Functional Disability Scores Research Articles

Development of an Interdisciplinary Pediatric Pain Rehabilitation Program

ObjectiveTo describe the development of a clinically and financially successful interdisciplinary pediatric pain rehabilitation program at a large tertiary academic medical center and present demographic and clinical information on the first 1000 patients.Patients and MethodsAll patients who were consecutively admitted to this program between October 1, 2008, and March 31, 2015 were included in this review. The patients ranged in age from 9 to 24 years. The program is a 3-week, hospital-based outpatient treatment program that requires substantial parental involvement. At admission and discharge, patients completed the Center for Epidemiologic Studies of Depression Scale for Children, the Functional Disability Inventory, and the Pain Catastrophizing Scale for Children. Opioid use was also assessed.ResultsAt admission, patients reported substantial pain-associated disability and depressive symptoms; they had elevated pain catastrophizing scores, and 16% were taking opioids. Primary sites/types of pain included head, abdomen, and generalized. Functional disability scores decreased significantly, from 27 to 9 after the program (P<.001). Depression scale scores improved from 27 to 14 (P<.001). Pain catastrophizing scores decreased significantly, from 26 to 14 (P<.001), at discharge from the program. All but 4 patients successfully tapered off of all opioid use by the conclusion of the program.ConclusionParticipation in a multidisciplinary pediatric pain rehabilitation program can be successful, with significant decreases in disability, depression symptoms, and pain catastrophizing, as well as discontinuation of opioid use.

Abstract 698: Functional outcome and socio-psychological problems for bone &amp; soft tissue sarcoma patients in childhood &amp; AYA generation

Abstract [Objective] To elucidate the problems between functional and sociological outcomes in patients of bone and soft tissue sarcomas in childhood and adolescent/young adult (AYA) generation. [Method] Clinical (prognostic and functional) and socio-psychological outcomes were retrospectively analyzed in 50 patients with bone and soft tissue sarcomas under 29 years old treated in our institute from 1998 to 2014. [Results] Twenty-two patients under 15 and 28 of AYA generation (15 to 29 years old) (28 male and 22 female) were subjected, including 35 cases of bone and 15 cases of soft tissue sarcomas, and 39 of extremity cases. Most common diagnosis was osteosarcoma of 27 cases. Limb-sparing surgery was performed in 30 cases, including 14 of prosthetic and 8 of biological reconstruction for bone tumors. Overall Survival rates were 79% for 2 year and 61% for 5 year follow-up periods. 70% of the patients experienced limited activities; 50% in high school and college students experienced drop-out or delay, suspension and repeating the same class; 56% faced to their job lost or limitation of job search; 20% experienced changes of relationship with families and partners (Table). Most taken palliative care intervention was the counseling for family members and caregivers, besides pain management and psychological care. Correlation coefficient failed to show a significant correlation between functional score and sociological disability score both in all limb sparing cases (R2 = 0.2664) and in osteosarcoma cases ((R2 = 0.1757) . [Conclusion] The sociological problems for patients in this particular group could be focused on school life, job search and relationship with families and partners. QOL is a multidimensional measure with various domains, such as physical, psychological, social well-being, spiritual health as well as functional ability, therefore, multi-disciplinary care for socio-physiological and psychological disadvantage must be taken for this group of patients at earliest convenience. Reletionship between physiological and socio-psychological problemsSubjectAll patientsLimb-spared patinetsLimitation of activities70% (30/43)75% (21/28)School dropout/delay in high-schoolers &amp; college students50% (14/28)32% (8/25)Lost jobs/job search difficulties56% (9/16)33% (3/9)Changing social reletions with families &amp; partners20% (8/40)21% (3/28) Citation Format: Kanya Honoki, Toshiaki Shinomiya, Hiromasa Fujii, Takashi Ishihara, Shinji Tsukamoto, Shingo Kishi, Yumiko Kondo, Akira Kido, Toshifumi Tsujiuchi, Midori Shima, Yasuhito Tanaka. Functional outcome and socio-psychological problems for bone &amp; soft tissue sarcoma patients in childhood &amp; AYA generation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 698. doi:10.1158/1538-7445.AM2017-698

Meaningful patient engagement in inflammatory arthritis: development of the Patient Motivation Questionnaire.

