Intraoperative hand strength as an indicator of consciousness during awake craniotomy: a prospective, observational study

Awake craniotomy enables mapping and monitoring of brain functions. For successful procedures, rapid awakening and the precise evaluation of consciousness are required. A prospective, observational study conducted to test whether intraoperative hand strength could be a sensitive indicator of consciousness during the awake phase of awake craniotomy. Twenty-three patients who underwent awake craniotomy were included. Subtle changes of the level of consciousness were assessed by the Japan Coma Scale (JCS). The associations of hand strength on the unaffected side with the predicted plasma concentration (Cp) of propofol, the bispectral index (BIS), and the JCS were analyzed. Hand strength relative to the preoperative maximum hand strength on the unaffected side showed significant correlations with the Cp of propofol (ρ = − 0.219, p = 0.007), the BIS (ρ = 0.259, p = 0.002), and the JCS (τ = − 0.508, p = 0.001). Receiver operating characteristic curve analysis for discriminating JCS 0–1 and JCS ≥ 2 demonstrated that the area under the curve was 0.76 for hand strength, 0.78 for Cp of propofol, and 0.66 for BIS. With a cutoff value of 75% for hand strength, the sensitivity was 0.76, and the specificity was 0.67. These data demonstrated that hand strength is a useful indicator for assessing the intraoperative level of consciousness during awake craniotomy.

Efficacy of Bilateral Lower Limb Training over Unilateral to Re-educate Balance and Walking in Post-stroke Survivors: A Protocol for Randomized Clinical Trial

Background: One of the significant causes of morbidity worldwide and an essential contributor to disability is Stroke. As said by the National Stroke Association, nine post-stroke survivors out of 10 experience some degree of weakness post-stroke. The hemiplegic patients with sub-acute stroke, who will undergo training to both the lower limb overtraining to only involved side will have an improvement in balance and walking. The goal of this study is to see how much training to both the lower limb improves functional recovery in patients who have had a subacute stroke compared to unilateral, more insufficient limb training. Objective: The goal of this study was to see how training to both the lower limb overtraining to the hemiparetic lower limb on balance and walking in subacute stroke patients. Methods: A randomized clinical study with assessor blinding will be conducted with participants with subacute stroke (n=40). Participants will be randomized to one of two groups after performing baseline assessments: Group A or Group B.1st group will receive training only to the hemiparetic side, i.e., Motor Relearning Programme and Proprioceptive Neuromuscular Facilitation, and 2nd group participants will receive bilateral training, i.e., Strengthening to the unaffected side along with Motor Relearning Programme and Proprioceptive Neuromuscular Facilitation to the affected side. During the therapy period, we will assess lower limb function through static and dynamic balance, walking, and gait measures. Results: The purpose of the research is to look into the effect of training to both the lower limb overtraining to the hemiparetic lower limb on balance and walking in subacute stroke patients. The results of this study will be based on the outcome measures that are static and dynamic balance in the stroke patients and walking. Conclusion: The study's findings will shed more light on the benefits of training to both the lower limb overtraining to only involved side in patients post-stroke. If this trial proves successful, it will help post-stroke patients improve their balance and walking.

Triceps Surae Muscle Characteristics in Spastic Hemiparetic Stroke Survivors Treated with Botulinum Toxin Type A: Clinical Implications from Ultrasonographic Evaluation

Equinovarus foot is one of the most commonly spasticity related conditions in stroke survivors, leading to an impaired gait and poor functional performances. Notably, spastic muscles undergo a dynamic evolution following typical pathophysiological patterns. Botulinum Neurotoxin Type A (BoNT-A) is the gold standard for focal spasticity treatment, and ultrasound (US) imaging is widely recommended to guide injections and monitor muscle evolution. The role of BoNT-A in influencing muscle fibroadipose degeneration is still unclear. In this study, we analyzed medial gastrocnemius (MG) and soleus (SOL) US characteristics (cross-sectional area, muscle thickness, pennation angle, and mean echo intensity) in 53 patients. MG and SOL alterations, compared to the unaffected side, depend on the spasticity only and not on the BoNT-A treatment. In functionally preserved patients (functional ambulation classification, FAC > 3; modified Ashworth scale, MAS ≤ 2), the ultrasonographic changes of MG compared to ipsilateral SOL observed in the paretic limb alone seems to be due to histological, anatomical, pathophysiological, and biomechanical differences between the two muscles. In subjects with poor walking capability and more severe spasticity, such ipsilateral difference was found in both calves. In conclusion, BoNT-A does not seem to influence muscle degeneration. Similar muscles undergo different evolution depending on the grade of walking deficit and spasticity.

