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A review of spinal immobilization techniques.

Immobilization of the spine is an important skill for all emergency providers. This article reviews the literature regarding the equipment, adjuncts, and techniques involved in spinal immobilization. Current prehospital practice is to apply spinal immobilization liberally in cases of suspected neck or back injury. Rigid cervical collars, long backboards, and straps remain the standard implements for immobilizing supine patients. Tape, foam blocks, and towels can complement the basic items and improve stability. Padding may improve positioning and comfort. Intermediate-stage devices include the short backboard and newer commercial devices. Properly used, all provide reasonable immobilization of the sitting patient. Future directions for study include refinement of optimal body position, dynamic performance of all devices, and broadening study populations to include children and the elderly.

Emergency Medical Services↗

Physical therapy for the equine back.

Before a physical therapy and rehabilitation program is suggested, the end requirement must be considered. All physiotherapeutic machines are subject to laboratory screening. In the United States, the approval of the Food and Drug Administration is required; in the United Kingdom, certification by the National Physics Laboratory has been required by law since January 1996. Laboratory experiments are continually conducted to examine and evaluate the effects on tissues of varied electrical waveforms, low-intensity electrical currents, sound waves, and light rays delivered by a variety of therapeutic apparatuses. It is interesting to note that the tissues used for this work are derived from the rabbit, rat, and chick embryo. If these investigative procedures demonstrate benefit to tissue behavior following trauma in laboratory animals, they are then considered to be of benefit to humans. Surely, it must follow that equal benefit is to be derived by other species with similar tissues. Despite veterinarian prejudice to the contrary and by careful case selection rather than random application, horses can profit from the application of electrotherapy and derive benefit from rehabilitation; thus, an informed physical therapist should be considered a useful member of a "care" team. Because no two cases are ever the same, it is impossible to write a "recipe" book stating exactly the dosage, treatment time, or applications per week or per day. Success depends on an in-depth assessment of individual needs followed by an informed choice of therapy. In the case of physical therapy, this necessitates the use of the appropriate modality at the appropriate time, always taking into account the fact that tissue is living and is therefore in a continually changing state. The art of the physical therapist is to read the situation each time a patient is seen and to proceed according to the findings of the moment. The author regrets that there are no double-blind trials to quote or published research available to substantiate rehabilitation methods. The therapy principles relating to proprioceptive input, cortical re-education, muscle recoordination, and atrophy following both micro- and macrotrauma have been transferred in field work from humans to horses.

Animals↗

A non-MVC EMG normalization technique for the trunk musculature: Part 1. Method development.

Normalization of muscle activity has been commonly used to determine the amount of force exerted by a muscle. The most widely used reference point for normalization is the maximum voluntary contraction (MVC). However, MVCs are often subjective, and potentially limited by sensation of pain in injured individuals. The objective of the current study was to develop a normalization technique that predicts an electromyographic (EMG) reference point from sub-maximal exertions. Regression equations predicting maximum exerted trunk moments were developed from anthropometric measurements of 120 subjects. In addition, 20 subjects performed sub-maximal and maximal exertions to determine the necessary characteristic exertions needed for normalization purposes. For most of the trunk muscles, a highly linear relationship was found between EMG muscle activity and trunk moment exerted. This analysis determined that an EMG-moment reference point can be obtained via a set of sub-maximal exertions in combination with a predicted maximal exertion (expected maximum contraction or EMC) based upon anthropometric measurements. This normalization technique overcomes the limitations of the subjective nature for the MVC method providing a viable assessment method of individuals with a low back injury or those unwilling to exert an MVC as well as could be extended to other joints/muscles.

Adult↗

A non-MVC EMG normalization technique for the trunk musculature: Part 2. Validation and use to predict spinal loads.

