The effects of a prehabilitation programme based on therapeutic exercise, back care education, and pain neuroscience education in patients scheduled for lumbar radiculopathy surgery: A study protocol for a randomised controlled trial.

The aim of this present clinical trial is to evaluate the effectiveness of a multicomponent prehabilitation programme administered through educational videos versus another programme based on written exercise recommendations, in patients scheduled for lumbar radiculopathy surgery. This study will be a multicentre, controlled, randomised, parallel clinical trial. One hundred participants undergoing lumbar radiculopathy surgery who meet the established inclusion criteria will be recruited at different Spanish hospitals. The experimental group will follow a 4-week prehabilitation programme combining therapeutic exercise, back care education, and pain neuroscience education delivered through videos designed for consumption at home. The control group will be provided with written instructions to perform therapeutic exercises during the same prehabilitation time period. The primary outcome of the study will be disability, assessed using the Spanish version of the Oswestry Disability Index. The secondary outcomes will be pain perception, health-related quality of life, fear avoidance, kinesiophobia, catastrophising, anxiety, depression, physical activity, and the treatment satisfaction of the patients. This study will provide evidence for the effectiveness of a home-based multicomponent prehabilitation programme that addresses some already identified barriers to patient attendance in face-to-face programmes. Understanding the medium and long-term effects of pre-surgery lumbar muscle training and pain neuroscience education administered via instructional videos watched by patients at home, will help improve the design of prehabilitation programmes in this population while also improving the cost-effectiveness of such interventions.

Multimodal cell atlas of the ageing human skeletal muscle.

Muscle atrophy and functional decline (sarcopenia) are common manifestations of frailty and are critical contributors to morbidity and mortality in older people1. Deciphering the molecular mechanisms underlying sarcopenia has major implications for understanding human ageing2. Yet, progress has been slow, partly due to the difficulties of characterizing skeletal muscle niche heterogeneity (whereby myofibres are the most abundant) and obtaining well-characterized human samples3,4. Here we generate a single-cell/single-nucleus transcriptomic and chromatin accessibility map of human limb skeletal muscles encompassing over 387,000 cells/nuclei from individuals aged 15 to 99 years with distinct fitness and frailty levels. We describe how cell populations change during ageing, including the emergence of new populations in older people, and the cell-specific and multicellular network features (at the transcriptomic and epigenetic levels) associated with these changes. On the basis of cross-comparison with genetic data, we also identify key elements of chromatin architecture that mark susceptibility to sarcopenia. Our study provides a basis for identifying targets in the skeletal muscle that are amenable to medical, pharmacological and lifestyle interventions in late life.

Increased femoral anteversion in females with anterior knee pain relates to both the neck and the shaft of the femur.

INTRODUCTION: Increased femoral anteversion (FAV) can have many clinical manifestations, including anterior knee pain (AKP). To our knowledge, no studies have measured the location of FAV in a cohort of female AKP patients. The objective of this research is to determine whether the increased FAV in AKP females originates above the lesser trochanter, below the lesser trochanter or at both levels. MATERIALS AND METHODS: Thrity-seven consecutive AKP female patients (n = 66 femurs) were recruited prospectively. There were 17 patients (n = 26 femurs; mean age of 28 years) in whom the suspicion for the increased FAV of the femur was based on the clinical examination (pathological group-PG). The control group (CG) consisted of 20 patients (n = 40 femurs; mean age of 29 years) in whom there was no increased FAV from the clinical standpoint. All of them underwent a torsional computed tomography of the lower limbs. FAV was measured according to Murphy´s method. A segmental analysis of FAV was performed using the lesser trochanter as a landmark. RESULTS: Significant differences in the total FAV (18.7 ± 5.52 vs. 42.46 ± 6.33; p < 0.001), the neck version (54.88 ± 9.64 vs. 64.27 ± 11.25; p = 0.0006) and the diaphysis version (- 36.17 ± 8.93 vs. - 21.81 ± 11.73; p < 0.001) were observed between the CG and the PG. The difference in the diaphyseal angle between CG and PG accounts for 60% of the total difference between healthy and pathological groups, while the difference between both groups in the angle of the neck accounts for 40%. CONCLUSION: In chronic AKP female patients with increased FAV, the two segments of the femur contribute to the total FAV, with a different pattern among patients and controls, being the compensation mechanism of the diaphysis much lower in the pathological femurs than in the controls.

