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OBJECTIVE To evaluate the efficacy and safety of mesenchymal stem cells (MSCs) therapy in patients with tendon disorders enrolled in prospective clinical studies. METHODS We systematically searched prospective clinical studies that investigated the effects of MSC administration on human tendon disorders with at least a 6-month follow-up period in the PubMed-MEDLINE, EMBASE, and Cochrane Library databases. The primary outcome of interest was the change in pain on motion related to tendon disorders. Meta-regression analyses were performed to assess the relationship between MSC dose and pooled effect sizes in each cell dose. RESULTS Four prospective clinical trials that investigated the effect of MSCs on tendon disorders were retrieved. MSCs showed a significant pooled effect size (overall Hedges' g pooled standardized mean difference=1.868; 95% confidence interval, 1.274-2.462; p

The partial weight-bearing protocol after lower limb fracture is an important issue in postoperative rehabilitation. Because it is difficult to quantify the actual weight load and provide a constant weight, the protocol is unestablished. By training with a lower-body positive-pressure treadmill and using an in-shoe pressure-measuring device, partial weight-bearing exercise can be performed with quantified loads. This case series illustrates the applicability of an early quantitative partial weight-bearing rehabilitation program using lower-body positive-pressure treadmill with an in-shoe pressure-measuring device after periarticular tibial fractures, which provides a quantitatively predetermined constant load.

Background Here, we aimed to propose novel lateral whole‐body dual‐energy X‐ray absorptiometry (lateral DXA) as a simple tool for measuring spinal muscle mass and investigate the feasibility of lateral DXA to measure lumbar paraspinal muscle (LPM) mass compared with lumbosacral spine three‐dimensional magnetic resonance imaging (3D MRI). Methods Twenty consecutive participants were enrolled from a prospective observational cohort (SarcoSpine study). Lateral DXA was scanned with each participant in the lateral decubitus position. The region of interest was defined to analyse the LPM mass. LPM total volume, LPM cross‐sectional area at the L3 mid‐vertebra and L4/5 mid‐disc levels and each signal intensity were measured by 3D MRI. Isokinetic and isometric back extensor muscle strengths as well as back extensor endurance were examined. The correlation between lateral DXA‐based mass (weight) and 3D MRI‐based LPM volume was analysed. Results The mean age of the 20 participants (15 women, 5 men) was 72.2 ± 4.9 years. LPM mass by lateral DXA was positively correlated with LPM volume by 3D MRI (β = 0.333, r = 0.692, p

Although several studies have shown that low skeletal muscle mass is correlated with knee osteoarthritis, no studies have investigated the correlation between skeletal muscle mass and hip and lumbar spine osteoarthritis (OA). This study aimed to delineate the relationship between low skeletal muscle mass and radiographic OA (ROA) of the knee, hip, and lumbar spine. This is a cross-sectional study using the public data obtained from the Fifth Korean National Health and Nutrition Examination Survey (2010–2011). We included subjects aged ≥ 50 years who completed the surveys (3813 subjects). ROA was assessed by knee, hip, and lumbar spine radiographs and defined as Kellgren/Lawrence (KL) grade of at least 2 in the knee and lumbar spine, whereas KL grade ≥ 1 in the hip. Multivariate logistic regression analyses were performed to evaluate the effects of low skeletal muscle mass on radiographic joint degeneration. Appendicular skeletal muscle mass (ASM) was higher in subjects with healthy joints than in subjects with knee and lumbar spine ROA (18.9 ± 0.1 kg vs. 17.1 ± 0.2 kg, P

Purpose: Although several studies with animals have reported the effects of mesenchymal stem cells (MSCs) for tendon regeneration, little is known about the efficacy and safety of MSCs in human tendon disorders. We performed this meta-analysis to evaluate the efficacy and safety of MSC therapy in patients with tendon disorders enrolled in prospective clinical studies.Methods: We systematically searched prospective clinical studies investigating the effects of MSCs administration on human tendon disorders with at least a 6-month follow-up period on PubMed-Medline, Embase, and Cochrane Library databases. The primary outcome of interest was the change in pain on motion related to tendon disorders. We performed a pairwise meta-analysis using the fixed-effects model to assess treatment response, which was calculated by the standardized mean difference. Meta-regression analyses were performed to assess the relationship between MSCs dose and pooled effect sizes in each cell dose.Results: Four prospective clinical trials investigating the effect of MSCs on tendon disorders were retrieved. MSCs showed significant pooled effect size (overall Hedge’s g pooled standardized mean difference (SMD) = 1.868; 95% confidence interval [CI], 1.274–2.462; P < 0.001). The treatment with MSCs improved all the aspects analyzed, i.e. pain, functional scores, radiologic parameters (magnetic resonance image or ultrasonography), and arthroscopic findings. In the meta-regression analysis, there was a significant cell dose-dependent response in pain relief (Q = 9.06, P = 0.029). While three studies reported mild adverse events after MSCs injection, these were not severe and relieved spontaneously.Conclusions: Our meta-analysis revealed that MSC therapy may improve pain, function, radiologic, and arthroscopic parameters in patients with tendon disorders. Due to the small number of studies in this meta-analysis and considering the increasing MSCs applications, there is a strong need for large-scale randomized controlled trials to confirm the long-term functional improvement as well as the adverse effects of MSC therapies in tendon disorders.

