Predictors of azathioprine and mycophenolate mofetil response in patients with neuromyelitis optica spectrum disorder: A cohort study.

BACKGROUND: Relapse rates of 47 % have been reported in patients with neuromyelitis optica (NMOSD) using Azathioprine (AZA) and mycophenolate mofetil (MMF). Prediction of non-responders could help determine which patients are most likely to benefit from newer monoclonal antibody treatments from the outset. OBJECTIVES: To identify predictors of AZA and MMF treatment response in NMOSD. METHODS: Multicenter cohort study of NMOSD patients from Brazil and the United Kingdom, treated with AZA and MMF. An unsatisfactory response was defined as one severe or two non-severe attacks in a year. Cox regression was used to identify predictive factors of unsatisfactory response to AZA and MMF. RESULTS: 103 NMOSD patients, mean age 38 years, 83% female, and 65% of Black ethnic group were included. An unsatisfactory IS response was observed in 42% of patients over 2.5 years (IQR 1.0-8.8) years. A severe preceding attack was more common in non-responders (31.1% x 76.7%, p = <0.001). In multivariable analysis, severe attack (RR 3.13; 95 % CI 1.37-7.18, p = 0.007) or higher annualized relapse rate (RR 4.84; 95 % CI 2.01-11.65, p = < 0.001) predicted an unsatisfactory response. Interestingly, Black NMOSD patients had a lower risk of poor response (RR 0.39, 95 % CI 0.17-0.85, p = 0.019). CONCLUSION: Severe attack and a higher annualized relapse rate before AZA or MMF initiation were associated with an unsatisfactory IS response. In patients with these characteristics, treatment with higher-efficacy drugs should be considered from the outset.

Clinical and prognostic aspects of patients with the Neuromyelitis Optica Spectrum Disorder (NMOSD) from a cohort in Northeast Brazil.

INTRODUCTION: Neuromyelitis optica spectrum disorders (NMOSD) is a rare inflammatory and demyelinating disease of the central nervous system (CNS) more frequent in women and Afro-descendants. No previous epidemiological or prognostic study has been conducted in the region of the state of Bahia, Brazilian Northeast. OBJECTIVE: To evaluate clinical and prognostic aspects in patients with NMOSD from a cohort in northeastern Brazil. MATERIAL AND METHODS: A single-center retrospective study was conducted with consecutive patients diagnosed with NMOSD. Clinical and epidemiological characteristics were described. The degree of disability was expressed by the Expanded Disability Status Scale (EDSS). Worsening disability were analyzed through negative binomial regression adjusted for disease duration. RESULTS: Ninety-one patients were included, 72 (79.1%) female and 67 (73.6%) afro descendants. Mean age at onset was 36 (± 14) years and 73.3% were anti-aquaporin-4 antibody positive. Isolated transverse myelitis (32.9%) and isolated optic neuritis (22.4%) were the most frequent initial clinical syndromes. After multivariate analysis, optic neuritis (RR = 0.45; 95% CI = 0.23 - 0.88; p = 0.020) and dyslipidemia (RR = 0.40; 95% CI = 0.20 - 0.83; p = 0.014) were associated with slower disease progression. Area postrema involvement (RR = 6.70; 95% CI = 3.31 - 13.54; p < 0.001) and age at onset (RR = 1.03; 95% CI = 1.01 - 1.05; p = 0.003) were associated with faster disease progression. CONCLUSIONS: In the first clinical and prognostic study in northeastern Brazil, we identified area postrema involvement, age at onset, optic neuritis at fist syndrome and dyslipidemia as the main prognostic factors associated with disease progression.

Does adding hip strengthening exercises to manual therapy and segmental stabilization improve outcomes in patients with nonspecific low back pain? A randomized controlled trial.

