Greater Short-term Improvement Research Articles

General vs Local Anesthesia for Percutaneous Endoscopic Lumbar Discectomy (PELD): A Systematic Review and Meta-Analysis.

Systematic review. It remains unknown whether general anesthesia (GA) or local ± epidural anesthesia (LA) results in superior outcomes with percutaneous endoscopic lumbar discectomy (PELD). The present study sought to examine the impact of anesthesia type on patient-reported outcomes (PROs) and complications with PELD. Systematic review and meta-analysis examining PELD performed under GA or LA was conducted. Patient-reported outcomes including Visual Analog Scale (VAS)-leg/back, and Oswestry Disability Index (ODI) scores were collected. Complication, recurrent disc herniation, durotomy, and reoperation rates as well as surgical data were recorded. All outcomes were compared between pooled studies examining GA or LA. Sixty-eight studies consisting of 5269 patients (724GA, 4465 LA) were included in the meta-analysis. Overall complication rate was significantly higher in the GA group (9% vs 4%, P = .003). Durotomy rates, length of stay, recurrent disc herniation and reoperation rates were similar between groups. At the first follow-up timepoint, the LA group demonstrated significant improvements in VAS back and ODI scores (P < .05) while the GA group did not (P > .05). At the final follow-up (> 6months), the percent of patients achieving an excellent McNab score was significantly higher in the GA vs LA group (P < .001). Percutaneous endoscopic lumbar discectomy with LA may be associated with greater short-term improvement in VAS back pain and ODI scores. General anesthesia may be associated with more durable pain relief but a higher complication rate. Further systematic investigation is necessary to determine what short and long term benefits are associated with PELD performed under LA and GA.

Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial.

Non-invasive ventilation represents an established treatment for acute cardiogenic pulmonary oedema (ACPO) although no data regarding the best ventilatory strategy are available. We aimed to compare the effectiveness of helmet CPAP (hCPAP) and high flow nasal cannula (HFNC) in the early treatment of ACPO. Single-centre randomized controlled trial of patients admitted to the emergency department due to ACPO with hypoxemia and dyspnoea on face mask oxygen therapy. Patients were randomly assigned with a 1:1 ratio to receive hCPAP or HFNC and FiO2 set to achieve an arterial oxygen saturation >94%. The primary outcome was a reduction in respiratory rate; secondary outcomes included changes in heart rate, PaO2/FiO2 ratio, Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate (HACOR) score, Dyspnoea Scale, and intubation rate. Data were collected before hCPAP/HFNC placement and after 1 h of treatment. Amongst 188 patients randomized, hCPAP was more effective than HFNC in reducing respiratory rate [-12 (95% CI; 11-13) vs. -9 (95% CI; 8-10), P < 0.001] and was associated with greater heart rate reduction [-20 (95% CI; 17-23) vs. -15 (95% CI; 12-18), P = 0.042], P/F ratio improvement [+149 (95% CI; 135-163) vs. +120 (95% CI; 107-132), P = 0.003] as well as in HACOR scores [6 (0-12) vs. 4 (2-9), P < 0.001] and Dyspnoea Scale [4 (1-7) vs. 3.5 (1-6), P = 0.003]. No differences in intubation rate were noted (P = 0.321). Amongst patients with ACPO, hCPAP resulted in a greater short-term improvement in respiratory and hemodynamic parameters as compared with HFNC. Clinical trial submission: NMRR-17-1839-36966 (IIR). Registry name: Medical Research and Ethics Committee of Malaysia Ministry of Health. Clinicaltrials.gov identifier: NCT04005092. URL registry: https://clinicaltrials.gov/ct2/show/NCT04005092.

