Strict Immobilization Research Articles

Re-re-irradiation for palliation: knowns, unknowns, and next steps.

With improving rates of survival among patients with metastatic malignancies, the request for palliative re-irradiation and re-re-irradiation continues to grow despite an absence of standardized guidelines. With only limited data regarding extra-cranial third-course palliative radiation, many radiation oncologists may feel uncomfortable proceeding with third-course irradiation of the same site. The review explores the available modern data regarding re-re-irradiation. A literature review identified four modern peer-reviewed studies investigating palliative, extra-cranial third-course irradiation with external beam radiation. These studies were retrospective, small, and heterogenous. While they reported comparable rates of pain palliation to first course irradiation and low rates of acute toxicity, interpretation is complicated by heterogeneous treatment parameters and insufficient reporting of cumulative dose equivalents and time intervals. With limited data available, it is critical to prioritize patient safety and quality of life in palliative radiotherapy. Patient selection should be meticulous, considering factors such as initial treatment response and predicted life expectancy. Conformal radiation techniques, strict immobilization, and daily image guidance should be employed to minimize toxicity to organs at risk (OARs). Long-term follow-up is essential for identifying and managing late toxicities effectively. Despite the scarcity of data, retrospective series suggest that extra-cranial third course irradiation can provide effective pain palliation comparable to first-course irradiation with tolerable rates of toxicity. However, careful consideration of patient prognosis and adherence to established principles of palliative radiotherapy are essential in decision-making. Further research and long-term follow-up are needed to refine treatment strategies and ensure safe and efficacious care delivery in this complex clinical scenario.

Clinical and functional outcomes of 405 Achilles tendon ruptures after a minimum follow-up of 1 year

ObjectiveThe results of surgical versus conservative treatment of acute Achilles tendon ruptures are still controversial. The objective of this study was to compare surgical and conservative treatment at a minimum follow-up of 1 year in terms of the complications, functional outcomes and clinical results. HypothesesThere is no difference in the complications, clinical results and functional outcomes between the two treatment groups. There is no difference in the occurrence of complications or the clinical results due to the immobilization or rehabilitation protocols. MethodsThis was a retrospective comparative, multicenter, non-randomized study of acute Achilles tendon ruptures treated between 01/01/2018 and 31/12/2019 at 21 study sites in France. All patients who received surgical or conservative treatment were included. The demographics, sports participation, nature of treatment, immobilization parameters (type, duration, position) and rehabilitation protocol were collected. Rerupture, general and specific complications, clinical results (heel-rise test, single-leg hop, calf circumference, ankle dorsiflexion) and the functional outcomes (ATRS, VISA-A, EFAS, SF-12) were collected at the final review. ResultsFour hundred five patients were reviewed at a mean follow-up of 24 (±7) months. Surgical treatment was done in 372 patients (92%) and conservative treatment in 33 patients (8%), with these two sets of patients having comparable preoperative characteristics. There was a similar number of reruptures in the conservative group (3 cases, 9%) as in the surgical group (15 cases, 4%) (p=0.176). There were more general complications in the conservative group (24%) than in the surgical group (11%) (p=0.04). There was a 9% rate of surgery-related complications (infection, nerve damage, anesthesia after-effects). The ATRS (p=0.017), EFAS Total (p=0.013), EFAS daily living (p=0.008), and SF-12 physical (p=0.01) were better in the surgical group. Strict then relative immobilization provided the best balance between functional recovery (EFAS total of 33, p<0.01) and tendon lengthening (0°, p=0.01) without increasing the occurrence of rerupture (2%, p=0.18). Early weightbearing accompanied by immobilization and rehabilitation within 30 days did not lead to more reruptures than if it was started beyond 30 days (p=0.082 and p=0.07). ConclusionsThis study found no differences in the number of reruptures between surgical treatment and conservative treatment of acute Achilles tendon ruptures. Surgical treatment led to better clinical results but had a variable effect on improving the functional scores. No matter which treatment is used, in the ideal case, 3 weeks of strict immobilization in equinus should be followed by progressive reduction over the next 3 weeks. Early weightbearing and mobilization within 30 days did not increase the risk of rerupture; it actually optimized the clinical and functional outcomes. Level of evidenceIII; retrospective comparative, non-randomized.

