Quantitative Romberg using a force plate: an objective measure for cervical myelopathy

BACKGROUND CONTEXT

Surgical decision making for cervical spondylotic myelopathy (CSM) relies on evaluation of symptoms and physical examination. The Romberg test is a clinical exam used to identify balance issues with CSM. However, the Romberg test has a subjective interpretation and has a binary (positive or negative) result.

PURPOSE

This study aims to compare force plate pressure readings during a standard Romberg test in patients with CSM to age-matched normal healthy volunteers.

STUDY DESIGN/SETTING

Prospective cross sectional observational comparative cohort from a single multi-surgeon spine center.

PATIENT SAMPLE

Patients who were clinically diagnosed with CSM were compared to age-matched healthy volunteers without a clinical history of spine pathology.

OUTCOME MEASURES

Quantitative Romberg Force Plate Measurements METHODS: Patients with CSM requiring surgery and healthy normal volunteers were asked to perform the Romberg test while on a force plate measuring the center of pressure (COP): standing up straight with arms extended for 30 seconds with eyes open, followed by 30 seconds with eyes closed. The change for total sway area, sway frequency and sway speed with eyes closed and eyes open were calculated and compared between patients with CSM and healthy volunteers.

RESULTS

Thirty-four CSM patients were age-matched to 34 healthy volunteers. There was a larger change in quantitative Romberg measurements with eyes open versus eyes closed in CSM patients compared to normal volunteers for maximum lateral movement (10.79 cm vs. 0.94 cm, p=.003), maximum anterior-posterior movement (15.06 cm vs. 10.00 cm p=.201), total lateral CoP movement (89.82cm vs. 18.71cm, p=.007), total AP CoP movement (154.68 cm vs. 87.47 cm, p=.601), total CoP trace movement (199.79 cm vs. 88.44 cm, p=.014), sway area (284.74 cm² vs. 57.76 cm², p=.006), and average speed (7.00 cm/s vs. 2.91 cm/s, p=.006).

DISCUSSION

Poor standing balance can be quantified in patients with CSM. Quantifying standing balance in patients with CSM shows significantly worse objective measures than age-matched healthy volunteers. The Romberg test on a force plate may help diagnose and evaluate patients with CSM, guide patient management and potentially grade the severity of spinal pathology. Further studies are needed to determine its utility in monitoring disease progression and measure treatment effectiveness.

Validity and reliability of the Australian Therapy Outcome Measures - Physiotherapy, for podiatry (AusTOMs-PT for use in podiatry)

Background

Valid and reliable outcome measure enable measurement of health care service impact. There are limited valid and reliable outcome measures for use in podiatry practice to measure the impact of treatment. This research aimed to test the face validity of the AusTOMs for Physiotherapy (AusTOMs-PT), it’s adaptability to podiatry clinical practice and the reliability of its use with podiatrists.

Methods

Stage 1 used a nominal group technique with podiatrists who worked in public and/or private settings. All podiatrists underwent self-directed training in the AusTOMs framework and measures prior to interviews or focus group discussion. Discussion was centred about transferability of the core scales of the AusTOMs-PT and an adjunct measure, AusTOMs for Occupational Therapy (AusTOMs-OT) to podiatry practice.

Stage 2 used 10 case studies representative of people who had foot or ankle concerns. Podiatrists were recruited and trained in the use of the relevant AusTOMs-PT scales. Podiatrists individually scored the cases at two timepoints (1 month apart) using the six scales from the AusTOMs-PT deemed by stage 1 as relevant to podiatry. Intra and inter-rater reliability of scales were determined using intraclass correlation coefficients (ICCs).

Results

Thirteen podiatrists participated in individual or focus group interviews in Stage 1. Consensus was gained on six of the nine core scales adopted from the AusTOMs-PT. These were 1. Balance and Postural Control, 3. Musculoskeletal Movement Related Functions, 4. Neurological Movement Related Functions, 5. Pain, 7. Sensory Functions, 8. Skin Functions. Each core scale rated the functional domains of Impairment, Activity Limitation, Participation Restriction and Wellbeing/Distress relating to that presentation of goals of the person in the case study.

There were 22 podiatrists complete training and scored two rounds of case studies using the six scales in Stage 2. There were 91%(n = 20) participants with an intra-rater ICC > 0.5 (moderate or greater). Each domain had an inter-rater reliability of > 0.9 (excellent) during the first round.

Conclusions

The AusTOMs-PT for use in podiatry may be implemented to record change in impairment, function, participation and wellbeing of people receiving podiatry treatment. Podiatry specific training and mentoring, together with repeated use could be expected to improve intra-reliability.

