Tatjana Paternostro-Sluga

Effects of whole-body vibration in patients with multiple sclerosis: a pilot study

Objective: To examine whether a whole-body vibration (mechanical oscillations) in comparison to a placebo administration leads to better postural control, mobility and balance in patients with multiple sclerosis. Design: Double-blind, randomized controlled trial. Setting: Outpatient clinic of a university department of physical medicine and rehabilitation. Subjects: Twelve multiple sclerosis patients with moderate disability (Kurtzkes Expanded Disability Status Scale 2.5-5) were allocated either to the intervention group or to the placebo group. Interventions: In the intervention group a whole-body vibration at low frequency (2.0-4.4 Hz oscillations at 3-mm amplitude) in five series of 1 min each with a 1-min break between the series was applied. In the placebo group a Burst-transcutaneous electrical nerve stimulation (TENS) application on the nondominant forearm in five series of 1 min each with a 1-min break between the series was applied as well. Main outcome measures: Posturographic assessment using the Sensory Organization Test, the Timed Get Up and Go Test and the Functional Reach Test immediately preceding the application, 15 min, one week and two weeks after the application. The statistical analysis was applied to the change score from preapplication values to values 15 min, one week and two weeks post intervention. Results: Compared with the placebo group the intervention group showed advantages in terms of the Sensory Organization Test and the Timed Get Up and Go Test at each time point of measurement after the application. The effects were strongest one week after the intervention, where significant differences for the change score (p=0.041) were found for the Timed Get Up and Go Test with the mean score reducing from 9.2 s (preapplication) to 8.2 s one week after whole-body vibration and increasing from 9.5 s (preapplication) to 10.2 s one week after placebo application. The mean values of the posturographic assessment increased from 70.5 points (preapplication) to 77.5 points one week after whole body vibration and increased only from 67.2 points (preapplication) to 67.5 points one week after the placebo application. No differences were found for the Functional Reach Test. Conclusion: The results of this pilot study indicated that whole-body vibration may positively influence the postural control and mobility in multiple sclerosis patients.

Lumbar intervertebral disc abnormalities: comparison of quantitative T2 mapping with conventional MR at 3.0 T

ObjectiveTo assess the relationship of morphologically defined lumbar disc abnormalities with quantitative T2 mapping.MethodsFifty-three patients, mean age 39xa0years, with low back pain were examined by MRI at 3xa0T (sagittal T1-fast spin echo (FSE), three-plane T2-FSE for morphological MRI, multi-echo spin echo for T2 mapping). All discs were classified morphologically. Regions of interest (ROIs) for the annulus were drawn. The space in between was defined as the nucleus pulposus (NP). To evaluate differences between the classified groups, univariate ANOVA with post hoc Games–Howell and paired two-tailed t tests were used.ResultsIn 265 discs we found 39 focal herniations, 10 annular tears, 123 bulging discs and 103 “normal discs”. T2 values of the NP between discs with annular tear and all other groups were statistically significantly different (all pu2009≤u20090.01). Discs with annular tears showed markedly lower NP T2 values than discs without. The difference in NP T2 values between discs with focal herniation and normal discs (pu2009=u20090.005) was statistically significant. There was no difference in NP T2 values between bulging and herniated discs (pu2009=u20090.11)ConclusionQuantitative T2 mapping of the nucleus pulposus of the intervertebral disc in the lumbar spine at 3xa0T reveals significant differences in discs with herniation and annular tears compared with discs without these abnormalities.