Early ambulation protocol after diagnostic transfemoral cerebral angiography: an evidence-based practice project

BackgroundNo uniform consensus has been achieved regarding the ambulation protocol after transfemoral cerebral angiography (TFA). Until now, in most hospitals patients are prescribed 8-12 h strict immobilization along with bed rest in the supine position after TFA in China, which causes great discomfort to patients.ObjectiveTo evaluate the effect of an evidence-based early ambulation protocol on the prevention of vascular complications and general discomfort in patients following transfemoral cerebral angiography (TFA).MethodsA prospective quasi-experimental study was conducted on 214 patients undergoing TFA with manual compression. Patients in the experimental group were placed supine position for 2 h with a sandbag placed on the wound dressing, followed by a semi-seated position for another 2 h. After this period, patients took 2 h bed rest (move freely) with the sandbag removed, and were allowed to get out of bed 6 h after TFA. Patients in the control group were restricted to an 8 h bed rest in a supine position with the affected leg straight and immobilized. The vascular complications (bleeding, hematoma, ecchymosis) and levels of comfort (low back pain, leg pain, and blood pressure) were evaluated after the procedure. Numeric Rating Scale (NRS) pain scores, systolic blood pressure (SBP); diastolic blood pressure (DBP) were measured hourly for 8 h after TFA.ResultsThere was no significant difference in the two groups with regard to vascular complications including bleeding events (P = 0.621), bleeding volume (P = 0.321), and area of hematoma (P = 0.156).The area of ecchymosis in the experimental group was significantly smaller than the control group (P = 0.031). Compared with the control group, the NRS score for low back pain in the 4th, 5th, 6th, 7th, and 8th hour after TFA were significantly lower (P < 0.05), and the NRS score for leg pain in the 5th, 6th, 7th, 8th hour after TFA were significantly lower (P < 0.05). The SBP and DBP in the 6th, 7th, and 8th hour after TFA were significantly lower than the control group (all P < 0.05).ConclusionsThe evidence-based early ambulation protocol can effectively and safely increase comfort and decrease the pain level for patients undergoing TFA, without change in the incidence of vascular complications.

How a broken vertebra can lead to a fatal hemorrhage: a case report

BackgroundUnintentional falls are common among the elderly and given the expected increase of the aging population, these falls contribute to a high number of admissions to the emergency department. Relatively low-energy trauma mechanisms can lead to serious injuries in the elderly, with contributing factors being comorbidities, medication use and degenerative abnormalities.Case presentationA 94-year-old female suffered an unintentional fall at home. Upon arrival of the ambulance at her house she was hemodynamically stable and mobilized to the gurney with assistance. During primary survey at the emergency department, her blood pressure and oxygen saturation decreased, she was not able to move her legs anymore and lost consciousness. A full-body CTA was performed, which showed a fracture through the vertebral body of L2 with significant dislocation and a large active bleeding of the corpus, extending to the retroperitoneum and the epidural space. Despite resuscitation, her vital signs deteriorated and given the severe abnormalities on CTA, it was decided to discontinue further treatment, after which she deceased. The performed CTA and an x-ray from 2016 suggested diffuse idiopathic skeletal hyperostosis, which might have contributed to the severity and instability of the vertebral fracture. Mobilization after the fall might have increased the dislocation of the fracture. The use of oral anticoagulants worsened the subsequent bleeding and the extension to the epidural space caused the paralysis of the legs.ConclusionsIt is important to be aware of the possible serious consequences of unintentional falls in the elderly population and to provide strict immobilization of the spinal column until proper imaging.

Functional recovery of patients after shoulder joint replacement

Currently, shoulder arthroplasty is being actively introduced into surgical practice, indications for operations are expanding, and the number of patients operated with severe injuries and diseases of the proximal humerus and shoulder joint is growing. The decrease in the effectiveness of restoring the painless functioning of shoulder, household independence and quality of life of patients after surgery may be due not only to the severity of damage to the shoulders joint structures of the before surgery, shortcomings in surgical techniques and the development of postoperative complications, but, possibly, the imperfection of medical rehabilitation programs for these patients.&#x0D; To date, the content of the rehabilitation protocol for the early postoperative period has not been sufficiently substantiated, the need for strict immobilization of the operated joint, as well as the long-term benefits and effectiveness of early rehabilitation remains unclear.&#x0D; The article attempts to summarize the available data on the physical rehabilitation of patients after shoulder joint replacement with various types of endoprostheses in the early and late postoperative periods.

