The effects of high-velocity low-amplitude thrust manipulation and mobilisation techniques on pressure pain threshold in the lumbar spine

ObjectiveTo compare changes in pressure pain threshold (PPT) following spinal high-velocity low-amplitude thrust manipulation (HVLAT) and spinal mobilisation.DesignFifty asymptomatic subjects (mean age 27 (6) years; 29 males and 21 females) volunteered to participate in a randomised controlled, singled blinded design study. Subjects were screened for suitability and were randomly allocated into one of three intervention groups where they received either a unilateral spinal HVLAT or a spinal mobilisation of the lumbar spine, or a sham ‘laser’ procedure (control). PPT measurements were made immediately pre- and post-intervention, using a hand-held algometer which was positioned directly over the lumbar spinous process. A two-way ANOVA with repeated measures was conducted to determine PPT changes between the groups. Statistical significance was set at the 0.05 level.ResultsThere were no significant differences in PPT across time for each of the groups (P = 0.584). The mobilisation group displayed a small increase, though not a significant change in the mean pressure pain threshold (0.434(0.55) kg/cm²), although effect size was considered to be large (ES = 0.78). The HVLAT group demonstrated a decrease in the mean PPT (?0.173(0.48)) (ES = 0.36, small), and a smaller decrease was noted for the control group (0.105(0.425) kg/cm²) (ES = 0.25, small).ConclusionNeither spinal HVLAT nor mobilisation had a significant effect on PPT of the lumbar spine in asymptomatic subjects. Only spinal mobilisation appeared to have a greater mean increase in PPT and effect size than the control group. Further investigation into the hypoalgesic effects of these techniques on symptomatic subjects is suggested.     

Treadmill versus overground gait training in patients with lower limb burn injury: A matched control study

IntroductionGait impairment is commonly seen in patients with a lower limb burn injury (LLBI). Therefore, the aim of this study was to investigate the effects of two different gait training modes on gait symmetry, functional mobility and kinesiophobia in patients with LLBI.MethodsThis matched control study was conducted between January 2017 and August 2018. Patients with LLBI (n = 28) were allocated to 2 different groups by matching according to burn localization, age, and gender. Group 1 (overground group: n = 14) received overground gait training in addition to standard burn rehabilitation, and Group 2 (treadmill group: n = 14) received treadmill gait training in addition to standard burn rehabilitation. The rehabilitation program and gait training were started when the patient was admitted to the hospital and ended on discharge. These physical therapy interventions were performed 5 days per week. The gait training intensity, including walking speed and duration, was determined according to patient tolerance. Gait parameters, functional mobility, kinesiophobia and pain values were evaluated with GAITRite, the timed up-and-go test (TUG), Tampa Kinesiophobia Scale and Visual Analogue Scale, respectively. These evaluations were made twice; on admission and immediately prior to discharge. Gait symmetry was calculated using the Symmetry Index.ResultsThe baseline characteristics of the groups and initial outcome values were similar. In the comparison of the differences between the overground and treadmill groups, the change in kinesiophobia and TUG values were significantly higher in the treadmill group (p = 0.01, p = 0.02, respectively). The intragroup comparisons showed significant differences in SI in respect of step length (p = 0.004), swing (p = 0.006), stance (p = 0.008) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the overground group. Statistically significant differences were determined in step length (p = 0.01), swing (p = 0.01), stance (p = 0.02) and velocity (p = 0.001), cadence (p = 0.001), TUG (p = 0.001), kinesiophobia (p = 0.001) and pain (p = 0.001) in the treadmill group, when pre and post-training values were compared.ConclusionsThe results of this study have shown that treadmill gait training was more effective in the improvement of functional mobility and reduction in kinesiophobia levels of patients with LLBI compared to overground gait training. Both overground and treadmill gait training also provide greater improvements in the velocity and cadence, and gait symmetry for step length, swing and stance in patients with LLBI.Clinical trial registration numberNCT03217526.     

