The Effect of Endoscopic Partial Plantar Fasciotomy on Morphologic and Functional Properties of the Foot

BACKGROUND

The lifetime risk of plantar fasciitis is 10%, and operative treatment in the form of endoscopic partial plantar fascia release are often performed in cases refractory for nonsurgical treatment. The effect of the operation on the biomechanical properties of the foot has only been sparsely studied.

METHODS

This is a prospective, observational study of 25 patients with plantar fasciitis, for a minimum of 3 months, verified by ultrasonographic scanning, who had endoscopic partial fasciotomy. A bony spur was resected if present. At the calcaneal insertion, the medial half of the central band of the plantar fascia was excised in full thickness. The biomechanical properties of the foot were evaluated before surgery and 12 months postoperatively.

RESULTS

Foot length increased 0.17 cm (P = .03), the width of the central zone 0.35 cm (P = .019), the modified arch index 0.05 (P = .032), and the Foot Posture Index 1.0 (P = .0014). There were no significant changes in rearfoot eversion angle, ankle dorsiflexion and jump distance, or in magnetic resonance imaging-measured 3D navicular position from pre- to postoperation, with or without loading, and no changes in ultrasonographically measured heel pad thickness. A tantalum bead (0.7-mm-diameter) was inserted during operation into the most proximal part of the released medial plantar fascia. Radiographs obtained few days postoperatively and 1 year later revealed no changes in the tantalum-calcaneus distance in supine position, but an increase from 48.3 to 50.7 mm (P = .045) in one-leg standing, suggesting a higher flexibility of the remaining fascia. Patients with a body mass index above and below 27.0 demonstrated no significant differences in any of the assessments at 12 months.

CONCLUSION

There were minimal changes in the measured foot morphologic and functional properties at 1-year follow-up, after endoscopic partial plantar fascia release.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

The relationship between ultrasonography with or without contrast and the clinical outcome in plantar fasciitis

BACKGROUND

Plantar fasciitis (PF) is a common disorder without objective parameters for disease severity.

PURPOSE

to investigate whether structural changes in the plantar fascia and heel fat pad determined by ultrasound scanning with or without contrast is related to outcome measures in patients with symptomatic PF, and to investigate whether there is an association between changes in US findings and improvement in pain and function.

METHODS

All patients (n=90) in a randomized controlled trial treated with training and/or glucocorticosteroid injection were assessed for morning pain, function pain, Foot Function Index (FFI) and ultrasound measured thickness of the fascia and heel fat pad at entry, and after 6 months. Thirty patients were included in a longitudinal study that assessed pain, function and microvascular volume (MV) by Contrast Enhanced Ultrasound at entry and after 5 months of treatment.

RESULTS

None of the ultrasound parameters at the initial examination were related to clinical outcomes at 5-6 months. Changes in US measured thickness of the fascia but not the fat pad correlated with improvement in all outcome measures at 6 months (FFI: r=0.30, p=0.005, morning pain: r=0.21, p=0.046, function pain: r=0.28, p=0.007. MV did not change despite significant improvement in symptoms.

CONCLUSION

Changes in ultrasound measured fascia thickness is associated with clinical improvement in PF patients.

Effect of Ultrasonography-Guided Corticosteroid Injection vs Placebo Added to Exercise Therapy for Achilles Tendinopathy: A Randomized Clinical Trial

Importance

Corticosteroid injections and exercise therapy are commonly used to treat chronic midportion Achilles tendinopathy, but the evidence for this combination is limited.

Objective

To investigate the effect of corticosteroid injection and exercise therapy compared with placebo injection and exercise therapy for patients with Achilles tendinopathy.

Design, Setting, and Participants

This was a participant-blinded, physician-blinded, and assessor-blinded randomized clinical trial of patients with Achilles tendinopathy verified by ultrasonography. Assessment of pain and function were conducted at baseline and at 1, 2, 3, 6, 12, and 24 months. Patients were recruited from a university medical clinic and a private rheumatology clinic in Denmark between April 2016 and September 2018. Data analysis was performed from June to September 2021.

Interventions

Corticosteroid injection and placebo injection were performed with ultrasonography guidance. Exercise therapy was based on previous trials and consisted of 3 exercises done every second day.

