A Role for Superficial Heat Therapy in the Management of Non-Specific, Mild-to-Moderate Low Back Pain in Current Clinical Practice: A Narrative Review.

Low back pain (LBP) is a leading cause of disability. It significantly impacts the patient's quality of life, limits their daily living activities, and reduces their work productivity. To reduce the burden of LBP, several pharmacological and non-pharmacological treatment options are available. This review summarizes the role of superficial heat therapy in the management of non-specific mild-to-moderate LBP. First, we outline the common causes of LBP, then discuss the general mechanisms of heat therapy on (LBP), and finally review the published evidence regarding the impact of superficial heat therapy in patients with acute or chronic non-specific LBP. This review demonstrates that continuous, low-level heat therapy provides pain relief, improves muscular strength, and increases flexibility. Therefore, this effective, safe, easy-to-use, and cost-effective non-pharmacological pain relief option is relevant for the management of non-specific mild or moderate low back pain in current clinical practice.

Results of 200 Consecutive Ceramic-on-Ceramic Cementless Hip Arthroplasties in Patients Up To 50 Years of Age: A 5-24 Years of Follow-Up Study.

BACKGROUND: Ceramic-on-ceramic (CoC) bearings due to their mechanical properties can be used in primary total hip arthroplasty (THA) especially in young patients requiring a long-lasting implant. The goal of this study is to analyze the results of a series of 200 consecutive CoC THAs in patients aged 50 years or less at the time of surgery. METHODS: A retrospective study was conducted on the first 200 consecutive CoC arthroplasties performed using the direct lateral approach on 105 females and 81 males (14 bilateral cases) with an average age of 44.2 (16-50) years. The diagnosis was primary or post-traumatic osteoarthritis in 94 cases, avascular necrosis of the femoral head in 47, displaced intracapsular femoral neck fracture in 29, osteoarthritis secondary to developmental dysplasia of the hip/Legg-Calvè-Perthes disease/slipped capital femoral epiphysis in 20, and rheumatic diseases in 10 cases. The preoperative Harris Hip Score was 32.5 on average (range 15-55). All the implants were cementless. In 177 THAs the coupling was alumina-on-alumina, and in 23 cases the coupling was AMC-on-AMC (alumina matrix composite). RESULTS: Twenty-five patients with 28 THAs were lost at the final follow-up, 2 stems were revised due to subsidence, 1 cup was revised due to malposition, 1 femoral head was changed because of impingement, and 1 THA was revised for periprosthetic infection. Three patients sustained a Vancouver B1 periprosthetic femoral fracture. At the final follow-up (mean 14.9 years; minimum 5 years to maximum 24 years), 172 THAs were eligible for clinical and radiographic evaluation: none was revised for wear and/or breakage of the ceramic components. Harris Hip Score rose up to a mean value of 90.1 (52-100). CONCLUSION: The present report demonstrates that CoC coupling offers excellent long-term results in THA performed in young patients with very low wear and no adverse effects caused by the material.

A minimum 20-year outcome of 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon.

BACKGROUND:: Ceramic-on-ceramic (CoC) is currently a viable bearing combination in primary total hip arthroplasty (THA) and, due to its mechanical properties, it can be used in young patients requiring a long-lasting implant. The aim of this study is to report the results of a series of CoC THAs at a minimum 20 years follow-up. METHODS:: A retrospective study was conducted on the 1st 100 consecutive alumina-on-alumina arthroplasties performed by a single surgeon on 51 females and 40 males with an average age of 60.7 years. The mean preoperative Harris Hip Score was 35. The press-fit cup consisted of a pure titanium core with a titanium alloy mesh. Both the inlay and the head were made of dense polycrystalline surgical-grade alumina. The 32-mm femoral head was anchored on 3 different femoral components. RESULTS:: 19 patients with 22 THAs were died or lost, 2 anatomic cementless stems were revised due to sinking, 1 THA was revised for periprosthetic infection. 2 patients sustained a Vancouver B1 periprosthetic femoral fracture. None of the 78 THAs eligible for this study were revised for wear, breakage, noise of the ceramic components. None of the cups, none of the cemented stems, none of the cementless straight stems failed. HHS raised up to a mean value of 95. CONCLUSIONS:: The present report demonstrates that CoC coupling offers minimal wear at a long-term follow-up. Further studies are needed to evaluate whether the modern ceramic composites will confirm such excellent results in total hip replacement.

Methylsulfonylmethane and boswellic acids versus glucosamine sulfate in the treatment of knee arthritis: Randomized trial.