Hirayama disease in Austria

ObjectivesHirayama disease (HD) is a segmental cervical myelopathy which affects the C7-D1 myotomes and presents with unilateral or asymmetric upper limb weakness/wasting. The study aimed at systematically collecting cases of HD in Austria and at describing and discussing their presentation on clinical and instrumental investigations and at comparing them with cases reported from other countries.MethodsNeurological Departments of secondary and tertiary centers and colleagues in outpatient units involved in the management of neuromuscular disorders in Austria were contacted and asked to provide standardised data about their HD cases.ResultsAltogether, nine unrelated cases were included. Mean age at onset was 18.3 years (range: 12.5–27 years). The female-to-male ratio was 0.29. Mean disease duration was 18.8 years. All patients presented with weakness or wasting of the distal upper limb muscles. A single arm (right: n = 2, left: n = 3) was affected in five cases and both arms in four. Six patients presented with tremor, two with fasciculations. EMG showed chronic neurogenic changes in all patients. Conventional cervical MRI was normal (n = 1), showed focal atrophy (n = 3), an intramedullary lesion (n = 3), or abnormal straightening of the cervical spine (n = 1). Dynamic MRI in a single patient showed anterior displacement of the dorsal dura, prominent epidural space, compressed cord over the posterior surface of vertebra C5-6, and a prominent crescent-shaped mass. Two patients received physiotherapy with beneficial effect in one.ConclusionsHD rarely also occurs in Austria, predominantly males are affected, and clinical presentation, course and outcome are not at variance from cases in other European or non-European countries.     

Using a clinical judgement model to understand the impact of validated pain assessment tools for burn clinicians and adult patients in the ICU: A multi-methods study

BackgroundIntensive care (ICU) patients’ burn pain is difficult to assess, communicate and address, risking chronic pain syndromes and psychological morbidity.AimsTo understand how the introduction of validated pain tools (Critical Care Pain Observation Tool [CPOT], Numerical Rating Scale [NRS], Pain Assessment in Advanced Dementia [PAINAD]) affected clinical judgement processes, analgesia/sedation administration and the experience of burn-injured patients.MethodsConsecutive chart review compared type and amount of analgesia/sedation administered, ventilation time and length of ICU/hospital stay between consecutive burn patients pre- and 6-months post-intervention (n = 70). Analysis of 36 qualitative interviews with ICU clinicians (n = 12) and burn-injured adults (n = 12) pre- and post-intervention was guided by Tanner's (2006) Clinical Judgement Model.ResultsOverall, there was a significant increase in morphine (P = 0.04) and propofol (P = 0.04) use and a trend towards increased paracetamol (P = 0.06) use post-intervention. There was a trend towards greater Midazolam use for TBSA < 20% (P = 0.06), and significantly increased propofol use for TBSA ≥ 20% (P = 0.03). Ventilation time and ICU/hospital length of stay were unchanged.Qualitative analysis revealed complex clinical judgement dependent on the context of the patient's situation, unit culture, background beliefs of clinicians and in knowing the patient. Whilst the CPOT and NRS enhanced analytic reasoning and pain advocacy, the PAINAD appeared redundant.ConclusionsEffective pain assessment, management and advocacy are assisted by evidence-based assessment practices.     

A comparison of energy consumption between the use of a walking frame,crutches and a Stride-on rehabilitation scooter