A Scoping Review of Postoperative Rehabilitation Protocols After Superior Capsular Reconstruction for Irreparable Rotator Cuff Tears

Background:Superior capsular reconstruction (SCR) is an option for patients with massive or irreparable rotator cuff tears.Purpose:To describe the literature on rehabilitation protocols after SCR of rotator cuff tears, with emphasis on the timing of the introduction of motion.Study Design:Scoping review; Level of evidence, 4.Methods:We conducted a scoping review of articles published on PubMed, Ovid, Embase, and the Cochrane Library from inception to October 2020. The methodological index for non-randomized studies (MINORS) was used to assess the individual studies. For each article, we summarized the study characteristics, patient demographics, and rehabilitation protocols after SCR: duration of immobilization, initiation of passive range of motion (ROM), active-assisted ROM, active ROM, strengthening, and return to activities. In a subgroup narrative analysis, rehabilitation protocols were stratified by graft type: autograft versus nonautograft (xenograft, allograft, and synthetic).Results:A total of 21 studies met the search criteria. Six studies had level 3 evidence and 15 had level 4 evidence; 16 studies were considered high quality according to the MINORS score. After SCR, an abduction immobilizer was recommended for a duration of 3 to 6 weeks. Of the 21 studies, 7 (33%) started passive ROM during the first week, and 5 reported strict immobilization without motion for up to 6 weeks. All 8 studies that reported return-to-sports timing recommended delaying return until at least 6 months postoperatively. Passive ROM was recommended earlier for patients with nonautograft versus autograft (χ2 = 225; P < .001). There was a high level of heterogeneity in the rehabilitation protocols after SCR.Conclusion:The majority of published protocols were descriptive. At present, there is little agreement on the published rehabilitation guidelines after SCR, precluding specific clinical best practice suggestions. Although there was a tendency of recommending early motion in nonautograft cases, the optimal protocols based on graft healing and functional outcomes require further verification based on the clinical outcomes from high-quality studies.

Does Immobilization Post Injection Reduce Contrast Extravasation in MR Arthrography of the Shoulder?

Contrast leakage after arthrography is common. We sought to investigate if immobilization could prevent it. The purpose of this study was to determine the effects on contrast extravasation and image quality produced by strict immobilization of the shoulder between arthrography puncture and subsequent MR imaging. Fifty patients underwent shoulder MR arthrography using a standard shoulder puncture in the anteroinferior quadrant. Ten milliliters of contrast mixture of saline, iodinated contrast, and gadolinium contrast was injected by a senior musculoskeletal (MSK) radiologist using a 21G needle. Half of the patients were immediately immobilized using a shoulder sling, and the other half were allowed to move their shoulder and arm freely during the time before MR imaging. MR arthrography was performed with a 3 T system using standard T1 and PD weighted sequences. The MR images were reviewed independently by 2 MSK radiologists and graded for extravasation using a five-point scale (1: none, 2: less than 2 cm, 3: 2-5 cm, 4: 5-10 cm, 5: more than 10 cm) and for image quality using a 5 point scale (1: poor, 5: good). The Pearson correlation was calculated to assess the correlation between leakage and image quality. There was no significant difference in amount of leakage between both groups, and global image quality was found equal in both groups. A negative correlation was found between leakage and quality assessment. This study shows that it cannot be avoided by strict shoulder immobilization and that it negatively affects image quality and interpretation.

Does Thermoplastic Mask Alleivates Skin Sparing Effect of Photons in Head and Neck Cancer Patients: A Pilot study

Introduction: Head and Neck tumors are mainly treated with concurrent chemoradiation. Treatment delivery with Megavoltage beam has the advantage of skin sparing effect but still skin reactions have been a major side effect since 2D era. Initially these reactions were due to the delivery with bilateral opposed portals but with advent of IMRT/ VMAT, it has been possible to escalate the tumor dose with the need of strict immobilization with thermoplastic mask. This thermoplastic mask may have a bolus effect and can result in increase in surface dose resulting in skin reactions. The aim of this study was to evaluate if any bolus effect of thermoplastic mask exists. Materials and Methods: A total of 15 patients of histologically proven carcinoma oropharynx and hypopharynx were taken. Patients were scanned for planning CT with thermoplastic mask. Another scan was taken in the same position but without thermoplastic mask. Same contouring and planning were done on both the scans. Plans were made and ascertained that all OAR’s and target volumes should get similar doses. Skin contoured on both the scans was evaluated for the dose received. Results: Mean dose received by skin in patients with thermoplastic mask was 48.15 GY while Mean dose received by skin in patients without thermoplastic mask was 43.18 GY. A paired t-test was applied on the dataset which revealed a statistically significant difference between the skin doses with and without mask with a p value of &lt; 0.05. Conclusion: Increase in skin dose can be attributed of the bolus effect of thermoplastic mask. This bolus effect should be considered once high dose to skin is observed during planning or patient develops skin reaction.

