A bioengineering investigation of cervical collar design and fit: Implications on skin health.

BACKGROUND: Cervical collars restrict cervical spine movement to minimise the risk of spinal cord injury. Collars apply mechanical loading to the skin putting it at risk of skin damage. Indeed, cervical collar-related pressure ulcers are unacceptably prevalent, especially at the occiput, mandibles, and chin. Collar design and fit are often key considerations for prevention. METHODS: This comprehensive study evaluated four commercial prehospital and acute care cervical collars. Pressure, microclimate, transepidermal water loss and skin hydration were measured at the interface between the device and the skin. Range of motion restriction was measured to evaluate effective immobilisation. Head, neck, and shoulder morphology was evaluated using three-dimensional scans. FINDINGS: The occiput experienced significantly higher interface pressures than the chin and mandibles for most collar designs. Interface pressure at the occiput was significantly higher for the Stiffneck extrication collar compared to the other collar designs. The Stiffneck collar also provided the most movement restriction, though not significantly more than other designs. Relative humidity at the device skin interface was significantly higher for the Stiffneck and Philadelphia collars corresponding to closed cell foam padding, in contrast to the open cell foams lined with permeable fabric used in the other collars. Collar discomfort correlated with both occipital pressure and skin humidity. INTERPRETATION: The occiput is at increased risk of cervical collar-related pressure ulcers during supine immobilisation, especially for Stiffneck extrication collars. Lined open-cell foams could be used to minimise skin humidity and increase comfort.

Immobilization in External Rotation Versus Arthroscopic Stabilization After Primary Anterior Shoulder Dislocation: A Systematic Review of Level 1 and 2 Studies.

BACKGROUND: Arthroscopic stabilization has been established as a superior treatment option for primary glenohumeral instability when compared with immobilization in internal rotation. However, immobilization in external rotation (ER) has recently gained interest as a viable nonoperative treatment option for patients with shoulder instability. PURPOSE: To compare the rates of recurrent instability and subsequent surgery in patients undergoing treatment for primary anterior shoulder dislocation with arthroscopic stabilization versus immobilization in ER. STUDY DESIGN: Systematic review; Level of evidence, 2. METHODS: A systematic review was performed by searching PubMed, the Cochrane Library, and Embase to identify studies that'evaluated patients being treated for primary anterior glenohumeral dislocation with either arthroscopic stabilization or immobilization in ER. The search phrase used various combinations of the keywords/phrases "primary closed reduction,""anterior shoulder dislocation,""traumatic,""primary,""treatment,""management,""immobilization,""external rotation,""surgical,""operative,""nonoperative," and "conservative." Inclusion criteria included patients undergoing treatment for primary anterior glenohumeral joint dislocation with either immobilization in ER or arthroscopic stabilization. Rates of recurrent instability, subsequent stabilization surgery, return to sports, positive postintervention apprehension tests, and patient-reported outcomes were evaluated. RESULTS: The 30 studies that met inclusion criteria included 760 patients undergoing arthroscopic stabilization (mean age, 23.1 years; mean follow-up time, 55.1 months) and 409 patients undergoing immobilization in ER (mean age, 29.8 years; mean follow-up time, 28.8 months). Overall, 8.8% of operative patients experienced recurrent instability at latest follow-up compared with 21.3% of patients who had undergone ER immobilization (P < .0001). Similarly, 5.7% of operative patients had undergone a subsequent stabilization procedure at latest follow-up compared with 11.3% of patients who had undergone ER immobilization (P = .0015). A higher rate of return to sports was found in the operative group (P < .05), but no other differences were found between groups. CONCLUSION: Patients undergoing arthroscopic treatment for primary anterior glenohumeral dislocation with arthroscopic stabilization can be expected to experience significantly lower rates of recurrent instability and subsequent stabilization procedures compared with patients undergoing ER immobilization.

Tuina in a Frozen Shoulder Rat Model: An Efficient and Reproducible Protocol.