Until now glucosamine sulfate (GS) has been the most widely used supplement and has been shown to be efficacious in the treatment of osteoarthritis (OA). Methylsulfonylmethane (MSM) and boswellic acids (BA) are new effective supplements for the management of inflammation and joint degeneration, according to previous experimental studies. The aim of our study is to test the effectiveness of association of MSM and BA in comparison with GS in knee arthritis.In this prospective randomized clinical trial, MEBAGA (Methylsulfonylmethane and Boswellic Acids versus Glucosamine sulfate in the treatment of knee Arthritis), 120 participants affected by arthritis of the knee were randomly assigned to an experimental group (MB group) or a control group (GS group) treated for 60 days with 5 g of MSM and 7.2 mg of BA or with 1500 mg of GS daily, respectively. At the 2-month (T1) and 6-months (T2) follow-up , the efficacy of these two nutraceuticals was assessed using the visual analog pain scale (VAS) and the Lequesne Index (LI) for joint function, along with the use of anti-inflammatory drugs (non-steroidal anti-inflammatory drugs and anti-cyclooxygenase-2).The repeated measures ANOVA analysis shows that for VAS, LI, and the use of anti-inflammatory drugs scores there are improvements due to the time in the two groups (respectively, F=26.0; P<0.0001; F=4.15; P=0.02; F=3.38; P=0.04), with a tendency to better values for the MB group at T2.On the basis of these preliminary data, we could support the efficacy of the MSM in association with BA in the treatment of OA. These results are consistent with the anti-inflammatory and chondroprotective effects previously occurred in experimental studies. This new combination of integration (MSM and BS) has presented good results and satisfactory in comparison with GS, until now the cornerstone of the treatment of arthritis in according to guidelines.

Comparison of shock wave therapy and nutraceutical composed of Echinacea angustifolia, alpha lipoic acid, conjugated linoleic acid and quercetin (perinerv) in patients with carpal tunnel syndrome.

Even though the initial treatment of carpal tunnel syndrome (CTS) is conservative, knowledge of the clinical effects of supplements and of some methods of physiotherapy is still preliminary. Many biological mechanisms can support the administration of shock wave therapy (ESWT) or of alpha lipoic acid (ALA) based nutraceutical, conjugated linoleic acid (GLA), anti-oxidants and Echinacea angustifolia for CTS. The shock waves reduce the nerve compression, produce an anti-inflammatory action, and accelerate the regeneration of neuropathy. ALA and GLA induce antioxidant protective actions, reduce inflammation, promote neuroregeneration, and decrease pain. The Echinacea modulates the endogenous cannabinoid system.The aim of study is to verify the efficiency of shock wave therapy versus nutraceutical composed of ALA, GLA, and Echinacea in CTS. Sixty patients were enrolled in this study and they were randomly assigned to one of two treatments. Both groups showed significant improvements in pain, symptoms' severity and functional scores, and electrodiagnostic results until the sixth month. We verified a trend to a better pain regression in the nutraceutical group. The presence of the medicinal Echinacea represents an added value to the antioxidant effect in ALA and GLA, which can justify this result. ESWT or the association of ALA, GLA, and Echinacea proved to be two effective treatments for controlling symptoms and improving the evolution of CTS.

Vertebral Bone Marrow Edema (VBME) in Conservatively Treated Acute Vertebral Compression Fractures (VCFs): Evolution and Clinical Correlations.

STUDY DESIGN: Prospective observational study. OBJECTIVE: To assess (1) the evolution of vertebral bone marrow edema (VBME) in patients with A1 vertebral compression fractures (VCFs) conservatively treated and (2) the relationship between VBME and clinical symptoms, evaluated as Visual Analogue Scale (VAS) back pain and Oswestry Disability Index (ODI). SUMMARY OF BACKGROUND DATA: VBME is a marker of acute-subacute vertebral fractures. Little is known about the evolution of VBME in conservatively managed VCFs, as well as its clinical meaning. METHODS: 82 thoracic or lumbar VCFs (21 post-traumatic; 61 osteoporotic VCFs), type A1 according to the AOSpine thoracolumbar spine injury classification system, in 80 patients were treated with C35 hyperextension brace for 3 months, bed rest for the first 25 days. Patients with osteoporotic fractures also received antiresorptive therapy and vitamin D supplementation. At 0 (T0), 30 (T1), 60 (T2), and 90 (T3) days, patients underwent magnetic resonance imaging evaluation and clinical evaluation, using VAS for pain and ODI.The paired t test was used to compare changes within groups at each follow-up versus baseline. The unpaired t test after ANOVA (analysis of variance) was used to compare the 2 groups at each follow-up.The association between VBME area, VAS score, and ODI score was analyzed by the Pearson correlation test. The tests were 2-tailed with a confidence level of 5%. RESULTS: A significant VBME mean area, VAS, and ODI scores reduction was recorded at 60 and 90-days follow-ups versus baseline. A positive correlation between VBME reduction and clinical symptoms improvement (VAS and ODI scores improvement) was found in both traumatic and osteoporotic VCFs. CONCLUSION: In benign A1 VCFs conservatively managed, VBME slowly decreases in the first 3 months of magnetic resonance imaging follow-up. This VBME reduction is related to clinical symptoms improvement. LEVEL OF EVIDENCE: 4.

