Analgesic effect of whole body cryotherapy in patients

with trapezius myofascial pain syndrome: A longitudinal, non-blinded, experimental

study

Association between peripheral arterial disease and diabetic foot ulcers in patients

with diabetes mellitus type 2

The use of DTT in the resolution of the interferences generated by daratumumab in

the blood bank

Early initiation of renal replacement therapy in acute

renal injury

Vol. 19 Num. 76 July-September 2017

eISSN 2530-0709ISSN 1665-5796

www.elsevier.es/rmuanl

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JOURNAL OF SCIENCE AND RESEARCHSCHOOL OF MEDICINE AND DR. JOS ELEUTERIO GONZLEZ UNIVERSITY HOSPITAL

UNIVERSIDAD AUTNOMA DE NUEVO LEN

Medicina Universitaria is a quarterly publication of Journal of Science and Research of the School of Medicine and Dr. Jos Eleuterio Gonzlez University Hospital of the UANL. ISSN 1665-5796, eISSN 2530-0709.Published and printed by: Masson Doyma Mxico, S.A. Av. Insurgentes Sur 1388, Piso 8, Col. Actipan, Del. Benito Jurez, CP 03230, Ciudad de Mxico. Phone numbers: 5524-1069, 5524-4920, Fax: 5524-0468. 2017 Universidad Autnoma de Nuevo Len. Medicina Universitaria is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). This journal and the individual contributions contained in it are protected under copyright, and the following terms and conditions apply to their use in addition to the terms of any Creative Commons or other user license that has been applied by the publisher to an individual article: Photocopying. Single photocopies of single articles may be made for personal use as allowed by national copyright laws. Permission is not required for photocopying of articles published under the CC BY license nor for photocopying for non-commercial purposes in accordance with any other user license applied by the publisher. Permission of the publisher and payment of a fee is required for all other photocopying.Derivative Works. Users may reproduce tables of contents or prepare lists of articles including abstracts for internal circulation within their institutions or companies. Other than for articles published under the CC BY license, permission of the publisher is required for resale or distribution outside the subscribing institution or company. For any subscribed articles or articles published under a CC BY-NC-ND license, permission of the publisher is required for all other derivative works, including compilations and translations.Storage or Usage. Except as outlined above or as set out in the relevant user license, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior written permission of the publisher.Author rights. Author(s) may have additional rights in their articles as set out in their agreement with the publisher (more information at http://www.elsevier.com/authorsrights). Indexed in: ARTEMISA (Artculos Editados en Mxico sobre Informacin en Salud), IMBIOMED (ndice Mexicano de Revistas Biomdicas) and LATINDEX.

General Director Edelmiro Prez Rodrguez School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Editor in Chief Flix Vilchez Cavazos Continuous Medical Education, Orthopedic Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Editor David Gmez Almaguer Hematology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Editor Francisco Javier Bosques Padilla Gastroenterology Services of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Technical Editor Carlos Alberto Acosta Olivo Orthopedic Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Technical Editor Alfredo Arias Cruz Clinical Immunology and Alergy Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Assistant Editor Jos Carlos Jaime Prez Hematology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Biostatistics Advisors

Eloy Crdenas Estrada Center for Research and Development of Health Sciences of the UANL, Nuevo Len, Mexico

Antonio Costilla Esquivel Department of Psychiatry of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

English translation and style

Emma Bertha Garca Quintanilla

Juan Pablo Figueroa Delgado

EDITORIAL BOARD

Hugo Alberto Barrera Saldaa

Department of Biochemistry and Molecular Medicine, School of Medicine of the Autonomous University of Nuevo Len in Monterrey, Nuevo Len, Mexico

Ruy Prez Tamayo Department of Experimental Medicine of the School of Medicine of the National Autonomous University of Mexico, Mexico City, Mexico

Guillermo J. Ruiz Argelles Hematology and Internal Medicine Center, Ruiz Clinic of Puebla, Puebla, Mexico