Frozen shoulder (FS) is a common condition with no defined optimal therapy. Tuina therapy, a traditional Chinese medicine (TCM) technique used to treat FS patients in Chinese hospitals, has demonstrated excellent results, but its mechanisms are not fully understood. Building on a previous study, this work aimed to develop a Tuina protocol for an FS rat model. We randomly divided 20 SD rats into control (C; n = 5), FS model (M; n = 5), FS model Tuina treatment (MT; n = 5), and FS model oral treatment (MO; n = 5) groups. This study used the cast immobilization method to establish the FS rat model. The effect of Tuina and oral dexamethasone on the glenohumeral range of motion (ROM) was evaluated, and the histological findings were assessed. Our study showed that Tuina and oral dexamethasone were able to improve shoulder active ROM and preserve the structure of the capsule, with Tuina therapy proving to be more effective than oral dexamethasone. In conclusion, the Tuina protocol established in this study was highly effective for FS.

Changes in passive stiffness and length of the semitendinosus muscles in rats with arthritis-induced knee flexion contracture.

BACKGROUND: Arthritis-induced joint contracture is caused by arthrogenic and myogenic factors. The arthrogenic factor, localized within the joint, is naturally accepted as the cause of contracture. However, the detailed mechanisms underlying arthritis-induced myogenic contracture are largely unknown. We aimed to elucidate the mechanisms of arthritis-induced myogenic contracture by examining the muscle mechanical properties. METHODS: Knee arthritis was induced in rats by injecting complete Freund's adjuvant into the right knees, while the untreated contralateral knees were used as controls. After one or four weeks of injection, passive stiffness, length, and collagen content of the semitendinosus muscles were assessed, along with passive knee extension range of motion. FINDINGS: After one week of injection, flexion contracture formation was confirmed by a decreased range of motion. Range of motion restriction was partially relieved by myotomy, but still remained even after myotomy, indicating the contribution of both myogenic and arthrogenic factors to contracture formation. After one week of injection, the stiffness of the semitendinosus muscle was significantly higher in the injected side than in the contralateral side. After four weeks of injection, the stiffness of the semitendinosus muscle in the injected side returned to levels comparable to the contralateral side, parallel to partial improvement of flexion contracture. Muscle length and collagen content did not change due to arthritis at both time points. INTERPRETATION: Our results suggest that increased muscle stiffness, rather than muscle shortening, contributes to myogenic contracture detected during the early stage of arthritis. The increased muscle stiffness cannot be explained by excess collagen.

Does initial skeletal muscle size or sex affect the magnitude of muscle loss in response to 14 days immobilization?

We aimed to determine whether there was a relationship between pre-immobilization skeletal muscle size and the magnitude of muscle atrophy following 14 days of unilateral lower limb immobilization. Our findings (n = 30) show that pre-immobilization leg fat-free mass and quadriceps cross-sectional area (CSA) were unrelated to the magnitude of muscle atrophy. However, sex-based differences may be present, but confirmatory work is required. In women, pre-immobilization leg fat-free mass and CSA were associated with changes in quadriceps CSA after immobilization (n = 9, r2 = 0.54-0.68; P < 0.05). The extent of muscle atrophy is not affected by initial muscle mass, but there is potential for sex-based differences.

Progression of microstructural deterioration in load-bearing immobilization osteopenia.

PURPOSE: Immobilization osteopenia is a major healthcare problem in clinical and social medicine. However, the mechanisms underlying this bone pathology caused by immobilization under load-bearing conditions are not yet fully understood. This study aimed to evaluate sequential changes to the three-dimensional microstructure of bone in load-bearing immobilization osteopenia using a fixed-limb rat model. MATERIALS AND METHOD: Eight-week-old specific-pathogen-free male Wistar rats were divided into an immobilized group and a control group (n = 60 each). Hind limbs in the immobilized group were fixed using orthopedic casts with fixation periods of 1, 2, 4, 8, and 12 weeks. Feeding and weight-bearing were freely permitted. Length of the right femur was measured after each fixation period and bone microstructure was analyzed by micro-computed tomography. The architectural parameters of cortical and cancellous bone were analyzed statistically. RESULTS: Femoral length was significantly shorter in the immobilized group than in the control group after 2 weeks. Total area and marrow area were significantly lower in the immobilized group than in the control group from 1 to 12 weeks. Cortical bone area, cortical thickness, and polar moment of inertia decreased significantly after 2 weeks. Some cancellous bone parameters showed osteoporotic changes at 2 weeks after immobilization and the gap with the control group widened as the fixation period extended (P < 0.05). CONCLUSION: The present results indicate that load-bearing immobilization triggers early deterioration of microstructure in both cortical and cancellous bone after 2 weeks.