The objective of this study is to develop a questionnaire for evaluating the patient's "motivation" and assess the psychometric properties of that measure in patients with chronic inflammatory arthritis. Using Rasch analysis and questions item pool, content analysis, and semi-structured group discussion, the questionnaire was developed including 10-item scale (0-10 on VAS scale). Construct validity was assessed by correlating the questionnaire score to parameters of disease activity (DAS-28, ASDAS, and DAPSA scores), functional disability, quality of life, patient self-helplessness measure, as well as the patients' compliance to therapy. Reliability and comprehensibility and sensitivity to change were also assessed. The questionnaire was assessed in 432 RA, 415 psoriatic arthritis patients, and 232 ankylosing spondylitis patients. Dimensionality analysis revealed a 1-factor solution, explaining 98% of the total variance. It showed acceptable validity as it correlated significantly with disease activity measures: DAS-28: r=-0.85, ASDAS: r=-0.86, and DAPSA: r=-0.89. It also correlated significantly with functional disability score: r=-0.91, QoL: r=-0.90, as well as patient self-helplessness: r=-0.88. The questionnaire was reliable (Cronbach's alpha 0.958) and had no misfitting items. In addition, it was comprehensible (9.4) and sensitive to change (p<0.01). The patient motivation score showed significant (p<0.01) variation with the medication compliance. The measure is a patient-reported tool that is valid, reliable, comprehensible, and unidimensional scale that reflects the patients' motivation and engagement. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor management and monitor changes.

Post-Thrombotic Syndrome and Functional Disability in Patients with Upper Extremity Deep Vein Thrombosis: A Prospective Cohort Study

Introduction. Upper extremity deep vein thrombosis (UEDVT) is a relatively uncommon event with potentially serious complications. Its clinical outcomes are not well studied. The objective of this study was to assess the incidence of post-thrombotic syndrome (PTS) and functional disability in patients with UEDVT.Patients and methods. This was a pre-specified analysis of a prospective cohort study at 5 Canadian centres. We enrolled adult patients with a symptomatic UEDVT confirmed by compression ultrasound involving the brachial or more proximal veins, with or without a pulmonary embolism (PE). Exclusions included pregnancy, dialysis catheter thrombosis, active or high bleeding risk, platelet count <100x109/L, creatinine clearance < 30 ml/min, on warfarin for other indications, hemodynamically unstable PE, acute leukemia or undergoing a stem cell transplant within 3 months, geographical inaccessibility, life expectancy <3 months or treatment with low molecular weight heparin (LMWH) or warfarin for more than 7 days since diagnosis. Standardized treatment regimens were used as follows: spontaneous or central venous catheter (CVC)-related UEDVT were treated with dalteparin at therapeutic doses for at least 5 days followed by warfarin adjusted according to INR results. Spontaneous UEDVT was treated for at least 6 months and CVC-related events were treated for at least 3 months or for as long as the line remained in place and for at least 1 month after line removal. Cancer patients with non CVC-related UEDVT were treated using dalteparin alone for a minimum of 6 months. Outcomes were assessed at 12, 18 and 24 months and included the occurrence of PTS evaluated using a modified Villalta Score. PTS was defined for patients with a score of 5 or greater and severe PTS was defined by a score of 15 or higher. Functional disability was evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Patients were followed for 2 years. Data was analyzed using descriptive statistics. Confidence intervals for proportions were estimated using the Wilson’s score method. Groups were compared using χ2 and Student’s t- tests, as appropriate. The study was approved by all institutional review boards.Results. Between 2009 and 2012, we enrolled 141 patients: 75 with spontaneous and 66 with CVC related UEDVT. Mean age was 51 years and 55% were males. There were 78, 59 and 56 patients with evaluable data at 12, 18 and 24 months, respectively. The percentage of patients with ipsilateral PTS is shown in Table 1. There was no difference between patients with spontaneous or CVC- related UEDVT. Functional disability scores are shown in Table 2. Overall, patients developing PTS had higher functional disability at all time points, compared to patients without PTS.Conclusion. In this prospective cohort study PTS occurred in approximately one fifth of patients after UEDVT and was associated with more functional disability, although the majority of cases were mild according to the modified Villata score. No differences were observed between CVC-related and spontaneous UEDVT. [Display omitted] [Display omitted] DisclosuresLazo-Langner:Bayer: Honoraria; Pfizer: Honoraria; Daiichi Sankyo: Research Funding. Wells:Itreas: Other: Served on a Writing Committee; BMS/Pfizer: Research Funding; Bayer Healthcare: Other: Speaker Fees and Advisory Board; Janssen Pharmaceuticals: Consultancy. Carrier:BMS: Research Funding; Leo Pharma: Research Funding. Kovacs:Daiichi Sankyo Pharma: Research Funding; LEO Pharma: Honoraria; Bayer: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding.

Factors associated with quality of life and functional disability among rheumatoid arthritis patients treated with disease-modifying anti-rheumatic drugs for at least 6 months.

