Non-local muscle fatigue is mediated at spinal and supraspinal levels.

The objective was to measure the corticospinal excitability and motoneuron responsiveness of the right and left Biceps Brachii (BB), and left Abductor Digiti Minimi (ADM) muscles in response to submaximal isotonic fatiguing contractions performed by the right BB muscle. With the familiarization session, ten young moderately active male subjects came to the lab on seven occasions. Three sets of 3 min seated elbow curls at 25% of one-repetition maximum (1RM) separated by a 1-min rest performed by the right BB muscle were used as the fatiguing protocol. The motor evoked potential (MEP), cervicomedullary motor evoked potential (CMEP), and compound muscle action potential (Mmax) of the right BB muscle (baseline and after each set of the fatiguing task), the left BB and ADM muscles (baseline, post-fatigue, post-10, and post-20 min) were measured. MEP and CMEP were then normalized to Mmax for statistical analysis. The results showed that in the right BB muscle, there was a significant reduction in the MEP after performing the fatiguing task (p= 0.03), while no significant effect of time was seen in the CMEP (p= 0.07). In the left BB muscle, the MEP significantly decreased from pre-fatigue to post-fatigue (p= 0.01) and post-10 (p= 0.001), while there was a significant decline in the CMEP post-fatigue (p= 0.03). In the left ADM muscle, MEP significantly decreased post-fatigue (p= 0.03) and no changes were seen in the CMEP (p= 0.12). These results not only confirm the incidence of non-local muscle fatigue (NLMF) in response to performing submaximal isotonic fatiguing contractions but also as a new finding, imply that both spinal and supraspinal modulations account for the NLMF response.

Subacromial Injections of Low- or High-Molecular-Weight Hyaluronate Versus Physical Therapy for Shoulder Tendinopathy: A Randomized Triple-Blind Controlled Trial.

OBJECTIVE: Shoulder tendinopathy is a prevalent and debilitating problem. We compared the effects of subacromial high- or low-molecular-weight hyaluronate injection with physical therapy (PT) in shoulder tendinopathy. DESIGN: A triple-blinded randomized controlled trial. SETTING: We conducted the trial in an outpatient clinic at a teaching hospital. PARTICIPANTS: In total, 79 patients with shoulder tendinopathy were randomly allocated to high- (n = 27) or low-molecular-weight (n = 28) hyaluronate or PT (n = 24) groups. INTERVENTIONS: We administered a 20-mg injection of high- or low-molecular-weight hyaluronate. For PT, we prescribed 10 sessions of physiotherapy and exercise. OUTCOME MEASURES: The primary outcome was shoulder pain and the secondary outcomes included Disability of the Arm Shoulder and Hand score, shoulder range of movement and QoL. We measured the outcomes at baseline, 1, and 3 months of treatment, and assessed shoulder pain at the sixth month postintervention. RESULTS: The interventions were all clinically beneficial in the management of tendinopathy for high- (n = 25) and low-molecular-weight (n = 24) hyaluronate and PT (n = 19) groups (all P < 0.05). However, between-group analyses indicated that hyaluronate preparations were more effective in controlling pain, decreasing disability, increasing range of motion, and improving the quality of life (all P < 0.05). The pain and subjective feeling of rigidity at the injection area ( P = 0.012) were less prominent for low-molecular-weight hyaluronate. CONCLUSION: High- or low-molecular-weight hyaluronate is more effective than PT in the treatment of shoulder tendinopathy. The clinical benefits of hyaluronate last for at least 3 months, and the pain alleviation sustains partially for 6 months. Shoulder injection of low-molecular-weight hyaluronate is more tolerable to the patient than high-molecular-weight hyaluronate.

High- Versus Low-Molecular-Weight Hyaluronic Acid for the Treatment of Rotator Cuff Tendinopathy: A Triple-Blind Randomized Comparative Trial.