Long-Term High-Level Exercise Promotes Muscle Reinnervation With Age

The histologic features of aging muscle suggest that denervation contributes to atrophy, that immobility accelerates the process, and that routine exercise may protect against loss of motor units and muscle tissue. Here, we compared muscle biopsies from sedentary and physically active seniors and found that seniors with a long history of high-level recreational activity up to the time of muscle biopsy had 1) lower loss of muscle strength versus young men (32% loss in physically active vs 51% loss in sedentary seniors); 2) fewer small angulated (denervated) myofibers; 3) a higher percentage of fiber-type groups (reinnervated muscle fibers) that were almost exclusive of the slow type; and 4) sparse normal-size muscle fibers coexpressing fast and slow myosin heavy chains, which is not compatible with exercise-driven muscle-type transformation. The biopsies from the old physically active seniors varied from sparse fiber-type groupings to almost fully transformed muscle, suggesting that coexpressing fibers appear to fill gaps. Altogether, the data show that long-term physical activity promotes reinnervation of muscle fibers and suggest that decades of high-level exercise allow the body to adapt to age-related denervation by saving otherwise lost muscle fibers through selective recruitment to slow motor units. These effects on size and structure of myofibers may delay functional decline in late aging.

Parametric T2 and T2* mapping techniques to visualize intervertebral disc degeneration in patients with low back pain: initial results on the clinical use of 3.0 Tesla MRI

ObjectiveTo assess, compare and correlate quantitative T2 and T2* relaxation time measurements of intervertebral discs (IVDs) in patients suffering from low back pain, with respect to the IVD degeneration as assessed by the morphological Pfirrmann Score. Special focus was on the spatial variation of T2 and T2* between the annulus fibrosus (AF) and the nucleus pulposus (NP).Materials and MethodsThirty patients (mean age: 38.1u2009±u20099.1xa0years; 20 female, 10 male) suffering from low back pain were included. Morphological (sagittal T1-FSE, sagittal and axial T2-FSE) and biochemical (sagittal T2- and T2* mapping) MRI was performed at 3xa0Tesla covering IVDs L1–L2 to L5–S1. All IVDs were morphologically classified using the Pfirrmann score. Region-of-interest (ROI) analysis was performed on midsagittal T2 and T2* maps at five ROIs from anterior to posterior to obtain information on spatial variation between the AF and the NP. Statistical analysis-of-variance and Pearson correlation was performed.ResultsThe spatial variation as an increase in T2 and T2* values from the AF to the NP was highest at Pfirmann grade I and declined at higher Pfirmann grades II–IV (pu2009<u20090.05). With increased IVD degeneration, T2 and T2* revealed a clear differences in the NP, whereas T2* was additionally able to depict changes in the posterior AF. Correlation between T2 and T2* showed a medium Pearson’s correlation (0.210 to 0.356 [pu2009<u20090.001]).ConclusionThe clear differentiation of IVD degeneration and the possible quantification by means of T2 and fast T2* mapping may provide a new tool for follow-up therapy protocols in patients with low back pain.

Quantitative T2 evaluation at 3.0 T compared to morphological grading of the lumbar intervertebral disc: A standardized evaluation approach in patients with low back pain

BACKGROUNDnThe purpose of our investigation was to compare quantitative T2 relaxation time measurement evaluation of lumbar intervertebral discs with morphological grading in young to middle-aged patients with low back pain, using a standardized region-of-interest evaluation approach.nnnPATIENTS AND METHODSnThree hundred thirty lumbar discs from 66 patients (mean age, 39 years) with low back pain were examined on a 3.0T MR unit. Sagittal T1-FSE, sagittal, coronal, and axial T2-weighted FSE for morphological MRI, as well as a multi-echo spin-echo sequence for T2 mapping, were performed. Morphologically, all discs were classified according to Pfirrmann et al. Equally sized rectangular regions of interest (ROIs) for the annulus fibrosus were selected anteriorly and posteriorly in the outermost 20% of the disc. The space between was defined as the nucleus pulposus. To assess the reproducibility of this evaluation, inter- and intraobserver statistics were performed.nnnRESULTSnThe Pfirrmann scoring of 330 discs showed the following results: grade I: six discs (1.8%); grade II: 189 (57.3%); grade III: 96 (29.1%); grade IV: 38 (11.5%); and grade V: one (0.3%). The mean T2 values (in milliseconds) for the anterior and the posterior annulus, and the nucleus pulposus for the respective Pfirrmann groups were: I: 57/30/239; II: 44/67/129; III: 42/51/82; and IV: 42/44/56. The nucleus pulposus T2 values showed a stepwise decrease from Pfirrmann grade I to IV. The posterior annulus showed the highest T2 values in Pfirrmann group II, while the anterior annulus showed relatively constant T2 values in all Pfirrmann groups. The inter- and intraobserver analysis yielded intraclass correlation coefficients (ICC) for average measures in a range from 0.82 (anterior annulus) to 0.99 (nucleus).nnnCONCLUSIONSnOur standardized method of region-specific quantitative T2 relaxation time evaluation seems to be able to characterize different degrees of disc degeneration quantitatively. The reproducibility of our ROI measurements is sufficient to encourage the use of this method in future investigations, particularly for longitudinal studies.

