The effect of nature-based music intervention on adaptation and anxiety levels in patients with COVID-19 placed in the prone position: A randomized controlled trial.

OBJECTIVE: To examine the effect of listening to nature-based music on anxiety, physiological parameters, and adjustment to the prone position in conscious and hypoxemic COVID-19 patients. DESIGN: A single-blinded randomized control trial design. SETTING: The study was conducted in the intensive care unit of a state hospital in Turkey. Sixty-four patients were randomized into an intervention group and a control group. METHODS: A nature-based music intervention was applied in addition to routine care to the intervention group in the prone position, while the control group received routine care in the same position. The study outcomes included state-trait anxiety, physiological parameters, and prone time within 24 h. Measurements were performed in the supine position (Time: T0), in the 30th minute in the prone position (T1), and in the 30th minute of the supine position given following the prone position (T2). Data analysis included independent samples t-test in independent groups and repeated measures ANOVA in dependent groups. RESULTS: State anxiety fell statistically significantly in the intervention group compared to that of the control group (39.1 ± 6.6 vs. 43.4 ± 7.9, p = 0.025). At T2, the heart rate of the intervention group did not increase, but it increased significantly in the control group compared to T0 and T1 values (87.8 ± 9.8 vs. 91.1 ± 10.8; p = 0.000). The oxygen saturation of the intervention group increased significantly compared to that of the control group (94.5 ± 2.3 vs. 93.4 ± 1.9, p = 0.035). The prone position time of the intervention group was significantly greater than that of the control group (11.5 ± 1.5 vs. 10.8 ± 1.1, p = 0.04). CONCLUSIONS: It was found that nature-based music intervention applied to conscious and hypoxemic COVID-19 patients in the prone position improved anxiety and oxygen saturation and increased the prone position time. IMPLICATIONS FOR CLINICAL PRACTICE: Listening to nature-based music in prone position may reduce anxiety in conscious patients with hypoxemic respiratory failure, it may increase adjustment to the prone position, and it may improve oxygenation and heart rate.

Effect of diaphragm manual release versus conventional breathing exercises and prone positioning on physical functional performance in women with COVID-19: A randomized trial.

INTRODUCTION: Manual therapy has recently gained much interest in managing COVID-19 patients. This study aimed to mainly compare the effect of diaphragm manual release to the effect of conventional breathing exercises and prone positioning on physical functional performance in women with COVID-19. METHODS: Forty COVID-19 women patients completed this study. They were randomly assigned to two groups. Group A received diaphragm manual release, and group B received conventional breathing exercises and prone positioning. Both groups received pharmacological treatment. Inclusion criteria were moderate COVID-19 illness, women patients, and ages from 35 to 45 years. The outcome measures were 6-min walk distance (6MWD), chest expansion, Barthel index (BI), oxygen saturation, fatigue Assessment Scale (FAS), and Medical Research Council (MRC) dyspnea scale. RESULTS: Both groups showed significant improvements in all outcome measures compared to the baseline (p < 0.001). Compared to group B, group A showed more significant improvements in the 6MWD (MD, 22.75 m; 95% CI, 15.21 to 30.29; p < 0.001), chest expansion (MD, 0.80 cm; 95% CI, 0.46 to 1.14; p < 0.001), BI (MD, 9.50; 95% CI, 5.69 to 13.31; p < 0.001), the O2 saturation (MD, 1.3%; 95% CI, 0.71 to 1.89; p < 0.001), the FAS (MD, -4.70; 95% CI, -6.69 to -2.71; p < 0.001), and dyspnea severity assessed by the MRC dyspnea scale (p = 0.013) post-intervention. CONCLUSION: Combined with pharmacological treatment, diaphragm manual release could be superior to conventional breathing exercises and prone positioning in improving physical functional performance, chest expansion, daily living activities, O2 saturation, and measures of fatigue and dyspnea in middle-aged women with moderate COVID-19 illness. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR), retrospective, PACTR202302877569441.