BackgroundFollowing foot and ankle surgery, patients may be required to mobilise non-weight bearing, requiring a walking aid such as crutches, walking frame or a Stride-on rehabilitation scooter, which aims to reduce the amount of work required. The energy consumption of mobilising using a Stride-on scooter has not previously been investigated, and we aim to establish this.MethodsTen healthy volunteers (5 males:5 females) aged 20–40 years mobilised independently, then with each mobility device for 3 min at 1 km/h on a treadmill, with rest periods, whilst undergoing Cardio-Pulmonary Exercise Testing (CPET). Oxygen consumption (VO₂), carbon dioxide excretion (VCO₂), minute ventilation (MV), respiratory rate (RR) and pulse (HR) were measured at baseline, and after 3 min of walking, without and with all 3 devices. Wilcoxon signed rank test was carried out to calculate significance with non-parametric values with Bonferroni correction.ResultsThree-point crutch mobilisation demonstrated significant increases in VO₂ (0.7 L), VCO₂ (0.7 L), MV (16.7 L/min), pulse (24.8 bpm) and RR (11.4 breaths/min) compared to walking (p < 0.05). Mobilisation with a frame produced significant (p < 0.05) increases compared to walking; VO₂ (0.7 L), VCO₂ (0.7 L), MV (18.3 L/min), pulse (35.9 bpm), and RR (11.7 breaths/min). Tests using the Stride-on demonstrated no significant increase compared to walking with regards to VO₂ (0.1 L; p = 0.959), VCO₂ (0.2 L; p = 0.332), pulse (10.1 bpm; p = 0.575), and RR (4.7 breaths/min; p = 0.633). The MV was significantly higher compared to walking (4.3 L/min; p < 0.05).DiscussionEnergy required for unit distance ambulation with a Stride-on device is similar to walking, and significantly lower than with a walking frame in single legged stance and three-point crutch mobilisation. This justifies its use as part of routine practice aiding early mobilisation of patients requiring restricted weight bearing or single legged weight bearing, especially in those with reduced cardio-pulmonary reserve as it is less physiologically demanding and does not rely on upper body strength.     

Dynamic contrast-enhanced ultrasound (CEUS) after open and minimally invasive locked plating of proximal humerus fractures

IntroductionClosed reduction and locked plate fixation of proximal humerus fractures with the minimally invasive deltoid-splitting approach intends to minimize soft tissue damage although axillary nerve injury has been reported. The aim of this study was to assess the deltoid muscle perfusion with dynamic contrast-enhanced ultrasound (CEUS) as novel technique and evaluate its relation to the functional and neurologic outcome after open (ORIF) and minimally invasive (MIPO) fracture fixation.Patients and methods50 patients, 30 with deltopectoral ORIF and 20 with deltoid-splitting MIPO approach were examined 6–49 months after surgery. Only patients with a healthy, contralateral shoulder were selected. Shoulder function, satisfaction as well as psychosocial outcome were assessed with established scores (Constant, DASH, Simple Shoulder Test, ASES, SF-12). Electromyography (EMG) of the deltoid muscle was performed to determine axillary nerve damage. Ultrasound of both shoulders included CEUS and Power Doppler after deltoid muscle activation via active abduction for two minutes.ResultsNone of the examinations and scores showed significant differences between ORIF and MIPO patients, the psychosocial outcome was similar. The fracture types were equally distributed in both groups. The normalized Constant Score was 76.3 ± 18.6 in the ORIF and 81.6 ± 16.1 in the MIPO group (p = 0.373). Deltoid muscle perfusion in CEUS and Power Doppler revealed no differences between both approaches. EMG excluded functionally relevant axillary nerve injuries. Compared with the contralateral shoulder, Constant- and ASES-Scores (p ≤ 0.001 for both ORIF and MIPO) as well as the deltoid CEUS perfusion (ORIF p = 0.035; MIPO p = 0.030) were significantly worse for both approaches.ConclusionsConvincing consensus of functional, ultrasonographic and neurologic examinations demonstrated comparable outcomes after deltopectoral and deltoid-splitting approach. The quantification of the deltoid muscle perfusion with CEUS indicates that the proclaimed benefits of the MIPO approach on soft tissue might not be as great as expected.     

Neurotisation du nerf du chef long du muscle triceps sur le nerf axillaire,dans les paralysies isolées du deltoïde

AimNerve transfer of the nerve branch to long head of triceps onto the axillary nerve has joined the therapeutic armamentarium for isolated deltoid paralysis cases. We report our experience in the case of a non-excisable neuroma of the axillary nerve at its origin from the posterior cord.MethodsEight patients of average age 28 (15–38) were included in a retrospective study with one operating surgeon. Clinical assessment included analytical testing of the deltoid muscle, pain score (VAS) and a functional assessment. Minimum follow-up was 24 months.ResultsPreoperative delay was 10.8 months. In seven cases, recovery was M4 for the posterior deltoid, M3 for the middle deltoid and M2 for the anterior deltoid. The elbow was stable, strong and painless (VAS = 2). Cocontraction was found. No morbidity was found at the donor site. The last case was a failure.DiscussionIn absence of spontaneous recovery, the surgical treatment of deltoid palsy restores a stable strong shoulder and prevents overloading of the rotator cuff. This nerve transfer initially used in brachial plexus surgery gives results comparable to those using grafts, which is the standard treatment of reference avoiding approach of the plexus. The inconvenience is the persistence of cocontractions and a fatigue phenomenon.ConclusionThe nerve transfer of the nerve to the long head of triceps to the axillary nerve is the technique of choice for re-innervation of the deltoid.     