Cervical dystonia (CD) is a chronic neurological movement disorder that causes involuntary neck muscle contractions, leading to abnormal movements or posture of the head. However, objective evaluation of severity of CD is lacking in the clinical practice. This study aimed to provide an objective evaluation of the severity of CD based on three-dimensional (3D) kinematics of the neck using wearable inertial sensors. Each inertial sensor was attached to the anterior chest and head of eight patients with idiopathic CD. The involuntary movements of neck were quantified by the rotation angle (RA) and magnitude of angular velocity (MAV) through axis-angle representation expressing 3D rotation. The characteristic posture of each patient was visualized. Four kinematic parameters, the mean and peak values of RA and MAV (Meanangle, Peakangle, Meanvel, and Peakvel) were calculated and correlation between each parameter values and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores from all patients was analyzed to assess clinical validity. The test–retest reliability of the parameters was examined as well. Correlation coefficients of the Meanangle and Peakangle with TWSTRS were 0.28 and 0.69, respectively, whereas those of the Meanvel and Peakvel were 0.84 and 0.84, respectively. The MAV parameters showed a higher correlation with clinical severity than RA parameters. The intraclass correlation coefficients of the four parameters between the test–retest were more than 0.9. We conclude that objective evaluation of severity of CD based on kinematic parameters is clinically valid and has test–retest reliability.

In this study, we conducted an experiment for validating a motion estimation system used in novel mirror therapy. The proposed motion estimation system consists of two parts. The first part is motion estimation using attitude and heading reference system sensors. The system attaches a reference frame to a patient to provide flexibility to the patient’s movements. The second part is a compensation algorithm that uses principal component analysis (PCA). Ten subjects performed simple reaching tasks for the validation experiment. The results showed success rate of 89.67% under normal conditions. The PCA-based compensation algorithm increases the success rate from 89.67 to 92.89%. Accurate capturing of healthy arm motion will make effective robot-aided mirror therapy systems feasible.

BACKGROUND The standard position for examining the lateral elbow with ultrasonography is an "extended" or "slightly flexed" position. However, because the radial collateral ligament (RCL) is more deeply attached on the lateral epicondyle than the common extensor tendon, an anisotropic artifact of the RCL could be observed in the conventional positions, making it difficult to fully visualize the RCL. OBJECTIVES To determine optimal elbow positions for accurate identification of the RCL and to explore the relevant landmarks in ultrasonography. DESIGN Prospective study. SETTING Tertiary university hospital. PARTICIPANTS Forty healthy elbows of 20 participants. METHODS The RCL was evaluated using ultrasonography in six elbow flexion positions (0°, 30°, 60°, 90°, 120°, and 140°). The relative depth, defined as the depth of the capitellum subtracted by the depth of the radial head under ultrasonography, was measured at each angle. The rates of successful identification of ultrasonographic landmarks for localizing the RCL were calculated. After ultrasonography, the optimal elbow position for identifying the RCL was determined by group consensus. MAIN OUTCOME MEASUREMENTS Relative depth between radial head and capitellum, rates of successful identification of ultrasonographic landmarks, and consensus-based determination of the optimal angle. RESULTS The relative depth significantly decreased with an increase in the flexion angle (P for trend

Context:Gluteal-muscle strength has been identified as an important component of injury prevention and rehabilitation in several common knee injuries. However, many conventionally prescribed gluteal-strengthening exercises are not performed during dynamic weight-bearing activities, which is when most injuries occur.Objectives:To compare lower-limb muscle-activation patterns between conventional gluteal-strengthening exercises and off-axis elliptical exercises with motorized foot-plate perturbations designed to activate gluteal muscles during dynamic exercise.Evidence Acquisition:Twelve healthy volunteers (26.1 ± 4.7 y) participated in the study. They performed 3 conventional exercises (single-leg squat, forward lunge, and clamshell) and 3 elliptical exercises (regular, while resisting an adduction force, and while resisting an internal-rotation torque). Gluteus medius (GMed) and maximus (GMax), quadriceps, hamstrings, and gastrocnemius muscle activations during each exercise were recorded using surface electromyography (EMG) and normalized to maximal voluntary isometric contraction (MVIC).Evidence Synthesis:Normalized GMed EMG was the highest during the adduction-resistance elliptical exercise (22.4% ± 14.8% MVIC), significantly greater than forward lunge (8.2% ± 3.8% MVIC) and regular elliptical (6.4% ± 2.5% MVIC) and similar to clamshell (19.1% ± 8.8% MVIC) and single-leg squat (18.4% ± 7.9% MVIC). Normalized GMax EMG during adduction-resistance (11.1% ± 7.6% MVIC) and internal-rotation-resistance elliptical (7.4% ± 3.8% MVIC) was significantly greater than regular elliptical (4.4% ± 2.4% MVIC) and was similar to conventional exercises. The single-leg squat required more muscle activation from the quadriceps and gastrocnemius than the elliptical exercises.Conclusions:Off-axis elliptical exercise while resisting an adduction force or internal-rotation torque activates gluteal muscles dynamically while avoiding excessive quadriceps activation during a functional weight-bearing activity compared with conventional gluteal-strengthening exercises.

