3: Rehabilitation principles for treating chronic musculoskeletal injuries

Evaluation of patients for rehabilitation after musculoskeletal injury involves identifying, grading and assessing the injury and its impact on the patient's normal activities. Management is guided by a multidisciplinary team, comprising the patient, doctor and physical therapist, with other health professionals recruited as required. Parallel interventions involving the various team members are specified in a customised management plan. The key component of the plan is active mobilisation utilising strengthening, flexibility and endurance exercise programs. Passive physical treatments (heat, ice, and manual therapy), as well as drug therapy and psychological interventions, are used as adjunctive therapy. Biomechanical devices or techniques (eg, orthotic devices) may also be helpful. Coexisting conditions such as depression and drug dependence are treated at the same time as the injury. Effective team communication, simulated environmental testing and, for those employed, contact with the employer facilitate a staged return to normal living, sports and occupational activities.

Shoulder Kinematics Is Not Influenced by External Load During Elevation in the Scapular Plane

The current study aimed to compare the shoulder kinematics (3D scapular orientation, scapular angular displacement and scapulohumeral rhythm) of asymptomatic participants under unloaded and loaded conditions during unilateral shoulder elevation in the scapular plane. We used a repeated-measures design with a convenience sample. Eleven male participants with an age range of 21–28 years with no recent history of shoulder injury participated in the study. The participants performed isometric shoulder elevation from a neutral position to approximately 150 degrees of elevation in the scapular plane in intervals of approximately 30 degrees during unloaded and loaded conditions. Shoulder kinematic data were obtained with videogrammetry. During shoulder elevation, the scapula rotated upwardly and externally, and tilted posteriorly. The addition of an external load did not affect 3D scapular orientation, scapular angular displacement, or scapulohumeral rhythm throughout shoulder elevation (P > .05). In clinical practice, clinicians should expect to observe upward and external rotation and posterior tilt of the scapula during their assessments of shoulder elevation. Such behavior was not influenced by an external load normalized to 5% of body weight when performed in an asymptomatic population.

Protocolo de fisioterapia, com auxílio de biofeedback electromiográfico, em utentes com disfunções do ombro: efeitos na dor, funcionalidade e estabilidade dinâmica

