Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Femoral bone mineral density at the time of hip fracture is higher in women with versus without type 2 diabetes mellitus: a cross-sectional study.

PURPOSE: To compare femoral bone mineral density (BMD) levels in hip-fracture women with versus without type 2 diabetes mellitus (T2DM). We hypothesized that BMD levels could be higher in the women with T2DM than in controls and we aimed to quantify the BMD discrepancy associated with the presence of T2DM. METHODS: At a median of 20 days after the occurrence of an original hip fracture due to fragility we measured BMD by dual-energy x-ray absorptiometry at the non-fractured femur. RESULTS: We studied 751 women with subacute hip fracture. Femoral BMD was significantly higher in the 111 women with T2DM than in the 640 without diabetes: mean T-score between-group difference was 0.50, (95% CI from 0.30 to 0.69, P < 0.001). The association between the presence of T2DM and femoral BMD persisted after adjustment for age, body mass index, hip-fracture type, neurologic diseases, parathyroid hormone, 25-hydroxyvitamin D and estimated glomerular filtration rate (P < 0.001). For a woman without versus with T2DM, the adjusted odds ratio to have a femoral BMD T-score below the threshold of - 2.5 was 2.13 (95% CI from 1.33 to 3.42, P = 0.002). CONCLUSIONS: Fragility fractures of the hip occurred in women with T2DM at a femoral BMD level higher than in control women. In the clinical assessment of fracture risk, we support the adjustment based on the 0.5 BMD T-score difference between women with and without T2DM, although further data from robust longitudinal studies is needed to validate the BMD-based adjustment of fracture risk estimation.

Oxygen-ozone therapy for the treatment of low back pain: a systematic review of randomized controlled trials.

OBJECTIVE: The aim of the study was to review the available literature on the application of oxygen-ozone therapy (OOT) in the treatment of low back pain (LBP), to understand its therapeutic potential and compare it with other available treatment options. MATERIALS AND METHODS: A systematic review was performed on the PubMed and Scopus databases, with the following inclusion criteria: (1) randomized controlled trials (RCTs), (2) published in the last 20 years, (3) dealing with OOT in patients with LBP and herniated disc, (4) comparing the results of OOT with those of other treatments. The risk of bias was assessed by the Cochrane Risk of Bias tool. RESULTS: Fifteen studies involving 2597 patients in total were included. Patients in the control groups received different treatments, from oral drugs to other injections, instrumental therapy and even surgery: corticosteroids were used in 5 studies, analgesic therapy in 2 studies; placebo, microdiscectomy, laser-therapy, TENS and postural rehabilitation, percutaneous radiofrequency intradiscal thermocoagulation and psoas compartmental block were tested in the other trials. Looking at the quality of the literature, none of the studies included reached "good quality" standard, 3 were ranked as "fair" and the rest were considered "poor". Comparison of OOT results with other approaches showed that, in the majority of studies, OOT was superior to the control treatment, and also when compared to microdiscectomy, ozone showed non inferiority in terms of clinical outcomes. CONCLUSIONS: The analysis of literature revealed overall poor methodologic quality, with most studies flawed by relevant bias. However, OOT has proven to be a safe treatment with beneficial effects in pain control and functional recovery at short to medium term follow-up.

The role of PET in a clinically silent and ultrasound negative synovitis in the course of rheumatoid arthritis - a case report.

We present a case report of a rheumatoid arthritis patient, who underwent a PET scan, which revealed inflammation of multiple joints, which was missed by both physical and ultrasound examinations. A 55-year old woman with a long-term rheumatoid arthritis, who had undergone arthroplasty of the left knee in the past, consulted with the rheumatologist for pain in the left knee. The physical examination revealed signs of inflammation in the left knee and right elbow. The inflammatory parameters were high. Ultrasound showed intraarticular effusion without signs of active synovitis in the left knee. The ultrasound assessment of the other joints (hands, wrists and feet) was also negative for active synovitis, while positron-emission tomography (PET) revealed increased glucose metabolism at the level of the medial side of the left knee, left radio-ulno-carpal joint, I-II-III metacarpo-phalangeal joints bilaterally, right II metatarso-phalangeal joint, and left II-III metatarso-phalangeal joints. This case report demonstrates that PET might be more sensitive than ultrasound in detecting subclinical joint inflammation.

Effectiveness of an innovative mattress overlay for improving rehabilitation in low back pain: A pilot randomized controlled study.