Estimates of the amount of force exerted by a muscle using electromyography (EMG) rely partially upon the accuracy of the reference point used in the normalization technique. Accurate representations of muscle activities are essential for use in EMG-driven spinal loading models. The expected maximum contraction (EMC) normalization method was evaluated to explore whether it could be used to assess individuals who are not capable of performing a maximum exertion such as a person with a low back injury. Hence, this study evaluated the utility of an EMG normalization method (Marras and Davis, A non-MVC EMG normalization technique, Part 1, method development. Journal of Electromyography and Kinesiology 2000) that draws upon sub-maximal exertions to determine the reference points needed for normalization of the muscle activities. The EMC normalization technique was compared to traditional MVC-based EMG normalization by evaluating the spinal loads for 20 subjects (10 males and 10 females) performing dynamic lifts. The spinal loads (estimated via an EMG-assisted model) for the two normalization techniques were very similar with differences being <8%. The model performance variables indicated that both normalization techniques performed well (r(2)>0.9 and average error below 6%) with only the muscle gain being affected by normalization method as a result in different reference points. Based on these results, the proposed normalization technique was considered to be a viable method for EMG normalization and for use in EMG-assisted models. This technique should permit the quantitative evaluation of muscle activity for subjects unable to produce maximum exertions.

Adult↗

An electromyographic study of isokinetic axial rotation in young adults.

BACKGROUND CONTEXT: Trunk rotation is associated with over 60% of all low back injuries. However, there are gaps in the knowledge about trunk rotation. PURPOSE: To study the axial rotation torque and electromyographs (EMGs) of seven trunk muscles bilaterally in static and isokinetic modes with increasing angular velocity to determine qualitative and quantitative muscle response. STUDY DESIGN: An electromyographic study of seven trunk muscles bilaterally was carried out in 50 normal subjects during static and isokinetic axial rotation at varying angular velocity. The qualitative and quantitative force and EMG measures were made and analyzed phenomenologically and statistically. METHODS: Fifty normal young adults (27 men, 23 women) performed an isometric maximal voluntary contraction (MVC) from the neutral upright-seated posture to their right and left. Also, these subjects performed isokinetic axial rotation from neutral seated position to right and left, and from prerotated right and left "end of range posture" toward the neutral at 10, 20 and 40 degrees per second angular velocity. All experimental trials were made on axial rotation tester designed for the study. EMG was recorded from the erector spinae at L3 and T10 vertebral levels, latissimus dorsi, pectoralis major, rectus abdominis and external and internal obliques bilaterally. The torque and EMG in isokinetic condition were normalized against those of isometric condition. Descriptive statistics were calculated. Data were subjected to analysis of variance, and torque was regressed on EMG. RESULTS: The peak isokinetic torques were significantly lower than the isometric torques (p<.01), but the EMGs of the isokinetic conditions were significantly higher than those of isometric trials (p<.01). The isokinetic axial rotation torque decreased by 1 Nm to 1.5 Nm with per degree increase in velocity of rotation, with the values for 10, 20 and 40 degrees per second angular velocities being significantly different (p<.01). There was a significant increase (p<.01) in percent EMG (up to 28%) per unit torque with increasing angular velocity of rotation. The rotation torque from prerotated position to neutral was significantly higher than that of rotation away from the neutral (p<.001). The EMG magnitude increased significantly with increasing velocity (2% to 17% at 10 degrees per second), 21% to 28% at 20 degrees per second, 30% to 36% at 40 degrees per second). Regression analysis revealed poor predictability of torque based on EMG. The latter was suggested because of the role and behavior of the ligaments and joint capsules of the spine. CONCLUSION: The axial rotation is initiated and maintained by the contralateral external obliques, ipsilateral latissimus dorsi and internal oblique. The ipsilateral erector spinae likely play a stabilizer role. The isometric torque is greater than the isokinetic, which decreases with increasing velocity. Even with decreasing torque, EMG progressively increases, indicating a disproportionally higher stress in the spinal connective tissues potentiating injury. The data presented here suggest that, for safety, load and velocity of rotation should be kept low.

Abdomen↗

Gender-related differences in treatment outcomes for patients with musculoskeletal disorders.