Home-Based vs Supervised Inpatient and/or Outpatient Rehabilitation Following Knee Meniscectomy

Arthroscopic meniscectomy is one of the most common orthopedic procedures. The optimal postoperative approach remains debated. To compare outcomes associated with home-based rehabilitation programs (HBP) vs standard inpatient and/or outpatient supervised physical therapy (IOP) following arthroscopic isolated meniscectomy (AM). A systematic literature search was conducted on PubMed, Web of Science, Cochrane Library, and Scopus databases on March 15, 2021. The included studies were published from 1982 to 2019. Randomized clinical trials of patients treated with HBP vs IOP after AM were included. Data were independently screened and extracted by 2 authors according to the Preferred Reporting Items for Systematic Reviews (PRISMA) reporting guideline. The meta-analysis was performed using a random-effect model; when an I2 < 25% was observed, the fixed-effect model was used. The Hartung-Knapp correction was applied. The primary outcome was the Lysholm score (scale of 0-100 with higher scores indicating better knee function) and secondary outcomes were subjective International Knee Documentation Committee (IKDC) score, knee extension and flexion, thigh girth, horizontal and vertical hop test, and days to return to work, as indicated in the PROSPERO registration. Outcomes were measured in the short-term (ranging from 28 to 50 days) and the midterm (6 months). In this meta-analysis of 8 RCTs including 434 patients, IOP was associated with a greater short-term improvement in Lysholm score compared with HBP, with a mean difference of -8.64 points (95% CI, -15.14 to -2.13 points; P = .02) between the 2 approached, but the sensitivity analysis showed no difference. Similarly, no statistically significant difference was detected at midterm for Lysholm score, with a mean difference between groups of -4.78 points (95% CI, -9.98 to 0.42 points; P = .07). HBP was associated with a greater short-term improvement in thigh girth, with a mean difference between groups of 1.38 cm (95% CI, 0.27 to 2.48 cm; P = .01), whereas IOP was associated with a better short-term vertical hop score, with a mean difference between groups of -3.25 cm (95% CI, -6.20 to -0.29 cm; P = .03). No differences were found for all the other secondary outcomes. No intervention was found to be superior in terms of physical and functional outcomes as well as work-related and patient-reported outcomes, both at short-term and midterm follow-up. Overall, these results suggest that HBP may be an effective management approach after AM in the general population.

Short-term impact of combining pain neuroscience education with exercise for chronic musculoskeletal pain: a systematic review and meta-analysis.

Exercise and pain neuroscience education (PNE) have both been used as standalone treatments for chronic musculoskeletal pain. The evidence supporting PNE as an adjunct to exercise therapy is growing but remains unclear. The aim of this systematic review and meta-analysis was to evaluate the effect of combining PNE and exercise for patients with chronic musculoskeletal pain, when compared with exercise alone. A systematic search of electronic databases was conducted from inception to November 6, 2020. A quality effects model was used to meta-analyze outcomes where possible. Five high-quality randomized controlled studies (n = 460) were included in this review. The PEDro scale was used to assess the quality of individual studies, and Grading of Recommendations, Assessment, Development, and Evaluation analysis was conducted to determine the quality of evidence for each outcome. Meta-analyses were performed for pain intensity, disability, kinesiophobia, and pain catastrophizing using data reported between 0 and 12 weeks postintervention. Long-term outcomes (>12 weeks) were only available for 2 studies and therefore were not suitable for meta-analysis. Meta-analysis revealed a significant difference in pain (weighted mean differences, -2.09/10; 95% confidence interval [CI], -3.38 to -0.80; low certainty), disability (standardized mean difference, -0.68; 95% CI, -1.17 to -0.20; low certainty), kinesiophobia (standardized mean difference, -1.20; CI, -1.84 to -0.57; moderate certainty), and pain catastrophizing (weighted mean differences, -7.72; 95% CI, -12.26 to -3.18; very low certainty) that favoured the combination of PNE and exercise. These findings suggest that combining PNE and exercise in the management of chronic musculoskeletal pain results in greater short-term improvements in pain, disability, kinesiophobia, and pain catastrophizing relative to exercise alone.

Stranger in a strange land: genetic variation of native insect resistance biomarkers in UK Sitka spruce (Picea sitchensis [Bong.] Carr.)

