Upper-extremity Function Research Articles

Bundling implementation strategies supports outcome measure adoption in stroke rehabilitation: preliminary findings

BackgroundOver 80% of people who experience a stroke present with residual impairment of the upper extremity, such as the shoulder, elbow, wrist, and hand. However, rarely do stroke rehabilitation practitioners (e.g., occupational therapists) use standardized outcome measures to objectively evaluate upper extremity function. Accordingly, the purpose of this project was to develop a bundle of implementation strategies that supports practitioners’ adoption of the Fugl-Meyer Assessment of the Upper Extremity in stroke rehabilitation practice.MethodsWe used tenets of Implementation Mapping to guide the development of our implementation strategy bundle. We partnered with one, large academic health system serving over 200 stroke patients annually through intensive rehabilitation care. Strategies were selected and developed through a multi-method process that included a review of the literature, qualitative input from our health system’s practitioners and managers, and expert consultation. We also specified the hypothesized implementation “mechanisms” our strategies intended to change. Practitioners’ adoption (yes/no) of the Fugl-Meyer Assessment was calculated by analyzing electronic health record documentation of the 6-month time frame before strategies were deployed compared to the 6-month time frame after deployment.ResultsPractitioners were exposed to the following implementation strategies to support Fugl-Meyer adoption: conduct educational meetings, prepare outcome measure champions, provide equipment, develop training materials, and adapt documentation systems. In the 6-months before deployment of our implementation strategies, practitioners implemented the Fugl-Meyer with 14.8% of stroke patients. In the six months after deployment, adoption of the Fugl-Meyer increased to 73.8% (p < .001).ConclusionsWhen systematically developed in collaboration with health system partners, a bundle of implementation strategies may support outcome measure adoption in stroke rehabilitation. Improving the use of standardized outcome measures is of paramount importance in stroke rehabilitation to objectively monitor patients’ progress or decline, to demonstrate the value of rehabilitation services for enhancing patients’ recovery, and to advocate for continued reimbursement for rehabilitation care. Future opportunities lie in further specifying the mechanisms through which implementation strategies are intended to work and how those mechanisms contribute to strategy effectiveness.Trial registrationNCT registration: NCT04888416; May 06, 2021.

Effects of moderate physical activity on diabetic adhesive capsulitis: a randomized clinical trial.

Moderate physical activity (MPA) has proven advantages for glycemic control, cardiovascular health, and functional independence. However, physical activity is not part of routine conventional physical therapy (CPT) in managing diabetic adhesive capsulitis patients. To determine the effects of moderate MPA on diabetic adhesive capsulitis (AC). A randomized control trial was conducted at the Combined Military Hospital (CMH), Muzaffarabad, Pakistan from March 2022 to October 2022. A total of n = 44 patients with diabetic AC, aged 40 to 65 years, HbA1c > 6.5% were enrolled. Group A received MPA and CPT, while Group B only received CPT for six weeks. The upper extremity function, pain, and range of motion were assessed at baseline, third week, and sixth week through the disability of arm, shoulder, and hand (DASH) questionnaire, numeric pain rating scale (NPRSS), and goniometer respectively. The NPRS score and ROMs showed significant improvement (p < 0.05) in group A compared to group B with a large effect size. When comparing the mean difference of the DASH score (73 + 7.21 vs. 57.9 + 12.64, p < 0.001, Cohen's d = 1.46) was significantly improved with large effect size in group A as compared to group B. MPA along with CPT has positive effects on patient pain, range of motion, and disability in patients with diabetic adhesive capsulitis.

EngageHealth: a mobile device application designed to deliver stroke rehabilitation exercises using asynchronous video recordings

