Functional outcomes and life satisfaction in long-term survivors of pediatric sarcomas

OBJECTIVES: To describe the inter-relationships among impairments, performance, and disabilities in survivors of pediatric sarcoma and to identify measurements that profile survivors at risk for functional loss. DESIGN: Prospective, cross-sectional. SETTING: Research facility. PARTICIPANTS: Thirty-two participants in National Cancer Institute clinical trials. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Range of motion (ROM), strength, limb volume, grip strength, walk velocity, Assessment of Motor and Process Skills (AMPS); Human Activity Profile (HAP), Sickness Impact Profile (SIP), standard form of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36); and vocational attitudes and leisure satisfaction. RESULTS: Twenty of 30 survivors tested had moderate or severe loss of ROM; 13 of 31 tested had 90% or less of predicted walk velocity; all of whom had trunk or lower-extremity lesions. Women with decreased ROM (r=.50, P=.06) or strength (r=.74, P=.002) had slow gait velocity. Sixteen of 31 tested were more than 1 standard deviation below normal grip strength. Eighteen had increased limb volume. These 18 had low physical competence (SF-36) (r=-.70, P=.001) and high SIP scores (r=.73, P=.005). AMPS scores were lower than those of the matched normed sample (P<.001). HAP identified 15 of 30 who had moderately or severely reduced activity. Leisure satisfaction was higher in the subjects (P<.001). Eight reported cancer had negatively impacted work and 17 reported that it negatively impacted vocational plans. CONCLUSIONS: Survivors with lower-extremity or truncal lesions and women with decreased ROM and strength likely have slow walk velocity, low exercise tolerance, and high risk for functional loss. They should be identified using ROM, strength, limb volume, and walk time measures.     

Perceived control is a concurrent predictor of activity limitations in patients with chronic idiopathic axonal polyneuropathy

OBJECTIVES: To investigate (1) whether control perceptions (person's perception of ease or difficulty of performing behavior) and emotions contribute to activity limitations and if so (2) whether these variables mediate the relation between impairment and activity limitations in patients with chronic idiopathic axonal polyneuropathy (CIAP). DESIGN: Cross-sectional study. SETTING: Outpatient clinics of a university medical center. PARTICIPANTS: Fifty-six patients diagnosed with CIAP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Control perceptions about performing activities (questionnaire based on the theory of planned behavior), emotions (Hospital Anxiety and Depression Scale), activity limitations (performance: Shuttle Walk Test [SWT]; self-report: Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36] physical functioning subscale, self-reported ability to walk), and physical impairments (muscle strength, sensory function). RESULTS: Control perceptions significantly (P<.01) correlated with all measures of activity limitations (r range, .58-.69). Hierarchical multiple regression analyses showed that perceived control explained 9% of the variance in the SWT (beta=.34, P<.01), 12% in the SF-36 (beta=.40, P<.01), and 24% in ability to walk (beta=.54, P<.01). In all measures of activity limitations, perceived control significantly mediated the effect of impairment. CONCLUSIONS: Perceived control explained and mediated variance in activity limitations, whereas emotions did not. This suggests that increasing patients' perceptions of control might enhance performance of activities, even without changes in impairment.     

Osteogenesis imperfecta in childhood: impairment and disability. A prospective study with 4-year follow-up

