Effects of inspiratory muscle training on pulmonary function, diaphragmatic thickness, balance and exercise capacity in people after stroke: a systematic review and meta-analysis.

PURPOSE: To examine the effects of inspiratory muscle training (IMT) on pulmonary and diaphragmatic function, exercise capacity, balance and quality of life (QOL), in post-stroke individuals. METHODS: A literature search was conducted using MEDLINE, CINAHL, EMBASE, PubMed, PEDro, Web of Science and China Biological Medicine databases. Randomized controlled trials (RCTs) with a PEDro score ≥6 focusing on the effects of IMT were included. The GRADE system was used to determine the certainty of evidence for each outcome. RESULTS: Nine studies (255 participants) were included. IMT significantly increased forced expiratory volume in one second (FEV1) (4 studies, 112 participants, mean difference (MD)=0.18 litre, 95% confidence interval (CI): 0.14-0.23); maximal inspiratory pressure (MIP) (8 studies, 226 participants, MD = 6.37 cm H2O, 95% CI: 1.26-11.49); and diaphragm thickness fraction (DTf) on both sides (MD of affected side vs. unaffected side: 51 vs. 37%). The evidence certainty for diaphragmatic function was moderate. No significant change was observed in forced vital capacity (FVC), balance function, exercise capacity and QOL. CONCLUSION: This review reveals moderate evidence certainty in support of IMT improving diaphragmatic function. It appears that a training intensity between 30 and 50% MIP results in a significantly improved MIP.

Stroke not only impacts motor function but also affects respiratory function, especially diaphragmatic function.Inspiratory muscle training (IMT) is an intervention that has been used to improve the strength and endurance of inspiratory muscles.There is evidence of moderate certainty which cautiously recommends IMT to improve diaphragmatic function after stroke.The evidence supporting IMT for the enhancement of forced vital capacity, balance function, exercise capacity and quality of life in stroke patients is inadequate.

rTMS for Poststroke Pusher Syndrome: A Randomized, Patient-Blinded Controlled Clinical Trial.

BACKGROUND: Patients with poststroke pusher syndrome (PS) require longer duration of rehabilitation and more supplemental care after discharge. Effective treatment of PS remains a challenge. The role of repetitive transcranial magnetic stimulation (rTMS) for PS has not been examined. OBJECTIVE: Assess the efficacy of rTMS for patients with poststroke PS in reducing pushing behavior, enhancing motor recovery and improving mobility. METHODS: A randomized, patient- and assessor-blinded sham-controlled trial with intention-to-treat analysis was conducted. Thirty-four eligible patients with poststroke PS were randomly allocated to receive either rTMS or sham rTMS for 2 weeks. Pushing behavior on the Burke lateropulsion scale and scale for contraversive pushing, motor function on Fugl-Meyer assessment scale-motor domain (FMA-m) and mobility on modified Rivermead mobility index were measured at baseline, 1 and 2 weeks after intervention. Repeated-measures analysis of covariance was used for data analysis. RESULTS: There was no significant interaction between intervention and time on Burke lateropulsion scale (F = 2.747, P = .076), scale for contraversive pushing (F = 1.583, P = .214), or change of modified Rivermead mobility index (F = 1.183, P = .297). However, a significant interaction between intervention and time was observed for FMA-m (F = 5.464, P = .019). Post hoc comparisons of FMA-m show better improvement in rTMS group with mean differences of 12.7 (95% CI -7.3 to 32.7) and 15.7 (95% CI -4.6 to 36.0) at post-treatment week 1 and week 2 respectively. CONCLUSIONS: rTMS did not demonstrate significant efficacy in improving pushing behavior and mobility in patients with PS. However, rTMS might have potential effect in enhancing motor function for patients with PS. REGISTRATION: The study was registered in the Chinese Clinical Trial Registry (registration No. ChiCTR2200058015 at http://www.chictr.org.cn/searchprojen.aspx) on March 26, 2022.

