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Poster 151: Ultrasonographic Change After Local Steroid Injection for Carpal Tunnel Syndrome
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2006. All of them have been recommended for surgical management at other hospitals but sought a nonsurgical alternative. The visual analog scale (VAS) of radicular pain was 5 or higher. Interventions: Treatment package comprises Korean herbal medicine, Chuna (a Korean style systemic manipulative therapy), acupuncture, bee venom acupuncture (subcutaneous or intramuscular). Treatment schedule for a total of 24 weeks involves weekly clinic visits during which relevant therapies are carried out and the medicine for the following week is given. Outcome measurements are assessed at baseline, 2, 4, 8, 12, 24 weeks, 1 year, and 2 year. Clinical data were obtained at baseline from physician questionnaire and examination. Main Outcome Measures: Outcome measures are VAS of radicular pain, Owestry Disability Index (Korean Version) and SF-36. Results: Of 92 patients, 78 (84.7%) remained in the 24 week treatment plan and 64 (69.6%) could be checked at 1-year follow up. Finally, 57 (62%) could be checked at 2-year follow up. The mean scores of VAS, ODI, and SF-36 at baseline were 7.24, 41.31, and 36, respectively. At 24 weeks, they were 0.91, 12.5 and 68.63, respectively. Pain and functional disability decreases as the patients get more treatments during the treatment period. At 1 year, they were 0.83, 8.27, and 72, respectively. They were 0.45, 6.14, and 77.36, respectively at 2-year evaluation. Conclusions: These results suggest that this integrative treatment package can be an effective conservative treatment choice for some surgical candidates with lumbar disk herniation.
Poster 150 Trunk Muscle Activation Amplitudes During Gait in Adults Between 50 and 80 Years of Age With and Without Chronic Low Back Pain. Ed Hanada, MD (Dalhousie University/Capital District Health Authority, Halifax, NS, Canada); Mark F. Johnson, MSc PT; Cheryl L. Kozey, PhD. Disclosures: E. Hanada, None. Objective: To investigate abdominal and low back muscle activation amplitudes during walking in older adults experiencing chronic low back pain (CLBP). Design: Observational cohort study. Setting: Neuromuscular function laboratory. Participants: Nine CLBP and 9 asymptomatic (CON) participants between 50 and 80 years of age. Main Outcome Measures: Roland-Morris Disability, Activities-specific Balance Confidence Scale questionnaires, the short battery of physical performance measure, and trunk muscle activation. Surface EMGs were recorded over the left and right lower rectus abdomini (LRA), internal obliques (IO), lateral erector spinae longissimus (LES) and lumbar multifidus (LM) muscles while participants walked across a
PRESENTATIONS
pressure sensor mat at their self-selected speed. EMG data during each loading response (LR) and mid-stance (MSt) subphases of gait were root mean-squared and normalized to maximal voluntary isometric contractions (MVIC). Data Analysis: Two sample t tests were used to compare group demographic information and spatiotemporal gait parameters, while EMG differences between groups and subphases were analyzed for each muscle with general linear models, followed by Tukey HSD post hoc comparisons. Results: There were no significant between-group differences in questionnaires, or functional performance measures. The CLBP group walked with a significantly wider base of support (P⬍.001). The CON group activated their LRA (P⬍.001) and right IO (P⫽.02) significantly more than the CLBP group, while the CLBP group activated their left LES and both LM (P⬍.001) significantly more than the CON group. Both groups activated the left LM significantly more during the left LR than right LR (P⬍.001), and during the right MSt the CLBP group activated their right IO significantly less than the CON group (P⫽.0315). Conclusions: These muscle activation amplitude differences illustrate altered trunk muscle co-activation strategies for older adults with CLBP that may be more discriminative of specific deficits that can better guide therapy than gait parameters, questionnaires, or functional performance measures.
