Effects of botulinum toxin injections in the upper limbs of children with cerebral palsy: A systematic review of the literature

BACKGROUND

Spasticity is a common motor disorder in children with cerebral palsy (CP). Upper limb CP impairment has a significant negative impact on daily activities. Botulinum toxin (BTX-A) injections are widely used to reduce spasticity, but their effectiveness is not well-defined. We performed a systematic review of literature to answer questions about the effectiveness of BTX-A injections in the upper limb in children with CP.

METHODS

A systematic review of literature was conducted according to PRISMA guidelines. Eligible studies were randomized controlled trials with a high level of evidence on BTX-A upper limb injections in children. The outcomes analyzed included the study population, spasticity, quality of movement, activity limitations, quality of life, pain, appearance and side effects.

RESULTS

A total of 24 studies were included. The number of patients included was 1358 with a mean age between 3 and 11years. Improvement after BTX-A injection compared to the control group was observed for spasticity (n=10/19 studies), bimanual activities (Assisting Hand Assessment) (n=3/7), activity limitations (n=6/11), pain (n=2/2) and appearance (n=2/2). No study found an improvement in quality of life. Side effects were described in 16 studies and were moderate in all cases.

CONCLUSION

This review of literature showed that BTX-A injections can improve spasticity and particularly activity limitations when reasonable objectives are established.

LEVEL OF EVIDENCE

IV, systematic review.

Case report

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Solitary infantile myofibromatosis in the upper extremities: Case report

Infantile myofibromatosis (IM) is a mesenchymal tumor that may present in infants in a couple of major forms: solitary (myofibroma) and multicentric (myofibromatosis) which can be more subdivided into IM without or with visceral involvement. The tumors present as nodular lesions in the soft tissues, bones, and/or internal organs. Although the success of imaging in suggesting the correct diagnosis can't be denied, histopathology and Immunohistochemical examinations are necessary to confirm the diagnosis of IM as it might be misdiagnosed as a malignant tumor. We report a case of solitary infantile myofibromatosis in the upper extremities discovered in a 9-year-old girl. She had swelling and an enlargement on the posterior forearm on the ulnar side. The X-ray showed a lytic lesion with swollen soft tissue. The patient underwent an MRI which suggested the diagnosis of myofibroma. Then, solitary myofibroma was confirmed histologically. Infancy's most prevalent fibrous tumor is IM. Its prognosis depends on the visceral involvement. Imaging, especially MRI is the ideal tool to diagnose it.

Effects of free versus restricted arm movements on postural control in normal and modified sensory conditions in young and older adults

The purpose of this study was to explore the effects of arm movements on postural control when standing under different sensory conditions in healthy young and older adults. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and 15 older (mean ± SD age; 73.3 ± 5.0 years) adults completed the modified Romberg test, which uses four task manipulations (i.e. eyes open and eyes closed on a firm and foam surface) to compromise the fidelity of sensory feedback mechanisms. Each participant completed the tasks under two arm movement conditions: restricted and free arm movements. Centre of pressure (COP) range and frequency were calculated to characterise postural performance and strategy, respectively. Older adults showed greater COP range with restricted compared to free arm movements during all modified sensory conditions, with these effects most prominent in the medio-lateral (ML) plane (all p < .05, Cohen's d = 0.69-1.61). Compared to the free arm movement condition, there was an increase in ML displacement and frequency when arm movements were restricted during only the most challenging (i.e. vestibular dominant) task in young adults (all p < .05, d = 0.645-0.83). Finally, main age effects for the arm restriction cost (p < .05) indicates a greater reliance on an upper body strategy in older compared to young adults, independent of sensory availability/accuracy. These findings indicate that older adults compensate for the loss of accuracy in sensory input by increasing reliance on upper body movement strategies.

Effects of elastic kinesiology taping on shoulder proprioception: a systematic review

BACKGROUND

Shoulder injuries are associated with proprioceptive deficits. Elastic kinesiology tape (KT) is used for treating musculoskeletal disorders, including shoulder injuries, as it arguably improves proprioception.

OBJECTIVE

To synthesize the evidence on the effects of elastic KT on proprioception in healthy and pathological shoulders.

METHODS

Four databases (PubMed, WoS, CINAHL, SPORTDiscus) were searched for studies that investigated the effects of elastic KT on shoulder proprioception. Outcome measures were active joint position sense (AJPS), passive joint position sense (PJPS), kinesthesia, sense of force (SoF), and sense of velocity (SoV). Risk of bias (RoB) was assessed using the Cochrane Collaboration RoB tool for randomized controlled trials (RCTs), and the ROBINS-1 for non-RCTs, while the certainty of evidence was determined using GRADE.

RESULTS

Eight studies (5 RCTs, 3 non-RCTs) were included, yielding 187 shoulders (102 healthy and 85 pathological shoulders). RoB ranged from low (2 studies), moderate (5 studies), to high (1 study). Elastic KT has a mixed effect on AJPS of healthy shoulders (n=79) (low certainty). Elastic KT improves AJPS (subacromial pain syndrome and rotator cuff tendinopathy, n=52) and PJPS (chronic hemiparetic shoulders, n=13) among pathological shoulders (very low certainty). Elastic KT has no effect on kinesthesia among individuals with subacromial pain syndrome (n=30) (very low certainty).

CONCLUSION

There is very low to low certainty of evidence that elastic KT enhances shoulder AJPS and PJPS. The aggregate of evidence is currently so low that any recommendation on the effectiveness of elastic KT on shoulder proprioception remains speculative.

Exploring how arm movement moderates the effect of task difficulty on balance performance in young and older adults

Emerging evidence highlights that arm movements exert a substantial and functionally relevant contribution on quiet standing balance control in young adults. Ageing is associated with "non-functional" compensatory postural control strategies (i.e., lower limb co-contraction), which in turn, may increase the reliance on an upper body strategy to control upright stance. Thus, the primary purpose of this study was to compare the effects of free versus restricted arm movements on balance performance in young and older adults, during tasks of different difficulty. Fifteen young (mean ± SD age; 21.3 ± 4.2 years) and fifteen older (mean ± SD age; 73.3 ± 5.0 years) adults performed bipedal, semi-tandem and tandem balance tasks under two arm position conditions: restricted arm movements and free arm movements. Centre of pressure (COP) amplitude and frequency were calculated as indices of postural performance and strategy, respectively. Especially in older adults, restriction of arm movement resulted in increased sway amplitude and frequency, which was primarily observed for the mediolateral direction. Further, increasing balance task difficulty raised the arm restriction cost (ARC; a new measure to quantify free vs. restricted arm movement differences in postural control) that was more prominent in older adults. These findings indicate the ARC provides a measure of reliance on the upper body for balance control and that arm movement is important for postural control in older adults, especially during tasks of greater difficulty.