Predictive value of texture analysis on lumbar MRI in patients with chronic low back pain.

PURPOSE: The aim of this study was to determine whether MRI texture analysis could predict the prognosis of patients with non-specific chronic low back pain. METHODS: A prospective observational study was conducted on 100 patients with non-specific chronic low back pain, who underwent a conventional MRI, followed by rehabilitation treatment, and revisited after 6 months. Sociodemographic variables, numeric pain scale (NPS) value, and the degree of disability as measured by the Roland-Morris disability questionnaire (RMDQ), were collected. The MRI analysis included segmentation of regions of interest (vertebral endplates and intervertebral disks from L3-L4 to L5-S1, paravertebral musculature at the L4-L5 space) to extract texture variables (PyRadiomics software). The classification random forest algorithm was applied to identify individuals who would improve less than 30% in the NPS or would score more than 4 in the RMDQ at the end of the follow-up. Sensitivity, specificity, and the area under the ROC curve were calculated. RESULTS: The final series included 94 patients. The predictive model for classifying patients whose pain did not improve by 30% or more offered a sensitivity of 0.86, specificity 0.57, and area under the ROC curve 0.71. The predictive model for classifying patients with a RMDQ score 4 or more offered a sensitivity of 0.83, specificity of 0.20, and area under the ROC curve of 0.52. CONCLUSION: The texture analysis of lumbar MRI could help identify patients who are more likely to improve their non-specific chronic low back pain through rehabilitation programs, allowing a personalized therapeutic plan to be established.

Central sensitization negatively influences the level of disability in female patients with anterior knee pain.

PURPOSE: To define the prevalence of Central Sensitization (CS) in patients with Anterior Knee Pain (AKP) and determine whether there is an association between CS and the magnitude of pain, disability, quality-of-life and psychological impairment. METHODS: The data of a total of 44 AKP female patients with a mean age of 27.7 years (15-50) recruited consecutively from hospital outpatient knee clinics were prospectively included in this study. The patients had no antecedents of knee trauma or surgery and no history of injury or disease of the nervous system. There were also 50 healthy female controls with a mean age of 26.1 years (16-46). CS was evaluated using the Central Sensitization Inventory (CSI). Quality-of-life was evaluated using the EuroQoL-5D questionnaire. Self-reporting of clinical pain intensity was obtained using the Visual Analogue Scale. The Kujala Knee Scale and IKDC form were used to evaluate disability. Anxiety and depression were evaluated using the Hospital Anxiety and Depression Subscale (HAD). Kinesiophobia was measured with the Tampa Scale for Kinesiophobia (TSK-11) and catastrophizing by means of the Pain Catastrophizing Scale (PCS). RESULTS: Sixteen AKP patients (36%), and 2 (4%) of the healthy controls presented with central sensitization (p < 0.01). AKP patients with CS have a greater degree of disability based on the Kujala Scale and higher levels of anxiety and depression than AKP patients without CS. The score of AKP patients in the CSI correlated weakly with disability and quality of life and moderately with anxiety and depression. However, no association was seen between CSI score and pain intensity, nor with catastrophizing and kinesiophobia. A multivariate logistic regression analysis showed that only depression was statistically significant in the prediction of the presence of CS (odds ratio 1.45; 95% CI 1.07 to 1.96). CONCLUSIONS: AKP patients have a significantly higher prevalence of CS in comparison with what has been reported for the general population. This finding suggests the presence of altered pain modulation in a subgroup of AKP patients. LEVEL OF EVIDENCE: Level III.

Has Arthroscopic Meniscectomy Use Changed in Response to the Evidence? A Large-database Study From Spain.

