Effect of photobiomodulation combined with physical therapy on functional performance in children with myelomeningocele: A protocol randomized clinical blind study.

INTRODUCTION: Myelomeningocele is a severe type of spina bifida, resulting from improper closure of the neural tube. This condition drastically affects the structures of the spinal cord resulting in deficiencies. The combination of these deficiencies results in an overall decrease in mobility and functional participation amongst this population. Physiotherapy plays an essential role in rehabilitating people with MMC. The current literature shows that resources such as photobiomodulation (PBM) may support the rehabilitation of neurological conditions. The aim of the proposed study is to evaluate the effects of photobiomodulation (PBM) combined with physical therapy on functional performance in children with low lumbosacral myelomeningocele. MATERIALS AND METHODS: This is a protocol randomized clinical blind study, that will include 30 individuals of both sexes, aged between 5 to 8 years, diagnosed with low and sacral lumbar myelomeningocele and capable of performing the sit-to-stand task. The participants will be randomly assigned into two treatment groups: PBM + physiotherapeutic exercises and sham PBM + physiotherapeutic exercises. Irradiation will be carried out with light emitting diode (LED) at a wavelength of 850 nm, energy of 25 J per point, 50 seconds per point and a power of 200 mW. The same device will be used in the placebo group but will not emit light. Muscle activity will be assessed using a portable electromyograph (BTS Engineering) and the sit-to-stand task will be performed as a measure of functioning. Electrodes will be positioned on the lateral gastrocnemius, tibialis anterior and rectus femoris muscles. The Pediatric Evaluation of Disability Inventory will be used to assess functional independence. Quality of life will be assessed using the Child Health Questionnaire-Parent Form 50. Changes in participation will be assessed using the Participation and Environment Measure for Children and Youth. The data will be analyzed with the aid of GraphPad PRISM. DISCUSSION: The results of this study can contribute to a better understanding of the effectiveness of PBM on functioning and quality of life in children with myelomeningocele. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04425330.

Impact of ß-hydroxy-ß-methylbutyrate (HMB) on muscle loss and protein metabolism in critically ill patients: A RCT.

PURPOSE: Muscle wasting deteriorates life quality after critical illness and increases mortality. Wasting starts upon admission to intensive care unit (ICU). We aimed to determine whether ß-hydroxy-ß-methylbutyrate (HMB), a metabolite of leucine, can attenuate this process. METHODS: Prospective randomized, placebo-controlled double blind trial. INCLUSION CRITERIA: ICU patients depending on mechanical ventilation on day 3 having a functional gastrointestinal tract. They were randomized to HMB (3 g/day) or placebo (maltodextrin) from day 4 on for 30 days. PRIMARY OUTCOME: magnitude of loss of skeletal muscle area (SMA) of the quadriceps femoris measured by ultrasound at days 4 and 15. SECONDARY OUTCOMES: body composition, change in protein metabolism assessed by amino acids tracer pulse, and global health at 60 days. Data are mean [95% CI]. Statistics by ANCOVA with correction for confounders sex, age and/or BMI. RESULTS: Thirty patients completed the trial, aged 65 [59, 71] years, SAPS2 score 48 [43, 52] and SOFA 8.5 [7.4, 9.7]. The loss of total SMA was 11% between days 4 and 15 (p < 0.001), but not different between the groups (p = 0.86). In the HMB group, net protein breakdown (Δ Estimate HMB-Placebo: -153 [-242, -63]; p = 0.0021) and production of several amino acid was significantly reduced, while phase angle increased more (0.66 [0.09, 1.24]; p = 0.0247), and SF-12 global health improved more (Δ Estimate HMB-Placebo: 27.39 [1.594, 53.19], p = 0.04). CONCLUSION: HMB treatment did not significantly reduce muscle wasting over 10 days of observation (primary endpoint), but resulted in significantly improved amino acid metabolism, reduced net protein breakdown, a higher phase angle and better global health. CLINICALTRIALS. GOV IDENTIFIER: NCT03628365.

Longitudinal study of knee load avoidant movement behavior after total knee arthroplasty with recommendations for future retraining interventions.

BACKGROUND: This study aimed to evaluate clinical and biomechanical changes in self-report survey, quadriceps strength and gait analysis over 3- and 6-months post-total knee arthroplasty (TKA) and confirm the immediate effects of two forms of kinetic biofeedback on improving inter-limb biomechanics during a physically demanding decline walking task. METHODS: Thirty patients with unilateral TKA underwent testing at 3- and 6-months following surgery. All underwent self-report survey, quadriceps strength and gait analysis testing. Patients were assigned to one of two types of biofeedback [vertical ground reaction force (vGRF), knee extensor moment (KEM)]. RESULTS: No decrease in gait asymmetry was observed in non-biofeedback trials over time (p > 0.05), despite significant improvements in self-report physical function (p < 0.01, Cohen d = 0.44), pain interference (p = 0.01, Cohen d = 0.68), numeric knee pain (p = 0.01, Cohen d = 0.74) and quadriceps strength (p = 0.01, Cohen d = 0.49) outcomes. KEM biofeedback induced significant decrease in total support moment (p = 0.05, Cohen f2 = 0.14) and knee extensor moment (p = 0.05, Cohen f2 = 0.21) asymmetry compared to using vGRF biofeedback at 6-months. vGRF biofeedback demonstrated significant decrease in hip flexion kinematic asymmetry compared to KEM biofeedback (p = 0.05, Cohen f2 = 0.18) at 6-months. CONCLUSION: Gait compensation remained similar from 3- to 6-months during a task requiring greater knee demand compared to overground walking post-TKA, despite improvements in self-report survey and quadriceps strength. Single session gait symmetry training at 6-month supports findings at 3-month testing that motor learning is possible. KEM biofeedback is more effective at immediately improving joint kinetic loading compared to vGRF biofeedback post-TKA.

