Motor Impairment and Its Influence in Gait Velocity and Asymmetry in Community Ambulating Hemiplegic Individuals.

OBJECTIVES: To determine the most important motor impairments that are predictors of gait velocity and spatiotemporal symmetrical ratio in patients with stroke. DESIGN: Cross-sectional, descriptive analysis study. SETTING: Human performance laboratory of the University of Santo Tomas. PARTICIPANTS: Individuals with chronic stroke (N=55; 34 men, 21 women) who are community dwellers. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The gait velocity and spatiotemporal symmetrical ratio (step length; step, stance, swing, single-leg support, and double-leg support stance times) was determined using Vicon motion capture. We also calculated motor impairment of the leg and foot using Brunnstrom's stages of motor recovery, evaluated muscle strength using the scoring system described by Collin and Wade, and assessed spasticity using by the modified Ashworth Scale. RESULTS: Regression analysis showed that plantarflexor strength is a predictor of gait velocity and all temporospatial symmetry ratio. Knee flexor and extensor strength are predictors in single-leg support time and double-leg support time symmetry ratio, respectively. On the other hand, hip adductor and quadriceps spasticity are predictors of swing time and step length symmetry ratio. CONCLUSION: Different motor impairments are predictors of stroke gait abnormality. Interventions should be focused on these motor impairments to allow for optimal gait rehabilitation results.

Diagnostic Accuracy of Ultrasound Parameters in Carpal Tunnel Syndrome: Additional Criteria for Diagnosis.

OBJECTIVES: To determine the diagnostic capacity of ultrasound (US) in detecting carpal tunnel syndrome (CTS). METHODS: Volunteer adults with and without CTS symptoms were recruited from offices in metropolitan Manila, where employees' work was hand/wrist intensive. Carpal tunnel syndrome was independently diagnosed by a reference standard (positive findings on a physical examination and nerve conduction studies). Blinded US measurements were taken of the median nerve (cross-sectional area, hypervascularity, wrist-to-forearm ratio, wrist-forearm difference, swelling ratio, flattening ratio, and palmar bowing of the flexor retinaculum) at the carpal tunnel inlet and carpal tunnel outlet (CTO). RESULTS: A total of 117 eligible consenting participants (234 hands) were included, with 54 hands (23.1%) with a diagnosis of CTS. There were no anthropometric differences between arms with and without CTS. Men and women older than 33 years were 5 times more likely to report CTS than younger people. A CTO wrist-forearm difference of greater than 0.03 cm had the strongest association with CTS (odds ratio, 4.7; 95% confidence interval, 1.4-15.9), with an area under the curve of 0.58 (sensitivity, 94.4%; specificity, 21.7%). The area under the curve increased to 0.59 when the next strongest measurement (CTO hypervascularity of 1+: odds ratio, 3.8; 95% confidence interval, 1.8-8.1) was included (sensitivity, 98.1%; specificity, 27.7%). Adding further US parameters did not improve the diagnostic capacity of US for CTS. Diagnostic capacity was independent of age and the duration of CTS symptoms. CONCLUSIONS: Combining US findings for the CTO wrist-forearm difference and hypervascularity provides a sensitive, alternative diagnostic tool for CTS.

Stratifying Minimal Versus Severe Pain in Knee Osteoarthritis Using a Musculoskeletal Ultrasound Protocol.