Contribution of imaging in the initial management of ballistic trauma

IntroductionThe purpose of this study is to specify the role of imaging in the initial management of ballistic traumas.MethodsThis is a retrospective study that colligated 83 victims of a gunshot wound during demonstrations, treated in our trauma centre between 12 January and 3 February 2011. All of the patients were haemodynamically stable and examined by conventional radiography and/or ultrasound and/or 16-slice CT-scan (CT).ResultsThe mean age of the victims was 26 years with a sex ratio of 0.02. All wounds were unique. Injury to the limbs was most common in 75.5% of the cases (n = 64) followed by that of the torso in 19.5% of the cases (n = 16). Wounds in the spine (n = 2), brain (n = 2) and facial skeleton (n = 1) were observed. Conventional x-rays objectified 32 cases of open fractures 95% of which were in the legs. Twenty-one of the victims of gunshot wounds had a CT-scan that objectified the path of the bullet and an assessment of the wound was made in all cases. The confrontation of the data from the CT-scan and that noted during surgery and during the monitoring demonstrated that the CT-scan is very efficient in the diagnosis of pleural effusion, vascular wounds, thoracic parenchymatous wounds and wounds of the solid organs and brain lesions and the facial skeleton. However, the sensitivity is low for the diagnosis of hollow organs.ConclusionThe CT-scan is very useful in the initial care of stable patients with gunshot wounds as regards the haemodynamics and helps objectify the path of the bullet and obtain a precise assessment of the damage. Conventional x-rays are unavoidable for wounds to the legs and spine.     

Endovascular Repair of the Thoracic Aorta: Predictors of 30-Day Mortality in Patients on the New Zealand Thoracic Aortic Stent Database (NZ TAS)

ObjectivesTo evaluate data in the New Zealand Thoracic Aortic Stent database to try and identify a scoring system that could predict 30-day mortality in patients undergoing stenting of the descending thoracic aorta (TEVAR).DesignRetrospective analysis of the New Zealand thoracic aortic stent database between December 2001 and August 2007.Materials and methodsThe 30-day mortality of the 122 patients is 7.38% (n = 9). Risk factors were recorded based on the Society of Thoracic Surgeons (STS) risk score. Glasgow aneurysm score was calculated and the pathology being treated analysed. Univariate analyisis was carried out.ResultsThe mortality of three pathology groups was compared. 30-day mortality was 2.04% (n = 1) in the elective aneurysm group, 17.95% (n = 7) in the complicated Stanford type B dissection group, and 0% (n = 0) in the trauma group. Thirty-day mortality is significantly higher in the dissection group compared with the elective aneurysm (p = 0.02) and trauma (p = 0.03) groups. The most frequent risk factors in the dissection group of patients were peripheral vascular disease, smoking and hypertension. Although percentage mortality is higher with increasing GAS, the results are not statistically significant (p = 0.34). No independent risk factors were identified from the STS risk score data.ConclusionNo specific risk score system seems to be able to predict mortality in TEVAR patients.     

Bone mineral density changes following discontinuation of ronacaleret treatment: Off-treatment extension of a randomized,dose-finding phase II trial

