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Shear wave elastography is an emerging diagnostic tool used to assess for changes in the stiffness of muscle. Each region of the muscle may have a different stiffness; therefore, the anatomical region should be carefully selected. Machine vendors each have unique methods for calculating the returned stiffness values and, consequently, a high level of agreement in measurement between machines (quantified using the intraclass correlation coefficient [ICC] and Bland-Altman analysis) will allow research findings to be translated to the clinic. This study assessed three locations within the biceps muscle (50% and 75% of the distance between the acromioclavicular joint and antecubital fossa, and superior to distal myotendinous junction [MTJ]) of 32 healthy volunteers with two different machines, the Canon Aplio i600 and SuperSonic Imagine Aixplorer (SSI), to compare the reported shear wave velocities and the variability by coefficient of variation (CV) and ICC. There was no difference in the CV between machines, but a significant difference in the CV at muscle regions, with the 75% location having a 40.2% reduction in CV. The 75% location had the highest ICC values with good posterior mean ICCs of 0.84 on the Canon and 0.83 on the SSI. The 50% and MTJ locations had poor ICC values. The 75% location provided the lowest CV and highest ICC and should be used for future stiffness assessments.

We aim to compare the postoperative clinical outcomes, through patient-reported outcome measures (PROMs) and minimum clinically important difference (MCID), in patients undergoing cervical disc replacement (CDR) with preoperative predominant neck pain (pNP) or arm pain (pAP).Patients undergoing primary CDR were separated into pNP or pAP cohorts. Demographic, perioperative characteristics, PROMs at preoperative and postoperative time points, and MCID were compared using inferential statistics. Assessed PROMs included Patient-Reported Outcome Measurement Information System-Physical Function (PROMIS-PF), 12-Item Short Form Physical/Mental Component Score (SF-12 PCS/MCS), visual analog scale (VAS) neck, VAS arm, and Neck Disability Index.There were a total of 84 patients, with 54 patients in the pNP cohort. The pNP cohort showed significant postoperative improvement in all PROMs, except for 6-week and 1-year SF-12 PCS, 1-year SF-12 MCS, and 6-month VAS arm score (P ≤ 0.023, all). The pAP cohort showed significant postoperative improvement in all PROMs, apart from 6-month to 1-year SF-12 PCS, and all SF-12 MCS (P ≤ 0.041, all). Greater MCID achievement rates were found in the pNP cohort for SF-12 MCS (P = 0.030). The pAP cohort had higher MCID achievement rates in VAS arm score and Neck Disability Index (P ≤ 0.046, all).Independent of predominant pain location, patients reported improved physical function, pain, and disability outcomes. Patients with pNP had higher MCID achievement rates in mental function. Patients with pAP had higher rates of MCID achievement in arm pain and disability outcomes. Considering the predominant location of preoperative pain may be helpful in managing expectations for patients undergoing CDR.

Obtaining CCTA images with optimal injection location such as the arm or leg is important to avoid the artifacts caused by the CM. This study compares the computed tomography (CT) numbers and visualization scores of the three-dimensional (3D) images of the lumens of the blood vessels in the arm or leg during cardiac computed tomography angiography (CCTA) in neonatal and infant patients.Between January 2017 and January 2020, 253 consecutive patients were considered for inclusion. We used the estimated propensity scores as a function of the demographic data, including age, body weight, and injection location (right or left side) in the arm (n = 58) and leg (n = 58) of neonatal and infant patients. We compared the mean CT numbers of the pulmonary artery, ascending aorta, and left superior vena cava; contrast-noise ratios (CNR); and visualization scores between the arm and leg as the injection locations.The mean CT numbers during CCTA for the arm and leg were 479.4 and 461.3 HU in the ascending aorta, 464.2 and 448.1 HU in the pulmonary artery, and 232.8 and 220.1 HU in the left superior vena cava, respectively. The mean image noise (SD) and CNR values, respectively, were 38.9 HU and 12.1 for the arm as the injection location and 39.1 HU and 12.3 for the leg as the injection location. The median visualization scores of volume rendering of the 3D images were 3.0 and 3.0 for the arm and leg injection sites, respectively. There were no significant differences in the mean CT numbers of the ascending aorta, pulmonary artery, and left superior vena cava; SD value; CNR; and visualization scores between the arm and leg injection locations.The CT numbers of the lumen of the blood vessel and visualization scores of the 3D images of the arm and leg injection locations are equal during CCTA in neonatal and infant patients with congenital heart disease.

The relationship between contraction strength of the flexor-pronator muscles (FPMs) and elbow valgus braking function has not been clarified.The purpose of this study was to investigate changes in medial elbow joint space when there is a difference in contraction strength of FPMs under elbow valgus stress.Subjects were 20 healthy male university students, and the elbow joint on the nondominant hand side was used for measurements. The body position for limb measurement was sitting in a chair, with the shoulder abducted 60° and in 90° of external rotation, with 90° of elbow flexion. At first, maximum voluntary contraction (MVC) of the FPMs by grip motion was measured using a hand grip dynamometer under 60-N valgus stress. Contraction strengths of 10% MVC, 30% MVC, and 50% MVC were used. Ultrasonographic images of the medial elbow joint space (JS) were taken in the starting limb position. Using the Telos device system, load was then gradually increased by +10 N/s, and at the time of 60-N valgus stress, an image of the JS was taken. Furthermore, the subject adjusted to the set contraction strength (for about 5 sec) with 60-N valgus stress applied, and an image of the JS was taken while maintaining the set contraction strength. Each MVC condition (10% MVC, 30% MVC, and 50% MVC) was performed randomly. Three ultrasonographic images were taken within 10 seconds, and the average value of the three images was adopted as the JS.Compared with the JS under 60-N valgus stress, the JS was significantly reduced under 60-N valgus stress + 50% MVC. No significant difference was observed between the starting limb position and 60-N valgus stress + 50% MVC.FPMs may require muscle activity ≥50% MVC to brake 60-N elbow valgus stress.

As arthroplasty leads to bone loss, we hypothesized that humeral bone mineral density (BMD) is lower after total shoulder arthroplasty (TSA) in the operative versus non-operative arm. However, there is no clinical approach to measure humeral BMD with dual-energy x-ray absorptiometry (DXA). The purposes of this pilot study were to develop DXA methodology to measure humerus BMD, propose humerus regions of interest (ROIs), compare TSA BMD to the non-operative arm, correlate humeral BMD with standard sites, and evaluate measurement reproducibility.Thirty-eight adults 1-5 years post-TSA had standard clinical DXA scans plus full humerus scans using the atypical femur fracture feature; precision was assessed in a subset (n = 32). Six custom ROIs were used to measure BMD throughout the humerus. Radius and humeral BMD were compared between arms by paired t-test and correlated ipsilaterally using Pearson's Correlation. Custom ROI BMD precision was assessed using the International Society for Clinical Densitometry (ISCD) advanced precision calculator.Study included 38 subjects (24M/14F), with mean (SD) age and time post-surgery of 69.6 (7.7) years and 2.5 (1.3) years respectively. BMD was lower (plt; 0.01) at all custom humerus sites (3.8% to 8.2%) on the surgical side but not different at radius sites. Humeral BMD correlated positively with ipsilateral ultra-distal and 1/3 radius (r = 0.54 to 0.86; plt; 0.05). Custom BMD precision (%CV) ranged from 6.0-16.0%.Humerus BMD can be measured using DXA and is lower in the TSA arm. Radius BMD correlated with humeral BMD but was not lower in the surgical arm. BMD precision was worse than usual clinical sites; use of software optimized for the femur is a notable limitation and likely contributes to suboptimal precision. Further study to assess the clinical utility of humeral BMD is needed. Automation and optimization of these measurements should improve precision.

