Validity and reliability of serratus anterior hand held dynamometry

MR Neurography and Quantitative Muscle MRI of Parsonage Turner Syndrome Involving the Long Thoracic Nerve

BACKGROUND

Parsonage-Turner syndrome (PTS) is characterized by severe, acute upper extremity pain and subsequent paresis and most commonly involves the long thoracic nerve (LTN). While MR neurography (MRN) can detect LTN hourglass-like constrictions (HGCs), quantitative muscle MRI (qMRI) can quantify serratus anterior muscle (SAM) neurogenic changes.

PURPOSE/HYPOTHESIS

1) To characterize qMRI findings in LTN-involved PTS. 2) To investigate associations between qMRI and clinical assessments of HGCs/electromyography (EMG).

STUDY TYPE

Prospective.

POPULATION

30 PTS subjects (25 M/5 F, mean/range age = 39/15-67 years) with LTN involvement who underwent bilateral chest wall qMRI and unilateral brachial plexus MRN.

FIELD STRENGTH/SEQUENCES

3.0 Tesla/multiecho spin-echo T2-mapping, diffusion-weighted echo-planar-imaging, multiecho gradient echo.

ASSESSMENT

qMRI was performed to obtain T2, muscle diameter fat fraction (FF), and cross-sectional area of the SAM. Clinical reports of MRN and EMG were obtained; from MRN, the number of HGCs; from EMG, SAM measurements of motor unit recruitment levels, fibrillations, and positive sharp waves. qMRI/MRN were performed within 90 days of EMG. EMG was performed on average 185 days from symptom onset (all ≥2 weeks from symptom onset) and 5 days preceding MRI.

STATISTICAL TESTS

Paired t-tests were used to compare qMRI measures in the affected SAM versus the contralateral, unaffected side (P < 0.05 deemed statistically significant). Kendall's tau was used to determine associations between qMRI against HGCs and EMG.

RESULTS

Relative to the unaffected SAM, the affected SAM had increased T2 (50.42 ± 6.62 vs. 39.09 ± 4.23 msec) and FF (8.45 ± 9.69 vs. 4.03% ± 1.97%), and decreased muscle diameter (74.26 ± 21.54 vs. 88.73 ± 17.61 μm) and cross-sectional area (9.21 ± 3.75 vs. 16.77 ± 6.40 mm2). There were weak to negligible associations (tau = -0.229 to <0.001, P = 0.054-1.00) between individual qMRI biomarkers and clinical assessments of HGCs and EMG.

DATA CONCLUSION

qMRI changes in the SAM were observed in subjects with PTS involving the LTN.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Intra- and interrater reliability of belt-stabilized hand-held dynamometer in scapular protraction strength tests in individuals with shoulder pain

PURPOSE

Scapular protraction strength can be evaluated using a hand-held dynamometer (HHD). However, it is necessary to measure the reliability of HHD in individuals with shoulder pain and to minimize the limitations related to the evaluator and the low methodological quality cited in previous studies. This study assessed, with methodological enhancement, the intra- and interrater reliability of belt-stabilized HHD in the assessment of scapular protraction strength in individuals with shoulder pain.

METHOD

Fifty individuals with unilateral symptoms of subacromial pain syndrome (20 men, aged 40.5 ± 15.3 years) were evaluated in two sessions using the belt-stabilized HHD for maximum isometric strength of scapular protraction with the individual in the sitting and supine positions. Reliability values were obtained using the intraclass correlation coefficient with the standard error of measurement (SEM and %SEM) and the minimal detectable change (MDC).

RESULTS

The intra- and interrater HHD reliability were excellent for all measurements ranging from 0.88 to 0.96 (SEM = 2.0-4.0 kg; %SEM 12 to 17; MDC = 6-11 kg).

CONCLUSION

Belt-stabilized HHD is reliable for the assessment of scapular protraction strength in individuals with subacromial pain syndrome in both the sitting and supine positions.