To determine characteristics of rheumatoid arthritis (RA) patients in Korea using disease-modifying anti-rheumatic drugs (DMARDs) for at least 6 months, and to identify factors associated with poor health-related outcomes. A total of 2000 RA patients aged > 20 years, treated with DMARDs for at least 6 months, and signed informed consent, were enrolled in this non-interventional, multicenter, cross-sectional observational study from December 2012 to June 2013. Health-related quality of life (HRQoL) was measured using EuroQuol 5D (EQ-5D) and functional disability was measured using the Korean Health Assessment Questionnaire (KHAQ). Univariate and multivariate linear regression analyses were used to determine the association between patient characteristics and patient-reported outcomes (PROs). Of all RA patients, 84% were female, patients with low Disease Activity Score of 28 joints erythrocyte sedimentation rate (DAS-28-ESR < 3.2) was 54%, while moderate (DAS-28-ESR 3.2-5.1) and high disease activity score (DAS-28-ESR > 5.1) were 38% and 7.6%, respectively. Mean EQ-5D index score and KHAQ score were 0.6 ± 0.28 and 0.7 ± 0.67, respectively. In multivariate analysis with both PROs, average HRQoL and functional disability score appeared to be worse in persons with older age compared to younger age (P < 0.001), and worse in females compared to males (P < 0.001). Compared to patients having lower DAS (< 3.2), those with moderate and highest DAS (3.2-5.1 and > 5.1) had worse outcome measures (P < 0.001). In this study, higher DAS was one of the most influential factors for poor PROs among all other factors. Therefore, we could suggest appropriate treatment approaches according to DAS along with other significantly associated factors with PROs in the early stage of RA.

Structural explanation of poor prognosis of amyotrophic lateral sclerosis in the non‐demented state

Amyotrophic lateral sclerosis (ALS), a motor neuron disease, is associated with various cortical symptoms including mild cognitive decline with behavior changes, suggesting the involvement of extra-motor areas in ALS. Our aim was to investigate the specific patterns of brain atrophy in sporadic, impaired ALS patients without commonly known genetic mutations using voxel-based morphometry. Forty-seven patients with sporadic ALS and 28 age-matched healthy controls were recruited. ALS participants were divided into three groups according to comprehensive neuropsychological testing: pure (ALS-pure), cognitive impairment (ALSci) and behavioral impairment (ALSbi). Quantitative comparison of brain atrophy patterns was performed amongst these three groups using voxel-based analysis. All analyses were adjusted for total intracranial volume, age, sex, disease duration and functional disability score. The ALSci group exhibited decreased volume in the left cerebellum, fusiform gyrus, optic radiations and corticospinal tracts compared to healthy controls. ALSci patient imaging showed decreased brain volume in the bilateral cerebellum, right putamen gray matter and bilateral superior longitudinal fasciculi white matter compared to pure ALS patients (P < 0.001 uncorrected, corrected for the entire volume). Compared to healthy controls, ALS-pure and ALSbi groups did not show any significant volume changes in gray and white matter. These findings also support the hypothesis that ALS pathogenesis has a dual focality of onset (cortex and anterior horn) with contiguous spread outwards. Additionally, neuropsychological features may be an important predictor of progression and survival rates in ALS.

Repeated courses of intratympanic dexamethasone injection are effective for intractable Meniere’s disease

Conclusion: Intra-tympanic dexamethasone injection (ITD) could serve as a first-line intra-tympanic (IT) treatment for Meniere’s disease (MD), regardless of hearing level. Even if the response to initial ITD course was unsatisfactory, a repeated course may be beneficial with some patients.Objectives: This study examined the effect of repeated courses of ITD administered on demand and investigated the possibility of ITD as an initial IT treatment for medically intractable MD patients.Method: Fifty-one patients who had been diagnosed with definite MD and given course(s) of ITD treatment were included. Vertigo control, pure tone average and functional disability scores were evaluated against the American Academy of Otolaryngology-Head and Neck Surgery guidelines for MD.Results: Vertigo disappeared or was substantially controlled in 58.8% and 23.5% of the patients, respectively, after the first ITD course. A repeated course further raised the complete vertigo control rate by 15.7% and intra-tympanic gentamycin injection could be postponed or avoided in 78.6% of the patients who required repeated IT treatment. Hearing was unchanged after the first course of ITD (p > .05). No significant differences were detected in the clinical profiles or laboratory findings between patients receiving single course of ITD and those on multiple courses (p > .05).

Toward Electronic Health Recording: Evaluation of Electronic Patient-reported Outcome Measures System for Remote Monitoring of Early Rheumatoid Arthritis.

