Review of General Dental Council and General Medical Council "fitness to practise" hearings related to maxillofacial surgery.

Dually-registered specialists in oral and maxillofacial surgery (OMFS) may be subject to disciplinary hearings by the General Medical Council (GMC) and the General Dental Council (GDC) for the same allegations, a phenomenon referred to as "double jeopardy" within the specialty. Previous efforts by both councils to simplify regulatory arrangements have made little progress. We have therefore reviewed the range and scope of fitness to practise (FTP) proceedings relevant to OMFS. We searched the online GMC register to find registered OMFS specialists and obtained FTP proceedings from 2004-2016 through a Freedom of Information request from the GDC. We then searched for cases relevant to OMFS, and cross-checked GMC and GDC registers for dual registration before reviewing relevant cases and identifying and discussing themes. Seven OMFS specialists are currently subject to GMC sanctions. A total of 22 GDC hearings related to OMFS, all of which began after 2011. Six involved the practice of OMFS, work within an OMFS department, or work by a dually-registered doctor. While "double jeopardy" is uncommon, it does happen. The cases reviewed raise issues about the remit of the GDC and their understanding of clinical practice in OMFS. We found no evidence of progress in attempts to simplify FTP proceedings. The number of GDC hearings relevant to OMFS is increasing.

Scheduling terminology for oral and maxillofacial surgery. Are we speaking a universal language?

Use of a universal vocabulary to assist with the scheduling of operations has been shown to considerably reduce delays and improve the use of theatre resources. Within the UK the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has established a classification to assist with the triage of both emergency and non-emergency operating lists. We completed a survey to assess the uptake and understanding of this classification when scheduling maxillofacial operations. From a list of eight scheduling terms, respondents had to choose one each for 20 different clinical situations (that represented equally) immediate, urgent, expedited, and elective operations as defined by them. A total of 50 surveys were collated. Only 65% of answers selected represented NCPOD terms. 25% of answers represented a term higher and 18% a term lower, on the scale of intervention for the same category of situation. Current NCEPOD terms do not seem to be used universally and are poorly understood. Considerable variation in terminology exists when scheduling maxillofacial operations.

Errors in interpretation of neck levels in postoperative pathological specimens.

Accurate orientation of pathological specimens is of fundamental importance, and specimens that are divided postoperatively may be misinterpreted. We asked surgeons and pathologists to identify boundaries between nodal levels on a clinical photograph of a neck dissection specimen. Few participants were able to identify the boundaries between levels accurately, with several important errors where a marked level contained none of the relevant anatomical tissue. Most errors were in level I, and the number decreased towards level IV. Errors were made by both pathologists and surgeons. The boundaries of level IIA were consistently overestimated, which may have implications for previous studies that evaluated patterns of nodal spread.

The technique of delivery of peri-operative analgesia does not affect the rehabilitation or outcomes following total knee arthroplasty.

AIMS: This non-blinded randomised controlled trial compared the effect of patient-controlled epidural analgesia (PCEA) versus local infiltration analgesia (LIA) within an established enhanced recovery programme on the attainment of discharge criteria and recovery one year after total knee arthroplasty (TKA). The hypothesis was that LIA would increase the proportion of patients discharged from rehabilitation by the fourth post-operative day but would not affect outcomes at one year. PATIENTS AND METHODS: A total of 242 patients were randomised; 20 were excluded due to failure of spinal anaesthesia leaving 109 patients in the PCEA group and 113 in the LIA group. Patients were reviewed at six weeks and one year post-operatively. RESULTS: There was no difference in the proportion of patients discharged from rehabilitation by the fourth post-operative day, (77% in the PCEA group, 82% in the LIA group, p = 0.33), mean length of stay (four days in each group, p = 0.540), day of first mobilisation (p = 0.013) or pain (p = 0.278). There was no difference in mean Oxford Knee Scores (41 points in each group, p = 0.915) or the rate of complications in the two groups. CONCLUSION: Both techniques provided adequate pain relief, enabled early mobilisation and accelerated rehabilitation and good patient-reported outcomes up to one year post-operatively. PCEA and LIA are associated with similar clinical outcomes following TKA. Cite this article: Bone Joint J 2016;98-B1189-96.