BACKGROUND: The literature is unclear on the need for hip strengthening in persons with low back pain (LBP). OBJECTIVES: To investigate the effectiveness of hip strengthening exercises when added to manual therapy and lumbar segmental stabilization in patients with chronic nonspecific LBP. METHODS: Seventy patients with chronic nonspecific LBP were randomly assigned to either the manual therapy and lumbar segmental stabilization group or the manual therapy and lumbar segmental stabilization plus specific hip strengthening group. A 10 cm visual analogue scale and the Rolland-Morris Questionnaire were the primary clinical outcome measures at baseline, at the end of treatment (posttreatment), and 6- and 12-months posttreatment. Hip strength and kinematics were measured as secondary outcomes . RESULTS: While within-group improvements in pain, disability, and hip extensors strength occurred in both groups, there were no significant between-group differences at posttreatment or follow-ups. Mean difference in changes in pain level between groups at posttreatment and at 6- and 12-month follow-up were 0.5 points (95% confidence interval [CI]: -0.5, 1.5), 0.3 points (95% CI: -0.9, 1.5), and 0.0 points (95% CI: -1.1, 1.1), respectively. The mean differences in changes in disability were 0.8 points (95% CI: -1.3, 2.7), 0.0 points (95% CI: -2.4, 2.4), and 0.4 points (95% CI: -2.0, 2.8), respectively. Finally, we did not observe any between-group differences for any of the other outcomes at any timepoint. CONCLUSION: The addition of specific hip strengthening does not appear to result in improved clinical outcomes for patients with nonspecific LBP.

Recommendations by the Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and the Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) on vaccination in general and specifically against SARS-CoV-2 for patients with demyelinating diseases of the central nervous system / Recomendações do Departamento Científico de Neuroimunologia da Academia Brasileira de Neurologia (DCNI/ABN) e do Comitê Brasileiro de Tratamento e Pesquisa em Esclerose Múltipla e Doenças Neuroimunológicas (BCTRIMS) sobre vacinação em geral e contra a SARS-CoV-2 para pacientes com doenças desmielinizantes do sistema nervoso central

ABSTRACT The Scientific Department of Neuroimmunology of the Brazilian Academy of Neurology (DCNI/ABN) and Brazilian Committee for Treatment and Research in Multiple Sclerosis and Neuroimmunological Diseases (BCTRIMS) provide recommendations in this document for vaccination of the population with demyelinating diseases of the central nervous system (CNS) against infections in general and against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes COVID-19. We emphasize the seriousness of the current situation in view of the spread of COVID-19 in our country. Therefore, reference guides on vaccination for clinicians, patients, and public health authorities are particularly important to prevent some infectious diseases. The DCNI/ABN and BCTRIMS recommend that patients with CNS demyelinating diseases (e.g., MS and NMOSD) be continually monitored for updates to their vaccination schedule, especially at the beginning or before a change in treatment with a disease modifying drug (DMD). It is also important to note that vaccines are safe, and physicians should encourage their use in all patients. Clearly, special care should be taken when live attenuated viruses are involved. Finally, it is important for physicians to verify which DMD the patient is receiving and when the last dose was taken, as each drug may affect the induction of immune response differently.

RESUMO O DC de Neuroimunologia da ABN e o BCTRIMS trazem, nesse documento, as recomendações sobre vacinação da população com doenças desmielinizantes do sistema nervoso central (SNC) contra infecções em geral e contra o coronavírus da síndrome respiratória aguda grave 2 (SARS-CoV-2), causador da COVID-19. Destaca-se a gravidade do atual momento frente ao avanço da COVID-19 em nosso País, o que torna mais evidente e importante a criação de guia de referência para orientação aos médicos, pacientes e autoridades de saúde pública quanto à vacinação, meio efetivo e seguro no controle de determinadas doenças infecciosa. O DCNI/ABN e o BCTRIMS recomendam que os pacientes com doenças desmielinizantes do SNC (ex., EM e NMOSD) sejam constantemente monitorados, quanto a atualização do seu calendário vacinal, especialmente, no início ou antes da mudança do tratamento com uma droga modificadora de doença (DMD). É importante também salientar que as vacinas são seguras e os médicos devem estimular o seu uso em todos os pacientes. Evidentemente, deve ser dada especial atenção às vacinas com vírus vivos atenuados. Por fim, é importante que os médicos verifiquem qual DMD o paciente está em uso e quando foi feita a sua última dose, pois cada fármaco pode interagir de forma diferente com a indução da resposta imune.

Clinical Features of COVID-19 on Patients With Neuromyelitis Optica Spectrum Disorders.