To assess the use of electronic patient-reported outcome measures (ePROM) in standard clinical practice for early rheumatoid arthritis (RA) management, the ePROM ability to enhance clinical care, and how computing technology can improve the patients' adherence to therapy. In a double-blinded randomized-controlled study, 211 patients with early RA diagnosed according to American College of Rheumatology/European League Against Rheumatism criteria completed a PROM in paper format at their first clinic visit. Patients were then randomized to Group 1, which completed an ePROM questionnaire monthly, or Group 2, which continued the standard paper PROM format. Over a 12-month period, Group 1 patients were assessed every 3 months in the clinic, whereas Group 2 patients were assessed in the clinic initially monthly for 6 months, then every 3 months. The primary endpoint was the equivalence of outcomes [Routine Assessment of Patient Index Data 3 (RAPID-3) and 28-joint Disease Activity Score (DAS28)] in both groups. The secondary endpoint was the patients' adherence to their medications. There was no significant difference between disease activity measures as well as DAS28 and RAPID-3 scores at 3, 6, and 12 months of management, although there was a trend toward lower patient-reported tender joint count and functional disability score in the active group versus the control group. The patients' adherence to antirheumatic therapy was significantly higher (p < 0.01) in the ePROM group, whereas stopping disease-modifying antirheumatic drugs for intolerability was significantly higher (p < 0.01) in the control group at 12 months of treatment. We found ePROM equivalent to standard paper PROM format. Further, it enabled the patients to personally monitor how they are doing regarding their disease activity and helped to optimize their adherence to their treatment.

Role of Epidural Injections to Prevent Surgical Intervention in Patients with Chronic Sciatica: A Systematic Review and Meta-Analysis.

Objective: The aim of this study is to evaluate the efficacy of the different types of epidural injections (EI) to prevent surgical intervention in patients suffering from chronic sciatica due to lumbar disc herniation (LDH).Material and Methods: Studies were identified by searching PubMed, MEDLINE, and Google Scholar to retrieve all available relevant articles. Lists of references of several systematic reviews were also used for scanning further references. Publications from the past ten years (2006-2016) were considered, and all studies selected were in the English language only. The studies employed specified the use of EI to treat sciatica caused by LDH. A total of 19 papers meeting the eligibility criteria (mentioned below) were included in this study. The pain scores, functional disability scores, and surgical rates from these studies were considered, and meta-analysis was performed.Outcome measures: Pain scores, functional disability scores, and surgical rates were assessed from the included studies. The Numeric Rating Scale (NRS) and Visual Analogue Scale (VAS) have been the most commonly used baseline scales for pain evaluation followed by the Verbal Numerical Rating Scale (VNRS) and Japanese Orthopedic Association (JOA). The Oswestry Disability Index (ODI) and Roland Morris Disability Questionnaire (RMDQ) scales were used for the functional disability scoring system in the literature.Results: Significant improvement in the pain scores and functional disability scores were observed. Additionally, greater than 80% of the patients suffering from chronic sciatica caused by LDH could successfully prevent surgical intervention after EI treatment with or without steroids.Conclusion: The management of sciatica with EI treatment results in significant improvements in the pain score, functional disability score, and surgical rate. We concluded that EI provides new hope to prevent surgical intervention in patients suffering from sciatica caused by LDH.

Non-Invasive Brain Stimulation to Enhance Post-Stroke Recovery.

Brain plasticity after stroke remains poorly understood. Patients may improve spontaneously within the first 3 months and then more slowly in the coming year. The first day, decreased edema and reperfusion of the ischemic penumbra may possibly account for these phenomena, but the improvement during the next weeks suggests plasticity phenomena and cortical reorganization of the brain ischemic areas and of more remote areas. Indeed, the injured ischemic motor cortex has a reduced cortical excitability at the acute phase and a suspension of the topographic representation of affected muscles, whereas the contralateral motor cortex has an increased excitability and an enlarged somatomotor representation; furthermore, contralateral cortex exerts a transcallosal interhemispheric inhibition on the ischemic cortex. This results from the imbalance of the physiological reciprocal interhemispheric inhibition of each hemisphere on the other, contributing to worsening of neurological deficit. Cortical excitability is measurable through transcranial magnetic stimulation (TMS) and prognosis has been established according to the presence of motor evoked potentials (MEP) at the acute phase of stroke, which is predictive of better recovery. Conversely, the lack of response to early stimulation is associated with a poor functional outcome. Non-invasive stimulation techniques such as repetitive TMS (rTMS) or transcranial direct current stimulation (tDCS) have the potential to modulate brain cortical excitability with long lasting effects. In the setting of cerebrovascular disease, around 1000 stroke subjects have been included in placebo-controlled trials so far, most often with an objective of promoting motor recovery of the upper limb. High frequency repetitive stimulation (>3 Hz) rTMS, aiming to increase excitability of the ischemic cortex, or low frequency repetitive stimulation (≤1 Hz), aiming to reduce excitability of the contralateral homonymous cortex, or combined therapies, have shown various effects on the functional disability score and neurological scales of treated patients and on the duration of the treatment. We review here the patients’ characteristics and parameters of stimulation that could predict a good response, as well as safety issues. At last, we review what we have learnt from experimental studies and discuss potential directions to conduct future studies.