OBJECTIVES: To study (1). changes in anthropometrics, joint range of motion (ROM), muscle strength, functional ability, caregiver assistance, and level of ambulation in children with osteogenesis imperfecta (OI) and (2). the prediction of clinical characteristics at the level of ambulation at follow-up and the prediction of clinical characteristics on progression or regression at the level of ambulation over time. DESIGN: Prospective study with follow-up of 4 years. SETTING: A children's hospital that serves a nationwide center for treatment and research in children with OI in the Netherlands. PARTICIPANTS: At follow-up, 49 children (24 boys, 25 girls; mean age +/- standard deviation, 11.3+/-3.8y; range, 5.2-19.4y) participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Anthropometry, joint ROM, muscle strength, fracture frequency, intramedullary rodding, level of ambulation, functional ability, and caregiver assistance. RESULTS: In type I OI, total joint ROM decreased significantly over time, especially in the lower extremities, with a significant decrease in generalized joint hypermobility according to Bulbena (median start, 7.5; interquartile range [IQR], 4-9; median end, 6; IQR, 2-7; P<.001). In types III and IV, a severe decrease in total joint ROM was present without significant changes over time. No significant changes in total muscle strength (upper or lower extremities) in the different types of OI were measured at follow-up. In OI type I, a significant increase in self-care (P=.003) and social function (P=.008) was measured; in type III, a significant increase in self-care (P=.003), mobility (P=.004), and social function (P=.005) was measured, with a significant decrease in parental assistance in self-care (P=.02) and mobility (P=.005). In type IV, a significant increase was observed in the self-care (P=.01) and social function domains (P=.02). Type of OI (regression coefficient=-1.0; 95% confidence interval [CI], -1.64 to -0.47) and total muscle strength were the only significant predictors for level of ambulation (regression coefficient=.01; 95% CI,.17-.32). Body weight was significantly lower in the group that progressed in level of ambulation (P=.03), whereas children with a decline in level of ambulation had significantly higher body weight (P=.05). CONCLUSIONS: Ours is the first study with a long-term follow-up that provides information concerning the natural course of developmental outcome parameters of OI in childhood. Joint ROM and muscle strength did not change significantly over time, possibly because of the biomechanical skeletal properties of the different OI types. Functional ability improved significantly over time, but, especially in types III and IV, did not reach normative values, possibly because of a plateau phase in functional ability. Knowledge of the natural course of the disease is essential to interpret the results from intervention studies.     

Acupuncture for upper-extremity rehabilitation in chronic stroke: a randomized sham-controlled study

OBJECTIVE: To compare the effects of traditional Chinese acupuncture with sham acupuncture on upper-extremity (UE) function and quality of life (QOL) in patients with chronic hemiparesis from stroke. DESIGN: A prospective, sham-controlled, randomized controlled trial (RCT). SETTING: Patients recruited through a hospital stroke rehabilitation program. PARTICIPANTS: Thirty-three subjects who incurred a stroke 0.8 to 24 years previously and had moderate to severe UE functional impairment. INTERVENTIONS: Active acupuncture tailored to traditional Chinese medicine diagnoses, including electroacupuncture, or sham acupuncture. Up to 20 treatment sessions (mean, 16.9) over a mean of 10.5 weeks. MAIN OUTCOME MEASURES: UE motor function, spasticity, grip strength, range of motion (ROM), activities of daily living, QOL, and mood. All outcomes were measured at baseline and after treatment. RESULTS: Intention-to-treat (ITT) analyses found no statistically significant differences in outcomes between active and sham acupuncture groups. Analyses of protocol-compliant subjects revealed significant improvement in wrist spasticity (P<.01) and both wrist (P<.01) and shoulder (P<.01) ROM in the active acupuncture group, and improvement trends in UE motor function (P=.09) and digit ROM (P=.06). CONCLUSIONS: Based on ITT analyses, we conclude that acupuncture does not improve UE function or QOL in patients with chronic stroke symptoms. However, gains in UE function observed in protocol-compliant subjects suggest traditional Chinese acupuncture may help patients with chronic stroke symptoms. These results must be interpreted cautiously because of small sample sizes and multiple, unadjusted, post hoc comparisons. A larger, more definitive RCT using a similar design is feasible and warranted.     

