Physical Medicine & Rehabilitation

The relation between loss of consciousness, severity of traumatic brain injury and injury of ascending reticular activating system in patients with traumatic brain injury Objective Loss of consciousness(LOC) is an indicator of the severity of traumatic brain injury(TBI) and the ascending reticular activating system(ARAS) has been considered as a main structure for consciousness. However, no study on the relation between LOC and ARAS injury in TBI has been reported. We investigated the relation between LOC, severity of TBI, and ARAS injury using diffusion tensor tractography(DTT). Design 120 patients were recruited. Three components of ARAS, fractional anisotropy(FA) and tract volume(TV) were measured. Results In lower dorsal and ventral ARAS, FA and TV value in mild group were higher than those of moderate and severe groups, and there was no difference between moderate and severe groups. In upper ARAS, FA value in mild group was higher than in moderate group, and in moderate group was higher than in severe group. TV value in mild group was higher than that of severe group. LOC showed moderate negative correlations with TV value of lower dorsal ARAS(r=-0.348), FA value of lower ventral ARAS(r=-0.343), and FA value of upper ARAS(r=-0.416). Conclusion Injury severity was different among three TBI groups in upper ARAS but did not differ between moderate and severe groups in lower dorsal and ventral ARAS. Corresponding author: Jong Bum Kim, MD, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University 317-1, Daemyung dong, Namku, Daegu, 705-717, Republic of Korea, Tel: 82-53-620-4098, FAX: 82-53-625-3508, e-mail: bum9839@naver.com CONFLICTS OF INTEREST. All authors report no conflict of interest All authors report no funding, grants, or equipment for this project All authors report no financial benefits All authors report no previous research, manuscript, or abstract in any form Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Interventions for Individuals with Neurological Disorders: A Systematic Review of Systematic Reviews Fall prevention requires a multifaceted approach that should include individual risk assessment and intervention strategies. Exercise interventions may mitigate most risk factors for falls (e.g., balance impairment, gait impairment, and muscle weakness). Numerous systematic reviews (SRs) or meta-analyses have assessed the effectiveness of exercise interventions among people with various types of neurological disorders; however, the evidence obtained has not been synthesized into an overview. Therefore, the present SR assessed SRs of exercise intervention for fall prevention among people with neurological disorders. The research sources were the Cochrane Database of Systematic Reviews, PubMed, and Embase. Eligible studies were selected, and data were extracted independently by two reviewers. A total of 15 studies (6 SRs and 9 meta-analyses) were included. These SRs examined in this study have demonstrated that exercise interventions reduced the number, frequency, and rate of falls among people with neurological disorders, including cognitive impairment, dementia, and Parkinson disease. Furthermore, the current study presented insufficient evidence regarding the effectiveness of exercise interventions for fall prevention among people with stroke, multiple sclerosis (MS), and diabetes mellitus with polyneuropathy (DMP). Therefore, additional investigations are necessary to evaluate the effectiveness of exercise for fall prevention among people with MS, stroke, and DMP. Correspondence to: Shih-Ching Chen, Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital, No. 252, Wu-Hsing St., Taipei City 110, Taiwan, Tel: 886-2-27372181 ext. 3538; Fax: 886-2-55589880; E-mail: csc@tmu.edu.tw Conflicts of Interest/Disclosure: The authors have no conflicts of interest to report. Funding: This study received no funding. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Not Always as it Seems: A Case of Ascending Paralysis No abstract available

Evaluation of Service Delivery Effectiveness through Patient Reported Outcome Measures Objective To report the demographic characteristics and functional mobility for individuals accessing an academic medical center mobility device clinic, and to compare functional mobility data across demographic characteristics and mobility device type. Design This study utilized a retrospective, cross-sectional design. Demographic, mobility type and patient reported outcome measure data for 833 clients was analyzed. The Functional Mobility Assessment (FMA) was utilized as the patient reported outcome measure to determine satisfaction. Results The average baseline FMA score was .59 (SD .25) on a 0-1 scale. Significant differences with the FMA scores were found across the mobility device types, with scooter and power wheelchair (PWC) groups reporting higher satisfaction scores than those in the cane/crutch/walker (CCW) or manual wheelchair (MWC) groups. Device type, gender, and age were each found to be significant predictors of satisfaction scores, p=<0.01. Conclusion Mobility device type is associated with satisfaction level. Mobility devices that offer higher levels of assistance are associated with increased satisfaction. The FMA, mobility device type, and demographic data provide baseline information for evaluating the effectiveness of an academic medical center mobility device clinic. Corresponding Author: Carmen P. DiGiovine, PhD, ATP/SMS RET, The Ohio State University, 453 W. 10th Avenue, Suite 406, Columbus OH 43210, carmen.digiovine@osumc.edu, Phone: 614-293-7876 Author Disclosures: Mark Schmeler receives royalties on the Functional Mobility Assessment (FMA) which was licensed to the Van G. Miller Group. Funding: The authors did not receive funding for this study. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Lifestyle risk behaviors among stroke survivors with and without diabetes Objective History of stroke and diabetes increase risk for cardiometabolic disease, which can be mitigated through lifestyle management. To evaluate lifestyle risk behaviors among stroke survivors, we compared the prevalence of three lifestyle risk behaviors—physical inactivity, consuming ≤1 fruit and ≤1 vegetable daily, and overweight/obesity—between stroke survivors with and without diabetes. Design Data from the 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS) were examined. Weighted and age-adjusted prevalence estimates, and crude and adjusted odds ratios (adjusted for sociodemographic characteristics), were calculated to compare lifestyle risk behaviors between U.S. stroke survivors with and without diabetes. Results Prevalence and adjusted odds ratios (AOR) for lifestyle risk behaviors were higher in participants with diabetes compared to those without diabetes for consuming ≤1 fruit and ≤1 vegetable daily (58.8% vs. 53.7%, AOR:1.14), physical inactivity (65.7% vs. 54.6%, AOR: 1.41), and overweight/obesity (87.2% vs. 63.1%, AOR: 2.42). Conclusion Prevalence of select lifestyle risk behaviors exceeds 50% in adults with stroke, but are higher in adults with diabetes compared to adults without diabetes. Effective interventions, community programs, and healthcare policy are needed to promote lifestyle management in adults with stroke, particularly among those with diabetes. CORRESPONDENCE: Ryan Bailey, PhD, OTR/L; Campus Box 1196, One Brookings Drive, St. Louis MO, 63110; Phone: 314-935-3073; Fax: (314) 935-4859; Email: baileyr@wustl.edu. AUTHOR DISCLOSURES: The authors report no conflicts of interest. This work was supported by the National Institutes of Health under Grant P30DK092950 and Grant 5T32HL130357-02. The contents of this work are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. The authors report no financial benefit to the authors from this study. At the time of submission, this work has not been previously presented in any form. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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.