RESUMO: Introdução: A dor e disfunções do movimento no complexo articular do ombro (CAO) são comuns e debilitantes. O uso de exercícios segundo os pressupostos de estabilidade dinâmica (ED), com auxílio de Biofeedback electromiográfico (BEMG) tem vindo a ser referido, como uma forma de aumentar a efectividade da intervenção nas disfunções do complexo articular do ombro (DCAO)Objectivo Principal: Estudar os efeitos de um protocolo de intervenção, com BEMG, cujas finalidades foram abolir a dor, aumentar a funcionalidade e a ED da omoplata, em utentes com DCAO. Objectivos secundários: Comparar os subgrupos e quanto às características, resultados, tempos de intervenção total e até atingir critérios de alta; Comparar os resultados nos momentos inicial e final. Métodos: Foi realizado um coorte clínico, longitudinal, retrospectivo, observacional, analítico. A amostra foi constituída por 82 sujeitos, divididos em dois subgrupos (n=53 SCSA e n=29 IGU). Os instrumentos de medida utilizados foram a EVA, o DASH, o SPADI e o BEMG. Foi seguido o protocolo de ED proposto por Santos e Matias (2007), de acordo com as 3 fases de intervenção por eles descritas, realizando uma sessão semanal, monitorizando exercícios que seguem estes princípios, com BEMG. Foram avaliadas as variáveis dor, postura, padrão de recrutamento, controlo motor, posição inicial da omoplata (PIO), amplitudes articulares (AA’s), força muscular (FM) e postura. Para analisar os dados, recorreu-se a estatística descritiva e inferencial. Resultados: A intervenção foi efectiva na abolição da dor no momento (0,43 para 0,00/10EVA no subgrupo SCSA e 0,66 para 0,00/10EVA no subgrupo IGU) na pior dor (5,47/10EVA para 0,06/10EVA no subgrupo SCSA e 5,28/10 para 0,14/10 no subgrupo IGU), no aumento da função (28,57 para 0,66/100DASH e 39,00 para 0,63/100SAPDI no subgrupo SCSA e 25,80 para 0,38/100DASH e 28,19 para 0,39/100 no subgrupo IGU) e no aumento da ED da omoplata com normalização do padrão de recrutamento, controlo motor, PIO dentro do espectro de normalidade e boa capacidade de controlar a sua posição, ao longo do movimento do membro superior (MS). A intervenção proporcionou, ainda a normalização das AA’s, FM e autocorrecção postural. O tempo médio de intervenção foi de 6,45semanas no subgrupo SCSA e 5,83sem no subgrupo IGU. Estes resultados são semelhantes comparativamente a estudos que utilizaram uma intervenção baseada nos mesmos princípios (Matias e Cruz, 2004; Cunha e Matias, 2006; Santos e Matias, 2007; Rodrigues e Matias, 2009). Conclusão: O protocolo de intervenção aplicado, com uso de exercícios baseados nos princípios da ED e uso de BEMG, permitiu o alcance dos objectivos, junto de utentes com DCAO (SCSA e IGU). Verificou-se que, independentemente da condição, os resultados foram idênticos em ambos subgrupos, não apresentando diferenças significativas entre as variáveis de medida final, o tempo total de intervenção e os tempos até atingir os critérios de alta, expecto para a Dor, sendo este superior no subgrupo SCSA.---------------------------------------- ABSTRACT:Introduction: Movement disorders and pain in the shoulder joint complex (SJC) are common and debilitating. The use of exercises under the premises of dynamic stability (DS), with the aid of electromyographic biofeedback (EMGBF) has been mentioned as a way to increase the effectiveness of the intervention in disorders of the shoulder joint complex (DSJC) Main Objective: To evaluate the results of an intervention protocol, with EMGBF whose aims were to abolish the pain, increase functionality and DS of the scapula in patients with DSJC. Objectives: To compare the subgroups and the characteristics, outcomes, and total intervention times to reach discharge criteria; to compare the results at the beginning and at the end. Methods: We conducted a clinical cohort, longitudinal, retrospective, observational analysis. The sample consisted of 82 subjects, divided into two subgroups (n = 53 shoulder impingement syndrome SIS n = 29 shoulder joint instability SJI). The measurement instruments used were the VAS, DASH, SPADI, and EMGBF. It was followed the DS protocol proposed by Santos and Matias (2007), according to the three phases of intervention, described by performing a weekly session, monitoring exercises that follow these principles, with EMGBF. The variables were pain, posture, recruitment pattern, motor control, the initial position of the scapula (IPS), range of motion (ROM), muscular strength (MS) and posture. To analyze the data, we used the descriptive and inferential statistics. Results: The intervention was effective in abolishing the pain at the time (0.43 to 0.00/10 VAS in the SIS subgroup and 0.66 to 0.00/10 VAS in the SJI subgroup) in worst pain (5.47 to 0,06/10 VAS in the SIS subgroup and 5.28/ to 0.14/10 VAS in the SJI subgroup), increasing the function (28,57 to 0,66/100 DASH and 39,00 to 0,63/100 SAPDI in the SIS subgroup and 25,80 to 0,38/100 DASH and 28,19 to 0,39/100 SPADI in the SJI subgroup) and the increase in DS of the scapula with normalization of the pattern recruitment, motor control, IPS within the spectrum of normalcy and good ability to control its position along the movement of the upper limb (UL). The intervention provided, although the normalization of ROM, MS and self-correcting posture. The average length of intervention was 6.45 weeks in the SIS subgroup and 5.83 in the IS subgroup. These results are comparable with similar studies that used an intervention based on the same principles (Matias e Cruz, 2004; Cunha e Matias, 2006; Santos e Matias, 2007; Rodrigues e Matias, 2009). Conclusion: The intervention protocol implemented with the use of exercises based on the principles of DS and the use of EMGBF was effective, allowing the accomplishment of goals, in patients with DSJC (SIS and SJI). It was found that, regardless of condition, the results were identical in both groups, showing no significant differences between the variables of the final measure, the total time of intervention and the times to reach discharge criteria, except for pain, which was higher in the SIS subgroup.

The venomous toadfish Thalassophryne nattereri (niquim or miquim): report of 43 injuries provoked in fishermen of Salinópolis (Pará State) and Aracaju (Sergipe State), Brazil

Fishes of family Batrachoididae are responsible for great number of injuries in fishermen in North and Northeast regions of Brazil. The genus Thalassophryne presents various venomous species of fishes found in the Brazilian coast, T. nattereri being the most common of them. The venom is ejected through two hollow spines on the dorsal fin and two on pre-opercular regions, which present a venomous gland in the base and can be erected or depressed by the fish. The manifestations of the envenoming were intense local pain, edema and erythema in 43 patients observed in Salinópolis (Pará State) and Aracaju (Sergipe State). There were no systemic manifestations, but necrosis was detected in eight and bacterial infection in ten injured fishermen. The circumstances of the contacts and therapeutic aspects are discussed. Envenoming by the genus Thalassophryne is important and frequent and should be considered of moderate severity grade, since there are not the excruciating pain or the massive local necrosis provoked by scorpionfishes (Scorpaena) or stingrays injuries nor the systemic manifestations that are the most important marker of severe envenoming.

