance for the difference between hip abductors (non-dominant>dominant). Discussion: Hip muscle weakness and asymmetry may predispose male Gaelic footballers to lower-limb injury, or may be the result of previous lower limb injuries. The results of this study inform future research to determine exactly the cause-effect relationship between hip muscle weakness and lower-limb injury in Gaelic football. Greater subject numbers and a prospective study design are needed to verify these results. References Wilson, F., Caffrey, S.S., King, E.E., Case, K.K. and Gissane, C.C. (2007) ‘A 6 month prospective study of injury in Gaelic football’, British Journal of Sports Medicine, 41(5), 317-321. Keywords: Strength, Hip muscle, Gaelic Football, Injury [O09] Does stabilising the scapula change glenohumeral movements in healthy subjects? M.C. Cairns 1, G. Neal 2. 1 University of Hertfordshire, UK; 2 Devon PCT, UK Introduction: Relative stability of the scapula during upper limb activities is key to successful function and glenohumeral joint movement relatively independent of the scapula (scapulo-glenohumeral dissociation) has been proposed as part of shoulder rehabilitation. Previous literature has indicated that ﬂexion to 90 and abduction to 60 whilst maintaining a relatively stable scapula (scapula setting or re-orientation) is used as a clinical test/goal. The main aim of this study was to identify if asymptomatic subjects could achieve the above ranges.

Methods: Repeated, within session intra-reliability testing was undertaken of all measurement procedures and showed high levels of ICCs. Scapula upward rotation was measured at rest, and during glenohumeral ﬂexion and abduction using the PlurimeterV inclinometer during unrestrained movement and with scapula setting. Range of glenohumeral ﬂexion and abduction were measured in each condition. Initial scapula movement was identiﬁed by palpation and the range recorded. Examiners were blind to all measures. Tests were undertaken in a random order on thirty asymptomatic subjects (mean age 49.1years (SD: 9.5)), on both arms. Results: Signiﬁcantly greater ROM was achieved before scapula movement was detected using scapula setting than when not used; mean (SD) 72.2 (18.8 ) and 36.6 (13.4 ) for ﬂexion [t=-12.088;P<0.000] and 60.5 (18.4 ) and 34.4 (18.3 ) for abduction [t=-9.385; P<0.000]). Analysis of variance of the angle of upward rotation at rest and initial scapula movement revealed a statistical signiﬁcant difference between setting and nonsetting for abduction. Discussion: Scapula re-orientation or setting was associated with less scapula rotation during upper limb movements suggesting healthy subjects can consciously control their scapulae. Replication with symptomatic populations is necessary, but results support the use of scapula training where excessive upward rotation may contributes to symptoms. Abduction to 60 without signiﬁcant scapula upward rotation may be a reasonable goal clinically but ﬂexion to 90 may be slightly ambitious. Keywords: Shoulder, Sacpula, stabilising [O10] Tactile thresholds are preserved yet cortical sensory function is impaired in chronic non-speciﬁc low back pain patients B.M. Wand 1, F. Di Pietro 2, P. George 1, N.E. O’Connell 1. 1 The University of Notre Dame, Australia; 2 Bunbury Hospital, Australia; 3 Brunel University, UK Introduction: A substantial amount of evidence points to an alteration in brain structure and function patients with chronic non-speciﬁc low back pain (CNSLBP) [1-6]. One interpretation of these ﬁndings is that the observed brain changes may represent a disruption of the brain’s representations of the body part and the resultant body perception disturbance may underpin this clinical problem. The current study aimed to investigate sensory dysfunction in CNSLBP. Speciﬁcally we aimed to distinguish cortically mediated sensory dysfunction from peripheral dysfunction by comparing simple tactile thresholds with more complex cortically mediated sensory tests Methods: We investigated tactile thresholds (TTH), two point discrimination (TPD) and graphaesthesia over the lumbar spine of 19 CLBP patients and 19 age and sex matched healthy controls as a way of investigating whether CLBP patients present with a perceptual disturbance of their lumbar spine. Differences in performance of the sensory tests was explored using the Mann Whitney U Test and one-way between groups multivariate analysis of variance. Results: We found no difference in tactile threshold between the two groups (P ¼ .0.751). There was a statistically signiﬁcant difference between controls and LBP for TPD: F(1,36) ¼ 10.15, p ¼ .003 and letter error rate: F(1, 36) ¼ 6.54 p ¼ 0.015. The data indicate that LBP patients had a larger lumbar TPD distance and a greater letter recognition error rate. Discussion: Both TPD and graphaesthesia are dependant on the integrity of the primary sensory cortex [7]. These data support existing ﬁndings of perceptual abnormality in chronic back pain [8] and the preservation of tactile thresholds is suggestive of cortical rather than peripheral sensory dysfunction. Amelioration of these abnormalities may present a target for therapeutic intervention. References 1. Apkarian AV, Sosa Y, Sonty S, Levy RM, Harden RN, Parrish TB and Gitelman DR. Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. J Neurosci. 2004a;24:10410-10415 2. Apkarian AV, Sosa Y, Krauss B, Thomas P, Fredrickson B, Levy R, Harden RN and Chialvo D. Chronic pain patients are impaired on an emotional decision-making task. Pain. 2004b;108:129-136 3. Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci Lett 1997;224:58.

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4. Grachev ID, Fredrickson BE, Apkarian AV. Abnormal brain chemistry in chronic back pain: An in vivo proton magnetic resonance spectroscopy study. Pain 2000, 89:7-18. 5. Grachev ID, Ramachandran TS, Thomas PS, Szeverenyi NM, Fredrickson BE: Association between dorsolateral prefrontal N-acetyl aspartate and depression in chronic back pain: An in vivo proton magnetic resonance spectroscopy study. J Neural Transm 2003, 110:287-312. 6. Schmidt-Wilcke T, Leinisch E, Ga?nßbauer S, Draganski B, Bogdahn U, Altmeppen J, May A: Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients. Pain 2006, 125:89-97. 7. Knecht S, Kunesch E, Schnitzler A. Parallel and serial processing of haptic information in man: Effects of parietal lesions on sensorimotor hand function. Neuropsychologia 1996; 34: 7: 669-687 8. Moseley GL. I can’t ﬁnd it! Distorted body image and tactile dysfunction in patients with chronic back pain. Pain. 2008; 15:140(1): 239-43 Keywords: Chronic low back pain, cortex, graphaesthesia, two-point discrimination [O11] The assessment of vibration sense in a healthy population: a study to assess the inter-rater reliability and validity of the tuning fork

2

E.M. O’ Conaire 1, 2, A.B. Rushton 1. Westminster Primary Care Trust, UK

1

University of Birmingham, UK;

Background: Impairment of vibration sense has been demonstrated as an early sign of nerve pathology, and importantly has been shown to precede clinical symptoms and changes in nerve conduction velocity. A range of devices are used to assess vibration, with moderate to substantial reliability demonstrated for the Somedic Vibrameter. However, devices are expensive and time-consuming for use in practice and tuning forks are frequently used, supported by poorly designed reliability studies. The aims of this study were to evaluate inter-rater reliability and precision of a novel device to improve use of a tuning fork, and to evaluate its concurrent validity compared to the Vibrameter. Methods: Following a power calculation, a double-blinded and prospective, reliability and validity study employed 19 asymptomatic subjects with no evidence of nerve pathology. Two experienced physiotherapists assessed the median nerve distribution using the Vibrameter and tuning fork, with the order of testing counterbalanced. Inter-rater reliability was determined using Intraclass Correlation Coefﬁcients (ICC 2,1), precision using Bland Altman plots and Standard Error of Measurement (SEM), and concurrent validity using Pearson’s Product Moment Correlation. Results: ICC (2,1) was 0.798 (Vibrameter) and 0.520 (tuning fork). SEM was 0.289 mm (Vibrameter) and 2.55 seconds (tuning fork). Bland Altman plots demonstrated one case lying outside 1.96 standard deviations for both the Vibrameter and tuning fork. Pearson’s Product Moment correlation ranged from 0.515 to 0.634 for the two raters. Discussion and conclusions: The results support previous ﬁndings of reliability of the Vibrameter. Assessment of vibration sense using the tuning fork and a novel device demonstrated strong correlation with the ﬁndings of the Vibrameter to support concurrent validity, although it possesses moderate inter-rater reliability. The ﬁndings suggest that the tuning fork and novel device may be clinically useful. Further research exploring reliability in pathological populations is now required. Keywords: Vibration, tuning fork, reliability, validity [O12] Reliability of the median neurodynamic test 1: a painful response analysis in healthy subjects M. Barbero 1, E. Castelli 2, A. Piatti 3, M. Egloff 1, R. Gatti 2. 1 Department of Health Sciences, University of Applied Sciences of Southern Switzerland, Switzerland; 2 Vita-Salute University, Italy; 3 Department of Innovative Technologies, University of Applied Sciences of Southern Switzerland, Switzerland Purpose: Neurodynamic tests have been recently introduced to assess the neural tissue mobility and sensitivity to mechanical stress. Interpretation

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of these tests relies on both the pain provocation and the motion restrictions. Therefore is it important for clinicians, to include a diagnosis of neurogenic disorder, to be aware of what are both a normal and an abnormal response. Normal response to Median Neurodynamic Test 1 (MNT1) have been described and variability among subjects reported. The purpose of this study was to establish the intra-examiner reliability of the painful response to MNT1 in healthy subjects. Methods: Three physical therapists after a period of training on MNT1 were involved in the study as assessors. Fifteen healthy volunteers were randomly allocated to ﬁve sessions in group of three. During each session assessors performed the MNT1 twice (t1, t2) on both sides (R,L) to all the subjects. Assessor and side order were randomized and subjects wait ﬁfteen minutes before receiving a test on the same side. Subjects were instructed to stop the test at submaximal pain and to record the response on a body chart. Analysis: To analyze the painful response body charts were split in twentyeight anatomical areas. Intra-examiner reliability of the painful response has been investigated using the Jaccard Similarity Test. Additionally, using the same test, in each subject left and right painful response have been compared. Results: The average value of Jaccard index between t1 and t2 was 0.61. The intra-examiners reliability of the operators were respectively 0.67, 0.65 and 0.51. Signiﬁcant differences between the operators have been observed. The average value of Jaccard index between left and right painful response was 0.74. Conclusions: The intra-examiner reliability of the MNT1 in healthy subjects seems to be generally poor and their clinical application to test neurogenic disorder needs to be further investigated. Keywords: median neurodynamic test 1, reliability, painful response, intraexaminer

[O13] ‘‘Reduced head steadiness in whiplash compared to non-traumatic neck pain patients.’’ A. Woodhouse, O. Vasseljen. Norwegian University of Science and Technology, Norway Background: Whiplash associated disorders (WAD) have been associated with motor control changes. The evidence is however inconclusive concerning differences between persons with persistent WAD and persons with non-traumatic chronic neck pain. The aim of this study was to investigate head steadiness during two isometric neck ﬂexor tests in WAD. Methods: A cross-sectional study compared head motion velocity in a group of WAD-patients (N ¼ 57), a group of chronic non-traumatic neck pain patients (N ¼ 57) and a group of asymptomatic volunteers (N ¼ 57). The subjects performed two isometric holding tests from a supine position (high load test) and from a 60 backwards recumbent seated position (low load test). Head motion was recorded as angular velocity using a 3D tracking system (Fastrak). Findings: In the low load task, the WAD group showed signiﬁcantly higher angular velocity compared to both control groups. A larger within group variability was observed in the WAD-group with a smaller proportion of the subjects showing high values of angular velocity. This ‘high velocity’ subgroup reported signiﬁcantly higher levels of dizziness compared to the rest of the WAD group. No differences in head steadiness were found for the high-load task. Interpretation: A low load isometric task differentiated between a group of WAD patients and two control groups in this study, with the WAD group showing higher angular velocity, or decreased ‘steadiness’ of the head. The large variation of ﬁndings within the WAD group indicates that decreased steadiness might be of particular importance to a smaller portion of WAD patients that also report higher levels of dizziness. Keywords: Whiplash, Chronic neck pain, Isometric holding, Head steadiness

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[O14] Randomised clinical trial for primary care patients with neck pain: manual therapy versus electrical stimulation E. Escortell 1, Y. Perez 2, R. Riesgo 1, S. Garrido 1, A. Asunsolo 2, ´ , Spain ˜o de Salud, Spain; 2 Universidad Alcala I. Fuentes 1. 1 Servicio Madrilen This study is performed in the setting of a random clinical trial that evaluates the effectiveness of manual therapy as opposed to electric stimulation in patients with mechanical neck disorders in Primary Care (PC). The method and preliminary results are described in a publication. At the moment the writing group is preparing another manuscript with the ﬁnal results after 6 months of follow-up. Objective: To compare the effectiveness of manual therapy (MT) and Transcutaneous Electrical Nerve Stimulation (TENS) in decreasing pain intensity in patients with subacute and chronic neck pain (NP) attending a Primary Care Physiotherapy Unit. Design: Randomized clinical trial, by random assignment and with a blind evaluation of the response variable. Project approved by an ethical review board. This study was supported by a public grant. Setting: 13 Primary Care Physiotherapy Units of four Primary Care Sanitary Areas in Madrid Region. Patients: 90 patients with subacute of chronic NP were included. Three patients withdrew after treatment. Interventions: 47 patients received MT, and 43 TENS. Main measurements: The primary outcome was pain intensity difference before and after treatment, measured as the mean value of a visual analogue scale (VAS): beginning of treatment, average pain in the last two weeks, worst pain in the last two weeks. Also sociodemographic and prognosis variables by treatment group, and adverse effects were measured. Results: Pain intensity difference before-after TENS was 21.3 mm (CI 95% 13.3 to 29.3), and before-after MT was 21.9 mm (CI 95% 16.2 to 27.6). The mean difference between groups was 0.58 (CI 95% -9 to 10.1). Conclusions: TENS and MT reduce signiﬁcantly patient-perceived pain intensity, but this study shows absence of evidence of a difference between both treatments. There are no conclusive results about the effectiveness of different physiotherapy treatments that set an intervention strategy. Keywords: Neck pain, Primary Health Care, Manual Therapy, TENS [O15] The initial effects of different rates of lumbar mobilisations on pressure pain thresholds in asymptomatic subjects

[O16] Factors affecting the safety of cervical manipulation L.C. Thomas 1, D.A. Rivett 1, C. Levi 1, 2. 1 The University of Newcastle, Australia; 2 John Hunter Hospital, Newcastle, Australia Cervical manipulation has occasionally been associated with neurovascular incidents, in particular dissection of the vertebral and internal carotid arteries leading to stroke. Patients suffering a craniocervical arterial dissection may have a pre-existing arteriopathy, vascular anomaly or genetic predisposition. Exposure to minor mechanical trauma such as neck manipulation may then cause a dissection. If individuals at risk can be identiﬁed, adequate contraindications for manipulation may be applied. In addition, if signs and symptoms of dissection can be more easily recognised medical treatment can be expedited. The study identiﬁed cases of young craniocervical arterial dissection in the Hunter and New England regions of New South Wales, Australia. Speciﬁcally, the aims were to identify risk factors in the patient history, examine the presenting features and gain an understanding of the natural history of craniocervical arterial dissection. Methods: Descriptive study comparing medical records review of a retrospective cohort of patients aged 55 years or less who had experienced a radiographically conﬁrmed vertebral or internal carotid artery dissection with age and sex matched controls, with stroke from some other cause. Records were inspected for details of clinical features, radiological investigations, presenting signs and symptoms and preceding events, in particular mechanical trauma of the head and neck. Results: The medical records of 42 patients (25 males) with a mean age of 37.7 years were inspected. Eighteen patients had sustained arterial dissections of the internal carotid, 23 of the vertebral and one of the basilar. Twenty-six (61%) patients compared with 4 (9%) controls reported an episode of mild mechanical trauma to the neck or head within the preceding two weeks, of which 11 (26%) cases, 1 control, involved manual therapy applied to the cervical spine. Fourteen (33%) patients were smokers compared with 25 (59.5%) controls and 9 (21%) had hypertension compared with 20 (47%) controls. Conclusions: Mild mechanical trauma to the head and neck including manual treatment of the cervical spine may be associated with craniocervical arterial dissection. Cardiovascular risk factors commonly associated with stroke were not strongly represented in these patients compared to controls.

E. Willett, C. Hebron. School of Health Professions. University of Brighton, UK

Keywords: vertebral artery, dissection, manipulation, risk factors

Introduction: Lumbar mobilisations are commonly used in clinical practise to reduce pain and increase function. Mobilisations in the cervical spine have been shown to reduce pain using pressure pain thresholds (PPT). Yet there is no evidence to conﬁrm that this happens in the lumbar spine. Furthermore there is little known about the effects of different treatment doses on the amount of hypoalgesia produced. It is unknown if changing the rate of application of mobilisations has an effect on hypoalgesia. The aim of this study was to investigate the immediate effects of lumbar posteroanterior mobilisations performed at different rates on PPTs. Pressure pain thresholds were measured in a number of locations in order to assess the extent of the analgesic response. Method and Results: A repeated measures single blind, randomised-trial was conducted on 30 asymptomatic subjects (22 female and 8 males). Pressure pain thresholds were measured at 4 sites in the upper and lower quadrants, before and after the application of lumbar spine posteroanterior mobilisations performed at 2 Hz, 1 Hz and quasi-static. The results demonstrated an immediate and signiﬁcant improvement in PPT measures (P< 0.000) irrespective of the rate or site tested. The effects were both local and widespread. There was no signiﬁcant difference between the rates of mobilisations on PPTs. Conclusion: This study provides new experimental evidence that lumbar spine posteroanterior mobilisations produce an immediate and signiﬁcant widespread hypoalgesic effect, regardless of the rate of mobilisation. Further research is now needed to investigate the effect on a patient population with low back pain. Keywords: back pain, mobilisations, pressure pain thresholds, spinal manipulative therapy

[O17] Speciﬁc motor control exercise for lumbo-pelvic pain of articular origin: A systematic review S.G.T. Gibbons 1, 2, J. Clark 1, 3. 1 Neuromuscular Rehabilitation Institute, Canada; 2 Memorial University of Newfoundland, Canada; 3 Manchester Metropolitan University, UK Introduction: Speciﬁc motor control exercises (SME) involving transverus abdominus and lumbar multiﬁdus are commonly used in the treatment of low back pain (LBP). The results of 5 previous reviews suggest SME are better than an inactive control, but not better than other forms of treatment. A washout effect may be occurring due to the heterogeneous nature of chronic low back pain. The purpose of this study was to conduct a systematic review of SME for LBP of articular origin. Methods: The PEDro scale was used to critique the papers. The levels of evidence used by the Cochrane collaboration were adopted to make recommendations. Only those studies describing an intervention involving SME were included. Inclusion criteria were: the study was an RCT; study group had to receive a SME; the study group had to have articular related pain; the paper had to score 6 or higher on the PEDro scale. Results: Four papers that met in the inclusion criteria were identiﬁed. One study permitted each of the following recommendations: There is moderate evidence for the use of speciﬁc stability exercise for articular chronic LBP when used alone or when combined with another form of active treatment. There is moderate evidence for the use of SME for articular sub-acute LBP when combined with another form of active treatment.

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Discussion: Although the paper does provide moderate support for the use of SME for LBP of articular origin, there are a number of factors which suggest that the results should be interpreted with caution. This does highlight that a washout effect may have occurred in previous reviews and that there does appear to be a group of clients with LBP that SME can beneﬁt. Further research is highly recommended and some suggestions for future trials are made. It is hoped that this paper will stimulate further discussion and research in this area. Keywords: speciﬁc motor control exercise, lumbo-pelvic, systematic review, stability exercise [O18] An unstable base of support decreases Serratus Anterior muscle activity during push-up plus exercise in patients with chronic shoulder pain H. Fredriksen 1, 2, M.A. Risberg 2, 5. 1 Norwegian Olympic and Paralympic Committee and Confederation of Sports, Norway; 2 Norwegian School of Sport Science, Norway; 3 NAR, Norway; 4 Orthopaedic Centre Ullevaal University Hospital, Norway; 5 Hjelp24NIMI, Norway Background: The exercise push-up with a plus (push-up+) is commonly used in rehabilitation programs to increase scapular control in patients with shoulder pain and dysfunction. The aim of the current study was to determine if performing push-up+ exercise on an unstable surface (slings) inﬂuences EMG amplitude of the scapulothoracic muscles when compared to a stable surface (ﬂoor) in patients with chronic shoulder pain Methods and measures: Thirty-six patients with shoulder pain of more than 4 weeks duration were randomized into two groups, performing; 1) one session of push-up+ exercise with their hands on the ﬂoor (stable group), or 2) one session of push-up+ exercise with their hands in slings (unstable group). Surface electromyograms were recorded from the serratus anterior (SA), the upper trapezius (UT) and lower trapezius (LT) muscles during the push-up+ exercise. Non-parametric tests were used to compare results between the groups. Results: There was a signiﬁcantly higher EMG activation of the SA muscle in the stable group compared to the unstable group (p ¼ 0.023), but no signiﬁcant differences of the UT and LT muscles. Clinical implications: This is the ﬁrst study to report scapulothoracic muscle activation data during push-up+ exercise in patients with shoulder pain and dysfunction. The results indicate that the rationale for using an unstable base of support in shoulder rehabilitation is probably not an increased activation of the scapulothoracic muscles. Keywords: shoulder, electromyography, scapula, rehabilitation [O19] The effect of exercise position on trapezius activity during a scapular setting exercise T. Crowley, K. McCreesh. University of Limerick, Ireland Background: The ability to position the scapula in a neutral posture is widely considered an important aspect of the rehabilitation of shoulder pathology, therefore physiotherapists frequently prescribe scapula setting exercises for individuals experiencing shoulder pathology. Objective: To determine the inﬂuence of position (prone lying or sitting) on the level middle and lower trapezius EMG activity, and to establish any relationship with the subjects preferred exercise position. Methods: EMG activity of middle and lower trapezius muscle ﬁbres was measured in 20 healthy subjects (11 male; mean age 27; range 20-55yrs) while performing a commonly used scapular setting exercise in both a sitting and prone position, using surface electrodes. Order of testing was randomised, and 3 measurements were taken in each position. Ethical approval for the study was received from the appropriate Committee. Results: No statistically signiﬁcant difference was found for mean EMG activity between the 2 positions for middle trapezius (p ¼ 0.881) or lower trapezius (p ¼ 0.940). There was however a signiﬁcant correlation between gender and preferred exercise position with the female subjects favouring the sitting position (p ¼ 0.043) Intra-tester reliability of the EMG measurements was good, with ICCs ranging from 0.71 to 0.97

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Conclusions: Exercise position during scapular setting exercises does not appear to inﬂuence middle or lower trapezius muscle activity in a normal population. There may be other factors that inﬂuence choice of exercise position, including client preference, and functional needs. Keywords: scapula training, Electromyography, Trapezius [O20] An advanced cervical neuromuscular task performed by Whiplash and chronic non-traumatic neck pain patients A. Woodhouse, O. Vasseljen. Norwegian University of Science and Technology, Norway Background: Reduced accuracy during trajectory head movements and more jerky and irregular movement patterns are reported in whiplash associated disorders (WAD) compared to healthy controls. There is however limited evidence on differentiating between WAD and chronic non-traumatic neck pain (CNP). The aim of this study was to investigate whether a trajectory movement task can differ between WAD patients, CNP patients and asymptomatic controls. Methods: A case-control study was conducted with three study groups included: A WAD group (N ¼ 33), a CNP group (N ¼ 44) and a healthy control group (N ¼ 48). Head motion was recorded using a 3Space FastrakÒ device (Polhemus, USA). Measurements were done in an unsupported standing position. A Fastrak sensor was attached to the subjects’ forehead, recording the position and the orientation of the head. With a laserbeam attached on top of the head, the subjects traced a horizontal ﬁgure of eight posted on the wall at three meters distance at a set pace (20 secs) while angular velocity was recorded. To get an impression of head motion smoothness, the head velocity of the movement signal was analyzed within frequencies from 1-6 Hz and the RMS-values of the different frequency levels were computed. The non-parametric Kruskall Wallis test was used to analyze group differences. Results: The WAD group was found to have signiﬁcantly higher velocity (median 0,83 /sec) compared to the healthy controls (median 0,72 /sec) at frequency levels between 2-5 Hz (p ¼ 0,02). The difference between the WAD group and the CNP group (median 0,78 /sec) did not reach statistical signiﬁcance. The results were highly dependent on a subgroup of WAD patients with particularly high velocities. Conclusion: The ﬁndings indicate less accurate movement patterns among WAD patients compared to healthy controls. There was a similar tendency of difference between the WAD group and the CNP group, but this was not statistically signiﬁcant. The rather slow frequency levels of the movement irregularities indicate that such ‘jerky movements’ are visible to clinicians when investigating these patients. [O21] Proposed classiﬁcation system for peripheral nerve disorders with a musculoskeletal underlying mechanism P. Moulaert, W. Dankaerts. K.U. Leuven, Belgium Pain originating from peripheral neural tissue has different clinical presentations. In order to guide targeted interventions and effective management a clinical useful sub-classiﬁcation system is required. This classiﬁcation system for peripheral nerve disorders should be based on identifying the underlying mechanism(s) driving the disorder. Within a broader biopsychosocial construct, classiﬁcation of the clinical ﬁndings must be correlated with medical imaging and possible co-existing pathoanatomical ﬁndings. It is proposed that there are three subgroups. Subgroup 1 is associated with high levels of pain and disability, due to an underlying pathology and secondary adaptive movement and/or control impairments. Management if appropriate should be based on physiological rather than mechanical principles. In Subgroup 2 the pain disorder is forebrain driven, secondary to a dominance of psycho-social factors. In Subgroup 3 the adaptive movement impairment and control impairments results in abnormal nerve tissue loading and chronic pain. In both,

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movement and control impairment the subdivision into a mechanosensitive and/or a stenotic (compression) group based on clinical ﬁndings and medical imaging is essential for management. Further sub-classifying into three sub-types is based on the extend of possible nerve conduction loss. The movement impairment is characterized by pain avoidence behaviour and is mostly adaptive due to higher neural tissue mechanosensitivity. Treatment techniques are predominantly passive. Control impairments are associated with faulty postures and/or repetitive movements that result in abnormal strain on the peripheral nerves. The control deﬁcit is maladaptive. Treatment aims to restore the control impairment, with an important role in preventing and adjusting faulty postures. Keywords: classiﬁcation, peripheral nerve disorders, underlying mechanism, management [O22] A combination of constraint-induced therapy and motor control retraining in the treatment of focal hand dystonia in musicians Case studies of a guitarist and ﬂautist P. Berque 1, H. Gray 2, C. Harkness 1, A. McFadyen 2. Inﬁrmary, UK; 2 Glasgow Caledonian University, UK

1

Glasgow Royal

Introduction: Focal hand dystonia (FHD) in musicians is a painless taskspeciﬁc motor disorder characterized by an involuntary loss of control and coordination of individual ﬁnger movements (ﬁgure 1).1,2 It is associated with decreased cortical inhibition,3 and maladaptive cortical reorganisation showing fusion of the representational zones of the digits in the primary somatosensory cortex.4 Research into rehabilitation strategies for FHD is lacking.5 The aim of this study was to investigate the effects of an innovative behavioural therapy intervention, aimed at normalising movement patterns, in two musicians affected by FHD.