Healing, Pain and Function after Midshaft Clavicular Fractures: A Systematic Review of Treatment with Immobilization and Rehabilitation.

To systematically evaluate the scientific literature examining the efficacy of nonoperative management for midshaft clavicular fractures, specifically looking at the effect of immobilization and/or functional rehabilitation. TYPE: Systematic review. MEDLINE (PubMed), EMBASE, CINAHL databases were searched. Inclusion criteria included adult patients enrolled in a controlled study evaluating bony healing, pain and/or function-related improvements after a strict nonoperative treatment plan for management of midshaft clavicle fractures. A total of 10 articles were included in the study. Only four studies contained level I evidence; four studies were prospective case series without a control, and one was a retrospective case series without a control. Half of studies used a strict immobilization period, and most utilized a period of functional rehabilitation. There were no direct comparisons between rehabilitation protocols. Studies without a strict immobilization period had a nonunion rate of 5% to 24% and residual pain in 35% to 83% of patients compared to studies with a strict immobilization period with a nonunion rate of 3% to 29% and residual pain in 14% to 49% of patients. Studies including functional rehabilitation protocol reported functional as measured by the Constant Shoulder Score of 87.8 to 96, out of a maximum of 100 representing no functional limitations, and nonunion rates of 12% to 25% compared to 81 to 85 and 3% to 29% in those without a rehabilitation protocol. No studies directly examine the effect of immobilization and functional rehabilitation on clinical outcomes for midshaft clavicular fractures. Future studies are needed to better elucidate the most effective treatment. I.

Physical Therapy Protocols for Arthroscopic Bankart Repair

Background:Outcomes after arthroscopic Bankart repair can be highly dependent on compliance and participation in physical therapy. Additionally, there are many variations in physician-recommended physical therapy protocols.Hypothesis:The rehabilitation protocols of academic orthopaedic surgery departments vary widely despite the presence of consensus protocols.Study Design:Descriptive epidemiology study.Level of Evidence:Level 3.Methods:Web-based arthroscopic Bankart rehabilitation protocols available online from Accreditation Council for Graduate Medical Education (ACGME)–accredited orthopaedic surgery programs were included for review. Individual protocols were reviewed to evaluate for the presence or absence of recommended therapies, goals for completion of ranges of motion, functional milestones, exercise start times, and recommended time to return to sport.Results:Thirty protocols from 27 (16.4%) total institutions were identified out of 164 eligible for review. Overall, 9 (30%) protocols recommended an initial period of strict immobilization. Variability existed between the recommended time periods for sling immobilization (mean, 4.8 ± 1.8 weeks). The types of exercises and their start dates were also inconsistent. Goals to full passive range of motion (mean, 9.2 ± 2.8 weeks) and full active range of motion (mean, 12.2 ± 2.8 weeks) were consistent with other published protocols; however, wide ranges existed within the reviewed protocols as a whole. Only 10 protocols (33.3%) included a timeline for return to sport, and only 3 (10%) gave an estimate for return to game competition. Variation also existed when compared with the American Society of Shoulder and Elbow Therapists’ (ASSET) consensus protocol.Conclusion:Rehabilitation protocols after arthroscopic Bankart repair were found to be highly variable. They also varied with regard to published consensus protocols. This discrepancy may lead to confusion among therapists and patients.Clinical Relevance:This study highlights the importance of attending surgeons being very clear and specific with regard to their physical therapy instructions to patients and therapists.

