Rib cage distortion and dynamic hyperinflation during two exercise intensities in people with COPD.

BACKGROUND: The relationship between rib cage (RC) motion abnormalities, dynamic hyperinflation (DH), and exercise capacity in people with COPD is controversial. AIM: To investigate RC distortion and operational chest wall volumes during moderate and high constant-rate exercises in people with COPD. METHODS: Seven male participants [median(Q1-Q3) age: 63(60.0-66.0) years; FEV1: 39.0(38.0-63.0)% of predicted] performed a symptom-limited incremental exercise testing on cycle ergometer, followed by constant-rate tests (60 % and 80 % of peak work rate). Optoelectronic plethysmography was used to evaluate RC distortion: phase angle-PhAng, inspiratory phase ratio-PhRIB, expiratory phase ratio-PhREB; and chest wall volumes: end-inspiratory volume-Vei and end-expiratory volume-Vee. RESULTS: PhRIB and PhREB significantly increased during both constant-rate exercise tests, without difference between them. In general, Vei of the chest wall significantly increased in both exercise intensities while Vee did not change. CONCLUSIONS: The occurrence of RC distortion seemed not to limit the exercise capacity in people with COPD evaluated, and it was present even in the absence of DH.

Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial.

BACKGROUND: The pelvic floor muscle (PFM) is associated with respiratory function. We investigated the effects of PFM training by pelvic floor electrical stimulation (PFES) on PFM strength, diaphragm excursion, and upper rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence (SUI). METHODS: In total, 33 participants with SUI were divided into PFES and control groups. The two groups were measured pre- and post-8 weeks of training. Diaphragm excursion and upper rib cage movement during tidal and forceful breathing and coughing and PFM strength were measured using sonography, electromagnetic sensors, and perineometry. RESULTS: There were significant difference of main effect between pre- and post-training and between groups in PFM strength (between groups: P = .001, between time: P < .001) and diaphragm excursion during forceful breathing (between groups: P = .015, between time: P = .026) and coughing (between groups: P = .035, between time: P = .006). There were significant differences in diaphragm excursion during tidal (P = .002) and forceful breathing (P = .005) and coughing (P < .001) between pre- and post-training in the PFES group. Elevation of the upper rib cage during tidal (P < .001) and forceful breathing (P = .001) was significantly decreased after 8 weeks of training in the PFES group. Widening in the horizontal plane in the upper rib cage during forceful breathing (P < .001) was significantly increased after 8 weeks of training in the PFES group. PFM strength (P < .001) was significantly increased after 8 weeks of training in the PFES group. CONCLUSIONS: Pelvic floor muscles training by electrical stimulation can improve diaphragm excursion and breathing patterns in women with SUI.

Consideraciones bucodentales en pacientes con Síndrome de Morquio / Dental considerations of the morquio síndrome

La mucopolisacaridosis tipo IV (MPS-IV) también conocida como enfermedad de Morquio en recuerdo del pediatra uruguayo Luis Morquio que la describió por primera vez, es una enfermedad congénita causada por la deficiencia de la enzima N-acetilgalactosamina 6 sulfatasa o de la enzima B-Galactosidasa. Estas anomalías enzimáticas tienen como consecuencia que se acumulen en diferentes tejidos del organismo cantidades elevadas de mucopolisacaridos. En la bibliografía se describe con detalle los defectos del esmalte que presentan los pacientes diagnosticados del síndrome de Morquio. Estos defectos son una característica aparentemente constante en la enfermedad y, por lo tanto, hace necesaria las visitas al odontólogo para su control evitándose problemas mayores. Dichos defectos consisten en un esmalte anormalmente delgado, que es áspero debido a los numerosos hoyos diminutos y a una superficie irregular. La delgadez del esmalte da como resultado una forma alterada y decoloración de los dientes que, añadido a los diastemas interdentales, provocan alteraciones en la oclusión. Aparte de estos defectos, el esmalte es histológicamente normal y tiene una du-reza y radiodensidad normales. El trata-miento odontológico de los pacientes con MPS-IV requiere colaboración multidisciplinar, debido a que las manifestaciones orales de la enfermedad pueden aparecer a cualquier edad, resultando en ocasiones tedioso para el paciente y complicado para el profesional. Especial mención merecen las terapias utilizadas como trata-miento sintomático de la enfermedad, así como el manejo de la vía aérea en el caso de intervenciones bajo anestesia general o sedación para tratar ciertas patologías del territorio bucomaxilodental

