Chen-Yu Hung

Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials.

Background: Postoperative shoulder stiffness complicates functional recovery after arthroscopic rotator cuff repair. Purpose: To compare early passive range of motion (ROM) exercise with a delayed rehabilitation protocol with regard to the effectiveness of stiffness reduction and functional improvements and rates of improper healing in patients undergoing arthroscopic repair for torn rotator cuffs. Study Design: Systematic review and meta-analysis. Methods: Randomized controlled trials (RCTs) comparing both rehabilitation approaches were identified in PubMed and Scopus. Between-group differences in shoulder function were transformed to effect sizes for comparisons, whereas the effectiveness against stiffness and the risk of tendon failure were reported using standardized mean differences of ROM degrees and odds ratios (ORs) of recurrent tears, respectively. Results: Six RCTs were included, consisting of 482 patients. No significant difference in shoulder function existed across both protocols. The early ROM group demonstrated more improvement in shoulder forward flexion than the delayed rehabilitation group, with a standardized mean difference of 7.45° (95% CI, 3.20°-11.70°) at 6 months and 3.51° (95% CI, 0.31°-6.71°) at 12 months. Early ROM exercise tended to cause a higher rate of recurrent tendon tears (OR, 1.43; 95% CI, 0.90-2.28), and the effect became statistically significant (OR, 1.93; 95% CI, 1.04-3.60) after excluding 2 RCTs that recruited only those patients with small to medium-sized tears. Conclusion: Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair but was likely to result in improper tendon healing in shoulders with large-sized tears. The choice of either protocol should be based on an accommodation of the risks of recurrent tears and postoperative shoulder stiffness.

Effectiveness of Bisphosphonate Analogues and Functional Electrical Stimulation on Attenuating Post-Injury Osteoporosis in Spinal Cord Injury Patients- a Systematic Review and Meta-Analysis

Background Various pharmacologic and non-pharmacologic approaches have been applied to reduce sublesional bone loss after spinal cord injury (SCI), and the results are inconsistent across the studies. The objective of this meta-analysis was to investigate whether the two most-studied interventions, bisphosphonate analogues and functional electrical stimulation (FES), could effectively decrease bone mineral density (BMD) attenuation and/or restore lost BMD in the SCI population. Methods Randomized controlled trials, quasi-experimental studies, and prospective follow-up studies employing bisphosphonates or FES to treat post-SCI osteoporosis were identified in PubMed and Scopus. The primary outcome was the percentage of BMD change from baseline measured by dual-energy X-ray absorptiometry (DEXA) or computed tomography (CT). Data were extracted from four points: the 3rd, 6th, 12th, and 18th month after intervention. Results A total of 19 studies were included in the analysis and involved 364 patients and 14 healthy individuals. Acute SCI participants treated with bisphosphonate therapy demonstrated a trend toward less bone loss than participants who received placebos or usual care. A significant difference in BMD decline was noted between both groups at the 3rd and 12th month post-medication. The subgroup analysis failed to show the superiority of intravenous bisphosphonate over oral administration. Regarding FES training, chronic SCI patients had 5.96% (95% CI, 2.08% to 9.84%), 7.21% (95%CI, 1.79% to 12.62%), and 9.56% (95% CI, 2.86% to 16.26%) increases in BMD at the 3rd, 6th, and 12th months post-treatment, respectively. The studies employing FES ≥5 days per week were likely to have better effectiveness than studies using FES ≤3 days per week. Conclusions Our meta-analysis indicated bisphosphonate administration early following SCI effectively attenuated sublesional bone loss. FES intervention for chronic SCI patients could significantly increase sublesional BMD near the site of maximal mechanical loading.

Sonographic Tracking of the Lower Limb Peripheral Nerves: A Pictorial Essay and Video Demonstration.

ABSTRACTCompared with the upper limbs, sonographic tracking of peripheral nerves in the lower limbs is more challenging. The overlying muscles are larger, hindering visualization of the deeply embedded nerves by using a linear transducer. The use of a curvilinear transducer—providing an extended view with better penetration for the field of interest—may be useful for scanning the nerves in the hip and thigh. Application of the Doppler mode helps localization of the target nerve by identifying the accompanying vessels. Aiming to demonstrate the relevant tracking techniques, the present article comprises a series of ultrasound images and videos showing how to scan the nerves in the lower limb, that is, femoral, obturator, pudendal, lateral femoral cutaneous, sciatic, saphenous, sural, tibial, and peroneal nerves.

