A rare case of pemetrexed-induced diffuse punctal and canalicular stenosis: management by coronary balloon puncto-canaliculoplasty.

Several chemotherapeutic agents are known to induce lacrimal drainage stenosis and obstruction, resulting in epiphora. Pemetrexed is one such drug and is used in the management of mesotheliomas and non-small cell lung carcinomas. Pemetrexed inhibits folate metabolism at multiple levels. The present case is the second report of pemetrexed induced punctal and canalicular stenosis, but the first to document dacryoendoscopy findings and report balloon puncto-canaliculoplasty as a minimally-invasive treatment option.

Acquired lacrimal fistula: classification and management.

PURPOSE: To classify the acquired lacrimal fistulae (ALF) and assess the outcomes following surgical management. METHODS: Retrospective, interventional study of all patients presenting with ALF over a 3.5-year period was performed. The fistulae were classified based on photographic evidence with respect to their location, size and nature. Primary outcome measures were complete healing of the fistulous opening and resolution of discharge or leakage from it. Secondary outcome measures were resolution of epiphora and patency of the lacrimal drainage system. RESULTS: 84 eyes of 82 patients who had acquired lacrimal fistulae were analysed. The mean duration of the fistulae presence was 10.12 months. The etiology of ALF was spontaneous following lacrimal abscess rupture in 79 eyes and was secondary to incision and drainage in the remaining 5 eyes. Thirty eyes had fistulectomy along with definitive surgery for the associated nasolacrimal duct obstruction (NLDO), 15 eyes underwent definitive surgery without an additional fistulectomy and 4 fistulae healed spontaneously prior to intervention for NLDO. The resolution of ALF did not differ in between those who underwent fistulectomy versus those who did not. The exceptions were 2 chronic large fistulae with cutaneous lining which needed a definite fistulectomy for resolution along with surgery for NLDO. CONCLUSION: Most of the acquired fistulae heal by themselves irrespective of the nature, size and location and need no additional treatment in the form of fistulectomy. However, this is not true for those that are large and have a cutaneous lining.

Lacrimal Intrasaccal Polyp With Inspissated Mucopeptide Concretions.

Lacrimal sac mucopeptide concretions are not uncommon and usually identified following the lacrimal sac marsupialization during a dacryocystorhinostomy. A 39-year-old female presented with epiphora and discharge of 8 months duration and was diagnosed as primary acquired nasolacrimal duct obstruction. During the endoscopic dacryocystorhinostomy, a large intrasaccal polyp arising from the posterosuperior wall of the lacrimal sac with multiple inspissated mucopeptide concretions was noted. The lesion was excised, and the mucopeptide concretions were removed. Histopathology was suggestive of an intrasaccal polypoidal granuloma. To the best of the authors' knowledge, this is the first report of an intrasaccal polyp-like lesion secondary to a granulomatous response to a lacrimal sac mucopeptide concretion. It is important to be aware of this entity. The retrieval of mucopeptide concretion or lacrimal sac dacryoliths should prompt the surgeon to initiate an intraoperative endoscopic assessment of the sac before proceeding with the surgery.

Effectiveness of Faradic and Russian currents on plantar flexor muscle spasticity, ankle motor recovery, and functional gait in stroke patients.

BACKGROUND AND PURPOSE: Spasticity is a major disabling symptom in patients post stroke. Though studies have demonstrated that electrical stimulation (ES) can reduce spasticity and improve passive ankle range of motion (ROM), not many studies have evaluated the effectiveness of ES on active ankle ROM. The purpose of this study was to determine the effectiveness of Faradic and Russian currents in the reduction of ankle plantar-flexor spasticity and improving motor recovery in patients post stroke. METHODS: Eighty-three patients (29 females and 54 males; mean age of 57.12 years) were randomly assigned to Group 1 (task-oriented exercises), Group 2 (Faradic current for 10 min and task-oriented exercises), and Group 3 (Russian current for 10 min and task-oriented exercises) for a period of 5 sessions per week for 6 weeks. All patients were assessed for soleus and gastrocnemius muscles spasticity measured by modified modified Ashworth scale; active and passive range ROM measured by goniometer; and functional ambulation measured by modified Emory Functional Ambulation Profile at the time of recruitment to study and after 6 weeks. RESULTS: Both the types of stimulation and exercises were not associated with improvements in modified Emory Functional Ambulation Profile (p > 0.05). The results showed that all the groups are effective in improving passive ankle ROM (p < 0.05) and reducing soleus and gastrocnemius muscles spasticity (p < 0.05). Though all the groups were effective in improving active ankle ROM, no group was found to be superior to another after treatment CONCLUSION: Adding ES to exercises are associated with low to medium effect sizes (<0.5) in reducing spasticity and improving ankle ROM.