Mucopolysaccharidosis type IV (MPS-IV) also known as Morquio’s disease in memory of the Uruguayan pediatrician Luis Morquio who described it for the first time, is a congenital disease caused by the deficiency of the enzyme N-acetylgalactosamine 6 sulfatase or enzyme B -Galactosidase. These enzymatic anomalies result in high amounts of mucopolysaccharides accumulating in different tissues of the organism. The enamel defects presented by patients diagnosed with Morquio syndrome are described in detail in the bibliography. These defects are an apparently constant feature in the disease and, therefore, make visits to the dentist necessary for their control, avoiding major problems. These defects consist of an abnormally thin enamel that is rough due to numerous tiny holes and an irregular surface. The thinness of the enamel results in an altered form and discoloration of the teeth, which added to the interdental diastemas, cause alterations in the occlusion. Apart from these defects, the enamel is histologically normal and has a normal hardness and radiodensity.Dental treatment of patients with MPS-IV requires multidisciplinary collaboration, because the oral manifestations of the disease can appear at any age, being sometimes tedious for the patient and complicated for the professional. Special mention should be made of the therapies used as a symptomatic treatment of the disease, as well as the management of the airway in the case of interventions under general anesthesia or sedation to treat certain pathologies of the bucomaxillodental territory

Balance and musculoskeletal flexibility in children with obesity: a cross-sectional study.

BACKGROUND: Studies on the influence of obesity on different physical parameters such as postural balance and musculoskeletal flexibility are limited and have reported varying results. OBJECTIVES: Measure effect of childhood obesity on balance and musculoskeletal flexibility in Saudi children. DESIGN: Cross-sectional. SETTING: Physiotherapy laboratory. SUBJECTS AND METHODS: The study included a representative sample of Saudi elementary school children selected from a convenience sample of 150 children. Balance was examined using the Biodex balance system. Calf muscle flexibility was measured by the weight-bearing ankle lunge test while the chest flexibility was measured by the chest expansion test. MAIN OUTCOME MEASURES: Postural stability indices and flexibility parameters. SAMPLE SIZE: 90 elementary school children aged 6 to 11 years, 47 of normal weight and 43 obese children. RESULTS: All stability indices at different stability levels were significantly impaired in children with obesity ( P≤.05). In terms of musculo-skeletal flexibility, the weight-bearing lunge test distance was shorter in children with obesity ( P=.01). In the chest expansion test, there was no significant difference between the two groups ( P=.32). CONCLUSIONS: Postural balance at different stability levels was impaired in children with obesity and in all planes. The calf muscles were less flexible in obese children. LIMITATIONS: Unblinded, convenience sample so findings are not generalizable. CONFLICT OF INTEREST: None.

Quadrangular Fixation of Pectus Bars to Prevent Displacement in Nuss Procedure.

BACKGROUND: Double pectus bars are sometimes inserted to correct pectus excavatum. Method of double-bar fixation to prevent bar displacement has been rarely reported. We have used quadrangular fixation of the double pectus bars. The objective of this study was to compare results of the quadrangular fixation procedure with those of the classic separate fixation procedure. METHODS: From September 2011 to January 2016, 86 patients underwent Nuss procedure with double-bar insertion. In 44 patients, each bar was fixed separately (group A). In 42 patients, quadrangular fixation of the bars was performed with metal plates (group B). Patient demographics, Haller index (HI), bar displacement index (BDI), and reoperation rate were compared between the two groups. RESULTS: The mean patient age was 17.2 years (range: 3-40 years) in group A and 17.8 years (range: 4-30 years) in group B. There was no significant difference in preoperative or postoperative HIs between the two groups (all p >0.05). Early complication rates were 15.9% in group A and 9.5% in group B (p > 0.05). In group A, three patients underwent surgery to correct bar displacement (6.8% of reoperation rate), whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (p < 0.01). CONCLUSIONS: When quadrangular fixation was performed with upper and lower pectus bars bilaterally fixed by connecting each bar with plates, bar displacement was prevented more effectively than separate fixation, thus minimizing reoperation.

Dynamic 3D Reconstruction of Thoracic Cage and Abdomen in Children and Adolescents With Scoliosis: Preliminary Results of Optical Reflective Motion Analysis Assessment.