Caloric Intake with High Ratio of Enteral Nutrition Associated with Lower Hospital Mortality for Patients with Acute Respiratory Distress Syndrome Using Prone Position Therapy.

Positioning patients in the prone position leads to reduced hospital mortality rates for those with severe acute respiratory distress syndrome (ARDS). What constitutes the optimal feeding strategy for prone patients with ARDS is controversial. We conducted a retrospective study that enrolled 110 prone patients with ARDS in two medical intensive care units (ICUs) from September 2015 to November 2018. Inclusion criteria were as follows: age ≥20 years, diagnosis of respiratory failure requiring mechanical ventilation, diagnosis of ARDS within 72 h of ICU admission, placement in a prone position within the first 7 days of ICU admission, and ICU stay of more than 7 days. Exclusion criteria were as follows: nil per os orders because of gastrointestinal bleeding or hemodynamic instability, and ventilator dependency because of chronic respiratory failure. The consecutive daily enteral nutrition(EN)/EN + parenteral nutrition(PN) ratio could predict hospital mortality rates within the first 7 days of admission when using generalized estimating equations (p = 0.013). A higher average EN/EN + PN ratio within the first 7 days predicted (hazard ratio: 0.97, confidence interval: 0.96-0.99) lower hospital mortality rates. To reduce hospital mortality rates, caloric intake with a higher EN ratio may be considered for patients in prone positions with ARDS.

Air embolism during lumbar surgery in the prone position.

Only a few clinical cases of cerebral arterial gas embolism during spinal surgery are published. It seems important not to overlook this diagnosis in order to initiate rapid appropriate treatment. This was a suspected case of paradoxical gas embolism revealed postoperatively by neurological deficits and whose recovery was noted during hyperbaric oxygen treatment. Unfortunately, no complementary examination showed gas embolism and only the context, the clinical picture and the case evolution evoke this diagnosis. The diagnostic difficulty in the immediate postoperative period is highlighted.

Energy Achievement Rate Is an Independent Factor Associated with Intensive Care Unit Mortality in High-Nutritional-Risk Patients with Acute Respiratory Distress Syndrome Requiring Prolonged Prone Positioning Therapy.

Early enteral nutrition (EN) and a nutrition target >60% are recommended for patients in the intensive care unit (ICU), even for those with acute respiratory distress syndrome (ARDS). Prolonged prone positioning (PP) therapy (>48 h) is the rescue therapy of ARDS, but it may worsen the feeding status because it requires the heavy sedation and total paralysis of patients. Our previous studies demonstrated that energy achievement rate (EAR) >65% was a good prognostic factor in ICU. However, its impact on the mortality of patients with ARDS requiring prolonged PP therapy remains unclear. We retrospectively analyzed 79 patients with high nutritional risk (modified nutrition risk in the critically ill; mNUTRIC score ≥5); and identified factors associated with ICU mortality by using a Cox regression model. Through univariate analysis, mNUTRIC score, comorbid with malignancy, actual energy intake, and EAR (%) were associated with ICU mortality. By multivariate analysis, EAR (%) was a strong predictive factor of ICU mortality (HR: 0.19, 95% CI: 0.07-0.56). EAR >65% was associated with lower 14-day, 28-day, and ICU mortality after adjustment for confounding factors. We suggest early EN and increase EAR >65% may benefit patients with ARDS who required prolonged PP therapy.

Treating ARDS-associated air embolism: a question of priorities.

Gas embolism is a potential and often life-threatening complication of central venous catheters. We report a case of air embolism after tearing of the central catheter associated with severe acute respiratory distress syndrome. The severity of the clinical situation meant choices had to be made regarding the order of treatments. This clinical case provided useful eye-openers for patient management regarding the prioritization of treatments as well as the possibilities offered by hyperbaric oxygen therapy.

Nutrition Support During Prone Positioning: An Old Technique Reawakened by COVID-19.

