Uri Givon

Gait analysis in multiple sclerosis: Characterization of temporal–spatial parameters using GAITRite functional ambulation system

BACKGROUND Gait impairment is a significant problem in multiple sclerosis (MS), leading to decreased activity and limitations in function. However, specific characterization of abnormal gait in MS patients has only been described in small groups of patients, mainly using observational tools. OBJECTIVE The aim of the current study was to characterize the spatio-temporal gait parameters in MS patients and ascribe them to clinical variables, in order to enable target-oriented management. METHODS Eighty-one MS patients with relatively short disease duration (5.3; S.E.=0.3) able of independent walking and 25 age-matched healthy subjects were evaluated using the GAITRite Functional Ambulation System. Subjects also underwent a thorough neurological examination to assess their disability using the Expanded Disability Status Scale (EDSS). Gait parameters were compared between patients and able-bodied controls to characterize the gait impairments in MS. Within the group of patients the correlation of gait parameters with clinical neurological variables was investigated. RESULTS MS patients demonstrated significant impairments in all spatio-temporal gait parameters compared to able-bodied healthy subjects. MS patients had a mean Functional Ambulation Profile (FAP) score of 83.0 and a mean velocity of 85.5m/s while the controls had a FAP score of 95.0 (p<0.001) and a velocity of 138.6m/s (p<0.001). Cadence was 94.4 steps/min in MS patients and 115.2 in controls (p<0.001). Step length was 45.3 cm in MS patients and 72.1 cm in controls (p<0.001). FAP score negatively correlated with disease duration (p<0.001) and EDSS (p<0.001). The most significant correlations of the FAP were found with the pyramidal (p<0.002), and the cerebellar (p<0.05) functional scores. Specifically, gait velocity, single support time and swing time negatively correlated with the pyramidal functional score, while double support time positively correlated with the pyramidal score. The base support width positively correlated with cerebellar functional score. CONCLUSIONS Gait parameters were impaired in MS, even in patients with relatively short disease duration. The impaired gait patterns correlated with the associated neurological disability. Specific and accurate assessment of gait can be a useful tool to monitor MS evolution and can be used to advise target-oriented rehabilitative management of MS patients.

Monteggia and equivalent lesions. A study of 41 cases.

Forty-one patients who suffered from a Monteggia fracture and were treated between 1984 and 1993 were reviewed retrospectively using a new motion score of the elbow joint. There were 14 children and 27 adults of whom 34 were available for review. The results in children were significantly better than those of the adults. Among the adults, the final results of the patients who had a Bado Type 1 equivalent injury were significantly worse than those of the other groups, especially when associated with a fracture of the radial head. The type of fracture, open or closed, the presence of a fracture of the olecranon, and the energy level of the trauma did not have any significant prognostic value. Good correlation was shown between the new motion score and the Figgie elbow score. The Bado Type 1 equivalent injuries should be considered as a special subgroup of the Monteggia lesion, necessitating extra attention in treatment and rehabilitation, and a close followup of the patient.

Treatment of septic arthritis of the hip joint by repeated ultrasound-guided aspirations.

Arthrotomy of the hip joint followed by a variable period of drainage or continuous irrigation and drainage is considered the accepted treatment of septic arthritis of the hip joint (SAHJ). The authors reviewed the results of a cohort of children with SAHJ with repeated aspirations of the hip joint. Thirty-four children diagnosed with SAHJ were treated with repeated aspirations of the hip joint. The aspirations were performed under ultrasound guidance and topical anesthesia or under sedation. After the aspiration the joint was irrigated using the same needle, and the procedure was repeated daily. Six of the patients were operated on and then treated with aspirations because of drain dislodgement or clogging. Twenty-eight of the patients were treated primarily with repeated aspirations. Four of those patients did not improve and underwent arthrotomies, and 24 were treated only by repeated aspirations and healed completely. The mean number of aspirations was 3.6 (range 3–5), and 75% of the patients resumed walking after 24 hours. The mean follow-up time was 7.4 years (range 3–18). No complications were seen. Repeated aspiration is a safe and efficacious method of treatment for SAHJ. This method of treatment is not associated with surgery and its complications and prevents scarring of the skin and the need for general anesthesia. Faster return to normal activity was noted in this series.

