Neuromusculoskeletal Injuries Research Articles

The point prevalence of South African male soccer players' injuries in the Gauteng province.

The ever-evolving game of soccer is a complex physical contact team sport, exposing its participants to injury. To identify the point prevalence of soccer injuries among young amateur, semi-professional, and professional South African male soccer players. The participation of male amateur (n=54), semiprofessional (n=34), and professional (n=57) players provided a cross-sectional overview of the nature of the most predominant types and anatomical sites of injuries affecting soccer players (average age 23.9±4.7 years). All participants completed the Fuller soccer injury questionnaire, ISAK somatotype profiling and knee flexion/extension isokinetic concentric peak torque (Nm) evaluations at 60°/s. Fifty per cent of the players sustained soccer injuries (X 2=0.9). Knee (20%) and ankle (19%) were the most vulnerable sites (X 2=0.00001). Knee-injured players' right quadriceps torque (199±37 vs 223±38 Nm) and percentage right quadriceps torque relative to body mass (286±54 vs 311 ±39%) was significantly weaker than the non-injured players (p<0.01). The injured players' right hamstrings/quadriceps (H/Q) torque ratio further significantly differed from the non-injured players' H/Q torque ratios (79±17 vs 70±9%) (p<0.01). Male soccer players experience neuromusculoskeletal injuries, with their knees and ankles being the most vulnerable. Knee-injured players had weaker quadriceps isokinetic strength than non-injured players.

Physiotherapists’ Use of Outcome Measure Tools in the Assessment of Neuro-Musculoskeletal Injuries for Short-Term Functional Rehabilitation Domains to Minimize Impairments and Disability following Commercial Motorcycle Road-Related Accident, Eldoret, Kenya

Bed immobilization remains a core intervention to stabilize neuro-musculoskeletal injuries following commercial motorcycle-related road traffic accidents. Despite timely operative and conservative management, most patients remain handicapped, requiring short- and long-term physical therapy. That calls for physiotherapists to assess and make use of outcome measure tools to determine the level of impairments and disability and make informed decisions when developing management goals. The objective of the study was to determine short-term functional rehabilitation domains, the use of outcome measure tools, and physiotherapy interventions used to minimize impairments and disability following a commercial motorcycle road-related accident in Eldoret, Kenya. Biopsychosocial theory guided the study. A prospective cohort study was adopted. Purposive sampling was used for the selection of 79 participants for 6 months between March 2021 and July 2021 in level 5 hospitals in Eldoret, Kenya. The target population included post-operative patients in both male and female orthopedics wards, physiotherapists, and social workers in the orthopedic department of Moi Teaching and Referral Hospital. The study population was 150 patients. A self-administered, structured questionnaire was used. The data collected was entered and analyzed with SPSS 20. The findings of this study revealed that forty-four percent (44%) of total participants were bedridden for fracture immobilization and spinal cord injuries for more than 3 days before and after orthopedic and neurological surgery. The majority (100%) of the participants had been referred for physiotherapy rehabilitation. All 100 participants were assessed with different outcome measure tools for neuro-musculoskeletal injuries to determine the level of physical function. Forty-three percent (43%) had lost functional abilities of the upper extremity (19 males, 15 females). Fifty-one-point nine percent (51.9%) had lost physical function due to lower extremity fractures (39% (26 males, 15 females) and 24% (15 males, 4 females) with spinal cord injuries. Four participants (5%) reported lost days to school, and 94.9% reported lost days to income-generating activities (27 females, 48 males). The majority (100%) of the participants pre- and post-operatively were assessed with standardized outcome measure tools that remain significant for prompt best evidence-based physiotherapy practices. Pain (100%) and impaired physical functions (100%) were the main rehabilitation domains that posed the biggest challenge to patients’ post-trauma. Multicomponent physiotherapy interventions ranging from stretching, strengthening, breathing exercises, bed positioning, mobility and transfers, balance and coordination, and gait training tailored to patients’ physical function levels, prevention of muscle atrophy and strength, and joint stiffness were core. This study recommended short-term physiotherapy rehabilitation on early bed mobilization and ambulation for patients, which remains core for the restoration of physical functional levels and a return formula to socioeconomic status.

Differential Acute Adipogenic Signaling Changes Following Neuromusculoskeletal Injuries