Figure 2. Constraint-induced therapy for both players.

the treatment period for both pieces (table 1)(ﬁgure 3). Results also showed a trend towards a substantial increase in the metronome speed achieved with good motor control (table 2). Discussion: There preliminary results suggest that this innovative protocol may be of great value for the treatment of musicians affected by FHD, with a trend towards normalisation of movement patterns. Tailored task-speciﬁc retraining9 may allow normal cortical segregation to be re-established and normal ﬁne motor control to be restored.10

Figure 1. Dystonic pattern for the ﬂute player: maintained ﬂexion of D5.

Methods: Two professional musicians, a 53 year old guitarist and 48 year old ﬂautist, volunteered to take part in this novel retraining protocol. Intensive constraint-induced therapy6 involved playing speciﬁc ﬁnger combinations for the dystonic ﬁnger, with a splint immobilising the compensatory digit (ﬁgure 2). Motor control retraining involved playing without splints at slow speed, while maintaining good movement patterns. Video recordings of the subjects playing an easy and a medium difﬁculty piece were used for data analysis every two months up to 12 months. The Frequency of Abnormal Movements scale (FAM)7 and the change in metronome speed achieved during motor control retraining8 were chosen as outcome measures. It was hypothesised that there would be signiﬁcant differences in the FAM scores and metronome speeds achieved over time. Results: Results revealed that the mean number of abnormal movements per second of instrumental playing decreased by approximately 80% over

Figure 3. Frequency of abnormal movements (FAM) scale: mean values for each subject and for each piece.

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Table 1. FAM Scale: Mean Values for Both Subjects, Expressed in Number of Abnormal Movements per Second. Easy Piece

Day 1 Day 8 Month Month Month Month Month Month

2 4 6 8 10 12x

Medium Piece

Mean

SD*

Mean

SD*

1.67 1.29 0.93 0.52 0.71 0.51 0.32 N/A

0.4313 0.6647 0.1414 0.6647 0.6293 0.6576 0.4525 N/A

2.36 2.22 1.77 1.10 0.89 0.48 0.49 N/A

0.6010 0.2546 0.8132 0.0212 0.3536 0.4879 0.6788 N/A

x No mean data available for month 12, since the ﬂute player was excluded after month 10 following injection of 40 units of disport into the ulnar portion of the left ﬂexor digitorum profondus of the ﬁfth ﬁnger. * Standard deviation.

Table 2. Metronome Speed Scores for Both Subjects and Both Musical Pieces, Expressed in Beats Per Minute (bpm). Flute Playery

Guitar Player Easy Day 1 Day 8 Month Month Month Month Month Month

2 4 6 8 10 12

44 56 63 76 80 104 120 120

x

#

Medium

Easy*

Mediumz

34 52 60 66 72 126 126 126

15 16.5 18 21 24 28 33 -

12.5 13.5 13.5 19 20 23 33 -

y Scores were calculated over 10 months only. After this, the ﬂute player received a botulinum toxin injection and was excluded from the study. x Normal tempo for easy piece was 69bpm. # Normal tempo for medium difﬁculty piece was 88bpm. * Normal tempo for easy piece was 66bpm. z Normal tempo for medium difﬁculty piece was 66bpm.

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[O23] Comparison of the energy cost of walking between patients with Charcot-Marie-Tooth IA and healthy individuals F. Menotti 1, F. Felici 1, A. Damiani 2, R. Vannicelli 2, F. Mangiola 2, A. Macaluso 1. 1 University of Rome Foro Italico, Italy; 2 UILDM Sezione Laziale, Italy It has been shown that the quality of life of patients with neuromuscular diseases is correlated to the ability of walking. The energy cost of walking is a quantitative measure able to detect also minor walking impairments. The aim of this preliminary investigation was to compare the walking energy cost of patients with Charcot-Marie-Tooth IA, with low severity of walking impairment, and healthy individuals. Six patients with Charcot-Marie-Tooth IA (36 10 years; meanS.D.), 3 males and 3 females, Barthel > 90 and Tinetti > 20, were recruited by a consultant neurologist of the ‘‘UILDM Sezione Laziale’’, and 6 healthy individuals were matched for age and gender. Oxygen consumption was measured using a telemetric device (Cosmed K4 b2) on an oval shaped 23m walkway circuit (rectilinear for 7-m on each side) for 5 min at their selfselected walking speeds (slow, comfortable and fast). Walking energy cost per unit of distance (WECd) was calculated in J kg1$m1. Statistical comparisons between groups and speeds were carried out by ANOVA for repeated measures followed by Student’s t-tests with Bonferroni adjustment where appropriate, with signiﬁcance set at P < 0.05. The ANOVA showed no signiﬁcant effect of pathology on walking speed, although there was a tendency for speed to be lower in the patients than in the controls at both comfortable (0.93 0.15 vs 1.16 0.21 m$s1) and fast speed (1.30 0.19 vs 1.60 0.24 m$s1). There was, instead, a signiﬁcant effect of pathology on the WECd and the post-hoc revealed a signiﬁcant difference at both comfortable and fast speed (P < 0.05; Figure 1). a signiﬁcantly different from healthy controls; b signiﬁcantly different from comfortable and slow speed.

Keywords: Focal dystonia; Hand injuries; Musicians; Motor control; Rehabilitation; Cortical plasticity; Sensory motor performance; Movement disorder.

References 1. Lim VK, Altenmu¨ller E, Bradshaw JL: Focal dystonia: current theories. Human Movement Science 2001; 20:875-914. 2. Charness ME, Schlaug G: Brain mapping in musicians with focal taskspeciﬁc dystonia. Dystonia 4: Adv Neurol 2004; 94:231-238. 3. Hallett M: Dystonia: abnormal movements result from loss of inhibition. Dystonia 4: Adv in Neurol 2004; 94:1-9. 4. Elbert T, Candia V, Altenmu¨ller E, Rau H, Sterr A, Rockstroh B, Pantev C, Taub E: Alteration of digital representations in somatosensory cortex in focal hand dystonia. Neuroreport 1998; 9:3571-3575. 5. Jabusch HC, Zschucke D, Schmidt A, Schuele S, Altenmu¨ller E: Focal dystonia in musicians: treatment strategies and long-term outcome in 144 patients. Movement Disorders 2005; 20(12):1623-1626. 6. Candia V, Scha¨fer T, Taub E, Rau H, Altenmu¨ller E, Rockstroh B, Elbert T: Sensory motor retuning : a behavioural treatment for focal hand dystonia of pianists and guitarists. Arch Phys Med Rehab 2002; 83:1342-1348. 7. Spector JT, Brandfonbrener AG: A new method for quantiﬁcation of musician’s dystonia: the frequency of abnormal movements scale. Med Probl Perform Art 2005; 20:157-162. 8. Sakai N: Slow-down exercise for the treatment of focal hand dystonia in pianists. Med Probl Perform Art 2006; 21:25-28. 9. Van Vliet P, Heneghan NR: Motor control and the management of musculoskeletal dysfunction. Manual Ther 2006; 11:208-213. 10. Byl NN: Focal hand dystonia may result from aberrant neuroplasticity. Dystonia 4: Adv in Neurol 2004; 94:19-28.

The higher WECd (lower economy) in the patients with Charcot-MarieTooth IA, with low severity of the impairment, with respect to the healthy individuals is likely to be due to altered walking patterns and muscle recruitment. Keywords: oxygen consumption, walking speed, walking economy, muscle dystrophy

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[O24] Neurological soft signs are present more often and to a greater extent in adults with chronic low back pain with cognitive learning deﬁcits S.G.T. Gibbons. 1 Neuromuscular Rehabilitation Institute, Canada; 2 Memorial University of Newfoundland, Canada Introduction: Primitive reﬂexes (PR) are part of a group of neurological soft signs and are known to be present in several different health related conditions. They are related to altered motor and cognitive function. If PR are present more in chronic low back pain (CLBP) patients, it may have implications for clinicians in providing education and who try to teach exercises involving ﬁne motor function. The purpose of this study was to investigate if PR are present more in subjects with CLBP compared to normal subjects. Materials and methods: 7 PR were assessed in 58 subjects (age range 2454; mean 41.8; 37F / 21 M) with CLBP and 37 matched controls (age range 22- 52; mean 39.6; 26F / 11 M) by 1 experienced physiotherapist, twice between 5 – 14 days. 3 measurements were taken each session. Subjects were included if they were between the ages of 19-55, had CLBP for more than a year, had a Roland Morris Disability Questionnaire score greater than 15 and a score greater than 79 on the Motor Control Abilities Questionnaire. The presence or absence of the PR and the severity of them were rated on a 5 point scale (0-4). Analysis: SPSS softwear (version 16) was used for statistical analysis. Descriptive statistics were used to describe within group items, the MannWhitney U test was used to describe between groups differences and intratester reliability was assessed with the intra-class correlation coefﬁcient (ICC) using repeated measures ANOVA. Results: ICC were good between the ﬁrst and second measurements between the control group (0.89) and the CLBP group (0.81). The mean score in the control group was 3.2, while in the CLBP group it was 11.8 (P < 0.001). In the control group, no subject had all reﬂexes present, while in the CLBP group 67.2% had all reﬂexes present (P < 0.001). Conclusions: PR may be present in CLBP subjects greater than normal subjects. This may have implications for clinicians when providing information and prescribing therapeutic exercise. Further research is warranted in this area. Keywords: chronic low back pain, primitive reﬂexes, cognitive function

[O25] Impaired control of scapular rotation during a clinical dissociation test in people with a history of shoulder pain S. Mottram 1, M. Warner 1, P. Chappell 2, D. Morrissey 3, M. Stokes 1. 1 Schools of Health Sciences, University of Southampton, UK; 2 Electronics and Computer Science, University of Southampton, UK; 3 University of London, UK Introduction: Reduced upward rotation of the scapula has been found in people with shoulder dysfunction during functional tasks and arm elevation. [1, 2] The purpose of this study was to evaluate the use of a clinical test to detect such altered kinematics in people with a history of shoulder pain. The test is based on the concept of ‘dissociation’ deﬁned here as inability to control movement of the scapula whilst moving the arm. Methods: Nineteen healthy people were studied; 13 (9 female) controls with no history of shoulder pain (mean age 30.6 years, SD 9.1) and 6 (5 males) with a history of shoulder pain (mean age 44.3 years, SD 14.7). The test involved passive placement of the scapula in mid-range position and the subject aimed to maintain this position during shoulder ﬂexion to 90o, and when lowering the arm to their side. A six-camera Vicon 460 (Oxford, UK) motion capture system recorded the scapular position relative to the thorax during the test. Results: At 90o ﬂexion, signiﬁcantly greater upward rotation (p ¼ 0.03) had occurred in the control group (-13.2 4.6) compared with the pain history group (-7.8 5.3). A greater difference (8.2 , p ¼ 0.004) was found between the groups at the end of the test: -0.3 4.4 controls; and 7.9 6.4 in the history of pain group, indicating downward rotation of the scapula.

Discussion: During ﬂexion, the impaired upward scapular rotation conﬁrms the ﬁndings of previous studies. The novel ﬁnding of increased downward rotation position compared to controls at the end of the test, suggests that the history of pain subjects were unable to control downward rotation movement of the scapula. This ﬁnding is consistent with the uncontrolled movement theory [3]. Research is required to validate this test by comparing blinded clinical observations with motion analysis results. References 1. Lin JJ, Hanten WP, Olson SL et al. 2005 J Electromyogr Kinesiol 15(6): 576-86 2. Ludewig PM, Cook TM 2000 Phys Ther 80(3):276-91 3. Comerford M J, Mottram S L 2001 Manual Therapy 6:15-26 Acknowledgments We thank the Private Physiotherapy Educational Foundation and Vicon Oxford for funding, Faizura Fadzil for technical assistance and the participants. Keywords: Scapula, Control of movement, Kinematics [O26] Validating recruitment of posterior gluteus medius ﬁbres during two muscle tests and exploration of the kinetic control rating system for these tests N .V. Jeal, P. Browning, University of Hertfordshire, UK Introduction: There is evidence of altered gluteus medius (GM) function in lower quadrant dysfunction (Nadler et al 2002, Fredericson et al 2002, Ireland et al 2003, Leetun et al 2004, Niemuth et al 2005, Crossley et al 2006, Tyler et al 2006). Anecdotal evidence suggests that it is posterior gluteus medius (PGM) ﬁbres that are weak and require retraining (Sahrmann 2002, McConnell 2002, Lee 2005, Kendall et al 2005, Comerford and Kinetic Control 2006). The PGM and clamshell tests have emerged to test and retrain PGM. They are widely advocated within physiotherapy literature (Sahrmann 2002, Comerford and Kinetic Control 2006, Kendall et al 2005, Lee 2005). Purpose: The purpose of this study was to validate the recruitment of PGM ﬁbres during the PGM tests by measuring change in PGM muscle cross sectional diameter (CSD) using real time ultrasound (Figure 1 and 2). The PGM tests are thought to be difﬁcult for asymptomatic subjects to pass using the Kinetic Control rating system (KCRS). The secondary purpose of this study was to determine how many asymptomatic subjects are able to pass the tests using this rating system. Methodology: The experimental study was undertaken on 31 asymptomatic subjects (23 females, 8 males, 18-48 years of age). A Picus (Pie medical company) ultrasound machine in conjunction with a curvi-linear

Figure 1 PGM CSD at rest on real time ultrasound

Oral Abstracts / Manual Therapy 14 (2009) S11–S30

Figure 2 PGM CSD during test on real time ultrasound

PGM CSD during PGM test 6 5

cm

4 3 2 1 0

subjects CSD at rest CSD during PGM test Figure 3 PGM CSD during PGM test

PGM CSD during Clamshell test 6 5

cm

4 3 2 1

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tests did signiﬁcantly recruit PGM ﬁbres (ﬁgure 3 and 4). Considering PGM’s theorised importance in pelvic and lower limb support, clinicians can now accurately test and rehabilitate PGM ﬁbres in their patients. The results indicate that only 32% of subjects were able to pass the PGM test and 61% were able to pass the clamshell. The high failure rate of asymptomatic subjects during these tests suggests that the arbitrarily set pass rate of the KCRS may be not appropriate for this population. References Bewyer, D. & Chen, J. (2005). Gluteus medius tendon rupture as a source for back, buttock and leg pain: case report. The Iowa orthopaedic journal, 25, 187-89. Bland, M. (2000). An introduction to medical statistics. (3rd ed). Oxford university press. Brindle, T. J. et. al. (2003). Electromyographic changes in the gluteus medius during stair ascent and descent in subjects with anterior knee pain. Knee surgery, sports traumatology and arthroscopy, 11, 244-51. Comerford, M. & Kinetic Control (2006). Course notes and Rating system. http://www.kineticcontrol.com/pages/research/documents/ MicrosoftWord-Ratingsystem0706.pdf. (online) 14/04/07. Crossley, K. M. et. al. (2006). Hip muscle activity is altered in patellofemoral pain: Clinical implications. Medicine and science in sports and exercise, 38 (5), supplement, 716. Fredericson, M. et. al. (2002). Hip abductor weakness in distance runners with iliotibial band syndrome. Clinical journal of sports medicine, 10, 169-75. Ireland, M. L. et.al. (2003). Hip strength in females with and without patellofemoral pain. Journal of orthopaedic and sports physical therapy, 33, 671-76. Kendall, F. P. et.al. (2005). Muscles, testing and function with posture and pain. (5th ed). Lippincott, Williams and Wilkins. Lee, D. (2005). The pelvic girdle, (3rd ed), Churchill Livingstone. Chap 10 Leetun, D. T. et.al. (2004). Core stability measures as risk factors for lower extremity injury in athletes. Medicine and science in sports and exercise, 36 (6), 926-34. Mascal, C. L. et.al. (2006). Management of patellofemoral pain targeting hip, pelvis and trunk muscle function: 2 case reports. Orthopaedic division review, May-June, 33-45. McConnell, J. (2002). Recalcitrant chronic low back pain and leg pain – a new theory and different approach to management. Manual therapy, 7 (4), 183-92. Montes, R. (2001). Changes in cross sectional diameter of muscle ultrasonography between relaxation and maximum contraction in normal young subjects. Physiotherapy, 87 (4), 172-78. Nadler, S. F. et.al. (2002). Hip muscle imbalance and low back pain in athletes: inﬂuence of core strengthening. Medicine and science in sports and exercise, 34 (1), 9-16. Niemuth, P. E. et.al. (2005). Hip muscle weakness and overuse injuries in recreational runners. Clinical journal of sports medicine, 15 (1), 14-21. Piva, S. R. et.al. (2005). Strength around the hip and ﬂexibility of soft tissues in individuals with and without patellofemoral pain syndrome. Journal of orthopaedic and sports physical therapy, 35, 793-801. Sahrmann, S. A. (2002). Diagnosis and treatment of movement impairment syndromes. Chap 4, page 147-174. St Louis, Mo. London: Mosby. Tyler, T. F. et.al. (2006). The role of hip muscle function in the treatment of patellofemoral pain syndrome. The American journal of sports medicine, 34 (4), 630-6.

0

subjects CSD at rest CSD during clamshell Figure 4 PGM CSD during clamshell test

5.0 Mhz transducer was used to determine the change in CSD of PGM ﬁbres during both the PGM and Clamshell tests. Results and Conclusions: The results indicated that the PGM (p ¼ 0.001 z ¼ 3.22, df 20, 2 tailed) and Clamshell (p ¼ 0.012, z ¼ 2.51, df 30, 2 tailed)

Keywords: Gluteus Medius, Posterior Gluteus Medius, Ultrasound, Kinetic Control rating scale

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[O27] The development, initial reliability and construct validity of the motor control abilities questionnaire S.G.T. Gibbons. 1 Neuromuscular Rehabilitation Institute, Canada; 2 Memorial University of Newfoundland, Canada Introduction: Speciﬁc motor control exercises (SME) are commonly used to rehabilitate musculoskeletal dysfunction. SME require the client to have a variety of learning based skills. A small number of clients do not appear to be able to learn these exercises. The purpose of this study were: to development a tool that could screen patients to predict if they could learn SME; to assess the internal consistency and the test – retest reliability of the instrument; to assess the construct validity. Methods: The item generation consisted of 3 phases. Phase 1: A semistructured interview was conducted with 31 clients who had not progressed with a SME program to identify problems or barriers for the failure of the program. Phase 2: A chart review was performed on 27 clients who had not progressed with a program as above. Phase 3: 114 patients who ﬁt the above criteria ﬁlled out 16 related questionnaires. 50 items were generated based on the responses from the questionnaires and the semistructured interview, and a 5 point Likert scale was used. The subgroups consisted of questions relating to cognitive and sensory motor function. Test-retest reliability: The questionnaire was administered to 265 subjects with chronic low back pain, twice, one week. Construct validity: The questionnaire was given to 394 subjects with the clinician blind, and their ability to perform the exercises was rated. SPSS version 15 was used for the statistical analysis. Internal consistency reliability was assessed with Cronbach’s a and test retest reliability was assessed with Pearson’s r. A standard 2 x 2 was used to calculate sensitivity and speciﬁcity. Results: Test retest reliability ranged from 0.75-0.88. Internal consistency reliability ranged from 0.77 to 0.94 (standardized). Using a cut off value of 80 the sensitivity 0.88 and speciﬁcity 0.98 were, respectively. Discussion: The instrument appears to be stable over a one week period with acceptable test – retest reliability. The internal consistency is also acceptable, however an exploratory factor analysis with higher a number of subjects is required. The initial sensitivity and speciﬁcity values provide preliminary construct validity for the questionnaire. Further assessment is warranted for this instrument. Keywords: chronic low back pain, questionnaire, cognitive function, motor control

[O28] Motor control and physical ﬁtness training prevent musculoskeletal injuries in professional dancers N.A. Roussel 1, 2, L. Daenen 1, 5, D. Vissers 1, D Lambeets 1, A. Schutt 2, A. Van Moorsel 2, S. Mottram 3, S. Truijen 1, J. Nijs 1, 4. 1 Division of Musculoskeletal Physiotherapy, Artesis University College Antwerp, Belgium; 2 Royal Conservatoire, Artesis University College Antwerp, Belgium; 3 Vrije Universiteit Brussel, Belgium; 4 Kinetic Control, UK; 5 University of Antwerp and University Hospital Antwerp, Belgium Introduction: Dancers experience signiﬁcant more low back pain (LBP) than non-dancers and are at increased risk for developing musculoskeletal injuries1,2. We have previously shown that altered lumbopelvic motor control in dancers is associated with an increased risk of developing musculoskeletal injuries3. The purpose of the present study is to examine the inﬂuence of an exercise therapy intervention, consisting of motor control training and a general cardiovascular and strength training, on musculoskeletal injury rate in professional dancers. Methods: We ﬁrst recorded injury rate during a 6-months prospective follow up study without intervention in all students following a full-time professional Dance Program in Belgium. Afterwards, a 6-months prospective study with intervention was conducted. Before and after the intervention, a blinded assessment of lumbopelvic motor control3 and physical ﬁtness (submaximal bicycle exercise test and explosive strength assessment) was performed. The intervention consisted of lumbopelvic motor control training and a cardiovascular and strength training program

(running, cycling, crossrunner, and ﬂoor exercises). Injuries were collected every two weeks by a blinded observer. Results: Twenty-six injuries were registered in 32 dancers during the prospective study without intervention, and twenty injuries were registered in during the study with intervention. After the intervention the dancers showed signiﬁcant improvements in all ﬁtness tests and in the motor control tests (p < 0.05). In 7 of 8 motor control tests, there was a clinical important improvement, i.e. exceeding 20% improvement. The peak oxygen uptake at 75% of the maximal heart frequency improved with 25% (p < 0.001). Discussion: The results of this study suggests a combination of regular dance training and additional exercise therapy improves the physical condition, explosive strength and motor control in dancers and reduces the injury rate. As no control group has been used in the present study, further research regarding the effectiveness of this additional training is required. 1. McMeeken JM, Tully E, Stillman B, Natrass C, Bygott I, Story I. The experience of back pain in young Australians. Manual Therapy 2001;6(4):213-20. 2. Garrick J, Requa R. Ballet injuries. An analysis of epidemiology and ﬁnancial outcome. The American Journal of Sports Medicine 1993;21(4):586-90. 3. Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalised joint hypermobility is associated with increased injury in dancers: A prospective study. Manual Therapy 2009. doi:10.1016/j.math.2008. Keywords: Injury, Dance, Rehabilitation, Exercises [O29] Induced transducer orientation during ultrasound imaging: Effects on abdominal muscle thickness and bladder position J.L. Whittaker 1, 2, M.B. Warner 1, M.J. Stokes 1. 1 University of Southampton, UK; 2 Whittaker Physiotherapy Consulting, Canada Introduction: The clinical use of ultrasound imaging (USI) by physiotherapists is increasing. However, it is unknown if the clinical environment is conducive to valid and reliable interpretations during these dynamic studies as USI measurements are inﬂuenced by transducer motion. This study aimed to investigate how much transducer motion can occur before error is introduced for measurements of transversus abdominis (TrA) muscle thickness and bladder base position. Methods: Repeated USI measurements of TrA thickness and bladder base (cranial /caudal and ventral/dorsal) position were calculated from images recorded at various induced transducer orientations (quantiﬁed by digital optical motion capture system; Vicon) on eight healthy volunteers. Repeated measures analysis of variance was performed to determine if measurements obtained at induced transducer orientations were statistically different (p < 0.05) from a reference image (00 tilt). Motion data corresponding to statistically equivalent measurements were summarized to provide a range of acceptable transducer motion (clockwise; CW/ counter clockwise; CCW rotation, cranial/caudal and medial/lateral tilting, inward/outward translation) relative to the pelvis. Results: There were no signiﬁcant changes of TrA thickness or bladder base position for the directions and amounts of induced transducer motion (Table 1). Table 1: Guidelines of acceptable transducer motion for measurements of TrA thickness and bladder (BLD) base position (anterior/posterior; AP, cranial/caudal; CC).

Measurement

CW/CCW motion (degrees)

Cranial/ Caudal tilt (degrees)

Medial/ Lateral tilt (degrees)

Inward/ Outward motion (mm)

TrA BLD Base AP BLD Base CC

9o 14o < 10o

5o 10o 10o

5o 8o 8o

unknown < 8 mm 8 mm

Discussion: This study has indicated some guidance for acceptable amounts of transducer motion when measuring TrA thickness and bladder

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base position during dynamic USI studies. These ﬁndings are potentially useful for future sonographic studies investigating these parameters. Acknowledgments We thank Ion Medical Solutions, USA and Vicon, Oxford UK for funding. Keywords: Ultrasound Imaging Technique, Transversus abdominis, Bladder, Validity [O30] Factors inﬂuencing the use of standardized outcome measures in daily practice: a survey in Dutch physiotherapists R.A.H.M. Swinkels 1, R.P.S. van Peppen 2, Beurskens 1. 1 Zuyd University, Netherlands; Sciences, Netherlands

H. Wittink 2, A.J.H.M. University of Applied

2

Introduction: Despite the recommendation in guidelines to use standardized outcome measures there are indications that majority of physiotherapists do not do in daily clinical practice. The aim of this study was to investigate stimulating and hampering factors in the use of measurement instruments. The project focussed in particular on physiotherapist working in primary health care and physiotherapists working in a nursing home. Methods: A literature search is performed to stimulating and hampering factors for implementation in health care in general and implementation of measurement instruments in particular. Furthermore, we also used 40 semi-structured interviews for a qualitative analysis and a survey of physiotherapists for a quantitative analysis. Results: Based on literature, lack of time and lack of knowledge (unfamiliarity) demonstrate to be the most hampering factors. Another study, concerning the use of standardized outcome measures in stroke-patients demonstrated that the most frequent mentioned barriers were ‘problems with changing behaviour’, ‘measuring takes too much time’ and ‘lack of ﬁnancial compensation’ . In the semi-structured interviews the most frequent mentioned hampering factor is lack of knowledge, routine and experience. Other barriers mentioned were lack of time, ﬁnancial compensation, lack of feedback, poor availability and problems with interpretation. The digital survey was send out to 2900 physiotherapists, of who 468 send back completed questionnaires (16%). In primary health care setting 72% of respondents indicated to use standardized outcome measures, and 97% of physiotherapists working in nursing home claimed to use outcome measures. 48% indicated to use 0-2 instruments; 36% uses 3-5 outcome measures. Discussion: If literature search and semistructured interviews are compared with the digital survey there are strong indications that the survey-responders are a biased group and probably overestimating the use of outcome measures. It is advised to create core-sets of measurement instruments, and to develop tailor-made courses with lot of feedback. Keywords: outcome measures, hampering factors, implementation [O31] Positioning of elbow ﬂexion versus elbow extension for measuring grip strength and muscle activation in lateral epicondylitis M. Isintas Arik, F. Can. Hacettepe University, Turkey The purpose of this study was to determine the effect of positioning of the elbow on grip strength and forearm muscle activation. 25 female and 5 male, a total of 30 patients (average age of 42.97 2.22 years) with unilateral epicondylitis have been studied and controlled with 30 healthy adults consisted of 28 female and 2 male (mean age 35.67 1.94 years).Maximum grip strength was measured using Hand Dynamometer at elbow ﬂexion and extension. Muscle activity was measured using surface EMG while subjects gripped with maximum voluntary contraction (MVC) in elbow ﬂexion and in full extension. Surface EMG electrodes were placed over the extensor carpi radialis brevis and over the ﬂexor digitorum superﬁcialis for forearm extensors and ﬂexors.