[Optimization of rehabilitation of elderly and senile patients with primary traumatic dislocation of the shoulder.]

Тhe aim of the study is to improve the treatment outcomes of elderly patients with primary traumatic shoulder dislocation by developing an atraumatic rehabilitation method. The study included 56 patients aged over 60 years with primary traumatic dislocation of the shoulder. The patients of the first group (29 patients) after the dislocation of the shoulder was corrected, functional treatment was performed using orthoses and a developed course of physical therapy. Patients of the second group (27 patients) were treated according to the traditional method with the use of plaster immobilization after the dislocation of the shoulder was corrected. Shoulder joint radiography, MRI, determination of potentials in biologically active points (BAT) during the first 2-3 days after dislocation were used to diagnose shoulder dislocation and assess outcomes. To assess the immediate results, the electrical potential in BAHT was studied after 1,3 and 6 months. In 70,3% of group 1 patients, positive outcomes were obtained after 3-6 months on the ASES scale, while in the second group such results were achieved only in 57,3% of patients, and on the UCLA scale 22,8 and 19,2%, respectively. Thus, the use of the proposed tactics of functional treatment makes it possible to significantly (p<0,05) improve outcomes in patients of the older age group.

Muscle contractile exercise through a belt electrode device prevents myofiber atrophy, muscle contracture, and muscular pain in immobilized rat gastrocnemius muscle.

PURPOSE: Immobilization of skeletal muscles causes muscle atrophy, muscle contracture, and muscle pain, the mechanisms of which are related to macrophage accumulation. However, muscle contractile exercise through a belt electrode device may mitigate macrophage accumulation. We hypothesized that such exercise would be effective in preventing myofiber atrophy, muscle contracture, and muscular pain. This study tested this hypothesis in immobilized rat gastrocnemius muscle. MATERIALS AND METHODS: A total of 32 rats were divided into the following control and experimental groups: immobilization (immobilized treatment only), low-frequency (LF; immobilized treatment and muscle contractile exercise with a 2 s (do) /6 s (rest) duty cycle), and high-frequency (HF; immobilized treatment and muscle contractile exercise with a 2 s (do)/2 s (rest) duty cycle). Electrical stimulation was performed at 50 Hz and 4.7 mA, and muscle contractile exercise was applied to the lower limb muscles for 15 or 20 min/session (once daily) for 2 weeks (6 times/week). After the behavioral tests, the bilateral gastrocnemius muscles were collected for analysis. RESULTS: The number of macrophages, the Atrogin-1 and MuRF-1 mRNA expression, and the hydroxyproline content in the HF group were lower than those in the immobilization and LF groups. The cross-sectional area (CSA) of type IIb myofibers in the superficial region, the PGC-1α mRNA expression, and the range of motion of dorsiflexion in the HF group were significantly higher than those in the immobilization and LF groups. The pressure pain thresholds in the LF and HF groups were significantly higher than that in the immobilization group, and the nerve growth factor (NGF) content in the LF and HF groups was significantly lower than that in the immobilization group. CONCLUSION: Muscle contractile exercise through the belt electrode device may be effective in preventing immobilization-induced myofiber atrophy, muscle contracture, and muscular pain in the immobilized rat gastrocnemius muscle.

Soft collar for acute cervical spine injury immobilisation -patient experiences and outcomes: A single centre mixed methods study.