BACKGROUND: Several randomized clinical trials on the treatment of meniscal tears have shown that surgery is not superior to nonoperative treatment in middle-aged and older adults. However, clinical practice has not changed consistently worldwide in response to this evidence, and arthroscopic meniscectomy remains one of the most frequently performed operations. QUESTIONS/PURPOSES: (1) How has the use of arthroscopic meniscectomy changed in Spain between 2003 and 2018, particularly in middle-aged (35 to 59 years) and older patients (over 60 years) relative to younger patients? (2) How have surgical volumes changed across different healthcare areas in the same health system? (3) How has the proportion of outpatient versus inpatient arthroscopic procedures changed over time? METHODS: Data on all 420,228 arthroscopic meniscectomies performed in Spain between 2003 and 2018 were obtained through the Atlas of Variations in Medical Practice project (these years were chosen because data in that atlas for 2002 and 2019 were incomplete). This database has been promoted by the Spanish Health Ministry since 2002, and it collects basic information on all admissions to public and public-private partnership hospitals. The Spanish population of 2003 was used to calculate age- and sex-standardized rates of interventions per 10,000 inhabitants and year. To assess the change in standardized rates among the age groups over the study period, a linear regression analysis was used. Standard small-area variation statistics were used to analyze variation among healthcare areas. Data on outpatient surgery and length of stay for inpatient procedures were also included. RESULTS: The standardized rate of arthroscopic meniscectomy in Spain in 2003 was 4.8 procedures per 10,000 population (95% CI 3.9 to 5.6), while in 2018, there were 6.3 procedures per 10,000 population (95% CI 5.4 to 7.3), which represents an increase of 33%. Standardized rates increased slightly in the age group < 35 years (0.06 interventions per 10,000 inhabitants per year [95% CI 0.05 to 0.08]), whereas they increased more markedly in the age groups of 35 to 59 years (0.14 interventions per 10,000 inhabitants per year [95% CI 0.11 to 0.17]) and in those 60 years and older (0.13 interventions per 10,000 inhabitants per year [95% CI 0.09 to 0.17]). The variability among healthcare areas in the meniscectomy rate progressively decreased from 2003 to 2018. In 2003, 32% (6544 of 20,384) of knee arthroscopies were performed on an outpatient basis, while in 2018, these accounted for 67% (19,573 of 29,430). CONCLUSION: We observed a progressive increase in arthroscopic meniscectomies in Spain; this procedure was more prevalent in older patients presumed to have degenerative pathologic findings. This increase occurred despite increasing high-level evidence of a lack of the additional benefit of meniscectomy over other less-invasive treatments in middle-aged and older people. Our study highlights the need for action in health systems with the use of financial, regulatory, or incentive strategies to reduce the use of low-value procedures, as well as interventions to disseminate the available evidence to clinicians and patients. Research is needed to identify the barriers that are preventing the reversal of interventions that high-quality evidence shows are ineffective. LEVEL OF EVIDENCE: Level III, therapeutic study.

Glucose 6-P Dehydrogenase-An Antioxidant Enzyme with Regulatory Functions in Skeletal Muscle during Exercise.

Hypomorphic Glucose 6-P dehydrogenase (G6PD) alleles, which cause G6PD deficiency, affect around one in twenty people worldwide. The high incidence of G6PD deficiency may reflect an evolutionary adaptation to the widespread prevalence of malaria, as G6PD-deficient red blood cells (RBCs) are hostile to the malaria parasites that infect humans. Although medical interest in this enzyme deficiency has been mainly focused on RBCs, more recent evidence suggests that there are broader implications for G6PD deficiency in health, including in skeletal muscle diseases. G6PD catalyzes the rate-limiting step in the pentose phosphate pathway (PPP), which provides the precursors of nucleotide synthesis for DNA replication as well as reduced nicotinamide adenine dinucleotide phosphate (NADPH). NADPH is involved in the detoxification of cellular reactive oxygen species (ROS) and de novo lipid synthesis. An association between increased PPP activity and the stimulation of cell growth has been reported in different tissues including the skeletal muscle, liver, and kidney. PPP activity is increased in skeletal muscle during embryogenesis, denervation, ischemia, mechanical overload, the injection of myonecrotic agents, and physical exercise. In fact, the highest relative increase in the activity of skeletal muscle enzymes after one bout of exhaustive exercise is that of G6PD, suggesting that the activation of the PPP occurs in skeletal muscle to provide substrates for muscle repair. The age-associated loss in muscle mass and strength leads to a decrease in G6PD activity and protein content in skeletal muscle. G6PD overexpression in Drosophila Melanogaster and mice protects against metabolic stress, oxidative damage, and age-associated functional decline, and results in an extended median lifespan. This review discusses whether the well-known positive effects of exercise training in skeletal muscle are mediated through an increase in G6PD.

Beyond the Brain: MIDS Extends BIDS to Multiple Modalities and Anatomical Regions.