Bionic reconstruction to restore hand function after brachial plexus injury: a case series of three patients

BACKGROUNDnBrachial plexus injuries can permanently impair hand function, yet present surgical reconstruction provides only poor results. Here, we present for the first time bionic reconstruction; a combined technique of selective nerve and muscle transfers, elective amputation, and prosthetic rehabilitation to regain hand function.nnnMETHODSnBetween April 2011, and May 2014, three patients with global brachial plexus injury including lower root avulsions underwent bionic reconstruction. Treatment occurred in two stages; first, to identify and create useful electromyographic signals for prosthetic control, and second, to amputate the hand and replace it with a mechatronic prosthesis. Before amputation, the patients had a specifically tailored rehabilitation programme to enhance electromyographic signals and cognitive control of the prosthesis. Final prosthetic fitting was applied as early as 6 weeks after amputation.nnnFINDINGSnBionic reconstruction successfully enabled prosthetic hand use in all three patients. After 3 months, mean Action Research Arm Test score increased from 5·3 (SD 4·73) to 30·7 (14·0). Mean Southampton Hand Assessment Procedure score improved from 9·3 (SD 1·5) to 65·3 (SD 19·4). Mean Disabilities of Arm, Shoulder and Hand score improved from 46·5 (SD 18·7) to 11·7 (SD 8·42).nnnINTERPRETATIONnFor patients with global brachial plexus injury with lower root avulsions, who have no alternative treatment, bionic reconstruction offers a means to restore hand function.nnnFUNDINGnAustrian Council for Research and Technology Development, Austrian Federal Ministry of Science, Research & Economy, and European Research Council Advanced Grant DEMOVE.

Effect of short-term unloading on T2 relaxation time in the lumbar intervertebral disc—in vivo magnetic resonance imaging study at 3.0 tesla

Background context Diurnal changes in T2 values, indicative for changes in water content, have been reported in the lumbar intervertebral discs. However, data concerning short-term T2 changes are missing. Purpose The purpose of this study was to investigate the short-term effects of unloading on T2 values in lumbar intervertebral discs in vivo. Study design Experimental study with repeated measurements of lumbar discs T2 relaxation time during a period of 38 minutes of supine posture. Patient sample Forty-one patients with acute or chronic low back pain (visual analog scale ≥3). Outcome measures T2 relaxation time in the intervertebral disc, lumbar lordosis angle, and intervertebral disc height. Methods Forty-one patients (mean age, 41.6 years) were investigated in the supine position using a 3-tesla magnetic resonance system. Sagittal T2 mapping was performed immediately after unloading and after a mean delay of 38 minutes. No patient movement was allowed between the measurements. One region of interest (ROI) was manually placed in both the anterior and the posterior annulus fibrosus (AF) and three ROIs in the nucleus pulposus (NP). Results There was a statistically significant decrease in the anterior NP (−2.7 ms; p<.05) and an increase in T2 values in the posterior AF (+3.5 ms; p<.001). Discs with initially low T2 values in the NP showed minor increase in the posterior AF (+1.6 ms; p<.05), whereas a major increase in the posterior AF was found in discs with initially high T2 values in the NP (+6.8 ms; p=.001). Patients examined in the morning showed no differences, but those investigated in the afternoon showed a decrease in the anterior NP (−5.3 ms; p<.05) and an increase in the posterior AF (+7.8 ms; p=.002). No significant differences were observed in other regions. Correlation analysis showed moderate correlations between the time of investigation and T2 changes in the posterior AF (r=0.46; p=.002). Conclusions A shift of water from the anterior to the posterior disc regions seems to occur after unloading the lumbar spine in the supine position. The clinical relevance of these changes needs to be investigated.