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The grip strength of the involved side was similar with the uninvolved side in ﬂexion, while involved side (18.68 9.43 kg) was signiﬁcantly lower than the uninvolved side (22.08 7.96 kg) in extension. There was difference in grip strength in ﬂexion between the study and the control group (study group:20.23 9.12 kg, control group:25.53 7.16 kg, t:-2.44) and also in extension (study group:18.68 9.43 kg, control group:26.28 8.31, t:-3.31).In extension, MVC of the forearm ﬂexors in the study group was lower than the control group (t:-2.21, p < 0.03). MVC of the forearm ﬂexors in ﬂexion compared with the control group was also different. There was a difference in MVC of the forearm ﬂexors in extension (164.87 109.16 mV), while no difference in extensors (204.23 125.19 mV) between involved and uninvolved side. This study results revealed that grip strength generally greater in the elbow extension than ﬂexion and MVC of the extensor muscles is more affected by the elbow extension. As a conclusion from the clinical perspective, to determine the most appropriate positioning of the elbow is very important in assessment and also treatment of the lateral epicondylitis. Keywords: lateral epicondylitis, grip strength, surface electromyography, maximum voluntary contraction

[O32] The reliability of a wireless monitor for measurement of lumbar spine posture K. O’Sullivan 1, L. Galleotti 1,2, W. Dankaerts 2, 3, L. O’Sullivan 1, P. O’Sullivan 4. 1 University of Limerick, Ireland; 2 Catholic University, Belgium; 3 Association University, Belgium; 4 Curtin University of Technology, Australia Introduction: Low back pain (LBP) is a common and costly musculoskeletal disorder (Hansson, Ihlebæk et al. 2006), requiring consideration of multiple factors including lumbar posture and movement patterns (Dankaerts, O’Sullivan et al. 2006). Most LBP research has been done using complex and time-consuming laboratory-based motion analysis systems (Dankaerts, O’Sullivan et al. 2006), which do not allow analysis outside the laboratory e.g. in occupational settings. The SELS SPC monitor is capable of monitoring spinal posture in real-time via wireless technology. This study examined the reliability (intra-rater and inter-rater) of this novel monitor for measuring spinal posture during two commonly provocative tasks in subjects with LBP. Methods: 20 healthy subjects participated in the study. The reliability of two tasks (usual sitting posture, and forward bending) was examined using intra-class correlation coefﬁcients (ICC) and Bland and Altman methods. Results: Intra-rater reliability was excellent for both tasks (ICC ¼ 0.837 – 0.874, with low mean differences). Similarly inter-rater reliability was excellent for both tasks (ICC ¼ 0.914 – 0.940, with low mean differences). Discussion: This novel wireless posture monitor appears to be a reliable method for measuring lumbar posture and movement patterns. This non-invasive device may have signiﬁcant clinical utility for assessing and providing feedback on spinal postures and movement patterns in occupational environments. Further research is required to investigate the validity of this new monitor, and its application in clinical trials. References Dankaerts, W., P. B. O’Sullivan, et al. (2006). ‘‘Differences in sitting postures are associated with non-speciﬁc chronic low back pain disorders when sub-classiﬁed.’’ Spine 31(6): 698-704. Hansson, T., C. Ihlebæk, et al. (2006). ‘‘Prevalence of low back pain and sickness absence: A ‘‘borderline’’ study in Norway and Sweden.’’ Scandinavian Journal of Public Health 34: 555-558. Keywords: Posture, Low back pain, Wireless technology, Reliability

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[O33] Primitive reﬂex inhibition and sensory motor training improves cognitive learning function and symptoms in chronic disabling low back pain: A case series S.G.T. Gibbons 1, 2. 1 Neuromuscular Rehabilitation 2 Memorial University of Newfoundland, Canada

Institute,

Canada,;

Introduction: Cognitive learning problems are common in chronic pain and are associated with neurological soft signs. These present a potential important barrier to rehabilitation. Primitive reﬂex inhibition (PRI) and sensorimotor rehabilitation (SR) improves cognitive function in subgroups of children with learning disabilities, thus provides a potential rehabilitation option for chronic low back pain (CLBP). Methods: 56 subjects (34F/22 M) who had failed to beneﬁt from an active exercise program and a speciﬁc motor control combined movement control exercise program participated in the study. The main outcome was the Motor Control Abilities Questionnaire (MCAQ) which assesses aspects of cognitive learning and sensorimotor function. Secondary outcomes included: Quadruple Pain Numerical Rating Scale (QNRS), Roland Morris Disability Questionnaire, Patient Speciﬁc Functional Questionnaire, quality of life (SF36v2) and the ability to learn lower abdominal hollowing and a lumbar spine movement control exercise. The subjects attended a clinic once a week for 12 weeks to progress through a PRI program individual to their initial presentation. They were asked to perform the movements at home twice a day. 27 subjects continued for another twelve weeks and added SR. Results: The mean change in score on the MCAQ was a decrease of 32.7 (range 17-51). Pain decreased a mean of 15.6, disability decreased a mean of 4.6, function increased a mean of 16.7, quality of life increased a mean of 23.2. 48 subjects were able to learn the speciﬁc exercises and could participate in a standard exercise program. Discussion: Signiﬁcant cognitive learning dysfunction reduces a client’s ability to beneﬁt from many standard types of therapy when skills such as reading and concentrating are involved. This study provides preliminary evidence that a PRI and SR may improve cognitive dysfunction and other health beneﬁts in a sub-group of CLBP subjects. This group represents an important sub-classiﬁcation in chronic musculoskeletal conditions. Keywords: case series, primitive reﬂexes, sensorimotor function [O34] The graduated return to activity for low back pain: Exploring the patient’s perspective of physiotherapy M. Perry 1, S. Dean 2, S. Hudson 2, L. Hale 1, D. Baxter 1. 1 Centre for Physiotherapy Research, University of Otago, New Zealand; 2 Rehabilitation Teaching and Research Unit, University of Otago, New Zealand Introduction: Remaining active and programmes encouraging a graduated return to activity are currently considered best practice for people with low back pain (LBP)1,3. However, the optimal means of delivering activity advice and rehabilitation in people with LBP remains unclear. Patient beliefs regarding the nature of the problem affect behaviour, adherence and outcomes2,5. The aim of this study was to explore the experiences of physiotherapy and being physically active in people with LBP with respect to the Stages of Behaviour Change4 model. Method: In-depth, semi-structured interviews were conducted with ﬁfteen (8 female, 5 male) purposively selected participants on completion of physiotherapy for acute and chronic LBP. Interview data were recorded, transcribed, and coded for emergent themes using descriptive content analysis and detailed interpretation characteristic of the Interpretative Phenomenological Analysis (IPA) method of analysis. Results: It appeared that the decision to seek help was related to participant’s perceived level of control over the pain. Only when participants perceived that pain was in control of their life and ‘‘all consuming’’, thereby affecting all physical activities, was professional advice sought. Activity participation could only increase after a trusting relationship was established with the physiotherapist. The participants perceived that they needed to ‘‘take responsibility’’ and have ‘‘knowledge for coping’’ if they were to improve activity participation. On completing physiotherapy treatment participants perceived that they were still walking a ‘‘tightrope of control’’, trying to participate in life while managing the pain. Participants perceived

that increasing activity was ‘‘trial and error’’ and the fear of pain regaining control prevented a return to participation in many activities. Conclusion: Participants perceived that physiotherapy was important for increasing physical activity; however, rehabilitation ﬁnished just as a behaviour change had occurred. Participants remained uncertain of how to return to many usual activities and were therefore unable to adhere to physiotherapy advice. References: 1. ACC. Best practice guidelines. New Zealand acute low back pain guide. Guide to assessing psychosocial yellow ﬂags in acute low back pain. New Zealand: ACC, 2003. 2. Borkan, J., Reis, S., Hermoni, D. et al. Talking about the pain: a patientcentered study of low back pain in primary care. Social Science and Medicine 1995; 40:977-988. 3. Hurwitz, E., Morgenstern, H., & Chiao, C. Effects of recreational physical activity and back exercises on low back pain and psychological distress: ﬁndings from the UCLA Low Back Pain Study. American Journal of Public Health 2005; 95:1817-1824. 4. Marcus, B., & Simkin, L. The transtheoretical model: applications to exercise behavior. Medicine & Science in Sports & Exercise, 1994; 26(11):1400-1404. 5. Underwood, M., Harding, G., & Klaber Moffett, J. Patient perceptions of physical therapy within a trial for back pain treatments (UK BEAM Trial). Rheumatology 2006; 45:751-756 Keywords: Low back pain, Behaviour change, Physiotherapy, Activity [O35] Talking function: Personal accounts of acute non-speciﬁc low back pain experiences C.A. McCrum 1, 2, A.P. Moore 1, V. Hall 3. 1 Clinical Research Centre for Health Professions, University of Brighton, UK; 2 East Sussex Hospitals NHS Trust, UK; 3 School of Nursing and Midwifery, University of Brighton, UK The purpose of this research study was to explore personal experiences of acute non-speciﬁc low back pain and perspectives on factors inﬂuencing recovery. This qualitative study explored accounts of the impact, responses and meanings at different stages through experiences of recovery or persistent problems. Despite continuing research, there remain signiﬁcant challenges in achieving effective intervention to prevent transitions to chronic pain and disability. Evidence associating pathology, physical ﬁndings or speciﬁc treatments with outcome is limited. Rather, psychosocial factors appear most associated with developing chronic problems and disability. However, achieving effective intervention remains challenging despite a biopsychosocial focus and screening approaches. Exploring individual perspectives through the acute phase aimed to broaden insights from existing research in acute low back pain. Twenty-one participants experiencing acute non-speciﬁc low back pain (<6 weeks) were interviewed near onset through to twelve weeks. Participants also completed a contextualising timeline of signiﬁcant events and impacts preceding and concurrent with back pain onset, and a seven day narrative diary between interviews. A narrative-discursive analytic approach was used to explore impacts, consequences and meanings constructed within the personal accounts during recovery or persistent experiences of acute low back pain. Findings showed that accounts conveyed contrasting dilemmas of right and wrong, personal responsibility and risk, personal qualities and identity, and moral accountability. Individual sense-making was both temporally and outcome inﬂuenced. Accounts could be seen to accomplish micro-social functions in the interactional context which might otherwise be understood as contradictory, variable or inconsistent. Accounts served not only descriptive functions but performed complex concurrent interactional functions, with important implications for interpreting meanings. Attending to the functional complexities of communication offers important insights for practice and challenges some often taken-for–granted assumptions for interpreting personal accounts. Incorporating microsociological perspectives to broaden current understandings within physiotherapy interventions appears a valuable direction for further research. Keywords: acute low back pain, experience, narrative, discourse analysis

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[O36] Prediction of functional disability in patients with stiff shoulder: Posterior shoulder muscle stiffness and rotation deﬁcit J.-J. Lin 1, 2, J.-l. Yang 3, C.-J. Hung 1, P.-L. Yang 1. 1 School of Physical Therapy, College of Medicine, National Taiwan University, Taiwan; 2 Center of Physical Therapy, National Taiwan University Hospital, Taiwan; 3 Department of Physical Medicine & Rehabilitation, National Taiwan University Hospital, Taiwan Clinically, it is important to precisely target the involved anatomical structure (muscle or capsule) that is the source of functional disability. However, research to support the relationships between functional disability, stiffness of muscles, and restricted shoulder motion has been limited in quantity. The purpose of this study was to investigate the correlations between functional disability, posterior shoulder muscle stiffness, and rotation deﬁcit. Forty subjects (9 males and 31 females, age 58.9 10.2 years) with stiff shoulder were recruited and divided into severe (20 subjects) and mild hypomobility groups according to joint play assessment. Functional status, range of motion of rotation, and stiffness in 4 muscles (posterior deltoid, infraspinatus, teres minor and teres major) of the affected shoulder were measured using Flexilevel Scale of Shoulder Function (FLEX-SF), a goniometer, and a myotonometer, respectively. Correlation and stepwise regression models between impairment variables (the muscle stiffness and rotation) and functional disability were calculated. Signiﬁcant correlations were found between impairment measures (muscle stiffness and rotation) and functional disability except teres major muscle stiffness. Based on regression model, muscle stiffness and rotation was determined to be predictive of functional disability (R2 ¼ 0.563 for severe hypomobility group and R2 ¼ 0.721 for mild hypomobility group). For the severe hypomobility group, posterior deltoid muscle stiffness accounted for 41% of the variance of functional disability beyond stiffness from other muscles and rotation. For the mild hypomobility group, external rotation and muscle stiffness in infraspinatus/teres minor accounted for 62% of the variance of functional disability. In conclusion, this study provides evidence that muscle stiffness and rotation are related to shoulder functional disability. Posterior deltoid is important to consider in the rehabilitation of patients with severe shoulder joint hypomobility whereas external rotation and infraspinatus/teres minor muscles play roles of functional disability in patients with mild shoulder joint hypomobility. Keywords: muscle stiffness, stiff shoulder, functional disability, range of motion [O37] Scapular positioning in overhead athletes with and without shoulder pain: A case-control study F. Struyf 1, 2, J. Nijs 1, 2, J. De Graeve 1, S. Mottram 3, R. Meeusen 2. 1 Artesis University College Antwerp, Belgium; 2 Vrije Universiteit Brussel, Belgium; 3 Kinetic Control, UK Introduction: Changes in scapular positioning are considered important risk factors for developing shoulder disorders. The speciﬁc purpose for this study was to analyse the scapular positioning pattern (scapular upward rotation, posterior tilt and scapular motor control) in a group of subjects with shoulder pain relative to a group of subjects without symptoms. Methods: Thirty-six shoulder pain patients (19 men, 17 women), their age ranging between 18 and 60 years (mean standard deviation [SD], 33 11 yr) with a mean duration of overhead sports activity of 12.8 8.8 yr and a mean Shoulder Disability Questionnaire score of 35.8 13.5 were compared with 36 unimpaired athlete’s free of shoulder pain and with a mean duration of overhead sports activity of 11.9 9.5 yr, matched for gender, age and Body Mass Index in a multi-centre blinded case control study. The blinded assessor performed visual observation, the measurement of the distance between the acromion and the table, inclinometry and the kinetic medial rotation test for dynamic scapular control in random order. Results: The clinical assessment protocol for scapular positioning did not show signiﬁcant differences between the subjects with and without

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shoulder pain. When comparing the painful shoulder with the pain free shoulder within the group of patients, tilting was more present on the painful side (12/36) then on the pain free side (8/36) (p < 0.01) and 77% (10/36) of the positive MRT scores were on the painful side, in contrast to 23% (3/36) on the pain free side (p < 0.01). Discussion: Patients with shoulder pain demonstrated scapular asymmetry in the sagittal plane, observed visually as titling on the painful side. Additionally, patients with shoulder pain show a lack of scapular motor control on their painful side in contrast to their pain free side. No scapular positioning or motor control differences were found in people with or without shoulder pain. Keywords: shoulder, scapula, athletes, pain [O38] Muscle recruitment of the scapula in patients with traumatic and insidious onset neck pain H. Helgadottir 1, E. Kristjansson 2, E. Einarsson 3, H. Jonsson 4. 1 University of Iceland, Iceland; 2 Bakstofan Physical Therapy Clinic, Iceland; ce:bold>3Eﬂing Physical Therapy Clinic, Iceland; 4 Lanspitali University Hospital, Iceland Introduction: Altered muscle activity has been demonstrated in the cervical ﬂexors and the upper trapezius in patients with neck pain. Clinical experience suggests that these patients may demonstrate an altered activity in the stabilizing musculature of the scapula. No scientiﬁc evidence exists to conﬁrm this. It is considered that faulty recruitment pattern of the scapular musculature may cause an overload on the cervical spine. Objective: The purpose of this study was to determine the onset of the recruitment of trapezius and serratus anterior in two groups of patients with chronic neck pain. Study Population: Two groups of patients with traumatic (whiplash) and insidious onset neck pain partizipated and an asymptomatic control group for baseline measurements. Method: Surface electromyography (sEMG) synchronized with a threedimensional tracking device (Fastrak) was used to measure the activity of the upper-, middle-, lower trapezius and the serratus anterior muscles during arm elevation and descend. Results: Signiﬁcant differences in onset of the recruitment of the trapezius and serratus anterior were found between the patients groups versus the control group. Signiﬁcant differences were also revealed between the two patient groups. Conculsions: 1. Signiﬁcant differences were found in the muscle recruitment of the scapula between two patients groups with neck pain versus an asymptomatic control group and between the two patients groups, respectively. 2. Disturbed onset of the recruitment of scapular muscle may depend on the origin of pain. 3. Surface EMG and the Fastrak device are useful clinical assessment tools for muscle recruitment of the stabilizing muscles of the scapula. Hence more succesfull treatment program can be developed for patients with neck pain. Keywords: Motion analysis, Cervical Spine, Scapula, Electromyography [O39] An investigation into the effects of a simulated effusion in healthy subjects on knee kinematics and lower limb muscle activity during a single leg drop landing G.F. Coughlan 1, R. Mc Loughlin 2, U.J. McCarthy Persson 1, B.M. Caulﬁeld 1. 1 School of Physiotherapy and Performance Science, University College Dublin, Ireland; 2 O’Neill’s Sports Injury Clinic, University College Dublin, Ireland Introduction: Arthrogenic muscle inhibition (AMI) is deﬁned as an ongoing reﬂex inhibition of the musculature surrounding a joint following distension or damage to the structures of that joint [Hopkins and Ingersoll, 2000]. AMI following joint injury may affect movement and muscle recruitment, which may impair rehabilitation and delay the return to activity. The purpose of this pilot investigation was to assess the effects of a simulated knee effusion on knee kinematics and lower limb EMG in healthy subjects.

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[O40] Patients with chronic low back pain exhibit altered breathing patterns during motor control assessment N.A. Roussel 1, 2, J. Nijs 1, 3, S. Truijen 1, S. Mottram 4, L. Vervecken 1, G. Stassijns 2. 1 Artesis University College Antwerp, Belgium; 2 University of Antwerp, Belgium; 3 Vrije Universiteit Brussel, Belgium; 4 Kinetic Control, UK

Fig 1: Mean Knee Angular Displacement in Sagittal Plane

Fig 2: Mean Knee Angular Displacement in Coronal Plane

Methods: Knee angular displacement and velocity in the sagittal and coronal plane as well as lower limb EMG (vastus medialis, vastus lateralis, biceps femoris, gastrocnemius) were measured in the period 250 milliseconds pre initial contact to 250 milliseconds post initial contact during a single leg drop jump in 8 healthy subjects (25.5 years 4.8, 174.1 cm 0.09, 66.3 kg 5.8) twice before (C1 and C2) and once after (PE) a simulated knee joint effusion of 60 millilitres. Results: Repeated measures ANOVA (GLM 3 factor analysis (C1, C2 and PE)) and post hoc testing (C1vC2, C2vPE, C1vPE) revealed no statistically signiﬁcant differences in pre and post effusion in knee kinematic (Fig 1 and Fig 2) or lower limb EMG measures undertaken in 8 healthy subjects during a single leg drop landing task. Discussion: Motor control of dynamic activities such as a single leg drop landing may not be altered following a simulated effusion. Despite this level of effusion having an effect on patients in a clinical setting, it may not be sufﬁcient to elicit major changes in movement patterns and muscle function during high velocity cyclical tasks in healthy subjects following a simulated effusion. The presence of a long-term effusion with associated inﬂammation and pain in acute or chronically injured patients with adaptations to learned movement and muscle recruitment patterns may be responsible for the loss of proprioception and muscle inhibition as observed in clinical situations. References Hopkins JT, Ingersoll CD. Arthrogenic muscle inhibition: a limiting factor in joint rehabilitation. J. Sport Rehab. 2000; 9: 135-59. Keywords: Movement Analysis, EMG, Rehabilitation, Simulate Knee Effusion

Introduction: A non-optimal coordination of postural, respiratory and continence functions of trunk muscles has been proposed as explanation for the observed relationship between disorders of continence, respiration and low back pain (LBP)1. Patients with LBP have impaired motor control2, but information about the inﬂuence of LBP on respiratory patterns during lumbopelvic motor control assessment is lacking. The purpose of the study is to evaluate the breathing pattern in patients with chronic LBP and in healthy subjects, both at rest and during motor control assessment. Methods: Ten healthy subjects and ten patients with chronic LBP participated at the study. The breathing pattern was evaluated at rest (supine position and relaxed breathing) and while performing clinical motor control assessment3,4. A blinded observer analyzed the breathing pattern using visual inspection and manual palpation. Costo-diaphragmatic breathing was deﬁned as an outwards movement of the abdomen combined with an elevation of the thorax during inspiration and was considered as optimal breathing pattern. Subjects ﬁlled in visual analogue scales for the assessment of pain intensity during the tests. Results: At rest, no signiﬁcant differences were found between the breathing pattern of patients and healthy subjects (p > 0.05). In contrast, signiﬁcantly more altered breathing patterns were observed in chronic LBP-patients during motor control tests (p ¼ 0.01). Changes in breathing pattern during motor control assessment were not related to pain severity (p > 0.01), but were related to motor control dysfunction (p ¼ 0.01) Discussion: The results of this study suggest that chronic LBP-patients exhibit altered breathing patterns during performances in which trunk stability muscles are challenged. It has been shown that respiratory movements represent a greater disturbance to posture in LBP-patients5 and that diaphragmal contraction enhances spinal stiffness in healthy subjects6. Clinicians should therefore evaluate the breathing pattern in LBP-patients, as they may recruit the diaphragm to enhance lumbopelvic stability, thereby disadvantaging respiration. 1. Smith MD, Russell A, Hodges PW (2006) Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. The Australian Journal of Physiotherapy 52(1): 11-16. 2. O’Sullivan P: Diagnosis and classiﬁcation of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Man Ther 2005, 10(4):242-255. 3. Roussel NA, Nijs J, Truijen S, et al (2007) Low back pain: clinimetric properties of the Trendelenburg test, active straight leg raise test, and breathing pattern during active straight leg raising. J Manipulative Physiol Ther 30: 270-8 4. Roussel NA, Nijs J, Mottram S, Van Moorsel A, Truijen S, Stassijns G. Altered lumbopelvic movement control but not generalised joint hypermobility is associated with increased injury in dancers: A prospective study. Manual Therapy 2009. doi:10.1016/j.math.2008. 5. Hamaoui A, Do Mc, Poupard L, et al (2002) Does respiration perturb body balance more in chronic low back pain subjects than in healthy subjects? Clin Biomech 17: 548-5506. Hodges PW, Eriksson AE, Shirley D, et al (2005) Intra-abdominal pressure increases stiffness of the lumbar spine. J Biomech 38: 1873-80 Keywords: low back pain, motor control, breathing, chronic

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[O41] Hypermobility (HM) - Inﬂuence of passive and active tone U. Stutz 1, G. Luder 1, H. Ziswiler 2, M. Stettler 3, C. Mebes 1, L. Radlinger 3. 1 Institute of Physiotherapy, Inselspital, University Hospital Bern, Switzerland; 2 RIA University Hospital of Bern, Switzerland; 3 Bern University of Applied Sciences Health, Switzerland Objective: Hypothesis: passive and active tone differ between normomobile and hypermobile women. Relevance: HM leads to joint and soft tissue troubles and physical therapy implications are more based on practical than scientiﬁc evidence (1). Diagnosis and documentation typically result from the Beighton Score (BS) (2) and manual testing. Materials /Methods: In this cross-section study women without acute trauma or operation of the lower limbs and back were included: hypermobile women (Beightonscore: 7.6 1.1; n ¼ 13) and normo-mobile women (Beightonscore 0.5 0.5; n ¼ 18). Measurements of the passive tone: angular mobility of the hip and knee (hydrogoniometer), muscle cross-section area of the thigh (ultrasound), resting tension with the straight leg raise (SLR; SLR-device) and ventral tibia-translation (TL; rolimeter). Measurements of the active tone: maximum strength and rate of force development of the knee ﬂexion and extension (force transducer), single-leg standing (forceplate), additional recording of painful situations in daily life (questionnaires). Analysis: Descriptive statistics and comparison of two independent groups (nonparametric, Mann-Withney-U-Test) were performed using SPSS. Results: Hypermobile women had a higher mobility in the hip and knee and additionally a reduced cross-section area in the rectus femoris and hamstrings muscles. No differences were found in SLR and TL. Hypermobile women showed a higher rate of force development in knee extension and had a higher mediolateral sway during single-leg standing. They also described to have more painful limitations during daily life. Conclusions: Currently range of motion, muscle cross section, single-leg stand, rate of force development and painful situations discriminate normo-mobile from hypermobile These results and the inconsistent literature make more studies necessary. References (1) Simmonds JV, Keer RJ. J Man Th. 2007;12 (4) 298-309. (2) Hakim A, Grahame R. Best Pract Res Clin Rheumatol 2003; 17(6):989-1004. (3) Magnusson SP et al. J Rheumatol. 2001; 28(12):2720-5; (4) Gajdosik RL. Europ J Appl Physiol. 2002; 87:20-227

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Inter-rater reliability was good to excellent for group B, with ICCs ranging from 0.917 to 0.926 and from 0.957 to 0.981 for the painful and non-painful shoulders. The dominant supraspinatus is 5.6% thicker, and has 11.86% greater CSA than the non-dominant supraspinatus in group A. The non-painful dominant supraspinatus is 10.21% thicker, and has 14.97% greater CSA than the painful non-dominant supraspinatus in group B. The non-painful non-dominant supraspinatus is on average 8.86% thicker and has 11.32% greater CSA than the painful dominant supraspinatus in group B. Conclusions: Ultrasound is a reliable measure of supraspinatus size in subjects with and without shoulder pain. Differences exist in supraspinatus size between the dominant and non-dominant and painful and non-painful shoulders. Ultrasound is an appropriate and user-friendly tool to measure muscle atrophy in shoulder pain disorders.

Figure 1: US image of supraspinatus

Keywords: Supraspinatus, Real-time ultrasound, Muscle thickness & crosssectional area, reliability [O43] Two clinical tests are highly accurate when diagnosing unilateral shoulder tendinopathy: An ultrasonography study

Keywords: Hypermobility, Active Tone, Passive Tone, discrimination [O42] Reliability of real-time ultrasound measurement of supraspinatus size in normal subjects and subjects with unilateral shoulder pain A. Roche, K. McCreesh. University of Limerick, Ireland Background: Ultrasound (US) is becoming increasingly popular in measurement of muscle characteristics including cross-sectional area (CSA) and thickness. Shoulder pain is likely to result in altered size of the rotator cuff muscles. To date, limited work has been carried out on US measurement of supraspinatus. Kayatose and Magee (2001) reported ICC values of 0.93 for US measurement of normal subjects. No work has been carried out on shoulder pain populations. Methods: Ultrasound scanning was performed with a Philips Aquila realtime ultrasound machine by two raters on healthy subjects (Group A, n ¼ 20) and subjects with unilateral shoulder pain (Group B, n ¼ 18). Subjects were scanned in sitting with a 5 MHz probe at midpoint of supraspinatus length. Three scans were taken of each shoulder. CSA and T were measured using Image J. Intra-class correlation coefﬁcients (ICC), and Bland and Altman methods of agreement assessed inter-rater reliability. Independent t-tests assessed between shoulder differences in T & CSA. Results: Inter-rater reliability was moderate to good for group A, with ICCs ranging from 0.751 to 0.808 and 0.808 to 0.898 for the left and right shoulder.