Ralph Weissleder Harvard Medical School, Massachusetts General Hospital, Boston, USA

Oliverio Welsh Lozano Dermatology Service of the School of Medicine and the"Dr. Jos Eleuterio Gonzlez" University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

EDITORIAL COMMITTEE

Ariel Ernesto Arias Ramrez Pharmacy School at the University of Montral, Ottawa, Canada

Alejandro C. Arroliga Scott & White, Texas A&M Health Science Center College of Medicine, Temple, USA

Norbert W. Brattig Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany

Mara de los ngeles Castro Corona Immunology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Ricardo M. Cerda Flores School of Nursing of the Universidad Autnoma de Nuevo Len, Monterrey, Nuevo Len, Mexico

Adrin Chapa-Rodrguez Childrens Hospital, LSU Health, San Antonio, TX, USA

Salvador Cruz Flores Department of Neurology, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA

Jos Alberto Gonzlez Gonzlez Gastroenterology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Oscar Gonzlez Llano Hematology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Patricia Judith Bertha de Gortari Gallardo

Neuroscience Direction at the National Institute of Psychiatry of the UNAM, Mexico City, Mexico

Francisco Forriol Campos Department of Clinical Sciences at the School of Medicine at the Monteprncipe Campus, University of San Pablo CEU, Boadilla del Monte, Madrid, Spain

Alejandra Garca Quintanilla Department of Mayan Culture and Regional Identities at the Autonomous University of Yucatn, Mrida, Mexico

Elvira Garza Gonzlez Gastroenterology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Pali Hungin School of Medicine and Health at Durtham Univertity, Stockton-on-Tees, United Kingdom

Jos Luis Iglesias Benavides Obstetrics and Gynecology Service of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Patricia Ileana Joseph Bravo Department of Developmental Genetics and Molecular Physiology of the Biotechnology Institute at the UNAM, Cuernavaca, Mexico

Susana Kofman Alfaro Genetics Unit of the General Hospital of Mxico, Mexico City, Mexico

David Kershenobich Stalnikowitz School of Medicine of the UNAM, Mexico City, Mexico

Francisco Lpez Jimnez Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, USA

Xavier Lpez Karpovitch Department of Hematology and Oncology of the Salvador Zubirn National Institute of Medical Sciences and Nutrition, Mexico City, Mexico

Laura E. Martnez de Villarreal Department of Genetics of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Nahum Mndez Snchez Department of Biomedical Research, Clnica Mdica Sur Foundation, Mexico City, Mexico

Claudia Elizalde Molina Dental School, Autonomous University of Nuevo Leon, Monterrey, Mexico

Guillermo I. Prez Prez Department of Medicine (Translational Medicine) and Microbiology, New York University School of Medicine, New York, USA

Mario Henry Rodrguez Lpez Research Center of Infectious diseases, National Institute of Public Health, Cuernavaca, Morelos, Mexico

Isaas Rodrguez Balderrama Department of Pediatrics of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Alejandro Ruiz Argelles Hematology and Internal Medicine Center, Ruiz Clinic of Puebla, Puebla, Mexico

Guillermo J. Ruiz Delgado Hematology and Internal Medicine Center, Ruiz Clinic of Puebla, Puebla, Mexico

Jos Javier Snchez Hernndez Department of Preventive Medicine, Public Health and Microbiology, at the School of Medicine of the Autonomous University of Madrid, Madrid, Spain

Josep Maria Segur Vilalta Traumatology and Orthopedic Surgery Services, Hospital Clnic, Barcelona, Spain

Gregorio A. Sicard Department of Surgery, Washington University School of Medicine, St. Louis, USA

Rolando Tijerina Menchaca Department of Microbiology of the School of Medicine and the Dr. Jos Eleuterio Gonzlez University Hospital of the UANL, Monterrey, Nuevo Len, Mexico

Lyuba Varticovski Laboratory of Receptor Biology and Gene Expression, Center for Cancer Research, National Cancer Institute, Annapolis, USA