Medical high-protein nutrition therapy and loss of muscle mass in adult ICU patients: A randomized controlled trial.

BACKGROUND & AIMS: The degradation of muscle mass and loss of functional proteins due to catabolism are associated with adverse outcomes in critically ill patients. While an adequate supply of protein within a medical nutrition concept is suggested to minimize proteolysis, the specificities on appropriate dosage and timing are still under debate. The current study aimed to evaluate the effect of two different quantities of protein as part of a standardized energetically controlled nutrition therapy for the preservation of muscle mass in the later phase of critical illness. METHODS: A randomized controlled trial was conducted in 42 critically ill patients (age 65 ± 15; 12 females; SAPS 45 ± 11; TISS 20 ± 7; SOFA-score 7 ± 3). The subjects were randomly assigned to either the intervention (1.8 g protein/kg body weight [BW]/d) or standard (1.2 g protein/kg BW/d) group. Nutrient supply via enteral and/or parenteral nutrition was calculated based on the individual energy expenditure measured by indirect calorimetry and target protein content. Quadriceps muscle layer thickness (QMLT) was observed through sonography at inclusion, and during the follow-up period, two and four weeks after inclusion. The measurement points were fixed on two sides at the midpoint and two-thirds between the anterior superior iliac spine and top of the patella. The data were analyzed descriptively wherein chi-squared tests or unpaired two-samle t-tests checked group differences. Daily changes in muscle mass were estimated using a linear mixed model. All data are shown as the mean ± standard deviation (SD). RESULTS: Actual protein intake reached 1.5 ± 0.5 g and 1.0 ± 0.5 g/kg BW/d in the intervention and standard group, respectively. Mean values of all measurements of QMLT at inclusion (day 13 ± 2 after ICU admission) were 13.5 ± 7.4 mm and 13.4 ± 7.1 mm in the intervention and standard group, respectively (P = 0.967). In both the groups, QMLT decreased over time (P < 0.001), while the estimated mean values of daily QMLT changes were -0.15 ± 0.08 mm (intervention) and -0.28 ± 0.08 mm (standard) without significant between-group differences (intervention effect, P = 0.368; time x intervention effect, P = 0.242). Illness scores and clinical outcomes showed no group differences. CONCLUSION: In this single-center trial the increased amounts of protein (1.5 g vs. 1.0 g/kg BW/d) provided through medical nutrition therapy in the late phase of critical illness did not achieve a statistically significant impact on the loss of muscle mass in long-term immobilized ICU patients. Larger multi-center trials are needed to evaluate whether observed numerical differences in muscle mass could be a true finding, and will translate into improved clinical outcomes. TRIAL REGISTRATION: German Clinical Trials Register (http://www.drks.de/), DRKS-ID: DRKS00013594.

The Effect of Diacutaneous Fibrolysis on Local and Widespread Hyperalgesia and Muscle Length in Patients With Patellofemoral Pain Syndrome: Secondary Analysis of a Pretest-Posttest Clinical Trial.

CONTEXT: Localized and widespread hyperalgesia has been observed in patients with patellofemoral pain. Diacutaneous fibrolysis (DF) has shown to be effective in reducing pain in several musculoskeletal conditions including patellofemoral pain syndrome, but no studies have evaluated the effects of this technique in reducing localized and widespread hyperalgesia. OBJECTIVE: To assess the effect of DF on the pressure pain threshold and muscle length tests in patients with patellofemoral pain syndrome. DESIGN: A single-group, pretest-posttest clinical trial. SETTING: University of Zaragoza. PARTICIPANTS: Forty-six subjects with patellofemoral pain (20 males and 26 females: age 27.8 [6.9] y). INTERVENTION: Three sessions of DF. MAIN OUTCOME MEASURES: Pressure pain threshold using a handheld pressure algometer (4 sites around the knee, on tibialis anterior muscle, and one remote site on the upper contralateral limb); muscle length test of the iliotibial band, rectus femoris, and hamstring muscles; and patient-perceived treatment effect score. RESULTS: The application of 3 sessions of DF significantly increased the pressure pain threshold in all sites at posttreatment evaluation (P < .001) and at a 1-week follow-up (P < .001). A significant increase in muscle length was also observed at the posttreatment evaluation (P < .001) and 1-week follow-up (P < .001). Ninety-seven percent of the patients reported subjective improvement at posttreatment and at 1-week follow-up. CONCLUSION: This study found that local and widespread hyperalgesia was significantly reduced after 3 sessions of diacutaneous fibrolysis and at the 1-week follow-up. A significant improvement on muscle length tests was also observed, with high clinical satisfaction among patients.

