Conservative Treatment Protocol Research Articles

Evidence-Based Update on the Surgical Technique and Clinical Outcomes of Retrograde Drilling: A Systematic Review.

Retrograde drilling is an established surgical technique to treat osteochondral lesions of the talus (OLT). It involves non-trans-articular drilling to induce subchondral bone revascularization and bone formation without damaging the overlying articular cartilage. The present study aimed to elucidate the heterogeneity of clinical studies on retrograde drilling for OLT. A systematic search of the MEDLINE, Web of Science, EMBASE, and Cochrane Library databases for studies published between January 1996 and August 27, 2022, was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by two independent reviewers. The included studies were evaluated for their level of evidence (LoE) and quality of evidence (QoE) using the Modified Coleman Methodology Score. Variables reporting surgical and clinical outcomes and complications were evaluated. Eleven studies with 207 ankles were included (mean follow-up period = 31.1 months). The mean LoE was 3.8 (LoE 3: two studies, LoE 4: nine studies), and the mean QoE was 50.8 (fair: three studies, poor: eight studies). Ten studies used the American Orthopedic Foot and Ankle Society (AOFAS) score, which improved from 57.9 preoperatively to 86.1 postoperatively. The period and protocol of conservative treatment, lesion character, surgical technique, and postoperative protocol were inconsistent or underreported. This systematic review revealed that low LoE and poor QoE, coupled with heterogeneity among the included studies, impede definitive conclusions regarding the effectiveness of this technique. Consequently, well-designed clinical trials are essential to develop standardized clinical guidelines for using retrograde drilling in OLT.

Techniques for conservative treatment of peri-implantitis

Relevance. Dental implants are widely used to restore the patient’s teeth. They have become aworthy alternative to removable dentures. With the accumulation of clinical experience, the indications for dental implantation expanded, and as aresult, the evaluation of long-term results became possible. In parallel with the expansion of clinical use of dental implants and the introduction of the technology into everyday practice, the experience of complications and errors accumulated, and from single publications in the 1990s, at the very beginning of development, to large-­scale studies in the 10s. And if in the early period of implantology development the success of treatment was mainly associated with implant survival, then modern research focuses on the state of tissues around the implant, and the influence of processes in them on the overall outcome of treatment. One of the main complications is inflammation of peri-implant tissues - peri-implantitis. Modern authors define peri-implantitis as an inflammatory process affecting the tissues around afunctionally integrated implant, resulting in loss of supporting bone. Continued bone loss around the implant can significantly impair implant stability and function. The authors review the scientific literature describing experimental conservative treatment protocols for peri-implantitis and attempts to achieve osseointegration. Conclusion. The reviewed literature advocated various methods of surgical regenerative treatment for peri-implantitis, including the use of bone substitutes, methods of detoxification of implant surfaces, and the administration of antimicrobial agents. There are many different protocols for the treatment of peri-implantitis; they all share the same goal of reducing disease progression and bone loss by eliminating bacterial infection. The controversy over the proper approach to treating peri-implantitis and restoring osseointegration clearly demonstrates the need for more research to answer this question.

Frequency of patients presenting with Hand Infection and treatment modalities

Introduction: Infections of the hand are one of the most common infections reported by the caring physicians and surgeons. Common types of hand infections include: bite wounds, felon, necrotizing fasciitis, paronychia, flexor tenosynovitis, subcutaneous/cellulitis, osteomyelitis and septic arthritis. Aims: The aim of this study to identify the main etiological factors, possible complications due to acute hand infection and treatment modalities performed in our selected group of patients. Materials and Method: This was a prospective Cross Sectional Observational Study based on 58 patients conducted at King Abdullah Hospital, Bisha, Saudi Arabia. Period of study was one year from May 2022 to April 2023. Patients of all age group were included. Male patients were 16 (27.5%) while females were 42 (72.4%). Result: Most of the patients were gardener / farmer 15 (25.9%), minor children 12 (20.7%), and housewife / maid 9 (15.5%). Major mechanism of injury was penetrating trauma 41 (70.7%). Majority of the patients were between 20 years to 50 years of age group. The risk factors associated with hand infection includes diabetes mellitus 13 (22.4%) and hypertension 5 (8.6%). The smokers were 13 (22.4%) patients. Most of the patients were Saudi national 30 (51.7%) followed by Egyptian12 (20.7%), Pakistani and Sudanese 4 (6.9% each). Surgical intervention includes, incision and drainage in 40 (68.9%) cases while amputation was performed in 3 (5.2%) cases. There were 15 (25.9%) patients treated with conservative treatment protocol. Major organisms causing infection was staphylococcus aureus 28 (48.30%) including methicillin resistant staphylococcus aureus (MRSA). There was no growth in 5 (8.6%) patients and for 19 (32.8%) patients no drainage collection was available and therefore their samples were not analyzed for bacteriology. We have categorized the diagnosis into 6 groups as subcutaneous infection 27 (41.5%), acute Paronychia 11 (16.9%), web space infection 10 (15.4%), pulp space infection7 (10.8%), flexor tenosynovitis 6 (9.2%) and midpalmer/thenar 4 (6.2%). Conclusion: Early clinical diagnosis based on occupational history and control of co-morbid disease such as diabetes mellites, smoking etc is effective in the treatment and prevention of hand infection to avoid devastating surgical intervention of partial or total diabetic hand amputation.

