BACKGROUND CONTEXT: Neck pain is common, disabling, and costly. The effectiveness of patient education strategies is unclear.

PURPOSE: To assess whether patient education strategies are of benefit for pain, function/disability, global perceived effect, quality of life, or patient satisfaction, in adults with neck pain with or without radiculopathy.

STUDY DESIGN: Cochrane systematic review.

METHODS: Computerized bibliographic databases were searched from their start to May 31, 2008. Eligible studies were randomized trials investigating the effectiveness of patient education strategies for neck pain. Paired independent reviewers carried out study selection, data abstraction, and methodological quality assessment. Relative risk and standardized mean differences were calculated. Because of differences in intervention type or disorder, no studies were considered appropriate to pool.

RESULTS: Of the 10 selected trials, two (20%) were rated as of high quality. Patient education was assessed as follows: 1) eight trials of advice focusing on activation compared with no treatment, or to various active treatments, including therapeutic exercise, manual therapy, and cognitive behavioral therapy, showed either inferiority or no difference for pain, spanning a full range of follow-up periods, acuity and disorder types. When compared with rest, two trials that assessed acute whiplash-associated disorder showed moderate evidence of no difference for advice focusing on activation; 2) two trials studying advice focusing on pain and stress coping skills found moderate evidence of no benefit for chronic neck pain at intermediate- to long-term follow-up; and 3) one trial compared the effects of neck school to no treatment, yielding limited evidence of no benefit for pain, at intermediate-term follow-up in mixed acute/subacute/chronic neck pain.

CONCLUSIONS: This review has not shown effectiveness for educational interventions for neck pain of various acuity stages and disorder types and at various follow-up periods, including advice to activate, advice on stress coping skills, and neck school. In future research, further attention to methodological quality is necessary. Studies of multimodal interventions should consider study designs, such as factorial designs, that permit discrimination of specific educational components.

OBJECTIVE: to evaluate the efficacy of capsular distension combined with intraarticular glucocorticoid injections and immediate physical therapy in the treatment of adhesive capsulitis.

METHOD: a prospective open study of patients with adhesive capsulitis. Clinical and radiological criteria was used for diagnosis. Clinical evaluation was realized before treatment, at the end of the treatment, after 1 month, 3 months and 6 months. It carried on: the measure of pain and handicap intensity by an Visual Analogue Scale, the algo-functional score of Constant, the measure of passive articular mobilities. We ended in a success of the treatment when the visual analogue scale of handicap < 30, the score of Constant >70, the passive abduction >90 and the external rotation (RE) >45 degrees.

RESULTS: 19 patients were included, mean aged 56 years with capsular retraction evolving on average for 8.5 months. The parameters of evaluation of pain function and handicap improved significantly since the end of treatment. This improvement continued until 6 months after the treatment. Earning in articular amplitudes was significant since the end of treatment for forward extension and internal rotation. However, the improvement in abduction and internal rotation was significant only at 3 months. In spite of this early significant improvement in external rotation, 6 patients had an important limitation of the RE (<20 degrees). A subacromial bursography with steroid injection was proposed to them because subacromial bursa is almost consistently involved by retraction. Only, 4 patients among them accepted it. Out come was favorable in every case with a external rotation >45 degrees at I month of the treatment. The rate of success which was only 47.3% at the end of the treatment, is crossed in 73.6% at 1 month and reaches 89.4% at 6 months.

CONCLUSION: The therapeutic association capsular distension, intraarticular steroid injections and physical therapy allows to shorten the course of adhesive capsulitis. Burso-infiltration seems to be effective as therapeutic complement in case of persistence of an articular limitation.

OBJECTIVE: The goal of this study was to determine the benefits of a functional retraining programme (with or without daily isokinetic reinforcement of the trunk muscles) in patients with lower-back pain.

METHOD: Two groups of 30 patients took part in the study. The control group (CG) underwent a four-week reconditioning program in a day hospital, whereas a second interventional group (IG) additionally performed daily isokinetic training of the trunk muscles. Three evaluations were carried out: before hospitalization (T1), immediately after hospitalization (T2) and three months postrehabilitation (T3).

RESULTS: We observed an improvement in each parameter after rehabilitation, regardless of the group. A decrease in the DALLAS scores revealed a reduced impact of lower-back pain on the patients' lives. Pain experienced fell by 24%, analgesic treatment was significantly decreased (CG: -53%; IG: -56%), muscle endurance was improved (quadriceps: +30%, abdominal muscles: +20%, paraspinal muscles: +23%, quadratus lumborum: +33%) and the patients were more supple, as revealed by a decrease in the finger-to-ground distance (at T1, CG: 12.9+/-6.1cm; IG: 13.6+/-5.5 cm at T1; CG: 2.2+/-5.4 cm; IG: 2.8+/-5.1cm at T2). The sole difference for CG and IG at T2 resulted from an improvement in the performance of the trunk extensor muscles, which was significantly greater in the IG (CG: +14%; IG: +20%). Three months after rehabilitation, the benefits were still present for the two groups and, indeed, were even greater for certain parameters.

CONCLUSION: Regardless of the protocol, the patients improved in both physical and psychological terms and these improvements were maintained over a short period, at least. Our results confirmed that one functional recovery programme is not superior to another for patients with lower-back pain.

INTRODUCTION: In homeopathy ARNICA is widely used as a woundhealing medication and for the treatment of hematomas.

OBJECTIVE: In this pilot study the efficacy and safety of ARNICA D12 in patients following varicose vein surgery were investigated.

DESIGN: Prospective, randomized, double-blind, placebo-controlled pilot trial according to ICH GCP guidelines.

SETTING: The study was conducted by a surgeon at the Angiosurgical Clinic, Berlin- Buch.

INTERVENTION: After randomized allocation, 60 patients received either ARNICA D12 or placebo. Start of medication occurred the evening before operation with 5 globules. On the operation day one preoperative and hourly postoperative dosages after awakening were given. On days 2-14 of the study 5 globules 3 times a day were given.

OUTCOME CRITERIA: Surface (in cm(2) and using a three-point verbal rating scale) and intensity of hematomas induced by operation, complications of wound healing, and intensity of pain (five-point verbal rating scale) as well as efficacy and safety of the study medication were assessed.

RESULTS: Hematoma surface was reduced (from day 7 to day 14) under ARNICA by 75.5% and under placebo by 71.5% (p = 0.4726). The comparison of hematoma surface (small, medium, large) using the verbal rating scale yielded a value of p = 0.1260. Pain score decreased by 1.0 +/- 2.2 points under ARNICA and 0.3 +/- 0.8 points under placebo (p = 0.1977). Remission or improvement of pain was observed in 43.3% of patients in the ARNICA group and in 27.6% of patients in the placebo group. Tolerability was rated as very good in all cases.

CONCLUSION: The results of this pilot study showed a trend towards a beneficial effect of ARNICA D12 with regard to reduction of hematoma and pain during the postoperative course. For a statistically significant proof of efficacy of ARNICA D12 in patients following varicose vein surgery a larger sample size is necessary.

BACKGROUND: Carpal tunnel syndrome is one of the major health problems of workers who perform tasks entailing intense manual stress and repetitive movements of the upper limbs. The implementation of regulations and social changes, as well as the incorporation of women into the working world bring to bear the need of ascertaining whether any changes have taken place in the pattern of occurrence of this syndrome and in the factors conditioning the same. The objectives of this study are to know the frequency with which this syndrome occurs in the province of Alicante, to discover the work-related characteristics of those individuals affected thereby, to analyze the procedure followed for treatment and rehabilitation and to delve into the situation of those affected upon their return to work.

METHODS: Descriptive, cross-sectional study. The population studies was comprised of all those workers for whom an occupational disease report was remitted to the Safety and Health Commission within the 1996-2004 period.

RESULTS: A total of 266 reports of occupational disease due to carpal tunnel syndrome were filed. The incidence rate was 4.2 cases per 100,000 workers. A total of 62.8% of the cases were females, 25% of whom were under 30 years of age. The average length of employment at the company was 132.3 months.

CONCLUSIONS: The risk factors most often mentioned are performing repetitive movements and activities requiring manual strength.

AIM: The aim of our study is to evaluate the efficacy of joint distension during arthrography followed by an intra articular corticosteroid injection.

METHODS: This procedure associated to a physical therapy started immediately after joint distension and performed during 3 months in the treatment of 20 patients suffering from adhesive capsulitis of the shoulder were assessed.

RESULTS: Patients were evaluated on D 90:90% of them have regression of pain, 70% have an improvement of deficiency and ranges of motion of the shoulder. Adhesive capsulitis of the shoulder is a disabling pathology but, generally, with good evolution. It is a clinical diagnosis.

CONCLUSION: Joint distension associated to physical therapy has an interest in treatment because of therapeutic and antalgic effect and also restoration of range of movement.

BACKGROUND: Surgical and nonsurgical treatments of Achilles tendon ruptures are available. Nonsurgical treatment using immobilization does not have the varying degrees of infection as seen with surgical procedures, but it frequently is linked to muscle atrophy, weakness, and higher rates of rerupture than surgical treatment. This study reports the results of 64 patients with Achilles tendon ruptures treated surgically and with early mobilization.

METHODS: Surgery of the ruptured tendon involved dividing the proximal stump into two separate strands and the distal stump into a single strand. The repair was advanced to a V-Y formation, and nonabsorbable sutures were used for repair. After wound closure, an early mobilization rehabilitation program was initiated, which consisted of wearing a moveable ankle brace for 4 to 6 weeks in 0 to 15 degrees of dorsiflexion and 10 weeks of regular exercises.

RESULTS: All 64 patients resumed normal activities in an average of 3.3 months regardless of whether the rupture was acute or chronic. Tendons healed with no reruptures. There were 13 complications, all wound infections, which healed when treated with antibiotics. The infection rate dropped markedly when wounds were inspected and dressings changed 1 week postoperatively, instead of at 2 weeks.

CONCLUSION: Surgery combined with early mobilization reduces range of motion loss, increases blood supply, and reduces the degree of muscle atrophy that typically occurs after Achilles tendon rupture, thereby decreasing the time to resumption of normal activities. Applying tension to the tendon also improved strength of the calf muscles and improved ankle movement. The main concern with early mobilization is rerupture, but this was lessened by patients carefully following the weightbearing and early mobilization protocols. The results of this study strengthen the argument to employ early mobilization rehabilitation after surgical repair.

BACKGROUND: Many patients suffer patellar instability that may relate to transient patellar tracking abnormalities.

OBJECTIVE: To develop and test a technique to measure dynamic patellar tracking.

STUDY DESIGN: Controlled laboratory and in vivo study.

METHOD: A functional knee brace was modified to allow an ultrasound transducer to be mounted laterally to the femur, following the path of the patella during knee movement. An ultrasound system was used to measure patellar mediolateral position parallel to the femoral transepicondylar axis. Ten subjects with no patellar instability were studied to obtain patellar tracking and accuracy data.

RESULTS: The interobserver and intraobserver reproducibility ranged from 0.2 +/- 0.1 mm to 1.0 +/- 0.5 mm. The accuracy of the ultrasound measurement was checked against magnetic resonance imaging and was 0.6 +/- 1.9 mm. The patella moved medially then laterally from extension to flexion when sitting. Squatting and stepping produced a more lateral path, without the initial medial translation. The patella was more lateral during knee extension than during flexion.

CONCLUSIONS: This novel method for measurement of dynamic patellar mediolateral tracking was found to have good intraobserver and interobserver reproducibility, and the measurements matched closely with those obtained from magnetic resonance imaging reconstructions of static patellar positions. Some preliminary data for tracking in 3 activities were obtained from 10 normal knees.

CONTEXT: Active physical training is commonly recommended for patients with chronic neck pain; however, its efficacy has not been demonstrated in randomized studies.

OBJECTIVE: To evaluate the efficacy of intensive isometric neck strength training and lighter endurance training of neck muscles on pain and disability in women with chronic, nonspecific neck pain.

DESIGN: Examiner-blinded randomized controlled trial conducted between February 2000 and March 2002.

SETTING: Participants were recruited from occupational health care systems in southern and eastern Finland.

PATIENTS: A total of 180 female office workers between the ages of 25 and 53 years with chronic, nonspecific neck pain.

INTERVENTIONS: Patients were randomly assigned to either 2 training groups or to a control group, with 60 patients in each group. The endurance training group performed dynamic neck exercises, which included lifting the head up from the supine and prone positions. The strength training group performed high-intensity isometric neck strengthening and stabilization exercises with an elastic band. Both training groups performed dynamic exercises for the shoulders and upper extremities with dumbbells. All groups were advised to do aerobic and stretching exercises regularly 3 times a week.

MAIN OUTCOME MEASURES: Neck pain and disability were assessed by a visual analog scale, the neck and shoulder pain and disability index, and the Vernon neck disability index. Intermediate outcome measures included mood assessed by a short depression inventory and by maximal isometric neck strength and range of motion measures.

RESULTS: At the 12-month follow-up visit, both neck pain and disability had decreased in both training groups compared with the control group (P<.001). Maximal isometric neck strength had improved flexion by 110%, rotation by 76%, and extension by 69% in the strength training group. The respective improvements in the endurance training group were 28%, 29%, and 16% and in the control group were 10%, 10%, and 7%. Range of motion had also improved statistically significantly in both training groups compared with the control group in rotation, but only the strength training group had statistically significant improvements in lateral flexion and in flexion and extension.

CONCLUSIONS: Both strength and endurance training for 12 months were effective methods for decreasing pain and disability in women with chronic, nonspecific neck pain. Stretching and fitness training are commonly advised for patients with chronic neck pain, but stretching and aerobic exercising alone proved to be a much less effective form of training than strength training.

BACKGROUND: Although conventional non-pharmacological and pharmacological treatments for insomnia are effective in many people, alternative therapies such as acupuncture are still widely practiced. However, it remains unclear whether the existing evidence is rigorous enough to support its use.

OBJECTIVES: To determine the efficacy and safety of acupuncture in people with insomnia. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO, Dissertation Abstracts International, CINAHL, AMED (the Allied and Complementary Medicine Database), TCMLARS (Traditional Chinese Medical Literature Analysis and Retrieval System), National Center for Complementary and Alternative Medicine, the National Institute of Health Clinical Trials Database, the Chinese Acupuncture Trials Register, the Trials Register of the Cochrane Complementary Medicine Field, from inception to 2006, and the sleep bibliography, which is available at www.websciences.org/bibliosleep. We searched reference lists of retrieved articles, and contacted trial authors and experts in the field for information on ongoing/completed trials. SELECTION CRITERIA: Randomised controlled trials evaluating any form of acupuncture involving participants of any age with any type of insomnia were included. Included trials compared acupuncture with placebo or sham or no treatment, or acupuncture plus other treatments compared with the same other treatments. Trials that compared only acupuncture methods or compared acupuncture alone against other treatments alone were excluded, since they did not yield the net effect of acupuncture. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed quality according to a set of criteria for risk of selection bias, performance bias, attrition bias and detection bias. Relative risk (RR) and standardised mean difference (SMD) with 95% confidence intervals were used for binary and continuous outcomes respectively. Data were combined in meta-analyses (on an intention-to-treat basis), where more than one trial without significant clinical heterogeneity presented the same outcome.

MAIN RESULTS: Seven trials met the inclusion criteria. The studies included 590 participants with insomnia, of whom 56 dropped out. Participant age ranged from 15 to 98 years, and the duration of insomnia varied from 6 months to 19 years. Co-existing medical conditions contributing to insomnia included stroke, end-stage renal disease and pregnancy. Apart from conventional needle acupuncture, different variants of acupuncture such as acupressure, auricular magnetic and seed therapy, and transcutaneous electrical acupoint stimulation (TEAS) were evaluated. Meta-analysis was limited because of considerable heterogeneity between comparison groups and between outcome measures.Based on the findings from individual trials, the review suggested that acupuncture and acupressure may help to improve sleep quality scores when compared to placebo (SMD = -1.08, 95% CI = -1.86 to -0.31, p=0.006) or no treatment (SMD -0.55, 95% CI = -0.89 to -0.21, p=0.002). TEAS also resulted in better sleep quality score in one trial (SMD = -0.74, 95% CI = -1.22 to -0.26, p=0.003). However, the efficacy of acupuncture or its variants was inconsistent between studies for many sleep parameters, such as sleep onset latency, total sleep duration and wake after sleep onset. The combined result from three studies reporting subjective insomnia improvement showed that acupuncture or its variants was not more significantly effective than control (RR = 1.66, 95% CI = 0.68 to -4.03) and significant statistical heterogeneity was observed. Only one study reported an adverse event, with one out of 16 patients (6.3%) withdrawing from acupuncture because of pain.

AUTHORS' CONCLUSIONS: The small number of randomised controlled trials, together with the poor methodological quality and significant clinical heterogeneity, means that the current evidence is not sufficiently extensive or rigorous to support the use of any form of acupuncture for the treatment of insomnia. Larger high quality clinical trials employing appropriate randomisation concealment and blinding with longer follow-up are needed to further investigate the efficacy and safety of acupuncture for the treatment of insomnia.

BACKGROUND: Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied, as are the perceptions of benefits. Acupuncture has been used as an alternative to more traditional treatments for musculoskeletal pain. This review summarizes the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck pain.

OBJECTIVES: To determine the effects of acupuncture for individuals with neck pain.

SEARCH STRATEGY: We searched CENTRAL (2006, issue 1) and MEDLINE, EMBASE, MANTIS, CINAHL from their beginning to February 2006. We searched reference lists and the acupuncture database TCMLARS in China.

SELECTION CRITERIA: Any published trial using randomized (RCT) or quasi-randomized (quasi-RCT) assignment to the intervention groups, either in full text or abstract form, were included.

DATA COLLECTION AND ANALYSIS: Two reviewers made independent decisions for each step of the review: article inclusion, data abstraction and assessment of trial methodological quality. Study quality was assessed using the Jadad criteria. Consensus was used to resolve disagreements. When clinical heterogeneity was absent, we combined studies using random-effects meta-analysis models.

MAIN RESULTS: We did not find any trials that examined the effects of acupuncture for acute or subacute pain, but we found 10 trials that examined acupuncture treatments for chronic neck pain. Overall, methodological quality had a mean of 2.3/5 on the Jadad Scale. For chronic mechanical neck disorders, there was moderate evidence that acupuncture was more effective for pain relief than some types of sham controls, measured immediately post-treatment. There was moderate evidence that acupuncture was more effective than inactive, sham treatments measured immediately post-treatment and at short-term follow-up (pooled standardized mean difference (SMD) -0.37, 95% confidence interval (CI) -0.61 to -0.12). There was limited evidence that acupuncture was more effective than massage at short-term follow-up. For chronic neck disorders with radicular symptoms, there was moderate evidence that acupuncture was more effective than a wait-list control at short-term follow-up.

AUTHORS' CONCLUSIONS: There is moderate evidence that acupuncture relieves pain better than some sham treatments, measured at the end of the treatment. There is moderate evidence that those who received acupuncture reported less pain at short term follow-up than those on a waiting list. There is also moderate evidence that acupuncture is more effective than inactive treatments for relieving pain post-treatment and this is maintained at short-term follow-up.

OBJECTIVES: To study the analgesic effect of acupuncture and placebo acupuncture and to explore whether the type of the placebo acupuncture is associated with the estimated effect of acupuncture.

DESIGN: Systematic review and meta-analysis of three armed randomised clinical trials.

DATA SOURCES: Cochrane Library, Medline, Embase, Biological Abstracts, and PsycLIT. Data extraction and analysis Standardised mean differences from each trial were used to estimate the effect of acupuncture and placebo acupuncture. The different types of placebo acupuncture were ranked from 1 to 5 according to assessment of the possibility of a physiological effect, and this ranking was meta-regressed with the effect of acupuncture.