BackgroundStroke survivors who receive more rehabilitation therapy achieve better functional outcomes. The amount of rehabilitation that patients receive is, however, limited due to constraints of the healthcare system.ObjectiveTo assess whether EngageHealth, a mobile device application designed to deliver stroke rehabilitation exercises using asynchronous video recordings, increases the amount of outpatient rehabilitation in stroke patients and improves their upper extremity function and quality of life.DesignProspective single-arm study consisting of a 2-week pre-intervention phase without EngageHealth followed by a 4-week intervention period with EngageHealth.SettingAmbulatory care.ParticipantsTwenty-four stroke patients with upper extremity impairment were recruited at the Stanford Stroke Center outpatient clinic.InterventionsParticipants were instructed to use the EngageHealth application daily.Main outcome measuresAdherence, user experience, and change in the upper extremity Fugl-Meyer (UE-FM), Quality of Life in Neurological Disorders (Neuro-QoL), and Stroke Impact Scale (SIS).ResultsOf 23 participants, five (22%) used the application for 17 days, six (26%) used the application for 9–16 days, and 12 (52%) used it &amp;lt; 9 days. Sixty-three percent of participants would recommend the application to other stroke survivors, with fifty percent indicating they would continue using the application, if available. During the pre-intervention phase, there were no changes in hand function. During the intervention period, participants improved by 4 points on the UE-FM (P &amp;lt; 0.01), and 15 points in the hand-function domain of SIS (P = 0.03). Videos of participants' exercises were successfully recorded, allowing the clinician to review videos of the participants' completed tasks asynchronously. In-depth interviews revealed that participants viewed the EngageHealth application favorably, and that their perceived usefulness of the exercises affected their motivation.ConclusionsUse of the EngageHealth application in the home environment may improve upper extremity function in subacute/chronic stroke patients. Additional support strategies should be implemented in future studies to improve adherence. These findings from a prospective single-arm study, support the design of a randomized controlled trial to determine the efficacy of long-term use of the EngageHealth application.

Evaluation of fatigue and fatigability in people with Duchenne muscular dystrophy using a dynamic arm support – a pilot study

Background Due to progressive muscle wasting and weakness in patients with Duchenne Muscular Dystrophy (DMD), physical fatigability increases, upper extremity function reduces, which negatively impacts quality of life. Assistive technology such as dynamic arm supports (DAS) may help reduce this fatigability. This study aims to assess whether the novel Yumen ‘EXone’ DAS can reduce upper extremity fatigue and fatigability in DMD patients and healthy controls (HC), both with and without the DAS. Additionally, longitudinal changes in DMD patients were evaluated. Methods Five DMD patients from the Yumen Bionics pioneer program and five HCs participated. Two submaximal tests simulating drinking and reaching were performed for two minutes, each with and without DAS. DMD participants completed these tests twice, at baseline (T0) and after 6-9 months (T1), while HCs completed them once. Physical fatigability was measured by the number of repetitions and changes in surface electromyography (sEMG) amplitude. Subjective fatigue was assessed using the Borg Scale (6-20) Rate of Perceived Exertion (RPE). Results DMD participants generally performed more repetitions with the DAS than without. HCs showed similar or increased repetitions with the DAS. Assessing fatigability with sEMG was difficult due to the compensatory mechanisms used for the tests. Subjective fatigue scores on the Borg Scale were lower with the DAS for both DMD patients and HCs. Conclusion The Yumen ‘EXone’ DAS effectively reduces both fatigue and fatigability in DMD patients and healthy controls. Despite the methodological shortcomings, this research is one of the first studies investigating the impact of DAS on fatigue and fatigability.

Effect of Aquatic Bilateral Exercise on the Function of Upper Extremity in a Child with Hemiplegic Cerebral Palsy : Single-subject Experimental Study

Effect of Aquatic Bilateral Exercise on the Function of Upper Extremity in a Child with Hemiplegic Cerebral Palsy : Single-subject Experimental Study

Effect of Repetitive Transcranial Magnetic Stimulation on Upper Extremity Function in Stroke Patients : Literature Review

Effect of Repetitive Transcranial Magnetic Stimulation on Upper Extremity Function in Stroke Patients : Literature Review

A Treatment Algorithm for Free Vascularized Bone Reconstruction in Rare Large Osseous Defects Involving the Wrist.

Large bone defects of the distal radius and/or carpus following tumor resection, trauma, or infection are extremely rare. There are few case reports and series in the literature on the reconstruction approaches required in such cases. Therefore, large studies cannot be used to guide the therapeutic decisions of reconstructive plastic and hand surgeons. The objective of this study is to propose a treatment algorithm to predict the functional outcome and quality of life for the different techniques of free vascularized bone reconstruction in the interval between the distal radius, the carpus, and/or the proximal metacarpal. The algorithm was developed based on our own case studies and the few treatment approaches described in the literature. It can be applied to rare cases of massive bone defects in the wrist. The flowchart enables surgeons to develop an individualized reconstruction concept for various intervals of bone defects in the area of the distal radius and proximal metacarpal bones. Ultimately, the treatment algorithm aims to maximize future quality of life (QoL) and function of the distal upper extremity in rare cases of massive wrist-bone defects.

