Rhizarthrosis Part I: A Literature Review.

Rhizarthrosis (RA), or trapeziometacarpal osteoarthritis, is an arthritic degenerative process that affects the first joint of the thumb. The objective of this work is to provide therapists with an overview of the fundamental issues related to the therapeutic management of trapeziometacarpal joint instability. Prevalent in females, especially post-menopause, and linked to age, RA involves ligament and muscle structures, with causes ranging from hormonal influences to mechanical factors. Understanding the biomechanics, stability, and factors contributing to RA is crucial for effective intervention. This study explores the role of ligaments, muscles, and anatomical variants in thumb joint degeneration, emphasizing the importance of stability and congruence. RA manifests as pain at the base of the thumb, limiting grip strength and hindering everyday tasks. Pain initially occurs during specific movements but can progress to constant discomfort, affecting sleep. Chronic RA leads to joint stiffness, deformities like the "Z thumb," and muscle atrophy, impacting daily functions. Clinical evaluation involves pain assessment, joint mobility examination, and palpation. Diagnostic tests like the grind test and lever test aid in confirming RA. Radiographic examination reveals joint space degeneration and osteophytes and helps classify RA stages using the Eaton-Littler classification. Conservative treatment aims to alleviate pain, reduce joint stress, and enhance function. Orthoses help stabilize the joint. Therapeutic exercises, emphasizing muscle strength and dynamic stability, prove beneficial. Manual therapies like neurodynamic, Kaltenborn, Mulligan, and Maitland techniques target pain reduction and improve joint mechanics. The studies on conservative approaches provide evidence that a multimodal intervention consisting of joint mobilization, neural mobilization, and exercise is beneficial in reducing pain in patients with RA. When conservative therapy fails, surgical intervention is indicated.

Rhizarthrosis Part II: A New Approach of Manual Therapy and Therapeutic Exercise.

Rhizarthrosis (RA), also known as trapezium-metacarpal osteoarthritis, is a degenerative condition affecting the thumb's first joint, leading to functional impairment and pain. Conservative treatment options are preferred for mild to moderate cases (Eaton-Littler grades I and II) and typically encompass a range of therapeutic modalities, including manual therapy. However, for the existing manual therapy techniques, there is a lack of comparative studies for efficacy, and therapeutic exercises are often generic and non-specific to RA. This study proposes a novel treatment protocol that combines manual therapy with specific therapeutic exercises grounded in the biomechanical analysis of the trapeziometacarpal joint. The focus is on enhancing joint stability, reducing pain, and improving function. The manual therapy component includes three phases. A passive phase, during which joint distractions are applied to alleviate discomfort and improve joint mobility. An active phase that addresses joint mobility on the adduction-abduction plane, the first plane of movement to suffer limitation: the therapist facilitates the isometric adduction of the thumb, followed by an assisted abduction. A second active phase is where Mulligan's Mobilization With Movement concept is applied. This technique involves passive pain-free joint mobilization with simultaneous active finger movements, to provide additional therapeutic benefits. The therapeutic exercises component focuses on strengthening the first dorsal interosseous muscle as an abductor to reduce thumb adductor muscle activation and joint stress. Patients are encouraged to perform finger spreading exercises using a rubber band between the first and fifth fingers, emphasizing first dorsal interosseous activation and stability of the thumb. This type of muscle strengthening does not involve movement of the trapeziometacarpal joint. It is recommended to start performing 5-10 repetitions or 5 seconds of isometric contraction, repeat throughout the day, and progressively increase the load by adding a turn to the rubber band or changing it, increasing the number of repetitions bringing it to 15 and/or increase the isometric contraction time to 10/15 seconds. The proposed therapeutic rationale, informed by biomechanical insights, lays a promising foundation for further investigation. Nevertheless, empirical validation through rigorous clinical trials remains essential to substantiate its clinical utility and advance the management of RA.

Correction: Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question.

[This corrects the article DOI: 10.7759/cureus.58443.].