Objective To compare the clinical outcomes following conservative treatment and arthroscopic repair in patients with a rotator cuff tear. Methods In this retrospective study, patients aged >50 years with a symptomatic rotator cuff tear were reviewed. The rotator cuff tendons were evaluated using ultrasonography, shoulder magnetic resonance imaging or MR arthrography, and the patients with either a high-grade partial-thickness or small-to-medium-sized (≤3 cm) full-thickness tear were included in this study. The primary outcome measures were a pain assessment score and range of motion (ROM) at 1-year follow-up. The secondary outcomes were the rate of tear progression or retear along with the rate of symptom aggravation after the treatments. Results A total of 357 patients were enrolled, including 183 patients that received conservative treatment and 174 patients who received an arthroscopic repair. The pain assessment score (p50 years old with a less than medium-sized rotator cuff tear in a 1-year follow-up period. Further study is warranted to find the optimal combination of conservative treatment for a symptomatic rotator cuff tear.

Surface electromyogram (sEMG) is often used by to objectively measure muscular activity during rehabilitation exercises. sEMG is accurate, but it is unsuitable for uses outside the clinic, and patients can benefit from an unobtrusive device which can be readily used to ubiquitously measure abdominal muscle activation. In this study, we present a pressure sensor system which can be latched onto a belt to measure abdominal muscle activation. sEMG and pressure sensor output were measured in 15 healthy young males during isometric trunk flexion exercise (public trials registration number, KCT0002351), and the results were highly correlated (median R > 0.939). As initial contact force can change the pressure sensor sensitivity, the experiment was performed at two different levels of belt tightness, but the correlations did not significantly improve after tightening the belt, suggesting that the system can be used to ubiquitously and unobtrusively monitor abdominal muscle activity with minimal discomfort.

Ultrasound-guided percutaneous barbotage is an effective treatment for rotator cuff calcific tendinopathy, providing rapid and substantial pain relief. We present the case of a 49-year-old woman with aggravated pain early after ultrasound-guided barbotage of a large calcific deposit in the supraspinatus tendon. Subsequent examination revealed a thick calcification spreading along the subacromial-subdeltoid bursa space, suggesting acute calcific bursitis complicated by barbotage. Additional barbotage alleviated her pain completely. Therefore, a high index of suspicion for acute calcific bursitis is required in patients with unresolved or aggravated pain after barbotage. Repeated barbotage could be effective for this condition.

Background Tightening and contracture of the joint capsule are hallmarks of adhesive capsulitis of the shoulder (ACS). However, quantification of capsular stiffness and its relation to clinical features have not been investigated thoroughly. Objectives To quantify capsular stiffness during intra-articular hydraulic distension (IHD) and to investigate its relationships with pain severity, symptom duration, range of motion (ROM), gender, and diabetes status. Design Case series. Setting University outpatient clinic of physical medicine and rehabilitation. Participants A total of 107 consecutive patients with ACS who underwent IHD. Methods Pressure-volume monitoring data during IHD, pain severity, symptom duration, shoulder ROM, and diabetes status were obtained by retrospective chart review. Capsular stiffness ( K cap ) was measured by calculating the slope of the elastic phase in pressure-volume curves. ROM was evaluated in 3 directions (flexion, abduction, and external rotation) with a goniometer, and the sum of the 3 ROMs was calculated. Main Outcome Measurements Pearson correlation coefficients and comparisons of averages were used to analyze the relationships between K cap and clinical features. Results The mean K cap of the total group of participants was 26.0 ± 14.2 mmHg/mL. Shoulder pain in motion or rest did not correlate with K cap . Patients with stiffer capsules had smaller sums of ROMs ( r = −.298, P = .002), with distinct limitations in external rotation and abduction ( r = −.278, P = .004 and r = −.313, P = .001, respectively). Women had significantly stiffer capsules than men (29.5 ± 14.3 versus 20.2 ± 12.1 mmHg/mL, P = .001). Diabetes status had no significant effect on capsular stiffness. Conclusions Capsular stiffness of the glenohumeral joint significantly correlated with limitation in shoulder ROM, especially in the abduction and external rotation directions, whereas there were no meaningful relationships with shoulder pain during motion or rest. This is the first study to reveal the relationships between in vivo quantified capsular stiffness and shoulder ROM limitations.

The article presents numerical analyses on the effects of field-scale hydraulic heterogeneity and air injection rate for production behavior of in situ combustion. Hydraulic heterogeneity is an essential reservoir property on determining the movement of a combustion front while the air injection rate is a key operational factor on maintaining the combustion front. Hydraulic heterogeneity affects significantly occurring viscous fingerings but may not be critical at the averaged cumulative production. The lower air injection rate results in the extensive combustion front and the large amount of ultimate recovery if the front is maintained before it reaches a production well.