Decreased strength and mobility in patients after anterior cervical diskectomy compared with healthy subjects

OBJECTIVE: To evaluate whether patients acquired normal physical function after cervical disk prolapse and surgery compared with healthy matched controls. DESIGN: Cross-sectional study. SETTING: Hospital in central Finland. PARTICIPANTS: Fifty-three patients with cervical diskectomy and 53 healthy matched controls. INTERVENTIONS: Not applicable.Main Outcome Measures: Postoperative physical function was studied by measuring muscle strength and range of motion (ROM) values of the neck and grip strength. Disability was assessed by the neck and shoulder pain index and by the Oswestry index, mood by the Short Depression Inventory; and pain on a visual analog scale (VAS). RESULTS: Most patients recovered well after the operation. Forty-three percent of the patients still experienced moderate or high pain (VAS score, >30mm). Subjective pain and disability were associated with decreased neck movement and strength. Both ROM and cervical muscle strength values were significantly lower (P<.001) in all the measured directions in cervical disk surgery patients compared with healthy controls. ROM was mostly confined in extension (25%). Muscle strength of the neck was mostly confined in both rotation directions (38%). No statistically significant difference in grip strength was found between the groups. CONCLUSION: The loss of muscle strength and ROM is clearly visible postoperatively and thus the effectiveness of the early identification and rehabilitation of these deficits merits further studies.     

Multiple epiphyseal dysplasia misdiagnosed as bioinactive growth hormone disorder

We have reported a case of multiple epiphyseal dysplasia (MED) that was misdiagnosed for many years as bioinactive growth hormone disorder. The condition was misdiagnosed because of its rarity and the physicians' lack of familiarity with it. MED should be considered in the differential diagnosis of a child with short stature and delayed growth. Close follow-up of a patient receiving growth hormone is necessary.     

Validity of an Alternate Hand Behind Back Shoulder Range of Motion Measurement in Patients With Shoulder Pain and Movement Dysfunction

Objectives

The purpose of this study was to determine the criterion-related validity of a novel method of measuring hand behind back (HBB) shoulder range of motion (ROM) for evaluating pain and disability in people with shoulder pain and movement impairment.

Shoulder pain, range of motion, and functional motor skills after acute tetraplegia

OBJECTIVES: To investigate (1) the prevalence and course of shoulder pain in acute tetraplegia and (2) its relationship with range of motion (ROM) and function and any associated risk factors. DESIGN: A longitudinal prospective study. SETTING: Spinal injury unit in an Australian hospital. PARTICIPANTS: Inpatients with acute tetraplegia. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographics, pain intensity, shoulder ROM, and functional motor skills. RESULTS: The prevalence of pain during rehabilitation was 85%. Risk factors associated with pain during rehabilitation included age less than 30 years or more than 50 years (F=8.892, P=.064), admission motor level at C2-5 (F=5.833, P=.016), admission sensory level at C2-5 (F=7.543, P=.006), lower left upper limb (P=.005; 95% confidence interval [CI], -14.74 to -2.86) and total American Spinal Injury Association motor scores (P=.009; 95% CI, -29.53 to -4.67), and a shorter duration of bedrest (F=5.794, P=.055). Subjects with pain lost ROM in left abduction (P=.038; 95% CI, -25.9 to -0.9) and right abduction (P=.05; 95% CI, -30 to 9.3). No relationship existed between shoulder pain and functional motor skills on discharge. CONCLUSION: Shoulder pain is common in acute tetraplegia and is associated with loss of shoulder ROM. Risk factors identified include age, injury level, and duration of bedrest. Areas for further study are identified.     

Predictive factors and correlates for pain in postpoliomyelitis syndrome patients

OBJECTIVE: To identify predictive and associated factors for muscle and joint pain in postpoliomyelitis syndrome (PPS). DESIGN: Cross-sectional study design. SETTING: Postpolio clinics. PARTICIPANTS: Baseline data on 126 PPS patients entered into a multicentered clinical trial. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adjusted odds ratios were computed by using logistic regression modeling. Patients with or without muscle or joint pain were compared with regard to predictors and associated factors. RESULTS: In multivariate analyses for muscle pain, significant predictive and associated factors were female gender (P=.0006), longer duration of general fatigue (P=.019), and a lower score on the general health scale (P=.009) of the Medical Outcomes Study 36-Item Short-From Health Survey (SF-36). In multivariate analyses for joint pain, significant predictive and associated factors were female gender (P<.003), longer latency (duration of stability after polio; P=.008), younger age at interview (P<.002), greater weakness at acute polio (P<.07), weaker lower-extremity muscle strength (P<.04), and a lower SF-36 general health scale score (P<.02). CONCLUSIONS: Women are more likely to report muscle and joint pain in PPS. Greater initial motor unit involvement and lower-extremity weakness may be additional important factors for determining joint pain. Both muscle and joint pain are associated with reductions in quality of life.     