Brain Imaging Data Structure (BIDS) provides a valuable tool to organise brain imaging data into a clear and easy standard directory structure. Moreover, BIDS is widely supported by the scientific community and has been established as a powerful standard for medical imaging management. Nonetheless, the original BIDS is restricted to magnetic resonance imaging (MRI) of the brain, limiting its implantation to other techniques and anatomical regions. We developed Medical Imaging Data Structure (MIDS), conceived to extend BIDS methodology to other anatomical regions and multiple imaging systems in these areas. The MIDS standard was developed to store and manage medical images as an extension of BIDS. It allows the user to handily save studies of multiple anatomical regions and imaging techniques. Besides, MIDS improves the classification of multiple images within the structure, allowing the possibility to unify them in a single study to apply on them preprocessing or artificial intelligence algorithms. Finally, the results generated are saved in the derivatives folder.

Beyond the Brain: MIDS Extends BIDS to Multiple Modalities and Anatomical Regions.

Brain Imaging Data Structure (BIDS) provides a valuable tool to organise brain imaging data into a clear and easy standard directory structure. Moreover, BIDS is widely supported by the scientific community and has been established as a powerful standard for medical imaging management. Nonetheless, the original BIDS is restricted to magnetic resonance imaging (MRI) of the brain, limiting its implantation to other techniques and anatomical regions. We developed Medical Imaging Data Structure (MIDS), conceived to extend BIDS methodology to other anatomical regions and multiple imaging systems in these areas. The MIDS standard was developed to store and manage medical images as an extension of BIDS. It allows the user to handily save studies of multiple anatomical regions and imaging techniques. Besides, MIDS improves the classification of multiple images within the structure, allowing the possibility to unify them in a single study to apply on them preprocessing or artificial intelligence algorithms. Finally, the results generated are saved in the derivatives folder.

The incidence of complications after derotational femoral and/or tibial osteotomies in patellofemoral disorders in adolescents and active young patients: a systematic review with meta-analysis.

PURPOSE: To quantify the risk of perioperative and postoperative complications of derotational femoral and/or tibial osteotomies in patellofemoral disorders (anterior knee pain and patellar instability) in adolescents and active young patients. METHODS: MEDLINE, EMBASE, Cochrane and Scopus databases were used to identify studies published from database inception and June 30, 2021. Meta-analysis was performed to pool the rates of complications related to femur and tibia osteotomies. Values of proportion of complications were expressed as proportions and 95% confidence intervals (CI) and then transformed using a Freeman Tukey double arcsine transformation. Meta-regression was used to explore factors that potentially may influence on heterogeneity such as year of publication, quality of the included studies and site of the osteotomy. RESULTS: The 22 studies identified included a total of 648 derotational osteotomies in 494 patients. Studies consisted of 20 case series (non-comparative) and 2 comparative observational non-randomized cohorts. Tibial osteotomies showed higher risk of complications than femoral osteotomies (random pooled prevalence 9%; 95% CI 4-15% versus 1%; 95% CI 0-5%, respectively, p < 0.01). The meta-regression analysis of the articles showed that the only parameters responsible of the variance in number of complications were the osteotomy site. CONCLUSIONS: Derotational femoral and/or tibial osteotomy is a safe surgical procedure in the treatment of patellofemoral disorders (anterior knee pain and patellar instability) in adolescents and active young people. LEVEL OF EVIDENCE: IV.

Osteopathic Manipulative Treatment Including Specific Diaphragm Techniques Improves Pain and Disability in Chronic Nonspecific Low Back Pain: A Randomized Trial.

OBJECTIVE: To investigate the effects of an osteopathic manipulative treatment (OMT), which includes a diaphragm intervention compared to the same OMT with a sham diaphragm intervention in chronic nonspecific low back pain (NS-CLBP). DESIGN: Parallel group randomized controlled trial. SETTING: Private and institutional health centers. PARTICIPANTS: Participants (N=66) (18-60y) with a diagnosis of NS-CLBP lasting at least 3 months. INTERVENTIONS: Participants were randomized to receive either an OMT protocol including specific diaphragm techniques (n=33) or the same OMT protocol with a sham diaphragm intervention (n=33), conducted in 5 sessions provided during 4 weeks. MAIN OUTCOME MEASURES: The primary outcomes were pain (evaluated with the Short-Form McGill Pain Questionnaire [SF-MPQ] and the visual analog scale [VAS]) and disability (assessed with the Roland-Morris Questionnaire [RMQ] and the Oswestry Disability Index [ODI]). Secondary outcomes were fear-avoidance beliefs, level of anxiety and depression, and pain catastrophization. All outcome measures were evaluated at baseline, at week 4, and at week 12. RESULTS: A statistically significant reduction was observed in the experimental group compared to the sham group in all variables assessed at week 4 and at week 12 (SF-MPQ [mean difference -6.2; 95% confidence interval, -8.6 to -3.8]; VAS [mean difference -2.7; 95% confidence interval, -3.6 to -1.8]; RMQ [mean difference -3.8; 95% confidence interval, -5.4 to -2.2]; ODI [mean difference -10.6; 95% confidence interval, -14.9 to 6.3]). Moreover, improvements in pain and disability were clinically relevant. CONCLUSIONS: An OMT protocol that includes diaphragm techniques produces significant and clinically relevant improvements in pain and disability in patients with NS-CLBP compared to the same OMT protocol using sham diaphragm techniques.