Acute respiratory distress syndrome (ARDS) is a complex disease characterized by inflammation, resulting in diffuse alveolar damage, proliferation, and fibrosis, and carries a high mortality rate. Recently, the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has overwhelmed healthcare systems worldwide, as many patients have required hospitalization for the management of respiratory failure similar in nature to ARDS. In addition to lung-protective ventilation strategies aimed to maintain an oxygen saturation >90%, a ratio of partial pressure of oxygen to fraction of inspired oxygen >200, a pH of 7.25-7.40, and a plateau pressure <35 cm H2 O, prone positioning has emerged as an effective treatment strategy for severe ARDS by improving oxygenation and secretion clearance. Although early nutrition assessment and intervention are recommended for acutely and critically ill patients, rotational therapy may present challenges in providing this care. Here, we will describe the pathophysiology of ARDS and the rationale for use of prone positioning and review the considerations and challenges of providing nutrition therapy for patients in the prone position.

Critical illness neuro-myopathy (CINM) and focal amyotrophy in intensive care unit (ICU) patients with SARS-CoV-2: a case series.

We found four patients with some characteristic phenotype in our ICU, characterized by focal hypotrophies of the shoulder girdle and the bilateral peroneal district and underlying critical illness neuro-myopathy. In our opinion, these hypotrophies are secondary to the prone position. Is our intention to start early treatment protocol with electrostimulation to evaluate the effectiveness in the prevention of critical illness and focal hypotrophies in ICU SARS-CoV-2 patients, to increase chances of returning to a preinfection functional status.

Psychometric Properties of Pressure Pain Thresholds Measured in 2 Positions for Adults With and Without Neck-Shoulder Pain and Tenderness.

OBJECTIVE: The purpose of this study was to determine the psychometric properties of pressure pain threshold (PPT) testing in adults with and without neck-shoulder pain and tenderness and to compare the differences in PPT measurements between the seated and prone positions. METHODS: Thirty asymptomatic adults and 30 symptomatic patients with intermittent neck-shoulder pain and tenderness completed the study. A pressure algometer was used to assess PPTs at specific points on the middle deltoid, levator scapulae, and upper trapezius muscles of the dominant side of the asymptomatic individuals and the painful side of the patients. Four trials were performed on each muscle in both the seated and prone positions. To determine between-day reliability, a subset of the participants returned to repeat the testing. RESULTS: The intraclass correlation coefficients showed good to excellent within-session reliability and fair to excellent between-day reliability of PPT measurements in both the seated and prone positions for both groups. There were significant differences between groups for all muscles in both positions (P < .05) except for the upper trapezius muscle in the prone position. In addition, significant differences were found between the 2 testing positions for the middle deltoid and upper trapezius muscles in the symptomatic group and for the middle deltoid muscle in the asymptomatic group. CONCLUSION: The results of the study suggest that PPT testing could be useful for distinguishing individuals with and without neck-shoulder pain and tenderness. Further, the patient's position should be considered when testing PPT, specifically at the middle deltoid or upper trapezius muscles.

Force transmission between thoracic and cervical segments of the spine during prone-lying high-velocity low-amplitude spinal manipulation: A proof of principle for the concept of regional interdependence.

BACKGROUND: Regional interdependence is conceptually based on observations that applying manual therapy to a remote anatomical region has an effect in the area of the patient's primary complaint. The current model for regional interdependence depends on force transmissibility within the body. This investigation sought to determine transmissibility between forces applied to the thoracic spine during prone-lying high-velocity low-amplitude spinal manipulative therapy and the cervical spine. METHODS: A chiropractic treatment table was modified to allow (or disallow) translation of the headrest in the caudal-cephalad direction when unlocked (or locked). Prone-lying high-velocity low-amplitude spinal manipulative therapy was applied to the thoracic region of 9 healthy participants with the headrest in both configurations. Head and thorax kinematics and kinetics were measured at interfaces between participant and the external environment, which included the clinician's hands. Compressive forces at the cervicothoracic junction and angular kinematics of the cervical spine were derived. Ratios between the clinician-applied forces (input) and the cervical compressive force (output) were also determined. FINDINGS: The cervical spine extended during all high-velocity low-amplitude spinal manipulative therapy trials. Force input-to-output ratios exceeded 1 for high-velocity low-amplitude spinal manipulative therapy trials performed with the headrest in the locked configuration, which was greater than ratios for the unlocked configuration. INTERPRETATION: Forces imparted to thoracic spine during high-velocity low-amplitude spinal manipulative therapy were transmitted to the cervical spine, which provided a precursor for the regional interdependence model for manual therapy. Friction between the participant's face and the treatment table's head rest likely amplified cervical compressive forces.