Main Outcomes and Measures

The primary outcome was the Victorian Institute of Sports Assessment-Achilles (VISA-A) score (range, 1-100, with 100 representing no symptoms) at 6 months. Secondary outcomes included pain measured using a 100-mm Visual Analog Scale for morning pain and pain during exercise (with higher scores indicating worse pain), global assessment (Likert scale), and tendon thickness.

Results

A total of 100 patients were included, with 52 randomized to placebo (mean age, 46 years [95% CI, 44-48 years]; 32 men [62%]) and 48 randomized to corticosteroid injection (mean age, 47 years [95% CI, 45-49 years]; 28 men [58%]). Patients in the 2 groups had similar height (mean [SD], 177 [8] cm), weight (mean [SD], 79 [12] kg), and VISA-A score (mean [SD], 46 [18]) at baseline. The group receiving exercise therapy combined with corticosteroid injections had a 17.7-point (95% CI, 8.4-27.0 points; P < .001) larger improvement in VISA-A score compared with patients receiving exercise therapy combined with placebo injections at 6 months. No severe adverse events were observed in either group, and there was no deterioration in the long term (2-year follow-up).

Conclusions and Relevance

Corticosteroid injections combined with exercise therapy were associated with better outcomes in the treatment of Achilles tendinopathy compared with placebo injections and exercise therapy. A combination of exercise therapy and corticosteroid injection should be considered in the management of long-standing Achilles tendinopathy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02580630.

Liquid Chromatographic Method to Determine Narasin in Feedingstuffs and Premixtures: Development, Validation, and Interlaboratory Study

A reversed-phase liquid chromatography (LC) method for narasin in feedingstuffs and premixtures was developed, validated, and interlaboratory studied. The extraction solvent was methanol–K2HPO4 solution (9 + 1, v/v). Narasin was detected at 600 nm after post-column derivatization with dimethylamino-benzaldehyde. Recovery was &gt;90%. The repeatability (RSDr) in feed (20–140 mg/kg) ranged between 1.2 and 10.5%; the within-laboratory reproducibility (RSDR) ranged between 2.2 and 4.9%. The limit of determination was &lt;20 mg/kg. Other feed additives did not interfere in the assay. The method showed ruggedness against changes in the composition of extraction solvent, eluent, and conditions for post-column reactions. In an interlaboratory study, 5 broiler feeds (4 positive, 1 blank) and 1 premixture were analyzed by 13 laboratories. The RSDr of the feedingstuffs (20–120 mg/kg) varied between 2.17 and 7.57%. The HORRAT ranged between 0.77 and 0.88, with recoveries between 82 and 104%. One laboratory detected small signals in the blank sample, calculated as 0.6 and 2.8 mg/kg. For the premixture, acceptable results for reproducibility could only be obtained after modification of the method: the RSDr was 4.42% and the HORRAT was 1.56 (12 laboratories).

Plantar fasciitis treated with endoscopic partial plantar fasciotomy-One-year clinical and ultrasonographic follow-up

BACKGROUND

Endoscopic operations for plantar fasciitis generally have good clinical outcome. The aim of this study was to record the effect of endoscopic partial fasciotomy and heel spur removal and evaluate by ultrasonography whether the fascia regenerates and the heel spur reforms.

METHODS

Eleven consecutive patients were evaluated before and 3, 6 and 12 months after surgery. Operations were performed endoscopically using a deep fascial approach with a medial and a lateral portal. Bony spurs were removed and the medial half of the plantar fascia was transected. All patients followed a standardized rehabilitation program.

RESULTS

Median Foot Function Index values decreased from 119 pre-surgery to 69 and 12 (p=0.004), at 3 months and 1year post-operatively respectively. Median VAS-score for first step pain was likewise reduced from median 71mm to 29mm and 7mm (p=0.004), respectively. Median fascial thickness at the medial insertion was 6.0mm (range 4.6-6.8mm) pre-operatively. A heel spur was present in 9 cases. One year postoperatively a well-defined fascia in the area of resection was demonstrated in 8 cases. In the rest of the cases scar tissue made it impossible to clearly outline the fascia. Nine of the feet showed good medial fascial tensioning. There was no evidence of recurrence of the bony spur.