Efficacy and tolerability of perampanel in ten patients with Lafora disease

Lafora disease (LD) is a fatal intractable adolescence-onset progressive myoclonus epilepsy. Recently, two single-case studies reported drastic reductions in seizures and myoclonus with the AMPA antagonist perampanel and improved activities of daily living. We proceeded to study the effect of perampanel on 10 patients with genetically confirmed LD with disease duration ranging from 2 to 27years. Open-label perampanel was added to ongoing medications to a mean dose of 6.7mg/day. Seizures, myoclonus, functional disability, and cognition scores were measured for the third and ninth months following initiation and compared with those of the month prior to the start of therapy. Three patients withdrew because of inefficacy or side effects. Four had significant reduction in seizures of greater than 74% from baseline. Seven had major improvement in myoclonus with group-adjusted sum score of myoclonus intensity reduced from 7.01 at baseline to 5.67 and 5.18 at 3 and 9months, respectively. There was no significant improvement in disability and cognition. While not universal, perampanel adjunctive therapy appears to confer particular benefit not commonly seen with other antiepileptic drugs on seizures and myoclonus in LD. Improvement in the extremely disabling myoclonus of LD is a major benefit in this devastating disease.

Is Coraco-Clavicular Stabilisation Alone Sufficient for the Endoscopic Treatment of Severe Acromio-Clavicular Separation (Rockwood Types III, IV, and V)?

The primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromio-clavicular joint disruption (ACJD). Our hypothesis was that at 1 year combined acromio-clavicular and coraco-clavicular stabilisation improves radiological outcomes compared to coraco-clavicular stabilisation alone. A prospective multicentre study evaluated clinical outcome (pain, QuickDASH, and Constant’s score), and anatomical outcomes (standard XRays and dynamic radiographs). 116 patients (48% type III, 30% type IV, 22% type V), minimal FU was 1 year. Coraco-clavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromio-clavicular stabilisation in 50%. The Constant’s score ≥85/100 and a subjective QuickDASH functional disability score ≤10 in 75% of patients. The radiographic analysis showed significant improvements and in the horizontal plane. The anatomical outcome correlated significantly with the functional outcome (absolute R value =0.19 and p=0.045). Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromio-clavicular stabilisation in the horizontal plane (p=0.02). The coraco-clavicular ratio on the antero-posterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02). This study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coraco-clavicular junction and at the acromio-clavicular joint. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10 days.

Normalisation of brain spectroscopy findings in Niemann-Pick disease type C patients treated with miglustat.

Niemann–Pick disease type C (NP-C) is a fatal progressive neurolipidosis involving neuronal storage of cholesterol and gangliosides. Miglustat, an inhibitor of glycosphingolipid synthesis, has been approved to treat neurological manifestations in adults and children with NP-C. This open-label observational study in adults with confirmed NP-C evaluated the efficacy of miglustat (200 mg t.i.d.) based on composite functional disability (CFD) scores and brain proton magnetic resonance spectroscopy (H-MRS) measurement of choline (Cho)/N-acetyl aspartate (NAA) ratio in the centrum ovale. Overall, 16 patients were included and received miglustat for a mean period of 30.6 months: 12 continued on miglustat throughout follow up, and 4 discontinued miglustat because of adverse effects (n = 2) or perceived lack of efficacy (n = 2). In the ‘continued’ subgroup, the mean (SD) annual progression of CFD scores decreased from 0.75 (0.94) before treatment to 0.29 (1.29) during the period between miglustat initiation and last follow-up. In the discontinued subgroup, CFD progression increased from 0.48 (0.44) pre-treatment to 1.49 (1.31) at last follow up (off treatment). Mean (SD) Cho/NAA ratio [normal level 0.48 (0.076)] decreased during miglustat treatment in the continued subgroup: 0.64 (0.12) at baseline (miglustat initiation), 0.59 (0.17) at 12-month follow up, and 0.48 (0.09) at 24-month follow up. Cho/NAA ratio remained relatively stable in the discontinued subgroup: 0.57 (0.15), 0.53 (0.04) and 0.55 (0.09), respectively. In conclusion, H-MRS Cho/NAA ratio might serve as an objective, quantitative neurological marker of brain dysfunction in NP-C, allowing longitudinal analysis of the therapeutic effect of miglustat.Electronic supplementary materialThe online version of this article (doi:10.1007/s00415-016-8051-1) contains supplementary material, which is available to authorized users.