Golf-related sports injuries of the musculoskeletal system

The purpose of this study was to evaluate the characteristics of golf-related musculoskeletal injuries. Golfers were retrospectively surveyed through a 50-item questionnaire. Golfers were divided into injured and noninjured groups according to the presence or absence of musculoskeletal injuries. Of the 208 respondents, 64.0% suffered golf-related injuries, most of which were minor injuries caused by overuse in the early 9.9 weeks. According to the anatomical distribution, the most injured parts were upper limbs, spine, trunk, and lower limbs in that order. As for the distribution by part, the hand and wrist were the most vulnerable, and the lateral elbow damage was 3 times more common than the inner elbow. Self-management for injuries was the most common treatment, and regular preventive exercise accounted for 30% of the injured. Overall, more than half of the respondents suffered from musculoskeletal injuries, self-management was the most common, and less than one-third did regular exercise to prevent injuries. Therefore, active management to prevent golf-related musculoskeletal injuries may be necessary.

Upper limb contribution during tandem gait in multiple sclerosis: An early marker of balance impairments

Tandem gait is widely used during clinical exams to evaluate dynamic balance in chronic diseases, such as multiple sclerosis (MS). The early detection of balance impairments in MS is challenging to improve the understanding of patients' complaints. The objective was to propose two indexes to quantify the contributions and inefficiency of limb and trunk movements during tandem gait in early-stage MS patients. Fifteen patients with remitting-relapsed MS, with a median Expanded Disability Status Scale of 2.5 [0-4] were compared to 15 matched healthy participants. Three-dimensional motion analysis was performed during tandem gait to calculate spatiotemporal parameters, contribution and inefficiency indexes, based on the linear momentum of body segments. Compared to healthy participants, MS patients at the early stage of disease executed tandem gait with higher speed (p = 0.03) and increased step length (p = 0.03). The contribution indexes of upper limbs were significantly decreased during swing phase in MS patients. The inefficiency index for the upper limbs were around twice higher for MS patients compared to healthy participants. Since the additional movements concerned only light body segments and not contribute to the whole-body forward progression during tandem gait, they could reflected more both upper limb movements alterations and restoring movements to avoid loss of balance during tandem gait around swing phase in MS. These quantified indexes could be used as physical markers to quantify both the balance deterioration and the efficiency of rehabilitation program during the follow up of MS from the early stage of their disease.

Fractures of the limbs: basic concepts for the emergency department

Traumatic injuries of the limbs are very common and account for a large number of imaging examinations, especially in emergency departments. These injuries can often be resolved if they are recognized and treated appropriately. Their diagnosis requires a complete clinical assessment and the correct interpretation of the appropriate imaging tests. Radiologists play an important role, especially in diagnosing lesions that can go undetected. To this end, radiologists need to know the normal anatomy and its variants, the mechanisms of injury, and the indications for different imaging tests, among which plain-film X-rays are the main technique for the initial evaluation. This article aims to review the relevant characteristics of limb fractures in adults and of lesions that can be associated with these fractures, as well as how to describe them to ensure appropriate clinical management.

Acute effects of two caffeine doses on bar velocity during the bench press exercise among women habituated to caffeine: a randomized, crossover, double-blind study involving control and placebo conditions

PURPOSE

The main goal of this study was to evaluate the effectiveness of two different doses of caffeine (3 and 6 mg/kg) to enhance bar velocity during the bench press in women habituated to caffeine.

METHODS

Twelve recreationally trained women (age: 23.3 ± 0.8 years, body mass: 60.7 ± 5.7 kg, bench press one-repetition maximum (1RM): 44.3 ± 7.8 kg, daily caffeine ingestion: 5.7 ± 2.0 mg/kg/day) participated in a randomized double-blind experimental design. Each participant performed four different experimental sessions: after no supplementation (control, CON), after ingesting 3 and 6 mg/kg of caffeine (CAF-3 and CAF-6, respectively), or after ingesting a placebo (PLAC). In each experimental session, the participants performed 3 sets of 3 repetitions of the bench press exercise at 50% 1RM.

RESULTS

A two-way repeated-measures ANOVA with subsequent post hoc analyses indicated significant increases in peak velocity (p < 0.01; ES = 0.91) and mean velocity (p < 0.01; ES = 0.78) after the intake of CAF-6 compared to CON. The study did not show significant differences in bar velocity between CAF-6 and PLAC and between CAF-3 and PLAC. No significant differences in bar velocity were observed between CAF-3 and CAF-6 conditions.

CONCLUSION

These results suggest that 6 mg/kg of caffeine can be an effective dose to improve power-specific training outcomes in women habituated to caffeine. However, the ergogenic effect of 6 mg/kg of caffeine may be derived from a combination of biological effects and expectancy, as this dose was only superior to the control condition with no differences over the placebo.

Test-retest reliability of static and dynamic motor fatigability protocols using grip and pinch strength in typically developing children

Upper limb motor fatigability is an important debilitating factor for activities of daily living in clinical pediatric populations. However, the reliability of fatigability protocols in these populations is currently unknown. Therefore, the current study investigates test-retest reliability of a static and dynamic motor fatigability protocol for grip and pinch strength in typically developing children (TDC). Eighty-nine TDC (35 boys, 54 girls; mean age 10 years 11 months) used a grip and pinch dynamometer for static (sustained) and dynamic (repeated) contractions during 30s. For static motor fatigability (SFI), mean (Fmean) and SD (Fvar) of force were calculated, and for dynamic motor fatigability, F mean and number of peaks (Npeaks) were calculated. Intraclass correlation coefficients (ICC) were calculated. ICCs of F mean in static and dynamic motor fatigability were high (ICC: 0.94-0.96 and 0.91-0.98). ICCs were moderate to high for F var (ICC: 0.67-0.85). The SFI showed moderate ICCs (ICC: 0.69-0.77). ICCs were moderate to high for N peaks (ICC: 0.78-0.91).Conclusion: The results suggest that static and dynamic motor fatigability in for grip and pinch can be used reliably in TD children aged 6-18 years. What is Known: •Psychometric properties of motor fatigability protocols using grip and pinch in children are lacking. •Motor fatigability in grip and pinch is an important debilitating symptom in multiple neurologic populations. What is New: •Static fatigability can be investigated using a 30-s maximum sustained grip strength protocol in children. •Dynamic fatigability can be investigated using a 30-s maximum repeated grip strength protocol in children.

