Gait Adaptation to a Phase-Specific Nociceptive Electrical Stimulation Applied at the Ankle: A Model to Study Musculoskeletal-Like Pain

Introduction: Lower limb pain, whether induced experimentally or as a result of a musculoskeletal injury, can impair motor control, leading to gait adaptations such as increased muscle stiffness or modified load distribution around joints. These adaptations may initially reduce pain but can also lead to longer-term maladaptive plasticity and to the development of chronic pain. In humans, many current experimental musculoskeletal-like pain models are invasive, and most don’t accurately reproduce the movement-related characteristics of musculoskeletal pain. The main objective of this study was to measure pain adaptation strategies during gait of a musculoskeletal-like experimental pain protocol induced by phase-specific, non-invasive electrical stimulation.Methods: Sixteen healthy participants walked on a treadmill at 4 km/h for three consecutive periods (BASELINE, PAIN, and POST-PAIN). Painful electrical stimulations were delivered at heel strike for the duration of heel contact (HC) using electrodes placed around the right lateral malleolus to mimic ankle sprains. Gait adaptations were quantified bilaterally using instrumented pressure-sensitive insoles. One-way ANOVAs and group time course analyses were performed to characterize the impact of electrical stimulation on heel and forefoot contact pressure and contact duration.Results: During the first few painful strides, peak HC pressure decreased on the painful side (8.6 ± 1.0%, p < 0.0001) and increased on the non-stimulated side (11.9 ± 0.9%, p < 0.0001) while HC duration was significantly reduced bilaterally (painful: 12.1 ± 0.9%, p < 0.0001; non-stimulated: 4.8 ± 0.8%, p < 0.0001). No clinically meaningful modifications were observed for the forefoot. One minute after the onset of painful stimulation, perceived pain levels stabilized and peak HC pressure remained significantly decreased on the painful side, while the other gait adaptations returned to pre-stimulation values.Discussion: These results demonstrate that a non-invasive, phase-specific pain can produce a stable painful gait pattern. Therefore, this protocol will be useful to study musculoskeletal pain locomotor adaptation strategies under controlled conditions.

The Effects of Custom-made Foot Orthoses on Foot Pain, Foot Function, Gait Function and Freeliving Walking Activities in Psoriatic Arthritis (PsA) Patients: a Pre-experimental Trial

Introduction: Foot involvement is a major concern in psoriatic arthritis (PsA) as it can lead to severe levels of foot pain and disability as well as reduced mobility and quality of life. Previous studies have shown moderate efficacy in reducing foot pain and disability in rheumatoid arthritis patients with the use of custom-made foot orthoses (CFO). However, evidence on the efficacy of CFO in PsA patients is lacking.Objectives: Explore the effects of CFO on foot function, foot and lower limb pain, gait function, and freeliving walking activities (FWA) in PsA patients.Methods: A Pre-experimental study including 20 PsA patients (mean age: 54.10 ± 9.06 y and disease duration: 11.53 ± 10.22 y), was conducted. All the participants received and wore CFO for a 7-week period. Foot and lower limb pain and foot function were measured before and after the intervention using the numerical rating scale (NRS) and the foot function index (FFI). Gait function was assessed from gait spatiotemporal parameters (STPs) extracted during a 10-meter walk test with an gait analysis system (Mobility Lab). Freeliving walking activities (step count, freeliving cadence, time spent in different ambulatory physical activities (APA)) were recorded over 7 days using accelerometer data collected from an instrumented sock worn during waking hours.Results: PsA patients reported severe baseline levels of foot pain (54.46 ± 14.58 %) and disability (46.65 ± 16.14%) on the FFI. Statistically and clinically significant improvements with large effect sizes (Cohen’s effect size > 1, p<0.005) in foot pain and foot function were observed after 7 weeks of CFO use. A significant correlation (r=-0.64, p<0.01) between CFO wear time after the adaption period and foot function on the FFI at 7 weeks was observed. However, no significant changes were demonstrated for gait STP nor for free-living walking activities after 7 weeks of CFO use.Conclusion: Results support the clinical and biomechanical plausibility of using CFO with PsA patients to reduce pain and improve foot function. Larger and controlled studies are needed to confirm these findings and a multidisciplinary approach including the prescription of exercise therapy and physiotherapy in combination with CFO could be relevant to improve STP and promote APA in PsA patients.Study registration: ClinicalTrials.gov, NCT05075343, Retrospectively registered on 29 September 2021.