Stress fractures in the Israeli defense forces from 1995 to 1996.

This study, encompassing 2591 Israeli soldiers, characterized Israeli soldiers with stress fractures to profile individuals who are prone to experience stress fractures: 318 with clinically and scintigraphically proven high grade stress fractures; 237 soldiers with symptoms but with normal scintigraphy; and 2036 soldiers with no symptoms. Soldiers with high grade stress fractures weighed less (68.4 ± 7.9 kg versus 70.5 ± 12.4 kg), smoked less, and reported fewer previous stress fractures, had fewer reports of stress fractures in their family histories, and had fewer incidences of bone diseases than did control subjects. Serum levels of bone specific alkaline phosphatase and osteocalcin were elevated in patients with high grade stress fractures compared with control subjects with no symptoms: 37.6 versus 26.2 units/L, and 10.8 versus 8.8 ng/mL, respectively. Levels of 25-hydroxy vitamin D were lower in patients with high grade stress fractures (25.3 ng/mL) than in control subjects (29.8 ng/mL). This study revealed that several parameters can distinguish soldiers with high grade stress fractures, but their predictive value and precise pathogenetic role remain unclear.

Effect of Alfacalcidol on multiple sclerosis-related fatigue: A randomized, double-blind placebo-controlled study

Context: Fatigue is one of the most common and disabling symptoms of multiple sclerosis (MS); however, there is no medication that has been approved specifically to treat MS-related fatigue. Objective: We aimed to evaluate the effect of vitamin D analogue, Alfacalcidol, on MS-related fatigue. Design, settings, participants: This was a randomized, double-blind, parallel group, placebo-controlled trial in patients with clinically definite MS by McDonald criteria conducted in a single university-affiliated medical center in Israel. Randomly selected patients from the Sheba MS Registry computerized database (N=600) were assessed using the self-report Fatigue Severity Scale (FSS). Patients with clinically meaningful fatigue (N=259) were further assessed for trial eligibility, and MS patients with significant fatigue (N=158; 61%, 118 females, mean age 41.1 ± 9.2 years and mean disease duration of 6.2 ± 5.5 years) were included in the study and randomized to receive treatment or placebo. Intervention: Alfacalcidol (1 mcg/d, N=80) or placebo (N=78) was administered for six consecutive months. Main outcome measure: The primary endpoint of the study was the change between Alfacalcidol and placebo-treated patients in the Fatigue Impact Scale (FIS) score; the cut-off point for improvement was defined as 30% decrease. All analyses followed the intention-to-treat principle and were performed for all participants based on the group they were randomly allocated regardless of whether or not they dropped out. Results: Alfacalcidol decreased the mean relative FIS score as compared with placebo (–41.6% vs. –27.4%, p=0.007, respectively). This advantage was further emphasized when the modified FIS (MFIS) relative change was calculated. Quality of Life (QoL) improved in Alfacalcidol-treated patients as compared with placebo in the RAYS psychological (p=0.033) and social (p=0.043) sub-scales. The Alfacalcidol-treated group had reduced number of relapses (p=0.006) and higher proportion of relapse-free patients (p=0.007). Reduction of relapses by Alfacalcidol became significant at 4 months of treatment, was sustained at 6 months and decayed 2 months after drug discontinuation. Alfacalcidol treatment was safe and no serious adverse events were recorded. Conclusion: Alfacalcidol is a safe and effective treatment strategy to decrease fatigue and improve QoL in patients with MS.

Cost-Utility Analysis of Total Hip Arthroplasties: Technology Assessment of Surgical Procedures by Mailed Questionnaires

A retrospective study comparing 700 consecutive total hip arthroplasties, utilizing four types of implants, was performed. Questionnaires based on hip scores were sent to 593 living patients. Useful responses were received from 363 (61%) patients. Hip scores and quality-adjusted life-years were calculated. Multiple regression analysis, controlling for all possible biases, demonstrated one cementless implant as superior to all others. We believe that the use of mailed questionnaires is a simple and convenient system of follow-up, saving patients the need for outpatient clinic visits. The validity of such replies, however, has yet to be established.