Investigation of psychosocial factors on upper limb musculoskeletal disorders and the prevalence of its musculoskeletal disorders among nurses: a systematic review and meta-analysis

OBJECTIVE

Musculoskeletal disorders are one of the most important occupational problems especially among nurses. The aim of this study was to investigate the prevalence of musculoskeletal disorders in upper limbs and its associated psychosocial factors in the workplace.

METHODS

A systematic review was conducted by searching the Medline/PubMed, EMBASE, Scopus, ISI/web of knowledge and Google Scholar databases. The authors classified studies into categories of psychological work stressors and musculoskeletal problems. The statistical analysis was performed using Stata software.

RESULTS

We found 1742 articles in our initial search. After reviewing the titles, abstracts and full texts, 66 articles were finally analyzed. Psychosocial factors affecting the prevalence of upper limb musculoskeletal disorders among nurses were identified which included boring work, inadequate staffing, job demands, insufficient support, time pressure, decision latitude, job dissatisfaction, and job stress. There was a significant relationship between these factors and prevalence of musculoskeletal disorders in the wrists, shoulders, neck and shoulders, and wrists and hands.

CONCLUSION

Collectively, the results of this study provide strong evidence of some psychosocial factors affecting the prevalence of upper limb musculoskeletal disorders among nurses. Thus, organizational interventions to minimize these stressors may be promising in reducing one risk factor for the development of nurses' musculoskeletal disorders. These interventions should not only consider the factors of physical ergonomics but also seek to improve the organizational aspects of the workplace.

Hand Function as Predictor of Motor Symptom Severity in Individuals with Parkinson's Disease

INTRODUCTION

Parkinson's disease (PD) leads to deficits in upper limb strength and manual dexterity and consequently resulting in functional impairment. Handgrip strength is correlated with the motor symptom severity of the disease, but there is a gap in the literature about the influence of freezing in PD patients.

OBJECTIVE

The objective is to study the correlation between handgrip strength and motor symptom severity considering the freezing phenomenon and to verify variables that can predict Unified Parkinson's Disease Rating Scale (UPDRS) III.

METHODS

This is a multicenter cross-sectional study in PD. 101 patients were divided into 2 groups: freezing of gait (FOG) (n = 51) and nonfreezing (nFOG) (n = 52). Freezing of Gait Questionnaire (FOGQ); UPDRS II and III sections; Hoehn and Yahr (HY) scale; handgrip dynamometry (HD); 9 Hole Peg Test (9-HPT) were assessed.

RESULTS

In both groups, HD was correlated to UPDRS III (nFOG: -0.308; FOG: -0.301), UPDRS total (nFOG: -0.379; FOG: -0.368), UPDRS item 23 (nFOG: -0.404; FOG: -0.605), and UPDRS item 24 (nFOG: -0.405; FOG: -0.515). For the correlation to UPDRS II (0.320) and 9-HPT (-0.323), only nFOG group presented significance. For the UPDRS 25 (-0.437), only FOG group presented statistical significance. The UPDRS III can be predicted by 9-HPT, age, and HY in nFOG patients (Adjusted R2 = 0.416). In FOG group, UPDRS III can be predicted by HD, 9-HPT, age, and HY (Adjusted R2 = 0.491).

CONCLUSION

Handgrip strength showed to be predictive of motor impairment only in the FOG group. Our results showed clinical profile differences of motor symptoms considering freezers and nonfreezers with PD.

Prevalence of work related musculoskeletal disorders in Italian workers: is there an underestimation of the related occupational risk factors?

Background

Work-related musculoskeletal disorders (WMSDs) represent an important socio-economic burden. The current risk assessment and management involved in the ethiopathogenesis of WMSDs is based on observational tools and checklists, which have some limitations in terms of accuracy and reliability. The aim of this study was to assess WMSD prevalence and identify possible correlations with several socio-demographic and work-related variables in a large cohort representative of Italian workers in order to improve our understanding of the WMSD phenomenon.

Methods

This study includes data from INSuLa, a cross-sectional nationally representative survey of health and safety at work, developed by the Italian Workers’ Compensation Authority. A total of 8000 Italian workers were included. Multivariate logistic regression analyses were performed to evaluate the association of independent variables, such as workers’ perceptions of exposure to biomechanical/ergonomic and video display unit (VDU) risks (Risk Perceived) and the actual risk exposure (Risk Detected) on Back, Lower and Upper limb pain. Socio-demographic, occupational and other health-related variables were included to investigate possible association with musculoskeletal disorders.

Results

Workers perceiving a significant exposure to biomechanical/ergonomic and VDU risks but not included in a health surveillance program for them (Risk Perceived/No Risk Detected) have had significantly higher odds of reporting musculoskeletal disorders. Regarding the biomechanical/ergonomic risk these workers are in the 19–24 age range (39.9%), transportation, warehousing/information and communication sectors (38.9%) and are employed in companies with more than 250 workers (35.8%). Regarding VDU risk, workers are in the 45–54 age range (24.5%), professional, financial and business services (38.0%) and come from companies with more than 250 employees (25.6%).

Conclusions

Within the occupational safety and health management systems an appropriate assessment of occupational risk factors correlated to musculoskeletal disorders (mainly biomechanical/ergonomic and VDU) and the correct definition of their exposure levels is essential to adequately prevent the onset of WMSDs. In this regard, our findings provide useful information to design novel approaches, aimed at improving our understanding of emerging risks, identifying gaps in current risk assessment strategies and enhancing workplace interventions are mandatory to improve the occupational risk assessment and management process and therefore implement the subsequent health surveillance systems.

Ischemic preconditioning has no effect on maximal arm cycling exercise in women

PURPOSE

We investigated the effect of ischemic preconditioning (IPC) on performance of a 3 min maximal effort arm ergometer test in young women.