Abstract Reforestation in the British Isles (UK and Ireland) has been dominated with the use of an exotic conifer tree species, Sitka spruce (Picea sitchensis [Bong.] Carr.). Sitka breeding in the UK was developed from a single provenance, the Haida Gwaii Islands (Canada), which is both well suited to the British climate and highly susceptible to the white pine weevil (Pissodes strobi L.) in its native range. We examined variation and heritability of insect resistance related traits and assessed potential trade-offs with tree growth in 50 full-sibling families and 13 clonally replicated genotypes growing in the UK. We measured bark levels of three terpenes (dehydroabietic acid, (+)-3-carene and terpinolene) shown to confer resistance to the white pine weevil in Sitka spruce’s native range, on the principle that these defence compounds may also contribute to pest resistance in the UK. We compared our results with published findings from the native range and also used individuals from a Haida Gwaii seed lot grown in the UK for comparison of terpene levels. Dehydroabietic acid content in the UK breeding population was similar to populations from resistant native populations, but (+)-3-carene and terpinolene levels were relatively low. Narrow sense heritability for dehydroabietic acid, (+)-3-carene and terpinolene was estimated as 0.20, 0.93 and 0.98, respectively from the full-sib data, and this evidence of genetic variance was supported by estimates of broad sense heritability from the smaller clonal study. Terpene content was found to be positively correlated to growth traits. The heritability estimates and genetic correlations indicate that selective breeding should be effective in raising levels in the UK breeding population of the three candidate terpenes implicated in weevil resistance. However, low levels observed indicate that other provenances from the native range may produce greater short-term improvements for two of the terpenes.

The Intermarriage Life Satisfaction Premium

Research on the consequences of intermarriage is almost exclusively looking at immigrants’ labour market outcomes, with little attention given to non-economic indicators. Drawing from set-point theory and taking on a dynamic approach, the authors examine whether having a different- versus a same-origin partner is subject to a selection on life satisfaction, or associated with a greater short-term improvement in migrants and natives’ subjective well-being (SWB). The paper also aims to investigate whether gains from exogamy diminish at a faster rate than those from endogamy, and whether intermarriage produces a long-term drop in SWB. Using data from the German Socio-Economic Panel and controlling for time-varying unobserved heterogeneity, we run a set of random- and fixed-effects models that uncover changes in life satisfaction before and after the transition into a mixed marriage. Results provide evidence of a selection on life satisfaction for exogamous first generation migrant men. Findings also show that with the exception of migrant men, there is an inter-partnering SWB gain, albeit insignificant, in the pre-marital cohabitation phase. Native women display an intermarriage premium when transitioning to marriage and shortly after, but also a significant SWB drop in later years. Overall, contrary to previous studies that did not account for unobserved characteristics, we show that in the long run, mixed marriages are not more detrimental to SWB than unions involving same-origin partners.

Short-Term Outcome Predictors in Patients With Primary Adhesive Capsulitis Treated With Ultrasound-Guided Hydrodilatation With Corticosteroids.

Glenohumeral joint hydrodilatation with corticosteroids has been proposed as an effective secondary therapeutic procedure for primary adhesive capsulitis. However, little is known about which subgroup of patients would benefit from this procedure. This study aimed to identify covariates associated with improved prognosis in patients receiving ultrasound-guided hydrodilatation with corticosteroid injection. This was a cohort study. Data on baseline demographic characteristics, disease status, past medical conditions, and initial ultrasonographic findings were collected. Linear and logistic regression analyses were performed to determine the prognostic factors associated with better clinical outcomes. Fifty-three patients (54 shoulders) were included. Linear regression analysis showed that coracohumeral ligament thickness of less than 3 mm, use of analgesics before hydrodilatation, and female sex were associated with good improvement in the Shoulder Pain and Disability Index score. Multivariate logistic regression analysis showed that coracohumeral ligament thickness of less than 3 mm on ultrasound was associated with a strong tendency (P = 0.054) of reaching the minimal detectable change. In addition, capsule rupture did not play a role in determining the clinical efficacy of hydrodilatation. In patients with primary adhesive capsulitis, coracohumeral ligament thickness of less than 3 mm is correlated with greater short-term improvement in the Shoulder Pain and Disability Index score after ultrasound-guided hydrodilatation with steroid injection is performed.

Implant- supported fixed prostheses give greatest OHRQoL improvement.