Functional electrical stimulation combined with botulinum toxin type A to improve hand function in children with spastic hemiparesis – a pilot study

ZusammenfassungHINTERGRUND: Kinder mit spastischer Hemiparese leiden häufig unter einer eingeschränkten Handfunktion. Gründe dafür sind Paresen, Spastizität sowie eine gestörte motorische Kontrolle. Ziel dieser Studie war die Effektivität der kombinierten Anwendung von funktioneller Elektrostimulation mit Botulinum Toxin A bei diesen Kindern zu untersuchen. DESIGN: Randomisiert, kontrolliert, Beobachter-geblindet, Pilotstudie. PATIENTEN: Kinder mit eingeschränkter Handfunktion aufgrund einer spastischen Hemiparese. INTERVENTIONEN: Die Einteilung erfolgte in zwei Gruppen: Die erste Gruppe erhielt eine kombinierte Behandlung von funktioneller Elektrostimulation mit Botulinum Toxin A, die zweite Gruppe wurde nur mit Botulinum Toxin A behandelt. Das Toxin wurde entsprechend der Klinik in die Armmuskulatur injiziert. Nach fünf bis sechs Tagen wurde mit der funktionellen Elektrostimulation der Hand- und Fingerextensoren begonnen. Die Behandlung erfolgte mittels Heimgerät zuhause und wurde zweimal täglich für 15 Minuten, über insgesamt drei Monate, appliziert. UNTERSUCHUNGSPARAMETER: Aktiver und passiver Bewegungsumfang, Muskeltonus, Muskelkraft und Funktionstests für Kinder. ERGEBNISSE: Sechs Kinder im Alter zwischen 7 und 17 Jahren mit spastischer Hemiparese wurden in die Studie eingeschlossen. In beiden Gruppen verbesserten sich der aktive und passive Bewegungsumfang, der Muskeltonus und die Muskelkraft nach 3 und 6 Monaten im Vergleich zur Ausgangsuntersuchung. Eine Verbesserung bei den Funktionstests zeigte sich nur in der Gruppe mit der kombinierten Behandlung. DISKUSSION: Die Kombination von funktioneller Elektrostimulation mit Botulinum Toxin A ist eine vielversprechende Therapieoption zur Verbesserung der Handfunktion bei Kindern mit spastischer Hemiparese.SummaryBACKGROUND: Children with spastic hemiparesis frequently present with impaired hand function due to paresis, spasticity, and disturbed motor control. The aim of this study was to examine the effectiveness of functional electrical stimulation in combination with botulinum toxin type A in these children. DESIGN: Randomized, controlled, observer-blinded pilot study. SUBJECTS: Children with impaired hand function. INTERVENTIONS: Either a combined treatment group (functional electrical stimulation and botulinum toxin type A) or a botulinum toxin type A group alone. Botulinum toxin type A was injected into arm muscles according to the patients clinical requirements. Functional electrical stimulation of the wrist and finger extensor muscles was started after five to six days. Patients were given a stimulation device and asked to use it at home twice daily for 15 min, for a total period of three months. MAIN MEASURES: Active and passive range of motion, muscle tone, muscle strength, and functional tests for children. RESULTS: Six children aged between 7 and 17 years with spastic hemiparesis were enrolled. In both groups, active and passive range of motion, muscle tone, and muscle strength improved after three and six months compared to baseline data. The functional score was improved only in the group that received combined treatment. CONCLUSIONS: Combined treatment with functional electrical stimulation and botulinum toxin type A is a promising treatment option to improve upper limb function in children with spastic hemiparesis.

