Whole body vibration improves maximum voluntary isometric contraction of knee extensors in patients with chronic kidney disease: A randomized controlled trial

Background: Whole body vibration (WBV) training improves maximum voluntary isometric contraction (MVIC) of knee extensors, postural balance, functional capacity, and quality of life (QOL) in several diseases. The objective was to assess the efficacy of WBV training in patients with chronic kidney disease (CKD) on hemodialysis (HD) in the interdialytic period. Method: A randomized, controlled trial study with concealed allocation, intention-to-treat analysis, and triple blinding. Sixteen patients with CKD of both genders aged over 40 years were allocated in two groups, the WBV group or the sham group, training 2 times a week for 12 weeks. The primary outcome was knee extensor muscle strength, and the secondary outcomes were quadriceps thickness, distance walked, balance, and QOL. Results: The WBV group improved MVIC of knee extensors with a difference between groups in improvement of 117.29 N (95% CI, 32.25–202.24) at the end of training. The other outcomes were not different between groups. Practical applications: The WBV program has shown to be effective and may be able to help in prescribing the appropriate training program for CKD. Conclusion: WBV training improves MVIC of knee extensors in patients with CKD on HD in the interdialytic period. WBV training could be considered in the management of patients with CKD.     

An itchy rash and muscle weakness

Dermatomyositis is a rare disease affecting primarily skin and muscles and is associated with malignancies, especially in at‐risk patients. Clinical presentations vary widely but proximal muscle weakness and typical skin findings should prompt consideration of the diagnosis. Immunosuppressive therapy is required, as is continued screening for malignant disease during follow‐up.     

Muscle strength assessment in critically ill patients with handheld dynamometry: An investigation of reliability,minimal detectable change,and time to peak force generation

Purpose

Dynamometry is an objective tool for volitional strength evaluation that may overcome the limited sensitivity of the Medical Research Council scale for manual muscle tests, particularly at grades 4 and 5. The primary aims of this study were to investigate the reliability, minimal detectable change, and time to peak muscle force, measured with portable dynamometry, in critically ill patients.

Materials and methods

Isometric hand grip, elbow flexion, and knee extension were measured with portable dynamometry.

Results

Interrater consistency (intraclass correlation coefficient [95% confidence interval]) (0.782 [0.321-0.930] to 0.946 [0.840-0.982]) and test-retest agreement (0.819 [0.390-0.943] to 0.918 [0.779-0.970]) were acceptable for all dynamometry forces, with the exception of left elbow flexion. Despite generally good reliability, a mean change (upper 95% confidence interval) of 2.8 (7.8) kg, 1.9 (5.2) kg, and 2.6(7.1) kg may be required from a patient's baseline force measurement of right grip, elbow flexion, and knee extension to reflect real force changes. There was also a delay in the time for critically ill patients to generate peak muscle forces, compared with healthy controls (P ≤ .001).

Conclusions

Dynamometry can provide reliable measurements in alert critically ill patients, but moderate changes in strength may be required to overcome measurement error, during the acute recovery period. Deficits in force timing may reflect impaired neuromuscular control.     

Epsom Salt Ingestion Leading to Severe Hypermagnesemia Necessitating Dialysis

BackgroundHypermagnesemia is an often overlooked electrolyte abnormality that has a myriad of presenting symptoms. It has been observed after both accidental and intentional ingestions of magnesium-containing compounds, and as in the case presented, Epsom salts, which are primarily magnesium sulfate.Case ReportA 56-year-old man presented to the emergency department reporting weakness after an ingestion of Epsom salts used as a laxative and was found to be bradycardic and hypotensive. He subsequently developed altered mental status and respiratory depression necessitating intubation. His magnesium level was found to be > 3.91 mmol/L (> 9.5 mg/dL). He was given multiple doses of calcium gluconate and generous i.v. fluids with furosemide, with minimal improvement. However, his magnesium level corrected rapidly after initiation of dialysis, and 3 days later he was discharged home in good condition with normal neurologic function.Why Should an Emergency Physician Be Aware of This?Keeping a high level of suspicion for, and quickly recognizing, hypermagnesemia allows for prompt initiation of treatment, which can avoid significant hemodynamic or respiratory compromise. Mainstays of treatment are i.v. calcium and i.v. fluids. Loop diuretics may be given as an adjunct as well. Dialysis should be considered in cases of severe hypermagnesemia because it results in rapid correction of magnesium levels.     