J. Joensen 1, 2, C. Couppe 3, J.M. Bjordal 1, 2. 1 Bergen University College, Norway; 2 University of Bergen, Norway; 3 University of Copenhagen, Denmark Objective: In asymptomatic, normal tendons, the difference in tendon thickness between sides is less than 15%. In this study, three tests were used to examine differences between symptomatic and asymptomatic shoulders. Design: Cross-sectional study. The three tests were performed in sequence. The observer was blinded in the maximal pain-free isometric force test (PFF). Setting: Outpatient physiotherapy clinic at Bergen University College, Norway. Participants: Sixty-four patients with an exclusive, tentative diagnose of unilateral shoulder tendinopathy. Main outcome measure: Difference in maximal pain-free isometric force (PFFdiff), tendon pain pressure (PPTdiff) and tendon thickness (TTdiff) measured by Ultrasonography. Results: This paper follows the STARD recommendations for papers on diagnostic accuracy. When cut-off values for within-subject side differences were selected at 0.8 mm for tendon thickness (TTdiff), 10 N for maximal pain-free isometric force (PFFdiff) and 0.6 kg for tendon pain pressure (PPTdiff), positive tests were found in 92% of patients. All three tests were sensitive for the detection of within-subject side differences with the selected cut-off values (TTdiff, n ¼ 60/64; PPTdiff, n ¼ 59/64; PFFdiff, n ¼ 57/64; p > 0.35). There were strong agreements between the three tests: TTdiff and PFFdiff, 0.89; TTdiff and PPTdiff, 0.83; and PFFdiff and PPTdiff,

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0.84. When both clinical tests were positive (PFFdiff and PPTdiff), the positive predictive value was excellent (94%) for ﬁnding increased tendon thickness in the symptomatic side on Ultrasonography. Conclusion: Within the limitations of this partially blinded study, patients with unilateral shoulder tendinopathy exhibited signiﬁcant differences between sides in all three tests. The combination of the two clinical tests seems to be valid for the detection of unilateral shoulder tendinopathy of other diagnoses has been excluded. Keywords: Physical examination, Tendons, Ultrasonography, Clinical tests [O44] The multiple hop test: a discriminative or evaluative instrument for chronic ankle instability? C.J. Eechaute, P.H. Vaes. The Physical Therapy Department of the Vrije Universiteit Brussel, Belgium Background: The multiple hop test is a recently validated clinical evaluation method for the assessment of the dynamic postural control in patients with chronic ankle instability1. However, when developing a new measurement instrument, one should consider whether the instrument can be used to discriminate between subjects or whether it is able to measure a change over time for the evaluation of treatments2. Methods: Twenty-nine healthy subjects and 29 patients with chronic ankle instability performed a multiple hop test twice with a one-week time interval. Subjects hopped on 10 different tape markers with one leg while trying to keep balance. The time needed to perform the test and the number of balance errors were assessed. The minimal detectable change of the outcomes was calculated based upon their standard error of measurement. The sensitivity and speciﬁcity of different cut-off points were calculated based upon a Receiver Operating Characteristic (ROC) curve at a 95% conﬁdence interval. Results: The minimal detectable change (evaluative parameter) of the outcomes in patients is respectively 6,4 sec. and 7 errors. Considering the means of the outcomes of the patient sample (time value ¼ 41,1-41,5 sec; number of balance errors ¼ 16,3-17,2 errors) as cut-off points (discriminative parameter), the speciﬁcity is respectively 90% (sensitivity ¼ 61%; ROC area ¼ 79%) and 93 % (sensitivity ¼ 47%; ROC area ¼ 80%). Discussion: Scores should change by 15% (time value) and by 41% (balance errors) before it can be considered that the change in postural control of patients indicates a real improvement or deterioration and that it is not the result is of measurement error. When considering the mean values of both outcomes in patients as cut-off points, the probability of a false positive test is low. Conclusion: The multiple hop test may be more a discriminative rather than a evaluative test for chronic ankle instability. References 1. Eechaute C, Vaes P, Duquet W. Functional performance deﬁcits in patients with CAI: Validity of the multiple hop test. Clin J Sports Med. 2008; 18: 124-129. 2. Devet H, Terwee C, Bouter L. Current challenges in clinimetrics. J Clin Epidemiol. 2003, 56 1137–1141. Keywords: joint instability, postural control, hop test, clinimetrics [O45] Support for modiﬁcations to the anteromedial reach test (an anterior cruciate ligament rehabilitation outcome measure) N.P. Bent 1, A.B. Rushton 1, C.C. Wright 1, M.E. Batt 2. Birmingham, UK; 2 Nottingham University Hospitals, UK

1

University of

Introduction: The Anteromedial Reach Test (ART) is a performance-based outcome measure for assessing dynamic knee stability in anterior cruciate ligament (ACL)-injured patients. Patients perform a single-legged squat while reaching as far as possible with the other leg in an anteromedial direction. Good reliability has been demonstrated in uninjured and ACLdeﬁcient populations,1 although protocol limitations might compromise its validity, e.g. no normalisation for leg length or consideration of learning effects. The aims of this study were to determine the number of practice

trials required for familiarisation with ART, and evaluate the inﬂuence of leg length on ART scores. Methods: A repeated measures design evaluated healthy participants (n ¼ 32 to detect a moderate effect, with power ¼ 80% and signiﬁcance level ¼ 5%2), <45 years, with no history of lower limb, lumbar spine, neurological, balance, or uncorrected vision disorders. Ethical approval was obtained. Participants performed 15 ART trials on each leg (order of limb testing was counterbalanced), and the distance reached and leg length were recorded. A two-way repeated measures ANOVA (factors of trial and limb) evaluated learning effects, and a moving average graph was plotted to identify completion of participant familiarisation. A Pearson correlation coefﬁcient examined the relationship between leg length and ART scores. Results: The two-way repeated measures ANOVA revealed a signiﬁcant main effect of trial (p < 0.001) indicating a learning effect, but no main effect of limb (p ¼ 0.20) or interaction between limb and trial (p ¼ 0.65). The moving average graph identiﬁed that participant familiarisation was complete after 8 trials. A moderate correlation (r ¼ 0.46) was observed between ART scores and leg length. Discussion: When using the ART with uninjured participants, 8 practice trials are required, and scores should be normalised by expressing them as a percentage of leg length. Although previous data suggests a similar learning curve for ACL-injured patients,1 further investigation is required to conﬁrm this. References (1) Rice K, Hunt A, Batt M. The Antero-medial Reach Test: assessment of the reliability of a new functional test for anterior cruciate ligament deﬁciency. Br J Sports Med 2004;38:651. (2) Sim J, Wright C. Research in Health Care: Concepts, Designs and Methods. Cheltenham: Nelson Thornes; 2000 Keywords: anterior cruciate ligament, outcome measures, outcomes assessment, rehabilitation

[O46] Ultrasound measurement of the anterior tibial muscle group: reliability and dominance effects S. Egan, K. McCreesh. University of Limerick, Ireland Background: Knowledge of normal muscle characteristics is crucial in planning rehabilitation programmes for injured athletes. There is a high incidence of ankle and anterior tibial symptoms in football players, however little is known about the effect of limb dominance on the anterior tibial muscle group (ATMG). Objectives: To assess the effect of limb dominance on ATMG thickness in Gaelic footballers and non-football playing controls using ultrasound measurements, and to compare results from transverse and longitudinal scans. Methods: Bilateral ultrasound scans were taken to assess the ATMG size in 10 Gaelic footballers and 10 sedentary controls (age range 18-25yrs), using a previously published protocol. Both transverse and longitudinal images were taken. Muscle thickness measurements were carried out blind to group, using the Image-J programme. Results: Muscle thickness on the dominant leg was signiﬁcantly greater than the non-dominant leg in the footballers (p ¼ 0.001), with a mean difference of 7.3%, while there was no signiﬁcant dominance effect in the controls (p ¼ 0.409). There was no signiﬁcant difference between the measurements from transverse or longitudinal scans. Intersession reliability was excellent (ICC 0.995-0.997). Conclusions: A signiﬁcant dominance effect exists in ATMG size in this group of Gaelic footballers, likely attributable to the kicking action involved in the sport. This should be taken into account when rehabilitating footballers with anterior tibial pathology. Ultrasound is a reliable tool to measure ATMG thickness, and measurement may be taken in transverse or longitudinal section. Keywords: anterior tibial muscles, leg dominance, ultrasound

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[O47] Effects of manual therapy followed by speciﬁc active exercises on the improvement of functional disability of chronic low back pain patients P. Balthazard 1, P. Demeulenaere 1, P. De´riaz 3. 1 HECVSante´, Switzerland; 2 CHUV, Romande de Re´adaptation, Switzerland

De Goumoens 2, O. Switzerland; 3 Clinique

Introduction: This study investigates the effects of manual therapy followed by speciﬁc active exercises on the improvement of functional disability of chronic low back pain patients. The literature recommends active exercises for chronic low back pain. However, the physical activity tends to be limited by pain and, in some cases, by a fear-avoidance process, conducting to a general physical deconditioning. Moreover, the literature recognizes acute analgesic effect of manual therapy. We postulated that this analgesic effect may facilitate the compliance to perform subsequent active exercises and, consequently, improves the treatments efﬁcacy of these patients. Methods: Population: 42 patients, aged 20 to 65 years old (28 males, 14 females), suffering from chronic low back pain without complications and co-morbidities, were randomly distributed into two groups, i.e. a manual therapy (MT) and a control (C) group. Interventions: Each patient followed nine physiotherapy sessions over a period of 4 to 8 weeks: the MT group received MT + speciﬁc exercise therapy (SET); the C group, sham ultrasound + SET. Outcomes: ‘‘Pain intensity-VAS’’, ‘‘Oswestry Disability IndexODI’’ and ‘‘Fear-Avoidance Beliefs Questionnaire-FABQ’’ were evaluated before treatment, after the 9th session, at 3 and 6-months after the end of treatment. Statistically, the results were treated by a one factor ANOVA with repeated measurements. A signiﬁcant difference response between treatments was assessed with the treatment x time interaction. Results: Thirty-eight out of 42 subjects completed the study. The improvement of the ODI score was signiﬁcantly better for the MT group (p ¼ 0.01). The progression of the VAS and the FABQ scores was not signiﬁcantly different between groups, p ¼ 0.44 and p ¼ 0.25 respectively. 18 16 14 12 10 8 6 4 2 0 1

2

3

4

Time ODI Placebo

ODI Manual Therapy

Interaction:p=0.0131

Discussion: Manual therapy followed by speciﬁc active exercises improves the recovery of functional disability. The mechanisms, by which manual therapy affects active exercises and functional disability, appear to be not or only partly associated with pain or fear-avoidance. Keywords: Speciﬁc active exercises, Manual therapy, Disability, Chronic low back pain [O48] The effect of cetylated fatty esters and physical therapy on myofascial pain syndrome of the neck D. Sharan 1, B.N. Jacob 1, P.S. Ajeesh 1, R. Barathur 2, J. Bookout 2. 1 RECOUP Neuromusculoskeletal Rehabilitation Centre, India; 2 Cymbiotics Inc, USA Introduction: This double-blinded study examined effects of topically applied Cetyl Fatty Ester Complex (CFEC) on Myofascial Pain Syndrome (MPS). Methods: 107 patients volunteered to study effects of topical CFEC treatment with and without physical therapy (PT). CFEC cream contained 8 cetylated fatty esters and menthol in cream base. The placebo cream was the same without cetylated fatty esters. Patients with MPS of neck with at

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least 2 myofascial trigger points (TrPs) were accepted. There were 3 randomly assigned groups: topical CFEC cream only (n ¼ 35), CFEC cream plus PT (n ¼ 37), and placebo cream plus PT (n ¼ 35). Therapeutic sessions were twice/week and topical cream was applied liberally twice/day, if designated. Responses were compared to baseline (5 weeks treatment; 3 assessment visits) for following: therapist work-up, palpation tenderness, TrP algometer readings, Cervical Range of Motion (CROMÒ), and participant response evaluators [neck pain & disability visual analogue scale (NPDVAS), Neck Disability Index (NDI), and 36-item short-form health survey (SF36)]. Results: Therapy plus topical CFEC provided the fastest and most effective treatment modality. In some areas of pain management and improvements in neck disability, topical CFEC application alone was as effective as placebo plus therapy. Discussion: Cetylated fatty acid derivatives may effectively reduce pain and symptoms associated with neck MPS. Combined with therapy, patient improvements were better in most measurements than therapy with placebo cream application. Although topical cream alone did increase cranial range of motion, therapy was the most effective treatment for CROM increase. This is the ﬁrst double-blinded study showing that Cetylated fatty esters aid in treating and reducing symptoms of MPS. Keywords: Myofascial Pain Syndrome, Cetylated Fatty Esters, Physical Therapy, Neck Disability Index

[O49] The relationship between change in function and change in psychosocial parameters in individuals with chronic low back pain C.G. Ryan, W. MacLaren, M.H. Granat. Glasgow Caledonian University, UK Introduction: Change in psychosocial parameters is associated with change in self-reported function in individuals with chronic low back pain (CLBP). It has not been shown if changes in these psychosocial parameters are associated with changes in objective measures of functioning. The aim of this study was to investigate the relationship between change in psychological parameters and change in subjective and objective functional measures in individuals with CLBP. Method: Function and psychosocial measures were assessed pre and post an intervention for individuals with CLBP (n ¼ 31). The psychological variables were collected using standardised questionnaires; Pain self-efﬁcacy scale, Modiﬁed Zung depression index, Modiﬁed somatic perceptions questionnaire, the Tampa scale of Kinesiophobia fear and harm subscales, and a Pain numerical rating scale. Function was measured using self-report (The Roland Morris Disability Questionnaire) and estimated energy expenditure (EE) measured using the activPALÔ activity monitor. Two stepwise regression analyses were used to assess the relationship between change in both function markers and psychosocial variables. Interim results are presented in this abstract. Results: The greater the improvement in pain self-efﬁcacy and depression the greater the improvement in self-reported function (p < 0.05). There was a direct relationship between change in fear of harm and energy expenditure (p ¼ 0.01), however, the direction of the relationship was counterintuitive with greater improvements in fear or harm associated with a smaller increase in EE. Discussion: Changes in psychosocial variables were associated with changes in subjective and objective markers of functioning in individuals with CLBP. The direction of the relationship depended on the functional measure used. The counterintuitive relationship found between fear of harm and EE is not easily explainable and demonstrates the usefulness of supplementing subjective functional data with objective data. Further investigation of the relationship is warranted with a larger sample. Keywords: function, psychosocial, low back pain, physical activity

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[O50] Research priorities physiotherapy

Oral Abstracts / Manual Therapy 14 (2009) S11–S30

for

A. Rushton 1, A. Moore 2. Brighton, UK

1

postgraduate

theses

in

University of Birmingham, UK;

manipulative

2

University of

Background: Research priorities are commonly established to identify gaps and maximise opportunities in developing an evidence base. Within the specialist area of musculoskeletal physiotherapy, numerous postgraduate research theses are completed each year, and although some are published, greater potential for their inﬂuence exists. Methodology: This study identiﬁed international research priorities for theses developed using a consensual Delphi method. Central to the process were the roles of the researcher and research consumer, and participants comprised course tutors and expert clinicians nominated by the Member Organisations of the International Federation of Orthopaedic Manipulative Therapy through purposive sampling (n ¼ 91). Round 1 requested >10 priorities for theses, and content analysis identiﬁed research themes. Round 2 requested participants rank the importance of each theme on a 1-5 scale, and round 3 requested ranking the importance and feasibility of the research question areas within agreed themes. Descriptive analysis and Kendall’s Coefﬁcient of Concordance enabled interpretation of consensus. Thematic analysis explored the insights afforded by qualitative data from open questions for each round. Findings: The response rate of 68% was good, identifying 23 research themes from round 1. Round 2 agreed 14 research themes as important. Participant rating of the importance and feasibility of research question areas in round 3 supported identiﬁcation of 43/159 research question areas as priorities; demonstrating discrimination of the process. The context of the postgraduate thesis was clearly communicated within the qualitative data. Discussion and conclusions: Research themes were broad, for example, reliability of assessment tools and patient focused research, and the prioritised research questions emphasise preliminary work necessary to enable subsequent research development. The priorities therefore represent dynamic and evolving areas of importance to musculoskeletal physiotherapy. The measurement validity of the research question areas was good. Establishing priorities provides a vision of how postgraduate theses can contribute to the developing evidence base. Keywords: research, priorities, musculoskeletal, postgraduate

[O51] Cognitive learning and sensorimotor function provide a protective effect from disability in low back pain S.G.T. Gibbons 1, 2. 1 Neuromuscular Rehabilitation Memorial University of Newfoundland, Canada

Institute,

Canada;

2

Introduction: It is well established that pain and disability are not directly related. Recent research shows that cognitive learning function (CLF) is associated with psychological reactions and cognitive errors such as fear or anxiety, which are linked to disability. Methods: A cross sectional study was performed on 263 individuals who had chronic low back pain (LBP) for more than a year from the age of 18-60 (147 female; 116 male). They completed the Roland Morris Disability Questionnaire (RMDQ), the Patient Speciﬁc Functional Questionnaire, the Quadruple Numerical Rating Scale, and the Motor Control Abilities Questionnaire (MCAQ). Work status was assessed with the work measure subgroup of the F4 Functional Scale. The MCAQ consists of items that rate aspects of CLF, sensorimotor function (SF). Previously determined cut off points of 20 and below and 80 or greater were used. Statistical analysis was done with a t test and rate ratio from a standard 2 x 2 table. Results: 23 Subjects who scored 20 or under on the MCAQ minimal disability associated with their pain. The mean RMDQ score was 1.7. The mean pain level was 5.7. The subjects who scored above 80 on the MCAQ (n ¼ 18) had a mean pain score of 6.8 and a mean RMDQ score of 16.8. This was signiﬁcant (p < 0.05). The rate ratio of being disabled from work if the score is below 20 was 0.03. Discussion: The results from this study allow us to hypothesize that certain aspects of CLF and SF may provide a preventative effect from disability due to LBP. It is hypothesized that CLF deﬁcits do not allow normal problem solving to develop, limit normal appraisal of the threat value of pain and contribute to the development of psychological reactions. The identiﬁcation of cognitive learning abilities may be an important new sub-classiﬁcation method. A larger sample size is required to conﬁrm these ﬁndings. Keywords: disability, cognitive function, risk screening

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Interactive Poster Abstracts / Manual Therapy 14 (2009) S32–S36

[IAP01] Practical use of the Hypothesis-Orientated Algorithm for Clinicians II (HOAC II, part 1) E.J. Thoomes, M. Schmitt. SOMT, Netherlands Introduction: The use of algorithms is advocated in contemporary clinical reasoning. The Hypothesis-Orientated Algorithm for Clinicians II (HOAC II) 1 recognises 2 major types of patient problems (existing and anticipated) as well as 2 ways of identifying patient problems: Patient-identiﬁed problems (PIPs) and non-patient-identiﬁed problems (NPIPs). PIPs usually consist of functional limitations and disabilities as described in the ICF 2,3; they often exist when the therapist sees the patient. While the patient identiﬁes the problem, the therapist needs to generate a hypothesis as to the cause of the problem and he then needs to establish testing criteria which can be used to evaluate the outcome of interventions and the correctness of the hypothesis and patient care strategies. Methods: Using a recognizable case history, we followed the algorithm, requiring us to develop a strategy for the examination that was based on initial hypotheses developed from the medical history and other data obtained prior to the examination. The examination was then tailored to identify and quantify relevant impairments that were hypothesized to be causing the problems. Next we established goals. Goals for existing problems usually represent measurable target levels (dis-)ability that a patient will be able to achieve as a result of the intervention. Each goal must have a temporal element; an expectation as to when the goal will be met. Goals are always patient centered and always represent outcomes that have value to the patient’s current quality of life or future quality of life. Then we deﬁned testing criteria that were used to examine the correctness of the hypotheses. Testing criteria usually represent speciﬁed measurements of achievements at the impairment level that, if obtained, will result in the resolution of the problem if the hypotheses are correct. Results: We demonstrated the clinical application of HOAC II and showed how disablement terms can be integrated into patient management in a way that enhances practice. The case history was illustrative in that it demonstrated how all elements of HOAC II can be addressed for, what are considered relatively common, types of patient problems. We believe that by applying the HOAC II on an individual patient basis, therapists will be ideally positioned to apply evidence to patient care and to defend their interventions to colleagues and to third party payers. Discussion: The process of identifying PIP’s and NPIP’s, goal setting and using objective testing criteria, aid clinicians in making (manipulative) physiotherapy a more objective (multi) modality of treatment. It also stimulates EBCP in physiotherapy management of patients, necessitating a constant update of relevant knowledge with contemporary literature and research outcome of today’s physiotherapist as a health care professional. References 1. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient management. Phys Ther. 2003 May; 83(5):455-70. 2. Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G.Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002 Nov;82(11):1098-107. 3. Finger ME, Cieza A, Stoll J, Stucki G, Huber EO. Identiﬁcation of intervention categories for physical therapy, based on the international classiﬁcation of functioning, disability and health: a Delphi exercise. Phys Ther. 2006 Sep;86(9):1203-20. Keywords: Clinical Reasoning, HOAC II, Elite Athlete, Low Back Pain [IAP02] Evaluation of the change in recruitment of Multiﬁdis and Transversus Abdominus following manual facilitation K.J. Jones, J. Wray, M. McBride, N. Ellis, C. Harraway. Cardiff University, United Kingdom The importance of stabilising the spine is heightened in athletes with a weak core leading to less efﬁcient movement and potential injury.

Evidence indicates that spinal stability training could prevent injury, enhance performance and accelerate post injury rehabilitation. The intervention being investigated has not previously been objectively evaluated in any population. The purpose of the present study was to investigate the effect of a manual facilitation technique on bilateral activity of Multiﬁdis (MT), Transverse Abdominus/Internal Oblique (TA/IO), External Oblique (EO), Erector Spinae (ES) in both sitting and standing. A same subject experimental design was implemented. A healthy convenience sample (mean (SD) age 26.45 years (5.25) (n ¼ 22; 13 female) was recruited. The intervention is a speciﬁc manual facilitation applied to MT, which aims to enhance proprioceptive awareness and facilitate an active neutral alignment of the lumbar spine. This is described as the optimum alignment for efﬁcient spinal stability and activation of the deep muscle stabilisers. Surface Electromyography was used to evaluate. Data was analysed using a repeated measures ANOVA (alpha 0.05). Local ethical approval was obtained from School of Healthcare studies, Cardiff University. The results indicate that following intervention there was a signiﬁcant increase in all the target muscles with a highly signiﬁcant increase of the deep muscle stabilisers, TA/IO and MT. In sitting, left MT (p ¼ 0.000), right MT (p ¼ 0.002), left ES (p ¼ 0.029), right ES (p ¼ 0.015), left TA/IO (p ¼ 0.000), right TA/IO (p ¼ 0.000), left EO (p ¼ 0.008), right EO (p ¼ 0.044). In standing, left MT (p ¼ 0.000), right MT (p ¼ 0.000), left ES (p ¼ 0.008), right ES (p ¼ 0.010), left TA/IO (p ¼ 0.000), right TA/IO (p ¼ 0.000), left EO (p ¼ 0.001), right EO (p ¼ 0.001). Clinically this technique has potential to be useful in the retraining of athletes to isolate the deep stabilisers prior to progressing on to independent exercises and integration into more challenging sporting activities. Keywords: Manual facilitation of Multiﬁdis, Spinal stability, SEMG evaluation of deep stabilisers [IAP03] The incidence of pelvic instability in subjects with chronic groin pain R.M. O’Sullivan. Institute of Technology Carlow, Ireland The purpose of this study was to examine the incidence of pelvic instability in subjects with chronic groin pain compared to a sporting participation matched control group. Groin pain is prevalent in many sports and it is not uncommon that this pain should become chronic. There are many proposed reasons for this chronicity, including a large differential diagnosis in the region and the presence of two or more pathologies coexisting. Recently, research has begun to focus on the involvement of pelvic instability in this long-standing pain. A recent study found the action of the transversus abdominis to be delayed in patients with longstanding groin pain, and such a delay can lead to the lower limb moving through an unstable base (Cowan et al., 2004). 11 subjects (mean age 24 6.9) suffering from chronic groin pain within the last three years, and 11 subjects with no history of groin pain (mean age 20.2 2.1) were recruited. The pressure biofeedback unit (pbu) was used for quantifying of pelvic instability in three tests that challenge pelvic stability – supine knee ﬂexion, knee drop out and leg extension. These tests were performed in random order and the changes in pressure (mmHg) as indicated by the pbu recorded for statistical purposes. A one way ANOVA found there to be a signiﬁcant difference between the groups for all three tests (p < 0.05). An unpaired t-test highlighted a signiﬁcant difference in the changes of pbu pressures between the affected limb in the groin group and the left leg of the control group for all three tests (p < 0.05). There was also a signiﬁcant difference between the affected and the unaffected legs in the groin pain group in all three tests (p < 0.05). Therefore, the hypothesis was accepted that subjects with chronic groin pain have signiﬁcantly more pelvic instability compared to a matched control group. Keywords: chronic groin pain; lumbopelvic stability; pbu