New Evidence of Prehistoric Neurosurgery in Italy: The Case of Castello Del Tartaro.

Archaeological evidence of trepanation during the European Bronze Age is numerous and testifies a wide application of neurosurgical practices during prehistory. In some particular cases, trepanation may be associated with other peculiar evidence concerning funerary practices. The aim of this paper is to present the case of a woman from the Recent Bronze Age site of Castello del Tartaro (Verona, Italy), who was buried in a prone position and whose skeletal remains presented evidence of probable frontal trepanation. The association between a deviant burial and trepanation could be of interest in better understanding the history and perception of neurosurgical practices during prehistory.

The Variation of Cross-Sectional Area of the Sciatic Nerve in Flexion-Distraction Technique: A Cross-Sectional Study.

OBJECTIVE: The purpose of this study was to compare the cross-sectional area of the sciatic nerve in different positions of spinal manipulation using flexion-distraction technique. METHODS: Thirty healthy participants were assessed in 6 different flexion-distraction technique positions of varying lumbar, knee, and ankle positions. Participants stood in the following 3 positions with the lumbar in the neutral position: (A) with knee extended, (B) with knee flexed, and (C) with the knee extended and ankle dorsiflexion. Participants then stood in the following 3 positions with the lumbar flexed: (D) with the knee extended, (E) with the knee flexed, and (F) with knee extended and ankle dorsiflexion. The cross-sectional area (CSA) of the sciatic nerve was measured with ultrasound imaging in transverse sections in the posterior medial region of the left thigh. The CSA values measured at each position were compared. RESULTS: We analyzed 180 ultrasound images. The cross-sectional area of the sciatic nerve (in mm2) in position B (mean; standard deviation) (59.71-17.41) presented a higher mean cross-sectional area value compared with position D (51.18-13.81; P =.005), position F (48.71-15.16; P = .004), and position C (48.37-16.35; P = .009). CONCLUSION: The combination of knee extension and ankle dorsiflexion reduced the CSA of the sciatic nerve, and flexing the knee and keeping the ankle in the neutral position increased it.

Characteristics of sauna deaths in Korea in relation to different blood alcohol concentrations.

Although the benefits of sauna bathing have been demonstrated in epidemiological studies, sauna deaths have been reported. The aim of this study was to determine the demographic and forensic characteristics associated with different blood alcohol concentrations (BACs) in sauna deaths in Korea. In this retrospective analysis, data were collected from a nationwide pool in Korea between January 2008 and December 2015 to determine the role of alcohol intoxication in sauna deaths based on the subjects' BAC and to evaluate the demographic and forensic characteristics associated with different BACs. One hundred and three deaths were classified into 2 groups: the non-intoxication (NI) group (BAC,<0.08%; n = 27) and the intoxication (I) group (BAC,≥0.08%; n = 76). Demographic and forensic characteristics were compared between the groups using a multinomial logistic regression analysis. The proportions of decedents who were male (odds ratio: 17.4, 95.0% confidence interval: 3.8-79.8) and in a prone position at the scene of death (odds ratio: 11.3, 95.0% confidence interval: 2.1-60.1) were significantly higher (P < 0.001 and P < 0.05, retrospectively) in the I group than in the NI group. However, no significant differences were observed with respect to obesity, coronary artery narrowing, and liver pathology. Sauna deaths exhibited different characteristics according to BACs detected at autopsy. The differences in sauna deaths between the I and NI groups may have implications for the targeted prevention of sauna deaths associated with alcohol consumption.

