External to internal glenohumeral strength ratio in non-traumatic rotator cuff pathologies.

Background and study aims: A correct agonist -antagonist strength relationship for shoulder external and internal rotation is necessary for functional stability of the shoulder. This strength relationship is described by the ratio of external to internal strength (ER/IR).The aim of this stydy is to produce comparative data as regards the ER/IR ratio in subjects with different non-traumatic rotator cuff diseases. Design and setting: A cross-sectional study in an outpatient clinic in a tertiary care university hospital. Methods: In 55 subjects with rotator cuff disease (confirmed by physical examination and assessed by ultrasound and magnetic resonance arthrography), the ER/IR ratio of the shoulder was isometrically measured with a hand-held dynamometer and compared with values pertaining to the unaffected shoulder of the same individuals. Results: The mean ER/IR values in the overall group were 0.89 (SD 0.18) and 0.94 (SD 0.22) for the affected and unaffected shoulders, respectively. The ratio was 0.87 (SD 0.23) in patients with subdeltoid bursitis, 0.88 (SD 0.16) in rotator cuff tendinopathy and 0.87 (SD 0.22) in patients with rotator cuff tears. Conclusions: The ER/IR ratio appears to be similar between the affected and unaffected shoulders of subjects with nontraumatic cuff pathologies.

Neonatal brachial plexus palsy and hand representation in children and young adults.

AIM: To assess the impact of neonatal brachial plexus palsy (NBPP) on higher-order hand representation. METHOD: Eighty-two left-handed children and adolescents with and without right-sided NBPP were recruited. Thirty-one participants with NBPP (mean age [SD] 11y 4mo [4y 4mo]; age range 6y 2mo-21y 0mo; 15 females; C5-6, n=4, C5-7, n=12, C5-T1, n=11, C5-T1 with Horner sign, n=4) were assessed along with 30 controls (mean age 11y 5mo [4y 4mo]; age range 6y 7mo-21y 7mo; 14 females). Participants' estimated hand size and shape on measure of implicit and explicit hand representation was assessed. A linear mixed model (LMM) was used to investigate the effect of condition, sensorimotor impairment, and age. RESULTS: Individuals with NBPP showed a significant difference in implicit hand representation between affected and non-affected hands. LMM confirmed a significant influence of the severity of sensorimotor injury. Only the estimated implicit hand representation was associated with age, with a significant difference between 6- to 8-year-olds and 9- to 10-year-olds. INTERPRETATION: The effect of sensorimotor impairment on central hand representation in individuals with NBPP is specific due to its implicit component and is characterized by finger length underestimation in the affected hand compared to the characteristic underestimation in the unaffected hand. Neither NBPP nor age impacted the explicit hand estimate. This study confirms the importance of sensorimotor contribution to the development of implicit hand representation.

Distal biceps tendon ruptures: more efficient diagnostics for a better outcome.

Distal biceps tendon ruptures are a rare pathology, but can have significant functional repercussions. Rapid, accurate diagnosis and treatment are essential for a favorable prognosis. During the diagnostic process of distal biceps tendon ruptures, several problems can emerge. An answer to the following clinical questions is given based on an extensive literature review. - Which clinical tests are the most sensitive/ specific for clinical examination? - Can ultrasound evaluation of the distal biceps tendon be optimized? - Is ultrasound an equivalent alternative to MRI in the diagnosis of distal biceps tendon injuries? An extensive literature search was conducted through Pubmed and Embase. The search strategy was developed systematically in the Medline data- base (PubMed interface), using medical subject headings as well as free text words. A standardized clinical examination of the distal biceps tendon consisting of the Hook test, the Passive Forearm Pronation Test and the Biceps Crease Interval test has a high accuracy for correct diagnosis of full-thickness ruptures. Furthermore, Cobra sign, Supinator view and Pronator view give an additional value to the standard ultrasound examination of the distal biceps tendon. Finally, ultrasound can be considered a trustworthy and cost-effective alternative to MRI in evaluation of distal biceps tendon ruptures.