Older Male Construction Workers and Sustainability: Work-Related Risk Factors and Health Problems

This study aims to analyze the characteristics of working conditions, exposure to risk factors, and health-related problems of older male construction workers. In this study, 1519 male construction workers were the subjects of study, and the working conditions, exposure to occupational risk factors, and physical health-related problems were compared among workers under 50 years, in their 50s, and 60 or over. Older male construction workers have lower educational backgrounds and lower average salaries. The degree of exposure to risk factors was higher in workers aged 60 or over than other age groups, such as high temperature, awkward posture, manual material handling, standing posture, repetitive motion, fumes/dust, vapor, skin contact, and tobacco smoke. In addition, the complaint rate of hearing problems, overall fatigue, backache, upper limb pain, or lower limb pain was higher in older workers. In particular, the complaint rate of musculoskeletal pain was 56.6%, overall fatigue was 40.3%, and the rate of depression symptoms was 41.9%. This study shows a high prevalence of musculoskeletal disorders, overall fatigue, and depression symptoms of male elderly construction workers, suggesting that comprehensive support is needed to improve not only the working conditions of workers but also psychological health problems.

A 2 Years Girls with Nephroblastoma: A Case Report

Introduction: Wilm's tumor, also known as nephroblastoma, is a common complication in children with renal cancer. It was responsible for 6% of all malignancies. It almost always affects children under the age of five. 90% of cases are diagnosed before the age of three, with the peak incidence occurring between the ages of two and five years. The case of a 2-year-old girl with Wilm's tumor is shown below. The majority of cases are unilateral, but 5% to 10% of the time both kidneys are affected. Case Presentation: A 2-year-old girl was taken to the hospital with a chief complaint of a lump in the abdomen, fever, vomiting and fatigue, nausea, swelling, pain in the abdomen, weakness. On physical examination the patient has experienced in weakness the upper and lower limb, pain experiencing in the abdomen and presenting lumps in the abdomen S1 and S2 are heard in the cardiological system, and air entry is bilaterally equal in the respiratory system. Pupils are reflected light, tone, and a palpable smooth abdominal mass is frequently discovered by chance. The infant was never admitted to a neonatal intensive care unit (NICU). There had been no previous evidence of neonatal sepsis or jaundice. For a year, the girl was breastfed. The right side of the abdomen was where the first symptoms appeared. Small at first, but quickly grew larger and more asymmetrical.

Bilateral basal ganglia ischemia associated with COVID-19: a case report and review of the literature

Background Coronavirus disease 2019, caused by the severe acute respiratory syndrome coronavirus 2, has a broad clinical spectrum, from asymptomatic to multi-organ dysfunction. Acute cerebrovascular events associated with coronavirus disease 2019 are mainly due to the severe acute respiratory syndrome coronavirus 2-induced prothrombotic state. Bilateral basal ganglia ischemia is rarely reported. Case presentation We report the case of a 64-year-old Asian (Pakistani) gentleman who presented initially with fever, cough, and shortness of breath, likely due to respiratory involvement by severe acute respiratory syndrome coronavirus 2. Later, he developed bilateral lower limb pain, followed by confusion and decreased level of consciousness. Accentuated large hypodense opacities were seen in the left and right basal ganglia, with mass effects on the left frontal horn. Conclusion This case demonstrates the importance of neuroimaging in the effective management of patients with neurological signs associated with coronavirus disease 2019.

