Physical Medicine & Rehabilitation

A randomized control trial of comparing ultrasound-guided ozone (O2-O3) vs corticosteroid injection in patients with shoulder impingement Introduction Ozone has been recently used as a safe alternative treatment in musculoskeletal disorders with fewer side effects than corticosteroids. The aim of this study was to compare the efficacy of a single injection of ozone with that of a corticosteroid in the treatment of shoulder impingement. Design 30 patients with shoulder pain and clinical signs and symptoms of impingement were randomly assigned into two groups: ultrasound-guided injection with ozone or corticosteroid. Patients' symptoms were evaluated by Visual Analog Scale (VAS), Constant score, Shoulder Pain and Disability Scale (SPADI), shoulder range of motion (ROM) and ultra-sonographic measures before treatment, two weeks and two months after injections. Results Patients' VAS, SPADI and Constant score improved significantly in both groups (P<0.001), but the benefits were in favor of corticosteroid group (P<0.001). At intervals between the two follow-ups, an improvement was observed in the VAS score among patients receiving ozone, while during the same interval, patients' pain slightly worsened in the corticosteroid group. The ROM and ultra-sonographic measures did not show statistical differences between the two groups. Conclusion Corticosteroid injection improves the pain and disability scores more significantly than a one-time ozone injection. Ozone may serve as an alternative modalities in treating shoulder impingement when the use of steroids is contraindicated. *Corresponding author: Mohamad Sadegh Khabbaz All correspondence should be addressed to: Mohamad Sadegh Khabbaz, MD. Department of Physical Medicine and Rehabilitation, Firoozgar hospital, Valieasr square, Tehran, Iran. Fax: +98[21]88942970, Tel: +98[21]88908519, Mobile: +989120766393, E-mail: m.sadegh.khabbaz@gmail.com Author Disclosures: There is no conflict of interest. No funding or grants or equipment provided for the project from any source and there are no financial benefits to the authors. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Effect of 4-channel Neuromuscular Electrical Stimulation on Swallowing Kinematics and Pressures: A Pilot Study Objective The purpose of this study was to evaluate the effectiveness of the sequential 4-channel neuromuscular electrical stimulation (NMES) system. Design As a prospective case-control study, ten healthy subjects and ten patients with dysphagia were prospectively enrolled. Swallowing with and without sequential 4-channel NMES (suprahyoid, infrahyoid muscles) was evaluated via videofluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). Results Results showed that the sequential 4-channel NMES significantly improved the videofluoroscopic dysphagia scale (VDS) during thick-fluid swallowing in patients with dysphagia. Furthermore, the kinematic analysis of VFSS showed a tendency that NMES reduced duration of hyoid bone movement during thin- or thick-fluid swallowing. The HRM parameters –maximal pressure of velopharynx (VP), tongue base (TB), cricopharyngeal pressure (CP), minimal upper esophageal sphincter (UES) pressure, area of VP, UES activity time, and duration of nadir UES – during thin-fluid swallowing were significantly improve in both groups compared with the HRM parameters without NMES. Conclusion The sequential 4-channel NMES may help improve the parameters of VFSS, kinematic analysis of the hyoid bone movement, and HRM during swallowing. Further investigations are needed to better examine the effects of NMES in patients with dysphagia. Donghwi Park and Jee Hyun Suh contributed equally to this paper and should therefore be regarded as equivalent first authors. Address corresponding author: Ju Seok Ryu, M.D., Ph.D. Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea, 463-707 (e-mail: jseok337@snu.ac.kr), Tel : 82-31-787-7739, Fax : 82-31-787-4051 Acknowledgement: The authors gratefully appreciate MRCC team of Seoul National University Bundang Hospital for their work in the area of statistics in this study Financial support: This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2016R1D1A1B03935130) Conflict of interest: No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Expiratory Muscle Strength Training on Swallowing and Cough Functions in Patients with Neurological Diseases: A meta-analysis Objective The aim of this review is to evaluate and summarize the results of published studies exploring the effects of expiratory muscle strength training (EMST) on swallowing and cough functions in patients with neurological diseases. Data sources Embase, PubMed, and the Cochrane Library. Review methods Randomized controlled trials or pretest/posttest studies of adults with neurological diseases were included. The data included basic population characteristics, penetration-aspiration scores (PAS), peak expiratory flow rate (PEFR), cough volume acceleration (CVA) and maximum expiratory pressure (PEMax). Results Ten studies were included in this meta-analysis. Compared with the control groups, EMST in patients with neurological diseases significantly reduced the PAS (risk ratio (RR)=-0.94, 95% confidence interval (CI), 1.27–-0.61, P<0.01) but did not increase the voluntary cough PEFR (RR=0.57, 95% CI, 0.62–1.77, P=0.35), CVA (RR=33.87, 95% CI, 57.11–124.85, P=0.47) or PEMax (RR=14.78, 95% CI, 16.98–46.54, P=0.36). Conclusion EMST might improve swallowing function in patients with neurological diseases. However, conclusive evidence supporting the use of this approach in isolation for improving cough function is unavailable. Additional multicenter, randomized clinical trials performed using reliable and valid cough function outcome measures are required to explore the effects of EMST on cough function. Correspondence: Qi Fang. Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China. Tel:+86-13606213892. E-mail: fangqi_008@126.com; Huiling Li, The First Affiliated Hospital of Soochow University/School of Nursing, Soochow University, No. 188 Shizi Street, Suzhou, China. Tel: +86-512-65221437 Author Disclosures: The authors read and approved the final manuscript and declare that there was no conflict of interest. This work was funded by Postgraduate Research & Practice Innovation Program of Jiangsu Province; Integrated Care Model For Patients With Dysphagia After Stroke [grant number KYCX18_254], and National Key Research And Development Program of China [grant number 2017YFC0114302] Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Painful Foot Disorders in the Geriatric Population: A Narrative Review Painful foot disorders are highly prevalent among older adults causing a significant impact on mobility, function, and risk of falls. Despite its significance, foot pain is often interpreted as a normal part of aging and relatively ignored by health care providers as well as by the elderly themselves. Accurate diagnosis of the cause of foot pain is possible for most cases via clinical evaluation without a costly workup. Clinicians should consider, not only musculoskeletal pathologies, but also vascular and neurological disorders in older patients with foot pain. Fortunately, a majority of patients improve with physiatric, non-operative interventions involving biomechanical analysis, function oriented rehabilitation programs and therapeutic exercise, the use of proper footwear and orthoses, and selected percutaneous interventions, as indicated. In this review, we discuss the physiologic changes of the aging foot relevant to foot pain, the impact of painful foot disorders on function and other key outcomes, and principles of diagnosis and intervention. We also briefly describe painful foot disorders of the elderly commonly encountered in a physiatric practice. Previous presentation of the data: not applicable Financial support: none Corresponding author: Mooyeon Oh-Park, M.D. Address: Burke Rehabilitation Hospital, 785 Mamaroneck Av, White Plains, NY, 10605, U.S.A. Email: mohpark@burke.org Painful Foot Disorders in the Geriatric Population: A Narrative Review Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of Platelet Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study Objective This study aims to assess whether ultrasound guided injection of platelet rich plasma (PRP) can safely and effectively treat symptoms associated with acetabular hip labral tears. Design Institutional Review Board (IRB) approval was gained for a prospective study of eight patients (N=8), who have previously failed conservative management, to receive ultrasound-guided injection of PRP at the site of hip labrum tear. We assessed pain reduction and functional ability at baseline, and then 2, 6, and 8 weeks after injection, using the Visual Analogue Scale (VAS) and Harris Hip Score (HHS), respectively. Results Statistically significant differences in HHS were seen two (86.5 +/- 10.8, p<0.01), six (88.0 +/- 10.7) p<0.01), and eight weeks (92.1 +/- 11.6, p<0.01) after injection as compared to baseline (76.0 +/- 13.4). Corresponding improvements were seen in VAS two (1.0, p<0.01 at rest, 2.5, p<0.01 with activity), six (0.9, p<0.01 at rest, 2.3, p<0.01 with activity), and eight weeks (0.5, p<0.01 at rest, 1.3, p<0.01 with activity) compared to baseline (3.8 at rest, 5.4 with activity). Conclusions Ultrasound-guided injection of PRP holds promise as an emerging, minimally-invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears. Correspondence: Arthur Jason De Luigi, DO, MHSA, 10825 N. 140th Way, Scottsdale, AZ 85259301793-2136. ajweege@yahoo.com Author Disclosures: Arthur Jason De Luigi, DO, MHSA Daniel Blatz, MD Christopher Karam, MD Zachary Gustin, MD Andrew H. Gordon, MD Competing Interests-None for any author Funding or grants or equipment provided for the project from any source-None for any author Financial benefits to the authors-None to any author Details of any previous presentation of the research, manuscript, or abstract in any form: Please note that we have presented this research at both national and local conferences. This research was selected as a Scientific Paper Presentation at the 2015 Association for Academic Physiatrists conference held in San Antonio, Texas. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Administration of Platelet Rich Plasma to Hip Labral Tears Reduces Pain and Improves Function.Scientific Paper (Podium) Presentation, Annual Meeting of the Association of Academic Physiatrists. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Improved Hip Function and Pain Alleviation after Single Administration of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Oral Poster Presentation, Annual Meeting of the American Medical Society for Sports Medicine. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Functional Improvement and Pain Reduction after Single Injection of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Poster Presentation, MedStar Health Research Institute Research Symposium. 2015. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A NEW THRESHOLD FOR APPENDICULAR LEAN MASS DISCRIMINATES MUSCLE WEAKNESS IN WOMEN WITH HIP FRACTURE: A CROSS-SECTIONAL STUDY. Objective To investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass (aLM), aLM-to-body-mass-index ratio and aLM/height2 to separate weak and non-weak women. Secondly, we aimed to explore alternative thresholds for the 3 measures of muscle mass to discriminate weakness. Design Cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed aLM by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength <16 kg. Results Weakness was not significantly associated with aLM <15.02 kg, aLM-to-body-mass-index ratio <0.512 or aLM/height2 <5.67 kg/m2. For aLM (but not for the other 2 measures of muscle mass) an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ2 (1, n=160)=10.77 (p=0.001). The association between aLM <11.87 kg and grip strength <16 kg persisted after adjustment for age and body mass index: odds ratio =2.50 (95% CI 1.17-5.34; p=0.018). Conclusions Data suggests that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For aLM an alternative cutoff-point actually separated weak and non-weak women. CORRESPONDING AUTHOR: Dr. Marco Di Monaco, Osteoporosis Research Center, Division of Physical Medicine and Rehabilitation, Presidio Sanitario San Camillo, Strada Santa Margherita 136, 10131, Torino, Italy. Tel. 0039 011 8199411; Fax 0039 011 8193012; Email Marco.di.monaco@alice.it,m.di-monaco@h-sancamillo.to.it DISCLOSURES: All the authors have no conflicts of interest. The study was not funded. The authors had no financial benefits for the study. The results have not been previously presented. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Letter to the Editor Regarding the Article "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) lesion" No abstract available

Authors' Response to the Letter to the Editor on "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) Lesion" No abstract available

EMG Evaluation of Bodyweight Exercise Progression in a Validated ACL Injury Rehabilitation Program: Cross-sectional Study Objectives Regaining muscle strength is essential for successful outcome after anterior cruciate ligament (ACL) injury, why progression of exercise intensity in ACL injury rehabilitation is important. Thus, this study evaluated hamstring and quadriceps muscle activity progression during bodyweight exercises used in a validated ACL injury rehabilitation program. Design The study design involved single-occasion repeated measures in a randomized manner. Twenty healthy athletes (nine females) performed nine bodyweight exercises (three exercises per rehabilitation phase). Surface electromyography signals were recorded for hamstring (semitendinosus, biceps femoris) and quadriceps (vastus medialis, vastus lateralis) muscles, and normalized to isometric peak EMG (nEMG). Results Hamstring muscle activity did not increase from one rehabilitation phase to the next, ranging between 8-45% nEMG for semitendinosus and 11-54% nEMG for biceps femoris. Only one exercise (Cook hip lift) exhibited hamstring muscle activities above 60% nEMG. By contrast, quadriceps muscle activity increased, and late phase exercises displayed high nEMG (vastus lateralis >60% and vastus medialis >90% nEMG). Conclusion The examined bodyweight exercises did not progress for hamstring muscle activity but successfully progressed for quadriceps muscles activity. This study highlights the need for consensus on exercise selection when targeting the hamstring muscles in the rehabilitation after ACL injury. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Conflicts of interest None declared. Funding None declared. Corresponding author: Mette Kreutzfeldt Zebis E-mail corresponding author: mzeb@kp.dk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Differences in the mitochondrial and lipid droplet morphology in female office workers with trapezius myalgia, compared to healthy controls. A muscle biopsy study Objective Trapezius myalgia, or more specific, myofascial dysfunction of the upper trapezius mainly affects women performing jobs requiring prolonged low level activation of the muscle. This continuous low muscle load can be accompanied by a shift to a more anaerobic energy metabolism, causing pain. To investigate whether morphological signs of an impaired aerobic metabolism are present in female office workers with trapezius myalgia. Design Muscle biopsy analysis, using electron and light microscopy, was performed to compare mitochondrial and fat droplet morphology, and irregular muscle fibers, between female office workers with (n=17) and without (n= 15) work-related trapezius myalgia. Results The patient group showed a significantly higher mean area (P=0.023) and proportion (P=0.029) for the subsarcolemmal and intermyofibrillar mitochondria respectively, compared to the control group. A significantly lower mean area of subsarcolemmal lipid droplets was found in the patient group (P=0.015), which also displayed a significantly higher proportion of lipid droplets touching the mitochondria (P=0.035). A significantly higher amount of muscle fibers with COX deficient areas were found in the patient group (P=0.030). Conclusion The results of the present study may be indicatve for an impaired oxidative metabolism in work-related trapezius myalgia. However, additional research is necessary to confirm this hypothesis. Corresponding author: Kayleigh De Meulemeester Corneel Heymanslaan 10, 9000 Ghent (Belgium) Kayleigh.demeulemeester@ugent.be No conflicts of interest were present in writing this article. Kayleigh De Meulemeester is funded by BOF- UGent 01N04215. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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