Hand size representation in healthy children and young adults.

Whereas we experience our body as a coherent volumetric object, the brain appears to maintain highly fragmented representations of individual body parts. Little is known about how body representations of hand size and shape are built and evolve during infancy and young adulthood. This study aimed to investigate the effect of hand side, handedness, and age on the development of central hand size representation. The observational study with comparison groups was conducted with 90 typically developing Belgian school children and young adults (48 male and 42 female; age range = 5.0-23.0 years; 49 left-handed and 41 right-handed). Participants estimated their hand size and shape using two different tasks. In the localization task, participants were verbally cued to judge the locations of 10 anatomical landmarks of an occluded hand. An implicit hand size map was constructed and compared with actual hand dimensions. In the template selection task, the explicit hand shape was measured with a depictive method. Hand shape indexes were calculated and compared for the actual, implicit, and explicit conditions. Participants were divided into four age groups (5-8 years, 9-10 years, 11-16 years, and 17-23 years). Implicit hand maps featured underestimation of finger length and overestimation of hand width, which is already present in the youngest children. Linear mixed modeling revealed no influence of hand side on finger length underestimation; nonetheless, a significant main effect of age (p = .001) was exposed. Sinistrals aged 11 to 16 years showed significantly less underestimation (p = .03) than dextrals of the same age. As for the hand shape, the implicit condition differed significantly with the actual and explicit conditions (p < .001). Again, the implicit shape index was subjected to handedness and age effects, with significant differences being found between sinistrals and dextrals in the age groups of 9 and 10 years (p = .029) and 11 to 16 years (p < .001). In conclusion, the implicit metric component of the hand representation in children and young adults is misperceived, featuring shortened fingers and broadened hands since a very young age. Crucially, the finger length underestimation increases with age and shows a different developmental trajectory for sinistrals and dextrals. In contrast, the explicit hand shape is approximately veridical and seems immune from age and handedness effects. This study confirms the dual character of somatoperception and establishes a point of reference for children and young adults.

Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review.

Neonatal brachial plexus palsy (NBPP) is a prominent form of newborn morbidity with a potentially disabling persistence. Neurosurgical intervention is indicated in select NBPP patients. Early prognostic assessment would facilitate rational selection of those infants for surgery. We conducted a systematic literature review to determine the prognostic value of early electrodiagnosis (EDx) in NBPP. We included 16 observational studies with a total sample size of 747 children. Risk of bias and quality of evidence were rated. Wide variation was found in EDx techniques, outcome algorithms, and decisionmaking. Nevertheless, the most methodologically sound studies support the use of EDx, at standardized time-frames, as a key prognostic modality for complementing clinical judgment and neuroimaging. An accurate knowledge of the underlying anatomy of the nerve injury helps to counsel families and to guide reconstructive strategy.

Risk factors for neonatal brachial plexus palsy: a systematic review and meta-analysis.

AIM: To provide a comprehensive update on the most prevalent, significant risk factors for neonatal brachial plexus palsy (NBPP). METHOD: Cochrane CENTRAL, MEDLINE, Web of Science, Embase, and ClinicalTrials.gov were searched for relevant publications up to March 2019. Studies assessing risk factors of NBPP in relation to typically developing comparison individuals were included. Meta-analysis was performed for the five most significant risk factors, on the basis of the PRISMA statement and MOOSE guidelines. Pooled odds ratios (ORs), 95% confidence intervals (CIs), and across-study heterogeneity (I2 ) were reported. Reporting bias and quality of evidence was rated. In addition, we assessed the incidence of NBPP. RESULTS: Twenty-two observational studies with a total sample size of 29 419 037 live births were selected. Significant risk factors included shoulder dystocia (OR 115.27; 95% CI 81.35-163.35; I2 =92%), macrosomia (OR 9.75; 95% CI 8.29-11.46; I2 =70%), (gestational) diabetes (OR 5.33; 95% CI 3.77-7.55; I2 =59%), instrumental delivery (OR 3.8; 95% CI 2.77-5.23; I2 =77%), and breech delivery (OR 2.49; 95% CI 1.67-3.7; I2 =70%). Caesarean section appeared as a protective factor (OR 0.13; 95% CI 0.11-0.16; I2 =41%). The pooled overall incidence of NBPP was 1.74 per 1000 live births. It has decreased in recent years. INTERPRETATION: The incidence of NBPP is decreasing. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are risk factors for NBPP. Caesarean section appears as a protective factor. WHAT THIS PAPER ADDS: The overall incidence of neonatal brachial plexus palsy is 1.74 per 1000 live births. The incidence has declined significantly. Shoulder dystocia, macrosomia, maternal diabetes, instrumental delivery, and breech delivery are the main risk factors. Prevention is difficult owing to unpredictability and often labour-related risk.