METHODS

Twenty healthy women (23.1 (SD 3.3) years) performed a 3 min maximal effort arm cycling exercise, preceded by IPC on both arms or SHAM in a counterbalanced randomized crossover design. Both blood flow (via high resolution ultrasound; n = 17) and muscle oxygenation/deoxygenation (via near infrared spectroscopy; n = 5) were measured throughout the IPC/SHAM. Performance and perceptual/physiological (i.e., heart rate, blood lactate, rating of perceived exertion, and triceps brachialis oxygenation) parameters were recorded during the exercise test.

RESULTS

Occlusion during IPC completely blocked brachial artery blood flow, decreased oxygenated hemoglobin/myoglobin (Δ[oxy(Hb + Mb)]), and increased deoxygenated Hb/Mb (Δ[deoxy(Hb + Mb)]). There were no differences (P > 0.797) in performance (peak, mean, and end power output) or in any perceptual/physiological variables during the 3 min all-out test between IPC/SHAM. During exercise, Δ[oxy(Hb + Mb)] initially decreased with no differences (P ≥ 0.296) between conditions and returned towards baseline by the completion of the test while Δ[deoxy(Hb + Mb)] increased with no differences between conditions and remained elevated until completion of the test (P ≥ 0.755).

CONCLUSIONS

We verified the successful application of IPC via blood flow and NIRS measures but found no effects on performance of a 3 min maximal effort arm cranking test in young women.

Can arm movements improve postural stability during challenging standing balance tasks?

BACKGROUND

There is growing evidence that arm movements make a substantial and functionally relevant contribution to dynamic balance. Additional insight of the important role of arm movements may be gained by quantifying the effects of arm restriction on the performance of commonly recommended static balance tasks of increasing difficulty.

RESEARCH QUESTION

The purpose of the present study was to determine whether restricting/permitting arm movements influences postural sway during tasks of various levels of difficulty.

METHODS

A total of 20 healthy and physically active adults (females; n = 10; age, 20.7 ± 1.3 years) randomly completed (a) quiet standing postural control tasks of increasing difficulty (bipedal, tandem, unipedal) on a fixed and foam surface, and (b) a dynamic postural control task (Y balance test), under two different verbally conveyed instructions of arm position; (1) restricted arm movement and (2) free arm movement. Centre of pressure outcomes measured during quiet standing served as a measure of static balance performance.

RESULTS

The results showed that restricting movements of the arms elicited large magnitude (Cohen's d = 0.97 - 1.28) increases in mediolateral postural sway (P < 0.05) but not anteroposterior (P > 0.05) sway. These effects were only observed during challenging (tandem and unipedal) standing balance tasks. Restricting arm movements elicited a marked reduction in the Y Balance reach distance (all directions, P < 0.001, d = -0.53 to -1.15).

SIGNIFICANCE

The findings from the present study suggest that the contribution of the arms only become relevant when frontal plane balance is challenged. Moreover, the data indicate that arm movements are vital for the control of mediolateral postural sway.

Effects of cycling while typing on upper limb and performance characteristics

Active computer workstations may help reduce workplace sedentarism. However, their impact on the upper limb musculoskeletal system is unknown. Subjects participated in two 60-min computer laptop-based Bike-and-Type sessions at different cycling intensities (LOW, HIGH). Upper trapezius and wrist extensor muscle blood flow, sensitivity and pain thresholds, and typing performance were measured intermittently. Neck/shoulder discomfort increased over time (p < 0.001), and was higher in the HIGH intensity (p = 0.036). Blood flow to the trapezius (p = 0.041) and wrist (p = 0.021) muscles were higher during HIGH, and wrist blood flow increased over time (p = 0.01). Trapezius sensitivity threshold significantly decreased over time (p = 0.003). There were no effects on pressure pain thresholds (interaction p = 0.091). Average typing speed was greater during HIGH (p = 0.046) and increased over time (p < 0.001). Time spent biking while typing effectively improved performance, which may facilitate muscle regeneration, although effects depend on biking intensity.

Extravascular findings during upper limb computed tomographic angiography focusing on undiagnosed malignancy

BACKGROUND

Computer tomography angiography (CTA) has been an established method for diagnostic vascular disease of lower limbs. Recently, the method is widely used for diagnosis of vascular pathologies in the upper limbs too. It also has increased the possibilities of this scans being reviewed by no specially trained radiologists. This increases the risk of incidental non vascular findings to be missed or misinterpreted. The study is focusing in the frequency of extravascular incidental finding (EVIF) and highlights the importance for both the reporting radiologist and the referring physician recognizing the frequency of EVIFs.

AIM

To analyse the frequency of EVIF identified on computed angiography (CT) of the upper limb.

METHODS

A total of 1383 CT angiographic studies of the peripheral arterial system were performed between August 2015 and August 2017. All upper limb CTAs (n = 79) were retrospectively reviewed for the presence of non-vascular incidental findings within the chest, abdomen/pelvis, musculoskeletal system or head and neck. These EVIFs were subsequently grouped into 3 categories based on clinical significance. EVIFs of immediate clinical relevance were included in category A, findings considered indeterminate but most likely benign were placed in category B, while incidental findings of no clinical significance were included in category C.

RESULTS

Complete imaging datasets were available in 74/79 (93.7%). Patient demographics included 39 (52.7%) females and 35 (47.2%) males with a mean age of 59 ± 19.5 years (range 19-93 years). A total of 153 EVIFs were reported in 52 patients (70.3%). Of these, 44 EVIFs (28.7%) were found in the chest, 83 (54.2%) in the abdomen, 14 (9.2%) in the musculoskeletal system and 9 (5.8%) in the head and neck. Thirteen EVIFs (8.4%) identified in 11 patients were noted to be of immediate clinical significance (Category A), 50 EVIFs (32.3%) were identified in 20 patients and were considered indeterminate but most likely benign, while the remaining 91 EVIFs (59.5%) identified in 21 patients were determined to be of no clinical significance (Category C). One index case of malignancy (1.3%) and four cases of new disseminated metastatic disease (5.4%) were identified.

CONCLUSION

Our study of upper limb CTA examinations demonstrated a frequency of 8.4% for extravascular incidental findings of immediate clinical significance. We highlight the importance for both the reporting radiologist and the referring physician of the need to recognize the frequency with which EVIFs are identified in the upper limb peripheral arterial system and of the necessity for further clinical and imaging work-up.

A Game Changer: 'The Use of Digital Technologies in the Management of Upper Limb Rehabilitation'

Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both-pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.