Comparative effectiveness of autologous blood-derived products, shock-wave therapy and corticosteroids for treatment of plantar fasciitis: a network meta-analysis

OBJECTIVE To compare the efficacy of autologous blood-derived products (ABPs), CSs and shock-wave (SW) therapy in the treatment of plantar fasciitis. METHODS Electronic databases were searched for studies that compared ABPs, CSs and SW therapy for the treatment of plantar fasciitis, published up to June 2014. The primary and secondary outcomes were reduction in visual analogue scale (VAS) score at 3 and 6 months and odds ratio of treatment success, respectively. Groups were compared by traditional pair-wise meta-analysis and by network meta-analysis. RESULTS Seven randomized controlled trials and three quasi-experimental studies that included 604 patients were enrolled. Pair-wise meta-analysis indicated a trend favouring ABPs over CSs regarding VAS reduction at 3 months; this benefit was significant in a subgroup analysis of platelet-rich plasma (PRP) vs CSs. There were no significant between-group differences in VAS reduction at 6 months and in treatment success. Network meta-analysis showed that ABPs had the highest probability of being the best treatment at 3 months, but ABPs were slightly inferior to SW for VAS reduction at 6 months. Although SW therapy had the highest likelihood of treatment success, the between-group differences in probabilities were less remarkable than those for pain reduction at 3 and 6 months. CONCLUSION ABPs, followed by CSs, were best in providing relief from pain at 3 months. SW therapy and ABPs had similar probabilities of providing pain relief at 6 months, and were better than CSs at that time. Subgroup analysis indicated that an ABP regimen consisting of platelet-rich plasma improves treatment efficacy.

Reduced Flexibility Associated with Metabolic Syndrome in Community-Dwelling Elders

Background The ageing process may lead to reductions in physical fitness, a known risk factor in the development of metabolic syndrome. The purpose of the current study was to evaluate cross-sectional and combined associations of metabolic syndrome with body composition and physical fitness in a community based geriatric population. Methods A total of 628 community-dwelling elders attending a geriatric health examination were enrolled in the study. The diagnosis of metabolic syndrome was based on the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) criterion with Asian cutoff of waist girth was adopted in this study. Body composition was obtained using bioimpedance analysis, and physical fitness was evaluated through the measurement of muscle strength (handgrip force), lower extremity muscle endurance (sit-to-stand test), flexibility (sit-and-reach test), and cardiorespiratory endurance (2-minute step test). Multivariable logistic regression and correlation analysis were performed to determine the association of metabolic syndrome with body composition and functionality variables. Results Metabolic syndrome was associated with increased skeletal muscle index (SMI) (odds ratio (OR), 1.61, 95% confidence interval (CI), 1.25–2.07) and decreased flexibility (OR, 0.97, 95% CI, 0.95–0.99) compared with those without metabolic syndrome. When body mass index was accounted for in the analysis, the association of SMI with metabolic syndrome was reduced. Waist circumference was positively correlated with SMI but negatively correlated with flexibility, whereas high density lipoprotein was positively correlated with flexibility but negatively correlated with SMI. Conclusion Reduced flexibility was positively associated with metabolic syndrome independent of age, gender, body composition, and functionality measurements in a community based geriatric population. Significant associations between metabolic syndrome with muscle strength and cardiorespiratory fitness in the elderly were not observed. Furthermore, flexibility should be included in the complete evaluation for metabolic syndrome.

Quantitative ultrasound facilitates the exploration of morphological association of the long head biceps tendon with supraspinatus tendon full thickness tear.

Backgrounds Pathology of the long head biceps tendon (LHBT) is associated with rotator cuff tears but whether the LHBT texture changes following supraspinatus tendon full thickness tear (SSFT) can be detected at the extra-articular segment remains unknown. This cross-sectional study aimed to explore the morphological differences of the LHBT in shoulders with and without deficient rotator cuffs by using quantitative ultrasound. Materials and Methods We selected 145 cases with SSFT and 145 age-and- gender-matched controls. The width, thickness, flattening ratio, cross-sectional area, and echogenicity ratio of the LHBT were measured and a general linear model was used to clarify the relationship between rotator cuff pathology and LHBT morphology. The receiver operating characteristic curves of each parameter were constructed for SSFT discrimination and the maximal Youden indexes were used to define the best cut-off points. Results We found increased thickness and cross-sectional area but decreased flattening ratio in shoulders with SSFT, and no between-group differences in the width and echogenicity ratio. The LHBT appearance was modified by biceps peritendinous effusion and medial subluxation, but not by the size of SSFT. The flattening ratio was the best discriminator for SSFT with an area under curve of 0.81 (95% confidence interval, 0.76–0.86). The cut-off values to differentiate between the non-tear and tear groups were 2.00 mm of the thickness, 1.73 of the flattening ratio and 10.53 mm2 of the cross-sectional area. Conclusion Quantitative ultrasound facilitated the detection of the LHBT morphological changes following SSFT and demonstrated its potential utility in discriminating rotator cuff deficiency.

Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis

Background Increasing evidence has supported the use of dextrose prolotherapy for patients with osteoarthritis. However, the real benefits may be affected by differences in injection protocols, comparative regimens, and evaluation scales. Methods PubMed and Scopus were searched from the earliest record until February 2016. One single-arm study and five randomized controlled trials were included, comprising 326 participants. We estimated the effect sizes of pain reduction before and after serial dextrose injections and compared the values between dextrose prolotherapy, comparative regimens, and exercise 6 months after the initial injection. Results Regarding the treatment arm using dextrose prolotherapy, the effect sizes compared with baseline were 0.65 (95% confidence interval [CI], 0.14–1.17), 0.84 (95% CI, 0.40–1.27), 0.85 (95% CI, 0.60–1.10), and 0.87 (95% CI, 0.53–1.21) after the first, second, third, and fourth or more injections, respectively. The overall effect of dextrose was better than control injections (effect size, 0.36; 95% CI, 0.10–0.63). Dextrose prolotherapy had a superior effect compared with local anesthesia (effect size, 0.38; 95% CI, 0.07–0.70) and exercise (effect size, 0.71; 95% CI, 0.30–1.11). There was an insignificant advantage of dextrose over corticosteroids (effect size, 0.31; 95% CI, –0.18 to 0.80) which was only estimated from one study. Conclusion Dextrose injections decreased pain in osteoarthritis patients but did not exhibit a positive dose–response relationship following serial injections. Dextrose prolotherapy was found to provide a better therapeutic effect than exercise, local anesthetics, and probably corticosteroids when patients were retested 6 months following the initial injection.

Sonographic Nerve Tracking in the Cervical Region: A Pictorial Essay and Video Demonstration.

ABSTRACTImaging of the nerves in the cervical region is more complicated than those of the extremities. Although high-resolution ultrasound enables the depiction of peripheral nerves’ morphology and their associations with the adjacent soft tissues, precise identification of the nerves in the neck is still challenging. Familiarization with the cervical nerve tracking techniques can help interventional physiatrists explore/treat relevant entrapment syndromes, so does guiding proper electrode placement during nerve conduction studies. The present article integrates serial ultrasound images and videos to demonstrate how to scan brachial plexus, superficial cervical plexus, cranial nerves in the neck region, and certain branches of the major cervical nerves.

Can Quantification of Biceps Peritendinous Effusion Predict Rotator Cuff Pathologies?: A Retrospective Analysis of 1352 Shoulder Ultrasound.

ObjectiveThe purposes of this study were to determine the best cutoff value for bicipital peritendinous effusion (BPE) and to test its diagnostic performance as regards shoulders with and without rotator cuff pathology. DesignWe reviewed the sonographic reports of 1352 patients with suspected shoulder disorders between January 2011 and June 2012. The associations between BPE and rotator cuff abnormalities were explored by logistic regression and adjusted for age, sex, affected side, and clinical diagnosis of frozen shoulder. The receiver operating characteristic curves were constructed to assess the ability of BPE to discriminate certain rotator cuff pathologies. Maximal Youden indexes were used to define the best cutoff points, which were later applied on the validation data set for its discriminative ability. ResultsSonographic findings of subscapularis tendinopathy, subdeltoid bursitis, supraspinatus full-thickness tear, and supraspinatus articular-sided partial-thickness tear were found to be associated with BPE. The cutoff values of BPE to differentiate those lesions were 1.0, 0.9, 1.5, and 1.5 mm, respectively. Validation of the diagnostic performance of BPE at defined thicknesses yielded good negative predictive values for the aforementioned rotator cuff abnormalities. ConclusionsSonographically detected BPE seems to be in association with certain rotator cuff pathologies, and it can be utilized as an adjuvant finding to rule out such rotator cuff abnormalities. To Claim CME Credits:Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives:Upon completion of this article, the reader should be able (1) to realize the association between the biceps peritendinous effusion and other sonographic abnormal findings regarding the shoulder joint, (2) to understand the possible mechanism of biceps peritendinous effusion production, and (3) to use biceps peritendinous effusion as an adjuvant finding to rule out rotator cuff abnormalities. Level:Advanced Accreditation:The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Snapping Thumb and Superficial Radial Nerve Entrapment in De Quervain Disease: Ultrasound Imaging/Guidance Revisited

Dear Editor: A 73-year-old female described right lateral wrist pain for the last 6 months which had not responded effectively to physical therapy. She also felt a snapping sensation when she intended to extend her affected thumb. Under the impression of recalcitrant de Quervain disease, she was referred for an ultrasound (US) examination. The US images disclosed accessory tendons and a vertical septum inside the first dorsal extensor compartment (Figure ⇓A). Compared with the asymptomatic side, the tendons at the painful side appeared swollen, wrapped by a hypervascular retinaculum (not shown). The dynamic US images clearly identified a snapping phenomenon when the extensor pollicis brevis (EPB) tendon glided over …