Reactivation of Herpes Simplex Virus Following Sphenopalatine Ganglion Nerve Block: Case Report and Review of the Literature.

A 36-year-old woman with no significant past medical history underwent a sphenopalatine ganglion block for treatment of a month-long migraine headache refractory to conservative treatment protocols. The headache resolved initially, but 1 day following the procedure, the headache recurred. The patient also developed an erythematous and edematous rash which cultures confirmed to be herpes simplex virus (HSV). Following several unsuccessful treatment modalities, the patient received valacyclovir, which resulted in resolution of her headache. Underlying HSV-1 infection may cause intractable migraine headache and nerve blocks may potentiate reactivation of latent HSV infection that caused the skin lesion in this case.

Favorable Remodeling After TEVAR in Uncomplicated Acute and Subacute Type B Aortic Dissection in Comparison to Conservative Treatment: A Midterm Analysis.

The purpose of the study was to evaluate the midterm and long-term outcomes of patients who underwent thoracic endovascular aortic repair (TEVAR) procedure to treat an uncomplicated acute and subacute type B aortic dissection (uATBAD) with high risk for subsequent aortic complications compared with the group of patients who received a conservative treatment protocol during the same period. Between 2008 and 2019, 35 patients who had TEVAR due to uATBAD and those with conservative procedure (n=18) were included in a retrospective analysis and follow-up study. The primary endpoints were false lumen thrombosis/perfusion, true lumen diameter, and aortic dilatation. The aortic-related mortality, reintervention, and long-term survival were the secondary endpoints. In the study period, 53 patients (22 females) with a mean age of 61.1±13 years were included. No 30-day and in-hospital mortality was recorded. Permanent neurological deficits occurred in 2 patients (5.7%). In the TEVAR group (n=35) and in a median follow-up period of 34 months, a significant reduction of maximum aortic and false lumen diameter as well as a significant increase of true lumen diameter were detected (p<0.001 each). Complete false lumen thrombosis increased from 6% preoperatively to 60% at follow-up. The median difference in aortic, false lumen, and true lumen diameter was -5 mm (interquartile range [IQR]=-28 to 8 mm), -11 mm (IQR=-53 to 10 mm), and 7 mm (IQR=-13 to 17 mm), respectively. In 3 patients (8.6%), a reintervention was needed. Two patients (1 aortic-related) died during follow-up. The estimated survival according to Kaplan-Meyer analysis was 94.1% after 3 years and 87.5% after 5 years. Similar to the TEVAR group, no 30-day or in-hospital mortality was recorded in the conservative group. During follow-up, 2 patients died and 5 patients underwent conversion-TEVAR (28%). In a median follow-up period of 26 months (range=150), a significant increase of maximum aortic diameter (p=0.006) and a tendency to augmentation of the false lumen (p=0.06) were noted. No significant reduction of the true lumen was seen. Thoracic endovascular aortic repair in patients at high risk of subsequent aortic complications in uncomplicated acute and subacute type B aortic dissection is safe and is associated with favorable midterm outcomes regarding aortic remodeling. In a retrospective, single center analysis of prospectively collected data with follow-up, we compared 35 patients with high-risk features who recieved TEVAR in acute and sub-acute uncomplicated type B aortic dissection to a control-group (n=18). The TEVAR group showed a significant positive remoduling (reduction of max. aortic and false lumen diameter and increase of true lumen diameter (p<0.001 each)) during follow-up with an estimated survival of 94.1% after 3 years and 87.5% after 5 years.