BACKGROUND AND OBJECTIVE: Sleep disorders should be routinely evaluated and treated in low back pain (LBP) patients because they represent an important contributor to pain. However, no study thus far has investigated the potential benefit to LBP management of a device improving the sleep quality. Therefore, aim of this study was to assess the effectiveness of an innovative mattress overlay as add-on treatment to LBP rehabilitation. METHODS: Thirty eight LBP patients were randomized to standard rehabilitation plus mattress overlay use (cases) or standard rehabilitation only (controls). The intervention duration was 2 months and the following assessments were performed before and after: pain intensity; level of perceived back disability and sleep health; spine mobility; thickness and echo intensity of the lumbar multifidus. RESULTS: Significant pre-post-intervention improvements were observed in cases for resting and movement pain, perceived back disability, sleep, fingertip-to-floor distance, multifidus thickness (∼ 6% increase) and echo intensity (∼ 13% decrease). On the contrary, all these variables remained constant between the two experimental phases in controls. CONCLUSIONS: A combination of rehabilitation and mattress overlay use seems an effective approach for improvement of pain, perceived back disability, sleep, spine mobility, and lumbar multifidus size and structure of LBP patients.

Dynamic brace is a good option to treat first anterior shoulder dislocation in season.

PURPOSE: We evaluate the ability of in-season competitive athletes to return to competition after an anterior shoulder instability treated conservatively with a new dynamic brace combined with a specific rehabilitation program. METHODS: Twenty soccer players affected by traumatic anterior shoulder dislocation have been enrolled in the "Footballer In Season Fast Rehab" project during 2 consecutive football seasons. We excluded patients affected by rotator cuff tears and the bony defect over 25%. All the players have been treated the day after the first dislocation with a new dynamic brace used until the end of the second month after the first glenohumeral dislocation combined with a specific rehab protocol. Athletes were evaluated for the time necessary to completely resume sport activities, to complete the season, and for the recurrence of dislocation. RESULTS: All the athletes enrolled in this study were able to come back on the ground in approximately 40 days after the dislocation except 2 of them. Only two athletes claimed a slight discomfort at the return to play. One athlete had a traumatic relapse of the instability, 50 days after the dislocation. Another athlete claimed to have had a subluxation during a training session 45 days after the dislocation. 90% of the athletes were able to end the season without any shoulder discomfort. CONCLUSIONS: The dynamic brace combined to the rehabilitation protocol represents the solution that allows a quick start of resumption of training while maintaining a stable pain-free shoulder. LEVEL OF EVIDENCE: Level 4.

A new magnetic device for quadriplegia.

STUDY DESIGN: Case report. OBJECTIVES: The objective of this study was to evaluate whether a new custom-made magnetic device might enable a patient affected with quadriplegia to self-feed. SETTING: Day Hospital of the Unipolar Spinal Unit, CTO Hospital, Turin, Italy. METHODS: Three magnets were affixed to a custom-made device and to a specially modified cutlery and a bottle of water. RESULTS: The magnetic device permitted the patient to feed himself autonomously, using both a knife and a fork to eat and a bottle of water to drink. CONCLUSION: Such a magnetic device might be useful for self-feeding in a patient with quadriplegia.

Differences in proprioception, muscle force control and comfort between conventional and new-generation knee and ankle orthoses.

The aim of this study was to compare muscle force control and proprioception between conventional and new-generation experimental orthoses. Sixteen healthy subjects participated in a single-blind controlled trial in which two different types of orthosis were applied to the dominant knee or ankle, while the following variables were evaluated: muscle force control (accuracy), joint position sense, kinesthesia, static balance as well as subjective outcomes. The use of experimental orthoses resulted in better force accuracy during isometric knee extensions compared to conventional orthoses (P=0.005). Moreover, the use of experimental orthoses resulted in better force accuracy during concentric (P=0.010) and eccentric (P=0.014) ankle plantar flexions and better knee joint kinesthesia in the flexed position (P=0.004) compared to conventional orthoses. Subjective comfort (P<0.001) and preference scores were higher with experimental orthoses compared to conventional ones. In conclusion, orthosis type affected static and dynamic muscle force control, kinesthesia, and perceived comfort in healthy subjects. New-generation experimental knee and ankle orthoses may thus be recommended for prophylactic joint bracing during physical activity and to improve the compliance for orthosis use, particularly in patients who require long-term bracing.

Quasi-VMAT in high-grade glioma radiation therapy.