Scoliosis and Lower Limb Inequality: To Lift or Not to Lift, That Is the Question.

In subjects with scoliotic alterations of the spine, asymmetrical lengths of the lower limbs are frequently observed, a condition commonly referred to as leg length inequality (LLI) or discrepancy (LLD). This asymmetry can induce pelvic misalignments, manifested by an asymmetric height of the iliac crests, and consequently an alteration of the spine's axis. Although correcting this discrepancy might appear to be a straightforward solution, further investigation may reveal other indications. The purpose of this article is to aid clinicians confronted with the decision of whether to compensate for an LLI in individuals with scoliosis, encompassing both adolescents and adults. It presents a literature review on the incidence of LLIs in the general population, distinguishing between structural LLI (sLLI) and functional LLI (fLLI) types of LLIs, and quantifying their magnitude with clinical and instrumental evaluation. Additionally, it links these two types of LLIs to the type of scoliosis (structural or functional). From a clinical perspective, it also examines the compensatory mechanisms employed by the pelvis in the presence of structural or functional LLIs in order to draw useful indications for therapeutic decisions. Moreover, it proposes an additional evaluation parameter in the coronal plane, namely the central sacral vertical line (CSVL), to aid in the decision-making process regarding LLI compensation. Although this parameter has been documented in the literature, it has been little associated with LLIs. The findings indicate that scoliotic discrepancies should be compensated (conservatively or surgically) only when the imbalance of the femoral heads is on the same side as the imbalance of the sacrum and the iliac crests; this corrective action should result in a reduction of the overhang in the coronal plane.

Immediate Effect of Simulated High Heels on Pelvic and Spinal Posture in Healthy Young Subjects: A Cross-Sectional Study.

Background Investigations regarding the role of high-heeled shoes in the alteration of the spinopelvic profile attempted to identify a correlation with pain in the lower back. Conclusions from these studies, however, are controversial. In authors knowledge no studies were carried out to investigate the effect of heels on male population, which has been overlooked due to gender-related customs. Research question What is the immediate effect of the height of heels on the sagittal back profile (trunk inclination (TI), pelvic inclination, lordotic lumbar angle (ITL-ILS), kyphotic dorsal angle, lumbar arrow, and cervical arrow) in females and males, not used to wearing high-heeled shoes? Methods One hundred healthy young adult subjects were enrolled. Three were excluded. The remaining 97 subjects (48 female and 49 male) underwent a three-dimensional analysis of the posterior surface of the trunk, using rasterstereography. The spinopelvic profile in the barefoot condition, and with the heel raised by 3 and 7 cm, was recorded. To evaluate the reproducibility of the measure, the neutral evaluation was repeated twice in 23 subjects (13 males, 10 females). Results The change of heel height did not show statistically significant differences for any of the variables used; instead, significant differences were found stratifying the results according to the sex of the subjects tested. Test-retest evaluation in the neutral condition showed no significant differences using the Student's t-test (p > 0.05). Repeatability was excellent and significant for all data used (minimum TI r = 0.85, maximum ITL-ILS r = 0.97). Significance Studying the effect of heels on the spino-pelvic profile also in the male population is crucial for promoting gender-inclusive healthcare, enhancing occupational health practices and developing possible preventive measures. Nevertheless, in the sample of females and males evaluated in this study, the different heights of heel lift did not immediately induce significant changes in pelvis and spine posture. If there is therefore a correlation between low-back pain and the use of heels, it should not reasonably be sought in the immediate change of the spino-pelvic profile caused by raising the heels. However, the variables analyzed differed according to sex.

Involvement of Myofascial Spiral Chains of the Lower Limb in Semi-unipodal Balance: A Pilot Study.