ContextParathyroidectomy in patients with hyperparathyroidism can produce subsequent increases in bone mineral density (BMD). Ronacaleret, a selective calcium-sensing receptor antagonist that stimulates endogenous parathyroid hormone release, induced mild hyperparathyroidism.ObjectiveThe aim of this study is to evaluate whether BMD changes after cessation of ronacaleret treatment.DesignObservational, off-treatment, extension of a randomized, placebo-controlled, dose-ranging phase II trial.SettingFifteen academic centers in seven countries.PatientsPostmenopausal women with low BMD; 171 out of 569 women in the parent study were enrolled in the extension study.InterventionsSubjects were treated with ronacaleret 100 mg (n = 16), 200 mg (n = 38), 300 mg (n = 35), or 400 mg (n = 32) once daily, alendronate 70 mg (n = 17) once weekly, or matching placebo (n = 33) for 10–12 months; BMD was measured after discontinuation of ronacaleret or alendronate treatment.Main outcome measureMean percent change in lumbar spine areal BMD by dual-energy X-ray absorptiometry at 6–12 months after discontinuing ronacaleret or alendronate compared with the 10- to 12-month BMD measurement of the parent study.ResultsAt the lumbar spine, all doses of ronacaleret resulted in gains in BMD while on treatment. These increases in BMD were maintained or increased after discontinuation of ronacaleret. All doses of ronacaleret caused bone loss at the total hip while on active treatment. However, there was an attenuation of this loss in the off-treatment extension study.ConclusionThe gain in BMD at the lumbar spine was maintained post-treatment and the loss of BMD at the total hip was attenuated. We hypothesize that there may have been some bone remineralization after cessation of ronacaleret.     

The effects of high-velocity,low-amplitude manipulation and muscle energy technique on suboccipital tenderness

Background and objectivesHigh-velocity, low-amplitude (HVLA) manipulation and muscle energy technique (MET) are commonly advocated by manual therapists to resolve pain and dysfunction. The aim of this controlled, single blinded study was to investigate whether HVLA manipulation of the occipito–atlantal (OA) joint and/or an MET stretch had an effect on pressure pain thresholds (PPT) in the suboccipital musculature in an asymptomatic population.MethodsParticipants (N = 90; mean age = 23 ± 5; 29 males and 61 females) were screened for suitability and PPT measurements were made using a hand-held electronic algometer which was positioned centrally in the suboccipital region. Participants were randomly allocated into three intervention groups and then received an HVLA thrust to cavitate the right and left OA joints, an MET stretch applied to the suboccipital muscles bilaterally, or a sham ‘functional’ technique. Post-intervention PPT measurements were recorded at 5 and 30 min.AnalysisAnalysis of the PPT data using a SPANOVA revealed a significant difference over time (F_2,174 = 8.80, P < 0.01), but no significant difference between the groups (F_2,87 = 0.08, P = 0.93). Within-group changes were further analysed using paired t-tests and repeated measures ANOVA which revealed significant changes at 5 min post treatment in the HVLA (P < 0.01) and MET groups (P < 0.01), but not in the control (P = 0.35). At the 30 min interval a significant change was calculated for the MET group (P < 0.03), but not in the HVLA (P = 0.29) or control group (P = 0.21).ConclusionNeither HVLA manipulation nor MET significantly changed the PPT of the suboccipital muscles in asymptomatic participants. Both techniques produced greater mean increases in PPT and effect sizes compared to the control group, and investigation of the effect of these techniques in a symptomatic population is recommended.     

Duration of breastfeeding as a risk factor for vertebral fractures

PurposeAmong the risk factors for osteoporosis and fractures, gynecological history (fertile period, parity and breastfeeding) play an important part. Changes in calcium metabolism to enable an adequate mineral transfer to the milk have a prominent role in bone loss during breastfeeding. Data on the influence of breastfeeding in postmenopausal osteoporosis are inconsistent. The aim of the present study was to identify any association between duration of breastfeeding and vertebral fractures in postmenopausal women.MethodsAll patients underwent the following tests: bone mineral density measurements of the lumbar spine (L1–L4) and the total and femoral neck using dual-energy X-ray absorptiometry and antero-posterior and lateral radiography of the thoracic and lumbar spine to identify vertebral fractures.ResultsThe study involved 752 women with a mean age of 64.5 ± 9.3; 23% of them reported vertebral osteoporotic fractures. The women with vertebral fractures had breastfed for longer periods (11.8 ± 12.9 vs. 9.3 ± 11.2 months, p = 0.03) and had more pregnancies (2.6 ± 2.2 vs. 2.2 ± 1.3, p = 0.002). Breastfeeding for more than 18 months was associated with a two-fold risk of developing vertebral fractures (OR 2.12, 95% CI 1.14–5.38, p = 0.04), particularly in those without current or past use of drugs positively affecting bone.ConclusionsOur study showed an association between long periods of breastfeeding and vertebral fractures, supporting a role for lengthy lactation as a risk factor for osteoporotic fractures after menopause. Bearing in mind all the benefits of breastfeeding, this finding suggests the importance of an adequate calcium and vitamin D intake during pregnancy and breastfeeding, with the aid of dietary supplements if necessary.     