Lower-limb risk factors for falls in people with diabetes mellitus.

BACKGROUND: Older people with diabetes mellitus (DM) may be at high risk of falling because of general risk factors for falls as well as disease-specific factors. AIMS: To determine the prevalence of falls and to investigate lower-limb factors for falls in older people with DM. Methods Sixty patients with DM over 55 years of age were recruited. 'Fallers' were those who self-reported at least one fall in the previous year. In addition to diabetes status and demographic information, the following were assessed: neuropathy symptom score (NSS), neuropathy disability score (NDS), foot deformity score (FDS), Tinetti performance-oriented assessment of mobility (POMA), ankle muscle strength and gait parameters. Data from 'fallers' and 'non-fallers' were compared and logistic regression analysis performed to identify variables predictive of falls. RESULTS: Thirty-five per cent (n = 21) of participants had fallen in the preceding year. Compared with 'non-fallers', there was a greater incidence of peripheral neuropathy among 'fallers' (86% of 'fallers' and 56% of 'non-fallers'), higher vibration perception threshold (P = 0.04), slower gait velocity (P < 0.001), lower muscle strength for dorsiflexion, plantarflexion, inversion and eversion (all P < 0.001) and higher incidence of bony prominences and prominent metatarsal heads (both P < 0.001). There was a strong and significant correlation between dorsiflexion muscle strength and gait velocity. Logistic regression analysis determined that walking velocity, strength of ankle dorsiflexors and NSS accurately predicted 75% of 'fallers'. CONCLUSIONS: Simple clinical measures of gait velocity and ankle muscle strength may be used to identify people with DM at risk of falling, allowing preventative strategies to be implemented.

Quadriceps activity and physical activity profiles over long durations in patients with osteoarthritis of the knee and controls.

Exercise is recommended as a non-pharmacological, non-invasive intervention for osteoarthritis (OA) of the knee. Physiological data concerning the duration and intensity of muscle activity or physical activity profiles during normal daily activity for this population is lacking. Our aim was to explore this using surface Electromyography (EMG) and accelerometer-based activity monitoring. Thirty-four patients with knee OA, mean (SD) age 63.2 (9.8) years and 30 aged-matched asymptomatic controls 64.1 (10.9) years participated. The duration of recording was similar in knee OA and control groups - median (IRQ range) 12:34 (10:11-14:17)h and 13:10 (12:02-14:56)h, respectively (p=0.514). VM and VL were quiescent for 81.8 (75.3-91.0) to 89.2 (81.5-94.7)% of the time. VM was active for significantly longer durations than VL in the highest intensity band for those with knee OA (p=0.00), and for longer durations in those with knee OA compared to controls (p=0.027). The median (IRQ range) percentage of the total recording time spent in an upright posture was 32.4 (28.3-43.9)% and 38.8 (33.6-45.8)%, and time spent stepping or walking was 12.7 (9.7-16.4)% and 16.0 (11.9-19.6)% for those with knee OA and controls respectively. These novel data may prove useful for designing therapeutic exercise programmes and lifestyle changes for those with knee OA.

Exercise for improving balance in older people.