Introduction/Background Videogame based exercise, namely exergame, is an innovative approach to enhance physical activity in the elderly. This study was done to evaluate the safety, compliance, adherence and efficacy of exergames using wearable sensors. Material and method Sixty aged people (77.5 ± 6.4 years) played 3 exergames including abdominal bracing, Q-setting and balance training games for 12 weeks. Wearable pressure sensors were applied on the abdominal and quadriceps muscles and magnetic sensors under the soles to monitor accuracy and intensity of targeted activities. Safety and compliance were assessed by dropout ratio and personal interviews. Adherence to progression of sessions was measured by calculating total exertional index, the duration of exertional pressure or step-on status, and compared between the earlier and later weeks. A simplified frailty screening battery was devised to measure skeletal muscle mass, grip strength, walking speed, unipedal stance test and short geriatric depression scale before and after the exercise program. Results Fifty-four participants completed. Dropout reaseons were lack of time (4), ankle fracture by unrelated activity (1) and fear of aggravating pre-existing sciatica (1). 14.8% and 5.6% of participants complained of leg pain and difficulty in exercising, respectively. The total exertional indices were significantly increased in the later phase of sessions, showing 35.9 ± 23.9 kPa·min vs 41.6 ± 28.0 kPa·min (P = 0.013), 129.5 ± 76.5 kPa·min vs 147.4 ± 81.2 kPa·min (P = 0.040), and 12.1 ± 3.0 vs 13.1 ± 2.6 steps (P = 0.018) for abdominal bracing, Q-setting and balance training games, respectively. There were statistically significant improvements in skeletal muscle index (33.7 ± 3.7% vs 34.4 ± 4.1%, P = 0.004), grip strength (20.0 ± 5.6 kgf vs 21.5 ± 5.5 kgf, P = 0.000), walking speed (0.89 ± 0.19 m/s vs 1.26 ± 0.19 m/s, P = 0.000), and balance ability (10.8 ± 7.6 s vs 15.4 ± 9.8 s, P = 0.000) after the exercises. Conclusion This study demonstrates that three exergames developed in this study can be safely done with high compliance for 12 weeks, improving skeletal muscle mass, muscle strength, function and balance.

Because of chronicity and poor environments, elderly leprosy survivors might be at greater risk of developing obesity and sarcopenia than healthy individuals. This study aimed to investigate whether body composition and the prevalence of obesity and sarcopenia among elderly leprosy survivors with no or mild physical impairment differ from those of the general population. A total of 36 leprosy survivors aged 65-90 years with no or mild physical impairment were recruited. Individuals matched for sex, age, and height were selected as a control group from the Fourth Korea National Health and Nutrition Examination Survey. Anthropometric characteristics, body composition, appendicular skeletal muscle mass (ASM), modified skeletal muscle mass index (SMI), and the prevalence of obesity and sarcopenia were compared between the leprosy survivors and the control group. Compared to the control group, the leprosy survivors had higher body weight, BMI, total fat mass, and total fat percentage. The leprosy survivor group also had lower ASM (P=0.035) and SMI (P

Previous studies of the effects of body fat on bone mineral density (BMD) have shown conflicting results depending on the age, sex, and menopausal status of the subjects. The purpose of the present study was to investigate the effects of body fat on BMD using data from the Fifth Korea National Health and Nutrition Examination Survey, which was conducted in 2010. Our data were drawn from a relevant population within the survey's range of participants, yielding a total of 4,138 subjects aged 20-93 years (1,133 men

This study characterizes tonic and phasic stretch reflex and stiffness and viscosity changes associated with spastic hemiparesis. Perturbations were applied to the ankle of 27 hemiparetic and 36 healthy subjects under relaxed or active contracting conditions. A nonlinear delay differential equation model characterized phasic and tonic stretch reflex gains, elastic stiffness, and viscous damping. Tendon reflex was characterized with reflex gain and threshold. Reflexively, tonic reflex gain was increased in spastic ankles at rest ( P < 0.038) and was not regulated with muscle contraction, indicating impaired tonic stretch reflex. Phasic-reflex gain in spastic plantar flexors was higher and increased faster with plantar flexor contraction ( P < 0.012) than controls ( P < 0.023) and higher in dorsi-flexors at lower torques ( P < 0.038), primarily because of its increase at rest ( P = 0.045), indicating exaggerated phasic stretch reflex especially in more spastic plantar flexors, which showed higher phasic stretch reflex gain than dorsi-flexors ( P < 0.032). Spasticity was associated with increased tendon reflex gain ( P = 0.002) and decreased threshold ( P < 0.001). Mechanically, stiffness in spastic ankles was higher than that in controls across plantar flexion/dorsi-flexion torque levels ( P < 0.032), and the more spastic plantar flexors were stiffer than dorsi-flexors at comparable torques ( P < 0.031). Increased stiffness in spastic ankles was mainly due to passive stiffness increase ( P < 0.001), indicating increased connective tissues/shortened fascicles. Viscous damping in spastic ankles was increased across the plantar flexion torque levels and at lower dorsi-flexion torques, reflecting increased passive viscous damping ( P = 0.033). The more spastic plantar flexors showed higher viscous damping than dorsi-flexors at comparable torque levels ( P < 0.047). Simultaneous characterizations of reflex and nonreflex changes in spastic hemiparesis may help to evaluate and treat them more effectively.