Vestibular rehabilitation therapy on balance and gait in patients after stroke: a systematic review and meta-analysis.

BACKGROUND: There is limited evidence to support the use of vestibular rehabilitation therapy (VRT) on improving balance and gait in patients after stroke. This systematic review aimed to evaluate the effects of VRT in addition to usual rehabilitation compared with usual rehabilitation on improving balance and gait for patients after stroke. METHODS: This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis statement guidelines. Ten electronic databases were searched up to 1 June 2023 without restrictions in language and publication status. The PEDro scale and the Grading of Recommendations Assessment Development, and Evaluation were used to evaluate the risk of bias and the certainty of evidence. The meta-analysis was conducted with Review Manager 5.3. RESULTS: Fifteen randomised controlled trials with 769 participants were included. PEDro scale was used to assess the risk of bias with a mean score of 5.9 (0.7). VRT was effective in improving balance for patients after stroke (SMD = 0.59, 95% CI (0.40, 0.78), p < 0.00001), particularly for patients after stroke that occurred within 6 months (SMD = 0.56, 95% CI (0.33, 0.79), p < 0.00001) with moderate certainty of evidence. Subgroup analysis showed that VRT provided as gaze stability exercises combined with swivel chair training (SMD = 0.85, 95% CI (0.48, 1.22), p < 0.00001) and head movements (SMD = 0.75, 95% CI (0.43, 1.07), p < 0.00001) could significantly improve balance. Four-week VRT had better effect on balance improvement (SMD = 0.64, 95% CI (0.40, 0.89), p < 0.00001) than the less than 4-week VRT. The pooled mean difference of values of Timed Up-and-Go test showed that VRT could significantly improve gait function for patients after stroke (MD = -4.32, 95% CI (-6.65, -1.99), p = 0.0003), particularly for patients after stroke that occurred within 6 months (MD = -3.92, 95% CI (-6.83, -1.00), p = 0.008) with moderate certainty of evidence. CONCLUSIONS: There is moderate certainty of evidence supporting the positive effect of VRT in improving balance and gait of patients after stroke. TRIAL REGISTRATION: PROSPERO CRD42023434304.

Pediatric Rehabilitation Therapy and Physiotherapy Education in China.

AIMS: To explore the pediatric rehabilitation curriculum, clinical placement, faculty characteristics, facilitators and barriers to curriculum implementation, and satisfaction of graduates of entry-level programs of rehabilitation therapy and physiotherapy in China. METHODS: Two online cross-sectional surveys were conducted. With stratified random sampling, faculty were contacted to provide information on pediatric rehabilitation education in Survey A. In Survey B, the satisfaction of 2019 graduates was collected. Fifty-three faculty members (response rate 96.4%) completed Survey A and 154 graduates (response rate 85.6%) completed Survey B. RESULTS: There were variations in pediatric rehabilitation curriculum setting, clinical placement, and faculty characteristics. The key facilitator to implementation was a stand-alone pediatric course. The insufficient number of teachers was identified as the major barrier. The median satisfaction level of all 2019 graduates for curricular setting, faculty and placement was 4 (satisfied). The satisfaction level of 2019 graduates of programs accredited by the World Physiotherapy was statistically higher than that of graduates of non-accredited programs in curricular setting and faculty. CONCLUSIONS: The results support the need for faculty development and guidelines on minimum standards for entry-level pediatric rehabilitation education in China.

Reliability and validity of sit-to-stand test protocols in patients with coronary artery disease.