BACKGROUND: Cervical collars are used as standard care for neck immobilisation after cervical spine injury. Although evidence for the most effective type of collar is lacking, there is evidence regarding adverse patient outcomes when managed in a semi or rigid collar. In response to the evidence of complications and adverse effects when using a hard collar, a large Australian adult trauma hospital that specializes in spinal care, changed its policy from hard to soft collars when managing acute cervical spine injury. OBJECTIVE: The aim of this study was to investigate patients' experiences and outcomes when wearing a soft collar for acute cervical spine injury management in hospital. METHOD: A single centre mixed method sequential study design was used. RESULTS: Medical records from 136 patients were examined and no adverse events resulting from collar use were recorded. Interviews with 20 patients revealed that they understood the value of wearing a soft collar. The soft collars were considered supportive and well tolerated, with good adherence to recommendations for use. CONCLUSIONS: Understanding the patients' experiences informs better care management. This study suggests that soft collars are well tolerated, do not result in pressure injuries or other adverse events and are suitable for managing acute cervical spine injury.

Development of a novel knee contracture mouse model by immobilization using external fixation.

AIMS: Several studies have used animal models to examine knee joint contracture; however, few reports detail the construction process of a knee joint contracture model in a mouse. The use of mouse models is beneficial, as genetically modified mice can be used to investigate the pathogenesis of joint contracture. Compared to others, mouse models are associated with a lower cost to evaluate therapeutic effects. Here, we describe a novel knee contracture mouse model by immobilization using external fixation. METHODS: The knee joints of mice were immobilized by external fixation using a splint and tape. The passive extension range of motion (ROM), histological and immunohistochemical changes, and expression levels of fibrosis-related genes at 2 and 4 weeks were compared between the immobilized (Im group) and non-immobilized (Non-Im group) groups. RESULTS: The extension ROM at 4 weeks was significantly lower in the Im group than in the Non-Im group (p < 0.01). At 2 and 4 weeks, the thickness and area of the joint capsule were significantly greater in the Im group than in the Non-Im group (p < 0.01 in all cases). At 2 weeks, the mRNA expression levels of the fibrosis-related genes, except for the transforming growth factor-ß1, and the protein levels of cellular communication network factor 2 and vimentin in the joint capsule were significantly higher in the Im group (p < 0.01 in all cases). CONCLUSION: This mouse model may serve as a useful tool to investigate the etiology of joint contracture and establish new treatment methods.

Immobilization-Related Hypercalcemia in a COVID-19 Patient With Prolonged Intensive Care Unit Stay.

ABSTRACT: Immobilization-related hypercalcemia is an uncommon finding in patients admitted to intensive care unit. We report a case of severe hypercalcemia in a COVID-19 patient admitted to intensive care unit for hypoxemic respiratory failure. He developed an acute kidney injury requiring continuous renal replacement therapy with regional citrate anticoagulation. Citrate chelates ionized calcium and stop the coagulation cascade locally, preventing filter clotting. Calcium is then given intravenously to a specific target (normocalcemia). It is only when calcium infusion has been stopped that bone resorption and hypercalcemia were unmasked.

Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature

Abstract Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

A rat model of hip joint contracture induced by mono-articular hip joint immobilization.

BACKGROUND: To elucidate the formation process and therapeutic targets of hip flexion contracture, we developed a rat model of hip flexion contracture induced by hip mono-articular immobilization. METHODS: Kirschner wires inserted into the femur and hip bone were anchored at the hip in a flexed position in the immobilization groups and unanchored in the sham groups for up to four weeks. Age-matched untreated rats were used as controls. Hip extension range of motion (RoM) was measured at three different extension moments (7.5, 15, and 22.5 N•mm) in each successive myotomy step as follows: before myotomy, after sequential myotomy of the tensor fascia lata, quadriceps muscle, iliopsoas muscle, and after myotomy of all residual muscles (the gluteus medius and adductor muscles). Histological analysis of the hip joint was also performed. FINDINGS: After four weeks of immobilization, the RoM before myotomy at 22.5 N•mm was significantly decreased by 29° compared with controls, and this value was unaltered in the sham group. Analyses following serial myotomy suggested that the structures responsible for myogenic contracture were the tensor fascia lata, iliopsoas, gluteus medius, and adductor muscles because the RoMs were increased by these myotomies. Unexpectedly, arthrogenic contracture was not detected at moments other than at 7.5 N•mm, even after four weeks of immobilization. Histological analysis confirmed that pathological changes were not apparent in the anterior capsule of the hip joint. INTERPRETATION: The present findings suggest that myogenic contracture may be an important therapeutic target for immobilization-induced hip flexion contracture.