Data sources Medline, Cochrane Central, Cochrane Database of Systematic Reviews, National Health Service Economic Evaluation Database, Health Technology Assessment Database, Web of Science and the abstracts of conference proceedings for International Association for Dental Research meetings.Study selection Randomised controlled trials (RCTs), non-RCTs, and cohort studies measuring pre-treatment to post-treatment change in oral health-related quality of life (OHRQoL) score using validated measures were included.Data extraction and synthesis Two reviewers independently screened and selected studies, and extracted data. Risk of bias was assessed independently using the Cochrane tool for RCTs and the Newcastle Ottawa Scale for non-randomised studies. Random effects meta-analysis was used to compare change in OHRQoL scores.Results Twenty one cohort studies and two RCTs were included. Eight studies investigated implant-supported crowns (ISCs), ten studies reported on implant-supported fixed dental prostheses (IFDPs), nine on dental prostheses (TFDPs) and two implant-supported removable dental prostheses (IRDPs). Seventeen papers contributed to the meta-analysis. At nine months the pooled mean OHRQoL change was 15.3 for TFDP, 11.9 for RPD, and 14.9 for IFDP and the pooled standardised OHRQoL change >9 months was 13.2 for TFDP and 15.8 for IFDP. Direct comparisons nine months between TFDP against IFDP and RPD against IFDP significantly favoured IFDP in both cases.Conclusions TFDP and IFDP had short- and long-term positive effects on OHRQoL. RPDs positively affected OHRQoL in the short term. IFDP showed greater short-term improvement in OHRQoL than RPD and TFDP.

Effects of Liraglutide and Behavioral Weight Loss on Food Cravings, Eating Behaviors, and Eating Disorder Psychopathology.

This exploratory analysis examined the effects of intensive behavioral therapy (IBT) for obesity ("IBT-alone"), IBT plus liraglutide 3.0 mg/d ("IBT-liraglutide"), and IBT plus liraglutide 3.0 mg/d plus 12 weeks of a portion-controlled diet that provided 1,000 to 1,200 kcal/d ("Multicomponent") on changes in food cravings, eating behaviors, and eating disorder psychopathology at 24 and 52 weeks post randomization. Adults with obesity (mean age = 47.6 ± 11.8 years and BMI = 38.4 ± 4.9 kg/m2 ; 79.3% female; 54.0% non-Hispanic white; 44.7% black) were randomized to IBT-alone (n = 50), IBT-liraglutide (n = 50), or Multicomponent (n = 50). At weeks 24 and 52, liraglutide-treated groups reported significantly larger declines in weight concern relative to the IBT-alone group. At week 24, compared with IBT-alone, liraglutide-treated groups reported significantly greater reductions in dietary disinhibition, global eating disorder psychopathology, and shape concern. TheMulticomponent grouphad significantly greater reductions in binge eating at week 24 relative tothe IBT-alonegroup. However, differences among groups were no longer significant at week 52. Groups did not differ in total food cravings at week 24 or 52. The combination of liraglutide and IBT was associated with greater short-term improvements in dietary disinhibition, global eating disorder psychopathology, and shape concern than IBT alone.

Comparative Clinical Effectiveness of Nonsurgical Treatment Methods in Patients With Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) is the most common reason for spine surgery in older US adults. There is an evidence gap about nonsurgical LSS treatment options. To explore the comparative clinical effectiveness of 3 nonsurgical interventions for patients with LSS. Three-arm randomized clinical trial of 3 years' duration (November 2013 to June 2016). Analysis began in August 2016. All interventions were delivered during 6 weeks with follow-up at 2 months and 6 months at an outpatient research clinic. Patients older than 60 years with LSS were recruited from the general public. Eligibility required anatomical evidence of central canal and/or lateral recess stenosis (magnetic resonance imaging/computed tomography) and clinical symptoms associated with LSS (neurogenic claudication; less symptoms with flexion). Analysis was intention to treat. Medical care, group exercise, and manual therapy/individualized exercise. Medical care consisted of medications and/or epidural injections provided by a physiatrist. Group exercise classes were supervised by fitness instructors in senior community centers. Manual therapy/individualized exercise consisted of spinal mobilization, stretches, and strength training provided by chiropractors and physical therapists. Primary outcomes were between-group differences at 2 months in self-reported symptoms and physical function measured by the Swiss Spinal Stenosis questionnaire (score range, 12-55) and a measure of walking capacity using the self-paced walking test (meters walked for 0 to 30 minutes). A total of 259 participants (mean [SD] age, 72.4 [7.8] years; 137 women [52.9%]) were allocated to medical care (88 [34.0%]), group exercise (84 [32.4%]), or manual therapy/individualized exercise (87 [33.6%]). Adjusted between-group analyses at 2 months showed manual therapy/individualized exercise had greater improvement of symptoms and physical function compared with medical care (-2.0; 95% CI, -3.6 to -0.4) or group exercise (-2.4; 95% CI, -4.1 to -0.8). Manual therapy/individualized exercise had a greater proportion of responders (≥30% improvement) in symptoms and physical function (20%) and walking capacity (65.3%) at 2 months compared with medical care (7.6% and 48.7%, respectively) or group exercise (3.0% and 46.2%, respectively). At 6 months, there were no between-group differences in mean outcome scores or responder rates. A combination of manual therapy/individualized exercise provides greater short-term improvement in symptoms and physical function and walking capacity than medical care or group exercises, although all 3 interventions were associated with improvements in long-term walking capacity. ClinicalTrials.gov Identifier: NCT01943435.

