Non-surgical treatment of pain associated with posterior tibial tendon dysfunction: study protocol for a randomised clinical trial

BACKGROUND Symptoms associated with pes planovalgus or flatfeet occur frequently, even though some people with a flatfoot deformity remain asymptomatic. Pes planovalgus is proposed to be associated with foot/ankle pain and poor function. Concurrently, the multifactorial weakness of the tibialis posterior muscle and its tendon can lead to a flattening of the longitudinal arch of the foot. Those affected can experience functional impairment and pain. Less severe cases at an early stage are eligible for non-surgical treatment and foot orthoses are considered to be the first line approach. Furthermore, strengthening of arch and ankle stabilising muscles are thought to contribute to active compensation of the deformity leading to stress relief of soft tissue structures. There is only limited evidence concerning the numerous therapy approaches, and so far, no data are available showing functional benefits that accompany these interventions. METHODS After clinical diagnosis and clarification of inclusion criteria (e.g., age 40-70, current complaint of foot and ankle pain more than three months, posterior tibial tendon dysfunction stage I & II, longitudinal arch flattening verified by radiography), sixty participants with posterior tibial tendon dysfunction associated complaints will be included in the study and will be randomly assigned to one of three different intervention groups: (i) foot orthoses only (FOO), (ii) foot orthoses and eccentric exercise (FOE), or (iii) sham foot orthoses only (FOS). Participants in the FOO and FOE groups will be allocated individualised foot orthoses, the latter combined with eccentric exercise for ankle stabilisation and strengthening of the tibialis posterior muscle. Participants in the FOS group will be allocated sham foot orthoses only. During the intervention period of 12 weeks, all participants will be encouraged to follow an educational program for dosed foot load management (e.g., to stop activity if they experience increasing pain). Functional impairment will be evaluated pre- and post-intervention by the Foot Function Index. Further outcome measures include the Pain Disability Index, Visual Analogue Scale for pain, SF-12, kinematic data from 3D-movement analysis and neuromuscular activity during level and downstairs walking. Measuring outcomes pre- and post-intervention will allow the calculation of intervention effects by 3×3 Analysis of Variance (ANOVA) with repeated measures. DISCUSSION The purpose of this randomised trial is to evaluate the therapeutic benefit of three different non-surgical treatment regimens in participants with posterior tibial tendon dysfunction and accompanying pes planovalgus. Furthermore, the analysis of changes in gait mechanics and neuromuscular control will contribute to an enhanced understanding of functional changes and eventually optimise conservative management strategies for these patients. TRIAL REGISTRATION ClinicalTrials.gov Protocol Registration System: ClinicalTrials.gov ID NCT01839669.

Synchronous Holocene climatic oscillations recorded on the Swiss Plateau and at timberline in the Alps

Eight synchronous pre-Roman cold phases were found at 9600–9200, 8600–8150, 7550–6900, 6600– 6200, 5350–4900, 4600–4400, 3500–3200 and 2600–2350 radiocarbon years BP by reconstructing past climate at two sites on the Swiss Plateau and at timberline in the Alps. The cooling events during the early-and mid-Holocene represent temperature values similar to today, and apparently the onset of cooling events represents a deviation from today's mean annual temperature of about 1°C and is triggered at a 1000-year periodicity. At Wallisellen-Langachermoos (440 m), a former oligotrophic lake near Zürich, the correlation between sum mertime lake levels and the seed production of the amphi-Atlantic aquatic plantNajas flexilis was used to reconstruct lake levels over a 3000-year period during the first part of the Holocene. At Lake Seedorf on the western Swiss Plateau (609 m) the sedimentological, palynological and macrofossil record revealed fluctuations of lake levels for the complete Holocene. From Lago Basso in the southern Alps (2250 m, Val San Giacomo near Splügen Pass, Northern Italy) the terrestrial plant macrofossils – especiallyPinus cembra andLarix – allowed the reconstruction of timberline fluctuations controlled by climate. A similar climatic pattern was found at Gouillé Rion pond in the central Swiss Alps (2343 m, Val d'Hérémence) with plant macrofossils and pollen concentrations and percentages. We postulate that these climatic events are detectable throughout central Europe by independent methods in combination with precise AMS-radiocarbon datings on terrestrial plant remains. Our data fit other proxy records of regional climatic change, such as cool intervals from Greenland ice cores, glacier movements in the Swiss and Austrian Alps, and dendro-densitometry on subfossil wood, as well as the palaeoclimatic data from the Jura Mountains of France obtained by sedimentological analyses. Thus our data indicate that the Northern Hemisphere climate was less stable during the Holocene than previously believed.