Partial tears of the distal biceps tendon can be difficult to diagnose based on clinical examination and magnetic resonance imaging (MRI).Patients from a single surgeon's practice from 2000 to 2018 with a partial distal biceps tendon tear were retrospectively reviewed to determine the utility of the distal biceps palpation-rotation test in the detection of partial tears. This test is performed by palpating the bicipital tuberosity at the lateral forearm while ranging the forearm from supination to pronation with the arm adducted at the patient's side and the elbow flexed to 90°. A positive test elicits tenderness at the tuberosity with the arm in pronation but not in supination. Examination findings were correlated with MRI reports confirming a partial tear. Twelve cadaveric arms were dissected to determine overall pronosupination range of motion, the degree of pronation at which the bicipital tuberosity is maximally palpable, and anatomic measurements of the bicipital tuberosity to guide the optimal technique when carrying out the maneuver.Ninety-nine patients were diagnosed with a partial distal biceps tendon, of whom 34 had available MRI reports and complete physical examination documentation. Thirty-three of 34 patients (97%) had partial tears on MRI. The hook test was negative in all cases. All patients had tenderness with resisted supination. In those with MRI-confirmed partial tears, the palpation-rotation test was positive in all patients (100% sensitivity). The bicipital tuberosity was maximally palpated at the dorsolateral forearm at a mean 20° of pronation, and the proximal and distal boundaries of the radial tuberosity were 2.5 cm and 5.3 cm, on average, distal to the radial head, respectively.A positive palpation-rotation test was seen in 33 of 33 patients (100% sensitivity), as correlated with MRI. The combination of an intact distal biceps tendon within the antecubital fossa, tenderness on resisted supination, and a positive palpation-rotation test are highly suggestive of a partial distal biceps tendon tear.

Despite advances in understanding of corticospinal motor control and stroke pathophysiology, current rehabilitation therapies for poststroke upper limb paresis have limited efficacy at the level of impairment. To address this problem, we make the conceptual case for a new treatment approach. We first summarize current understanding of motor control deficits in the arm and hand after stroke and their shared physiological mechanisms with spinal cord injury (SCI). We then review studies of spinal cord stimulation (SCS) for recovery of locomotion after SCI, which provide convincing evidence for enhancement of residual corticospinal function. By extrapolation, we argue for using cervical SCS to restore upper limb motor control after stroke.

There are various approaches to the distal humerus when managing a distal humeral fracture, and controversy exists regarding which approach is optimal. The purpose of this study was to report the outcomes of the triceps tongue (TT) approach when used for osteosynthesis of AO type 13-A, B, and C distal humeral fractures. Secondarily, we aimed to compare the outcomes of the TT approach vs. olecranon osteotomy (OO) when used for osteosynthesis of AO type 13-C distal humeral fractures.We performed a retrospective review of patients with distal humeral fractures treated with open reduction-internal fixation by either a TT or OO approach between 2007 and 2019 at 2 separate institutions. TT patients with AO type 13-C fractures were matched to OO patients at a 1:1 ratio based on age, sex, and fracture characteristics. Surgical time, intraoperative blood loss, elbow motion, fracture union, complications, and Disabilities of the Arm, Shoulder and Hand scores were compared.A total of 28 patients treated with the TT approach were assessed, and the matched TT and OO cohorts each comprised 15 patients. The TT group showed less blood loss (119.3 mL vs. 268.5 mL, P = .03), had greater maximal flexion (126° vs. 116°, P = .03), and achieved a larger flexion-extension arc (108° vs. 93°, P = .05) than the OO group. In the OO cohort, 27% of patients had complications directly related to the OO, and OO patients had a higher rate of postoperative ulnar nerve neuritis (33% vs. 0%, P = .04). There was no difference in Disabilities of the Arm, Shoulder and Hand score (P = .08), procedure time (P = .2), total number of patients with ≥1 complication (P = .5), difficulty with union (P = .7), or number of patients requiring revision surgery (P = .7).The TT approach is a safe and effective approach for the treatment of distal humeral fractures. When compared with the OO approach for AO type 13-C fractures, the TT approach did not differ regarding functional outcomes but showed increased range of motion, decreased intraoperative blood loss, and a lower rate of postoperative ulnar nerve neuritis. The TT approach should be considered as a safe and reliable first-line approach for intra-articular distal humeral fractures because it allows adequate visualization of the articular surface, eliminates complications related to osteotomy including delayed union or nonunion and hardware failure or irritation, and allows for easy conversion to total elbow arthroplasty.

Treating recurrent anterior shoulder instability in participants in collision sports, patients with capsulolabral defects, and patients with bipolar bone loss remains challenging. The study purpose was to investigate the effect of long head of the biceps transfer (LHBT) on load-to-dislocation biomechanics in a repetitive serial shoulder dislocation cadaveric model comparing LHBT with the Latarjet and Bankart procedures-the first-line treatment methods for chronic traumatic anterior shoulder instability with and without anterior glenoid bone loss, respectively.In this controlled laboratory study, 8 fresh-frozen cadaveric shoulders with different conditions were dislocated in sequence using a custom test frame. The muscle loading configuration simulated the arm in the apprehension position, and biceps loads of 20 N and 40 N were used for the static glenohumeral position analysis to evaluate the sling effect. Sequential experimental conditions consisted of the intact state, second and third dislocations, chronic instability, Bankart repair, first LHBT, subcritical glenoid bone loss, second LHBT, and Latarjet procedure.The pectoralis major and joint reaction loads to dislocation sequentially decreased with serial dislocations in all specimens, with the lowest value in the subcritical glenoid bone defect condition. In the setting of chronic instability, the pectoralis load to dislocation was significantly higher with the Bankart repair (P = .031) and LHBT (P.001), at 71% and 85% of the intact value, respectively. Direct comparison of the pectoralis load to dislocation favored LHBT over Bankart repair (P = .015). In the subcritical defect scenario, LHBT did not significantly increase the load to dislocate, and the Latarjet procedure demonstrated a higher load to dislocate than LHBT (P.001). All 3 surgical procedures tested significantly increased the angle of horizontal abduction at the time of dislocation and restored the glenohumeral position to closer to the intact state. Doubling the biceps load leveraged the sling effect, pulling the humeral head farther posterior-superiorly, but this was not enough to overcome the effect of a 20% subcritical glenoid bone defect.In a serial dislocation model, LHBT effectively stabilized the glenohumeral joint in a simulated chronic instability scenario, increasing the pectoralis major load-to-dislocate and glenohumeral joint reaction force components at the time of dislocation and restoring relative glenohumeral positioning to close to the intact state. The Latarjet procedure outperformed LHBT in stabilizing shoulders in the 20% subcritical glenoid bone defect condition.

Background Children with Down Syndrome (DS) present with neuromuscular disturbances leading to delayed developmental milestones, poor quality of movement and poor balance. The aim of this study is to discuss the role of trunk muscle strength in the functional performance of children with DS. Methodology 28 children were recruited in the study, 14 with DS and 14 age and gender-matched controls. Trunk muscle strength, reaching ability and balance were assessed using a Handheld Dynamometer, Modified Functional Reach test and Pediatric Balance Scale, respectively. Results Children with DS present with poorer trunk muscle strength, reaching ability and balance as compared to typically developing (TD) children. There was a positive correlation between trunk muscle strength and lateral reaching in children with DS. A strong to moderate correlation was observed between the trunk muscle strength and balance in children with DS. Discussion Children with DS demonstrated a significantly weak trunk muscle groups. Lateral reaching distance is reduced due to the poor proximal control and they present with near-normal forward reach distance attributed to compensation using the lower trunk muscles. They exhibit poor balance in the components that require a small base of support. Conclusion Children with DS exhibit weak trunk muscles along with lesser reaching distance and poor balance. Also, trunk muscle strength influences lateral reaching ability. Trunk muscle strength, mainly trunk extensors impacted functional balance in sitting, standing and while performing transfers.