Ultrasound-guided intrasphincteric botulinum toxin injection relieves obstructive defecation due to Hirschsprung's disease and internal anal sphincter achalasia

PurposeChronic obstructive defecation can occur in patients with Hirschsprung Disease (HD) and internal anal sphincter (IAS) achalasia. Injection of Botulinum Toxin (BoTox) into the IAS can temporarily relieve obstructive defecation, but can be challenging when performed by tactile sense alone. We compared results of BoTox injections with and without ultrasound (US) guidance. MethodsWe retrospectively reviewed BoTox injections into the IAS for obstructive defecation over 5years. Analyzed outcomes included short-term improvement, defined as resolution of enterocolitis, new ability to spontaneously defecate, and/or normalization of bowel movement frequency 2weeks post-operatively, as well as requirement of more definitive surgical therapy (myotomy/myomectomy, colectomy, colostomy, cecostomy/appendicostomy, and/or sacral nerve stimulator implantation). Outcomes were compared using t-test and Fisher's Exact test, with significance defined as p<0.05. ResultsTwelve patients who underwent BoTox injection were included, including 5 patients who underwent injections both with and without ultrasound. Ten underwent an ultrasound-guided injection (13 injection procedures), 5 of whom had HD. Seven underwent an injection without ultrasound guidance (17 injection procedures), 5 of whom had HD. Procedures performed with US resulted in greater short-term improvement (76% versus 65% without ultrasound) and less requirement of a definitive procedure for obstructive defecation (p<0.05). ConclusionsUS-guided BoTox injection is safe and effective for obstructive defecation, and may decrease the need for a definitive operation. Level of EvidenceIII.

The effectiveness of manual therapy for the management of musculoskeletal disorders of the upper and lower extremities: a systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration.

BackgroundMusculoskeletal disorders (MSDs) of the upper and lower extremities are common in the general population and place a significant burden on the health care system. Manual therapy is recommended by clinical practice guidelines for the management of these injuries; however, there is limited evidence to support its effectiveness. The purpose of our review was to investigate the effectiveness of manual therapy in adults or children with MSDs of the upper or lower extremity.MethodsRandomized controlled trials (RCTs), cohort studies, and case–control studies evaluating the effectiveness of manual therapy were eligible. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials from 1990 to 2015. Paired reviewers screened studies for relevance and critically appraised relevant studies using the Scottish Intercollegiate Guidelines Network criteria. Studies with low risk of bias were synthesized following best-evidence synthesis principles. Where available, we computed mean changes between groups, relative risks and 95 % CI.ResultsWe screened 6047 articles. Seven RCTs were critically appraised and three had low risk of bias. For adults with nonspecific shoulder pain of variable duration, cervicothoracic spinal manipulation and mobilization in addition to usual care may improve self-perceived recovery compared to usual care alone. For adults with subacromial impingement syndrome of variable duration, neck mobilization in addition to a multimodal shoulder program of care provides no added benefit. Finally, for adults with grade I-II ankle sprains of variable duration, lower extremity mobilization in addition to home exercise and advice provides greater short-term improvements in activities and function over home exercise and advice alone. No studies were included that evaluated the effectiveness of manual therapy in children or for the management of other extremity injuries in adults.ConclusionsThe current evidence on the effectiveness of manual therapy for MSDs of the upper and lower extremities is limited. The available evidence supports the use of manual therapy for non-specific shoulder pain and ankle sprains, but not for subacromial impingement syndrome in adults. Future research is needed to determine the effectiveness of manual therapy and guide clinical practice.Systematic review registration numberCRD42014009899