Identification of Risk Factors for Intraoperative Acquired Pressure Injury in Patients Undergoing Neurosurgery: A Retrospective Single-Center Study.

BACKGROUND Risk factors for intraoperative acquired pressure injury (IAPI) in patients undergoing various surgical procedures have been described in previous studies. However, whether risk factors for IAPI in patients undergoing neurosurgery differ remains unknown. The aim of the present study was to explore independent risk factors for IAPI in patients undergoing neurosurgery. MATERIAL AND METHODS Data from 465 patients who underwent neurosurgery between October 2017and December 2018 and who were at high risk of IAPIs were retrospectively analyzed. Independent risk factors for IAPI were evaluated using univariate and multivariate logistic regression models. RESULTS Sixty-nine IAPIs (14.8%) in 465 patients undergoing neurosurgery were assessed. Multivariate logistic regression analyses showed that being overweight (odds ratio [OR] 2.685; 95% confidence interval [CI] 1.206-5.975; P=0.016), prone position (OR 7.502, 95% CI 2.470-22.787. P<0.001), lateral position (OR 15.301, 95% CI 4.903-47.753, P<0.001), use of a head frame (OR 3.716, 95% CI 1.431-9.653, P=0.007), surgical times of 4 to 8 h (OR 7.276, 95% CI 2.249-23.542, P<0.001), and surgical times ≥8 h (OR 173.248, 95% CI 32.629-919.896, P<0.001) all were associated with an increased risk of IAPI in patients undergoing neurosurgery. The factors associated with reduced risk of IAPI were high serum albumin levels (OR 0.099, 95% CI 0.016-0.608, P=0.013) and use of memory sponge pads (OR 0.064, 95% CI 0.020-0.202, P<0.001). CONCLUSIONS The present study indicates that being overweight, prone and lateral positioning, use of a head frame, and longer surgical times are associated with an increased risk of IAPI in patients undergoing neurosurgery. Prospective studies should be conducted to verify these findings and consideration should be given to use of these factors in clinical practice to identify high-risk patients.

Effect of metformin treatment and its time of administration on joint capsular fibrosis induced by mouse knee immobilization.

Joint contracture leads to major patient discomfort. Metformin, one of the most extensively used oral drugs against type 2 diabetes has recently been found to suppress tissue fibrosis as well. However, its role in suppressing tissue fibrosis in joint contractures remains unknown. In this study, we examined the role of metformin treatment in suppressing joint capsular fibrosis and the most effective time of its administration. Joint capsular fibrosis was induced by immobilizing the knee joints of mice using splints and tapes. Metformin was administered intraperitoneally every alternate day after immobilization. Histological and immunohistochemical changes and expression of fibrosis-related genes were evaluated. Metformin treatment significantly suppressed fibrosis in joint capsules based on histological and immunohistochemical evaluation. Joint capsular tissue from metformin-treated mice also showed decreased expression of fibrosis-related genes. Early, but not late, metformin administration showed the same effect on fibrosis suppression in joint capsule as the whole treatment period. The expression of fibrosis-related genes was most suppressed in mice administered with metformin early. These studies demonstrated that metformin treatment can suppress joint capsular fibrosis and the most effective time to administer it is early after joint immobilization; a delay of more than 2 weeks of administration is less effective.

Nail disorders associated with cast immobilization of the forearm and wrist: report of two cases and review of the literature.

Cast immobilization is used in the management of various injuries of joints and/or limbs. A variety of nail disorders have been reported in association with cast immobilization of the forearm and wrist among a limited number of patients so far. The mechanism was not clearly identified in some of these cases. Here, the authors report two patients with nail disorders appeared after the removal of immobilization cast of forearm and wrist and review the literature.