Systematic review of quality of life following pleurectomy decortication and extrapleural pneumonectomy for malignant pleural mesothelioma

BACKGROUND

Few studies have focused on quality of life (QoL) after treatment of malignant pleural mesothelioma (MPM). There are still questions as to which surgical procedure, extrapleural pneumonectomy (EPP) or pleurectomy decortication (P/D) is most effective and results in better survival outcomes, involves fewer complications, and results in better QoL. Here we performed a literature review on MPM patients to assess and compare QoL changes after P/D and EPP.

METHODS

Research articles concerning QoL after mesothelioma surgery were identified through May 2018 in Medline. For inclusion, studies were 1) cohort or randomized controlled trials (RCT) design, 2) included standardized QoL instruments, 3) reported QoL measurement after surgery, 4) described the type of surgery performed (EPP or P/D), 5) were written in English. Measures of lung function (FEV1, FVC) and measures from the EORTC-C30 were compared 6 months following surgery with preoperative values.

RESULTS

QoL data was extracted from 17 articles (14 datasets), encompassing 659 patients (102 EPP, 432 P/D); the available evidence was of low quality. While two studies directly compared QoL between the two surgical procedures, additional data was available from one arm of two RCTs, as the RCTs were not comparing EPP and P/D. The remaining data was reported from observational studies. While QoL was still compromised 6 months following surgery, from the limited and low quality data available it would appear that P/D patients had better QoL than EPP patients across all measures. Physical function, social function and global health were better at follow-up for P/D than for EPP, while other indicators such as pain and cough were similar. Forced Expiratory Volume (FEV1) and Forced Vital Capacity (FVC) were reported in one study only, and were higher at follow-up for P/D compared to EPP.

CONCLUSIONS

Although the existing evidence is limited and of low quality, it suggests that P/D patients have better QoL than EPP patients following surgery. QoL outcomes should be factored into the choice of surgical procedure for MPM patients, and the possible effects on lung function and QoL should be discussed with patients when presenting surgical treatment options.

A novel fluoroscopic method for multidimensional evaluation of swallowing function

OBJECTIVE

Dynamic videofluoroscopic swallow study (VFSS) is used to investigate swallowing movements. However, it requires prolonged radiation exposure and mainly provides qualitative information. Herein, we present a multi-dimensional method for analyzing swallowing based on a pulsed, low-dose fluoroscopy technique that uses serial-shot images and evaluates the size, position, and temporal profile of the bolus to obtain a more comprehensive and realistic analysis of swallowing movements.

METHODS

Fifteen healthy adults drank two liquids: 20mL of pure water followed by 20mL of contrast medium mixture in a fluoroscopic study. Data were recorded in serial-shot images (7.5 frames/second, 1024×1024-pixel resolution, DICOM format). The images from the water and contrast swallows were inverted, synchronized, and subtracted to visualize the bolus in each frame. The pathway of the bolus was divided into 15 parts traversing the oropharynx, hypopharynx, and upper esophagus, and the total gray value was measured in each section. The results were presented as contour graphs.

RESULTS

The contour graphs allowed for information on the size, anatomical location, and temporal location of the bolus during swallowing to be displayed simultaneously. Two distinct swallowing patterns were observed in the subjects. The bolus showed two peaks-one in the hypopharynx and one in the upper esophagus-in all subjects. However, in nine of the 15 subjects, the two peaks were in different frames, whereas in six of the subjects, the two peaks were in the same frame.

CONCLUSION

We developed a new method for quantitatively evaluating swallowing. The technique allows for multidimensional assessment of the size, position, and temporal profile of the movement of the bolus across the pharynx. This method evaluates the swallowing movements using sharp, high-resolution images obtained by serial-shot, pulsed fluoroscopy with low radiation exposure. Additional studies are required to further clarify the variability of swallowing patterns and their clinical relevance in the evaluation of swallowing movements in healthy subjects and in patients with swallowing disorders.

Functional Measures Developed for Clinical Populations Identified Impairment Among Active Workers with Upper Extremity Disorders

PURPOSE

Few studies have explored measures of function across a range of health outcomes in a general working population. Using four upper extremity (UE) case definitions from the scientific literature, we described the performance of functional measures of work, activities of daily living, and overall health.

METHODS

A sample of 573 workers completed several functional measures: modified recall versions of the QuickDASH, Levine Functional Status Scale (FSS), DASH Work module (DASH-W), and standard SF-8 physical component score. We determined case status based on four UE case definitions: (1) UE symptoms, (2) UE musculoskeletal disorders (MSD), (3) carpal tunnel syndrome (CTS), and (4) work limitations due to UE symptoms. We calculated effect sizes for each case definition to show the magnitude of the differences that were detected between cases and non-cases for each case definition on each functional measure. Sensitivity and specificity analyses showed how well each measure identified functional impairments across the UE case definitions.