Interactive Poster Abstracts / Manual Therapy 14 (2009) S32–S36

[IAP04] A comparison of two styles of the football instep kick and their relationship to lumbopelvic stability A.R. Barr, A. Burden. Manchester Metropolitan University, United Kingdom Objectives: To investigate the differences between the follow through (FT) and non follow through (NFT) kicking techniques, their relationships with lumbopelvic stability, and to draw inferences for injury potential. Design: A VICON system measured the three-dimensional (3D) positions of 6 reﬂective markers on participants’ trunk to gain angular displacement of the spine during the different kicking techniques. A pressure biofeedback unit was used to measure participants’ lumbopelvic stability. Setting: The data collection area in the Department of Exercise and Sports Science, Manchester Metropolitan University, Cheshire was used for 3D motion-capture. Lumbopelvic stability testing was performed at the Bolton Wanderers FC training facility. Participants: Twelve male professional footballers with mean ( SD), age 19 ( 5) yrs, height 181.6 (18) cms and mass 78.6 (25) kg were used in the study. Main Outcome Measures: 1) Differences in motion of the lower spine between the FT and NFT kicks were analysed using paired t-tests. 2) Differences in spinal rotation and lumbopelvic stability between left and right sides were also analysed using paired t-tests. 3) Relationships between lumbopelvic stability and lower spine motion were analysed for both FT and NFT kicks using Spearman’s rank order correlation. Results: Signiﬁcantly greater end ranges of spinal motion were discovered for NFT kicks compared to FT kicks (P < 0.001). Signiﬁcantly greater left lower spine rotation was found compared to right rotation for both kicks. Signiﬁcantly lower left rotation stability scores were found compared to right (P < 0.002). A signiﬁcant inverse relationship was found between lower spine extension and extension stability for both kicks (P < 0.001). Conclusion: NFT kicks are thought to have increased risk of injury to the lumbopelvic region compared to FT kicks due to greater end ranges of spinal motion. Reduced left rotational stability is linked to increased left lower spine rotation from frequently performed right footed kicks. Poor extension stability is thought to increase the risk of lumbopelvic extension injury when kicking. Keywords: Instep Kick, Lumbopelvic stability, 3D analysis [IAP05] A comparison of metacarpophalangeal with cervical apophysial joint manipulation using high velocity low amplitude thrust (HVLAT) techniques A. Harwich. Private Practice, United Kingdom High velocity, low amplitude thrust (HVLAT) techniques are commonly used in manual therapy. There is general agreement that the ‘cracking’, which occurs on HVLAT, is due to a phenomenon known as cavitation. The precise mechanism of cavitation in synovial joints, achieved by sudden separation of the joint surfaces by manual techniques, has only been investigated for distraction of the joint surfaces of metacarpophalangeal (MCP) joints. It is assumed that in both spinal and peripheral joints any synovial joint cavitation phenomenon is essentially the same mechanism as occurs in metacarpophalangeal joints. However, HVLAT on MCP joints can be performed in many different ways and a common alternative to distraction is into ﬂexion. Moreover, the MCP distraction HVLAT is a symmetric separation of the joint surfaces and thus cannot be the same motion as produces hyperﬂexion MCP HVLAT. This paper sets out to compare MCP with cervical apophysial joint manipulation using HVLAT consistent with the technique as described by several authors. By constructing an idealised, simpliﬁed graphical model of the joint, the two mechanisms, distraction and hyperﬂexion HVLAT of the MCP joint, were compared graphically together with a qualitative vector analysis. An important ﬁnding was that, using similar methods, HVLAT on cervical apophysial joints was shown to be the analogue of the MCP hyperﬂexion HVLAT. The analysis reveals aspects of HVLAT technique that have not previously been emphasised or that have been ambiguously described or erroneously reported. Although no agreed pathway has been mapped out that would

S33

explain the therapeutic beneﬁts of using HVLAT technique, it is concluded that this analysis points to a much more clearly deﬁned physiological dysfunction common to very many synovial joints that is addressed by the high velocity low amplitude thrust (HVLAT) technique. Keywords: Synovial Joint, Cavitation, high velocity low amplitude thrust, metacarpophalangeal joint [IAP06] Self-reported assessment of disability and performance-based assessment of disability are inﬂuenced by different patient characteristics in acute low back pain N.E. O’Connell 2, J. McAuley 3, 4, L.H. B.M. Wand 1, P. Formby 1, DeSouza 2. 1 The University of Notre Dame, Australia; 2 Brunel University, United Kingdom; 3 The George Institute for International Health, Australia; 4 University of Sydney, Australia Introduction: Studies on low back pain (LBP) patients indicate a discrepancy between self-reported disability and actual daily activity levels [1,2] and the level of agreement between performance based measures of disability and self reported measures of disability is not strong [3-7]. The purpose of this study was to establish the feasibility of using a performance-based assessment of disability in the acute LBP population, and to investigate the relationship between self reported disability and performance-based evaluation in this population. Methods: 94 patients with ALBP aged between 20 and 55 years of age undertook a battery of functional tasks and completed a self reported disability questionnaire. The tasks included timed repeated sit-to-stand, the timed up-and-go test, timed lying supine to standing, and a timed ﬁvemetre walk. Results were combined to give an overall score. Internal consistency, the relationship between self reported disability and performance based assessment of disability and the relationships between patient proﬁle and the two disability measures were investigated. Results: The tests were well tolerated by this group. The protocol demonstrated good internal consistency (Cronbach’s alpha ¼ 0.86). The performance base measure of disability was only moderately correlated with self report (Pearsons r ¼ 0.471 p < 0.001). Univariate and multivariate analyses demonstrate that self reported and performance based measures of disability are inﬂuenced by different clinical characteristics. Speciﬁcally, self reported disability appears to be more strongly related to the patient’s psychological status than performance based assessment. Discussion: The protocol was quick and easy to perform. It appears that self reported measures are more inﬂuenced by the patients’ psychological status than performance based assessments and may give a distorted view of the actual functional consequences of an ALBP episode. To fully understand the functional consequences of ALBP it may be advisable to use both self report and performance based assessments of disability. References 1. Verbunt JA, Westerterp KR, van der Heijden GJ, Seelen HA, Vlaeyen JW, Knottnerus JA Physical activity in daily life in patients with chronic low back pain. Arch Phys Med Rehabil. 2001; 82(6):726-30 2. Verbunt JA, Sieben JM, Seelen HA, Vlaeyen JW, Bousema EJ, van der Heijden GJ, Knottnerus JA. (2005) Decline in physical activity, disability and pain-related fear in sub-acute low back pain. Eur J Pain. 2005; 9(4):417-25 3. Alschuler KN, Theisen-Goodvich ME, Haig AJ, Geisser ME A comparison of the relationship between depression, perceived disability, and physical performance in persons with chronic pain. Eur J Pain. 2008; 12(6):757-64 4. Gross DP, Battie´ MC Construct validity of a kinesiophysical functional capacity evaluation administered within a worker’s compensation environment. J Occup Rehabil. 2003; 13(4):287-95. 5. Lee CE, Simmonds MJ, Novy DM, Jones S Self-reports and clinicianmeasured physical function among patients with low back pain: a comparison. Arch Phys Med Rehabil. 2001; 82(2):227-31 6. Novy DM, Simmonds MJ, Lee CE. Physical performance tasks: what are the underlying constructs? Arch Phys Med Rehabil. 2002; 83(1):44-7 7. Simmonds MJ, Olson SL, Jones S, Hussein T, Lee CE, Novy D, Radwan H. Psychometric characteristics and clinical usefulness of physical performance tests in patients with low back pain. Spine. 1998; 23(22):2412-21 Keywords: Low Back Pain, Disability, Performance tests, Functional capacity

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Interactive Poster Abstracts / Manual Therapy 14 (2009) S32–S36

[IAP07] Scapular positioning and motor control in children and adults: A casecontrol study using clinical measurements 1, 2

1, 2

1

3

1

F. Struyf , J. Nijs , S. Horsten , S. Mottram , S. Truijen , R. Meeusen 2. 1 Artesis University College Antwerp, Belgium; 2 Vrije Universiteit Brussel, Belgium; 3 Kinetic Control, United Kingdom Introduction: The scapular muscular system is the major contributor of scapular positioning. In addition, children show improvement in strength, ﬂexibility and muscular endurance from childhood through adolescence. Thus, differences in scapular positioning and motor control between adults and children may occur. The hypothesis for this study was that the scapular positioning and motor control varies between adults and children. It also aimed to provide normative data for the use of the clinical tests for the assessment of scapular positioning in clinical practice. Methods: A case-control design was used. Ninety-two shoulders of 46 adults, their age ranging between 18 and 86 years, and 116 shoulders of 59 children, 6-17 years of age, were included in the study. Scapular positioning data were collected using a clinical assessment protocol including visual observation of titling and winging, measurement of forward shoulder posture, measurement of scapular upward rotation, and the assessment of scapular motor control. Results: The observation protocol for scapular winging and tilting did not show signiﬁcant differences between adults and children or between any of the ﬁve subgroups. After controlling for body mass index, forward shoulder posture (relaxed) was signiﬁcantly smaller in children than in adults (P < 0.01). In addition, children showed greater scapular upward rotation (90.8 ; SD 16.1 ) than adults (83.0 ; SD 15.8 ). No signiﬁcant differences were seen between children and adults in scapular motor control. Discussion: Children and adults show signiﬁcant differences in scapular upward rotation and forward shoulder posture. No difference is noted in scapular motor control. Our results provide normative data for scapular upward rotation and forward shoulder posture in children and adults. Keywords: scapular, shoulder, age, clinical [IAP08] The effect of patella taping on lower limb joint movement and anterior knee pain E. Harrington, A.M. Clifford. University of Limerick, Ireland Purpose: To investigate the effects of medial glide patella taping (MGPT) on lower-limb joint angle change and knee pain during a unilateral squat in a symptomatic population complaining of patellofemoral pain syndrome (PFPS). Relevance: MGPT, ﬁrst described by McConnell1 and is an adjunct commonly used in the management of PFPS. Despite this, the mechanism behind the clinical success remains unclear. Participants: Following ethical approval, a sample of convenience of subjects with a six month history of unilateral or bilateral PFPS2 volunteered to participate in the study. Methods: Subjects were required to squat once on the symptomatic leg under three conditions (placebo tape, MGPT and control respectively). Kinematic data was recorded using the CODA mpx64 motion analysis system. A record of subjects’ pain according to the Numerical Rating Scale (NRS) under each condition was also noted. Analysis: Changes were analysed using Friedman and Wilcoxon Signed Ranks tests. Results: Fifteen symptomatic knees were analysed. MGPT resulted in a signiﬁcantly greater single-legged squat depth compared to placebo tape (p ¼ 0.008) and control (p ¼ 0.0012) by a mean of 108 and 48 respectively. A statistically signiﬁcant reduction in pain during a single-legged squat was found when the patellofemoral joint was glided medially compared to squatting with placebo tape (p ¼ 0.001) or control (p ¼ 0.001). This reﬂected a clinically signiﬁcant decrease in pain by 2 points on the NRS. Conclusion: MGPT produces signiﬁcant increases in squat depth with associated signiﬁcant reductions in patellofemoral pain in a symptomatic population.

Implication: MGPT will enable PFPS patients to complete their rehabilitation exercises with less pain and through a greater range of movement. References 1 McConnell J. The management of chondromalaciae patellae: a long term solution. Aust J Phys Ther 1986; 32: 215-223. 2 Callaghan MJ, Selfe J. Patellar taping for patellofemoral pain syndrome in adults. Coch Data Syst Rev 2007; 3. Keywords: Anterior knee pain, Kinematics, Taping, Squat [IAP9] Are there alterations to feedback mechanisms controlling the shoulder complex in painfree subjects with hypermobility? H.M. Jeremiah 1, 3, C.M. Alexander 2. 1 UCL, United Kingdom; 2 Imperial College Healthcare NHS Trust, United Kingdom; 3 RNOH NHS Trust, United Kingdom The objective of this study was to explore joint hypermobility, the range of shoulder movement, the ability to re-position the shoulder joint and one measure of reﬂex control of the upper and lower ﬁbres of trapezius in pain free people with and without joint hypermobility syndrome. With ethical approval and informed consent 24 subjects were assessed for hypermobility using the Brighton criteria. Shoulder range of movement was measured using a ﬂuid goniometer, the ability to re-position the shoulder was measured using photographic analysis. In addition, a reﬂex in trapezius was evoked using electrical stimulation of the ulna nerve. Shoulder range, joint reposition sense and the reﬂex latency of the hypermobility group and the non hypermobile group were compared. There was a greater range of shoulder movement in the people with hypermobility when compared to the non hypermobile group (p ¼ 0.004). There was no difference in the shoulder joint repositioning test between the hypermobile and non hypermobile groups (p ¼ 0.27), however, the people with hypermobility displayed a larger degree of variability in this measure (p ¼ 0.014). Finally there was no difference in the latency of the trapezius reﬂexes (p ¼ 0.86). In conclusion, in a group of people with hypermobility without shoulder problems there was no difference in either the shoulder joint reposition test or this trapezius reﬂex latency when compared to a non hypermobile group. This suggests that some mechanisms of feedback might not be different in asymptomatic hypermobile subjects. Keywords: Hypermobility, Proprioception, Reﬂex, Shoulder

[IAP10] The inﬂuence of sensorimotor incongruence on musculoskeletal injuries in musicians L. Daenen 1, 2, N.A. Roussel 1, 2, P. Cras 3, J. Nijs 1,4. 1 Division of Musculoskeletal Physiotherapy, Artesis University College, Belgium; 2 Royal Conservatoire; Artesis University College, Belgium; 3 University of Antwerp & University Hospital Antwerp, Belgium; 4 Vrije Universiteit Brussel, Belgium Introduction: Musicians daily perform complex repetitive movements and are at increased risk for developing musculoskeletal symptoms1, such as pain, stiffness, muscle cramps, etc. In the majority of the symptoms, however, no speciﬁc diagnose can be made. It has been suggested that a conﬂict between motor activity and sensory feedback may be a persistent source of nociception in the central nervous system. Presenting incongruent information to healthy subjects induced pain and sensory disturbances in healthy individuals.2 Moreover, a sensory-motor mismatch exacerbates pain and sensory perceptions in patients with chronic pain3, suggesting a possible aetiological role for sensory-motor incongruence in the development of (chronic) pain. The purpose of this study is to determine whether a conﬂict between motor intention and sensory feedback may explain the musculoskeletal symptoms of upper extremities and vertebral column in professional musicians. Methods: Twenty students following a professional Master in violin performed a task simulating sensory-motor incongruence of upper extremities. All participants were asked to ﬂex/extend both arms in a congruent/

Interactive Poster Abstracts / Manual Therapy 14 (2009) S32–S36

incongruent manner for 20-s viewing a whiteboard or mirror surface2,3. Afterwards, the subjects were asked whether any changes in sensory experience occurred during the test2,3. The investigator was blinded to the symptoms of the subjects at the moment of testing. The subjects ﬁlled in several questionnaires aiming at analyzing psychosocial characteristics and medical history. Finally, the occurrence of new injuries was registered during a 6-months follow-up. Results: Signiﬁcant more musicians with current musculoskeletal injuries experienced sensory disturbances during the incongruent task (p < 0.05). A logistic regression analysis revealed that high results of the pain catastrophizing scale and a positive sensory-motor incongruence test at baseline assessment were predictive for the occurrence of new injuries during the prospective part (p < 0.05). Conclusions: Musicians sensitive to sensory-motor incongruence and demonstrating pain catastrophizing are at increased risk for developing injuries. 1. Lederman R, Muscle Nerve 2003, 27:549-561 2. McCabe CS et al, Rheumatology 2005;44:509-516. 3. McCabe CS et al, Rheumatology 2007;46:1587-1592.

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Table 1 Linear regression models1) for explaining the variance in ability to stabilize the lumbo-pelvic region during movement control tests Model equations2) Female personnel

Male personnel

R2 Motor control

¼

Motor control

¼

Motor control

¼

Motor control

¼

Keywords: pain, musicians, sensory-motor incongruences, injuries [IAP11] Prediction of the ability to stabilize the lumbo-pelvic region from physical performance tests B. Aasa 1, U. Aasa 2. 1 Norrlandskliniken, Sweden; 2 University of Umeå, Sweden The aim of the study was to evaluate the ability of female and male ambulance personnel to maintain their lumbo-pelvic region in a neutral position during movement control tests and to investigate whether physical performance and/or low back pain could explain the variance in movement control. The study was conducted at two ambulance stations and 62 of 89 personnel volunteered (22 women and 40 men). The design was a cross-sectional single-blinded study, i.e., the physiotherapist did not know how the subjects performed in the physical performance tests or if they reported back-pain. The physical capacity tests were ‘‘ability to carry weights up and down three ﬂights of stairs’’ (outcome: heart rate [time >70% of estimated HRmax]), cardio-respiratory capacity (VO2max), isometric lifting strength (N), hand-grip strength (kg) and isometric endurance of the back muscles (s). For movement control, we used the tests ‘‘standing bow’’ and sitting bilateral knee extension to assess ﬂexion control, supine double leg lower and prone knee ﬂexion for extension control and sitting unilateral knee extension, prone knee ﬂexion and prone hip rotation for rotation control. Each test scored one point (total range 0-10 points). The male personnel performed signiﬁcantly higher in VO2max, lifting strength, hand grip strength and developed less fatigue during carrying weights compared to the female personnel. Signiﬁcantly more female than male personnel controlled ﬂexion and rotation. Explained variances of movement control in the linear regression (forward stepwise) analyses are presented in table 1. In conclusion, VO2max, isometric back endurance and carrying weights could signiﬁcantly explain the variance in ability to stabilize the lumbo-pelvic region among the male but not among the female personnel. Since low back pain could explain the faulty movements to a high extent, especially among the women, it might be favourable to add motor control training to their traditional core strength training. Keywords: movement control, low back, physical performance tests, Ambulance personnel

1

3)

4.511 + 0.883 * VO2max (l x min ) -0.013 * Isometric back endurance + 0.013 * Heart rate (time [s] >70% of estimated HRmax) during carrying a loaded stretcher 7.405 + 0.060 * VO2max (l x min1) -0.005 * Isometric back endurance + 0.002 * Heart rate (time [s] >70% of estimated HRmax) during carrying a loaded stretcher – 3.855 * Activity limitation during the past 12 months due to low back pain

0.20

-5.743 + 1.934 * VO2max (l x min1) -0.013 * Isometric back endurance + 0.026 * Heart rate (time [s] >70% of estimated HRmax) during carrying a loaded stretcher -5.082 + 1.862 * VO2max (l x min1) -0.011 * Isometric back endurance + 0.025 * Heart rate (time [s] >70% of estimated HRmax) during carrying a loaded stretcher – 0.964 * Activity limitation during the past 12 months due to low back pain

0.36

0.63

0.38

1)

According to the regression formula: Y ¼ a + bX1 + cX2 + dX3 Among the male personnel, all predictors in the models were signiﬁcant. Among the female personnel, only the variable ‘‘activity limitation during the past 12 months due to low back pain’’ was signiﬁcant. 3) The squared correlation coefﬁcient, adjusted for differences in variance between variables. 2)

[IAP12] Changes in mechanosensitivity due to lumbopelvic and ankle positioning G.M. Homstøl, B.O. Homstøl. NHP-Neuromucsuloskeletal Health & Performance, Norway Neurodynamic Release (NDR) is a new and innovative approach which explores the inﬂuence of mechanosensitivity to movement on neuromusculoskeletal health and performance. A reduction in mechanosensitivity has been found to signiﬁcantly decrease pain and disability in patients with chronic neck and back pain and reduce symptom response and risk of re-injury, as well as enhance performance in athletes. The site of mechanosensitivity (stretch sensation) on movement testing directs treatment. The aim of this pilot study was hence to investigate the change in site(s) when altering the lumbopelvic and ankle position in the NDR movement test called Sitting Single Knee Extension. A convenience sample of 15 semi-professional male footballer players from a Norwegian 2nd division team was recruited. The players age ranged from 17-31 years (mean 23,9 years), height 173-193 cm (mean 182,7 cm) and weight 70-91 kg (mean 78,3 kg). They had a history of various neuromusculoskeletal complaints, but no current pain or pathology in the lower quadrant including the lumbopelvic region. The movement test was performed 4 times on each leg with different combinations (Table 1) to full knee extension. The data was analysed based on number of positive tests (stretch sensation present) and number of body regions the site(s) was present. Changes due to position was analyzed based on category of response compared to the original movement test; no change in body region, increase or decrease in body regions and change of body region (original site(s) resolved, but new site(s) present). Compared to the original test procedure there were only minor changes to the number of positive tests when sitting with the lumbopelvic region (0%) or ankle (8%) relaxed, from which only 14% and 4% changed site of mechanosensitivity. When a relaxed lumbopelvic and ankle position was combined it was the position of least positive tests.

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Interactive Poster Abstracts / Manual Therapy 14 (2009) S32–S36

Table 1: Test results

Ankle Dorsiflexed

Ankle relaxed Positive tests: 27/30

Lumbopelvic Neutral

Original test procedure

No change: 17

Positive tests: 29/30

Increased: 2 Decreased: 7 Change: 1

Positive tests: 29/30

Lumbopelvic Relaxed

Positive tests: 18/30

No change: 18

No change: 10

Increased: 3

Increased: 3

Decreased: 4

Decreased: 3

Change: 4

Change: 2

Keywords: Neurodynamic Release, Mechanosensitivity to movement, Movement sequencing, Athletes [IAP13] Relationships between disability, catastrophizing and pain thresholds in whiplash injury: A longitudinal analysis K. Rivest 1, 2, J.P. Dumas 3, S.J. De Serres 1, J.N. Coˆte´ 1, 2. 1 Jewish Rehabilitation Hospital Research Center, Canada; 2 McGill University, Canada; 3 Sherbrooke University, Canada Introduction: Recent work shows that movement dysfunction in whiplashassociated disorders (WAD) may be associated with sensory deﬁcits. Mechanisms of sensory hypersensitivity are not well understood and may be associated with psychological features. However, it is unclear how these relationships evolve as chronicity develops. We examined relationships between disability, catastrophizing and pain thresholds in subjects with WAD over a one year period. Methods: Individuals who sustained a whiplash injury grade I-III following a motor vehicle accident were examined within one month (visit 1) and at 3 and 6 months and 1 year post-injury (visits 2 to 4). Scores on the Neck Disability Index (NDI) and Pain Catastrophizing Scale (PCS) were taken at each visit. Sensory dysfunction was assessed using a thermo testing apparatus measuring cervical spine cold pain threshold (CPT), and a pressure algometer measuring cervical (PPTcx) and distal (PPTdist) pressure pain thresholds. Results: At the ﬁrst visit (n ¼ 40), both CPT (r ¼ 0.52) and PPTcx (r ¼ -0.38) were correlated with NDI but PPTdistal (r ¼ -0.06) was not. There was a low correlation between PCS and CPT (r ¼ 0.45) but no relationships between PCS and PPT (cervical, r ¼ -0.18, and distal, r ¼ -0.01). At visit 2 (n ¼ 32), similar relationships were found between CPT and PCS (r ¼ 0.43) and between CPT and NDI (r ¼ 0.45). At visits 3 and 4 (n ¼ 26 and 22, respectively), these correlations became very low and non signiﬁcant. Mean NDI scores were 33 at visit 1 (moderate / severe disability), and 21, 16 and 13 at visits 2 to 4 (mild disability). Discussion: Individuals with higher neck disability and catastrophic thinking presented with hypersensitivity to cold in the acute phase. Although these relationships were still present 3-month post-injury, they seem to decrease over time. This may be explained by the average decrease in disability, although other factors may play parts in the persistence of symptoms. Keywords: whiplash, sensory dysfunction, catastrophizing, longitudinal

[IAP14] ‘‘Patient-centred care’’; It’s meaning for musculoskeletal physiotherapists and patients with low back pain – the physiotherapists perspective M.T. Sexton 1, A.P. Moore 2, C.M. Ramage 2. 1 University of Hertfordshire, United Kingdom; 2 University of Brighton, United Kingdom Introduction: Patient-centred care has become synonymous with highquality health care. Whilst the concept emerged over 30 years ago, it is still not clear what it is, upon what theories it is based or how to measure it (Epstein et al., 2005). Within physiotherapy, there is some evidence that that the therapeutic relationship inﬂuences patient satisfaction (Grimmer et al, 1999) and treatment outcomes (Arnetz et al., 2004; Klaber Moffett and Richardson, 1997), however there has been minimal discussion of the concept. The aim of this research was to construct a theory of patient-centred care in musculoskeletal physiotherapy based on a Grounded Theory approach. Methods: Purposive sampling was initially used to select participants. Subsequently theoretical sampling was adopted whereby analysis of the data informed the sample selection. Individual semi-structured interviews were carried out. These were audio taped and then transcribed verbatim. Analysis involved a process of coding and categorisation of the data. This occurred simultaneously with data collection allowing the ﬂexibility to change focus and pursue leads revealed by the ongoing analysis. Results: Analysis of the data revealed a number of key themes including individualised care, a psychosocial approach, the provision of information and the development of a therapeutic relationship. All dimensions were perceived to be adversely affected by the constraints of the modern healthcare system. Discussion: Individualised care was identiﬁed as the most important component of patient-centred care with the development of a therapeutic relationship key to optimising outcomes. The adoption of a psychosocial approach was considered as central to this process; however therapists felt ill-prepared for addressing these factors. Patient expectations were identiﬁed as an important area to address in the ultimate goal of selfmanagement. Time pressures impacted signiﬁcantly on the therapist’s ability to individualise their care. The next stage in the study will be an exploration of the patient’s perspective. Keywords: Patient-centred care, Musculoskeletal physiotherapy, Low back pain

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Poster Abstracts / Manual Therapy 14 (2009) S40–S52

[P01] A preliminary investigation into the comparison of cervical range of motion between self stretching and sustained natural apophyseal glides by manual therapist in an asymptomatic population A. Yoshikawa 1, 2, R. Yanagihashi 1, T. Fujiwara 1, 2, K. Abe 2. Institute of Health Sciences, Japan; 2 ShinShu University, Japan

1

Koriyama

Introduction: Physiotherapist applies spinal manipulative therapy techniques in the clinical practice for the management of neuromusculoskeletal pain and dysfunction frequently. There is increasing number of reports encouraging clinical effects of The Mulligan’s mobilization with movement treatment techniques. However, their fundamental mechanism is not fully understood. This investigation aimed to compare the effect of the Mulligan’s sustained natural apophyseal glide (SNAGs) technique to the C5/6 intervertebral joint (with cervical ﬂexion) and self stretching of cervical ﬂexion in an asymptomatic population. Methods: Sixteen asymptomatic subjects, ﬁfteen male and one female, aged from 21 to 32 (mean; 26 years), participated in a laboratory-based experiment. The research design was repeated measures design which is consisted of control (three times measurements), self stretching (self stretch ﬁve times), and the ﬁve times SNAG treatment comparisons. The measurement session was divided into two days, the control and self stretching, and the treatment. Cervical ﬂexion angle from natural sitting position and the pressure force of the right thumb for the C5 spinous process by the expert therapist were used as indicator of the comparison between self exercise and the SNAGs treatment. Results: The mean manipulating force applied to the C5 in the SNAGs was 9.1 N (SD 2.9). The mean neck ﬂexion angle in the sixteen subjects showed 58.6 degree (SD 10.6) at the control measurement, 61.3 degree (SD 11) at the self stretching, and 68.0 degree (SD 10.7) at the SNAGs. There were statistically signiﬁcant improvements of the neck ﬂexion between the control and the SNAGs. Discussion: The result showed the SNAG technique had more effective to improving range of motion than self exercise under the same number of trial because the accessory movement of the joint, which can be changed by manipulative intervention, might not be improved by self stretching. Keywords: manual therapy, cervical spine, mobilization with movement, joint kinematics [P02] Evaluation of ankylosing spondylitis spinal mobility using an optical motion capture system