肌力练习对膝关节骨关节炎肌肉软弱的影响

目的 :了解肌力练习对膝关节骨关节炎患者肌肉软弱的影响。方法 :对照比较 2 6个患肢 3— 6周肌力练习前后和 19个患肢被动活动前后的等速运动肌力参数。结果 :两组均表现出不同程度的肌力增加 ,肌力练习组在减轻肌肉软弱上更为成功。结论 :肌力练习可通过募集来减轻骨关节炎患者的肌肉抑制。     

Muscle power is an important measure to detect deficits in muscle function in hip osteoarthritis: a cross-sectional study

Purpose: To investigate between-leg differences in hip and thigh muscle strength and leg extensor power in patients with unilateral hip osteoarthritis. Further, to compare between-leg differences in knee extensor strength and leg extensor power between patients and healthy peers.

Methods: Seventy-two patients (60–87 years) with radiographic and symptomatic hip osteoarthritis not awaiting hip replacement and 35 healthy peers (63–82 years) were included. Hip and thigh muscle strength and leg extensor power were measured in patients and knee extensor strength and leg extensor power in healthy.

Results: The symptomatic extremity in patients was significantly (p?t-test) weaker compared with the non-symptomatic extremity for five hip muscles (8–17%), knee extensors (11%) and leg extensor power (19%). Healthy older adults had asymmetry in knee extensor strength (6%, p?Conclusions: Patients had generalized weakening of the affected lower extremity and numerically the largest asymmetry was evident for leg extensor power. In contrast, healthy peers had no asymmetry in leg extensor power. These results indicate that exercise interventions focusing on improving leg extensor power of the symptomatic lower extremity and reducing asymmetry may be beneficial for patients with hip osteoarthritis.

• Implications for Rehabilitation

• Even in patients with mild symptoms not awaiting hip replacement a generalized muscle weakening of the symptomatic lower extremity seems to be present.

• Between-leg differences in leg extensor power (force?×?velocity) appears to be relatively large (19%) in patients with unilateral hip osteoarthritis in contrast to healthy peers who show no asymmetry.

• Compared to muscle strength the relationship between functional performance and leg extensor power seems to be stronger, and more strongly related to power of the symptomatic lower extremity.

• Our results indicate that exercise interventions focusing on improving leg extensor power of the symptomatic lower extremity and reducing asymmetry may be beneficial for patients with mild symptoms not awaiting hip replacement.

     

Frailty Assessment in the Emergency Department

Background

Frailty (defined as weakness, slowness, weight loss, exhaustion, and physical inactivity) is characterized by increased vulnerability to stressors. Frail older patients are at increased risk of Emergency Department (ED) visits, hospitalization, disability, and death.

Objectives

Our aims were to determine the prevalence of frailty (and assess the feasibility of measuring frailty) in older ED patients. We also assessed the correlation of self-reported speed and weakness to measured values and the association between frailty and function.

Methods

We performed a study of discharged ED patients aged ≥ 65 years. We used Fried’s frailty definition and a validated activities-of-daily-living (ADL) scale. We measured self-reported and objective weakness and slowness. Data were reported as means and proportions with 95% confidence interval (CI); associations were measured using 95% CI for the differences. Ninety patients provided a 95% CI of ± 10%.

Results

The mean age of the 90 patients was 76 ± 6.4 SD years; 51% were male. Mean assessment time was 7.4 min (95% CI 6.9–7.9). Twenty percent of patients were frail (18/90, 95% CI 12–30%). Self-report was 18% sensitive and 90% specific for objective weakness; self-report was 42% sensitive and 86% specific for objective slowness. Frail and weak patients were more likely dependent in one or more ADLs (26% difference, 95% CI 1–51% and 20% difference, 95% CI 1–41%, respectively).

Conclusions

Frailty is common in discharged older ED patients. Self-reported weakness and slowness are poor predictors of their objective counterparts. Frailty was associated with ADL dependence. These two domains may be reliable markers for elderly ED patients at high risk for adverse outcomes.     

Gastric Volvulus Through Morgagni Hernia: An Easily Overlooked Emergency

Background

Intractable vomiting in an elderly patient is an emergency condition requiring prompt diagnosis and intervention. Acute gastric outlet obstruction due to gastric volvulus through Morgagni-type diaphragmatic hernia is an exceedingly rare cause of this nonspecific complaint.