Sudden, Severe, Idiopathic Occlusal Relationship Change Coexisting with Pain-Related Temporomandibular Disorders: A Case Report.

The article presents a case of a young female patient who sought help due to myofascial pain followed by a sudden occlusal change (anterior open bite (AOB)) that occurred shortly after the administration of a soft night guard that had been previously provided by a general dentist. Palpation of the masseter and temporal muscles elicited the presence of familiar pain. After magnetic resonance imaging of temporomandibular joints, which ruled out disc displacement, the final diagnosis was myalgia. Since the patient had myalgia and malocclusion, the therapy included treatment of both conditions. Temporomandibular disorders (TMDs) management included a combination of kinesiotherapy, pharmacotherapy, and a stabilization splint. After TMD symptoms had resolved, the patient underwent an orthodontic evaluation. Cephalometric analysis revealed skeletal class II, retrognathic face, convex profile, and normal vertical growth pattern. Orthodontic treatment included a fixed appliance with vertical intermaxillary elastics. After 19 months of treatment, both sides achieved acceptable occlusion with Class I. Since the patient had myalgia and severe malocclusion, it was important to follow a systematic diagnostic and therapeutic workflow. Although it is impossible to establish a relationship between TMD symptoms and orthodontic therapy, patients who have TMD symptoms should have their pain resolved through a conservative treatment protocol before commencement of orthodontic treatment. The beginning of orthodontic therapy comes into consideration only when the TMD pain resolves.

Treating melasma with the 1064nm Nd:YAG laser with a 650-microsecond pulse duration: A clinical evaluation.

The effective treatment of melasma remains a challenge that necessitates a multifaceted approach that includes strict sun protection, bleaching creams, chemical peels, and laser therapy. The 1064nm Nd:YAG laser with a 650-microsecond pulse duration provides a safe option for all skin types. We treated 10 patients with the 1064nm Nd:YAG laser with a 650-microsecond pulse duration. Treatments were performed every 2-4weeks. Using a conservative treatment protocol, lightening of melasma occurred as early as 3weeks post-treatment, with all subjects requiring several treatment sessions to achieve adequate resolution of their melasma. The majority of subjects experienced up to 25% improvement after two treatments, and an even more noticeable improvement after the 3rd treatment session. None reported any associated pain or discomfort. Advantages of this laser modality include essentially no pain or downtime, lower risk of rebound, and the ability to safely treat all skin types with melasma. Therefore, the 1064nm Nd:YAG laser with a 650-microsecond pulse duration serves as a treatment option for melasma.

Investigation of the perceptual and cognitive asymmetry in the auditory system in patients with adolescent idiopathic scoliosis.

BackgroundStudies have shown that perceptual and cognitive asymmetries are present in the auditory system in patients with adolescent idiopathic scoliosis (AIS). The Dichotic Listening (DL) paradigm was formerly performed in non-forced (NF) conditions only, and no study has examined the conditions of attention to one ear.ObjectiveTo investigate the perceptual and cognitive asymmetry in the auditory system in patients with AIS as well as the asymmetry changes according to the curvature characteristics of patients with AIS.MethodThe DL paradigm was performed on 38 patients with AIS and 10 healthy individuals in all conditions (NF, Forced Right [FR], Forced Left [FL]).ResultsIn the NF and FL conditions, the mean number of correct responses for the left ear was significantly lower in patients with AIS than in healthy individuals (p < 0.05). The correct responses for the right ear in the NF condition, right and left ear in the FR condition, and right ear in the FL condition did not show a significant difference between the groups (p > 0.05). Also, there was no difference between patients with AIS with both functional 3-curve and 4-curve (p > 0.05).ConclusionOur study indicates perceptual and cognitive asymmetry or lateralisation in the auditory system in patients with AIS. The asymmetry might be caused by the inability to direct their attention to the left ear, which is not affected by their curvature type. Further studies are needed to investigate perceptual and cognitive asymmetry behaviour models in the auditory system in patients with AIS.Clinical implicationsDetermination of perceptual and cognitive asymmetry in the auditory system may offer a new perspective on conservative treatment protocols for AIS patients. Besides, the DL paradigm can be easily used in patients with AIS as a non-invasive evaluation method in clinics.