Conservative treatment for leg oedema and the effect on nocturnal polyuria in patients with spinal cord injury.

OBJECTIVES: To evaluate the possible influence of non-pharmacological interventions, such as compressive bandages and intermittent pneumatic compression (IPC), on leg oedema and nocturnal polyuria (NP), and the possible interrelation between both pathologies in patients with spinal cord injury (SCI), as patients with SCI often have leg oedema and during the night the oedema decreases as a result of natural drainage mechanisms that can cause NP. PATIENTS AND METHODS: Patients with SCI who followed their first rehabilitation after their SCI with bilateral leg oedema and/or with as much or a larger urine volume at night as during the day. The patients were all wheelchair users and followed the rehabilitation programme daily for 3 weeks. In all, 24 patients, aged between 21 and 63 years, were selected for participation in the 3-week rehabilitation programme. During the first week, baseline data were collected. During the second week, IPC was executed from the moment the patient went to lie down. During the third week, the patients wore multilayer compressive bandages. Leg circumference was measured in the morning before sitting up and at the moment they went to lie down in bed. During each study week, a daily frequency-volume chart (24 h) was completed. RESULTS: The leg volume of both legs was significantly different between the morning and evening (right leg F = 103.90, P < 0.001; left leg F = 100.77, P < 0.001) and between the three treatments (right F = 9.70, P < 0.001; left F = 9.66, P < 0.001). There was a significant difference between the compressive bandages and the baseline period (right and left leg, both P < 0.001) and between the compressive bandages and IPC (right leg P = 0.009 and left leg P = 0.015). There was no significant difference between IPC and the baseline. When no treatment or IPC was used, urine production was significantly higher during the bed-rest period. The urine production was significantly lower comparing the use of compressive bandages to baseline and IPC, during bed rest (P = 0.009) and during sleep (P < 0.001). There was a significant decrease in absolute voided volume at night with the compressive bandages as treatment (P < 0.001). There was a significant positive association between the leg volume change during the day and the urine-production ratio, 100 mL increase in leg volume was associated with 8% increase in the log-transformed urine-production ratio. CONCLUSION: There are alternative treatment options for patients with SCI who have oedema or NP. Oedema formation and urine production appear to be related to each other. Therefore, the use of compressive bandages was shown to be a valuable treatment option to improve both leg oedema and NP.

Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial.

PURPOSE: To investigate superior value of adding heavy load eccentric training to conservative treatment in patients with subacromial impingement. METHODS: Sixty-one patients with subacromial impingement were included and randomly allocated to the traditional rotator cuff training (TT) group (n = 30, mean age = 39.4 ± 13.1 years) or traditional rotator training combined with heavy load eccentric training (TT + ET) group (n = 31, mean age = 40.2 ± 12.9 years). Isometric strength was measured to abduction at 0°, 45° and 90° of scapular abduction and to internal and external rotation. The SPADI questionnaire was used to measure shoulder pain and function. Patients rated subjective perception of improvement. Outcome was assessed at baseline, at 6 and 12 weeks after start of the intervention. Both groups received 9 physiotherapy treatments over 12 weeks. At home, the TT group performed traditional rotator cuff strengthening exercises 1x/day. The TT + ET group performed the same exercises 1x/day and a heavy load eccentric exercise 2x/day. RESULTS: After treatment, isometric strength had significantly increased in all directions, and SPADI score had significantly decreased. The TT + ET group showed a 15% higher gain in abduction strength at 90° of scapular abduction. Chi-square tests showed patients' self-rated perception of improvement was similar in both groups. CONCLUSION: Adding heavy load eccentric training resulted in a higher gain in isometric strength at 90° of scapular abduction, but was not superior for decreasing pain and improving shoulder function. This study showed that the combination of a limited amount of physiotherapy sessions combined with a daily home exercise programme is highly effective in patients with impingement. LEVEL OF EVIDENCE: II.