Injuries and envenoming by aquatic animals in fishermen of Coxim and Corumbá municipalities, state of Mato Grosso do Sul, Brazil: identification of the causative agents, clinical aspects and first aid measures

INTRODUCTION: The fishes of continental Brazil have socioeconomic importance due to their potential for sport fishing and commercial and subsistence uses, as seen in the Upper Paraguay River Basin, particularly in the municipalities of the Pantanal region, where it is the second largest economic activity. Injuries caused in professional fishermen are common and poorly studied, as in other regions of the country. METHODS: Data were obtained from questionnaires and interviews with 100 professional fishermen, 50 in each municipality, between December 2008 and October 2009. RESULTS: All the fishermen reported some kind of injury caused by fish stings (78% of injuries) and fish, alligator and snake bites (22%) on the hands (46% of cases) and feet (35% of cases). Most of the patients had mild symptoms. The most severe cases were associated with secondary bacterial infections and required specific treatment and prolonged recovery associated with social and economic losses. CONCLUSIONS: The results of this study indicate that the stressful work conditions, inattention to basic preventive measures and carelessness were factors that contributed to accidents and that the toxicity and ability to inflict mechanical trauma of some aquatic species, plus the ineffective use of first aid and hospital treatment, contributed to the high morbidity and complications in many cases. Data from this study are relevant to the fishing communities of the Pantanal region, since they reveal high rates of accidents, lack of knowledge concerning first aid, initial treatment, injury prevention and lack of medical follow-up of the population.

Observation of initial clinical manifestations and repercussions from the treatment of 314 human injuries caused by black sea urchins (Echinometra lucunter) on the southeastern Brazilian coast

INTRODUCTION: Injuries caused by sea urchins are the most common caused by marine animals in humans in Brazil, with the black sea urchin (Echinometra lucunter) causing the most injuries to bathers. METHODS: This study observed 314 human wounds with emphasis on the early observation of clinical signs and symptoms and their implications on the recommended treatment. RESULTS: All the injuries were caused by black sea urchins and were observed in bathers. The lesions and the pain were associated with penetration of the spines; there was no early inflammation or pain without pressure on the wounded places. Complications arising from this kind on injury, including infections and foreign body granulomas, are associated with the permanence of the spines in the wounds. CONCLUSIONS: The study confirmed that this kind of injury is the most common accident caused by aquatic animals in Brazil. The main therapeutical recommendation is early removal of the spines to prevent late complications, such as infections and the formation of foreign body granulomas.

Injuries caused by aquatic animals in Brazil: an analysis of the data present in the information system for notifiable diseases

AbstractINTRODUCTION:We present a review of injuries in humans caused by aquatic animals in Brazil using the Information System for Notifiable Diseases [ Sistema de Informação de Agravos de Notificação (SINAN)] database.METHODS:A descriptive and retrospective epidemiological study was conducted from 2007 to 2013.RESULTS:A total of 4,118 accidents were recorded. Of these accidents, 88.7% (3,651) were caused by venomous species, and 11.3% (467) were caused by poisonous, traumatic or unidentified aquatic animals. Most of the events were injuries by stingrays (69%) and jellyfish (13.1%). The North region was responsible for the majority of reports (66.2%), with a significant emphasis on accidents caused by freshwater stingrays (92.2% or 2,317 cases). In the South region, the region with the second highest number of records (15.7%), jellyfish caused the majority of accidents (83.7% or 452 cases). The Northeastern region, with 12.5% of the records, was notable because almost all accidents were caused by toadfish (95.6% or 174 cases).CONCLUSIONS:Although a comparison of different databases has not been performed, the data presented in this study, compared to local and regional surveys, raises the hypothesis of underreporting of accidents. As the SINAN is the official system for the notification of accidents by venomous animals in Brazil, it is imperative that its operation be reviewed and improved, given that effective measures to prevent accidents by venomous animals depend on a reliable database and the ability to accurately report the true conditions.