Study of Radial Nerve Injury Caused By Gunshot Wounds and Explosive Injuries among Iraqi Soldiers

BACKGROUND

Gunshot wounds and blast injuries to the upper limbs produce complex wounds requiring management by multiple surgical specialities.

AIM

We sought to determine the pattern of peripheral nerve injuries among Iraqi soldiers in the war.

METHODS

We performed a 3 year retrospective cohort analysis based on medical records of patients with sustaining gunshot wounds and blast injuries to the upper limbs. Ethical approval was obtained from the institutional review board. The patients included were male, serving military personnel of all age groups and ranks presenting with weakness or sensory loss of radial nerve. Three hundred eighteen patients aged 24 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. In these patients, the physical examination and electrodiagnostic study were carried out by experienced neurologists. Seddon's classification system was used to assess the severity of the injury. The data related to the types of fracture, the type of damage, the factors causing damage and the failure of treatment were entered into the IBM SPSS 23 software after extraction of files. Based on mid-range indicators and data distribution, traumatic injuries among Iraqi soldiers in the war against ISIL were then investigated.

RESULTS

A group of 318 patients with mean age of 25.41 ± 6 years were enrolled in the study, of which 127 patients were included with an open fracture and 191 patients with closed lesions. All 127 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. 113 of 127 subjects had primary repair of the radial nerve and recovered well. 14 of 127 subjects were not recovered. 3 of them had iatrogenic radial nerve injury due to the internal fixation device. Furthermore, all 191 patients with closed injuries recovered well. The average time to initial signs of recovery was 8 weeks (range, 1-27 weeks). Axonotmesis and Neurotmesis were found in 283 (89%) subjects. The average time to full recovery was determined to be 6 months (range, 1-22 months). The blast was found to be the main cause of nerve injury in 236 (74.2%) cases, followed by gunshot damage (21.4%, 68 subjects), falling from height and motor vehicle accidents (4.4%, 14 subjects) and multiple injuries (17%, 54 cases).

CONCLUSIONS

Trauma caused by factors such as explosions and gunshot worsens the condition of the injuries and presents the treatment conditions with many challenges. However, the success rate in post-surgical recovery of humerus fracture and injured radial nerve can be remarkably higher in young people as compared to other age groups.

Quantitative assessment of upper limb functional impairments in people with Parkinson's disease

BACKGROUND

In clinical routine, upper limb motor disorders of people with Parkinson's disease are commonly assessed using scale- or timed tests, but such tools are not fully suitable for providing detailed information about their type and magnitude. To partly overcome these limitations, the present study aims to quantitatively investigate upper limb functional impairments through quantitative analysis of the "hand-to-mouth" task.

METHODS

Twenty-five individuals with Parkinson's disease and 20 age-matched healthy individuals underwent a kinematic analysis of the hand-to-mouth task from which spatio-temporal and kinematic measures, including summary measures (Arm Variable Score and Arm Profile Score), were calculated and correlated with clinical scores (Hoehn & Yahr, H&Y and the Unified Parkinson Disease Rating Scale, UPDRS).

FINDINGS

The "hand-to-mouth" movement is significantly altered in individuals with Parkinson's disease, especially in terms of reduced velocity, reduced range of motion of elbow flexion-extension and deviation from a physiologic pattern (Arm Profile Score 12.8° vs. 10.1° of unaffected, P = 0.002). Significant moderate correlations were found between movement duration and UPDRS-III (rho = 0.478, P = 0.001) and between the Arm Profile Score and H&Y (rho = 0.481, P = 0.024) and UPDRS-III (rho = 0.326, P = 0.001).

INTERPRETATION

On the basis of such findings, we can state that the kinematic analysis of "hand-to-mouth" movement, and in particular the summary indexes, are suitable for easily representing upper limb movement alterations in people with Parkinson's disease, thus allowing the monitoring either of disease progression or effectiveness of pharmacologic and rehabilitative treatments.

The prevalence of occupational musculoskeletal disorders in Iran: A meta-analysis study

BACKGROUND

Prevention of Work-Related Musculoskeletal Disorders (WRMSDs) is crucial as they jeopardize the well-being of the workforce in workplaces and are prevalent in developed and developing countries.

OBJECTIVE

This study aimed to determine the prevalence of WRMSDs among Iranian workers.

METHODS

A systematic review and meta-analysis of WRMSDs in Iran was performed by searching relevant keywords in authentic databases and search engines such as SID, Google Scholar, Medlib and PubMed. Twenty-seven published articles in the field of WRMSDs from 2001 to 2010 were searched. Meta-analysis and random effects approach were used to analyze data. Heterogeneity investigation of articles was done using I2 index.

RESULTS

The total sample size was 6,090 workers with a mean of 225 samples per study. The upper and lower back had the highest prevalence rate of self-reported WRMSDs with 38.1% (95% CI: 29.9-46.4), and 50% (95% CI: 42.5-57.5), respectively. Also, knee had the highest prevalence among lower extremity disorders with 42.1% prevalence rate (95% CI:35.1-49.1).

CONCLUSIONS

A high prevalence of WRMSDs in upper and lower limbs was reported in Iran. Trainings with regard to occupational ergonomics and industrial hygiene programs were recommended for minimizing the work-related risks of musculoskeletal disorders.

Human arm joints reconstruction algorithm in rehabilitation therapies assisted by end-effector robotic devices

Background

End-effector robots are commonly used in robot-assisted neuro-rehabilitation therapies for upper limbs where the patient’s hand can be easily attached to a splint. Nevertheless, they are not able to estimate and control the kinematic configuration of the upper limb during the therapy. However, the Range of Motion (ROM) together with the clinical assessment scales offers a comprehensive assessment to the therapist. Our aim is to present a robust and stable kinematic reconstruction algorithm to accurately measure the upper limb joints using only an accelerometer placed onto the upper arm.

Methods

The proposed algorithm is based on the inverse of the augmented Jaciobian as the algorithm (Papaleo, et al., Med Biol Eng Comput 53(9):815–28, 2015). However, the estimation of the elbow joint location is performed through the computation of the rotation measured by the accelerometer during the arm movement, making the algorithm more robust against shoulder movements. Furthermore, we present a method to compute the initial configuration of the upper limb necessary to start the integration method, a protocol to manually measure the upper arm and forearm lengths, and a shoulder position estimation. An optoelectronic system was used to test the accuracy of the proposed algorithm whilst healthy subjects were performing upper limb movements holding the end effector of the seven Degrees of Freedom (DoF) robot. In addition, the previous and the proposed algorithms were studied during a neuro-rehabilitation therapy assisted by the ‘PUPArm’ planar robot with three post-stroke patients.