DATA SYNTHESIS: Thirteen trials (3025 patients) involving a variety of pain conditions were eligible. The allocation of patients was adequately concealed in eight trials. The clinicians managing the acupuncture and placebo acupuncture treatments were not blinded in any of the trials. One clearly outlying trial (70 patients) was excluded. A small difference was found between acupuncture and placebo acupuncture: standardised mean difference -0.17 (95% confidence interval -0.26 to -0.08), corresponding to 4 mm (2 mm to 6 mm) on a 100 mm visual analogue scale. No statistically significant heterogeneity was present (P=0.10, I(2)=36%). A moderate difference was found between placebo acupuncture and no acupuncture: standardised mean difference -0.42 (-0.60 to -0.23). However, considerable heterogeneity (P<0.001, I(2)=66%) was also found, as large trials reported both small and large effects of placebo. No association was detected between the type of placebo acupuncture and the effect of acupuncture (P=0.60).

CONCLUSIONS: A small analgesic effect of acupuncture was found, which seems to lack clinical relevance and cannot be clearly distinguished from bias. Whether needling at acupuncture points, or at any site, reduces pain independently of the psychological impact of the treatment ritual is unclear.

BACKGROUND AND PURPOSE: There is still a lack of evidence about the beneficial effects of ultrasound (US) intervention for the management of soft tissue problems. Thus, this study was designed to assess the effectiveness of US over a placebo intervention when added to other physical therapy interventions and exercise in the management of shoulder disorders.

SUBJECTS AND METHODS: Forty patients who were diagnosed by ultrasonography or magnetic resonance imaging to have a periarticular soft tissue disorder of the shoulder were randomly assigned to either a group that received true US (n=20; mean time since onset of pain=8.7 months, SD=8.8, range=1-36) or a group that received sham US (n=20; mean time since onset of pain=8.1 months, SD=10.8, range=1-42). Besides true or sham US (10 minutes), superficial heat (10 minutes), electrical stimulation (15 minutes), and an exercise program (15-30 minutes) were administered to both groups 5 days each week for 3 weeks.

RESULTS: Subjects showed within-group improvements in pain, range of motion, Shoulder Disability Questionnaire scores, and Health Assessment Questionnaire scores with the intervention, but the differences did not reach significance when compared between the groups.

DISCUSSION AND CONCLUSION: The results suggest that true US, compared with sham US, brings no further benefit when applied in addition to other physical therapy interventions in the management of soft tissue disorders of the shoulder.

BACKGROUND: Basic musculoskeletal knowledge is essential to the practice of medicine. A validated musculoskeletal cognitive examination was given to medical students, residents, and staff physicians in multiple disciplines of medicine to assess the adequacy of their musculoskeletal medicine training.

METHODS: The examination was given to 334 volunteers consisting of medical students, residents, and staff physicians. Analysis of the data collected and comparisons across disciplines were performed.

RESULTS: The average cognitive examination score was 57%. Sixty-nine participants (21%) obtained a score of >/=73.1%, the recommended mean passing score. Of the sixty-nine with a passing score, forty (58%) were orthopaedic residents and staff physicians with an overall average score of 94%. Differences in the average scores for the orthopaedic residents compared with all other specialties were significant (p < 0.001). The average score was 69% for the 124 participants who stated that they had taken a required or an elective course in orthopaedics during their training compared with an average score of 50% for the 210 who had not taken an orthopaedic course (p < 0.001). When the scores of those in orthopaedics were excluded, the average score for the participants who had taken an orthopaedic course was 59%; this difference remained significant (p < 0.001).

CONCLUSIONS: Seventy-nine percent of the participants failed the basic musculoskeletal cognitive examination. This suggests that training in musculoskeletal medicine is inadequate in both medical school and nonorthopaedic residency training programs. Among the nonorthopaedists, scores were significantly better if they had taken a medical school course or residency rotation in orthopaedics, suggesting that a rotation in orthopaedics would improve the general level of musculoskeletal knowledge.

BACKGROUND: Various guidelines for the management of low back pain have been developed to enhance the effectiveness and efficiency of care. Evidence that guideline-adherent care results in better health outcomes, however, is not conclusive.

OBJECTIVE: The main objective of this study was to assess whether a higher percentage of adherence to the Dutch physical and manual therapy guidelines for low back pain is related to improved outcomes. The study further explored whether this relationship differs for the individual steps of the process of care and for distinct subgroups of patients.

DESIGN: This was an observational prospective cohort study (2005-2006) in the Netherlands that included a sample of 61 private practice therapists and 145 patients.

METHODS: Therapists recorded the process of care and the number of treatment sessions in Web-based patient files. Guideline adherence was assessed using quality indicators. Physical functioning was measured by the Dutch version of the Quebec Back Pain and Disability Scale, and average pain was measured with a visual analog scale. Relationships between the percentage of guideline adherence and outcomes of care were evaluated with regression analyses.

RESULTS: Higher percentages of adherence were associated with fewer functional limitations (beta=-0.21, P=.023) and fewer treatment sessions (beta=-0.27, P=.005).

LIMITATIONS: The relatively small self-selected sample might limit external validity, but it is not expected that the small sample greatly influenced the internal validity of the study. Larger samples are required to enable adequate subgroup analyses.

CONCLUSIONS: The results indicate that higher percentages of guideline adherence are related to better improvement of physical functioning and to a lower utilization of care. A proper assessment of the relationship between the process of physical therapy care and outcomes may require a comprehensive set of process indicators to measure guideline adherence.

BACKGROUND: Adhesive Capsulitis (AC) affects patient of all ages, and stretching protocols are commonly prescribed for this condition. Dynamic splinting has been shown effective in contracture reduction from pathologies including Trismus to plantar fasciitis. The purpose of this study was to examine the efficacy of dynamic splinting on patients with AC.

METHODS: This controlled, cohort study, was conducted at four physical therapy, sports medicine clinics in Texas and California. Sixty-two patients diagnosed with Stage II Adhesive Capsulitis were grouped by intervention. The intervention categories were as follows: Group I (Control); Group II (Physical Therapy exclusively with standardized protocols); Group III; (Shoulder Dynasplint system exclusively); Group IV (Combined treatment with Shoulder Dynasplint and standardized Physical Therapy). The duration of this study was 90 days for all groups, and the main outcome measures were change in active, external rotation.

RESULTS: Significant difference was found for all treatment groups (p < 0.001) following a one-way ANOVA. The greatest change with the smallest standard deviation was for the combined treatment group IV, (mean change of 29 degrees ).

CONCLUSION: The difference for the combined treatment group was attributed to patients' receiving the best PT combined with structured "home therapy" that contributed an additional 90 hours of end-range stretching. This adjunct should be included in the standard of care for adhesive Capsulitis. TRIAL REGISTRATION: Trial Number: NCT00873158.

OBJECTIVE: To explore the incidence and risk of adverse events with manual therapies.

METHOD: The main health electronic databases, plus those specific to allied medicine and manual therapy, were searched. Our inclusion criteria were: manual therapies only; administered by regulated therapists; a clearly described intervention; adverse events reported. We performed a meta-analysis using incident estimates of proportions and random effects models.

RESULTS: Eight prospective cohort studies and 31 manual therapy RCTs were accepted. The incidence estimate of proportions for minor or moderate transient adverse events after manual therapy was approximately 41% (CI 95% 17-68) in the cohort studies and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse events approximately 0.13%. The pooled relative risk (RR) for experiencing adverse events with exercise, or with sham/passive/control interventions compared to manual therapy was similar, but for drug therapies greater (RR 0.05, CI 95% 0.01-0.20) and less with usual care (RR 1.91, CI 95% 1.39-2.64).

CONCLUSIONS: The risk of major adverse events with manual therapy is low, but around half of manual therapy patients may experience minor to moderate adverse events after treatment. The relative risk of adverse events appears greater with drug therapy but less with usual care.

STUDY DESIGN: Inception cohort study.

OBJECTIVE: To provide the first reliable estimate of the 1-year incidence of recurrence in subjects recently recovered from acute nonspecific low back pain (LBP) and to determine factors predictive of recurrence in 1 year.

SUMMARY OF BACKGROUND DATA: Previous studies provide potentially flawed estimates of recurrence of LBP because they do not restrict the cohort to those who have recovered and are therefore eligible for a recurrence.

METHODS: We identified 1334 consecutive patients who presented to primary care with acute LBP; of these 353 subjects recovered before 6 weeks and entered the current study. The primary outcome measure was recurrence of LBP in the next year. Specifically, an episode of recurrence was defined in 2 ways: recall of recurrence at the 12-month follow-up and report of pain at the 3- or 12-month follow-up. Risk factors for recurrence were assessed at baseline. Pain intensity was assessed at 6 weeks, 3 months, and 12 months and recurrence at 12 months. Factors that could plausibly affect recurrence were chosen a priori and evaluated using a multivariable regression analysis.

RESULTS: Recurrence of LBP was found to be much less common than previous estimates suggest, ranging from 24% (95% CI = 20%-28%) using "12-month recall" definition of recurrence, to 33% (95% CI = 28%-38%) using "pain at follow-up" definition of recurrence. However, only 1 factor, previous episode(s) of LBP, was consistently predictive of recurrence within the next 12 months (odds ratio = 1.8-2.0, P = 0.00-0.05).

CONCLUSION: This study challenges the assumption that the majority of subjects will have a recurrence of LBP in a 1-year period. After the resolution of an episode of acute LBP, about 25% of subjects will have a recurrence in the next year. It is difficult to predict who will have a recurrence within the next year.

PURPOSE: To identify the structure of the iliotibial tract at knee level, as well as its insertions, layer arrangement, and relationship with other structures of the lateral region of the knee and to compare the findings with available literature.

METHODS: Ten detailed anatomic dissections were performed by using incisions as recommended by the literature in fresh cadaver knees identifying the iliotibial tract components.

RESULTS: The authors observed an iliotibial tract arrangement in superficial, deep, and capsular-osseous layers. Insertions have been described as follows: at linea aspera, at the upper border of the lateral epicondyle, at the patella, and at Gerdy's tibial tuberculum and across the capsular-osseous layer.

CONCLUSIONS: The iliotibial tract (ITT) has important interconnections to the femur, the patella, and the lateral tibia; the iliopatellar band joins the ITT to the patella through the superficial oblique retinaculum and the lateral femoropatellar ligament, and the ITT capsular-osseous layer presents differentiated fibers in an arched arrangement that borders the femoral condyle and inserts laterally to the Gerdy's tubercle. CLINICAL RELEVANCE: The iliotibial tract can be considered as an anterolateral knee stabilizer, particularly its capsular-osseous layer, which, together with the anterior cruciate ligament, constitutes a functional unit forming a spatial "horseshoe" form. The detailed description of the structures forming iliotibial tract plays an important role in the study of knee instabilities. Its important tibial, femoral, and patellar connections are described so that better understanding of tibial femoral instability on the lateral side as well as patellofemoral instability can be achieved and mechanisms of repair can be conceived.

BACKGROUND: Chiropractors claim to locate, analyze and diagnose a putative spinal lesion known as subluxation and apply the mode of spinal manipulation (adjustment) for the correction of this lesion.

AIM: The purpose of this examination is to review the current evidence on the epidemiology of the subluxation construct and to evaluate the subluxation by applying epidemiologic criteria for it's significance as a causal factor.

METHODS: The databases of PubMed, Cinahl, and Mantis were searched for studies using the keywords subluxation, epidemiology, manipulation, dose-response, temporality, odds ratio, relative risk, biological plausibility, coherence, and analogy.

RESULTS: The criteria for causation in epidemiology are strength (strength of association), consistency, specificity, temporality (temporal sequence), dose response, experimental evidence, biological plausibility, coherence, and analogy. Applied to the subluxation all of these criteria remain for the most part unfulfilled.

CONCLUSION: There is a significant lack of evidence to fulfill the basic criteria of causation. This lack of crucial supportive epidemiologic evidence prohibits the accurate promulgation of the chiropractic subluxation.

BACKGROUND: Recent approaches to outcome measurement involving Computerized Adaptive Testing (CAT) offer an approach for measuring disability in low back pain (LBP) in a way that can reduce the burden upon patient and professional. The aim of this study was to explore the potential of CAT in LBP for measuring disability as defined in the International Classification of Functioning, Disability and Health (ICF) which includes impairments, activity limitation, and participation restriction.

METHODS: 266 patients with low back pain answered questions from a range of widely used questionnaires. An exploratory factor analysis (EFA) was used to identify disability dimensions which were then subjected to Rasch analysis. Reliability was tested by internal consistency and person separation index (PSI). Discriminant validity of disability levels were evaluated by Spearman correlation coefficient (r), intraclass correlation coefficient [ICC(2,1)] and the Bland-Altman approach. A CAT was developed for each dimension, and the results checked against simulated and real applications from a further 133 patients.

RESULTS: Factor analytic techniques identified two dimensions named "body functions" and "activity-participation". After deletion of some items for failure to fit the Rasch model, the remaining items were mostly free of Differential Item Functioning (DIF) for age and gender. Reliability exceeded 0.90 for both dimensions. The disability levels generated using all items and those obtained from the real CAT application were highly correlated (i.e. >0.97 for both dimensions). On average, 19 and 14 items were needed to estimate the precise disability levels using the initial CAT for the first and second dimension. However, a marginal increase in the standard error of the estimate across successive iterations substantially reduced the number of items required to make an estimate.

CONCLUSIONS: Using a combination approach of EFA and Rasch analysis this study has shown that it is possible to calibrate items onto a single metric in a way that can be used to provide the basis of a CAT application. Thus there is an opportunity to obtain a wide variety of information to evaluate the biopsychosocial model in its more complex forms, without necessarily increasing the burden of information collection for patients.

BACKGROUND: This study explored the feasibility of using an Internet survey of people with fibromyalgia (FM), with a view to providing information on demographics, sources of information, symptoms, functionality, perceived aggravating factors, perceived triggering events, health care utilization, management strategies, and medication use.

METHODS: A survey questionnaire was developed by the National Fibromyalgia Association (NFA) in conjunction with a task force of "experts in the field". The questionnaire underwent several rounds of testing to improve its face validity, content validity, clarity and readability before it was mounted on the internet. The questionnaire consisted of 121 items and is available online at the website of the National Fibromyalgia Association.

RESULTS: The questionnaire was completed by 2,569 people. Most were from the United States, with at least one respondent from each of the 50 states. Respondents were predominantly middle-aged Caucasian females, most of whom had FM symptoms for > or = 4 years. The most common problems were morning stiffness, fatigue, nonrestorative sleep, pain, concentration, and memory. Aggravating factors included: emotional distress, weather changes, insomnia, and strenuous activity. Respondents rated the most effective management modalities as rest, heat, pain medications, antidepressants, and hypnotics. The most commonly used medications were: acetaminophen, ibuprofen, naproxen, cyclobenzaprine, amitriptyline, and aspirin. The medications perceived to be the most effective were: hydrocodone preparations, aprazolam, oxycodone preparations, zolpidem, cyclobenzaprine, and clonazepam.

CONCLUSION: This survey provides a snap-shot of FM at the end of 2005, as reported by a self-selected population of people. This descriptive data has a heuristic function, in that it identifies several issues for further research, such as the prescribing habits of FM health care providers, the role of emotional precipitants, the impact of obesity, the significance of low back pain and the nature of FM related stiffness.

BACKGROUND: Deviated wrist postures and pinch grip use have been linked to the development of carpal tunnel syndrome and are likely related to the size and shape of the carpal tunnel. The purpose of this study was to quantify carpal tunnel dimensions with changes in wrist posture and pinch grip.

METHODS: Eight healthy volunteers (4 male, 4 female) underwent magnetic resonance imaging of their dominant wrists under seven conditions which included: 30 degrees wrist extension, neutral and 30 degrees flexion (with and without a 10N pinch force) and a fist with a neutral wrist. Cross-sectional area of the carpal tunnel and its contents were calculated at 3mm increments along the length of the tunnel and integrated to calculate volumes. Ratios were calculated between the contents of the tunnel to the tunnel itself for area and volume. FINDINGS: The use of a correction factor significantly reduced volume and distal carpal tunnel area in flexed and extended wrists. Carpal tunnel areas were largest in neutral and smallest at the distal end with wrist flexion. An extended wrist resulted in the smallest carpal tunnel and content volumes as well as the smallest carpal tunnel content volume to carpal tunnel volume ratios. While men had significantly larger areas and volumes than women for both the carpal tunnel and it contents, there were no differences in ratios between the contents and tunnel size.

INTERPRETATION: A simple correction factor for non-perpendicular magnetic resonance images proved useful in relating volume changes to known pressure changes within the carpal tunnel. More inclusive and detailed evaluation of the carpal tunnel and its contents is required to fully understand mechanisms for median nerve compression in the carpal tunnel.

BACKGROUND: We determined prospectively the long-term outcomes of nonoperative treatment of chronic patellofemoral pain syndrome.

METHODS: Of forty-nine patients in a prospective, randomized, double-blind study of unilateral chronic patellofemoral pain syndrome in the knee, forty-five were reexamined seven years after the initial trial of treatment. In the earlier trial, the short-term (six-month) effects of intra-articular injections of glycosaminoglycan polysulfate combined with intensive quadriceps-muscle exercises were compared with those of injections of a placebo combined with exercises and with those of exercises alone. At seven years, the follow-up consisted of standardized subjective, functional, and clinical assessments and muscle-strength measurements as well as magnetic resonance imaging, radiography, and bone-densitometry measurements of the knee.

RESULTS: At six months, complete subjective, functional, and clinical recovery had occurred in almost three-fourths of the patients and, with the numbers available for study, neither significant nor clinically important differences among the three initial treatment groups were detected. The subjective and functional parameters showed few changes between six months and seven years; almost three-fourths of the patients still had full subjective and functional recovery at the time of the latest follow-up. However, according to the physician's clinical evaluation, the number of patients who had no symptoms on the patellar compression and apprehension tests decreased over time, from forty-two (93 percent) and forty (89 percent) of forty-five patients at six months to thirty (67 percent) and thirty-one (69 percent) at seven years; these changes were significant (p = 0.002 and p = 0.023, respectively). The number of patients who had crepitation on the patellar compression test increased over time, from twenty-six (58 percent) at six months to thirty-six (80 percent) at seven years (p = 0.021). The physician's overall assessment showed a similar trend, with thirty-four patients (76 percent) having had complete recovery at six months compared with thirty (67 percent) at seven years; however, with the numbers available, this change was not significant (p = 0.420). Magnetic resonance imaging, performed for thirty-seven patients, revealed no abnormalities in twenty-four (65 percent), mild abnormalities in four (11 percent), moderate abnormalities (a 25 to 75 percent decrease in the thickness of the cartilage) in seven (19 percent), and overt patellofemoral osteoarthritis in two (5 percent) at seven years.

CONCLUSIONS: The seven-year overall outcome was good in approximately two-thirds of the patients. However, the remaining patients still had symptoms or objective signs of a patellofemoral abnormality.

STUDY DESIGN: Cross-sectional.

OBJECTIVES: To investigate whether females seeking physical therapy treatment for unilateral patellofemoral pain syndrome (PFPS) exhibit deficiencies in hip strength compared to a control group.

BACKGROUND: Decreased hip strength may be associated with poor control of lower extremity motion during weight-bearing activities, leading to abnormal patellofemoral motions and pain. Previous studies exploring the presence of hip strength impairments in subjects with PFPS have reported conflicting results.

METHODS AND MEASURES: Twenty females, aged 12 to 35 years, participated in the study. Ten subjects with unilateral PFPS were compared to 10 control subjects with no known knee pathologies. Hip abduction, extension, and external rotation strength were tested using a handheld dynamometer. A limb symmetry index (LSI) was used to quantify physical performance for all tests.