Introduction Single-leg stance has been extensively studied for functional evaluation, therapeutic exercise, sports training, and fall prevention. However, the motor strategies of the supporting limb have been investigated only at the ankle level. It is not known, at the hip, how the muscular system reacts to medial and lateral imbalances. We hypothesize, based on a myofascial chain approach, that the balance is managed by the front and back spiral chains. The aim of this work was to perform a preliminary experimental analysis to verify the spiral chain hypothesis, testing a method to investigate the motor strategies underlying equilibrium. Methods Five healthy subjects (i.e. without neurological or orthopedic pathologies affecting the upright position) underwent perturbations of their monopodal balance while a surface electromyographic analysis of gluteus maximus, gluteus medius, adductor longus (ADD), tibialis anterior (TA), and peroneus longus (PL) was executed. The percentage of electrical activation with respect to maximal contraction was calculated for each muscle investigated. The coordination in activation between the hip and ankle muscles was analyzed by the Pearson correlation coefficient. Results Of the studied muscles, TA (43% of maximal contraction) and gluteus medius (28%) had the average highest reaction to lateral imbalance and the highest correlation coefficient (0.89, p-value<0.01); PL (35%) and ADD (16%) were the most relevant in counteracting the medial imbalance (correlation coefficient=0.83, p-value<0.01).  Conclusion The study was performed on a few subjects, and the muscles of the lower limb were only partially investigated. However, the consistency of the results with former experimental studies provided preliminary evidence of the adequacy of the method adopted. The correlation of hip and ankle muscle activations was in line with the spiral chain hypothesis.

Effect of Ankle-Foot Orthoses in Pediatric Patients with Hereditary Motor-Sensory Neuropathy: A Case Series Study.

(1) Aims: to evaluate the effect on gait performance and standing stability of ankle-foot orthoses (AFO) in pediatric patients with hereditary motor-sensory neuropathy (HMSN). (2) Methods: a retrospective case-series study including three adolescents (S1, S2, S3, mean age 14 years) with HMSN. The subjects were evaluated barefoot, with carbon AFO (Botter) and with solid AFO (SAFO) by means of: gait analysis, stabilometry and gait functional tests (10 Meter Walk Test, 2 Minute Walk Test). Finally, the CSD-OPUS questionnaire was administered to the assess satisfaction and impact of the orthoses on life quality. (3) Results: orthoses improved gait and stability performance. Botter allowed greater ankle movement than SAFO and provided greater push-off power. This, combined with the carbon elastic energy return, might explain better performances in the 2MWT, with a larger distance traveled compared to SAFO for both S1 (110 m vs. 72 m) and S2 (170 m vs. 155 m) and, compared to barefoot walking, also for S3 (211 m vs. 160 m), for which SAFO analysis was not available. Both orthoses improved performance at the stabilometric analysis. The CSD-OPUS questionnaire showed a significantly higher level of satisfaction with Botter for the subjects (S1, S2) who completed the comparison. (4) Conclusions: Both orthoses improved gait and standing, though Botter proved to be better tolerated and more effective in improving gait endurance.

Preserving Ambulation in a Gene Therapy-Treated Girl Affected by Metachromatic Leukodystrophy: A Case Report.

(1) Background: Atidarsagene autotemcel is a hematopoietic stem and progenitor cell gene therapy (HSPC-GT) approved to treat early-onset metachromatic leukodystrophy (MLD). The purpose of this case report is to describe the long-term management of residual gait impairment of a child with late infantile MLD treated with HSPC-GT. (2) Methods: Assessment included Gross Motor Function Measure-88, nerve conduction study, body mass index (BMI), Modified Tardieu Scale, passive range of motion, modified Medical Research Council scale, and gait analysis. Interventions included orthoses, a walker, orthopedic surgery, physiotherapy, and botulinum. (3) Results: Orthoses and a walker were fundamental to maintaining ambulation. Orthopedic surgery positively influenced gait by reducing equinovarus. Nonetheless, unilateral recurrence of varo-supination was observed, attributable to spasticity and muscle imbalance. Botulinum improved foot alignment but induced transient overall weakness. A significant increase in BMI occurred. Finally, a shift to bilateral valgopronation was observed, more easily managed with orthoses. (4) Conclusions: HSPC-GT preserved survival and locomotor abilities. Rehabilitation was then considered fundamental as a complementary treatment. Muscle imbalance and increased BMI contributed to gait deterioration in the growing phase. Caution is recommended when considering botulinum in similar subjects, as the risk of inducing overall weakness can outweigh the benefits of spasticity reduction.