The impact of rotator cuff tendinopathy on proprioception, measuring force sensation.

BACKGROUND: The impact of rotator cuff tendinopathy and related impingement on proprioception is not well understood. Numerous quantitative and qualitative changes in shoulder muscles have been shown in patients with rotator cuff tendinopathy. These findings suggest that control of force might be affected. This investigation wants to evaluate force sensation, a submodality of proprioception, in patients with rotator cuff tendinopathy. METHODS: Thirty-six patients with rotator cuff tendinopathy and 30 matched healthy subjects performed force reproduction tests to isometric external and internal rotation to investigate how accurately they could reproduce a fixed target (50% MVC). Relative error, constant error, and force steadiness were calculated to evaluate respectively magnitude of error made during the test, direction of this error (overshoot or undershoot), and fluctuations of produced forces. RESULTS: Patients significantly overshoot the target (mean, 6.04% of target) while healthy subjects underestimate the target (mean, -5.76% of target). Relative error and force steadiness are similar in patients with rotator cuff tendinopathy and healthy subjects. Force reproduction tests, as executed in this study, were found to be highly reliable (ICC 0.849 and 0.909). Errors were significantly larger during external rotation tests, compared to internal rotation. CONCLUSION: Patients overestimate the target during force reproduction tests. This should be taken into account in the rehabilitation of patients with rotator cuff tendinopathy; however, precision of force sensation and steadiness of force exertion remains unaltered. This might indicate that control of muscle force is preserved.

ULTRASONOGRAPHIC PRESENTATION OF NODULAR CYSTIC FAT NECROSIS AFTER A LOW-VELOCITY TRAUMA: A CASE REPORT.

Objective: Morel-Lavallée lesion is a well-known entity after a high-energy, shearing trauma. Another form of lesion in the subcutaneous tissue is fat necrosis, presenting as a palpable mass. The most common presentation of fat necrosis is oil cysts, which occur mainly in the breast. However, in the lower extremities fat necrosis appears as nodular cystic fat necrosis. We report here a case of a patient with multiple injuries after a low-velocity trauma, who developed fat necrosis. Results: Six months after the traumatic event the patient reported multiple subcutaneous lumps on the right knee. On ultrasonography, the probable diagnosis of post-traumatic fat necrosis with consequent development of nodular cystic fat necrosis was seen. The diagnosis was confirmed based on magnetic resonance imaging (MRI). Discussion: Fat necrosis should be included in the differential diagnosis in cases of tissue injuries after a trauma. Fat necrosis can present months or years after the initial injury. It is a benign entity and is the result of an organized haemorrhage, swelling and oedema that progresses with fibrosis. There is no absolute need for surgical treatment.

Effect of whole body vibration on intracompartmental pressure in the lower leg.