BACKGROUND CONTEXT: Clinicians have long hypothesized that gender may be a risk factor in treatment outcomes of patients with chronic disability associated with musculoskeletal disorders. Although the scientific literature shows a higher prevalence of occupational low back injury in men, and a higher rate of repetitive motion and neck injuries in women, few studies have comprehensively investigated the role of gender regarding cost-related outcome variables of significance after work-related injuries. PURPOSE: This study was designed to examine the relationship between gender and biopsychosocial treatment outcomes in a predominately chronically disabled spinal disorder (CDSD) workers' compensation cohort undergoing a tertiary functional restoration program. STUDY DESIGN: A prospective comparison cohort study investigating the effect of gender on biopsychosocial treatment outcomes as risk factors for rehabilitation failure. PATIENT SAMPLE: A cohort of 1,827 consecutively treated patients with CDSD were placed into two gender-based groups: men (n=1,158, average age 40.7+/-10 years) and women (n=669, average age 42.5+/-10 years). OUTCOME MEASURES: Before the start of the program, and again upon completion of the program, all patients received a standard psychosocial assessment and were assessed on a variety of physical factors (leading to a cumulative score, calculated on the basis of the aggregates and averages of these physical measures). A structured clinical interview examining socioeconomic outcomes was conducted at 1 year after program completion, and at least partial information was obtained from this interview on all patients in the present study. METHODS: All patients underwent a medically directed functional restoration program combining quantitatively guided exercise progression with a multimodal disability management approach using psychological and case management techniques. RESULTS: Men had a significantly higher rate of lumbar injury than women, whereas women had a significantly higher rate of cervical injury. Men returned to work and retained work at a 40 hours/week job at a higher rate at 1-year follow-up. Women evidenced a higher rate of health care-seeking behaviors from new providers. On physical testing immediately after treatment, men had a significantly higher cumulative physical score (gender normalized), both before and after treatment. On depression and disability questionnaires, men showed fewer pre- and posttreatment depressive symptoms with lower pretreatment disability scores. CONCLUSIONS: The present study represents the first large-scale examination of the relationship between gender and treatment outcomes for a population with CDSD after work injuries. There was a pattern of moderately better 1-year posttreatment socioeconomic outcome for men. On psychosocial measures, men showed lower disability and depression scores than women, with higher levels of physical functioning both before and after treatment. Overall, male patients with CDSD appeared to show somewhat better biopsychosocial outcomes. This leaves the question of identifying gender-specific risk factors to explain these differences.

Absenteeism↗

Post-traumatic ligamentum flavum hematoma: a case report.

We present the case of a 64-year-old female treated surgically for ligamentum flavum hematoma that caused progressive radiculopathy. Initially, she suffered from an acute onset of lower back pain. Only a history of minor back injury was discovered. She rapidly became unable to walk. Magnetic resonance imaging demonstrated an epidural mass lesion at L3 to L4 that was continuous with the left ligamentum flavum. The mass was hypointense on T1-weighted images and centrally hyperintense and marginally hypointense on T2-weighted images. The margin was well enhanced by gadopentetate dimeglumine administration. After removal of the mass, the patient's symptoms completely resolved. Before surgery, we believe accurate diagnosis of ligamentum flavum hematoma can be based on magnetic resonance imaging.

Accidental Falls↗

Development of chronic daily headache: a clinical study.

We studied the development of chronic daily headache in 258 headache practice patients, 50 men and 208 women. Chronic daily headache was defined as headaches occurring at least 5 days per week for at least 1 year. Twenty-two percent of the patients had daily headaches from the onset, and 78% initially experienced intermittent headaches. Of the patients with initially intermittent headaches, 19% experienced an abrupt transition into daily headaches and 81% a gradual one. The distribution of the age of daily headache onset was the same in the patients with daily headaches from the onset and in those with initially intermittent headaches but with abrupt transition into daily headaches. The distribution of the circumstances of daily headache onset was also the same in the groups. The most common circumstance of abrupt onset of daily headaches was head, neck, or back injury, in 61% caused by a motor vehicle accident. In the patients with initially intermittent headaches but with gradual transition into daily headaches, the transition took an average of 10.7 years.

Adolescent↗

Circumstances of onset of chronic headache in patients attending a specialty practice.

In a data base of 1013 patients with chronic headache, 44.1% reported the onset of headaches before the age of 20 (preadult-onset headache) and 55.9% at or after that age (adult-onset headache). Circumstances of headache onset were mentioned significantly more frequently in the latter than in the former group (8.5% versus 38.2%, P < .001). The 10 most common circumstances of headache onset in adult-onset chronic headache, accounting for 87.9% of all circumstances mentioned, are further discussed. The 3 most common factors, accounting for 58.4% of all circumstances, were head, neck, or back injury; stress; and pregnancy. Illnesses, influenzalike and otherwise, and estrogen administration for birth control or hormone replacement shared the fourth place. It is concluded that in the etiology of chronic headache, other than genetic factors should be considered as well.

Attention↗

Trunk muscle activation in open stance and square stance tennis forehands.