Daily protein supplementation attenuates immobilization-induced blunting of postabsorptive muscle mTORC1 activation in middle-aged men.

Disuse-induced muscle atrophy is accompanied by a blunted postprandial response of the mammalian target of rapamycin complex 1 (mTORC1) pathway. Conflicting observations exist as to whether postabsorptive mTORC1 pathway activation is also blunted by disuse and plays a role in atrophy. It is unknown whether changes in habitual protein intake alter mTORC1 regulatory proteins and how they may contribute to the development of anabolic resistance. The primary objective of this study was to characterize the downstream responsiveness of skeletal muscle mTORC1 activation and its upstream regulatory factors, following 14 days of lower limb disuse in middle-aged men (45-60 yr). The participants were further randomized to receive daily supplementation of 20 g/d of protein (n = 12; milk protein concentrate) or isocaloric carbohydrate placebo (n = 13). Immobilization reduced postabsorptive skeletal muscle phosphorylation of the mTORC1 downstream targets, 4E-BP1, P70S6K, and ribosomal protein S6 (RPS6), with phosphorylation of the latter two decreasing to a greater extent in the placebo, compared with the protein supplementation groups (37% ± 13% vs. 14% ± 11% and 38% ± 20% vs. 25% ± 8%, respectively). Sestrin2 protein was also downregulated following immobilization irrespective of supplement group, despite a corresponding increase in its mRNA content. This decrease in Sestrin2 protein was negatively correlated with the immobilization-induced change in the in silico-predicted regulator miR-23b-3p. No other measured upstream proteins were altered by immobilization or supplementation. Immobilization downregulated postabsorptive mTORC1 pathway activation, and 20 g/day of protein supplementation attenuated the decrease in phosphorylation of targets regulating muscle protein synthesis.

Standardizing fatigue-resistance testing during electrical stimulation of paralysed human quadriceps muscles, a practical approach.

BACKGROUND: Rapid onset of muscular fatigue is still one of the main issues of functional electrical stimulation (FES). A promising technique, known as distributed stimulation, aims to activate sub-units of a muscle at a lower stimulation frequency to increase fatigue-resistance. Besides a general agreement on the beneficial effects, the great heterogeneity of evaluation techniques, raises the demand for a standardized method to better reflect the requirements of a practical application. METHODS: This study investigated the fatigue-development of 6 paralysed quadriceps muscles over the course of 180 dynamic contractions, evaluating different electrode-configurations (conventional and distributed stimulation). For a standardized comparison, fatigue-testing was performed at 40% of the peak-torque during a maximal evoked contraction (MEC). Further, we assessed the isometric torque for each electrode-configuration at different knee-extension-angles (70°-170°, 10° steps). RESULTS: Our results showed no significant difference in the fatigue-index for any of the tested electrode-configurations, compared to conventional-stimulation. We conjecture that the positive effects of distributed stimulation become less pronounced at higher stimulation amplitudes. The isometric torque produced at different knee-extension angles was similar for most electrode-configurations. Maximal torque-production was found at 130°-140° knee-extension-angle, which correlates with the maximal knee-flexion-angles during running. CONCLUSION: In most practical applications, FES is intended to initiate dynamic movements. Therefore, it is crucial to assess fatigue-resistance by using dynamic contractions. Reporting the relationship between produced torque and knee-extension-angle can help to observe the stability of a chosen electrode-configuration for a targeted range-of-motion. Additionally, we suggest to perform fatigue testing at higher forces (e.g. 40% of the maximal evoked torque) in pre-trained subjects with SCI to better reflect the practical demands of FES-applications.

A Comparison of Neuromuscular Electrical Stimulation Parameters for Postoperative Quadriceps Strength in Patients After Knee Surgery: A Systematic Review.

CONTEXT: Postoperative quadriceps strength weakness after knee surgery is a persistent issue patients and health care providers encounter. OBJECTIVE: To investigate the effect of neuromuscular electrical stimulation (NMES) parameters on quadriceps strength after knee surgery. DATA SOURCES: CINAHL, MEDLINE, SPORTDiscus, and PubMed were systematically searched in December 2018. STUDY SELECTION: Studies were excluded if they did not assess quadriceps strength or if they failed to report the NMES parameters or quadriceps strength values. Additionally, studies that applied NMES to numerous muscle groups or simultaneously with other modalities/treatments were excluded. Study quality was assessed with the Physiotherapy Evidence Database (PEDro) scale for randomized controlled trials. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 1. DATA EXTRACTION: Treatment parameters for each NMES treatment was extracted for comparison. Quadriceps strength means and standard deviations were extracted and utilized to calculate Hedge g effect sizes with 95% CIs. RESULTS: Eight RCTs were included with an average Physiotherapy Evidence Database scale score of 5 ± 2. Hedge g effect sizes ranged from small (-0.37; 95% CI, -1.00 to 0.25) to large (1.13; 95% CI, 0.49 to 1.77). Based on the Strength of Recommendation Taxonomy Quality of Evidence table, the majority of the studies included were low quality RCTs categorized as level 2: limited quality patient-oriented evidence. CONCLUSION: Because of inconsistent evidence among studies, grade B evidence exists to support the use of NMES to aid in the recovery of quadriceps strength after knee surgery. Based on the parameters utilized by studies demonstrating optimal treatment effects, it is recommended to implement NMES treatment during the first 2 postoperative weeks at a frequency of ≥50 Hz, at maximum tolerable intensity, with a biphasic current, with large electrodes and a duty cycle ratio of 1:2 to 1:3 (2- to 3-second ramp).

