Therapeutic approach to dysphagia in post-COVID patients in a rehabilitation unit: a descriptive longitudinal study.

BACKGROUND: A high rate of hospitalized patients for COVID-19 had dysphagia, frequently underdiagnosed, and not treated, inducing a prolonged dysphagia with protracted recovery. Specific treatments and protocols have not been well described yet. AIM: Given the potential benefits of respiratory muscle training (IEMT) and neuromuscular stimulation (NMES) in dysphagia treatment, this study aimed to assess the feasibility of the protocol used for treating dysphagia in patients who experienced prolonged hospitalization for COVID-19. DESIGN: Observational, descriptive, prospective study. SETTING: Department of Physical Medicine and Rehabilitation of a tertiary University hospital. POPULATION: Fifty-eight COVID-19 patients were admitted for intensive rehabilitation (March 2020 to October 2021) were prospectively studied. METHODS: Dysphagia was diagnosed using videofluoroscopy and treated with a 3-week protocol adapted from neuromuscular stimulation (NMES) in a motor threshold and inspiratory/expiratory muscle strength training (IEMST), five sets of five repetitions three times daily for 3 weeks. Feasibility was assessed with adherence, outcomes achieved, and occurrence of adverse/unexpected events. Respiratory function (peak cough flow, maximal inspiratory/expiratory pressures) and swallow function (Penetration-Aspiration Scale and Bolus Residue Scale measured by videofluoroscopy) were recorded descriptive statistics, Student's t test for numerical data, and Wilcoxon Test for ordinal variables were applied. SPPSS vs28 and STATA version 15.1 (StataCorp, College Station, TX, USA) were used for statistical analysis. P values 0.05 were considered significant. RESULTS: Dysphagia was highly prevalent in severe COVID-19 patients (86.6%); all respiratory and swallow parameters improved after a 3-week intervention and 12 of 18 patients dependent on tube feeding resumed a normal diet (66.7%; McNemar P=0.03), and 84.09% attended a no restriction diet at discharge. Adherence to treatment was 85%. No significant adverse events were detected. CONCLUSIONS: We conclude that a structured swallowing-exercise training intervention based on IEMT and NMES is feasible and safe in prolonged hospitalization post-COVID patients. CLINICAL REHABILITATION IMPACT: To describe rehabilitation protocols used to treat dysphagia in post-COVID patients will help us to optimize the available techniques in each center and to induce a faster recovery avoiding potential complications.

Shoulder Strength Changes One Year After Axillary Lymph Node Dissection or Sentinel Lymph Node Biopsy in Patients With Breast Cancer.

OBJECTIVES: To assess the changes in shoulder strength of patients with breast cancer during the first year after surgery; and to compare the effect of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) on shoulder strength. DESIGN: Prospective longitudinal observational study from presurgery to 1 year after. SETTING: Tertiary hospital. PARTICIPANTS: Of 129 consecutive patients examined for eligibility, a sample of women (N=112) with breast cancer were included (44 underwent ALND, and 68 underwent SLNB). INTERVENTIONS: Not applicable. MAIN OUTCOMES MEASURES: Difference between the affected and unaffected arm in strength of shoulder external rotators, internal rotators, abductors, and serratus anterior, measured by dynamometry. Evaluations were performed prior to surgery and at 1, 6, and 12 months after surgery. RESULTS: After breast cancer ALND surgery, strength decreased significantly at the first month for internal rotators, without having recovered presurgery values after 1 year of follow-up, with a mean difference of 2.26kg (P=.011). There was no significant loss of strength for patients treated with SLNB. The loss of shoulder range of motion was only significant the first month for the ALND group. The factors identified as associated with strength loss in the general estimating equation models were the ALND surgery and having received physical/occupational therapy during follow-up. CONCLUSIONS: One year after breast cancer surgery, patients treated with ALND had not recovered their previous shoulder internal rotators strength, whereas those who underwent SLNB presented no significant loss of strength. This provides important information for designing rehabilitation programs targeted specifically at the affected muscle group after nodal surgical approach.

Balance 1 year after TKA: correlation with clinical variables.

Knee osteoarthritis results in changes that affect balance. It has been reported that osteoarthritis worsens proprioception and increases the risk of falling. The objective of this study was to assess changes in balance among patients with knee osteoarthritis at 1 year after total knee arthroplasty (TKA) surgery and its relationship with clinical variables. This prospective, observational study evaluated 44 patients before and 1 year after TKA. Variables analyzed included age, body mass index, pain, range of motion for both knees, bilateral quadriceps and hamstrings muscle strength, gait velocity, and Knee Society score. Balance and posture control were assessed using the following computerized posturography tests: the weight bearing test, modified Clinical Test of Sensory Interaction on Balance (mCTSIB) test, and sit-to-stand test. Pre- and postoperative differences were analyzed using Wilcoxon and chi-square tests, and effect size was measured using standardized response mean. Correlations were assessed by the Spearman test. One year after TKA, some improvement in balance tests was observed. Significant differences were observed in the mCTSIB test: foam surface with open eyes (P≤.001), foam surface with closed eyes (P≤.001), and composite value (P≤.001). Effect size was moderate to high. Age showed significant correlation with mCTSIB composite value changes (-0.369; P=.037). No significant correlations were found between posturographic tests and other analyzed variables. Balance measured by computerized posturography improved 1 year after TKA. Significant changes were observed between open and closed eyes using a foam surface for the mCTSIB test. A mild negative correlation was found between age and posturographic changes.