Prevalence of Musculoskeletal Pain in Bio-Pharmaceutical Industry Workers

The purpose of this study was to identify the prevalence of musculoskeletal problems in bio-pharmaceutical industry workers. A cross sectional survey was conducted on 33 bio-pharmaceutical industry workers by administering the Extended Nordic Musculoskeletal Questionnaire to quantify the musculoskeletal pain and activity limitation in 9 body regions. The Rapid Office Strain Assessment was used to assess the work-related postures and ergonomics of the computer operators in this industry. A Self-Designed Questionnaire was administered to obtain data regarding the various musculoskeletal problems faced by Bio-pharmaceutical industrial workers, work-related risk factors and various postures attained throughout the day. Out of the 33 workers investigated, 21 workers (63%) of the workers experienced musculoskeletal pain. Isolated spine pain was the commonest, and was reported in 8 out of 21 individuals (38%). Spine with upper and lower limb pain was the next most common, and was reported in 5 out of 21 individuals (24%). 4 out of 21 individuals had spine and lower limb pain (19%). The Rapid Office Strain Assessment scores of all the workers was above 5 indicating “high risk” which implied that immediate ergonomic change was necessary. This study concluded that there was 63% prevalence of musculoskeletal pain. The most common site of pain were the spine, followed by pain in the spine with both upper and lower extremities. All the workers were exposed to different ergonomic risk factors. The study concluded that implementation of ergonomic interventions may minimize the risks of work related musculoskeletal pain. Key words: Work-related musculoskeletal disorders, Extended Nordic Musculoskeletal Questionnaire, Rapid Office Strain Assessment, Ergonomic hazards.

Risk Factors and Management of Unexplained Limb Pain among Growing Children in a Tertiary Hospital

Introduction: Recurrent lower limb pain (growing pain) is the most common presenting problem of children referred to pediatric rheumatology clinics. The exact nature and aetiology still remains unclear despite the various hypotheses and theories presented in the international literature. Parents become apprehensive as physician are unsure regarding accurate diagnosis of unexplained limb pain. Objectives: To determine the risk factors of unexplained limb pain in growing children and measures taken for their management. Materials and Methods: This cross sectional study was conducted among 60 children of 3 to 12 years who presented with unexplained limb pains between July to December, 2012 in Paediatric OPD of Combined Military Hospital (CMH) Dhaka. Results: Mean age of the respondents was 7.4 years. Prevalence of growing pain was 75%, overweight 13.3% and obesity was 15.6%. The calf (37.3%) was the most common affected site for pain and in 68.3% and 31.7% cases pain occurred during night and evening respectively. Pain frequency was as follows: daily 8%; weekly 48%; monthly 31%; and every 3 months 13%. Growing Pain usually occur at slow growing period (80.4%) than rapid growing period (19.6%). The main therapeutic approach was massaging (84.4%) the painful limbs and to a lesser extent, the intake of oral anti-inflammatory agents (31.1%). All patients had laboratory tests within normal values. Conclusions: Growing pain (GP) is a frequent non-inflammatory syndrome that is relatively common in children and usually benign. It commonly affects the lower extremities of children. Precise history taking and physical examination makes clinical diagnosis easier. Patients’ and family eassurance is of utmost importance in management of GP. JAFMC Bangladesh. Vol 16, No 2 (December) 2020: 59-62

P090 Rheumatic symptoms as the first manifestations of underlying systemic disorders