Soleus H-Reflex Change in Poststroke Spasticity: Modulation due to Body Position

Purpose. This study is aimed at exploring how soleus H-reflex change in poststroke patients with spasticity influenced by body position. Materials and Methods. Twenty-four stroke patients with spastic hemiplegia and twelve age-matched healthy controls were investigated. Maximal Hoffmann-reflex (Hmax) and motor potential (Mmax) were elicited at the popliteal fossa in both prone and standing positions, respectively, and the Hmax/Mmax ratio at each body position was determined. Compare changes in reflex behavior in both spastic and contralateral muscles of stroke survivors in prone and standing positions, and match healthy subjects in the same position. Results. In healthy subjects, Hmax and Hmax/Mmax ratios were significantly decreased in the standing position compared to the prone position (Hmax: p = 0.000 , Hmax/Mmax: p = 0.016 ). However, Hmax/Mmax ratios were increased in standing position on both sides in poststroke patients with spasticity (unaffected side: p = 0.006 , affected side: p = 0.095 ). The Hmax and Hmax/Mmax ratios were significantly more increased on the affected side than unaffected side irrespective of the position. Conclusions. The motor neuron excitability of both sides was not suppressed but instead upregulated in the standing position in subjects with spasticity, which may suggest that there was abnormal regulation of the Ia pathway on both sides.

Postural Difference between the Interventions Reflecting the Concept of Mirror Therapy in Healthy Subjects

(1) Background: Mirror therapy is one of the promising interventions for the upper limb rehabilitation of stroke patients. Postural asymmetry during mirror therapy was pointed out as a possibility to influence stroke patients’ rehabilitation negatively. However, it is still difficult to find studies on the postural changes in mirror therapy concept interventions. This study compared three methods of postural differences as follows: traditional mirror therapy (mirror); displaying the real-time movement of the unaffected side on the screen above the affected side (screen); and playing a pre-recorded movement of the unaffected side on a tablet placed on a movable box where the affected hand is put inside (movable). (2) Methods: to observe a kinematic difference, we recruited 16 healthy volunteers to go through three different interventions (mirror, screen, movable). The motion capture system made observations on the postures before and during interventions, then compared and analyzed. (3) Results: while using the mirror, the sitting posture was observed to become asymmetric, and the following unique posture was observed where the target hand went further from the trunk while performing tasks. In addition, the shoulder of the target side came forward, and the difference between both elbow flexion angles was also observed. On the other hand, the screen or movable device did not cause a significant change in the sitting posture, and no additional postural differences were observed either. (4) Conclusions: mirror therapy showed a tendency to cause lateral flexion opposite the target hand, thus, creating additional postural change. However, developed methods controlled spine tilt, and enabled the keeping of the midline while sitting during the intervention.

Leg length discrepancy in patients with Perthes’ disease

Aims Perthes’ disease (PD) often results in femoral head deformity and leg length discrepancy (LLD). Our objective was to analyze femoral morphology in PD patients at skeletal maturity to assess where the LLD originates, and evaluate the effect of contralateral epiphysiodesis for length equalization on proximal and subtrochanteric femoral lengths. Methods All patients treated for PD in our institution between January 2013 and June 2020 were reviewed retrospectively. Patients with unilateral PD, LLD of ≥ 5 mm, and long-leg standing radiographs at skeletal maturity were included. Total leg length, femoral and tibial length, articulotrochanteric distance (ATD), and subtrochanteric femoral length were compared between PD side and the unaffected side. Furthermore, we compared leg length measurements between patients who did and who did not have a contralateral epiphysiodesis. Results Overall, 79 patients were included, of whom 21 underwent contralateral epiphysiodesis for leg length correction. In the complete cohort, the mean LLD was 1.8 cm (95% confidence interval (CI) 1.5 to 2.0), mean ATD difference was 1.8 cm (95% CI -2.1 to -1.9), and mean subtrochanteric difference was -0.2 cm (95% CI -0.4 to 0.1). In the epiphysiodesis group, the mean LLD before epiphysiodesis was 2.7 cm (95% CI 1.3 to 3.4) and 1.3 cm (95% CI -0.5 to 3.8) at skeletal maturity. In the nonepiphysiodesis group the mean LLD was 2.0 cm (95% CI 0.5 to 5.1; p = 0.016). The subtrochanteric region on the PD side was significantly longer at skeletal maturity in the epiphysiodesis group compared to the nonepiphysiodesis group (-1.0 cm (95% CI -2.4 to 0.6) vs 0.1 cm (95% CI -1.0 to 2.1); p < 0.001). Conclusion This study demonstrates that LLD after PD originates from the proximal segment only. In patients who had contralateral epiphysiodesis to balance leg length, this is achieved by creating a difference in subtrochanteric length. Arthroplasty surgeons need to be aware that shortening of the proximal femur segment in PD patients may be misleading, as the ipsilateral subtrochanteric length in these patients can be longer. Therefore, we strongly advise long-leg standing films for THA planning in PD patients in order to avoid inadvertently lengthening the limb. Cite this article: Bone Joint J 2021;103-B(11):1736–1741.