BACKGROUND: Whole body vibration has important effects on neuromuscular functions. It seems to be a promising tool in the conservative treatment and rehabilitation of compartment syndrome. In the present study we investigated the effect of whole body vibration on intracompartmental pressure in the lower leg during a strenuous static exercise program. METHODS: We conducted a cross-over pilot study in which fifteen healthy male subjects participated. They twice performed a 20.5-min static exercise program on the Fitvibe Medical whole body vibration device, once with 27 Hz vibrations and once without. The intracompartmental pressure was measured by two examiners at the superficial posterior compartment of the left and right lower leg, at rest and during the exercise programs. RESULTS: A general linear model for repeated measures showed a significant difference between the exercise program with vibrations and that without (P = 0.001) and a significant difference in intracompartmental pressure for the factor time of measurement (P < 0.001). Mean intracompartmental pressure was at any point in time lower in the vibrating than in the non-vibrating exercise conditions, though not always significant. In the program with vibrations the exercise pressures showed a non-significant trend to decrease (from 23.5 mmHg to 21.3 mmHg) as the program advanced, while in the non-vibration program, there was a trend to increase (from 24.1 to 27.9 mmHg). CONCLUSIONS: The mean intracompartmental pressure was lower when whole body vibration at 27 Hz was superimposed. Therefore, whole body vibration seems to be a possible tool to lower intracompartmental pressure. Further research is needed to confirm whether these findings are also applicable in patients, athletes, and in dynamic exercises.

Opinion paper: the role of work in the management of medically unexplained physical symptoms.

OBJECTIVES: Patients with medically unexplained physical symptoms suffer from chronic fatigue and/or pain in combination with a variety of other symptoms. A flexible, biopsychosocial approach is needed for diagnostic screening and global management. It is crucial to involve the direct patient environment, including family, friends, colleagues as well as health providers, evaluation, and reintegration sector. The aim of this paper is to review the importance of work in the management of medically unexplained physical symptoms. METHODS: In this paper, different actors involved explain their views and handling concerning work in the management of MUPS. RESULTS: Symptom severity and lack of understanding from the environment can negatively impact on earning an independent income from labor for years. Work, whether or not paid, is however, an important life domain with positive effects on physical, psychological, and social well-being. Therefore, health actors are pivotal in starting the professional reintegration process as soon as possible and should discuss this item from the early stage onward. Support services can be consulted in mutual interaction as required. A case manager, acting as a central intermediator within this multidisciplinary approach, may promote effective communication and coordination between the patients and their surrounding actors. CONCLUSION: The professional reintegration process should start as soon as possible within the management of medically unexplained physical symptoms. As such, the care sector, the evaluation sector, and the professional integration sector should collaborate and effectively communicate with each other.

The impact of muscular variation on the neurodynamic test for the median nerve in a healthy population with Langer's axillary arch.

OBJECTIVE: The neurodynamic test of the median nerve (ULNT1) is frequently used to assess the mechanics and physiology of the brachial plexus and median nerve. The present study looks for a positive ULNT1 in a healthy population with Langer's axillary arch (LAA) and analyzes whether LAA affects the elbow extension range of motion (EE-ROM) of the ULNT1. METHOD: Of 640 volunteers screened, 26 LAA sides were finally included. Additional history taking revealed "minor symptoms" in some subjects. Minor symptoms do not qualify as a disorder because there is no interference with daily activities and no medical advice is sought. This study investigates whether the ULNT1 can (re)produce minor symptoms or abnormal responses in subjects with LAA. The EE-ROM was compared between the subjects' left and right side, and the subtraction angle-which is the effect of placing the cervical spine in contralateral lateral flexion-was compared between LAA sides and controls. RESULTS: Langer's axillary arch sides showed a significant increase in the occurrence of minor symptoms and positive ULNT1, but no influence was observed on the EE-ROM. CONCLUSIONS: These findings suggest that LAA may be capable of transiently provoking the axillary neurovascular bundle. The unaffected EE-ROM may be the consequence of a vascular origin of the minor symptoms or the consequence of an ulnar nerve/medial cord response to the ULNT1.

Diastematomyelia and late onset presentation: a case report of a 72-year-old woman.