Tibial Nerve Stimulation for Treating Neurogenic Lower Urinary Tract Dysfunction: A Systematic Review

CONTEXT Tibial nerve stimulation (TNS) is a promising therapy for non-neurogenic lower urinary tract dysfunction and might also be a valuable option for patients with an underlying neurological disorder. OBJECTIVE We systematically reviewed all available evidence on the efficacy and safety of TNS for treating neurogenic lower urinary tract dysfunction (NLUTD). EVIDENCE ACQUISITION The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. EVIDENCE SYNTHESIS After screening 1943 articles, 16 studies (4 randomized controlled trials [RCTs], 9 prospective cohort studies, 2 retrospective case series, and 1 case report) enrolling 469 patients (283 women and 186 men) were included. Five studies reported on acute TNS and 11 on chronic TNS. In acute and chronic TNS, the mean increase of maximum cystometric capacity ranged from 56 to 132mL and from 49 to 150mL, and the mean increase of bladder volume at first detrusor overactivity ranged from 44 to 92mL and from 93 to 121mL, respectively. In acute and chronic TNS, the mean decrease of maximum detrusor pressure during the storage phase ranged from 5 to 15cm H2O and from 4 to 21cm H2O, respectively. In chronic TNS, the mean decrease in number of voids per 24h, in number of leakages per 24h, and in postvoid residual ranged from 3 to 7, from 1 to 4, and from 15 to 55mL, respectively. No TNS-related adverse events have been reported. Risk of bias and confounding was high in most studies. CONCLUSIONS Although preliminary data of RCTs and non-RCTs suggest TNS might be effective and safe for treating NLUTD, the evidence base is poor, derived from small, mostly noncomparative studies with a high risk of bias and confounding. More reliable data from well-designed RCTs are needed to reach definitive conclusions. PATIENT SUMMARY Early data suggest tibial nerve stimulation might be effective and safe for treating neurogenic lower urinary tract dysfunction, but more reliable evidence is required.

Paleomagnetic of basalts from the Kerguelen Plateau

Paleomagnetic measurements were performed on 106 basalt samples collected from Holes 747C, 748C, 749C, and 750B. Basalt samples were recovered from the southern portion of the Kerguelen Plateau and the transitional zone between the northern and southern plateau in the south central Indian Ocean. The ages of basalts range from 100 to 115 Ma. In addition to the preliminary shipboard measurements (Schlich, Wise, et al., 1989, doi:10.2973/odp.proc.ir.120.1989), characteristic inclinations of the magnetization were obtained using mainly stepwise thermal demagnetization of the samples. Reliable paleomagnetic results were obtained from three sites (Sites 747, 748, and 749). The paleomagnetic inclinations of Sites 747, 748, and 749 are -51°, -63°, and -62°, respectively. The considerable differences between the paleomagnetic and present inclinations of about 70° at Sites 747, 748, and 749 indicate that displacement in the direction of the geomagnetic meridian has taken place since formation of the basalt. Shallower paleomagnetic inclinations than the present inclinations at each site imply a southward movement of the sites with respect to the geomagnetic pole. By comparing the apparent polar wander path of Antarctica with the virtual geomagnetic pole (VGP) of the Southern Kerguelen Plateau, we have concluded that no major tectonic movement has taken place between the Kerguelen Plateau and Antarctica since formation of the basalt (i.e., 100-115 Ma). The angular dispersion of the VGP for the Kerguelen Plateau is calculated as 17°.

Diversity and faunal composition of benthic foraminifera in Hole 44-390A on the Blake Nose Plateau

Benthic foraminiferal assemblages are a widespread tool to understand changes in organic matter flux and bottom-water oxygenation and their relation to paleoceanographic changes in the Upper Cretaceous oceans. In this study, assemblage data (diversity, total number, and number per species and gram) from Deep Sea Drilling Project (DSDP) Site 390 (Blake Nose, western North Atlantic) were processed for the lower Maastrichtian (Globotruncana falsostuarti - Gansserina gansseri Planktic Foraminiferal Zone). These data document significant changes in nutrient flux to the sea floor as well as bottom-water oxygenation during this time interval. Parallel to the observed changes in the benthic foraminiferal assemblages the number of inoceramid shells decreases, reflecting also a significant increase in bottom-water oxygenation. We speculate, that these data could reflect the onset of a shift from warmer low-latitude to cooler high-latitude deep-water sources. This speculation will predate the major reorganization of the oceanic circulation resulting in a circulation mode similar to today at the Early/Late Maastrichtian boundary by ~1 Ma and therefore improves our understanding of Late Cretaceous paleoceanography.