Objectives To investigate the arm–leg coordination from different perspectives of motor control during the underwater start sequence to understand whether differences exist between the three competitive breaststroke swimming events. Design Cross-sectional study. Methods Forty-one breaststroke races (with race times relative to the world record): 50-meter (n = 14, 87.6%), 100-meter (n = 14, 88.5%) and 200-meter (n = 13, 85.4%) were recorded. A race analysis system tracked the two-dimensional displacement of the head. Key points from the underwater start sequence were obtained from notational analysis in order to compute seven time-gaps and four phases to assess the arm–leg coordination and timing of the dolphin kick. A one-way ANOVA with Bonferroni post-hoc correction was used to assess differences between the time gaps and phases for the three events. Results Differences between the three events were found for total underwater glide, and the first (T0) and second (T1) major glide phase. No differences between the events were found in relative duration and distance for the time gaps related to arm–leg coordination (T1–3, T4, T6) and timing of the dolphin kick (T4–5) during the underwater start sequence. Conclusions The arm–leg coordination and timing of the dolphin kick showed no difference between the events, but the total underwater glide duration was longer in both the 100- and 200-meter compared with the 50-meter start. This shows that swimmers did not change the complex inter-limb coordination between the competitive events, but only modified the least complex movement, gliding, to adapt to the swimming speed of the respective events.

Study Design This is a validation study. Background Tracking limb movement with body worn sensors allows clinicians to measure limb dynamics to guide treatment for patients with movement disorders. The current gold standard, 3-dimensional optical motion capture, is costly, time-consuming, requires specific training, and is conducted in specialized laboratories. Purpose The purpose of our study was to a compare consumer-grade inertial sensor to a laboratory-grade sensor to provide additional methods for capturing limb dynamics. Methods The participants wore an Apple Watch and a laboratory-grade Xsens sensor on each wrist during 3 conditions: walk, fast-walk, and run. Acceleration data were collected simultaneously on each device per wrist for all conditions. Intraclass correlation coefficients and Bland-Altman plots were calculated to measure intra-/interdevice reliability, evaluate bias, and limits of agreement. Results Intradevice ICCs showed good reliability during walk and fast-walk (0.79-0.87) and excellent reliability during run (0.94-0.97) conditions. Inter-device ICCs yielded moderate reliability during walk (0.52 ± 0.22) and excellent reliability in fast-walk and run (0.93 ± 0.02, 1.00 ± 0.01) conditions. Bland-Altman plots showed small biases with 90% or more of the data contained within the limits of agreement. Discussion Our study demonstrates reliability and agreement between the two devices, suggesting that both can reliably capture upper extremity motion data during gait trials. Conclusion Our findings support further study of consumer-grade motion trackers to measure arm activity for clinical use. These devices are inexpensive, user-friendly, and allow for data collection outside of the laboratory.

Purpose We summarize the indications, assess the modes of failure, and analyze the clinical and functional outcomes of revision biceps tenodesis after failed primary surgical treatment of long head of biceps (LHB) pathology. Methods A computerized search of PubMed, EMBASE, and CINAHL databases and manual screening of selected article reference lists was performed in September 2020. Randomized controlled trial, cohort, case-control, and case series studies reporting clinical outcomes of revision biceps tenodesis following failed LHB surgery were eligible. Patient demographics, indications for revision, intraoperative findings, surgical techniques, and patient-reported outcomes were recorded. Functional assessment and pain scores were assessed and summarized as forest plots with means and 95% confidence intervals. Results Five of 465 identified studies met inclusion criteria, encompassing 70 revision biceps tenodesis procedures with mean follow-up of 2.4-6.4 years. The failed index procedure was biceps tenodesis in 62 patients and tenotomy in 8 patients. The most common indications for revision were pain or cramping and rerupture, cited by 4 and 3 articles, respectively. After failed conservative treatment, open subpectoral revision tenodesis was performed with concomitant arthroscopic debridement in 65 of 70 cases. Common intraoperative findings at time of revision were adhesions or scarring (39.0-83.0%), fixation failure (8.7-75.0%), and biceps rupture (17.4-80.0%). Revision tenodesis patients reported good to excellent functional outcomes with improvements in Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons Shoulder, and visual analog scale pain scores, and satisfaction ranged from 88.0 to 100%. All studies demonstrated moderate quality of evidence and risk of bias when critically appraised. Conclusion This systematic review of 5 moderate risk of bias studies demonstrated that the most common reasons for revision biceps tenodesis were pain or cramping and rerupture. Open subpectoral revision tenodesis with concomitant arthroscopic debridement provided improvements in functional scores with high patient satisfaction at mid-term follow up. Level of Evidence IV, Systematic Review of level III and IV investigations.

Importance Arthroscopic suprapectoral biceps tenodesis (ABT) and open subpectoral biceps tenodesis (OBT) are two surgical treatment options for relief of long head of the biceps tendon (LHBT) pathology and superior labrum anterior to posterior (SLAP) tears. There is insufficient knowledge regarding the clinical superiority of one technique over the other. Objective To systematically review the literature in order to compare the clinical outcomes and safety of ABT and OBT for treatment of LHBT or SLAP pathology. Evidence review A systematic review was performed by searching PubMed, the Cochrane Library and Embase to identify studies that compared the clinical efficacy of ABT versus OBT. The search phrase used was: (bicep OR biceps OR biceps brachii OR long head of biceps brachii OR biceps tendinopathy) AND (tenodesis). Patients were assessed based on the American Shoulder and Elbow Surgeons Score, the visual analogue scale, the Single Assessment Numeric Evaluation, Constant-Murley Score, clinical failure, range of motion, bicipital groove pain and strength. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed, and both the Cochrane Collaboration’s and Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) risk of bias tools were used to evaluate risk of bias. Findings Eight studies (one level I, seven level III) met inclusion criteria, including 326 patients undergoing ABT and 381 patients undergoing OBT. No differences were found in treatment failure rates or patient-reported outcome scores between groups in any study. One study found OBT patients to experience significantly increased range of shoulder forward flexion when compared with ABT patients (p=0.049). Two studies found ABT patients to experience significantly more postoperative stiffness when compared with OBT patients (p Conclusions Patients undergoing ABT and OBT can be expected to experience similar improvements in clinical outcomes at latest follow-up without differences treatment failure or functional performance. ABT patients may experience an increased incidence of stiffness in the early postoperative period. Level of evidence III.

Purpose The aim of the present study was to investigate the efficacy of a new upper limb fixation method—body pillow position for preventing postoperative ipsilateral shoulder pain (ISP) in patients undergoing lung resection. Design An experimental study design was used. Methods We conducted two comparisons (group A: the previous position using the arm fixation device; group B: the body pillow position) at random and examined an arm fixation method that is effective for ISP prophylaxis in patients undergoing surgery in the lateral decubitus position. Findings We approached 87 patients, two were excluded, and, thus, 85 were randomly assigned to group A (n = 43) or group B (n = 42). No significant differences were observed in the frequency of ISP between groups A and B (25.6% vs 26.2%). The intensity of ISP between both groups was analyzed by a repeated-measures analysis of variance and was shown to decrease over time in 22 patients (P = .010). The intensity of ISP on postoperative days 0 to 3 was slightly lower in group B than in group A (P = .158). Risk factors for ISP were the duration of surgery (odds ratio, 1.01; 95% confidence interval, 1.00 to 1.01) and pre-existing shoulder stiffness (odds ratio, 5.15; 95% confidence interval, 1.07 to 24.83). Conclusions There was no significance in the frequency of ISP between group A and group B. The intensity of ISP on postoperative days 0 to 3 was lower in group B than in group A, although there was no significant difference. It is important perspective for perioperative care providers to prevent ISP for early postoperative recovery and improvement of postoperative quality of life. These results suggested that we must consider a better position for preventing postoperative ISP in patients undergoing lung resection.

