Finding the Needle in the Hay Stack: Population-based Study of Prediagnostic Symptomatic Interval in Children With CNS Tumors.

Central nervous system (CNS) tumors in children are a devastating diagnosis and delay in diagnosis is well documented in the literature. The aim of this study was to document and characterize time to diagnosis of CNS tumors among children 0 to 17 years of age in a pediatric center. A retrospective chart review was conducted of medical records of children with CNS tumors from 2000 to 2016 in British Columbia, Canada and 148 reports were available for review. Average age at diagnosis was 87.8 months (SD=59.7; median=72). One third (30%) were diagnosed after a single visit to a health care provider and 11 (7.7%) after more than 4 visits. Median time to diagnosis (prediagnostic symptomatic interval [PSI]) was 62 days (average 197±341 d; range, 0 to 2047 d). Longest period was time from first symptom to first health care provider visit (PSI1, median 37 d). Tumors in the posterior fossa and symptoms of ataxia or paresis were associated with a significantly shorter PSI. CNS tumors in children continue to pose a diagnostic challenge with variability in time to diagnosis. Our population-based study suggests variability in time to diagnosis with a need for education of families to identify symptoms associated with CNS tumors.

Outcomes and complications for individual neurosurgeons for the treatment of Chiari I malformation at a children's hospital.

PURPOSE: The aim of this study was to evaluate the outcomes and complications for individual surgeons at British Columbia Children's Hospital for the treatment of Chiari I Malformation (CMI) in children. METHODS: This was a retrospective review of patients with CMI who had surgery from 1986 to 2015. We assessed the Chicago Chiari Outcome Scores (CCOS) and complication rates by surgeon. RESULTS: Seventy patients, 38 males and 32 females, underwent posterior fossa decompression including 14 extradural and 56 intradural approaches. Syringomyelia was present in 74.3%. Most syringomyelia improved with no difference between intradural and extradural surgeries. After initial surgery, 13 patients (18.6%) had complications including 2/14 (14.3%) of extradural and 11/56 (19.6%) of intradural surgeries. Two patients required surgical intervention for complications whereas 11 had transient complications. The complication rate by surgeon ranged from 11 to 20% for extradural (2 surgeons only) and 10.5 to 40% for intradural surgeries (4 surgeons). The CCOS ranged from 12 to 15 for extradural and 6 to 16 for intradural. The CCOS ranges for surgeons 1 and 2 were 12-15 and 13-15 respectively for extradural. The CCOS ranges for surgeons 1, 2, 3, and 4 were 12-16, 6-15, 12-16, and 12-16 respectively for intradural. Thirteen patients had a second surgery for CMI. The final CCOS was good in 86% and moderate in 14%. CONCLUSION: There was variability in surgeries performed at BCCH by different surgeons, with variations in CCOS and complication rates. This information is important during decision making, consent process, and for quality improvement.

Choosing Wisely Canada: Pediatric Neurosurgery Recommendations.

OBJECTIVES: Choosing Wisely Canada is an evidence-based, patient-focused, physician-led campaign to improve the delivery of medical care in Canada. The goal of this study was to produce Canadian recommendations for physicians treating patients with selected paediatric neurosurgery issues. METHODS: Paediatric neurosurgeons practicing in Canada were invited to participate. Suggestions were obtained using an anonymous questionnaire, and then ranked anonymously by the participating surgeons. Suggestions that received consensus from participants were discussed at the 2016 annual Canadian Pediatric Neurosurgery Study Group meeting. Suggestions that were not evidence based, or that would not have a substantive population impact were eliminated. All remaining suggestions were anonymously ranked by the group and the top five recommendations were submitted to Choosing Wisely Canada. RESULTS: The final five recommendations include: 1) don't order a computed tomography scan to investigate macrocephaly (order an ultrasound or magnetic resonance imaging scan); 2) don't image a midline dimple related to the coccyx in an asymptomatic infant or child; 3) don't use computed tomography scans for routine imaging of children with hydrocephalus. Fast sequence nonsedated magnetic resonance imaging scans or ultrasounds provide adequate information to assess patients without exposing them to radiation or an anesthetic; 4) don't recommend helmets for mild to severe positional flattening; 5) don't do routine surveillance imaging for incidentally discovered Chiari I malformation. CONCLUSIONS: Five Choosing Wisely Canada recommendations were produced to support care of patients with paediatric neurosurgical issues. While these recommendations will apply to the majority of children with the involved conditions, occasionally, deviation from these recommendations may be clinically indicated.