Assessment of Physical Tests in 6-11 Years Old Children: Findings from the Play Lifestyle and Activity in Youth (PLAY) Study

The purpose was to evaluate selected physical tests in children and to compare the outcomes by sex. A cross-sectional study design was used to evaluate children 6-11 years who completed five physical tests: hand grip, vertical jump, sit and reach, Y-balance, and obstacle course (time and score). The outcome measures including test results were descriptively examined and compared by sex. The study participants consisted of 133 children (62 males and 71 females, with a median age of 7.8 years). Girls showed superior sit and reach performance (p = 0.002) compared with boys. Boys demonstrated better Y-balance scores (p = 0.007) and faster obstacle time (p = 0.042) than girls. Sex comparison within three age groups (6-<8 years, 8-<10 years, and 10-<12 years) showed that girls performed better on the sit and reach compared with boys in the in 6-<8 years (p = 0.009). Boys demonstrated higher Y-balance scores (p = 0.017) and faster obstacle time (p = 0.007) compared with girls in the 8-<10-year age group. These data will serve to guide future efforts to evaluate normative measures of physical literacy and guide targeted training interventions to promote sustained physical activity in children with deficits relative to their age and sex norms.

Effectiveness of an outpatient rehabilitation programme in patients with neuralgic amyotrophy and scapular dyskinesia: a randomised controlled trial

BACKGROUND

Neuralgic amyotrophy (NA) is an acute inflammation of nerves within the brachial plexus territory leading to severe pain and multifocal paresis resulting in >60% of patients having residual complaints and functional limitations correlated with scapular dyskinesia. Our primary aim was to compare the effects of multidisciplinary rehabilitation (MR), focused on motor relearning to improve scapular dyskinesia and self-management strategies for reducing pain and fatigue, with usual care (UC) on shoulder, arm and hand functional capability in patients with NA.

METHODS

In a non-blinded randomised controlled trial (RCT), patients with NA (aged≥18 years, scapular dyskinesia, >8 weeks after onset) were randomised to either an MR or an UC group. MR consisted of a diagnostic multidisciplinary consultation and eight sessions of physical and occupational therapy. Primary outcome was functional capability of the shoulder, arm and hand assessed with the Shoulder Rating Questionnaire-Dutch Language Version (SRQ-DLV).

RESULTS

We included 47 patients with NA; due to drop-out, there were 22 participants in MR and 15 in UC for primary analysis. The mean group difference adjusted for sex, age and SRQ-DLV baseline score was 8.60 (95%CI: 0.26 to 16.94, p=0.044). The proportion attaining a minimal clinically relevant SRQ-DLV improvement (≥12) was larger for the MR group (59%) than the UC group (33%) with a number needed to treat of 4.

CONCLUSION

This RCT shows that an MR programme focused on motor relearning to improve scapular dyskinesia, combined with self-management strategies for reducing pain and fatigue, shows more beneficial effects on shoulder, arm and hand functional capability than UC in patients with NA.

TRIAL REGISTRATION NUMBER

NCT03441347.

Evaluation of primary and accessory respiratory muscles and their influence on exercise capacity and dyspnea in pulmonary arterial hypertension

BACKGROUND

Skeletal and respiratory muscle disfunction has been described in pulmonary arterial hypertension (PAH), however, involvement of accessory respiratory muscles and their association with symptomatology in PAH is unclear.

OBJECTIVES

To assess the primary and accessory respiratory muscles and their influence on exercise tolerance and dyspnea.

METHODS

27 patients and 27 healthy controls were included. Serratus anterior (SA), pectoralis muscles (PM) and sternocleidomastoid (SCM) muscle strength were evaluated as accessory respiratory muscles, maximal inspiratory (MIP) and expiratory pressures (MEP) as primary respiratory muscles, and quadriceps as peripheral muscle. Exercise capacity was evaluated with 6-min walk test (6MWT), dyspnea with modified Medical Council Research (MMRC) and London Chest Activity of Daily Living (LCADL) scales.

RESULTS

All evaluated muscles, except SCM, and 6MWT were decreased in patient group (p < 0.01). SA was the most affected muscle among primary and accessory respiratory muscles (Cohen's-d = 1.35). All evaluated muscles significantly correlated to 6MWT (r = 0.428-0.525). A multivariate model including SA, SCM and MIP was the best model for predicting 6MWT (R = 0.606; R² = 0.368; p = 0.013) and SA strength had the most impact on the 6MWT (B = 1.242; β = 0.340). None of the models including respiratory muscles were able to predict dyspnea, however PM and SA strength correlated to LCADL _total (r = -0.493) and MMRC (r = -0.523), respectively.