Poster 151 Ultrasonographic Change After Local Steroid Injection for Carpal Tunnel Syndrome. Sang Hee Im (Jeju National University School of Medicine, Jeju, Republic of Korea); Jinseok Kim; Yong Wook Kim, MD, PhD; Sang Chul Lee, MD, PhD. Disclosures: S. Im, None. Objective: To evaluate ultrasonographic change of median nerve after local steroid injection in carpal tunnel syndrome (CTS). Design: Prospective case series with 3-month follow-up. Setting: University rehabilitation hospital. Participants: Eleven individuals with 19 affected wrists with CTS diagnosed by electrodiagnostic study enrolled. Interventions: All patients were injected with 40 mg of triamcinolone acetonide and evaluated by ultrasonography at baseline, 1 week, 1 month and 3 months after steroid injection in carpal tunnel. Ultrasonographic follow-up values were compared with baseline values. Main Outcome Measures: Ultrasonographic parameter: cross-sectional area and flattening ratio (transverse/anteroposterior diameter) Results: Fifteen wrists showed clinical improvement at 1 week and all patients showed improvement at 1 month after injection. The following mean values of ultrasonographic parameter at baseline, 1 week, 1 month, and 3 months after
PM&R
steroid injection are as follows: cross-sectional area 15.68, 15.26, 13.53*, 11.70* mm2; flattening ratio 3.20, 3.16, 3.12, 3.10 (*P⬍.05). Conclusions: As a treatment effect of steroid injection in CTS, clinical improvement precedes morphological change of entrapped median nerve. Ultrasonography using the parameter cross-sectional area of median nerve might be a useful tool for monitoring the improvement of median nerve after CTS injection.
Poster 152 Ultrasound Imaging of Myofascial Trigger Points and Adjacent Soft Tissue. Robin Ortiz, BS (National Institutes of Health, Bethesda, MD); Tadesse M. Gebreab, BS; Naomi Lynn H. Gerber, MD; Jay P. Shah, MD; Siddhartha Sikdar, PhD. Disclosures: R. Ortiz, None. Objective: To evaluate an ultrasound (US) imaging scale for visualization and some characterization of myofascial trigger points (MTrPs) and adjacent soft tissue and to assess interrater reliability. Design: Descriptive study. Setting: Biomedical research center. Participants: 16 subjects meeting the Travell and Simons criteria for MTrPs of hypersensitive nodules in a taut band in the upper trapezius. Interventions: None. Main Outcome Measures: MTrPs were evaluated by physical examination and US imaging. Sites in each subject were labeled as either active MTrP (spontaneously painful), latent MTrP (nonpainful), or absent MTrP based on physical examination. Vibration sonoelastography (VSE), to assess stiffness, was performed by color Doppler variance imaging, while simultaneously inducing vibrations (⬃100 Hz) with a handheld massage vibrator. VSE and grayscale 2D US were analyzed to assign each site a tissue imaging score (TIS) as follows: 0 ⫽ uniform echogenicity and stiffness; 1 ⫽ focal hypoechoic, stiff nodule; 2 ⫽ multiple stiff nodules. Blood flow in the neighborhood of MTrPs was assessed using Doppler imaging. Each site was assigned a blood flow waveform score (BFS) as follows: 0 ⫽ no diastolic flow; 1 ⫽ elevated diastolic flow; 2 ⫽ oscillatory and/or retrograde diastolic flow. Two independent raters scored the images. Results: Our results show that MTrPs appear as focal, hypoechoic regions on 2D US, indicating local changes in tissue echogenicity, and as focal regions of reduced vibration amplitude on VSE, indicating a localized stiff nodule. MTrPs were more likely to have higher TIS and BFS compared with normal muscle (P⬍.05, Mann-Whitney test). Blood flow near MTrPs was retrograde in diastole indicating a highly resistive and compliant vascular bed, consistent with possible blood vessel compression. The BFS score showed a strong
Vol. 2, Iss. 9S, 2010
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intraclass correlation of 0.80 between the 2 raters, while the TIS score showed an intraclass correlation of 0.57. Conclusions: Current findings demonstrate validity and interrater reliability of our scoring technique for visualizing MTrPs.