Background Joint and limb pain is a common presenting complaint within the paediatric population, affecting 10–20% of school-age children. They are also a major reason for referral to paediatric rheumatology clinics (1). The differential diagnosis for joint pain and/or swelling can include both benign and malignant causes. Studies have found that &lt; =1% of musculoskeletal complaints are caused by neoplasia, mostly acute lymphoblastic leukaemia (ALL) (1). It is essential to exclude life-threatening conditions such as infections and malignancies before initiation of treatment for presumptive Juvenile Idiopathic Arthritis (JIA) (2). The objective of this case series is to highlight the musculoskeletal features and the clinical course among children with haematological malignancies. Methods Charts of patients referred from rheumatology clinic to the haemato-oncology clinic were selected. A detailed chart review was then carried out to obtain information on clinical presentation, diagnostic work up and clinical progress of the patient. Results Case 1 CS, A 2 year and 2 months old girl who presented to paediatric rheumatology clinic with 5 month history of lower limb pain associated with a fever of 40’C. The pain progressively worsened leading to inability to walk. She had previously been treated for Idiopathic Thrombocytopenic Purpura with steroids. Initial Bone Marrow Aspiration (BMA) had ruled out leukaemia. Four months later, her condition had worsened and was referred to our facility where a peripheral blood film and flow cytometry confirmed B cell ALL. Treatment was initiated but unfortunately the patient’s condition deteriorated and eventually passed away. Case 2 NM, a 2 year and 10 months old girl presented to our paediatric rheumatology clinic with bilateral foot pain for 8 weeks. She was initially limping and progressed to inability to walk within a month. Rheumatology review in Tanzania diagnosed the patient as JIA and started on steroids. On examination, systemic findings were normal except bilateral ankle joint effusion and tenderness. An X-ray displayed bilateral transverse lucencies in the metaphyseal ends of the tibia and fibula. BMA was done and confirmed ALL. Treatment was initiated and the patient attained remission after 18 months of therapy. She remains well 2 years after completion of therapy. Case 3 NC, a 4-year-old girl, presented with multiple joint pains for 2 weeks. Pain was associated with night awakening and recurrent fevers. C-Reactive Protein (CRP) was persistently high and was treated with several courses of antibiotics. She was assessed by a haemato-oncologist with unremarkable findings. A decision was made to do a BMA and flow cytometry, which confirmed B cell ALL. Conclusion Musculoskeletal complaints are frequently the initial manifestations of acute leukaemia in childhood (60%) and should be considered in the differential diagnosis of JIA (3). Initially laboratory test results can be normal therefore it is necessary to follow these children closely and request serial tests, until there is a clearly defined diagnosis of neoplasia. Finally, malignancy should be eliminated before introduction of immunosuppressive therapy as the use of steroids may mask and delay its diagnosis (2).

Adult-onset presentation of cervicothoracic split cord malformation: illustrative case

BACKGROUND A 60-year-old female presented with a 6-month history of progressive lower limb pain, weakness, and declining mobility. She was initially diagnosed as having possible hip osteoarthritis or ligamental knee injury. She was eventually seen by a neurologist, who admitted her to a tertiary hospital with new-onset upper motor neuron signs and urinary incontinence. Magnetic resonance imaging of the whole spine revealed evidence of C7–T2 type 1 split cord malformation (SCM) necessitating urgent spinal surgery. She had an excellent outcome with intensive rehabilitation and returned to her premorbid level of function and mobility. OBSERVATIONS The patient presented with nonspecific symptoms, which led to multiple referrals and a significant delay in her diagnosis. LESSONS Clinicians should be aware of the importance of a detailed history with thorough neurological and spinal examinations.

Is adiposity associated with back and lower limb pain? A systematic review

Background Back and lower limb pain have a major impact on physical function and quality of life. While obesity is a modifiable risk factor for musculoskeletal pain, the role of adiposity is less clear. This systematic review aimed to examine the relationship between both adiposity and its distribution and back and lower limb pain. Methods A systematic search of electronic databases was conducted to identify studies that examined the association between anthropometric and/or direct measures of adiposity and site specific musculoskeletal pain. Risk of bias was assessed and a best evidence synthesis was performed. Results A total of 56 studies were identified which examined 4 pain regions, including the lower back (36 studies), hip (two studies), knee (13 studies) and foot (eight studies). 31(55%) studies were assessed as having low to moderate risk of bias. 17(30%) studies were cohort in design. The best evidence synthesis provided evidence of a relationship between central adiposity and low back and knee pain, but not hip or foot pain. There was also evidence of a longitudinal relationship between adiposity and the presence of back, knee and foot pain, as well as incident and increasing foot pain. Conclusions This systematic review provides evidence of an association between both body fat and its central distribution and low back and knee pain, and a longitudinal relationship between adiposity and back, knee and foot pain. These results highlight the potential for targeting adiposity in the development of novel treatments at these sites.