Efficacy of low-frequency low-intensity electrotherapy in the treatment of breast cancer-related lymphoedema: a cross-over randomized trial.

OBJECTIVE: To compare the efficacy of low-frequency low-intensity electrotherapy and manual lymphatic drainage in the treatment of chronic upper limb breast cancer-related lymphoedema. DESIGN: Cross-over single-blind random clinical trial. SETTING: Rehabilitation service. PARTICIPANTS: Thirty-six women with chronic upper limb breast cancer-related lymphoedema. METHODS: Patients were randomized to undergo 10 sessions of manual lymphatic drainage followed by 10 sessions of low-frequency low-intensity electrotherapy or to undergo first low-frequency low-intensity electrotherapy followed by manual lymphatic drainage. There was a month of washout time between treatments. Each patient was examined just before and after each treatment. Researchers and outcome assessors were blinded for assigned treatment. MEASURES: Outcomes were lymphoedema volume, pain, heaviness and tightness, and health-related quality of life measured with the Functional Assessment of Cancer Therapy Questionnaire for Breast Cancer version 4 (FACT-B+4). Carry-over, period and treatment effects were analysed. Treatment effect was assessed using paired t-test. RESULTS: Thirty patients finalized treatment. Comparing the changes in low-frequency low-intensity electrotherapy with manual lymphatic drainage changes, there were no significant differences. Low-frequency low-intensity electrotherapy did not reduce lymphoedema volume (mean of change = 19.77 mL, P = 0.36), but significant reductions were observed in pain, heaviness and tightness (mean of change = 13.1, 16.2 and 6.4 mm, respectively), and FACT-B+4 summaries improved significantly (Trial Outcome Index mean of change = 5.4, P = 0.015). Manual lymphatic drainage showed no significant changes in any of the outcomes CONCLUSION: Although there are no significant differences between treatment changes, the observed trend towards a better health-related quality of life is remarkable in low-frequency low-intensity electrotherapy.

Analysis of the expectations of elderly patients before undergoing total knee replacement.

The opinion of patients expressed in terms of satisfaction is extremely important in any evaluation of total knee arthroplasty (TKA) results. The primary endpoint of this study was to determine the quantitative and qualitative expectations of elderly patients before undergoing TKA. Cross-sectional study of 497 patients over 65 years was performed before TKA. Main variables collected: demographic, functioning, pain, comorbidity, depression and expectations assessed with the Hospital for Special Knee Replacement Expectation Survey. Statistical tests used were: Student's t-test, analysis of variance, Spearman's ρ and multivariate regression analysis. The means of the total and maximum expectations were 12.3±1.63 and 9.5±1.78 (±S.D.), respectively. Between 90 and 100% of patients referred expectations to improvement regarding pain, basic functional activities (walking, climbing stairs, knee mobility, general mobility) and general well being. There were statistically significant correlations with age (r=-0.321), pain before operation (r=-0.206), expected pain at 6 months (r=-0.206), depressive symptoms (r=-0.180) and the Barthel index (BI) (r=0.154). One can conclude, that the expectations of improvement among patients before TKA are high and may be classified as expectations of improvement of pain, basic functional activities and general well being. Age, pain intensity and presence of depression correlate inversely with the amount of expectations.

Assessment of angle velocity in girls with adolescent idiopathic scoliosis.

BACKGROUND: Although it has been demonstrated that the peak height velocity (PHV) is a predictive factor of progression in adolescent idiopathic scoliosis (AIS), little is known about the usefulness of angle progression in clinical practice. The purpose of this study was to establish a relationship between height and angle velocities, as well as to determine if peak angle velocity (PAV) occurs at the same time than PHV. METHODS: A retrospective study of a cohort of girls with idiopathic scoliotic curves greater than 10 degrees . Data of 132 girls who participated in a previous retrospective study about growth in AIS were used to calculate height and angle velocities. Relationship between height and angle velocities was estimated by the use of a Linear Mixed Model. RESULTS: PHV and PAV take place simultaneously 1 year before menarche in progressive curves managed with a brace in AIS. Changes in angle velocity are influenced by changes in height growth velocity, in such a way that as from 6 months post-menarche, height growth velocity in this group of girls estimates curve progression velocity (beta-coefficient -0.88, p = 0.04). CONCLUSION: As from 6 months post-menarche, there is an inverse relationship between height velocity and curve progression in the group of AIS girls with progressive curves managed with a brace. Because height velocity is decreasing from 1 year before menarche, this finding corroborates that at the end of puberty, there is still a risk of progression in this group of girls despite bracing. The assessment of both height and angle velocity might be useful in clinical practice at the time of assessing brace effectiveness and how long bracing has to be indicated.