Background Context Clinicians regard lumbar lordotic curvature (LLC) with respect to low back pain (LBP) in a contradictory fashion. The time-honored point of view is that LLC itself, or its increment causes LBP. On the other hand, recently, the biomechanical role of LLC has been emphasized and loss of lordosis is considered a possible cause of LBP. The relationship between LLC and LBP has immense clinical significance, since it serves as the basis of therapeutic exercises for treating and preventing LBP. Purpose This study aimed to (1) determine the difference in LLC in those with and without LBP and to (2) investigate confounding factors that might affect the association between LLC and LBP. Study Design Systematic review and meta-analysis. Patient Sample The inclusion criteria consisted of observational studies that included information on lumbar lordotic angle (LLA) assessed by radiologic image, in both LBP patients and healthy controls. Studies solely involving pediatric populations, or addressing spinal conditions of non-degenerative causes, were excluded. Methods A systematic electronic search of Medline, Embase, Cochrane library, CINAHL, Scopus, PEDro, and Web of Science using terms related with lumbar alignment and Boolean logic was performed; (lumbar lordo*) or (lumbar alignment) or (sagittal alignment) or (sagittal balance). Standardized mean differences (SMD) and 95% confidence intervals (CI) were estimated and chi-square and I 2 statistics were used to assess within-group heterogeneity by random effect model. Additionally, the age and gender of participants, spinal disease entity, and the severity and duration of LBP were evaluated as possible confounding factors. Results A total of 13 studies consisting of 796 LBP patients and 927 healthy controls were identified. Overall, LBP patients tended to have smaller LLA, compared to healthy controls. However, the studies were heterogeneous. In the meta-regression analysis, the factors of age, severity of LBP, and spinal disease entity were revealed to contribute significantly to variance between studies. In the subgroup analysis of the five studies that compared patients with disc herniation or degeneration to healthy controls, LBP patients had smaller LLA (SMD: -0.94, 95% CI: -1.19 to -0.69) with sufficient homogeneity based on significance level 0.1 (I 2 = 45.7%, p=0.118). In the six age-matched studies, LBP patients had smaller LLA, compared to healthy controls (SMD: -0.33, 95% CI: -0.46 to -0.21) without statistical heterogeneity (I 2 = 0%, p=0.916). Conclusion This meta-analysis demonstrates a strong relationship between LBP and decreased LLC, especially when compared to age-matched healthy controls. Among specific diseases, LBP by disc herniation or degeneration was shown to be substantially associated with the loss of LLC.

Mirror therapy has been performed as effective occupational therapy in a clinical setting for functional recovery of a hemiplegic arm after stroke. It is conducted by eliciting an illusion through use of a mirror as if the hemiplegic arm is moving in real-time while moving the healthy arm. It can facilitate brain neuroplasticity through activation of the sensorimotor cortex. However, conventional mirror therapy has a critical limitation in that the hemiplegic arm is not actually moving. Thus, we developed a real-time 2-axis mirror robot system as a simple add-on module for conventional mirror therapy using a closed feedback mechanism, which enables real-time movement of the hemiplegic arm. We used 3 Attitude and Heading Reference System sensors, 2 brushless DC motors for elbow and wrist joints, and exoskeletal frames. In a feasibility study on 6 healthy subjects, robotic mirror therapy was safe and feasible. We further selected tasks useful for activities of daily living training through feedback from rehabilitation doctors. A chronic stroke patient showed improvement in the Fugl-Meyer assessment scale and elbow flexor spasticity after a 2-week application of the mirror robot system. Robotic mirror therapy may enhance proprioceptive input to the sensory cortex, which is considered to be important in neuroplasticity and functional recovery of hemiplegic arms. The mirror robot system presented herein can be easily developed and utilized effectively to advance occupational therapy.

Background We theorized that active cervical extension should influence the position of the nucleus pulposus (NP) within the intervertebral disk (IVD) in the sagittal plane. Although several studies on the lumbar IVD have been conducted, there are no quantitative data for in vivo positional changes of the NP in the cervical IVD. Objective To evaluate the influence and mechanism of cervical extension on the deformation and migration of IVD and NP in the sagittal plane and understand underlying mechanisms of the extension maneuver. Design Asymptomatic subjects underwent magnetic resonance imaging while supine with their cervical spines in neutral and extended positions. Setting Academic medical center. Participants Ten young, healthy male participants (age range 19-30 years; mean 22.4 ± 1.64 years). Methods T2-weighted sagittal images from C3-C4 to C6-C7 of subjects in both neutral and extension positions were analyzed. Main outcome measurements Deformation of IVD and positional change of NP were quantified and compared between neutral and extension positions. Intersegmental angles between vertebrae, horizontal positions of anterior and posterior IVD and NP margins, IVD outer and inner heights, and sagittal morphology of NP were quantified and compared between the neutral and extension positions. Correlations between the measured parameters and segmental extension angle were also investigated. Results Anterior and posterior IVD margins moved posteriorly with respect to the vertebral body in extension. Both NP margins remained unchanged relative to the vertebral body but moved anteriorly with respect to the IVD. IVD outer and inner heights in the anterior region increased in extension, and morphological changes of the NP were less noticeable when compared with its relative migration within the IVD. Most of the intradiskal changes were linearly correlated with the segmental extension angle. Conclusions Cervical extension induces anterior migration of the NP away from the posterior disk margin and may have a clinical effect on diskogenic neck pain resulting from internal disk disruption. Level of evidence Not applicable.