CONCLUSIONS

Endoscopic partial plantar fascia resection reduced pain symptoms and increased function significantly 3 months after operation, with additional effect achieved 12 months after surgery. Based on ultrasonography the resected fascia regenerated/healed, and a calcaneal spur did not recur.

[Medical risks in extreme sports]

The boundaries for what is characterised as extreme sport are constantly expanding, and the activities are becoming more and more strenuous with medical hazards for the athletes. This review is a description of: 1) athletes' most common medical risks and 2) a series of precautions.

[Tendinopathy in athletes]

Tendinopathy is a condition of tendon overuse and is a very common cause of morbidity among recreational and competitive athletes. Chronic overload results in degenerative changes of the tendon, which becomes painful and swollen with impaired function. A reduction in the overloading activity is the mainstay of the treatment. A rehabilitating programme consisting of controlled loading of the affected tendon should follow this. Other modalities, which may facilitate treatment, are: injections with corticosteroid, platelet-rich plasma, and of high volume, as well as shock-wave therapy and surgery.

10-year follow-up after standardised treatment for Achilles tendinopathy

Background

Achilles tendinopathy is a common and often long-lasting injury. We present a 10-year follow-up on a pragmatic study on Achilles tendinopathy treated with controlled exercises supplemented with corticosteroid injections if necessary in order to continue training.

Methods

All patients who completed the original study (n=93) were invited for a 10-year follow-up. 83% participated. Patients were evaluated with ultrasound scanning (n=58) and with a questionnaire (n=77) using the same outcome measures as in the primary study. The 10-year overall outcome on a 4-point scale (excellent, good, fair, poor), other treatments and adverse event and present activity level were recorded.

Results

Excellent outcome was reported in 63% and good outcome in 27%. 76% reported an activity level at 75%-100% of preinjury level. The average Victorian Institute of Sports Assessment-Achilles score for all patients was 84 (SD 19). 16% had surgery. Three ruptures occurred 5-8 years after the primary study. The improvement from entry to 6 months in the primary study was maintained until 10-year follow-up. Insertional tendinopathy did not differ from mid-substance tendinopathy in any outcome measure (short term and long term). We encountered no prognostic markers on ultrasound for the long-term outcome; however, present heterogeneity and increased flow resemble present pain. Thickened tendons seem to maintain their thickness despite improvement of symptoms.

Conclusion

One to two corticosteroid injections are a safe and effective supplement to controlled exercises in the treatment of Achilles tendon pain with no signs of deterioration in the very long term. Mid-substance and insertional tendinopathies benefit equally from this treatment.

Applicability of contrast-enhanced ultrasound in the diagnosis of plantar fasciitis

Contrast-enhanced ultrasound (CEUS) is used to visualize the microvascularization in various tissues. The purpose of this study was to investigate whether CEUS could be used to visualize the microvascular volume (MV) in the plantar fascia, and to compare the method to clinical symptoms and B-mode ultrasound (US) in patients with plantar fasciitis (PF). Twenty patients with unilateral PF were included and were divided by US in insertional thickening (10), midsubstance thickening (5), and no US changes (5). The MV was measured simultaneously in both heels. Four areas in the plantar fascia and plantar fat pad were measured independently by two observers. Inter- and intra-observer correlation analyses were performed. The asymptomatic heels showed a constantly low MV, and for the whole group of patients, a significantly higher MV was found in the symptomatic plantar fascia and plantar fat pad. Inter-observer correlation as well as intra-observer agreement was excellent. The MV in the plantar fascia and plantar fat pad can be measured reliably using CEUS, suggesting that it is a reproducible method to examine patients with plantar fasciitis.

Sonographic measurements of the achilles tendon, plantar fascia, and heel fat pad are reliable: A test-retest intra- and intertester study

PURPOSE

To determine intra- and interobserver reliability and precision of sonographic (US) scanning in measuring thickness of the Achilles tendon, plantar fascia, and heel fat pad in patients with heel pain.