Background Mechanosensitivity changes and trigger points in the infraspinatus muscle are associated with several painful conditions of the upper limb. The aim of this study was to assess the effect of different postures of the upper quadrant on the pressure pain threshold (PPT) of the infraspinatus muscle. Methods This was an observational, cross-sectional study. Fifty-four subjects with and without shoulder pain (Asymptomatic subjects = 27, mean age 26.9 ± 4.92 years, BMI 23.73 ± 3.87), (symptomatic subjects = 27, mean age 27.6 ± 3.68 years, BMI 24.35 ± 3.86) were evaluated with a pressure algometer on the infraspinatus muscle belly, in four different positions of the upper quadrant: rest position (P1), passive scapular retraction position (P2), cervical contralateral inclination position (P3), and suprascapular nerve provocation position (P4). The assessed side was randomly chosen and all measurements were taken in sitting position. Results No differences were observed between groups. The within-group analysis showed differences for both factors: “Positions” (F = 69.91; p = 0.001) and the interaction “Positions^Group” (F = 3.36; p = 0.02). The pairwise post-hoc analysis showed differences for the retracted position (P2) compared to others P1 (p = 0.001), P3 (p = 0.001), and P4 (p = 0.001), with higher PPT results achieved on the retracted position. Differences between P4 vs. P1 (p = 0.03) were also observed, with higher values for P4. Conclusion Placing the scapular girdle in a passive scapular retraction position significantly reduces the pressure sensitivity at the infraspinatus muscle. Physiotherapists can take into account these results when assessing and treating patients with upper quadrant pain syndromes.

Background Key nutrient deficits remain widespread throughout sub-Saharan Africa (SSA) whereas noncommunicable diseases (NCDs) now cause one-third of deaths. Easy-to-use metrics are needed to track contributions of diet quality to this double burden. Objectives We evaluated comparative performance of a novel food-based Global Diet Quality Score (GDQS) against other diet metrics in capturing nutrient adequacy and undernutrition in rural SSA adults. Methods We scored the GDQS, Minimum Dietary Diversity–Women (MDD-W), and Alternative Healthy Eating Index–2010 (AHEI-2010) using FFQ data from rural men and nonpregnant, nonlactating women of reproductive age (15–49 y) in 10 SSA countries. We evaluated Spearman correlations between metrics and energy-adjusted nutrient intakes, and age-adjusted associations with BMI, midupper arm circumference (MUAC), and hemoglobin in regression models. Results Correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B-12 adequacy were 0.34 (95% CI: 0.30, 0.38) in men and 0.37 (95% CI: 0.32, 0.41) in women. The GDQS was associated (P

Recurrence of shoulder glenohumeral instability is exacerbated in cases of glenoid bone loss. Surgical bone transfer techniques well address the issue. Innovative soft-tissue tendon transfers may fill the defect plus provide a sling effect. Double-sling transfer of both the conjoined tendons and long head biceps tendon for glenoid bone loss in patients with shoulder instability shows biomechanical benefit in shoulder abduction and external rotation. However, as the sling effect is less pronounced in mid-range arm position, the benefit of double-sling transfer may be insufficient. Moreover, the biomechanical models are limited relative to the complexity of clinical glenohumeral function, and obviously limited to time-zero analysis. We should be careful before we abandon bony augmentation procedures.

Background The lumbar spine displays its greatest mobility in ventral flexion, which is a potential risk factor for low back pain. The relative contribution of each segment to the complete flexion is denoted the spine rhythm, which is required to distinguish between normal and abnormal spinal profiles, and as well to calculate the spinal forces in musculoskeletal models. Nevertheless, different spine rhythms have been reported in literature and the effect of arm position has not been demonstrated. We therefore aimed to investigate the effects of different arm positions on spine rhythm during ventral flexion. Methods A nonradiologic back measurement device was used to determine the real-time back lordosis during ventral flexion while participants (10 male and 10 female without low back pain) held their arms at 6 different positions. Results During flexion with the arms naturally hanging down at both sides, the lumbar range of flexion was 52.6° ± 13.1°. Different arm positions displayed nonsignificant effect on lumbar range of flexion (P > 0.05). The middle and lower levels contributed more to the whole lumbar range of flexion than the upper level (P Conclusions The lumbar spine displayed greater flexion in the middle and lower levels and its flexion rhythm remained unchanged at different arm positions. These results strike importance to explore for more reasons explaining the different lumbar flexion rhythms reported in literature.

Background The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes. Methods Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity. Results One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = −0.155, P = .527) or body mass index (r = −0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed. Conclusion The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.

Background Distal biceps endoscopy has emerged as a minimally invasive alternative to open procedures for distal biceps tendon (DBT) pathology. The purpose of this study was to systematically describe the static and dynamic appearance and variations of the DBT insertional region using a standardized endoscopic technique and dissection in healthy cadaveric elbows. Methods Endoscopic assessment of the DBT insertional region was performed using a standard proximal parabiceps portal in 20 fresh frozen cadaveric upper extremities. A 6-point endoscopic evaluation of the DBT and bicipitoradial bursa was performed in a static supination position and with dynamic rotation. Anatomic variations in the DBT insertional characteristics, as well as the extent and appearance of the intrabursal space, were documented. Each cadaver was then dissected to correlate endoscopic findings with gross anatomic structures. Results A bare oval tuberosity area (n = 20) bounded by the supinator and DBT was observed. The DBT inserted ulnar to the bare area (n = 16) and the presence of an intervening wide (n = 1) or narrow (n = 3) tuberosity sulcus were documented. The dorsoradial DBT surface was consistently intrabursal and was differentiated into 2-5 fiber bundles (n = 15). The volar-ulnar DBT surface was always extrabursal and was associated with endoscopically identifiable proximal and distal fat pads. The bicipitoradial bursa formed a bursal sac that was attached to the dorsoradial (n = 13) or volar (n = 7) aspect of the tuberosity and extended proximally along the DBT for 3-5 cm (parabiceps space). A distinct ligament-like band (transverse radioulnar ligament) extended transversely across the proximal radioulnar space and appeared to form a sling that provided ulnar support to the DBT during dynamic rotation. The intact DBT surface was robust and could not be breached, even with firm pressure using a probe. Conclusions The bare tuberosity area, the bursal sac, and the parabiceps space are consistent anatomic landmarks that can be used during DBT endoscopy. An insertional tuberosity sulcus and DBT surface differentiation are normal anatomic variations. The transverse radioulnar ligament provides ulnar support for the DBT during pronation and forms a pulley mechanism for smooth tendon gliding motion.

Arm movements make a substantial and functionally relevant contribution to quiet standing and dynamic balance tasks. The impact of restricted arm movements on balance control is particularly important for children as their postural control system is not fully matured.This study investigated the effects of arm movements on lower body joint kinematics and dynamic postural stability during anterior and lateral dynamic movements in children.Eighteen boys (age, 10.1 ± 1.6 years) completed an anterior and a lateral jump-landing task under two different verbally conveyed instructions of arm position; (1) arms placed flat across the chest touching the contralateral shoulder (i.e., restricted arm movement) and (2) arm movement without restriction. Lower body joint kinematics were recorded and used to calculate mean joint position, joint range of motion (ROM) and joint movement variability.Restricting arm movements resulted in a reduction of joint movement variability and joint ROM of the pelvis during the lateral jump (p0.05), but increased joint movement variability and joint ROM of the pelvis during the anterior jump (p0.05).The reduced joint movement variability and joint ROM with restricted arm movements during the lateral jump may represent a potential compensatory 'stiffenin strategy', whilst the increase during the anterior jump suggest an exploratory strategy. These novel findings highlight that it is important for children to be introduced to different dynamic task constraints so that they can learn to control and organise the motor system degrees of freedom appropriately.