Objective

Our aim was to highlight that Morgagni hernia, although rare in adults, should be suspected in the appropriate clinical setting, and that a clue toward diagnosis often comes from routine chest and abdominal x-ray studies. In addition, we emphasize the atypical radiological findings and importance of emergency surgical intervention in such a case.

Case Report

We describe the case of a 78-year-old woman who presented to the Emergency Department with a 4-day history of intractable vomiting, and with no definitive clue to the diagnosis on examination. Her routine chest and abdomen x-ray studies suggested abnormal air-fluid level at right hemithorax, which prompted a computed tomography (CT) scan of the abdomen and an upper gastrointestinal contrast study. Gastric volvulus through a foramen of Morgagni was diagnosed and transthoracic reduction of the contents was performed, along with repair of the defect.

Conclusions

A symptomatic Morgagni hernia in adults, although rare, can present with a variety of symptoms ranging from nonspecific complaints of bloating and indigestion to the more severe complaint of intestinal obstruction. Gastric volvulus and obstructive features are less frequently reported as acute complications of these hernias, which need early identification and intervention.     

Combining strength training and botulinum neurotoxin intervention in children with cerebral palsy: the impact on muscle morphology and strength

Purpose: Investigate the combination effects of strength training and Botulinum Toxin Type-A (BoNT-A) on muscle strength and morphology in children with Cerebral Palsy (CP). Methods: Fifteen children receiving BoNT-A, classified as Spastic Diplegic CP, GMFCS I-II, and aged 5–12 years were recruited for this study. Randomly allocated to 10 weeks of strength training either before or after BoNT-A, children were assessed over 6 months. Eight of the 15 children also completed a control period. The Modified Ashworth Scale measured spasticity. The Goal Attainment Scale (GAS) assessed achievement of functional goals. Magnetic Resonance Imaging assessed muscle volume (MV). Instrumented dynamometry assessed strength. Results: Spasticity was significantly reduced following BoNT-A injection (p = 0.033). Children made significant isokinetic strength gains (mean p = 0.022, ES = 0.57) in the intervention period compared to the control period (mean p = 0.15, ES = 0.56). Irrespective of timing, significant strength improvements were seen immediately (10 weeks) and over 6 months for all children. This was also the case for improvements in the GAS (immediately: mean p = 0.007, ES = 4.17, 6 months: mean p = 0.029, ES = 0.99), and improvements in MV in all assessed muscles. Conclusion: The simultaneous use of BoNT-A and strength training was successful in spasticity reduction, improving strength and achieving functional goals, over and above treatment with BoNT-A alone. Muscles targeted for BoNT-A injection should be included in strength training.

Implications for Rehabilitation

Cerebral Palsy

• Botulinum toxin type-A (BoNT-A) and strength training are available interventions that, on their own have found success in managing spasticity and muscle weakness (both significant motor impairments), respectively in children with Cerebral Palsy (CP).

• This study has demonstrated that the concurrent treatment of BoNT-A and strength training can achieve positive outcomes in terms of strength, spasticity and for the achievement of set functional goals.

• The results of this study show that the improved muscle strength can be associated with hypertrophy, which could indicate the potential role of strength training in altering the rate of muscle growth, in an aim to improve the failure of muscle growth associated with CP.

• Home based strength training, based on a child’s individual goals is shown to be successful in improving strength and goal attainment for children with CP.

     

Effects of electrical muscle stimulation early in the quadriceps and tibialis anterior muscle of critically ill patients

Abstract

Background: Electrical muscle stimulation (EMS) is applied to critically ill patients in order to improve their muscle strength, thereby preventing hypotrophy and promoting functional recovery. Objective: To assess the effects of early EMS on the range of movement of the ankle joint, and on thigh and leg circumference in critically ill patients. Methods: This is a prospective randomized clinical trial comprising 11 patients undergoing mechanical ventilation. Before and after EMS the thigh and leg circumference in both lower limbs and the goniometry of the tibiotarsal joint were measured. The angle of 90° on the goniometer was taken as the standard neutral position (NP), with the arm fixed on the lateral malleolus of the ankle joint. Other measurements, namely dorsiflexion and plantar flexion, referred to as mobile arm, were taken from the NP. These recordings were obtained following an active contraction of the patients’ muscles. Results: Compared with the electrostimulated limb, a difference in dorsiflexion of the control limb was observed (96.2?±?24.9 versus 119.9?±?14.1°; p?=?0.01). A girth of 10?cm of the leg was found in limb reduction when compared to the electrostimulated one (24.7?±?3.1 versus 26.4?±?4.0?cm; p?=?0.03). Conclusions: EMS used at low current intensity and for a short duration failed to prevent muscle atrophy in critically ill patients. However, we did find a significant improvement in active dorsiflexion of the ankle joint suggesting that it could help to prevent against stance plantar flexion in these patients.     

