1) To compare the average cost of an emergency department (ED) visit for various minor musculoskeletal disorders between two models of care (physiotherapist and ED physician or ED physician alone); ...2) To evaluate the incremental cost-effectiveness ratio (ICER) of these two models of care over a 3-month period post-initial visit; and 3) To estimate the ICER of three ED models of care (physiotherapist and ED physician, ED physician alone, physiotherapist alone) over a two-year period. Obj.1: The costs incurred by participants in the two groups during their ED visit will be calculated using the Time-Driven Activity-Based Costing (TDABC) method. These costs will be compared using generalized linear models. Obj. 2: The ICER of the two models will be evaluated over three months via a cost-utility analysis that will combine costs and effectiveness data (quality-adjusted life years) using both Health system and Societal perspectives (patient + health system costs). Obj. 3: The 2-year ICER of the three above-mentioned models will be estimated using a mathematical model including a decision tree (0-3 months post-visit) and a Markov model (3-24 months post-visit), also using both Health system and Societal perspectives. Data to answer the three objectives will come from data collected during a randomized clinical trial (n = 78, CHU de Québec)which will be supplemented with data obtained via some of the CHU de Québec administrative databases (nominative data; SIURGE (ED management software), Cristal-Net (patient electronic record), and the ED's pharmacy transactions directory; administrative data: drug costs repository), the literature, and public cost repositories. This study will help to determine which model of care is most efficient for the management of individuals who come to the ED with minor musculoskeletal disorders. The increased involvement of various health professionals in the management of patients in the ED paves the way for the development of new avenues of practice and more efficient organization of services.
Maximal isometric muscle strength (MIMS) assessment is a key component of physiotherapists' work. Hand-held dynamometry (HHD) is a simple and quick method to obtain quantified MIMS values that have ...been shown to be valid, reliable, and more responsive than manual muscle testing. However, the lack of MIMS reference values for several muscle groups in healthy adults with well-known psychometric properties limits the use and the interpretation of these measures obtained with HHD in clinic.
To determine the intra- and inter-rater reliability, standard error of measurement (SEM) and minimal detectable change (MDC) of MIMS torque values obtained with HHD.
Intra and Inter-rater Reliability Study. The MIMS torque of 17 muscle groups was assessed by two independent raters at three different times in 30 healthy adults using a standardized HHD protocol using the MEDup™ (Atlas Medic, Québec, Canada). Participants were excluded if they presented any of the following criteria: 1) participation in sport at a competitive level; 2) degenerative or neuromusculoskeletal disease that could affect torque measurements; 3) traumatic experience or disease in the previous years that could affect their muscle function; and 4) use of medication that could impact muscle strength (e.g., muscle relaxants, analgesics, opioids) at the time of the evaluation. Intra- and inter-rater reliability were determined using two-way mixed (intra) and random effects (inter) absolute agreement intraclass correlation coefficients (ICC: 95% confidence interval) models. SEM and MDC were calculated from these data.
Intra- and inter-rater reliability were excellent with ICC (95% confidence interval) varying from 0.90 to 0.99 (0.85-0.99) and 0.89 to 0.99 (0.55-0.995), respectively. Absolute SEM and MDC for intra-rater reliability ranged from 0.14 to 3.20 Nm and 0.38 to 8.87 Nm, respectively, and from 0.17 to 5.80 Nm and 0.47 to 16.06 Nm for inter-rater reliability, respectively.
The excellent reliability obtained in this study suggest that the use of such a standardized HHD protocol is a method of choice for MIMS torque measurements in both clinical and research settings. And the identification of the now known metrological qualities of such a protocol should encourage and promote the optimal use of manual dynamometry.
Myotonic dystrophy type 1 (DM1) is a neuromuscular disorder presenting with major muscle impairments. However, few studies have addressed muscle strength progression using quantitative methods. The ...aims of this study were to document muscle strength changes in eight muscle groups among adults with DM1 over a 9-year period, and to compare this progression between phenotypes (adult and late-onset) and sex. Patients with a genetic diagnosis of DM1 with the late-onset or the adult phenotype were recruited at baseline through the clinical registry of the Saguenay Neuromuscular Clinic. The maximum isometric muscle strength was measured at baseline and 9 years later using a standardized protocol of quantitative muscle testing. Muscle groups included were shoulder abductors, elbow flexors/extensors, wrist extensors, hip flexors, knee flexors/extensors, and ankle dorsiflexors. For the whole group, a mean loss of 24.5–52.8% was observed over the 9-year period for all muscle groups, except for hip flexors which remained stable. Generally, men were stronger and showed a significant greater rate of decline of muscle strength than women. The adult and late-onset phenotypes taken separately also showed a significant and similar decline over the 9-year period, except for the wrist and knee extensors where muscle strength of participants with the adult phenotype decreased faster than in the late-onset phenotype. The similar rate of decline of muscle strength loss observed between phenotypes highlights the need to develop interventions to prevent this decline, even for patients with the late-onset phenotype who are often considered as mildly impaired, and therefore neglected by the rehabilitation services.