RESULTS: The symptomatic limbs of subjects with PFPS exhibited impairments in hip strength for all variables tested. LSI values in subjects with PFPS (range, 71%-79%) were significantly lower than those in control subjects (range, 93%-101%) (P< or =.007). A secondary analysis of data normalized to body mass demonstrated that the symptomatic limbs of subjects with PFPS had 52% less hip extension strength (P<.001), 27% less hip abduction strength (P = .007), and 30% less hip external rotation strength (P= .004) when compared to the weaker limbs of control subjects.

CONCLUSION: Females aged 12 to 35 presenting with unilateral PFPS demonstrate significant impairments in hip strength compared to control subjects when LSI values or body mass normalized values are used to quantify physical performance of the symptomatic limb.

PURPOSE: To evaluate the prevalence and radiologic findings of annular tear (especially of contrast material enhancement), bulging disk, and disk herniation on T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance (MR) images in people without low back pain (LBP) or sciatica.

MATERIALS AND METHODS: Thirty-six volunteers without LBP and/or sciatica (18 with no symptoms in their lifetime and 18 who were pain free for at least 6 months) were examined with sagittal and axial T2-weighted fast spin-echo (SE) and sagittal gadolinium-enhanced T1- weighted fast SE imaging. The prevalence and MR findings of bulging disk, focal protrusion, extrusion, and nonenhancing or enhancing annular tears were assessed.

RESULTS: The prevalence of bulging disk and focal disk protrusion was 81% (29 volunteers) and 33% (12 volunteers), respectively. There were no extrusions. Twenty-eight annular tears were found in 20 patients (56%); 27 tears (96%) also showed contrast enhancement.

CONCLUSION: Annular tears and focal disk protrusions on MR images, with or without contrast enhancement, are frequently found in an asymptomatic population. Extruded disk herniation, displacement of nerve root, and interruption of annuloligamentous complex are unusual findings in an asymptomatic population and can be more closely related to patients with LBP or sciatica.

BACKGROUND: Homoeopathy is widely used, but specific effects of homoeopathic remedies seem implausible. Bias in the conduct and reporting of trials is a possible explanation for positive findings of trials of both homoeopathy and conventional medicine. We analysed trials of homoeopathy and conventional medicine and estimated treatment effects in trials least likely to be affected by bias.

METHODS: Placebo-controlled trials of homoeopathy were identified by a comprehensive literature search, which covered 19 electronic databases, reference lists of relevant papers, and contacts with experts. Trials in conventional medicine matched to homoeopathy trials for disorder and type of outcome were randomly selected from the Cochrane Controlled Trials Register (issue 1, 2003). Data were extracted in duplicate and outcomes coded so that odds ratios below 1 indicated benefit. Trials described as double-blind, with adequate randomisation, were assumed to be of higher methodological quality. Bias effects were examined in funnel plots and meta-regression models.

FINDINGS: 110 homoeopathy trials and 110 matched conventional-medicine trials were analysed. The median study size was 65 participants (range ten to 1573). 21 homoeopathy trials (19%) and nine (8%) conventional-medicine trials were of higher quality. In both groups, smaller trials and those of lower quality showed more beneficial treatment effects than larger and higher-quality trials. When the analysis was restricted to large trials of higher quality, the odds ratio was 0.88 (95% CI 0.65-1.19) for homoeopathy (eight trials) and 0.58 (0.39-0.85) for conventional medicine (six trials).

INTERPRETATION: Biases are present in placebo-controlled trials of both homoeopathy and conventional medicine. When account was taken for these biases in the analysis, there was weak evidence for a specific effect of homoeopathic remedies, but strong evidence for specific effects of conventional interventions. This finding is compatible with the notion that the clinical effects of homoeopathy are placebo effects.

BACKGROUND: Knee osteoarthritis (OA) is a progressive disease that initially affects the articular cartilage. Observational studies have shown benefits for arthroscopic debridement (AD) on the osteoarthritic knee, but other recent studies have yielded conflicting results that suggest AD may not be effective.

OBJECTIVES: To identify the effectiveness of AD in knee OA on pain and function. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006); MEDLINE (1966 to August, 2006); CINAHL (1982 to 2006); EMBASE (1988 to 2006) and Web of Science (1900 to 2006) and screened the bibliographies, reference lists and cited web sites of papers. SELECTION CRITERIA: We included randomised controlled trials (RCT) or controlled clinical trials (CCT) assessing effectiveness of AD compared to another surgical procedure, including sham or placebo surgery and other non-surgical interventions, in patients with a diagnosis of primary or secondary OA of the knees, who did not have other joint involvement or conditions requiring long term use of non-steroidal anti-inflammatory drugs (NSAIDs). The main outcomes were pain relief and improved function of the knee. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data. Results are presented using weighted mean difference (WMD) for continuous data and relative risk (RR) for dichotomous data, and the number needed to treat to benefit (NNTB) or harm (NNTH).

MAIN RESULTS: Three RCTs were included with a total of 271 patients. They had different comparison groups and a moderate risk of bias. One study compared AD with lavage and with sham surgery. Compared to lavage the study found no significant difference. Compared to sham surgery placebo, the study found worse outcomes for AD at two weeks (WMD for pain 8.7, 95% CI 1.7 to 15.8, and function 7.7, 95% CI 1.1 to 14.3; NNTH=5) and no significant difference at two years. The second trial, at higher risk of bias, compared AD and arthroscopic washout, and found that AD significantly reduced knee pain compared to washout at five years (RR 5.5, 95% CI 1.7 to 15.5; NNTB=3). The third trial, also at higher risk of bias, compared AD to closed-needle lavage, and found no significant difference.

AUTHORS' CONCLUSIONS: There is 'gold' level evidence that AD has no benefit for undiscriminated OA (mechanical or inflammatory causes).

BACKGROUND: Various approaches have been proposed to treat articular cartilage lesions, which are plagued by inherent limited healing potential.

PURPOSE: To compare the clinical outcome of patients treated with second-generation autologous chondrocyte implantation implants with those treated with the microfracture repair technique at 5-year follow-up.

STUDY DESIGN: Cohort study; Level of evidence, 2.

METHODS: Eighty active patients (mean age, 29.8 years) and grade III to IV cartilage lesions of the femoral condyles or trochlea were treated with arthroscopic second-generation autologous chondrocyte implantation Hyalograft C or microfracture (40 patients per group). Patients achieved a minimum 5-year follow-up and were prospectively evaluated.

RESULTS: Both groups showed statistically significant improvement of all clinical scores from preoperative interval to 5-year follow-up. There was a significant improvement for the International Knee Documentation Committee subjective score from pre-operative to 5-year follow-up (Wilcoxon test, P < .001). In the microfracture group, the International Knee Documentation Committee objective score increased from 2.5% normal and nearly normal knees before the operation to 75% normal and nearly normal knees at 5-year follow-up, and the subjective score increased from 41.1 +/- 12.3 preoperatively to 70.2 +/- 14.7 at 5-year follow-up. In the group treated with Hyalograft C, the International Knee Documentation Committee objective score increased from 15% normal and nearly normal knees before the operation to 90% normal and nearly normal knees at 5-year follow-up, and its subjective score increased from 40.5 +/- 15.2 preoperatively to 80.2 +/- 19.1 at 5-year follow-up (Wilcoxon test, P < .001). When comparing the groups, better improvement of the International Knee Documentation Committee objective (P < .001) and subjective (P = .003) scores was observed in the Hyalograft C group at 5-year follow-up. The return to sports at 2 years was similar in both groups and remained stable after 5 years in the Hyalograft C group; it worsened in the microfracture group.

CONCLUSION: Both methods have shown satisfactory clinical outcome at medium-term follow-up. Better clinical results and sport activity resumption were noted in the group treated with second-generation autologous chondrocyte transplantation.

BACKGROUND: The phenotype of large diameter sensory afferent neurons changes in several models of neuropathic pain. We asked if similar changes also occur in "functional" pain syndromes.

METHODOLOGY/PRINCIPAL FINDINGS: Acidic saline (AS, pH 4.0) injections into the masseter muscle were used to induce persistent myalgia. Controls received saline at pH 7.2. Nocifensive responses of Experimental rats to applications of Von Frey Filaments to the masseters were above control levels 1-38 days post-injection. This effect was bilateral. Expression of c-Fos in the Trigeminal Mesencephalic Nucleus (NVmes), which contains the somata of masseter muscle spindle afferents (MSA), was above baseline levels 1 and 4 days after AS. The resting membrane potentials of neurons exposed to AS (n = 167) were hyperpolarized when compared to their control counterparts (n = 141), as were their thresholds for firing, high frequency membrane oscillations (HFMO), bursting, inward and outward rectification. The amplitude of HFMO was increased and spontaneous ectopic firing occurred in 10% of acid-exposed neurons, but never in Controls. These changes appeared within the same time frame as the observed nocifensive behaviour. Ectopic action potentials can travel centrally, but also antidromically to the peripheral terminals of MSA where they could cause neurotransmitter release and activation of adjacent fibre terminals. Using immunohistochemistry, we confirmed that annulospiral endings of masseter MSA express the glutamate vesicular transporter VGLUT1, indicating that they can release glutamate. Many capsules also contained fine fibers that were labelled by markers associated with nociceptors (calcitonin gene-related peptide, Substance P, P2X3 receptors and TRPV1 receptors) and that expressed the metabotropic glutamate receptor, mGluR5. Antagonists of glutamatergic receptors given together with the 2(nd) injection of AS prevented the hypersensitivity observed bilaterally but were ineffective if given contralaterally.

CONCLUSIONS/SIGNIFICANCE: Low pH leads to changes in several electrical properties of MSA, including initiation of ectopic action potentials which could propagate centrally but could also invade the peripheral endings causing glutamate release and activation of nearby nociceptors within the spindle capsule. This peripheral drive could contribute both to the transition to, and maintenance of, persistent muscle pain as seen in some "functional" pain syndromes.

OBJECTIVE: To determine if transcutaneous electric nerve stimulation (TENS) is efficacious in the treatment of pain in neurologic disorders.

METHODS: We performed a systematic literature search of Medline and the Cochrane Library from inception to April 2009.

RESULTS: There are conflicting reports of TENS compared to sham TENS in the treatment of chronic low back pain, with 2 Class II studies showing benefit, but 2 Class I studies and another Class II study not showing benefit. Because the Class I studies are stronger evidence, TENS is established as ineffective for the treatment of chronic low back pain (2 Class I studies). TENS is probably effective in treating painful diabetic neuropathy (2 Class II studies).

RECOMMENDATIONS: Transcutaneous electric nerve stimulation (TENS) is not recommended for the treatment of chronic low back pain (Level A). TENS should be considered in the treatment of painful diabetic neuropathy (Level B). Further research into the mechanism of action of TENS is needed, as well as more rigorous studies for determination of efficacy.

BACKGROUND: A Food and Drug Administration advisory in 2006 warned against the off-label use of quinine sulfate and its derivatives in the treatment of muscle cramps. Physicians are faced with a difficult scenario in choosing a treatment regimen for patients with muscle cramps. This American Academy of Neurology assessment systematically reviews the available evidence on the symptomatic treatment of muscle cramps.

METHODS: A total of 563 potential articles were reviewed, of which 24 met the inclusion criteria of prospective trials evaluating the efficacy of a particular treatment on muscle cramps as a primary or secondary outcome.

RESULTS: There are Class I studies showing the efficacy of quinine derivatives for treatment of muscle cramps. However, the benefit is modest and there are adverse effects from published prospective trials as well as case reports. There is one Class II study each to support the use of Naftidrofuryl, vitamin B complex, lidocaine, and diltiazem in the treatment of muscle cramps.

RECOMMENDATIONS: Although likely effective (Level A), quinine derivatives should be avoided for routine use in the management of muscle cramps because of the potential of toxicity, but in select patients they can be considered for an individual therapeutic trial once potential side effects are taken into account. Vitamin B complex, Naftidrofuryl, and calcium channel blockers such as diltiazem are possibly effective and may be considered in the management of muscle cramps (Level C). Further studies are needed to identify agents that are effective and safe for the treatment of muscle cramps.

OBJECTIVES: To explore whether impairment of muscle strength, soft tissue length, movement control, postural and biomechanic alterations, and psychologic factors are associated with physical function and pain in patients with patellofemoral pain syndrome (PFPS).

DESIGN: Cross-sectional study.

SETTING: Rehabilitation outpatient.

PARTICIPANTS: Seventy-four patients diagnosed with PFPS.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Measurements were self-reported function and pain; strength of quadriceps, hip abduction, and hip external rotation; length of hamstrings, quadriceps, plantar flexors, iliotibial band/tensor fasciae latae complex, and lateral retinaculum; foot pronation; Q-angle; tibial torsion; visual observation of quality of movement during a lateral step-down task; anxiety; and fear-avoidance beliefs.

RESULTS: After controlling for age and sex, anxiety and fear-avoidance beliefs about work and physical activity were associated with function, while only fear-avoidance beliefs about work and physical activity were associated with pain.

CONCLUSIONS: Psychologic factors were the only associates of function and pain in patients with PFPS. Factors related to physical impairments did not associate to function or pain. Our results should be validated in other samples of patients with PFPS. Further studies should determine the role of other psychologic factors, and how they relate to anxiety and fear-avoidance beliefs in these patients.

OBJECTIVES: Chronic low back pain (CLBP) adversely affects many quality of life components, and is reported to impair sleep. The aim of this review was to determine the association between CLBP and sleep.

METHODS: This review comprised 3 phases: an electronic database search (PubMed, Cinahl Plus, EMBASE, PsychInfo, Pedro, and Cochrane Library) identified potential articles; these were screened for inclusion criteria by 2 independent reviewers; extraction of data from accepted articles; and rating of internal validity by 2 independent reviewers and strength of the evidence using valid and reliable scales.

RESULTS: The search generated 17 articles that fulfilled the inclusion criteria (quantitative n=14 and qualitative n=3). CLBP was found to relate to several dimensions of sleep including: sleep disturbance and duration (n=15), sleep affecting day-time function (n=5), sleep quality (n=4), sleep satisfaction and distress (n=4), sleep efficiency (n=4), ability to fall asleep (n=3), and activity during sleep (n=3). Consistent evidence found that CLBP was associated with greater sleep disturbance; reduced sleep duration and sleep quality; increased time taken to fall asleep; poor day-time function; and greater sleep dissatisfaction and distress. Inconsistent evidence was found that sleep efficiency and activity were adversely associated with CLBP.

DISCUSSION: Many dimensions of sleep are adversely associated with CLBP. Management strategies for CLBP need to address these to maximize quality of life in this patient cohort.

BACKGROUND/OBJECTIVES: Iron is essential for a number of enzymes involved in neurotransmitter synthesis. Analysis of cerebrospinal fluid in fibromyalgia syndrome (FMS) has shown a reduction in the concentration of biogenic amine metabolites, including dopamine, norepinephrine and serotonin. This study aimed to investigate the association of ferritin with FMS.

SUBJECTS/METHODS: A total of 46 patients with primary FMS participated in this case-control study, and 46 healthy females who were age matched to the patients were used as the control group. Venous blood samples collected from all subjects were used to evaluate serum ferritin, vitamin B12 and folic acid levels.

RESULTS: The mean serum ferritin levels in the fibromyalgia (FM) and control groups were 27.3+/-20.9 and 43.8+/-30.8 ng/ml, respectively, and the difference was statistically significant (P=0.003). Binary multiple logistic regression analysis with age, body mass index, smoking status and vitamin B12, as well as folic acid and ferritin levels showed that having a serum ferritin level <50 ng/ml caused a 6.5-fold increased risk for FMS.

CONCLUSIONS: Our study implicates a possible association between FM and decreased ferritin level, even for ferritin in normal ranges. We suggest that iron as a cofactor in serotonin and dopamine production may have a role in the etiology of FMS.

BACKGROUND: Epidemiological studies have reported an association between self-reported short sleep duration and high blood pressure (BP). Our objective was to examine both cross-sectional and longitudinal associations between objectively measured sleep and BP.

METHODS: This study is ancillary to the Coronary Artery Risk Development in Young Adults (CARDIA) cohort study. Blood pressure was measured in 2000 and 2001 and in 2005 and 2006. Sleep was measured twice using wrist actigraphy for 3 consecutive days between 2003 and 2005. Sleep duration and sleep maintenance (a component of sleep quality) were calculated. Analyses included 578 African Americans and whites aged 33 to 45 years at baseline. Outcome measures were systolic BP (SBP) and diastolic BP (DBP) levels, 5-year change in BP, and incident hypertension.

RESULTS: After we excluded the patients who were taking antihypertensive medications and adjusted for age, race, and sex, shorter sleep duration and lower sleep maintenance predicted significantly higher SBP and DBP levels cross-sectionally as well as more adverse changes in SBP and DBP levels over 5 years (all P < .05). Short sleep duration also predicted significantly increased odds of incident hypertension (odds ratio, 1.37; 95% confidence interval, 1.05-1.78). Adjustment for 16 additional covariates, including snoring and daytime sleepiness, slightly attenuated the associations between sleep and BP. Sleep duration appeared to mediate the difference between African Americans and whites in DBP change over time (P = .02).

CONCLUSION: Reduced sleep duration and consolidation predicted higher BP levels and adverse changes in BP, suggesting the need for studies to investigate whether interventions to optimize sleep may reduce BP.

BACKGROUND: Few studies have evaluated the effectiveness of massage for chronic low back pain.

OBJECTIVE: To compare the effectiveness of 2 types of massage and usual care for chronic back pain.

DESIGN: Parallel-group randomized, controlled trial. Randomization was computer-generated, with centralized allocation concealment. Participants were blinded to massage type but not to assignment to massage versus usual care. Massage therapists were unblinded. The study personnel who assessed outcomes were blinded to treatment assignment. (ClinicalTrials.gov registration number: NCT00371384)

SETTING: An integrated health care delivery system in the Seattle area.

PATIENTS: 401 persons 20 to 65 years of age with nonspecific chronic low back pain.

INTERVENTION: Structural massage (n = 132), relaxation massage (n = 136), or usual care (n = 133).

MEASUREMENTS: Roland Disability Questionnaire (RDQ) and symptom bothersomeness scores at 10 weeks (primary outcome) and at 26 and 52 weeks (secondary outcomes). Mean group differences of at least 2 points on the RDQ and at least 1.5 points on the symptom bothersomeness scale were considered clinically meaningful.

RESULTS: The massage groups had similar functional outcomes at 10 weeks. The adjusted mean RDQ score was 2.9 points (95% CI, 1.8 to 4.0 points) lower in the relaxation group and 2.5 points (CI, 1.4 to 3.5 points) lower in the structural massage group than in the usual care group, and adjusted mean symptom bothersomeness scores were 1.7 points (CI, 1.2 to 2.2 points) lower with relaxation massage and 1.4 points (CI, 0.8 to 1.9 points) lower with structural massage. The beneficial effects of relaxation massage on function (but not on symptom reduction) persisted at 52 weeks but were small.

LIMITATION: Participants were not blinded to treatment.

CONCLUSION: Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.

PRIMARY FUNDING SOURCE: National Center for Complementary and Alternative Medicine.

PURPOSE: Does physical deconditioning (loss of cardiovascular capacity and strength/endurance of paraspinal muscles) exist in patients with chronic low back pain (CLBP) and are treatments specifically aimed to reduce these signs effective?

METHOD: Systematic literature search in PUBMED, MEDLINE, EMBASE and PsycINFO until December 2004 to identify observational studies regarding deconditioning signs and high quality RCTs regarding the effectiveness of cardiovascular and/or muscle strengthening exercises. Internal validity of the RCTs was assessed by using a checklist of nine methodology criteria in accordance with the Cochrane Collaboration.

RESULTS: There is conflicting evidence that cardiovascular deconditioning is present in CLBP and limited evidence for wasting of the multifidus muscle. No study examined the effectiveness of cardiovascular training specifically. General and lumbar muscle strengthening are equally effective as other active treatments. Only moderate evidence is available for the effectiveness of intensive low back extensor muscle strengthening compared to less intensive strengthening.