The natural history and management of patients with congenital deficits associated with lumbosacral lipomas.

INTRODUCTION: Many patients with lumbosacral lipoma are asymptomatic; however, a significant proportion will have neurological deficits present at birth. Implication of these deficits with respect to natural history and management are not well understood. METHODS: A retrospective review of all infants with lumbosacral lipoma seen at BCCH between 1997 and 2013 was carried out. The study population was stratified on the presence of a congenital, non-progressive deficit and subdivided on treatment approach. The subsequent developments of deficits resulting in untethering procedures were recorded. RESULTS: Of the 44 infants in this study, 24 patients had no neurologic deficit while 20 patients had a fixed, non-progressive deficit evident at birth. Ten of 24 patients without a neurological deficit at birth underwent a prophylactic untethering with 3 eventually requiring repeat untethering after, on average, 62.7 months. Eleven of 14 asymptomatic, monitored patients required untethering for clinical deterioration. Two required a second untethering procedure after 48.7 months. Ten of 20 infants with congenital deficits present at birth underwent prophylactic untethering, and 4 required further surgery after 124 months. Ten patients underwent observation with 8 eventually requiring surgery. Two required repeat untethered after 154 months. The complication rates and operative burden for patients are similar whether prophylactic or delayed surgery is performed. CONCLUSION: The presence of congenital neurologic deficit does not affect the likelihood of deterioration in patients managed expectantly; prophylactic detethering of these patients did not prevent delayed neurologic deterioration. Comparing the need for repeat surgery in prophylactically untethered patients with initial untethering of patients operated upon at the time of deterioration, prophylactic untethering may confer a benefit with respect to subsequent symptomatic tethering if complication rates are low. However, in a setting with multidisciplinary follow-up, a period of observation for patients and intervention when patients become symptomatic is an acceptable approach for patients with or without congenital deficits.

Minimizing blood transfusions in the surgical correction of craniosynostosis: a 10-year single-center experience.

INTRODUCTION: Our center previously reported low transfusion rates for craniosynostosis surgery by two experienced neurosurgeons using standard intraoperative techniques and acceptance of low hemoglobin levels. This study evaluated whether low rates were maintained over the last 10 years and if a less experienced neurosurgeon, trained in and practicing in the same environment, could achieve similar outcomes. METHODS: All craniosynostosis operations performed in children between 2004 and 2015 were reviewed retrospectively. Transfusion rates were calculated. Analyses examined the relationship of transfusion to craniosynostosis type, surgical procedure, redo operation, surgeon, and perioperative hemoglobin levels. RESULTS: Two hundred eighteen patients were included: 71 open sagittal, 28 endoscopic-assisted sagittal, 32 unicoronal, 14 bicoronal, 42 metopic, and 31 multisuture. Median age at operation was 9.1 months. Overall transfusion rate was 24 %: 17 % open sagittal, 7 % endoscopic-assisted sagittal, 6 % unicoronal, 21 % bicoronal, 45 % metopic, and 45 % multisuture. The timing of transfusions were 75, 21, and 4 % for intraoperative, postoperative, and both, respectively. Patients not receiving transfusion had a mean lowest hemoglobin of 87 g/l (range 61-111) intraoperatively and 83 g/l (range 58-115) postoperatively. Mean lowest hemoglobin values were significantly lower in those necessitating intraoperative (75 g/l, range 54-102) or postoperative (59 g/l, range 51-71) transfusions. There was no significant difference in transfusion rate between less and more experienced surgeons. There were no cardiovascular complications or mortalities. CONCLUSION: In craniosynostosis surgery, reproducible, long-term low blood transfusion rates were able to be maintained at a single center by careful intraoperative technique and acceptance of low intraoperative and postoperative hemoglobin levels in hemodynamically stable patients. Furthermore, low rates were also achieved by an inexperienced neurosurgeon in the group. This suggests that these results may be achievable by other neurosurgeons, who follow a similar protocol.

Does Muscular Force of the Upper Body Increase Following Acute, Direct Vibration?