Association between ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality in mechanically ventilated critically ill patient: A single-center prospective observational study.

BACKGROUND & AIMS: In critically ill patients, direct measurement of skeletal muscle using bedside ultrasound (US) may identify a patient population that might benefit more from optimal nutrition practices. When US is not available, survey measures of nutrition risk and functional status that are associated with muscle status may be used to identify patients with low muscularity. This study aims to determine the association between baseline and changing ultrasound quadriceps muscle status with premorbid functional status and 60-day mortality. METHODS: This single-center prospective observational study was conducted in a general ICU. Mechanically ventilated critically ill adult patients (age ≥18 years) without pre-existing systemic neuromuscular diseases and expected to stay for ≥96 h in the ICU were included. US measurements were performed within 48 h of ICU admission (baseline), at day 7, day 14 of ICU stay and at ICU discharge (if stay >14 days). Quadriceps muscle layer thickness (QMLT), rectus femoris cross sectional area (RFCSA), vastus intermedius pennation angle (PA) and fascicle length (FL), and rectus femoris echogenicity (mean and standard deviation [SD]) were measured. Patients' next-of-kin were interviewed by using established questionnaires for their pre-hospitalization nutritional risk (nutrition risk screening-2002) and functional status (SARC-F, clinical frailty scale [CFS], Katz activities of daily living [ADL] and Lawton Instrumental ADL). RESULTS: Ninety patients were recruited. A total of 86, 53, 24 and 10 US measures were analyzed, which were performed at a median of 1, 7, 14 and 22 days from ICU admission, respectively. QMLT, RFCSA and PA reduced significantly over time. The overall trend of change of FL was not significant. The only independent predictor of 60-day mortality was the change of QMLT from baseline to day 7 (adjusted odds ratio 0.95 for every 1% less QMLT loss, 95% confidence interval 0.91-0.99; p = 0.02). Baseline measures of high nutrition risk (modified nutrition risk in critically ill ≥5), sarcopenia (SARC-F ≥4) and frailty (CFS ≥5) were associated with lower baseline QMLT, RFCSA and PA and higher 60-day mortality. CONCLUSIONS: Every 1% loss of QMLT over the first week of critical illness was associated with 5% higher odds of 60-day mortality. SARC-F, CFS and mNUTRIC are associated with quadriceps muscle status and 60-day mortality and may serve as a potential simple and indirect measures of premorbid muscle status at ICU admission.

Computed Tomography Image Analysis of Neuromuscular Electrical Stimulation in the Treatment of Knee Osteoarthritis with Different Radiologic Characteristics Based on Iterative Reconstruction Algorithm.

OBJECTIVE: To use computed tomography image analysis of iterative reconstruction algorithm to understand effect of neuromuscular electrical stimulation of quadriceps on motor function rehabilitation after total knee arthroplasty. METHODS: After total knee arthroplasty, 104 patients were randomly divided into 2 groups. The treatment group comprised 52 patients. The quadriceps femoris was stimulated by neuromuscular electrical stimulation, and patients were required to actively extend the knee along with the current stimulation. In the second group, which received cutaneous nerve electrical stimulation, 2 sets of electrodes were placed on knee pain points. All patients participated in conventional rehabilitation and were discharged from the hospital a mean 14.89 ± 3.65 days after treatment. Visual analog scale, range of motion of knee joint, and Knee Injury and Osteoarthritis Score were evaluated before discharge. The mean interval between follow-up evaluations after discharge was 9.5 months. Knee Society Score and Knee Injury and Osteoarthritis Score were assessed during follow-up. RESULTS: Visual analog scale scores of treatment and control groups at discharge were 18.11 ± 9.66 and 16.13 ± 4.25, and active range of motion of the knee joint was 103.21° ± 15.44° and (99.21° ± 15.19°, respectively. Limitation of active knee extension in the treatment group was 1.93° ± 3.47°, which was significantly smaller than in the control group (6.26° ± 4.28°). CONCLUSIONS: Neuromuscular electrical stimulation of the quadriceps muscle early after total knee arthroplasty helps to improve the function of the knee extension device and accelerate functional rehabilitation. Computed tomography has found that changes in tibial subchondral bone plate and subchondral cancellous bone in patients with knee osteoarthritis are mainly due to destruction of ultrastructural homeostasis. This change may be the cause of knee osteoarthritis.

Enhanced dimethylarginine degradation improves coronary flow reserve and exercise tolerance in Duchenne muscular dystrophy carrier mice.