A Randomized Controlled Trial of Home-Based Virtual Rehabilitation to Improve Adherence to Prescribed Home Therapy after Burn Injury: A Northwest Regional Burn Model System Trial.

Daily rehabilitation after burn injury is vital for prevention of function-limiting contractures. However, adherence to prescribed therapy following acute burn hospitalization has historically been low and not well-studied. Studies involving virtual reality technology have demonstrated an association with improved functional outcomes in burn therapy. We conducted a five-year randomized controlled trial comparing 12 weeks of a home-based virtual rehabilitation (HBVR) system with standard burn therapy. Our primary outcome was adherence to prescribed home therapy, measured by e-diary self-report. Secondary outcomes included steps walked daily and patient-reported outcomes regarding stiffness, upper extremity function, and mobility. We enrolled 50 subjects, of which 48 provided data for analysis (23 HBVR, 25 control). Overall adherence to prescribed home therapy was low, 37.2% in the HBVR group and 60.0% in the control group. Reasons for non-adherence in the HBVR group included lack of time, engagement, and replacement of therapy with other physical activity. However, some subjects enjoyed HBVR and believed it aided their recovery. There was no difference in daily steps walked between the two groups. Daily walking gradually improved from 3,500 steps per day in the first week after baseline and plateaued at 6,000 steps per day at week five. There were no differences in stiffness, upper extremity function, and mobility between the two groups at baseline and 3-, 6-, and 12-month follow-up. Subjects demonstrated improved upper extremity function and mobility in the first year after discharge that coincided with increasing stiffness.

UPPER EXTREMITY SELECTIVE VOLUNTARY MOTOR CONTROL IN CHILDREN WITH UNILATERAL CEREBRAL PALSY AND ITS ASSOCIATION WITH UPPER EXTREMITY FUNCTIONS

Purpose: The study aimed to define the upper extremity selective voluntary motor control (SVMC) in children with unilateral Cerebral Palsy (CP). It was also aimed to investigate the relationship between upper extremity SVMC and upper extremity functions. Methods: Twenty-four children diagnosed with unilateral CP, aged between 6 and 18, were included in the study. The Quality of Upper Extremity Skills Test (QUEST) assessed the upper extremity functions. Manual dexterity was measured using the Jebsen-Taylor Hand Function Test (JTT) timed tasks. The SVMC of the upper extremity was measured using the Selective Control of Upper Extremity Scale (SCUES) using the videotape recording method. Results: Statistically significant decreases in SCUES scores from shoulder to fingers were recorded using the Page statistical test for trend (p

Application of Non‐Immersive Virtual Reality in Cerebral Palsy Children: A Systematic Review

ABSTRACTCerebral palsy (CP) is a movement disorder caused by brain damage. Virtual reality (VR) can improve motor function and daily life activities in CP patients. This systematic review examines the use of non‐immersive VR in treating CP children. The objective is to evaluate the effectiveness of non‐immersive VR in rehabilitating CP children as a standalone intervention or in combination with traditional therapy. The review follows the PRISMA guidelines and includes a comprehensive search of five bibliographic databases. Two reviewers independently assess the search results, evaluate full‐text publications, and extract relevant data. The outcomes were described by the International Classification of Functioning, Disability, and Health for Children and Youth (ICF‐CY) framework. A total of 20 English‐language studies published between January 2013 and January 2023 are included in the review based on predefined inclusion and exclusion criteria. The findings demonstrate that non‐immersive VR, when used in conjunction with traditional therapy, yields positive effects on body structure and function (hand function, grip strength, and upper extremity function), activity (motor function, activities of daily life [ADL], balance), and participation (caretakers' assessment, usability, motivation, and user satisfaction) in CP children. Moreover, non‐immersive VR alone is found to be more efficient than traditional therapy in improving manual dexterity in CP children. The non‐immersive VR can be effective in rehabilitating CP children, and the review concludes by recommending future research with larger sample sizes and randomized trials to investigate further the potential benefits of non‐immersive VR in this population.