BACKGROUND: Shoulder pain most commonly originates from the tendon structures of the rotator cuff. OBJECTIVE: We compared the clinical effects of high- versus low-molecular-weight (LMW) hyaluronic acid for the management of rotator cuff tendinopathy. METHODS: We carried out a parallel, triple-blind, randomized comparative trial at a teaching hospital. In total, 56 patients aged 16 to 70 years with rotator cuff tendinopathy were randomly allocated to 2 groups. We administered a single shoulder injection of either 1 mL of 1% high- (>2000 kDa) or 1 mL of 1% LMW hyaluronate (500-700 kDa) to the corresponding groups. The primary outcome was the intensity of shoulder pain. The secondary outcomes were range of motion and disability of the shoulder, and quality of life. We performed the measurements at baseline and at 1, 4, and 12 weeks postintervention. The pain measurements were repeated at the sixth month postintervention. RESULTS: Comparisons of baseline versus 3 months showed that both interventions were beneficial in the management of the tendinopathy (all P values <0.05). However, between-group analyses did not indicate any clinically significant difference between the 2 medications. The pain, induration (P = 0.007), and inflammation at the site of the injection were less prominent for LMW hyaluronate. CONCLUSION AND RELEVANCE: Both medications are effective for the treatment of tendinopathy. The benefits last at least for 3 months, and pain alleviation lasts partially for 6 months. The shoulder injection of LMW hyaluronate is more tolerable to the patient. Therefore, we recommend LMW hyaluronate as the first choice for the management of rotator cuff tendinopathy.

Biofeedback versus electrical stimulation for sexual dysfunction: a randomized clinical trial.

INTRODUCTION AND HYPOTHESIS: Sexual dysfunction is a common problem in the general population. We compared the effects of biofeedback and electrical stimulation on the symptoms of sexual pain dysfunction in women with urinary stress incontinence. METHODS: We carried out a parallel randomized clinical trial in an outpatient department for physical medicine and rehabilitation at a university hospital. Based on DSM-5 criteria for sexual dysfunction, 22 patients with sexual dysfunction and stress incontinence were included and randomly allocated to each study arm. The primary outcome measure was the total score on the Female Sexual Function Index. Each group underwent pertinent treatment for 100 min, two times a week for 6 weeks. RESULTS: Both groups showed favorable outcomes in increasing Female Sexual Function Index mean scores and their domains. However, for improving sexual function, women in the biofeedback group benefited more than those receiving electrical stimulation. Biofeedback raised desire, arousal, lubrication, orgasm, and satisfaction scores more than electrical stimulation (all p ≤ 0.025). Both interventions decreased pain during or following vaginal penetration similarly (p = 0.985). CONCLUSIONS: Both biofeedback and electrical stimulation increased the Female Sexual Function Index score. However, to improve sexual function, women undergoing biofeedback seem to benefit more than those receiving electrical stimulation. We recommend considering the prescription of biofeedback for the treatment of sexual dysfunction because of its efficacy, lack of adverse effects, and easy application.

Periarticular Neurofascial Dextrose Prolotherapy Versus Physiotherapy for the Treatment of Chronic Rotator Cuff Tendinopathy: Randomized Clinical Trial.

BACKGROUND/OBJECTIVE: Rotator cuff tendinopathy is a common cause of shoulder pain. We aimed to compare periarticular (neurofascial) dextrose prolotherapy versus physiotherapy for treatment of chronic rotator cuff tendinopathy in the short term. METHODS: We carried out a randomized clinical trial with 2 arms at a university hospital. In total, 66 patients with chronic rotator cuff tendinopathy, proven by magnetic resonance imaging, were randomly allocated to 2 groups. The outcomes were change in shoulder pain intensity (primary) and disability (secondary) index using a questionnaire for Shoulder Pain and Disability Index. For physiotherapy, participants received superficial heat, transcutaneous electrical nerve stimulation, and pulsed ultrasound. Also, they carried out an exercise program, 10 sessions of 30 minutes for 3 weeks. For prolotherapy, we used 8 mL of 12.5% dextrose and 40 mg of 2% lidocaine. The mixture was injected 2 times with 1-week interval superficially around the shoulder joint and to tender points along the suprascapular nerve. RESULTS: Neurofascial dextrose was more effective than physiotherapy for alleviating pain in 2 weeks (p < 0.001), and they were similar 3 months after the interventions (p = 0.055). For disability, dextrose was more effective than physiotherapy 2 weeks and 3 months (both p < 0.001) after the interventions. However, the changes in the physiotherapy group seemed to be more sustained. CONCLUSIONS: Both interventions are effective for the short-term management of rotator cuff tendinopathy. However, prolotherapy is more successful as the initial treatment. Besides, the treatment time is much shorter for dextrose prolotherapy compared with physiotherapy.

Platelet-rich plasma therapy or arthroscopic surgery on repair of anterior cruciate ligament rupture.