Duchenne muscular dystrophy (DMD) is an X-linked disease caused by null mutations in dystrophin and characterized by muscle degeneration. Cardiomyopathy is common and often prevalent at similar frequency in female DMD carriers irrespective of whether they manifest skeletal muscle disease. Impaired muscle nitric oxide (NO) production in DMD disrupts muscle blood flow regulation and exaggerates postexercise fatigue. We show that circulating levels of endogenous methylated arginines including asymmetric dimethylarginine (ADMA), which act as NO synthase inhibitors, are elevated by acute necrotic muscle damage and in chronically necrotic dystrophin-deficient mice. We therefore hypothesized that excessive ADMA impairs muscle NO production and diminishes exercise tolerance in DMD. We used transgenic expression of dimethylarginine dimethylaminohydrolase 1 (DDAH), which degrades methylated arginines, to investigate their contribution to exercise-induced fatigue in DMD. Although infusion of exogenous ADMA was sufficient to impair exercise performance in wild-type mice, transgenic DDAH expression did not rescue exercise-induced fatigue in dystrophin-deficient male mdx mice. Surprisingly, DDAH transgene expression did attenuate exercise-induced fatigue in dystrophin-heterozygous female mdx carrier mice. Improved exercise tolerance was associated with reduced heart weight and improved cardiac ß-adrenergic responsiveness in DDAH-transgenic mdx carriers. We conclude that DDAH overexpression increases exercise tolerance in female DMD carriers, possibly by limiting cardiac pathology and preserving the heart's responses to changes in physiological demand. Methylated arginine metabolism may be a new target to improve exercise tolerance and cardiac function in DMD carriers or act as an adjuvant to promote NO signaling alongside therapies that partially restore dystrophin expression in patients with DMD.NEW & NOTEWORTHY Duchenne muscular dystrophy (DMD) carriers are at risk for cardiomyopathy. The nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) is released from damaged muscle in DMD and impairs exercise performance. Transgenic expression of dimethylarginine dimethylaminohydrolase to degrade ADMA prevents cardiac hypertrophy, improves cardiac function, and improves exercise tolerance in DMD carrier mice. These findings highlight the relevance of ADMA to muscular dystrophy and have important implications for therapies targeting nitric oxide in patients with DMD and DMD carriers.

The Effect of Foam Rolling Versus IASTM on Knee Range of Motion, Fascial Displacement, and Patient Satisfaction.

CONTEXT: Soft tissue restrictions have been linked to poor flexibility and decreased range of motion (ROM). To decrease the soft tissue restrictions and ultimately increase ROM/flexibility, myofascial release techniques, such as foam rolling (FR) and instrument-assisted soft tissue mobilization (IASTM), have been used. However, the benefit regarding which technique is more beneficial remains unknown. OBJECTIVE: To examine the effects of myofascial release techniques (FR vs the instrumented portion of IASTM) on knee joint ROM, rectus femoris (RF) and biceps femoris (BF) fascial displacement, and patient satisfaction. DESIGN: Randomized controlled clinical trial. SETTING: Mid-Atlantic University. PARTICIPANTS: Twenty moderately active participants (age 21.1 [2.0] y) with variable levels of soft tissue restriction in the quadriceps and hamstrings started and completed the study. Participants were randomly assigned to 2 groups, FR or IASTM. INTERVENTIONS: All participants completed the same warm-up prior to the intervention. The FR group followed the proper FR protocol for gluteals/iliotibial band, quadriceps, and hamstrings/adductors, and the participants were monitored while the protocol was completed. The IASTM group received treatment on the gluteals/iliotibial band followed by the quadriceps, adductors, and hamstrings. Participants in both groups attended intervention sessions twice per week for 3 weeks. Prior to the start, knee ROM measurements were taken, along with fascial displacement measured via ultrasound. Upon completion of the study, posttest measurements were completed. A patient satisfaction survey was also administered at this time. MAIN OUTCOME MEASURES: Pretest to posttest knee ROM measurements, RF and BF fascial displacement, and patient satisfaction. RESULTS: Both groups improved pretest to posttest for knee-extension ROM, with a slight trend toward increased knee-extension ROM for the FR group. Both groups improved pretest to posttest for BF and RF fascial displacement, in favor of the IASTM group for BF fascial displacement. Both groups were equally satisfied. CONCLUSIONS: As both groups improved pretest to posttest, either treatment could be used.

Transcutaneous Electrical Nerve Stimulation Improves Stair Climbing Capacity in People with Knee Osteoarthritis.

This study aimed to examine the effect of transcutaneous electrical nerve stimulation (TENS) on stair climbing capacity in individuals with pre-radiographic to mild knee osteoarthritis (OA). This is a secondary analysis of data from a single, participant-blinded, randomized controlled trial with a pre-post design. Participants with pre-radiographic to mild knee OA (mean age, 59.1 years; 72.9% women) were randomly assigned into two groups, a TENS (n = 30) and a sham-TENS groups (n = 29). TENS or sham-TENS treatments were applied to all participants by using the prototype TENS device with pre-specified parameters. The primary outcome measures included valid and reliable functional measures for stair climbing (stair-climb test [SCT]), visual analog scale for knee pain during the SCT, and quadriceps muscle strength. TENS improved SCT time by 0.41 s (95% confidence interval [CI]: 0.07, 0.75). The time reduction in the transition phase explains the TENS therapeutic effect. Post-hoc correlation analyses revealed a non-significant but positive relationship between the pain relief effect and improved 11-step SCT time in the TENS group but not in the sham-TENS group. These results indicate that the TENS intervention may be an option for reducing the burden of early-stage knee OA.