Effects and underlying mechanisms of unstable shoes on chronic low back pain: a randomized controlled trial.

OBJECTIVE: To investigate the effects that wearing unstable shoes has on disability, trunk muscle activity, and lumbar spine range of motion (ROM) in patients with chronic lower back pain (CLBP). DESIGN: Randomized controlled trial. SETTING: Orthopedic Surgery Service. PARTICIPANTS: We randomized 40 adults with nonspecific CLBP either to an unstable shoes group ( n = 20) or to the control group ( n = 20). INTERVENTION: The participants in the unstable shoes group were advised to wear these shoes for a minimum of six hours a day for four weeks. Control group participants were asked to continue wearing their regular shoes. OUTCOME MEASURES: Our primary outcome was measurement of back-related dysfunction, assessed using the Roland-Morris Disability Questionnaire. Secondary outcomes included changes in electromyographic (EMG) activity of erector spinae (ES), rectus abdominis (RA), internus obliquus (IO), and externus obliquus (EO) muscles, and changes in lumbar spine ROM. RESULTS: Between-group analysis highlighted a significant decrease in disability in the unstable shoes group compared to the control (-5, 95% confidence interval (CI) = -8.4 to -1.6). Our results revealed a significant increase in the percentage of RA, ES, IO, and EO EMG activity and in lumbar spine ROM in the unstable shoes group compared to the control group. Moreover, our results showed a significant negative correlation between disability and the percentage of ES, RA, and IO muscle activity at the end of the intervention. CONCLUSION: This study shows that the use of unstable shoes contributes to improvements in disability, which are likely related to increased trunk muscle activity and lumbar spine ROM.

Effects of Myofascial Release in Nonspecific Chronic Low Back Pain: A Randomized Clinical Trial.

STUDY DESIGN: Double-blind, randomized parallel sham-controlled trial with concealed allocation and intention-to treat analysis. OBJECTIVE: To investigate the effects of an isolate myofascial release (MFR) protocol on pain, disability, and fear-avoidance beliefs in patients with chronic low back pain (CLBP). SUMMARY OF BACKGROUND DATA: MFR is a form of manual medicine widely used by physiotherapists in the management of different musculoskeletal pathologies. Up to this moment, no previous studies have reported the effects of an isolated MFR treatment in patients with CLBP. METHODS: Fifty-four participants, with nonspecific CLBP, were randomized to MFR group (n = 27) receiving four sessions of myofascial treatment, each lasting 40 minutes, and to control group (n = 27) receiving a sham MFR. Variables studied were pain measured by means Short Form McGill Pain Questionnaire (SF-MPQ) and visual analog scale (VAS), disability measured with Roland Morris Questionnaire, and fear-avoidance beliefs measured with Fear-Avoidance Beliefs Questionnaire. RESULTS: Subjects receiving MFR displayed significant improvements in pain (SF-MPQ) (mean difference -7.8; 95% confidence interval [CI]: -14.5 to -1.1, P = 0.023) and sensory SF-MPQ subscale (mean difference -6.1; 95% CI: -10.8 to -1.5, P = 0.011) compared to the sham group, but no differences were found in VAS between groups. Disability and the Fear-Avoidance Beliefs Questionnaire score also displayed a significant decrease in the MFR group (P < 0.05) as compared to sham MFR. CONCLUSION: MFR therapy produced a significant improvement in both pain and disability. Because the minimal clinically important differences in pain and disability are, however, included in the 95% CI, we cannot know whether this improvement is clinically relevant. LEVEL OF EVIDENCE: 2.