Following traumatic injury, neuromusculoskeletal tissue undergoes extensive plastic modification. Changes can be observed at the local and systemic levels and can involve tissue function, signaling, and local composition. Currently there is limited understanding of early adipogenic changes following some traumatic injuries, which is needed to understand the long-term lack of functional muscle recovery. The objective of this project was to examine plasticity after injury, namely systemic and local adipogenic signaling and fat droplet deposition following volumetric muscle loss (VML) and denervation injuries. We hypothesized there would be differential changes in local and systemic adipogenic signaling, specifically changes in fat droplet accumulation following neuromusculoskeletal injuries. Adult C57B1/6J mice (n=36; 6 male, 6 female/group): posterior compartment VML, tibial nerve denervation, and naïve control. Both injury models target plantarflexor muscles. Mice were euthanized 72-hrs post-injury. In vivo muscle function was assessed, and gastrocnemius, liver, and serum were saved for analysis. Whole gastrocnemius muscles from a subset (n=4/group) were saved for histology, and five standardized sections were systematically obtained 1.5mm apart; muscle sections were stained with H&amp;E and Oil-Red-O to evaluate total fiber number and fat droplet accumulation, respectively. Data were analyzed by two- and three-way ANOVA with Tukey’s HSD post hoc. Maximal torque declined ~81 and 98% following VML and denervation injury, respectively (main effect p&lt;0.001), and VML-injured muscle was more fatigable than injury naïve (main effect p=0.001). Following denervation, liver insulin-like growth factor 1 (IGF-1) was increased ~52% compared to other groups, and was most pronounced in males (main effect injury p&lt;0.001; sex p=0.021). VML injury resulted in a 4-fold higher muscle IGF-1 regardless of sex (interaction p=0.021), and greater muscle interleukin-6 (IL-6), which was more pronounced in females (main effect injury p=0.001; sex p=0.049). Platelet-derived factor growth receptor (PDFGRα) expression was diminished following VML injury in both sexes (interaction p=0.016); suggesting a decrease in fibro-adipogenic progenitors (FAPs) and an alternative origin responsible for increases in IGF-1 and IL-6 rather than FAPs. Serum leptin concentrations were blunted following both VML- and denervation-injury (main effect p=0.002), which may illicit alterations in the regenerative process, specifically the maintenance of muscle quality. Serum IGF-1 and IL-6 concentrations were not affected by injury (p≥0.164). Histological analysis revealed a significant decrease in total fiber number across the middle three sections of the VML-injured muscle (i.e., the section initially injured) compared to other groups (p≤0.034). Findings provide a foundation for characterizing adipocyte development in the muscle remaining after injury and identify therapeutic targets for rehabilitative and nutritional approaches to address contractile and metabolic impairments following injury. Future work should elucidate the time course of adipogenic signaling following these injuries, with particular interest in their relationship to changes in metabolic and contractile impairments. R01-AR078903 (JAC &amp; SMG); University of Minnesota UROP (BAC). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Factors Associated With Neuromusculoskeletal Injury and Disability in Navy and Marine Corps Personnel.

Neuromusculoskeletal injuries (NMSKI) are very common in the military, which contribute to short- and long-term disability. Population-level NMSKI, limited duty (LIMDU), and long-term disability episode counts in the U.S. Navy (USN) and U.S. Marine Corps (USMC) from December 2016 to August 2021 were extracted from the Musculoskeletal Naval Epidemiological Surveillance Tool. The incidence of NMSKI, LIMDU, and long-term disability was calculated. A hurdle negative binomial regression evaluated the association of body region, sex, age, rank, age by rank, and service branch on NMSKI, LIMDU, and long-term disability incidence. From December 2016 to August 2021, there were 2,004,196 NMSKI episodes (USN: 3,285/1,000 Sailors; USMC: 4,418/1,000 Marines), 16,791 LIMDU episodes (USN: 32/1,000 Sailors; USMC: 29/1,000 Marines), and 2,783 long-term disability episodes (USN: 5/1,000 Sailors; USMC: 5/1,000 Marines). There was a large-magnitude protective effect on NMSKI during the pandemic (relative risk, USN: 0.70; USMC: 0.75). Low back and ankle-foot were the most common, primarily affecting female personnel, aged 25-44 years, senior enlisted, in the USMC. Shoulder, arm, pelvis-hip, and knee conditions had the greatest rates of disability, with female sex, enlisted ranks, aged 18-24 years, and service in the USMC having the most salient risk factors. Body region, sex, age, rank, and branch were the salient factors for NMSKI. The significant protective effect during the pandemic was likely a function of reduced physical exposure and limited access to nonurgent care. Geographically accessible specialized care, aligned with communities with the greatest risk, is needed for timely NMSKI prevention, assessment, and treatment.

Are Factors of Posture and Balance Integrated in Research Studies on Upper Extremity Musculoskeletal Pain in Instrumental Musicians?: A Scoping Review.

It is widely believed that posture and balance stressors are factors in playing-related pain for musicians using hand-held musical instruments. This purpose of this scoping review was to assess the available literature relative to the effects of posture and balance in musicians with neuromusculoskeletal injuries. A search of Medline, Web of Science, and SportDiscus seeking articles combining posture and balance considerations with pain in performing artists was performed. From 1,403 articles initially identified by the search parameters, the further abstract/title review for relevance and inclusiveness of pain and posture/balance variables in performing artists resulted in the retention of 29 articles for this full-text scoping review. The full-text analysis assessed publication type, study design, participant population, methodology, statistical methods, main results, and whether the study evaluated the relationship between posture/balance and pain in musicians. Overall, most of the studies including musicians were observational or descriptive. Although, in recent years, there has been an increase in the number of interventional studies regarding posture, balance and pain in musicians, there is still minimal evidence about the contribution of posture and balance characteristics to pain in musician performers. To reliably establish a predictable relationship with injury symptomatology experienced by musicians, it is essential to integrate standardized, validated measurements of posture and balance in the evaluation of all musicians who report to a health professional with neuromusculoskeletal pain. This will not only allow researchers to determine the effect of postural righting dysfunction on neuromusculoskeletal injuries in musicians, but also may provide a foundation for clinicians to develop effective interventions.