The Anterior Cruciate Ligament (ACL) rupture reduces knee stability. In old patients with ACL rupture, surgery is not recommended due to the person's low level of activity and knee osteoarthritis. Platelet-rich plasma (PRP) is a good treatment option in inflammatory cases in orthopedics. Hence, the aim of this study was to assess and comparison of the effect of PRP and arthroscopic surgery on anterior cruciate ligament rupture. This is a clinical trial that was performed in 2020-2021 in Tehran. 100 patients were randomly divided into two groups. The first group of patients underwent ACL tendon repair surgery by arthroscopy and tendon graft. The second group were treated by PRP injection. Both groups of patients were visited from 3 months to 14 months after surgery or PRP treatments. The pain was assessed by Visual Analogue Scale (VAS), we also used Knee Score by the Oxford Score Knee Outcome Scale (OKS) to assess patient's functions. The mean VAS score was 3.05 ± 2.47 in patients in surgery group and mean VAS score was 4.39± 2.66 in patients in the PRP group (p = 0.03). These data showed significant improvements in VAS score in both groups with higher improvements in surgical group. After procedures, the ROM was 120.33 ± 19.60º in surgery group and 109.31 ± 17.22º in PRP group (p = 0.03). Patients in both groups had significantly decreased pain severity after 14 months, but the patients in the surgical treatment group had significantly lower pain and higher ROM compared to PRP group.

Neurofascial Dextrose Prolotherapy for Managing Chronic Ankle Ligament Injury.

Objectives: Due to the anti-inflammatory effects of dextrose prolotherapy, we evaluated the effectiveness of extra-articular, neurofascial dextrose prolotherapy in chronic ankle ligament injury. Methods: Patients with chronic ankle ligament injury entered this uncontrolled before-after study based on eligibility criteria. Patients who consented to participate in the study filled out the prepared questionnaire containing demographic data, the Cumberland ankle instability tool (CAIT), and the Visual Analogue Scale (VAS). The initial CAIT score of less than 25 indicated functional instability following an ankle sprain. Patients underwent neurofascial prolotherapy with dextrose 12.5%. Two injections within one month were done. The CAIT was completed one, three, and six months after the intervention. Results: Twenty-five patients with chronic ankle ligament injury were investigated. The mean CAIT score was 1.88 (± 2.35) before the intervention, which increased significantly over the study (P < 0.001). The CAIT score reached 21.84 (± 6.04) in the sixth month after the intervention. Moreover, the VAS score decreased significantly over the study from 6.12 (± 2.35) before the intervention to 1.24 (± 0.43) in the sixth month after the intervention (P < 0.001). Conclusions: Our findings revealed the therapeutic effectiveness of dextrose neurofascial prolotherapy in decreasing pain and functional instability in patients suffering chronic ankle pain due to ligamentous injury accompanied by chronic ankle instability.

Transcranial direct current stimulation for knee osteoarthritis: a single-blind randomized sham-controlled trial.

OBJECTIVE: To evaluate the effects of transcranial direct current stimulation on pain and other symptoms of knee osteoarthritis. METHODS: We performed a single-blind randomized sham-controlled trial with two parallel arms in an outpatient clinic of physical medicine and rehabilitation at a teaching hospital. We randomized 54 patients, 30-70 years of age, with knee osteoarthritis into two groups. They had morning stiffness ≤ 30 min, knee pain ≥ 3 months, joint crepitus, and Kellgren-Lawrence grade 1 or 2 on radiographs. For the active stimulation we administered 2 mA current, 20 min for each session and for the sham group 30 s stimulation and 20 min no current. Using the 10/20 International EEG system, the anode was fixed over the contralateral primary motor cortex (C3 or C4), and the cathode was placed on the ipsilateral supraorbital region (Fp1 or Fp2), with respect to the included knee. The program was repeated once daily over 5 consecutive days. Both groups received acetaminophen. We assessed the patients before and after the interventions, and three months post-intervention. The primary outcome was knee pain on the visual analog scale, and the secondary outcome was the Knee injury and Osteoarthritis Outcome Score. RESULTS: There was a statistically significant reduction in the intensity of pain within sham and active groups (both p < 0.001), but no significant difference between the groups (p = 0.226). Analyses of the Knee injury and Osteoarthritis Outcome Scores showed no clinically important changes. CONCLUSIONS: Transcranial direct current stimulation does not reduce knee pain, does not abate other symptoms, and does not restore knee function in patients with knee osteoarthritis. The pain reduction in our study could be attributed to either placebo or the acetaminophen effect.