Where are standardized and validated conservative treatment protocols for knee osteoarthritis?

An editorial calling for a discussion of actual protocol-sharing for the non-operative management of knee osteoarthritis.

Проблемы диагностики и лечения асептического некроза головки бедренной кости в современной травматологии и ортопедии (обзор литературы)

administration of corticosteroids or blood diseases. Early diagnosis is difficult, there is no conservative treatment protocol with proven effectiveness, and the organ-preserving surgical treatments which have been used may not always postpone hip arthroplasty. Arthroplasty provides good results in the short and long-term postoperative period, but the prevalence of this disease among young people requires developing new methods of conservative and operative treatment. Objective To determine the problems of diagnosis and treatment of aseptic necrosis of the femoral head; to study the experience of current approaches and concepts in the diagnosis and treatment of ANFH; determine the range of the most effective methods for treating this pathology; to establish the relevance of further research on this issue. Materials and methods Literature review was conducted of the sources from PubMed and Google Scholar databases. The material was selected that corresponded to the stated purpose of the research topic. For describing some aspects of the aetiology, pathogenesis and development of methods for diagnosing and treating ANFH, earlier publications (2009–2014) were also used. Results The main views on the aetiology and pathogenesis of ANFH have been studied. Classical and current diagnostic methods for ANFH were reviewed as well as current operative and conservative approaches to the treatment of this pathology. A review of the main classifications was conducted. Discussion Early detection and examination of at-risk patients plays an important role in the diagnosis of ANFH. The results of clinical trials on the use of bisphosphonates seem mixed, as the meta-analysis in five randomized clinical trials (RCTs) in 2016 showed no statistically significant improvement in patients with ANFH. Hyperbaric oxygenation reduces interstitial ischemia by increasing extracellular oxygen concentration and shows encouraging results. Core decompression is recognized as the standard care in the early stages of ANFH. At present, the use of combined treatment with bisphosphonates, core-decompression and mesenchymal stem cells has been investigated. Combined therapy may be effective in slowing the progression of collapse at an early stage of ANFH, but further research is needed to have long-term results. Conclusion Aseptic necrosis of the femoral head is a severe polyetiological disease that has not been sufficiently studied. For its diagnosis, it is necessary to take into account the possible risk factors and to ensure an early MRI study. At present, there is no data on a conservative method of treating the early stages of ANFH, which would have high evidence and effectiveness not only in the immediate, but also in the long-term follow-up. It is necessary to conduct additional prospective randomized clinical trials to determine the effectiveness of already known and developed methods of cell therapy in the treatment of ANFH.

Evaluation of two conservative different treatment protocols for symptomatic proximal deep caries management in molar teeth; an 18-month clinical report

Aim: The primary aim of this clinical trial was to observe the clinical success in conservative management of symptomatic deep proximal caries in permanent molar teeth with two treatment pulpotomy with Biodentine and indirect pulp capping with calcium hydroxide. Materials and Methods: A total of 71 patients who reported to department for the management of symptomatic proximal deep carious lesions in molar teeth participated in the trial. Posttreatment clinical success at 18 months was defined as asymptomatic teeth positively responding to cold pulp sensibility test (only in indirect pulp capping) and absence of periapical infection. Chi-squared test and Kaplan–Meier survival analysis were done. Results: Chi-squared test revealed no significant association between pulp status and posttreatment follow-up in both the treatment groups. Kaplan–Meier survival analysis showed mean survival of pulpotomy procedure for moderate and ambiguous pulp as 66.16 and 67.77 weeks, respectively, with no significant difference for two different pulp statuses. In indirect pulp capping procedure, there was significant difference (P = 0.038) (Log-rank Mantel-Cox) between the two pulp status category with moderate pulpitis having mean survival period of 69.27 weeks and ambiguous pulp with 42.83 weeks. Conclusion: Pulpotomy with Biodentine yielded better results than compared to indirect pulp capping.

Conservative non-surgical management in medication related osteonecrosis of the jaw: A retrospective study.