Effects of percutaneous neuromodulation in neuromusculoskeletal pathologies: A systematic review.

Background:Percutaneous neuromodulation (PNM) consists in using electrical stimulation on a peripheral nerve by using a needle as an electrode in order to lessen the pain and restore both neuromuscular and nervous system functions. The aims of the present study were to evaluate the current scientific evidence of the effects of PNM on pain and physical capabilities in neuromusculoskeletal injuries.Methods:Data sources: There was used the PRISMA protocol. In order to do the literature research, there were used the PubMed, Cochrane, Scopus, and Web of Science databases. Study selection or eligibility criteria: There were also included experimental clinical trials published between 2010 and nowadays, tested on humans, which feature treatment based on needles with electrical stimulation in order to treat neuromusculoskeletal injuries. Study appraisal and synthesis methods: A quality assessment was performed according to the PEDro scale and reviewed the impact factor and quartile of the journalResults:The treatment resulted in significant improvement in terms of pain intensity, pressure pain threshold, balance, muscular endurance, functionality/disability, subjective improvement, function of the descending pain modulatory system, and intake of drugs. Limitations: the lack of previous research studies on the subject and the lack of data on opioid intake in the selected studies.Conclusion:Treatment based on PNM may be an alternative when treating injuries in soft tissues without significant side effects. However, there are few articles investigating the effects of PNM so more evidence is needed to draw solid conclusions.

Surgical outcomes of supine PCNL in spinal deformity patients: A tertiary care hospital experience.

Percutaneous nephrolithotomy (PCNL) is treatment of choice now a days in patients with spinal deformity with large kidney stones. Objectives of our present study to compare in which position it is better to perform and costs minimum complications after surgery. A total of 14 patients with spinal deformity having nephrolithiasis were selected randomly. No preferences for age, gender, size, location, and laterality of stone or BMI. All the patients were fit according to AUA guideline criteria for management by PCNL. Preoperative and postoperative data were collected in all operated patients. Descriptive statistics were performed as means, standard deviations, and ranges using Microsoft excel. For categorical variables percentage were used. A total of 14 patients with spinal deformity having nephrolithiasis underwent PCNL. Seven patients operated in prone position and seven patients operated in modified supine position within approximately 2 years. As compared to prone position in supine position there were reduced operative time, little or no change in Hb concentration, shorter hospital stay, little intraoperative blood loss, and higher significant stone free rate were detected. Supine PCNL in spinal deformity patients with nephrolithiasis is an alternative to the standard prone PCNL. It provides an additional benefit of large operative field performing the procedure in a single position, reduces total operating time, less anesthesia related complications, less neuromusculoskeletal injury, and reduce physical strain on operating surgeon.

Muscle Engagement Monitoring Using Self-Adhesive Elastic Nanocomposite Fabrics.

Insight into, and measurements of, muscle contraction during movement may help improve the assessment of muscle function, quantification of athletic performance, and understanding of muscle behavior, prior to and during rehabilitation following neuromusculoskeletal injury. A self-adhesive, elastic fabric, nanocomposite, skin-strain sensor was developed and validated for human movement monitoring. We hypothesized that skin-strain measurements from these wearables would reveal different degrees of muscle engagement during functional movements. To test this hypothesis, the strain sensing properties of the elastic fabric sensors, especially their linearity, stability, repeatability, and sensitivity, were first verified using load frame tests. Human subject tests conducted in parallel with optical motion capture confirmed that they can reliably measure tensile and compressive skin-strains across the calf and tibialis anterior. Then, a pilot study was conducted to assess the correlation of skin-strain measurements with surface electromyography (sEMG) signals. Subjects did biceps curls with different weights, and the responses of the elastic fabric sensors worn over the biceps brachii and flexor carpi radialis (i.e., forearm) were well-correlated with sEMG muscle engagement measures. These nanocomposite fabric sensors were validated for monitoring muscle engagement during functional activities and did not suffer from the motion artifacts typically observed when using sEMGs in free-living community settings.