Results

The proposed algorithm reports a Root Mean Square Error (RMSE) of 2.13cm in the elbow joint location and 1.89cm in the wrist joint location with high correlation. These errors lead to a RMSE about 3.5 degrees (mean of the seven joints) with high correlation in all the joints with respect to the real upper limb acquired through the optoelectronic system. Then, the estimation of the upper limb joints through both algorithms reveal an instability on the previous when shoulder movement appear due to the inevitable trunk compensation in post-stroke patients.

Conclusions

The proposed algorithm is able to accurately estimate the human upper limb joints during a neuro-rehabilitation therapy assisted by end-effector robots. In addition, the implemented protocol can be followed in a clinical environment without optoelectronic systems using only one accelerometer attached in the upper arm. Thus, the ROM can be perfectly determined and could become an objective assessment parameter for a comprehensive assessment.

Electronic supplementary material

The online version of this article (10.1186/s12984-018-0348-0) contains supplementary material, which is available to authorized users.

Validation of the Arm Profile Score in assessing upper limb functional impairments in people with multiple sclerosis

BACKGROUND

Although upper limb (UL) impairments are widespread in people with Multiple Sclerosis (pwMS), there is limited quantitative evidence concerning their specific features. The aim of this study is to validate a synthetic measure based on kinematic data to define the degree of deviation from a physiologic pattern during the "hand to mouth" (HTM) task.

METHODS

Twenty pwMS (mean age 51.2 SD 11.1) years, Expanded Disability Status Scale (EDSS) score in the range 2-6.5, underwent a kinematic analysis of the HTM task using a motion capture system. Spatio-temporal parameters and synthetic indexes (Arm Variable Score, AVS and Arm Profile Score, APS) were calculated and compared with those of age-matched healthy individuals. Kinematic data were correlated with the EDSS score and clinical tests such as the Nine Hole Peg Test (NHPT) and hand-grip strength (HGS).

FINDINGS

PwMS exhibit reduced velocity, increased movement duration, sway of adjusting and frequency of direction changes as well as higher APS values (15.4° vs. 8.6°, P<0.001) with respect to controls due to alterations in trunk flexion-extension, shoulder abduction-adduction, flexion-extension and rotation and elbow flexion-extension. Moderate-to-large correlations were found between APS and EDSS (rho=0.609, P<0.001), NHPT (rho=0.468, P=0.03) and HGS (rho=-0.627 P<0.001).

INTERPRETATION

The kinematic analysis of HTM provides useful information in quantifying UL impairments in pwMS. The APS index appears suitable to represent UL movement deviations from the physiological pattern in pwMS and to assess disease progression or effectiveness of pharmacologic and rehabilitative treatments effectiveness.

A 9-year follow-up study of the natural progression of upper limb performance in myotonic dystrophy type 1: A similar decline for phenotypes but not for gender

This study aimed to document and compare the decline of upper limb performance among adults with myotonic dystrophy type 1 according to phenotype and gender. A longitudinal descriptive design compared upper limb performance at baseline and follow-up of 70 women and 38 men with the late-onset or adult phenotypes. Grip strength and pinch strength as well as gross dexterity and fine dexterity were assessed. All four performance measures decreased significantly (p <0.001). The decline over time was similar for individuals with the late-onset and adult-onset phenotypes, but differed according to gender. For late-onset and adult-onset phenotypes respectively, women lost less grip strength than men: 0.4 and minus 0.8 kg (2.0% and -9.4%) in women vs. minus 7.4 and minus 3.1 kg (-19.2% and -30.7%) in men. A similar situation was found for gross dexterity: minus 3.0 and minus 3.2 blocks (-4.6% and -5.9%) in women vs. minus 12.4 and minus 8.7 blocks (-19.4% and -16.6%) in men. Pinch gauge had the smallest standard deviations and was one of the only measurement tools with significant detectable changes in relation to the standard error of measurement. Given these results, health professionals and researchers should consider phenotype and gender differently when planning health services or future studies. Indeed, as their upper limb strength and dexterity differed, even if their decline was similar, the phenotypes should not be pooled. Finally, the use of the pinch gauge to assess long-term change in upper limb ability seems preferable to the three other measurements.

Three-dimensional kinematics of upper limb anatomical movements in asymptomatic adults: Dominant vs. non-dominant

The effect of dominance on upper limb (UL) kinematics has only been studied on scapular movements. Moreover, when an anatomical UL movement is performed in a specific plane, secondary movements in the remaining planes involuntarily occur. These secondary movements have not been previously evaluated. The aim of this study was to compare the kinematics of primary and secondary angles of dominant and non-dominant UL during anatomical movements in asymptomatic adults. 25 asymptomatic adults performed 6 anatomical movements bilaterally: shoulder flexion-extension, abduction-adduction, horizontal abduction-adduction, internal-external rotation, elbow flexion-extension and wrist pronation-supination. Kinematics of the dominant and non-dominant UL were compared by their ranges of motion (ROM) and their angular waveforms (Coefficient of Multiple Correlations, CMC). The comparison between dominant and non-dominant UL kinematics showed different strategies of movement, most notably during elbow flexion-extension (CMC=0.29): the dominant UL exhibited more pronation at maximal elbow flexion. Significant secondary angles were found on most of the UL anatomical movements; e.g. a secondary ROM of shoulder (humero-thoracic) external-internal rotation (69°±16°) was found when the subject intended to perform maximal shoulder abduction-adduction (119°±21°). Bias of dominance should be considered when comparing pathological limb to the controlateral one. Normative values of primary and secondary angles during anatomical movements could be used as a reference for future studies on UL of subjects with neurological or orthopedic pathologies.