Relation between spasticity, weakness and contracture of the elbow flexors and upper limb activity after stroke: An observational study

Purpose. Understanding the relationship between the motor impairments and their impact on physical activity will allow rehabilitation after stroke to be based on scientific principles. The aims of this study were to determine: (i) the relative contribution of weakness and spasticity to contracture, and (ii) the relative contribution of all three impairments to limitations in physical activity during the first 12 months after stroke.

Method. This longitudinal observational study charted the evolution of weakness (loss of maximal force), spasticity (stretch-evoked EMG) and contracture (loss of joint range) of the elbow flexors and limitations in upper limb activity (Motor Assessment Scale) for a year after stroke in 27 subjects who had suffered a first stroke. Spasticity was measured as abnormal reflex activity, weakness was measured as loss of maximum isometric torque, contracture was measured as the difference in range of motion between the affected and intact side, and limitations in physical activity were measured on a clinical scale.

Results. The major independent contributors to contracture were spasticity for the first four months after stroke (p = 0.0001 - 0.10) and weakness thereafter (p = 0.01 - 0.05). However, the major and only independent contributor to limitations in physical activity throughout the year was weakness (p = 0.0001 - 0.05).

Conclusions. For the first time, from a longitudinal study, the findings show that spasticity can cause contracture after stroke, consistent with the prevailing clinical view. However, weakness is the main contributor to activity limitations.     

Relation between spasticity,weakness and contracture of the elbow flexors and upper limb activity after stroke: An observational study

Purpose. Understanding the relationship between the motor impairments and their impact on physical activity will allow rehabilitation after stroke to be based on scientific principles. The aims of this study were to determine: (i) the relative contribution of weakness and spasticity to contracture, and (ii) the relative contribution of all three impairments to limitations in physical activity during the first 12 months after stroke.

Method. This longitudinal observational study charted the evolution of weakness (loss of maximal force), spasticity (stretch-evoked EMG) and contracture (loss of joint range) of the elbow flexors and limitations in upper limb activity (Motor Assessment Scale) for a year after stroke in 27 subjects who had suffered a first stroke. Spasticity was measured as abnormal reflex activity, weakness was measured as loss of maximum isometric torque, contracture was measured as the difference in range of motion between the affected and intact side, and limitations in physical activity were measured on a clinical scale.

Results. The major independent contributors to contracture were spasticity for the first four months after stroke (p = 0.0001 – 0.10) and weakness thereafter (p = 0.01 – 0.05). However, the major and only independent contributor to limitations in physical activity throughout the year was weakness (p = 0.0001 – 0.05).

Conclusions. For the first time, from a longitudinal study, the findings show that spasticity can cause contracture after stroke, consistent with the prevailing clinical view. However, weakness is the main contributor to activity limitations.     

After Gestational Diabetes: An Overlooked Care Transition in Primary Care

Women with history of gestational diabetes mellitus (GDM) have significant risk for developing type 2 diabetes (T2D), especially within 6 years of giving birth. Children exposed to GDM-complicated pregnancies may also experience future metabolic abnormalities. Care transitions following GDM-complicated pregnancies are often fragmented resulting in missed opportunities to implement T2D prevention strategies. Primary care providers of women with history of GDM and their children have opportunities to deliver transgenerational health promotion interventions encompassing: T2D screening, reproductive life planning, lifestyle changes to support reduction of GDM-related metabolic risks, self-advocacy for lifelong T2D screening, weight management, and promotion of breastfeeding.     

床旁超声量化评估重症患者肌肉的研究进展

重症监护室(ICU)患者意识水平的限制给肌力评估带来巨大的挑战,而肌肉超声检查无需患者配合,且能够客观地观察到肌肉横截面积、厚度、回声强度和羽状角等参数的显著变化,可在ICU早期识别肌肉萎缩。同时,肌肉超声技术易被ICU医生和护士掌握,表现出良好的信度,对识别ICU获得性衰弱高风险患者有一定的意义。此外,超声量化评估肌肉对预测患者结局具有良好的价值。目前仍缺乏超声对ICU获得性衰弱诊断价值的大样本研究,标准化的超声评估方案亦需进一步探讨。