Cheerleader Positional Differences In Balance Performance While Wearing New And Old Cheer Shoes

PURPOSE: Throughout a cheerleading season flyers and bases experience position-specific balance demands while stunting that could be affected by the breakdown of footwear as the season continues. Balance performance has not been well investigated between a “new” and “old” cheer shoe when comparing between the position of flyer and base. The purpose of the study was to examine the difference in balance performance of “old” and “new” cheer shoes between flyers and bases. METHODS: Twenty-five healthy male and female collegiate cheerleaders, nine flyers and sixteen bases free of neuromusculoskeletal injuries participated in the study. Shoe age was defined as “new” if brand new from the box, and “old” if worn for more than 64 hours of training. Balance conditions were randomized for each participant and included three stances: bilateral stance, unilateral stance on the dominant limb, and unilateral stance on nondominant limb. All stances were performed on the force plate and foam pad. The average sway velocity (VEL) of the center of pressure was used to quantify balance in the anterior-posterior (AP) and medial-lateral (ML) directions. Separate two-way ANOVAs were used to explore main effects for shoe and position, and interactions between shoe and position for each condition. RESULTS: No main effects for shoe or interactions of shoe and position were observed, P>.05. The ML_VEL and AP_VEL of the bases were significantly lower for the bilateral stance, dominant limb, and non-dominant limb stance on the firm force plate (P<.001), and bilateral stance and dominant limb stance on the foam pad (P<.001). No difference between position was observed for nondominant stance on foam pad (ML_VEL: p=.721; AP_VEL: p=.757). CONCLUSIONS: The results suggest that balance performance was not affected by the wear of the cheer shoe but was different between stunt position. Bases exhibited greater balance performance compared to flyers in both a bilateral stance and unilateral stance. It may be beneficial for future research to explore additional measures of balance when performing more dynamic tasks to target the demands of each position.

Personalized digital humans for rehabilitation and assistive devices

Introduction: Ultrasound is routinely used by rehabilitation specialists to establish differential diagnosis of the residuum’s neuromusculoskeletal issues experienced by former and active Service Members suffering from limb loss1. Ultrasound offers real-time, non-ionizing, unspecialised facility assessment. Conventional imaging modalities record a qualitative static image. More fundamental signal/data display modalities such as the raw radio-frequency signal and A-mode are rarely utilised, although offer specialised opportunities, particularly for quantitative tissue characterisation, when the subject is mobile, and when several anatomical locations need to be synchronously assessed. Our aim is to develop a wearable ultrasound biosensor system that provides real-time assessment of various anatomical compartment dimensions within a post-amputation residual lower limb of former and active Service Members, termed Dynamic Anatomical Ultrasonography (DAU). Methods and results: The Olympus Omniscan MX is a highly-portable and rugged ultrasound instrument aimed primarily at the industrial sector. It incorporates the facility to connect up to eight individual single-element ultrasound transducers. A custom pseudo prosthetic socket was created for an asymptomatic subject, to which were attached two 1 MHz, 19 mm diameter ultrasound transducers, as shown in Fig. 1A. Ultrasound signal data was recorded for a defined measurement period of 10 seconds as the subject repeatedly lifted and lowered their thigh. Utilising the semi-automated time-gate signal detection facility, the depth of the femur bone surface was recorded, shown in Fig. 1B. Discussion/future directions: We have demonstrated the ability to monitor motions of the femur; of particular note is that measurements were obtained through the socket and silicone liner in addition to the overlying soft tissues. It is hypothesised that knowledge of the dynamic behaviour of the various tissue compartments will improve our understanding of the biomechanics associated with the residual limb of individuals suffering from limb loss and, furthermore, facilitate the fitting and development of bionics prostheses for former and active Service Members2. Our long-term aim is to investigate whether a combination of ultrasound and mechanical load biomarker data, fed into a ‘Digital Twin’ computational simulation will improve socket design, restore mobility, facilitate return to active duty, and, ultimately, enhance users’ quality of life. Acknowledgements: This work was supported by the FY19 Defense Medical Research and Development Program through the Joint Program Committee 8 / Clinical and Rehabilitative Medicine Research Program Restoring Warfighters with Neuromusculoskeletal Injuries Research Award (RESTORE) under Award No. W81XWH2110215-DM190659. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the FY19 Defense Medical Research and Development Program. References 1Frossard LA, Powrie R, Langton CM. In-vivo kinestic system to sustain residuum health of service members with lower limb loss: from proof-of-concept to digital twin. Military Health System Research Symposium. Abstract #MHSRS-19-00882. Kissimmee, FL, US 2019:111 2Frossard LA, Lloyd DG. The future of bionic limbs. Res Feat 2021; 134:74-77. https://doi.org/10.26904/RF-134-7477