Remote Versus in-Person Exercise Instruction for Chronic Nonspecific Low Back Pain Lasting 12 Weeks or Longer: A Randomized Clinical Trial.

BACKGROUND: Low back pain is a common health problem. We compared the effects of a remote exercise instruction with in-person exercise instruction on the pain and disability of people with nonspecific low back pain for more than 12 weeks. MATERIAL AND METHODS: We carried out a randomized clinical trial with two study arms in an outpatient clinic at a University Hospital. A total of 56 patients were included and randomly allocated to each study arm. The primary outcome was the intensity of the low back pain. The secondary outcome was the Oswestry Disability Questionnaire score. We measured the outcomes before the intervention and in one and three months after completion of the program. The program consisted of core stability exercises and included flexibility and strengthening for all patients. Participants in the remote exercise group carried out the exercises at home two times a day for four weeks. They were followed by telephone calls. Patients in the in-person exercise group received the same exercises at the clinic, three times a week for four weeks. RESULTS: Between-group comparisons indicated that there were no significant differences between the two approaches in changing pain (p = 0.93) and disability scores (p = 0.74) from the baseline to three months postintervention values. CONCLUSIONS: There was no measurable difference between an exercise program delivered remotely compared to in-person.

Therapeutic Effects of Intra-articular Botulinum Neurotoxin Versus Physical Therapy in Knee Osteoarthritis.

BACKGROUND: Knee osteoarthritis (KOA) is the most common cause of chronic knee pain, and disability and different modalities have been used to improve pain and function. Botulinum toxin intra-articular injection is proposed to manage resistant joint pains. OBJECTIVES: This study was carried out to compare therapeutic effects of intra-articular botulinum neurotoxin (BTX) versus physical therapy (PT) in KOA. METHODS: In this single-blind randomized clinical trial, patients with KOA attending to Imam-Reza Hospital, Tehran, Iran, from June 2018 to March 2019 were enrolled. Patients who met the inclusion criteria were randomly divided into BTX receiving a single intra-articular dose of 100 units (250 units from disport brand) and PT groups. The study was described for patients, and informed consent forms were received. For assessment of the pain and related severity, the VAS score and KOOS scales were used. Post-intervention assessment was done 1, 3, and 6 months after the intervention. The level of significance was set at α = 0.05. All data analyses were performed with SPSS version 26 for windows. RESULTS: In this study, 50 patients were randomly divided into BTX and PT groups. All patients completed the study, and there was no loss to follow-up. There was no significant difference between demographic data of the two groups, including age and BMI. The VAS score was similar in the two groups at the beginning. KOOS subscales were not significantly different, but the quality of life was better in the BTX than the PT group (86.2 ± 15 vs. 72.1 ± 11.5, P < 0.001). One month after the intervention, all KOOS subscales were improved in the BTX group in comparison to the PT group (P < 0.001). This difference was statistically significant in the 3rd (P < 0.001 in all comparisons except Sport/Rec subscale in which P = 0.02) and 6th months (P < 0.001) after the intervention, and the improvement in all KOOS subscales and VAS score were higher in the BTX group than the PT group. The trend of KOOS subscales and VAS score was improved over time in the BTX (P < 0.001 in all tests), but the PT group showed no improvement (P > 0.05) except for Sport/Rec and VAS score (P < 0.001). CONCLUSIONS: Totally, it is concluded that the use of BTX can reduce pain and improve the function and quality of life in patients with KOA.

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial.

OBJECTIVE: We evaluated the efficacy of spinal manipulation for the management of nonacute lumbar radiculopathy. METHODS: In a university hospital we performed a randomized controlled trial with 2 parallel arms. Patients (n = 44) with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups. The primary outcome was the intensity of the low back pain on a visual analog scale. The secondary outcome was the Oswestry Disability Questionnaire score. We also measured spinal ranges of motion. The assessments were carried out at the baseline, immediately after intervention, and at 3 months' follow-up. All patients underwent physiotherapy. The manipulation group received three sessions of manipulation therapy 1 week apart. For manipulation, we used Robert Maigne's technique. RESULTS: Both groups experienced a decrease in back and leg pain significantly (all P ≤ 0.003). However, only the manipulation group showed significantly favorable results in the Oswestry scores (P < 0.001), and the straight leg raise test (P = 0.001). All ranges of motion increased significantly with manipulation (all P < 0.001), but the control group showed favorable results only in right and left rotations and in extension (all P < 0.001). Between-group analyses showed significantly better outcomes for manipulation in all measurements (all P ≤ 0.009) with large effect sizes. CONCLUSION: Spinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.