Background: Sit-To-Stand (STS) tests are reported as feasible alternatives for the assessment of functional fitness but the reliability of these tests in people with coronary artery disease (CAD) has not been reported. This study explored the test-retest reliability, convergent and known-groups validity of the five times, 30-sec and 1-min sit-to-stand test (FTSTS test, 30-s STS test and 1-min STS test respectively) in patients with CAD. The feasibility of applying these tests to distinguish the level of risk for cardiovascular events in CAD patients was also investigated. Methods: Patients with stable CAD performed a 6MWT and 3 STS tests in random order on the same day. Receiver operating characteristic (ROC) curve analyses were conducted using STS test data to differentiate patients with low or high risk of cardiovascular events based on the risk level determined by distance covered in the 6MWT as > or ≤ 419 m. Thirty patients repeated the 3 STS tests on the following day. Results: 112 subjects with diagnoses of atherosclerosis or post-percutaneous coronary intervention, or post-acute myocardial infarction (post-AMI) participated in the validity analysis. All 3 STS tests demonstrated moderate and significant correlation with the 6MWT (coefficient values r for the FTSTS, 30-s STS and 1-min STS tests were-0.53, 0.57 and 0.55 respectively). Correlations between left ventricular ejection fraction (LVEF) and all STS tests and between 6MWT and LVEF were only weak (r values ranged from 0.27 to 0.31). Subgroup analysis showed participants in the post-AMI group performed worse in all tests compared to non-myocardial infarction (non-MI) group. The area under the curve (AUC) was 0.80 for FTSTS (sensitivity: 75.0%, specificity: 73.8%, optimal cut-off: >11.7 sec), and the AUC, sensitivity, specificity and optimal cut-off for 30-s STS and 1-min STS test were 0.83, 75.0%, 76.2%, ≤ 12 repetitions and 0.80, 71.4%, 73.8%, ≤ 23 repetitions respectively. The intraclass correlation coefficients (ICC) for repeated measurements of the FTSTS, 30-s STS and 1-min STS tests were 0.96, 0.95 and 0.96 respectively, with the minimal detectable change (MDC95) computed to be 1.1 sec 1.8 repetitions and 3.9 repetitions respectively. Conclusions: All STS tests demonstrated good test-retest reliability, convergent and known-groups validity. STS tests may discriminate low from high levels of risk for a cardiovascular event in patients with CAD.

rTMS for poststroke pusher syndrome: study protocol for a randomised, patient-blinded controlled clinical trial.

INTRODUCTION: Poststroke pusher syndrome (PS) prevalence is high. Patients with PS require longer rehabilitation with prolonged length of stay. Effective treatment of PS remains a challenge for rehabilitation professionals. Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuromodulation technique that is effective and recommended in the clinical guidelines of stroke rehabilitation. However, the role of rTMS for PS has not been examined. The study is to assess the efficacy of a specific rTMS programme for patients with PS in reducing pushing behaviour, enhancing motor recovery and improving mobility, as well as testing the safety of rTMS for patients with PS. METHODS AND ANALYSIS: A randomised, patient and assessor blinded sham-controlled trial with two parallel groups will be conducted. Thirty-four eligible patients with PS will be randomly allocated to receive either rTMS or sham rTMS for 3 weeks. The primary assessment outcome is the pushing behaviour measured by the Burke Lateropulsion Scale and Scale for Contraversive Pushing. The secondary outcomes are the motor functions and mobility measured by the Fugl-Meyer Assessment Scale (motor domain) and Modified Rivermead Mobility Index, and any adverse events. Assessment will be performed at baseline and 1 week, 2 weeks and 3 weeks after intervention. Repeated-measures analysis of variance will be used for data analysis with the level of significance level set at 0.05. ETHICS AND DISSEMINATION: The protocol has been approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University on 23 March 2022 (2022-133). The trial findings will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry (ChiCTR2200058015).

Stroke volume and cardiac output during 6 minute-walk tests are strong predictors of maximal oxygen uptake in people after stroke.