Differences in pain perception in women using concentric and monopolar needles

OBJECTIVE: To examine pain perception using concentric needle electrodes and monopolar needle electrodes in an all-female study group without underlying hand or arm pain complaints, using study subjects as their own controls. DESIGN: Prospective randomized study. Two muscles--the biceps and abductor pollicis brevis (APB)--were examined using both a concentric needle electrode and a monopolar needle electrode. SETTING: University community. PARTICIPANTS: Eighty healthy female employees at the University of Utah and Primary Children's Hospital were enrolled. All completed the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pain scores. Posttest verbal analog pain scale (0-10) measures were obtained after each muscle was studied. A subset of subjects (n=51) was asked to identify needle preference after completion of the study. RESULTS: There was no significant difference in mean pain scores between the concentric needle electrode and the monopolar needle electrode (3.06 and 3.10, respectively; P=.803). The APB muscle was significantly more painful than the biceps muscle with both needle types (mean pain scores, 3.92 and 2.24, respectively; P<.001). In the subset of subjects asked to identify needle preference after completion of the study, 21 chose a concentric needle electrode and 30 a monopolar needle electrode. This difference was not statistically significant. However, verbal analog pain scores were lower with the needle preferred by each subject (P<.20). CONCLUSIONS: There is no significant difference in mean pain scores reported between a concentric needle electrode and a monopolar needle electrode. Subjects were clear on the needle they preferred, and the pain scores reported for the less painful needle were lower than those for the other needle.     

Improvement of voluntary quadriceps muscle activation after total knee arthroplasty

OBJECTIVE: To evaluate the maximal voluntary contraction (MVC) force and the voluntary activation of the quadriceps femoris muscle in patients with knee osteoarthritis (OA) before and after total knee arthroplasty (TKA). DESIGN: A prospective intervention study. SETTING: University hospital clinic in Germany. PATIENTS: Fifty patients (32 women, 18 men; mean age +/- standard deviation, 65.8+/-5.6 y) with knee OA and 23 healthy age- and gender-matched control subjects. INTERVENTION: Unilateral TKA without patella resurfacing. MAIN OUTCOME MEASURES: Voluntary activation, MVC, and true maximal contraction forces of the bilateral quadriceps femoris muscles, using the twitch interpolation technique before and 33+/-8 months after TKA. Assessment of postoperative knee pain by the Lewis score. RESULTS: Voluntary activation increased bilaterally after surgery (P<.01 operated side, P=.02 nonoperated side) but remained lower than the voluntary activation of the controls. MVC (P<.001) and true maximal contraction forces (P=.01) increased significantly on the operated side. MVC remained unchanged (P=.45), and true maximal contraction forces decreased significantly (P=.04) on the nonoperated side. CONCLUSION: Patients with knee OA have significant bilateral voluntary activation deficits that are, at least in part, reversible within 3 years after TKA. Rehabilitation programs immediately after TKA should focus on reduction of voluntary activation deficits. After voluntary activation improves, physical therapy should target the augmentation of quadriceps femoris muscle strength.     