OBJECTIVE: The aim of this cross-sectional correlational study was to determine the association of pain with morphologic and inflammatory sonographic findings in patients with knee osteoarthritis. METHODS: A total of 113 participants with knee osteoarthritis were assessed using visual analog scale pain score and sonography. Ultrasound evaluation included morphologic changes (ie, articular cartilage degeneration, medial and lateral meniscal protrusion, and presence of osteophytes on the joint margins) and inflammatory changes (ie suprapatellar effusion and/or synovitis, Baker cyst, superficial and deep infrapatellar effusion, pes anserine tendinopathy, and Hoffa panniculitis). RESULTS: Cluster analysis via Ward's method grouped patients with minimal pain (visual analog scale score, 0-4) and with substantial pain (visual analog scale score, 5-10). Stepwise logistic regression yielded 5 variables that significantly explained the variation in the probability of perceived substantial pain at 10% level of significance: lateral cartilage clarity (LCC; P = .025), medial cartilage clarity (MCC; P = .20), medial cartilage thickness (MCT; P = .041), medial meniscus protrusion (MMP) (P = .029), and osteophytes at medial femoral margin (P = .082), with 63% overall prediction accuracy. When age and sex were added, 4 variables remained significant at a 10% level of significance: LCC, MCC, MCT, and MMP, with 65% overall prediction accuracy. The receiver operating characteristic curve of this model was 0.667. CONCLUSION: The study was able to demonstrate that morphologic abnormalities in the ultrasound parameters for LCC, MCC, MCT, and MMP were able to predict significant joint pain in knee osteoarthritis. There were no inflammatory changes that contributed to significant joint pain in this study.

Inter-Rater and Intra-Rater Reliability of Sonographic Median Nerve and Wrist Measurements.

BACKGROUND: Electrophysiologic studies have been considered the "gold standard" in diagnosing carpal tunnel syndrome (CTS); however, reports of false-negative results, as well as discomfort for the patient during the procedure has paved the use of ultrasound, being a painless and cost-efficient tool, as an alternative means for its diagnosis. Various ultrasound parameters assessing the median nerve and wrist dimensions have been described, but description of landmarks to assess these in a reliable manner has been lacking. METHODOLOGY: A systematic search of different databases yielded data regarding ultrasound parameters for CTS diagnosis, the landmarks used, and presence of reliability testing. Based on this, three sonologists discussed the external and sonographic landmarks that will be used in measuring the median nerve measurements, bowing of the flexor retinaculum and the carpal tunnel dimensions. A pilot test with two consecutive healthy participants using the discussed ultrasound parameters was carried out, and results were subjected to inter- and intra-rater reliability testing. Modifications were accordingly made on the acquisition of ultrasound image using external landmarks. The reliability testing proper was done with ten consecutive healthy participants. RESULTS: Based on the systematic review and the pilot study, external landmarks were used to locate the median nerve in the forearm, carpal tunnel inlet and outlet. For the forearm measurement, it was taken 10 cm proximal from the distal palmar crease. The distal palmar crease was the external landmark used for the carpal tunnel inlet, while for the carpal tunnel outlet; it was measured 1 cm distal to the distal palmar crease. Instead of using the inner edge of the hook of hamate and trapezium, the apices of these bones were used as the landmarks in measuring the carpal tunnel outlet dimensions. There was excellent intra-rater reliability (mid-forearm, carpal tunnel inlet and outlet) except for the following: cross-sectional area (CSA) of the median nerve at the carpal tunnel inlet and outlet; and bowing of the flexor retinaculum. All the parameters had an excellent inter-rater reliability measured at the three levels (intraclass correlation [ICC]: Of 0.77-0.99) except for CSA of the median nerve at the levels of the forearm (fair-to-good with ICC of 0.71) and the carpal tunnel inlet (fair-to-good reliability of ICC: 0.43). CONCLUSION: There was an improved inter- and intra-rater reliability when external landmarks were used instead of sonographic landmarks.

Updating contextualized clinical practice guidelines on stroke rehabilitation and low back pain management using a novel assessment framework that standardizes decisions.