METHODS

Seventeen consecutive patients referred with heel pain were included. Two evaluators blinded to the diagnosis performed independently US scanning of both feet without any dialogue with the patient. The examiner left the room, and the next examiner entered. All patients had two US scans performed by each examiner. Two months later, the US images were randomly presented to the evaluators for measurements. Reliability and agreement were assessed by calculation of intraclass correlation coefficient (ICC), 95% limits of agreement (LOA), and typical error (TE). LOA was calculated as a percentage of the mean thickness of each structure to obtain a unitless parameter.

RESULTS

We found excellent intratester reliability (ICC 0.78-0.98) and good intertester reliability using one measurement (ICC 0.72-0.91) and excellent (ICC 0.85-0.95) when using average of two measurements. The intratester agreements were good with LOA: 9.5-23.4% and TE: 3.4-8.4%. The intertester agreements were acceptable using one measurement with LOA: 16.1-36.4%, and better using two measurements with LOA: 14.4-33.2%.

CONCLUSIONS

US is a reliable technique of measurement in the daily clinic, and one single measurement is sufficient. In research, we recommend that the same observer performs the US measurements, if one single scanning is preferred; if more researchers are involved, the average measurement of two US scans is recommended. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:480-486, 2016.

Can positional MRI predict dynamic changes in the medial plantar arch? An exploratory pilot study

BACKGROUND

Positional MRI (pMRI) allows for three-dimensional visual assessment of navicular position. In this exploratory pilot study pMRI was validated against a stretch sensor device, which measures movement of the medial plantar arch. We hypothesized that a combined pMRI measure incorporating both vertical and medial displacement of the navicular bone induced by loading would be correlated with corresponding stretch sensor measurements.

METHODS

10 voluntary participants were included in the study. Both pMRI and subsequent stretch sensor measurements were performed in a) supine, b) standing and c) standing position with addition of 10 % body weight during static loading of the foot. Stretch sensor measurements were also performed during barefoot walking.

RESULTS

The total change in navicular position measured by pMRI was 10.3 mm (CI: 7.0 to 13.5 mm). No further displacement occurred when adding 10 % bodyweight (mean difference: 0.7 mm (CI: -0.7 to 2.0 mm), P = 0.29). The total navicular displacement correlated with stretch sensor measurement under static loading conditions (Spearman's rho = 0.66, P = 0.04) but not with measurements during walking (Spearman's rho = 0.58, P = 0.08).

CONCLUSIONS

Total navicular bone displacements determined by pMRI showed concurrent validity with stretch sensor measurements but only so under static loading conditions. Although assessment of total navicular displacement by combining concomitant vertical and medial navicular bone movements would appear advantageous compared to monoplanar measurement the combined measure did not seem to predict dynamic changes of the medial foot arch during walking, which are among several possible factors depending on different walking patterns.

Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting

In published efficacy studies on Achilles tendinopathy (AT) exercise alone results in improvement in 60-90% of the cases. However, this high success rate cannot be expected in usual clinical practice. We prospectively investigated the effectiveness of a treatment regimen consisting of home-based exercises (concentric, eccentric, and stretching) and optional glucocorticosteroid (GCS) injections in patients with (AT) in a usual clinical setting. Patients unable to commence or progress in exercise were offered GCS, hypothesizing that the GCS would facilitate exercise. Ninety-three consecutive patients with AT referred to two outpatient rheumatology clinics were registered, and seen at five visits over a 6-month period. Exercises seemed to have a slow, but long-lasting effect with GCS having a dramatic short-term effect on symptoms. Twenty-six percent of the patients could proceed with training alone, the remainder received one to three supplementary GCS. There were significant improvements on all outcome variables over time (P ≤ 0.001). At follow-up, 42 had no more symptoms, 29 good result, 16 slightly improved, 4 unchanged, and 2 slightly worse. Overall, 94% of the patients had improved, and we thus recommend the use of GCS injections in AT patients if training alone does not lead to improvement.