Poster 153 Walking Assessment in People With Lumbar Spinal Stenosis: Capacity, Performance, and Self-report Measures. Justin Conway, BA (University of Michigan, Ann Arbor, MI); Andrew J. Haig, MD; Christy Tomkins, PhD. Disclosures: J. Conway, None. Objective: To examine the relationship between survey instruments, tested walking capacity, and daily ambulatory performance in people diagnosed with lumbar spinal stenosis (LSS). Design: Prospective laboratory and clinical observational study. Setting: Tertiary care spine clinic. Participants: 12 subjects with clinical stenosis significant enough to be scheduled for epidural injection. Interventions: Subjects filled out functional questionnaires; performed a Self-Paced Walking Test (SPWT) of up to 30 minutes; and wore an Actigraph activity monitor during waking hours for 7 days. Main Outcome Measures: Questionnaire (including the Swiss Spinal Stenosis Questionnaire, Pain Disability Index, Oswestry Disability Index, Quebec Back Pain Disability Scale, and SF-36), laboratory walk testing (walking capacity) and activity monitors (community ambulation). Results: There was no statistically significant relationship between walking capacity (SPWT) and community ambulation per day (activity monitors), however the maximum time of continuous activity during community ambulation had a strong relationship (r⫽0.63) with the SPWT. Fifteen selfreport measures of ambulation were significantly correlated with the SPWT, activity monitor, or both. Of these, 13 (87%) were more highly correlated to the SPWT than the activity monitor. The SPWT test had a strong relationship (r⬎.60, P⬍.05) with global function scales, but community ambulation did not. Conclusions: Ambulation limitation is the hallmark of impairment in LSS. Capacity and performance have been defined as 2 distinct aspects of disability. The results indicate that walking capacity and walking performance in LSS appear to be different constructs. Survey instruments appear to reflect capacity rather than performance. Since increased walking in the community is both a specific desired outcome for stenosis intervention and an important contributor to overall health, this dissociation between walking capacity and performance has implications for the clinical management and outcomes assessment of people with LSS.
2006. All of them have been recommended for surgical management at other hospitals but sought a nonsurgical alternative. The visual analog scale (VAS) of radicular pain was 5 or higher. Interventions: Treatment package comprises Korean herbal medicine, Chuna (a Korean style systemic manipulative therapy), acupuncture, bee venom acupuncture (subcutaneous or intramuscular). Treatment schedule for a total of 24 weeks involves weekly clinic visits during which relevant therapies are carried out and the medicine for the following week is given. Outcome measurements are assessed at baseline, 2, 4, 8, 12, 24 weeks, 1 year, and 2 year. Clinical data were obtained at baseline from physician questionnaire and examination. Main Outcome Measures: Outcome measures are VAS of radicular pain, Owestry Disability Index (Korean Version) and SF-36. Results: Of 92 patients, 78 (84.7%) remained in the 24 week treatment plan and 64 (69.6%) could be checked at 1-year follow up. Finally, 57 (62%) could be checked at 2-year follow up. The mean scores of VAS, ODI, and SF-36 at baseline were 7.24, 41.31, and 36, respectively. At 24 weeks, they were 0.91, 12.5 and 68.63, respectively. Pain and functional disability decreases as the patients get more treatments during the treatment period. At 1 year, they were 0.83, 8.27, and 72, respectively. They were 0.45, 6.14, and 77.36, respectively at 2-year evaluation. Conclusions: These results suggest that this integrative treatment package can be an effective conservative treatment choice for some surgical candidates with lumbar disk herniation.