Paleolithic nutrition for metabolic syndrome: systematic review and meta-analysis

Paleolithic nutrition, which has attracted substantial public attention lately because of its putative health benefits, differs radically from dietary patterns currently recommended in guidelines, particularly in terms of its recommendation to exclude grains, dairy, and nutritional products of industry. We evaluated whether a Paleolithic nutritional pattern improves risk factors for chronic disease more than do other dietary interventions. We conducted a systematic review of randomized controlled trials (RCTs) that compared the Paleolithic nutritional pattern with any other dietary pattern in participants with one or more of the 5 components of metabolic syndrome. Two reviewers independently extracted study data and assessed risk of bias. Outcome data were extracted from the first measurement time point (≤6 mo). A random-effects model was used to estimate the average intervention effect. The quality of the evidence was rated with the use of the Grading of Recommendations Assessment, Development and Evaluation approach. Four RCTs that involved 159 participants were included. The 4 control diets were based on distinct national nutrition guidelines but were broadly similar. Paleolithic nutrition resulted in greater short-term improvements than did the control diets (random-effects model) for waist circumference (mean difference: -2.38 cm; 95% CI: -4.73, -0.04 cm), triglycerides (-0.40 mmol/L; 95% CI: -0.76, -0.04 mmol/L), systolic blood pressure (-3.64 mm Hg; 95% CI: -7.36, 0.08 mm Hg), diastolic blood pressure (-2.48 mm Hg; 95% CI: -4.98, 0.02 mm Hg), HDL cholesterol (0.12 mmol/L; 95% CI: -0.03, 0.28 mmol/L), and fasting blood sugar (-0.16 mmol/L; 95% CI: -0.44, 0.11 mmol/L). The quality of the evidence for each of the 5 metabolic components was moderate. The home-delivery (n = 1) and dietary recommendation (n = 3) RCTs showed similar effects with the exception of greater improvements in triglycerides relative to the control with the home delivery. None of the RCTs evaluated an improvement in quality of life. The Paleolithic diet resulted in greater short-term improvements in metabolic syndrome components than did guideline-based control diets. The available data warrant additional evaluations of the health benefits of Paleolithic nutrition. This systematic review was registered at PROSPERO (www.crd.york.ac.uk/PROSPERO) as CRD42014015119.

Mobile health, exercise and metabolic risk: a randomized controlled trial.

BackgroundIt was hypothesized that a mobile health (mHealth) intervention would elicit greater improvements in systolic blood pressure and other cardiometabolic risk factors at 12 weeks, which would be better maintained over 52 weeks, compared to the active control intervention.MethodsEligible participants (≥2 metabolic syndrome risk factors) were randomized to the mHealth intervention (n = 75) or the active control group (n = 74). Blood pressure and other cardiometabolic risk factors were measured at baseline and at 12, 24 and 52 weeks. Both groups received an individualized exercise prescription and the intervention group additionally received a technology kit for home monitoring of biometrics and physical activity.ResultsAnalyses were conducted on 67 participants in the intervention group (aged 56.7 ± 9.7 years; 71.6% female) and 60 participants in the active control group (aged 59.1 ± 8.4 years; 76.7% female). At 12 weeks, baseline adjusted mean change in systolic blood pressure (primary outcome) was greater in the active control group compared to the intervention group (-5.68 mmHg; 95% CI -10.86 to -0.50 mmHg; p = 0.03), but there were no differences between groups in mean change for secondary outcomes. Over 52-weeks, the difference in mean change for systolic blood pressure was no longer apparent between groups, but remained significant across the entire population (time: p < 0.001).ConclusionsIn participants with increased cardiometabolic risk, exercise prescription alone had greater short-term improvements in systolic blood pressure compared to the mHealth intervention, though over 52 weeks, improvements were equal between interventions.Trial registrationClinicalTrials.gov http://NCT01944124Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2458-14-1082) contains supplementary material, which is available to authorized users.