BACKGROUND AND OBJECTIVES: To describe the clinical features and disease outcomes of coronavirus disease 2019 (COVID-19) in patients with neuromyelitis optica spectrum disorder (NMOSD). METHODS: The Neuroimmunology Brazilian Study Group has set up the report of severe acute respiratory syndrome (SARS-CoV2) cases in patients with NMOSD (pwNMOSD) using a designed web-based case report form. All neuroimmunology outpatient centers and individual neurologists were invited to register their patients across the country. Data collected between March 19 and July 25, 2020, were uploaded at the REDONE.br platform. Inclusion criteria were as follows: (1) NMOSD diagnosis according to the 2015 International Panel Criteria and (2) confirmed SARS-CoV2 infection (reverse transcription-polymerase chain reaction or serology) or clinical suspicion of COVID-19, diagnosed according to Center for Disease Control / Council of State and Territorial Epidemiologists (CDC/CSTE) case definition. Demographic and NMOSD-related clinical data, comorbidities, disease-modifying therapy (DMT), COVID-19 clinical features, and severity were described. RESULTS: Among the 2,061 pwNMOSD followed up by Brazilian neurologists involved on the registry of COVID-19 in pwNMOSD at the REDONE.br platform, 34 patients (29 women) aged 37 years (range 8-77), with disease onset at 31 years (range 4-69) and disease duration of 6 years (range 0.2-20.5), developed COVID-19 (18 confirmed and 16 probable cases). Most patients exhibited mild disease, being treated at home (77%); 4 patients required admission at intensive care units (severe cases); and 1 patient died. Five of 34 (15%) presented neurologic manifestations (relapse or pseudoexacerbation) during or after SARS-CoV2 infection. DISCUSSION: Most NMOSD patients with COVID-19 presented mild disease forms. However, pwNMOSD had much higher odds of hospitalization and intensive care unit admission comparing with the general Brazilian population. The frequency of death was not clearly different. NMOSD disability, DMT type, and comorbidities were not associated with COVID-19 outcome. SARS-CoV2 infection was demonstrated as a risk factor for NMOSD relapses. Collaborative studies using shared NMOSD data are needed to suitably define factors related to COVID-19 severity and neurologic manifestations.

The Long-Term Prognosis in People With Recent Onset Low Back Pain From Emergency Departments: An Inception Cohort Study.

Most studies investigating the course of recent-onset low back pain (LBP) included patients from primary care. We aimed to describe the prognosis in people with recent-onset LBP presenting to emergency departments (EDs) and to identify prognostic factors for nonrecovery. This inception cohort study with a 1-year follow-up recruited 600 consecutive acute LBP patients presenting to 4 EDs. The outcomes measured the days to recover from pain, recover from disability, return to previous work hours and duties, and complete recovery. Within 12 months, 73% of participants (95% confidence interval [CI] = 69-77) recovered from pain, 86% (95% CI = 82-90) recovered from disability, 79% (95% CI = 71-87) returned to previous work hours and duties, and 70% (95% CI = 66-74) completely recovered. The median recovery times were 67 days (95% CI = 54-80) to recover from pain, 37 days (95% CI = 31-43) to recover from disability, 37 days (95% CI = 25-49) to return to previous work hours and duties, and 70 days (95% CI = 57-83) to recover completely. Higher pain levels, a higher perceived risk of persistent LBP, more days of reduced activity due to LBP, more pain sites, and higher duration of LBP were associated with complete nonrecovery within 6 months. PERSPECTIVE: This information relates to prognosis and to likely recovery times for patients with recent-onset LBP in EDs. The findings also confirm previous factors associated with poor outcomes in patients with recent-onset LBP.

Timed Average Mean Maximum Velocity (TAMMV) of Cerebral Blood Flow of Children and Adolescents with Sickle cell Disease: correlation with clinical and hematological profiles in country.

BACKGROUND: Detection of abnormal TAMMV with transcranial Doppler is fundamental in primary stroke prevention in children with sickle cell disease (SCD). The study aimed at evaluating TAMMV and correlating it with clinical and hematological profiles of children and adolescent with SCD. METHODS: Transcranial Doppler was performed on subjects aged 2-16 years, using a 2 MHz probe placed over the transtemporal windows. Pulse oximetry was used to determine the peripheral oxygen saturation while clinical and hematological profiles were retrieved from their medical records. RESULTS: One hundred and thirty five patients were recruited. The mean TAMMV was 125cm/s. Patients with HbSS had a significantly higher TAMMV (131cm/s) than those with HbSC (107cm/s). Only one (0.74%) patient had abnormal TAMMV. TAMMV correlated inversely with oxygen saturation, Hct and patient's age, and positively with white cell and platelet counts. Previous history of acute chest syndrome (ACS) and recurrent painful crises increased the risk of development of abnormal and conditional velocity. CONCLUSION: Frequency of abnormal TAMMV in this study was low. Younger children and those with HbSS had higher TAMMV. Age, oxygen saturation and haematocrit correlated negatively while white cell and platelet counts correlated positively with TAMMV. Previous history of ACS and recurrent bone pain were associated with increased risk of having abnormal and conditional TAMMV.