Proprioception in old age is thought to be poorer due to degeneration of the central (CNS) and peripheral nervous systems (PNS). We tested whether community-dwelling older adults (65–83 years) make larger proprioceptive errors than young adults (18–22 years) using a natural reaching task. Subjects moved the right arm to touch the index fingertip to the stationary or moving left index fingertip. The range of locations of the target index fingertip was large, sampling the natural workspace of the human arm. The target arm was moved actively by the subject or passively by the experimenter and reaching arm movements towards the target were made under visual guidance, or with vision blocked (proprioceptive guidance). Subjects did not know the direction or speed of upcoming target hand motion in the passive conditions. Mean 3D distance errors between the right and left index finger tips were small in both groups and only slightly larger when vision was blocked than when allowed, but averaged 2–5 mm larger in older than in younger adults in moving (p = 0.002) and stationary (p = 0.07) conditions, respectively. Variable errors were small and similar in the two groups (p > 0.35). Importantly, clearly larger errors were observed for reaching to the stationary than to the moving index fingertip in both groups, demonstrating that dynamic proprioceptive information during movement permits more accurate localization of the endpoint of the moving arm. This novel finding demonstrates the importance of dynamic proprioceptive information in movement guidance and bimanual coordination.

Background Based on Euler/Cardan analysis, prior investigations have reported up to 80° of glenohumeral (GH) external rotation during arm elevation, dependent on the plane of elevation (PoE). However, the subtraction of Euler/Cardan angles does not compute the rotation around the humerus’ longitudinal axis (i.e. axial rotation). Clinicians want to understand the true rotation around the humerus’ longitudinal axis and rely on laboratories to inform their understanding of underlying shoulder biomechanics, especially for the GH joint since its motion cannot be visually ascertained. True GH axial rotation has not been previously measured in vivo, and its difference from Euler/Cardan (apparent) axial rotation is unknown. Research question What is the true GH axial rotation during arm elevation and external rotation, and does it vary from apparent axial rotation and by PoE? Methods Twenty healthy subjects (10 M/10 F, ages 22–66) were recorded using biplane fluoroscopy while performing arm elevation in the coronal, scapular and sagittal planes, and external rotation in 0° and 90° of abduction. Apparent GH axial rotation was computed using the xz’y’’ and yx’y’’ sequences. True GH axial rotation was computed by integrating the projection of GH angular velocity onto the humerus’ longitudinal axis. One-dimensional statistical parametric mapping was utilized to compare apparent versus true axial rotation, axial rotation versus 0°, and detect differences in axial rotation by PoE. Results In contrast to apparent axial rotation, true GH axial rotation does not differ by PoE and is not different than 0° during arm elevation at higher elevation angles. The spherical area between the sequence-specific and actual humeral trajectory explains the difference between apparent and true axial rotation. Significance Proper quantification of axial rotation is important because biomechanics literature informs clinical understanding of shoulder biomechanics. Clinicians care about true axial rotation, which should be reported in future studies of shoulder kinematics.

Background and aims Prior studies have described an association between calf circumference and cardiovascular disorders. We evaluated the associations between calf, thigh, and arm circumference and cardiovascular and all-cause mortality. Methods and results We performed a retrospective cohort study of 11,871 patients in the 1999–2004 National Health and Nutrition Examination Survey (NHANES) to determine the association between calf circumference and cardiovascular and all-cause mortality using univariate and multivariate Cox proportional hazards. We additionally examined the association between thigh and arm circumference and mortality. In the multivariable Cox regression for the female stratum, each centimeter increase in calf circumference was associated with a hazard ratio of 0.88 (95% CI 0.84–0.92), and a hazard ratio of 0.90 (95% CI 0.85–0.95) for cardiovascular death. In the model with males, the hazard ratio for higher calf circumference was 0.92 (95% CI 0.88–0.96) for all-cause mortality and 0.94 (95% CI 0.89–0.99) for cardiovascular death. There was a statistically significant association between higher thigh circumference and lower risk of all-cause and cardiovascular mortality. Arm circumference was not similarly associated with mortality in the multivariate model. Conclusion Calf and thigh circumference may provide important prognostic information regarding cardiovascular and all-cause mortality. Future prospective studies should examine the role of extremity circumference and cardiovascular events.

Background The ideal surgical treatment of long head of biceps pathology is unclear. This review evaluates Level I studies comparing tenotomy and tenodesis for the management of long head of biceps pathology. Methods Medline, EMBASE, and the Cochrane Library databases were searched from database inception though April 17, 2020. Clinical outcomes including Constant-Murley Shoulder Outcome Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) shoulder score, pain on visual analog scale, postoperative strength, and Popeye deformity were evaluated. Dichotomous outcomes were pooled into relative risk ratios whereas continuous outcomes were pooled into weighted mean differences using random effects meta-analysis. Results A total of 5 studies (227 tenotomy and 227 tenodesis patients) met the final inclusion criteria. Postoperative improvement across all outcomes was observed regardless of surgical treatment. Pooled analysis demonstrated no statistically significant difference for Constant-Murley Shoulder Outcome Score, ASES, pain, or flexion strength. Tenodesis was superior to tenotomy in reducing the risk of Popeye deformity (relative risk ratio 3.07, confidence interval 1.87, 5.02; P Conclusion Tenotomy and tenodesis of the long head of the biceps results in comparable postoperative clinical and functional outcomes. Tenodesis is superior to tenotomy in preventing Popeye deformity postoperatively.

Background and purpose This study was conducted to evaluate the longitudinal impact of postmastectomy radiation therapy (PMRT) on persistent severe lymphedema (PSL) using arm volume measurements by an infrared optoelectronic volumetry. Materials and methods Of the patients who underwent mastectomy between 2008 and 2016, we included 330 patients with secondary arm lymphedema. Percentage of excessive volume (PEV) of the arm were serially assessed using an optoelectronic volumetry 1, 3, 6, 12, 18, 24, 36, and 48 months after the lymphedema diagnosis (Tlymh_Dx). We defined PSL as 2 or more episodes of PEV ≥ 20%. Risk factors for PSL were evaluated using stepwise regression analyses. Results Patients who received PMRT (n = 202, 61.2%) were more likely to have larger extent of axillary node dissection (AND), and frequent stage II/III lymphedema at Tlymh_Dx than those who did not receive PMRT (p Conclusion PMRT, especially RNI, was associated with a consistent increase in PEV in patients with arm lymphedema. Therefore, timely physical therapy is necessary for this patient population.

Summary Objective Non-invasive Remote Ischemic Conditioning (RIC) offers an approach to reduce tissue damage in various organs/tissues. Besides attenuation of Ischemia-Reperfusion injury (I/R), beneficial effects on cutaneous microcirculation of free microsurgical flaps have been reported. Given the recency of this technique, there are considerable gaps in the current understanding of its mechanism of action. As a result, clinical transfer of RIC is prolongated in several fields. We aimed to optimize the RIC protocol by examination of different RIC-cycle numbers and its effect on changes of cutaneous microcirculation and duration. Methods 80 subjects were divided into groups (1, 3, 5, 7 RIC cycles). RIC was applied via an inflatable tourniquet. Cutaneous microcirculation was continuously assessed at the contralateral anterior lateral thigh utilizing a ©O2C-device continuously. Results RIC caused significant and sustained changes in microcirculation. Four hours after completion of RIC, a maximum increase of +80.8% (CI 1.395–2.221) in blood flow and +23.5% (CI 1.098–1.372) in tissue oxygen saturation was measured (three-cycle group). A higher number of applied cycles was accompanied with significant higher mean pain. Conclusion Acute improvement of cutaneous microcirculation due to RIC lasted for at least 4 h after completion of the RIC-protocol. Dose-dependent effects of RIC are likely. With regard to the increase in pain, we recommend a RIC protocol of 3 cycles for future clinical application.