Joseph Varon University of Texas Health Science Center at Houston, Houston, USA

Jordi Sierra Gil Hematology Service at the Santa Creu i Sant Pau Hospital, Barcelona, Spain

Conte

nts

Volume 19Issue 76July-September 2017

EDITORIAL109 Effective medicine and the economy

D. Gmez-Almaguer, J.C. Jaime-Prez

ORIGINAL ARTICLES111 Association between ischiotibial muscle fl exibility, functional capacity and pain in

patients with knee osteoarthritisP.P. Flores-Garza, .A. Garca-Espinoza, K. Salas-Longoria, . Salas-Fraire

115 Analgesic effect of whole body cryotherapy in patients with trapezius myofascial pain syndrome: A longitudinal, non-blinded, experimental study.A. Garca-Espinoza, . Salas-Fraire, P.P. Flores-Garza, K. Salas-Longoria, J.A. Valadez-Lira

123 Association between peripheral arterial disease and diabetic foot ulcers in patients with diabetes mellitus type 2M.. Tresierra-Ayala, A. Garca Rojas

SCIENTIFIC LETTER127 The use of DTT in the resolution of the interferences generated by daratumumab

in the blood bankM.C. Barrientos-Soto, M. Castaeda-Garca, A. Herrera-Garca, S. Padilla-Lpez, M.A. Dimas-Adame, R. Cazares-Tamez

REVIEW ARTICLE131 Early initiation of renal replacement therapy in acute renal injury

O. Torres Aguilar, R.J. Maya Quint, G. Rodrguez Prieto, M. Leal, J.F. Castilleja Leal

EXPERTS CORNER: A PERSONAL APPROACH140 Distal radius fractures: Still a common problem

C. Acosta-Olivo

143 Actinomycetoma by Nocardia brasiliensis: A neglected disease and a surprising laboratory for experimental medicineM.C. Salinas-Carmona

145 Child and adolescent obesityL.G. Hinojosa Amaya

Medicina Universitaria. 2017;19(76):109---110

www.elsevier.es/rmuanl

EDITORIAL

Effective medicine and the economy

If we tried practicing the perfect medicine according tointernational guidelines and using the most efficient diag-nostic procedures and medications, it is quite possiblethat the health budget of a third-world developing coun-try would run out within weeks. This becomes more obviouswhen studying or treating rare (Gaucher, nocturnal paroxys-mal hemoglobinuria) or highly complex (cancer transplants)diseases. The most popular medical guides, which are inci-dentally very trendy nowadays, are usually developed in firstworld countries. For Mexico, the ones created in the UnitedStates (US) are often the most attractive for vicinity reasons,and because they come from the most powerful country inthe world. We ought to keep in mind that Mexicos per capitaincome is under USD 9000 a year, compared to the USAs55,000 dollars a year. This explains the difficulty of tryingto match our medicine to the one practiced in the US inresources and costs represents.

Recently, several countries, including the US, havestressed the high cost of new medications, making themunaffordable for the public health system, and sometimes,even for the private sector. A good example can be observedin the new drugs for cancer treatment, among them ischronic granulocytic leukemia (CGL). CGL is a hematologicneoplasia with a worldwide prevalence of approximately1.2---1.5 million patients. It occurs more frequently amongstadults, regardless of the patients economic status, andis characterized by presenting the Philadelphia chromo-some, which generates the Bcr-abl gene with tyrosine kinaseactivity, which is responsible for perpetuating the disease.However, there are medications, such as imatinib, whichhas been approved since 2001, and the new Bcr-abl tyro-sine kinase inhibitors (TKIs), which act as targeted therapyto treat this disease. These medications have been, with-out a doubt, the most successful pharmaceuticals developedfor cancer, exceeding all expectations for CGL patients. Infact, with the use of TKIs, LGCs annual mortality rate is2%, compared to the historical control of 10---20%. Moreover,the estimated survival rate at ten years went from under20% to over 80%. All of the above, however, is provided thepatient receives proper treatment with an indefinite adher-ence. This causes patients who lack insurance to become

financial victims, having to pay high costs annually to remainalive.