ObjectivesTo date, the best treatment for Medication Related Osteonecrosis of the jaw (MRONJ) is controversial. Recent studies suggest different therapies, considering the stage of MRONJ; however, sometimes patients, although with remarkable extension of disease, cannot undergo surgery. The purpose of present preliminary study was to evaluate the efficacy of conservative non‐surgical treatment of MRONJ lesions in a cohort of patients ineligible for surgery or refusing any surgical treatment for stage II and III of MRONJ.Materials and methodsPatients with MRONJ (staging II or III) ineligible for surgical treatment were selected for a retrospective study. A conservative non‐surgical therapy (antibiotics and antiseptic) was administered for 1 year. Five scheduled checks were performed to assess changes in signs and symptoms during the observational period.ResultsOur observation was carried out on 12 patients. Improvement of signs and symptoms of disease were observed in population.ConclusionThis study suggests that non‐surgical treatment may be a valid therapeutic option in patients ineligible for surgery. The sample size is small, further studies should be carried out to satisfy the aim of a conservative non‐surgical treatment protocol establishment.

Dual-task Balance Control In Adolescent Athletes Following Concussion

PURPOSE: Previous research has identified deficient dual-task balance control at the time of return to play (RTP) and possible worsening after RTP in older adolescents/young adults with concussion. We investigated these issues in younger concussion patients, hypothesizing they would have slower walking speed and increased medial-lateral (ML) center of mass (COM) movement, which would normalize by RTP but worsen after resuming activity. METHODS: 13 concussed adolescents (7 male; age 10-17 years) were prospectively evaluated at their initial visit (mean 18, range 4-43 days post-concussion), at RTP clearance (46, range 12-173 days post-concussion), and one month later (26, range 20-41 days post-RTP). Standing balance was assessed using range and root mean squared (RMS) COM motion during 2-leg, eyes open standing while performing audio Stroop, side-to-side head turn (HT), and side-to-side thumb tracking tasks. Dynamic balance was assessed using walking speed and COM ML range and velocity during walking alone and with head turn and verbal fluency (reciting words starting with “F”) dual tasks. Patients were compared to 11 controls (3 male) using t-tests, and changes over time were evaluated using linear mixed-effects regression. RESULTS: During standing, patients had higher COM ML RMS than controls at baseline during HT and higher COM anterior-posterior (AP) range during thumb tracking. COM ML motion decreased from baseline to RTP (HT range -6.5mm, p=0.058; HT RMS -16.8mm, p=0.002; thumb range 9.2mm, p=0.012) and increased from RTP to 1 month follow-up (HT RMS +10.0mm, p=0.040; Stroop RMS +8.4mm, p=0.086). Patients walked slower than controls at baseline during all tasks, and COM ML range was higher in patients during verbal fluency at baseline and RTP. Walking speed increased from baseline to RTP during verbal fluency (+7.8cm/s, p=0.044), from RTP to post-RTP in single task walking (+6.1cm/s, p=0.041), and at each successive visit during HT (+6.0cm/s and +6.5cm/s, p<0.07). COM ML range decreased in patients from baseline to RTP with verbal fluency (-14.7mm, p=0.011) and from RTP to post-RTP in single task walking (-4.0mm, p=0.061). CONCLUSION: Balance control deficits improved by RTP and only worsened post-RTP during dual-task standing, suggesting that current conservative treatment protocols are appropriate.

Oculomotor Function In Adolescent Athletes Following Concussion

PURPOSE: Visual impairments affect up to 90% of patients post-concussion and may include deficits in fixation accuracy, smooth pursuit, saccadic latencies, vergence, accommodation, or vestibule-ocular reflexes. Quantitative assessment of oculomotor function may provide a sensitive measure of concussion recovery since coordinated eye movements require the use of diverse and widely dispersed areas of the brain. This study quantified oculomotor function over time in adolescents following concussion, hypothesizing that initial deficits would resolve by the time of RTP and remain stable after RTP. METHODS: 13 adolescent athletes with mild to moderate concussion (7 male; mean age 15.1, SD 2.1, range 10-17 years) were prospectively evaluated at their initial visit (mean 18, range 4-43 days post-concussion), at the time of RTP clearance (mean 46, range 12-173 days post-concussion), and one month later (mean 26, range 20-41 days after RTP). 11 controls without past concussion or injury (3 male; mean age 12.3, SD 3.1, range 8-17 years) were tested at similar timepoints. Eye tracking was recorded as subjects followed a target moving on a screen in predefined patterns related to sinusoid and trapezoid smooth pursuit, vergence, saccade, and anti-saccade. Metrics characterizing the speed, accuracy, and variability of tracking were compared between groups and visits using t-tests and linear mixed-effects regression. RESULTS: At baseline, patients tended to have greater overshoot and greater variability in tracking compared with controls, though the differences were not statistically significant. Overshoot (coef -1.97, SE 0.98, p=0.045), variability of tracking (-1.04, SE 0.53, p=0.048), and variability of overshoot (-2.59, SE 1.04, p=0.013) decreased from baseline to RTP. Undershoot during sinusoid smooth pursuit tended to decrease from RTP to 1-month follow-up (-0.16, SE 0.09, P=0.080). The rate of convergence in the distance vergence task increased (0.27, SE 0.10, p=0.005) while the rate of divergence decreased (-0.32, SE 0.17, p=0.068) between these time points. CONCLUSION: Possible deficits in eye tracking resolved by the time of RTP and generally remained stable or continued improving after RTP, suggesting that oculomotor function recovers sufficiently under current conservative treatment protocols.