PURPOSE: To compare a quasi-volumetric modulated arc therapy (qVMAT) with three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) for the treatment of high-grade gliomas. The qVMAT technique is a fast method of radiation therapy in which multiple equispaced beams analogous to those in rotation therapy are radiated in succession. PATIENTS AND METHODS: This study included 12 patients with a planning target volume (PTV) that overlapped at least one organ at risk (OAR). 3D-CRT was planned using 2-3 non-coplanar beams, whereby the field-in-field technique (FIF) was used to divide each field into 1-3 subfields to shield the OAR. The qVMAT strategy was planned with 15 equispaced beams and IMRT was planned using 9 beams with a total of 80 segments. Inverse planning for qVMAT and IMRT was performed by direct machine parameter optimization (DMPO) to deliver a homogenous dose distribution of 60 Gy within the PTV and simultaneously limit the dose received by the OARs to the recommended values. Finally, the effect of introducing a maximum dose objective (max. dose < 54 Gy) for a virtual OAR in the form of a 0.5 cm ring around the PTV was investigated. RESULTS: The qVMAT method gave rise to significantly improved PTV95% and conformity index (CI) values in comparison to 3D-CRT (PTV95% = 90.7 % vs. 82.0 %; CI = 0.79 vs. 0.74, respectively). A further improvement was achieved by IMRT (PTV95% = 94.4 %, CI = 0.78). In qVMAT and IMRT, the addition of a 0.5 cm ring around the PTV produced a significant increase in CI (0.87 and 0.88, respectively), but dosage homogeneity within the PTV was considerably reduced (PTV95% = 88.5 % and 92.3 %, respectively). The time required for qVMAT dose delivery was similar to that required using 3D-CRT. CONCLUSION: These findings suggest that qVMAT should be preferred to 3D-CRT for the treatment of high-grade gliomas. The qVMAT method could be applied in hospitals, for example, which have limited departmental resources and are not equipped with systems capable of VMAT delivery.

Cemented fixed-bearing PFC total knee arthroplasty: survival and failure analysis at 12-17 years.

BACKGROUND: Total knee arthroplasty (TKA) is the appropriate treatment for degenerative pathology of the knee. Implant surveillance is mandatory to improve clinical results. We present the long-term results of a series of consecutive TKA Press Fit Condylar (J&J), cemented fixed bearing with selective patellar resurfacing in nonselected patients. MATERIALS AND METHODS: In this prospective case series, 223 TKA were clinically and radiographically evaluated using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation and Scoring System. RESULTS: There were 197 patients, with an average age of 68.4 years [95% confidence interval (CI) 52.7-84.1 years]; 49 arthroplasties were implanted in men (21.1%) and 184 (78.9%) in women. The average follow-up was approximately 13.5 years (162.1 months; 95% CI 132.3-191.9), and it was possible to evaluate 179 implants (76.8% of the implanted prosthesis) in 176 patients. The average HSS score increased from 61.5 (95% CI 60.4-62.7) to 89.4 (95% CI 87.7-.93.5) points. The cumulative average survival rate at 15 years (the endpoint being failure with revision) was 90.6%  ± 2% standard deviation. Resurfacing the patella did not make a difference in terms of implant survival. Progressive radiolucent lines were observed around 20 implants (14.3%); all were revised. CONCLUSIONS: The PFC system is an excellent prosthetic solution. Early clinical complications, mechanical axis and patellar resurfacing do not correlate with implant failure, whereas progressive radiolucent lines do.

Torino 2006. XX Olympic and IX Paralympic Winter Games: the ENT experience.

A total of 27 competition days, more than 3000 athletes, over 10,000 components of the Olympic family, 3,500 workers, 2,500 volunteers, an overall business of more than 2 billion Euros. These, in a nutshell, are just a few of the data concerning the XX Olympic and the IX Paralympic Winter Games, Torino, Italy, 2006. Such a huge event, obviously required a meticulously organized medical service to cope with the healthcare of the athletes, official workers and the Olympic family, distributed over a geographic area of approximately 80 km in diameter. An ENT service was organized within the medical service, which was divided between 3 Polyclinics, in which 12 ENT Specialists were on duty. The present report gives an account of the final data concerning the service involved, together with a description of the approach used in the actual organization, with a view to providing useful information for colleagues who will be called upon, for a similar service, in future Olympic Winter Games. The ENT healthcare offered was confirmed to be proportional to the requirements, both from a qualitative and quantitative point of view. All the ENT specialists involved, reported having gained an immense store of human experience from having lived the Olympic atmosphere as a volunteer exerting one's own profession. The facilities available in the Polyclinics, which were at a considerable distance from the Hospital, were found to be more than adequate with respect to the pathological conditions and service requested, particularly in 17% of the cases which would otherwise have been sent to a Hospital Outpatient Unit at least 80 km away.

Hyperhomocysteinemia in winter elite athletes: a longitudinal study.