Reliability of the assessment of disc degeneration on the lateral DXA scans

IntroductionGiven the prevalence and costs induced by osteoarthritis (OA), it is necessary to find a cheap and safe technique to evaluate it reliably.ObjectiveTo assess the value of the lateral dual energy X-ray absorptiometry (DXA) spine scans for the diagnosis of disc degeneration.MethodSeventy-seven individuals aged 18 and over, with or without disc degeneration, had both lateral thoracolumbar spine radiographs and DXA spine scans (≤ 6 months between both exams). Disc degeneration was assessed using the Lane score. The images of 20 randomly selected individuals were assessed by two readers.ResultsAlmost 13% of the thoracic levels were not assessable on the DXA scans. For the identification of the intervertebral levels on the DXA scans as interpretable or not, the intra-reader agreement was good (κ = 0.81) and the inter-reader agreement was fair (κ = 0.27–0.36). For the diagnostic criteria (osteophytes, disc space narrowing, osteosclerosis, overall grade), the intra-reader agreement was excellent for the radiographs (κ = 0.89–0.92), good for the DXA scans (κ = 0.64–0.83) and fair to moderate for the between-method comparison (κ = 0.25–0.44). The inter-reader agreement was moderate to good for the radiographs (κ = 0.49–0.66) and fair to good for the DXA scans (κ = 0.32–0.74). In the per patient analysis (the most severe grade), the intra-reader agreement was excellent for the radiographs (κ = 0.85–0.94), moderate to excellent for the DXA scans (κ = 0.53–0.85) and poor to good for the between-methods comparison (κ = 0.17–0.63).ConclusionOur results do not support the use of DXA scans for the assessment of thoracolumbar disc degeneration.     

Lesion detection on a combined “All-in-One” window compared to conventional window settings in thoracic oncology chest CT examinations

PurposeThe purpose of this study was to investigate if lesion detection using a single “All-in-One” (AIO) window was non-inferior to lesion detection on conventional window settings in thoracic oncology chest computed tomography (CT) examinations.Materials and methodsIn a retrospective study, 50 consecutive chest CT examinations of 50 patients (31 men, 19 women; mean age 64 ± 10 [SD] years, range: 35–82 years) containing 417 lesions, were reviewed by 6 radiologists, subdivided into 2 groups of 3 radiologists each, with similar levels of expertise in each group (senior staff member, junior staff member and radiology resident). All examinations were reviewed in conventional or AIO window settings by one of the groups. A ‘lesion’ was defined as any abnormality seen on the chest CT examination, including both benign and malignant lesions, findings in chest and upper abdomen, and measurable and non-measurable disease. Lesions were listed as ‘missed’ when they were not seen by at least two out of three observers. F-tests were used to evaluate the significance of the variables of interest within a mixed model framework and kappa statistics to report interobserver agreement.ResultsOn a reader level, 54/417 lesions (12.9%) were not detected by the senior staff member reading the studies in conventional window settings and 45/417 (10.8%) by the senior staff member reading the AIO images. For the junior staff member and radiology resident this was respectively 55/417 (13.2%) and 67/417 (16.1%) for the conventional window settings and 43/417 (10.3%) and 61/417 (14.6%) for the AIO window. On a lesion level, 68/417 (16.3%) were defined as ‘missed’ lesions (lesions not detected by at least 2 readers): 21/68 (30.9%) on the AIO-window, 30/68 (44.1%) on conventional views and 17/68 (25.0%) on both views. The use of the AIO window did not result in an increase of missed lesions (P > 0.99). Interobserver agreement in both groups was similar (P = 0.46). Regarding lesions that were categorized as ‘missed’ on the AIO window or on conventional window settings, there was no effect of location (chest or upper abdomen) (P = 0.35), window (P = 0.97) and organ (P = 0.98).ConclusionsA single AIO-window is non-inferior to multiple conventional window settings for lesion detection on chest CT examinations in thoracic oncology patients.     