Ultrasound therapy in chronic leg ulceration: a meta-analysis

We reviewed all articles on ultrasound therapy published since 1950 to assess the evidence for an effect of this therapy in the treatment of chronic leg ulcers. Fourteen studies concerning ultrasound therapy, chronic leg ulcers, and wound healing were found. The six studies that fulfilled inclusion criteria for a randomized controlled trial were generally found lacking with respect to description of ulcer etiology-treated area, ultrasound head area, control of ultrasound apparatus, sham ultrasound apparatus, and follow-up evaluations. However, all six studies presented their data in a way that made pooling possible with respect to a decrease in ulcer area as a percent of the starting area. A standardized effect size was applied and gave evidence for a significant effect of ultrasound, showing a 16.9% (CI95: 6.3% to 27.5%, p = 0.011) mean difference in healing after 4 weeks of treatment and a 14.5% (CI95: 6.6% to 22.3%, p = 0.005) mean difference after 8 weeks of treatment compared with control treatment. In three studies, the number of healed ulcers was assessed, and pooling showed a nonsignificant (p = 0.06) therapeutic gain of 15% (CI95: 1% to 30%). This analysis would suggest that ultrasound has the best effect being delivered in low doses around the edge of the ulcer, but further studies are required to confirm this possible effect and to evaluate a possible dose-response relationship.

Determinants of musculoskeletal flexibility: viscoelastic properties, cross-sectional area, EMG and stretch tolerance

Cross-sectional area, stiffness, viscoelastic stress relaxation, stretch tolerance and EMG activity of the human hamstring muscle group were examined in endurance-trained athletes with varying flexibility. Subjects were defined as tight (n = 10) or normal (n = 8) based on a clinical toe-touch test. Cross-sectional area was computed from magnetic resonance imagining (MRI) images. Torque (Nm) offered by the hamstring muscle group, electromyographic (EMG) activity, knee joint angle and velocity were continuously monitored during two standardized stretch protocols. Protocol 1 consisted of a slow stretch at 0.087 rad/s (dynamic phase) to a pre-determined final angle followed by a 90-s static phase. In the dynamic phase final angle and stiffness was lower in tight (28.0+/-2.9 Nm/rad) than normal subjects (54.9+/-6.5 Nm/rad), P<0.01. In the static phase tight subjects had lower peak (15.4+/-1.8 Nm) and final torque (10.8+/-1.6 Nm) than normal subjects (31.6+/-4.1 Nm, 24.1+/-3.7 Nm, respectively)(P<0.01), but torque decline was similar. Protocol 2 consisted of a slow stretch to the point of pain and here tight subjects reached a lower maximal angle, torque, stiffness and energy than normal subjects (P<0.01). On the other hand, stiffness was greater in tight subjects in the common range (P<0.01). Cross-sectional area of the hamstring muscles and EMG activity during the stretch did not differ between the groups. However, lateral hamstring cross-sectional area was positively related to mid-range stiffness (P<0.05), but inversely related to final stiffness, peak torque and the toe-touch test (P<0.01). Final angle and peak torque in protocol 1 combined to improve the predictability of the toe-touch test (R2=0.77, P<0.001). These data show that the toe-touch test is largely a measure of hamstring flexibility. Further, subjects with a restricted joint range of movement on a clinical toe-touch test have stiffer hamstring muscles and a lower stretch tolerance.

The treatment of acute soft tissue trauma in Danish emergency rooms

Rest, ice, compression, elevation (RICE) is the most recommended treatment for acute traumatic soft tissue injuries. A questionnaire was given to all Danish emergency rooms (n = 5) regarding their routines for acute treatment of ankle sprains and muscle contusions. Complete answers were received from 37 emergency rooms (73%), covering the treatment of 111 ankle sprains and 101 muscle contusions. Treatment with RICE was given in a minority of injuries, ice (21%), compression (32%) and elevation (58%) similarly between injury types. A complete RICE treatment was rarely applied (3%). Verbal information on RICE and rehabilitation was given in less than half of the cases. We conclude that the acute treatment of ankle sprains and muscle contusions in the Danish emergency rooms is not applied in accordance with consensus from international literature, and that the instruction in rehabilitation should be improved.