Other physical and functional markers of bone stress injury

Introduction: Rehabilitation specialists need to improve differential diagnosis of the neuromusculoskeletal health issues of the residuum experienced by former and active Service Members suffering from limb loss1. The development of a portable and non-invasive diagnostic device seeks to help maintain residuum health and support bionic solutions. Here, we outline the latest developments of an In-vivo Kinetic system 2.0 (Fig. 1), a diagnostic device that combines:•Measurements of the mechanical loading applied to the site of amputation using portable wireless sensors2,•Measurement of the tissue distribution within the residuum made by the newly developed Dynamic Anatomical Ultrasonography,•Neuromusculoskeletal modelling or “digital twinning” of the residuum for a real-time personalized animation of the residuum during static and dynamic loading conditions3. Technology readiness levels (TRL) were estimated at 7, 2, and 4 for the loading, ultrasound, and modelling parts, respectively. Thus, demonstrating feasibility to develop an integrated, wearable and non-invasive In-vivo Kinetic system 2.0 capable of performing patient-specific differential diagnosis of residuum health under real world conditions4. However, barriers inherent to biosensors (e.g., ultrasound measurements, synchronisation), the creation of a digital twin (e.g., tissues mechanical property) and integration (e.g., discrepancies of TRLs) continue to be challenging. The clinical roll-out of the device will require overcoming these issues and consideration of discrepancies between the skills of practitioners and siloed health care organizations. Discussion/future directions: This system will provide unparalleled holistic insight into residuum health and productively disrupt the current model of health care. Hopefully, this diagnostic device will facilitate restoration of mobility, return to active duty, and, ultimately, improve life of the growing population suffering from limb loss considering bionic solutions. Acknowledgements: This work was supported by the FY19 Defense Medical Research and Development Program through the Joint Program Committee 8 / Clinical and Rehabilitative Medicine Research Program Restoring Warfighters with Neuromusculoskeletal Injuries Research Award (RESTORE) under Award No. W81XWH2110215-DM190659. Opinions, interpretations, conclusions, and recommendations are those of the author and are not necessarily endorsed by the FY19 Defense Medical Research and Development Program. References 1Frossard LA, Lloyd DG. The future of bionic limbs. Res Feat 2021; 134:54-57. https://doi.org/10.26904/RF-134-7477 2Pather S, Vertriest S, Sondergeld P, et al. Load characteristics following transfemoral amputation in individuals fitted with bone-anchored prostheses: a scoping review protocol. JBI Data Sys Rev Imp Rep 2018; 16(6):1286-1310. https://doi.org/10.11124/JBISRIR-2017-003398 3Sartori M, Lloyd DG, Farina D. Neural data-driven musculoskeletal modelling for personalized neurorehabilitation technologies. IEEE Trans Biomed Eng 2016; 63(5):879-893. https://doi.org/10.1109/TBME.2016.2563138 4Frossard LA, Powrie R, Langton CM. In-vivo kinestic system to sustain residuum health of service members with lower limb loss: from proof-of-concept to digital twin. Military Health System Research Symposium. Abstract #MHSRS-19-00882. Kissimmee, FL, US 2019:111

Development of dynamic anatomical ultrasonography to advance personalised prosthetics

Introduction: Military personnel can suffer limb loss and subsequently use bionic limbs affixed to their residuum. The residuum’s different musculoskeletal tissues undergo continual adaptation due to stress-strains experienced during daily activities, affecting residuum health. These stress-strains depend on the interface between the prosthesis and residuum, it is therefore critical to assess the residuum’s internal stress-strains during daily activities to optimise prothesis design and use. A framework is presented to create a Digital Twin of an amputee’s residuum that operates in real-time and validated using a phantom of the residuum1. Methods and results: The current workflow used for real-time Achilles’ tendon (AT) strain is being translated for use with the residuum2 (Fig. 1). Dynamic Anatomical Ultrasonography3 is used to measure the unloaded and loaded 3D shape of the AT or residuum (Fig. 1A) to generate unloaded and loaded solid meshes (Fig. 1B). Since the external loading state of AT or residuum is known, material properties can be inversely determined, and internal stress-strain distribution ascertained using finite element models (FEM) (Fig. 1 C). Next a range of loads are applied to the AT or residuum FEM that generate a matrix of corresponding stress-strains (Fig. D). A Machine Learning (ML) model is trained to link all loading and stress-strains states (Fig. E). Operationally, external loading, e.g., real-time residuum loading measured using prosthesis-embedded load-cell, are applied to the ML model to estimate the AT or residuum stress-strain, which is rendered in real-time on a smart phone (Fig. 1G and 2B). Workflow validation uses a phantom of the residuum and its internal structures of known material properties. The phantom, placed in the Dynamic Anatomical Ultrasonography rig (Fig. 2A), has forces applied to phantom’s femur and socket, and 3D shape changes of the different tissues measured. Discussion/future directions: This workflow generates AT stress-strain in real-time while a person is walking and is being translated for use in estimating residuum stress-strain during daily activities, enabling personalised prothesis design and use for military personnel. Acknowledgements: This work was supported by the FY19 Defense Medical Research and Development Program through the Joint Program Committee 8 / Clinical and Rehabilitative Medicine Research Program Restoring Warfighters with Neuromusculoskeletal Injuries Research Award (RESTORE) under Award No. W81XWH2110215-DM190659. Opinions, interpretations, conclusions, and recommendations are those of the author and are not necessarily endorsed by the FY19 Defense Medical Research and Development Program. References 1Frossard LA, Lloyd DG. The future of bionic limbs. Res Feat. 2021; 134: 74-77. https://doi.org/10.26904/RF-134-7477 2Pizzolato C, Shim VB, Lloyd DG, et al. Targeted Achilles tendon training and rehabilitation using personalized and real-time multi-scale models of the neuromusculoskeletal system. Front Bioeng Biotechnol 2020; 8:878. https://doi.org/10.3389/fbioe.2020.00878 3Langton CM, Barrett RS, Powrie R, et al. Development of dynamic anatomical ultrasonography to advance personalised prosthetics. MQ Military Biomarkers Symposium 2022.