Granisetron vs. lidocaine injection to trigger points in the management of myofascial pain syndrome: a double-blind randomized clinical trial.

OBJECTIVES: Granisetron and lidocaine injections have been used for the management of myofascial pain syndrome. This study was aimed to compare the efficacy of granisetron and lidocaine injections to trigger points of upper trapezius in the management of myofascial pain syndrome. METHODS: We performed a double-blind randomized clinical trial in an outpatient clinic of physical medicine and rehabilitation at a teaching hospital. A total of 40 patients aged ≥18 with neck pain due to myofascial pain syndrome were included. They had pain for at least one month with the intensity of at least 30 mm on a 100 mm visual analog scale. Each participant received a single dose of 1 mL lidocaine 2% or 1 mg (in 1 mL) granisetron. The solutions were injected into a maximum of three trigger points of the upper trapezius. We instructed all patients to remain active while avoiding strenuous activity for three or four days, and to perform stretch exercise and massage of their upper trapezius muscles. We assessed the patients before the interventions, and one month and three months post-injection. The primary outcome was the Neck Disability Index and the secondary outcome was the Neck Pain and Disability Scale. RESULTS: Both interventions were successful in reducing neck pain and disability (all p-values <0.001). However, the neck pain and disability responded more favorably to lidocaine than granisetron (p=0.001 for Neck Disability Index, and p=0.006 for Neck Pain and Disability Scale). No significant side-effect was recognized for both groups. CONCLUSIONS: Both lidocaine and granisetron injections to trigger points are effective and safe for the management of the syndrome and the benefits remain at least for three months. However, lidocaine is more effective in reducing pain and disability. The injections are well-tolerated, although a transient pain at the site of injections is a common complaint. One mL of lidocaine 2% is more effective than 1 mg (in 1 mL) granisetron for injecting into the trigger points of the upper trapezius in myofascial pain syndrome.

Low Molecular-weight Hyaluronic Acid Versus Physiotherapy for the Treatment of Supraspinatus Tendinopathy: A Randomized Comparative Clinical Trial.

INTRODUCTION: The tendons of the rotator cuff are major sources of shoulder pain. This study aimed to compare the effects of low molecular-weight hyaluronic acid with physiotherapy (PT) in patients with supraspinatus tendinopathy (ST). METHODS: We carried out a parallel two-group randomized comparative clinical trial in an outpatient clinic of physical medicine and rehabilitation at a teaching hospital. In total, 51 patients (31 women) aged 20 to 55 years with ST were randomly allocated to subacromial hyaluronate injection (n = 28) and PT (n = 23) groups. For the hyaluronate group, we administered a single injection of 2 mL (20 mg) hyaluronate 1% (500 to 700 kDa). For PT, we prescribed three sessions of treatment per week for 12 weeks, totaling 36 sessions including rotator cuff activation exercises. The primary outcome was shoulder pain in the visual analog scale. The secondary outcomes included the range of movement and the disability score of the shoulder, and a World Health Organization questionnaire on quality of life. We did the measurements at the baseline and at one, four, and 12 weeks after intervention. RESULTS: The results showed that both interventions were beneficial in the management of ST. However, hyaluronate was more effective in reducing shoulder pain at rest and during activities (both P < 0.001, effect size = 0.52 and 0.68, respectively). The two interventions similarly decreased patients' disability (P = 0.196). Hyaluronate improved shoulder motion and the quality of life better than PT. CONCLUSION: In the treatment of ST, low molecular-weight hyaluronate is more effective than PT, at least for three months. Particularly, hyaluronate is more successful in alleviating pain.

Randomized controlled trial of aquatic exercise for treatment of knee osteoarthritis in elderly people.