THE EFFECT OF TRUNK STABILITY TRAINING ON UPPER EXTREMITY ENDURANCE, STABILITY AND SHOULDER JOINT PROPRIOCEPTION IN POSTMENOPAUSAL WOMEN

Purpose: The incidence of shoulder pathologies is increasing in postmenopausal women. In this period, there is a need for protective approaches to be applied to prevent shoulder injuries. The aim of this study is to investigate the effects of clinical pilates exercises on upper extremity stability, endurance, function and shoulder joint proprioception in postmenopausal women. Methods: 30 postmenopausal women between the ages of 40-60 were included in our study. Participants were given clinical pilates training for 6 weeks, 3 days a week, 60 minutes by a physiotherapist. Before and after pilates training, dynamic stability of the shoulder was evaluated with Closed Kinetic Chain Upper Extremity Stability Test (CKCUES Test) and Upper Quarter Y Balance Test (UQYBT). Upper extremity muscle endurance was evaluated with the modified push up test. Laser Pointer-Assisted Angle Reproduction Test (LP-ART) was used to evaluate shoulder joint position sense. Results: A statistically significant difference was found in CKCUES Test (p=0.000, r=0.594), UQYBT (p=0.000, r=0.537), modified push up (p=0.000, r=0.594), LP-ART abduction (p=0.000, r= 0.491) and LP-ART flexion (p=0.000, r=0.484) at end of the training compared to the pre-training. The exercise program was found to be highly effective on all parameters. Conclusion: It was concluded that clinical pilates training applied in postmenopausal women increased the dynamic stability of the shoulder, endurance and position sense. Trunk stabilization exercises may be beneficial as a preventive approach in the prevention of shoulder pathologies in postmenopausal women.

Validity and reliability of the Six-Minute Pegboard Ring Test for assessing functional capacity and upper limb function in persons with multiple sclerosis

BackgroundThe timed walk test is essential for assessing the functional capacity of persons with multiple sclerosis (MS). When a decline in ambulation ability and loss of function in the later stages of MS is observed, it is imperative to utilize alternative methods for measuring functional capacity. ObjectiveTo investigate the validity and reliability of the Six-Minute Pegboard Ring Test (6PBRT) in persons with MS. MethodsForty-three persons with MS were included in this study. Disease severity was quantified using the Expanded Disability Status Scale (EDSS). The 6PBRT was employed to assess upper extremity function during exercise stress, and vital signs were monitored pre- and post-test. Muscle strength was measured using a digital dynamometer for shoulder flexor, shoulder abductor, and grip strength, in addition to a hand dynamometer. Manual dexterity was evaluated through the 9-Hole Peg Test (9HPT), and walking endurance was assessed using the 2-Minute Walk Test (2MWT). Test-retest reliability was computed using the intraclass correlation coefficient (ICC). ResultsThe ICC value for the 6PBRT was 0.96 (95% CI 0.92–0.97), indicating excellent test-retest reliability. Significant differences in vital signs were observed before and after conducting the 6PBRT (p < 0.05). A strong negative correlation was found between the 6PBRT score and EDSS (r = -0.650, p < 0.001). The 9HPT of the dominant side demonstrated a moderate correlation with the 6PBRT score (r = -0.502, p = 0.001), whereas no significant correlation was shown between the non-dominant side 9HPT and the 6PBRT score (p > 0.05). Moreover, a positive moderate correlation was shown between the performance on the 2MWT and the 6PBRT score (r = 0.413, p = 0.006). However, no significant correlation was detected between the proximal muscle strength of the upper extremity, handgrip strength, and the 6PBRT score in individuals with multiple sclerosis (p > 0.05). ConclusionThe 6PBRT is a reliable and valid tool to evaluate upper extremity function and exercise capacity in persons with MS.

Effects of Sling-Suspension-Based Active Shoulder Joint Exercise on Shoulder Joint Subluxation, Pain, Muscle Strength, and Upper Limb Function in Patients with Subacute Stroke.