Extracorporeal shockwave therapy in the management of plantar fasciitis: A randomized controlled trial

BackgroundThis study aimed at estimating the extent to which a combination therapy of extracorporeal shockwave therapy (ESWT) with usual care (exercise and orthotic support) improve functional ability in the patient with plantar fasciitis when compared to usual care alone.MethodsParticipants with plantar fasciitis were randomly allocated into two groups: ESWT (n = 23), and control (n = 21). All participants received home exercise program with orthotic support. In addition, ESWT group received 2000 shock waves with 0.02 mJ/mm² for three sessions. Functional outcomes were measured by function subscale of American orthopedic foot and ankle society (AOFAS-F) score and 12 minutes walking test including walking speed, cadence. The scores were recorded at baseline, third week and third month after the treatment. Analysis was performed using repeated measures ANOVA, and an intention to treat approach using multiple imputations.ResultsResults showed that there was a significant improvement in AOFAS-F total score and walking speed over three months in both groups (p < 0.001, p = 0.04 respectively); improvements in AOFAS-F were particularly in activity limitation (p = 0.001), walking distance (p = 0.02) and walking surface (p = 0.02). Groups were comparable with each other for both walking speed and AOFAS-F in any assessment time (p > 0.05). However, groups performed differently in cadence where there was an increase in cadence in ESWT group whereas a decline in control at the third month (p = 0.07).ConclusionThe results revealed that ESWT did not have an additive benefit over usual care to improve foot function and walking performance in patient with plantar fasciitis over three months post-treatment.     

Effect of selected exercises on in-shoe plantar pressures in people with diabetes and peripheral neuropathy

BackgroundIn people with diabetes and peripheral neuropathy (DM + PN), injury risk is not clearly known for weight bearing (WB) vs. non-weight bearing (NWB) exercise. In-shoe peak plantar pressures (PPP) often are used as a surrogate indicator of injury to the insensitive foot.ObjectiveCompare PPPs in people with DM + PN during selected WB and NWB exercises.MethodsFifteen subjects with DM + PN participated. PPPs were recorded for the forefoot, midfoot, and heel during level walking and compared to; WB exercises – treadmill walking, heel and toe raises, sit to stands, stair climbing, single leg standing; and NWB exercises – stationary bicycling, balance ball exercise and plantar flexion exercise.ResultsCompared to level walking; mean forefoot PPP during treadmill walking was 13% higher, but this difference was eliminated when walking speed was used as a covariate. Mean PPPs were similar or substantially lower for other exercises, except for higher forefoot PPP with heel raise exercises.ConclusionsSlow progression and regular monitoring of insensitive feet are recommended for all exercises, but especially for heel raises, and increases in walking speed. The remaining WB and NWB exercises pose no greater risk to the insensitive foot due to increases in PPP compared to level walking.     

Combined Aspirin and Cilostazol Treatment is Associated with Reduced Platelet Aggregation and Prevention of Exercise-Induced Platelet Activation

BackgroundCilostazol has proven efficacy in increasing walking distance in claudicants, but it has not been demonstrated to be more effective than placebo in secondary cardiovascular prevention. The direct effect of exercise on platelet function remains less well defined. We have investigated the effect of combination treatment with aspirin and cilostazol on platelet activity in claudicants subjected to repeated treadmill exercise.MethodsNineteen claudicants completed a double-blind, randomised, controlled, cross-over trial. Each subject received a 2-week course of aspirin (75 mg) and placebo and aspirin and cilostazol (100 mg twice daily). Following each 2-week treatment period, patients participated in a standardised treadmill test (3.2 km h^?1, 10° incline) walking to maximal claudication distance. The exercise was repeated thrice in total, and blood was sampled before and after exercise. Platelet activation was measured using free platelet counting aggregation, flow cytometry for surface markers of platelet activation and soluble P-selectin assay.ResultsCompared to aspirin and placebo, combination treatment with aspirin and cilostazol was associated with reduced arachidonic-acid-induced platelet aggregation (p < 0.01, Wilcoxon signed-rank test). Aspirin and placebo treatment were associated with elevated P-selectin expression, platelet-monocyte aggregation and reduced CD42b expression (p < 0.05, Wilcoxon signed-rank test) post-exercise. No difference was seen in spontaneous platelet aggregation whilst soluble P-selectin was reduced post-exercise with combination treatment with aspirin and cilostazol (p < 0.05, Wilcoxon signed-rank test).ConclusionsCombination treatment with aspirin and cilostazol results in suppression of platelet activation and reduces the effect of exercise on platelets. The benefit seen may be a result of cilostazol enhancing the inhibitory effect of aspirin on the cyclo-oxygenase pathway.     