BACKGROUND: Clinical practice guidelines need to be regularly updated with current literature in order to remain relevant. This paper reports on the approach taken by the Philippine Academy of Rehabilitation Medicine (PARM). This dovetails with its writing guide, which underpinned its foundational work in contextualizing guidelines for stroke and low back pain (LBP) in 2011. METHODS: Working groups of Filipino rehabilitation physicians and allied health practitioners met to reconsider and modify, where indicated, the 'typical' Filipino patient care pathways established in the foundation guidelines. New clinical guidelines on stroke and low back pain which had been published internationally in the last 3 years were identified using a search of electronic databases. The methodological quality of each guideline was assessed using the iCAHE Guideline Quality Checklist, and only those guidelines which provided full text references, evidence hierarchy and quality appraisal of the included literature, were included in the PARM update. Each of the PARM-endorsed recommendations was then reviewed, in light of new literature presented in the included clinical guidelines. A novel standard updating approach was developed based on the criteria reported by Johnston et al. (Int J Technol Assess Health Care 19(4):646-655, 2003) and then modified to incorporate wording from the foundational PARM writing guide. The new updating tool was debated, pilot-tested and agreed upon by the PARM working groups, before being applied to the guideline updating process. RESULTS: Ten new guidelines on stroke and eleven for low back pain were identified. Guideline quality scores were moderate to good, however not all guidelines comprehensively linked the evidence body underpinning recommendations with the literature. Consequently only five stroke and four low back pain guidelines were included. The modified PARM updating guide was applied by all working groups to ensure standardization of the wording of updated recommendations and the underpinning evidence bases. CONCLUSIONS: The updating tool provides a simple, standard and novel approach that incorporates evidence hierarchy and quality, and wordings of recommendations. It could be used efficiently by other guideline updaters particularly in developing countries, where resources for guideline development and updates are limited. When many people are involved in guideline writing, there is always the possibility of 'slippage' in use of wording and interpretation of evidence. The PARM updating tool provides a mechanism for maintaining a standard process for guideline updating processes that can be followed by clinicians with basic training in evidence-based practice principles.

Protocol for audit of current Filipino practice in rehabilitation of stroke inpatients.

BACKGROUND: Stroke is one of the leading medical conditions in the Philippines. Over 500,000 Filipinos suffer from stroke annually. Provision of evidence-based medical and rehabilitation management for stroke patients has been a challenge due to existing environmental, social, and local health system issues. Thus, existing western guidelines on stroke rehabilitation were contextualized to draft recommendations relevant to the local Philippine setting. Prior to fully implementing the guidelines, an audit of current practice needs to be undertaken, thus the purpose of this audit protocol. METHODS: A clinical audit of current practices in stroke rehabilitation in the Philippines will be undertaken. A consensus list of data items to be captured was identified by the audit team during a 2-day meeting in 2012. These items, including patient demographics, type of stroke, time to referral for rehabilitation management, length of hospital stay, and other relevant descriptors of stroke management were included as part of the audit. Hospitals in the Philippines will be recruited to take part in the audit activity. Recruitment will be via the registry of the Philippine Academy of Rehabilitation Medicine, where 90% of physiatrists (medical doctors specialized in rehabilitation medicine) are active members and are affiliated with various hospitals in the Philippines. Data collectors will be identified and trained in the audit process. A pilot audit will be conducted to test the feasibility of the audit protocol, and refinements to the protocol will be undertaken as necessary. The comprehensive audit process will take place for a period of 3 months. Data will be encoded using MS Excel(®). Data will be reported as means and percentages as appropriate. Subgroup analysis will be undertaken to look into differences and variability of stroke patient descriptors and rehabilitation activities. CONCLUSION: This audit study is an ambitious project, but given the "need" to conduct the audit to identify "gaps" in current practice, and the value it can bring to serve as a platform for implementation of evidence-based stroke management in the Philippines to achieve best patient and health outcomes, the audit team is more than ready to take up the challenge.

Radial nerve measurements in nonsymptomatic upper extremities of Filipinos: A cross-sectional study.