The aim of the current study was to examine the acute effect of direct vibration has on bicep curl force-generating capacity. 11 healthy team and individual sport-trained males performed right and left DB bicep curl at 50% of 1 RM where peak force (PF), mean force (MF), rate of force development (RFD) and electromyography (EMG) were assessed during the concentric phase before and immediately after direct vibration. Using new vibration technology utilizing a pulsing frequency (0-170 Hz) each arm was randomly assigned to receive either 10 min of direct vibration or control (no vibration). Following direct vibration PF increased 6.6±4.5 N (difference pre-post±90 CL; p>0.05) compared to control FP (-1.2±65 N; p>0.05) however, this was not significant. Furthermore, there were no other significant changes (p>0.05) in MP, RFD and EMG between vibration and control arms. This is in agreement with other research that has reported that acute strength changes from vibration elicits negligible changes, however it appears that there are no detrimental effects of using this new vibration device.

The Acute Effect of Direct Vibration on Muscular Power Performance in Master Athletes.

This study examined the acute effect of direct vibration on biceps brachii muscular power in master athletes. 10 healthy male national representative master field-hockey players were randomly assigned to receive 10 min of pulsing sinusoidal vibration or no vibration (control) to the right and left biceps brachii. Pre- and post-testing included lifting 2 repetitions of standing dumbbell (DB) biceps curl at 50% 1 RM (repetition maximum). Mechanical peak power (PP), mean concentric power (MCP) and normalised electromyography (EMG) was assessed during the concentric phase of the biceps curl. Following vibration PP increased 44.3±23.6 W (difference pre-post; p=0.013) compared to control (5.9±9.5 W; p=0.334). Similarly, MCP increased 12.0±4.5 W (p=0.002) compared to control (1.5±0.8 W; p=0.397). However, there was no significant difference in normalised EMG between vibration and control (p>0.05). The increase in PP and MCP did not coincide with an increase in EMG and suggests that other mechanisms may be contributing to changes in muscle performance. Given its ease of use and portability the vibratory device may be considered as an alternative warm-up modality immediately prior to explosive activities.

Intraoperative ultrasound in pediatric brain tumors: does the surgeon get it right?

PURPOSE: Intraoperative ultrasound (iUS) is a valuable tool-inexpensive, adds minimal surgical time, and involves minimal risk. The diagnostic predictive value of iUS is not fully characterized in Pediatric Neurosurgery. Our objective is to determine if surgeon-completed iUS has good concordance with post-operative MRI in estimating extent of surgical resection (EOR) of pediatric brain tumors. METHODS: We reviewed charts of all pediatric brain tumor resections (single institution 2006-2013). Those with iUS and postoperative imaging (<1 week) were included. The surgeon's estimation of the EOR based on iUS and the post-operative neuroimaging results (gold standard) were collected, as well as information about the patients/tumors. RESULTS: Two hundred two resections were reviewed and 58 cases were included. Twenty-six of the excluded cases utilized iUS but did not have EOR indicated. The concordance of interpretation between iUS and post-operative MRI was 98.3%. Of 43 cases where iUS suggested gross total resection, 42 were confirmed on MRI (negative predictive value (NPV), 98%). All 15 cases where iUS suggested subtotal resection were confirmed on MRI (positive predictive value (PPV), 100 %). Agreement between iUS and post-operative imaging had an overall Kappa score of 0.956, signifying almost perfect agreement. CONCLUSION: The results from this study suggest that iUS is reliable with both residual tumor (PPV-100%) and when it suggests no residual (NPV-98%) in tumors that are easily identifiable on iUS. However, tumors that were difficult to visualize on iUS were potentially excluded, and therefore, these results should not be extrapolated for all brain tumor types.

Does Vibration Warm-up Enhance Kinetic and Temporal Sprint Parameters?

The aim of this study was to investigate the efficacy of vibration warm-up to enhance sprint performance. 12 males involved in representative team sports performed 4 warm-up conditions in a randomised order performed at least 24 h apart; VbX warm-up (VbX-WU); Neural activation warm-up (Neu-WU); Dynamic warm-up (Dyn-WU) and Control (No VbX). Participants completed 5 m sprint at 30 s, 2:30 min and 5 min post warm-up where sprint time, kinetics, and temporal components were recorded. There was no significant (p>0.05) main effect or interaction effect between the split sprint times of 1 m, 2.5 m, and 5 m. There was a condition effect where vertical mean force was significantly higher (p<0.05) in Dyn-WU and Control compared to Neu-WU. No other significant (p>0.05) main and interaction effects in sprint kinetic and temporal parameters existed. Overall, all 4 warm-up conditions produced comparable results for sprint performance, and there was no detrimental effect on short-duration sprint performance using VbX-WU. Therefore, VbX could be useful for adding variety to the training warm-up or be included into the main warm-up routine as a supplementary modality.