J.L. Garrido-Castro 1, R. Medina-Carnicer 1, E. Collantes 2, A.M. Galisteo 1, C. Gonzalez-Navas 2, D. Ruiz-Vilchez 2. 1 Cordoba University, Spain; 2 University Hospital Reina Soﬁa, Spain Background: Assessment of spinal mobility is fundamental for the evolution and response to the treatment of ankylosing spondyltis (AS). AS produce a reduction of mobility that must be measured. BASMI index, which includes ﬁve different measurements, is the recommended instrument by ASAS nevertheless it is slightly sensitive to the determination of small changes in the measures. Motion capture is an emerging technology used to analyze the human movement and is a promising tool for an objective quantiﬁcation of disease activity in the spine of AS patients. Objectives: To validate the use of an optical motion capture system for analyzing spinal mobility in patients with AS comparing the results obtained with conventional metrology measurements, radiology and self administered questionnaires. Methods: 33 AS patients and 20 healthy subjects (control group) where measured using conventional metrology by two different rheumatologists and by a motion analysis system, the SOMCAM3D [1], in three different occasions: two in the same day and another one two weeks before. Results: Measurements obtained by the system had higher reliability. ICC for conventional metrologies varies from 0.66 (Schober) to 0.96 (tragus-to-wall distance). Motion Analysis ICC’s varies from 0.91 (Schober) to 0.99 (Finger to ﬂoor distance). All similar measurements obtained by the motion analysis had higher reliability than the conventional ones. New measurements had been deﬁned with high ICC and correlation values. In the two weeks retest reliability ICC was also excellent (0.96 to 0.99). Measurements had greater correlation with radiological parameters and with health questionnaires (ASQOL, BASFI, BASDAI). Conclusion: The system provides an accurate and practical method for measuring the reduction of ROM in AS. We are starting to use it on the evaluation of response to the biological treatments and effectiveness of rehabilitation programs. Reference 1. Castro J.L.G. et al. Design and evaluation of a new three-dimensional motion capture system based on video. Gait & Posture 24 (2006) 126–129. Keywords: motion capture, ankylosing spondylitis, spinal mobility, kinematics

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

[P03] Associations between movement control tests and acuity of goaldirected arm movements to visible and invisible targets in patients with persistent neck-shoulder pain B. Aasa 1, M. Djupsjo¨backa 3, T. Rudolfsson 2, 3, U. Aasa 2. 1 Norrlandskliniken, ¨vle, Sweden Sweden; 2 University of Umeå, Sweden; 3 University of Ga The ability to position the scapula is essential for an optimal arm function and inappropriate control of the scapular positioning has been linked to neck-shoulder disorders. Further, the cervical muscle activation patterns might inﬂuence on the chronicity of neck-shoulder disorders. The present study compared the outcomes of ﬁve movement control tests and a pointing task for the right arm between 17 patients with persistent neckshoulder pain and 17 age- and gender matched healthy controls. The study was designed as a single-blinded, controlled and comparative group study. The movement control tests included ‘‘Head rotation’’ (can subject prevent chin poke/sidebending), ‘‘Cervical extension’’ (prevent forward translation), ‘‘Slow and fast arm medial rotation’’ (prevent forward tilt of the scapula and anterior translation/gleno-humeral medial rotation) and ‘‘Inner range hold of scapular protraction and upward rotation’’. The pointing task included pointing to a target 15 times in 3 separate conditions; horizontal adduction with vision, horizontal abduction with vision and horizontal abduction while the light was switched off during the movement. The starting position was always at waist height with the arm resting in front of the subject. The outcome was end-point variability in 3 dimensions (volume of a 95% CI ellipsoid). The results demonstrated a signiﬁcant difference between patients and controls regarding their ability to control the movements in the movement control tests. There were no differences between groups in end-point variability, when the test was performed in full vision, but in condition 3, when pointing was performed without vision, the subjects with pain had higher end-point variability. In conclusion, an interaction between persistent pain and motor control during movement tests was shown The ﬁnding that the patients had reduced end-point precision compared to the controls only while pointing without vision may imply that they used vision to compensate for an impaired proprioceptive control of arm movements. Keywords: neck-shoulder pain, movement control, proprioception, vision [P04] Electrical muscle stimulation training for deep spinal stabilisers results in signiﬁcant reductions in pain and disability scores in patients with chronic low back pain S. Coghlan, L. Crowe, U. McCarthyPersson, B. Caulﬁeld. University College Dublin, Ireland The objective of this study was to investigate the effects of a deep spinal electrical muscle stimulation (EMS) programme on measures of pain & disability in a group of subjects with chronic low back pain. A randomised controlled pilot study was carried out with an EMS group (n ¼ 13) and a TENS group (n ¼ 9), both consisting of men and women with a chronic (> 3month) history of lower lumbar somatic back pain. The EMS group received a six week home treatment programme of EMS targeting the deep spinal and abdominal muscles whilst the TENS group underwent a programme of standard TENS treatment targeting sensory nerves over the same time period. Pain and disability levels were evaluated at baseline and follow up using the Visual Analogue Score (VAS) and Roland Disability Questionnaire (RDQ) respectively. Paired t-tests were used to compare within group means whereas independent t-tests were used to compare between groups. Results are outlined in Table 1. Signiﬁcant improvements were noted in the treatment and control group following the intervention period with both showing improvements in pain and disability measures. There was a deﬁnite trend towards a larger improvement in RDQ scores in the EMS group though this did not reach the level of signiﬁcance due to small subject numbers. The results of this pilot study suggest that the use of EMS training for deep spinal stabilisers is effective in improving pain and disability measures in subjects with chronic somatic low back pain. There is now a need to carry out further studies with larger numbers of subjects to conﬁrm these ﬁndings and to

Pain - VAS Treatment group (EMS) Control group (TENS) Between group comparison (LoS) Disability - RDQ Treatment group (EMS) Control group (TENS) Between group comparison (LoS)

S41

Baseline

Follow up

Within group comparison (LoS)

Change

4.6 (1.0) 4.6 (1.4) 0.96

1.9 (1.3) 2.5 (1.1) 0.21

0.0001

2.7 (1.6) 2.0 (1.2) 0.27

6.7 (2.5) 8.4 (4.3) 0.28

1.6 (1.2) 4.5 (2.9) 0.01

0.001 -

0.00006 0.002 -

5.1 (2.8) 3.9 (2.7) 0.37

Table 1. Pain and disability at baseline and follow up including change for treatment and control groups (values are mean (SD)). LoS ¼ Level of Signiﬁcance

investigate the concurrent training effects on spinal and abdominal muscle function. Keywords: electrical muscle stimulation, low back pain

[P05] The reliability and validity of a clinical test of passive inter-segmental lumbar ﬂexion? C.M. Davies 1, C. McCarthy 2, J. McCluskey 3, B.J. Introwicz 1, A.D. Pandyan 1. 1 Keele University, UK; 2 St Mary’s Hospital London, UK; 3 Private Practitioner, MACP, UK Background: The Passive physiological intervertebral movement test (PPIVM) is used by Manual Therapists as part of their clinical examination when screening for spinal dysfunction. The intra-tester reliability for this examination procedure has previously been judged as fair and inter-tester poor. However, the validity of this test has not been investigated. Aim: A study to investigate inter-tester reliability and validity of lumbar ﬂexion PPIVM for intersegmental levels of L4/5 and L5/S1 Method: A convenience sample of asymptomatic subjects. Two expert manual therapy assessors graded L4/5 and L5/S1 PPIVM tests once on each subject in a random order. Grading was noted as hypomobile, normal or hypermobile. Agreement between assessors was analysed using the Cohen’s Kappa coefﬁcient. Separation of spinous processes at L4/L5 and L5/ S1 was measured as an angle using a geometrical method involving a ﬂexicurve. An ANOVA was used to analyse if grades of the PPIVM test systematically varied with the ﬂexicurve angle. The modiﬁed Scho¨ber’s test was conducted before and after all measurements, for control purposes. Results: Thirty nine adults (34 female, 5 male) mean age 21 years (range 18 – 34 years) were recruited. Inter-tester reliability was poor (k ¼ 0.03; SE ¼ 0.113 for L4/5 and k ¼ 0.016; SE ¼ 0.112 for L5/S1). Those classiﬁed as having hypo-mobility had a smaller separation than those with normal mobility or hyper-mobility at L4/5 (p < 0.05) for each individual assessor, a similar trend was not seen at L5/S1. The mean difference between the pre and post modiﬁed Scho¨ber’s test was 0.16 cm (SE ¼ 0.039). Conclusion: This study suggests that the lumbar ﬂexion PPIVM test has poor inter-tester reliability and very limited validity when used as an outcome measure of spinal dysfunction. Future work should look at whether reliability improves if the test is investigated as an examination procedure to assist with treatment selection. Keywords: PPIVM, Reliability, Validity

S42

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

[P06] A pilot study: Effectiveness of a lateral glide cervical spine mobilisation on Cervicobrachial (neck and arm) pain E.J. Salt 1, 2, S.M. Kelly 2, C.C. Wright 2. 1 Burton Hospital NHS Foundation Trust, UK; 2 The University of Birmingham, UK Introduction: There is some evidence to support effectiveness of the lateral glide technique for the treatment of patients with cervicobrachial pain, but no substantive studies have been completed in this area. This pilot study was planned to reﬁne a protocol and provide data for a power calculation for a proposed RCT. Methods: The pilot was a randomised controlled study, with participants randomised to receive either a self-management programme (control group) or a self-management programme with the addition of a lateral glide technique to C5/6 (intervention group). Participants in both groups received up to six weekly sessions. Participants were aged 28-80 years, with neck pain radiating to one arm in a dermatological distribution. The assessor was blinded to group allocation; however it was not possible to blind therapists or participants. The primary outcome measures were Visual Analogue Scales (VAS) for average and for worst pain. Secondary outcome measures were the Global Rating of Change, Neck and Upper Limb Index and Short-Form 36. Outcomes were assessed at baseline and at 6 weeks. Results: Eighteen participants were recruited, with 8 randomised to receive the lateral glide treatment. There was an 83% follow up at 6 weeks. Although no statistically signiﬁcant difference was identiﬁed between the groups, there was a weak indication of greater improvement for the intervention group for worst pain (p ¼ 0.15), function (p ¼ 0.77) and general health (p ¼ 0.70). No clinically important changes were identiﬁed. Discussion: The pilot study supports clinical feasibility of the protocol for use in the proposed RCT and provides data for a power calculation. The Tampa scale of kinesiophobia, the Self complete leeds assessment of neuropathic symptoms and signs, the upper limb nerve extensibility test and measurement of cervical range of movement will be included in the proposed trial to cover the WHO dimensions of functioning, disability and health. Keywords: cervicobrachial, pain, lateral glide technique, self-management

[P07] The movement dysfunction concept in the disablement model as a basis for contemporary clinical reasoning in chronic pain patients E.J. Thoomes, M. Schmitt. SOMT, Netherlands Introduction: Contemporary clinical reasoning has seen a paradigm shift from a biomedical to a biopsychosocial viewpoint. Many colleagues claim they act in accordance with it, but that is not always the case. Using the disablement model1,2 as a starting point for assessment and treatment might be more in line with current Quality of Life outcome measures for treatment. Methods: We have become increasingly aware that there is a poor correlation between pathology and functional limitations. This is even more evident in the clinical reasoning process for chronic complaints. Where there might be a correlation between pathology and impairments in acute pain, this is not often present in the chronic pain patient. In the Disablement process, the therapist, together with the patient, ﬁrst deﬁnes which functions and activities in the Activities of Daily Life (ADL) are limited. These can be evaluated by using valid and reliable questionnaires, giving the opportunity to re-assess patients in an objective way. It is the expertise of the therapist to then assess which components of the functional limitations need to be addressed and which movement dysfunction(s) might underpin them. Results: The Rehabilitation Problem-Solving Form (RPS-Form)3 allows health care professionals to analyze patient problems, to focus on speciﬁc targets, and to relate the salient disabilities to relevant and modiﬁable variables. It was designed to address the patients’ perspectives and enhance their participation in the decision-making process, being based on the International Classiﬁcation of Functioning, Disability, and Health (ICF) Model of Functioning and Disability4. It could provide a common

language for the description of human functioning and therefore facilitate multidisciplinary responsibility and coordination of interventions. Discussion: The use of the RPS-Form in clinical practice is demonstrated by presenting a movement dysfunction assessment of a patient with chronic low back pain, and the ensuing proposed treatment strategies and modalities. References 1. Escalante A, Del Rinco´n I. The disablement process in rheumatoid arthritis. Arthritis Rheum. 2002 Jun 15;47(3):333-42. 2. Denegar CR, Vela LI, Evans TA. Evidence-based sports medicine: outcomes instruments for active populations. Clin Sports Med. 2008 Jul;27(3):339-51, vii. 3. Steiner WA, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G.Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther. 2002 Nov;82(11):1098-107. 4. Finger ME, Cieza A, Stoll J, Stucki G, Huber EO. Identiﬁcation of intervention categories for physical therapy, based on the international classiﬁcation of functioning, disability and health: a Delphi exercise. Phys Ther. 2006 Sep;86(9):1203-20. Keywords: Clinical Reasoning, ICF, Chronic Pain, Movement Dysfunction [P08] Effects of proprioceptive exercises on posterior pelvic tilt strength and proprioception level in chronic low back pain G. Coskun, F. Can. Hacettepe University, Turkey This study was performed to investigate the effects of proprioceptive exercises on proprioception and posterior pelvic tilt strength in patients of chronic low back pain. Thirty patients with low back pain were included in the study. Patients were randomly divided into two groups; Group 1 underwent stabilization exercises and group 2 underwent stabilization plus proprioceptive exercises. All subjects were evaluated for pain intensity (visual analog scale), active and passive proprioceptive sensation (Biodex System Pro 3 Izokinetic System), posterior pelvic tilt strength (The Stabilizer Pressure Biofeedback Unit). Treatment program for the both groups was 3 days per week for 6 weeks. Stabilization and stabilization plus proprioception groups were assessed before and after the treatment In both Group 1 and group 2 there was signiﬁcant pain relief in resting and activity (p < 0.01). In both groups pelvic tilt muscle strength improved signiﬁcantly after the treatment as compared to pre-treatment (p < 0.05). Pelvic tilt strength was better in Group 1 than Group 2 but signiﬁcant differences were not found. Passive extension, active extension, active ﬂexion proprioception values improved signiﬁcantly in group 2. In conclusion, both stabilization exercises and proprioception plus stabilization exercises have been found that they have beneﬁcial effects on pain relief, pelvic tilt strength and proprioception, but proprioception exercises are needed to insert to the exercises program to be included in more beneﬁts in proprioception. Inclusion of proprioceptive exercises has more effect on proprioception in patients with chronic low back pain. This beneﬁt may decrease the risk of new injuries in lumbar region and to increase body awareness and trunk control of individuals with chronic low back pain. Keywords: Low back pain, trunk muscle strength, lumbar region. [P09] The inﬂuence of neurodynamic release on self perceived lumbopelvic movement control: An explorative pilot study G.M. Homstøl, B.O. Homstøl. NHP-Neuromusculoskeletal Health & Performance, Norway Neurodynamic Release (NDR) is a new and innovative approach which explores the inﬂuence of mechanosensitivity to movement on neuromusculoskeletal health and performance. To date, NDR has demonstrated clinical signiﬁcant results on pain, disability and quality of life in patients with chronic non-traumatic neck or back pain and found to positively inﬂuence symptom response, risk of re-injury and performance in athletes. However, no study has investigated the onset of mechanosensitivity to the onset of self perceived lumbopelvic movement control and if NDR can change it.

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

A convenience sample of 15 semi-professional male football players from a Norwegian 2nd division team participated in the explorative pilot study. The players age ranged from 17-31 years (mean 23,9 years), height 173193 cm (mean 182,7 cm) and weight 70-91 kg (mean 78,3 kg). They had a history of various neuromusculoskeletal complaints, but no current pain or pathology in the lower quadrant including the lumbopelvic region. During the NDR movement test called Sitting Single Knee Extension with the lumbo-pelvic region in neutral and ankle dorsiﬂexed, the onset of mechanosensitivity (stretch sensation) and loss of lumbopelvic neutral (self-perceived) was registered pre- and post a session of NDR treatment (10 minutes on each leg). The data was analysed based on category of response (Table 1) to full knee extension.

Table 1: Responses to NDR movement test

Pre- Treatment

Post- Treatment

No loss of LPN, No mechanosensitivity No loss of LPN, Mechanosensitivity Loss of LPN, No mechanosensitivity Loss of LPN, Mechanosensitivity prior to loss Loss of LPN, Mechanosensitivity at same time Loss of LPN, Mechanosensitivity after loss

3/30

13/30

0/30

0/30

2/30

3/30

3/30

2/30

19/30

8/30

3/30

4/30

LPN ¼ LumboPelvic Neutral The results indicate that NDR treatment can enhance self perceived lumbopelvic movement control. The research questions will be followed up with a randomized controlled trial in young athletes. Keywords: Neurodynamic Release, Mechanosensitivity to movement, Movement control, Athletes [P10] The analysis of neck-back muscular fatigue due to prolonged musculoskeletal load from casual computer work in different sitting postures W.H. Cho, W.Y. Lee, H. Choi. Sungkyunkwan University, Korea Recent rapid computerization of industry and business forced ofﬁce workers to be seated at visual display terminals (VDTs) for a long time. Consequently, the number of people suffering from chronic fatigue in the neck-back region is increasing due to the continuous computer work. In the previous studies dealing with the muscle fatigue of ofﬁce workers, the characteristics of trapezius fatigue due to VDT work have been described. However, it still remains unclear why and how serious chronic muscle fatigue is induced. In this study, a series of experiments was conducted to investigate the effects of the prolonged musculoskeletal loads on muscular fatigue and muscle activity of neck-back muscles. Six subjects (males) participated and performed the prolonged casual computer work. EMG signals from six muscles of the dominant neck-back regions were acquired and recorded by using a computerized data recording and analysis system. Power spectrum function of EMG was calculated off-line by means of a signal processing software package. Power spectrum functions were smoothed with a moving average ﬁlter of 21 points and normalized with respect to the maximal value achieved during the trials. Muscle activity and median frequencies of Sternocleidomastoid (SCM) in turtle neck posture was approximately 51%, which were less than those in normal neck posture. SCM also showed the biggest decrease in median frequency. The results from this study provide the insight into the neck-back injury mechanism of turtle neck patients. Furthermore, they will be helpful in developing rehabilitation programs for restoring patients’ neck-back functions.

S43

Keywords: muscular fatigue, EMG, computer work, musculoskeletal load [P11] Reliability and effects of chronic pain and movement repetition on shoulder functional outcome measures J.N. Coˆte´ 1, 2. K.V. Lomond 1, 2, Rehabilitation Hospital, Canada

1

McGill University, Canada;

2

Jewish

Introduction: Return to work (RTW) is a priority of occupational health professionals. One primary determinant of RTW is the degree of functional limitation; thus, the ability to reliably assess workers’ functional capacity is essential. Our objective was to compare shoulder functional outcomes between healthy individuals and others with neck/shoulder pain, assess reliability and examine the inﬂuence of repetitive movements on shoulder functional measures. Methods: Sixteen participants with neck/shoulder pain (intensity 3/10 for > 3 months) and an age and sex-matched control group performed ﬂexion and abduction active range of motion (ROM), and cumulative power output (PO) in a pushing/pulling task using the Baltimore Therapeutic Equipment Simulator II (Sim-II) in two consecutive sessions. In session 1, tasks were assessed before and after subjects performed a repetitive arm task until scoring 8 out of 10 on either the Borg CR10 scale or on a 10-point numeric rating scale (NRS). Heart rate (HR) was also recorded. Results: ANOVA Group x session analyses revealed a signiﬁcant interaction effect for abduction with higher ROM in session 2 in the pain group, while signiﬁcant group main effects indicated higher abduction and ﬂexion ROM in the control group. Analyses of between-session reliability showed that intra-class correlation coefﬁcients were > 0.85 for all functional measures in both groups, except the pain group’s PO (0.53). Repetitive task duration was signiﬁcantly shorter in the pain group (4 min vs 7 min). Following repetitive movements, signiﬁcant group x time interactions for Borg and NRS scores indicated larger increases in the control group. Signiﬁcant main time effects demonstrated increased HR and lower PO after the repetitive task. Discussion: The protocol effectively detected both pain- and time-related impairments, whereby HR and PO were sensitive to movement duration and ROM to pain. This knowledge can be implemented in designing effective RTW and workplace assessments. Keywords: chronic neck/shoulder pain, functional capacity evaluation, reliability, repetitive movements [P12] The effect of balance training on sensorimotor function in young physical therapy students - a RCT ¨ r Physiotherapie in Gru ¨ nstadt, Germany K. Beinert. Schule fu Background: Sensorimotor impairments have gained interest in musculoskeletal research. People with neck pain show disturbed postural stability and impaired joint position sense. Research has shown that inﬂuencing neck muscles and neck receptors alter postural stability. Whether postural stability can alter cervical joint position sense is not published. Design: Randomized controlled trial with unblinded treatment and blinded outcome assessment. 37 subjects, treatment for 5 weeks, with a follow up of 6 weeks 12 weeks and 3 months. Objective: To determine, whether postural stability training can improve cervical kinaesthesia in young people with mild, subclinical neck pain against a control group. Method: The intervention group participated in a individual postural stability training. Single leg stance, tandem stance and stance on a wobble board were progressed with closed eyes and head movements. A session took 15 min, one exercise 5 minutes. We trained 3 times a week. Results: Both groups improved. Absolute error to 30 Ext relocation improved statistically signiﬁcant with p ¼ 0,014 in the intervention group. Absolute error for rotation was with 0,088 statistically not signiﬁcant, perhaps due to the small sample size. Regression analysis showed improved postural stability in the treatment group compared to the control group in subjects, who had impaired postural stability.

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Conclusion: Postural stability training might contribute to a better joint position sense. Further research is necessary to determine the effect of postural stability training in symptomatic subjects. Keywords: Cervical kinaesthesia, Postural stability, RCT [P13] Does age affect star excursion balance test scores over the course of one year? R.J. Butler 1, K.B. Kiesel 1, P. Gorman 2, P.J. Plisky 2. 1 University of Evansville, USA; 2 ProRehab PC, USA Introduction: With the increasing incidence of injuries in youth athletics, sports medicine practitioners are beginning to exam ways to systematically screen athletes for injury risk in order to provide appropriate training. One screening tool that has been developed is the Star Excursion Balance Test (SEBT). The SEBT measures an individual’s dynamic balance by assessing unilateral lower extremity reach in three different directions. Previous research on the SEBT has indicated that an asymmetrical anterior reach and the composite reach distance normalized to limb length are predictive of lower extremity injury. However, no studies have examined whether the SEBT scores change over the course of the year and whether age effects the change in scores. Methods: One hundred and ﬁfty-six high school (13-17 yo) and college (age 18-20 yo) athletes were assessed for dynamic balance using the Y Balance Test Protocol at baseline and one year later. In order to assess changes in the reach scores, a repeated measures ANOVA, using age as the between subjects factor and time as the repeated factor, was utilized. The variables of interest were left and right limb differences, normalized reach distance, and normalized composite reach score. Results: There was a signiﬁcant interaction for age and time for the difference in posterior lateral reach direction (p < 0.02). There was a signiﬁcant main effect for age for the difference in the anterior reach direction score (p < 0.04). No signiﬁcant interactions or main effects were observed for the normalized composite reach score for the left and right legs. Discussion: The results of this study suggest that the change in Y Balance Test score over the course of the year may be effected by age of the participants. Further research studies should establish normative data for different ages of the population. Keywords: injury prediction, maturation, score stability, injury risk [P14] Fundamental movement dysfunction as measured by the functional movement screen shifts the probability of predicting a musculoskeletal injury in ﬁreﬁghters

2

K.B. Kiesel 1, 2, P.J. Plisky 2, R.J. Bulter 1. ProRehab-PC, USA

1

University of Evansville, USA;

Introduction: Fireﬁghters face many occupational risks including musculoskeletal injury. Injury rates of ﬁreﬁghters are among the highest in all occupations. Previous research has demonstrated that improving ﬂexibility did not decrease injury incidence, but did reduce time-loss and severity of injury. Fireﬁghters perform unpredictable awkward movements making standardized ﬂexibility and ergonomic programs limited in utility for this population. Sports medicine professionals have begun to utilize fundamental movement testing and training programs. Because of the nature of ﬁreﬁghting, and the need for ﬁreﬁghters to stay ﬁt as they age, a more comprehensive movement oriented testing and training program may be beneﬁcial. A study on ﬁreﬁghters demonstrated that those who have been injured scored lower on a standardized functional movement test than those who have not been injured. The purpose of this study was to examine the relationship between ﬁreﬁghters’ scores on a fundamental movement screen, the Functional Movement ScreenÔ (FMS) and the likelihood of a time-loss injury over the course of a 16-week training academy.