Use of the STarT Back Screening Tool in patients with chronic low back pain receiving physical therapy interventions.

BACKGROUND: The STarT Back Screening Tool (SBST) is used to stratify care. It is unclear if the SBST approach works as well for patients in low- and medium-income countries as for patients from high-income countries. OBJECTIVES: (1) To investigate whether patients with chronic low back pain (LBP) stratified by the SBST are different at baseline; (2) to describe the clinical course for each SBST subgroup; (3) to investigate the SBST utility to predict clinical outcomes; and (4) to determine which SBST subgroup show greater clinical improvement. DESIGN: This is a secondary analysis of data derived from a previously published clinical trial. METHODS: 148 patients with chronic nonspecific LBP were included. Pain intensity, disability, global perceived effect, and the SBST were assessed at baseline and at 5, 12, and 24 weeks after baseline. Descriptive data were provided and ANOVA, unadjusted and adjusted regression models, and linear mixed models were used for data analysis. RESULTS: Duration of symptoms, use of medication, pain, disability, and global perceived effect were different between SBST subgroups. Clinical improvements over a 6-month period were consistently greater in patients classified as high risk. The SBST was able to predict disability but this predictability decreased when the analysis was adjusted for possible confounders. CONCLUSION: Clinical outcomes were different between SBST subgroups over 6 months. Adjusting for confounders influenced the predictability of SBST. Patients classified as high risk presented higher improvements in terms of disability.

Addition of specific hip strengthening exercises to conventional rehabilitation therapy for low back pain: a systematic review and meta-analysis.

OBJECTIVE: To examine the effectiveness of hip strengthening exercises in reducing pain and disability in persons with low back pain. METHODS: We searched for randomized controlled clinical trials on MEDLINE, the Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, LILACS, Scielo and CINAHL from the earliest date available to June 2020. Studies that included hip strengthening exercises for persons with low back pain and included pain and/or disability as an outcome measure were evaluated by two independent reviewers. Mean difference (MD), and 95% confidence interval (CI) were estimated by random effect models. RESULTS: Five studies met the eligibility criteria (309 patients). Four studies included hip strengthening in conjunction with other interventions, while one study evaluated hip strengthening as a standalone intervention. Hip strengthening exercises improved pain (MD -5.4 mm, 95% CI: -8.9 to -1.8 mm), and disability (MD -2.9; 95% CI: -5.6 to -0.1) in persons with low back pain compared to interventions in which hip strengthening was not utilized. The quality of evidence for the pain outcome, was assessed as being moderate. The quality of evidence for the outcome of self-reported disability, was assessed as being low. CONCLUSION: Addition of specific hip strengthening exercises to conventional rehabilitation therapy may be beneficial for improving pain and disability in persons with low back pain.

Profile of Patients With Acute Low Back Pain Who Sought Emergency Departments: A Cross-sectional Study.

STUDY DESIGN: A cross-sectional study. OBJECTIVE: The aim of this study is to describe the profile of patients with acute low back pain (LBP) who sought emergency departments (EDs) in Brazilian public hospitals. We also described the profile of these patients according to the STarT Back Screening Tool (SBST). SUMMARY OF BACKGROUND DATA: LBP is the most common musculoskeletal condition worldwide and is one of the main complaints in EDs. There is a lack of evidence describing the profile of these patients from low- to middle-income countries. METHODS: This is a cross-sectional study involving patients with a new episode of nonspecific acute LBP that was conducted between August 2014 and August 2016. Variables related to clinical, psychological, sociodemographic and work status characteristics were investigated through structured, in-person oral questionnaire. RESULTS: A total of 600 patients were included in the study. The majority of the patients were women (58%), with a median of eight points on pain intensity (measured on an 11-point scale) and 17 points on disability (measured on a 24-item questionnaire). With regards to the SBST evaluation, 295 (49.2%) patients were classified as being at high risk of developing an unfavorable prognosis with a median pain intensity of nine points on pain intensity, 20 points on disability, and seven points on depression (measured on an 11-point scale). Despite this, the majority of the patients (74%) continued working normally without interference from LBP. CONCLUSION: Identifying the profile of patients seeking care in EDs can help to define effective management for LBP in low- and middle-income countries. Patients with nonspecific acute LBP who seek EDs in Brazil present high levels of pain intensity and disability. Most patients were classified as having a high risk of developing an unfavorable prognosis. LEVEL OF EVIDENCE: 2.