Enquête de prévalence sur le sondage vésical dans un centre hospitalo-universitaire

Urinary tract infection is the most common healthcare-association infection, especially because of urinary catheter. We evaluated our practices concerning catheter insertion and management in our institution. We conducted a single-centre descriptive cross-sectional study during 1week in September2014 in all adult departments. We noted prevalence, indications, length, management of urinary catheter (UC) and symptomatic catheter-associated urinary tract infections (SCAUTI). Amongst 1046patients audited, 125 (12%) had UC. The mean age was 72years (64.8-79.2). UC prevalence was higher in surgical (88%) and medical (87%) intensive care, urology (50%), geriatrics (18%) and long-term care (18%) departments. The average catheterisation length was 7.8days (3.8-11.8); it was shorter in surgery than in medicine departments (3.6 vs 9.7days, P<0.001). Catheters were present for more than 4days in 60% of the cases. Acute urinary retention was the most frequent indication (59%), significantly more in medical than surgical departments (75% vs 26%). Others indications were perioperative (17%), diuresis monitoring (12%), strict immobilization (4%) and unnecessary indications or staff comfort (4%). A SCAUTI was present in 10% of cases, mostly in medicine department (30% vs 8%). The prevalence of our institution is higher than the national prevalence (8.1%), but still below the European average (17.2%). Control of the risk of CAUTI requires compliance with UC appropriate indications, UC management, and prompt removal of unnecessary UC. 4.

Retrospective evaluation of 211 patients with maxillofacial reconstruction using parietal bone graft for implants insertion.

For a century, autologous bone grafts have been used in maxillofacial reconstruction. The ideal bone harvest site and grafting procedure remains a point of contention in regards to obtaining optimal long-term results with sufficient bone quantity and density without serious complications. More recently, confronted with growing patient requests and biomaterials development, maxillofacial surgeons and dentists have been considering these issues as they relate to pre-implant surgery. This study sought to evaluate implant success rate and complications following pre-implant surgery with parietal bone grafting. A retrospective study was carried out on patients who underwent maxillofacial reconstruction of different sites (symphysis, mandibular corpus, maxillary sinus and premaxilla) for the purpose of implant insertion. 311 procedures in 211 patients were included. The implant osseointegration rate was around 95%. Clinical follow-up ranged from 10 months to 11 years. A secondary procedure was performed in 6.1% of cases and we noted no serious complications at the harvest site. With good revascularization and osseointegration of the graft, the use of parietal bone leads to an implant success rate similar to that seen in the literature. Moreover, the use of this material results in few infections and low bone resorption provided there is strict immobilization of the graft and no tension on the soft tissue sutures. Parietal bone grafts technique possess the required qualities for the success of implant surgery, offering results at least as interesting as others using autogenous bone and with no serious complications on donor site.

The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation following arthroscopic rotator cuff repair

This is a consensus statement on rehabilitation developed by the American Society of Shoulder and Elbow Therapists. The purpose of this statement is to aid clinical decision making during the rehabilitation of patients after arthroscopic rotator cuff repair. The overarching philosophy of rehabilitation is centered on the principle of the gradual application of controlled stresses to the healing rotator cuff repair with consideration of rotator cuff tear size, tissue quality, and patient variables. This statement describes a rehabilitation framework that includes a 2-week period of strict immobilization and a staged introduction of protected, passive range of motion during weeks 2-6 postoperatively, followed by restoration of active range of motion, and then progressive strengthening beginning at postoperative week 12. When appropriate, rehabilitation continues with a functional progression for return to athletic or demanding work activities. This document represents the first consensus rehabilitation statement developed by a multidisciplinary society of international rehabilitation professionals specifically for the postoperative care of patients after arthroscopic rotator cuff repair.

The Fifth Metatarsal Base: Anatomic Evaluation Regarding Fracture Mechanism and Treatment Algorithms

Fractures occurring within the 1.5-cm proximal portion of the fifth metatarsal are commonly considered avulsion fractures. The exact mechanisms of such fractures are controversial. The present study focused on determining the likely mechanism of fracture according to the exact anatomy to allow for more successful treatment. The research sample included 10 frozen cadaveric specimens. The lateral band of the plantar fascia, peroneus brevis, and articular surface were identified and separated from their attachments, thereby splitting the fifth metatarsal base into zones A, B, and C. In zone A, the attachment of the plantar fascia was 6.6 ± 2.2 mm from the inferior aspect, 9.5 ± 2.9 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. In zone B, the attachment of the peroneus brevis was 12.0 ± 2.2 mm from the inferior aspect, 10.2 ± 2.2 mm from the proximal aspect, and 11.5 ± 0.9 mm from the lateral aspect. Zone C was measured from the border of zone B and encompassed the articulation of the fifth metatarsal to the cuboid. We propose that fractures occurring in the most proximal end of the fifth metatarsal, zone A, are caused by a lateral band of plantar fascia and might be able to be treated conservatively by immobilization with weightbearing. We also propose that fractures occurring in zones B and C result from traumatic tension on peroneus brevis and might need to be treated with strict immobilization and non-weightbearing or open reduction internal fixation.