Background and Objectives: We investigated the effects of sling-suspension-based active shoulder joint exercise training on shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke. Materials and Methods: Twenty-eight patients with subacute stroke were randomly assigned to either the sling-suspension-based active shoulder joint exercise (SASE) group (n = 14) or the motorized upper extremity exercise (MUEE) group (n = 14). The SASE group actively performed shoulder joint flexion, extension, abduction, adduction, external and internal rotation, and horizontal abduction and adduction using a sling suspension system, whereas the MUEE group underwent an exercise program using a motorized upper extremity exercise machine. All participants underwent a 4-week intervention with 30 min of exercise once a day for 5 days a week. Additionally, both groups received general physical therapy and functional electrical stimulation for 30 min twice a day for 5 days a week. Shoulder joint subluxation was measured by radiographic examination before and after training, and pain was evaluated in the splenius, upper trapezius, and infraspinatus muscles using pressure parameters. In addition, a manual muscle tester was used to assess the muscle strength of the shoulder joint flexors, extensors, abductors, adductors, and external and internal rotators, and the Fugl-Mayer Assessment (FMA) and Manual Functional Test (MFT) were used to evaluate upper extremity function. Results: A significant group-time interaction was observed for pain, with F-values of F(1, 26) = 7.470, p < 0.011 for the splenius and F(1, 26) = 9.623, p < 0.005 for the upper trapezius. A significant time-group interaction was observed for the muscle strength of the shoulder, with F-values of F(1, 26) = 13.211, p < 0.001; F(1, 26) = 4.974, p = 0.035 and F(1, 26) = 9.674, p = 0.004 for flexors, abductors, and external rotators, respectively. A significant time-group interaction was observed in the FMA, with F-values of F(1, 26) = 13.243, p < 0.001. When comparing the interaction effects between time and group for MFT scores, a significant difference was observed, with F-values of F(1, 26) = 32.386, p < 0.001. Conclusions: This study confirmed that sling-suspension-based active shoulder joint exercises are effective in improving shoulder joint subluxation, pain, muscle strength, and upper extremity function in patients with subacute stroke.

Effectiveness of mixed reality-based rehabilitation on hands and fingers by individual finger-movement tracking in patients with stroke

BackgroundMixed reality (MR) is helpful in hand training for patients with stroke, allowing them to fully submerge in a virtual space while interacting with real objects. The recognition of individual finger movements is required for MR rehabilitation. This study aimed to assess the effectiveness of updated MR-board 2, adding finger training for patients with stroke.MethodsTwenty-one participants with hemiplegic stroke (10 with left hemiplegia and 11 with right hemiplegia; nine female patients; 56.7 ± 14.2 years of age; and onset of stroke 32.7 ± 34.8 months) participated in this study. MR-board 2 comprised a board plate, a depth camera, plastic-shaped objects, a monitor, a palm-worn camera, and seven gamified training programs. All participants performed 20 self-training sessions involving 30-min training using MR-board 2. The outcome measurements for upper extremity function were the Fugl–Meyer assessment (FMA) upper extremity score, repeated number of finger flexion and extension (Repeat-FE), the thumb opposition test (TOT), Box and Block Test score (BBT), Wolf Motor Function Test score (WMFT), and Stroke Impact Scale (SIS). One-way repeated measures analysis of variance and the post hoc test were applied for the measurements. MR-board 2 recorded the fingers’ active range of motion (AROM) and Dunnett’s test was used for pairwise comparisons.ResultsExcept for the FMA-proximal score (p = 0.617) and TOT (p = 0.005), other FMA scores, BBT score, Repeat-FE, WMFT score, and SIS stroke recovery improved significantly (p < 0.001) during MR-board 2 training and were maintained until follow-up. All AROM values of the finger joints changed significantly during training (p < 0.001).ConclusionsMR-board 2 self-training, which includes natural interactions between humans and computers using a tangible user interface and real-time tracking of the fingers, improved upper limb function across impairment, activity, and participation. MR-board 2 could be used as a self-training tool for patients with stroke, improving their quality of life.Trial registration number: This study was registered with the Clinical Research Information Service (CRIS: KCT0004167).

Effectiveness of Virtual Reality in Occupational Therapy for Post-Stroke Adults: A Systematic Review.