Influence of specific muscle training on pain,activity limitation and kinesiophobia in women with back pain post‐partum — A ‘Single‐subject research design’

Background and Purpose . Many women suffer from back pain and experience activity limitation post‐partum. To our knowledge the physiological factors and physiotherapy related to back pain post‐partum have received limited evaluation and the effectiveness of specific physiotherapeutic approaches to exercise should be tested. In addition, there has been limited research on kinesiophobia in women with back pain post‐partum. The purpose of the current study was to test the influence of specific trunk muscle training on pain, activity limitation and kinesiophobia in 10 subjects with back pain post‐partum. Method . The treatment consisted of specific deep muscle training of the transversus abdominus and multifidus muscles. Pain was rated based on the visual analogue scale (VAS) and pain drawings. Activity limitation was recorded using the Disability Rating Index. Kinesiophobia was evaluated using the Swedish version of the Tampa Scale for Kinesiophobia. An A–B–A single‐subject research design was used and a number of measurements were obtained during each phase. The analysis consisted of a visual inspection and a two standard deviation band test (2‐SD). Results . The visual analysis showed a trend towards reduced pain and activity limitation for all 10 subjects. The 2‐SD test showed mixed results among all subjects. In addition, all subjects reported kinesiophobia before and after treatment. Conclusions . Individual specific deep muscle training of the transversus abdominus and multifidus muscles reduced pain and activity limitation in women with back pain post‐partum. Further research is needed to determine more precisely how kinesiophobia affects women with back pain post‐partum. Copyright © 2007 John Wiley & Sons, Ltd.     

Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial

OBJECTIVE: To assess the effects of acetic acid iontophoresis on the treatment of calcifying tendinitis of the shoulder. DESIGN: Double-blind randomized controlled trial. SETTING: Ambulatory academic hospital in Quebec, Canada. PARTICIPANTS: Thirty-six subjects with a calcifying tendinitis of the shoulder. INTERVENTIONS: Subjects were randomized into 1 of 2 groups: physiotherapy during 6 weeks (10 sessions) plus acetic acid iontophoresis for the treatment group (n=18) and sham acetic acid iontophoresis for the control group (n=18). MAIN OUTCOME MEASURES: The Shoulder Pain and Disability Index (SPADI), shoulder range of motion (ROM); and radiologic evaluation of shoulder calcifications. RESULTS: Nine patients dropped out, leaving 27 assessable subjects for analysis. Interim analysis showed that, in both groups, treatment led to improvement, as measured by the SPADI score (P=.004), ROM of the shoulder for abduction (P<.001), internal rotation (P=.001), external rotation (P<.001), and the mean number of calcifications per subject (P=.010). Although no formal significant intervention effects (P=.13) were found for the primary endpoint (SPADI), exploratory analyses suggest a greater improvement in the treatment group (P=.001) than in the control group (P=.33). CONCLUSIONS: Despite a trend toward greater improvement in the SPADI score in the treatment group, the use of acetic acid iontophoresis and physiotherapy for the treatment of calcifying tendinitis of the shoulder did not result in better clinical and radiologic effects than those observed in subjects treated by physiotherapyalone.     

The effect of zaltoprofen on physiotherapy for limited shoulder movement in breast cancer patients: a single-blinded before-after trial

OBJECTIVE: To determine the efficacy of oral administration of zaltoprofen on shoulder range of motion (ROM) exercises for breast cancer patients after surgery. DESIGN: Single-blind, before-after trial. SETTING: Rehabilitation facility in a Japanese university hospital. PARTICIPANTS: Forty breast cancer patients (age range, 37-72y) with limited shoulder movement after surgery. INTERVENTION: Single session of physiotherapy (PT) with or without oral administration of zaltoprofen. MAIN OUTCOME MEASURES: Active shoulder ROM in flexion, abduction, and external rotation, as well as subjective pain score during shoulder movements. RESULTS: Active shoulder movements after ingesting a zaltoprofen tablet significantly improved in flexion, abduction (P<.001), and external rotation (P<.005). PT treatment improved flexion and abduction ROM in both the zaltoprofen and control groups and led to significantly larger flexion and abduction movements in the zaltoprofen group than in the control group (P<.01). There were no differences in pain scores between groups, but 2 patients who did not receive zaltoprofen complained of increased pain just after ROM exercises. CONCLUSION: Zaltoprofen taken orally before ROM exercises for painful shoulder after breast cancer surgery may enhance the effects of PT.     