Muscle mass, strength and functional outcomes in critically ill patients after cardiothoracic surgery: does neuromuscular electrical stimulation help? The Catastim 2 randomized controlled trial.

BackgroundThe effects of neuromuscular electrical stimulation (NMES) in critically ill patients after cardiothoracic surgery are unknown. The objectives were to investigate whether NMES prevents loss of muscle layer thickness (MLT) and strength and to observe the time variation of MLT and strength from preoperative day to hospital discharge.MethodsIn this randomized controlled trial, 54 critically ill patients were randomized into four strata based on the SAPS II score. Patients were blinded to the intervention. In the intervention group, quadriceps muscles were electrically stimulated bilaterally from the first postoperative day until ICU discharge for a maximum of 14 days. In the control group, the electrodes were applied, but no electricity was delivered. The primary outcomes were MLT measured by ultrasonography and muscle strength evaluated with the Medical Research Council (MRC) scale. The secondary functional outcomes were average mobility level, FIM score, Timed Up and Go Test and SF-12 health survey. Additional variables of interest were grip strength and the relation between fluid balance and MLT. Linear mixed models were used to assess the effect of NMES on MLT, MRC score and grip strength.ResultsNMES had no significant effect on MLT. Patients in the NMES group regained muscle strength 4.5 times faster than patients in the control group. During the first three postoperative days, there was a positive correlation between change in MLT and cumulative fluid balance (ru2009=u20090.43, Pu2009=u20090.01). At hospital discharge, all patients regained preoperative levels of muscle strength, but not of MLT. Patients did not regain their preoperative levels of average mobility (Pu2009=u20090.04) and FIM score (Pu2009=u20090.02) at hospital discharge, independent of group allocation.ConclusionsNMES had no effect on MLT, but was associated with a higher rate in regaining muscle strength during the ICU stay. Regression of intramuscular edema during the ICU stay interfered with measurement of changes in MLT. At hospital discharge patients had regained preoperative levels of muscle strength, but still showed residual functional disability and decreased MLT compared to pre-ICU levels in both groups.Trial registrationClinicaltrials.gov identifier NCT02391103. Registered on 7 March 2015.

Functional and Psychosocial Outcomes of Hand Transplantation Compared with Prosthetic Fitting in Below-Elbow Amputees: A Multicenter Cohort Study

Background Hand-transplantation and improvements in the field of prostheses opened new frontiers in restoring hand function in below-elbow amputees. Both concepts aim at restoring reliable hand function, however, the indications, advantages and limitations for each treatment must be carefully considered depending on level and extent of amputation. Here we report our findings of a multi-center cohort study comparing hand function and quality-of-life of people with transplanted versus prosthetic hands. Methods Hand function in amputees with either transplant or prostheses was tested with Action Research Arm Test (ARAT), Southampton Hand Assessment Procedure (SHAP) and the Disabilities of the Arm, Shoulder and Hand measure (DASH). Quality-of-life was compared with the Short-Form 36 (SF-36). Results Transplanted patients (n = 5) achieved a mean ARAT score of 40.86 ± 8.07 and an average SHAP score of 75.00 ± 11.06. Prosthetic patients (n = 7) achieved a mean ARAT score of 39.00 ± 3.61 and an average SHAP score of 75.43 ± 10.81. There was no significant difference between transplanted and prosthetic hands in ARAT, SHAP or DASH. While quality-of-life metrics were equivocal for four scales of the SF-36, transplanted patients reported significantly higher scores in “role-physical” (p = 0.006), “vitality” (p = 0.008), “role-emotional” (p = 0.035) and “mental-health” (p = 0.003). Conclusions The indications for hand transplantation or prosthetic fitting in below-elbow amputees require careful consideration. As functional outcomes were not significantly different between groups, patient’s best interests and the route of least harm should guide treatment. Due to the immunosuppressive side-effects, the indication for allotransplantation must still be restrictive, the best being bilateral amputees.