Background: In recent years, there has been a growing use of technological advancements to enhance the rehabilitation of individuals who have suffered from cerebrovascular accidents. Virtual reality rehabilitation programs enable patients to engage in a customized therapy program while interacting with a computer-generated environment. Therefore, our goal was to investigate the effectiveness of virtual reality in occupational therapy for people's rehabilitation after a cerebrovascular accident. Methods: We systematically searched databases (Pubmed/Medline, Scopus, Web of Science, and Science Direct) for randomized controlled trials published within the last 10 years. Studies involving adult stroke survivors undergoing virtual reality-based interventions aimed at improving upper-extremity motor function were included. The quality assessment followed PRISMA guidelines, with the risk of bias assessed using the Cochrane tool (version 6.4) and methodological quality evaluated using GRADEpro. Results: We selected sixteen studies that met the main criteria for the implementation of virtual reality technology. The interventions described in the articles focused mainly on the upper extremities and their fine motor skills. Conclusions: When used in conventional treatments to improve people's motor and cognitive functions after a cerebrovascular accident, virtual reality emerges as a beneficial tool. Additionally, virtual reality encourages adherence to the interventional process of rehabilitation through occupational therapy.

Evaluation of the effects of a gamified, fully immersive and stroke-specific virtual reality intervention for improving disability and quality of life in patients with stroke in the subacute phase: study protocol of the RESET randomised trial

Stroke is the leading cause of disability and the second cause of death worldwide. The increasing burden of stroke underscores the importance of optimising rehabilitation protocols. Virtual reality (VR) can...

Effects of Video-Based Exercises and Conventional Physiotherapy on Upper Extremity Functionality, Selective Motor Control, and Proprioception in Unilateral Cerebral Palsy: A Randomized Controlled Trial.

Objective: The present study was conducted to evaluate the effects of video-based exercises added to conventional physiotherapy (CPT) on upper extremity functionality, selective motor control, and proprioception in individuals with unilateral cerebral palsy (UCP). Materials and Methods: Thirty patients with UCP were randomized into two groups: the intervention group (15 individuals with a mean age of 9.2 ± 3.8 years) and the control group (15 individuals with a mean age of 8.3 ± 4.1 years). The intervention group received 8 weeks of video-based exercises, and the control group received 8 weeks of conventional physiotherapy. Upper extremity functional abilities, upper extremity selective motor control, proprioception, and entertainment levels were evaluated before and after the intervention for all groups. Results: While a significant change was observed in the mean scores of the ABILHAND-Kids, Selective Control of the Upper Extremity Scale right-left scores, shoulder flexion, shoulder abduction, and elbow flexion proprioception angles after the video-based exercises in the intervention group (P < 0.05), a significant change was observed only in the 60-degree flexion angle in the control group (P = 0.001). In the comparison between the groups, there were significant differences in post-intervention value only in shoulder flexion and abduction angles, whereas there was no difference between the groups in elbow flexion angles (P > 0.05). Conclusion: Incorporating video-based exercises into the upper extremity rehabilitation processes of individuals with UCP is beneficial in terms of upper extremity functionality, selective motor control, and proprioception.

Psychosocial and functional impact of successful digital replantation – A cohort study of 36 patients with a median follow-up of 6 years

IntroductionThis study aims to evaluate the long-term psychosocial and functional outcomes of successful digital replantation following traumatic amputation. MethodsPatients that underwent successful replantation (i.e. no secondary amputation following replantation) of one or more traumatically amputated digits between January 2009 and April 2019 were invited to participate in this study. In addition to a custom questionnaire on psychosocial and socioeconomic aspects of life, various Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires regarding global health, upper extremity function, and depressive symptoms were completed. Bivariate analyses were performed to identify significant associations between outcomes and explanatory variables. ResultsThirty-six patients were successfully enrolled and completed the questionnaires at a median follow-up of 6.1 years. The median PROMIS score for Upper Extremity Function (40.6) was considerably different from the score that is typically found in the general population (all PROMIS instruments are calibrated with a control group score of 50.0), but the median PROMIS scores for Global Health – Physical (49.0), Global Health – Mental (50.7), and Depression (45.6) were comparable to those among the general population. Dominant hand injury, a greater number of injured digits, higher age at the time of injury, and the need for neuropathic pain medication were associated with lower Upper Extremity Function scores (all p < 0.05). Additionally, the presence of neuroma was associated with negative changes in both household finances and mental well-being (p < 0.05). ConclusionsAt long-term follow-up, a majority of patients that underwent replantation of traumatically amputated digits seem to cope well based on psychosocial and functional outcomes. However, neuropathic pain and the presence of neuroma are strong negative factors. Specific attention to digital nerves at the time of surgery is crucial in the management of traumatic amputations.