Effects of the McKenzie protocol on pregnancy- related back pain

ABSTRACT INTRODUCTION AND AIM: Back pain (BP) is a common complaint of women during pregnancy, and it constituted a burden to the affected individuals. The objective of this study was to determine the effects of McKenzie protocol (MP) in managing pregnancy-related BP among women. MATERIALS AND METHODS: Women with pregnancy-related BP were purposively recruited and randomly assigned to McKenzie protocol plus usual care (MPG) and Usual care only (UCG). The participants in the MPG were treated with MP in addition to the usual care. The women in the UCG received usual care only. Participants were treated within six weeks and then assessed. Pre and post-intervention pain intensity and disability level were assessed using Numerical pain rating scale and Modified Ronald Morris Disability Questionnaires. Data obtained were analyzed using descriptive and inferential statistics. RESULTS: There were no statistically significant differences in the independent t-test comparison of the pre-treatment pain intensity [LBP (p = 0 . 989), HBP (p = 0 .306), PGP (0 .296)] and functional disability scores [LBP (p = 0. 483); HBP (p = 0. 306), PGP(P = 0. 209)] between MPG and UCG respectively. At the end of the 6 weeks of intervention the independent t-test comparison of the post-treatment pain and disability scores of the participants in the MPG and UCG showed statistically significant difference in pain intensity score reduction [LBP (p = 0. 001), HBP (p = 0. 001), PGP (p = 0. 001)] and disability score reduction [LBP (p = 0. 001), HBP (p = 0. 001), PGP (p = 0. 001)] respectively. CONCLUSION: Addition of McKenzie protocol to usual care produced significant relief from back pain and disability of participants in the MPG at the end of six weeks intervention irrespective of back pain types. It is recommended that McKenzie protocol should be considered in the management of pregnancy- related back pain. Keywords: McKenzie protocol, usual care, pregnancy- related back pain.

Is coracoclavicular stabilisation alone sufficient for the endoscopic treatment of severe acromioclavicular joint dislocation (Rockwood types III, IV, and V)?

BackgroundThe primary objective was to evaluate correlations linking anatomical to functional outcomes after endoscopically assisted repair of acute acromioclavicular joint dislocation (ACJD). HypothesisCombined acromioclavicular and coracoclavicular stabilisation improves radiological outcomes compared to coracoclavicular stabilisation alone. Material and methodsA prospective multicentre study was performed. Clinical outcome measures were pain intensity on a visual analogue scale (VAS), subjective functional impairment (QuickDASH score), and Constant's score. Anatomical outcomes were assessed on standard radiographs (anteroposterior view of the acromioclavicular girdle and bilateral axillary views) obtained preoperatively and postoperatively and on postoperative dynamic radiographs taken as described by Tauber et al. ResultsOf 116 patients with acute ACJD included in the study, 48% had type III, 30% type IV, and 22% type V ACJD according to the Rockwood classification. Coracoclavicular stabilisation was achieved using a double endobutton in 93% of patients, and concomitant acromioclavicular stabilisation was performed in 50% of patients. The objective functional outcome was good, with an unweighted Constant's score≥85/100 and a subjective QuickDASH functional disability score≤10 in 75% of patients. The radiographic analysis showed significant improvements from the preoperative to the 1-year postoperative values in the vertical plane (decrease in the coracoclavicular ratio from 214 to 128%, p=10−6) and in the horizontal plane (decrease in posterior displacement from 4 to 0mm, p=5×10−5). The anatomical outcome correlated significantly with the functional outcome (absolute R value=0.19 and p=0.045). We found no statistically significant differences across the various types of constructs used. Intra-operative control of the acromioclavicular joint did not improve the result. Implantation of a biological graft significantly improved both the anatomical outcome in the vertical plane (p=0.04) and acromioclavicular stabilisation in the horizontal plane (p=0.02). The coracoclavicular ratio on the anteroposterior radiograph was adversely affected by a longer time from injury to surgery (p=0.02) and by a higher body mass index (BMI) (p=0.006). High BMI also had a negative effect on the difference in the distance separating the anterior edge of the acromion from the anterior edge of the clavicle between the injured and uninjured sides, as assessed on the axillary views (p=0.009). ConclusionThis study demonstrates that acute ACJD requires stabilisation in both planes, i.e., at the coracoclavicular junction and at the acromioclavicular joint. Coracoclavicular stabilisation alone is not sufficient, regardless of the type of implant used. Implantation of a biological graft should be considered when the time from injury to surgery is longer than 10days. The weight of the upper limb should be taken into account, with 6weeks of immobilisation to unload the construct in patients who have high BMI values. Level of evidenceII, prospective non-randomised comparative study.