INTRODUCTION: Despite reports on the association of radial nerve (RN) size and lateral epicondylalgia (LE), Filipino normative values on RN size in healthy elbows are not established. An association with upper extremity anthropometric measurements is likewise not reported. METHODS: Musculoskeletal ultrasound measurements of the RN at the level of the lateral epicondyle (RN-LE), posterior interosseous nerve at the level of the radial head and supinator (PIN-RH and PIN-sup), and superficial RN (SRN) in the elbows of healthy Filipinos were made in Manila from January-September 2011. RESULTS: A total of 198 elbows of 99 healthy participants aged 43 years (range, 33-48 years) [median(IQR)] were investigated. Men have larger PIN-RH, PIN-sup, and SRN compared with women. Arm length was associated with PIN-RH, PIN-sup, and SRN (P < 0.05). Activities and elbow circumference measurements (at 2 levels) were associated with PIN-RH. CONCLUSIONS: RN reference values can now be used for comparison in elbows with LE.

Is what Filipino children eat between meals associated with body mass index?

The study aimed to assess the association between childhood obesity and snacking. A total of 396 students in grades 4 to 6 enrolled in an elementary school in the Philippines were the participants in this study. Demographic profile; anthropometric measures of height, weight, body mass index; and information about snacking were gathered. Obese group had statistically more servings of sweetened drinks and low-quality snacks. Female obese subjects have statistically more servings at nighttime and greater total snack servings. For the whole cohort, the odds ratio of being overweight with high total snack servings was 2.12 (95% confidence interval = 1.25-3.62) whereas the odds ratio of being obese with calories obtained from snacking was 2.08 (95% confidence interval = 1.01-4.26). Nighttime snacks and bad-quality foods should be minimized. Moreover, reducing food portions at any snack time will protect children from being overweight.

Depressive symptoms among cancer patients in a Philippine tertiary hospital: prevalence, factors, and influence on health-related quality of life.

BACKGROUND: The World Health Organization recognizes depression as one of the most burdensome diseases in the world. Among cancer patients, depression is significantly associated with shorter survival, independent of the influence of biomedical prognostic factors. Although cancer is the third leading cause of morbidity and mortality among Filipinos, little is known about depressive symptoms and their influence on health-related quality of life in this population. We assessed the prevalence of, and factors associated with, depressive symptoms and their influence on health-related quality of life in Filipino patients with cancer. METHODS: The Patient Health Questionnaire (PHQ)-8 and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 were administered to all inpatients and outpatients, age >=18 years presenting for cancer treatment. RESULTS: Twenty-two percent (n=53/247) were categorized as depressed, using a PHQ-8 cutoff of ≥10. Depressed patients scored lower on cognitive, emotional, role, physical, and social functioning than those who scored PHQ<10 (all P<0.001). Depression varied by disease status, performance status and marital status (all P<0.001). However, only performance status (OR [odds ratio]=2.20; 95% CI=1.60, 3.00) and disease status (OR=2.4; 95% CI=1.13, 5.22) were significantly associated with depression in the multivariable model. CONCLUSIONS: Depression is prevalent in Filipino cancer patients. The findings provide empirical support for the development of mental health services in this understudied population. This study, the first to assess the prevalence of and factors associated with depression in Filipino cancer patients, needs further validation.

The association of physical fitness with body mass index and waist circumference in Filipino preadolescents.

AIM: The objective of this study is are to examine the association of preadolescent obesity using body mass index (BMI) and waist circumference (WC) with health-related physical fitness components. METHODS: Grades 4 to 6 students in 2 private schools in Manila were included in this study. Height, weight, WC, and BMI were obtained. Physical fitness field tests were sit-and-reach test, 1-minute sit-ups, standing broad jump, 40-m sprint, and 20-m shuttle run. RESULTS: Obese subjects had poorer scores in the field tests except in the sit-and-reach test. BMI and WC were significantly negatively associated with all the physical fitness parameters, except for the 40-m sprint where positive correlation was observed, and in the sit-and-reach test where no correlation was seen. CONCLUSION: In the management of preadolescent overweight and obesity, exercise programs should therefore be designed toward enhancing these fitness parameters, while not sacrificing enjoyment and creativity.

Evidence on the effectiveness of topical nitroglycerin in the treatment of tendinopathies: a systematic review and meta-analysis.

