Cervical isometric exercises improve dysphagia and cervical spine malalignment following stroke with hemiparesis: a randomized controlled trial.

BACKGROUND: Hemiparesis following stroke can cause cervical spine scoliosis, kyphosis or hyperlordosis. These abnormal cervical alignments can contribute to dysphagia. The benefit of cervical isometric exercises to improve swallowing has not been previously studied. AIM: To evaluate the use of cervical isometric exercises in dysphagic adult patients with cervical spine alignment disorders due to hemiparesis after stroke. DESIGN: A randomized controlled trial. SETTING: University Hospital, PMR Department. POPULATION: Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase. METHODS: In addition to the standard physical and speech therapy therapeutic approach for 12 weeks, cervical isometric exercises were conducted by a group of patients (experimental group). Patients had cervical spine radiographs in erect (sitting or standing) position coronal and sagittal C2-C7 Cobb angle and a videofluoroscopic swallowing study to evaluate deglutition (0=normal, 1=penetration, 2=aspiration) at 2 time points (at the beginning and at the end of the therapeutic program). RESULTS: Seventy consecutive patients with hemiparesis of a mean (SD) age of 52±15 years were included in the study and were randomized in 2 groups. Thirty-seven of them (experimental group) conducted cervical isometric exercises in addition to their therapeutic program. At the last follow-up, patients had improved (P<0.001) cervical alignment, in both coronal and sagittal plane, and deglutition. Patients who conducted cervical isometric exercises (experimental group) had more pronounced correction (P<0.001) of cervical alignment in both planes and achieved greater improvement (P<0.05) of deglutition too, than patients who did not conduct such exercises (control group). CONCLUSIONS: Dysphagic adult patients with hemiparesis after stroke in the rehabilitation phase who underwent cervical isometric strengthening exercises showed more significant correction of cervical alignment and more pronounced improvement in deglutition compared to patients who did not include cervical isometric exercises in their therapeutic program. CLINICAL REHABILITATION IMPACT: The additional use of cervical isometric exercises in hemiparetic stroke patients with dysphagic symptoms lead to more pronounced improvement of their swallowing function compared to such patients who are subjected to speech therapy only. Furthermore, these exercises are shown to be beneficial for cervical spine alignment too.

The effectiveness of hydrokinesiotherapy on postural balance of hemiplegic patients after stroke: a systematic review and meta-analysis.

OBJECTIVE: To summarize evidence on the effects of hydrokinesiotherapy (HT) on postural balance in hemiplegic patients after stroke and compare them with conventional land therapy. DATA SOURCES: A literature search until October 2017 was conducted on CINAHL, PubMed, Cochrane EBM Reviews, Cochrane Clinical Trials, DARE, MEDLINE, Physiotherapy Evidence Database (PEDro), PsycInfo and Rehabilitation and Sports Medicine Source. REVIEW METHODS: Only randomized controlled trials with pre-intervention and post-intervention assessment on postural control have been included. Assessment of the quality (by Downs and Black quality assessment tool) of the included studies was performed by two reviewers, and a meta-analysis was undertaken. RESULTS: A total of 11 trials on postural control with 305 stroke patients were included. The majority of studies showed a beneficial effect of HT in postural control of the patients. The meta-analysis showed statistically significant improvement ( P < 0.05) in Berg Balance Scale (BBS), mediolateral (ML) and anteroposterior (AP) sway velocity of center of pressure with eyes closed (EC) in both groups, but the mean differences in BBS (3.85 points), ML sway velocity of center of pressure (1.38 points) and AP sway velocity of center of pressure (1.64 points) were statistically improved ( P < 0.05) in HT over land therapy program. CONCLUSION: HT is superior to land therapy program regarding postural balance in terms of BBS, ML and AP sway velocity of center of pressure.

A new, low cost, locking plate for the long-term fixation of a critical size bone defect in the ratfemur: in vivo performance, biomechanical and finite element analysis.

BACKGROUND: The optimum fixation device for the critical size bone defect is not established yet. OBJECTIVE: A reliable, feasible and low-cost fixation device for the long-term maintenance of a critical bone defect. METHODS: A custom-made plate made of poly-methyl-methacrylate was used for the fixation of a critical defect of rats' femurs. The screws were securely fixing both on the plate and the bone. A three point bending test, aimed to resemble the in vivo loading pattern, a Finite Element Analysis and a 24-week in vivo monitoring of the integrity of the plate fixation were utilized. RESULTS: The plate has linear and reproducible behavior. It presents no discontinuities in the stress field of the fixation. Its properties are attributed to the material and the locking principle. It fails beyond the level of magnitude of the normal ambulatory loads. In vivo, 100% of the plates maintained the bone defect intact up to 12 weeks and 85% of them at 24 weeks. CONCLUSION: This novel locking plate shows optimal biomechanical performance and reliability with high long-term in vivo survival rate. It is fully implantable, inexpensive and easily manufactured. It can be qualified for long term critical defect fixation in bone regeneration studies.