Ultrasound therapy in musculoskeletal disorders: a meta-analysis

We have reviewed 293 papers published since 1950 to assess the evidence of effect of ultrasound in the treatment of musculoskeletal disorders. Twenty-two clinical papers describing trials comparing ultrasound treatment with sham-ultrasound treated, non-ultrasound treatment and untreated groups were found. These papers were evaluated with respect to a list of criteria which should be met in this type of trial. They were generally found lacking with respect to description of drop-outs, randomisation methods, ultrasound apparatus, sham-ultrasound apparatus, control of apparatus, mode of delivery, size of sound-head, treated area and follow-up time. In 16 of these trials, ultrasound treatments were compared with sham-ultrasound and in 13 cases data were presented in a way that made pooling possible. Two standardized effect sizes (dd/r and dd/s) were applied to the results to enable evaluation of the effect of ultrasound treatment on pain. None of the methods (dd/r = 0.64%, confidence limits -6.7 to 7.5%; and dd/s = 0.24, confidence limits -0.01 to 0.49) gave evidence that pain relief could be achieved by ultrasound treatment. Hence we found no reason to analyze the other papers where ultrasound treatment was compared with another treatment or an untreated control group. We found a significant influence of degree of blinding using the d/s for the analysis (t test, P = 0.009), while when the d/r was used, only a trend was found (P = 0.10). An analysis of the effect of proper randomisation on the result was not possible because of inadequate description of the methods used. We conclude that the use of ultrasound in treatment of musculoskeletal disorders is based on empirical experience, but is lacking firm evidence from well-designed controlled studies. One question remaining is whether ultrasound treatment can augment an effect of exercise therapy with respect to musculoskeletal disorders.

Exercises for chronic low back pain: a clinical trial

Different training models are effective for the treatment of chronic low back pain, but no consensus has been found. Earlier studies have emphasized training of spinal mobility and back strength. To evaluate if other physiological parameters, such as coordination, are of equal importance, we performed a randomized trial on 40 consecutive patients with chronic low back pain. Two training models were compared: 1) intensive training of muscle endurance and 2) muscle training, including coordination. In both groups, training was performed 1 hour twice a week for 3 months. Pain score, disability score, and spinal mobility improved in both training groups without differences between the two groups. Only intensive training of muscle endurance improved isokinetic back muscle strength. At study entry, we found a significant correlation between spinal mobility and dysfunction, but after the training, no correlation was found between improvement of spinal mobility or isokinetic back extension strength and improvement of function or pain level. We conclude that coordination training for patients with chronic low back pain is as equally effective as endurance training.

Supervised endurance exercise training compared to home training after first lumbar diskectomy: a clinical trial

OBJECTIVE

We performed a randomised trial to evaluate if intensive supervised training of the back should be offered to all patients after a first lumbar diskectomy.

METHODS

Forty consecutive patients were, after a first lumbar diskectomy, randomly allocated to 2 groups undergoing "supervised training" twice a week for 3 months in an outpatient clinic or "home training" after 2 hours of instruction.

RESULTS

The two rehabilitation models both showed a significant effect on spinal mobility, isokinetic trunk flexion strength, isokinetic trunk extension strength and daily function. These improvements were unchanged at follow up 3 months later. The pain score remained unchanged, however, throughout the trial in both groups. No differences in effect between the two rehabilitation models could be found for any of the assessed parameters. Thirteen patients did not complete the trial, including 9 from the supervised endurance trained group, mainly because of increased pain and reprolaps (n = 4). Four patients dropped out of the home trained group, only one because of increased pain. The differences in drop-out rate and training side effects were, however, not statistically significant.

CONCLUSION

We conclude that it is not worthwhile to implement 3 months of supervised intensive endurance training as opposed to home training in all cases of first lumbar diskectomy, although a beneficial effect and better compliance might be found for a selected group of such patients.

Low energy laser therapy in rheumatoid arthritis

Low energy laser (LEL) is a widely used treatment for a variety of musculoskeletal disorders although convincing documentation of the effect is missing. We have examined the LEL effect on Rheumatoid Arthritis (RA) in a double blind placebo controlled study. Twenty-two patients completed the study (10 receiving LEL treatment) according to the protocol. A significant effect on pain score was found due to LEL treatment, but when data were corrected for disease variation the effect disappeared. No effect of LEL could be demonstrated on the other assessed variables: grip strength, morning stiffness, flexibility, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP). In conclusion, we did not find that LEL had any clinically relevant effects on RA.

Rebox: an adjunct in physical medicine?