Responses of cutaneous C-fiber afferents and spinal microglia after hindlimb cast immobilization in rats.

Previous studies have shown that persistent limb immobilization using a cast increases nociceptive behavior to somatic stimuli in rats. However, the peripheral neural mechanisms of nociception remain unclear. Using single-fiber electrophysiological recordings in vitro, we examined the general characteristics of cutaneous C-fiber afferents in the saphenous nerve and their responsiveness to mechanical and heat stimuli in a rat model of immobilization-induced pain by subjecting the rats to hindlimb cast immobilization for 4 weeks. The mechanical response of C-fibers appeared to increase in the model; however, statistical analysis revealed that neither the response threshold nor the response magnitude was altered. The general characteristics and heat responses of the C-fibers were not altered. The number of microglia and cell diameters significantly increased in the superficial dorsal horn of the lumbar spinal cord. Thus, activated microglia-mediated spinal mechanisms are associated with the induction of nociceptive hypersensitivity in rats after persistent cast immobilization.

The Effect of Balloon-Blowing Exercise on Postoperative Pulmonary Functions in Patients Undergoing Total Hip Arthroplasty.

General anesthesia, prolonged immobilization, and pain may adversely affect pulmonary function in patients undergoing prosthetic surgery. The aim of this study was to evaluate the effect of balloon-blowing exercises on pulmonary functions in patients undergoing total hip arthroplasty. The patients in the experimental group performed three sets of balloon-blowing exercises in the morning, at noon, and in the evening on the first to third days postoperatively. The increase in forced vital capacity (FVC) values between the control and experimental groups in the postoperative period was statistically significant (p < .001), in favor of the experimental group. The increase in forced expiratory volume during the first second (FEV1)/FVC ratio was found to be significantly higher in the experimental group than in the control group (p < .001). Patients who performed balloon-blowing exercises increased their FVC and FEV1/FVC ratio.

Blood flow restriction in the presence or absence of muscle contractions does not preserve vasculature structure and function following 14-days of limb immobilization.

PURPOSE: Limb immobilization causes local vasculature to experience detrimental adaptations. Simple strategies to increase blood flow (heating, fidgeting) successfully prevent acute (≤ 1 day) impairments; however, none have leveraged the hyperemic response over prolonged periods (weeks) mirroring injury rehabilitation. Throughout a 14-day unilateral limb immobilization, we sought to preserve vascular structure and responsiveness by repeatedly activating a reactive hyperemic response via blood flow restriction (BFR) and amplifying this stimulus by combining BFR with electric muscle stimulation (EMS). METHODS: Young healthy adults (M:F = 14:17, age = 22.4 ± 3.7 years) were randomly assigned to control, BFR, or BFR + EMS groups. BFR and BFR + EMS groups were treated for 30 min twice daily (3 × 10 min ischemia-reperfusion cycles; 15% maximal voluntary contraction EMS), 5 days/week (20 total sessions). Before and after immobilization, artery diameter, flow-mediated dilation (FMD) and blood flow measures were collected in the superficial femoral artery (SFA). RESULTS: Following immobilization, there was less retrograde blood velocity (+ 1.8 ± 3.6 cm s-1, P = 0.01), but not retrograde shear (P = 0.097). All groups displayed reduced baseline and peak SFA diameter following immobilization (- 0.46 ± 0.41 mm and - 0.43 ± 0.39 mm, P < 0.01); however, there were no differences by group or across time for FMD (% diameter change, shear-corrected, or allometrically scaled) nor microvascular function assessed by peak flow capacity. CONCLUSION: Following immobilization, our results reveal (1) neither BFR nor BFR + EMS mitigate artery structure impairments, (2) intervention-induced shear stress did not affect vascular function assessed by FMD, and (3) retrograde blood velocity is reduced at rest offering potential insight to mechanisms of flow regulation. In conclusion, BFR appears insufficient as a treatment strategy for preventing macrovascular dysfunction during limb immobilization.