Caudal vs transforaminal epidural steroid injections as short-term (6 months) pain relief in lumbar spinal stenosis patients with sciatica.

OBJECTIVE: The aim of this study is to evaluate prospectively the efficacy of caudal epidural steroid injection (CESI) and transforaminal epidural steroid injection (TFESI) in lumbar spinal stenosis patients with sciatic pain. DESIGN: Prospective clinical study. SETTING AND PATIENTS: Thirty-one patients (average age 62 years) from two hospitals, with single dermotomal distribution of sciatic pain due to spinal stenosis were included in the study. INTERVENTIONS: Patients underwent epidural steroid injections done by the same injectionist. Eleven patients from one hospital were included in the CESI group, while the TFESI group consisted of 20 comparable patients from the second site. OUTCOME MEASURES: Primary outcome measure was the complete relief or at least 50% reduction of pain (visual analog scale [VAS]) at 6 months postinjection. Secondary outcome measures were the improvement of function (of at least 15 points of Oswestry Disability Index [ODI]) at 6 months and the changes of VAS and ODI and at 2 weeks, at 3 months, and at 6 months postinjection. RESULTS: A significantly greater number of stenosis patients showed pain relief at 6 months postinjection with TFSI (90%) than with CESI (54.54%). All patients with TFSI showed improvement of function at 6 months while only three (27.27%) patients with caudal epidural improved functionally. Out of the total 31 patients, two patients from group A underwent a second CESI at 15 days postinjection and decompressive spine surgery between 3 and 6 months postinjection. CONCLUSIONS: The effectiveness of transforaminal steroid injection for the stenosis patients with sciatica was superior to caudal at 6 months postinjection.

Effectiveness of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity in hemiplegic patients: a randomized controlled trial.

PURPOSE: To compare the effects of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity. METHOD: A randomized controlled study was conducted in a tertiary university hospital. Twenty-seven adult hemiplegic patients with spasticity due to brain or spinal cord damage were included. Spastic muscles were injected with botulinum toxin with or without EMG guidance. The modified Ashworth scale and modified Barthel index in each patient pre- and post-injection were documented. RESULTS: In group A, which consisted of 15 patients (55.55%), the injection was administered with needle electromyographic guidance, while in 12 patients (44.44%) of group B without electromyographic guidance with the use of anatomic landmarks only. The follow-up period was 3 months. At 3 weeks post-injection, spasticity was decreased (p < 0.05) in all patients and the mean (SD) reduction of spasticity was higher (p < 0.05) in group A (1.67 (0.5)) than group B (1.25 (0.46)). Similarly, the mean (SD) functional modified Barthel index improved statistically significantly (p < 0.001) post-injection (45.37 (8.43)) than pre-injection (54.07 (9.610), especially in group A (p < 0.05). CONCLUSION: The effectiveness of intramuscular botulinum toxin injection for the treatment of spasticity in hemiplegic patients is superior when performed with needle electromyographic guidance than without electromyography. IMPLICATIONS FOR REHABILITATION: It is recommended that botulinum toxin muscle injections of hemiplegic limbs be performed with EMG guidance More spasticity reduction and functional improvement at 3 months post-injection was observed in patients injected with botulinum toxin by the use of combined EMG guidance and anatomic landmarks EMG guidance might also save amount of botulinum toxin due to less spasticity observed during injection than when injection is performed with anatomic landmarks only.

Dysphagia associated with cervical spine and postural disorders.

Difficulties with swallowing may be both persistent and life threatening for the majority of those who experience it irrespective of age, gender, and race. The purpose of this review is to define oropharyngeal dysphagia and describe its relationship to cervical spine disorders and postural disturbances due to either congenital or acquired disorders. The etiology and diagnosis of dysphagia are analyzed, focusing on cervical spine pathology associated with dysphagia as severe cervical spine disorders and postural disturbances largely have been held accountable for deglutition disorders. Scoliosis, kyphosis­lordosis, and osteophytes are the primary focus of this review in an attempt to elucidate the link between cervical spine disorders and dysphagia. It is important for physicians to be knowledgeable about what triggers oropharyngeal dysphagia in cases of cervical spine and postural disorders. Moreover, the optimum treatment for dysphagia, including the use of therapeutic maneuvers during deglutition, neck exercises, and surgical treatment, is discussed.

Management of acute acromioclavicular joint dislocation with a double-button fixation system.

