The Effect of Manual Therapy on Muscle Stiffness in Healthy Individuals

The purpose of this study was to evaluate the immediate and delayed changes in muscle stiffness (in a resting and contracted state) related to DN of the gastrocnemius compared to a sham DN condition. To further investigate this relationship, we investigated these changes at the site of the TP, as well as at a standard site (medial head of the gastrocnemius). We hypothesize that gastrocnemius DN reduces muscle stiffness in individuals with TP

Normative Parameters of Gastrocnemius Muscle Stiffness and Associations with Patient Characteristics and Function

# Background Quantifying muscle stiffness may aid in the diagnosis and management of individuals with muscle pathology. Therefore, the primary purpose of this study was to establish normative parameters and variance estimates of muscle stiffness in the gastrocnemius muscle in a resting and contracted state. A secondary aim was to identify demographic, anthropometric, medical history factors, and biomechanical factors related to muscle stiffness. # Methods Stiffness of the gastrocnemius muscle was measured in both a resting and contracted state in 102 asymptomatic individuals in this cross-sectional study. Differences based on muscle state (resting vs contracted) and sex (female vs male) were assessed using a 2 X 2 analysis of variance (ANOVA). Associations between muscle stiffness and sex, age, BMI, race, exercise frequency, exercise duration, force production, and step length were assessed using correlation analysis. # Results Gastrocnemius muscle stiffness significantly increased from a resting to a contracted state $$mean difference: 217.5 (95$$. In addition, muscles stiffness was 35% greater for males than females in a resting state and 76% greater in a contracted state. Greater muscle stiffness in a relaxed and contracted state was associated with larger plantarflexion force production (*r* = .26, p < 0.01 and *r* = .23, p < 0.01 respectively). # Conclusion Identifying normative parameters and variance estimates of muscle stiffness in asymptomatic individuals may help guide diagnosing and managing individuals with aberrant muscle function. # Level of Evidence 2b Individual Cohort Study # Clinical Relevance *What is known about the subject:* Muscle stiffness has been shown to be related to individuals with pathology such as Achilles tendinopathy; however, research is sparse regarding normative values of muscle stiffness. Measuring muscle stiffness may also be a way to potentially predict individuals prone to injury or to monitor the effectiveness of management strategies. *What this study adds to existing knowledge:* This study establishes defined estimates of muscle stiffness of the gastrocnemius in both a relaxed and contracted state in healthy individuals. Myotonometry measures of muscle stiffness demonstrated an increase in stiffness during contraction that varies by sex. Greater gastrocnemius muscle stiffness was associated with increased plantarflexion force production

Functional and corticomotor changes in individuals with tetraplegia following unimanual or bimanual massed practice training with somatosensory stimulation: A pilot study

Background and Purpose: In individuals with cervical spinal cord injury (SCI), damage to spinal pathways results in deficits of hand function; maladaptive cortical changes further impair function. Unimanual massed practice (MP) training with somatosensory stimulation (SS) has been shown to improve hand function and increase corticomotor excitability after SCI. However, bimanual training may be more beneficial as these individuals have bilateral impairment. We compared clinical and corticomotor changes associated with unimanual versus bimanual MP training, each combined with SS. Methods: Participants were 13 individuals with chronic tetraplegia who had at least minimal voluntary control of the thenar muscles of 1 hand. The participants were randomly assigned to unimanual MP + SS or bimanual MP + SS. Clinical outcome measures included tests of unimanual (Jebsen Taylor Hand Function Test; JTT) and bimanual hand function (Chedoke Arm and Hand Activity Inventory; CAHAI), sensory function (monofilament test), and pinch grip strength. Neurophysiological outcome measures were corticomotor map area, center of gravity (COG), of the corticomotor map and corticomotor threshold as assessed by transcranial magnetic stimulation. Results: There were no significant differences in outcomes between the unimanual MP + SS versus bimanual MP + SS groups, both groups showed significant improvements in the JTT, CAHAI, and monofilament test. However, trends suggest that the unimanual MP + SS group had greater improvement in the JTT whereas the bimanual MP + SS group had greater improvement on the CAHAI. Functional changes were accompanied by a strong trend toward increased corticomotor map area. Discussion and Conclusion: When combined with SS, both unimanual and bimanual MP training improve hand function and sensation in individuals with tetraplegia. Changes in hand function seem to be associated with increased corticomotor map area. Copyright © 2010 Neurology Section, APTA