Effectiveness comparison between carbon spring and hinged ankle-foot orthoses in crouch gait treatment of children with diplegic cerebral palsy: a randomized crossover trial.

BACKGROUND: Children with cerebral palsy (CP) often present a loss of effectiveness of the plantarflexors/knee-extensors couple that leads to crouch gait. When treating a child with crouch gait by means of ankle foot orthoses, preserving or restoring push off power is a key issue. AIM: To compare carbon-fiber spring (Carbon Ankle Seven® [CAFO], Ottobock® HealthCare, Duderstadt, Germany) and hinged ankle-foot orthoses (HAFO) effectiveness in improving functionality and walking ability in children with diplegic CP and crouch gait. DESIGN: Randomized crossover trial. SETTING: Hospital center. POPULATION: Ten children with diplegic CP and crouch gait, 5 males and 5 females, aged 11 (4) years. METHODS: The gait of each child was evaluated by means of instrumental gait analysis with both CAFO and HAFO, in a randomized order and after a 4-week adaptation period. The primary outcome measure was the change in ankle power generation. As secondary outcome measures, knee joint kinematics, stride length, walking speed, Observational Gait Scale, and preferred orthosis were considered. RESULTS: The median of the energy produced in stance was superior with CAFO (+2.2 J/kg, IQR 4.7, P=0.006), and the energy absorbed inferior (-3.3 J/kg, IQR 4.3, P=0.011). No statistically significant difference was found for any other parameter. Preference of the children was equally distributed between the two orthoses. CONCLUSIONS: No evident superiority of CAFO with respect to HAFO was found in improving gait performance of children with CP and crouch gait. Nevertheless, the results suggest the possibility that CAFO permits an energy saving and reduction of the more compromising deficits. CLINICAL REHABILITATION IMPACT: The final choice of the participants indicates that CAFOs are preferred by older and heavier children, but the preference does not correlate with the performance of the orthoses during gait.

Gait-Based Diplegia Classification Using LSMT Networks.

Diplegia is a specific subcategory of the wide spectrum of motion disorders gathered under the name of cerebral palsy. Recent works proposed to use gait analysis for diplegia classification paving the way for automated analysis. A clinically established gait-based classification system divides diplegic patients into 4 main forms, each one associated with a peculiar walking pattern. In this work, we apply two different deep learning techniques, namely, multilayer perceptron and recurrent neural networks, to automatically classify children into the 4 clinical forms. For the analysis, we used a dataset comprising gait data of 174 patients collected by means of an optoelectronic system. The measurements describing walking patterns have been processed to extract 27 angular parameters and then used to train both kinds of neural networks. Classification results are comparable with those provided by experts in 3 out of 4 forms.

Development of a prosthesis shoulder mechanism for upper limb amputees: application of an original design methodology to optimize functionality and wearability.

The application of a design methodology for the determination of the optimal prosthesis architecture for a given upper limb amputee is presented in this paper along with the discussion of its results. In particular, a novel procedure was used to provide the main guidelines for the design of an actuated shoulder articulation for externally powered prostheses. The topology and the geometry of the new articulation were determined as the optimal compromise between wearability (for the ease of use and the patient's comfort) and functionality of the device (in terms of mobility, velocity, payload, etc.). This choice was based on kinematic and kinetostatic analyses of different upper limb prosthesis models and on purpose-built indices that were set up to evaluate the models from different viewpoints. Only 12 of the 31 simulated prostheses proved a sufficient level of functionality: among these, the optimal solution was an articulation having two actuated revolute joints with orthogonal axes for the elevation of the upper arm in any vertical plane and a frictional joint for the passive adjustment of the humeral intra-extra rotation. A prototype of the mechanism is at the clinical test stage.