SBOTE study: extracorporeal shock wave therapy versus electrical stimulation after botulinum toxin type a injection for post-stroke spasticity-a prospective randomized trial.

Research is on-going to identify new methods of biostimulation to increase the effect of botulinum toxin type A (BTX-A) in the treatment of spasticity. The Spasticity treated by Botulinum Toxin and ESWT (SBOTE) study is a prospective, randomized controlled trial assessing the effectiveness of extracorporeal shock wave therapy (ESWT) given immediately after BTX-A injections compared with electrical stimulation (ES) given immediately after BTX-A therapy for the management of focal upper limb spasticity in stroke patients. ES was given for 30 min twice a day for 5 days starting at 5 Hz; ESWT was given once a day for 5 days. At study follow-up, patients treated with BTX-A injections and ESWT showed a statistically greater significance and continuous decrease of spasticity measure (modified Ashworth scale [MAS]: 1.37, 1.75 and 1.58 at 15, 30 and 90 days post-treatment, respectively), of spasms (spasm frequency scale [SFS]: 0.8 and 0.25 at 30 and 90 days post-treatment, respectively) and of pain (visual analogue scale [VAS]: 1.94 and 1.87 at 30 and 90 days, respectively) compared with patients treated with BTX-A injections and ES (MAS: 2.37, 2.18 and 2.18, respectively) (p < 0.05) (SFS: 1.5 and 1.06, respectively) (p < 0.05) (VAS: 2.44 and 2.69 respectively) (p < 0.05). ESWT enhances the effect of BTX-A to a greater extent than ES, probably by modulating rheology of the muscle and neurotransmission at the neuromuscular junction.

SWAAT study: extracorporeal shock wave therapy and arginine supplementation and other nutraceuticals for insertional Achilles tendinopathy.

INTRODUCTION: Extracorporeal shockwave therapy (ESWT) produces good results in the treatment of insertional Achilles tendinopathy. The efficacy of combined administration of dietary supplements with ESWT has not yet been studied. METHODS: In this prospective, randomized clinical trial, Shock Waves therapy and Arginine for Achilles Tendinopathy (SWAAT), subjects affected by insertional Achilles tendinopathy were enrolled. Between January and October 2011, all participants underwent three sessions of ESWT. In addition, the patients in the experimental group received a daily dietary supplement containing arginine, Vinitrox (Bio Serae Laboratories SAS, Bram, France), collagen, methyl-sulfonyl-methane, vitamin C, and bromelain, while the control group patients received placebo. RESULTS: There was no statistically significant difference in the visual analog scale (VAS) score between the two groups at 2 months (3.9 vs. 5.1; P=0.07), whereas at 6 months the value was significantly lower in the experimental group (2.0 vs. 2.9; P=0.04). The difference in the Ankle-Hindfoot Scale score at 2 and 6 months of follow-up (FU) was significantly in favor of the experimental group (2 months: 85.4 vs. 72.1; P=0.0035; 6 months: 92.4 vs. 76.5; P=0.0002). The Roles and Maudsley score also showed a statistically significant difference between the two groups in favor of the experimental arm as regards patient satisfaction (at 2 months: 1.7 vs. 2.8; P<0.0001; at 6 months: 1.5 vs. 2.3; P<0.001). There was a statistically significant reduction in tissue oximetry values compared to baseline in both treatment groups at 2 and 6 months of FU. Comparing the groups, only at the last FU, at 6 months, was a significantly lower oximetry value observed in the experimental group versus controls (60.2 vs. 66.0; P=0.007). CONCLUSION: On the basis of the results obtained in this study, the authors conclude that in the treatment of insertional Achilles tendinopathy, ESWT induces a hemodynamic re-equilibrium with an amelioration in tendon trophism [corrected]. The addition of specific dietary supplements could improve the therapeutic response.

I-ONE therapy in patients undergoing total knee arthroplasty: a prospective, randomized and controlled study.