BACKGROUND AND OBJECTIVES: The 6-minute walk test (6MWT) is a field test commonly used to predict peak oxygen consumption (VO2peak) in people after stroke. Inclusion of cardiodynamic variables measured by impedance cardiography (ICG) during a 6MWT has been shown to improve prediction of VO2peak in healthy adults but these data have not been considered in people after stroke. This study investigates whether the prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT in people after stroke. METHODS: This was a cross-sectional study. Patients diagnosed with stroke underwent in random order, a maximal cardiopulmonary exercise test (CPET) and 6MWT in separate dates. Heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG during all tests. Oxygen consumption was recorded by a metabolic cart during the CPET. Recorded data were subjected to multiple regression analyses to generate VO2peak prediction equations. RESULTS: Fifty-nine patients, mean age 50.0±11.7 years were included in the analysis. The mean distance covered in the 6MWT (6MWD) was 294±13 m, VO2peak was 19.2±3.2 ml/min/kg. Mean peak HR, SV and CO recorded during 6MWT were 109±6 bpm, 86.3±8.8 ml, 9.4±1.2 L/min and during CPET were 135±14 bpm, 86.6±9 ml, 11.7±2 L/min respectively. The prediction equation with inclusion of cardiodynamic variables: 16.855 + (-0.060 x age) + (0.196 x BMI) + (0.01 x 6MWD) + (-0.416 x SV6MWT) + (3.587 x CO 6MWT) has a higher squared multiple correlation (R2) and a lower standard error of estimate (SEE) and SEE% compared to the equation using 6MWD as the only predictor. CONCLUSION: Inclusion of SV and CO measured during the 6MWT in stroke patients further improved the VO2peak prediction power compared to using 6MWD as a lone predictor.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation-Implications for Physiotherapists.

Objectives: To investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI). Methods: A total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op. Results: The mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as "high risk" prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ. Conclusion: This is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Cardiodynamic variables measured by impedance cardiography during a 6-minute walk test are reliable predictors of peak oxygen consumption in young healthy adults.

Accurate prediction of aerobic capacity is necessary to guide appropriate exercise prescription. It is common to use 6-minute walk distance (6MWD) to predict peak oxygen uptake (VO2peak) in the clinical environment. The aim of this study was to determine whether prediction of VO2peak can be improved by the inclusion of cardiovascular indices derived by impedance cardiography (ICG) during the 6MWT. A total of 62 healthy university students aged 21±1 years completed in separate days, a cardiopulmonary exercise test (CPET) and two 6MWTs (30 min apart), during which heart rate (HR), stroke volume (SV) and cardiac output (CO) were measured by ICG (PhysioFlow® PF07 EnduroTM). The CPET was conducted with the Ergoselect 200 Ergoline and oxygen consumption measured by a MasterScreenTM CPX breath-by-breath metabolic cart. Multiple regression analyses were conducted to generate VO2peak prediction equations using 6MWD with, or without the cardiovascular indices recorded at the end of the best performed 6MWT as predictor variables. The mean peak HR (bpm), SV (ml) and CO (L/min) recorded during 6MWT were 156±18, 95.6±9, 15±2.8 and during CPET were 176±16, 91.3±8, 16.2±2.7, respectively. Analyses revealed the following VO2peak prediction equation: VO2peak = 100.297+(0.019x6MWD)+(-0.598xHR6MWT)+(-1.236xSV6MWT) + (8.671 x CO6MWT). This equation has a squared multiple correlation (R2) of 0.866, standard error of the estimate (SEE) of 2.28 mL/kg/min and SEE:VO2peak (SEE%) of 7.2%. Cross-validation of equation stability using predicted residual sum of squares (PRESS) statistics showed a R2 (Rp2), SEE (SEEp) and SEEp% of 0.842, 2.38 mL/kg/min and 7.6% respectively. The minimal shrinkage of R2 implied regression model stability. Correlation between measured and predicted VO2peak using this equation was strong (r = 0.931, p<0.001). When 6MWD alone was used as the predictor for VO2peak, the generated equation had a lower R2 (0.549), and a higher SEE (4.08 mL/kg/min) and SEE% (12.9%). This is the first study which included cardiac indices during a 6MWT as variables for VO2peak prediction. Our results suggest that inclusion of cardiac indices measured during the 6MWT more accurately predicts VO2peak than using 6MWD data alone.