On the assessment of coordination between upper extremities: towards a common language between rehabilitation engineers, clinicians and neuroscientists

Well-developed coordination of the upper extremities is critical for function in everyday life. Interlimb coordination is an intuitive, yet subjective concept that refers to spatio-temporal relationships between kinematic, kinetic and physiological variables of two or more limbs executing a motor task with a common goal. While both the clinical and neuroscience communities agree on the relevance of assessing and quantifying interlimb coordination, rehabilitation engineers struggle to translate the knowledge and needs of clinicians and neuroscientists into technological devices for the impaired. The use of ambiguous definitions in the scientific literature, and lack of common agreement on what should be measured, present large barriers to advancements in this area. Here, we present the different definitions and approaches to assess and quantify interlimb coordination in the clinic, in motor control studies, and by state-of-the-art robotic devices. We then propose a taxonomy of interlimb activities and give recommendations for future neuroscience-based robotic- and sensor-based assessments of upper limb function that are applicable to the everyday clinical practice. We believe this is the first step towards our long-term goal of unifying different fields and help the generation of more consistent and effective tools for neurorehabilitation.

Efficacy of Secukinumab on Moderate-to-severe Plaque Psoriasis Affecting Different Body Regions: a Pooled Analysis of Four Phase 3 Studies

Introduction

The impact of psoriasis varies with the body region affected. In addition, patients have different perceptions of disease improvement and treatment satisfaction based on the location of skin clearance with treatment. The monoclonal antibody secukinumab selectively targets interleukin-17A—a central cytokine of psoriasis—and provides rapid and sustained clearance for moderate-to-severe psoriasis affecting all body regions. The objective of this study was to evaluate the efficacy of secukinumab on moderate-to-severe psoriasis affecting the trunk, upper limbs, and lower limbs.

Methods

Data were pooled from four phase 3 studies. To be included in the analysis for each body region, patients were required to have a Psoriasis Area and Severity Index (PASI) score ≥12 for that body region and psoriasis covering ≥10% of the surface area of that region. Secukinumab was administered at Baseline, Weeks 1, 2 and 3, and then every 4 weeks from Week 4 to 48.

Results

Across the trunk, upper limbs, and lower limbs, initial PASI subscore responses were sustained to Week 52. At Week 52, trunk (T) PASI 90/100 responses were achieved by 78.4%/71.1% of patients receiving secukinumab 300 mg, respectively, and by 66.3%/56.9% of patients receiving secukinumab 150 mg, respectively. At Week 52, upper limb (UL) PASI 90/100 responses were achieved by 67.3%/59.1% of patients receiving secukinumab 300 mg, respectively, and by 50.3%/43.3% of patients receiving secukinumab 150 mg, respectively. At Week 52, lower limb (LL) PASI 90/100 responses were achieved by 63.9%/55.3% of patients receiving secukinumab 300 mg, respectively, and by 45.1%/36.4% of patients receiving secukinumab 150 mg, respectively. A 50% reduction in mean PASI subscore occurred after 2.8, 2.9, and 3.4 weeks with secukinumab 300 mg on the trunk, upper limbs, and lower limbs, respectively.

Conclusion

Secukinumab provided robust and sustained efficacy for moderate-to-severe psoriasis affecting the trunk, upper limbs, and lower limbs.

Funding

Novartis Pharmaceuticals Corporation.

Trial registration

ClinicalTrials.gov identifiers: NCT01365455, NCT01358578, NCT01555125, and NCT01636687.

The concurrence of musculoskeletal pain and associated work-related factors: a cross sectional study

Background

Several recent studies have described the presence of musculoskeletal complaints, presenting evidence that multisite musculoskeletal pain (MP) is more often present than single-site musculoskeletal pain. However, less is known about determinants of this multimorbidity, particularly, concerning the role of occupational factors and, mainly, what determines single or multisite pain. This study described the associations between pain in different body sites and investigated related factors to MP in workers from Brazil.

Methods

A total of 1070 workers (228 women and 842 men), from urban cleaning services and from shoe manufacturers, participated in this cross sectional study (response 97 %). Interviewer-administered questionnaire included sociodemographic factors, physical and psychosocial work demands, leisure-time activities and musculoskeletal pain which was presence of pain in previous seven days, considering eight body sites and MP, the sum score of all painful sites, varying 0–8. A factor analysis was performed that captured the nine variables of physical exposure into two latent factors. Associations of pain between different body sites were assessed. Cox regression analyses, presenting the prevalence ratio (PR), showed the related factors to MP.

Results

In the previous seven days, 30 % of workers had MP. For all body sites, comorbidity ranged from 72 % to 91 %. Having pain in one body site is associated with pain in other site and the associations between proximal sites were stronger than between more distal sites. High exposure to manual material handling and awkward postures (PR = 1.5, 95 % CI 1.1–2.0), job strain (PR = 1.2, 95 % CI 1.0–1.6), and low social support (PR = 1.3, 95 % CI 1.0–1.7) and being woman (PR = 1.7, 95 % CI 1.3–2.3) were associated with MP. Risk factors for single–site pain and for subsequent musculoskeletal comorbidity were very similar, suggesting an additive effect of risk factors.

Conclusions

Most workers reported MP that was associated with several work-related factors. The findings support the idea that multisite pain is a continuum of single-site pain, maintained by exposure to several risk factors, rather than the result of a specific risk factor that initiates the multisite pain but not single-site pain. Workplace interventions are needed to decrease the number of pain sites, in order to improve the worker’s health.

Kinematic upper limb evaluation of children and adolescents with cerebral palsy: a systematic review of the literature

[Purpose] The aim of the present study was to perform a review of the literature on objective measures of upper limb movements in children and adolescents with cerebral palsy and describe the methods used to investigate upper limb kinematics in this population. [Materials and Methods] An extensive database search was performed using the keywords kinematics, upper limb, and cerebral palsy. A total of 146 papers were identified, but only five met the inclusion criteria. [Results] No consensus was found regarding the data collection, processing, and analysis procedures or reporting of the results. [Conclusion] Standardization of the protocol for 3D upper limb movement analysis will provide the foundation for comparable, reproducible results and eventually facilitate the planning of treatment interventions.

Velocity, aerobic power and metabolic cost of whole body and arms only front crawl swimming at various stroke rates

PURPOSE

Stroke rate (SR) has not been considered in previous research examining the relative roles of the limbs in front-crawl performance. This study compared velocity, aerobic power ([Formula: see text]) and metabolic cost (C) between whole body (WB) and arms only (AO) front-crawl swimming across various intensities while controlling SR.

METHODS

Twenty Australian national swimmers performed six 200 m front-crawl efforts under two conditions: (1) WB swimming and, (2) AO swimming. Participants completed the 200 m trials under three SR conditions: "low" (22-26 stroke-cycles min(-1)), "moderate" (30-34 stroke-cycles min(-1) and "high" (38-42 stroke-cycles min(-1)). [Formula: see text] was continuously measured, with C, velocity, SR, and kick rate calculated for each effort.