Mental Simulation Practice Has Beneficial Effects on Patients' Physical Function Following Lower Limb Arthroplasty: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine the effectiveness of mental simulation practice (MSP) on measures of physical function recovery in patients who have undergone a joint replacement surgery of lower limbs. DATA SOURCES: A systematic review was conducted using CINAHL, PubMed/MEDLINE, Embase, SPORTDiscus, PEDro, Cochrane Register of Controlled Trials, and Google Scholar from the earliest record until August 16, 2019. STUDY SELECTION: The following inclusion criteria were used to determine eligibility for studies: (1) randomized and matched controlled trials recruiting men and women who underwent primary unilateral joint arthroplasty; (2) the study examined the effects of MSP intervention on measures of physical function recovery (both performance-based and patient self-reported); and (3) measures of interest were compared between MSP and control groups. A total of 8 papers (7 studies) met the inclusion criteria and were included. DATA EXTRACTION: Data were extracted by 1 reviewer and checked by a second reviewer, independently. DATA SYNTHESIS: When compared with standard physical therapy (SPT), MSP showed an effect on physical function in general (effect size [ES], 0.67; 95% confidence interval [CI], 0.38-0.96; n=7), maximal voluntary strength of knee extensor muscles of the affected leg (ES, 1.41; 95% CI, 0.64-2.18; n=2), brisk walking speed (ES, 1.20; 95% CI, 0.58-1.83; n=2), brisk walking speed with dual task (ES, 1.02; 95% CI, 0.41-1.63; n=2), timed up-to go test (ES, 0.96; 95% CI, 0.15-1.77; n=3), and active flexion of the affected leg (ES, 0.70; 95% CI, 0.29-1.11; n=4). Finally, meta-regression analysis revealed that the effects of MSP were significantly predicted only by total number of training sessions per study. CONCLUSIONS: The present meta-analysis demonstrated that MSP intervention has multiple positive effects on measures of physical function recovery in patients who have undergone total knee or hip replacement surgery in comparison with SPT. Thus, MSP can be applied as an effective complementary therapy to SPT in physical rehabilitation of this specific population, especially in the early postacute and acute phase.

The effectiveness of superimposed neuromuscular electrical stimulation combined with strengthening exercises on patellofemoral pain: A randomized controlled pilot trial.

BACKGROUND: Patellofemoral pain (PFP) is one of the most common disorders of the knee. Neuromuscular electrical stimulation (NMES) is often assumed by clinicians to be an effective adjunctive therapy to quadriceps strengthening. OBJECTIVE: The aim of this study was to assess the efficacy of superimposed NMES combined with strengthening exercises to improve the recovery of quadriceps strength and function in patients with PFP. METHODS: This study was planned as a single blind randomized controlled pilot study. A total of twenty-seven patients diagnosed with PFP were randomly assigned into 2 groups. Patients received superimposed NMES in addition to the standardized program (Group I) or only the standardized program (Group II). The patients in both groups were treated 3 times a week for 6 weeks and followed at 12 weeks. Primary outcome measure was quadriceps isokinetic muscle strength. The changes in dependent variables before treatment, 6th, and 12th weeks were analyzed using a 2 × 3 mixed-model analysis of variance. RESULTS: There were significant improvements in the within groups statistics of all parameters for both groups (p< 0.05). No differences in quadriceps strength, Kujala and Lysholm scores between groups were found at the different time points [F (2, 21) = 0.86; p= 0.12, F (2, 21) = 0.001; p= 0.97, F (2, 21) = 0.12; p= 0.73, respectively]. CONCLUSIONS: The results indicate that superimposed NMES combined with the standardized rehabilitation program has no clinically significant superiority to standardized rehabilitation program alone.

Traditional Chinese acupressure massage ameliorates systemic inflammatory responses and joint mobility limitation after acute repeated jumping exercise.

CONTEXT: Alternative medical and training approaches to accelerate recovery among athletes are growing in popularity. The potential benefits of acupressure massage on attenuating muscle soreness and promoting post-exercise recovery capacity are still unclear. OBJECTIVE: This study compares the effects of traditional Chinese acupressure massage (TCAM) and active recovery, on subject recovery capacity after acute repeated jumping exercise. DESIGN: Twenty healthy male athletes were randomly assigned to traditional Chinese acupressure massage (TCAM; N = 10) or active recovery (AR; performing low-intensity exercise during post-exercise recovery; N = 10) groups. TCAM and AR intervention were applied after repeated jumping exercise. Pain scale, knee active/passive range of motion (AROM/PROM), jumping performance, quadriceps maximum voluntary contraction force, creatine kinase, and leukocyte subpopulations were measured at baseline, after and 48 h after exercise. RESULTS: No significant interaction effects were observed between the jumping performance, quadriceps maximum voluntary contraction (MVC) force, power-to-weight ratio for the two groups before the exercise, after the exercise, and 48 h post exercise. However, the knee flexion AROM/PROM was greater in the TCAM group than that for the AR group (p = 0.005). There were no differences in the VAS, MVC, and jumping performance between treatments. The white blood cell (p = 0.024), and monocytes (p = 0.023) responses were lower in the TCAM group. CONCLUSIONS: We demonstrated that TCAM generates beneficial effects on attenuating joint mobility limitations and lowering systemic inflammatory responses after acute exercise in athletes. These findings suggest that TCAM may be a practical alternative approach for athletes participating in consecutive competitions containing eccentric elements.