BACKGROUND: Diminished ability to maintain balance may be associated with an increased risk of falling. In older adults, falls commonly lead to injury, loss of independence, associated illness and early death. Although some exercise interventions with balance and muscle strengthening components have been shown to reduce falls it is not known which elements, or combination of elements, of exercise interventions are most effective for improving balance in older people. OBJECTIVES: To present the best evidence for effectiveness of exercise interventions designed to improve balance in older people living in the community or in institutional care. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (Feb 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), other databases and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials testing exercise interventions designed to improve balance in older people were included. We excluded trials of interventions targeting individuals with specific conditions in order not to broaden the scope of this review too widely. Trials were included where participants were randomised to receive the following: a single exercise intervention or a multiple exercise intervention and a control group (usual activities or attention or recreational activity). Trials comparing two or more exercise interventions and a control group were also included. DATA COLLECTION AND ANALYSIS: Three pairs of members of the review team independently assessed trial quality and extracted data. For each trial, relative risk and 95% confidence intervals were calculated for dichotomous outcomes, and mean differences and 95% confidence intervals calculated for continuous outcomes. Where appropriate, results of comparable groups of trials were pooled and 95% confidence intervals calculated. MAIN RESULTS: For the 34 included studies there were 2883 participants at entry. Statistically significant improvements in balance ability were observed for exercise interventions compared to usual activity. Interventions involving gait; balance; co-ordination and functional exercises; muscle strengthening; and multiple exercise types appear to have the greatest impact on indirect measures of balance. There was trend towards an improvement in balance with cycling on a static cycle. However, there was limited evidence that effects were long-lasting. AUTHORS' CONCLUSIONS: Exercise appears to have statistically significant beneficial effects on balance ability in the short term but the strength of evidence contained within these trials is limited. Many of these mainly small studies demonstrated a range of methodological weaknesses. The failure across the included studies to apply a core set of standardised outcome measures to determine balance ability restricts the capacity to compare or pool different trials from which firm conclusions regarding efficacy can be made. Further standardisation in timing of outcome assessment is also required as is longer term follow-up of outcomes to determine any lasting effects.

Exercise for treating anterior cruciate ligament injuries in combination with collateral ligament and meniscal damage of the knee in adults.

BACKGROUND: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. The ACL may be damaged in isolation but often other ligaments and menisci are implicated. The injury may be managed surgically or conservatively. Injury causes pain, effusion and inflammation leading to alteration in muscle function. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation. OBJECTIVES: To present the best evidence for effectiveness of exercise used in the treatment of ACL injuries in combination with collateral ligament and meniscal damage to the knee in adults, on return to work and pre-injury levels of activity. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1996 to October 2006), EMBASE (1980 to October 2006), other databases and reference lists of articles. SELECTION CRITERIA: We included randomised controlled trials and quasi-randomised trials testing exercise programmes designed to treat adults with ACL injuries in combination with collateral ligament and meniscal damage. Included trials randomised participants to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials. MAIN RESULTS: Five trials (243 participants) evaluated different exercise programmes following ACL reconstruction and one trial (100 participants) compared supervised with self-monitored exercises as part of conservative treatment. No study compared the effect of exercise versus no exercise. Methodological quality scores varied considerably across the trials; participant and assessor blinding were poorly reported. Pooling of data was rarely possible due to the wide variety of comparisons, outcome measures and time points reported, and lack of appropriate data. Insufficient evidence was found to support the efficacy of one exercise intervention over another. AUTHORS' CONCLUSIONS: This review has demonstrated an absence of evidence to support one form of exercise intervention over another. Further research should be considered in the form of large scale well-designed and well-reported randomised controlled trials with suitable outcome measures and surveillance periods. Suitable outcome measures should include a measure of functional outcome relevant to the individual.

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation.

BACKGROUND: Dysvascularity accounts for 75% of all lower limb amputations in the UK. Around 37% of these are at transfemoral level (mid-thigh), with the majority of people being over the age of 60 and having existing co-morbidities. A significant number of these amputees will be prescribed a lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. OBJECTIVES: We aimed to identify and summarise the evidence from randomised controlled trials evaluating rehabilitation interventions for prosthetic ambulation following unilateral transfemoral amputation in older dysvascular people, whether community dwelling or institutionalised. SEARCH STRATEGY: We searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (July 2006), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 3), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006), CINAHL (1982 to December 2005), AMED (1985 to December 2005), several more specialised databases and reference lists of articles. We also searched the UK National Research Register (Issue 2, 2005) for ongoing trials and contacted experts in the field. No language restrictions were applied. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular people. DATA COLLECTION AND ANALYSIS: Two authors independently scanned the search results for potentially eligible studies and then, on obtaining full reports of these, selected studies for inclusion and exclusion. Two authors independently assessed methodological quality and extracted data. No data pooling was possible. MAIN RESULTS: Of 38 full reports obtained for consideration, one trial was included and four were excluded. The sole included trial was a short-term crossover randomised trial which tested the effects of adding three seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. The trial found that four participants preferred the lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the addition of the heaviest weight (1625 g). AUTHORS' CONCLUSIONS: There is a lack of evidence from randomised controlled trials to inform the choice of prosthetic rehabilitation, including the optimum weight of prosthesis, after unilateral transfemoral amputation in older dysvascular people. A programme of research, including randomised controlled trials to examine key interventions, is urgently required in this area.