Electromyography of the trunk muscles were compared between the open and square stance forehand drives of 14 collegiate tennis players. Surface EMG were bilaterally collected from the rectus abdominis (RA), external oblique (EO), and erector spinae (ES) in open and square stance forehand drives. EMG data were transferred by telemetry, 12 bit A/D converted at 1000 Hz, and stored for analysis. Rectified and smoothed EMG data were normalized (NEMG) to maximal isometric voluntary contractions and mean NEMG were calculated during the forward swing and follow through phases of the stroke. A 2 x 2 x 2 x 6 factorial ANOVA (Gender, Stance, Phase, Muscle) with repeated measures on Subject showed significant (p < 0.05) effects of Gender, Muscle, Phase, and several interactions. The nonsignificant differences in muscle activation between stances did not support the belief of tennis experts that open stance forehands require greater trunk activation than square stance forehands. Mean NEMG of the ES were significantly (p < 0.05) larger than EO or RA, which was consistent with observations of tennis-specific strength imbalances and increasing incidence of low back injuries in tennis.

Abdomen↗

Sports injuries in floorball: a prospective one-year follow-up study.

Two hundred and ninety-five licensed floorball players from Finnish premier to fifth division were observed prospectively for one season to study the incidence, nature, causes and severity of floorball injuries. During the study period, 100 out of the 295 (34 %) players sustained 120 injuries. Thirty-seven percent (73/199) of the male players and 28 % (27/96) of the females suffered from an injury. The injury rate was 1.0 per 1000 practice hours for both sexes. The injury rates per 1000 game hours were 23.7 for men and 15.9 for women. One hundred injuries (83 %) were acute and the remaining 20 (17 %) were overuse injuries. Sprain was the most common type of injury in men while overuse injuries were the most frequent injury type in women. The lower extremity was involved in 62 %, spine or trunk in 19 % and upper extremity in 10 % of the injuries. The most commonly injured sites were the knee and ankle (22 % and 20 % of all injuries), followed by head and neck (8 %). In both sexes the majority of injuries were minor, level II, injuries. Ten of the knee injuries (38 %) were serious, level IV injuries, of which seven were ACL ruptures. In conclusion, the individual risk of injury in floorball is relatively low in game practice while rather high during the game itself. Before initiation of clinical trials on prevention of floorball injuries, an exact knowledge of the risk factors and mechanisms of floorball injuries are needed.

Adult↗

Post-traumatic distal nerve entrapment syndrome.

Eleven patients with paralysis of muscle groups in the upper or lower extremity were clinically diagnosed after previous proximal direct trauma to the corresponding peripheral nerves, without complete nerve disruption. Patients were seen within an average of 8 months after trauma (minimum 3 months and maximum 2 years after). Nerve lesions were caused either by gunshot, motor-vehicle accident, and other direct trauma or, in one case, after tumor excision. All patients presented with complete sensory and motor loss distal to the trauma site, but demonstrated a positive Tinel sign and pain on testing over the "classic" (distal) anatomic nerve entrapment sites only. After surgical release through decompression of the nerve compression site distal to the trauma, a recovery of sensory function was achieved after surgery in all cases. Good-to-excellent restoration of motor function (M4/M5) was achieved in 63 percent of all cases. Twenty-five percent had no or only poor improvement in motor function, despite a good sensory recovery. Those patients in whom nerve compression sites were surgically released before 6 months after trauma had an improvement in almost all neural functions, compared to those patients who underwent surgery later than 9 months post trauma. A possible explanation of traumatically caused neurogenic paralysis with subsequent distal nerve compressions is provided, using the "double crush syndrome" hypothesis.

Adolescent↗

The industrial back problem: role of the industrial hygienist and ergonomics.

This article discusses a major and costly problem in industry today--the industrial back problem. What does industrial hygiene have to do with back accident problems? This article relates the problem to the basic philosphy of industrial hygiene and ergonomics. Information is provided to give the reader a better understanding of the back problem. The role of industrial hygiene and ergonomics is explained as a help to industry in curbing the high costs and workdays lost due to perplexing back problems in industry.

Adult↗

The effects of a sloped ground surface on trunk kinematics and L5/S1 moment during lifting.