RESULTS

All measures discriminated between cases and non-cases for each case definition with the largest effect sizes for CTS and work limitations, particularly for the modified FSS and DASH-W measures. Specificity was high and sensitivity was low for outcomes of UE symptoms and UE MSD in all measures. Sensitivity was high for CTS and work limitations.

CONCLUSIONS

Functional measures developed specifically for use in clinical, treatment-seeking populations may identify mild levels of impairment in relatively healthy, active working populations, but measures performed better among workers with CTS or those reporting limitations at work.

Outcomes of cochlear implanted children with cerebral palsy: A holistic approach

OBJECTIVE

Analyze the progress of hearing and language in a group of children with cerebral palsy (CP) who have received cochlear implants (CI) and compare their progress in the clinical and functional domains.

METHODS

This is a prospective transdisciplinary study developed within a tertiary referral center, with a group of nine cochlear-implanted children with CP, two- to seven-year-old. The assessments undertaken included audiological, language, and communication assessments complemented by the assessment of functional abilities and the level of independence as evaluated by the Pediatric Evaluation of Disability Inventory (PEDI) and Gross Motor Function Classification System (GMFCS).

RESULTS

The outcomes varied, as two children achieved hearing comprehension in open-set evaluations. These children presented the same type of CP, athetosis, but with different functional skills and GMFCS levels. Only one of the subjects had any spoken language at the single-word level.

CONCLUSIONS

A holistic view of change and development is central to understanding progress made in children with CP who received cochlear implants (CI). The functional evaluation of these children with CP is a useful tool for monitoring their progress and measuring their outcomes with CI.

Optimizing electrical impedance myography measurements by using a multifrequency ratio: a study in Duchenne muscular dystrophy

OBJECTIVE

Electrical impedance myography (EIM) is an electrophysiological technique for neuromuscular evaluation that is impacted by subcutaneous fat (SF). Exploiting the differing frequency dependences of muscle and fat, we assessed a 2-frequency EIM phase ratio in Duchenne muscular dystrophy (DMD) boys.

METHODS

Twenty-eight DMD boys aged 2-13years underwent EIM and the 6-minute walk test (6MWT). For each subject, 50kHz phase data was input into the numerator while 20-500kHz phase values were input into the denominator. We then performed correlation analyses seeking to identify the denominator frequency that simultaneously optimized SF and 6MWT correlations. This optimized ratio was then tested in 24 healthy boys.

RESULTS

50kHz phase correlated to 6MWT in DMD boys with R=0.52, p=0.0066, and to SF thickness with R=-0.67, p<0.001. An optimized ratio of 50/200kHz phase reduced the correlation of SF thickness to R=-0.075, p=0.45 while improving the relationship to the 6MWT (R=0.60, p=0.001). In normal subjects, the optimization decreased SF correlation from R=0.61 from R=0.16 with 6MWT correlation remaining unchanged.

CONCLUSIONS

The 50/200kHz EIM phase ratio removes the impact of SF while maintaining EIM's association with function.

SIGNIFICANCE

The use of a phase ratio may enhance EIM's application for evaluation of neuromuscular disease.

Disease severity and functional factors associated with walking performance in polyostotic fibrous dysplasia

The purpose of this study was to determine the association between measures of disease severity, impairment, and ambulation ability in persons with polyostotic fibrous dysplasia (PFD). A cross-sectional sample of 81 patients (ages 5-57) with polyostotic fibrous dysplasia was evaluated as part of an ongoing study. Subjects were scored on the Skeletal Disease Burden Score (SDBS), completed a 9-minute walk test (9MW), manual muscle testing (MMT), and measurements of range of motion (ROM). Correlations between continuous variables were calculated using the Pearson correlation coefficient and ordinal variables by Spearman correlation coefficient. It was found that subjects with more severe disease walked slower than those with less skeletal disease, with the exception of the youngest subjects. Walking velocity was faster in subjects with better hip strength and range of motion and slower in those with bilateral coxa vara. Those subjects with more severe disease had less range of motion, were weaker at the hips, and more likely to have leg length discrepancy. Skeletal disease severity was associated with hip weakness, leg length discrepancy, and loss of range of motion. In most cases, findings did not differ in the presence or absence of associated endocrinopathies. Skeletal disease severity, MMT and ROM each has an impact on walking efficiency in persons with PFD. These findings suggest that treatment focused on strategies to improve or, at least, maintain hip strength and range of motion, correct leg length discrepancies and hip malalignment may help preserve ambulation ability in persons with PFD and that treatment should begin at a young age.