Methods: A retrospective analysis was conducted examining the relationship between a subject’s composite FMS score (0-21) and their likelihood of injury. Results: A score of 13 was calculated as the cut point at which the FMS is considered positive to rule in an injury. This is the point which maximized speciﬁcity (0.82) and sensitivity (0.60). The OR was 7.1 (CI95 1.7-29.5), the LR+ was 3.5; (CI95 1.4-6.3), and the LR- was 0.48 (CI95 0.21-0.85). Based on a pre-test probability 0.27, the post-test probability was 0.56. Discussion Data revealed that ﬁreﬁghters with a score of 13 on the FMSÔ shifted the probability of sustaining an injury over the course of a training academy. These results should be considered as preliminary and should only serve to generate a hypothesis to be tested in a prospective study. Keywords: Fundamental Movement Testing, Injury Predication, Fireﬁghters, Musculoskeletal Injury [P15] Pain physiology during exercise is abnormal in chronic fatigue syndrome, but not in chronic low back pain L. Daenen 1, 3, N.A. Roussel 1, M. Meeus 1, 2, S. Truijen 1, J. Nijs 1, 2. 1 Artesis University College Antwerp, Belgium; 2 Vrije Universiteit Brussel, Belgium; 3 University of Antwerp and University Hospital Antwerp, Belgium Introduction: Pain thresholds increase during physical activity in healthy individuals, due to the release of endogen opoids and growth factors1. In contrast, a decrease in pressure pain threshold (PPT) after exercise was found in a pilot study of 6 patients with Chronic Fatigue Syndrome (CFS)2. CFS patients often experience chronic widespread pain with exacerbations of pain after exercise, which could be explained by deﬁcits in central pain mechanisms. Although decreased PPT’s have been found in patients with chronic low back pain (LBP)3, controversy exists about the functioning of central pain mechanisms in these patients. The purpose of the present study is to compare the response of a submaximal exercise challenge on pain threshold in patients with chronic LBP, CFS, and healthy subjects. Methods: Twenty-six CFS patients with chronic widespread pain, 21 chronic non-speciﬁc LBP-patients and 31 healthy matched controls volunteered for the study. A power analysis was performed to establish the sample size. All subjects underwent a submaximal exercise protocol on a bicycle ergometer. PPT’s were measured with an algometer at the hand, spine, deltoid and calf before and after exercise. A power analysis was performed to establish the sample size. Repeated measures ANOVA was used to compare the thresholds between groups. Results: At baseline assessment, CFS patients presented signiﬁcant lower PPT’s compared to healthy subjects and to LBP-patients (p<.05). After exercise PPT’s decreased in CFS patients, while they increased in the other two groups. The difference in pain threshold evolution was signiﬁcant compared to the healthy controls (p<.01), but not to the LBP-patients. No signiﬁcant differences were found between the healthy subjects and the patients with LBP (p > 0.05). Conclusions: The decrease in pain thresholds following exercise suggests abnormal central pain processing in CFS patients. Pain physiology during exercise appears normal in patients with chronic LBP. 1. Koltyn & Arbogast . Br J Sports Med. 1998;32:20-4. 2. Whiteside et al. Pain. 2004;109:497-9. 3. Farasyn & Meeusen. Eur J Pain. 2005;9:375-81. Keywords: pain physiology, chronic, exercise, central sensitization [P16] Inmediate effect of the ostheopatic manipulation of the ankle joint on plantar pressures during gait ˜ o 1, F. Ramos 2, R. Ferna´ndez 1, A. Go´mez 3. 1 Physical M. Barcia 1, S. Patin ˜a), Spain; ˜a, Spain; 2 Hospital Modelo (A Corun University of A Corun 3 University of Murcia, Spain Introduction: Lateral ankle sprains are one of the most frequent problems in the sports practice (Patel DV, Warren RF 1999), approximately the 25% of

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

the injuries (Mack RP 1982). The lateral ankle sprain is the most usual (Ruth CJ, 1961; Brooks SC y cols., 1981; McCulloch PG y cols., 1985). Loss of the mobility of the talus can play a relevant role in the adaptation of the foot to the surface during walking, because it has two important biomechanics repercussions: - Less perception of the Subtalar inversion and eversion (Refshauge y cols. 2003; Monagham y cols. 2006; Willems TM y cols. 2005; Denegar CR y cols. 2002). - Restriction of the Talocrural dorsiﬂexion (Refshauge y cols. 2003; Monagham y cols. 2006; Niska M y cols. 2003; Tabrizi P y cols. 2000). The aim of this study is to assess the immediate effect of caudal Talocrural Joint manipulation on plantar pressures during gait, in subjects with a mechanical restriction of the mobility of this joint, symptomatic or not. Methods: We performed a randomized, simple blind, repeated-measures study and intra-subject comparison study. 30 subjects between 18 and 21 years old were included. The study inclusion criteria required individuals to have: a) Talocrural dorsiﬂexion restriction, b) Loss caudal mobility of the Talus, c) No injury which contraindicates ostheopatic manipulation. We applied the manipulation technique, before and after of a plantar pressure assessment with Biofoot-IBV (baropodometric system). Results: The results obtained revealed statistically signiﬁcant differences between the premanipulation and the postmanipulation values in the percentage of posterior load of the foot. Discussion: Plantar pressures assessment could be used as a suitable method for Physical Therapy research. The application of Caudal Talocrral Joint Manipulation redistributes foot load in our sample of young individuals. Further studies assessing baropodometric changes after foot manipulative procedures are now required. Keywords: ostheopatic manipulation, plantar pressures, assessment, physical therapy [P17] New perspective in sports injury prevention in an America’s Cup Sailing Prevention of sport injuries in an America’s Cup M. Hadala 1, 2, C. Barrios 2. 1 Dept of Physiology, University of Valencia, Spain; Orthopaedics & Trauma Unit, Dept of Surgery, University of Valencia, Spain

2

Purpose: To analyze the effectiveness in reducing the number of sport injuries after application of different strategies of preventive physiotherapy during competition periods in an America’s Cup sailing. Methods: A prospective physiotherapy intervention study during competition periods over three seasons was conducted on an America’s Cup Yachting Crew of 30 professional sailors. In the 2 ﬁrst acts (2004), athletes did not receive any preventive physiotherapy. In the 2 acts celebrated in 2005, preventive intervention (phase I) consisted of (PNF) stretching exercises prior to the yacht race and preventative taping. During the 4 acts corresponding to the 2006 season, the physiotherapy program was implemented adding articular mobilization before competition, ice-baths after competition, and kinesiotaping (phase II). In the last act and the Luis Vuitton Cup (2007), a recovery program with ‘core stability’ exercises based on Performance Stability Concept, post-competition stretching exercises, and 12 hours of compressive clothing were added (phase III). Results: In the pre-intervention phase (2004), the rate of injured sailors/ competition day was 1.66, decreasing to 0.60 in 2007 (phase III). In 2004, muscle injuries reached 61% (22 of 36). In 2007, after phase 3 of the preventive program, muscle injuries decreased to 14% (5 of 36). In the preintervention period, mastmen, grinders, and bowmen showed a rate of 2.88 injuries/competition day. After phase III, this group only suffered 0.5 injuries/competition day. Conclusions: Sailors at high risk of injury should focus on low load and high-load training where rotational movements are challenging. Crew members with a moderate risk of injury should undertake both low and high load training that also involves rotational movements and strength but which is based more on interval and aerobic conditioning. Sailors at a low risk of injury should focus on low-load motor control and high load training with aerobic sessions only. Keywords: epidemiology, incidence, rehabilitation, performance-stability

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[P18] Effect of rocker shoes on ground reaction force in patients with rheumatoid arthritis M.S. Ghasemi, M. Bagherzadeh. Iran University of Medical Science, Iran Background: Rheumatoid arthritis patients alter their gait pattern to compensate for painful foot symptom. The heel strike, foot ﬂat and toe-off sequence have been show to be replace by a ﬂat footed type of gait. The three rocker functions of the feet are impaired: the ﬁrst is minimally affected, the second is prolonged and the third is reduced. Rocker shoes are commonly prescribed for reducing foot pain, but limited research has been reported regarding gait and pain improvement with this shoes. The aim of this study was to determine the effect of rocker shoes in rheumatoid arthritis. Methods: Twenty two patients with foot and ankle due to rheumatoid arthritis were include in this study and received heel-to-toe rocker shoes. The ground reaction force and stance phase duration measured using Bertec force plate. Patients walking at self selected cadence in three trials: Bare foot, Control shoe and Rocker shoe. Results: The preliminary results shows that the vertical Ground Reaction Force (GRF) peaks were reduced in patients with rocker shoes compared by normal shoe. Also the stance phase duration shows increase in patients wearing the rocker shoe. Conclusions: Rocker shoe reduces the vertical GRF peak, normalized ground reaction force and it is regarded as comfortable and acceptable footwear in rheumatoid arthritis patients with foot and ankle pain. Keywords: Rheumatoid arthritis, Rocker shoe, Ground Reaction Force (GRF), Gait

[P19] Effect of insole on Ground Reaction Force and Centre of Pressure in subjects with ﬂexible ﬂat foot M.S. Ghasemi, F. Khanmohammad. Iran University of Medical Science, Iran Background: Gait analysis is becoming more recognized as most important clinical tools in biomechanical, in pre surgery planning, post surgery monitoring and evaluation of different treatment techniques such as conservative approach. Change in gait by use of insole provides easy-tounderstand information regarding the inﬂuence of insole on gait pattern in subjects with ﬂexible ﬂat foot. The purpose of this study is to determine and compare the effect of a PORON insole on Ground Reaction Force (GRF) and Centre of Pressure (COP) with EVA insole in subjects with ﬂexible ﬂat foot. Method: 22 subjects with ﬂexible ﬂat foot, ages between 18 – 40 years were participated in this study. 11 subjects were given EVA insole and 11 subjects were received PORON insole. Each subject were required to walk with own normal speed across a force plate in bare foot, walking with and without insoles over two a weeks trial periods. Common insole includes an EVA outsole and leather sole in contact with the foot. PORON insole includes an EVA outsole and leather midsole, that a PORON layer were placed in contact with the foot. Result: The preliminary results obtained in this study shows that the use of insoles increases the vertical GRF, and hence anterior-posterior and mediolateral GRF with the use of insoles are decreased. The effects of PORON insole on GRF were much greater than EVA insole and the decrease of GRF in 3 conditions in the post trial were greater than pre post trial. Decrease of the peaks GRF is more with shoe in comparison with barefoot condition. Displacement of the COP is less with insole in comparison with barefoot condition. Displacement of the COP is less in two sessions in comparison with one session. Keywords: Gait, Flat foot, Centre of Pressure (COP), Insole

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Poster Abstracts / Manual Therapy 14 (2009) S40–S52

[P20] The self-reported aggravating activities of people with chronic nonspeciﬁc low back pain do not involve consistent directions of spinal movement: An observational study B.M. Wand 1, R. Hunter 2, N.E. O’Connell 3, L. Marston 4, J. McAuley 5, 6. 1 The University of Notre Dame, Australia; 2 SportsMed Subiaco, Australia; 3 Brunel University, UK; 4 University College London Medical School, UK; 5 The George Institute for International Health, Australia; 6 University of Sydney, Australia Introduction: It is commonly suggested that the chronic non-speciﬁc back pain (CNSLBP) population is a heterogeneous group that contains distinct sub-groups and that research that does not account for sub-grouping may deliver a diluted estimate of treatment effects [1-3]. Inherent in three common sub-grouping systems is the grouping of patients based on the direction of painful movement of the spine [4-6]. A reasonable prediction of these models is that the most problematic functional tasks should move the spine in a similar way. To test this prediction we investigated the presence of a directional pattern in the self-reported aggravating activities of CNSLBP patients. If directional bias is an important feature of chronic low back pain, we hypothesized that its presence in patients’ self reported aggravating activities should be greater than chance. Methods: This was an observational study on data obtained from 240 chronic non speciﬁc low back pain patients. Clinicians classiﬁed each of the three patient-nominated aggravating activities from the Patient Speciﬁc Functional Scale by direction of lumbar spine movement or loading. A directional pattern was demonstrated when all nominated activities moved or loaded the spine into the same direction. Analyses were undertaken to determine if the proportion of patients demonstrating a directional pattern was greater than would be expected by chance. Results: In some patients, all tasks did load the spine into the same direction, but this proportion did not differ from chance (p ¼ 0.328). There were no clinical or demographic differences between those who displayed a directional pattern and those who did not (all p > 0.05). Discussion: The results do not demonstrate a consistent pattern of adverse movement or loading in individual patients with chronic non-speciﬁc low back pain, suggesting that a directional pattern of aggravating factors might not be an important feature of chronic non-speciﬁc low back pain. Reference 1. Dankaerts W, O’Sullivan P, Straker L, Burnett A, Skouen J (2006b) The inter-examiner reliability of a classiﬁcation method for non-speciﬁc chronic low back pain patients with motor control impairment. Manual Therapy 11: 28-39. 2. Delitto A (2005) Research in low back pain: time to stop seeking the elusive ‘‘magic bullet’’. Physical Therapy 85: 206-208. 3. McCarthy CJ, Cairns MC (2005) Why is the recent research regarding non-speciﬁc pain so non-speciﬁc? Manual Therapy 10: 239-241. 4. McKenzie R, May S (2003) The Lumbar Spine: Mechanical Diagnosis & Therapy. (2 edn). Waikanae: Spinal Publications New Zealand Limited. 5. O’Sullivan PB (2005) Diagnosis and classiﬁcation of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Manual Therapy 10: 242-255. 6. Sahrmann S (2002) Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby, Inc. Keywords: Chronic non-speciﬁc low back pain, Classiﬁcation, Physiotherapy [P21] Internal consistency of the Multidimensional Affect and Pain Survey (MAPS) in neck and back pain

2

O.M. Crummey 1, 3, D.J. Martin 1, K. Rome 2. 1 Teesside University, UK; Auckland University of Technology, New Zealand; 3 St Johns Hospital, UK

Introduction: The MAPS questionnaire uses 101 verbal descriptors of the experience of pain (Clark 1995). The descriptors are grouped into three main dimensions sensory pain, emotional pain and wellbeing, each of which is further subdivided into 30 smaller groupings –17 for sensory pain, eight for emotional pain and ﬁve for wellbeing. The aim of the study was to compare the structure of MAPS for neck pain with that for back pain.

Methods: In an observational cohort study, participants were 167 people with neck pain and 167 people with back pain referred for outpatient physiotherapy recruited by convenience sampling over a period of six months. Each received a copy of MAPS by post with a follow up after two weeks if required. For neck pain the return rate was 62%: n ¼ 104 (72 women), mean (1SD) age 51.5 (15.37) years. For back pain there was a 70% return rate: n ¼ 117 (66 women), mean (1SD) age 44.8 (13.43) years. Neck pain and back pain were analysed separately. The internal consistency of the three dimensions was assessed using Chronbach’s alpha and a discriminability index. The discriminability index (Pallant 2005; Field, 2005) for each item was calculated by correlating the item with the total score of the larger grouping: values of 0.35 or above were considered acceptable (Griswold and Clark 2005). Results: Cronbach’s Discriminability alpha index Neck: sensory 0.96 0.56 Neck: emotional 0.96 0.66 Neck: well being 0.93 0.63 Back: sensory 0.95 0.48 Back: emotional 0.95 0.62 Back: well being 0.92 0.59 Conclusion: This is the ﬁrst analysis of the internal consistency of MAPS for neck pain and for back pain. The results support the basic structure of the questionnaire in both cases. MAPS is supported as a useful tool to investigate the impact of neck and back pain. Keywords: Neck, Back, MAPS, Internal consistency [P22] Condition management program – A biopsychosocial approach of dealing with physical problems of people on incapacity beneﬁt P. Agarwal 1, 2. 1 Chartered Society of Physiotherapists, UK; 2 Manipal University, India Cognitive behavioural therapy (CBT) is a widely researched area and its use in the ﬁeld of physiotherapy has been reported with positive results This presentation is an introduction to Condition Management Program (CMP) in the Pathways to Work (PtW) initiative. It will highlight the importance of clinical application of recent research in CBT and pain sciences in a speciﬁc population - people on incapacity beneﬁt (IB). The Green paper titled ‘‘Pathways to Work – Helping people into employment’’ was issued in November 2002. Pathways to Work is a joint programme led by the Department for Work and Pensions along with the Department of Health in order to enable people with health conditions to move into work and to become independent. CMP is a health rehabilitation program delivered by qualiﬁed health care professionals like physiotherapists, occupational therapists, psychologists and others. It is an integral part of PtW project as it offers an added value to the care and treatment of patients of working age with long-term health conditions like rheumatoid arthritis, diabetes, cardiac and respiratory problems and many more. People who stay on IB for longer duration are less likely to go back to work. The main barriers identiﬁed for failure to return to work are biomechanical problems leading to faulty movement patterns, chronic pain, fear avoidance and lack of conﬁdence and motivation. Physiotherapists work as case managers in CMP. They use CBT along with exercise programs to help people overcome fear avoidance and chronic pain factors. Three main aims of CMP are education of the client about his condition, reassurance and advice on how to best manage his condition. The main elements of CMP are pain management, individual and group CBT, education about the condition, joint protection techniques, energy conservation methods and exercise programs to name a few. Keywords: Cognitive Behavioural Therapy, Condition Management Program, Chronic Pain, Fear avoidance

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[P23] Effect of lumbar stabilization exercises as home program in treatment of young women with non speciﬁc low back pain P. Agarwa 1, 2. 1 Chartered Society Of Physiotherapists, UK; University, India

2

Manipal

Non speciﬁc low back pain (NSLBP) represents approximately 80% of primary care low back pain (LBP) presentations. NSLBP disorders exist where mal-adaptive movement and motor control impairments appear to result in ongoing abnormal tissue loading and mechanically provoked pain. Purpose: To compare the effect of lumbar stabilization exercises along with back care and ergonomic advice over back care and ergonomic advice alone, when given as a home program in young women with NSLBP. Methods: 40 subjects were included in the experimental group by purposive sampling. An age and gender matched control group of 28 subjects was selected. Setting: Outpatient department of physiotherapy, Kasturba Hospital, Manipal, India. Outcome measures: VAS, Oswestry Disability Index, Rolland Morris Disability Questionnaire. Subjects with complaints of LBP were screened for non-speciﬁc presentation. A written informed consent was obtained and physical examination of the low back and lower extremity was done to identify speciﬁc muscular imbalance. Subjects in the experimental group were given home exercise program which included lumbar stabilization exercises, ﬂexibility training and lower extremity proximal muscle strengthening. Home programme included advice on back care and ergonomics. Subjects in the control group were given advice on back care and ergonomics. Results: The statistical signiﬁcance was set at 0.05 with 95% conﬁdence interval. The results of Wilcoxon signed rank test for the experimental group as well as for the control group suggested a statistically signiﬁcant decrease in pain and disability (VAS, ODI and RMQ) at the end of 6 weeks. MannWhitney’s analysis between the groups suggested a statistically signiﬁcant decrease in pain and disability. There was greater improvement in the experimental group as compared to the control group. Discussion: This signiﬁcant difference in global improvement suggests that the difference can be attributed to the addition of stabilization exercises to back care and ergonomic advice. Keywords: Non speciﬁc low back pain, Stabilization exercise, Home programme, Back care [P24] The effect of performing a passive intervertebral mobilisation (PAIVM) using thumb and pisiform craniovertebral angle and lumbar spine position

accessory grip on

P. J. Coales, H. Fursman, S. Greenwood. Cardiff University, UK The relationship between low back pain, cervical injury and physical handling is established indicating posture plays an important role in spinal loading. In 2005 UK physiotherapy career prevalence rate of musculoskeletal injury was 68% (CSP, 2005) with risk factors including performing manual therapy techniques. Little research has investigated the effects of performing therapeutic techniques on therapists’ posture. The aim was to investigate the effect of performing a Passive Intervertebral Accessory Mobilisation (PAIVM) using thumb and pisiform grip on craniovertebral angle (CVA) and lumbar spine position. A same-subject cross over design used 22 healthy Cardiff University Physiotherapy students (4 males 18 females age 22.3 years þ 3.3). Reﬂective markers were placed over C7, T12 and L5. A video recorded each participant performing grade III PAIVMs using the thumb and pisiform randomly ordered for 30 seconds over L3. SiliconCOACH measured CVA (angle between horizontal and line drawn between C7 and tragus) and lumbar spine position (angle between vertical and line drawn between L5 and T12). A two tailed related t–test demonstrated signiﬁcant differences in CVA (p ¼ 0.001) with decreased CVA using the thumb technique, and lumbar spine position (p ¼ 0.001) with increased ﬂexion when using pisiform grip. Findings show the thumb technique produces greater forward head posture and using the pisiform grip results in increased ﬂexion at the

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lumbar spine. Both postures are known to increase spinal loading. Many physiotherapists adapt working position to avoid injury, in this case of the thumb, but need to consider the effects of the adapted position on the cervical and lumbar spine. Due to limitations of sample size and subject experience in PAIVMs further research is required to gain more knowledge of spinal mechanics when performing PAIVMs and other therapeutic techniques in order to better understand tasks which pose increased risk of injury to physiotherapists. Keywords: Physiotherapist, working posture, PAIVM [P25] The effect of carrying a backpack with and without a waist strap on craniovertebral angle P.J. Coales, S. Evans. Cardiff University, UK Backpacks commonly used for carrying loads have been linked to increased forward head position (FHP) shown by decreased craniovertebral angle (CVA). This posture has been shown to increase strain on cervical structures including musculature. The Chartered Society of Physiotherapy (CSP) advises use of backpacks with shoulder straps and a waist strap to reduce this risk. There is a lack of evidence of the effect wearing a waist strap has on the posture of backpack users. The aim was to assess the effect on CVA of using a waist strap Twenty healthy Cardiff University Physiotherapy students (15 females, 5 males, age 22.05 4.5 years) participated in a crossover design. Each subject walked on a treadmill for two ﬁve minute periods with and without a waist strap carrying a backpack loaded to 20% bodyweight. A marker was placed on C7 and a video recording taken of the last minute of walking for each condition. Heel strike was marked on the ﬁlm and SiliconCOACH software recorded the CVA (angle between horizontal and line drawn between C7 and tragus) during the last ten heel strikes and a mean CVA was calculated for each individual during both conditions. A two-tailed related T test demonstrated a signiﬁcant difference between CVA with and without a waist strap (p ¼ 0.01) showing that wearing a waist strap whilst carrying a backpack signiﬁcantly increases CVA, so reducing FHP, compared to no waist strap. Wearing a waist strap whilst carrying a backpack does improve head on neck position. This supports previous ﬁndings showing postural improvements when using a waist strap. Limitations of the study include the measurement of the CVA only, the small number and age range of subjects. Further research is needed to determine the extent of these limitations and the overall inﬂuence of waist strap use on trunk posture. Keywords: backpack, waiststrap, craniovertebral angle

[P26] Comparison of sitting on a gym ball alone versus sitting on a gym ball plus dynamic limb movements for chronic back pain: A 6-month follow-up clinical trial P. Pensri 1, R. Huangchumnong 2, M. Chaikumarn 1. University, Thailand; 2 Sawanpracharak Hospital, Thailand

1

Chulalongkorn

Introduction: Sitting on a gym ball can be beneﬁcial in facilitating spinal stabilizing muscle function and activating proprioception, balance and equilibrium control.1 It may be used for the rehabilitation of patients with low back pain (LBP). However, scientiﬁc evidence to support the speciﬁc use on this condition is rare. Therefore, we compared the effects of two exercise interventions; a ‘‘sitting on a gym ball alone’’ program (program A) with a ‘‘sitting on a gym ball plus dynamic limb movements’’ program (program B) for the decrease of disability at 6 months in patients with chronic LBP. Methods: Forty subjects were randomly assigned either program A (n ¼ 20) or program B (n ¼ 20) and were asked to perform the prescribed exercise at home for at least 20 minutes per day, 5 days per week for 8 weeks. The primary outcome was change in the score on the RolandMorris Disability Questionnaire at 6 months. Results: All subjects reached 6-month follow-up. At baseline, the medians and interquartile ranges (Q1, Q3) of the disability scores were 3.5 (2, 5) for

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Poster Abstracts / Manual Therapy 14 (2009) S40–S52

the program A group and 5.5 (3, 7.8) for the program B group. The decrease in disability scores were 3 (1,4) and 5 (2.25, 7) at 6 months. When the baseline and the follow-up scores were compared, Wilcoxon signed ranks test demonstrated the statistically signiﬁcant changes of disability of both groups (p < 0.05). In addition, Mann-Whitney U test showed that subjects in a program B group were more likely to have a greater decrease in disability than those in a program A group (p ¼ 0.049). Discussion: The two spinal stabilizing exercise programs; sitting on a gym ball with and without dynamic limb movements for 8 weeks; were proved to reduce disability in patients with chronic LBP. Evidently, the beneﬁts were maintained at a long-term follow-up. Reference 1. Vera-Garcia FJ, Grenier SG, McGill SM. Abdominal muscle response during curl-ups on both stable and labile surfaces. Phys Ther 2000; 80: 564-69. Keywords: back pain, stabilisation exercise, disability, gym ball [P27] Psychosocial factors predicting functional outcome after total knee replacement: Preliminary results P.A. Roche 1, M.L. van der Linden 1, P.J. Rowe 2, R.W. Nutton 3. 1 Queen Margaret University, UK; 2 Strathclyde University, UK; 3 Royal Inﬁrmary Edinburgh, UK Introduction: Osteoarthritis is the most common cause of disability in older people. In Scotland alone over 3000 people undergo Total Knee Arthroplasty (TKA) each year. Identifying factors that predict functional outcome is an important strategy for optimal rehabilitation following TKA. This ongoing study employs a bio-psychosocial approach and the International Classiﬁcation of Functional, Disability and Health to examine the degree to which pre-operative scores in three classes of factors, predict post-operative scores of the function component of the (Western Ontario McMaster University Osteoarthritis Index (WOMAC) after TKA. Methods: Sixty patients (mean age 68 +/- 6 years) were assessed on average 38 days prior and 12 months after TKA. Pre-operative measures were grouped in three different domains; the Demographic Domain (D1) included age and Body Mass Index, the Body Function and Structures Domain (D2) included knee range of motion in long sitting, knee extensor moment, Pain VAS and the stiffness component of the WOMAC. The Personal/Psychosocial Domain (D3) included the Tampa scale assessing ‘fear of movement’; a measure of learned helplessness due to pain and the Stanford Arthritis Self-Efﬁcacy Scale. Results: Prior to surgery, high scores of functional disability were positively and signiﬁcantly associated with scores of pain, stiffness, fear of movement and learned helplessness, and negatively and signiﬁcantly associated with low scores of self-efﬁcacy (- .459, p > .05). Preliminary results of hierarchical multiple regression analysis indicate that the presurgical scores in D3 contributed signiﬁcantly to scores of functional outcome 12 months after surgery. Discussion: Preliminary results indicate that pre and post surgical management of patients with end-stage osteoarthritis should include assessment of individual patient’s avoidance of movement, perceived ‘helplessness’ and perceived self-efﬁcacy to function. Each of these factors can respond well to a bio-psychosocial model of rehabilitation for patients with Total Knee Replacement. Keywords: Bio-psychosocial, Prediction, Surgical Outcome, Osteaorhtritis [P28] Devising and adaptation to current development of a new test of balance and coordination for children with motor problems and ability to walk R. Go´mez Sales, A. Go´mez Conesa, M. D. Hidalogo Montesinos. Murcia University, Spain Introduction: Children with motor problems, like cerebral palsy or DCD (developmental coordination disorder), have coordination and balance handicaps. There are currently few reliable tools to assess balance and

coordination in children with motor problems. Furthermore, there are activities that are not well deﬁned for children with typical development related to balance and coordination. Methods: During the development of a new test to measure balance and coordination in children with motor problems, to 5 years or more with walking capacity, the investigation analyze test items whose age of achievement is not sufﬁciently well documented in the literature of motor development in a sample of healthy children. A threshold of difﬁculty was placed at level of 75% of correct implementation, in order to make it easy to adapt to children with later motor problems. Results: After a review of scientiﬁc literature and consultation with a panel of experts, it was developed a test with 30 situational items related to balance and coordination for children from 5 to 16 years, with motor problems and the ability to walk. Each item has 4 possible levels, ranging from non-performance (1) until the correct (4). Among the 30 items, 19 are scientiﬁcally documented in the scope of motor maturity according to age, and the remaining 11 items were set for an investigation with children without motor problems, to determine whether test has the appropriate age difﬁculty to adapt to motor problem children. An example of one item: 29) to hop with right leg among ﬁve rings of 61 centimetres, in a straight line without placing the lift leg in the ﬂoor. 103 school-age of southeast of Spain from 5 to 8 years, and with typical development participated in the study. Discussion: Both girls and boys, had the lowest average score in 30 items (hopping with left leg). Children get an average score of 3.5510 and a standard deviation of 0.7377. In the case of girls the mean score is 3.4259 and standard deviation of 0.79151. The ANOVA tests was F: 15.40, showing a statistical signiﬁcance of p <0.01. Of the 11 items surveyed, 9 were kept for the test of 5 to 8 years, the remaining 2 items were kept for the aged of 8 or more, as a result of the study. The scale has a right consistency, with Cronbach’s alpha value: 0.729. Healthy children probed the test to have a structure similar to the curve of normality. The instrument is capable of being administered to children with motor problems with ability to walk. Keywords: balance, coordination, test, motor problems [P29] Psychometric properties of 11 items situational balance and coordination new test in children with typical development and adaptation to children with motor problems R. Go´mez Sales, A.A. Go´mez Conesa, M.D. Hidalgo Montesinos. Murcia University, Spain Introduction: In the assessment of balance and coordination in children with motor problems, which is very important to functional reach, the tools to assess the function and postural control are insufﬁcient. As a result of the lack of valid and reliable instruments to assess coordination and balance in children from 5 years and older with motor problems, a tool was developed. Methods: The sample consists in 103 scholar children between 5 and 8 years in a south-eastern Spanish region. Exclusion criteria were having motor problems and not following typical development. The age range of children was placed between 5 and 8 years. The instrument consists in 11 items. Each item has 4 possible responses, ordered by difﬁculty in a type of Likert scale. We analyzed the correlation corrected item-total scale, the Cronbach’s alpha, also was practiced a hypothesis contrast. Results: The highest scoring total corrected-correlation item-scale was 0.701, and the lowest is 0.056. For the sample of children with normal development, except two items 1 and 6, all the 9 items were above 0.3 which represents an adequate item-total correlation for the remaining 9 items. Items 1 and 6, although lower, are higher from 0 and with positive sign. In the descriptive analysis of the full scale for the sample of 103 healthy subjects, the average values were 38.1456 (DT: 2.54145) which represents a high value. In terms of reliability of the scale formed for eleven items, the Cronbach’s alpha obtained a value of 0.729, which represents an adequate value. The coefﬁcient based on the elements was 0.736. The ANOVA, with critical level p less than 0.001, had the value of F: 15.406. Discussion: The total values of item-scale correlation corrected, except for two items, has an adequate item-total correlation. Future research will

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

S49

need a review of the lower two items. Cronbach’s alpha coefﬁcient is also adequate. The results of descriptive analysis were in harmony with the aim of the study to adapt to children with motor problems, so the test´s items are easy enough for children with typical development.

