Jeffrey R. Basford

Virtual reality in stroke rehabilitation: still more virtual than real.

Purpose. To assess the utility of virtual reality (VR) in stroke rehabilitation. Method. The Medline, Proquest, AMED, CINAHL, EMBASE and PsychInfo databases were electronically searched from inception/1980 to February 2005, using the Keywords: Virtual reality, rehabilitation, stroke, physiotherapy/physical therapy and hemiplegia. Articles that met the studys inclusion criteria were required to: (i) be published in an English language peer reviewed journal, (ii) involve the use of VR in a stroke rehabilitation setting; and (iii) report impairment and/or activity oriented outcome measures. Two assessors independently assessed each studys quality using the American Academy for Cerebral Palsy and Developmental Medicine (AACPDM) grading system. Results. Eleven papers met the inclusion criteria: Five addressed upper limb rehabilitation, three gait and balance, two cognitive interventions, and one both upper and lower limb rehabilitation. Three were judged to be AACPDM Level I/Weak, two Level III/Weak, three Level IV/Weak and three Level V quality of evidence. All articles involved before and after interventions; three randomized controlled trials obtained statistical significance, the remaining eight studies found VR-based therapy to be beneficial. None of the studies reported any significant adverse effects. Conclusion. VR is a potentially exciting and safe tool for stroke rehabilitation but its evidence base is too limited by design and power issues to permit a definitive assessment of its value. Thus, while the findings of this review are generally positive, the level of evidence is still weak to moderate, in terms of research quality. Further study in the form of rigorous controlled studies is warranted.

The Effectiveness of Physiotherapy Exercises in Subacromial Impingement Syndrome: A Systematic Review and Meta-Analysis

OBJECTIVE To evaluate the effectiveness of exercise in the treatment of people with subacromial impingement syndrome (SAIS). METHODS A systematic review and meta-analysis were conducted. Ten electronic databases were searched from the dates of their inception until August 2010. Included studies were randomized controlled trials investigating exercise in the management of SAIS. Outcomes were pain, strength, function, and quality of life. Data were summarized qualitatively using a best evidence synthesis. Treatment effect size and variance of individual studies were used to give an overall summary effect and data were converted to standardized mean difference with 95% confidence intervals (standardized mean difference (SMD) (CI)). RESULTS Sixteen studies were included (n = 1162). There was strong evidence that exercise decreases pain and improves function at short-term follow-up. There was also moderate evidence that exercise results in short-term improvement in mental well-being and a long-term improvement in function for those with SAIS. The most common risk of bias across the studies was inadequately concealed treatment allocation. Six studies in the review were suitable for meta-analysis. Exercise had a small positive effect on strength of the rotator cuff in the short term (SMD -0.46 (-0.76, 0.16); P = 0.003) and a small positive effect on long-term function (SMD -0.31 (-0.57, 0.04); P = 0.02). CONCLUSIONS Physiotherapy exercises are effective in the management of SAIS. However, heterogeneity of the exercise interventions, coupled with poor reporting of exercise protocols, prevented conclusions being drawn about which specific components of the exercise protocols (ie, type, intensity, frequency and duration) are associated with best outcomes.

A randomized controlled evaluation of low-intensity laser therapy: Plantar fasciitis

OBJECTIVE To determine whether low-intensity laser irradiation, a widespread but controversial physical therapy agent, is an effective treatment of plantar fasciitis. DESIGN A randomized, double-blinded, placebo-controlled clinical study. SETTING A sports medicine clinic. SUBJECTS Thirty-two otherwise healthy individuals with plantar fasciitis of more than 1 months duration. INTERVENTION Dummy or active irradiation with a 30 mW .83 microm GaAlAs continuous-wave infrared (IR) diode laser three times a week for 4 weeks. MEASUREMENTS Morning pain, pain with toe walking, tenderness to palpation, windlass test response, medication consumption, and orthotic use were evaluated immediately before the study, as well as at the midpoint and end of treatment. Subjects were also evaluated at a follow-up 1 month after their last treatment. RESULTS No significant differences were found between the groups in any of the outcome measures either during treatment or at the 1-month follow-up. Treatment, however, was well tolerated and side effects were minimal. CONCLUSIONS Low-intensity IR laser therapy appears safe but, at least within the parameters of this study, is not beneficial in the treatment of plantar fasciitis.

Dysphagia in inflammatory myopathy: clinical characteristics, treatment strategies, and outcome in 62 patients.