Relating Brain Damage to Brain Plasticity in Patients With Multiple Sclerosis

Background. Failure of adaptive plasticity with increasing pathology is suggested to contribute to progression of disability in multiple sclerosis (MS). However, functional impairments can be reduced with practice, suggesting that brain plasticity is preserved even in patients with substantial damage. Objective. Here, functional magnetic resonance imaging (fMRI) was used to probe systems-level mechanisms of brain plasticity associated with improvements in visuomotor performance in MS patients and related to measures of microstructural damage. Methods. 23 MS patients and 12 healthy controls underwent brain fMRI during the first practice session of a visuomotor task (short-term practice) and after 2 weeks of daily practice with the same task (longer-term practice). Participants also underwent a structural brain MRI scan. Results. Patients performed more poorly than controls at baseline. Nonetheless, with practice, patients showed performance improvements similar to controls and independent of the extent of MRI measures of brain pathology. Different relationships between performance improvements and activations were found between groups: greater short-term improvements were associated with lower activation in the sensorimotor, posterior cingulate, and parahippocampal cortices for patients, whereas greater long-term improvements correlated with smaller activation reductions in the visual cortex of controls. Conclusions. Brain plasticity for visuomotor practice is preserved in MS patients despite a high burden of cerebral pathology. Cognitive systems different from those acting in controls contribute to this plasticity in patients. These findings challenge the notion that increasing pathology is accompanied by an outright failure of adaptive plasticity, supporting a neuroscientific rationale for recovery-oriented strategies even in chronically disabled patients.

Comparison of Short-term SF-36 Results Between Total Joint Arthroplasty and Cervical Spine Decompression and Fusion or Arthroplasty

Cohort comparison of results of meta-analysis. To compare improvement in SF-36 after cervical spine surgery to total hip and joint arthroplasty. Health-related quality of life outcome instruments allow comparison of different diseases and change with various treatments. Total hip and knee arthroplasty are accepted procedures with excellent outcomes. It is unknown if treatment of cervical spine disease approaches those results. A meta-analysis of SF-36 outcomes of total hip and knee arthroplasty was performed and compared to results after cervical discectomy and arthroplasty or fusion. Pooled means and SD were calculated and compared among treatment groups using analysis of variance. Eighteen studies reporting results in patients having total hip and knee arthroplasty and 2 randomized controlled studies of cervical disc arthroplasty were identified. The baseline physical function was worse in the joint arthroplasty patients and the mental health scores were worse in the cervical spine patients. The mean improvements in PCS for disc, fusion, total hip, and total knee arthroplasty were 14.2, 12.5, 12.2, and 9.6, respectively. The improvement in the physical component score (SF-36) was significantly greater in the cervical arthroplasty compared to the other 3 groups. Cervical fusion improvement was similar to total hip arthroplasty and both were greater than total knee arthroplasty. MCS domain improvement was significantly better in the cervical spine groups. The SF-36 results were surprising and showed equal or greater short-term improvement in cervical spine patient's pain and function than that observed after joint arthroplasty, although all groups had substantial improvement. Greater MCS improvement was likely caused by a ceiling effect as joint arthroplasty on average had normal scores at baseline.

