The Musculoskeletal Examination

The lead article for this issue of the Journal of Musculoskeletal Pain [JMP] comes from Bergen and Oslo, Norway (1). It begins with a fairly profound statement that is too often ignored in this age of sonographic, radiographic, magnetic, and nuclear imaging. The authors state that “Musculoskeletal complaints manifest themselves in physical changes that can be examined in a valid and reliable way.” The focus of the authors' report is on the informed systematic palpation of muscles and skin. The purpose of that examination is to populate the clinical database with numeric information that is achievable without resorting to the use of expensive machinery. As with any other scientific endeavor, systematic methodology is needed to effectively perform the examination and, indeed, methodologies reign supreme in this report. The reader should not expect that a quick reading of this report will magically achieve the interpretative skills possessed by the authors. On the other hand, the authors have applied their knowledge of the problem to the task of simplifying the methodology, so that these skills can be within the reach of any clinician who is willing to invest a reasonable effort into learning how to apply that methodology. It seems likely that the authors' new protocol for muscle and skin evaluation will be widely adopted for objective documentation of soft tissue examination findings, especially in situations where a numeric value for the current status would be useful.

The second research contribution comes from Istanbul, Turkey (2). The authors evaluated the relationships between clinical symptoms of patients with carpal tunnel syndrome [CTS] and the findings from electromyography. They documented subjective complaints using the Boston Carpal Tunnel Syndrome Questionnaire and a neuropathy questionnaire referred to as DN4 questions. The authors modified Padua et al.'s (3) neurophysiological classification of CTS. Thus, the patients were classified electrophysiologically as falling into one of three groups: mild sensory, mild motor-sensory, or severe motor-sensory CTS. The criteria for these designations are provided by the authors in their Materials and Methods section. The reader is advised to critically evaluate the authors' findings. Ponder particularly the potential value of applying the DN4 neuropathology questions to patients with CTS.

A study reported from Ankara, Turkey (4) evaluated the strength of shoulder rotators in patients with the shoulder impingement syndrome. The procedure involved the use of a computerized isokinetic dynamometer with the shoulder in the scapular plane at 45 degrees of abduction and 30 degrees of forward flexion, while the elbow was in 90 degrees of flexion. Isokinetic strength evaluation for internal and external rotation of the shoulder was first accomplished at an angular velocity of 90 degrees per second, and then at an angular velocity of 180 degrees per second. Based on the results, the authors propose an interesting biomechanical explanation for the development of the impingement syndrome.

Pain emanating from the region of one or more sacroiliac [SI] joint[s] in women with SI area back pain is the focus of a report from Tehran, Iran (5). The authors evaluated the ability of women with a diagnosis of SI joint pain to extend one of their legs to a vertical ankle height of 20 cm [straight leg raise] while lying prone on an examining table. The side on which this maneuver caused the most severe pain was the one studied. The procedure was monitored by documenting the severity of the pain induced and by surface electromyography of the pelvic musculature. The procedure was studied de novo and after applying a 5 cm wide non-elastic belt around the pelvis at the level of the anterior superior iliac spine tightened to 50 N to compress the pelvis. The question to be answered was whether this compression would reduce the SI joint pain and allow the straight leg raising test to be accomplished more comfortably. If so, subsequent questions might be: What next? Is the belt practical therapy? If worn persistently, will it facilitate a permanent correction or will it weaken the structural muscles by disuse? Perhaps an etiologic diagnosis would be a valuable guide?

A report on an alternative treatment for chronic low back pain [LBP] with tai chi comes from Fujian, China (6). This study was designed to compare the efficacy of tai chi when compared with other forms of exercise for retired athletes who had developed LBP. The authors reported that, in the last five years, their institution has treated more than a 1000 retired athletes with LBP caused by a slipped disk. That is a remarkably large number of cases. This report pertains to a six-month, double-blind, randomized controlled trial with 320 retired athletes, between 25 and 45 years of age, who had experienced LBP for one to five years and reported a 100 mm visual analog scale severity of pain between 40 and 100 mm. Potential study candidates were excluded if they had received any physical treatment in the prior three months. The participants were randomly allocated to a tai chi training group [N = 141], or to other forms of exercise [N = 132] composed of a swimming group [N = 38], a jogging group [N = 47], and a backward walking group [N = 47], and finally, there was a non-exercise control group [N = 47]. The exercise groups were to participate daily on their own for 30 minutes after a 15 minute warm-up. The aggressiveness of the exercise was clearly specified for the tai chi group, but not for the other forms of exercise. It is important to note that all the patients received a complete spa package of physical therapy including massage, traditional Chinese manipulation, traction, and electrotherapy. The authors state that, “At the beginning of our trial, participants were told that these exercises were helpful with alleviating back pain.” It is unclear whether this hopeful statement was given to the non-exercise group as well, in which case, they might feel deprived of a helpful intervention. The outcomes assessor was blinded to group assignment. The main outcome instrument was a LBP visual analog scale administered at baseline, at three-months, and at six-months. The participant groups were not different at baseline. During the trial, nine patients from the tai chi group and seven from the other groups were lost to follow-up. The reader will want to consult the paper to learn how tai chi compared with other forms of exercise as interventions for LBP by comparison with the no-exercise control group. When interpreting the results, do not ignore the potential additive or synergistic effects of the complete spa package which was received by all.