Effect of stretching of piriformis and iliopsoas in coccydynia.

Pain in the coccyx is referred as coccydynia. The pain aggravates in weight bearing i.e. sitting. Total 48 persons with coccydynia diagnosed clinically were recruited and randomly assigned into one of the 3 groups. Experimental group I were treated by stretching of piriformis and iliopsoas muscles, experimental group II were treated by stretching of piriformis and iliopsoas muscles and Maitland's rhythmic oscillatory thoracic mobilization over the hypomobile segments and the conventional group were treated by seat cushioning + Sitz bath + Phonophorosis. All participants underwent an initial baseline assessment for Pressure Pain Threshold (PPT) by using modified syringe algometer and pain free sitting duration. All the subjects were advised to minimise sitting posture and use a seat cushion. Treatment was given for 3 weeks, 5 sessions per week and post-treatment evaluation was done after completion of 3 weeks. Follow up evaluation was done after 1 month. DATA ANALYSIS: The data was analyzed by using 3 × 3 ANOVA. Tukey's HSD post-Hoc analysis was used for all pair wise comparison. RESULTS: The overall results of the study showed that there was significant improvement in pain pressure threshold and pain free sitting in both the experimental groups with treatment and improvement continued after cessation of therapy, whereas the conventional group did not improve significantly.

Identification of the components associated with functioning using the international classification of functioning, disability and health comprehensive core set for stroke in Indian stroke survivors.

OBJECTIVES: Rehabilitation interventions are expected to ensure best possible recovery and minimize functional disability in stroke survivors. However, not many studies have investigated patterns of recovery and outcomes after stroke in low-income countries. The objective of this study is to identify the biological, psychological, and social components associated with functioning over time in Indian stroke patients using the International Classification of Functioning, Disability and Health (ICF)-based tools and the Functional Independence Measure (FIM). METHODS: The functioning profile of stroke survivors who received a standard multi-disciplinary rehabilitation was prospectively assessed using the ICF and the FIM at admission (baseline), at 12 & 24 weeks. Descriptive analyses were performed to identify changes in the frequencies of ICF categories and qualifiers from admission to follow-up. RESULTS: One hundred and twenty-seven participants (mean age of 56 years) with mean FIM score 68 at baseline participated and completed the study. The mean FIM score at follow-up was 108. The numbers and frequency of ICF categories for activities and participation reduced after rehabilitation. More numbers of environmental factors were identified as barriers at follow-up (15 out of 33) compared to baseline. Within the components of Activities and Participation, significant improvement in functioning was found in 43 out of 51 categories. CONCLUSION: The results show a reduction in frequencies in ICF activities and participation categories corresponding to basic activities of daily living. Categories corresponding to employment and social integration showed little or no improvement.

Effect of cervical mobilization and ischemic compression therapy on contralateral cervical side flexion and pressure pain threshold in latent upper trapezius trigger points.

Studies have shown a clinical relationship between trigger points and joint impairments. However the cause-and effect relationship between muscle and joint dysfunctions in trigger points could not be established. The purpose of this study was to investigate effects of mobilization and ischemic compression therapy on cervical range of motion and pressure pain sensitivity in participants with latent trigger point in the upper trapezius muscle. Ninety asymptomatic participants with upper trapezius latent trigger point were randomized in to 3 groups: mobilization, ischemic compression and a control. The outcomes were measured over a 2 week period. Repeated measures ANOVA showed statistically and clinically significant pre to post improvement in both the interventional groups compared to control (p < 0.05). However the effect sizes between the intervention groups were small (<0.3) revealing minimal clinical detectable difference.

Mobilisation of the thoracic spine in the management of spondylolisthesis.