Assessment of Sarcopenia Among Community-Dwelling At-Risk Frail Adults Aged 65 Years and Older Who Received Multidomain Lifestyle Interventions: A Secondary Analysis of a Randomized Clinical Trial.

Importance: There is little understanding of the outcomes associated with active lifestyle interventions for sarcopenia among older persons. Objective: To determine the association of 6-month multidomain lifestyle interventions (physical exercise, nutritional enhancement, cognitive training, combined treatment, and standard care) with change in sarcopenia status and physical function among adults 65 years and older. Design, Setting, and Participants: Post hoc secondary analysis of a parallel-group randomized clinical trial conducted from September 1, 2012, to September 1, 2014, at community centers providing services to elderly individuals in Singapore. Participants included a subsample of 92 community-dwelling prefrail or frail older persons with sarcopenia aged 65 years and older. Data were analyzed from June 1, 2017, to January 1, 2018. Interventions: The 5 intervention groups were a 6-month duration of physical exercise that included resistance and balance training, nutritional enhancement with a commercial oral nutrition supplement formula, cognitive training, a combination of the preceding 3 interventions, and standard care (control). Main Outcomes and Measures: Primary outcomes were changes in sarcopenia status and its components, appendicular skeletal muscle index (ASMI), knee extension strength (KES), and gait speed (GS) at 3 months and 6 months following the intervention. Sarcopenia was defined as the presence of both low ASMI and low KES and/or GS. Results: In 92 participants with sarcopenia, the mean (SD) age was 70.0 (4.7) years and 59 (64.1%) were female. Seventy-eight participants received active interventions and 14 received standard care. Of 92 total participants, the number who remained sarcopenic was reduced to 48 (of 73) after 3 months and 51 (of 75) after 6 months of intervention, indicating that 25 of 92 participants (27.2%) experienced sarcopenia reduction at 3 months and 24 of 92 (26.1%) had sarcopenia reduction at 6 months. Low KES was present in 88 of 92 patients (95.6%), and low GS in 30 of 92 patients (32.6%) at baseline. Among the components of sarcopenia, GS had the greatest change associated with active interventions, with 22 of 30 participants (73.3%) free of low GS at 6 months; in comparison, 17 of 88 participants (19.3%) were free of low KES at 6 months and 7 of 92 participants (7.6%) were free of low ASMI at 6 months. Men experienced greater reduction in sarcopenia than women (χ2 = 5.925; P = .02), as did those with younger age (t = -2.078; P = .04) or higher ASMI (mean [SD] ASMI, 5.74 [0.77] vs 5.14 [0.77] kg/m2; P = .002). Participants in the active intervention group experienced statistically significant decreases in sarcopenia score and its components at 3 months and 6 months from baseline (F = 14.138; P < .001), but the intervention was not associated with significant differences in ASMI, KES, and GS vs standard care. Conclusions and Relevance: This study suggests that older persons with sarcopenia are responsive to the effects of multidomain lifestyle interventions. Sarcopenia reduction was most pronounced through improved gait speed, and occurred more among those who were male, were younger, or had greater muscle mass.

Immediate responses of multi-focal low level laser therapy on quadriceps in knee osteoarthritis patients.

Low-level laser therapy (LLLT) applying on knee osteoarthritis (OA) patients has shown positive outcomes in analgesic effect and functional recovery. However, few studies applied such therapy on large area of quadriceps muscle in these patients. The aim of this study was to evaluate immediate effect of multi-focal LLLT on quadriceps of knee OA patients in pain and functional performance. Fifty-one participants with knee OA were enrolled and evaluated before (T1) and immediately after intervention (T2) by knee joint pain in numeric rating scale (NRS), walking speed, timed five-chair stands, and quadriceps strength by isokinetic dynamometer. Intervention with two multi-focal Gallium-Aluminum-Arsenide laser devices, each device with 36 laser diodes (wavelength 808 ± 10 nm, continuous, mean power 50 mW, 30 minutes), applied simultaneously over bilateral quadriceps with a total dose of 180 J for each thigh. The multi-focal LLLT significantly improved knee joint pain as measured by the NRS (54% reduction), timed five-chair stands, and walking speed (P < .05). Knee extensor strength also increased in terms of peak torque and force of concentric and eccentric contraction as measured by isokinetic dynamometer (P < .05). In conclusion, single-session multi-focal LLLT on quadriceps in knee OA patients has immediate beneficial effect on knee pain reduction, quadriceps strengthening and functional performance recovery. Long-term effect requires further investigation. Multi-focal LLLT on quadriceps might serve as an alternative non-invasive treatment option in these patients.

The role of maximum compressed thickness of the quadriceps femoris muscle measured by ultrasonography in assessing nutritional risk in critically-ill patients with different volume statuses.