BACKGROUND: We would like to present the case of a 72-year-old woman, in whom diastematomyelia was surprisingly discovered when looking for an explanation for her neurological and urological complaints. Diastematomyelia is a rare disease in the group of "spinal dysraphisms," mostly discovered at birth and very rare at advanced age. The clinical pattern could be seen in the general presentation of 'tethered cord' and there are 2 types of presentation with a different treatment. CASE REPORT: In our case report the two dominant complaints were pain in the right foot and sphincter problems. Further investigations ultimately revealed diastematomyelia. Surgical resection of the septum was one of the possibilities, but because of the limited clinical impact, a conservative treatment was followed. CLINICAL REHABILITATION IMPACT: In conclusion this case shows that even at advanced age diastematomyelia can be first discovered, so attention to this rare disease stays important.

The Role of the Vascular and Structural Response to Activity in the Development of Achilles Tendinopathy: A Prospective Study.

BACKGROUND: Several risk factors have been suggested in the development of Achilles tendinopathy, but large-scale prospective studies are limited. PURPOSE: To investigate the role of the vascular response to activity of the Achilles tendon, tendon thickness, ultrasound tissue characterization (UTC) of tendon structure, and foot posture as possible risk factors in the development of Achilles tendinopathy. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: The study began with 351 first-year students at Ghent University. After 51 students were excluded, 300 were tested in the academic years 2013-2014 and 2014-2015 and were followed prospectively for 2 consecutive years by use of a multilevel registration method. Of those, 250 students were included in the statistical analysis. At baseline, foot posture index and UTC were investigated bilaterally. Blood flow and tendon thickness were measured before and after a running activity. Cox regression analyses were performed to identify significant contributors to the development of Achilles tendinopathy. RESULTS: During the 2-year follow-up, 27 of the included 250 participants developed Achilles tendinopathy (11%). Significant predictive effects were found for female sex and blood flow response after running ( P = .022 and P = .019, respectively). The risk of developing Achilles tendinopathy increased if the blood flow increase after running was reduced, regardless of sex, foot pronation, and timing of flow measurements. The model had a predictive accuracy of 81.5% regarding the development of Achilles tendinopathy, with a specificity of 85.0% and a sensitivity of 50.0%. CONCLUSION: This prospective study identified both female sex and the diminished blood flow response after running as significant risk factors for the development of Achilles tendinopathy. UTC of tendon structure, Achilles tendon thickness, and foot posture did not significantly contribute to the prediction of Achilles tendinopathy. A general evaluation of tendon structure by UTC, measurement of tendon thickness, or determination of the foot posture index will not allow clinicians to identify patients at risk for developing Achilles tendinopathy. Furthermore, it may be possible to improve blood flow after activity by using noninvasive techniques (such as prostaglandins, compression stockings, heat, massage, and vibration techniques). These techniques may be useful in the prevention and management of Achilles tendinopathy, but further research is needed.

Effect of static and ballistic stretching on the muscle-tendon tissue properties.

PURPOSE: Many studies have been undertaken to define the effects of static and ballistic stretching. However, most researchers have focused their attention on joint range-of-motion measures. The objective of the present study was to investigate whether static- and ballistic-stretching programs had different effects on passive resistive torque measured during isokinetic passive motion of the ankle joint and tendon stiffness measured by ultrasound imaging. METHODS: Eighty-one healthy subjects were randomized into three groups: a static-stretch group, a ballistic-stretch group, and a control group. Both stretching groups performed a 6-wk stretching program for the calf muscles. Before and after this period, all subjects were evaluated for ankle range of motion, passive resistive torque of the plantar flexors, and the stiffness of the Achilles tendon. RESULTS: The results of the study reveal that the dorsiflexion range of motion was increased significantly in all groups. Static stretching resulted in a significant decrease of the passive resistive torque, but there was no change in Achilles tendon stiffness. In contrast, ballistic stretching had no significant effect on the passive resistive torque of the plantar flexors. However, a significant decrease in stiffness of the Achilles tendon was observed in the ballistic-stretch group. CONCLUSION: These findings provide evidence that static and ballistic stretching have different effects on passive resistive torque and tendon stiffness, and both types of stretching should be considered for training and rehabilitation programs.