INTRODUCTION: Segmental instability due to lumbar spondylolisthesis is a potential cause of chronic low back pain. Hypomobility of the spine results in compensatory segmental hypermobility of the segment above or below restricted segments. Therefore, the aim of the study is to determine the effects of mobilisation of the hypomobile upper thoracic spine along with conventional flexion exercises and stretching of short hip flexors on the degree of slippage and the functions of the persons with lumbar spondylolisthesis. METHODOLOGY: All patients with spondylolisthesis were randomly assigned into two groups: Group I - Experimental group, treated with mobilisation of the thoracic spine along with the conventional physiotherapy and Group II - Conventional group, treated with conventional stretching, strengthening, and lumbar flexion exercise programme. RESULTS: The experimental group treated with mobilisation of the thoracic spine shows a significant reduction in the percentage of vertebral slip from pre-treatment to post-treatment measurements. CONCLUSION: Low back pain due to spondylolisthesis may be benefited by mobilisation of the thoracic spine along with stretching of short hip flexors, piriformis, lumbar flexion range of motion exercises, core strengthening exercises, etc.

Effects of unilateral posteroanterior mobilization in subjects with sacralized lumbosacral transitional vertebrae.

AIM OF THE STUDY: To find out the efficacy of unilateral posteroanterior (PA) mobilization over type IA and type IIA sacralized lumbosacral transitional vertebrae in patients with low back pain with or without leg pain. RESEARCH DESIGN: experimental randomized control study. SAMPLE SIZE: 30 subjects, SAMPLING: simple random sampling. GROUP A - 15 subjects - self lumbar mobility and stretching exercises + Unilateral PA mobilization + hot pack. GROUP B - 15 subjects - self lumbar mobility and stretching exercises + hot pack. Before initiating treatment, subjects were assessed for dependent variables: Pain intensity by VAS, Forward bending and side bending ROM by modified finger to floor method with the help of an inch-tape and functions by Modified Oswestry Functional Disability Questionnaires. Post test measurements were taken after completion 2 weeks of therapy. The results of the study suggest that unilateral PA pressure is an effective mobilization method in reducing low back pain, improving ROM and related disability as compared to impairment based exercises alone in patients with low back pain with or without radiation to lower limbs having abnormally large transverse processes and hypomobile type IA and IIA lumbo-sacral transitional vertebrae.

Effectiveness of hip abductor strengthening on health status, strength, endurance and six minute walk test in participants with medial compartment symptomatic knee osteoarthritis.

BACKGROUND AND OBJECTIVES: Decreased activity of hip abductor musculature has been suggested as a contributing factor for the disease progression in participants with symptomatic knee osteoarthritis (OA). In this study, the effectiveness of 6 weeks isolated hip abductor strengthening on WOMAC, 6 minute walk test and hip strength and endurance in participants with symptomatic medial compartment knee OA were studied. MATERIAL AND METHOD: Thirty persons with medial compartment knee OA were randomized to hip abductor strengthening group (n = 15) and conventional group (n = 15). Both the groups received intervention for 5 times per week for 6 weeks. 6 minute walk test, health status (WOMAC), hip strength (by modified syphgmomanometer) and hip endurance (number of repetitions) were assessed at baseline and post intervention. The dependent variables were analyzed using 2 × 2 ANOVA, with repeated measurement as second factor to determine the effects of the intervention on each outcome variable. RESULTS: Significant group-by-time interactions were observed for each variable of interest. Post hoc testing revealed that all the outcome measures improved significantly in the hip abductor strengthening group following the 6-week intervention than the control group. CONCLUSION: The incorporation of hip-strengthening exercises may be considered along with conventional exercises when designing a rehabilitation program for persons with knee OA.

Effect of Transcutaneous Electrical Nerve Stimulation on Plantar Flexor Muscle Spasticity and Walking Speed in Stroke Patients.

BACKGROUND AND PURPOSE: Spasticity is a major disabling symptom in patients post stroke. Although studies have demonstrated that transcutaneous electrical nerve stimulation (TENS) can reduce spasticity, the duration of single session TENS is a subject of debate. The purpose of this study was to determine the sustainability of the effects of TENS applied over common peroneal nerve in the reduction of ankle plantar-flexor spasticity and improving gait speed in patients post stroke. METHODS: Thirty patients (11 women and 19 men) (mean age of 46.46 years) were randomly assigned to group 1 (task oriented exercises), group 2 (TENS for 30 min and task oriented exercises) and group 3 (TENS for 60 min and task oriented exercises) for a period of five sessions per week for 6 weeks. All patients were assessed for ankle plantar-flexor spasticity, passive ankle dorsi-flexion range of motion, clonus and timed up and go test at the time of recruitment to study, at 3 and 6 weeks of therapeutic intervention. RESULTS: The overall results of the study suggest that there was a decrease in ankle plantar flexor spasticity, ankle clonus and timed up and go score in all the groups. A greater reduction of spasticity was seen in TENS groups (groups 2 and 3) when compared to control. No significant improvement was found in timed up and go test (TUG) scores between groups. CONCLUSION: Both 30 min and 60 min of application of TENS are effective in reducing spasticity of ankle plantar flexors, improving walking ability and increase the effectiveness of task related training. Based on the effect size, we would recommend a longer duration application for the reduction of spasticity. Copyright © 2015 John Wiley & Sons, Ltd.