BACKGROUND: In patients with untreated scoliosis or in those with posterior spinal instrumented fusion (PSF), the movements of neither the thoracic cage (ThC) nor the abdomen (ABD) during quiet and deep breathing have been well defined in the literature. The purpose of this study was to evaluate kinematic variations in the ThC and ABD during quiet and deep breathing by optical reflective motion analysis (ORMA) in children with scoliosis. METHODS: The study included 6 healthy children (group A), 7 subjects with untreated scoliosis over 50 degrees (group B), and 8 patients with scoliosis treated by PSF (group C). After anthropometric measurements (standing height, sitting height, arm span, chest perimeter, body weight, body mass index, T1-T12, and L1-L5 length) were obtained, the movements of subjects during quiet and deep breathing were measured with a 10-camera 3-dimensional ORMA system (82 markers) with the subjects in a standard standing position. RESULTS: No significant differences were observed in sex, age, weight, height, or arm span (P>0.05). Significant differences were observed in the chest perimeter, Cobb angle, and body mass index (P<0.05). ThC and ABD movements during quiet and deep breathing decreased significantly in group B and C when compared with group A (P<0.05). Group B showed decreased expansion of the ThC (-52.4% to -58.3%) and relatively increased motion of the ABD compared with groups A and C (P<0.001). However, ABD expansion remained lower in group B than in groups A and C (-32.8% and -5.7%). PSF does not completely eliminate transverse plane kinematics, although a greater reduction was observed at instrumented than noninstrumented levels (-60.8% vs. -35.1%; P<0.05). CONCLUSIONS: ORMA is a useful tool for assessing alterations in the kinematics of the ThC and ABD caused by severe scoliosis and/or PSF. Compared with normal subjects, patients with severe scoliosis had poorer and less effective kinematics of the ThC and ABD. In contrast, operated subjects had better and more effective kinematics of the ThC and ABD, breathing curves, thoracic expansion, and abdominal movements closer to normal compared with patients with severe, untreated deformity. LEVEL OF EVIDENCE: Level III.

Impact of moderate-severe persistent allergic rhinitis on thoraco-abdominal kinematics and respiratory muscle function.

Objective: To assess thoraco-abdominal kinematics, respiratory muscle strength and electromyographic activity of the diaphragm (EAdi) in moderate-severe allergic rhinitis (AR) patients. Methods: A cross-sectional study involving 40 individuals (20 in the AR group) and 20 in the control group [CG]) was conducted. Ventilatory pattern and chest wall volume distribution (optoelectronic plethysmography), respiratory muscle strength (manovacuometry and sniff nasal inspiratory pressure [SNIP]), and EAdi were assessed in both groups. Results: The AR patients had impaired thoraco-abdominal kinematics (reduced total chest wall volume) (p = 0.004), lower values of total respiratory cycle time (p = 0.014) and expiratory time (p = 0.006). They also presented an increase of percentage contribution of the abdominal rib cage (p = 0.475) and respiratory rate (p = 0.019). A positive correlation among pulmonary rib cage tidal volume and MIP (r = 0.544; p < 0.001), SNIP (r = 0.615; p < 0.001), and MEP (r = 0.604; p < 0.001) was observed. After adjusting for age, BMI and gender through multivariate analysis, the individuals with AR presented lower values ​​of MIP (ß = -24.341; p < 0.001), MEP (ß = -0.277; p < 0.001), SNIP (ß = -34.687; p < 0.001) and RMS (ß = -0.041; p = 0.017). Conclusions: The individuals with moderate-severe persistent AR had worse respiratory muscle strength, diaphragm activation and chest wall volume distribution with a higher abdominal contribution to tidal volume than the control group. These findings reinforce the notion that the upper and lower airways work in an integrated and synergistic manner.

Improved Dynamics of Thoracic Cage and Exercise Capacity after Nuss Repair for Pectus Excavatum.