Venomous and poisonous arthropods: identification, clinical manifestations of envenomation, and treatments used in human injuries

Abstract This review presents the main species of venomous and poisonous arthropods, with commentary on the clinical manifestations provoked by the toxins and therapeutic measures used to treat human envenomations. The groups of arthopods discussed include the class Arachnida (spiders and scorpions, which are responsible for many injuries reported worldwide, including Brazil); the subphylum Myriapoda, with the classes Chilopoda and Diplopoda (centipedes and millipedes); and the subphylum Hexapoda, with the class Insecta and the orders Coleoptera (beetles), Hemiptera (stink bugs, giant water bugs, and cicadas), Hymenoptera (ants, wasps, and bees), and Lepidoptera (butterflies and moths).

Effect of hyperbaric oxygen on the regeneration of experimental crush injuries of nerves

Hyperbaric oxygen has been successfully used on treatment of acute ischemic injuries involving soft tissues and chronic injuries. In nerve crush injuries, the mechanisms involved are very similar to those found in ischemic injuries. Consequently, it is logical to hypothesize that hyperbaric oxygen should improve nerve repair, which is a critical step on functional recovery. In the present study, we created standard nerve crush injuries on sciatic nerves of rats, which underwent treatment with hyperbaric oxygen. Results were assessed by functional evaluation using walking-track analysis. The functional recovery indexes observed did not differ from control group. We concluded that hyperbaric oxygen therapy, in the schedule used, had no influence on functional recovery after nerve crush injuries.

ACL injuries identifiable for pre-participation imagiological analysis: Risk factors

Identification of pre-participation risk factors for noncontact anterior cruciate ligament (ACL) injuries has been attracting a great deal of interest in the sports medicine and traumatology communities. Appropriate methods that enable predicting which patients could benefit from pre- ventive strategies are most welcome. This would enable athlete-specific training and conditioning or tailored equipment in order to develop appropriate strategies to reduce incidence of injury. In order to accomplish these goals, the ideal system should be able to assess both anatomic and functional features. Complementarily, the screening method must be cost-effective and suited for widespread application. Anatomic study protocol requiring only standard X rays could answer some of such demands. Dynamic MRI/CT evaluation and electronically assisted pivot-shift evaluation can be powerful tools providing complementary information. These upcoming insights, when validated and properly combined, envision changing pre-participation knee examination in the near future. Herein different methods (validated or under research) aiming to improve the capacity to identify persons/athletes with higher risk for ACL injury are overviewed. 

Development of a subject-specific musculoskeletal shoulder model : inverse and forward dynamics applications

A prevalência de pessoas que referem dor no complexo articular do ombro, com concomitante limitação na capacidade para realizar atividades da vida diária, é elevada. Estes níveis de prevalência sobrecarregam quer os utentes, como a própria sociedade. A evidência científica atual indicia a existência de uma relação entre as alterações da articulação escápulo-torácica e as patologias associadas à articulação gleno-umeral. A capacidade de quantificar, cinemática e cineticamente, as disfunções ao nível das articulações escápulo-torácica e gleno-umeral, é algo de enorme importância, quer para a comunidade biomecânica, como para a clínica. No decorrer dos trabalhos desta tese foi desenvolvido, através do software OpenSim, um modelo tridimensional músculo-esquelético do complexo articular do ombro que inclui a representação do tórax/coluna, clavícula, omoplata, úmero, rádio, cúbito e articulações que permitem os movimentos relativos desses segmentos, assim como, 16 músculos e 4 ligamentos. Com um total de 11 graus de liberdade, incluindo um novo modelo articular escápulo-torácico, os resultados demonstram que este é capaz de reconstruir de forma precisa e rápida os movimentos escápulo-torácicos e glenoumerais, recorrendo para tal, à cinemática inversa, e à dinâmica inversa e direta. Conta ainda com um método de transformação inovador para determinar, com base nas especificidades dos sujeitos, os locais de inserção muscular. As principais motivações subjacentes ao desenvolvimento desta tese foram contribuir para o aprofundar do atual conhecimento sobre as disfunções do complexo articular do ombro e, simultaneamente, proporcionar à comunidade clínica uma ferramenta biomecânica de livre acesso com o intuito de melhor suportar as decisões clínicas e dessa forma concorrer para uma prática mais efetiva.