The annual cost of treatment for TKI varies, dependingon the region where it is commercialized and its gener-ation. For example, imatinib was the first to be createdand ranges between USD 24,000 (Russia) up to USD 92,000(US) per patient per year. In the case of desatinib, con-sidered to be one of the new TKIs, it costs vary from anestimated USD 22,000 (South Korea) up to USD 1,230,000(US) per year.1 In Mexico, the annual cost is USD 29,000 forimatinib and USD 49,500 for desatinib.2 Social security insti-tutions in Mexico and probably in many similar countriesobtain significant discounts. Nevertheless, because it is aprolonged treatment of continuous use, even over 10---15years in the majority of cases, the cost is truly astonishing,since there are new patients every year and the disease,which used to cause the deaths of almost everyone of them,does not anymore. Hence the prevalence of this leukemiaincreases day by day, and consequently the cost of itstreatment.

Several actions have been taken in an attempt to improvethis alarming situation, some of them consist of adoptingmore economical and profitable methods, which will in thelong-term achieve a longer survival rate. It is important totake into account the fact that high costs begin with thosenecessary to make a correct diagnosis, many times utilizingsophisticated methods, such as the use of molecular biologytools. Searching for better paths to reduce costs withoutlosing quality is useful, especially in developing countries,which represent over 80% of the worlds population. As anexample of the above, an analysis was published proposinga therapeutic focus for CGL which adapts to a limited-resource environment. This analysis includes alternativeslike hematopoietic cell transplants, which in the long run areeven more cost-effective. Moreover, there are actions from adifferent perspective in which a petition to the US Congresshas been filed to bring prices of medications against can-cer down. This petition has gathered over 39,000 signaturesthrough the platform change.org.1,2

Another notable example of adapting complex therapeu-tic interventions within health systems with limited resource

https://doi.org/10.1016/j.rmu.2017.08.0011665-5796/ 2017 Universidad Autonoma de Nuevo Leon. Published by Masson Doyma Mexico S.A. This is an open access article under theCC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

https://doi.org/10.1016/j.rmu.2017.08.001http://www.elsevier.es/rmuanlhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.rmu.2017.08.001&domain=pdfhttps://doi.org/10.1016/j.rmu.2017.08.001http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/

110 EDITORIAL

availability is the hematopoietic cell transplant (HCT),which constitutes contemporary management with the mostefficiency in multiple diseases, notably hematologic ones,including CGL, acute leukemias and lymphomas, amongothers. This procedure in most industrialized countries iscarried out following complicated and costly clinical and lab-oratory guides, which, if followed to the letter, would makethis procedure almost impossible in low- and middle-incomecountries. In response to the need to apply this therapeuticresource in a broad and generalized manner in less power-ful economies, an accessible, effective and the outpatientHCT program was developed in our country. This resultedin its implementation in several centers that adopted theseguidelines from a perspective of analysis and optimizationof costs for more than a decade, to the benefit of a con-siderable number of these patients. In general, the mostaffordable cost of HCT in the US is USD 100,000, and D 80,000in Europe. At the University Hospital of the UANL, Monter-rey, Mexico, this cost is around USD 10---15,000, a fraction ofthe cost of the same in high-income countries. This is possi-ble due to an austerity and optimization approach in the useof drugs and procedures. Added to the efforts of medical,laboratory and nursing personnel to pay extreme attentionto detail in the management of these patients, with a com-mitment to detect and take advantage of opportunities insavings and improvement in medication doses, duration, andcostly procedures. In addition to the collaboration and sup-port of the institutions in which these transplants are carriedout and non-governmental organizations focused on patientwell-being.3 On the other hand, the Foundation for theAccreditation of Cellular Therapy of the USA (FACT) grantedthe bone marrow transplantation unit of this University thecertification that guarantees its quality (unique in Mexicoand Latin America). Which is comparable from this point ofview to that of any similar institution in the USA.