Effectiveness of mobilization therapy and exercises in mechanical neck pain.

OBJECTIVES: While studies have looked into the effects of Maitland mobilization on symptom relief, to date, no work has specifically looked at the effects of Mulligan mobilization. The objective of this work was to compare the effectiveness of Maitland and Mulligan's mobilization and exercises on pain response, range of motion (ROM) and functional ability in patients with mechanical neck pain. METHODS: A total sample of 60 subjects (21-45 years of age) with complaints of insidious onset of mechanical pain that has lasted for less than 12 weeks and reduced ROM were randomly assigned to: group I - Maitland mobilization and exercises; group - II Mulligan mobilization and exercises; and group-III exercises only, and assessed for dependent variables by a blinded examiner. RESULTS: Post measurement readings revealed statistical significance with time (p < 0.00) and no significance between groups (p > 0.05) indicating no group is superior to another after treatment and at follow-up. The effect sizes between the treatment groups were small. CONCLUSION: Our results showed that manual therapy interventions were no better than supervised exercises in reducing pain, improving ROM and neck disability.

Effect of trunk muscles training using a star excursion balance test grid on strength, endurance and disability in persons with chronic low back pain.

BACKGROUND AND OBJECTIVES: Though core muscles strengthening using upper limbs in various positions and lower limbs in lying have been studied previously in patients with chronic low back pain (CLBP), no study has specifically looked in to the effects of a training program that requires prior motor planning in standing (functional position). The objective of this study was to evaluate the effectiveness of star excursion balance test (SEBT) grid training in improving the outcomes in patients with CLBP. MATERIALS AND METHOD: Sixty patients with mechanical CLBP who fulfilled our criteria were randomized in to two groups; experimental group received physical diagnostic specific interventions, core muscles strengthening and muscles training using the SEBT grid. The participants in control group received stationary cycling instead of SEBT grid training and the other interventions were uniform. The duration of study was 4 weeks. The dependent variables were analyzed using repeated measures 2 × 3 ANOVA. RESULTS: At the end of study, both the groups showed a significant reduction in disability and improvement in strength and endurance (p< 0.05). Post-hoc analysis showed that SEBT grid training was better than conventional exercises. Follow-up at 16 weeks revealed a statistically insignificant loss in strength and endurance in control group patients. This reduction was not associated with an increase in disability score. The experimental group patients continued showing improvement. CONCLUSION: The results of our study show that core muscles strengthening using a SEBT grid are more effective than conventional programs. We hypothesize SEBT training to have a significant role in skill learning. We recommend SEBT grid training to be incorporated in the treatment planning of persons with CLBP.

Effect of electrical stimulation to long head of biceps in reducing gleno humeral subluxation after stroke.

BACKGROUND: Glenohumeral subluxation is the most frequent complication in post stroke hemiplegia and its reduction has been considered an important goal. Though it has been demonstrated that cyclical electrical stimulation of posterior deltoid and supraspinatus muscles can reduce subluxation, the role of biceps has not been given due consideration. OBJECTIVE: The purpose of this study was to determine whether electrical stimulation to the long head of biceps could more effectively reduce gleno humeral subluxation. METHODS: 24 patients were selected and consecutively assigned to group 1 (electrical stimulation to supraspinatus & posterior deltoid) and group II (electrical stimulation to supraspinatus, posterior deltoid & long head of the biceps) along with routine physiotherapy and occupational therapy for a period of 5 weeks. All patients were assessed for shoulder subluxation, pain and shoulder active abduction range of motion at the time of recruitment to study and after 5 weeks of therapy. RESULTS: Both the groups showed significant improvement in parameters measured. Tukey's post hoc analysis showed the results were more significant in Group II. CONCLUSIONS: Electrical stimulation to biceps along with the supraspinatus and posterior deltoid can more effectively reduce shoulder subluxation.