Hyperhomocysteinemia is a well-established risk factor for cardiovascular diseases. The aims of this study were to longitudinally investigate, in a group of elite athletes, plasma homocysteine levels and to search for relationships with the muscular workload and the vitamin status. One hundred and three athletes (59 males and 44 females, respectively) were evaluated in different periods: namely the recovery period, the training period, and the competition period; 84 subjects (37 males and 47 females), served as controls. The evaluation sessions consisted in blood sampling and medical examination. The percentages of athletes with normal and elevated homocysteine levels, defined by levels below or above the limit of 15 mumol/l, were 68.0% and 32.0%, respectively, in the recovery period, and these percentages remained unchanged during the following periods. In the control group, relevant percentages were 92.9% and 7.1%, respectively. The comparison between plasma homocysteine of male and female, evaluated in the recovery period, showed significantly higher levels in the former group (18.8+/-18.0 micromol/l vs 10.7+/-5.9 micromol/l, p<0.001 respectively), as well as a higher proportion of individuals with hyperhomocysteinemia (24/59 vs 9/44, p<0.05). The correlation analyses showed a weak but significant negative correlation between homocysteine and folate in the three periods considered, while no significant relationship was observed between homocysteine and creatine-kinase. We found excess prevalence of hyperhomocysteinemia in elite athletes of winter sports. A strategy to understand which mechanisms in these athletes subserve hyperhomocysteinemia is essential in order to reduce the potential risk for future cardio-vascular morbidity and mortality.

Effects of the training status on the hormonal response and recovery from high-intensity isokinetic exercise: comparisons between endurance-trained athletes and sedentary subjects.

AIM: Aims of the study were: to determine the differences in the mechanical, hormonal and lactate responses to a high-intensity isokinetic exercise in two groups of endurance-trained athletes (EA, n = 11) and sedentary subjects (SED, n = 11); to evaluate the relationships between the hormonal and lactate responses; to evaluate the effects of the training status on the pituitary responsiveness to the exercise. METHODS: EA and SED completed, for each leg, 4 sets of 20 maximal concentric contractions of the knee extensor muscle groups at 180 degrees s-1 angular velocity. Blood and saliva for hormonal and lactate determinations were sampled before, immediately after the test and during the subsequent recovery of 2 hours. RESULTS: The exercise was completed by all subjects and elicited significant mechanical and biochemical responses both in EA and in SED subjects. No differences were found between the two groups both in the mechanical performances and in the increases of lactate and hormones of the pituitary-adrenal axis or in the comparison of the slopes of adrenocorticotropic hormone (ACTH), cortisol, and dehydroepiandrosterone recovery after the peak. The correlation analyses showed significant positive relationships between lactate peak values and percentages of change for ACTH (r2 = 0.16, P < 0.05), salivary cortisol (r2 = 0.42, P < 0.01), and serum cortisol (r2 = 0.56, P < 0.001). CONCLUSIONS: The adrenocortical activation was found, in this particular setting, at least partly dependent on the muscular lactate production, while no effect of the training status on the pituitary responsiveness to exercise was evident, as it was indirectly confirmed by no abnormalities in the rates of hormonal recovery after the exercise session.

Arthroscopic treatment of shoulder ochronotic arthropathy: a case report and review of literature.

Alcaptonuria is an inherited hereditary metabolic disorder, which is associated with various systemic abnormalities and related to the accumulation of homogentisic acid and a derived melanine-like pigment in the connective tissues; the latter is termed ochronosis. We present the arthroscopic findings in the shoulder of a 58-year-old female with ochronotic arthropathy and discuss the role of arthroscopy in the diagnosis and management of this rare metabolic disorder.

Heterotopic ossification of the ulnar collateral ligament: a description of a case in a top level weightlifting athlete.

The purpose of this paper is to describe a case of heterotopic ossification of the ulnar collateral ligament in a 29-year-old top level weightlifter. Plain radiography of the elbow determined the extent and location of heterotopic ossification. Ultrasound and MR imaging completed the instrumental set-up. This symptomatic case had the resolution of pain after 2 months of a supervised rehabilitation program. At one year follow-up the athlete is asymptomatic referring occasional minor pain only in the periods of vigorous training.

Role of exercise stress test in master athletes.