In conclusion, the development and application ofan accessible and effective medical practice, mainly incountries such as ours, depends on its careful planning anda culture of continuous improvement in the application ofresources for health, with the aim of providing the patientattention of the highest quality with the least expense ofresources and an ambitious long-term vision. In other words:the best medicine at the lowest possible cost.

References

1. Abboud C, Berman E, Cohen A, et al. The price of drugs forchronic myeloid leukemia (CML) is the reflection of the unsus-tainable cost of cancer drugs: from the perspective of a largegroup of experts in CML. Blood. 2013;121:4439---42.

2. Gmez-Almaguer D, Cant-Rodrguez OG, Gutirrez-Aguirre CH,Ruiz-Arguelles GJ. The treatment of CML at an environment withlimited resources. Hematology. 2016;21:576---82.

3. Jaime-Prez JC, Heredia-Salazar AC, Cant-Rodrguez OG, et al.Cost structure and clinical outcome of a stem cell transplantationprogram in a developing country: the experience in northeastMexico. Oncologist. 2015;20:386---92.

D. Gmez-Almaguer , J.C. Jaime-PrezHematology Service at the Dr. Jos E. Gonzlez

University Hospital of the UANL, Monterrey, N.L., Mexico Corresponding author at: Servicio de Hematologa,

Hospital Universitario Dr. Jos Eleuterio Gonzlez de laUANL, Av. Madero y Gonzalitos s/n, Colonia Mitras Centro,

C.P. 64460 Monterrey, N.L., Mexico. Tel.: +52 81 83 48 8510.E-mail address: dgomezalmaguer@gmail.com (D.

Gmez-Almaguer).Available online 27 September 2017

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Medicina Universitaria. 2017;19(76):111---114

www.elsevier.es/rmuanl

ORIGINAL ARTICLE

Association between ischiotibial muscle flexibility,functional capacity and pain in patients with kneeosteoarthritis

P.P. Flores-Garza , .A. Garca-Espinoza, K. Salas-Longoria, . Salas-Fraire

Department of Sports Medicine and Rehabilitation, School of Medicine and Dr. Jos Eleuterio Gonzlez University Hospital,Universidad Autnoma de Nuevo Len, Monterrey, Mexico

Received 19 January 2017; accepted 5 June 2017Available online 8 September 2017

KEYWORDSOsteoarthritis;Hamstring flexibility;Pain;Knee osteoarthritis

AbstractObjective: To determine the association between flexibility of the ischiotibial muscles, functionand pain in patients with knee osteoarthritis (OA).Methods: A total of 33 patients of both genders with an age greater than or equal to 40 years,clinically diagnosed with osteoarthritis in one or both knees with radiographic evidence ofthe disease, were recruited and evaluated. Participants underwent the WOMAC questionnaire,along with measurements of flexibility using a Lafayette flexometer and the Back Saver Sit andReach test. The correlation between the WOMAC questionnaire and its three components (pain,stiffness and functional limitation) was recorded. Total flexibility was obtained from the meanmeasurement of both knees.Results: A statistically significant correlation between the global WOMAC score and flexibilitywas found (0.38, p = 0.02). When the components were analyzed separately, a statisticallysignificant correlation between total flexibility and functional limitation (0.40, p = 0.01) wasevident; however, this was not so with the components of pain and stiffness.Conclusions: Greater ischiotibial flexibility reduces pain, stiffness, and significant functionallimitation in patients with knee OA. These results show that it is important to prescribe flexibilityexercises during physical therapy in these patients. 2017 Universidad Autonoma de Nuevo Leon. Published by Masson Doyma Mexico S.A. This isan open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Corresponding author at: Departamento de Medicina del Deporte y Rehabilitacin, Hospital Universitario Dr. Jos Eleuterio Gonzlez,Universidad Autnoma de Nuevo Len, Ave. Gonzalitos, Colonia Mitras Centro, Monterrey, C.P. 64460 Nuevo Len, Mexico. Tel.: +52 8183294207.