Effect of paddle grip on segmental fluid distribution and injuries occurrence in elite slalom paddlers.

AIM: The aim of this current study was to assess the segmental fluid distribution, grip strength and injury occurrence in elite slalom kayakers and canoeists. METHODS: Ninety three world-cup competitors (72 males; 21 females) took part in the study. Impedance analysis assessed segmental fluid asymmetry and a questionnaire evaluated injury occurrence during the three previous years. The effect of paddle grip (loose/fixed hand in kayakers, lower/upper hand in canoeists), morphological dominance (dominant/non-dominant) and discipline (canoe/kayak) was evaluated by repeated measures ANOVA. RESULTS: The findings indicated a significant effect of paddle grip in male canoeists on morphological asymmetry in the upper limbs (arm of lower paddle hand, mean fluid distribution 3.17, s=0.47 litres; arm of upper paddle hand mean fluid distribution 3.08, s=0.45 litres; P<0.001, ωp2=0.32). Significant morphological asymmetry was found also in kayakers but the effect of paddle grip was not substantial. Grip strength was not related to paddle grip. Paddlers with arm morphological asymmetry reported upper limb injury occurrence in 60% of cases, which was 3 times more than in paddlers without arm morphological asymmetry. CONCLUSION: As upper-limb asymmetry was directly associated with paddle grip in male canoeists, canoe paddling may lead to higher bilateral morphological asymmetry and therefore, injury occurrence.

Acute unilateral leg vibration exercise improves contralateral neuromuscular performance.

OBJECTIVES: To examine the post-exercise cross-transfer effects of acute whole body vibration (WBV). METHODS: Seventeen healthy male volunteers (20.8 ± 1.2 y) performed three unilateral vibration conditions in a randomized order: 1) WBV-50 Hz [high amplitude]; 2) WBV-30 Hz [low amplitude]; and 3) a control no WBV condition (Sham) applied to the dominant leg. Each condition involved maximal voluntary isometric contractions (MVC) followed by three leg press explosive repetitions (40% MVC) with non-dominant and dominant legs; which were conducted prior to and post vibration (immediately; 2 min and 5 min). Surface electromygraphy (sEMG) of the vastus lateralis (VL) and medial gastrocnemius (MG) were measured throughout each condition. RESULTS: A condition x leg x time interaction effect was detected (p=0.001) where 50 Hz-High in the stimulated leg enhanced mean velocity at post-2 min compared to 30 Hz-Low and Sham, remaining elevated at post-5 min. Similarly, 50 Hz-High in the non-stimulated leg increased mean velocity at post-immediately and post-2 min compared to 30 Hz-Low and Sham. There were no changes in sEMG of VL and GM in the stimulated and non-stimulated post-conditions. CONCLUSION: WBV (50 Hz) can augment cross-transfer in neuromuscular performance. WBV could provide an alternate method of unilateral training to promote cross education explosive strength.

Growing teratoma syndrome in intracranial non-germinomatous germ cell tumors (iNGGCTs): a risk for secondary malignant transformation­a report of two cases.

PURPOSE: About 5% of pediatric intracranial germ cell tumors and 20% of non-germinomatous germ cell tumors (NGGCT) progress to growing teratoma syndrome (GTS) following chemoradiotherapy. The growing teratoma is thought to arise from the chemotherapy-resistant, teratomatous portion of a germ cell tumor and is commonly benign but may undergo malignant transformation. METHODS: Two pediatric patients whose intracranial NGGCTs progressed to growing teratomas during chemotherapy and later transformed to secondary malignant tumors after partial resection and radiation therapy (RT). RESULTS: Both tumors were diagnosed by MRI scans and elevated serum and CSF markers. Following normalization of tumor markers with chemotherapy and initial decrease in tumor volume, subsequent imaging showed regrowth during chemotherapy with pathology revealing benign teratoma. RT was administered. Several years following this treatment, further growth was seen with pathology indicating malignant carcinoma in one patient and malignant rhabdomyosarcoma in the other. The patient with carcinoma received palliative care while the patient with the sarcoma received further resection, intensive chemotherapy, and an autologous stem cell transplant and is currently in remission, 36 months since malignant transformation. CONCLUSION: Malignant transformation of presumed residual teratoma has been seldom reported. Treatment of NGGCT involves platinum-based chemotherapy with craniospinal RT and boost to the primary site, with cure rates of around 80%. Teratomas are characteristically chemotherapy and RT resistant and are treated surgically. In the event that residual or growing teratoma is suspected, a complete resection should be considered early in the management as there is a risk of malignant transformation of residual teratoma.