Functional and early weight-bearing protocol for achilles tendon ruptures: a retrospective study.

Conservative treatment of achilles tendon rupture (ATR) might be favoured in centres with an early weight-bearing protocol, but no consensus exists on the clear definition of an early weight-bearing protocol. The aim of this study is to evaluate the introduction of an early weight-bearing conservative treatment protocol in patients with ATR compared to patients without this protocol. A single-centre retrospective study was performed. All patients presenting with an ATR during a 10-year period were included. Between January 1st 2008 and December 31st 2015, all patients were included for either operative or conservative treatment without an early weight-bearing protocol (non-EWB). Between January 1st 2016 and 30th June 2019, patients were, primarily, treated conservatively with early weight-bearing protocol (EWB). A primary-outcome parameter was re-rupture, and secondary-outcome parameters were treatment-related complications. In the period 2008-2015, 246 patients were treated with non-EWB. In the period 2016-2019, 58 patients were treated conservatively with EWB. No significant differences were found in re-rupture rates between non-EWB (5.3%) and conservative EWB (6.9%) (p = 0.536) or conservative non-EWB (9.4%) and conservative EWB (6.9%) (p = 0.283). Pulmonary embolism (1.0%) and deep venous thrombosis (1.0%) were observed in operative non-EWB patients. In conservative EWB patients, superficial pressure ulcers (5.2%) and treatment failure (5.2%) were observed. Conservative treatment of ATR with an early weight-bearing protocol showed similar re-rupture rates and complication rates compared to conservative and operative treatments without an early weight-bearing protocol.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm.

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes. A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria. A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports. A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

DUAL-TASK BALANCE CONTROL IN ADOLESCENT ATHLETES FOLLOWING CONCUSSION

Background:Previous research has identified deficient dual-task balance control at the time of return to play (RTP) and possible worsening after RTP in older adolescents/young adults with concussion. These findings have not been investigated in younger patients with concussion.Hypothesis/Purpose:We hypothesized that concussed adolescents would have slower walking speed and increased medial-lateral (ML) center of mass (COM) movement, which would normalize by the time of RTP but worsen after resuming activity.Methods:13 adolescent concussion patients (7 male; age 10-17 years) were prospectively evaluated at their initial visit (IV) (mean 18, range 4-43 days post-concussion), at RTP clearance (mean 46, range 12-173 days post-concussion), and one month later (mean 26, range 20-41 days post-RTP) along with 11 controls (3 male) seen for similarly timed visits. Standing balance was assessed using range and root mean squared (RMS) COM motion in the anterior-posterior (AP) and ML directions during standing on both legs with eyes open while performing quiet standing, dual-task audio Stroop, side-to-side head turns, and side-to-side thumb tracking tasks. Dynamic balance was assessed using walking speed and COM ML range and velocity during walking alone and with side-to-side head turns and verbal fluency (reciting words starting with “F”) dual tasks. Patients were compared against controls using t-tests, and changes over time were evaluated using linear mixed-effects regression.Results:During standing, patients had higher COM ML RMS than controls at IV during head turns and higher COM AP range during thumb tracking. COM ML motion decreased from IV to RTP (head turns range -6.5mm, p=0.058; head turns RMS -16.8mm, p=0.002; thumb range 9.2mm, p=0.012) and increased from RTP to 1 month follow-up (head turns RMS +10.0mm, p=0.040; Stroop RMS +8.4mm, p=0.086).Patients walked slower than controls at IV during all tasks, and COM ML range was higher in patients vs. controls during verbal fluency at IV and RTP. Walking speed increased from IV to RTP during verbal fluency (+7.8cm/s, p=0.044), from RTP to post-RTP in single task walking (+6.1cm/s, p=0.041), and at each successive visit during head turns (+6.0cm/s and +6.5cm/s, p<0.07). COM ML range also decreased in patients from IV to RTP with verbal fluency (-14.7mm, p=0.011) and from RTP to post-RTP in single task walking ( 4.0mm, p=0.061).Conclusion:Adolescent concussion patients had deficits in static and dynamic balance control at initial presentation. This tended to improve by RTP and only worsened post-RTP for dual-task ML control during standing, suggesting that current conservative treatment protocols are appropriate.