CONCLUSION: Probably reactivation caused by active treatment and not the reconditioning itself is the important factor in the reduction of disability. Further prospective and evaluative research into the role of physical deconditioning is necessary. It seems more promising to further explore the interplay between biological, social and psychological factors.

PERSPECTIVE: Smoking as well as prevalent allergies, and a history of hyperemesis gravidarum, seem to predict development of FM in women during 25 years of follow-up. This information may help in identifying persons at high risk of developing FM and thus initiate effective prevention strategies.

BACKGROUND: Joint pain, specifically chronic knee pain (CKP), is a frequent cause of chronic pain and limitation of function and mobility among older adults. Multiple evidence-based guidelines recommend exercise as a first-line treatment for all patients with CKP or knee osteoarthritis (KOA), yet healthcare practitioners' attitudes and beliefs may limit their implementation. This systematic review aims to identify the attitudes, beliefs and behaviours of General Practitioners (GPs) regarding the use of exercise for CKP/KOA.

METHODS: We searched four electronic databases between inception and January 2008, using subject headings to identify studies examining the attitudes, beliefs or behaviours of GPs regarding the use of exercise for the treatment of CKP/KOA in adults aged over 45 years in primary care. Studies referring to patellofemoral pain syndrome or CKP secondary to other causes or that occurring in a prosthetic joint were excluded. Once inclusion and exclusion criteria were applied, study data were extracted and summarised. Study quality was independently reviewed using two assessment tools.

RESULTS: From 2135 potentially relevant articles, 20 were suitable for inclusion. A variety of study methodologies and approaches to measuring attitudes beliefs and behaviours were used among the studies. Quality assessment revealed good reporting of study objective, type, outcome factors and, generally, the sampling frame. However, criticisms included use of small sample sizes, low response rates and under-reporting of non-responder factors. Although 99% of GPs agreed that exercise should be used for CKP/KOA and reported ever providing advice or referring to a physiotherapist, up to 29% believed that rest was the optimum management approach. The frequency of actual provision of exercise advice or physiotherapy referral was lower. Estimates of provision of exercise advice and physiotherapy referral were generally higher for vignette-based studies (exercise advice 9%-89%; physiotherapy referral 44%-77%) than reviews of actual practice (exercise advice 5%-52%; physiotherapy referral 13-63%). Advice to exercise and exercise prescription were not clearly differentiated.

CONCLUSIONS: Attitudes and beliefs of GPs towards exercise for CKP/KOA vary widely and exercise appears to be underused in the management of CKP/KOA. Limitations of the evidence base include the paucity of studies directly examining attitudes of GPs, poor methodological quality, limited generalisability of results and ambiguity concerning GPs' expected roles. Further investigation is required of the roles of GPs in using exercise as first-line management of CKP/KOA.

STUDY DESIGN AND OBJECTIVES: Our systematic review of randomized trials assessed whether manipulation and mobilization relieve pain or improve function/disability, patient satisfaction, and global perceived effect in adults with mechanical neck disorders.

SUMMARY OF BACKGROUND DATA: Neck disorders are common, disabling, and costly.

METHODS: Computerized bibliographic databases were searched up to March 2002. Two independent reviewers conducted study selection, data abstraction, and methodologic quality assessment. Relative risk and standardized mean differences were calculated. In the absence of heterogeneity, pooled effect measures were calculated using a random effects model.

RESULTS: Of the 33 selected trials, 42% were high quality trials. Single or multiple (3-11) sessions of manipulation or mobilization showed no benefit in pain relief when assessed against placebo, control groups, or other treatments for acute/subacute/chronic mechanical neck disorders with or without headache. There was strong evidence of benefit favoring multimodal care (mobilization and/or manipulation plus exercise) over a waiting list control for pain reduction [pooled standardized mean differences -0.85 (95% CI: -1.20 to -0.50)], improvement in function [pooled SMD -0.57 (95% CI: -0.94 to -0.21)] and global perceived effect [standardized mean differences -2.73 (95% CI: -3.30 to -2.16)] for subacute/chronic mechanical neck disorders with or without headache.

CONCLUSIONS: Mobilization and/or manipulation when used with exercise are beneficial for persistent mechanical neck disorders with or without headache. Done alone, manipulation and/or mobilization were not beneficial; when compared to one another, neither was superior. There was insufficient evidence available to draw conclusions for neck disorder with radicular findings. Factorial design would help determine the active agent(s) within a treatment mix.

BACKGROUND: Animal studies have shown that local application of platelet-rich plasma (PRP) stimulates tendon repair. Preliminary results from a retrospective case series have shown faster return to sports.

HYPOTHESIS: Autologous PRP stimulates healing of acute Achilles tendon ruptures.

STUDY DESIGN: Randomized controlled trial; Level of evidence, 2.

METHODS: Thirty patients were recruited consecutively. During surgery, tantalum beads were implanted in the Achilles tendon proximal and distal to the rupture. Before skin suture, randomization was performed, and 16 patients were injected with 10mL PRP (10 times higher platelet concentration than peripheral blood) whereas 14 were not. With 3-dimensional radiographs (roentgen stereophotogrammetric analysis; RSA), the distance between the beads was measured at 7, 19, and 52 weeks while the patient resisted different dorsal flexion moments over the ankle joint, thereby estimating tendon strain per load. An estimate of elasticity modulus was calculated using callus dimensions from computed tomography. At 1 year, functional outcome was evaluated, including the heel raise index and Achilles Tendon Total Rupture Score. The primary effect variables were elasticity modulus at 7 weeks and heel raise index at 1 year.

RESULTS: The mechanical variables showed a large degree of variation between patients that could not be explained by measuring error. No significant group differences in elasticity modulus could be shown. There was no significant difference in heel raise index. The Achilles Tendon Total Rupture Score was lower in the PRP group, suggesting a detrimental effect. There was a correlation between the elasticity modulus at 7 and 19 weeks and the heel raise index at 52 weeks.

CONCLUSION: The results suggest that PRP is not useful for treatment of Achilles tendon ruptures. The variation in elasticity modulus provides biologically relevant information, although it is unclear how early biomechanics is connected to late clinical results.

OBJECTIVE: To compare the effectiveness of manual therapy and ultrasound (US) with manual therapy and placebo ultrasound (placebo US) in the treatment of new episodes of unilateral shoulder pain referred for physiotherapy.

METHODS: In a multicentre, double blind, placebo-controlled randomized trial, participants were recruited with a clinical diagnosis of unilateral shoulder pain from nine primary care physiotherapy departments in Birmingham, UK. Recruitment took place from January 1999 to September 2001. Participants were 18 yrs old and above. Participants all received advice and home exercises and were randomized to additionally receive manual therapy plus US or manual therapy plus placebo US. The primary outcome measure was the Shoulder Disability Questionnaire (SDQ-UK). Outcomes were assessed at baseline, 2 weeks, 6 weeks and 6 months. Analysis was by intention to treat.

RESULTS: A total of 221 participants (mean age 56 yrs) were recruited. 113 participants were randomized to US and 108 to placebo US. There was 76% follow up at 6 weeks and 71% at 6 months. The mean (95% CI) reduction in SDQ scores at 6 weeks was 17 points (13-26) for US and 13 points (9-17) for placebo US (P = 0.06). There were no statistically significant differences at the 5% level in mean changes between groups at any of the time points.

CONCLUSIONS: The addition of US was not superior to placebo US when used as part of a package of physiotherapy in the short-term management of shoulder pain. This has important implications for physiotherapy practice.

BACKGROUND: Back and neck pain are important health problems with serious societal and economic implications. Conventional treatments have been shown to have limited benefit in improving patient outcomes. Complementary and Alternative Medicine (CAM) therapies offer additional options in the management of low back and neck pain. Many trials evaluating CAM therapies have poor quality and inconsistent results.

OBJECTIVES: To systematically review the efficacy, effectiveness, cost-effectiveness, and harms of acupuncture, spinal manipulation, mobilization, and massage techniques in management of back, neck, and/or thoracic pain.

DATA SOURCES: MEDLINE®, Cochrane Central, Cochrane Database of Systematic Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and reference lists of relevant articles were also searched.

STUDY SELECTION: All records were screened by two independent reviewers. Primary reports of comparative efficacy, effectiveness, harms, and/or economic evaluations from randomized controlled trials (RCTs) of the CAM therapies in adults (age ≥ 18 years) with back, neck, or thoracic pain were eligible. Non-randomized controlled trials and observational studies (casecontrol, cohort, cross-sectional) comparing harms were also included. Reviews, case reports, editorials, commentaries or letters were excluded.

DATA EXTRACTION: Two independent reviewers using a predefined form extracted data on study, participants, treatments, and outcome characteristics.

RESULTS: 265 RCTs and 5 non-RCTs were included. Acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain. For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain. Results from studies comparing manipulation to massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other therapies were inconsistent. Mobilization was superior to no treatment but not different from placebo in reducing low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute neck pain, mobilization compared to placebo significantly reduced neck pain. Mobilization and placebo did not differ in subjects with chronic neck pain. Massage was superior to placebo or no treatment in reducing pain and disability only amongst subjects with acute/sub-acute low back pain. Massage was also significantly better than physical therapy in improving back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07) or disability. For subjects with neck pain, massage was better than no treatment, placebo, or exercise in improving pain or disability, but not neck flexibility. Some evidence indicated higher costs for massage use compared to general practitioner care for low back pain. Reporting of harms in RCTs was poor and inconsistent. Subjects receiving CAM therapies reported soreness or bleeding on the site of application after acupuncture and worsening of pain after manipulation or massage. In two case-control studies cervical manipulation was shown to be significantly associated with vertebral artery dissection or vertebrobasilar vascular accident.

CONCLUSIONS: Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM therapies in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions.

OBJECTIVE: To determine the effectiveness (at the 0.1 level of statistical significance) of the Align-Right (roll-shaped) cervical pillow (ARCP) on neck pain severity and headache/neck pain medication use in chronic neck pain subjects.

DESIGN: The design was a "before/after" (i.e., a "pre/post" trial).

SUBJECTS: Twenty-eight subjects, 25-45 yr of age with cervical spine pain of biomechanical origin of > 2 on an 11-point ordinal pain scale.

OUTCOME MEASURES: The primary outcome measure was severity of morning and evening neck pain. The secondary outcome measure was daily quantity of analgesics ingested. The data were analyzed descriptively and inferentially for clinically and statistically significant pre/post intervention differences.

METHODS: Eligible subjects who successfully finished a 2-wk baseline data-gathering period by mailing in two properly completed diaries each received a pillow and four more diaries (to be filled in over the subsequent 4 wk). Three repeated-measures analyses of variance were performed using the Bonferroni-corrected level of statistical significance of 0.03. Ninety-five percent confidence intervals (for paired-samples mean differences) were also calculated for those pre/post differences that seemed descriptively clinically important.

RESULTS: The clinically and statistically significant reductions in neck/shoulder pain severity in this sample of chronic neck pain subjects suggest that the ARCP is an effective therapy for target populations with the same profile as this sample. Patient characteristics predicting suitability were not studied in this project.

CONCLUSION: The results suggest that the ARCP has clinically important beneficial effects on the neck pain severity of most chronic neck-pain sufferers. Further randomized clinical trial research comparing the ARCP with other commonly used cervical pillows is recommended.

PERSPECTIVE: This study has quantified determinants of pain, 6 months after non-life-threatening acute orthopaedic trauma. Psychosocial factors strongly predicted persistent pain, pain-related work disability, and pain severity. These findings may assist clinicians to determine the need for, and likely effectiveness of, individual pain-management approaches in this population.

OBJECTIVES: To investigate the biochemical milieu of the upper trapezius muscle in subjects with active, latent, or absent myofascial trigger points (MTPs) and to contrast this with that of the noninvolved gastrocnemius muscle.

DESIGN: We used a microanalytic technique, including needle insertions at standardized locations in subjects identified as active (having neck pain and MTP), latent (no neck pain but with MTP), or normal (no neck pain, no MTP). We followed a predetermined sampling schedule; first in the trapezius muscle and then in normal gastrocnemius muscle, to measure pH, bradykinin, substance P, calcitonin gene-related peptide, tumor necrosis factor alpha, interleukin 1beta (IL-1beta), IL-6, IL-8, serotonin, and norepinephrine, using immunocapillary electrophoresis and capillary electrochromatography. Pressure algometry was obtained. We compared analyte concentrations among groups with 2-way repeated-measures analysis of variance.

SETTING: A biomedical research facility.

PARTICIPANTS: Nine healthy volunteer subjects.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Preselected analyte concentrations.

RESULTS: Within the trapezius muscle, concentrations for all analytes were higher in active subjects than in latent or normal subjects (P<.002); pH was lower (P<.03). At needle insertion, analyte concentrations in the trapezius for the active group were always higher (pH not different) than concentrations in the gastrocnemius muscle. At all times within the gastrocnemius, the active group had higher concentrations of all analytes than did subjects in the latent and normal groups (P<.05); pH was lower (P<.01).

CONCLUSIONS: We have shown the feasibility of continuous, in vivo recovery of small molecules from soft tissue without harmful effects. Subjects with active MTPs in the trapezius muscle have a biochemical milieu of selected inflammatory mediators, neuropeptides, cytokines, and catecholamines different from subjects with latent or absent MTPs in their trapezius. These concentrations also differ quantitatively from a remote, uninvolved site in the gastrocnemius muscle. The milieu of the gastrocnemius in subjects with active MTPs in the trapezius differs from subjects without active MTPs.

CONTEXT: Therapeutic Touch (TT) is a widely used nursing practice rooted in mysticism but alleged to have a scientific basis. Practitioners of TT claim to treat many medical conditions by using their hands to manipulate a "human energy field" perceptible above the patient's skin.

OBJECTIVE: To investigate whether TT practitioners can actually perceive a "human energy field."

DESIGN: Twenty-one practitioners with TT experience for from 1 to 27 years were tested under blinded conditions to determine whether they could correctly identify which of their hands was closest to the investigator's hand. Placement of the investigator's hand was determined by flipping a coin. Fourteen practitioners were tested 10 times each, and 7 practitioners were tested 20 times each.

MAIN OUTCOME MEASURE: Practitioners of TT were asked to state whether the investigator's unseen hand hovered above their right hand or their left hand. To show the validity of TT theory, the practitioners should have been able to locate the investigator's hand 100% of the time. A score of 50% would be expected through chance alone.

RESULTS: Practitioners of TT identified the correct hand in only 123 (44%) of 280 trials, which is close to what would be expected for random chance. There was no significant correlation between the practitioner's score and length of experience (r=0.23). The statistical power of this experiment was sufficient to conclude that if TT practitioners could reliably detect a human energy field, the study would have demonstrated this.

CONCLUSIONS: Twenty-one experienced TT practitioners were unable to detect the investigator's "energy field." Their failure to substantiate TT's most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.

PURPOSE: Provide a current review of the literature concerning the epidemiology and risk factors for injuries in runners.

DATA SOURCES: The information in this paper is taken from a review of articles and book chapters (Source: PubMed and MEDLINE, years covered 1966-2006).

CONCLUSIONS: Understanding the precise causative nature of risk factors in running populations remains a challenging task. Comparison of various works in the literature is impeded by large variations in injury definition, subject population and study design. Weekly running volume continues to be considered a strong risk factor, however more work is needed to determine whether it is the absolute volume, or the increase in volume that is deleterious. Recent research has provided greater insight into the risks that previous injury and lack of full rehabilitation may play in recreational runners starting a training program. Variables related to excessive rear-foot eversion and pronation are frequently sited in combination with the incidence of specific injuries; however, the role of impact characteristics remains in debate. Isokinetic research of hip muscle function is helping to link our understanding of lower extremity kinematics, but requires more research to be proven as a causative factor. Future research in joint coupling and functional training of the complete lower extremity will be beneficial in implementing preventative interventions for running populations.

CONTEXT: Biomechanically, hip muscle strength and flexibility are necessary to control and facilitate proper distal limb motion while running. Only one study has investigated the effectiveness of rehabilitation of running injuries via hip muscle strengthening and only involved iliotibial band syndrome.

OBJECTIVE: To determine if increases in hip muscle strength and flexibility are associated with a significant reduction in pain associated with running injuries. It was hypothesized that patients would demonstrate a significant improvement in hip muscle strength and flexibility and a minimum 50% reduction in pain following a 4-6 week rehabilitation program.

DESIGN: Pre-test/post-test.

SETTING: Patients presenting to the Running Injury Clinic.

PATIENTS OR OTHER PARTICIPANTS: 284 consecutive patients presenting to the Clinic for various musculoskeletal running injuries (females: 183; males: 101; age: 37 years±8.3; weekly running mileage 35.7 km±9.4).

INTERVENTIONS: Patients were asked to report the average amount of pain they were experiencing while running using a 10cm visual analog scale (VAS). Hip internal and external rotator muscle flexibility was measured using a goniometer. The Thomas and Ober clinical tests were used to determine hip flexor and IT band flexibility. Hip muscle strength was measured using a standard 0-5 manual muscle scale. For statistical analysis, strength values were converted from a 0-5 scale to a percentage score assuming 5/5 equalled 100% and 3/5 equalled 50% of maximum isometric force. Minimum standards for each strength and flexibility measure were established through pilot work and literature. A rehabilitation program was prescribed to improve hip strength and/or flexibility where necessary. Paired t-tests (alpha=0.05) were used for statistical comparisons.

MAIN OUTCOME MEASURES: Pre-post comparisons of VAS and hip strength and flexibility measures following 4-6 weeks of rehabilitation.

RESULTS: Patellofemoral pain syndrome (n=54), iliotibial band syndrome (n=40), medial tibial stress syndrome (n=13), Achilles tendinopathy (n=10), and plantar fasciitis (n=10) accounted for the majority of injuries. 165 patients (58%) returned for follow-up assessment and reported a significant improvement in pain (VAS pre: 6.11cm±0.87 post: 0.89cm±1.22; P=0.01) and 89% reported at least a 50% improvement in pain. These patients also exhibited significant improvements in hip abductor (pre: 78.55%±11.07 post: 95.32%±7.81; P=0.02), flexor (pre: 77.11%±13.92 post: 91.94%±6.78; P=0.03), and external rotator (pre: 76.06%±14.94 post: 90.48%±10.70; P=0.03) muscle strength. Significant increases in hip internal rotator (pre: 39.67 deg±6.29 post 45.39 deg ±4.99; P=0.01) and external rotator (pre: 36.71 deg ±4.26 post: 44.16 deg ±3.74 deg; P=0.01) muscle flexibility was measured. 86% of patients who exhibited a positive Thomas or Ober’s test prior to the rehabilitation program exhibited no tissue inflexibility at follow-up.

CONCLUSIONS: The results from this study suggest that a hip strength and flexibility rehabilitation program, based on the biomechanics of running and specific clinical criteria, can effectively resolve pain associated with various musculoskeletal running injuries.

METHODS: We devised scintigraphic criteria that graded the blood-pool abnormalities as being localized to the plantar enthesis, being localized to half the length of the aponeurosis, or involving the whole aponeurosis. We evaluated 24 patients with an established diagnosis of plantar fasciitis, 8 of whom had bilateral disease, leading to a total of 32 feet injected.

RESULTS: After injection, pain was relieved either completely or nearly completely in 20 feet. The other 12 feet had short-term or no improvement, with persistent pain and loss of function at 4-5 wk after injection. Of the 20 feet responding to injection, 14 had focal hyperemia on blood-pool images and 6 had minimal extension into the proximal third of the plantar soft tissues. No patient with diffuse hyperemia in the plantar fascia had a response (5/12 feet). On the delayed images of the 20 responders, mild inferior calcaneal uptake was seen in 8 feet, moderate uptake in 6, and severe uptake in 6. These groups did not significantly differ (P > 0.05). The blood-pool studies had good reproducibility, with a kappa-value of 0.64.