Aim: The aim of this study is to assess the efficacy of aquatic exercise on pain, gait, and balance among elderly patients with knee osteoarthritis. Methods: We performed a randomized controlled trial at a university hospital. Overall, 32 men with knee osteoarthritis, aged ≥ 60 years, were included. Pain, balance, and gait were evaluated before and 2 months after interventions. The group control used acetaminophen and followed lifestyle recommendations. The intervention group performed the aquatic exercise three sessions per week for 8 weeks. Results: At the end of the study, mean pain scores were significantly different between the groups (p = 0.010). Within-group analyses showed that group intervention experienced significant pain relief (p = 0.019), whereas group control did not show the significant change (p = 0.493). There was significant improvement in favor of aquatic exercise with regard to static (p = 0.001) and dynamic (p = 0.001) balance, step length (p = 0.038), stride length (p < 0.001), and cadence (p < 0.001). However, we did not find a significant difference in step time and width between the two groups. Conclusions: Aquatic exercise would be beneficial in decreasing subjective pain of osteoarthritis. There are some recognizable improvements in patients' gait and balance as well.

Physical therapy, intra-articular dextrose prolotherapy, botulinum neurotoxin, and hyaluronic acid for knee osteoarthritis: randomized clinical trial.

This study aimed to compare the efficacy of four treatments in the management of knee osteoarthritis. We carried out a randomized clinical trial with four study arms in an outpatient Department of Physical Medicine and Rehabilitation at a University Hospital. In total, 120 patients with knee osteoarthritis ≥50 years of age were randomly allocated to four groups. The primary outcome was knee pain in visual analog scale and the secondary outcome was the Knee Injury and Osteoarthritis Outcome Score. The exercise was prescribed daily for all participants throughout the study. For physical therapy (group 1), participants received superficial heat, transcutaneous electrical nerve stimulation and pulsed ultrasound. We administered a single intra-articular injection of botulinum neurotoxin type A (group 2) and three injections of hyaluronic acid (group 3) or 20% dextrose (group 4) to patients in the corresponding groups. Mixed analysis of variance showed that there was statistically significant difference between the groups in pain (P < 0.001), and Knee Injury and Osteoarthritis Outcome Score (P < 0.001). Pairwise between- and within-group comparisons showed that botulinum neurotoxin and dextrose prolotherapy were the most, and hyaluronic acid was the least efficient treatments for controlling pain and recovering function in patients. An intra-articular injection of botulinum toxin type A or dextrose prolotherapy is effective first-line treatments. In the next place stands physical therapy particularly if the patient is not willing to continue regular exercise programs. Our study was not very supportive of intra-articular injection of hyaluronic acid as an effective treatment of knee osteoarthritis.

Intra-articular botulinum toxin type A for treatment of knee osteoarthritis: Clinical trial.

In recent years, there is a growing interest in new medical applications of botulinum toxin, including pain control, osteoarthritis treatment, and wound healing. While clinical applications of botulinum toxin seem promising, existing evidence regarding the therapeutic effects is still inadequate. The aim was to assess the efficacy of a single injection of abobotulinumtoxin A into the knee joint cavity to reduce pain in elderly people. We carried out a single group clinical trial in a University Hospital. Thirty participants (24 women) more than 50 years of age with knee osteoarthritis were included. Diagnosis of osteoarthritis was based on clinical and radiologic findings. We gave a single injection containing 250 units of Dysport (= 100 units of botulinum neurotoxin type A) diluted with 5 ml of normal saline. The primary outcome measure was knee pain. The secondary outcome was the patients' opinion about their knee and associated problems measured with the Knee injury and Osteoarthritis Outcome Score. The outcomes were measured at the baseline and at 4 weeks after the intervention. Within-group comparisons based on the Knee injury and Osteoarthritis Outcome Scores showed favorable results for joint pain and stiffness, sports, severity of symptoms, quality of life, and daily activities (all p-values < 0.001). Also, pain intensity, joint effusion, knee clicking and locking, and flexion-extension scores showed significant beneficial results (all p-values ≤ 0.005). We concluded that botulinum neurotoxin type A is an effective and safe initial treatment of knee osteoarthritis with clear clinical advantages. Patients' satisfaction, minimum adverse effects in addition to single-dose prescription make the toxin as a choice for the first-line therapy of osteoarthritis at least at the short-term in elderly people. The symptom relief increases the patient's compliance and willing to participate in other therapeutic programs. REGISTRATION: Iranian Registry of Clinical Trials (IRCT) website http://www.irct.ir/, a WHO Primary Register setup, with registration code: Irct ID: IRCT20180416039323N1.