The effect of a single high velocity low amplitude hip mobilization on strength in subjects with knee injuries.

BACKGROUND: Manual therapy have been used as a disinhibitory intervention to increase muscle activation before performing functional tasks that are limited by weakness. Knee injuries are commonly associated with weakness in quadriceps and gluteus. Currently, there is no evidence to support anecdotal experience that a hip distraction mobilization improves muscle performance in subjects with knee injuries and lower extremity weakness. OBJECTIVES: To determine if a hip distraction mobilization would result in an immediate change of maximal force output of the quadriceps and gluteus. DESIGN: Non-controlled observational pre-post design. METHODS: Forty individuals with knee pathology were included. Subjects underwent quadriceps, gluteus maximus, and gluteus medius muscle strength assessment before a single hip distraction of the symptomatic side. An immediate re-assessment of muscle strength of both symptomatic and asymptomatic sides followed the mobilization. RESULTS: /findings: Comparing pre-to post-mobilization strength on the symptomatic side, a significant increase was found with the gluteus maximus (average change = 2.0 kg [95%CI 0.6-3.4]; p < 0.01) but not gluteus medius (0.2 kg [-0.7-1.0]; p = 0.71) or quadriceps (0.1 kg [-1.4-1.7]; p = 0.86). When comparing the strength on the symptomatic side in subjects with weakness greater than the MDD95 (0.7-2.9 kg), a significant increase was again found for gluteus maximus (4.7 kg [2.6-6.8]; p < 0.01) but not for gluteus medius (0.2 kg [-1.0-1.4]; p = 0.71) or quadriceps (1.6 kg [-0.7-3.9]; p = 0.15). CONCLUSION: A single hip distraction resulted in a significant increase in gluteus maximus strength but did not produce a change in gluteus medius or quadriceps strength in subjects with knee injuries.

Photobiomodulation of Matrix Metalloproteinases in Rat Calcaneal Tendons.

Objective: The main objective was to verify the modulatory effects of MMP-1, MMP-3, and MMP-13 levels on the partially injured calcaneal tendons of rat exposure to photobiomodulation. Background: Photobiomodulation has been shown to have anti-inflammatory and regenerative effects on tendon injuries. However, there is still uncertainty regarding the beneficial effects in matrix metalloproteinase (MMP) levels, especially MMP-1, -3, and -13. Materials and methods: Sixty-five male Wistar rats were used. Sixty were submitted to a direct trauma on the calcaneal tendons and were randomly distributed into the following six groups: LASER 1, 3, and 7 (10 partially injured calcaneal tendons in each group treated with photobiomodulation for 1, 3, and 7 days, respectively) and Sham 1, 3, and 7 (same injury, with simulated photobiomodulation). The remaining five animals were allocated to the normal group (no injury or treatment procedure). The 780 nm low-level laser was applied with 70 mW of mean power and 17.5 J/cm2 of fluency for 10 sec, once a day. The tendons were surgically removed and analyzed for MMP-1, MMP-3, and MMP-13 through immunohistochemistry. Results: MMP-3 levels remained close to normal in all experimental groups (p > 0.05); however, reductions (p < 0.05) in MMP-1 and MMP-13 levels were detected in the groups submitted to one, three, and seven low level laser therapy applications. Conclusions: The photobiomodulation protocol was able to reduce MMP-1 and MMP-13 levels in injured calcaneal tendons.

Lower limb muscle strength in patients with low back pain: a systematic review and meta-analysis.