Is botulinum toxin type A effective in the treatment of spastic shoulder pain in patients after stroke? A double-blind randomized clinical trial.

OBJECTIVE: To determine the efficacy of botulinum toxin type A for the treatment of spastic shoulder pain in patients after stroke. DESIGN: Double-blind randomized clinical trial. PATIENTS: Of 31 patients enrolled from an acute-care hospital in Spain, 2 cases dropped out (drop-out rate 6.5%). Fourteen subjects were treated with infiltration of 500 units of botulinum toxin type A in the pectoralis major muscle of the paretic side, and 15 with a placebo. METHODS: After infiltration, both groups received transcutaneous electrical nerve stimulation for 6 weeks. Patients were assessed by the use of the Visual Analogue Scale for pain. A good result concerning pain was considered when the Visual Analogue Scale score was below 33.3 mm or less than half the initial score. The patients were followed-up for 6 months. RESULTS: The patients treated with botulinum toxin type A showed a significantly greater pain improvement from the first week post-infiltration. Persistent shoulder pain was observed more frequently in the placebo group, with relative risks in the range 0.32-0.41 during the follow-up period. CONCLUSION: Patients with spastic shoulder pain treated with a botulinum toxin type A infiltration in the pectoralis major muscle of the paretic side have a higher likelihood of pain relief (between 2.43- and 3.11-fold).

Cross-validation of a model for predicting functional status and length of stay in patients with stroke.

OBJECTIVE: In a study published in 2002, it was observed that a variable composed by the Functional Independence Measure (FIM) and the trunk control test at admission predicted 66.5% of the FIM at discharge in stroke patients. The objective was to confirm the reproducibility of this predictive model. METHODS: Retrospective study of 245 hemiparetic stroke inpatients of the rehabilitation department. The main variables studied were: trunk control test FIM at admission and compound variable (FIM+trunk control test) as independent variables and FIM at discharge and inpatient rehabilitation length of stay as dependent variables. RESULTS: Correlation between the compound variable and the length of stay was statistically significant (r=0.59), as was its correlation with the total FIM at discharge (r=0.82). The regression analysis predicted 34.3% of the length of stay variability and 66.4% of the total FIM at discharge variability. CONCLUSION: The compound variable is a reliable tool because of its reproducibility in predicting the functional level at hospital discharge in hemiparetic patients.

Growth and curve stabilization in girls with adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective study of a cohort of 132 girls with adolescent idiopathic scoliosis (AIS). OBJECTIVES: Evaluate the changes in height and scoliosis angle over time by the use of a mathematical model and determine a relationship between height and angle values in patients with AIS. SUMMARY OF BACKGROUND DATA: The influence of growth on idiopathic scoliosis (IS) is still not fully understood. Although it has not been completely demonstrated, it is accepted that a relationship exists between height growth and curve progression, as well as that curve stabilization occurs when growth ends, but it has not yet been demonstrated whether both occur at the same time. METHOD: One hundred thirty-two girls were included in a retrospective study. Inclusion criteria were: adolescent IS, Cobb angle > or =10 degrees , menarche age well documented, and follow-up of at least 2 years in 6-month controls. Main variables were: menarche age, height, Cobb angle, and treatment. Height and angle changes over the time were adjusted by several curvilinear regression models. Calculations were made of the gradient between each consecutive time point (first derivative function). Growth was considered as tending to stabilize when the function gradient changed its sign or was negligible. Height and Cobb angle correlation coefficients for repeated measures were estimated within patients for curves managed with observation and curves managed with a brace. Comparisons among these correlations were based on the Fisher-Z transformation. RESULTS: Height function gradient changed sign at 1 year postmenarche, and Cobb angle function gradient was negligible around menarche. There was a correlation between mean heights and mean angles, being higher for girls managed only with observation. When comparing mean heights in one semester with the mean heights of the previous one, there were statistically significant differences until 2.5 years postmenarche, although after the first year, these differences were clinically irrelevant. A significant increase for angle values was observed in the same period for the group of girls managed with observation and in the 6 months before menarche for the girls managed with a brace. CONCLUSIONS: A mathematical model was used to demonstrate when height and angle growths tend to stabilize (1 year after menarche for height values and at the time of menarche for angle values) in AIS. In the absence of a brace effect, a significant correlation between both growth rates was noted up until 2.5 years after menarche.