Noninvasive investigation of the cardiodynamic response to 6MWT in people after stroke using impedance cardiography.

This is a cross-section observational study that investigated the cardiodynamic response to a 6-minute walk test (6MWT) in patients after stroke using impedance cardiography (ICG). Patients diagnosed with stroke were invited to participate in a 6MWT on consecutive days. Heart rate (HR), cardiac output (CO), stroke volume (SV) and cardiac index (CI) were measured by ICG using the PhysioFlow® PF07 EnduroTM at 1-second intervals for 10 minutes prior to, during and for 10 minutes after each 6MWT. Oxygen saturation, perceived exertion score (modified Borg scale) and the distance covered at the end of each 6MWT were recorded. Twenty-nine patients (mean age 55.6±10.9 years) completed the study. The mean duration of stroke after diagnosis was 14.4±19.1 months. There were no differences in the measured data between the first and second 6MWT (mean intraclass correlation coefficient (ICC) range: 0.87-0.95). The 6 minute walk distance (6WMD) covered in the two 6MWTs was 246±126 and 255±130m respectively (p>0.05). Mean measured data for each subject at rest, and at the end of the better performed 6MWT were, respectively: HR 78±11 and 100±18 bpm; CO 5.5±1.2 and 8.9±2.6 l/min, SV 71.3±16 and 89.3±18.6 ml/beat and CI 3.0±0.6 and 4.9±1.3 l/min/m2. After commencement of the 6MWT, the increase in SV took 30 sec before the rise approaching a plateau, whereas HR, CO and CI continued to rise steeply for 90 sec before leveling off to a steady rise. After completion of the 6MWT, all parameters had returned to baseline by a mean of 3.5 min. Sub-group analysis showed that the increase in cardiac output was predominantly contributed by an increase in heart rate in participants diagnosed with stroke for less than 1 year, whereas both stroke volume and heart rate contributed similarly to the increase in cardiac output in participants with diagnosis of stroke for longer than 1 year. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) both returned to baseline within 2 minutes post 6MWT. HR recorded at the end of the 6MWT was 60.8±10.6% of the predicted maximal heart rate and perceived exertion score was 5±2. Correlations between 6MWD and HR, and between 6MWD and SV were weak, with correlation coefficients Spearman's rho (rs) =0.46, and 0.42, respectively (p<0.05). Correlation between 6MWD and CO and CI were higher (rs= 0.66 and 0.63, respectively (p<0.01)). This is the first study to report cardiac responses during a 6MWT in stroke patients. ICG is a reliable, non-invasive, repeatable method of measuring cardiodynamic data in stroke patients.

Effects of Exercise in Patients With Amyotrophic Lateral Sclerosis: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this study was to systematically review the efficacy and safety of exercise in patients with amyotrophic lateral sclerosis (ALS). DESIGN: Randomized controlled trials of exercises for ALS were searched in PubMed, EMBASE, Web of Science, Cochrane Library, China Biology Medicine database, China National Knowledge Internet, VIP database, and Wanfang database. The primary outcomes were functional ability, pulmonary function, and quality of life. The secondary outcomes were muscle strength, fatigue and adverse events. Meta-analysis was performed using the RevMan Version 5.3 software. RESULTS: Seven randomized controlled trials including 322 patients with ALS met the inclusion criteria. Meta-analysis showed that the functional scores at long-term (standardized means difference, 0.47; 95% confidence interval, 0.08-0.86; P = 0.02) and forced vital capacity percentage predicted (mean difference, 1.71; 95% confidence interval, 0.10-3.31; P = 0.04) of patients with ALS in the exercise group were significantly higher than those in the group of no exercise or usual care. No significant difference was observed in muscle strength and quality of life. Endurance or aerobic exercise improved the functional scores of patients with ALS (standardized means difference, 0.36; 95% confidence interval, 0.04-0.68; P = 0.03). Exercise did not aggravate fatigue or result in adverse event. CONCLUSION: Exercise can significantly improve the functional ability and pulmonary function of patients with ALS safely.