Genotype-phenotype correlation and course of transthyretin familial amyloid polyneuropathies in France.

ObjectiveTo compare the natural history of familial transthyretin amyloid polyneuropathies (FAP) due to the Val30Met, Ser77Tyr, and Ile107Val mutations in France with the classical Portuguese Val30Met FAP.MethodsWe compared 84 French patients with a control group of 110 Portuguese patients carrying the Val30Met mutation also living in France, all referred to and followed at the French National FAP Reference Center from 1988 to 2010. Clinical examination, functional and walking disability scores, nerve conduction studies, and muscle biopsies are reported. We also conducted a comprehensive literature review to further determine the range of phenotypic expression.ResultsBy comparison with Portuguese Val30Met FAP, French Ile107Val, Ser77Tyr, and LateVal30Met FAP showed more rapid and severe disease progression; onset of gait disorders was 3 times more rapid (p < 0.0001) and the rate of modified Norris test decline was up to 40 times faster in Ile107Val patients (p < 0.0001). Median survival was much shorter in Ile107Val and in Val30Met mutation with late onset (>50 years; LateMet30) FAP (p = 0.0005). Other distinctive features relative to the Portuguese patients included atypical clinical presentations, demyelination on nerve conduction studies (p = 0.0005), and difficult identification of amyloid deposits in nerve and muscle biopsies.InterpretationIle107Val and LateMet30 mutations are associated with the most debilitating and severe FAP ever described, with rapid onset of tetraparesis and shorter median survival. It could be explained by frequent large‐fiber involvement and associated demyelination and more severe axonal loss. These findings have major implications for genetic counseling and patient management as new therapeutic options are being assessed in clinical trials (TTR gene silencing). Ann Neurol 2015;78:901–916

Efficacy and Safety of Topiramate for Essential Tremor: A Meta-Analysis of Randomized Controlled Trials.

Essential tremor (ET) is the most common movement disorder that is frequently treated by propranolol or primidone. However, 30% of patients with ET do not respond to either propranolol or primidone. The objective of this study was to assess the efficacy and safety of topiramate for ET.We searched the MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for relevant randomized controlled trials on the effects of topiramate for ET. A meta-analysis technique was applied to estimate the efficacy and safety of topiramate. The primary outcome was the change in the Fahn–Tolosa–Marin tremor rating scale (TRS). The secondary outcomes included the respective change in the location, motor tasks/function and function disability scores, and adverse events.We included 3 randomized controlled trials with a total of 294 participants. Topiramate was significantly better than placebo in reducing TRS of patients with ET (mean difference [MD] −8.58, 95% confidence interval [CI] −15.46 to −1.70). Changes from the scales of upper limb tremor severity (MD −5.12, 95% CI −7.79 to −2.45), motor tasks/function (MD −5.07, 95% CI −7.12 to −3.03), and functional disability (MD −4.72, 95% CI −6.77 to −2.67) were significantly greater with topiramate than with placebo. More participants taking topiramate experienced adverse events leading to withdrawal than those taking placebo (risk difference 19%, 95% CI 11%–27%).There is consistent evidence supporting the efficacy of topiramate in treating ET; however, a significant proportion of participants withdrew due to its adverse effects.

Validity and Reliability of an Objective Measurement of Functional Impairment in Lumbar Degenerative Spine Disease: The Timed-Up-and-Go (TUG) Test

Background: The indication for surgical treatment of lumbar degenerative spine disease is generally based on patient-related factors such as pain, functional disability, and reduced health-related quality of life (hrQoL) in view of corresponding radiological imaging findings. In addition to subjective scores, objective measures of functional disability may be helpful in the process of clinical decision making. Methods: In a prospective two-center study, functional disability was determined in 253 patients scheduled for lumbar spine surgery and a representative cohort of n = 111 healthy subjects as the control group by a simple objective test, the timed-up-and-go (TUG) test. The TUG test outcome parameter (time in seconds) was correlated to validated subjective measures of pain (visual analogue scale [VAS]), functional disability scores (Oswestry, Roland–Morris, etc.), and hrQoL (Short Form-12, Euro Quol, etc.). Results: The TUG test showed excellent intrarater (intraclass correlation coefficient [ICC] 0.97) and interrater reliability (ICC 0.99) with a standard error of measurement of 0.21 and 0.23 seconds, respectively. The validity of the TUG test is demonstrated by appropriate relationships with the VAS back (Pearson correlation coefficient [PCC] 0.25) and VAS leg pain (PCC 0.29), functional impairment (Roland–Morris Disability Index [PCC 0.38] and Oswestry Disability Index [PCC 0.34]) as well as with health-related quality of life (SF-12 MCS [PCC −0.25]; SF-12 PCS [PCC −0.32]; and Euro-Qol [PCC-0.28]). The upper limit of normal was determined to be 11.52 seconds. Mild (<33th percentile), moderate (33th to 66th percentile), and severe disability (>66th percentile) as determined by the TUG test were determined as <13.4 seconds, 13.4–18.4 seconds, and >18.4 seconds, respectively. Conclusions: The TUG test is a quick, easy-to-use, valid, and reliable tool to objectively evaluate the functional impairment in patients with degenerative spine disease. Patients in the clinical setting with a TUG test time greater than 12 seconds can be considered to have functional impairment.

