Robot-aided assessment of lower extremity functions: a review.


The assessment of sensorimotor functions is extremely important to understand the health status of a patient and its change over time. Assessments are necessary to plan and adjust the therapy in order to maximize the chances of individual recovery. Nowadays, however, assessments are seldom used in clinical practice due to administrative constraints or to inadequate validity, reliability and responsiveness. In clinical trials, more sensitive and reliable measurement scales could unmask changes in physiological variables that would not be visible with existing clinical scores.In the last decades robotic devices have become available for neurorehabilitation training in clinical centers. Besides training, robotic devices can overcome some of the limitations in traditional clinical assessments by providing more objective, sensitive, reliable and time-efficient measurements. However, it is necessary to understand the clinical needs to be able to develop novel robot-aided assessment methods that can be integrated in clinical practice.This paper aims at providing researchers and developers in the field of robotic neurorehabilitation with a comprehensive review of assessment methods for the lower extremities. Among the ICF domains, we included those related to lower extremities sensorimotor functions and walking; for each chapter we present and discuss existing assessments used in routine clinical practice and contrast those to state-of-the-art instrumented and robot-aided technologies. Based on the shortcomings of current assessments, on the identified clinical needs and on the opportunities offered by robotic devices, we propose future directions for research in rehabilitation robotics.

The review and recommendations provided in this paper aim to guide the design of the next generation of robot-aided functional assessments, their validation and their translation to clinical practice.

Does adding mobilization to stretching improve outcomes for people with frozen shoulder? A randomized controlled clinical trial.

3d rendered illustration of a painful shoulder

The objective of this study was to assess the effectiveness of joint mobilization combined with stretching exercises in patients with frozen shoulder through a RCT involving 30 patients. All participants were randomly assigned to one of two treatment groups: joint mobilization and stretching versus stretching exercises alone. Both groups performed a home exercise program and were treated for six weeks (18 sessions). The primary outcome measures for functional assessment were the Disabilities of the Arm, Shoulder and Hand score and the Constant score. The secondary outcome measures were pain level, as evaluated with a visual analog scale, and range of motion, as measured using a conventional goniometer. Patients were assessed before treatment, at the end of the treatment, and after one year as follow-up. Two-by-two repeated-measures ANOVA with Bonferroni corrections revealed significant increases in abduction (91.9° [CI: 86.1-96.7] to 172.8° [CI: 169.7-175.5]), external rotation (28.1° [CI: 22.2-34.2] to 77.7° [CI: 70.3-83.0]) and Constant score (39.1 [CI: 35.3-42.6] to 80.5 [75.3-86.6]) at the one-year follow-up in the joint mobilization combined with stretching exercise group, whereas the group performing stretching exercise alone did not show such changes.

In the treatment of patients with frozen shoulder, joint mobilization combined with stretching exercises is better than stretching exercise alone in terms of external rotation, abduction range of motion and function score.

Combining Manual Therapy and Strength Training

Physical therapists have been utilizing manual therapy techniques for decades, and rightly so. With the benefits of increasing mobility and reducing pain, why wouldn’t you use such a powerful tool? However, many clinicians and researchers question the efficacy of manual therapy, providing the rationale that since it is most likely NOT promoting long-lasting structural change, why use it?

Here’s the Truth. Manual therapy is not SUPPOSED to make long-lasting structural change. We are simply decreasing threat perception to allow the client to solidify these transient changes with proper exercise! For strength training athletes participating in sports such powerlifting, weightlifting, or Crossfit, manual therapy can be especially beneficial. To explain, let me propose to you a scenario:

Joe the Weightlifter
Your patient Joe is a competitive weightlifter. He comes to your clinic complaining of neck “tightness and pain” during the overhead position of his snatches and jerks. You perform your examination and find that there are no strength deficits and his form is spot on. The only motion that reproduces his pain is cervical retraction and extension. What do you do? Joe is already strong. Simply telling him to “go get stronger” may not be the best approach here. Something needs to be done first.

Incorporate Manual Therapy 
You realize that manual therapy could be an excellent choice here. You decide to utilize isometric holds at his current end range of cervical retraction and extension to try and transiently increase threat-free ROM. You have some success but can’t get him quite where he needs to be. Next, you perform a cervicothoracic manipulation to further open his window of opportunity.


After the manipulation, you re-test cervical retraction and extension and find that Joe now has full threat-free ROM. For the strength athlete, this next step is PIVOTAL. Now that Joe has full threat-free ROM, you take him over to the squat rack and have him perform a snatch or jerk! This is how we solidify our manual therapy techniques!

Pain Science Education
You explain to Joe that although his neck hurt in the overhead position, his form is spot on and he’s actually as strong as an ox. He does NOT have any muscular imbalances, mobility restrictions, or scar tissue buildup, (insert more though viruses here). You simply helped him reset his nervous system so that his brain no longer associates the overhead lockout position with pain. It’s now HIS job to keep the window of opportunity open. You tell him to perform cervical retraction/extension utilizing isometric holds for pain modulation prior to his training sessions and Joe now presses overhead pain-free. His brain no longer associates this overhead position with pain. 
Manual therapy is not intended to promote long-lasting results, it simply opens the window of opportunity to allow the patient to exercise pain-free. Decrease threat perception with manual therapy, then SOLIDIFY these transient results with strength training to promote true structural adaptation. This is how we combine manual therapy and strength training!