RESULTS

Regardless of the SR condition and sex, AO velocity was consistently lower than WB velocity by ~11.0 % (p < 0.01). AO [Formula: see text] was lower than WB [Formula: see text] at all SR conditions for females (p < 0.01) and at the "high" SR for males (p < 0.01). C did not differ between WB and AO at any SR for both sexes (p > 0.01). When C was expressed as a function of velocity, WB and AO regression equations differed for males (p = 0.01) but not for females (p = 0.087). Kick rate increased as SR increased (p < 0.01), though the kick-to-stroke rate ratio remained constant.

CONCLUSION

Elite swimmers gain ~11 % in velocity from their kick and, when used in conjunction with the arm stroke at the swimmers' preferred frequency, the metabolic cost of WB and AO swimming is the same. Coaches should consider these results when prescribing AO sets if their intention is to reduce the metabolic load.

HUMAN BITE INJURIES ON THE JOS PLATEAU

BACKGROUND

Human bite injuries with the associated morbidity are not uncommon in this environment.

OBJECTIVE

To determine the pattern, management modalities and treatment outcome of human bites in Jos, Plateau State, Nigeria.

DESIGN

A prospective study of all human bite injuries managed at the Jos University Teaching Hospital, Jos, Nigeria between January 2012 and December 2014.

SETTING

Jos University Teaching Hospital, Jos, Nigeria.

MAIN OUTCOME MEASURES

The pattern and management outcome.

RESULTS

A total of 63 patients with human bite injuries were studied during the three-year period. There were 43 males and 20 females with a male:female ratio of 2:1. The age ranged from 8 - 65 years with a mean age of 30.2+/-17 years; in all about 75% of the patients fell into the 20 - 40 years bracket. Though all the social strata were affected, the bites were more common (50%) among the lower social classes and 70% of the patients presented late after 24 hours of sustaining bite injuries. Pain, bleeding, infected wounds, bite and scratch marks were the main presenting features. About 70% of the patients sustained major bites involving the underlying muscles and deeper structures while 89% of the patients sustained their bites during a fight, 8% while raping their victims, and in 3% of patients as they were being mugged. The bites were between spouses in 39% of cases, and between women in polygamous settings in 16%. The sites commonly affected were the upper limbs in 46%, chest in 21%, ears in 13%, abdomen in 10% and the penis in 6%. The associated injuries were scratch marks in 89%, blunt abdominal injuries in 29%, skin lacerations in 16% and urinary bladder/urethral injuries in 3%. There was no mortality but morbidity was 57% which included infections in 29%, disfigurement in 29%, penile injuries in 6% and minor urethral injuries in 3% of cases.

CONCLUSION

Human bite injuries in this tropical environment commonly affected the young male, the lower social class and the upper limbs; they were commonly sustained in assaults and domestic conflicts.

Thorough debridement and immediate primary wound closure for animal bite injuries of the upper limbs

PURPOSE

Animal bite injuries are often encountered in daily practice. In particular, these injuries of the upper limbs can result in severe functional impairment. We have performed early debridement of contaminated tissue and primary closure for these injuries.

METHODS

The subjects consisted of 15 patients (6 males and 9 females) aged 1-91 years (mean 53.6 years) who visited our hospital due to animal bite injuries (dog in 9 patients, cat in 6). The bite site was the forearm in 5 patients and the hand in 10. In the operating room, contaminated tissue was removed, and primary wound closure was performed after irrigation.

RESULTS

The bite penetrated to the muscle layer in 6 patients, tendon sheath in 5, joint in 1, bone in 1, and involved only the subcutaneous tissue in 3 patients. The mean period until the completion of wound treatment was 19.8 ± 8.4 days. As complications, numbness of finger, metaphalangeal joint contracture and superficial radial nerve injury were observed in each one case. In a patient with bite injury of the palmar and dorsal sides of the thumb reaching the bone, additional debridement was necessary. At the final observation, the visual analog scale was 1.2 ± 1.4, and the Quick Disabilities of the Arm, Shoulder, and Hand score was 9.7 ± 12.2.

CONCLUSIONS

Debridement to achieve wound closure is indispensable in patients with animal bite injuries of the upper limbs. The results of our study suggest that thorough debridement allows primary closure, even for animal bite injuries.

Upper limb function evaluation scales for individuals with cerebral palsy: a systematic review

[Purpose] The aim of the present study was to perform a systematic review of the literature on the scales and methods most often used for the evaluation of upper limb function in individuals with cerebral palsy. [Materials and Methods] Searches were conducted in the Medline, PEDro, Lilacs, Scielo, and PubMed databases. The following inclusion criteria were used for the selection of articles: randomized controlled study, evaluation of upper limb function in individuals with cerebral palsy, and publication between 2006 and 2014. The methodological quality of the articles was evaluated using the PEDro evidence scale. [Results] Five articles met the inclusion criteria and achieved 6 points or higher on the PEDro scale of methodological quality. [Conclusion] The studies analyzed used different evaluation scales, but no consensus has been reached thus far on which scale is the most appropriate. Thus, further studies are needed to establish an adequate method for the evaluation of upper limb function in individuals with cerebral palsy.

Multiple musculovascular anomalies in the superior extremities of a cadaver: a case report

During the evolution from the lower animals to man, the upper limbs have acquired a great mobility, but at the cost of their stability. The reverse is true for the lower limbs. The muscular anomalies which are common in the upper limbs are largely explainable on a phylogenetic basis. The same is true for the vascular anomalies. However, such anomalies are usually seen singly and they are never together in the same limb or in two limbs of the same body. The upper limbs which are being reported here had multiple musculovascular anomalies and some of these were bilateral. These include the superficial brachial artery, the accessory head of the biceps brachii, the accessory muscular slips which arose from the common flexor origin and went to the tendons of the flexor digitorum profundus and the flexor pollicis longus separately, bifurcation of the tendon of insertion of the brachioradialis and bifurcated (split) insertion of the third lumbrical on the adjacent fingers. Though all these variations have been described in the standard text books of Anatomy, their occurrence, together in one limb and the bilateral presentations of some of these, have never been encountered. Almost all these variations have been explained phylogenically, thus supporting the dictum, "The ontogeny repeats the phylogeny." Furthermore, their clinical significance has also been discussed.