Supine PCNL in autosomal dominant polycystic kidney disease.

Standard percutaneous nephrolithotomy (PCNL) has routinely been performed in prone position in autosomal dominant polycystic kidney disease (ADPKD) with nephrolithiasis. The objectives of our present study is to ensure optimum access to the renal collecting system, reducing operative time, and anesthetic morbidity during supine PCNL in ADPKD with nephrolithiasis. Seven patients were selected randomly. There were no preference for age, gender, size, location and laterality of stone, or BMI . All the patients fit into the AUA guideline criteria for management by percutaneous nephrolithotomy. Preoperative, perioperative, and follow up data were collected prospectively. Seven patients underwent supine PCNL in approximately 2.5 year in modified supine position. There was no intraoperative, post operative, or on follow up complications in any patient. In all the patients stones were cleared completely in single sitting. Supine PCNL in ADPKD with nephrolithiasis is an alternative with similar outcomes to the standard prone PCNL. It provides an additional benefit of performing the procedure in a single position, which is known to reduce total operating time, less anesthesia related complications, less neuromusculoskeletal injury, and reduce physical strain on operating.

Motor slacking during resisted treadmill walking: Can visual feedback of kinematics reduce this behavior?

Functional resistance training is frequently applied to rehabilitate individuals with neuromusculoskeletal injuries. It is performed by applying resistance in conjunction with a task-specific training, such as walking. However, the benefits of this training may be limited by motor slacking, a phenomenon in which the human body attempts to reduce muscle activation levels or movement excursions to minimize metabolic- or movement-related costs. While kinematic feedback could reduce one's tendency to minimize effort during training, this has not been verified experimentally. Does functional resistance training during walking lead to motor slacking, and can techniques such as visual feedback be used to reduce these effects? Fourteen able-bodied individuals participated in this experiment. Participants were trained by walking on a treadmill while a bidirectional resistance was applied to the knee using a robotic knee exoskeleton. During training, participants were either instructed to walk in a manner that felt natural or were provided real-time visual feedback of their kinematics. Electromyography and knee kinematics were measured to determine if adding resistance to the limb induced slacking and if feedback could reduce slacking behavior. Kinematic aftereffects were measured after training bouts to gauge adaptation. Functional resistance training without feedback significantly reduced knee flexion when compared to baseline walking, indicating that participants were slacking. This reduction in knee flexion did not improve with continued training. Providing visual feedback of knee joint kinematics during training significantly increased knee muscle activation and kinematic aftereffects. The findings indicate that individuals are susceptible to motor slacking during functional resistance training, which could affect outcomes of this training. However, motor slacking can be reduced if training is provided in conjunction with a feedback paradigm. This finding underscores the importance of using additional methods that externally motivate motor adaptation when the body is not intrinsically motivated to do so.

The Occupational Military Neuromusculoskeletal Injury Matrix.

Neuromusculoskeletal injuries (NMSKIs) are the primary cause of ambulatory visits, lost duty days, and disability discharges in the U.S. Military. Methods for accurately grouping injury diagnoses are required to allow for surveillance and research identifying risk factors and prevention strategies. The CDC method of grouping these diagnoses includes only the S and T codes (Injury, poisoning, and certain other consequences of external causes) from the ICD-10-CM. However, this does not include the majority of the NMSKI depleting soldier readiness; the M (Disease of the musculoskeletal system and connective tissue) and G (Diseases of the nervous system) codes should be included as these also contain injuries. The goal was to develop a new matrix that would comprehensively capture all NMSKIs experienced by military personnel. This paper details the development of the Occupational Military Neuromusculoskeletal Injury (OMNI) Matrix and characterizes the number and rates of active duty U.S. Army injuries as measured by the OMNI compared to other matrices. A team of researchers including physical therapists, physician assistants, occupational therapists, physicians, and epidemiologists developed the OMNI. The OMNI utilizes the commonly accepted injury definition inclusive of any anatomical complaint resulting in pain or dysfunction and categorizes injuries from the G, M, S, and T codes. The OMNI follows the CDC's matrix structure with three body region levels, each becoming more specific, and adds two levels called Description of the Injury. Additionally, the OMNI categorizes injuries as Injury Type (Acute, Overuse, Either, or Not Applicable), NMSKI-Type (NMSKI, NMSKI that could be caused by occupational/training tasks, and not an NMSKI), and a miscellaneous category that demarks injuries as Superficial, Blood Vessels, and/or Internal Organs. The different grouping methods in the OMNI provide standardization for many possible injury case definitions. The OMNI allows these injury categories to be included/excluded in a standardized fashion to meet the researchers' scientific questions. To enumerate the number of NMSKI that would be captured by the available matrices, the OMNI, the CDC's matrix, and the U.S. Army Public Health Center's (APHC) Taxonomy of Injuries were applied to active duty Army outpatient population data and all incident NMSKI diagnostic codes entered in electronic medical provider encounters for calendar years 2017 and 2018. Using the OMNI resulted in the capture of over 800,000 more injuries than the CDC's matrix and over 200,000 more than the APHC Taxonomy. The NMSKI rate utilizing the OMNI was 193 per 100 soldier-years in 2017 (892,780 NMSKI) compared to 23 per 100 soldier-years for the CDC's matrix, and 141 per 100 soldier-years for the APHC Taxonomy. The OMNI provides an updated standardized method of assessing injuries, particularly in occupational military injury research, that can be utilized for Military Performance Division of injury across many countries and still allow for replication of methods and comparison of results. Additionally, the OMNI has the capacity to capture a greater burden of injury beyond what is captured by other available matrices.