Guideline for diagnosis and treatment of subacromial pain syndrome

Treatment of “subacromial impingement syndrome” of the shoulder has changed drastically in the past decade. The anatomical explanation as “impingement” of the rotator cuff is not sufficient to cover the pathology. “Subacromial pain syndrome”, SAPS, describes the condition better. A working group formed from a number of Dutch specialist societies, joined by the Dutch Orthopedic Association, has produced a guideline based on the available scientific evidence. This resulted in a new outlook for the treatment of subacromial pain syndrome. The important conclusions and advice from this work are as follows:(1) The diagnosis SAPS can only be made using a combination of clinical tests. (2) SAPS should preferably be treated non-operatively. (3) Acute pain should be treated with analgetics if necessary. (4) Subacromial injection with corticosteroids is indicated for persistent or recurrent symptoms. (5) Diagnostic imaging is useful after 6 weeks of symptoms. Ultrasound examination is the recommended imaging, to exclude a rotator cuff rupture. (6) Occupational interventions are useful when complaints persist for longer than 6 weeks. (7) Exercise therapy should be specific and should be of low intensity and high frequency, combining eccentric training, attention to relaxation and posture, and treatment of myofascial trigger points (including stretching of the muscles) may be considered. (8) Strict immobilization and mobilization techniques are not recommended. (9) Tendinosis calcarea can be treated by shockwave (ESWT) or needling under ultrasound guidance (barbotage). (10) Rehabilitation in a specialized unit can be considered in chronic, treatment resistant SAPS, with pain perpetuating behavior. (11) There is no convincing evidence that surgical treatment for SAPS is more effective than conservature management. (12) There is no indication for the surgical treatment of asymptomatic rotator cuff tears.

Radiotherapy in pediatric patients without anesthesia or sedation: Feasibility and challenges

Conventionally fractionated radiotherapy treatment involves strict immobilization for accurate delivery and typically is delivered in five daily fractions every week for several weeks. To ensure rigid immobility during treatment planning and delivery in children, anesthesia or sedation has been used but valid concerns have been raised about the safety and long-term consequences of such practice on daily basis for prolonged periods. We tested the feasibility of avoiding daily anesthesia or sedation in our pediatric radiotherapy patients by extensive pretreatment counseling and demonstration of the treatment procedure ensuring their comfort and compliance.

The Tortoise Versus the Hare—It’s a Photo Finish

There are a number of known factors that can affect clinical outcomes and structural healing after rotator cuff repair. Some of these are fixed variables, such as patient age and comorbidities, tear size, and tissue quality, while others, such as patient-related factors like smoking, repair construct, and postoperative management, are modifiable and may allow for improvement in patient outcomes. The traditional school of thought regarding the initiation of postoperative rehabilitation following rotator cuff repair has favored early passive shoulder motion to prevent stiffness. Until recently, this approach has been largely uniform. However, over time, data suggesting poorer tendon healing in certain subsets of patients have accumulated, leading some surgeons to advocate a delayed rehabilitation protocol with an initial phase of strict immobilization. The theoretical “trade-off” of this approach would be to improve the likelihood of tendon healing at the potential expense of an increased risk of postoperative stiffness and a delayed recovery timeline. The current study by Keener and coauthors from Washington University analyzes this question and does so in a superb fashion. In this Level-I, prospective, randomized trial, the authors identified and enrolled 124 patients under the age of sixty-five years who underwent arthroscopic repair of a small or medium tear (<30 mm in anterior-to-posterior …

Changes in spatial ventricular gradient and QRS-T angle induced by strict 5-days immobilization, and effects of exercise countermeasure