Poster 150 Trunk Muscle Activation Amplitudes During Gait in Adults Between 50 and 80 Years of Age With and Without Chronic Low Back Pain. Ed Hanada, MD (Dalhousie University/Capital District Health Authority, Halifax, NS, Canada); Mark F. Johnson, MSc PT; Cheryl L. Kozey, PhD. Disclosures: E. Hanada, None. Objective: To investigate abdominal and low back muscle activation amplitudes during walking in older adults experiencing chronic low back pain (CLBP). Design: Observational cohort study. Setting: Neuromuscular function laboratory. Participants: Nine CLBP and 9 asymptomatic (CON) participants between 50 and 80 years of age. Main Outcome Measures: Roland-Morris Disability, Activities-specific Balance Confidence Scale questionnaires, the short battery of physical performance measure, and trunk muscle activation. Surface EMGs were recorded over the left and right lower rectus abdomini (LRA), internal obliques (IO), lateral erector spinae longissimus (LES) and lumbar multifidus (LM) muscles while participants walked across a
PRESENTATIONS
pressure sensor mat at their self-selected speed. EMG data during each loading response (LR) and mid-stance (MSt) subphases of gait were root mean-squared and normalized to maximal voluntary isometric contractions (MVIC). Data Analysis: Two sample t tests were used to compare group demographic information and spatiotemporal gait parameters, while EMG differences between groups and subphases were analyzed for each muscle with general linear models, followed by Tukey HSD post hoc comparisons. Results: There were no significant between-group differences in questionnaires, or functional performance measures. The CLBP group walked with a significantly wider base of support (P⬍.001). The CON group activated their LRA (P⬍.001) and right IO (P⫽.02) significantly more than the CLBP group, while the CLBP group activated their left LES and both LM (P⬍.001) significantly more than the CON group. Both groups activated the left LM significantly more during the left LR than right LR (P⬍.001), and during the right MSt the CLBP group activated their right IO significantly less than the CON group (P⫽.0315). Conclusions: These muscle activation amplitude differences illustrate altered trunk muscle co-activation strategies for older adults with CLBP that may be more discriminative of specific deficits that can better guide therapy than gait parameters, questionnaires, or functional performance measures.
Poster 151 Ultrasonographic Change After Local Steroid Injection for Carpal Tunnel Syndrome. Sang Hee Im (Jeju National University School of Medicine, Jeju, Republic of Korea); Jinseok Kim; Yong Wook Kim, MD, PhD; Sang Chul Lee, MD, PhD. Disclosures: S. Im, None. Objective: To evaluate ultrasonographic change of median nerve after local steroid injection in carpal tunnel syndrome (CTS). Design: Prospective case series with 3-month follow-up. Setting: University rehabilitation hospital. Participants: Eleven individuals with 19 affected wrists with CTS diagnosed by electrodiagnostic study enrolled. Interventions: All patients were injected with 40 mg of triamcinolone acetonide and evaluated by ultrasonography at baseline, 1 week, 1 month and 3 months after steroid injection in carpal tunnel. Ultrasonographic follow-up values were compared with baseline values. Main Outcome Measures: Ultrasonographic parameter: cross-sectional area and flattening ratio (transverse/anteroposterior diameter) Results: Fifteen wrists showed clinical improvement at 1 week and all patients showed improvement at 1 month after injection. The following mean values of ultrasonographic parameter at baseline, 1 week, 1 month, and 3 months after
PM&R
steroid injection are as follows: cross-sectional area 15.68, 15.26, 13.53*, 11.70* mm2; flattening ratio 3.20, 3.16, 3.12, 3.10 (*P⬍.05). Conclusions: As a treatment effect of steroid injection in CTS, clinical improvement precedes morphological change of entrapped median nerve. Ultrasonography using the parameter cross-sectional area of median nerve might be a useful tool for monitoring the improvement of median nerve after CTS injection.