Planktonic foraminiferal biostratigraphy and stable carbon isotope ratios of late middle Eocene sediments from Blake Plateau, West Atlantic Ocean

The muricate planktonic foraminiferal genera Morozovella and Acarinina were abundant and diverse during the upper Palaeocene to middle Eocene and dominated the tropical and subtropical assemblages. A significant biotic turnover in planktonic foraminifera occurred in the latest middle Eocene with a notable reduction in the acarininid lineage and the extinction of the morozovellids. These genera are extensively employed as palaeoclimatic and biostratigraphic markers and, therefore, this turnover episode is an important event in the record of the Cenozoic planktonic foraminifera. Sediments from the western North Atlantic (Ocean Drilling Program Site 1052) were examined in order to investigate these extinction events, in terms of both timing and mechanisms. Biostratigraphic events of the middle and late Eocene have been examined with a sampling resoluti on of approximately 3 kyr. These have been calibrated to the magneto- and astrochronology to accurately define the timing of key biostratigraphic events, particularly the extinction of Morozovella spinulosa which is a distinct biomarker for late middle Eocene sediments. High-resolution biostratigraphy reveals that the extinctions in the muricate group occurred in a stepwise form. The large acarininids (Acarinina praetopilensis) terminate 10 kyr prior to the extinction of M. spinulosa and small acarininids (Acarinina medizzai and Acarinina echinata) continue into the upper Eocene. High-resolution stable isotope analyses have been conducted on planktonic and benthic foraminifera from the western North Atlantic to reconstruct sea surface temperatures (SSTs) and deep water temperatures and the structure of the water column around this major biotic turnover. Whilst the extinctions of M. spinulosa and A. praetopilensis occur during a long-term cooling trend, the biotic turnover in the muricate group does not appear to be related to significant climatic change. Sea surface temperatures decrease slowly prior to the extinction events, and there is no evidence for a large-temperature shift associated with the faunal changes. The turnover event was therefore probably related to the increased surface water productivity and the deterioration of photosymbiotic partnerships with algae.

Oxygen and carbon isotopic composition of shells from Radix sp. in lakes across the Tibetan Plateau

The Tibetan Plateau (TP), including its surrounding mountain ranges, represents the largest store of ice outside the polar regions. It hosts numerous lakes as well as the head waters of major Asian rivers, on which billions of people depend, and it is particularly sensitive to climate change. The moisture transport to the TP is controlled by the Indian and Pacific monsoon and the Westerlies. Understanding the evolution of the interaction of these circulation systems requires studies on climate archives in different spatial and temporal contexts. The objective of this study is to learn more about the interannual variability of precipitation patterns across the TP and how different hydrologic systems react to different climatic factors. Aragonite shells of the aquatic gastropod Radix, which is widely distributed in the region, may represent suitable archives for inferring hydrologic and climatic signals in particularly high resolution. Therefore, sclerochronological studies of d18O and d13C ratios in Radix shells from seven lakes were conducted, each representing a different hydrologic and climatic setting, on a transect from the Pamirs across the TP. The shell patterns exhibit an increasing influence of precipitation and a decreasing influence of evaporation on the isotope compositions from west to east. d18O values of shells from lakes on the eastern and central TP (Donggi Cona, Yamdrok Yumco, Tarab Co) mirror monsoon signals, indicated by more negative values and higher variabilities compared to the more western lakes (Karakul, Bangong/Nyak, Manasarovar). In Yadang Co, located on the central southern TP, the monsoon rains did not reach the lake in the sampling year, although it is located in a region which is usually affected by monsoon circulation. The d18O values are used to differentiate the annual hydrological cycle into ice cover period, melt water period, precipitation period and evaporation period. d13C compositions in the shells particularly depend on specific habitats, which vary in biological productivity and in carbon sources. d18O and d13C patterns show a positive covariance in shells originating from large closed basins. The results show that Radix shells mirror general climatic differences between the seven lake regions. These differences reflect both regional and local climate signals in sub-seasonal resolution, without noticeable dependence on the particular lake system.