BACKGROUND: Pectus excavatum (PE) reduces the dynamics of the thoracic cage, with a negative impact on exercise capacity. We aimed to evaluate the effects of Nuss repair for PE on the dynamics of the thoracic cage and exercise capacity in adults. METHODS: This was a prospective observational study of 46 adults (mean age, 26.2 years) who underwent PE correction using the Nuss procedure between September 2016 and August 2017. Cirtometry was used to obtain measures of thoracic cage circumference at two levels (axillary level [AL] and xyphoid level [XL]), at the end points of inspiration and expiration. Circumference measures were obtained before surgery and at 1, 3, and 6 months after surgery. Exercise capacity was also evaluated using the 6-minute walk test (6MWT). The association between the 6MWT data and cirtometry measures was evaluated using Pearson's correlation. RESULTS: The circumference at maximum inspiration increased from baseline to 3 months after surgery (p < 0.01), at both the AL (84.5 ± 4.9 vs. 88.5 ± 5.1 cm) and XL (80.1 ± 4.8 vs. 83.7 ± 5.1 cm). The 6MWT also significantly improved from baseline to 3 months after surgical correction (544.7 ± 64.1 vs. 637.3 ± 59.4 m, p < 0.01), with this improvement being correlated to the increase in thoracic circumference on maximal inspiration at both the AL and XL (0.8424 and 0.7951, respectively). CONCLUSION: Improved dynamics of the thoracic cage were achieved after Nuss repair for PE in adults. This increase in thoracic circumference at maximum inspiration was associated with an improvement in exercise capacity at 3 months after surgery.

The Accuracy of Respiratory Calibration Methods for Estimating Lung Volume During Speech Breathing: A Comparison of Four Methods Across Three Adult Cohorts.

Purpose This study evaluated the accuracy of respiratory calibration methods for estimating lung volume during speech breathing. Method Respiratory kinematic data were acquired via inductance plethysmography in 32 young adults, 22 older adults, and 13 older adults with Parkinson's disease (PD). Raw rib cage (RC) and abdomen (AB) signals (V) were calibrated to liters using 4 correction methods: (a) isovolume maneuvers, (b) a constant 2:1 RC-to-AB ratio, (c) least squares method with RC correction only (LsqRC), and (d) least squares method with both RC and AB corrections (LsqRC/AB). Mean percent error, the absolute difference between estimated and actual lung volumes then normalized to each speaker's vital capacity, was calculated for each method. Results For young adults, the LsqRC/AB method significantly reduced mean percent error compared to all other methods. Although LsqRC/AB also resulted in smaller errors for older adults and adults with PD, LsqRC/AB and LsqRC were not significantly different from one another in these groups. Conclusion The LsqRC/AB method reduces errors across all cohorts, but older adults and adults with PD also have reduced errors when using LsqRC. Further research should investigate both least squares methods across larger age and disease severity ranges.

Changes in chest wall motion with removal of Nuss bar in repaired pectus excavatum - a cohort study.

BACKGROUND: The effects of the Nuss procedure on chest wall motion and spirometry have previously been described; we aimed to describe the effects of removal of the Nuss bar. METHODS: We studied 9 patients just prior to and 6 weeks after Nuss bar removal. Regional chest volume changes, synchrony of respiratory movement and spirometry were recorded using optoelectronic plethysmography (OEP) and compared. Recordings were performed at rest and exercise during cycle ergometry. RESULTS: There were small but statistically significant changes in tidal volumes of the diaphragmatic ribcage compartment during exercise (+ 48 ml, p = 0.038, Cohen's d = 0.12) and percentage contribution of the diaphragmatic ribcage to total tidal volumes at rest (+ 2.7 percentage points, p = 0.038, Cohen's d = 0.12). Synchrony of respiratory movements at rest and during exercise was unchanged following Nuss bar removal. There were no significant changes in spirometry and exercise capacity. CONCLUSIONS: The effects of Nuss bar removal on diaphragmatic ribcage motion are detectable but small and unlikely to be of clinical significance. No change in exercise capacity should be expected after Nuss bar removal. TRIAL REGISTRATION: Registered at ClinicalTrials.gov, identifier NCT02958683 , registered 5th August 2016, first patient enrolled July 2016, retrospectively registered.

Effect of High-Flow Nasal Cannula on Thoraco-Abdominal Synchrony in Pediatric Subjects After Cardiac Surgery.

BACKGROUND: We previously reported the effects of high-flow nasal cannula (HFNC) oxygen therapy on thoraco-abdominal synchrony. This study was designed to clarify the effect of HFNC on thoraco-abdominal synchrony in pediatric subjects after cardiac surgery and to investigate HFNC optimal flow in this population. METHODS: Thoraco-abdominal synchrony was evaluated with respiratory inductive plethysmography. After extubation, we delivered oxygen via face mask for 30 min to subjects with mild to moderate respiratory failure. Each subject then randomly received either 1 or 2 L/kg/min via HFNC for 30 min, followed by the other flow level via HFNC for 30 min. After HFNC, face mask delivery was resumed. Rib cage and abdominal movement were converted into volumes and 2 quantitative indexes: maximum compartmental amplitude/tidal volume (VT) ratio and phase angle. RESULTS: Ten subjects of median (interquartile range) age 7 (6-14) months and weighing 6.5 (5.3-8.8) kg were enrolled. Compared with the first delivery via face mask, breathing frequency, maximum compartmental amplitude/VT, phase angle, and minute volume significantly decreased at 2 L/kg/min (P < .05 for all) but not at 1 L/kg/min. PaCO2 did not differ among oxygen therapies. None of the measured variables differed between first and second face mask periods. CONCLUSIONS: After cardiac surgery, HFNC oxygen therapy at 2 L/kg/min improved thoraco-abdominal synchrony and decreased breathing frequency in pediatric subjects. (Clinical trial registration: UMIN000023426.).