The shoulder architecture of bears and other carnivores [by] D. Dwight Davis.

v.31:no.34(1949)

The Impact of prevention measures and organisational factors on occupational injuries

This paper analyses the impact of a series of managerial and organisational factors on occupational injuries. These consist of occupational safety measures, as regards both the intensity and the orientation of risk prevention in companies, and the adoption of certain work organisation practices, quality management and the use of flexible production technologies. We estimate a negative binomial regression based on a sample of 213 Spanish industrial establishments, defining a constant random parameter to take account of non-observable heterogeneity. Our results show that occupational safety measures, the intensive use of quality management tools and the empowerment of workers all help to reduce the number of injuries. We have also confirmed the presence of synergies between the organisational factors analysed and the development of an occupational safety strategy featuring participation and the extension of prevention to all levels of the organisation.

Validity, reliability and responsiveness of the French language translation of the Western Ontario Shoulder Instability Index (WOSI).

BACKGROUND: The WOSI (Western Ontario Shoulder Instability Index) is a self-administered quality of life questionnaire designed to be used as a primary outcome measure in clinical trials on shoulder instability, as well as to measure the effect of an intervention on any particular patient. It is validated and is reliable and sensitive. As it is designed to measure subjective outcome, it is important that translation should be methodologically rigorous, as it is subject to both linguistic and cultural interpretation. OBJECTIVE: To produce a French language version of the WOSI that is culturally adapted to both European and North American French-speaking populations. MATERIALS AND METHODS: A validated protocol was used to create a French language WOSI questionnaire (WOSI-Fr) that would be culturally acceptable for both European and North American French-speaking populations. Reliability and responsiveness analyses were carried out, and the WOSI-Fr was compared to the F-QuickDASH-D/S (Disability of the Arm, Shoulder and Hand-French translation), and Walch-Duplay scores. RESULTS: A French language version of the WOSI (WOSI-Fr) was accepted by a multinational committee. The WOSI-Fr was then validated using a total of 144 native French-speaking subjects from Canada and Switzerland. Comparison of results on two WOSI-Fr questionnaires completed at a mean interval of 16 days showed that the WOSI-Fr had strong reliability, with a Pearson and interclass correlation of r=0.85 (P=0.01) and ICC=0.84 [95% CI=0.78-0.88]. Responsiveness, at a mean 378.9 days after surgical intervention, showed strong correlation with that of the F-QuickDASH-D/S, with r=0.67 (P<0.01). Moreover, a standardized response means analysis to calculate effect size for both the WOSI-Fr and the F-QuickDASH-D/S showed that the WOSI-Fr had a significantly greater ability to detect change (SRM 1.55 versus 0.87 for the WOSI-Fr and F-QuickDASH-D/S respectively, P<0.01). The WOSI-Fr showed fair correlation with the Walch-Duplay. DISCUSSION: A French-language translation of the WOSI questionnaire was created and validated for use in both Canadian and Swiss French-speaking populations. This questionnaire will facilitate outcome assessment in French-speaking settings, collaboration in multinational studies and comparison between studies performed in different countries. TYPE OF STUDY: Multicenter cohort study. LEVEL OF EVIDENCE: II.

Static and dynamic shoulder stabilizer adaptations in javelin throwers: A preliminary study

BACKGROUND: Adaptations to Internal (IR) and external (ER) rotator shoulder muscles improving overhead throwing kinematics could lead to muscular strength imbalances and be considered an intrinsic risk factor for shoulder injury, as well as modified shoulder range of motion (RoM). OBJECTIVE: To establish profiles of internal and external rotation RoM and isokinetic IR and ER strength in adolescent- and national-level javelin throwers. METHODS: Fourteen healthy subjects were included in this preliminary cross-sectional study, 7 javelin throwers (JTG) and 7 nonathletes (CG). Passive internal and external rotation RoM were measured at 90 degrees of shoulder abduction. Isokinetic strength of dominant and non-dominant IR and ER was evaluated during concentric (60, 120 and 240 degrees/s) and eccentric (60 degrees/s) contractions by Con-Trex (R) dynamometer with the subject in a seated position with 45 degrees of shoulder abduction in the scapular plane. RESULTS: We reported significantly lower internal rotation and significantly higher external rotation RoM in JTG than in CG. Concentric and eccentric IR and ER strength were significantly higher for the dominant shoulder side in JTG (P < 0.05), without significant differences in ER/IR ratios. CONCLUSIONS: The main finding of this preliminary study confirmed static and dynamic shoulder stabilizer adaptations due to javelin throw practice in a population of adolescent- and national-level javelin throwers.