BACKGROUND: Total knee arthroplasty (TKA) is often associated with a severe local inflammatory reaction which, unless controlled, leads to persistent pain up to one year after surgery. Standard and accelerated rehabilitation protocols are currently being implemented after TKA, but no consensus exists regarding the long-term effects. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been demonstrated to exert an anti-inflammatory effect, to promote early functional recovery and to maintain a positive long-term effect in patients undergoing joint arthroscopy. The aim of this study was to evaluate whether PEMFs can be used to limit the pain and enhance patient recovery after TKA. METHODS: A prospective, randomized, controlled study in 30 patients undergoing TKA was conducted. Patients were randomized into experimental PEMFs or a control group. Patients in the experimental group were instructed to use I-ONE stimulator 4hours/day for 60days. Postoperatively, all patients received the same rehabilitation program. Treatment outcome was assessed using the Knee Society Score, SF-36 Health-Survey and VAS. Patients were evaluated pre-operatively and one, two, six and 12 months after TKA. Joint swelling and Non Steroidal Anti Inflammatory Drug (NSAID) consumption were recorded. Comparisons between the two groups were carried out using a two-tail heteroschedastic Student's t-test. Analysis of variance for each individual subject during the study was performed using ANOVA for multiple comparisons, applied on each group, and a Dunnet post hoc test. A p value < 0.05 was considered statistically significant. RESULTS: Pre-operatively, no differences were observed between groups in terms of age, sex, weight, height, Knee-Score, VAS, SF-36 and joint swelling, with the exception of the Functional Score. The Knee-Score, SF-36 and VAS demonstrated significantly positive outcomes in the I-ONE stimulated group compared with the controls at follow-ups. In the I-ONE group, NSAID use was reduced and joint swelling resolution was more rapid than in controls. The effect of I-ONE therapy was maintained after use of the device was discontinued. CONCLUSIONS: The results of the study show early functional recovery in the I-ONE group. I-ONE therapy should be considered after TKA to prevent the inflammatory reaction elicited by surgery, for pain relief and to speed functional recovery.

The "MESACA" study: methylsulfonylmethane and boswellic acids in the treatment of gonarthrosis.

INTRODUCTION: Osteoarthritis is a chronic rheumatoid disease mediated by metalloproteinases and inflammatory cytokines. Methylsulfonylmethane (MSM) and boswellic acids (BA) each show promise in the treatment of inflammatory processes, but the efficacy of combined treatment with these substances in the treatment of arthritis has not yet been studied. METHODS: In this prospective randomized clinical trial, MESACA (for "methylsulfonylmethane and boswellic acids in the treatment of knee arthritis"), 60 subjects affected by arthritis of the knee were randomly assigned to an experimental group treated for 60 days with 5 g of MSM and 7.2 mg of BA daily, or a control group which was administered a placebo. At 2 and 6 months follow-up (FU), the efficacy of combined treatment with these two dietary supplements was assessed using the visual analog pain scale (VAS) and the Lequesne index (LI) for joint function, as well as monitoring the use of anti-inflammatory drugs (nonsteroidal anti-inflammatory drugs and anti-cyclooxygenase-2). RESULTS: Pain, assessed with the VAS scale, was worse in the group treated with MSM and BA as compared with the placebo group at 2 months FU (3.8 vs. 2.7; P=0.04), whereas no difference between the two groups was observed at 6 months FU (2.7 vs. 3.6; P=0.2). No statistically significant differences were found in the LI between the two groups at either FU (2 months: 4.8 vs. 4.2; P=0.51; 6 months: 4.4 vs. 4.5; P=0.91). By contrast, a statistically significant difference in patients need for anti-inflammatory drugs was seen in the experimental as compared to the placebo group, even by 2 months FU (0.2 vs. 0.6 tablets/day; P<0.0001), that persisted up to the end of the study (0.1 vs. 0.6 tablets/day; P<0.0001). CONCLUSIONS: Although the combined administration of MSM and BA in the treatment of gonarthrosis was not shown to be more efficacious than placebo in the management of the clinical and functional picture, it significantly reduced patients need for anti-inflammatory drugs.

Deep vein thromboembolism after arthroscopy of the shoulder: two case reports and a review of the literature.

BACKGROUND: Deep vein thrombosis (DVT) has an incidence of 1 case per 1000 inhabitants in the general population and it is very rare after arthroscopy of the shoulder. Therefore, the current guidelines do not advise the administration of DVT prophylaxis in shoulder arthroscopy procedures. CASES PRESENTATION: We describe two cases of thrombosis of the arm after shoulder arthroscopy on a total of 10.452 shoulder arthroscopies performed during a period of ten years. One of two patients was further complicated by a bilateral pulmonary microembolism. In these two clinical cases the complication developed despite the absence of risk factors such as a concomitant neoplasm, thrombophilia, smoking habit, or a long duration of the procedure. CONCLUSIONS: The DVT after shoulder arthroscopy procedure remain a very rare complication. However, in view of the growing number of patients undergoing this procedure, this figure is expected to rise. The clinician surgeon should take in mind this possible complication that normally appears in the first 3 weeks after surgery, so to perform anti-coagulant treatment. Further clinical studies are therefore warranted to assess the true risk of VTE. In fact, the presence of "minor" predisposing factors that are not routinely studied, as well as the postoperative immobilization period, are potential risk factors that, associated with the invasiveness of the arthroscopy procedure, could trigger a thromboembolism.