E-mail address: dra.floresgarza@gmail.com (P.P. Flores-Garza).

http://dx.doi.org/10.1016/j.rmu.2017.06.0011665-5796/ 2017 Universidad Autonoma de Nuevo Leon. Published by Masson Doyma Mexico S.A. This is an open access article under theCC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

dx.doi.org/10.1016/j.rmu.2017.06.001http://www.elsevier.es/rmuanlhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.rmu.2017.06.001&domain=pdfhttp://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/mailto:dra.floresgarza@gmail.comdx.doi.org/10.1016/j.rmu.2017.06.001http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/

112 P.P. Flores-Garza et al.

Introduction

Osteoarthritis (OA) affects 60% of men and 70% of womenover the age of 70. The prevalence of OA has been increas-ing, and it is now one of the 10 leading causes of totaldisability in Mexico.1,2 The most affected joints are the kneeand hip.3

The prevalence of knee OA has been estimated to affectfrom 4 to 30% in adults depending on gender, age, and phys-ical activity.4,5 About 85% of the population over the age of60 has radiographic evidence of OA.6 This high predilectionfor the knee is mainly due to joint loading, which makes itsusceptible to wear and tear under pressure.7

The clinical manifestations of the disease include pain,decreased range of motion, quadriceps muscle weakness,and impaired proprioception.8 Multiple studies report acondition beyond the cartilage that affects muscles, ten-dons, ligaments, synovial capsule, and bone.9

Knee OA pain affects approximately 10---30% of adults,and of these, 25% are severely disabled owing to difficultyin performing the activities of daily living due to musclespasms or weakness.10---13

There is a clear association between decreased range ofmotion --- secondary to decreased flexibility, weakness, andmuscle spasms --- and disability.13

Exercise and physical therapy have an important role inthe treatment of knee OA, with the main objectives beingto reduce pain and inflammation, increase muscle strength,and finally, maintain or improve range of motion.14,15

Enhancement of range of motion, especially knee exten-sion, has been associated with improvement in pain andmuscle function.16,17 Despite this, it is not always considereda priority to work on flexibility.

Onigbinde (2013) found a difference by comparing meas-ures of flexibility between subjects with knee osteoarthritisand same-age subjects chosen as controls, concluding thatischiotibial flexibility was significantly lower in the affectedsubjects. It is unknown whether this decrease in ischi-otibial flexibility in people with knee osteoarthritis hasan impact on patients performance of activities of dailyliving.

Material and methods

This was a cross-sectional, observational correlation study.We recruited participants who were attending consultationand/or physical therapy at a sports medicine and reha-bilitation outpatient clinic. We included patients of bothgenders with an age greater than or equal to 40 years, whowere clinically diagnosed with osteoarthritis in one or bothknees with radiographic evidence of the disease (recentor under one-year-old weightbearing anteroposterior kneeradiographs).

We excluded patients with lumbar pathologies, or whowere diagnosed with a neurological disorder and/or withincomplete knee extension (>15 flexion) that may alter theflexibility test due to pain or impossibility of making an ade-quate lumbar flexion. Patients with poor technique whenperforming the flexibility test or who did not complete thequestionnaires were eliminated. A sample of 30 patients wascalculated using a simple correlation formula with a z value

of 1.96 and a significance level of 95% for a two-tailed test,and a z value of 0.84 with a power of 80% with a minimumexpected correlation of 0.5.

A Lafayette flexometer was built according to the spec-ifications in the Fitnessgram

/Activitygram

test adminis-

tration manual,18 using a 46 cm tape gradiated from 23 to23 cm, with 0 set parallel to the face of the box where thepatients foot was located.