The prone bridge test: Performance, validity, and reliability among older and younger adults.

INTRODUCTION: The prone bridge maneuver, or plank, has been viewed as a potential alternative to curl-ups for assessing trunk muscle performance. The purpose of this study was to assess prone bridge test performance, validity, and reliability among younger and older adults. METHOD: Sixty younger (20-35 years old) and 60 older (60-79 years old) participants completed this study. Groups were evenly divided by sex. Participants completed surveys regarding physical activity and abdominal exercise participation. Height, weight, body mass index (BMI), and waist circumference were measured. On two occasions, 5-9 days apart, participants held a prone bridge until volitional exhaustion or until repeated technique failure. Validity was examined using data from the first session: convergent validity by calculating correlations between survey responses, anthropometrics, and prone bridge time, known groups validity by using an ANOVA comparing bridge times of younger and older adults and of men and women. Test-retest reliability was examined by using a paired t-test to compare prone bridge times for Session1 and Session 2. Furthermore, an intraclass correlation coefficient (ICC) was used to characterize relative reliability and minimal detectable change (MDC95%) was used to describe absolute reliability. RESULTS: The mean prone bridge time was 145.3 ± 71.5 s, and was positively correlated with physical activity participation (p ≤ 0.001) and negatively correlated with BMI and waist circumference (p ≤ 0.003). Younger participants had significantly longer plank times than older participants (p = 0.003). The ICC between testing sessions was 0.915. CONCLUSION: The prone bridge test is a valid and reliable measure for evaluating abdominal performance in both younger and older adults.

Sensorineural hearing loss after spine surgery treated with hyperbaric oxygen therapy: two case reports.

Acute idiopathic sudden sensorineural hearing loss (ISSNHL) following lumbar spinal surgery is an exceedingly rare phenomenon. This paper presents a case of ISSNHL presenting acutely after lumbar spine decompression and fusion treated with transtympanic steroids and hyperbaric oxygen (HBO2) therapy. It also presents the ironic case of SSNHL secondary to presumed viral pathology sustained by the patient's operative surgeon who was treated with transtympanic steroids and HBO2 as well. Proposed etiologies of the patient's ISSNHL include: hypotension, prone operative position, malfitted/malpositioned headrest, microemboli from a cell-saver, and nitrous oxide anesthesia. The role of systemic hypotension as an etiology of ISSNHL is discussed given the fact that there are no reported cases of ISSNHL in orthopedic procedures performed with permissive hypotension. The initiation of steroids and HBO2 therapy has been shown to be an effective treatment for ISSNHL when started within 14 days of symptom onset. HBO2 and transtympanic steroids were initiated 10 days earlier in the operative surgeon, which showed to be a better treatment modality compared to the postoperative patient. ISSNHL in the acute postoperative period of lumbar spinal fusion surgery presents a unique treatment dilemma because systemic steroids are routinely avoided over concerns of pseudarthrosis. Of the seven documented cases of ISSNHL following lumbar spine surgery, none underwent HBO2 as a treatment modality.

Preoperative prone position exercises: a simple and novel method to improve tolerance to kyphoplasty for treatment of single level osteoporotic vertebral compression fractures.