Myofascial Induction Therapy Improves the Sequelae of Medical Treatment in Head and Neck Cancer Survivors: A Single-Blind, Placebo-Controlled, Randomized Cross-Over Study

Head and neck cancer (HNC) is the sixth most common cancer worldwide. Yet, less than 60% of HNC survivors receive adequate therapy for treatment-related sequelae. The objective of this study was to determine the efficacy of myofascial induction therapy (MIT) in improving cervical and shoulder pain and range of motion, maximal mouth opening, and cervical muscle function in HNC survivors. This crossover, blinded, placebo-controlled study involved 22 HNC survivors (average age 56.55 ± 12.71) of which 13 were males (59.1%) who received, in a crossover fashion, both a single 30-min session of MIT in the form of manual unwinding and simulated pulsed shortwave therapy (placebo), with a 4-week washout interval between the two. Cervical and shoulder pain (visual analogue scale) and range of motion (cervical range of motion device and goniometer), maximum mouth opening (digital caliper), and cervical muscle function (deep cervical flexor endurance test) were measured before and after the treatment and placebo sessions. A single session of MIT improved cervical and affected side shoulder pain, cervical range of motion, maximum mouth opening, and cervical muscle function. The associated effect sizes ranged from moderate to large. The present study suggests that MIT, in the form of manual unwinding, improves cervical (−3.91 ± 2.77) and affected-side shoulder (−3.64 ± 3.1) pain, cervical range of motion (flexion: 8.41 ± 8.26 deg; extension: 12.23 ± 6.55; affected-side rotation: 14.27 ± 11.05; unaffected-side rotation: 11.73 ± 8.65; affected-side lateroflexion: 7.95 ± 5.1; unaffected-side lateroflexion: 9.55 ± 6.6), maximum mouth opening (3.36 ± 3.4 mm), and cervical muscle function (8.09 ± 6.96 s) in HNC survivors.

RADIOLOGICAL ASSESSMENT OF KNEE JOINT WIDTH DIFFERENCES IN OLDER ADULTS WITH SYMPTOMATIC MEDIAL KNEE OSTEOARTHRITIS

Knee osteoarthritis (OA) is a degenerative articular disease. The knee joint space width (JSW) is used for grading the severity of knee OA. However, there is a lack of research on differences in the widths of knee joints between both lower limbs in unilateral OA. The purpose of this research was to examine the radiological difference in the affected knee joint and contralateral knee joint by analyzing unilateral older adults with medial knee OA using both knees’ JSW differences. Twenty-five subjects with unilateral medial knee OA participated. X-ray radiographs were used to assess knee JSW, and the paired [Formula: see text]-test was performed to assess the knee joint gap width between the affected side and the unaffected side in the respective medial and lateral sides. The independent [Formula: see text]-test compared the differences between the lateral and medial knee JSWs on the affected side and unaffected side. The paired [Formula: see text]-test did not show a significant difference in the medial and lateral knee JSW on the affected side compared to the unaffected side ([Formula: see text]; 0.11). Meanwhile, the independent [Formula: see text]-test revealed a significant difference between the affected and unaffected sides ([Formula: see text]). This study showed no significant changes in affected knee JSWs compared to unaffected sides, but the difference between the lateral and medial JSWs was significant between the knees affected and unaffected by OA in the older adults with medial knee OA.

Three-dimensional volumetric evaluation of the different mandibular segments using CBCT in patients affected by juvenile idiopathic arthritis: a cross-sectional study

Background There is currently no information on how different mandibular segments are affected by juvenile idiopathic arthritis. The aim of this paper is to assess volumetric differences of different mandibular segments in subjects with unilateral and bilateral JIA and to compare them with non-JIA control volumes. Materials and methods Forty subjects with unilateral TMJ involvement and 48 with bilateral TMJ involvement were selected for the case group and 45 subjects with no known rheumatic comorbidities for the control group. The mandible of each subject was divided according to a validated method into different paired volumes (hemimandible, condyle, ramus and hemibody). Results The ANOVA test revealed a statistically significant difference in all the groups for condylar and ramus volumes, and the pairwise comparison evidenced a statistically significant higher condylar and ramus volume in the control group (1444.47 mm3; 5715.44 mm3) than in the affected side in the unilateral JIA group (929.46 mm3; 4776.31 mm3) and the bilateral JIA group (1068.54 mm3; 5715.44 mm3). Moreover, there was also a higher condylar volume in the unaffected side in the unilateral JIA group (1419.39 mm3; 5566.24 mm3) than in the bilateral JIA group and the affected side in the unilateral JIA group. Conclusions The affected side of unilateral JIA patients showed statistically significant lower volumes in the hemimandible, in the condyle and in the ramus. The largest total mandibular volume was observed in the control group, followed by the unilateral JIA group and, lastly, by the bilateral JIA group.