Development of a short form of the Hong Kong Chinese orebro musculoskeletal pain screening questionnaire.

BACKGROUND: The Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) is a valid screening tool to identify those musculoskeletal patients at risk of developing chronicity and disability. A Hong Kong Chinese version of the OMPSQ (COMPSQ-HK) was developed with satisfactory construct validity and predictive validity. OBJECTIVE: The aim of this study was to develop a 10-item short form of the COMPSQ-HK (COMPSQ-HK10) and examine its measurement properties. METHODS: The 10 items were identified from the suggestion by the original author of OMPSQ. The data of the 10 items were extracted from the main study to develop the COMPSQ-HK conducted from 2010 to 2013. The internal consistency using Cronbach's alpha, test-retest reliability examining intraclass correlation coefficient (ICC 1 , 1 ), minimum detectable change and 95% limits of agreement, construct validity by correlating COMPSQ-HK10 with pain, disability score, kinesiophobia score and Medical Outcomes Study Short Form 12, and predictive validity investigating receiver operating characteristic (ROC) curve analyses with sick leave > 60 days and return-to-work status at one year were calculated. RESULTS: A total of 305 back patients and 160 neck patients were recruited with about 30% of patients lost to follow-up at one year. Both the internal consistency (Cronbach's alpha as 0.732 to 0.757) and test-retest reliabilities (ICC 1 , 1 as 0.868 for both back and neck patients) were satisfactory. The correlations between COMPSQ-HK10 and COMPSQ-HK for back and neck patients were excellent (Pearson r as 0.919 and 0.896, respectively, p < 0 . 001 ). The areas under the ROC curves for back and neck patients were similar for COMPSQ-HK10 and COMPSQ-HK, ranging from 0.603 to 0.712. A cut-off score of 54 of COMPSQ-HK10 was recommended in predicting "sick leave of more than 60 days at one year" and "return to work for at least four consecutive weeks at one year". CONCLUSION: The COMPSQ-HK10 has comparable measurement properties with the COMPSQ-HK. It is recommended to use the COMPSQ-HK10 for routine screening to identify patients of back and neck pain at risk of developing chronic pain and disability.

Trunk muscle endurance in Chinese adults.

BACKGROUND: Previous studies in non-Chinese populations have found a relationship between performance on isometric trunk muscle endurance tests and low back pain (LBP). However, the relationship between trunk muscle endurance and LBP in Chinese populations has received little attention and age-referenced data have not been reported. OBJECTIVE: Evaluate the relationship between age-referenced isometric trunk muscle endurance values and LBP in a Chinese cohort. METHODS: One hundred and eighty-eight participants (20-59-years) performed four timed-endurance tests (Biering-Sørensen, plank, left/right side bridge) in random order. Participants with a history of LBP completed an Oswestry Disability Index (ODI) and pain scale. Holding-times for the four tests were summed and receiver operating characteristic (ROC) curve analysis was performed to differentiate participants with and without LBP. RESULTS: Data were grouped by age. Analysis revealed similar endurance values to those reported in non-Chinese populations, except longer holding times were recorded in the 50-59 yr Chinese cohort. Pain scores were positively correlated with ODI scores. ROC curve analysis showed that the area under the curve was 0.723 and optimal cut-off was 288 sec (sensitivity and specificity both 0.75). CONCLUSIONS: This study is the first to describe trunk muscle endurance reference data in Chinese people. Individuals with a summed endurance time of < 288 seconds appear more likely to suffer LBP.

Lateral epicondylalgia: midlife crisis of a tendon.