OBJECTIVE: To evaluate evidence on the effectiveness of topical nitroglycerin (NTG) in treating tendinopathies. DATA SOURCES: Systematic searches were conducted on ScienceDirect, Scirus, Highwire Press Stanford University, PubMed Central, Directory of Open Access Journals, Free Medical Journals, Free Full Text, Bioline International, Findarticles, BioMed Central, IndMed, OpenMD, QMed, Geneva Foundation for Medical Education and Research, Scientific Electronic Library Online, eMedicine/Medscape/Medline, Biomedical E-journals, Current Contents Connect, Journal of Medical Internet Research, Cochrane, Turning Research Into Practice, Ovid, and EBSCO databases. There were no restrictions regarding the language of publication. STUDY SELECTION: All clinical controlled trials or randomized controlled trials (RCTs) evaluating the effects of NTG for patients with acute, subacute, or chronic tendinopathies, whether the said intervention was placebo-controlled or controlled against a comparator intervention, were considered for inclusion. DATA EXTRACTION: A reviewer extracted data from included studies using a data extraction form by the Joanna Briggs Institute. DATA SYNTHESIS: Methodologic quality of studies was assessed by 2 independent reviewers through a critical appraisal form by the Alberta Heritage Foundation. Qualitative analyses of data were done using a rating system devised by Van Tulder and colleagues. Where possible, meta-analyses of data were performed. Seven clinically relevant and high-quality RCTs involving 446 subjects were identified and included in this review. Meta-analysis showed that NTG has a positive effect in pain reduction during activities of daily living in chronic tendinopathies, with an odds ratio of 4.44 (95% confidence interval [CI], 2.34-8.40), and in both acute and chronic phases combined, with an odds ratio of 4.86 (95% CI, 2.62-9.02). There is also qualitative, strong (Level 1) evidence that NTG is effective in enhancing tendon forces in the chronic phase. There is limited and/or conflicting evidence (Level 3) for other outcomes in the chronic phase and all outcomes in the acute phase. There is a significant between-group difference between NTG and control in the incidence of headache, with an odds ratio of 1.73 (95% CI, 1.01-2.97). No significant difference was observed in the occurrence of contact dermatitis, with an odds ratio of 2.12 (95% CI, .89-5.02). CONCLUSIONS: In chronic tendinopathies, there is strong evidence for NTG in relieving pain during activities of daily living, and increasing tendon strength. Further studies are needed to explore the role of this promising intervention in all phases of tendinopathies.

Physical activity pattern of prepubescent Filipino school children during school days.

BACKGROUND: Little is known about pre-pubescent Filipino children's involvement in moderate-to-vigorous physical activity (MVPA). There are international guidelines regarding required levels of MVPA for healthy children. METHODS: This study describes participation of 11- to 12-year-olds in randomly selected public and private schools in San Juan, Metromanila, in MVPA and sports during a school day. The Filipino-modified Physical Activity Questionnaire for Older Children (F_PAQ_C) was administered in English and Filipino. Additional data was collected on sex, age, type of school, and amount of time spent using television and computers. Children's self-assessment of physical activities (1 question in the F_PAQ_C) was correlated with their cumulative F_PAQ_C score. RESULTS: Three hundred eighty subjects (167 boys, 213 girls) participated. Participation in MVPA varied between sex and age groups, from 56.1% to 65.0%. Fewer than 10% of participants were very active. The children were more active during physical education classes than at recess or lunch, after class, or in the evening. Walking for exercise, jumping, jogging and running, free play, and dance were most common. Boys, younger children, and private school students most commonly engaged in MVPA. Self-assessed physical activity had modest correlation (r(2)= 0.21) with cumulative F_PAQ_C score, after adjusting for sex, age, and school type. CONCLUSION: Most children were not physically active during the school day, except in physical education classes. To reduce the gap between recommended and current activity levels, more opportunities should be provided for preteen Filipino children to engage in MVPA during and after school.