Does acute side-alternating vibration exercise enhance ballistic upper-body power?

The aim of this study was to investigate the effects of acute vibration exercise, at 2 different frequencies, on upper body power output. Muscle activity (EMG) and upper-body peak power was measured in 12 healthy males during ballistic bench press throws at 30% of 1-repetition maximum on a Smith machine. Measures were made prior to, 30 s and 5 min after one of 3 conditions performed for 30 s in a press-up position: side-alternating vibration at 20 Hz, 26 Hz and no vibration. EMG was recorded in the anterior deltoid, triceps brachii and pectoralis major during ballistic bench press throws as well as during application of each condition. While peak power output was higher at 5 min post condition across all conditions, compared to baseline measures (P<0.05), only 20 Hz vibration resulted in a significant increase in peak power output (P<0.05) compared to no vibration. EMG was greater during both vibration conditions, compared to no vibration (P<0.001). However, this difference was not evident during bench press throws when no difference was seen in muscle activity between conditions. These findings suggest that 20 Hz vibration has an ergogenic effect on upper-body power that may be due to peripheral, rather than central, mediated mechanisms.

What would I want for my surgery?

If you were to have an operation tomorrow, would you want your surgical team members to feel comfortable speaking up, to defy hierarchy, to interact with each other just as well as they perform technical aspects of the procedure? Would you want to feel like part of the team? Your answers to these admittedly leading questions are based on the culture of the surgical team and the interdependence of team members and are at the heart of a current debate around the surgical checklist's effectiveness. In British Columbia (BC), many individuals responded to the paper by Urbach et al. (2014) that described the minimal impact on patient mortality after implementation of the surgical safety checklist in Ontario. They wrote to the Surgical Quality Action Network (SQAN) to express their perspectives, and interestingly, some refuted and others supported the conclusions. Given the strong reaction this study created in the surgical community, a number of key stakeholders have prepared a response in order to provide another perspective to the article and emphasize the checklist's value for improving the culture of surgical teams.

Does optic nerve sheath diameter on MRI decrease with clinically improved pediatric hydrocephalus?

INTRODUCTION: Serial change in ventricular size is recognized as an imperfect indicator of ongoing hydrocephalus in children. Potentially, other radiographic features may be useful in determining the success of hydrocephalus interventions. In this study, optic nerve sheath diameter (ONSD), optic nerve tortuosity, and optic disk bulging were assessed as indicators of hydrocephalus control in children who underwent endoscopic third ventriculostomy (ETV) or posterior fossa tumor resection. METHODS: Sixteen children underwent ETV or tumor resection for treatment of hydrocephalus. T2-weighted axial magnetic resonance images of the orbit were obtained, and the ONSD was measured posterior to the optic globe, pre- and post-intervention. Evidence of optic disk bulging and optic nerve tortuosity was also assessed. Ventricular size was estimated using the frontal and occipital horn ratio (FOR). RESULTS: There was a significant reduction in the ONSD post-ETV (n = 9) and after tumor resection (n = 7). Average preoperative ONSD was 6.21 versus 5.71 mm postoperatively (p = 0.0017).There was also an 88% (p = 0.011) and 60% (p = 0.23) reduction in optic disk bulging and tortuosity, respectively. The FOR normalized in the tumor resection group but not the ETV group. After intervention, all patients showed improvement in signs and symptoms of hydrocephalus. CONCLUSION: In our study population, ONSD decreased in response to measures to reduce hydrocephalus. Optic disk bulging also appears to resolve. Serial reduction in ONSD, and optic disk bulging may be indicators of improved hydrocephalus following pediatric neurosurgical interventions.

Does intermittent pneumatic leg compression enhance muscle recovery after strenuous eccentric exercise?