The general questionnaire recorded data, such as age,sex, the Kellgren and Lawrence system for ostheoarthrosisclassification, knee or knees affected, time since diagnosis,dominant leg, treatment received, and flexibility measures.The Spanish version of the Western Ontario and McMasterUniversities Osteoarthritis Index (WOMAC) v. 3.1 was usedto assess pain, stiffness, and physical function.

The study was approved by the Research Ethics Commit-tee of our institution. Patient consent was obtained afterverbally explaining and showing the procedure. The generalquestionnaire and the WOMAC were applied prior to the BSSRtest. In case of doubt or difficulty understanding the text,help was provided. Afterwards, the BSSR test was appliedto obtain flexibility measurements.19 The subjects sat on ahard surface, shoeless, with the box in front and their footflat against it. Patients were asked to flex the knee thatwas not going to be measured and place the sole of thatfoot on the floor in line with the other knee or just below.We verified that the hip of the unmeasured knee was flexedat 90 and that the measured knee was at 0 or less than15 of flexion. With their back and arms straight, and withhands overlapping, they were asked to inhale and exhale,then reach forward with their fingertips. The distance wasmeasured and the process was repeated 3 times for eachknee. Results were recorded by the physician. At the end ofthe test, patients were asked for a second signature, vali-dating their participation and agreement to use their resultsfor the purposes of this research.

We used the statistical program SPSS version 20 (SPSSInc., Armonk, NY) to conduct data analysis.

Pearsons correlation was used to determine the rela-tionship between mean flexibility and the WOMAC indexresults.

Results

A total of 33 patients were included in this study. Ofthese, 20 were women and 13 were men. The medianage was 63 years, with a dispersion (IQR) of 57---69 years(Table 1). Using the Kellgren---Lawrence classification, 48.5%of the subjects were grade 2; 69.7% of the patients werereceiving physical therapy at the time of the study. Bothknees were affected in most patients (66.7%), and 90.9%were right leg dominant. The mean flexibility measure was5.7 7.7 cm.

A statistically significant correlation between the globalWOMAC score (0.38, 95%CI: 0.68; 0.08, p = 0.02) andmeasuring flexibility was found (Table 2).

When the components were analyzed separately, a sta-tistically significant correlation (0.40, 95%CI: 0.7; 0.08,p = 0.01) was found between total flexibility and functionallimitation; however, there was no correlation between painand stiffness.

Flexibility and osteoarthritis 113

Table 1 General characteristics of the study population.

Gender, n (%)Female 20 (60.6)Male 13 (39.4)

Age, years (IQR) 63 (57---69)Time of diagnosis months (IQR) 6 (1.5---36)Total flexibility, cm mean SD 5.7 7.7Kellgren---Lawrence classification, n (%)

1 5 (15.1)2 16 (48.5)3 12 (36.4)

Use of physical therapy during measurements, n (%)Yes 23 (69.7)No 10 (30.3)

Knee(s) affected, n (%)Right 5 (15.1)Left 6 (18.2)Both 22 (66.7)

Dominant leg, n (%)Right 30 (90.9)Left 3 (9.1)

IQR, interquartile range; SD, standard deviation; cm, centime-ters.

Table 2 WOMAC correlation with average flexibility.

WOMAC score Pearson p

Pain 0.2 0.26Stiff 0.25 0.15Functional capacity 0.4 0.01Total 0.38 0.02WOMAC, Western Ontario and McMaster Universities Osteoarthri-tis Index.

There was a significant difference between groupsdivided by gender and the mean flexibility, age, andKellgren---Lawrence classification. While this study pre-sented a disparity in gender distribution, our sampleresulted in homogeneity when comparing gender to theother variables. There was no correlation between theaffected knee and the dominant leg.

Discussion

The sample of this study was small, yet the results correlateto those --- albeit scarce --- found in literature.