Rehabilitation for distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. OBJECTIVES: To examine the effects of rehabilitation interventions in adults with conservatively or surgically treated distal radial fractures. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE, EMBASE, CINAHL, AMED, PEDro, OTseeker and other databases, conference proceedings and reference lists of articles. No language restrictions were applied. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by adults. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians. DATA COLLECTION AND ANALYSIS: The authors independently selected and reviewed trials. Study authors were contacted for additional information. No data pooling was done. MAIN RESULTS: Fifteen trials, involving 746 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 27 participants whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. For interventions started during immobilisation, there was weak evidence of improved hand function for hand therapy in the days after plaster cast removal, with some beneficial effects continuing one month later (one trial). There was weak evidence of improved hand function in the short term, but not in the longer term (three months), for early occupational therapy (one trial), and of a lack of differences in outcome between supervised and unsupervised exercises (one trial). For interventions started post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (four trials), passive mobilisation (two trials), ice or pulsed electromagnetic field (one trial), or whirlpool immersion (one trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (one trial), intermittent pneumatic compression (one trial) and ultrasound (one trial). There was weak evidence of better short-term hand function in participants given physiotherapy than in those given instructions for home exercises by a surgeon (one trial). AUTHORS' CONCLUSIONS: The available evidence from randomised controlled trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

Exercise for treating isolated anterior cruciate ligament injuries in adults.

BACKGROUND: The anterior cruciate ligament (ACL) is the most frequently injured ligament of the knee. Injury causes pain, effusion and inflammation leading to the inability to fully activate the thigh muscles. Regaining muscular control is essential if the individual wishes to return to pre-injury level of function and patients will invariably be referred for rehabilitation. OBJECTIVES: To present the best evidence for effectiveness of exercise used in the rehabilitation of isolated ACL injuries in adults, on return to work and pre-injury levels of activity. SEARCH STRATEGY: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PEDro - The Physiotherapy Evidence Database, CINAHL, AMED, and reference lists of articles. SELECTION CRITERIA: Randomised controlled trials and quasi-randomised trials testing exercise programmes designed to rehabilitate adults with isolated ACL injuries. Trials where participants were randomised to receive any combination of the following: no care, usual care, a single-exercise intervention, and multiple-exercise interventions. The primary outcome measures of interest were returning to work and return to pre-injury level of activity post treatment, at six months and one year. DATA COLLECTION AND ANALYSIS: All trials judged to have met the inclusion criteria were independently assessed for methodological quality by use of a 15 point checklist. Pairs of authors independently extracted data. For each study, relative risk and 95% confidence intervals were calculated for dichotomous outcomes and mean differences and 95% confidence intervals calculated for continuous outcomes. MAIN RESULTS: Nine trials, involving 391 participants met the inclusion criteria of the review. Only two trials, involving 76 participants, reported conservative rehabilitation and seven trials, involving 315 participants, evaluated rehabilitation following ACL reconstruction. Methodological quality scores varied considerably across the trials, with the nature of participant and assessor blinding poorly reported. Trial comparisons fell into six categories. Pooling of data was rarely possible due to lack of appropriate data as well as the wide variety in outcome measures and time points reported. Insufficient evidence was found to support the efficacy of one exercise intervention over another. AUTHORS' CONCLUSIONS: This review has demonstrated an absence of evidence to support one form of exercise intervention against another and the use of supplementary exercises in the management of isolated ACL injuries. Further research in the form of large scale well designed randomised controlled trials with suitable outcome measures and surveillance periods, using standardised reporting should be considered.