Lowered ratio of corticospinal excitation to inhibition predicts greater disability, poorer motor and cognitive function in multiple sclerosis

ObjectiveInvestigate excitatory-inhibitory (E/I) (im)balance using transcranial magnetic stimulation (TMS) in individuals with Multiple Sclerosis (MS) and determine its validity as a neurophysiological biomarker of disability. MethodsParticipants with MS (n = 83) underwent TMS, cognitive, and motor function assessments. TMS-induced motor evoked potential amplitudes (excitability) and cortical silent periods (inhibition) were assessed bilaterally through recruitment curves. The E/I ratio was calculated as the ratio of excitation to inhibition. ResultsParticipants with greater disability (Expanded Disability Status Scale, EDSS≥3) exhibited lower excitability and increased inhibition compared to those with lower disability (EDSS<3). This resulted in lower E/I ratios in the higher disability group. Individuals with higher disability presented with asymmetrical E/I ratios between brain hemispheres, a pattern not present in the group with lower disability. In regression analyses controlling for demographics, lowered TMS-probed E/I ratio predicted variance in disability (R2 = 0.37, p < 0.001), upper extremity function (R2 = 0.35, p < 0.001), walking speed (R2 = 0.22, p = 0.005), and cognitive performance (R2 = 0.25, p = 0.007). Receiver Operating Characteristic curve analysis confirmed ‘excellent’ discriminative ability of the E/I ratio in distinguishing high and low disability. Finally, excitation superiorly correlated with the E/I ratio than overall inhibition in both hemispheres (p ≤ 0.01). ConclusionThe E/I ratio is a potential neurophysiological biomarker of disability level in MS, especially when assessed in the hemisphere corresponding to the weaker body side. Interventions aimed at increasing cortical excitation or reducing inhibition may restore E/I balance potentially stalling progression or improving function in MS.

Minimally invasive needle tenotomy vs. platelet rich plasma injection in the treatment of chronic elbow epicondylitis

BackgroundMedial and lateral epicondylitis, characterized by repetitive microtraumas to common flexor and extensor tendons respectively, are common causes of elbow pain in adults. Though symptoms generally are self-limiting, 10% of cases are refractory to conservative management, persisting for greater than 18 months and leading to surgery, which can have increased risk of complications. There is minimal data on sustained pain relief and functional benefit for newer non-surgical management options such as minimally invasive needle tenotomy (MINT) via Tenjet and platelet-rich plasma (PRP) for chronic elbow epicondylitis. Additionally, no previously established correlation exists between MRI severity of chronic epicondylitis with pain and functional improvement in MINT and PRP-treated patients. MethodsA retrospective review of 51 adults (n=23 for Tenjet; n=28 for PRP) was conducted to investigate long-term outcomes in pain relief (via Visual Analog Scale or VAS) and improvements in upper extremity function (via Quick Disability of the Arm, Shoulder, and Hand questionnaire or qDASH). These outcomes were correlated with radiographic evidence of epicondylitis severity, assessed by grade of epicondylitis and percentage thickness of tendon tears. ResultsThere were significant improvements in pain (VAS) but no significant differences in function (qDASH) following MINT and PRP. On average, VAS score improved by 2.6 (p<0.001) post-Tenjet and by 3.8 (p<0.001) post-PRP, combined for all follow-up time points. No adverse events were reported over the entire study. A significantly higher percentage of patient-reported pain relief was noted post-Tenjet at all follow-up time points. VAS and qDASH outcomes post-Tenjet and post-PRP were not correlated with initial MRI severity of epicondylitis. ConclusionsThere are multifactorial benefits of both Tenjet and PRP as safe, non-open surgical modalities that can be used, despite MRI severity, to provide sustained pain relief for patients with refractory elbow epicondylitis.