CONCLUSION: Critical evaluation of plantar blood-pool images provides prognostic information on the response to localized injection into the enthesis. Reporting such studies is simple and reproducible.

PURPOSE: : The objective of this study is to investigate the effect of three different workplace interventions on long-term compliance, muscle strength gains, and neck/shoulder pain in office workers.

METHODS: : A 1-yr randomized controlled intervention trial was done with three groups: specific resistance training (SRT, n = 180), all-round physical exercise (APE, n = 187), and reference intervention (REF, n = 182) with general health counseling. Physical tests were performed and questionnaires answered at pre-, mid-, and postintervention. The main outcome measures were compliance, changes in maximal muscle strength, and changes in intensity of neck/shoulder pain (scale 0-9) in those with and without pain at baseline.

RESULTS: : Regular participation was achieved by 54%, 31%, and 16% of those of the participants who answered the questionnaire in SRT (78%), APE (81%), and REF (80%), respectively, during the first half of the intervention period, and decreased to 35%, 28% and 9%, respectively, during the second half. Shoulder elevation strength increased 9-11% in SRT and APE (P < 0.0001). Participants with neck pain at baseline decreased the intensity of neck pain through SRT, from 5.0 +/- 0.2 to 3.4 +/- 0.2 (P < 0.0001), and through APE, from 5.0 +/- 0.2 to 3.6 +/- 0.2 (P < 0.001), whereas REF caused no change. For participants without shoulder pain at baseline, there was a significantly greater increase in pain over the 1-yr period in REF compared with SRT and APE (P < 0.01).

CONCLUSION: : Compliance was highest in SRT but generally decreased over time. SRT and APE caused increased shoulder elevation strength, were more effective than REF to decrease neck pain among those with symptoms at baseline, and prevent development of shoulder pain in those without symptoms at baseline.

OBJECTIVE: To summarize and to analyze the available literature on the efficacy of intra-articular injections of corticosteroids for low back pain.

DESIGN: Publications, in English, French, and German, were obtained that reported the proportions of patients who obtained complete relief of pain following intra-articular steroids, and that provided any form of follow-up. These publications were analyzed to determine the rationale, indications, and outcomes of the treatment.

RESULTS: The only rationale for intra-articular steroids appears to be the expectation that they should work. The most commonly used indication has been back pain, for which no specific diagnosis has been made. When the results of observational studies are pooled, they paint a picture of impressive immediate responses, but a rapid decay of outcomes by three and six months. Initial responses, however, are dissonant with the literature from controlled studies of the prevalence of lumbar zygapophysial joint pain. Moreover, controlled trials have shown that there is no attributable effect to the injection of steroids.

CONCLUSION: The apparent efficacy of lumbar intra-articular steroids is no greater than that of a sham injection. There is no justification for the continued use of this intervention. Better outcomes can be achieved with deliberate placebo therapy.

BACKGROUND: Botulinum toxin type A (BTA) (Botox) received Food and Drug Administration (FDA) approval for therapeutic treatment of strabismus and blepharospasm in 1989, cervical dystonia in 2000, and cosmetic treatment of glabellar wrinkles (Botox Cosmetic) in 2002. In 2002 alone there were approximately 1.1 to 1.6 million patients using cosmetic BTA. Our objective was to review adverse event (AE) reporting to the FDA after BTA administration.

METHODS: We reviewed all (therapeutic and cosmetic use) serious (per FDA regulations) AEs reported to the FDA for the 13.5 years since licensure of the product (December 1989-May 2003) and nonserious AEs reported from December 2001 to November 2002. AEs are reported to the FDA through the MedWatch system.

RESULTS: We reviewed 1437 AE reports; 406 followed therapeutic use of BTA (217 serious and 189 nonserious) and 1031 followed cosmetic use (36 serious and 995 nonserious). Reported AEs occurred predominantly in female patients, with a median age of 50 years. In the year December 2001 to November 2002, when both serious and nonserious reports were evaluated, the proportion of reports classified as serious was 33-fold higher for therapeutic than for cosmetic cases. The 217 serious AEs reported in therapeutic cases involved a wide spectrum of events and included all 28 reported deaths. Among cosmetic users, no deaths were reported and, of the 36 serious AEs, 30 were included as possible complications in the FDA-approved label. The remaining 6 serious AEs did not display a pattern suggesting a common causal relationship to BTA. Among the 995 cosmetic cases reported to have nonserious AEs, most commonly noted were lack of effect (623, 63%), injection site reaction (190, 19%), and ptosis (111, 11%).

CONCLUSIONS: Serious AEs were more likely to be reported for therapeutic than for cosmetic use, which may be related to higher doses, complicated underlying diseases, or both. Among cosmetic cases, few serious AEs were reported, and these were predominantly events that were previously recognized in clinical trials of BTA for the labeled use. This study is limited primarily by the incomplete nature of AE reporting by clinicians. Numerous departures from FDA-approved recommendations for drug dose, dilution, handling, site of injection, and storage were noted in these AE reports.

BACKGROUND: Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee.

METHODS: A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial.

RESULTS: At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and debridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and debridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference.

CONCLUSIONS: In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.

BACKGROUND: Neuromuscular electrical stimulation (NMES) has demonstrated efficacy in improving quadriceps muscle strength (force-generating capacity) and activation following knee replacement and ligamentous reconstruction. Yet, data are lacking to establish the efficacy of NMES in people with evidence of early radiographic osteoarthritis.

OBJECTIVE: The purpose of this study was to determine whether NMES is capable of improving quadriceps muscle strength and activation in women with mild and moderate knee osteoarthritis.

DESIGN: This study was a randomized controlled trial.

METHODS: Thirty women with radiographic evidence of mild or moderate knee osteoarthritis were randomly assigned to receive either no treatment (standard of care) or NMES treatments 3 times per week for 4 weeks. The effects of NMES on quadriceps muscle strength and activation were evaluated upon study enrollment, as well as at 5 and 16 weeks after study enrollment, which represent 1 and 12 weeks after cessation of NMES among the treated participants. The Western Ontario and McMaster Universities Osteoarthritis Index and a 40-foot (12.19-m) walk test were used at each testing session.

RESULTS: Improvements in quadriceps muscle strength or activation were not realized for the women in the intervention group. Quadriceps muscle strength and activation were similar across testing sessions for both groups.

LIMITATIONS: Women were enrolled based on radiographic evidence of osteoarthritis, not symptomatic osteoarthritis, which could have contributed to our null finding. A type II statistical error may have been committed despite an a priori power calculation. The assessor and the patients were not blinded to group assignment, which may have introduced bias into the study.

CONCLUSIONS: Four weeks of NMES delivered to women with mild and moderate osteoarthritis and mild strength deficits was insufficient to induce gains in quadriceps muscle strength or activation. Future research is needed to examine the dose-response relationship for NMES in people with early radiographic evidence of osteoarthritis.

OBJECTIVE: To determine the effect of a brace or harness on loads on internal spinal fixation devices.

DESIGN: The implant loads were measured in vivo using telemeterized internal spinal fixators.

BACKGROUND: Only limited information exists regarding the load reduction due to a brace or harness.

METHODS: A Boston overlap brace, a reclination brace, and a lumbotrain harness were examined to determine how they affect the loads on internal spinal fixation devices. The implant loads were measured using telemeterized fixators in six patients for several positions and activities, including sitting, standing, walking, bending forward, and lifting an extended leg in a supine position.

RESULTS: None of the braces studied were able to markedly reduce the loads on the fixators. Frequently even higher fixator loads were measured when wearing a brace or harness.

CONCLUSIONS: It does not seem helpful to brace patients after mono- or bisegmental stabilization of the lumbar spine.

METHODS: A prospective evaluation of 123 patients with calcaneal spurs in 136 heels and plantar heel pad pain in association with diabetes mellitus, body mass index >27, elevated uric acid and heel pad compressibility index, were matched with a control group of 141 patients (136 heels) without heel pad pain or co-morbid factors. This study was carried out between February 1997 and September 1999 in three hospitals. There were 91 females and 32 males in the study group, while the control group had 86 females and 55 males.

RESULTS: All patients in the study cohort presented with calcaneal spurs and plantar heel pad pain. The mean age for the males was 38.1 ± 2.4 and females 43.3 ± 0.8. 78.04% (96 patients) had body mass index (BMI) of over 27, in 48 patients (39.02%) uric acid levels were elevated above two standard deviations from the mean and 59 patients (47.96%) were diabetic, some with more than a single factor. The heel pad compressibility index of 0.54 ± 1.06 in males and 0.62 ± 0.02 in females of the study population was significantly greater than in the control population (males: 0.49 ± 0.4, females: 0.56 ± 1.8). The study and control groups were comparable with respect to age.

CONCLUSION: Calcaneal spurs cause plantar heel pad pain, but the roles of other co-morbid factors are significant. The excision of these spurs does not necessarily abolish pain. It is evident that heel pad compressibility increases with advancing age, weight gain, and diabetes mellitus, and contributes to the pathogenesis of plantar heel pain. This has an impact on the management of these patients, by de-emphasizing the role of surgical excision of these spurs.

BACKGROUND: Shock-absorbing and biomechanic shoe orthoses are frequently used in the prevention and treatment of back and lower extremity problems. One review concludes that the former is clinically effective in relation to prevention, whereas the latter has been tested in only 1 randomized clinical trial, concluding that stress fractures could be prevented.

OBJECTIVES: To investigate if biomechanic shoe orthoses can prevent problems in the back and lower extremities and if reducing the number of days off-duty because of back or lower extremity problems is possible.

DESIGN: Prospective, randomized, controlled intervention trial. STUDY

SUBJECTS: One female and 145 male military conscripts (aged 18 to 24 years), representing 25% of all new conscripts in a Danish regiment.

METHOD: Health data were collected by questionnaires at initiation of the study and 3 months later. Custom-made biomechanic shoe orthoses to be worn in military boots were provided to all in the study group during the 3-month intervention period. No intervention was provided for the control group. Differences between the 2 groups were tested with the chi-square test, and statistical significance was accepted at P <.05. Risk ratio (RR), risk difference (ARR), numbers needed to prevent (NNP), and cost per successfully prevented case were calculated.

OUTCOME VARIABLES: Outcome variables included self-reported back and/or lower extremity problems; specific problems in the back or knees or shin splints, Achilles tendonitis, sprained ankle, or other problems in the lower extremity; number of subjects with at least 1 day off-duty because of back or lower extremity problems and total number of days off-duty within the first 3 months of military service because of back or lower extremity problems.

RESULTS: Results were significantly better in an actual-use analysis in the intervention group for total number of subjects with back or lower extremity problems (RR 0.7, ARR 19%, NNP 5, cost 98 US dollars); number of subjects with shin splints (RR 0.2, ARR 19%, NNP 5, cost 101 US dollars); number of off-duty days because of back or lower extremity problems (RR 0.6, ARR < 1%, NNP 200, cost 3750 US dollars). In an intention-to-treat analysis, a significant difference was found for only number of subjects with shin splints (RR 0.3, ARR 18%, NNP 6 cost 105 US dollars), whereas a worst-case analysis revealed no significant differences between the study groups.

CONCLUSIONS: This study shows that it may be possible to prevent certain musculoskeletal problems in the back or lower extremities among military conscripts by using custom-made biomechanic shoe orthoses. However, because care-seeking for lower extremity problems is rare, using this method of prevention in military conscripts would be too costly. We also noted that the choice of statistical approach determined the outcome.

BACKGROUND: Exercise programs may vary in terms of duration, frequency, and dosage; whether they are supervised; and whether they include a home-based program. Uncritical pooling of heterogeneous exercise trials may result in misleading conclusions regarding the effects of exercise on chronic low back pain (CLBP).

PURPOSE: The purpose of this study was to establish the effect of exercise on pain and disability in patients with CLBP, with a major aim of explaining between-trial heterogeneity.

DATA SOURCES: Six databases were searched up to August 2008 using a computerized search strategy.

STUDY SELECTION: Eligible studies needed to be randomized clinical trials evaluating the effects of exercise for nonspecific CLBP.

OUTCOMES: Of interest were pain and disability measured on a continuous scale.

DATA EXTRACTION: Baseline demographic data, exercise features, and outcome data were extracted from all included trials.

DATA SYNTHESIS: Univariate meta-regressions were conducted to assess the associations between exercise effect sizes and 8 study-level variables: baseline severity of symptoms, number of exercise hours and sessions, supervision, individual tailoring, cognitive-behavioral component, intention-to-treat analysis, and concealment of allocation.

LIMITATIONS: Only study-level characteristics were included in the meta-regression analyses. Therefore, the implications of the findings should not be used to differentiate the likelihood of the effect of exercise based on patient characteristics.

CONCLUSIONS: The results show that, in general, when all types of exercise are analyzed, small but significant reductions in pain and disability are observed compared with minimal care or no treatment. Despite many possible sources of heterogeneity in exercise trials, only dosage was found to be significantly associated with effect sizes.

PERSPECTIVE: Myofascial pain is the most common form of musculoskeletal pain. Myofascial trigger points play an important role in the clinical manifestation of myofascial pain syndrome. Elucidating the role of central sensitization in the pathophysiology of trigger points is fundamental to developing optimal strategies in the management of myofascial pain syndrome.

OBJECTIVE: To determine the frequency, severity, prognosis, and patterns of carpal tunnel syndrome (CTS) in pregnancy.

DESIGN: Descriptive retrospective chart review using the Rochester Epidemiology Project medical record diagnostic indexing system to identify patients with new CTS occurring during pregnancy from 1987 to 1992 at our institution.

SETTING: Obstetrical practice, where two thirds of pregnant women in the county receive primary obstetrical care.

PATIENTS: Women pregnant during 1987 to 1992 who had a new diagnosis of CTS. Women with pregnancies at other dates or women who had CTS with onset before or after pregnancy were excluded.

OUTCOME MEASURES: Age, underlying medical problems, gestation interval, weight gain, number of pregnancies, presenting symptoms, onset and duration of symptoms before diagnosis, trimester of CTS diagnosis, treatment and response, and results of electrophysiologic studies are described.

RESULTS: Of 10,873 pregnant patients receiving antenatal care for 14,579 pregnancies, 50 (.34%) fulfilled the inclusion criteria. Their mean age was 30.5 +/- 4.0 yrs. Twelve patients (24%) were primigravid. Mean weight gain was 12.1 +/- 5.7 kg. CTS was diagnosed most frequently during the third trimester (n = 25, 50%). Symptom onset, when recorded, occurred with even distribution during each trimester: first, n = 11 (32%); second, n = 11 (32%); third, n = 12 (35%). For 37 patients in whom symptom duration was recorded, duration before diagnosis was 9.3 +/- 9.0 weeks. Paresthesia (88%) was most often bilateral (68%), and 67% of patients had pain. The Tinel sign was present over the median nerve at the wrist in 95%. Only nine patients had nerve conduction studies performed. During pregnancy, 37 women were treated nonsurgically with wrist orthoses, steroid injections, or both. Of treated patients for whom follow-up data were available, 25 of 26 improved, and 4 of 26 required surgery. Thirteen women had no treatment during pregnancy; three underwent surgery in the postpartum period. All 7 women in whom conservative treatment failed who underwent surgery had resolution of symptoms.

CONCLUSION: These results represent the frequency and patterns of clinically significant CTS in a large population of pregnant women. CTS severe enough to warrant treatment occurs infrequently in pregnancy and generally resolves spontaneously postpartum or responds to conservative treatment.

STUDY DESIGN: A double-blind, randomized, controlled trial.

OBJECTIVE: To determine the clinical effectiveness of therapeutic local anesthetic cervical medial branch blocks with or without steroid in managing chronic neck pain of facet joint origin.

SUMMARY OF BACKGROUND DATA: The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Intra-articular injections, medial branch nerve blocks, and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin.

METHODS: A total of 120 patients were included, with 60 patients in each of the local anesthetic and steroid groups. All the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, and the inclusion criteria. Group I consisted of medial branch blocks with bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Numerical pain scores, Neck Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months, and 12 months.

RESULTS: Significant pain relief (>or=50%) and functional status improvement was observed at 3 months, 6 months, and 12 months in over 83% of patients. The average number of treatments for 1 year was 3.5 +/- 1.0 in the nonsteroid group and 3.4 +/- 0.9 in the steroid group. Duration of average pain relief with each procedure was 14 +/- 6.9 weeks in the nonsteroid group, and it was 16 +/- 7.9 weeks in the steroid group. Significant relief and functional improvement was reported for 46 to 48 weeks in a year.

CONCLUSION: Therapeutic cervical medial branch nerve blocks, with or without steroids, may provide effective management for chronic neck pain of facet joint origin.

STUDY DESIGN: A double-blind, randomized, controlled trial.

OBJECTIVE: To determine the clinical effectiveness of therapeutic local anesthetic cervical medial branch blocks with or without steroid in managing chronic neck pain of facet joint origin.

SUMMARY OF BACKGROUND DATA: The prevalence of persistent neck pain, secondary to involvement of cervical facet or zygapophysial joints, has been described in controlled studies as varying from 39% to 67%. Intra-articular injections, medial branch nerve blocks, and neurolysis of medial branch nerves have been described in managing chronic neck pain of facet joint origin.

METHODS: A total of 120 patients were included, with 60 patients in each of the local anesthetic and steroid groups. All the patients met the diagnostic criteria of cervical facet joint pain by means of comparative, controlled diagnostic blocks, and the inclusion criteria. Group I consisted of medial branch blocks with bupivacaine. Group II consisted of cervical medial branch blocks with bupivacaine and steroid. Numerical pain scores, Neck Disability Index, opioid intake, and work status were evaluated at baseline, 3 months, 6 months, and 12 months.

RESULTS: Significant pain relief (>or=50%) and functional status improvement was observed at 3 months, 6 months, and 12 months in over 83% of patients. The average number of treatments for 1 year was 3.5 +/- 1.0 in the nonsteroid group and 3.4 +/- 0.9 in the steroid group. Duration of average pain relief with each procedure was 14 +/- 6.9 weeks in the nonsteroid group, and it was 16 +/- 7.9 weeks in the steroid group. Significant relief and functional improvement was reported for 46 to 48 weeks in a year.

CONCLUSION: Therapeutic cervical medial branch nerve blocks, with or without steroids, may provide effective management for chronic neck pain of facet joint origin.

OBJECTIVE: To compare three pillows with regard to pain intensity, pain relief, quality of sleep, disability, and overall satisfaction in subjects with benign cervical pain. The three pillows evaluated were the subjects' usual pillow, a roll pillow, and a water-based pillow.

STUDY DESIGN: Subjects used their usual pillows for the first week of this 5-week randomized crossover design study. They were subsequently randomly assigned to use each of the other two pillows for 2-week periods.

SETTING: Outpatient neurology and physiatry clinics.

PATIENTS: Forty-one subjects with benign cervical pain syndromes and free of cognitive impairments.

MAIN OUTCOME MEASURES: Visual analog scale (VAS), Sleep Questionnaire, Sickness Impact Profile (SIP), and a satisfaction scale rating the pillows.

RESULTS: The water-based pillow was associated with reduced morning pain intensity, increased pain relief, and improved quality of sleep. The duration of sleep was significantly shorter for the roll pillow. Overall SIP findings showed a significant advantage for the water-based pillow over the roll pillow and standard pillow.

CONCLUSIONS: Proper selection of a pillow can significantly reduce pain and improve quality of sleep but does not significantly affect disability outcomes measured by the SIP.

STUDY DESIGN: Experimental study of changes in muscle recruitment during trunk extension exercise at 40% of the repetition maximum, because of induced muscle pain.

OBJECTIVE: To investigate the effect of lumbar muscle pain on muscle activity of the trunk muscles using muscle functional magnetic resonance imaging.

SUMMARY OF BACKGROUND DATA: Changed muscle recruitment in patients has an important impact on the etiology and recurrence of low back pain. The mechanisms of these changes in muscle activity are still poorly understood. An experimental study investigating the cause-effect relationship of muscle pain on muscle recruitment patterns can help to clarify these mechanisms.