OCULOMOTOR FUNCTION IN ADOLESCENT ATHLETES FOLLOWING CONCUSSION

Background:Visual impairments affect up to 90% of patients post-concussion. These impairments may include deficits in fixation accuracy, smooth pursuit, saccadic latencies, vergence, accommodation, and vestibule-ocular reflexes. Quantitative assessment of oculomotor function may provide a sensitive and objective measure of concussion diagnosis and recovery since coordinated eye movements require the use of diverse and widely dispersed areas of the brain. This study quantified oculomotor function over time in adolescents following concussion.Hypothesis/Purpose:We hypothesized that adolescent concussion patients would demonstrate deficits of oculomotor function that would resolve by the time of return to play (RTP) and remain stable after RTP.Methods:13 adolescent athletes diagnosed with mild to moderate concussion (7 male; mean age 15.1, SD 2.1, range 10-17 years) were prospectively evaluated at their initial visit (mean 18, range 4-43 days post-concussion), at the time of clearance to RTP (mean 46, range 12-173 days post-concussion), and one month later (mean 26, range 20-41 days after RTP). 11 controls without past concussion or injury (3 male; mean age 12.3, SD 3.1, range 8-17 years) were also tested at similar time points. Eye tracking was recorded as participants followed a target moving on a screen in predefined patterns related to sinusoid and trapezoid smooth pursuit, vergence, saccade, and anti-saccade. Metrics characterizing the speed, accuracy, and variability of tracking were compared between groups and visits using t-tests and linear mixed-effects regression.Results:At their initial visit, patients tended to have greater overshoot and greater variability in tracking compared with controls (Table 1.1). Overshoot and variability of tracking during sinusoid smooth pursuit (both overall variability and variability of overshoot) decreased from initial visit to RTP (Table 1.2). Undershoot during sinusoid smooth pursuit tended to decrease from RTP to 1-month follow-up. The rate of convergence in the distance vergence task increased while the rate of divergence decreased between these time points.Conclusion:The main oculomotor deficits observed in concussed adolescents related to overshoot and variability of tracking during sinusoid smooth pursuit. These deficits resolved by the time of RTP and generally remained stable or continued improving after RTP. These results suggest that oculomotor function recovers sufficiently under current conservative treatment protocols.Table 1.1.Comparison of concussed patients at initial visit vs. controls ConcussedInitial VisitMean (SD)Control Mean (SD)p-valueSaccade latency0.44 (0.07)0.45 (0.07)0.72Anti-saccade latency0.65 (0.12)0.62 (0.08)0.41Rate of convergence1.44 (0.31)1.51 (0.25)0.62Rate of divergence1.56 (0.17)1.55 (0.24)0.94Sinusoid peak phase lag10.40 (6.75)10.55 (1.80)0.95 Sinusoid mean SD of error 3.19 (1.95) 2.00 (0.91) 0.075 Sinusoid mean overshoot 4.72 (4.23) 2.16 (1.54) 0.075 Sinusoid mean undershoot3.07 (0.91)2.90 (0.29)0.57Sinusoid SD overshoot5.17 (4.84)2.30 (1.80)0.080Sinusoid SD undershoot3.35 (1.11)3.28 (0.38)0.83Sinusoid smooth pursuit involves a target moving in a sinusoidal pattern in a horizontal direction. A full period of movement covers 35.6 degrees over 2.4 seconds.Table 1.2.Change between visits for patients Coef (SE)RTP vs. IVp-valueCoef (SE)Follow-up vs. RTPp-valueSaccade latency0.008 (0.022)0.739-0.034 (0.023)0.139Anti-saccade latency-0.015 (0.045)0.729-0.069 (0.050)0.166Rate of convergence-0.073 (0.088)0.410 0.269 (0.097) 0.005 Rate of divergence-0.021 (0.154)0.889 -0.315 (0.172) 0.068 Sinusoid peak phase lag1.52 (1.97)0.441-1.88 (2.05)0.359Sinusoid mean SD of error -1.04 (0.53) 0.048 0.49 (0.52)0.348Sinusoid mean overshoot -1.97 (0.98) 0.045 0.43 (0.97)0.657Sinusoid mean undershoot-0.02 (0.10)0.818 -0.16 (0.09) 0.080 Sinusoid SD overshoot -2.59 (1.04) 0.013 0.86 (1.02)0.396Sinusoid SD undershoot-0.17 (0.29)0.5690.15 (0.29)0.610Sinusoid smooth pursuit involves a target moving in a sinusoidal pattern in a horizontal direction. A full period of movement covers 35.6 degrees over 2.4 seconds.