•Maximal knee extensor muscle strength increased after 12 weeks of strength training.•Walking speed increased after training and was maintained at month 9.•Standing up capacity increased after ...training and was maintained at month 9.•Muscle fiber diameter did not significantly change after training.•Abnormal hypertrophic factor at baseline could influence fiber growth.
Myotonic dystrophy type 1 (DM1) is a multisystemic disease characterized by progressive muscle weakness. The aim of this project is to evaluate the effects of a 12-week lower limb strength training program in 11 men with DM1. Maximal isometric muscle strength, 30-second sit-to-stand, comfortable and maximal 10-m walk test (10 mwt) were evaluated at baseline, 6 and 12 weeks, and at 6 and 9 months. The one-repetition maximum strength evaluation method of the training exercises was completed at baseline, 6 and 12 weeks. Muscle biopsies were taken in the vastus lateralis at baseline and 12 weeks to evaluate muscle fiber typing and size (including atrophy/hypertrophy factors). Performance in strength and functional tests all significantly improved by week 12. Maximal isometric muscle strength of the knee extensors decreased by month 9, while improved walking speed and 30 second sit-to-stand performance were maintained. On average, there were no significant changes in fiber typing or size after training. Further analysis showed that individual abnormal hypertrophy factor at baseline could explain the different changes in muscle size among participants. Strength training induces maximal isometric muscle strength and lasting functional gains in DM1. Abnormal hypertrophy factor could be a key component to identify high and low responders to hypertrophy in DM1.
Highlights • Expert groups (6) on selection and validation of outcome measures in DM1. • Somnolence/Fatigue/Apathy new Special Interest Group. • Ongoing research projects to document metrological ...properties of several instruments.
Patients with posttraumatic stress disorder (PTSD) display several structural brain differences when compared with healthy individuals. However, findings are particularly inconsistent for soldiers ...with PTSD. Here, we characterized the brain morphometry of 37 soldiers from the Canadian Armed Forces with adulthood war‐related PTSD using structural magnetic resonance imaging. We assessed time since trauma, as well as PTSD, depressive, and anxiety symptoms with the Modified PTSD Symptoms Scale, Beck Depression Inventory, and Beck Anxiety Inventory, respectively. Whole‐brain morphometry was extracted with FreeSurfer and compared with a validated normative database of more than 2700 healthy individuals. Volume and thickness from several regions differed from the norms. Frontal regions were smaller and thinner, particularly the superior and rostral middle frontal gyri. Furthermore, smaller left rostral middle frontal gyrus, left pericalcarine cortex, and right fusiform gyrus were associated with more recent trauma. All subcortical structures were bigger, except the hippocampus. These findings suggest a particular brain morphometric signature of PTSD in soldiers. Smaller and thinner frontal and larger subcortical regions support impaired top‐down and/or downregulation of emotional response in PTSD. Finally, the correlation of smaller frontal, temporal, and occipital regions with more recent trauma might inform future therapeutic approaches.
Patients with posttraumatic stress disorder (PTSD) display several structural brain differences when compared with healthy individuals. However, findings are particularly inconsistent for soldiers with PTSD. Here, we characterized the brain morphometry of 37 soldiers with adulthood war‐related PTSD using structural magnetic resonance imaging and compared them with a validated normative database of more than 2700 healthy individuals.
ABSTRACT
Introduction
Lower limb strength has never been characterized separately for late‐onset and adult myotonic dystrophy type 1 (DM1) phenotypes.
Methods
The purpose of this study was to: (1) ...describe and compare lower limb strength between the 2 DM1 phenotypes; and (2) compare the impairment profiles obtained from 2 assessment methods manual (MMT) and quantitative (QMT) muscle testing among 107 patients.
Results
Both MMT and QMT showed more pronounced weakness in the adult phenotype. In the late‐onset phenotype, although MMT showed normal strength, QMT revealed a loss of 11.7%–20.4%. Participants with grade 1 or 2 on the Muscle Impairment Rating Scale had weakness detected using QMT, which suggests earlier muscle impairment than MMT alone would suggest.
Conclusions
To avoid muscle wasting, physical activity recommendations should be made for the late‐onset phenotype and in the early stages of the disease for the adult phenotype. MMT is not recommended for use in clinical trials. Muscle Nerve 56: 57–63, 2017.
Chronic pain, including chronic non-specific low back pain (CNSLBP), is often associated with body perception disturbances, but these have generally been assessed under static conditions. The ...objective of this study was to use a "virtual mirror" that scaled visual movement feedback to assess body perception during active movement in military personnel with CNSLBP (n = 15) as compared to military healthy control subjects (n = 15). Subjects performed a trunk flexion task while sitting and standing in front of a large screen displaying a full-body virtual mirror-image (avatar) in real-time. Avatar movements were scaled to appear greater, identical, or smaller than the subjects' actual movements. A total of 126 trials with 11 different scaling factors were pseudo-randomized across 6 blocks. After each trial, subjects had to decide whether the avatar's movements were "greater" or "smaller" than their own movements. Based on this two-alternative forced choice paradigm, a psychophysical curve was fitted to the data for each subject, and several metrics were derived from this curve. In addition, task adherence (kinematics) and virtual reality immersion were assessed. Groups displayed a similar ability to discriminate between different levels of movement scaling. Still, subjects with CNSLBP showed an abnormal performance and tended to overestimate their own movements (a right-shifted psychophysical curve). Subjects showed adequate task adherence, and on average virtual reality immersion was reported to be very good. In conclusion, these results extend previous work in patients with CNSLBP, and denote an important relationship between body perception, movement and pain. As such, the assessment of body perception during active movement can offer new avenues for understanding and managing body perception disturbances and abnormal movement patterns in patients with pain.