A very severe form of back pain is experienced by patients with osteoporotic vertebral fractures. Authors from Zhengzhou, Henan Province, China conducted a prospective study of percutaneous vertebroplasty as a management strategy for the severe pain of chronic [>3 months] osteoporotic spinal fractures (7). The diagnosis was established radiographically as evidenced by low signal in T1 and high signal in T2 on magnetic resonance imaging. The procedure involved fluoroscopically guided injection of polymethyl methacrylate into the collapsed vertebral body through a transpedicular needle placed with the benefit of local anesthesia. Injection of the cement ceased when substantial resistance was met, or when the cement reached the cortex edge of the vertebral body, or in the case of extraosseous extravasation of the cement. A total of 40 individuals were divided into two groups with one group receiving the therapeutic injection procedure while the other group was treated conservatively. Ninety percent of the study patients provided follow-up a full year after baseline. The results clearly call for further study.

On the topic of pain associated with traumatic spinal cord injury, comes a report by investigators from Bursa and Ankara, Turkey (8). The study was designed to determine the prevalence of pain in such patients and to characterize the pain they experienced. Several validated questionnaire instruments were used to assess the severity of the injury, the pain intensity, and the functional state of 90 affected patients.

Finally, authors from Lisbon and Coimbra, Portugal collaborated with an author from Oslo, Norway to develop and validate a Portuguese Language Version of the Tampa Scale for Kinesiophobia; yes, fear-based avoidance of therapeutic exercise (9). The original English version of this instrument had 17 questions and used a four-point Likert scale to assess the perception of risk and self-confidence to perform physical movements. The authors found scientific basis for reducing the numbers of items from 17 to 13 and then followed all of the steps involved in translation into Portuguese and validation for Portuguese language application. This instrument can now be applied to Portuguese-speaking people, most of which will be found in Portugal and Brazil. This manuscript can also serve as a model to the process of translation and validation of a questionnaire instrument for use in clinical study or medical care.

There are four useful case reports with helpful literature reviews. The first, from Mumbai, India (10), describes the development of complex regional pain syndrome with bilateral limb involvement in an adolescent. The authors report the findings and the interventions which led to gratifying improvement. The second case, from authors in Brescia, Italy (11), describes their inadvertent discovery that the muscles involved in cervical dystonia can be identified by positron emission tomography because they are hypermetabolic relative to uninvolved regional muscles. The third case comes from authors in Ankara, Turkey (12). They report the presentation and unfortunate outcome of a young male who developed bilateral foot drop resulting from exertion-related compartment syndrome. Health care professionals from all fields of endeavor will wish to put this condition in their memory banks because early diagnosis and intervention can change the course of history for such affected individuals. And finally, a 37 year old female presented with left hip area pain and was found to have a lumbosacral plexopathy due to a 2+ cm multilocular ganglion cyst which was compressing the sciatic nerve between the piriformis muscle and obturator internus muscle (13).

Please note the special interest columns which provide reviews of papers published in other medical journals since the previous issue of the JMP. The topical categories of these reviews are fibromyalgia syndrome, myofascial pain syndrome, and other soft tissue pain syndromes.

As always, readers of the JMP are invited to submit original manuscripts for blinded peer review, case reports of general interest, research ideas to promote further investigation, and letters to keep us all informed. The JMP editorial office frequently receives relevant books to be evaluated by and for the benefit of our readers. Book reviewers are allowed to keep the featured book after their evaluation report is completed. Readers who would be interested in being a book reviewer for the JMP, please communicate that to the editor [[email protected]].

Potential authors of contributions to the JMP should note that submissions and all communications between the authors and the JMP staff are to be accomplished online. Visit http://mc.manuscriptcentral.com/wjmp for more details.

The clear mandate of the International MYOPAIN Society [IMS], for which the JMP is the official journal, is to perpetuate the international meeting [MYOPAIN] that has been held every three years, but is moving soon to an every two years schedule. The next International MYOPAIN Meeting will be MYOPAIN 2013 which will be held in the beautiful Pacific seacoast town of Seattle, Washington, DC, United States. Dr Philip Mease, IMS Vice President and Program Chairman for the Seattle meeting is already making plans. Two years later, the International MYOPAIN 2015 Meeting will be held in the elegant Pacific coast town of Sydney, Australia, as the IMS hopes to better serve our growing numbers of members from Asia and the Pacific Rim. The IMS website www.myopain.com will offer details as they become available.

Be aware that Regional IMS Chapters are beginning to form. The first to be officially organized was in Thailand. Please contact Pradit Prateepavanich, MD, PhD [Department of Rehabilitation Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, E-mail: [email protected], [email protected]] if you wish to learn how.

If you have questions about anything pertaining to IMS, administrator Larry E Bodkin, Jr., M.S. [1876-B Eider Court, Tallahassee, FL 32308, United States; Tel: [phone], Fax: [phone]; E-mail: lbodkin@ myopain.org; Website www.myopain.org] will have the answers. All communications regarding IMS operations should be directed to Larry Bodkin and his staff. With Mr Bodkin's experienced leadership, we can expect growth and progress on many fronts. Dues payment and new member applications can be tendered via the www.myopain.org website.