Supine tubeless PCNL in horseshoe kidney (a series of cases).

Objective of this case series is accurate access to the respective calyx with stone in horseshoe kidney while performing percutaneous nephrolithotmy in supine position. Reducing operative time and anaesthetic morbidity while performing percutaneous nephrolithotomy in horseshoe kidney with nephrolithiasis in supine position. Four patient with one having bilateral renal calculi with horshoe kidney were selected randomly. There were no preference for age, gender; size, location and laterality of stone or BMI. All the patients fit into the AUA guideline criteria for management by percutaneous nephrolithotomy. Preoperative, perioperative and follow up data were collected. Four patients with one having bilateral renal calculi underwent supine tubeless PCNL in 1 year in GMSV position. There was no intraoperative, post operative or on follow up complications in any patient. In all the patients stones were cleared completely in single setting. Supine percutaneous nephrolithotomy in horseshoe kidney is an alternative to the standard prone percutaneous nephrolithotomy in the horseshoe kidney. It provides an additional benefit of performing the procedure in a single position, which is known to reduce total operating time, less anaesthesia related complications and less neuromusculoskeletal injury.

Characterization of Limited Duty Neuromusculoskeletal Injuries and Return to Duty Times in the U.S. Army During 2017-2018.

Neuromusculoskeletal injuries (MSKI) are the leading cause of medical encounters, lost or limited duty days, medical evacuations, and disability in the U.S. Army. In the U.S. Army, objective MSKI incidence rate metrics can be determined through medical encounter data (M2SKIs) with International Classification of Diseases (ICD) 9 and ICD 10 codes or through documented limited duty profiles (LDPs) documenting time-loss MSKI (TLMSKI). The purpose of the current study was to characterize the population incidence of TLMSKIs among U.S. Army soldiers. This study was approved by the Medical Research and Development Command's Institutional Review Board. This was a retrospective population-level study. The U.S. Army's eProfile system was utilized to characterize all LDPs issued during 2017-2018 and to describe the body regions injured and activities associated with these TLMSKIs. The incidence rate of TLMSKIs was found to be 44 and 40 TLMSKI/100 soldier-years for 2017 and 2018, respectively, which is lower than previously published incidence rates using MSKI receiving medical care. Approximately one quarter of the total active duty Army population in 2017 and 2018 recorded limited duty injuries, where those to the ankle/foot region resulted in the most LDPs and those to the knee resulted in the most lost duty days. The majority of all TLMSKIs were associated with fitness training-related activities. This descriptive study is the first to present the U.S. Army population rates for MSKIs that result in LDPs, representing key time losses when soldiers cannot participate in their military occupational and physical training tasks. This study utilizes the LDP system to calculate limited duty days instead of attempting to estimate this information from other means. The eProfile system is limited in that it combines body regions such as ankle/foot and does not allow isolation of ankle or foot independently. It is recommended that research and training programs target the identification, development, and validation of effective and scaleable strategies to maximize performance without severely reducing combat effectiveness because of training TLMSKIs.

Effects of elbow immobilization on upper extremity activity

BackgroundIt has been dogma that handedness greatly impacts daily activities. Interruptions in the ability to utilize the dominant arm due to neuromusculoskeletal injuries could negatively impact performance of activities of daily living. Daily activity can be measured using activity monitors. This study aimed to examine how arm dominance impacts function by immobilizing the arms of healthy individuals. MethodsTen individuals wore four upper extremity activity monitors for three days—one day without immobilization, one day with their dominant arm immobilized, and one day with their non-dominant arm immobilized. Triaxial acceleration data was used to calculate average daily activity and an asymmetry index. Between-condition differences were examined. FindingsDuring dominant arm immobilization, the dominant forearm had significantly less average daily activity when compared to the no immobilization day (p = .0001) and the non-dominant immobilized day (p < .0001). A similar trend was observed at the non-dominant forearm when the non-dominant arm was immobilized. Immobilization of an arm increased asymmetry index and reliance on the non-immobilized arm. Significant differences in asymmetry index were not observed between the two casted conditions. InterpretationWhen an upper extremity was casted, immobilized forearm and upper arm average daily activity was comparable. Dominance did not have an effect on asymmetry index. Immobilization affected asymmetry index compared to no immobilization. This study has demonstrated that regardless of arm immobilized, there will be a reliance on the contralateral limb about twice as much as the immobilized limb. This could prove problematic if the contralateral limb is restricted or injured, limiting independent.