Table 2. Reﬂexes evoked by radial nerve stimulation Muscle

Latency (ms)

Amplitude

Frequency of occurrence

Low threshold response

High threshold response

Keywords: pschycometric properties, new test, balance, coordination

Posterior deltoid SLR Posterior deltoid MLR Posterior deltoid LLR Infraspinatus MLR Infraspinatus LLR Latissimus dorsi MLR Latissimus dorsi LLR Teres major SLR Teres major MLR Teres major LLR

31.2 1.1

25.1 10.0

1/10 (10%)

1/1

0/1

39.0 4.7

22.5 8.5

8/10 (80%)

8/84

0/8

62.8 7.4

21.4 7.5

4/10 (40%)

4/41

0/4

2

[P30] An investigation of the afferent origin of reﬂexes from the hand and forearm to shoulder muscles in humans 1

1

2 1

S.C. Elliott , J.R. Hanson , C.M. Alexander . Imperial College Healthcare NHS Trust, UK

King’s College London, UK;

2

Introduction: Reﬂexes can be evoked from afferents originating in the hand and/or forearm to shoulder muscles. However, the origin of these reﬂexes has not been elucidated. Our aim was to investigate the origin of the afferents mediating these reﬂexes. Methods: With ethical approval and informed consent, rectiﬁed electromyographic (EMG) activity was recorded from posterior deltoid, infraspinatus, latissimus dorsi and teres major using surface electrodes in ten healthy subjects. Electrical stimuli were delivered percutaneously to the ulnar and radial nerves and their cutaneous afferents alone at various stimulus strengths. The resulting EMG was averaged and the frequency of occurrence, latency and amplitude of any reﬂexes were noted. Results: Reﬂexes in posterior deltoid, infraspinatus and latissimus dorsi could be evoked at low stimulus intensities. In contrast, higher threshold reﬂexes were evoked in teres major. Finally, stimulation of cutaneous afferents alone evoked some of these reﬂexes in each muscle.

Table 1. Reﬂexes evoked by ulnar nerve stimulation Muscle

Latency (ms)

Amplitude

Frequency of occurrence

Low threshold response

High threshold response

Posterior deltoid SLR Posterior deltoid MLR Posterior deltoid LLR Infraspinatus MLR Infraspinatus LLR Latissimus dorsi LLR Teres major MLR Teres major LLR

25.5 6.3

17.1 5.5

4/10 (40%)

3/4

1/4

29.8 14.2

4/10 (40%)

4/4

0/4

57.5 9.3

14.5 5.6

6/10 (60%)

4/61

2/6

46.6 7.3

15.7 4.6

3/10 (30%)

1/3

2/31

76.8 3.3

15.4 6.1

2/10 (20%)

1/2

1/2

24.8 4.1

22.2 9.5

3/8 (38%)

2/3

1/3

39.5 4.9

23.0 17.3

3/8 (38%)

2/31

1/3

52.8

12.3

1/8 (13%)

0/1

1/1

Latency (mean SD), amplitude (% above the background mean EMG). SLR ¼ short latency reﬂex, MLR ¼ medium latency reﬂex, LLR ¼ long latency reﬂex.124 indicates the number of subjects in whom a cutaneous reﬂex of comparable latency to those elicited by mixed nerve stimulation was found. Discussion: These results suggest a role for Group I and cutaneous afferents from the hand and/or forearm in the generation of some of these reﬂexes to shoulder muscles. Therefore use of the hand may modulate shoulder muscle activity. Acknowledgements S.C. Elliott gratefully acknowledges the ﬁnancial support of the CSP and MACP. Keywords: Reﬂex, Shoulder, Muscle

1

41.4 3.9

28.5 15.5

8/10 (80%)

3/8

5/8

66.9 5.4

28.3 9.8

6/10 (60%)

2/61

4/6

43.4 2.4

22.4 7.2

6/10 (60%)

3/6

3/6

1

39.8 4.5

58.8 6.0

25.7 13.5

5/10 (50%)

4/5

58.8 4.7

36.7 20.4

3/10 (30%)

1/3

2/3

47.0 3.9

21.8 12.3

6/8 (75%)

3/6

3/61

65.6 3.9

20.2 7.1

4/8 (50%)

0/4

4/4

1/5

The latency (mean SD), amplitude (% above the background mean EMG). SLR ¼ short latency reﬂex, MLR ¼ medium latency reﬂex, LLR ¼ long latency reﬂex. 1 indicates the number of subjects in whom a cutaneous reﬂex of comparable latency to those elicited by mixed nerve stimulation was found.

[P31] The McKenzie classiﬁcation system in the extremities – a reliability study using McKenzie assessment forms and experienced clinicians S.J. May 1, J. Ross 2. 1 Shefﬁeld Hallam University, UK; College of Medicine, Dentistry and Nursing, UK

2

Dundee University

Introduction: To investigate the reliability of experienced physiotherapists in classifying patients in McKenzie’s non-speciﬁc mechanical syndromes from extremity McKenzie assessment forms (McKenzie and May, 2000). Methods: Real patient vignettes (N ¼ 25) were collected during clinical practice; all identifying information was removed to make the assessment form anonymous, and the mechanical classiﬁcation chosen by the treating therapist was also deleted. The forms were saved in an electronic format. Forms were sent electronically to McKenzie Institute International Diploma holders worldwide, and a sheet for them to enter their classiﬁcation for each vignette and demographic details. Three repeat mailings were undertaken to maximise response rates. Results: Out of a sample frame of 126 therapists 97 therapists from 22 countries responded and provided classiﬁcation for the patient vignettes. Overall level of agreement was 92% and kappa was 0.83 (95% CI, 0.68, 0.98). There was little difference in reliability between upper (kappa 0.85) and lower limb (kappa 0.80) vignettes. Discussion: The use of the McKenzie approach with extremity patients is relatively novel and the relevant scientiﬁc literature is very limited. This is one of the ﬁrst studies to attempt to map the clinical value of this approach. This reliability analysis of McKenzie extremity assessment forms showed a very good level of reliability amongst a large number of experienced therapists in numerous countries. It is a ﬁrst step in attempting to establish the clinical utility of the McKenzie approach with extremity patients.

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Poster Abstracts / Manual Therapy 14 (2009) S40–S52

Reference McKenzie R, May S. The Human Extremities Mechanical Diagnosis and Therapy. Spinal Publications New Zealand Ltd, 2000. Keywords: McKenzie, extremity, reliability, assessment forms [P32] Speciﬁc directional exercises for low back pain: A case series A. Long 1, S.J. May 2, T. Fung 3. 1 Bonavista Physical Therapy, Canada; 2 Shefﬁeld Hallam University, UK; 3 University of Calgary, Canada Introduction: To determine if outcomes can be changed following initial poor response to exercise therapy when patients are given an alternative exercise prescription. Methods: Secondary analysis of a case series following RCT (Long et al. 2004). The primary inclusion criteria were subjects reporting they were unchanged or worse, or secondarily, those requesting a change in treatment, at completion of a previously published RCT which randomized subjects with Directional Preference into: 1) Matched exercises and advice or 2) Unmatched exercises and evidence-based advice. Subjects meeting the above criteria were then treated with an alternate exercise prescription. Those who participated in both the RCT and the following alternate care phase formed the cohort for the current series. ANOVA and McNemar tests compared outcomes during these two chronological intervals. Dropouts were included in the intention-to-treat analysis (carry-forward of last known data point). Results: Eighty-ﬁve subjects from the Unmatched group met the primary inclusion criteria and an additional 22 subjects were identiﬁed by the secondary criteria. Combined, these 107 subjects were offered Matched treatment and 96 consented. Those reporting improvement or resolution of symptoms increased from 22% in the ﬁrst two 2 weeks of Unmatched care to 84% after the following 2 weeks of Matched care. In addition, there were statistically signiﬁcant and clinically meaningful changes in ﬁve of seven outcomes (P<.001) over the following two weeks compared to the clinically unimportant changes documented in the prior two weeks (during the RCT). Conclusions: Poor outcomes resulting from nonspeciﬁc/unmatched exercise protocols appeared to be reversed, in this study, if subjects with directional preference are given matched, direction speciﬁc exercises. This study adds to the growing literature supporting a role for speciﬁc exercise in the care of back pain patients. Reference Long A, Donelson R, Fung T. Does it matter which exercise? A randomized control trial of exercise for low back pain. Spine 2004;29:2593-602. Keywords: Directional preference exercises, McKenzie, Low back pain, Classiﬁcation [P33] Clinical assessment of scapulohumeral function in patients with subacromial impingement: What do shoulder physiotherapists think and what do they do? V. Sparkes 1, R W van M.J. Smith 1, D. Jones 2, C. Connor 3, Deursen 1. 1 Cardiff University, UK; 2 Cardiff and Vale NHS Trust, UK; 3 Gwent Healthcare NHS Trust, UK Introduction: Altered scapulohumeral function (SHF) has been implicated in numerous shoulder pathologies including subacromial impingement (SI) and this provides a rationale for assessing SHF in the clinical setting. However a spectrum of approaches for assessing SHF is described in the published literature and there is anecdotal evidence that the methods of assessment used in the clinical setting vary widely between clinicians. Methods: In order to investigate current opinion and practice in relation to the clinical assessment of SHF, a questionnaire was issued at the 2008 British Elbow and Shoulder Society conference. Seventy-one percent (n ¼ 64) of attending Physiotherapists completed the questionnaire, with a mean experience of 14.4 years. Results: All Physiotherapist respondents indicated that they considered SHF to be relevant in a patient with SI. Whilst movement quality and

control were considered to be ‘‘very relevant’’ by 92% of such respondents, only 38% of respondents rated scapulohumeral position so highly. The primary method by which SHF was recorded was by the use of descriptive terminology (used by 97% of respondents). An established classiﬁcation system was used by only 9% of respondents, whilst the majority employed a heterogeneous mix of descriptive terms. Discussion: Such ﬁndings, combined with respondent’s comments such as ‘‘I use terminology that will remind me of what I’ve seen, but appreciate that if others read my notes they would not necessarily perceive exactly the same picture’’, provides evidence that whilst SHF is considered highly relevant, there is inconsistency in how SHF is assessed and recorded. Data from this questionnaire therefore provides a justiﬁcation for the development of a clinic-based methodology to standardise the describing and recording of SHF. Such a methodology is currently under development and clinicians will be invited to participate in its development. Keywords: Scapulohumeral Shoulder, Classiﬁcation

movement,

Subacromial

impingement,

[P34] The common therapeutic exercises’ effects on cardiovascular ﬁtness of stroke patients W. Tong, D. Yan, W. Tao, Medical University, China

D. Meng. First Afﬁliated Hospital of Nanjing

Objective: To evaluate the relationship between heart rate?HR??rate of perceived exertion(RPE) and oxygen consumption of stroke patients during the process of the common therapeutic exercises and to observe the cardiovascular response caused by the therapeutic exercises used in the convalescent and sequelae period of stroke. Methods: Eighteen stroke patients participated in the test. K4b2 Pulmonary Function Equipment was used to record HR(bpm) and ?1 1 !vml]>]> (ml min $kg ) during the training of sit-to-stand transfers, hip extension when standing, weight loading of the involved leg, raising of involved leg, climbing stairs, walking 60 meters respectively and also completing these exercises continuously. RPE was asked after every exercise was ﬁnished. Results: There was a moderate correlation between HR and energy expenditure?r?0.618?P < 0.001?and a low correlation between RPE and energy expenditure(r?0.325?P < 0.001).There was one or more participants in each exercise whose heart rate could reach the targeted heart rate zone and the longest duration was 8.5 minutes, which was not reach the time duration request of aerobic exercise. The time duration in targeted heart zone of consecutive exercise is longer than interval exercises. Conclusions: Heart rate is a better index than RPE in the evaluation of exercise intensity of stroke patients. The intensity of therapeutic exercises used in convalescent and sequelae period of stroke isn’t adequate to induce a cardiovascular training effect. Keywords: therapeutic exercises, stroke, aerobic training, exercises intensity [P35] An investigation into the usefulness of clinical tests by physiotherapists at extended scope level for meniscus lesions in the knee and labral lesions in the shoulder W. V. King 1, 2, C. Mercer 1, 2. 1 Worthing and Southlands hospitals NHS trust, UK; 2 Manipulative Association of Chartered Physiotherapists, UK Purpose/Aim: To determine the use, and knowledge of the evidence underpinning a range of common tests for meniscal lesions in the knee and labral lesions in the shoulder by extended scope physiotherapists (ESPs). Methods: A questionnaire was sent to musculoskeletal ESPs . The questionnaire listed tests commonly used for knee meniscus lesions and shoulder labral tears, and asked the ESPs to comment on the usefulness and evidence base for each. Results: 14 ESPs responded to the questionnaire. 100% answered questions related to meniscal lesions of the knee; 71% answered questions relating to

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

labral lesions of the shoulder. The most commonly used tests for meniscal lesions were McMurray’s (100%) and Joint Line Palpation (86%) . Other tests for meniscal lesions were used by 50% of clinicians or less. For shoulder SLAP lesions O’Brien’s test was used by 100% of clinicians; 60% used ‘‘other’’ tests. 40% of clinicians did not use clinical tests for the detection of posterior labral lesions. No test achieved more than 40%. 100% of clinicians used two tests or more to detect Meniscal and SLAP lesions with 79% of clinicians using 3 tests or more for meniscal lesions and 70% for SLAP lesions. There was a marked difference observed in the clinicians’ responses to questions relating to clinical use of the tests, clinical usefulness of the tests and opinion on the evidence behind each test. Clinicians tended to have strong views on the clinical use of the test, but progressively less opinion on clinical usefulness and evidence behind the tests. Conclusions: The results suggest that only a few select tests are consistently used by expert clinicians in order to detect meniscal and SLAP lesions. Conﬁdence in the usefulness and evidence base of each test appears to be less consistent even at extended scope level. Keywords: Extended-scope, Labral, Meniscal, Clinical-tests [P36] The use of a weight-bearing measuring device for accurate assessment and biofeedback training following lower limb pathology Y. Kaplan. Hebrew University of Jerusalem, Israel Introduction: One of the primary objectives of early rehabilitation in patients who have undergone lower limb surgery is to return them to weight-bearing as quickly as possible. Auditory biofeedback has been utilized in stroke rehabilitation, transtibial amputation and the implantation of artiﬁcial joints in order to provide performance-relevant cues to both patient and clinician about the occurrence, duration, and location of a force component of motor performance. It has not previously been reported in sports injury rehabilitation. The aim of this paper is to present a new weight-bearing auditory and visual biofeedback insole device (SmartstepÔ) using numerous case studies in order to exhibit both the computer assessment and auditory feedback responses in patients following lower limb surgery. Methods: 80 patients who had undergone various orthopedic surgeries following trauma were tested using the new insole device. If a weightbearing discrepancy was noted on evaluation, the patient-customized auditory feedback device was employed in order to attempt to restore equal weight-bearing in bilateral limbs. All patients signed consent forms and the use of the device was approved by the Helsinki Committee. Results: Whilst using the new patient-customized auditory feedback device, accurate weight-bearing comparisons between bilateral lower limbs were recorded. In most cases, after a single session utilizing the feedback device, weight-bearing values were objectively and statistically improved and in some cases maintained, without the feedback device being further employed. Discussion: Patients need to return to full weight-bearing rapidly following lower limb surgery. Use of the new patient-customized auditory biofeedback device provided a more accurate and rapid rehabilitation tool than previous reported methods. It may further prove to be a reliable and valid instrument for evaluating athletes prior to returning to sports after injury, especially in those cases where there was a signiﬁcant load difference between the affected and unaffected lower limb.

[P37] Percentage body-weight/ weight-bearing increasing speeds from walking to running

S51

(PBW/WB)

values

in

Y. Kaplan, Y. Barak, Y. Sonnenblick, G. Levin. Hebrew University of Jerusalem, Israel Introduction: Orthopedic surgeons and rehabilitation physicians frequently request limited weight-bearing for prolonged periods following certain bony or soft tissue pathologies as well as certain lower – limb surgical procedures. Jogging is a common activity that the injured athlete will seek to return to as soon as possible following injury or surgery. In order for the physician to be able to advise regarding weight-bearing in jogging, the PBW/WB values in increasing walking and jogging speeds must be known. These parameters as well as the gait distribution changes have eluded the rehabilitation community, mainly due to the technical inability to measure these paradigms. The aim of this paper is to determine the average PBW/WB values and gait distribution changes in a normal population sample during increasing speeds on a treadmill. Methods: A revolutionary weight-bearing and gait analysis system (SmartstepÔ) was utilized to accurately measure the PBW/WB values and gait distribution patterns in a sample of 10 asymptomatic subjects between the ages of 18-36 years of age (Average ¼ 27). The test measurements were conducted on a treadmill (TechnogymÔ ‘‘run excite 700’’), in order to accurately control the speed changes. The tested speeds were 4,6,8,10,12,14,16,18 and 20 km/hr consecutively. Each subject ran for a 15 second time period for each speed.

Keywords: weight-bearing, Biofeedback, Lower limb

Discussion: Whilst analyzing PBW in the entire-foot, as the speed increases, there is almost no change in the PBW from 12km/hr onwards. As speed increases from 4km/hr to 20km/hr, the PBW more than doubles itself. As opposed to the PBW on the entire-foot, the PBW on the fore-foot

S52

Poster Abstracts / Manual Therapy 14 (2009) S40–S52

[P38] Responsiveness of a patient speciﬁc outcome measure compared with the Oswestry Disability Index V2.1 and the Roland and Morris Disability Questionnaire for patients with sub-acute and chronic low back pain H. Frost, S. Lamb, S. Stewart Brown. University of Warwick, UK Patient speciﬁc outcome measures allow individuals to select and rate the relative importance of activities they consider of greatest relevance. However, there is a paucity of research reporting the responsiveness of these measures for patient with back pain. The aim of this study was to compare the responsiveness of a patient speciﬁc outcome measure with the Oswestry Disability Index v2.1 (ODI) and the Roland and Morris Disability Questionnaire (RMDQ) for patients with mild to moderate sub-acute and chronic low back pain. Two hundred and one patients were assessed at baseline and 12 months using the patient speciﬁc activity questionnaire (PSAQ), the ODI, the RMDQ and a transition rating scale. The latter was used to categorise patients into three groups (better, same or worse). Effect size statistics, receiver operating characteristic curves and one-way between groups ANOVA were used in the analysis.

increases to a maximum of 70%. The maximum fore-foot PBW is 30% higher to that of hind-foot. As the speed increases, the stance percentage reduces by 100% at 20km/hr with a concurrent increase in the swing percentage. The swing phase only increases by 6% from 10km/hr to 20km/ hr, even though the speed increases by 100%. The main change occurs between 8km/hr and 10km/hr, as walking progresses to running. The most signiﬁcant change in PBW occurs between 4km/hr and 12km/hr, as walking progresses to running. Therefore, this is what should be considered when recommending weight bearing activities to the athlete who intends returning to weight bearing following injury or surgery. Athletes can be encouraged to run at high speeds without concern of greatly increasing their PBW. Keywords: Weight-bearing, Walking, Running

Manual Therapy 14 (2009) S53

PRESENTERS’ INDEX

A AASA, B. AGARWAL, P. ALEXANDER, C. ARAB, A.M. B BALTHAZARD, P. BARBERO, M. BARCIA, M. BARR, A.R. BEINERT, K. BENT, N.P. BERQUE, P. C CAIRNS, M.C. CALLAGHAN, M. CAN, F. CAULFIELD, B. CHOI, H. CLARK, J. CLIFFORD, A.M. COALES, P. J. COMERFORD, M. COOK, C. COOK, G. ˆ TE´, J.N. CO COUGHLAN, G.F. CRUMMEY, O.M. D DAENEN, L. DANKAERTS, W. DAVIES, C.M. DIESEL, W. DIMITRIADIS, Z. E EECHAUTE, C.J. ELLIOTT, S.C. ESCORTELL, E. F FALLA, D. FEARN, J. FOSTER, N.E. FREDRIKSEN, H. FROST, H. G GALISTEO, A.M. GHASEMI, M.S. GIBBONS, S.G.T. ´ MEZ SALES, R. GO GRIMALDI, A. H HADALA, M. HARRIDGE, S.D.R. HARWICH, A. HELGADOTTIR, H. HOLMES, P. HOMSTØL, G.M. J JEAL, N.V. JEREMIAH, H.M. JOENSEN, J. JONES, K.J.

IAP12, P03 P22, P23 GL2 O06 O47 O12 P16 IAP04 P12 O45 O22 O09 GL4 O31, P08 P04 P10 O17 IAP09 P24, P25 GL6 K7 K5, CS5 IAP14, P11 O39 P21 O28, IAP11, P15 K2, CS2 P05 GL8 O02 O44 P30 O14 GL1 GL11 K9 O18 O03, P38 P02 P18, P19 O24, O27, O33, O51 P28, P29 K10, CS6 P17 K6 IAP05 O38 GL9 IAP13, P09 O26 IAP10 O43 IAP02

K KAPLAN, Y. KELLY, O. KIESEL, K.B. KING, W.V. KOOL, J. L LIN, J.-J. LUDEWIG, P.M. M MAY, S.J. MCCREESH, K. MCCRUM, C.A. MCLAUGHLIN, L. MENOTTI, F. MOSELEY, L. MOTTRAM, S. MOULAERT, P. O O’ CONAIRE, E.M. O’CONNELL, N.E. O’SULLIVAN, K. O’SULLIVAN, R.M. P PENSRI, P. PERRY, M. R ROCHE, A. ROCHE, P.A. ROTHWELL, J. RUSHTON, A. RYAN, C.G. S SAHRMANN, S. SALT, E.J. SEXTON, M.T. SHARAN, D. SPARKES, V. STRUYF, F. STUTZ, U. SWINKELS, R.A.H.M. T TEYHEN, D. THOMAS, L.C. THOOMES, E.J. TONG, W. V VAN DAELE, U. VASSELJEN, O VEEGER, D.J. (H.E.J.) W WHITTAKER, J.L. WILLETT, E. WILSON, I.M. WOBY, S. WOODHOUSE, A. Y YOSHIKAWA, A.

P36, P37 O08 P13, P14 P35 O05 O36 K4, CS4 P31, P32 O19, O46 O35 GL5 O23 K8, CS3 O25, O40 O21 O11 O10, IAP06, P20 O32 IAP03 P26 O34 O42 P27 K3 O50 O49 K1, CS1 P06 IAP15 O48 P33 O37, IAP08 O41 O30 GL3 O16 IAP01, P07 P34 O04 O13 GL10 O07, O29 O15 O01 GL7 O20 P01

Manual Therapy Journal - Volume 14, Issue 5, Pages 461-584 (October 2009)

Manual Therapy Journal - Volume 14, Issue 5, Pages 461-584 (October 2009)

Manual Therapy Journal - Volume 14, Issue 3, Pages 241-352 (June 2009)

Manual Therapy Journal - Volume 14, Issue 3, Pages 241-352 (June 2009)

Manual Therapy Journal - Volume 14, Issue 1, Pages 1-116 (February 2009)

Manual Therapy Journal - Volume 14, Issue 1, Pages 1-116 (February 2009)

Manual Therapy Journal - Volume 14, Issue 6, Pages 585-716 (December 2009)

Manual Therapy Journal - Volume 14, Issue 6, Pages 585-716 (December 2009)

Manual Therapy Journal - Volume 14, Issue 2, Pages 117-240 (April 2009)

Manual Therapy Journal - Volume 14, Issue 2, Pages 117-240 (April 2009)

Manual Therapy Journal - Volume 14, Issue 4, Pages 353-460 (August 2009)

Manual Therapy Journal - Volume 14, Issue 4, Pages 353-460 (August 2009)

October journal No.14 Autumn (1980)

October journal No.14 Autumn (1980)

Physical Therapy- Journal of the APTA- October 2009, Volume 89, Issue 10

Physical Therapy- Journal of the APTA- October 2009, Volume 89, Issue 10

Dr. Dobb's Journal (October)

Dr. Dobb's Journal (October)

Architectural Record - October 2009

Architectural Record - October 2009

Professional Photographer October 2009

Professional Photographer October 2009

Yoga Journal - November 2009

Yoga Journal - November 2009

ADVANCES IN CATALYSIS VOLUME 14, Volume 14

ADVANCES IN CATALYSIS VOLUME 14, Volume 14

Curso Manual Autocad 14

Curso Manual Autocad 14

Manual Therapy in Children

Manual Therapy in Children

Acupuncture in Manual Therapy

Acupuncture in Manual Therapy

Manual Medicine Therapy

Manual Medicine Therapy

The Relaxation Therapy Manual

The Relaxation Therapy Manual

Neuromuscular Therapy Manual

Neuromuscular Therapy Manual

Manual Therapy in Children

Manual Therapy in Children

Acupuncture in Manual Therapy

Acupuncture in Manual Therapy

Physical Therapy- Journal of the APTA- June 2009, Volume 89, Issue 6

Physical Therapy- Journal of the APTA- June 2009, Volume 89, Issue 6

Physical Therapy- Journal of the APTA- Feburary 2009, Volume 89, Issue 2

Physical Therapy- Journal of the APTA- Feburary 2009, Volume 89, Issue 2

Physical Therapy- Journal of the APTA- March 2009, Volume 89, Issue 3

Physical Therapy- Journal of the APTA- March 2009, Volume 89, Issue 3

Monsterous Manual: BESM D20 Supplement

Monsterous Manual: BESM D20 Supplement

Physical Therapy- Journal of the APTA- July 2009, Volume 89, Issue 7

Physical Therapy- Journal of the APTA- July 2009, Volume 89, Issue 7

Physical Therapy- Journal of the APTA- August 2009, Volume 89, Issue 8

Physical Therapy- Journal of the APTA- August 2009, Volume 89, Issue 8

Behavioral and Brain Sciences, Volume 32, Issue 5, October 2009

Behavioral and Brain Sciences, Volume 32, Issue 5, October 2009

Physical Therapy- Journal of the APTA- November 2009, Volume 89, Issue 11

Physical Therapy- Journal of the APTA- November 2009, Volume 89, Issue 11

Physical Therapy- Journal of the APTA- May 2009, Volume 89, Issue 5

Physical Therapy- Journal of the APTA- May 2009, Volume 89, Issue 5

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