Biomechanic changes in passive properties of hemiplegic ankles with spastic hypertonia

OBJECTIVE: To investigate quantitatively biomechanic changes in the passive properties of hemiplegic spastic ankles. DESIGN: Evaluation of spastic hypertonia by moving the ankle joint slowly between dorsiflexion and plantarflexion extreme positions under controlled joint torque and position. SETTING: Institutional research center. PARTICIPANTS: Twenty-four stroke patients with spastic ankles and 32 healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Passive resistance torque at controlled dorsiflexion and plantarflexion positions, dorsiflexion and plantarflexion range of motion (ROM) at controlled torques, and quasistatic stiffness and energy loss in dorsiflexion and plantarflexion. RESULTS: Spastic hypertonic ankles showed significant alterations of the passive properties in plantarflexion (P=.041) as well as in dorsiflexion (P=.016) directions. Compared with healthy controls, spastic ankles showed higher resistance torque (9.51+/-4.79Nm vs 6.21+/-3.64Nm, P=.016), higher quasistatic stiffness (.54+/-.19Nm/deg vs .35+/-.20Nm/deg, P=.001) at 10 degrees of dorsiflexion, larger normalized dorsiflexion energy loss (.068+/-.04J/deg vs .04+/-.02J/deg, P=.037), and decreased dorsiflexion ROM at 10Nm of resistance torque (10.77 degrees +/-8.69 degrees vs 20.02 degrees +/-11.67 degrees , P=.014). The resistance torque, ROM, and stiffness of spastic hypertonic ankles in plantarflexion showed similar changes (P<.05) to those in dorsiflexion. The passive ROM, joint stiffness, and resistance torque at controlled positions correlated with each other and also correlated with the Modified Ashworth Scale (P<.01). CONCLUSIONS: Various biomechanic changes in both plantar- and dorsiflexors are associated with spastic hypertonia of chronic stroke patients, and they can be evaluated quantitatively under well-controlled conditions. With simplifications, the various measures in this study can potentially be used to obtain more comprehensive and quantitative evaluations of spastic hypertonia in a clinical setting.     

Changes in flexed posture, musculoskeletal impairments, and physical performance after group exercise in community-dwelling older women

OBJECTIVE: To determine whether improvements in flexed posture, strength, range of motion (ROM), and physical performance would be observed after 12 weeks of group exercise in older women who because of age are prone to flexed posture and impaired physical function. DESIGN: Pretest-posttest of outcome measures. SETTING: Outpatient academic medical center. PARTICIPANTS: Twenty-one women with thoracic kyphosis of 50 degrees or greater. INTERVENTION: Multidimensional group exercise performed 2 times a week for 12 weeks. MAIN OUTCOME MEASURES: Primary dependent measures of flexed posture included kyphosis, forward head, and height. Other dependent measures included spinal extensor muscle strength; shoulder, hip, and knee ROM; balance; modified Physical Performance Test (PPT); jug test; and gait speed. RESULTS: Baseline kyphosis was 57 degrees +/-5.0 degrees , and age was 72.0+/-4.2 years. There were significant improvements in usual (-6 degrees +/-3 degrees ) and best kyphosis (-5 degrees +/-3 degrees ) (P<.001), spinal extensor muscle strength (21%+/-13% of peak torque/body weight, P<.001), popliteal angle (right, 7 degrees +/-7 degrees ; left, 9 degrees +/-10 degrees ; P<.001), modified PPT (2+/-2 points, P<.001), and jug test (-1.4+/-1.3s, P<.001). Age and modified PPT at baseline correlated with change in kyphosis (r=0.5, P=.02; r=.42, P=.055, respectively). CONCLUSIONS: Multidimensional group exercise reduced measured kyphosis and improved strength, ROM, and physical performance. This study provides a promising exercise intervention that may improve posture and physical performance in older women with flexed posture.     