INTRODUCTION: Numerous static and dynamic techniques have been described for the management of acute acromioclavicular (AC) joint dislocation. To date, no standard technique has been established and several complications have been described for each of these techniques. The purpose of the present study was to evaluate the functional and radiographic outcomes of acute AC joint reconstruction after a mini-open technique using the double-button fixation system. PATIENTS AND METHODS: Twelve patients with acute AC joint dislocation treated with the double-button fixation system by one surgeon were retrospectively reviewed. Functional assessment was performed by an independent reviewer using the DASH, Constant and the VAS scores. The coracoclavicular (CC) distance of the affected shoulder was assessed on a standard radiograph and compared with the contralateral normal one. RESULTS: Eight patients were operated on for grade III AC joint dislocation and 4 for grade IV. The mean age of the patients at the time of surgery was 27.5 years. The mean follow-up was 18.25 months (range: 12-30 months). At the most recent follow-up, the mean Constant score was 94.8 (range: 84-100) showing a significant increase compared with the mean pre-operative value of 34.4 (range: 25-52) (p<0.001). The mean DASH score was significantly decreased from 19.6 (range: 14-28) preoperatively to 0.25 (range: 0-3) at the last follow-up (p<0.001). The mean VAS score showed a significant decrease from 5.75 (range: 4-7) to 0.2 (range: 0-2) (p<0.001). The mean CC distance on the operated shoulder was found to have no significant difference from the CC distance on the contralateral normal side (10.5 vs. 10mm) (p>0.05). There was no evidence of AC joint osteoarthrosis, CC calcification or osteolysis of the distal clavicle or the coracoid process. CONCLUSIONS: The proposed mini-open technique provides adequate exposure of the base of the coracoid with minimal damage to the soft tissues surrounding the CC ligaments while ensures an excellent cosmetic result. We recommend this fast and relatively simple technique for all type IV injuries and for type III injuries in heavy manual workers and high-demand upper extremities athletes.

Shoulder abduction and external rotation restoration with nerve transfer.

INTRODUCTION: In upper brachial plexus palsy patients, loss of shoulder function and elbow flexion is obvious as the result of paralysed muscles innervated by the suprascapular, axillary and musculocutaneus nerve. Shoulder stabilisation, restoration of abduction and external rotation are important as more distal functions will be affected by the shoulder situation. PATIENTS AND METHODS: Between 2005 and 2011, eleven patients with upper type brachial plexus palsy were operated on with triceps nerve branch transfer to anterior axillary nerve branch and spinal accessory nerve transfer to the suprascapular nerve for shoulder abduction and external rotation restoration. Nine patients met the inclusion criteria for the study. All patients were men with ages ranged from 21 to 35 years (average, 27.4 years). The interval between injury and surgery ranged from 4 to 11 months (average, 7.2 months). Atrophy of the supraspinatus, infraspinatus and deltoid muscle and subluxation at the glenohumeral joint was obvious in all patients preoperatively. During the pre-op examination all patients had at least muscle grading 4 on the triceps muscle. RESULTS: The mean post-operative value of shoulder abduction was 112.2° (range: 60-170°) while preoperatively none of the patients was able for abduction (p<0.001). The mean post-operative value of shoulder external rotation was 66° (range: 35-110°) while preoperatively none of them was able for external rotation (p<0.001). Postoperative values of shoulder abduction were significantly better that those of external rotation (p=0.0004). The postoperative average muscle grading for shoulder abduction according the MRC scale was 3.6±0.5 and for the shoulder external rotation was 3.2±0.4. CONCLUSIONS: Combined nerve transfer by using the spinal accessory nerve for suprascapular nerve neurotisation and one of the triceps nerve branches for axillary nerve and teres minor branch neurotisation is an excellent choice for shoulder abduction and external rotation restoration.

Surgical treatment of lumbar spinal stenosis with microdecompression and interspinous distraction device insertion. A case series.

BACKGROUND: Interspinous distraction devices (IPDD) are indicated as stand-alone devices for the treatment of spinal stenosis. The purpose of this study is to evaluate the results of patients undergoing surgery for spinal stenosis with a combination of unilateral microdecompression and interspinous distraction device insertion. METHODS: This is a prospective clinical and radiological study of minimum 2 years follow-up. Twenty-two patients (average age 64.5 years) with low-back pain and unilateral sciatica underwent decompressive surgery for lumbar spinal stenosis. Visual Analogue Scale, Oswestry Disability Index and walking capacity plus radiologic measurements of posterior disc height of the involved level and lumbar lordosis Cobb angle were documented both preoperatively and postoperatively. One-sided posterior subarticular and foraminal decompression was conducted followed by dynamic stabilization of the diseased level with an IPDD (X-STOP). RESULTS: The average follow-up time was 27.4 months. Visual Analogue Scale and Oswestry Disability Index improved statistically significantly (p < 0.001) in the last follow-up exam. Also, the walking distance increased in all patients but two. Posterior intervertebral disc height of the diseased level widened average 1.8 mm in the postoperative radiograph compared to the preoperative. No major complication, including implant failure or spinous process breakage, has been observed. CONCLUSIONS: The described surgical technique using unilateral microdecompression and IPDD insertion is a clinically effective and radiologically viable treatment method for symptoms of spinal stenosis resistant to non-operative treatment.