CONCLUSION

SCM may be excessively used in PAH since it retains its strength. Considering the relationship of accessory respiratory muscles with exercise tolerance and dyspnea, monitoring the strength of these muscles in the clinical practice may help providing better management for PAH.

The Management of Valgus Extension Overload Syndrome Experienced with Hitting in a High School Baseball Player: A Case Report

Background

Valgus extension overload syndrome (VEOS) of the elbow is a condition associated with overhead athletes. However, the non-surgical management of these individuals is not well documented.

Purpose

To discuss the unique presentation, management, and outcomes of an adolescent baseball player with a chronic history of VEOS experienced during hitting.

Case Description

A 15-year-old right-handed high school baseball catcher presented with a six-month history of right-sided ulnar elbow pain. Elbow MRI w/ contrast was consistent with VEOS. The initial examination demonstrated excessive resting right-sided humeral external rotation compared to his left. Valgus stress testing in the subject's hitting position reproduced symptoms, which were alleviated with retest while correcting excessive humeral external rotation. Weakness of the humeral internal rotators and stiffness/shortness of the posterior shoulder were found and thought to relate to the humeral contribution to his elbow movement dysfunction. Rehabilitation emphasized addressing impairments contributing to excessive humeral external rotation with reintegration into batting.

Outcomes

After five weeks of physical therapy, the subject returned to soft toss hitting at approximately 75% velocity for the first time since symptom onset, without pain. At seven months after discharge, a phone conversation confirmed that the subject had returned to baseball without limitations.

Discussion

Despite the concept of 'regional interdependence', common proximal impairments are often assumed to contribute to elbow pain without a clear biomechanical rationale. Future research demonstrating the specific biomechanical effects of the shoulder on the elbow is needed, in addition to more accessible examination strategies to assess their relationship.

Level of Evidence

5.

OUP accepted manuscript

Neuralgic amyotrophy is a common peripheral nerve disorder caused by autoimmune inflammation of the brachial plexus, clinically characterized by acute pain and weakness of the shoulder muscles, followed by motor impairment. Despite recovery of the peripheral nerves, patients often have residual motor dysfunction of the upper extremity, leading to persistent pain related to altered biomechanics of the shoulder region. Building on clinical signs that suggest a role for cerebral mechanisms in these residual complaints, here we show and characterize cerebral alterations following neuralgic amyotrophy. Neuralgic amyotrophy patients often develop alternative motor strategies, which suggests that (mal)adaptations may occur in somatomotor and/or visuomotor brain areas. Here, we tested where changes in cerebral sensorimotor representations occur in neuralgic amyotrophy, while controlling for altered motor execution due to peripheral neuropathy. We additionally explore the relation between potential cerebral alterations in neuralgic amyotrophy and clinical symptoms. During functional MRI scanning, 39 neuralgic amyotrophy patients with persistent, lateralized symptoms in the right upper extremity and 23 matched healthy participants solved a hand laterality judgement task that can activate sensorimotor representations of the upper extremity, across somatomotor and visuomotor brain areas. Behavioural and cerebral responses confirmed the involvement of embodied, sensorimotor processes across groups. Compared with healthy participants, neuralgic amyotrophy patients were slower in hand laterality judgement and had decreased cerebral activity specific to their affected limb in two higher-order visual brain regions: the right extrastriate cortex and the parieto-occipital sulcus. Exploratory analyses revealed that across patients, extrastriate activity specific to the affected limb decreased as persistent pain increased, and affected limb-related parieto-occipital activity decreased as imagery performance of the affected limb became slower. These findings suggest that maladaptive cerebral plasticity in visuomotor areas involved in sensorimotor integration plays a role in residual motor dysfunction and subsequent persistent pain in neuralgic amyotrophy. Rehabilitation interventions that apply visuomotor strategies to improve sensorimotor integration may help to treat neuralgic amyotrophy patients.