Efficacy of tele-rehabilitation compared with office-based physical therapy in patients with knee osteoarthritis: A randomized clinical trial.

Introduction Knee osteoarthritis is a major cause of disability among the middle to senior age groups. Despite being effective, office-based physical therapy (OBPT) needs professional human resources and is both costly and time-consuming. We aimed to compare the efficacy of tele-rehabilitation (tele-rehab) compared with OBPT in patients with knee osteoarthritis. Methods In this randomized clinical trial, patients with symptomatic osteoarthritis of the knee were assigned to participate in either a 6-week home-based tele-rehab or an OBPT program between 2015 and 2016. Our primary outcome was the mean change from the baseline until 1 and 6 month's post-intervention in scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). We used analysis of variance for the repeated measure statistical test. Results A total of 54 patients entered the final analysis, with 27 in each group. The mean age of the patients was 58.2 ± 7.41 years and 60.2% were female. In the tele-rehab and OBPT group, KOOS scores increased from baseline to 6 months post-intervention (50.6 to 83.1 and 49.8 to 81.8) respectively. There was no significant difference between tele-rehab and OBPT groups in any of the studied scales. Discussion The tele-rehab program is as effective as OBPT in improving the function of patients with knee osteoarthritis. Considering the much lower time and cost consumed by tele-rehab, it is the recommended program for the older population living in remote sites.

Periarticular dextrose prolotherapy instead of intra-articular injection for pain and functional improvement in knee osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is a degenerative disease that can lead to painful and dysfunctional joints. Prolotherapy involves using injections to produce functional restoration of the soft tissues of the joint. Intra-articular injections are controversial because of the introduction of needles into the articular capsule. OBJECTIVES: To compare the effect of periarticular versus intra-articular prolotherapy on pain and disability in patients with knee OA. STUDY DESIGN: Randomized double-blind controlled clinical trial. SETTING: Single center, university hospital (Imam Hossein Hospital, Tehran, Iran). METHODS: A total of 104 patients with chronic knee OA were enrolled. In the intra-articular group, 8 mL of 10% dextrose and 2 mL of 2% lidocaine were injected. Injections were repeated at 1 and 2 weeks after the first injection. In the periarticular group, 5 mL of 20% dextrose and 5 mL of 1% lidocaine were injected subcutaneously at 4 points in the periarticular area. Pain and disability, as assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), were recorded at each follow-up visit at 1, 2, 3, 4, and 5 months post-injection. RESULTS: The visual analog scale score was significantly lower in the periarticular compared with the intra-articular group at the 2-, 3-, 4-, and 5-month visits but not at 1 month. Morning stiffness and difficulty in rising from sitting were improved in both groups and were not signifi-cantly different in the peri- and intra-articular groups. Pain, joint locking, and limitation scores were all improved in both groups. Difficulty in walking on flat surfaces or climbing stairs, and sitting and standing pain, were all improved in both groups from 1 to 5 months after treatment. LIMITATIONS: WOMAC scores are subjective and could be a limitation of the study. CONCLUSION: Periarticular prolotherapy has comparable effects on pain and disability due to knee OA to intra-articular injections, while avoiding risks of complications.

F wave to height or limb length ratios as rational alternatives for F wave latency in clinical electrodiagnostic medicine.

OBJECTIVE: To delineate the F wave latency/height (F min/He) or F wave latency/limb length (F min/L) ratio as a more useful alternative for the currently reported shortest latency in milliseconds. METHODS: One hundred and sixty-six healthy volunteers, 85 upper limbs and 84 lower limbs entered the study. Minimum F wave latencies were determined in median, ulnar, tibial and peroneal nerves. The F min/He and F min/L ratios of each nerve were calculated. RESULTS: F latencies of all nerves had significant correlation with height and limb length but there was no correlation between either F min/He or F min/L and height in any nerve except for peroneal F min/He (p = 0.04, r = 0.23). CONCLUSIONS: Using the F min/He or F min/L ratios are more accurate than reporting only the F wave minimum latency, since these ratios incorporate corrections for height and/or limb length. This method also eliminates the false positive and negative reports caused by using a single reference table for all heights. SIGNIFICANCE: A unique reference table can be produced using the F min/He or F min/L for all populations and races, so that the comparison between different population samples can be done easily. Also data of different investigations can be pooled together for meta-analysis purposes when a single reference table is used for different samples.