Collagen gene polymorphisms influence fracture risk and bone mass acquisition during childhood and adolescent growth

Fractures are common in childhood with incidence maximal during puberty, around the time of peak height velocity. The relationships between single nucleotide polymorphisms (SNPs) in COL1A1 and COL1A2, bone mass acquisition, and childhood fractures are unclear.We recruited 394 children and adolescents aged 4 to 16 years into a noninterventional case control study. All had suffered an episode of trauma leading to hospital presentation; 205 had sustained a fracture. We determined the frequency of COL1A1 Sp1 and COL1A2 PvuII SNPs. Lumbar spine dual-energy X-ray absorptiometry (DXA) measurements were compared between fracture and control groups according to genotype. Subgroup analyses were performed according to sex, pubertal status, and site of injury.We found that the COL1A2 ‘PP’ genotype approximately halved the odds of fracture in the study group as a whole (OR = 0.45 [95% CI = 0.24–0.82], p = 0.01). In particular, possession of the same genotype by subjects who had not yet progressed beyond midpuberty was associated with reduced odds of fracture (OR = 0.38 [95% CI = 0.19–0.79], p = 0.01) and significantly increased lumbar spine bone mineral content (p = 0.03) and areal bone mineral density (p = 0.007). The COL1A1 Sp1 binding site ‘s’ allele was associated with a trebling of the odds of fracture in prepubertal children (OR = 3.1 [95% CI = 1.43–6.61], p = 0.004), but there was no association with any DXA measures.This is the first paediatric study to our knowledge that shows an association of the COL1A2 PvuII restriction site ‘PP’ genotype with a reduced risk of fracture and of the COL1A1 Sp1 binding site ‘s’ allele with an increased risk. The association of these variants with fracture risk is greatest during periods of predominantly appendicular bone growth.     

Brain relaxation and electrolyte balance during resection of posterior fossa tumors under sitting position: Mannitol versus placebo

BackgroundMannitol can be negative for outcome, which may explain why we lack scientific support for its use. The purpose of this study was to compare the brain relaxation and electrolyte balance in group of patients with posterior fossa tumor underwent surgery in sitting position with or without mannitol.MethodsEighty patients scheduled for resection of posterior fossa tumor from April 2009 till April 2012 were enrolled in this prospective, double-blind, randomized study. All cases received general anesthesia and attained sitting position during surgery. Patients were enrolled into two groups, group I received mannitol (20%) 1 gm/kg just before opening the dura. Group II received placebo at the same time. Hemodynamics, duration of surgery, Brain Relaxation Score (BRS) in which surgeons assessed the condition of the brain as 1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm (leveled) brain, 4 = bulging brain were recorded. Blood losses, urine output and serum sodium and potassium levels were assessed. Any operative complications were recorded.ResultsNo difference in hemodynamics (HR and MBP) whereas CVP with mannitol was higher than with placebo (p < 0.01). No difference in brain relaxation score (p = 0.719) or operative complication between both groups. Mannitol was associated with higher urine output (p < 0.001), higher serum potassium and osmolarity (p < 0.001) and lower serum sodium (p < 0.001) than compared with placebo.ConclusionSurgery for posterior fossa in sitting position could be safely performed without the use of mannitol avoiding its adverse side effects with beneficial effects in terms of preserving hemodynamic, electrolytes balance, reasonable brain relaxation and fewer complications.