Cerebral oximetry and cognitive dysfunction in elderly patients undergoing surgery for hip fractures: a prospective observational study.

AIM: This study was conducted to examine perioperative cerebral oximetry changes in elderly patients undergoing hip fracture repair and evaluate the correlation between regional oxygen saturation (rSO(2)) values, postoperative cognitive dysfunction (POCD) and hospital stay. MATERIALS AND METHODS: This prospective observational study included 69 patients. Data recorded included demographic information, rSO(2) values from baseline until the second postoperative hour and Mini Mental State Examination (MMSE) scores preoperatively and on postoperative day 7. MMSE score ≤23 was considered evidence of cognitive dysfunction. Postoperative confusion or agitation, medications administered for postoperative agitation, and hospital length of stay were also recorded. Data were analyzed with Student's t-test, Pearson's correlation or multiple regression analysis as appropriate. RESULTS: Patient age was 74±13 years. Baseline left sided rSO(2) values were 60±10 and increased significantly after intubation. Baseline rSO(2) L<50 and <45 was observed in 11.6% and 10.1% of patients respectively. Perioperative cerebral desaturation occurred in 40% of patients. MMSE score was 26.23 ± 2.77 before surgery and 25.94 ± 2.52 on postoperative day 7 (p=0.326). MMSE scores ≤ 23 were observed preoperatively in 6 and postoperatively in 9 patients. Patients with cognitive dysfunction had lower preoperative hematocrit, hemoglobin, SpO(2) and rSO(2) values at all times, compared to patients who did not. There was no correlation between rSO(2) or POCD and hospital stay. Patients with baseline rSO(2) <5 required more medications for postoperative agitation. CONCLUSION: Cognitive dysfunction occurs preoperatively and postoperatively in elderly patients with hip fractures, and is associated with low cerebral rSO(2) values.

The scapholunate interosseous ligament afferent proprioceptive pathway: a human in vivo experimental study.

PURPOSE: To examine the afferent pathways of the scapholunate interosseous ligament (SLIL)-generated stimuli and their contribution to the overall carpal proprioception. METHODS: We examined 5 selected patients with preganglionic global root avulsion, confirmed by previous brachial plexus exploration, during the initial stage of carpal arthrodesis surgery. Despite their anesthetic-flail extremity, both the distal axon and the ganglionic cell were intact and able to transfer afferent stimuli. We placed electrodes subcutaneously over the adjacent areas of the ulnar, median, and radial nerves at the elbow region and performed an intraoperative neurophysiologic study. We studied the homologous sensory action potentials (SAPs) generated at the wrist in relaxation, flexion, extension, radial deviation, and ulnar deviation positions at each nerve and repeated them in 2 stages. The first took place with the SLIL intact and the second with the SLIL lacerated. The noise from the rest of the wrist elements was digitally eliminated. RESULTS: After the SLIL laceration, SAP intensities recorded at the median nerve in every wrist position were reduced. The radial and ulnar nerves showed differences of lesser degrees between the recorded SAP intensities before and after the ligament sectioning in every carpal position, with only the radial nerve following a specific pattern. The SAP intensity recorded at the median nerve in every carpal motion after the SLIL laceration was similar to the SAP intensity at relaxation with the SLIL intact, whereas recordings of various intensities were present for the radial and ulnar nerves. CONCLUSIONS: The SLIL generates proprioceptive stimuli at every wrist position. The main innervation of the whole SLIL derives from the anterior interosseous nerve; a partial contribution of the posterior interosseous nerve focused on the dorsal subregion of the ligament may also be present.

Cortical desmoid and the four clinical scenarios.

We reviewed four patients diagnosed with a cortical desmoid lesion at the distal posterior medial femur. Each case reflects a clinical scenario that can be present. Cortical desmoid is a benign, self-limited entity which occasionally can exhibit aggressive radiologic features. Here, we present the specific imaging features in association with patients history and clinical findings facilitating establishment of correct diagnosis. Exact diagnosis is important in order to avoid unnecessary biopsy and complicated therapeutic strategies.