OBJECTIVE: To systematically review the published studies that compare lower limb muscle strength in patients with low back pain to matched healthy controls. METHODS: We searched Medline, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), and Scopus up until December 2017. Studies comparing lower limb muscle strength in people diagnosed with low back pain to healthy control participants were included in the systematic review. RESULTS: 14 studies, which included 951 healthy controls and 919 patients with low back pain, fulfilled the inclusion criteria. Meta-analysis revealed a lower muscle strength of hip abductor/extensors and knee extensors in patients with low back pain in comparison to healthy controls. The average strength of hip abductors (Five studies, SMD=0.7 95% CI: 0.49 to 0.9) and hip extensors (Two studies, SMD=0.93, 95% CI: 0.62 to 1.23) was significantly lower in patients with low back pain compared to that of healthy controls. Knee extensor muscle strength was significantly lower in patients with low back pain compared to healthy controls (Three studies, WMD=0.31 Nm/kg, 95% CI: 0.1 to 0.5). The meta-analysis indicated a no significant difference in knee flexor muscle strength in patients with low back pain compared to healthy controls. CONCLUSIONS: Lower limb muscle is impaired in patients with low back pain.

Photobiomodulation of matrix metalloproteinases in rat calcaneal tendons

Objective: The main objective was to verify the modulatory effects of MMP-1, MMP-3, and MMP-13 levels on the partially injured calcaneal tendons of rat exposure to photobiomodulation. Background: Photobiomodulation has been shown to have anti-inflammatory and regenerative effects on tendon injuries. However, there is still uncertainty regarding the beneficial effects in matrix metalloproteinase (MMP) levels, especially MMP-1, -3, and -13. Materials and methods: Sixty-five male Wistar rats were used. Sixty were submitted to a direct trauma on the calcaneal tendons and were randomly distributed into the following six groups: LASER 1, 3, and 7 (10 partially injured calcaneal tendons in each group treated with photobiomodulation for 1, 3, and 7 days, respectively) and Sham 1, 3, and 7 (same injury, with simulated photobiomodulation). The remaining five animals were allocated to the normal group (no injury or treatment procedure). The 780?nm low-level laser was applied with 70?mW of mean power and 17.5 J/cm2 of fluency for 10 sec, once a day. The tendons were surgically removed and analyzed for MMP-1, MMP-3, and MMP-13 through immunohistochemistry. Results: MMP-3 levels remained close to normal in all experimental groups (p > 0.05); however, reductions (p < 0.05) in MMP-1 and MMP-13 levels were detected in the groups submitted to one, three, and seven low level laser therapy applications. Conclusions: The photobiomodulation protocol was able to reduce MMP-1 and MMP-13 levels in injured calcaneal tendons.

Photobiomodulation of matrix metalloproteinases in rat calcaneal tendons

Objective: The main objective was to verify the modulatory effects of MMP-1, MMP-3, and MMP-13 levels on the partially injured calcaneal tendons of rat exposure to photobiomodulation. Background: Photobiomodulation has been shown to have anti-inflammatory and regenerative effects on tendon injuries. However, there is still uncertainty regarding the beneficial effects in matrix metalloproteinase (MMP) levels, especially MMP-1, -3, and -13. Materials and methods: Sixty-five male Wistar rats were used. Sixty were submitted to a direct trauma on the calcaneal tendons and were randomly distributed into the following six groups: LASER 1, 3, and 7 (10 partially injured calcaneal tendons in each group treated with photobiomodulation for 1, 3, and 7 days, respectively) and Sham 1, 3, and 7 (same injury, with simulated photobiomodulation). The remaining five animals were allocated to the normal group (no injury or treatment procedure). The 780?nm low-level laser was applied with 70?mW of mean power and 17.5 J/cm2 of fluency for 10 sec, once a day. The tendons were surgically removed and analyzed for MMP-1, MMP-3, and MMP-13 through immunohistochemistry. Results: MMP-3 levels remained close to normal in all experimental groups (p > 0.05); however, reductions (p < 0.05) in MMP-1 and MMP-13 levels were detected in the groups submitted to one, three, and seven low level laser therapy applications. Conclusions: The photobiomodulation protocol was able to reduce MMP-1 and MMP-13 levels in injured calcaneal tendons.

STRENGTHENING THE GLUTEUS MAXIMUS IN SUBJECTS WITH SACROILIAC DYSFUNCTION.