The effect of intraarticular hydraulic distension (IHD) for a painful stiff shoulder (or adhesive capsulitis) has been affirmed, but whether rupturing the joint capsule during this process is beneficial remains controversial. By monitoring real-time pressure–volume (PV) profiles during IHD, we could infuse the largest possible volume without rupturing the capsule. Using the novel technique, we compared the short-term effects of IHD when the capsule was preserved versus when it was ruptured. Fifty-four patients with a painful stiff shoulder underwent IHDs intended to preserve or rupture the capsule and then classified into capsule-ruptured (n = 26) and capsule-preserved (n = 20) groups, based on the obtained PV profiles. Their profiles were triphasic or biphasic; eight with flat profiles were excluded from the comparison. Clinical outcomes were evaluated at 3-day and 1-month follow-ups, in terms of pain and range of motion (ROM). Although both groups showed significant increase in ROM and decrease in pain after IHD, the improvements were greater in the capsule-preserved group than in the ruptured group at both follow-up times, and in triphasic and biphasic cases. In conclusion, the therapeutic effects of IHD in short-term follow-ups were enhanced by preserving the capsule. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1688–1694, 2011

Introduction/Background When an intervertebral disc degenerates, structural deterioration occurs in a wide range of anatomical components within and adjacent to the disc, being clearly represented in cross-sectional imaging. To suggest reliable and valid MRI-based morphologic parameters to quantify lumbar disc degeneration, the reliabilities of 6 parameters were analyzed to choose those with high reliability. The selected parameters were further tested to determine validity by correlating with disc height, which is regarded as a hallmark of structural integrity of the intervertebral disc. Material and method Eighty-five patients over 60 years old who underwent MRI of the lumbar spine for mild low back pain were included. Two reviewers independently assessed the degree of degeneration and assigned one of the 4 ordinal scores from 0 to 3 in the following 6 parameters at 6 spinal segments: T2-signal intensity (T2-SI), disc extension beyond interspace (DEBIT), annular fissure, Modic changes, endplate integrity, and osteophytes. Inter-observer and intra-observer agreements were assessed using Cohen's kappa statistic. For those parameters with high reliability, relationships with disc height were examined by calculating Pearson's correlation coefficients. Results While intra-observer agreements were excellent for all parameters (weighted kappa range 0.801–0.875), the inter-observer agreements were substantial to excellent for T2-SI, DEBIT, Modic changes, and endplate integrity (weighted kappa range 0.629–0.874), moderate for osteophytes (weighted kappa 0.573), and only fair for annular fissure (weighted kappa 0.29). Modic changes (r = −0.497, P Conclusion To quantify lumbar disc degeneration using MRI, Modic changes, endplate integrity, osteophytes, T2-SI, and DEBIT could be used as reliable parameters. However, different weights might be applied to each parameter because validities to represent degeneration varied.

This study evaluated the effects of a three-dimensional (3D) imaging system on laparoscopy performance compared with the conventional 2D system using a novel one-camera 3D system. In this study, 21 novices and 6 experienced surgeons performed two tasks with 2D and 3D systems in 4 consecutive days. Performance time and error as well as subjective parameters such as depth perception and visual discomforts were assessed in each session. Electromyography was used to evaluate the usage of muscles. The 3D system provided significantly greater depth perception than the 2D system. The errors during the two tasks were significantly lower with 3D system in novice group, but performance time was not different between the 2D and 3D systems. The novices had more dizziness with the 3D system in first 2 days. However, the severity of dizziness was minimal (less than 2 of 10) and overcome with the passage of time. About 54% of the novices and 80% of the experienced surgeons preferred the 3D system. Electromyography (EMG) showed a tendency toward less usage of the right arm and more usage of the left arm with the 3D system. The new 3D imaging system increased the accuracy of laparoscopy performance, with greater depth perception and only minimal dizziness. The authors expect that the 3D laparoscopic system could provide good depth perception and accuracy in surgery.