PURPOSE: In this prospective observational study, we aimed to investigate the role of the maximum compressed (MC) and uncompressed (UC) thickness of the quadriceps femoris muscle (QFMT) measured by ultrasonography (USG) in the detection of nutritional risk in intensive care patients (ICPs) with different volume status. METHODS: 55 patients were included. Right, left, and total ucQFMT and mcQFMT measurements were obtained by a standard USG device within the first 48 hours after ICU admission. Clinical examination and the USG device were used to determine the volume status of the patients. SOFA, APACHE II, modified NUTRIC scores, and demographic data were collected. RESULTS: There was a significant difference between the nutritional risk of patients in terms of left, right, and total mcQFMT measurements (p=0.025, p=0.039; p=0.028, respectively), mechanical ventilation requirement (p=0.014), presence of infection (p=0.019), and sepsis (p=0.006). There was no significant difference between different volume statuses in terms of mcQFMT measurements. In the multi-variance analysis, mcQFMT measurements were found to be independently associated with high nutritional risk (p=0.019, Exp(B)=0.256, 95%CI=0.082-0.800 for modified NUTRIC score ≥ 5), and higher nutritional risk (p=0.009, Exp(B)=0.144, 95%CI=0.033-0.620 for modified NUTRIC score ≥ 6). a Total mcQFMT value below 1.36 cm was a predictor for higher nutritional risk with 79% sensitivity and 70% specificity (AUC=0.749, p=0.002, likelihood ratio=2.04). CONCLUSION: Ultrasonographic measurement of total mcQFMT can be used as a novel nutritional risk assessment parameter in medical ICPs with different volume statuses. Thus, patients who could benefit from aggressive nutritional therapy can be easily identified in these patient groups.

The role of maximum compressed thickness of the quadriceps femoris muscle measured by ultrasonography in assessing nutritional risk in critically-ill patients with different volume statuses

SUMMARY PURPOSE In this prospective observational study, we aimed to investigate the role of the maximum compressed (MC) and uncompressed (UC) thickness of the quadriceps femoris muscle (QFMT) measured by ultrasonography (USG) in the detection of nutritional risk in intensive care patients (ICPs) with different volume status. METHODS 55 patients were included. Right, left, and total ucQFMT and mcQFMT measurements were obtained by a standard USG device within the first 48 hours after ICU admission. Clinical examination and the USG device were used to determine the volume status of the patients. SOFA, APACHE II, modified NUTRIC scores, and demographic data were collected. RESULTS There was a significant difference between the nutritional risk of patients in terms of left, right, and total mcQFMT measurements (p=0.025, p=0.039; p=0.028, respectively), mechanical ventilation requirement (p=0.014), presence of infection (p=0.019), and sepsis (p=0.006). There was no significant difference between different volume statuses in terms of mcQFMT measurements. In the multi-variance analysis, mcQFMT measurements were found to be independently associated with high nutritional risk (p=0.019, Exp(B)=0.256, 95%CI=0.082-0.800 for modified NUTRIC score ≥ 5), and higher nutritional risk (p=0.009, Exp(B)=0.144, 95%CI=0.033-0.620 for modified NUTRIC score ≥ 6). a Total mcQFMT value below 1.36 cm was a predictor for higher nutritional risk with 79% sensitivity and 70% specificity (AUC=0.749, p=0.002, likelihood ratio=2.04). CONCLUSION Ultrasonographic measurement of total mcQFMT can be used as a novel nutritional risk assessment parameter in medical ICPs with different volume statuses. Thus, patients who could benefit from aggressive nutritional therapy can be easily identified in these patient groups.

RESUMO OBJETIVO Neste estudo observacional prospectivo, objetivamos investigar o papel da espessura do músculo quadríceps femoral (QFMT) comprimido (mc) e não comprimido (uc) medida pela ultrassonografia (USG) na detecção do risco nutricional em pacientes de terapia intensiva (ICPs) com status de volume diferente. MÉTODOS Cinquenta e cinco pacientes foram incluídos. As medidas direita, esquerda e total de ucQFMT e mcQFMT foram obtidas por um dispositivo USG padrão nas primeiras 48 horas após a admissão na UTI. O exame clínico e o dispositivo USG foram usados para determinar o status volumétrico dos pacientes. Sofa, Apache II, escores Nutric modificados e dados demográficos foram coletados. RESULTADOS Houve diferença significativa entre o risco nutricional dos pacientes em termos de medidas da QTFMT esquerda, direita e total (p=0,025, p=0,039; p=0,028, respectivamente), necessidade de ventilação mecânica (p=0,014), presença de infecção (p=0,019) e sepse (p=0,006). Não houve diferença significativa entre os diferentes status de volume em termos de medidas de mcQFMT. Na análise de variância múltipla, verificou-se que as medidas da FCFMT estavam independentemente associadas a alto risco nutricional (p=0,019, Exp (B)=0,256, 95%CI=0,082-0,800 para escore Nutric modificado ≥ 5) e maior risco nutricional (p=0,009, Exp (B)=0,144, 95%CI=0,033-0,620 para o escore Nutric modificado ≥ 6). O valor total de mcQFMT abaixo de 1,36 cm foi um preditor de maior risco nutricional com sensibilidade de 79% e especificidade de 70% (ASC=0,749, p=0,002, razão de verossimilhança = 2,04). CONCLUSÃO A medida ultrassonográfica do mcQFMT total pode ser usada como um novo parâmetro de avaliação de risco nutricional em ICPs médicas com diferentes status de volume. Assim, pacientes que podem se beneficiar de uma terapia nutricional agressiva podem ser facilmente identificados nesses grupos de pacientes.