BACKGROUND: The effectiveness of cardiovascular screening in minimising the risk of athletic field deaths in master athletes is not known. OBJECTIVE: To evaluate the prevalence and clinical significance of ST segment depression during a stress test in asymptomatic apparently healthy elderly athletes. METHODS: A total of 113 male subjects aged over 60 were studied (79 trained and 34 sedentary); 88 of them (62 trained and 26 sedentary) were followed up for four years (mean 2.16 years for athletes, 1.26 years for sedentary subjects), with a resting 12 lead electrocardiogram (ECG), symptom limited exercise ECG on a cycle ergometer, echocardiography, and 24 hour ECG Holter monitoring. RESULTS: A significant ST segment depression at peak exercise was detected in one athlete at the first evaluation. A further case was seen during the follow up period in a previously "negative" athlete. Both were asymptomatic, and single photon emission tomography and/or stress echocardiography were negative for myocardial ischaemia. The athletes remained symptom-free during the period of the study. One athlete died during the follow up for coronary artery disease: he showed polymorphous ventricular tachycardia during both the exercise test and Holter monitoring, but no significant ST segment depression. CONCLUSIONS: The finding of false positive ST segment depression in elderly athletes, although still not fully understood, may be related to the physiological cardiac remodelling induced by regular training. Thus athletes with exercise induced ST segment depression, with no associated symptoms and/or complex ventricular arrhythmias, and no adverse findings at second level cardiological testing, should be considered free from coronary disease and safe to continue athletic training.

A Simulator for X-ray images.

A simulator for X-ray images is presented based on a virtual X-ray source and a virtual human body obtained from tomographic slices. In the simulator it is possible to modify the tube potential, the anodic current, the exposure time, the filtration and some geometric parameters such as source-skin distance, orientation and field size. The virtual body consists of a three-dimensional voxel matrix in which CT numbers for each point of the body are stored. The interactions of X rays passing through the body are evaluated using the pencil beam technique. The image is obtained by computing the dose absorbed by the detector and converting it into optical density using a proper response function. The image spatial resolution is limited by the voxel size. The influence of each parameter on the image quality can be observed interactively. The dose absorbed in each point of the body is an important parameter obtained as output of the simulator.

Abnormal RNA expression of 11p15 imprinted genes and kidney developmental genes in Wilms' tumor.

Wilms' tumor (WT) is caused by abnormal development of embryonal kidney cells. WT cells are frequently affected by deletions or functional inactivation of maternal alleles at chromosome 11p15, which indicates that the loss of maternally expressed genes in this region plays an important role in WT pathogenesis. Maternally expressed genes indeed exist within an imprinted region at 11p15.5. Among these, BWR1C is highly expressed in fetal but not in adult kidney, which suggests that it may fulfil an important role in kidney development. Here, we demonstrate that the lack of BWR1C expression is common in WT. Its homology with the proapoptotic gene TDAG51 suggests that the loss of BWR1C expression may be relevant in WT development. In addition, the analysis of the expression of other 11p15 imprinted genes and kidney-developmentally regulated genes indicates that IGF2 overexpression, inappropriate coexpression of RET and GDNF and, in some cases, down-regulation of CDKN1C may also play an important role in the pathogenesis of WT. Our results add new elements to the understanding of the biological basis of WT, which may have implications for WT diagnosis and therapy.

Antitumor activity of taxol (NSC-125973) in human ovarian carcinomas growing in the peritoneal cavity of nude mice.

BACKGROUND: The unique mechanism of action of taxol (NSC-125973) as microtubule stabilizing agent and its potential activity in clinical trials have generated considerable interest in the development of this agent. As taxol was reported to be active on advanced and refractory ovarian carcinomas we focused our studies on the xenograft model of human ovarian carcinoma that develops ascites and tumor dissemination in the peritoneal cavity of nude mice. METHODS: The antitumor activity of taxol was evaluated on two human ovarian carcinoma xenografts (HOC8 and HOC22) transplanted i.p. in nude mice. Drug was given i.v. at doses of 20-34.5 mg/kg every four days three times (Q4 x 3) and the increment of life span (%ILS) was evaluated. Cisplatin at the dosage of 4mg/kg, Q4 x 3 was used as reference drug in each experiment. RESULTS: Taxol given at doses of 20 mg/kg and 34.5 mg/kg to early-stage HOC22 (treatment starting 3 days after tumor transplant) cured all the mice, while the same dose regimens given to advanced HOC22 (treatment starting 14 days after tumor transplant) significantly prolonged the survival time of the mice (ILS = 197% and 300%). Taxol given 3 days after HOC8 transplant significantly prolonged the survival time of tumor-bearing nude mice, inducing complete responses in 50% and 25% of mice receiving, respectively, 34.5 mg/kg/injection and 20 mg/kg/injection. On both ovarian carcinoma xenografts taxol was more active than equitoxic doses of the reference drug cisplatin. CONCLUSIONS: The therapeutic activity against ovarian carcinoma xenografts supports the potential of taxol in the treatment of this neoplasia and forms the basis for future investigations aimed at optimizing the therapeutic activity of taxol given alone or in combination with other drugs.