Ankle and subtalar motion during gait in arthritic patients

The purposes of this study were 1) to document ankle and subtalar motion during gait in 20 healthy subjects and in 25 patients with rheumatoid arthritis (RA) and 2) to determine stride characteristics with and without the use of an extended University of California Biomechanics Laboratory orthosis in RA patients with painful ankle and hindfoot deformity. An insole foot-switch system and ankle and subtalar electrogoniometers measured stride characteristics and dynamic range of motion (ROM). Arthritic patients demonstrated less ROM than healthy subjects except for ROM of hindfoot valgus. Arthritic patients also had slower gait velocity and less single limb support (SLS) time. In five new and five current orthotic wearers, a significant increase (p less than .01) in velocity and SLS time occurred with shoes and a further significant increase (p less than .01) occurred with the orthosis. Nine of 10 patients reported a decrease in ankle and hindfoot pain after using the orthosis. This study demonstrates the value of an orthosis for the treatment of arthritic patients with ankle and hindfoot pain and deformity.     

Predictors of delay in presentation to the ED in patients with suspected acute coronary syndromes

Delays in seeking medical attention for patients with acute coronary syndromes (ACS) preclude early application of life-saving treatment and diminish efficacy. Previous studies suggest 3-hour delays between onset of symptoms and ED arrival in patients with typical presentations of acute myocardial infarction (AMI). A prospective observational study was conducted in an urban ED measuring lag time (LT) among adults presenting within 48 hours of onset of symptoms suggestive of ACS. Univariate and multiple regression analyses were performed on 5 predictors: age, sex, symptoms at presentation, and 2 different outcomes (AMI and ACS). Three hundred seventy-four patients were enrolled. Mean age was 63 years with 38% 70 years or older. Seventy-three percent of all patients with suspected ACS presented with chest pain, 27% with atypical symptoms. Overall mean LT was 8.7 hours (standard deviation 11). In subgroup analysis, patients aged >/=70 years were more likely to have LTs >12 hours (29% vs. 19% P =.043) and patients without chest pain had longer mean LTs (11.6 vs. 7.6 hours, P =.01). Delay in ED presentation is group specific. Advanced age and patients with atypical symptoms are predictive of longer LTs. Contrary to previously published data, patients with symptoms suspicious for ACS can delay an average of 9 hours, which might alter current thinking in the prevention and care of these patients.     

Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs

OBJECTIVE: To investigate the changes in pressure pain threshold of the secondary (satellite) myofascial trigger points (MTrPs) after dry needling of a primary (key) active MTrP. DESIGN: Single blinded within-subject design, with the same subjects serving as their own controls (randomized). Fourteen patients with bilateral shoulder pain and active MTrPs in bilateral infraspinatus muscles were involved. An MTrP in the infraspinatus muscle on a randomly selected side was dry needled, and the MTrP on the contralateral side was not (control). Shoulder pain intensity, range of motion (ROM) of shoulder internal rotation, and pressure pain threshold of the MTrPs in the infraspinatus, anterior deltoid, and extensor carpi radialis longus muscles were measured in both sides before and immediately after dry needling. RESULTS: Both active and passive ROM of shoulder internal rotation, and the pressure pain threshold of MTrPs on the treated side, were significantly increased (P < 0.01), and the pain intensity of the treated shoulder was significantly reduced (P < 0.001) after dry needling. However, there were no significant changes in all parameters in the control (untreated) side. Percent changes in the data after needling were also analyzed. For every parameter, the percent change was significantly higher in the treated side than in the control side. CONCLUSIONS: This study provides evidence that dry needle-evoked inactivation of a primary (key) MTrP inhibits the activity in satellite MTrPs situated in its zone of pain referral. This supports the concept that activity in a primary MTrP leads to the development of activity in satellite MTrPs and the suggested spinal cord mechanism responsible for this phenomenon.