Poster 152 Ultrasound Imaging of Myofascial Trigger Points and Adjacent Soft Tissue. Robin Ortiz, BS (National Institutes of Health, Bethesda, MD); Tadesse M. Gebreab, BS; Naomi Lynn H. Gerber, MD; Jay P. Shah, MD; Siddhartha Sikdar, PhD. Disclosures: R. Ortiz, None. Objective: To evaluate an ultrasound (US) imaging scale for visualization and some characterization of myofascial trigger points (MTrPs) and adjacent soft tissue and to assess interrater reliability. Design: Descriptive study. Setting: Biomedical research center. Participants: 16 subjects meeting the Travell and Simons criteria for MTrPs of hypersensitive nodules in a taut band in the upper trapezius. Interventions: None. Main Outcome Measures: MTrPs were evaluated by physical examination and US imaging. Sites in each subject were labeled as either active MTrP (spontaneously painful), latent MTrP (nonpainful), or absent MTrP based on physical examination. Vibration sonoelastography (VSE), to assess stiffness, was performed by color Doppler variance imaging, while simultaneously inducing vibrations (⬃100 Hz) with a handheld massage vibrator. VSE and grayscale 2D US were analyzed to assign each site a tissue imaging score (TIS) as follows: 0 ⫽ uniform echogenicity and stiffness; 1 ⫽ focal hypoechoic, stiff nodule; 2 ⫽ multiple stiff nodules. Blood flow in the neighborhood of MTrPs was assessed using Doppler imaging. Each site was assigned a blood flow waveform score (BFS) as follows: 0 ⫽ no diastolic flow; 1 ⫽ elevated diastolic flow; 2 ⫽ oscillatory and/or retrograde diastolic flow. Two independent raters scored the images. Results: Our results show that MTrPs appear as focal, hypoechoic regions on 2D US, indicating local changes in tissue echogenicity, and as focal regions of reduced vibration amplitude on VSE, indicating a localized stiff nodule. MTrPs were more likely to have higher TIS and BFS compared with normal muscle (P⬍.05, Mann-Whitney test). Blood flow near MTrPs was retrograde in diastole indicating a highly resistive and compliant vascular bed, consistent with possible blood vessel compression. The BFS score showed a strong
Vol. 2, Iss. 9S, 2010
S71
intraclass correlation of 0.80 between the 2 raters, while the TIS score showed an intraclass correlation of 0.57. Conclusions: Current findings demonstrate validity and interrater reliability of our scoring technique for visualizing MTrPs.
Poster 153 Walking Assessment in People With Lumbar Spinal Stenosis: Capacity, Performance, and Self-report Measures. Justin Conway, BA (University of Michigan, Ann Arbor, MI); Andrew J. Haig, MD; Christy Tomkins, PhD. Disclosures: J. Conway, None. Objective: To examine the relationship between survey instruments, tested walking capacity, and daily ambulatory performance in people diagnosed with lumbar spinal stenosis (LSS). Design: Prospective laboratory and clinical observational study. Setting: Tertiary care spine clinic. Participants: 12 subjects with clinical stenosis significant enough to be scheduled for epidural injection. Interventions: Subjects filled out functional questionnaires; performed a Self-Paced Walking Test (SPWT) of up to 30 minutes; and wore an Actigraph activity monitor during waking hours for 7 days. Main Outcome Measures: Questionnaire (including the Swiss Spinal Stenosis Questionnaire, Pain Disability Index, Oswestry Disability Index, Quebec Back Pain Disability Scale, and SF-36), laboratory walk testing (walking capacity) and activity monitors (community ambulation). Results: There was no statistically significant relationship between walking capacity (SPWT) and community ambulation per day (activity monitors), however the maximum time of continuous activity during community ambulation had a strong relationship (r⫽0.63) with the SPWT. Fifteen selfreport measures of ambulation were significantly correlated with the SPWT, activity monitor, or both. Of these, 13 (87%) were more highly correlated to the SPWT than the activity monitor. The SPWT test had a strong relationship (r⬎.60, P⬍.05) with global function scales, but community ambulation did not. Conclusions: Ambulation limitation is the hallmark of impairment in LSS. Capacity and performance have been defined as 2 distinct aspects of disability. The results indicate that walking capacity and walking performance in LSS appear to be different constructs. Survey instruments appear to reflect capacity rather than performance. Since increased walking in the community is both a specific desired outcome for stenosis intervention and an important contributor to overall health, this dissociation between walking capacity and performance has implications for the clinical management and outcomes assessment of people with LSS.