Electrical therapy is used extensively in the treatment of musculoskeletal diseases. The best known form is transcutaneous electrical nerve stimulation (TENS). Rebox is another apparatus for electrical therapy that operates on much lower currents than TENS (0 to 300 microA). The effect of Rebox was tested on chronic lateral epicondylitis in 16 patients in a controlled crossover study. We found a significant effect of Rebox compared to placebo in respect to all the subjective and the objective variables: grip-strength, pain at power-grip and lifting a weightload with pronated forearm, and daily impairment.

[The whiplash injury. An overlooked and casually treated syndrome]

The whiplash trauma is defined as hyperextension followed by hyperflexion of the cervical spine or the reverse. The lesion occurs mainly in the occupants of a motor vehicle into which another vehicle collides from behind. Even when there is no radiographic evidence of injury, considerable lesions of the soft tissues may, nevertheless, be present. Review of the literature and the present authors' investigations reveal that up to 80% of the patients have chronic symptoms and 10% of these are severe enough to cause incapacity. The therapeutic regimen has not been well investigated but, at present, intermittent cooling and support by a collar for a few days followed by rapid mobilizing and exercises within the limit of pain are recommended.

Assessment of the delayed neurotoxicity of tributyl phosphate, tributoxyethyl phosphate, and dibutylphenyl phosphate

There industrial organophosphorus compounds were tested for their ability to cause organophosphorus compound-induced delayed neurotoxicity (OPIDN) in the adult hen. The compounds tested were tributyl phosphate (TBP), tributoxyethyl phosphate (TBEP), and dibutylphenyl phosphate (DBPP). The acute oral LD50 of TBP and DBPP were estimated to be 1,863 and 1,500 mg/kg, respectively, and the dose equal to the LD50 was used as a test dose. The acute oral LD50 of TBEP was greater than 5,000 mg/kg and 5,000 mg/kg was used as a test dose. An oral dose of 750 mg tri-o-cresyl phosphate (TOCP) was used as a positive control. For the acute delayed neurotoxicity test, hens were given two test doses of the test materials 21 days apart and killed 21 days after the second dose. None of the hens given TBP, TBEP, or DBPP exhibited nerve damage or clinical signs which distinguished them from untreated control animals. A single dose of TOCP resulted in paralysis and a histopathological profile typical of a distal neuropathy. For the assay of the inhibition of esterases, hens were killed 24 hours after a single dose equal to the greater of either the LD50 or 5000 mg/kg. TOCP administration resulted in over 90% inhibition of brain neurotoxic esterase (NTE), but none of the other three compounds inhibited NTE to an extent (greater than 70%) which would be expected to result in OPIDN. Administration of TOCP, TBEP, or DBPP resulted in approximately a 70% decrease in plasma butyrylcholinesterase (BuChE) activity. TBP caused a 2-3 fold increase in BuChE activity. TBEP administration resulted in about 45% inhibition of acetycholinesterase (AChE) in brain. These results indicate that TBP, TBEP, and DBPP are all unlikely to cause OPIDN with any single sublethal dose.

Absence of delayed neurotoxicity and increased plasma butyrylcholinesterase activity in triallate-treated hens

Triallate (S-2,3,3-trichloroallyl diisopropylthiocarbamate) was tested for the potential to produce delayed neurotoxicity. Hens were given single oral doses ranging from 312.5 to 2500 mg/kg of triallate, 750 mg/kg tri-o-cresyl phosphate (TOCP), or empty gelatin capsules on Days 1 and 21 and were killed on Day 42. In a second experiment, animals were administered daily oral doses of 25-300 mg/kg triallate or 10 mg/kg TOCP for 90 days. In a third experiment, animals were given single oral doses of 2500 mg/kg triallate, 750 mg/kg TOCP, or empty gelatin capsules and killed after 24 hr. Delayed neurotoxicity was observed only in TOCP-treated animals. Animals given daily doses of 300 mg/kg triallate became moribund after 30 days; however, histological examination revealed no lesions characteristic of organophosphorus-induced delayed neurotoxicity. Neurotoxic esterase was not significantly altered in triallate-treated animals while it was 95% inhibited in TOCP-treated animals. Plasma butyrylcholinesterase increased significantly 24 hr after treatment with triallate in a dose-dependent manner. In summary, triallate, a thiocarbamate, did not produce neurotoxicity which has been previously reported for some dithiocarbamates.