METHODS: In 15 healthy subjects, the muscle activity of the lumbar multifidus, lumbar erector spinae, and psoas muscles was investigated with muscle functional magnetic resonance imaging. Measurements at rest and after trunk extension exercise at 40% of repetition maximum were performed without and with induced pain.

RESULTS: The lumbar multifidus and lumbar erector spinae were significantly active during the trunk extension exercise, whereas the psoas showed no significant activity. The activity of the lumbar multifidus, lumbar erector spinae, and psoas muscles, was reduced bilaterally and multilevel during the exercise with unilateral low back muscle pain.

CONCLUSION: These data demonstrate that unilateral muscle pain can cause hypoactivity of muscles during trunk extension at 40% of the repetition maximum. The changes were not limited to the side and level of pain. Moreover, the inhibition was not limited to the multifidus muscle; also the lumbar erector spinae and psoas muscles showed decreased activity during the pain condition. Further research has to assess possible compensation mechanisms for this reduced activity in other muscles.

STUDY DESIGN: An intraoperative straight-leg-raising (SLR) test was conducted to investigate patients with lumbar disc herniation to observe the changes in intraradicular blood flow, which then were compared with the clinical features.

OBJECTIVE: The legs of each patient were hung down from the operating table as a reverse SLR test during surgery, and intraradicular blood flow was measured.

SUMMARY OF BACKGROUND DATA: It is not known whether intraradicular blood flow changes during the SLR test in patients with lumbar disc herniation.

METHODS: The subjects were 12 patients with lumbar disc herniation who underwent microdiscectomy. The patients were asked to adopt the prone position immediately before surgery, so that their legs hung down from the operating table. A reverse SLR test was performed to confirm the angle at which sciatica developed. During the operation, the nerve roots affected by the hernia were observed under a microscope. Then the needle sensor of a laser Doppler flow meter was inserted into each nerve root immediately above the hernia. The patient's legs were allowed to hang down to the angle at which sciatica had occurred, and the change in intraradicular blood flow was measured. After removal of the hernia, a similar procedure was repeated, and intraradicular blood flow was measured again.

RESULTS: Intraoperative microscopy showed that the hernia was adherent to the dura mater of the nerve roots in all patients. The intraoperative reverse SLR test showed that the hernia compressed the nerve roots, and that there was marked disturbance of gliding, which was reduced to only a few millimeters. During the test, intraradicular blood flow showed a sharp decrease at the angle that produced sciatica, which lasted for 1 minute. Intraradicular flow decreased by 40% to 98% (average, 70.6% +/- 20.5%) in the L5 nerve root, and by 41% to 96% (average, 72.0% +/- 22.9%) in the S1 nerve roots relative to the blood flow before the test. At 1 minute after completion of the test, intraradicular blood flow returned to the value obtained at baseline. After removal of the hernia, all thepatients showed smooth gliding of the nerve roots during the second intraoperative test, and there was no marked decrease in intraradicular blood flow.

CONCLUSIONS: This study demonstrated that the blood flow in the nerve root is reduced when the nerve root is compressed in vivo.

PERSPECTIVE: What happens to the intensity of pain induced by repeated noxious stimuli over time? Does it stay the same, increase or decrease? Here we show that weekly injections of hypertonic saline into the tibialis anterior cause decreases in local but increases in referred pain, suggesting central changes in processing noxious inputs.

OBJECTIVE: The purpose of this study was to determine the effect of different levels of exercise intensity on the timed finger-to-nose (FTN) task, a measure of upper limb coordination included in the Sport Concussion Assessment Tool (SCAT2).

METHODS: A three-group crossover randomised design was used to investigate changes in FTN times at three levels of exercise intensity; no exercise/rest (NE), moderate intensity exercise (ME) and high-intensity exercise (HE). Heart rates and a rating of perceived exertion (Borg Scale) were recorded to verify the level of exercise intensity. Participants performed three trials of the timed FTN task: pre-exercise, post-exercise and 15 min after the cessation of exercise. Linear mixed models were used to compare FTN change scores associated with exercise.

RESULTS: Ninety asymptomatic participants (45♂:45♀) aged 18-32 years completed the study. Changes in FTN scores from pre-exercise showed that the HE condition was facilitated relative to NE at post-exercise (8% faster, 95% CI 5% to 10%, p<0.001) and at post-15 (3% faster, 95% CI 1% to 6%, p=0.005). ME did not show such a facilitation following exercise (2% faster, 95% CI 0% to 4%, p=0.081 and 1% faster, 95% CI 1% to 4%, p=0.225 respectively).

CONCLUSIONS: Performance on the FTN task is enhanced by a short period of HE, and this effect persists for at least 15 min. There was no evidence of such an effect with ME.

OBJECTIVE: To study prospectively the relations of insomnia to the development of anxiety disorders and depression in a population-based sample.

DESIGN: Cohort study based on data from 2 general health surveys of the adult population.

SETTING: Two general health surveys in the adult population in Nord-Trondelag County of Norway, HUNT-1 performed in 1984-6 and HUNT-2 in 1995-7

PARTICIPANTS: Participants without significant anxiety and depression in HUNT-1 were categorized according to the presence and absence of insomnia in the 2 surveys (N=25,130). MEASUREMENTS AND

RESULTS: Anxiety disorders and depression in HUNT-2 were assessed by the Hospital Anxiety and Depression Scale and analyzed using multivariate logistic regression analysis adjusted for age, gender, education, comorbid depression/anxiety, and history of insomnia. Anxiety disorders in HUNT-2 were significantly associated with the group with insomnia in HUNT-1 only (OR 1.6; 95% CI, 1.1-2.3), the group with insomnia in HUNT-2 only (OR 3.4; 95% CI, 3.1-3.8), as well as with the group with insomnia in both surveys (OR 4.9; 95% CI, 3.8-6.4). Depression in HUNT-2 was significantly associated with the group with insomnia in HUNT-2 only (OR 1.8; 95% CI, 1.6-2.0), but not with the groups with insomnia in HUNT-1 only or with insomnia in both surveys.

CONCLUSIONS: Only a state-like association between insomnia and depression was found. In addition to being a state marker, insomnia may be a trait marker for individuals at risk for developing anxiety disorders. Results are consistent with insomnia being a risk factor for the development of anxiety disorders.

CONTEXT: Chronic pain is a major contributor to disability in older adults; however, the potential role of chronic pain as a risk factor for falls is poorly understood.

OBJECTIVE: To determine whether chronic musculoskeletal pain is associated with an increased occurrence of falls in a cohort of community-living older adults.

DESIGN, SETTING, AND PARTICIPANTS: The Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston Study is a population-based longitudinal study of falls involving 749 adults aged 70 years and older. Participants were enrolled from September 2005 through January 2008.

MAIN OUTCOME MEASURE: Participants recorded falls on monthly calendar postcards mailed to the study center during an 18-month period.

RESULTS: There were 1029 falls reported during the follow-up. A report of 2 or more locations of musculoskeletal pain at baseline was associated with greater occurrence of falls. The age-adjusted rates of falls per person-year were 1.18 (95% confidence interval [CI], 1.13-1.23) for the 300 participants with 2 or more sites of joint pain, 0.90 (95% CI, 0.87-0.92) for the 181 participants with single-site pain, and 0.78 (95% CI, 0.74-0.81) for the 267 participants with no joint pain. Similarly, more severe or disabling pain at baseline was associated with higher fall rates (P < .05). The association persisted after adjusting for multiple confounders and fall risk factors. The greatest risk for falls was observed in persons who had 2 or more pain sites (adjusted rate ratio [RR], 1.53; 95% CI, 1.17-1.99), and those in the highest tertiles of pain severity (adjusted RR, 1.53; 95% CI, 1.12-2.08) and pain interference with activities (adjusted RR, 1.53; 95%CI, 1.15-2.05), compared with their peers with no pain or those in the lowest tertiles of pain scores.

CONCLUSIONS: Chronic pain measured according to number of locations, severity, or pain interference with daily activities was associated with greater risk of falls in older adults.

PERSPECTIVE: This article reports on the familial contribution and the role of psychological factors in the relationship between chronic pain, and overweight and obesity. These findings can increase our understanding of the mechanisms underlying these 2 commonly comorbid sets of conditions.

OBJECTIVE: The aim of this clinical trial was to evaluate the effect of 15 myofascial therapy treatments using ischemic compression on shoulder trigger points in patients with chronic shoulder pain.

METHODS: Forty-one patients received 15 experimental treatments, which consisted of ischemic compressions on trigger points located in the supraspinatus muscle, the infraspinatus muscle, the deltoid muscle, and the biceps tendon. Eighteen patients received the control treatment involving 15 ischemic compression treatments of trigger points located in cervical and upper thoracic areas. Of the 18 patients forming the control group, 16 went on to receive 15 experimental treatments after having received their initial control treatments. Outcome measures included a validated 13-question questionnaire measuring shoulder pain and functional impairment. A second questionnaire was used to assess patients' perceived amelioration, using a scale from 0% to 100%. Outcome measure evaluation was completed for both groups at baseline after 15 treatments, 30 days after the last treatment, and finally for the experimental group only, 6 months later.

RESULTS: A significant group x time interval interaction was observed after the first 15 treatments, indicating that the experimental group had a significant reduction in their Shoulder Pain and Disability Index (SPADI) score compared with the control group (62% vs 18% amelioration). Moreover, the patients perceived percentages of amelioration were higher in the experimental group after 15 treatments (75% vs 29%). Finally, the control group subjects significantly reduced their SPADI scores after crossover (55%).

CONCLUSION: The results of this study suggest that myofascial therapy using ischemic compression on shoulder trigger points may reduce the symptoms of patients experiencing chronic shoulder pain.

OBJECTIVE: To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes.

DESIGN: Inception cohort study.

SETTING: Primary care.

PATIENTS: 103 patients with acute localised non-specific back pain lasting less than 72 hours.

MAIN OUTCOME MEASURES: Complete recovery (disappearance of both pain and disability) and return to work.

RESULTS: 90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery.These factors were also related to abseteeism from work. Absenteeism from work was also influenced by job satisfaction and gender.

CONCLUSIONS: The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which incluenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related incluences.

BACKGROUND: Knee osteoarthritis (OA) is a major cause of pain and functional limitation in older adults, yet longer-term studies of medical treatment of OA are limited.

OBJECTIVE: To evaluate the efficacy and safety of glucosamine and chondroitin sulphate (CS), alone or in combination, as well as celecoxib and placebo on painful knee OA over 2 years.

METHODS: A 24-month, double-blind, placebo-controlled study, conducted at nine sites in the US ancillary to the Glucosamine/chondroitin Arthritis Intervention Trial, enrolled 662 patients with knee OA who satisfied radiographic criteria (Kellgren/Lawrence grade 2 or 3 changes and baseline joint space width of at least 2 mm). This subset continued to receive their randomised treatment: glucosamine 500 mg three times daily, CS 400 mg three times daily, the combination of glucosamine and CS, celecoxib 200 mg daily, or placebo over 24 months. The primary outcome was a 20% reduction in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) pain over 24 months. Secondary outcomes included an Outcome Measures in Rheumatology/Osteoarthritis Research Society International response and change from baseline in WOMAC pain and function.

RESULTS: Compared with placebo, the odds of achieving a 20% reduction in WOMAC pain were celecoxib: 1.21, glucosamine: 1.16, combination glucosamine/CS: 0.83 and CS alone: 0.69, and were not statistically significant.

CONCLUSIONS: Over 2 years, no treatment achieved a clinically important difference in WOMAC pain or function as compared with placebo. However, glucosamine and celecoxib showed beneficial but not significant trends. Adverse reactions were similar among treatment groups and serious adverse events were rare for all treatments.

OBJECTIVE: To compare the mean time to first stool, number of stools, and side effects of three commonly used cathartics in pediatric ingestions.

DESIGN: This prospective clinical trial was a randomized, double-blinded comparison of sorbitol, magnesium citrate, magnesium sulfate, and water, administered with activated charcoal in the treatment of pediatric patients 1 to 5 years of age with acute ingestions. Outcome parameters were mean time to first stool, mean number of stools during 24 hours, and side effects.

RESULTS: One hundred sixteen patients completed the study. Significant differences in mean time to the first stool were detected among cathartic agents (F = 9.29), with sorbitol-treated patients having a shortest mean time to the first stool (mean, 8.48 hours). Sorbitol produced a significantly higher number of stools (mean, 2.79) in the 24-hour follow-up period than other cathartics (F = 3.49). The most common side effect of cathartic administration was emesis, which occurred more commonly in sorbitol-treated patients.

CONCLUSION: Sorbitol, when administered with activated charcoal in the treatment of children with acute ingestions, produced a shorter time to first stool and more stools than magnesium citrate, magnesium sulfate, or water.

BACKGROUND: It is unknown whether the incidence of peptic ulcer changes in areas with a high prevalence of Helicobacter pylori infection.

AIM: To determine trends in peptic ulcer complications in a community with a high prevalence of H. pylori infection.

METHODS: New endoscopic diagnoses of peptic ulcers and their complications from 1985 to 2000 were obtained. H. pylori infection in the adult population, the number of prescriptions for anti-secretory drugs and non-steroidal anti-inflammatory drugs were also evaluated.

RESULTS: Although the global prevalence of H. pylori infection remains high in this population (>60%), a 41.4 to 25.4% decrease in the incidence of peptic ulcers and ulcer complications was observed. This was associated with a decrease in the prevalence of H. pylori infection in people under 65 years of age, a 3.5-fold increase in the number of prescriptions of proton-pump inhibitors and an increase in the number of prescriptions of non-steroidal anti-inflammatory drugs, especially coxibs.

CONCLUSIONS: In an area with a high prevalence of H. pylori infection, the incidence of peptic ulcer and associated complications is declining rapidly. This was associated with a reduction of the prevalence of H. pylori infection in the young and a widespread use of proton-pump inhibitors. The increase in the use of non-steroidal anti-inflammatory drugs, especially coxibs, has not changed the tendency.

OBJECTIVE: We conducted a pilot trial to assess the effect of botulinum toxin B on palmar pain and discomfort in carpal tunnel syndrome (CTS) patients. Design. Randomized, double-blind, placebo-controlled.

PATIENTS: Twenty ambulatory CTS patients. Intervention. Botulinum toxin B or placebo injections into three hypothenar muscles anatomically linked or attached to the carpal tunnel and its tentorium, that is, the Opponens Digiti Minimi and Flexor Digiti Minimi, located with electromyography (EMG), and the Palmaris Brevis Muscle, anatomically located without EMG.

SETTING: New York City hospital.

OUTCOME MEASURES: Outcomes were measured with numeric ratings, with higher scores indicating worse outcomes. Daily, subjects recorded their 0-10 numeric ratings of overall pain levels and pain-related sleep disturbances. During weekly telephone calls, they reported their 0-10 ratings for overall pain, pain-related sleep disturbance, and CTS-related tingling during the night and day as experienced over the preceding 24 hours. For each of four clinic visits, we averaged each subject's ratings of nine quality of life indicators from the West Haven-Yale Multidimensional Pain Inventory (WHYMPI), each measured on a 0-6 numeric scale.

RESULTS: Over the 13-week trial, compared to baseline scores, the following outcomes predominantly showed decreases of statistical significance (P < or = 0.050) or borderline significance (0.050 < P < or = 0.10) for weeks 2 through 8: overall pain per daily diary entries and per weekly telephone reports, and pain-related sleep disturbance in the placebo group per phone report and in the botulinum toxin B group per diary report. CTS painful night tingling and day tingling, as well as the average scores of the WHYMPI quality of life indicators, showed improvements with statistical or borderline significance for almost each follow-up week. Between-group analyses, however, demonstrated that at each follow-up week, there was no statistically significant difference between the two study groups regarding changes from baseline in any study outcome.

CONCLUSION: Botulinum toxin B is not dramatically superior to placebo for the relief of CTS symptoms. Possible explanations of the improvements in each study group are explored.

STUDY DESIGN: A Cochrane review of randomized controlled trials.

OBJECTIVES: To collate the scientific evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis.

SUMMARY OF BACKGROUND DATA: Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures still is unclear.

METHODS: A highly sensitive search strategy identified all published randomized controlled trials. Cochrane methodology was used for meta-analysis of the results.

RESULTS: Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions. There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not improve clinical outcomes.

CONCLUSIONS: There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other trials become available.

BACKGROUND: Chronic sleep-onset insomnia is a prevalent health complaint in adults. Although behavioral and pharmacological therapies have been shown to be effective for insomnia, no placebo-controlled trials have evaluated their separate and combined effects for sleep-onset insomnia. The objective of this study was to evaluate the clinical efficacy of behavioral and pharmacological therapy, singly and in combination, for chronic sleep-onset insomnia.

METHODS: This was a randomized, placebo-controlled clinical trial that involved 63 young and middle-aged adults with chronic sleep-onset insomnia. Interventions included cognitive behavior therapy (CBT), pharmacotherapy, or combination therapy compared with placebo. The main outcome measures were sleep-onset latency as measured by sleep diaries; secondary measures included sleep diary measures of sleep efficiency and total sleep time, objective measures of sleep variables (Nightcap sleep monitor recorder), and measures of daytime functioning.

RESULTS: In most measures, CBT was the most sleep effective intervention; it produced the greatest changes in sleep-onset latency and sleep efficiency, yielded the largest number of normal sleepers after treatment, and maintained therapeutic gains at long-term follow-up. The combined treatment provided no advantage over CBT alone, whereas pharmacotherapy produced only moderate improvements during drug administration and returned measures toward baseline after drug use discontinuation.

CONCLUSIONS: These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.

CONTEXT: Use of nonpharmacological behavioral therapy has been suggested for treatment of chronic primary insomnia, but well-blinded, placebo-controlled trials demonstrating effective behavioral therapy for sleep-maintenance insomnia are lacking.

OBJECTIVE: To test the efficacy of a hybrid cognitive behavioral therapy (CBT) compared with both a first-generation behavioral treatment and a placebo therapy for treating primary sleep-maintenance insomnia.

DESIGN AND SETTING: Randomized, double-blind, placebo-controlled clinical trial conducted at a single academic medical center, with recruitment from January 1995 to July 1997.

PATIENTS: Seventy-five adults (n = 35 women; mean age, 55.3 years) with chronic primary sleep-maintenance insomnia (mean duration of symptoms, 13.6 years).

INTERVENTIONS: Patients were randomly assigned to receive CBT (sleep education, stimulus control, and time-in-bed restrictions; n = 25), progressive muscle relaxation training (RT; n = 25), or a quasi-desensitization (placebo) treatment (n = 25). Outpatient treatment lasted 6 weeks, with follow-up conducted at 6 months.

MAIN OUTCOME MEASURES: Objective (polysomnography) and subjective (sleep log) measures of total sleep time, middle and terminal wake time after sleep onset (WASO), and sleep efficiency; questionnaire measures of global insomnia symptoms, sleep-related self-efficacy, and mood.

RESULTS: Cognitive behavioral therapy produced larger improvements across the majority of outcome measures than did RT or placebo treatment. For example, sleep logs showed that CBT-treated patients achieved an average 54% reduction in their WASO whereas RT-treated and placebo-treated patients, respectively, achieved only 16% and 12% reductions in this measure. Recipients of CBT also showed a greater normalization of sleep and subjective symptoms than did the other groups with an average sleep time of more than 6 hours, middle WASO of 26.6 minutes, and sleep efficiency of 85.1%. In contrast, RT-treated patients continued to report a middle WASO of 43.3 minutes and sleep efficiency of 78.8%.

CONCLUSIONS: Our results suggest that CBT represents a viable intervention for primary sleep-maintenance insomnia. This treatment leads to clinically significant sleep improvements within 6 weeks and these improvements appear to endure through 6 months of follow-up.