There are many work environments that require workers to perform manual materials handling tasks on ground surfaces that are not perfectly flat (e.g. in agriculture, construction, and maritime workplaces). These sloped ground surfaces may have an impact on the lifting strategy/technique employed by the lifter, which may, in turn, alter the biomechanical loading of the spine. Describing the changes in kinematics and kinetics of the torso is the first step in assessing the impact of these changes and is the focus of the current research. Subjects' whole-body motions were recorded as they lifted a 10 kg box while standing on two inclined surfaces (facing an upward slope: 10 degrees and 20 degrees), two declined surfaces (facing a downward slope: -10 degrees and -20 degrees), and a flat surface (0 degrees) using three lifting techniques (leg lift, back lift and freestyle lift). These data were then used in a two-dimensional, five-segment dynamic biomechanical model (top-down) to evaluate the effect of these slopes on the net moment about the L5/S1 joint. The results of this study showed an interesting interaction effect wherein the net L5/S1 moment was relatively insensitive to changes in slope angle under the back lift condition, but showed a significant effect during the leg lift and freestyle lifting conditions. The results show that under the freestyle lifting condition the peak L5/S1 moment was significantly higher for the inclined surfaces as compared to the flat surfaces (6.8% greater) or declined surfaces (10.0% greater). Subsequent component analysis revealed that both trunk flexion angle and angular trunk acceleration were driving this response. Collectively, the results of this study indicate that ground slope angle does influence the lifting kinematics and kinetics and therefore needs to be considered when evaluating risk of low back injury in these working conditions.

Adult↗

An ergonomic evaluation of nursing assistants' job in a nursing home.

Thirty-eight nursing assistants (NAs) in a nursing home ranked and rated 16 different patient handling tasks for perceived stresses to the low back. The nursing assistants were observed for 79 4 h shifts and were videotaped for 14 4 h shifts to describe a typical workday and to determine the number of patient-handling tasks performed per shift, the use of assistive devices, and biomechanical stresses to the low back. In addition, data were collected on nursing assistants' and patients' characteristics. The top eight ranked tasks included transferring patient from toilet to wheelchair (WC), WC to toilet, WC to bed, bed to WC, bathtub to WC, chairlift to WC, weighing patients and lifting patients up in bed. The mean ratings of perceived exertion for these tasks were between 'somewhat hard' and 'hard'. The estimated compressive force on L5/S1 disc for the 50th percentile patient weight ranged from 3.7 to 4.9 KN. Nursing assistants worked in teams of two and performed 24 patient transfers per 8 h shift by manually lifting and carrying patients. Assistive devices (a hydraulic lift and gait belt) were used less than 2% of the time. Patient safety and comfort, lack of accessibility, physical stresses associated with the devices, lack of skill, increased transfer time, and lack of staffing were some of the reasons for not using these assistive devices. Environmental barriers (such as confined workplaces, an uneven floor surface, lack of adjustability of beds, stationary railings around the toilet, etc.) made the job more difficult. Nursing assistants had a high prevalence of low-back pain and 51% of nursing assistants visited a health care provider in the last three years for work related low-back pain.

Accidents, Occupational↗

Acceptable workloads for three common mining materials.

A series of psychophysical lifting studies was conducted to establish maximum acceptable weights of lift (MAWL) for three supply items commonly handled in underground coal mines (rock dust bags, ventilation stopping blocks, and crib blocks). Each study utilized 12 subjects, all of whom had considerable experience working in underground coal mines. Effects of lifting in four postures (standing, stooping under a 1.5 m ceiling, stooping under a 1.2 m ceiling, and kneeling) were investigated together with four lifting conditions (combinations of lifting symmetry and lifting height). The frequency of lifting was set at four per min, and the task duration was 15 min. Posture significantly affected the MAWL for the rock dust bag (standing MAWL was 7% greater than restricted postures and kneeling MAWL was 6.4% less than stopped); however, posture interacted with lifting conditions for both of the other materials. Physiological costs were found to be significantly greater in the stooped postures compared with kneeling for all materials. Other contrasts (standing versus restricted postures, stooping under 1.5 m ceiling versus stopping under 1.2 m ceiling) did not exhibit significantly different levels of energy expenditure. Energy expenditure was significantly affected by vertical lifting height; however, the plane of lifting had little influence on metabolic cost. Recommended acceptable workloads for the three materials are 20.0 kg for the rock dust bag, 16.5 kg for the ventilation stopping block, and 14.7 kg for the crib block. These results suggest that miners are often required to lift supplies that are substantially heavier than psychophysically acceptable lifting limits.

Accidents, Occupational↗