OBJECTIVE To assess the clinical characteristics, treatment, and outcome of patients with inflammatory myopathy-associated dysphagia. PATIENTS AND METHODS We retrospectively reviewed the medical records of all patients with inflammatory myopathy-associated dysphagia seen at the Mayo Clinic in Rochester, Minn, between January 1, 1997, and December 31, 2001. RESULTS A total of 783 patients were diagnosed as having inflammatory myopathy during the 5-year study period. Of these, 62 patients (41 women and 21 men; mean age, 68.6 years) had inflammatory myopathy-associated dysphagia: 26 with inclusion body myositis (IBM), 18 with dermatomyositis, 9 with polymyositis, and 9 with overlap syndrome. Dysphagia was a presenting symptom in 13 patients (21%), with the highest incidence in the IBM group. Videofluoroscopic examinations revealed pharyngeal pooling and impaired oropharyngeal and cricopharyngeal function. The benefits of swallowing compensation techniques and exercises were difficult to establish. Interventional procedures were performed in 24 patients (39%) and most frequently (62%) in patients with IBM, with cricopharyngeal myotomy being most beneficial. Patients with IBM had the least symptomatic improvement. Overall, 11 patients died during the median follow-up of 38 months, with respiratory failure due to aspiration pneumonia as the most common cause. Mortality was high in patients who required percutaneous endoscopic gastrostomy (7/11, 64%), and 1- year mortality was highest (31%) in those with dermatomyositis. CONCLUSION Dysphagia is a serious and at times presenting problem in patients with inflammatory myopathy. It occurs most frequently and appears to be most refractory in patients with IBM. The mortality rate was high in patients who required percutaneous endoscopic gastrostomy, and the 1-year mortality rate was the highest in patients with dermatomyositis.

The Effect of Seat Position on Wheelchair Propulsion Biomechanics

This study examined the effect of seat position on handrim biomechanics. Thirteen experienced users propelled a wheelchair over a smooth level floor at a self-selected speed. Kinetic and temporal-distance data were collected with the use of an instrumented rim and a motion analysis system. A custom-designed axle was used to change the seat position. We used repeated measures analysis of variance to evaluate if differences existed in the temporal-distance and kinetic data with change in seat position. Results showed that a shorter distance between the axle and shoulder (low seat height) improved the push time and push angle temporal variables (p < 0.0001). Tangential force output did not change with seat position. Axial and radial forces were highest in the lowest seat position (p < 0.001). Propulsion efficiency as measured by the fraction of effective force did not significantly change with seat position.

Ability of magnetic resonance elastography to assess taut bands

BACKGROUND Myofascial taut bands are central to diagnosis of myofascial pain. Despite their importance, we still lack either a laboratory test or imaging technique capable of objectively confirming either their nature or location. This study explores the ability of magnetic resonance elastography to localize and investigate the mechanical properties of myofascial taut bands on the basis of their effects on shear wave propagation. METHODS This study was conducted in three phases. The first involved the imaging of taut bands in gel phantoms, the second a finite element modeling of the phantom experiment, and the third a preliminary evaluation involving eight human subjects-four of whom had, and four of whom did not have myofascial pain. Experiments were performed with a 1.5 T magnetic resonance imaging scanner. Shear wave propagation was imaged and shear stiffness was reconstructed using matched filtering stiffness inversion algorithms. FINDINGS The gel phantom imaging and finite element calculation experiments supported our hypothesis that taut bands can be imaged based on its outstanding shear stiffness. The preliminary human study showed a statistically significant 50-100% (P=0.01) increase of shear stiffness in the taut band regions of the involved subjects relative to that of the controls or in nearby uninvolved muscle. INTERPRETATION This study suggests that magnetic resonance elastography may have a potential for objectively characterizing myofascial taut bands that have been up to now detectable only by the clinicians fingers.

Comparison of cold-quartz ultraviolet, low-energy laser, and occlusion in wound healing in a swine model.