A nonsurgical approach with repeated orthoptic evaluation is justified for most blow-out fractures

ObjectiveThis study presents the results of an updated clinical protocol for orbital blow-out fractures, with a special emphasis on nonsurgical treatment and orthoptic evaluation of functional improvement. MethodsA two-centre multidisciplinary prospective cohort study was designed to monitor the results of a clinical protocol by assessing ductions, diplopia, globe position, and fracture size. Patients underwent clinical assessment and orthoptic evaluation at first presentation and then at 2 weeks and 3/6/12 months after nonsurgical or surgical treatment. Outcome parameters were field of binocular single vision (BSV), ductions, degree of enophthalmos, a diplopia quality-of-life (QoL) questionnaire, and other sequelae or surgical complications. Results46 of the 58 patients who completed the 3, 6 and/or 12-month follow-up received nonsurgical treatment. There was full recovery without diplopia or enophthalmos (>2 mm) in 45 of the 58 patients. The other 13 patients had limited diplopia, mainly in extreme upward gaze (average BSV 90). Five of those 13 patients did not experience impairment of diplopia in daily life. The average QoL score at the end of follow-up was 97. No patients developed late enophthalmos. ConclusionThis study showed that a high percentage of patients with orbital floor and/or medial wall fracture recovered spontaneously without lasting diplopia or cosmetically disfiguring enophthalmos. The conservative treatment protocol assessed here underlines the importance of orthoptic evaluation of functional parameters.

Treatment of Scapular Dyskinesis with Reflexive Neuromuscular Stimulation: A Case Report

Introductory: Scapular dyskinesis is an abnormal movement of the scapula due to poor motor control of the surrounding musculature and can lead to other glenohumeral pathologies. The pathology results in the lateral tilting of the scapula during many glenohumeral joint movements and weight-bearing activities of the upper extremity (i.e. plank). The typical conservative treatment protocol focuses on strengthening surrounding musculature and is often a lengthy protocol. The problem with strengthening protocols is the failure to address the motor functioning of targeted muscles. Reactive Neuromuscular Stabilization (RNS) is a novel treatment that targets the central nervous system (CNS) to address that motor firing problem to restore the normal muscular and joint function. Purpose: The purpose of this case study is to demonstrate the efficacy and the outcomes of using RNS as a treatment for dysfunctions such as scapular dyskinesis. Clinical Diagnosis: A 20-year-old female intercollegiate swimmer presented with significant mid-back pain that failed to resolve without treatment. The patient tested positive for scapular dyskinesis as well as presented with a number of postural concerns, trigger points, and pain with multiple activities. The initial protocol for treatment for this patient was the typical conservative treatment protocol focused on strengthening. After six weeks of treatment without improvement, the clinician modified care to include RNS. Outcomes: Following three treatment across seven days, the patient’s symptoms significantly decreased and the patient met discharge criteria. At an eleven-month follow-up, the patient’s improvements were maintained. Clinical Bottom Line: The patient in this case report demonstrates the effectiveness of RNS while treating scapular dyskinesis and the importance of recognizing the cause of the dysfunction early within the evaluation.