Ribcage kinematics during exercise justifies thoracoscopic versus postero-lateral thoracotomy lobectomy prompt recovery.

OBJECTIVES: The video-assisted thoracic surgery (VATS) approach is encouraged over postero-lateral thoracotomy (PLT) for lobectomy in lung cancer. We compare the ribcage kinematics during exercise before and after both procedures, assuming that VATS, being minimally invasive, could better preserve ribcage expansion. METHODS: Thirty-one patients undergoing lobectomy by means of VATS (n = 20) or PLT (n = 11) were compared presurgery, after chest drainage removal (T1) and 2 months post-surgery (T2) during quiet breathing and incremental exercise. Spirometry, chest pain, ventilatory pattern and expansions of the ribcage (ΔVRC) and abdomen were measured. Furthermore, the expansion of the ribcage and abdomen in the operated (ΔVRC-OP and ΔVAB-OP, respectively) and non-operated (ΔVRC-NO and ΔVAB-NO, respectively) sides was also considered. RESULTS: At T1, in both groups, spirometry worsened and chest pain increased, being higher after PLT. Tidal volume (VT) decreased after PLT because the ribcage expanded less due to reduced ΔVRC-OP. Contrary to this, in VATS, there were no changes in VT and ΔVRC, although ΔVRC-OP was lower, because ΔVRC-NO increased at high level of exercise. At T2, ΔVRC-OP was completely restored after VATS. At high levels of exercise following PLT, although patients still showed reduced ΔVRC and ΔVRC-OP, VT was restored owing to increased ΔVAB-NO. CONCLUSIONS: We demonstrate VATS to have a reduced impact on ribcage kinematics while PLT induced restriction more markedly during exercise and still present 2 months after surgery. Patients adopt 2 different compensatory mechanisms, by shifting the expansion toward the contralateral ribcage after VATS and toward the abdomen after PLT. Our study justifies thoracoscopic lobectomy prompt recovery. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov (NCT02910453).

Scapulothoracic Joint Dysfunction.

Scapulothoracic derangements are often overlooked and hidden within the clinical fog created by complex back, shoulder, and rib symptoms. This study reviewed 200 magnetic resonance imaging and computed tomography studies dedicated for scapular imaging between January 2010 and May 2016. This article discusses scapulothoracic pathologies and imaging findings.

Influence of Sequential Ponte Osteotomies on the Human Thoracic Spine With a Rib Cage.

STUDY DESIGN: Biomechanical cadaveric study. OBJECTIVES: The purpose of this study was to determine the change in range of motion (ROM) of the human thoracic spine and rib cage due to sequential Ponte osteotomies (POs). SUMMARY OF BACKGROUND DATA: POs are often performed in deformity correction surgeries to provide flexibility in the sagittal plane at an estimated correction potential of 5° per PO, but no studies have evaluated the biomechanical impact of the procedure on a cadaveric model with an intact rib cage. METHODS: Seven human thoracic cadavers with intact rib cages were loaded with pure moments in flexion, extension, axial rotation, and lateral bending for five conditions: intact, PO at T9-T10, PO at T8-T9, PO at T7-T8, and PO at T6-T7. Motion of T1, T6, and T10 were measured, and overall (T1-T12) and regional (T6-T10) ROMs were reported for each mode of bending at each condition. RESULTS: POs increased ROM in flexion both overall (T1-T12) and regionally (T6-T10), although the magnitude of the increase was marginal (<1°/PO). No significant differences were found in axial rotation or lateral bending. CONCLUSIONS: POs may increase sagittal correction potential before fusion in patients with hyperkyphosis, though more work should be done to determine the magnitude of the changes. LEVEL OF EVIDENCE: Level V.