Purpose Optimization of CT scan practices can help achieve and maintain optimal radiation protection. The aim was to assess centering, scan length, and positioning of patients undergoing chest CT for suspected or known COVID-19 pneumonia and to investigate their effect on associated radiation doses. Methods With respective approvals from institutional review boards, we compiled CT imaging and radiation dose data from four hospitals belonging to four countries (Brazil, Iran, Italy, and USA) on 400 adult patients who underwent chest CT for suspected or known COVID-19 pneumonia between April 2020 and August 2020. We recorded patient demographics and volume CT dose index (CTDIvol) and dose length product (DLP). From thin-section CT images of each patient, we estimated the scan length and recorded the first and last vertebral bodies at the scan start and end locations. Patient mis-centering and arm position were recorded. Data were analyzed with analysis of variance (ANOVA). Results The extent and frequency of patient mis-centering did not differ across the four CT facilities (>0.09). The frequency of patients scanned with arms by their side (11–40% relative to those with arms up) had greater mis-centering and higher CTDIvol and DLP at 2/4 facilities (p = 0.027–0.05). Despite lack of variations in effective diameters (p = 0.14), there were significantly variations in scan lengths, CTDIvol and DLP across the four facilities (p Conclusions Mis-centering, over-scanning, and arms by the side are frequent issues with use of chest CT in COVID-19 pneumonia and are associated with higher radiation doses.

Purpose: To reconstruct the dose delivered during single-fraction urethra-sparing prostate stereotactic body radiotherapy (SBRT) accounting for intrafraction motion monitored by intraprostatic electromagnetic transponders (EMT). Methods: We analyzed data of 15 patients included in the phase I/II "ONE SHOT" trial and treated with a single fraction of 19 Gy to the planning target volume (PTV) and 17 Gy to the urethra planning risk volume. During delivery, prostate motion was tracked with implanted EMT. SBRT was interrupted when a 3-mm threshold was trespassed and corrected unless the offset was transient. Motion-encoded reconstructed (MER) plans were obtained by splitting the original plans into multiple sub-beams with isocenter shifts based on recorded EMT positions, mimicking prostate motion during treatment. We analyzed intrafraction motion and compared MER to planned doses. Results: The median EMT motion range (±SD) during delivery was 0.26 ± 0.09, 0.22 ± 0.14 and 0.18 ± 0.10 cm in the antero-posterior, supero-inferior, and left-right axes, respectively. Treatment interruptions were needed for 8 patients because of target motion beyond limits in the antero-posterior (n = 6) and/or supero-inferior directions (n = 4). Comparing MER vs. original plan there was a median relative dose difference of -1.9% (range, -7.9 to -1.0%) and of +0.5% (-0.3-1.7%) for PTV D98% and D2%, respectively. The clinical target volume remained sufficiently covered with a median D98% difference of -0.3% (-1.6-0.5%). Bladder and rectum dosimetric parameters showed significant differences between original and MER plans, but mostly remained within acceptable limits. Conclusions: The dosimetric impact of intrafraction prostate motion was minimal for target coverage for single-fraction prostate SBRT with real-time electromagnetic tracking combined with beam gating. Keywords: Dose reconstruction; Electromagnetic transponder; Intrafraction motion; Prostate cancer; Single-fraction; Stereotactic body radiotherapy.

Background Decaffeinated green tea extract (dGTE) can increase fat oxidation during leg exercise, but dGTE is unsuitable for many people (e.g., those with injuries/disabilities), and its effects on arm exercise and women are unknown. Methods Eight adults (23–37 years old, 4 women) performed an incremental arm cycle test to measure peak oxygen uptake (VO2peak), followed by four 1-h trials at 50% VO2peak. Subjects were randomly assigned to 650 mg of dGTE or placebo (PLA) for 4 weeks followed by a 4-week washout and crossover trial. Blood samples were obtained pre-exercise and post-exercise for glycerol and free fatty acid analysis. Respiratory gases were collected continuously. Results VO2 showed no differences across trials ((0.83–0.89) ± (0.19–0.25) L/min, p = 0.460), neither did energy expenditure ((264–266) ± (59–77) kcal, p = 0.420) nor fat oxidation (dGTE = 0.11 to 0.12 g/min vs. PLA = 0.10 to 0.09 g/min, p = 0.220). Fat oxidation as percentage of energy expenditure was not different for dGTE vs. PLA (23% ± 12% to 25% ± 11% vs. 23% ± 10% to 21% ± 9%, p = 0.532). Glycerol concentration increased post-exercise in all trials, independent of treatments (pre = (3.4–5.1) ± (0.6–2.6) mg/dL vs. post = (7.9–9.8) ± (2.6–3.7) mg/dL, p = 0.867, η2 = 0.005 for interaction), as did free fatty acid ((3.5–4.8) ± (1.4–2.2) mg/dL vs. (7.2–9.1) ± (2.6–4.5) mg/dL, p = 0.981, η2 = 0.000). Conclusion Chronic dGTE supplementation had no effect on lipolysis and fat oxidation during arm cycle exercise in men and women.

Introduction The purpose of this study was to reveal a functional role for arm-swing asymmetry during gait in healthy adults. To this end, the primary aim was to investigate the role of neuromuscular control on the asymmetry of propulsive and collision joint work at either end of the double-support phase (WDS) in the context of sidedness. The secondary aim was to investigate the effect of neuromuscular control on propulsive and collision joint work at either end of the single-support phase (WSS) in the context of arm-swing asymmetry. Methods Slow -walking trials of 25 participants were analysed using principal component analysis to generate movement synergies (PMk). Independent variables included the tightness of neuromuscular control (N1) formulated from the first PMk and the directional Arm-swing asymmetry index (dASI). Dependent variables included the difference between double-support collision and propulsive joint work (WDS) and a ratio consisting of the difference between single-support collision and propulsive work of both sides (WSS). A linear mixed-effects model was utilized for aim 1 while a multiple linear regression analysis was undertaken for aim 2. Results Healthy adult gait was accompanied by a left-side dominant arm-swing on average. For aim 1, N1 demonstrated a significant negative effect on WDS while sidedness had a negative direct effect and positive indirect effect through N1 on WDS. The most notable finding was the interaction between dASI and N1 which demonstrated a highly significant positive effect on WSS. Interpretation Evidence was put forward that arm-swing asymmetry during gait is related to footedness among healthy adults. Future studies should look to formally confirm this finding.

Functional electrical stimulation (FES) has been an effective treatment option in clinical rehabilitation such as motor function recovery after stroke. The main limitation of FES is the lack of stimulation efficiency in motor unit recruitment compared with voluntary contractions, which may cause the early onset of muscle fatigue. The stimulation efficiency of FES can be improved by optimizing electrode positions to target the motor point (MP). However, the location of MP relative to the skin may shift with the change of muscle geometry during dynamic exercise. Hence, the purpose of this study is to maintain the stimulation efficiency of FES in dynamic exercise by switching the stimulation position to follow the shift of MP. We first measured the shift of the MP of the biceps brachii with respect to the elbow joint angle, and then conducted an experiment to compare four stimulation methods: 2-channel simultaneous stimulation (SS), 2-channel time based shifting stimulation (TSS), 2-channel joint angle based shifting stimulation (JASS), and 3-channel JASS. TSS and JASS were designed as two different MP tracking strategies. The experimental results show that the 3-channel JASS caused the smallest decrease in the maximal elbow angle and the angular velocity. The results also suggest that MP tracking stimulation based on joint angle is effective for the sustainable induction of muscle contraction. Both tracking selectivity and tracking density were shown to be important to improve the stimulation efficiency of FES.

Antidepressant efficacy is influenced by patient expectations and, in randomized controlled trials (RCTs), the probability of receiving a placebo. It is unclear whether tolerability demonstrates a similar pattern. This study aimed to determine whether study design influences adverse event (AE) rates in antidepressant trials for subjects receiving active treatment or placebo.RCTs comparing one antidepressant to another antidepressant, placebo, or both in major depressive disorder (MDD) (1996-2018) were retrieved from Medline and PsycINFO. Clinicaltrials.gov was searched for unpublished trials. Of 1,997 studies screened, 77 trials were included. Studies were classified as drug-drug, drug-drug-placebo, or drug-placebo based on design and overall number of subjects experiencing any AE was recorded. Subgroup meta-analysis of proportions and meta-regression techniques were used to compare AE rates across study designs in patients receiving active antidepressant treatment and placebo.Among the actively treated, AE rates were lower in drug-drug trials (58.5%) compared to drug-drug-placebo (75.7%) and drug-placebo (76.4%) (the model reported coefficients for percent differences between AE rates of different study designs were B=17.0, p0.001 and B=17.8, p0.001, respectively). AE rates in patients receiving placebo were not different between study designs.The present study is limited by the diverse range of study populations, variability in reporting of AEs, and specific antidepressants employed in the included trials.The inclusion of a placebo arm in the study design was unexpectedly associated with higher rates of AEs among patients receiving active medication in antidepressant trials. This observation has important implications for interpretation of trial tolerability findings.

Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point.Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P.001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms6 months was predictive of a reduced likelihood to achieve PASS.This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

To analyze the impact of interarm blood pressure difference (IAD) on functional and cardiovascular parameters in patients with peripheral artery disease (PAD).Ninety-eight patients with PAD were recruited in this cross-sectional study. Patients with differences between the right and left arms of systolic and/or diastolic blood pressure ≥10 mm Hg were classified as IAD, whereas the remaining patients were classified as PAD control subjects. Functional parameters included were the 6-min walk test, short physical performance battery, walking impairment questionnaire (WIQ), and the walking estimated-limitation calculated by history. Systemic cardiovascular parameters included were arterial stiffness and heart rate variability. Local cardiovascular parameters assessed in both arms were brachial blood pressure and flow-mediated dilation.Patients with IAD presented higher systolic blood pressure and pulse pressure compared with control patients (P 0.01). The carotid femoral pulse wave velocity tended to be higher and flow-mediated dilation tended to be lower in PAD patients with IAD compared with control subjects (P 0.09). Patients with IAD presented lower scores in short physical performance battery (P = 0.012), WIQ distance (P = 0.003), WIQ speed (P = 0.008), WIQ stair climbing (P = 0.034), and walking estimated-limitation calculated by history (P = 0.026) when compared with PAD control patients.In patients with PAD, IAD is associated with lower physical function and impairments in cardiovascular parameters compared with PAD patients without IAD.

Chronic kidney disease (CKD) patients are at increased risk of sarcopenic muscle wasting, with increased mortality risk. Simple screening tests are required to detect sarcopenia to allow for interventional therapies. We wished to compare anthropometric and multifrequency bioimpedance (MFBIA) measurements of arm composition and muscle strength.We measured segmental MFBIA, mid arm upper circumference (MUAC) and triceps skin fold thickness (TSF), hand grip strength (HGS) and pinch strength (PS) in CKD patients attending out-patient review.We reviewed 146 patients; 94 male (64.4%), 93 (63.7%) diabetic, mean age 70.5 ± 15 years, weight 77.6 ± 17.1 kg, with a mean HGS of 25.2 ± 10.4, and PS 5.0 ± 1.9 kg. HGS and PS were correlated (r = 0.63, p 0.001). Male patients had greater HGS and PS (28.3 ± 10.1 vs 19.7 ± 7.0 kg; and 5.3 ± 2.0 vs 4.3 ± 1.1 kg, p 0.05) with greater arm muscle (3.2 ± 0.7 vs 2.4 ± 0.7 kg, p 0.05) and less arm fat (1.8 ± 1.3 vs 2.9 ± 1.8 kg, p 0.05), whereas there was no difference in anthropometric measurements of mid upper arm muscle or fat area. Whereas both HGS and PS correlated positively with MFBIA arm lean mass (r = 0.55, r = 0.37, p 0.001) and negatively for arm fat mass (r = -0.4, p 0.001, r = -0.32, p = 0.001) respectively, there were no correlations with anthropometric derived estimates of upper arm muscle or fat.In CKD patients, segmental MFBIA measurements of the arm, but not those derived from anthropometric measurements demonstrate gender differences and correlate with arm muscle strength, whereas there were no such correlations with anthropometric estimates of upper arm muscle or fat.

Although the literature on the association of workers' compensation (WC) status with negative outcomes after orthopedic surgery is extensive, there is a paucity of evidence on outcomes in WC recipients undergoing biceps tenodesis. We hypothesized that WC patients would report significantly worse outcomes postoperatively on patient-reported outcome measures (PROMs).Functional and health-related quality-of-life PROMs and a visual analog scale score for pain were administered preoperatively and at 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018 at our institution. Thirty-eight WC patients were matched 1:2 to non-WC patients by age, body mass index, and operative limb. The minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state were calculated for all patients via anchor- and distribution-based methods. Rates of achievement and the likelihood of achievement were determined.All patients showed significant improvements in all outcome measures (P.001). WC patients reported inferior postoperative scores on all PROMs examined. WC status significantly predicted a reduced likelihood of achieving substantial clinical benefit for the American Shoulder and Elbow Surgeons score (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.17-0.81; P = .01) and the patient acceptable symptom state (OR, 0.28; 95% CI, 0.12-0.65; P = .003) for the American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score (OR, 0.24; 95% CI, 0.10-0.61; P = .003), Constant-Murley Subjective Assessment (OR, 0.25; 95% CI, 0.08-0.77; P = .016), and visual analog scale pain score (OR, 0.27; 95% CI, 0.16-0.47; P.001).WC patients reported inferior scores on all postoperative PROMs and demonstrated lower odds of achieving substantial benefit and satisfaction regarding improvements in both function and pain compared with non-WC patients.

Introduction/Background Arm malposition in neonatal ICU radiographs may result in overlap of the arm soft tissues and chest wall giving the appearance of lamellar effusions. We aimed to determine the frequency of arm malposition on portable neonatal/infant intensive care unit (N/IICU) chest radiographs and the proportion of these mimicking lamellar effusions. Material and Methods We evaluated a subgroup of supine portable chest radiographs performed at the N/IICU. Two reviewers, at a tertiary pediatric hospital located in the USA, evaluated each radiograph in consensus and classified arm position for either side independently as (1) acceptable: arm abducted and separated from the chest and (2) compromised: arm down and in contact with chest soft tissue. The compromised cases were evaluated regarding any overlap between soft tissues of the arm and chest of sufficient degree to mimic a lamellar effusion. Results We reviewed 300 radiographs performed at the N/IICU (600 hemithoraces). The mean age was 1.8 ± 1.8 months. Of 600 hemithoraces, 233 (39%) showed arms down and in contact with the chest. In seven (1%) cases, the arm position was compromised and mimicked a lamellar effusion. We identified 32 (5%) true lamellar effusions in the whole sample; in 14 of the 32 cases with lamellar effusion, the radiographs were performed with the arms down. Conclusion Portable chest radiographs performed in the N/IICU without proper arm abduction represent a potential for misinterpretation of chest radiographs. Although the prevalence of mimickers of lamellar effusion is only around 1%, the prevalence of arms down on a portable chest radiograph is considerably high (39%).

Purpose The purpose of this meta-analysis and systematic review was to critically evaluate the biomechanical outcomes of different fixation constructs for a variety of biceps tenodesis techniques in cadaveric models based on both type of fixation and location. Methods A PROSPERO-registered systematic review (CCRD42018109243) of the current literature was conducted with the terms “long head of biceps” AND “tenodesis” AND “biomechanics” and numerous variations thereof in the PubMed, Embase, and Cochrane databases, yielding 1,460 abstracts. After screening by eligibility criteria, 18 full-text articles were included. The individual biomechanical factors evaluated included ultimate load to failure (in newtons), stiffness (in newtons per millimeter), and cyclic displacement (in millimeters). After reviewing the included literature, we performed a quality analysis of the studies (Quality Appraisal for Cadaveric Studies scale score) and a meta-analysis comparing raw mean differences in data between the suprapectoral and subpectoral fixation location groups, as well as between the fixation construct groups. Results Among the 18 included studies, 347 cadaveric specimens were evaluated for ultimate load to failure, stiffness, and cyclic displacement when comparing both location (suprapectoral vs subpectoral) and tenodesis fixation type (interference screw vs cortical button, suture anchor, or all–soft-tissue techniques). Interference screw fixation showed significantly greater mean stiffness by 8.0 N/mm (P = .013) compared with the other grouped techniques but did not show significant differences when evaluated for ultimate load to failure and cyclic displacement (P = .28 and P = .18, respectively). Additionally, no difference in construct strength was seen when comparing the fixation strength of suprapectoral versus subpectoral techniques for stiffness, ultimate load to failure, and cyclic loading (P = .47, P = .053, and P = .13, respectively). Conclusions In this meta-analysis, no significant biomechanical differences were found when the results were stratified by specific surgical technique (interference screw vs other tenodesis techniques) and location (suprapectoral vs subpectoral biceps tenodesis). Clinical Relevance As a result of this study, when biomechanically evaluating specific tenodesis constructs, the individual clinician has the liberty of choosing the fixation technique based on his or her preference and knowledge of shortcomings of each type of fixation construct.