Study design
Single‐blind parallel group randomized clinical trial.
Objectives
To compare the effects of neurocryostimulation (NCS) with those of traditional ice application on functional recovery, ...pain, edema and ankle dorsiflexion range of motion (ROM) in individuals receiving physiotherapy treatments for acute lateral ankle sprains (LAS).
Background
Ankle sprain is a very common injury and its management is often costly, with important short‐ and long‐term impacts on individuals and society. As new methods of therapy using cold (cryotherapy) are emerging for the treatment of musculoskeletal conditions, little evidence exists to support their use. NCS, which provokes a rapid cooling of the skin with the liberation of pressured CO2, is a method believed to accelerate the resorption of edema and recovery in the case of traumatic injuries.
Methods
Forty‐one participants with acute LAS were randomly assigned either to a group that received in‐clinic physiotherapy treatments and NCS (experimental NCS group, n = 20), or to a group that received the same in‐clinic physiotherapy treatments and traditional ice application (comparison ice group, n = 21). Primary (Lower Extremity Functional Scale ‐ LEFS) and secondary (visual analog scale for pain intensity at rest and during usual activities in the last 48 h, Figure of Eight measurement of edema, and weight bearing lunge for ankle dorsiflexion range of motion) outcomes were evaluated at baseline (T0), after one week (T1), two weeks (T2), four weeks (T4) and finally, after six weeks (T6). The effects of interventions were assessed using two‐way ANOVA‐type Nonparametric Analysis for Longitudinal Data (nparLD).
Results
No significant group‐time interaction or group effect was observed for all outcomes (0.995 ≥ p ≥ 0.057) following the intervention. Large time effects were however observed for all outcomes (p < 0.0001).
Conclusion
Results suggest that neurocryostimulation is no more effective than traditional ice application in improving functional recovery, pain, edema, and ankle dorsiflexion ROM during the first six weeks of physiotherapy treatments in individuals with acute LAS.
Level of evidence
Therapy, level 1b.
Trial registration
ClinicalTrials.gov, NCT02945618. Registered 23 October 2016 ‐ Retrospectively registered (25 participants recruited prior to registration, 17 participants after).
Abstract
Introduction
Shoulder pain, a leading reason to consult a physician or physiotherapist, continues to be a challenge to rehabilitate, particularly with a military population. A rotator cuff ...(RC) tendinopathy, the most important source of shoulder pain, is one of the leading reasons for sick leave or a discharge from active military service. Research encourages the use of exercise prescription for the management of a RC tendinopathy, however the ideal method of delivery (group setting versus one-on-one) remains uncertain. The purpose of this single-blind (evaluator) pilot randomized clinical trial was to compare two 6-week rehabilitation programs, a newly developed group-supervised neuromuscular training program and usual one-on-one physiotherapy care, on the pain and symptoms of Canadian soldiers affected by a RC tendinopathy.
Materials and Methods
Thirty-one soldiers with the Canadian Armed Forces were randomly assigned to (1) a group-supervised neuromuscular training program (UPEx-NTP) or; (2) one-on-one usual physiotherapy care (UPC). The primary outcome was the Disability of Arm, Hand and Shoulder (DASH) questionnaire. Secondary outcomes included the Western Ontario Rotator Cuff (WORC) Index, pain levels at rest, and maximum isometric voluntary contractions (MIVC) of the abductors and external (lateral) rotators of the affected shoulder. Both were assessed at baseline (T0), 6 (T6) and 12 (T12) weeks. Analysis included two-way repeated measures of variance for intention-to-treat (ITT) and per-protocol analyses.
Results
Eighty military members with a RC tendinopathy were contacted, resulting in 31 participants who were randomized for their active intervention, in the UPEx-NTP or UPC, respectively. No significant group (p ≥ 0.16) or group × time interactions (p ≥ 0.11) were found for either ITT or per-protocol analyses. A statistically significant time effect (p < 0.001) was established for the DASH and WORC, showing that both groups improved over time.
Conclusions
Our preliminary data demonstrates that both rehabilitation approaches, grounded in active exercises, were not statistically different from each other, and derived similar benefits over time for a military population. This suggests that a group intervention for a RC tendinopathy has potential to be just as effective as a one-on-one approach for a military population, an interesting avenue for an active working population. Larger sample sizes and further investigation are warranted regarding the cost and clinical resource benefits of a supervised group approach.
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