STUDY DESIGN: Case series. BACKGROUND AND PURPOSE: The literature has emphasized the use of exercise as an intervention for individuals with lumbopelvic pain. However, there is limited information to guide clinicians in exercise selection for those with sacroiliac (SI) joint dysfunction. Altered function of the gluteus maximus has been found in those with SI joint dysfunction. The objective of this case series was to assess the effectiveness of an exercise program directed at increasing gluteus maximus strength in those with clinical tests positive for SI joint dysfunction. CASE DESCRIPTIONS: The eight subjects in this series presented with lumbopelvic pain and clinical evidence of SI joint dysfunction. Each subject underwent 10 treatments over five weeks consisting of five exercises directed at strengthening the gluteus maximus. Radiological assessment and clinical examination were performed to rule out potential concurrent pathologies. Visual analog pain scale, the Oswestry Disability Index, and strength assessed via hand held dynamometry were measured pre- and post-intervention. OUTCOMES: A significant (p<0.001) weakness in gluteus maximus was noted when comparing the uninvolved and involved sides pre-intervention. After completing the strengthening exercise program over 10 visits, statistically significant (p<0.002) increases in gluteus maximus strength and function were found, as well as a decrease in pain. All subjects were discharged from physical therapy and able to return to their normal daily activities. DISCUSSION: The results of this case series support the use of gluteus maximus strengthening exercises in those with persistent lumbopelvic pain and clinical tests positive for SI joint dysfunction.

Adding motor control training to muscle strengthening did not substantially improve the effects on clinical or kinematic outcomes in women with patellofemoral pain: A randomised controlled trial.

DESIGN: Randomized controlled trial. BACKGROUND: Patients with Patellofemoral pain (PFP) usually present muscular weakness, pain and impaired motor control. Muscle strengthening is an effective treatment strategy for PFP, but the additional benefits of movement control training remain unknown. Therefore, the aim of this study was to compare the effects of movement control training associated with muscle strengthening, with a conventional program of strengthening alone in women with PFP. METHODS: Thirty-four women were randomly assigned to two groups. The Strengthening group (S group) performed 12 sessions to strengthen the knee and hip muscles. The Movement Control & Strengthening group (MC&S group) performed the same exercises and movement control training of the trunk and lower limbs. Effects of the treatment (i.e., between-group differences) were calculated using linear mixed models. Primary outcomes were function and pain intensity after completion of the treatment protocol. Secondary outcomes were; muscle strength and kinematic outcomes during the step down task after 4 weeks of treatment; and function and pain intensity 3 and 6 months after randomization. RESULTS: The MC&S group did not present significantly better function (MD -2.5 points, 95% CI;-10.7-5.5) or pain (MD -0.3 points, 95% CI;-1.7-1.0) at 4 weeks. There was a small difference in favour of the MC&S group for AKPS scores at 3 months (MD -8.5 points; 95% CI;-16.8 to -0.3). No significant between-group differences were observed for the other outcomes. CONCLUSION: Movement control training was no more effective than the isolated strengthening protocol, in terms of pain, function, muscle strength, or kinematics.

REHABILITATION OF SUBACROMIAL PAIN SYNDROME EMPHASIZING SCAPULAR DYSKINESIS IN AMATEUR ATHLETES: A CASE SERIES.

STUDY DESIGN: Case series. BACKGROUND AND PURPOSE: Scapular dyskinesis has been associated with several shoulder injuries. Recent literature has suggested that a greater activation of the scapular muscles can play an important role in reducing subacromial impingement in patients with shoulder pain. Thus, the purpose of this case series was to describe a rehabilitation program that emphasizes scapular dyskinesis correction for those with clinical evidence of subacromial pain syndrome. CASE DESCRIPTIONS: The four amateur athletes in this series showed clinical evidence of subacromial pain syndrome and scapular dyskinesis and each underwent a treatment protocol consisting of three phases. Phase 1 emphasized pain relief, scapular control, and recovery of normal range of motion (ROM), Phase 2 focused on muscular strengthening, and Phase 3 emphasized sensory motor training. OUTCOMES: All subjects demonstrated decreased pain, improved sports performance and function, increased muscular strength for shoulder elevation and external rotation, and increased ROM for internal rotation. Improvement in serratus anterior (SA) activation was also noted. DISCUSSION: The results of this case series suggest that subjects with clinical tests positive for subacromial pain syndrome can show significant improvement with an intervention focused on scapular dyskinesis correction. SA activation can play an important role in this process given that all subjects presented with better recruitment after rehabilitation, as measured by electromyography. LEVELS OF EVIDENCE: Level 4.