Surgical Therapy for Chronic Obstructive Pulmonary Disease

Many patients with severe chronic obstructive pulmonary disease (COPD) experience incapacitating breathlessness and exercise limitation. Multiple surgical techniques have been utilized to achieve resection of giant, localized bullae with documented short-term benefit in pulmonary function and dyspnea in highly selected patients. The poorest long-term outcome has been noted in those with greater degrees of emphysema in the remaining lung, greater underlying chronic bronchitis, and a bulla occupying less than one third of the hemithorax, particularly if compressed normal lung is not evident. Lung volume reduction surgery (LVRS) in the absence of giant bullae has become more widely accepted in selected patients. Bilateral LVRS procedures appear to result in greater short-term improvement than unilateral LVRS, whereas physiological benefits appear similar with video-assisted thoracoscopy (VATS) or median sternotomy (MS) techniques. Improvement in dyspnea and health status after LVRS has been documented and appears to be better preserved over longer-term follow-up than physiological improvement. Clear direction has been provided in identifying optimal candidates for bilateral LVRS; patients with a postbronchodilator forced expiratory volume in 1 second (FEV (1)) < or = 20% predicted and a diffusing capacity for carbon monoxide (DL (CO)) < or = 20% predicted or homogeneous emphysema exhibit a much higher mortality with LVRS than with medical management. Patients with upper-lobe predominant emphysema and a low postrehabilitation exercise tolerance exhibited a decreased risk of mortality after LVRS. Patients with non-upper lobe predominant emphysema on high-resolution computed tomography (HRCT) and a high postrehabilitation exercise capacity exhibit an increased risk of death after LVRS. Patients with upper lobe predominant emphysema and a high postrehabilitation exercise capacity or patients with non-upper lobe predominant emphysema and a low postrehabilitation exercise capacity do not have a survival advantage or disadvantage, whereas those with upper lobe predominant emphysema treated surgically are more likely to improve their exercise capacity after surgery. Lung transplantation is an option for a more limited number of patients. Consistent short-term spirometric improvement after both single- and double-lung transplant has been documented. Long-term results of lung transplantation are limited by significant complications that impair survival; an approximately 80% 1-year, 50% 5-year, and 35% 10-year survival has been reported. Bronchiolitis obliterans is the most important long-term complication of lung transplantation resulting in decreased pulmonary function. In general, a COPD patient can be considered an appropriate candidate for transplantation when the FEV (1) is below 25% predicted and/or the paCO (2) is > or = 55 mm Hg.

Chronic Spinal Pain

Study Design. A randomized controlled clinical trial was conducted. Objective. To compare medication, needle acupuncture, and spinal manipulation for managing chronic (>13 weeks duration) spinal pain because the value of medicinal and popular forms of alternative care for chronic spinal pain syndromes is uncertain. Summary of Background Data. Between February 1999 and October 2001, 115 patients without contraindication for the three treatment regimens were enrolled at the public hospital’s multidisciplinary spinal pain unit. Methods. One of three separate intervention protocols was used: medication, needle acupuncture, or chiropractic spinal manipulation. Patients were assessed before treatment by a sports medical physician for exclusion criteria and by a research assistant using the Oswestry Back Pain Disability Index (Oswestry), the Neck Disability Index (NDI), the Short-Form-36 Health Survey questionnaire (SF-36), visual analog scales (VAS) of pain intensity and ranges of movement. These instruments were administered again at 2, 5, and 9 weeks after the beginning of treatment. Results. Randomization proved to be successful. The highest proportion of early (asymptomatic status) recovery was found for manipulation (27.3%), followed by acupuncture (9.4%) and medication (5%). Manipulation achieved the best overall results, with improvements of 50% (P = 0.01) on the Oswestry scale, 38% (P = 0.08) on the NDI, 47% (P < 0.001) on the SF-36, and 50% (P < 0.01) on the VAS for back pain, 38% (P < 0.001) for lumbar standing flexion, 20% (P < 0.001) for lumbar sitting flexion, 25% (P = 0.1) for cervical sitting flexion, and 18% (P = 0.02) for cervical sitting extension. However, on the VAS for neck pain, acupuncture showed a better result than manipulation (50%vs 42%). Conclusions. The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication. However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.

Short- and long-term functional results after lung volume reduction surgery for severe emphysema.

Lung volume reduction surgery (LVRS) has emerged as a surgical therapeutic intervention for advanced emphysema. Designed for the relief of dyspnoea, LVRS has been demonstrated to be efficacious in a subset of carefully selected patients. Short-term improvements in dyspnoea are accompanied by improvements in forced expiratory volume in one second ranging 13-96%. Lung volumes likewise improve, with lessening of trapped gas, residual volume, and total lung capacity. Improvements in functional status and quality-of-life measures parallel the improvements in dyspnoea and lung function. One preliminary study suggests that life expectancy after 3 yrs may be improved following LVRS. Many questions regarding lung volume reduction surgery in terms of operative technique, selection of patients, and outcome remain to be answered. Data are available which begin to address some of these issues. Bilateral procedures have greater short-term improvements than unilateral procedures, but the rate of loss of function following the surgery may also be greater. Stapled resection of lung tissue has been demonstrated to be superior to laser ablation. In a majority of reports, outcome is superior in patients with heterogeneous distribution of their emphysema, and patients with alpha1-proteinase inhibitor deficiency emphysema do less well than patients with smoker's emphysema.