A randomized, blind, controlled study used six pigs to examine the effectiveness of low-energy HeNe laser irradiation (632.8nm), cold-quartz UV (254nm), occlusion, and exposure in the treatment of full thickness skin wounds. Laser-treated wounds received a nominal dose of 54mW daily on a schedule of six days/week, UV-treated wounds were given two minimal erythemal dose treatments, twice daily, six days a week, and occluded wounds were checked and dressings replaced as needed twice daily, six days a week. All wounds were treated until clinically healed. Time to closure, wound strength, and bacterial colonization were monitored. There were no complications. Although the laser-treated wounds healed faster than the exposed-control wounds (20.3 +/- 0.9 days vs 21.1 +/- 2 days), only the occluded wounds healed significantly (p less than or equal to 0.05) faster than the controls (18 +/- 1.6 days vs 20.6 +/- 1.4 days). No statistically significant difference in bacterial colonization or wound strength was noted although the occlusion-treated wounds tended to be the strongest.

Preventing and treating orthostatic hypotension: As easy as A, B, C

Orthostatic hypotension is a chronic, debilitating illness that is difficult to treat. The therapeutic goal is to improve postural symptoms, standing time, and function rather than to achieve upright normotension, which can lead to supine hypertension. Drug therapy alone is never adequate. Because orthostatic stress varies with circumstances during the day, a patient-oriented approach that emphasizes education and nonpharmacologic strategies is critical. We provide easy-to-remember management recommendations, using a combination of drug and nondrug treatments that have proven efficacious. Easy-to-remember management recommendations, using a combination of effective drug and nondrug treatments.

Measurement of muscle activity with magnetic resonance elastography

OBJECTIVE To non-invasively determine muscle activity. DESIGN A correlation analysis study. BACKGROUND Electromyography is traditionally used to measure the electrical activity of a muscle and can be used to estimate muscle contraction intensity. This approach, however, is limited not only in terms of the volume of tissue that can be monitored, but must be invasive if deep lying muscles are studied. We wished to avoid these limitations and used magnetic resonance elastography in an attempt to non-invasively determine muscle activity. This novel approach uses a conventional MRI system. However, in addition to the imaging gradients, an oscillating, motion sensitizing field gradient is applied to detect mechanical waves that have been generated within the tissue. The wavelength correlates with the stiffness of the muscle and hence with the activity of the muscle. METHODS Six volunteers (mean age: 30.1 years, range: 27-36 years) without orthopedic or neuromuscular abnormalities, lay supine with their legs within the coil of a MRI scanner. The wavelengths of mechanically generated shear waves in the tibialis anterior, medial and lateral head of the gastrocnemius and the soleus were measured as the subjects resisted ankle plantar-flexing (8.2 and 16.4 nm) and dorsi-flexing (20.2 and 40.4 nm) moments. The findings were then compared to EMG data collected under the same loading conditions. RESULTS Magnetic resonance elastography wavelengths were linearly correlated to the muscular activity as defined by electromyography. (TA, R(2)=0.89, P=0.02; MG, R(2)=0.82, P=0.05; LG, R(2)=0.88, P=0.03; S, R(2)=0.90, P=0.02) CONCLUSIONS Magnetic resonance elastography may be a promising tool for the non-invasive determination of muscle activity. RELEVANCE Magnetic resonance elastography has potential as the basis for a new non-invasive approach to study in vivo muscle function.

Agonist contractions against electrically stimulated antagonists

OBJECTIVE To assess an exercise program that uses electrically stimulated antagonists to resist agonist muscle contractions. DESIGN In 1 limb, electrically stimulated antagonists resisted elbow flexion and extension. In the other, stimulation occurred without volitional muscle contraction. SETTING A biomechanics laboratory in Japan. PARTICIPANTS Twelve men between the ages of 19 and 24 years. Subjects served as their own controls. INTERVENTION Subjects trained 3 times a week for 12 weeks. Each session consisted of 10 sets of 10 elbow flexor and extensor contractions. MAIN OUTCOME MEASURES Isokinetic elbow extension and flexion torques. Biceps and triceps brachii cross-sectional areas. RESULTS Elbow extension torques increased (32.85% at 30 degrees/s, 27.20% at 60 degrees/s, 26.16% at 90 degrees/s; all P<or=.02) over the training period in limbs that trained against electrically stimulated antagonists. Control limb extension torque increases were smaller (8.52% -14.91%) and did not reach statistical significance. Elbow flexion torques improved in both groups, but the changes did not reach statistical significance. Cross-sectional areas increased in all muscles but were most marked in the antagonist stimulated limbs: triceps 16.20% versus 4.25% (P=.01) and biceps 16.65% versus 7.00% (P=.005). CONCLUSIONS Exercises that use electrically stimulated antagonist muscles may be effective in increasing muscle strength and mass.