Physical Medicine & Rehabilitation

Patients with spinal muscular atrophy use high percentages of trunk muscle capacity to perform seated tasks Objective To investigate trunk function during seated upper extremity tasks in patients with spinal muscular atrophy (SMA) type 2 and 3. Design 17 persons with SMA and 15 healthy controls (HC) performed several tasks when sitting unsupported, such as reaching (and placing) forward and sideward. Joint torque and muscle activity were measured during maximum voluntary isometric contractions (MVIC). Three-dimensional kinematics and normalized muscle activity were analyzed when performing tasks. Results Trunk joint torques were significantly decreased, approximately 45%, in patients with SMA compared to HC. Active range of trunk motion was also significantly decreased in all directions. When performing tasks, the average back muscle activity was 27% and 56% of MVIC for respectively HC and SMA, and for abdominal muscles respectively 10% and 44% of MVIC. Trunk range of motion did not differ when performing daily tasks. Conclusion The trunk of patients with SMA is weaker compared to HC, reflected by reduced trunk torques and decreased active range of motion. Additionally, patients with SMA use high percentages of their trunk muscle capacity to perform tasks. Clinicians should take this into account for intervention development, because using high percentages of the maximum muscle capacity results in fatigue and muscle overloading. Full address corresponding author: Laura H.C. Peeters, MSc, Department of Rehabilitation, Radboudumc, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands, Email address corresponding author: laura.hc.peeters@radboudumc.nl Author disclosures: • Conflicts of interest: Nothing to declare. • Funding: This work was supported by the Netherlands Organisation for Scientific Research (NWO) (Grant number 13524, 13525). • Financial benefits to the authors: no financial benefits. Previous presentation of the research: a manuscript was published about trunk movement of the healthy controls. This group is also used to compare with the SMA patients. However, the focus of the published manuscript was on the movement of individual trunk segments, whether this manuscript describes and compares the trunk as one segment. Therefore figures, or data, does not overlap. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Resident Education of Ultrasound Guided Procedures: A Homemade Practice Model Pilot Study The goal of this study was to evaluate an agar model that could be used to train physicians to perform ultrasound-guided (USG) procedures. Eleven (N = 11) PM&R residents volunteered to be subjects. All subjects completed a questionnaire about their experience and comfort with USG procedures. In Phase I, subjects were instructed to identify specific structures and perform specific procedures on the agar models; these tasks were timed. All subjects were then given a short lecture on fundamentals of USG procedures and percutaneous needle tenotomy (PNT). In Phase II, subjects then performed the same tasks again on the agar model and completed the questionnaire again. Analysis was performed using paired t-tests. The number of structures successfully identified significantly increased from Phase I (mean = 1.45) to Phase II (mean = 2.54) (p=0.003). Time to complete the needle access task in Phase II (mean = 258 s) significantly decreased compared to Phase I (mean = 394s) (p=0.04). Subjectively, our participants reported that they felt more comfortable performing USG procedures (p=0.005) and felt more familiar with PNT (p=0.00004) after using the model. In conclusion, residents demonstrated improvement in USG procedural skills and reported increased comfort performing these procedures after training on the agar model. Correspondence: Dr. Jesse Charnoff, email: jcharno1@gmail.com, cell: 516-567-7254, fax: 305-355-2424, 1611 NW 12th Avenue Institute 532B, Miami, FL 33136 No funding was received for this study Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Mechanism of Hip Dislocation related to the Use of Abduction Bar and Hip Compression Bandage in Patients with Spastic Cerebral Palsy Objective To identify the differences of forces in the hip adductors between with or without the abduction bar (AB) and evaluate the effect of hip compression bandage on the spasticity of the adductor muscles. Design Thirty-three patients with cerebral palsy (Gross Motor Functional Classification System (GMFCS) IV and V) were prospectively included. Surface electromyography (S-EMG) was taken by attaching EMG on the adductor and abductor muscles. Theraband was used as hip compression bandage. S-EMG were taken when spasticity provoked with and without AB, as well as with both AB and hip compression bandage. Root mean square (RMS) values were measured. Results RMS values were significantly increased with AB in the adductor longus, adductor magnus, and tensor fascia lata muscles. Adductor Sum and Net Adduction Index showed significant increases after the use of AB. After applying hip compression bandage, the NET Adduction Index was significantly decreased. Conclusion Our results showed significant changes in the adductor muscles’ amplitude, Adduction Sum, and Net Adduction Index. These results indicate that forces which worsen hip dislocation may develop, and therefore, AB should either not be used for spastic CP patients or should only be used with hip compression wrapping in place as well. Sangyoung Kim and Dajeong Lee 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 Author Disclosures: This research was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant number : HI18C1169) 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.