INTRODUCTION: Cervical spine involvement is common and potentially severe in patients with rheumatoid arthritis (RA). The objectives of this study were to compare the prevalences of cervical spine abnormalities detected by standard radiography, computed tomography (CT), and magnetic resonance imaging (MRI) in patients with RA; and to identify factors associated with cervical spine involvement.

METHODS: We studied 40 patients who met American College of Rheumatology criteria for RA and had disease durations of 2 years or more. Each patient underwent a physical examination, laboratory tests, standard radiographs (anteroposterior, lateral, open-mouth, flexion, and extension views), MRI with dynamic maneuvers in (if not contraindicated), and CT.

RESULTS: Cervical spine involvement was found by at least one imaging technique in 29 (72.5%) patients (standard radiography, 47.5%; CT, 28.2%; and MRI, 70%) and was asymptomatic in 5 (17.2%) patients. C1-C2 pannus was the most common lesion (62.5% of cases), followed by atlantoaxial subluxation (AAS, 45%). The most common AAS pattern was anterior subluxation (25%), followed by lateral subluxation (15%) then by vertical, rotatory, and subaxial subluxations (10% each). Erosions of the dens were seen in 67.5% of patients by MRI, 41% by CT, and 12.5% by standard radiography. Of the 10 cases of anterior AAS by any modality, 9 were detected by standard radiography and 7 by MRI. CT was the best technique for visualizing atypical rotatory or lateral AAS. MRI was best for assessing the C1-C2 pannus, dens erosions, and neurologic impact of the rheumatoid lesions. The comparison of patients with and without cervical spine lesions suggested that higher modified Sharp score and C-reactive protein values predicted cervical spine involvement (P=0.002 and P=0.004, respectively).

CONCLUSION: Cervical spine involvement is common and may be asymptomatic, indicating that routine cervical spine imaging is indicated in patients with RA. Standard radiography including dynamic views constitutes the first-line imaging method of choice. Sensitivity and comprehensiveness of the assessment are greatest with MRI. MRI and CT are often reserved for selected patients. Cervical spine involvement is associated with disease activity and with rapidly progressive joint destruction.

OBJECTIVE: To investigate the therapeutic effects of physical agents administered before isokinetic exercise in women with knee osteoarthritis.

DESIGN: One hundred patients with bilateral knee osteoarthritis were randomized into five groups of 20 patients each: group 1 received short-wave diathermy + hot packs and isokinetic exercise; group 2 received transcutaneous electrical nerve stimulation + hot packs and isokinetic exercise; group 3 received ultrasound + hot packs and isokinetic exercise; group 4 received hot packs and isokinetic exercise; and group 5 served as controls and received only isokinetic exercise.

RESULTS: Pain and disability index scores were significantly reduced in each group. Patients in the study groups had significantly greater reductions in their visual analog scale scores and scores on the Lequesne index than did patients in the control group (group 5). They also showed greater increases than did controls in muscular strength at all angular velocities. In most parameters, improvements were greatest in groups 1 and 2 compared with groups 3 and 4.

CONCLUSIONS: Using physical agents before isokinetic exercises in women with knee osteoarthritis leads to augmented exercise performance, reduced pain, and improved function. Hot pack with a transcutaneous electrical nerve stimulator or short-wave diathermy has the best outcome.

BACKGROUND: Chronic low back pain is a common problem that has only modestly effective treatment options.

OBJECTIVE: To determine whether yoga is more effective than conventional therapeutic exercise or a self-care book for patients with chronic low back pain.

DESIGN: Randomized, controlled trial.

SETTING: A nonprofit, integrated health care system.

PATIENTS: 101 adults with chronic low back pain.

INTERVENTION: 12-week sessions of yoga or conventional therapeutic exercise classes or a self-care book.

MEASUREMENTS: Primary outcomes were back-related functional status (modified 24-point Roland Disability Scale) and "bothersomeness" of pain (11-point numerical scale). The primary time point was 12 weeks. Clinically significant change was considered to be 2.5 points on the functional status scale and 1.5 points on the bothersomeness scale. Secondary outcomes were days of restricted activity, general health status, and medication use.

RESULTS: After adjustment for baseline values, back-related function in the yoga group was superior to the book and exercise groups at 12 weeks (yoga vs. book: mean difference, -3.4 [95% CI, -5.1 to - 1.6] [P < 0.001]; yoga vs. exercise: mean difference, -1.8 [CI, -3.5 to - 0.1] [P = 0.034]). No significant differences in symptom bothersomeness were found between any 2 groups at 12 weeks; at 26 weeks, the yoga group was superior to the book group with respect to this measure (mean difference, -2.2 [CI, -3.2 to - 1.2]; P < 0.001). At 26 weeks, back-related function in the yoga group was superior to the book group (mean difference, -3.6 [CI, -5.4 to - 1.8]; P < 0.001).

LIMITATIONS: Participants in this study were followed for only 26 weeks after randomization. Only 1 instructor delivered each intervention.

CONCLUSIONS: Yoga was more effective than a self-care book for improving function and reducing chronic low back pain, and the benefits persisted for at least several months.

BACKGROUND AND PURPOSE: In many physical therapy programs for subjects with adhesive capsulitis of the shoulder, mobilization techniques are an important part of the intervention. The purpose of this study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder.

SUBJECTS: One hundred subjects with unilateral adhesive capsulitis lasting 3 months or more and a > or =50% decrease in passive joint mobility relative to the nonaffected side were enrolled in this study.

METHODS: Subjects randomly assigned to the HGMT group were treated with intensive passive mobilization techniques in end-range positions of the glenohumeral joint, and subjects in the LGMT group were treated with passive mobilization techniques within the pain-free zone. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups. Subjects were assessed at baseline and at 3, 6, and 12 months by a masked assessor. Primary outcome measures included active and passive range of motion and shoulder disability (Shoulder Rating Questionnaire [SRQ] and Shoulder Disability Questionnaire [SDQ]). An analysis of covariance with adjustments for baseline values and a general linear mixed-effect model for repeated measurements were used to compare the change scores for the 2 treatment groups at the various time points and over the total period of 1 year, respectively.

RESULTS: Overall, subjects in both groups improved over 12 months. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time points 3 and 12 months), and for active and passive external rotation (at 12 months). A statistically significant difference in trend between both groups over the total follow-up period of 12 months was found for passive external rotation, SRQ, and SDQ with greater change scores in the HGMT group.

DISCUSSION AND CONCLUSION: In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs, with the overall differences between the 2 interventions being small.

BACKGROUND AND PURPOSE: In many physical therapy programs for subjects with adhesive capsulitis of the shoulder, mobilization techniques are an important part of the intervention. The purpose of this study was to compare the effectiveness of high-grade mobilization techniques (HGMT) with that of low-grade mobilization techniques (LGMT) in subjects with adhesive capsulitis of the shoulder.

SUBJECTS: One hundred subjects with unilateral adhesive capsulitis lasting 3 months or more and a > or =50% decrease in passive joint mobility relative to the nonaffected side were enrolled in this study.

METHODS: Subjects randomly assigned to the HGMT group were treated with intensive passive mobilization techniques in end-range positions of the glenohumeral joint, and subjects in the LGMT group were treated with passive mobilization techniques within the pain-free zone. The duration of treatment was a maximum of 12 weeks (24 sessions) in both groups. Subjects were assessed at baseline and at 3, 6, and 12 months by a masked assessor. Primary outcome measures included active and passive range of motion and shoulder disability (Shoulder Rating Questionnaire [SRQ] and Shoulder Disability Questionnaire [SDQ]). An analysis of covariance with adjustments for baseline values and a general linear mixed-effect model for repeated measurements were used to compare the change scores for the 2 treatment groups at the various time points and over the total period of 1 year, respectively.

RESULTS: Overall, subjects in both groups improved over 12 months. Statistically significant greater change scores were found in the HGMT group for passive abduction (at the time points 3 and 12 months), and for active and passive external rotation (at 12 months). A statistically significant difference in trend between both groups over the total follow-up period of 12 months was found for passive external rotation, SRQ, and SDQ with greater change scores in the HGMT group.

DISCUSSION AND CONCLUSION: In subjects with adhesive capsulitis of the shoulder, HGMTs appear to be more effective in improving glenohumeral joint mobility and reducing disability than LGMTs, with the overall differences between the 2 interventions being small.

OBJECTIVE: We compared pain severity and time to resumption of activities in patients with cervical strains treated with a nonsteroidal anti-inflammatory drug (NSAID), a centrally acting muscle relaxant or both.

METHODS: We performed a double-blinded, randomized controlled trial of adults with cervical strains from motor vehicle collisions or from falls who presented to a suburban academic emergency department (ED). Patients were randomly assigned to receive ibuprofen 800 mg, cyclobenzaprine 5 mg or both, 3 times daily as needed for up to 7 days. Outcome measures included a pain score on a 100-mm visual analog scale, pain relief scores, the time to resumption of normal activities, the use of rescue medications, and adverse outcomes. We used repeated-measures analysis of variance to compare pain relief over time. Our sample size of 20 patients in each group had a power of 80% to detect a difference of 15 mm in pain relief scores between the highest and lowest groups.

RESULTS: We randomly assigned 61 patients to receive ibuprofen (n = 20), cyclobenzaprine (n = 21) or both (n = 20). Mean (standard deviation) age was 34 (11) years; 58% were women and 72% were white. Although pain scores improved over time in all groups, there were no significant differences between the groups in any of the outcome measures. The rate of adverse events was also similar between groups.

CONCLUSION: Our study suggests that there is little benefit to routinely using or adding cyclobenzaprine to NSAIDs for ED patients with acute cervical strain.

AIM: The purpose of this study was to compare strength differences between 2 groups of untrained women, who performed a single set of the leg press exercise once or twice per week.

METHODS: Twenty-one women were divided randomly into 2 groups: Group 1 (n=10) performed a single set of the leg press exercise once per week, while Group 2 (n=11) performed a single set of the leg press exercise twice per week for a period of 8 weeks. Throughout the duration of the study, an amount of resistance was utilized that allowed for a single set of 6 to 10 repetitions to muscular failure. At the conclusion of the study, subjects were tested for their 6-RM strength. A 2x2 ANOVA was used to compare strength differences. The a level was set at 0.05 in order for differences to be considered significant.

RESULTS: The 2x2 ANOVA demonstrated that strength increases were significant between tests (P=0.0001), but not significant between groups (P=0.757).

CONCLUSIONS: These results indicate that performing a single set of the leg press once or twice per week results in statistically similar strength gains in untrained women.

BACKGROUND: Strength training has been shown to benefit the health and function of older adults.

OBJECTIVE: To investigate whether one set of exercises performed once a week was as effective in increasing muscle strength as training twice a week.

METHODS: 18 subjects (7 women and 11 men) aged 65-79 years were randomly assigned to two groups. Both groups performed one set of exercises to muscular fatigue; group 1 trained 1 day/week and group 2 trained 2 days/week on three lower and three upper body exercises for 9 weeks. The data were analysed using a mixed model 2 x 2 analysis of variance.

RESULTS: A significant main effect of time (p<0.001), but not group, on one-repetition maximum scores was observed. No significant interaction was observed between time and group and therefore no difference in strength changes between training once a week versus twice a week after 9 weeks.

CONCLUSIONS: One set of exercises performed once weekly to muscle fatigue improved strength as well as twice a week in the older adult. Our results provide information that will assist in designing strength-training programmes that are more time and cost efficient in producing health and fitness benefits for older adults.

PRINCIPLE: A randomised, comparative prospective clinical trial was planned to compare the early response to different rehabilitation methods for adhesive capsulitis taking into consideration the clinical efficacy and the cost effectiveness of the methods.

METHODS: Forty patients with adhesive capsulitis were randomised into two treatment groups. The first group (CYR) received the Cyriax approach of deep friction massage and mobilisation exercises three times weekly. The second group (PT) had daily physical therapy including hot pack and short wave diathermy application. Both groups concluded their treatments with stretching exercises and were also instructed to a daily home exercise program. The primary end point of the study was to reach 80% of the normal passive range of motion (ROM) of the shoulder in all planes within a period of two weeks. Secondary end points were the overall ROM and pain response (spontaneous pain, night pain and pain with motion) to each treatment.

RESULTS: 19 patients in the CYR group (95%) and 13 patients in the PT group (65%) reached sufficient ROM at the end of the second week (p <0.05). The improvement in shoulder flexion, inner and outer rotation values and the decrease in pain with motion were significantly better in the CYR group after the first week of treatment.

CONCLUSION: The Cyriax method of rehabilitation provides a faster and better response than the conventional physical therapy methods in the early phase of treatment in adhesive capsulitis. The method is non-invasive, effective and requires fewer hospital visits for a sufficient early response.

BACKGROUND: The aim of the study was to compare the efficacies of steroid injections guided by scintigraphy, ultrasonography, and palpation in plantar fasciitis.

METHODS: A total of 35 heels of 27 patients were randomly assigned to three steroid injection groups: palpation-guided (pg), ultrasound-guided (ug), and scintigraphy-guided (sg). Patients were evaluated for pain intensity before the injections and at the last follow-up of 25.3 months with a 100-mm visual analog scale (VAS).

RESULTS: There were significant improvements in plantar fascia thickness, fat pad thickness, and VAS. Among the three groups of ug-pg, ug-sg, and pg-sg there were no statistically significant differences after treatment (P = 0.017, MWU = 36.5; P = 0.023, MWU = 29.5; and P = 0.006, MWU = 13, respectively).

CONCLUSIONS: The ug, pg, and sg injections were effective in the conservative treatment of plantar fasciitis. We are of the opinion that steroid injections should be performed, preferably with palpation or ultrasonographic guidance.

BACKGROUND: Consistent with osteopathic principles and practice, the nation's colleges of osteopathic medicine (COMs) have emphasized the significance of the musculoskeletal system to the practice of medicine. The authors hypothesized that graduating COM students would, therefore, demonstrate superior knowledge and competence in musculoskeletal medicine when compared with graduates of allopathic medical schools.

METHODS: The authors asked graduating COM students to complete a standardized and previously validated 25-question basic competency examination on musculoskeletal medicine in short-answer format. Originally developed and validated in the late 1990s, the examination was distributed to allopathic medical residents at the beginning of their residencies. The authors compare their results with those reported by Freedman and Bernstein for allopathic residents.

RESULTS: When the minimum passing level as determined by orthopedic program directors was applied to the results of these examinations, 70.4% of graduating COM students (n=54) and 82% of allopathic graduates (n=85) failed to demonstrate basic competency in musculoskeletal medicine. Similarly, the majority of both groups failed to attain the minimum passing level established by the directors of internal medicine programs (graduating COM students, 67%; allopathic graduates, 78%).

CONCLUSION: In an examination of competence levels for musculoskeletal medicine, students about to graduate from a COM fared only marginally better than did their allopathic counterparts. To ensure that all graduating COM students have attained a level of basic competence in musculoskeletal medicine, the authors recommend further study as a prelude to evaluation of the didactic and clinical curriculum at all 22 COMs and their branch campuses.

OBJECTIVE: To examine the effect of a comprehensive warm-up programme designed to reduce the risk of injuries in female youth football.

DESIGN: Cluster randomised controlled trial with clubs as the unit of randomisation.

SETTING: 125 football clubs from the south, east, and middle of Norway (65 clusters in the intervention group; 60 in the control group) followed for one league season (eight months).

PARTICIPANTS: 1892 female players aged 13-17 (1055 players in the intervention group; 837 players in the control group).

INTERVENTION: A comprehensive warm-up programme to improve strength, awareness, and neuromuscular control during static and dynamic movements.

MAIN OUTCOME MEASURE: Injuries to the lower extremity (foot, ankle, lower leg, knee, thigh, groin, and hip).

RESULTS: During one season, 264 players had relevant injuries: 121 players in the intervention group and 143 in the control group (rate ratio 0.71, 95% confidence interval 0.49 to 1.03). In the intervention group there was a significantly lower risk of injuries overall (0.68, 0.48 to 0.98), overuse injuries (0.47, 0.26 to 0.85), and severe injuries (0.55, 0.36 to 0.83).

CONCLUSION: Though the primary outcome of reduction in lower extremity injury did not reach significance, the risk of severe injuries, overuse injuries, and injuries overall was reduced. This indicates that a structured warm-up programme can prevent injuries in young female football players.

CONTEXT: Individuals suffering from patellofemoral pain have previously been reported to have decreased isometric strength of the hip musculature; however, no researchers have investigated concentric and eccentric torque of the hip musculature in individuals with patellofemoral pain.

OBJECTIVE: To compare concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain.

DESIGN: Case control.

SETTING: Research laboratory.

PATIENTS OR OTHER PARTICIPANTS: Twenty participants with patellofemoral pain (age = 26.8 +/- 4.5 years, height = 171.8 +/- 8.4 cm, mass = 72.4 +/- 16.8 kg) and 20 control participants (age = 25.6 +/- 2.8 years, height = 169.5 +/- 8.9 cm, mass = 70.0 +/- 16.9 kg) were tested. Volunteers with patellofemoral pain met the following criteria: knee pain greater than or equal to 3 cm on a 10-cm visual analog scale, insidious onset of symptoms not related to trauma, pain with palpation of the patellar facets, and knee pain during 2 of the following activities: stair climbing, jumping or running, squatting, kneeling, or prolonged sitting. Control participants were excluded if they had a prior history of patellofemoral pain, knee surgery in the past 2 years, or current lower extremity injury that limited participation in physical activity.

INTERVENTION(S): Concentric and eccentric torque of the hip musculature was measured on an isokinetic dynamometer. All volunteers performed 5 repetitions of each strength test. Separate multivariate analyses of variance were performed to compare concentric and eccentric torque of the hip extensors, abductors, and external rotators between groups.

MAIN OUTCOME MEASURE(S): Average and peak concentric and eccentric torque of the hip extensors, abductors, and external rotators. Torque measures were normalized to the participant's body weight multiplied by height.

RESULTS: The patellofemoral pain group was weaker than the control group for peak eccentric hip abduction torque (F(1,38) = 6.630, P = .014), and average concentric (F(1,38) = 4.156, P = .048) and eccentric (F(1,38) = 4.963, P = .032) hip external rotation torque.

CONCLUSIONS: The patellofemoral pain group displayed weakness in eccentric hip abduction and hip external rotation, which may allow for increased hip adduction and internal rotation during functional movements.

OBJECTIVE: Exercise-induced leg pain may be triggered by abnormally high compartment pressure. In addition to the more widely publicized anterior compartment syndrome, the deep posterior compartment syndrome can just as frequently occur, resulting in severe pain and disability due to muscle and nerve ischemia.

BACKGROUND: Obtaining a thorough history and compartmental pressure measurements are the usual components in the accurate diagnosis of compartment syndromes. While few other disorders mimic compartment syndromes, differential diagnoses must be considered. Surgical management of deep compartment syndrome, consisting of fasciotomy or fasciectomy, or both, is successful for most patients. DIFFERENTIAL DIAGNOSIS: Tibial stress fracture or microfracture, tibial periostitis, tibial periostalgia, distal deep posterior chronic compartment syndrome, proximal deep chronic compartment syndrome, superficial lateral compartment syndrome, deep venous thrombosis, popliteal artery entrapment, or chronic compartment syndrome. UNIQUENESS: Chronic deep compartment syndrome is one of the most common causes of exercise-induced leg pain in aerobic athletes. Therefore, the athletic trainer must be able to recognize the condition. Signs, symptoms, diagnosis, and surgical management of chronic deep compartment syndrome, chronic periostalgia, and superficial lateral compartment syndrame in a 21-year-old Division IA track and field athlete are presented.

CONCLUSIONS: With the correct diagnosis, persistent and methodical reevaluation, and appropriate management, the athlete can expect a successful treatment outcome.

OBJECTIVE: This study was conducted to discuss the conservative care used to treat a female collegiate volleyball player with acute costochondritis.