The Month of Birth and the Incidence of Multiple Sclerosis in the Israeli Population

Background: Recent studies on date of birth of multiple sclerosis (MS) patients showed a spring peak and an autumn nadir. We examined the effect of date of birth in a large group of MS patients and non-MS patients, compared to the general population in Israel. Methods: A retrospective analysis was performed in a large cohort of MS patients and patients with other neurological disorders. The date of birth, gender, and country of birth were identified for each patient. The results were compared to a national database. Results: There were 2,264 MS patients and 1,758 patients with other diagnoses. No significant peak or nadir in the date of birth was identified in either group, both in patients born in Israel or in immigrants. No difference was found compared to the national birth rate. When we controlled for the country of birth, there was no difference. Conclusion: An increased frequency of MS patients born in the months of April and May was considered as a proof of maternal influence. The results of our study show that this finding is not consistent worldwide. The month of birth was not found to be a significant factor in Israeli MS patients.

Reducing musculoskeletal disorders among computer operators: comparison between ergonomics interventions at the workplace.

Typing is associated with musculoskeletal disorders (MSDs) caused by multiple risk factors. This control study aimed to evaluate the efficacy of a workplace intervention for reducing MSDs among computer workers. Sixty-six subjects with and without MSD were assigned consecutively to one of three groups: ergonomics intervention (work site and body posture adjustments, muscle activity training and exercises) accompanied with biofeedback training, the same ergonomics intervention without biofeedback and a control group. Evaluation of MSDs, body posture, psychosocial status, upper extremity (UE) kinematics and muscle surface electromyography were carried out before and after the intervention in the workplace and the motion lab. Our main hypothesis that significant differences in the reduction of MSDs will exist between subjects in the study groups and controls was confirmed (χ2 = 13.3; p = 0.001). Significant changes were found in UE kinematics and posture as well. Both ergonomics interventions effectively reduced MSD and improved body posture. Practitioner Summary: This study aimed to test the efficacy of an individual workplace intervention programme among computer workers by evaluating musculoskeletal disorders (MSDs), body posture, upper extremity kinematics, muscle activity and psychosocial factors were tested. The proposed ergonomics interventions effectively reduced MSDs and improved body posture.

Titanium elastic nail--a useful instrument for the treatment of simple bone cyst.

A simple bone cyst is a common benign lytic lesion in the pediatric population. Successful methods of treatment include injections with bone marrow and curettage of the cyst and filling with bone graft or bone graft substitute. Opening the cyst walls and creating a connection with the medullary canal promote healing. We describe a simple method of opening the cyst walls without creating a large cortical defect, using the AO Titanium Elastic Nail. This flexible nail allows creation of connections to the medullary canal in several directions through one cortical hole.

Pediatric femoral shaft fractures: treatment strategies according to age - 13 years of experience in one medical center

ObjectiveThe objective of this study was to analyze our experience in treating femoral shaft fractures with different strategies, focusing on the first year after injury when the choice of method would have the greatest impact.MethodsWe reviewed the medical records of all children treated for femoral shaft fractures in our institution between 1997 and 2010. They were divided according to therapeutic approach: spica cast, skin traction, titanium elastic nail (TEN), external fixator, intramedullary medullary nail (IMN), and plating.ResultsThe 212 patients included 150 boys and 62 girls (M/F ratio 2.4:1, mean age 5 years, range 0–16). The postoperative radiographic results demonstrated solid union in all patients, with no malunions. Of the 151 children in the spica cast group, 10 required re-manipulation and casting due to loss of reduction with unaccepted angulation, 10 had contact dermatitis, and 2 had fever and pressure sores. All 21 elastic nail group children underwent re-operation to remove the hardware: 3 had soft tissue irritation at the insertion points, and 3 had leg length discrepancy (LLD). Of the 14 external fixation patients, 4 had LLD, 1 had a pin tract infection, and 1 had a fracture through a pinhole after a fall. There were no complications in the 12 IMN patients, the 3 plating patients, or the 11 skin traction patients. LLD rates in the spica group were 10.5% higher compared to those in the control group (other treatment modalities) (P = .03).ConclusionsTEN treatment was superior to spica casting for children who had reached an average age of 4 years.