Early Quantitative Partial Weight-bearing Exercise after Periarticular Fractures of the Tibia Using a Lower-Body Positive-Pressure Treadmill: A Case Series The partial weight-bearing protocol after lower extremity fracture is an important issue in postoperative rehabilitation. As it is difficult to quantify the actual weight-load and provide a constant weight, the protocol is unestablished. By training with a lower-body positive-pressure treadmill (LBPPT) and using an in-shoe pressure-measuring device, partial weight-bearing exercise can be performed with quantified loads. This case series illustrates the applicability of an early quantitative partial weight-bearing rehabilitation program using LBPPT with an in-shoe pressure-measuring device after periarticular tibial fractures, which provides a quantitatively predetermined constant load. Correspondence: Seung Hak Lee, MD, PhD, Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea, Department of Rehabilitation Medicine, Incheon Workers Compensation Hospital, Incheon, Republic of Korea. Fax: +82-2-743-7473, Tel: +82-2-2072-3940, E-mail: seunghak@gmail.com Disclosure: There are no conflicts of interest to declare. This study was supported by grant no. 04-2017-0760 from the SNUH Research Fund and the Research Center for Innovation in Medical Rehabilitation, funded by the Korea Workers' Compensation and Welfare Service. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Infections after large joint or bursa injection: a survey of 554 sports medicine physicians Objective Despite the ubiquity of intra-articular and bursal injections for the treatment of joint pain and bursitis, relatively little literature is available on the prevalence of infection following these procedures. The goal of this study was to identify the number of infections recalled by sports medicine physicians who perform injections of large joints and bursae at least once per month. Design A survey of physician members of the American Medical Society for Sports Medicine identified the reported number of recalled infections for each large joint/bursal location. Results Out of a total of 554 physicians, only 31 infections were recalled by 27 physicians. Only 4.87% of all physicians were aware of an infection following an injection during their career. On average, one infection was recalled out of 170 physician-years in practice. No differences in infection rates were observed when comparing primary specialties (p = 0.281). Conclusion This study, the largest to date, demonstrates that sports medicine physicians rarely encounter infections after large joint and bursa injections. Although rare, due to their catastrophic nature, risk mitigation strategies should be maintained. Corresponding Author: Daniel Cushman, MD, 590 Wakara Way, Salt Lake City, UT 84108, Phone: 801-587-7109, Fax: 801-587-5458. dan.cushman.work@gmail.com No funding was received for this study and the authors have no competing interests to disclose. Acknowledgements: The authors would like to thank the American Medical Society for Sports Medicine in allowing the dissemination of a research survey to their members. The authors would also like to thank the members who took the time to complete the survey. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Influence of anxiety and depression, self-rated return-to-work problems, and unemployment on the outcome of outpatient rehabilitation following shoulder arthroscopy Objective The objective was to research the influence of psychosocial confounders on outpatient rehabilitation after arthroscopic shoulder surgery. Design: This retrospective study included patients who underwent such rehabilitation in a single center between 01/2014 and 10/2016. Shoulder function (CSS - Constant Shoulder Score) and pain (VAS – visual analogue scale), improvements in these scores, and patient satisfaction were evaluated with regard to anxiety and depression (HADS – Hospital anxiety and depression scale), self-rated return-to-work problems (WBS - Würzburg screening), and employment status. Results The analysis included 176 patients. The mean CSS and VAS improved from 53.9±18 to 75.4±16.5 and 4.6±2.1 to 2.9±2.4cm, respectively. 84.1% of the patients were satisfied with the outcome. Unemployed patients (p=0.001) and HADS-positive ones (p=0.014) were less satisfied than their counterparts. Patients with a WBS-positive screening showed less improvement in pain (p=0.015), function (p=0.016), and satisfaction (p=0.002) than those without. Unemployed reported more pain (p=0.008) than employed patients when starting rehabilitation. At the end of rehabilitation, all psychosocial scores (HADS p=0.002; WBS p=0.001; unemployment p<0.001) negatively influenced pain, WBS (p=0.007) and unemployment (p=0.008) function. Conclusions Because we identified psychosocial factors that influence the success of outpatient shoulder rehabilitation, rehabilitation setup should be adjusted in patients with such problems. Corresponding author: PD Dr. Patrick Strube, Klinik für Orthopädie, University Hospital Jena, Campus Waldkliniken Eisenberg, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany, Tel. +49 (36691) 8 1439, Fax +49 (36691) 8 1856, e-mail: patrick.strube@uni-jena.de Author Disclosures: None of the authors has to report any competing interests or financial benefits. No funding, grant, or equipment was received for the present study. The study was not presented or published before. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Constraint-induced Movement Therapy for improving motor function of the paretic lower extremity after stroke: a case report A 56-year-old woman with chronic stroke and gait dysfunction was recruited for this study. A Lower-Extremity Constraint-Induced Movement Therapy (LE-CIMT) protocol was given consisting of 3.5 hours/day of supervised intervention activities on 10 consecutive weekdays. Motor training was intensive and involved shaping. In addition, a group of behavior management strategies was employed to induce further unsupervised practice and transference of motor skills from the laboratory to real world situations. Changes in functional mobility, walking speed, balance, level of assistance, perceived quality of movement and level of confidence while performing daily activities were assessed five times in both the baseline and intervention phases. The outcomes observed after the intervention were determined by calculating the difference between the average scores obtained in both phases. Changes in perceived quality of movement, level of confidence, level of assistance, and balance were observed. Correspondence: Sarah dos Anjos, University of Alabama at Birmingham, 1720 2nd Avenue South, SHPB360. Birmingham, AL, USA. 35.294-0001. Disclosures: The authors have no conflict of interest. No funding was received. Clinicaltrials.gov: NCT03114046 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effects of Whole Body Vibration on Motor Impairments in Patients with Neurological Disorders: A Systematic Review Objective This systematic review was conducted to examine the effects of whole body vibration (WBV) training on motor impairments among patients with neurological disorders, and to investigate which the whole body vibration training parameters induced improvement in motor impairments. Design PubMed, SCOPUS, PEDro, REHABDATA, and web of science were searched for randomized controlled trials and Pseudo- randomized controlled trials investigated the effect of WBV on motor impairments in patients with neurological disorders. The methodological quality was rated using the Cochrane Collaboration’s tool Results Twenty studies were included in this systematic review. Four studies included patients with multiple sclerosis, cerebral palsy (n=2), stroke (n=9), Parkinson’s disease (n=3), spinal cord injuries (n=1), and spino-cerebellar ataxia (n=1). The results showed different evidence of benefits and non-benefits for WBV training in motor impairments outcomes. Conclusion There is weak evidence for a positive effect of short-term WBV training on spasticity of lower extremities, mobility, balance and postural control. Besides, positive effect of the long-term effect of WBV training on mobility in patients with neurological disorders. The optimal WBV training parameters in treating patients with neurological disorders remain unclear. Anas Alashram, MSc, Doctorate Student in Neurology Department, Faculty of Medicine and Surgery, University of Rome "Tor Vergata", Italy, anasalashram@gmail.com Elvira Padua, PhD, Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy. elvira.padua@unisanraffaele.gov.it Giuseppe Annino, PhD, Department of Medicine System, University of Rome "Tor Vergata", Italy, g_annino@hotmail.com Correspond author: Anas R. Alashram, Deperatment of Neurology University of Rome Tor Vergata, Rome, Italy E-mail: anasalashram@gmail.com Sources of funding/acknowledgements: The authors have no source of funding or any potential conflicts of interest to disclose. Funding or grants or equipment provided for the project from any source: None. Financial benefits to the authors: None. Details of any previous presentation of the research, manuscript, or abstract in any form: None. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Ultrasound Imaging for Lateral Elbow Pain: Pinpointing the Epicondylosis No abstract available

Creation and initial validation of a picture-based version of the limitations of activity domain of the SF-36 Those with limited language comprehension or literacy face problems completing written questionnaires evaluating their health or physical status on which treatment plans are based. This brief report describes how a picture-based version of the 10 items in the limitations of activities (LoA) section of the SF-36 was developed iteratively and then piloted. Study participants: 101 community-living volunteers (58 female 43 male aged 18-93 years) educated to post-secondary level (52) high school grades 10-12 (44) and grade 9 or less (5). They first completed the picture-based SF-36LoA and described verbally and in writing what they understood each picture to mean, and then completed the English text version of the SF-36LoA domain for comparison assessment. Additional feedback suggested where pictures could be altered to increase information capture. Subjects rated their health as 26.7% excellent, 25.7% very good, 29.8% good, 10.9% fair and 6.9% poor. Analysis showed strong correlation between text-based SF-36LoA questions and the picture-based visual score – VSF-36LoA - (ICC=0.98) with question 10 correlating highest (ICC=0.90) and question 2 lowest (ICC=0.82). The VSF-36LoA is the first picture-based version of the SF-36; good correlation with the text-based version and global need warrants further development to aid those with limited literacy or language comprehension. Corresponding author: Macnab, Andrew John MD (London), Department of Pediatrics, University of British Columbia, Room C234, BC Children’s Hospital, 4500 Oak Street, Vancouver, BC Canada V6H 3N1, phone: 604 875 2850, fax: 604 875 2530, ajmacnab@gmail.com Submitted to: American Journal of Physical Medicine and Rehabilitation Funding: none received Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.