Ca2+‐induced Complex I Inactivity: A Model for Early Mitochondrial Dysfunction Following Volumetric Muscle Loss Injury

Calcium (Ca2+) is a secondary messenger, responsible for the regulation of a plethora of metabolic pathways that must be tightly regulated to avoid cytotoxicity 1. During early stage volumetric muscle loss (VML) injuries, damaged muscle fibers are open to the extracellular environment until the myofiber can be sealed, a process that may take hours 2– 3. This allows for free Ca2+ exchange between intra‐ and extracellular environments to concentrations beyond those appropriate for cell homeostasis. The purpose of this study was to model the changes in mitochondrial metabolism of early VML injuries as a response to a drastic increase of intracellular Ca2+.C57BL6 mice underwent unilateral surgery to create a VML defect in the gastrocnemius muscle, as approved by the University of Georgia’s Institutional Animal Care and Use Committee. Animals were sacrificed via CO2 inhalation, 18 hrs. following surgery. Total [Ca2+] per kg of tissue ([Ca2+]TWM) was measured using a BAPTA complexation assay. Gastrocnemius muscles from naïve mice were dissected into individual fiber bundles, permeabilized, and washed in either normal isotonic or Ca2+‐supplemented medium. Mitochondrial metabolic function and mitochondrial membrane potential were measured through oxygen consumption and Safranin‐O fluorescence rates, respectively, in a High‐Resolution Fluoro‐respirometer.[Ca2+]TWM was elevated in VML‐injured tissue, as expected (n=3, p&lt; 0.05). Acute Ca2+ exposure negatively affected Complex I (C‐I) activity of the electron transport chain. Specifically, C‐I activity was targeted by the addition of glutamate and malate (Glu‐Mal) and confirmed by the sequential addition of C‐I inhibitor Rotenone (Rot). In normal fibers, respiration increased after Glu‐Mal addition and subsequently decreased significantly following Rot, while Ca2+‐incubated fibers exhibited no change in oxygen consumption rate. Succinate (Succ) was used to rescue respiratory function by bypassing C‐I. Succ addition significantly increased oxygen consumption in both normal and Ca2+‐incubated fibers (n=3, p&lt;0.01), confirming a C‐I dysfunction in Ca2+‐treated fibers. Safranin fluorescence is sensitive to changes in mitochondrial membrane potential, decreasing with complex activity and increasing upon inhibition. In normal fibers, Safranin signal decreased with Glu‐Mal and Succ additions and increased with Rot, as expected. However, Ca2+‐treated fibers were only sensitive to Succ treatment, further supporting C‐I dysfunction (n=3, p&lt; 0.01).Herein, we show that an acute increase in intracellular Ca2+ negatively affects the process of oxidative phosphorylation within the mitochondria by disturbing the electron potential and inactivating Complex I. This alteration in membrane potential and decrease in complex activity may be the first step in a systematic shut down of mitochondrial metabolic function that leaves the muscle remaining after injury beyond the hope of effective repair.Support or Funding InformationFunded through the Department of Defense Neuromusculoskeletal Injuries Rehabilitation Research Award W81XWH‐18‐1‐0710 to SMG (UMinn) and JAC (UGA)A‐ Quantification of internal [Ca2+] of VML‐injured and control gastrocnemius muscles using BAPTA absorbance (n=3, p &lt; 0.05). B‐ Oxygen consumption rates of control and Ca2+‐treated muscle fibers after Complex I activation, inhibition, and bypass, respectively (n=3 in duplicate, p &lt; 0.05). C‐ Safranin‐O signal fluctuation in control and Ca2+‐treated muscle fibers after Complex I activation, inhibition, and bypass, respectively (n=3, p&lt; 0.05).Figure 1

Physical Therapy as a Force Multiplier: Population Health Perspectives to Address Short-Term Readiness and Long-Term Health of Military Service Members

Neuromusculoskeletal (NMSK) injuries are ubiquitous in the United States Armed Forces and pose a substantial threat to operational readiness. Many service members who sustain an NMSK injury progress to develop chronic conditions that may result in substantial decrease in function and physical activity across a lifetime. Both social and psychological factors may drive care-seeking and treatment compliance in service members following NMSK injury, contribute to the chronification of injury, which likely result in long-term cardiovascular consequences that contribute to morbidity and mortality. The decision to seek care following NMSK injury is ultimately related to the knowledge, beliefs, attitudes, and values of individual service members that are influenced by the military culture in which they serve. In this clinical perspective, the authors provided a theoretical framework on how psychosocial determinants of care-seeking may contribute to chronification of NMSK conditions and how this may influence long-term cardiovascular health. Cultural shifts and changes in health care delivery in the military may help to mitigate barriers to care and promote care-seeking with the clinician being viewed as a “force multiplier” or optimizer of readiness. Because there are substantial gaps still remaining in the evidence, the authors hope that this perspective will facilitate future research related to this topic.