Dr. Michael Mash, DPT, CSCS, FMS is a physical therapist and strength coach located in Pittsburgh, PA. He started his company, Barbell Rehab, with the mission to promote strength training in physical therapy by implementing more barbell lifts into clinical practice. You can follow him on Facebook and Instagram and contact him at his website

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Effectiveness and Economic Evaluation of Chiropractic Care for the Treatment of Low Back Pain: A Systematic Review of Pragmatic Studies.

Chiropractor treating patient's back etiopathy. Selective focus on hands

Low back pain (LBP) is one of the leading causes of disability worldwide and among the most common reasons for seeking primary sector care. Chiropractors, physical therapists and general practitioners are among those providers that treat LBP patients, but there is only limited evidence regarding the effectiveness and economic evaluation of care offered by these provider groups. The purpose of this study was to estimate the clinical effectiveness and to systematically review the literature of full economic evaluation of chiropractic care compared to other commonly used care approaches among adult patients with non-specific LBP. A comprehensive search strategy was conducted to identify 1) pragmatic randomized controlled trials (RCTs) and/or 2) full economic evaluations of chiropractic care for low back pain compared to standard care delivered by other healthcare providers. Studies published between 1990 and 4th June 2015 were considered. Primary outcomes included pain, functional status and global improvement. Study selection, critical quality appraisal and data extraction were conducted by two independent reviewers. Data from RCTs with low risk of bias were included in a meta-analysis to determine effect estimates. Cost estimates of full economic evaluations were converted to 2015 USD and results summarized using Slavin’s qualitative best-evidence synthesis. Six RCTs and three full economic evaluations were scientifically admissible. Five RCTs with low risk of bias compared chiropractic care to exercise therapy (n = 1), physical therapy (n = 3) and medical care (n = 1). Overall, we found similar effects for chiropractic care and the other types of care and no reports of serious adverse events. Three low to high quality full economic evaluations studies (one cost-effectiveness, one cost-minimization and one cost-benefit) compared chiropractic to medical care. Given the divergent conclusions (favours chiropractic, favours medical care, equivalent options), mixed-evidence was found for economic evaluations of chiropractic care compared to medical care.

Moderate evidence suggests that chiropractic care for LBP appears to be equally effective as physical therapy. Limited evidence suggests the same conclusion when chiropractic care is compared to exercise therapy and medical care although no firm conclusion can be reached at this time. No serious adverse events were reported for any type of care. Our review was also unable to clarify whether chiropractic or medical care is more cost-effective. Given the limited available evidence, the decision to seek or to refer patients for chiropractic care should be based on patient preference and values. Future studies are likely to have an important impact on our estimates as these were based on only a few admissible studies.

Untold Physio Stories S2:E5 – Here are Your Options with Dr. Gene Shirokobrod

A patient is presented with two options, an more aggressive approach that may flare them up but have faster results or, less aggressive and take longer.  The patient choose the “faster” approach…listen in to find out what happens.  Thanks to Gene Shirokobrod for returning for a follow up episode.
To find about more about Gene follow him on Updoc Media and his podcast Therapy Insiders.
Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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What tendon pathology is seen on imaging in people who have taken fluoroquinolones? A systematic review.

Runner touching painful knee. Athlete runner training accident. Sport running knee sprain.

Fluoroquinolones (FQs) are highly effective broad spectrum antibiotics. Clinical data reveal an increased incidence of tendon pain and rupture in those taking FQs, yet little is known about tendon structural changes. This review synthesises published data on tendon structural changes in people who have taken FQs. Eight databases were searched for potentially relevant articles (Medline, CINAHL, Biological Abstracts, AMED, Web of Knowledge, SCOPUS, SportDiscus and EMBASE) using MeSH and free-text searches. Inclusion and exclusion criteria determined which articles were used for this review. Twenty-six papers met the eligibility criteria. The Achilles tendon was most commonly affected, while ciprofloxacin and levofloxacin were the most commonly implicated FQs. Mean time to onset of symptoms was 16 days following first FQ dose. Imaging modalities used included MRI, B-mode ultrasound, and CT. Tendon measurements were rarely reported and intra-tendinous imaging findings were not reported in a consistent manner. Few studies imaged tendons bilaterally and only two studies were longitudinal in design.

Future studies should report imaging measures such as thickness and cross-sectional area, and use consistent descriptions of intra-tendinous changes during and post FQ treatment.

Help us to Build a Credible Evidence Based Resource for our Global Profession

Abstract model of man of DNA molecule. Eps 10

Shared knowledge and learning is something which the team at Physiopedia are passionate about. Expert knowledge, opinion and experience are one of the most inspirational ways of learning and you can be a part of it. If you would like to make a lasting contribution to the profession globally and learn in a new way, there is an excellent opportunity ahead.

Anatomy is integral to being a successful therapist and Physiopedia recognises this. The Anatomy Content Development Project is pushing the boundary of clinically relevant and accurate peer reviewed resource for those who wish to learn, improve and revise their knowledge. Physiotherapists’ are experts in functional anatomy, everyone has something to offer and we are inviting you to get involved.  Help us to create great physiotherapy specific pages on anatomy (like the ones listed below).  For your contribution you will receive a certificate to evidence your work and know that you have been part of developing this clinically relevant evidence based resource for our profession.

Examples of excellent anatomy pages:

These excellent anatomy pages then go on to become fundamental foundations for other projects like the ICRC Cerebral Palsy Content Development Project and the Spinal Cord Injury Content Creation Project. The projects then culminate in fantastic courses such as the Cerebral Palsy MOOC which are unrivalled learning experiences.

Creating and editing this content is an ideal to way to learn the basics of what Physiopedia has to offer. Consider this as your opportunity to contribute to our profession’s worldwide knowledge database. If you want to get involved in any of these projects then please get in touch via email.

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