Purpose: The spatial QRS-T angle (SA) and ventricular gradient (SVG) are classical ECG parameters that provide information on cardiac conduction system function and on ventricular action potential duration heterogeneity. Wide SA and reduced SVG are related to pathological conditions. Our aims were: 1) to assess the effects of 5 days immobilization (-6 degrees bed-rest, BR) on SA and SVG; 2) to evaluate the effectiveness of 25 min/day standing exercise (unilateral and bilateral heel raise, bilateral squatting (60°, 90° and 120°), bilateral and cross-hopping) as possible countermeasure. Methods: 10 healthy men (mean age 30±6) were enrolled in a cross-over design (wash out period: 2 months; control, CTRL, and exercise, EXE, groups) at DLR (Cologne, Germany) as part of the European Space Agency BR studies. High fidelity (1000 Hz) Holter ECG (12-leads, Mortara Instrument) was acquired before (PRE), the last day of BR (HDT5), and four days after the BR conclusion (POST). The night period (23:00-06:30) was selected for the analysis. X,Y,Z leads were derived (inverse Dower matrix) and vectorcardiogram computed. Selective beat averaging was used to obtain averages of P-QRS-T complexes preceded by the same stable heart rate (10 msec bin amplitude, in the range 900-1200 msec). For each averaged waveform (i.e., one for each bin), Twave maximum amplitude (Tmax), VG and SVG were computed. Results: Compared to PRE, a reduction in SVG (11%±3% and 9%±1%) and corresponding widening in SA (27%±9% and 21%±5%) were found at HDT5 in both CTRL and EXE, respectively. The EXE countermeasure significantly reduced both SVG and SA changes compared to CTRL. Tmax presented the same changes, being reduced of 8%±3% in CTRL and only of 4%±2% in EXE. At POST, in both groups SA was restored to PRE values; conversely, while in EXE the SVG returned to PRE values, in CTRL it was found still reduced by 3%. Also, while Tmax was back to PRE values in EXE, it was increased by 5% in CTRL. Conclusions: Despite the short-term -6° BR immobilization, cardiac adaptation to this deconditioning condition affected ventricular repolarization during the night period, thus widening SA and reducing SVG as result of increased heterogeneity, thus increasing the risk of arrhythmia development. Selective beat averaging allowed quantifying these changes. Application of 25 min/day standing exercise reduced, but not canceled, these effects. This should be taken into account in patients with cardiovascular diseases, when immobilized in bed, to proper adjust the pharmacological therapy or set the rehabilitation training, in order to avoid further complications.

Choc neurogénique traumatique

Traumatic neurogenic shock is a rare but serious complication of spinal cord injury. It associates bradycardia and hypotension caused by a medullary trauma. It is life-threatening for the patient and it aggravates the neurological deficit. Strict immobilization and a quick assessment of the gravity of cord injury are necessary as soon as prehospital care has begun. Initial treatment requires vasopressors associated with fluid resuscitation. Steroids are not recommended. Early decompression is recommended for incomplete deficit seen in the first 6hours. We relate the case of secondary spinal shock to a luxation C6/C7 treated in prehospital care.

Immediate passive motion versus immobilization after endoscopic supraspinatus tendon repair: A prospective randomized study

Rehabilitation programs after rotator cuff repair should allow recovery of shoulder function without preventing tendon healing. The aim of this randomized prospective study was to compare the clinical results after two types of postoperative management: immediate passive motion versus immobilization. We followed 100 patients, mean age 55 years old, who underwent arthroscopic repair of a non-retracted supraspinatus tear. Patients were randomized to receive postoperative management of immediate passive motion or strict immobilization for 6 weeks. A clinical evaluation was performed in 92 patients, and CT arthrography in 82. Mean follow-up was 15 months. The mean preoperative Constant score improved significantly from 46.1 points to 73.9 at the final follow-up. The rate of intact cuffs was 58.5%. Functional results were statistically better after immediate passive motion with a mean passive external rotation of 58.7° at the final follow-up versus 49.1° after immobilization (P=0.011), a passive anterior elevation of 172.4° versus 163.3° (P=0.094) respectively, a Constant score of 77.6 points versus 69.7 (P=0.045) respectively, and a lower rate of adhesive capsulitis and complex regional pain syndrome. Results for healing seemed to be slightly better with immobilization, but this was not statistically significant: the cuff had a normal appearance in 35.9% of cases after immobilization compared to 25.6% after passive motion, an image of intratendinous addition was found in 25.6% versus 30.2%, punctiform leaks in 23.1% versus 20.9%, and recurrent tears in 15.4% versus 23.3% respectively. The rehabilitation program that results in better tendon healing by preventing postoperative stiffness has not yet been identified. Our results suggest that early passive motion should be authorized: the functional results were better with no significant difference in healing.