Lateral weight transference exercises following acute stroke: a preliminary study of clinical effectiveness.

OBJECTIVES: To evaluate a training programme aimed at improving lateral weight transference in patients following acute stroke to determine main treatment effects, if any, to inform the design of future studies. DESIGN: A single-blind randomized controlled trial. SETTING: The Stroke Unit at The James Cook University Hospital, Middlesbrough, UK. SUBJECTS: Thirty-five patients with an acute stroke. INTERVENTIONS: All subjects received their usual care, including physiotherapy. The treatment group (n = 17) received 12 additional therapy sessions (over four weeks) comprising exercises aimed at improving lateral weight transference in sitting delivered by trained physiotherapy assistants. MAIN OUTCOME MEASURES: Measures of dynamic reaching, sitting and standing, and static standing balance were undertaken by a blind independent observer. RESULTS: Specific measures of weight displacement in standing and reaching, and timed standing up and sitting down did not detect any differences over time regardless of group. Neither were there any significant changes over time, except for sway during static standing (p < 0.01) and time to return to their original position during dynamic reaching (p = 0.01). CONCLUSIONS: A training programme aimed at improving lateral weight transference did not appear to enhance the rehabilitation of acute stroke patients. Improvements observed in postural control in standing and sitting may be attributable to usual care or natural recovery.

Auditory cues can modify the gait of persons with early-stage Parkinson's disease: a method for enhancing parkinsonian walking performance?

OBJECTIVE: To investigate whether systematically adjusting the rate of auditory cues induces corresponding modulations of the temporal and spatial parameters of gait of patients with early-stage Parkinson's disease. DESIGN: Subjects performed a series of 15 9-metre walks along a level floor under uncued and four cued conditions; the order of cued conditions was randomized. SETTING: A physiotherapy gymnasium, Manchester, UK. SUBJECTS: Eleven subjects with early-stage idiopathic Parkinson's disease. INTERVENTIONS: Preferred pace was established from the initial three uncued walks. The rate of auditory cues delivered throughout subsequent walks was systematically adjusted for each subject, representing 85, 92.5, 107.5 and 115% of their mean cadence at preferred walking pace. MAIN OUTCOME MEASURES: Mean cadence, mean stride length and mean velocity. RESULTS: Repeated measures ANOVA indicated that the mean velocity and mean cadence of subjects' gait significantly (p < or = 0.01) increased relative to baseline values at cue rates of 115 and 107.5% of cadence at preferred pace and decreased at cue rate of 85%. Mean stride length was unaffected by variations in cue rate. CONCLUSION: The rate of auditory cues, within the range tested, can modulate cadence and thus velocity of gait of subjects with early-stage Parkinson's disease. The provision of auditory cues provides a potential strategy for enhancing walking performance in these patients.

Rehabilitation for distal radial fractures in adults.