The pathogenesis and management of lateral epicondylalgia, or tennis elbow, a common ailment affecting middle-aged subjects of both genders continue to provoke controversy. Currently it is thought to be due to local tendon pathology, pain system changes, and motor system impairment. Its diagnosis is usually clinical, based on a classical history, as well as symptoms and signs. In selected cases, additional imaging (X-rays, ultrasound, and magnetic resonance imaging) can help to confirm the diagnosis. Different treatment modalities have been described, including the use of orthotics, non-steroidal anti-inflammatory drugs, steroid injections, topical glyceryl trinitrate, exercise therapy, manual therapy, ultrasound therapy, laser therapy, extracorporeal shockwave therapy, acupuncture, taping, platelet-rich plasma injections, hyaluronan gel injections, botulinum toxin injections, and surgery. Nevertheless, evidence to select the best treatment is lacking and the choice of therapy depends on the experience of the management team, availability of the equipment and expertise, and patient response. This article provides a snapshot of current medical practice for lateral epicondylalgia management.

Surgeons' static posture and movement repetitions in open and laparoscopic surgery.

BACKGROUND: There is increasing concern about the surgeon maintaining a static posture during laparoscopic surgery, which can contribute to musculoskeletal disorders. A series of studies are being conducted in Hong Kong examining the surgeons' real-time movements and electromyography in the operating theater during different operations. The present paper examines the postures and movements of surgeons during real-time open and laparoscopic procedures. MATERIALS AND METHODS: Fourteen surgeons participated in the study (12 men, 2 women). Cervical spine movements were measured using a biaxial inclinometer attached to the surgeon's head via a headband. Biaxial electrogoniometers were attached to the surgeon's bilateral shoulder joints. Real-time joint movements in sagittal and coronal planes were recorded during open and laparoscopic surgeries for periods ranging from 30 to 80 min. RESULTS: Surgeons generally maintained a flexed neck posture during open surgery and a more extended neck posture during laparoscopic procedures. There were statistically significant differences in mean neck posture and mean left shoulder abduction posture between the two types of surgery. Laparoscopic procedures showed a trend for longer duration in static posture in the neck, while open procedures showed trends for higher frequencies of movements. CONCLUSIONS: This study presented a novel approach to quantify the physical workload of surgeons using biomechanical parameters to describe duration of static posture and repetitiveness of movements. Results showed that long durations of static postures in laparoscopic surgery were closely associated with low-level muscle tension, which may contribute to an increased risk of surgeons developing musculoskeletal disorders.

Work-related musculoskeletal symptoms in surgeons.

INTRODUCTION: Surgeons are a unique group of healthcare professionals who are at risk for developing work-related musculoskeletal symptoms (WMS). The diversity of operating skills for laparoscopic and endovascular procedures impose different physical demands on surgeons, who also work under time pressure. The present study aims to examine the physical and psychosocial factors and their association with WMS among general surgeons in Hong Kong. METHOD: A survey was conducted among surgeons working in the General Surgery departments in public hospitals of Hong Kong. Over 500 questionnaires were mailed and 135 surgeons completed the survey successfully (response rate 27%). Questions included demographics, workload, ergonomic and psychosocial factors. The relationship of these factors with WMS symptoms in the past 12 months was examined. RESULTS: Results indicated a high prevalence rate of WMS symptoms in surgeons, mainly in the neck (82.9%), low back (68.1%), shoulder (57.8%) and upper back (52.6%) regions. Sustained static and/or awkward posture was perceived as the factor most commonly associated with neck symptoms by 88.9% of respondents. Logistic regression showed the total score for physical ergonomic factors was the most significant predictor for all 4 body regions of musculoskeletal symptoms, with OR of 2.028 (95%CI 1.29-3.19) for the neck, 1.809 (1.34-2.43) for shoulder and 1.716 (1.24-2.37) for the lower back. Workstyle score was significantly associated with the symptom severity in the low back region (P = .003) but not with the other regions. CONCLUSION: These results confirmed a strong association of physical and psychosocial factors with the musculoskeletal symptoms in surgeons. There is a potential for such musculoskeletal symptoms to escalate in the future, with rapid advances and increasing application of minimally invasive surgery.