Effectiveness of neuromuscular electrical stimulation for management of shoulder subluxation post-stroke: a systematic review with meta-analysis.

OBJECTIVES: To examine the effectiveness of neuromuscular electrical stimulation (NMES) for the management of shoulder subluxation after stroke including assessment of short (1 hour or less) and long (more than one hour) daily treatment duration. DATA SOURCES: MEDLINE, CENTRAL, CINAHL, WOS, KoreaMed, RISS and reference lists from inception to January 2017 Review methods: We considered randomized controlled trials that reported neuromuscular electrical stimulation for the treatment of shoulder subluxation post-stroke. Two reviewers independently selected trials for inclusion, assessed trial quality, and extracted data. RESULTS: Eleven studies were included (432 participants); seven studies were good quality, four were fair. There was a significant treatment effect of neuromuscular electrical stimulation for reduction of subluxation for persons with acute and subacute stroke (SMD:-1.11; 95% CI:-1.53, -0.68) with either short (SMD:-0.91; 95% CI:-1.43, -0.40) or long (SMD:-1.49; 95% CI:-2.31, -0.67) daily treatment duration. The effect for patients with chronic stroke was not significant (SMD:-1.25; 95% CI:-2.60, 0.11). There was no significant effect of neuromuscular electrical stimulation on arm function or shoulder pain. CONCLUSION: This meta-analysis suggests a beneficial effect of neuromuscular electrical stimulation, with either short or long daily treatment duration, for reducing shoulder subluxation in persons with acute and subacute stroke. No significant benefits were observed for persons with chronic stroke or for improving arm function or reducing shoulder pain.

A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study.

PURPOSE: We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change. METHODS: In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction. RESULTS: During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians. CONCLUSIONS: Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance.

Osteoradionecrosis of the cervical spine resulting from radiotherapy for primary head and neck malignancies: operative and nonoperative management. Case report.

Osteoradionecrosis is a process of dysvascular bone necrosis and fibrous replacement following exposure to high doses of radiation. The poorly vascularized necrotic tissue may cause pain and/or instability, and it cannot resist infection well, which may result in secondary osteomyelitis. When these processes affect the cervical spine, the resulting instability and neurological deficits can be devastating, and immediate reestablishment of spinal stability is paramount. Reconstruction of the cervical spine can be particularly challenging in this subgroup of patients in whom the spine is poorly vascularized after radical surgery, high-dose irradiation, and infection. The authors report three cases of cervical spine osteoradionecrosis following radiotherapy for primary head and neck malignancies. Two patients suffered secondary osteomyelitis, severe spinal deformity, and spinal cord compression. These patients underwent surgery in which a vascularized fibular graft and instrumentation were used to reconstruct the cervical spine; subsequently hyperbaric oxygen (HBO) therapy was instituted. Fusion occurred, spinal stability was restored, and neurological dysfunction resolved at the 2- and 4-year follow-up examinations, respectively. The third patient experienced pain and dysphagia but did not have osteomyelitis, spinal instability, or neurological deficits. He underwent HBO therapy alone, with improved symptoms and imaging findings. Hyperbaric oxygen is an essential part of treatment for osteoradionecrosis and may be sufficient by itself for uncomplicated cases, but surgery is required for patients with spinal instability, spinal cord compression, and/or infection. A vascularized fibular bone graft is a very helpful adjunct in these patients because it adds little morbidity and may increase the rate of spinal fusion.