BACKGROUND: Fracture of the distal radius is a common clinical problem, particularly in older white women with osteoporosis. OBJECTIVES: To examine the evidence for effectiveness of rehabilitation intervention(s) for adults with conservatively or surgically treated distal radial fractures. SEARCH STRATEGY: We searched the Cochrane Musculoskeletal Injuries Group specialised register (January 2002), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 2001), the Cochrane Rehabilitation and Related Therapies Field database, MEDLINE (1966 to January 2002), EMBASE (1988 to 2001 Week 50), CINAHL (1982 to December Week 2 2001), Current Controlled Trials (December 2001), AMED, PEDro, conference proceedings and reference lists of articles. SELECTION CRITERIA: Randomised or quasi-randomised clinical trials evaluating rehabilitation as part of the management of fractures of the distal radius sustained by skeletally mature patients. Rehabilitation interventions such as active and passive mobilisation exercises, and training for activities of daily living, could be used on their own or in combination, and be applied in various ways by various clinicians. DATA COLLECTION AND ANALYSIS: All trials meeting the selection criteria were independently assessed by all three reviewers for methodological quality. Data were extracted independently by two reviewers. The trials were grouped into categories relating to the main comparisons, and to when the intervention(s) commenced (for example, during or after plaster cast immobilisation). Quantitative data are presented using relative risks or mean differences together with 95 per cent confidence limits. MAIN RESULTS: Twelve trials, involving 601 mainly female and older patients, were included. Initial treatment was conservative, involving plaster cast immobilisation, in all but 20 patients whose fractures were fixed surgically. Though some trials were well conducted, others were methodologically compromised. No trial provided definitive evidence. Only very limited pooling of results from comparable trials was possible. During immobilisation, there was weak evidence of improved hand function in the short term, but not in the longer term, for early occupational therapy (1 trial), and of a lack of differences in outcome between supervised and unsupervised exercises (1 trial). Post-immobilisation, there was weak evidence of a lack of clinically significant differences in outcome in patients receiving formal rehabilitation therapy (3 trials), passive mobilisation (2 trials) or whirlpool immersion (1 trial) compared with no intervention. There was weak evidence of a short-term benefit of continuous passive motion (post external fixation) (1 trial), intermittent pneumatic compression (1 trial) and ultrasound (1 trial). There was weak evidence of better short-term hand function in patients given physiotherapy than in those given instructions for home exercises by a surgeon (1 trial). REVIEWER'S CONCLUSIONS: The available evidence from randomised trials is insufficient to establish the relative effectiveness of the various interventions used in the rehabilitation of adults with fractures of the distal radius.

The reliability of measuring quadriceps cross-sectional area with compound B ultrasound scanning.

Many therapists use thigh circumference as a measure of quadriceps size to evaluate the effect of an injury or effectiveness of an intervention. However, this technique has been shown to be unreliable, thus more accurate methods of measuring muscle size are required. The purpose of this study was to investigate the validity and reliability of measuring quadriceps cross-sectional area (CSA) with static compound B ultrasound scanning at the level of the mid-thigh. Repeated measures of known linear distances and CSAs were made with a planimetry device. Both face and criterion validity were demonstrated indicating that the device is reliable when measuring CSAs. A single rater located quadriceps muscle borders and measured CSAs on a series of ultrasound scans. A mean coefficient of variation (%CV = 1.7) was observed, signifying high intra-rater reliability. Two raters performed six scans on each of 15 subjects. Initial observation of these results suggest that the measurement of quadriceps CSA with compound B ultrasound scanning is reliable, mean %CVs = 2.8 and 1.9 for the two raters and 2.4 when their results were combined. When raters performed scans on 18 subjects on two occasions on the same day intra-class correlation coefficients (ICC) were high, 0.991 and 0.980 for raters A and B, respectively. Paired Student's t-tests revealed a significant difference (p < 0.05) for Rater B between CSAs measured for initial and relocated scans. However, this difference was calculated as 1.4-2.9% and was not of clinical importance. A significant difference (p < 0.05) was observed between measurements of CSAs made by both raters on the same subject. A calibration factor was calculated for transforming the measurements of Rater B, the use of which gave comparable values. ICCs using a fixed model for inter-rater reliability were 0.963 and 0.974 for actual and transformed values, respectively. This study observed differences between measures obtained by different raters and recommends that the calculation and employment of a calibration factor may be useful when comparing sequential measures made by different raters.

The use of patterned neuromuscular stimulation to improve hand function following surgery for ulnar neuropathy.

A 60-year-old man with wasting and weakness of the right hand following ulnar nerve entrapment at the elbow was referred for electrotherapy. An ulnar nerve transposition had been performed 2 years previously. This had produced some improvement in nerve conduction without significantly improving hand muscle function. The right first dorsal interosseous muscle (FDI) was stimulated for 4 hours per day over a 6-week period with a stimulus pattern replicating the discharge of a single motor unit from a healthy, fatigued FDI (patterned neuromuscular stimulation or PNMS). The response was assessed using a single case design. Significant improvements in the strength and fatigue resistance of the FDI were observed, associated with improvements in general hand function. PNMS may be useful in restoring hand function in patients with muscle atrophy following entrapment neuropathy.