Genitofemoral neuralgia: adding to the burden of chronic vulvar pain.

The vulva is a particularly common locus of chronic pain with neuropathic characteristics that occurs in women of any age, though most women with neuropathic type chronic vulvar pain will remain undiagnosed even following multiple physician visits. Here, we report on an exemplary case of a middle-aged woman who was referred to the Vulvovaginal Disease Clinic with debilitating vulvar burning and itching over the right labium majus that had been persisting for 2 years and was considered intractable. Careful history taking and clinical examination, followed by electrophysiological assessment through somatosensory evoked potentials was consistent with genitofemoral neuralgia, for which no obvious cause could be identified. Adequate pain relief was obtained with a serotonin-noradrenaline reuptake inhibitor and topical gabapentin cream. We briefly discuss the epidemiology, diagnosis, and treatment of genitofemoral neuralgia and provide a series of clues to guide clinicians in obtaining a presumptive diagnosis of specific neuropathic pain syndromes that may underlie chronic vulvar pain. We further aim to draw attention to the tremendous burden of chronic, unrecognized vulvar pain.

Nineteen reasons why physiatrists should do musculoskeletal ultrasound: EURO-MUSCULUS/USPRM recommendations.

This article is an eventual consensus of experts from the European Musculoskeletal Ultrasound Study Group (EURO-MUSCULUS) and the Ultrasound Study Group in Physical and Rehabilitation Medicine (USPRM) pertaining to the use of musculoskeletal ultrasound in physical and rehabilitation medicine. Nineteen important reasons (as regards general advantages, specific conditions in physical and rehabilitation medicine, as well as comparisons with other imaging tools) have been highlighted to consolidate the scenario of how/why the probe of ultrasound needs to become the stethoscope, the extended hand, and the pen of physiatrists.

Musculoskeletal ultrasonography in physical and rehabilitation medicine.

Musculoskeletal ultrasound has gained a significant place in the diagnosis and management of various musculoskeletal disorders due to its several advantages (being convenient, inexpensive, non-invasive, repeatable, providing dynamic imaging and not requiring any exposure to radiation). It has also become a valuable tool in the daily clinical practice of physical and rehabilitation medicine physicians; the musculoskeletal ultrasound probe having become synonymous with the physician's stethoscope. In this paper, aside from drawing attention to this growing issue in the agenda of PRM physicians, we will touch upon its basic technical features and certain aspects as regards muscle, tendon, ligament, nerve, joint lesions and ultrasound guided interventions.

Free radical scavengers versus methylprednisolone in the prevention of experimentally induced heterotopic ossification.

The etiology of heterotopic ossification (HO) is still obscure, it is difficult to devise an effective preventive or therapeutic approach. The options for the prevention of HO are still limited. The prophylactic effect of nonsteroidal anti-inflammatory drugs (NSAIDs) is insufficient. Moreover, NSAIDs increase the risk of nonunion and loosening in patients with multiple joint injuries. The present experimental study was designed to compare methylprednisolone with free radical scavengers for the prevention of HO. The model of Michelsson et al. was used to induce HO in the hind legs of 30 female New Zealand albino rabbits, weighing approx. 4 kg. The animals were randomized into three groups of 10 animals each, and received daily either placebo, a free radical scavenger cocktail [allopurinol and N-acetylcysteine (A/A)], or methylprednisolone in a randomized, double-blind fashion. Every four days, X-rays were obtained to measure the thickness and the length of new bone formation at the thigh. A statistically significant difference in thickness and length of newly formed bone was found between the three groups. In the placebo group HO increased from day 16 toward a medium length of 6 mm and a median thickness of 1.5 mm. In the A/A group, no signs of HO were found. In the methylprednisolone group, only one animal presented minor HO from day 32. Both free radical scavengers and methylprednisolone were found to inhibit HO, and may be considered effective measures for the prevention of heterotopic bone formation. However, it could not be demonstrated which of the two had the strongest inhibitory effect.