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Abdominal aortic aneurysm (AAA) is associated with morphological and functional changes in both aneurysmal and non-aneurysmal arteries. However, it remains uncertain whether similar changes also exist in the venous vasculature. The aim of this study was to evaluate global venous function in patients with AAA and controls.This experimental study comprised 31 men with AAA (mean ± standard deviation age 70.0 ± 2.8 years) and 29 male controls (aged 70.6 ± 3.4 years). Venous occlusion plethysmography (VOP) was used to evaluate arm venous compliance at venous pressures between 10 and 60 mmHg in steps of 5 mmHg. Compensatory mobilisation of venous capacitance blood (capacitance response) was measured with a volumetric technique during experimental hypovolaemia induced by lower body negative pressure (LBNP).The VOP induced pressure-volume curve was significantly less steep in patients with AAA (interaction, p .001), indicating lower venous compliance. Accordingly, the corresponding pressure-compliance curves displayed reduced venous compliance at lower venous pressures in patients with AAA vs. controls (interaction, p .001; AAA vs. control, p = .018). After adjusting for arterial hypertension, diabetes mellitus, hyperlipidaemia, chronic obstructive pulmonary disease, and smoking, VOP detected differences in venous compliance remained significant at low venous pressures, that is, at 10 mmHg (p = .008), 15 mmHg (p = .013), and 20 mmHg (p = .026). Mean venous compliance was negatively correlated with aortic diameter (r = -.332, p = .010). Mobilisation of venous capacitance response during LBNP was reduced by approximately 25% in patients with AAA (p = .030), and the redistribution of venous blood during LBNP was negatively correlated with aortic diameter (r = -.417, p = .007).Men with AAA demonstrated reduced venous compliance and, as a result, a lesser capacity to mobilise peripheral venous blood to the central circulation during hypovolaemic stress. These findings imply that the AAA disease may be accompanied by functional changes in the venous vascular wall.

Octopus arm nervous systems have great arm-local information processing capabilities, raising the possibility each arm functions semi-independently. A recent two-choice behavioral study suggests, however, that the brain is required to learn, and choose in each trial, correct arm direction.

Nutrition assessment is multidimensional; however, much of the literature examining the nutritional status of children with cerebral palsy (CP) focuses on a single dimension.The aim of the study was to evaluate nutritional status in children and adolescents with CP by comparing results from the Pediatric Subjective Global Nutrition Assessment (SGNA) with results from traditional anthropometric measures.This study was a cross-sectional observational study.This study was conducted in a tertiary hospital outpatient setting in Brisbane, Australia, from February 2017 to March 2018. A total of 89 children (63 boys) with CP aged between 2 and 18 years of age were included. All Gross Motor Function Classification System levels were observed. The majority of children were in Gross Motor Function Classification System I and II (57, 64%) compared with Gross Motor Function Classification System III to V (32, 36%). Children with feeding tubes and those acutely unwell or hospitalized were excluded.Children were classified as well nourished, moderately malnourished, or severely malnourished by dietitians using the SGNA. Weight, height, body mass index (BMI), triceps skinfold thickness, subscapular skinfold thickness, and mid upper arm circumference were measured and converted to z scores to account for age and sex differences. Moderate malnutrition was defined by z scores -2.00 to -2.99 and severe malnutrition as ≤-3.00 z scores.Multinomial logistic analyses were used to compare results from the SGNA and each single measurement. Continuous outcomes were transformed into z scores. Agreement was assessed with 2 categories: not malnourished and malnourished. Comparison statistics included percent agreement, sensitivity, and specificity.More children were classified as moderately or severely malnourished by SGNA than any of the anthropometric z score cutoffs. The majority of children were well nourished (n = 63) with 20 (22%) moderately malnourished and 6 (7%) severely malnourished by SGNA. The SGNA classified 11 children as malnourished that were not classified as malnourished by BMI. Children with moderate or severe malnutrition by SGNA had lower weight (P.001, P.001), BMI (P.001, P.001), mid upper arm circumference (P.001, P.001), triceps skinfold thickness (P = .01, P = .007), and subscapular skinfold thickness (P = .005, P = .02) z scores than well-nourished children.The SGNA identified more potentially malnourished children including children classified as well nourished by the single measurements such as BMI, height, and weight. The SGNA provided a clinically useful multidimensional approach to nutrition assessment for children with CP.

Background Isolated short head tears of the distal biceps are uncommon and often underappreciated. The aim of this study was to describe the presenting features and management of acute and chronic short head ruptures treated at our unit and in the published literature. Methods Six short head ruptures in 5 patients are described. The clinical and radiographic findings, operative techniques, and postoperative outcomes are reported for all patients. A systematic review of the existing literature was also performed. Results All patients presented with pain and weakness following an acute traumatic event. One patient presented with bilateral tears 3 years apart. Four of the ruptures underwent acute repair. Two ruptures presented chronically with retracted short head tears and were treated with allograft reconstruction of the short head. Preoperative magnetic resonance imaging findings demonstrated retraction of the short head affecting only 1 muscle belly, and in all patients the hook test was intact. All patients reported excellent functional outcome scores with no postoperative complications. The systematic review identified 9 previously reported cases, of which 8 were treated surgically with a successful outcome. Detailed analysis of these cases demonstrated clinical findings consistent with our cases, and these are outlined in depth in the article. Discussion/Conclusions Isolated short head ruptures are a rare and distinct form of distal biceps tear that present with consistent clinical findings that can aid in diagnosis. They present acutely, have a poor natural history akin to complete tears, and have good outcomes with acute and delayed reconstruction.

With the intricate anatomy of the hand and upper extremity, there are many possible etiologies of pain. In addition, one must be alert to conditions typically affecting other areas of the body presenting in the hand and upper extremity. To add to the complexity of diagnosis, one must also be aware of potential secondary gains. With this in mind, a thorough history, physical examination, and broad differential can help avoid mislabeling patients with uncommon ailments. In this article, we present 4 cases of unusual causes of hand and upper extremity pain.

Previous evidence suggests the intense resistance training session can increase the muscle hardness, while stretching protocols with high intensity and volume can decrease it. However, it remains unknown the effects of an exercise and a less intensive stretching maneuver on muscle stiffness of well-trained men. Herein we (i) analyze the acute effects of heavy bench press exercise on the pectoralis major muscle shear modulus of well-trained men and (ii) assess the effectiveness of a 1-min stretching maneuver applied on this muscle after the exercise using shear wave elastography. Fourteen participants performed three sets of bench press from 8 to 13 repetitions maximum. Immediately after the exercise, their right shoulder was passively stretched for 1 min (stretched side) while their left arm stayed relaxed along the side of the body (control side). Elastographic images were acquired for the pectoralis major mid-region of both sides before the exercise, immediately after the intervention and after 5 min of rest. Our results revealed that both the bench press exercise and the static stretching does not affect the pectoralis major shear modulus of well-trained men. Conversely, the shear modulus significantly decreased at 5 min after intervention with respect to immediately after, for both the stretched (from 5.52 to 4.29 kPa) and the control sides (from 5.87 to 4.56 kPa). Therefore, both resistance training session and 1-min static stretching were not sufficient to significantly change the pectoralis major muscle stiffness of well-trained men.