Stable isotope composition of carbonate components of Rhaetian shallow-water limestones of the Wombat Plateau

Stable oxygen- and carbon-isotope ratios of Rhaetian (upper Triassic) limestone samples from the Wombat Plateau, northwest Australia, were measured to explore possible diagenetic pathways that the material underwent after deposition in a shallow-water environment, before plateau submergence in the Early Cretaceous. Host sediment isotopic values cluster near typical marine carbonate values (d18O ranging from -2.57 per mil to +1.78 per mil and d13C, from +2.45 per mil to +4.01 per mil). Isotopic values of equant clear calcite lining or filling rock pores also plot in the field of marine cements (d18O = +1.59 per mil to -2.24 per mil and d13C = +4.25 per mil to +2.57 per mil), while isotopic values for neomorphic calcites replacing skeletal (megalodontid shell) carbonate material show a wider scatter of oxygen and carbon values, d18O ranging from +2.73 per milo to -6.2 per mil and d13C, from +5.04 per mil to +1.22 per mil. Selective dissolution of metastable carbonate phases (aragonite?) and neomorphic replacement of skeletal material probably occurred in a meteoric phreatic environment, although replacement products (inclusion-rich microspar, clear neomorphic spar, etc.) retained the original marine isotopic signature because transformation probably occurred in a closed system dominated by the composition of the dissolving phases (high rock/water ratio). The precipitation of late-stage equant (low-Mg?) calcite cement in the pores occurred in the presence of normal marine waters, probably in a deep-water environment, after plateau drowning. Covariance of d18O and d13C toward negative values indeed suggests influence of meteorically modified fluids. However, none of the samples shows negative carbon values, excluding the persistence of organic-rich soils on subaerial karstic surfaces (Caribbean-style diagenesis). Petrographical and geochemical data are consistent with the sedimentological evidence of plateau drowning in post-Rhaetian times and with a submarine origin of the >70-m.y.-long Jurassic hiatus.

40Ar-39Ar plateau and isochron ages from the Ninetyeast and Broken Ridges (Table 1)

Concordant plateau and isochron ages are obtained from 40Ar-39Ar incremental heating experiments on volcanic rocks recovered by drilling at three Leg 121 sites along the Ninetyeast Ridge and two dredge locations on the southern scarp of the Broken Ridge, eastern Indian Ocean. The new data confirm a northerly increase in the age of volcanism along the Ninetyeast Ridge, from 38 to 82 Ma; this lineament links current hotspot volcanism near the Kerguelen islands with the Rajmahal flood basalt eruptions at M0 time (117 ± 1 Ma). The Broken Ridge was formed over the same hotspot at 88-89 Ma, but later experienced rift-related volcanism in Paleocene time (63 Ma). The geometry and distribution of ages along these prominent volcanic ridges and the Mascarene-Chagos-Laccadive-Maldive ridge system in the western Indian Ocean are most compatible with plate motions over fixed hotspots near Kerguelen and Reunion islands, respectively.

Observation of manganese nodules and crusts in the Blake Plateau area

Visual observations of manganese deposits on the Blake plateau from a manned submersible indicate that the occurrence of manganese as nodules, slabs, or pavement may be related to localized environmental conditions. Manganese is concentrated at the crests of sand waves and, in areas of gentle slope, grades locally from nodules to solid pavement.

Accumulation rates of bulk sediment and total organic carbon for Ontong Java Plateau sediments

Organic geochemical investigations were performed on sediments of Leg 130 to reconstruct the depositional environment of the Ontong Java Plateau. The Miocene to Quaternary sediments collected during the drilling campaign are characterized by extremely low organic carbon contents. As indicated by C/N ratios and Rock-Eval data, most of the organic matter is probably of marine origin. Based on mass-accumulation rates of organic carbon, the paleoproductivity for the Miocene-Pliocene and the late Pliocene-Pleistocene time intervals as well as the modern surface-water production were estimated. The productivity values of the surface sediments (25-59 gC/m2/yr) reflect the various influences of the equatorial upwelling cell on the different sites. The accumulation rates of organic carbon are generally low; however, they show a distinct increase at 8 Ma and a decrease at 2 Ma.