Gender Differences in Subjective and Objective Measures for Patients with Lumbar Degenerative Disc Disease

Background: It has been observed that gender differences exist for the perception of pain. However, the genetic, biochemical, and developmental reasons behind this phenomenon remain unclear. This work aims to elucidate gender differences in subjective and objective measures of pain, functional disability, and health-related quality of life (hrQoL) in patients with lumbar degenerative disc disease (DDD). Methods: In a prospective two-center study, back and leg pain (using the visual analogue scale [VAS]), functional disability scores (Oswestry Disability Index [ODI] and Roland–Morris Disability Index [RMDI]), and hrQoL evaluation (using the EuroQol 5D (Eq. 5D) and Short-Form (SF-12)) were recorded for 253 consecutive patients scheduled for lumbar spine surgery (study group). In addition, objective functional disability was measured using the timed-up-and-go (TUG) test. The same examinations were applied to a healthy cohort of n = 110 subjects (control group). Results: One-hundred thirty-seven patients (46 females) had a microdiscectomy, 80 (42 females) a decompression, and 36 (19 females) a fusion procedure. Female patients were slightly older than male patients (61.0 vs. 56.6 years, p = 0.0306). All other baseline demographic data (body mass index [BMI], smoking status, ASA score, and Charlson comorbidity index [CCI]) were similar in both female and male patients (p > 0.0931). The mean TUG test time was 12.9 seconds in female and 10.1 seconds in male patients (p = 0.0004). Mean VAS back and leg pain was 4.5 and 5.3 in female patients compared with 3.5 and 4.5 in male patients (p = 0.0021 and 0.0246). The ODI was higher in female patients (51.2 vs. 46.3, p = 0.0042) and, correspondingly, the SF-12 PCS lower in female patients (28.8 vs. 31.3, p = 0.0060). All other subjective preoperative measures (RMDI, Eq. 5D, VAS and Eq. 5D Index, and SF-12 MCS) did not differ between female and male patients. In the healthy control group, female subjects took a mean of 1.1 seconds longer than males (6.5 vs. 5.4 seconds, p < 0.0001). There was no difference in the subjective measures between female and male controls subjects. Conclusions: We found significant gender differences in subjective and objective measures of pain intensity, functional disability, and hrQoL in patients with lumbar DDD. Female patients reported higher pain, higher disability, and more reduced hrQoL as compared with male patients. Correspondingly, the TUG test was significantly longer in female patients/controls.

Posterior cervical laminoplasty in the North American Population: A minimum of two year follow-up

BackgroundThe efficacy of expansile cervical laminoplasty for cervical spondylotic myelopathy has been validated in the literature. To date, however, the majority of large, long-term data in the literature have originated in Japan. Few studies have originated from North America that include follow up greater than one year, and none of these includes a single surgeon's experience. This paper presents the retrospective results of a single surgeon with an average follow up of 47 months in a large population of North American patients. MethodsA single surgeon's series of 80 consecutive patients who underwent expansile open-door laminoplasty for cervical myelopathy was reviewed. The severity of disability was graded using the Nurick Functional Disability Score and the Miami Upper Extremity Function (MUEF) score. Patients were evaluated preoperatively, six months postoperatively, and at a minimum of 24 months postoperatively. All examinations were performed by a single physician. MRI scans of the cervical spine were obtained at four months postoperatively in all patients. Radiographs were used to evaluate postoperative lordosis. ResultsAverage length of follow up was 47 months. Nurick scores improved from an average of 2.3 preoperatively to postoperative scores of 1.5 (p>.05) at six months and 1.4 (p>.05) at two years. MUEF scores also improved at both the six month and two year intervals. All patients had improved canal diameter on post-operative MRI scan evaluation obtained four months post-operatively. ConclusionThis study confirms that laminoplasty is a safe and effective treatment of cervical spondylotic myelopathy in the North American population. Level of evidenceCase Series Level IV.