Background As an initial step to study facial muscle strengthening by loaded neuromuscular electrical stimulation, we examined the feasibility of applying load to the zygomaticus major, quantified the maximal isometric force of the muscle by volition and electrical stimulation, and compared the measured forces with the results of facial kinematic analysis and electrodiagnostic study. Methods Eleven healthy subjects and two female patients with chronic unilateral facial palsy were enrolled. A custom made plastic bridge instrument with a centrally mounted load cell was attached at the mouth angle and to the skin overlying the zygomatic bone using double-sided adhesive tape to provide isometric resistance to skin movement during the muscle contraction. Findings The force by maximal voluntary contraction of the zygomaticus major averaged 196.4 g force and the contraction force by maximally tolerated stimulation reached 60.1%, on average, of the force by maximal voluntary contraction in normal subjects. There was a significant correlation only between the force by maximally tolerated stimulation and the amplitude of compound muscle action potentials. The force by maximal voluntary contraction of the paralytic side in the patients showed 32.3% and 20.1% of the mean value of the normal subjects. Interpretations This study demonstrates that an isometric load was possibly applied and a significant intensity of electrical stimulation could be tolerated and delivered to the isometrically loaded facial muscle. The isometric loading would be utilized for loaded facial neuromuscular electrical stimulation therapeutically and also for measurement of the force generation capacity of the zygomaticus major diagnostically.

Objective To test two questions raised by a previous study: whether high and steeply rising intra-articular (IA) pressure achieved by controlled fluid infusion would be specific to the painful stiff shoulder (PSS) and whether rupture occurs immediately after the appearance of the third phase so that it could be considered as a preruptural sign. Design Case series. Setting University Outpatient Clinic of Physical Medicine and Rehabilitation. Participants Fourteen PSS patients who had limited range of motion of the shoulder in at least 2 directions for more than a month were participants, and 6 shoulders of 5 people with other conditions including 2 healthy shoulders served as controls. Intervention and Main Outcome Measures Real-time pressure monitoring was done with fluid infusion in a constant-volume rate. For PSS patients, fluid was infused until rupture occurred. More than 25 mL of fluid was instilled in the shoulders of the control group. The pressure-volume (P-V) profiles, number of phases, maximal volume ( V max ) and pressure ( P v_max ) at V max , stiffness of the capsule ( K ph2 ), and the fluid volume ( V ph3 ) infused from the appearance of the triphasic curve to the rupture were evaluated. Results Among the 14 PSS patients, 12 demonstrated steeply increasing pressure (8 triphasic, 4 biphasic), but 2 showed flat and low-pressure profiles. In contrast, the entire control group revealed flat pressure profiles. The PSS subjects showed far higher P v_max at lower V max than the control subjects. The K ph2 was significantly higher in the PSS group. The V ph3 was 5.03 ± 3.18 mL ranging from 2.33 to 10.99 mL. Conclusions The steeply rising, high IA pressure can be considered as a predominant characteristic of the PSS compared with other conditions that showed flat, low-pressure profiles, suggesting the P-V profiles might be used in evaluation of the capsular tightness of various shoulder problems. The triphasic curve appears to be a preruptural sign; however, there are several practical limitations to terminating hydraulic distension before rupture occurs.

Chung SG, van Rey E, Bai Z, Rymer WZ, Roth EJ, Zhang L-Q. Separate quantification of reflex and nonreflex components of spastic hypertonia in chronic hemiparesis. Objectives To isolate and quantify reflex and nonreflex components of the spastic ankle plantarflexors in hemiplegia poststroke and to correlate them with clinical measures of spasticity, which may involve hyperactive stretch reflex and/or increased joint stiffness. Design To investigate reflex and nonreflex properties associated with spasticity in a case-control manner. Setting Research laboratory in a rehabilitation hospital. Participants Hemiplegic patients (n=17) and the same number of healthy subjects. Interventions Not applicable. Main Outcome Measures Tendon reflexes of spastic muscles were evaluated under an isometric condition, which essentially eliminated passive viscoelastic contributions associated with limb movement. Nonreflex components of spasticity were evaluated by moving the ankle joint slowly, which minimized reflex actions. The reflex and nonreflex measures were investigated and correlated with each other and with clinical measures. Results Compared with healthy subjects, patients with stroke showed a lower reflex threshold, higher electromyographic gains, and torque reflex gains, indicating hyperactive reflexes. For nonreflex properties, ankles of stroke patients showed higher stiffness, reduced range of motion (ROM), and larger resistant torque at comparable positions, reflecting peripheral soft-tissue changes at the ankle of the chronic stroke patients. Furthermore, the clinical reflex score correlated with all of the quantitative reflex measures but not with the nonreflex measures, whereas the dorsiflexion ROM showed a significant correlation with a nonreflex measure. The Modified Ashworth Scale was correlated with all of the reflex measures and 1 of the nonreflex measures. Conclusions Comprehensive and convenient evaluation of spasticity should be performed quantitatively with the separate measures of reflex and nonreflex components, especially in chronic conditions. With proper simplifications, the current method of separate quantification can potentially be used for convenient clinical evaluations of spasticity.

Herpes zoster, commonly known as shingles, is an infectious viral disease characterized by painful, unilateral skin blisters occurring in specific sensory dermatomes. Motor paresis is reported in 0.5% to 5% of patients. Although the mechanism of zoster paresis is still unclear, the virus can spread from the dorsal root ganglia to the anterior horn cell or anterior spinal nerve roots. It rarely involves the brachial plexus. We report a case of brachial plexitis following herpes zoster infection in which pathological lesions were diagnosed using brachial plexus magnetic resonance imaging and treated with ultrasound-guided perineural corticosteroid injection.