Cumulative environmental quality is associated with breast cancer incidence differentially by summary stage and urbanicity

Abstract Individual environmental contaminants have been associated with breast cancer; however, evaluations of multiple exposures simultaneously are limited. Herein, we evaluated associations between breast cancer summary stages and the Environmental Quality Index (EQI), which includes a range of environmental factors across five domains. The EQI (2000–2005) was linked to county-level age-standardized incidence rates (SIRs) obtained from the North Carolina Central Cancer Registry (2010–2014). Incidence rates and SIRs of total, in situ, localized, regional, and distant breast cancers were evaluated stratified by rural–urban status. In counties with poor environmental quality compared to those with good environmental quality, total breast cancer incidence was higher by 10.82 cases per 100,000 persons (95% CI 2.04, 19.60, p = 0.02). This association was most pronounced for localized breast cancer (β = 5.59, 95% CI 0.59, 10.58, p = 0.03). Higher incidence of early-stage disease (carcinoma in situ β = 5.25, 95% CI 2.34, 8.16, p = 0.00 and localized breast cancer β = 6.98, 95% CI 2.24, 11.73, p = 0.00) and total breast cancer (β = 11.44, 95% CI 3.01, 19.87, p = 0.01) occurred in counties with poor land quality, especially urban counties. Our analyses indicate significant associations between environmental quality and breast cancer incidence, which differ by breast cancer stage and urbanicity, identifying a critical need to assess cumulative environmental exposures in the context of cancer stage

Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

Background: Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PN\u27s ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis). Methods: A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey-Kramer P value adjustments. Results: Average - geometric mean [95% confidence interval (CI)] - diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Amongnonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant. Conclusions: Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women. Impact: Results support previous findings of PN\u27s positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs. ©2012 AACR

Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia

Background: Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PN\u27s ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis). Methods: A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey-Kramer P value adjustments. Results: Average - geometric mean [95% confidence interval (CI)] - diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Amongnonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant. Conclusions: Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women. Impact: Results support previous findings of PN\u27s positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs. ©2012 AACR

Implementation of inpatient models of pharmacogenetics programs

PURPOSE: The operational elements essential for establishing an inpatient pharmacogenetic service are reviewed, and the role of the pharmacist in the provision of genotype-guided drug therapy in pharmacogenetics programs at three institutions is highlighted. SUMMARY: Pharmacists are well positioned to assume important roles in facilitating the clinical use of genetic information to optimize drug therapy given their expertise in clinical pharmacology and therapeutics. Pharmacists have assumed important roles in implementing inpatient pharmacogenetics programs. This includes programs designed to incorporate genetic test results to optimize antiplatelet drug selection after percutaneous coronary intervention and personalize warfarin dosing. Pharmacist involvement occurs on many levels, including championing and leading pharmacogenetics implementation efforts, establishing clinical processes to support genotype-guided therapy, assisting the clinical staff with interpreting genetic test results and applying them to prescribing decisions, and educating other healthcare providers and patients on genomic medicine. The three inpatient pharmacogenetics programs described use reactive versus preemptive genotyping, the most feasible approach under the current third-party payment structure. All three sites also follow Clinical Pharmacogenetics Implementation Consortium guidelines for drug therapy recommendations based on genetic test results. CONCLUSION: With the clinical emergence of pharmacogenetics into the inpatient setting, it is important that pharmacists caring for hospitalized patients are well prepared to serve as experts in interpreting and applying genetic test results to guide drug therapy decisions. Since genetic test results may not be available until after patient discharge, pharmacists practicing in the ambulatory care setting should also be prepared to assist with genotype-guided drug therapy as part of transitions in care

Alirocumab and cardiovascular outcomes after acute coronary syndrome

BACKGROUN