BACKGROUND: The proper choice of anesthesia for kyphoplasty remains controversy. There are only a few clinical studies specially focusing on and giving detailed information about this treatment under local anesthesia with or without conscious sedation. To evaluate the effect of preoperative prone position exercises on patient tolerance to percutaneous kyphoplasty under local anesthesia. METHODS: Eighty-three patients with single level osteoporotic vertebral compression fractures were nonrandomly assigned to undergo percutaneous kyphoplasty under local anesthesia with preoperative prone position exercises or without. The number of procedure with or without a pause, need for intravenous sedation, and patient satisfactory were recorded and analyzed. Clinical outcomes were assessed using the visual analog scale and the Oswestry Disability Index. The follow-up time was 6 months. RESULTS: The baseline characteristics of both groups were comparable. The number of procedure without a pause in the exercises group was more than the control group (30/42 patients and 10/41 patients, respectively, P < 0.001), and fewer patients required intravenous sedation in the exercises group (7/42 and 28/41, respectively, P < 0.001). Patients in the exercises group were more satisfied compared to the control group (41/42 and 32/41, respectively, P < 0.01). There were no significant differences between the two groups with regard to improvement in pain and functional scores at all postoperative intervals. CONCLUSIONS: Prone position exercises may improve patient tolerance and satisfaction and reduce the need for intravenous sedation for those with single level vertebral compression fracture undergoing kyphoplasty under local anesthesia. We expect large sample size and multi-center randomized controlled trial studies to be conducted.

Effect of the Abdominal Hollowing and Bracing Maneuvers on Activity Pattern of the Lumbopelvic Muscles During Prone Hip Extension in Subjects With or Without Chronic Low Back Pain: A Preliminary Study.

OBJECTIVE: The purpose of this study was to compare the effect of abdominal hollowing (AH) and abdominal bracing (AB) maneuvers on the activity pattern of lumbopelvic muscles during prone hip extension (PHE) in participants with or without nonspecific chronic low back pain (CLBP). METHODS: Twenty women with or without CLBP participated in this cross-sectional observational study. The electromyographic activity (amplitude and onset time) of the contralateral erector spinae (CES), ipsilateral erector spinae (IES), gluteus maximus, and biceps femoris muscles was measured during PHE with and without abdominal maneuvers. A 3-way mixed model analysis of variance and post hoc tests were used for statistical analysis. RESULTS: Between-group comparisons showed that the CES onset delay during PHE alone was greater (P = .03) and the activity level of IES, CES, and biceps femoris in all maneuvers (P < .05) was higher in patients with CLBP than in asymptomatic participants. In asymptomatic participants, PHE + AH significantly decreased the signal amplitude (AMP) of IES (P = .01) and CES (P = .02) muscles. In participants with CLBP, IES muscle AMP was lower during PHE + AH compared with PHE + AB and PHE alone. With regard to onset delay, the results also showed no significant difference between maneuvers within either of the 2 groups (P > .05). CONCLUSIONS: Performance of the AH maneuver decreased the erector spinae muscle AMP in both groups, and neither maneuver altered the onset delay of any of the muscles in either group. The low back pain group showed higher levels of activity in all muscles (not statistically significant in gluteus maximus during all maneuvers). The groups were similar according to the onset delay of any of the muscles during either maneuver.

Surface anatomical landmarks for the location of posterior sacral foramina in sacral nerve stimulation.

BACKGROUND: Sacral nerve stimulation is a common treatment for various pelvic floor disorders. It consists of the percutaneous introduction of electrodes through the posterior sacral foramina for therapeutic stimulation of the target sacral spinal nerve. The aim of our study was to determine the surface anatomical landmarks of the sacrum to facilitate identification of the posterior sacral foramina. METHODS: This study was conducted on 20 human cadavers. The cadavers were placed in a prone position, and all the soft tissues of the sacral region were removed to allow exposure of the osseous structures. Different measurements were taken in relation to the posterior sacral foramina, the posterior superior iliac spine (PSIS) and the median sacral crest (MSC). A median coefficient of variation (CV) was determined. RESULTS: The diameter of the second sacral foramen showed the greatest variability. The distances between each individual foramen and the MSC had an acceptable variability (CV < 20%). In contrast, the distance between foramina had a high variability. The distance between PSIS and the second posterior sacral foramen was also found to have an acceptable variability (CV < 20%). However, the angle formed by an horizontal line between PSIS and a line between PSIS and S2 foramina had high variability. CONCLUSIONS: We found that the distance between sacral foramina and MSC is relatively constant while the distance between foramina and the relations between foramina and PSIS is highly variable. Detailed knowledge of the anatomy may facilitate electrode placement and is complementary to the regular use of fluoroscopy.