Background The coracohumeral ligament (CHL) is a thick capsular structure and markedly thickened when affected by adhesive capsulitis. Therapeutic stretching is the most commonly applied treatment for adhesive capsulitis, but optimal stretching postures for maximal therapeutic effects on the CHL have not been fully investigated. Objective To investigate the most effective stretching direction for the CHL by measuring the stretching intensity in 5 different directions and to determine whether the stretching intervention resulted in loosening of the ligament by comparing the changes of CHL tightness before and after stretching. Design Biomechanical cadaver study. Setting Academic institution cadaver laboratory. Participants Nine fresh frozen cadaveric shoulders. Methods A high-pressure balloon catheter inserted under the CHL and intraballoon pressure was measured, to evaluate CHL tightness without ligament damage as well as to augment and monitor stretching intensity. To find the optimal stretching direction, the glenohumeral joint was stretched from the neutral position into 5 directions sequentially under pressure-monitoring: flexion, extension [EX], external rotation [ER], EX+ER, and EX+ER+adduction [AD] directions. Main Outcome Measurements CHL tightness was determined by a surrogate parameter, the additional pressure created by the overlying CHL. The pressure increase (Δ P str ) by a specific directional stretch was considered as the stretching intensity. Results Δ P str by the 5 directions were mean (standard deviation) values of 0.03 ± 0.07 atm, 0.87 ± 1.31 atm, 1.13 ± 1.36 atm, 1.49 ± 1.32 atm, and 2.10 ± 1.70 atm, respectively, revealing the highest Δ P str by the EX+ER+AD stretch ( P P = .012) before and after the stretching manipulation. Conclusions EX+ER+AD of the glenohumeral joint resulted in the greatest increase in balloon pressure, implying that it could be the most effective stretching direction. A series of stretching manipulations assisted with an underlying pressure balloon were capable of decreasing CHL tightness. With further development and modification, high-pressure balloon-assisted stretching can be a potential therapeutic option to release tight CHL, including the advantage of augmenting and monitoring stretching intensity. Level of Evidence II

Selles RW, Li X, Lin F, Chung SG, Roth EJ, Zhang L-Q. Feedback-controlled and programmed stretching of the ankle plantarflexors and dorsiflexors in stroke: effects of a 4-week intervention program. Objective To investigate the effect of repeated feedback-controlled and programmed "intelligent" stretching of the ankle plantar- and dorsiflexors to treat subjects with ankle spasticity and/or contracture in stroke. Design Noncontrolled trial. Setting Institutional research center. Participants Subjects with spasticity and/or contracture after stroke. Interventions Stretching of the plantar- and dorsiflexors of the ankle 3 times a week for 45 minutes during a 4-week period by using a feedback-controlled and programmed stretching device. Main Outcome Measures Passive and active range of motion (ROM), muscle strength, joint stiffness, joint viscous damping, reflex excitability, comfortable walking speed, and subjective experiences of the subjects. Results Significant improvements were found in the passive ROM, maximum voluntary contraction, ankle stiffness, and comfortable walking speed. The visual analog scales indicated very positive subjective evaluation in terms of the comfort of stretching and the effect on their involved ankle. Conclusions Repeated feedback-controlled or intelligent stretching had a positive influence on the joint properties of the ankle with spasticity and/or contracture after stroke. The stretching device may be an effective and safe alternative to manual passive motion treatment by a therapist and has potential to be used to repeatedly and regularly stretch the ankle of subjects with spasticity and/or contracture without daily involvement of clinicians or physical therapists.

Glucocorticoids play a major role in the development of muscle atrophy in various medical conditions, such as cancer, burn injury, and sepsis, by inhibiting insulin signaling. In this study, we report a new pathway in which glucocorticoids reduce the levels of upstream insulin signaling components by downregulating the transcription of the gene encoding caveolin-1 (CAV1), a scaffolding protein present in the caveolar membrane. Treatment with the glucocorticoid dexamethasone (DEX) decreased CAV1 protein andCav1mRNA expression, with a concomitant reduction in insulin receptor alpha (IRα) and IR substrate 1 (IRS1) levels in C2C12 myotubes. On the basis of the results of promoter analysis using deletion mutants and site-directed mutagenesis a negative glucocorticoid-response element in the regulatory region of theCav1gene was identified, confirming thatCav1is a glucocorticoid-target gene.Cav1knockdown using siRNA decreased the protein levels of IRα and IRS1, and overexpression ofCav1prevented the DEX-induced decrease in IRα and IRS1 proteins, demonstrating a causal role ofCav1in the inhibition of insulin signaling. Moreover, injection of adenovirus expressingCav1into the gastrocnemius muscle of mice prevented DEX-induced atrophy. These results indicate that CAV1 is a critical regulator of muscle homeostasis, linking glucocorticoid signaling to the insulin signaling pathway, thereby providing a novel target for the prevention of glucocorticoid-induced muscle atrophy.