Intermittent pneumatic compression (IPC) has gained rapid popularity as a post-exercise recovery modality. Despite its widespread use and anecdotal claims for enhancing muscle recovery there is no scientific evidence to support its use. 10 healthy, active males performed a strenuous bout of eccentric exercise (3 sets of 100 repetitions) followed by IPC treatment or control performed immediately after exercise and at 24 and 48 h post-exercise. Muscular performance measurements were taken prior to exercise and 24, 48 and 72 h post-exercise and included single-leg vertical jump (VJ) and peak and average isometric [knee angle 75º] (ISO), concentric (CON) and eccentric (ECC) contractions performed at slow (30° · s⁻¹) and fast (180° · s⁻¹) velocities. Plasma creatine kinase (CK) samples were taken at pre- and post-exercise 24, 48 and 72 h. Strenuous eccentric exercise resulted in a significant decrease in peak ISO, peak and average CON (30° · s⁻¹) at 24 h compared to pre-exercise for both IPC and control, however VJ performance remained unchanged. There were no significant differences between conditions (IPC and control) or condition-time interactions for any of the contraction types (ISO, CON, ECC) or velocities (CON, ECC 30° · s⁻¹ and 180° · s⁻¹). However, CK was significantly elevated at 24 h compared to pre-exercise in both conditions (IPC and control). IPC did not attenuate muscle force loss following a bout of strenuous eccentric exercise in comparison to a control. While IPC has been used in the clinical setting to treat pathologic conditions, the parameters used to treat muscle damage following strenuous exercise in healthy participants are likely to be very different than those used to treat pathologic conditions.

Identification by families of pediatric adverse events and near misses overlooked by health care providers.

BACKGROUND: Identifying adverse events and near misses is essential to improving safety in the health care system. Patients are capable of reliably identifying and reporting adverse events. The effect of a patient safety reporting system used by families of pediatric inpatients on reporting of adverse events by health care providers has not previously been investigated. METHODS: Between Nov. 1, 2008, and Nov. 30, 2009, families of children discharged from a single ward of British Columbia's Children's Hospital were asked to respond to a questionnaire about adverse events and near misses during the hospital stay. Rates of reporting by health care providers for this period were compared with rates for the previous year. Family reports for specific incidents were matched with reports by health care providers to determine overlap. RESULTS: A total of 544 familes responded to the questionnaire. The estimated absolute increase in reports by health care providers per 100 admissions was 0.5% (95% confidence interval -1.8% to 2.7%). A total of 321 events were identified in 201 of the 544 family reports. Of these, 153 (48%) were determined to represent legitimate patient safety concerns. Only 8 (2.5%) of the adverse events reported by families were also reported by health care providers. INTERPRETATION: The introduction of a family-based system for reporting adverse events involving pediatric inpatients, administered at the time of discharge, did not change rates of reporting of adverse events and near misses by health care providers. Most reports submitted by families were not duplicated in the reporting system for health care providers, which suggests that families and staff members view safety-related events differently. However, almost half of the family reports represented legitimate patient safety concerns. Families appeared capable of providing valuable information for improving the safety of pediatric inpatients.

Is vibration exercise a useful addition to a weight management program?

Vibration exercise (VbX) has received a lot of attention as an exercise modality, which evokes muscular work and elevates metabolic rate that could be a potential method for weight reduction. Popular press has purported that VbX is quick and convenient, and 10 min of VbX is equivalent to 1 h of traditional exercise, where it has been marketed as the new weight-loss and body toning workout. However, research studies have shown that muscle activation occurs but the energy demand in response to VbX is quite low, where exhaustive VbX reported a metabolic demand of 23 mL/kg/min compared with 44 mL/kg/min from an exhaustive cycle test. Different vibration frequencies with varying amplitudes and loads have been tested, but only small increases in metabolic rate have been reported. Based on these findings, it has been indirectly calculated that a VbX session of 26 Hz for three continuous minutes would only incur a loss of ≈ 10.7 g fat/h. Following a 24-week program of VbX, no observed differences were found in body composition, and following 12 months of VbX, the time to reach peak V ˙O2 was significantly higher in conventional exercise compared with VbX. However, one study has reported that percentage body fat decreased by 3.2% after 8 months after VbX in comparison with resistance and control groups that performed no aerobic conditioning. The evidence to date suggests that VbX can increase whole and local oxygen uptake; however, with additional load, high vibration frequency, and/or amplitude, it cannot match the demands of conventional aerobic exercise. Therefore, caution is required when VbX programs are solely used for the purpose of reducing body fat without considering dietary and aerobic conditioning guidelines.