CLINICAL FEATURES: A 21-year-old collegiate volleyball player had right anterior chest pain and midthoracic stiffness of 8 months duration.

INTERVENTION AND OUTCOME: High-velocity, low-amplitude manipulation was performed to the associated hypokinetic costovertebral, costotransverse, and intervertebral zygapophyseal thoracic joints. Instrument-assisted soft tissue mobilization was performed by using the Graston technique. Pain levels improved on numeric pain scale, as did functional status identified on Dallas Pain Questionnaire and Functional Rating Index.

CONCLUSION: This athlete seemed to respond positively to manipulation, soft tissue mobilization, and taping.

OBJECTIVE: To detail the progress of a novice triathlete with an unusual mechanism of a tibialis posterior strain who underwent successful conservative treatment and rehabilitation. Tibialis posterior tendon dysfunction will be discussed as it relates to the case.

CLINICAL FEATURES: The clinical features of tibialis posterior dysfunction are swelling and edema posterior to the medial malleolus with pain and an inability to weight bear. This injury may occur in endurance athletes such as triathletes, most often occurring during running.

INTERVENTION AND OUTCOME: The conservative treatment approach used in this case consisted of medical acupuncture with electrical stimulation, Graston Technique((c)) a soft tissue instrument assisted mobilization technique, Active Release Technique((R)), ultrasound therapy with Traumeel, and rehabilitation. Gait analysis and orthotic prescription was completed when the patient was ready to return to play. Outcome measures included subjective pain rating and return to pre-injury activities. Objective measures included swelling and manual muscle testing.

CONCLUSION: A novice triathlete with a grade I tibialis posterior strain was quickly relieved of his symptoms and able to return to his triathlon training with conservative treatment. Practitioners treating this type of injury could consider including the soft tissue techniques, modalities and rehabilitation employed in our case for other patients with lower leg strains and/or tibialis posterior dysfunction.

PERSPECTIVE: This article evaluates the effect of a single 60-minute NGX-4010 application on ENF density and QST in healthy volunteers followed for 24 weeks. The results help predict the long-term safety of NGX-4010 applications in patients.

OBJECTIVE: To detail the progress of a patient with unresolved symptoms of Trigger thumb who underwent a treatment plan featuring Active Release Technique (ART) and Graston Technique.

CLINICAL FEATURES: The most important feature is painful snapping or restriction of movement, most notably in actively extending or flexing the digit. The cause of this flexor tendinopathy is believed to be multi-factorial including anatomical variations of the pulley system and biomechanical etiologies such as exposure to shear forces and unaccustomed activity. Conventional treatment aims at decreasing inflammation through corticosteroid injection or surgically removing imposing tissue.

INTERVENTION AND OUTCOME: The conservative treatment approach utilized in this case involved Active Release Technique (ART(R)) and Graston Technique (GT). An activity specific rehabilitation protocol was employed to re-establish thumb extensor strength and ice was used to control pain and any residual inflammation. Outcome measures included subjective pain ratings with range of motion and motion palpation of the first right phalangeal joint. Objective measures were made by assessing range of motion.

CONCLUSION: A patient with trigger thumb appeared to be relieved of his pain and disability after a treatment plan of GT and ART.

OBJECTIVE: Contrast therapy has a long history of use in sports medicine. Edema and ecchymosis reduction, vasodilation and vasoconstriction of blood vessels, blood flow changes, and influences on the inflammatory response are physiologic effects attributed to the ability of this modality to evoke tissue temperature fluctuations. Our purpose was to measure the change in human gastrocnemius intramuscular tissue temperature during a typical contrast therapy treatment.

DESIGN AND SETTING: A randomized-group design was used to examine differences between 2 groups of subjects following a 31-minute warm whirlpool (control) and a 31-minute contrast therapy (experimental) treatment. A hydrotherapy room in a small- college sports medicine facility served as the test environment.

SUBJECTS: Twenty (7 females and 13 males) healthy college students (age = 20.9 ± 1.2 years; ht = 178.5 ± 11.1 cm; wt = 79.2 ± 21.7 kg) volunteered to participate in this study. Subjects were randomly assigned to either a control or a treatment group.

MEASUREMENTS: Intramuscular tissue temperatures in the gastrocnemius were recorded every 30 seconds.

RESULTS: There was a significant difference in mean overall temperature change between the experimental group (0.85°C ± 0.60°C) and the control group (2.10°C ± 1.50°C). In addition, there were significant differences between the 2 groups at 10, 15, 16, 20, 21, 25, 26, 30, and 31 minutes. At each recording point, the control group temperature change was significantly higher than that of the experimental group. There was no difference in absolute temperatures at the 11-minute recording point between the groups.

CONCLUSIONS: Contrast therapy did not lead to significant fluctuations in muscle tissue temperature at 4 cm below the skin's surface. Therefore, it seems unlikely that the physiologic effects attributed to these fluctuations occur. A 1-minute exposure to a cold whirlpool during a typical contrast treatment does not appear to be long enough to significantly decrease tissue temperature after exposure to the warm hydrotherapy environment.

OBJECTIVE: The objective of this study was to identify core journals in physical therapy by identifying those that publish the most randomized controlled trials of physical therapy interventions, provide the highest-quality reports of randomized controlled trials, and have the highest journal impact factors. Design This study was an audit of a bibliographic database.

METHODS: All trials indexed in the Physiotherapy Evidence Database (PEDro) were analyzed. Journals that had published at least 80 trials were selected. The journals were ranked in 4 ways: number of trials published; mean total PEDro score of the trials published in the journal, regardless of publication year; mean total PEDro score of the trials published in the journal from 2000 to 2009; and 2008 journal impact factor.

RESULTS: The top 5 core journals in physical therapy, ranked by the total number of trials published, were Archives of Physical Medicine and Rehabilitation, Clinical Rehabilitation, Spine, British Medical Journal (BMJ), and Chest. When the mean total PEDro score was used as the ranking criterion, the top 5 journals were Journal of Physiotherapy, Journal of the American Medical Association (JAMA), Stroke, Spine, and Clinical Rehabilitation. When the mean total PEDro score of the trials published from 2000 to 2009 was used as the ranking criterion, the top 5 journals were Journal of Physiotherapy, JAMA, Lancet, BMJ, and Pain. The most highly ranked physical therapy-specific journals were Physical Therapy (ranked eighth on the basis of the number of trials published) and Journal of Physiotherapy (ranked first on the basis of the quality of trials). Finally, when the 2008 impact factor was used for ranking, the top 5 journals were JAMA, Lancet, BMJ, American Journal of Respiratory and Critical Care Medicine, and Thorax. There were no significant relationships among the rankings on the basis of trial quality, number of trials, or journal impact factor.

CONCLUSIONS: Physical therapists who are trying to keep up-to-date by reading the best available evidence on the effects of physical therapy interventions have to read more broadly than just physical therapy-specific journals. Readers of articles on physical therapy trials should be aware that high-quality trials are not necessarily published in journals with high impact factors.

OVERALL ARTICLE OBJECTIVE: To understand the concept of core strengthening.

BACKGROUND: According to the original model of cranial osteopathy, intrinsic rhythmic movements of the human brain cause rhythmic fluctuations of cerebrospinal fluid and specific relational changes among dural membranes, cranial bones, and the sacrum. Practitioners believe they can palpably modify parameters of this mechanism to a patient's health advantage.

DISCUSSION: This treatment regime lacks a biologically plausible mechanism, shows no diagnostic reliability, and offers little hope that any direct clinical effect will ever be shown. In spite of almost uniformly negative research findings, "cranial" methods remain popular with many practitioners and patients. SUMMARY: Until outcome studies show that these techniques produce a direct and positive clinical effect, they should be dropped from all academic curricula; insurance companies should stop paying for them; and patients should invest their time, money, and health elsewhere.

STUDY DESIGN: Quasi-experimental design.

OBJECTIVES: To determine if physical manipulation of the cranial vault sutures will result in changes of the intracranial pressure (ICP) along with movement at the coronal suture.

BACKGROUND: Craniosacral therapy is used to treat conditions ranging from headache pain to developmental disabilities. However, the biological premise for this technique has been theorized but not substantiated in the literature.

METHODS: Thirteen adult New Zealand white rabbits (oryctolagus cuniculus) were anesthetized and microplates were attached on either side of the coronal suture. Epidural ICP measurements were made using a NeuroMonitor transducer. Distractive loads of 5, 10, 15, and 20 g (simulating a craniosacral frontal lift technique) were applied sequentially across the coronal suture. Baseline and distraction radiographs and ICP were obtained. One animal underwent additional distractive loads between 100 and 10,000 g. Plate separation was measured using a digital caliper from the radiographs. Two-way analysis of variance was used to assess significant differences in ICP and suture movement.

RESULTS: No significant differences were noted between baseline and distraction suture separation (F = 0.045; P>.05) and between baseline and distraction ICP (F = 0.279; P>.05) at any load. In the single animal that underwent additional distractive forces, movement across the coronal suture was not seen until the 500-g force, which produced 0.30 mm of separation but no corresponding ICP changes.

CONCLUSION: Low loads of force, similar to those used clinically when performing a craniosacral frontal lift technique, resulted in no significant changes in coronal suture movement or ICP in rabbits. These results suggest that a different biological basis for craniosacral therapy should be explored.

OBJECTIVE: To review the literature regarding the curve of the cervical spine in normal and injured persons, emphasizing common variations in cervical curvature and their possible clinical significance. DATA SOURCE: A MEDLINE literature search of the English-language, human literature was performed using multiple search strategies relevant to radiography, posture, lordosis, injury, diagnosis and prognosis of the cervical spine (MESH: cervical vertebrae). Additionally, article bibliographies were searched for further relevant articles. No publication time limit was imposed.

STUDY SELECTION: Articles were identified by the author as being directly relevant to the objective and scope of this review.

DATA EXTRACTION: Data was extracted as presented in each original article.

DATA SYNTHESIS: The articles reviewed indicate that a wide range of normal exists in the posture and configuration of the cervical spine. Although kyphotic angulation and straightening or reversal of cervical lordosis are commonly seen following trauma, they may be normal variants. Muscle spasm is a widely used explanation for these variations when seen in patients with pain or trauma. Kyphotic angulation is often associated with posterior ligamentous injury of a motion segment. Prognostic significance of these variations is claimed by some authors.

CONCLUSION: There is little evidence to support the contention that altered cervical curvatures are of prognostic significance. Although kyphotic angulation is associated with anterior subluxation (hyperflexion sprain), it is not a reliable diagnostic criterion for that condition. It is reasonable to assume that straightening or reversal of a previously lordotic cervical curve is the result of muscular spasm, but more specific interpretation is not supported by the literature. More study is needed to characterize the specific dynamics and etiologies involved in the determination of cervical spine configuration.

BACKGROUND: Deep transverse friction massage (DTFM) is one of several physiotherapy interventions suggested for the management of tendinitis pain.

OBJECTIVES: To assess the efficacy of DTFM for treating tendinitis. SEARCH STRATEGY: We searched the MEDLINE, EMBASE, HealthSTAR, Sports Discus, CINAHL, the Cochrane Controlled Trials Register, PEDro, the specialized registry of the Cochrane musculoskeletal group and the Cochrane field of Physical and Related Therapies up to the end of June 2002. The reference list of the trials and key experts in the area were also consulted for additional studies. SELECTION CRITERIA: All randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing therapeutic ultrasound with control or another active intervention in patients with all types of tendinitis, such as iliotibial band friction syndrome and extensor carpi radialis tendinitis (i.e. tennis elbow or lateral epicondylitis or lateralis epicondylitis humeri), were selected. DATA COLLECTION AND ANALYSIS: Two reviewers determined the studies to be included based upon the inclusion and exclusion criteria (LB, VR). Data were independently abstracted by two reviewers (VR, LB), and checked by a third reviewer (BS) using a pre-developed form of the Cochrane Musculoskeletal Group. The two reviewers, using a validated checklist, assessed the methodological quality of the RCTs and CCTs independently. The pooled analysis was performed using weighted mean differences (WMDs) for continuous outcomes.

MAIN RESULTS: One RCT included patients with ITBFS. DTFM combined with rest, stretching exercises, cryotherapy and therapeutic ultrasound was compared to the control group (rest, stretching exercises, cryotherapy and therapeutic ultrasound only). This trial showed no statistical difference in the three types of pain relief measured after four consecutive sessions of DTFM combined with other physiotherapy modalities for runners. There was a clinically important relative percentage difference in pain while running of 22%. A RCT on ECRT showed no statistical difference in pain relief, grip strength and the three types of functional status measured after 9 consecutive sessions within 5 weeks of DTFM compared with other physiotherapy modalities. REVIEWER'S

CONCLUSIONS: DTFM combined with other physiotherapy modalities did not show consistent benefit over the control of pain, or improvement of grip strength and functional status for patients with ITBFS or for patients with ECRT. These conclusions are limited by the small sample size of the included RCTs. No conclusions can be drawn concerning the use or non use of DTFM for the treatment of ITBFS. Future trials, utilizing specific ITBFS methods and adequate sample sizes are needed, before conclusions can be drawn regarding the specific effect of DTFM on tendinitis.

OBJECTIVE: To evaluate efficacy and tolerability of once-daily cyclobenzaprine extended release (CER) 15- and 30-mg capsules in patients with muscle spasm associated with acute, painful musculoskeletal conditions.

METHODS: Two identically designed, randomized, double-blind, placebo- and active-controlled, parallel-group studies in patients aged 18-75 years with muscle spasm associated with neck or back pain. Patients received CER 15 or 30 mg once daily, cyclobenzaprine immediate release (CIR) 10 mg three times daily, or placebo for 14 days. Primary efficacy measures were patient's rating of medication helpfulness and physician's clinical global assessment of response to therapy at day 4. Secondary measures were patient's rating of medication helpfulness and physician's clinical global assessment of response (days 8 and 14), relief from local pain, global impression of change, restriction in activities of daily living, restriction of movement, daytime drowsiness, quality of nighttime sleep (days 4, 8, and 14), and quality of life (days 8 and 14).

RESULTS: A total of 156/254 randomized patients in study 1 and 174/250 in study 2 completed 14 days of treatment. Significant improvements in patient's rating of medication helpfulness were reported with CER versus placebo (CER 30 mg, study 1, p = 0.007; CER 15 mg, study 2, p = 0.018) at day 4. Significant improvements with CER 30 mg versus placebo were also seen at day 4 in study 1 for patient-rated global impression of change (p = 0.008), relief of local pain (p = 0.004), and restriction of movement (p = 0.002). Neither study reported differences between study groups on the physician's clinical global assessment. Improvements with CER were comparable to that of CIR. In both studies, daytime drowsiness was reported more frequently in active treatment groups than in the placebo group; however, reports of drowsiness decreased over time in all groups. In general, daytime drowsiness was reported more frequently in CIR groups than in CER groups. More adverse events were reported in the active treatment groups versus placebo and were similar in the CER and CIR groups, except somnolence, which occurred more frequently with CIR.

CONCLUSIONS: Once-daily CER 15 mg (study 2) and CER 30 mg (study 1) were effective in treating muscle spasm associated with painful musculoskeletal conditions after 4 days of treatment. Differences between CER and placebo groups did not reach statistical significance on all efficacy measures, and the protocols were not powered to detect differences between active treatment arms. CER was generally safe and well tolerated, with low rates of somnolence.

BACKGROUND: Neuropathic pain commonly affects the back and legs and is associated with severe disability and psychological illness. It is unclear how patients with predominantly neuropathic pain due to failed back surgery syndrome (FBSS) compare with patients with other chronic pain conditions. AIMS: To present data on characteristics associated with FBSS patients compared with those with complex regional pain syndrome, rheumatoid and osteoarthritis, and fibromyalgia.

METHODS: The PROCESS (Prospective Randomized Controlled Multicenter Trial of the Effectiveness of Spinal Cord Stimulation, ISRCTN 77527324) trial randomized 100 patients to spinal cord stimulation (n = 52) plus conventional medical management (CMM) or CMM alone (n = 48). Baseline patient parameters included age, sex, time since last surgery, employment status, pain location and severity (visual analogue scale), health-related quality of life (HRQoL), level of disability, medication, and nondrug therapies. Reference population data was drawn from the literature.

RESULTS: At baseline, patients in the PROCESS study had a similar age and gender profile compared with other conditions. PROCESS patients suffered from greater leg pain and had lower HRQoL. PROCESS patients treatment cost was higher and they commonly took opioids, while antidepressants and nonsteroidal anti-inflammatory drugs were more often used for other conditions. Prior to baseline, 87% of patients had tried at least 4 different treatment modalities.

CONCLUSIONS: Patients suffering from chronic pain of neuropathic origin following FBSS often fail to obtain adequate relief with conventional therapies (eg, medication, nondrug therapies) and suffer greater pain and lower HRQoL compared with patients with other chronic pain conditions. Neuropathic FBSS patients may require alternative and possibly more (cost-) effective treatments, which should be considered earlier in their therapeutic management.

OBJECTIVE: To investigate the presence of a "functionally normal" cervical lordosis and identify if this and the amount of forward head posture are related to neck complaints.

METHODS: Using the posterior tangent method, an angle of cervical lordosis was measured from C2 through C7 vertebrae on 277 lateral cervical x-rays. Anterior weight bearing was measured as the horizontal distance of the posterior superior body of the C2 vertebra compared to a vertical line drawn superiorly from the posterior inferior body of the C7 vertebra. The measurements were sorted into 2 groups, cervical complaint and noncervical complaint groups. The data were then partitioned into age by decades, sex, and angle categories.

RESULTS: Patients with lordosis of 20 degrees or less were more likely to have cervicogenic symptoms (P < .001). The association between cervical pain and lordosis of 0 degrees or less was significant (P < .0001). The odds that a patient with cervical pain had a lordosis of 0 degrees or less was 18 times greater than for a patient with a noncervical complaint. Patients with cervical pain had less lordosis and this was consistent over all age ranges. Males had larger median cervical lordosis than females (20 degrees vs 14 degrees) (2-sided Mann-Whitney U test, P = .016). When partitioned by age grouping, this trend is significant only in the 40- to 49-year-old range (2-sided Mann-Whitney U test, P < .01).

CONCLUSION: We found a statistically significant association between cervical pain and lordosis < 20 degrees and a "clinically normal" range for cervical lordosis of 31 degrees to 40 degrees. Maintenance of a lordosis in the range of 31 degrees to 40 degrees could be a clinical goal for chiropractic treatment.

BACKGROUND: The sacroiliac joint (SIJ) can be a source of low back and lower limb pain. The SIJ pain can originate not only from the joint space but also from the ligaments supporting the joint. Its diagnosis has been difficult because the physical and radiological examinations have proved less than satisfactory. Thus, to know the specific sites of SIJ pain, if these exist, could be very useful for making the diagnosis. The purpose of the present study was to identify the main site of SIJ pain according to the patient's pointing with one finger and to confirm the site by a pain-provocation test and periarticular lidocaine injection.

METHODS: Forty-six of 247 consecutive patients with low back pain at our outpatient clinic, who could indicate with one finger the main site of the pain, which presented at only one site and was reproducible, were the subjects of this study. The main site of pain was anatomically confirmed by fluoroscopy. Then, a periarticular SIJ injection was performed. The patients were blindly assessed and a diagram of the main site of the SIJ pain was made.

RESULTS: There were 19 males and 27 females and the age averaged 50 years. Eight patients showed a positive placebo response and were excluded from this study. Twenty-five of the remaining 38 patients indicated the main site of pain at the posterior-superior iliac spine (PSIS) or within 2 cm of the PSIS, and 18 of these patients showed a positive effect with periarticular SIJ block. The other 13 patients, including 2 patients with a positive response to the periarticular block, did not show the PSIS as the main site of pain.

CONCLUSIONS: Our study clearly indicated that when patients point to the PSIS or within 2 cm of it as the main site of low back pain, using one finger, the SIJ should be considered as the origin of their low back pain.