Our current findings showed that the mean ischiotibialflexibility of our subjects (Table 1) is considerably lower thanthe age and gender-appropriate measures recommendedby the American College of Sports Medicine in healthysubjects, and thus concordant with previously publishedevidence.7,20,21

Several studies have pointed out the relation betweenflexibility and musculoskeletal dysfunction. However, thereis no published evidence that qualitatively demonstratesthat the loss of isquiotibial flexibility affects quality of lifeand function in activities of daily living.13,16,17

In this study, we found a relationship between WOMACscore and flexibility: the lower the flexibility of the ischiotib-ial muscles, the greater the pain, stiffness, and functionallimitation.

Of the three separate fields the WOMAC test evaluates,there was specifically a significant relation with flexibilityand functional limitations, i.e., ischiotibial flexibility has agreater impact on functional limitation, and even though ithas a correlational tendency with pain and stiffness, it wasnot statistically significant.

While it was not the purpose of this study, we foundsome interesting data: the greater the Kellgren---Lawrenceclassification, the greater the pain and functional limita-tion. Mean flexibility was also more impaired in those witha grade 3 in the Kellgren---Lawrence classification than thosewith grades 1 and 2. Stiffness was also greater in grade 3knee osteoarthritis, however it does not obey the descend-ant order previously found. These results may be affectedby the unequal distribution between the grade groups. Eventhough the majority of the patients said they were right-legdominant, there was no correlation between this and theWOMAC score or measured flexibility.

This study did not account if patients were activelyenrolled in physical therapy, and if they were, if it involvedflexibility exercises. Some patients referred to an improve-ment in flexibility posterior to physical therapy sessions, yetthis could not be corroborated due to a lack of control sub-jects and tracing, as this was not our main objective. Also,although the WOMAC questionnaire evaluates some very spe-cific situations and activities that can cause pain, stiffnessand functional limitation, it is not capable of inferring ajudgment on the quality of life; it would be interesting toassess if there is a relation between the Kellgren---Lawrenceclassification, functional limitation, pain, and quality oflife.

Conclusion

In conclusion, greater ischiotibial flexibility is associatedwith less pain, stiffness, and functional limitation. However,its main impact was in functional limitation: greater flexi-bility resulted in a better performance in activities of dailyliving.

It would be appropriate to take these results as a sub-stantiated suggestion to provide greater importance toprescribing flexibility exercises during physical therapy inthese patients, creating a more integral treatment.

Even so, it is suggested to conduct a study with a largerpopulation of patients that takes accounts physical therapyand quality of life into account as variables.

Ethical disclosures

Protection of human and animal subjects. The authorsdeclare that no experiments were performed on humans oranimals for this study.

Confidentiality of data. The authors declare that they havefollowed the protocols of their work center on the publica-tion of patient data.

114 P.P. Flores-Garza et al.

Right to privacy and informed consent. The authorsdeclare that no patient data appear in this article.

Funding

This research was financed with resources from the SportsMedicine and Rehabilitation Department of the Hospital Uni-versitario Dr Jose Eleuterio Gonzalez, of the UniversidadAutonoma de Nuevo Leon.

Conflicts of interest

The authors do not have any conflict of interest to declare.

Acknowledgements

The authors would like to thank Sergio Lozano-Rodriguez,M.D. and Alejandro Quiroga-Garza, M.D. for their help in thetranslation and editing of this manuscript; and Nery Alvarez,M.D. for his knowledge and help in statistical analysis.

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Medicina Universitaria. 2017;19(76):115---122

www.elsevier.es/rmuanl

ORIGINAL ARTICLE

Analgesic effect of whole body cryotherapy in patientswith trapezius myofascial pain syndrome:A longitudinal, non-blinded, experimental study

.A. Garca-Espinoza , . Salas-Fraire, P.P. Flores-Garza, K. Salas-Longoria,J.A. Valadez-Lira

Department of Sports Medicine and Rehabilitation of the Dr. Jos Eleuterio Gonzlez University Hospital of the AutonomousUniversity of Nuevo Len, Monterrey, Mexico

Received 3 March 2017; accepted 10 July 2017Available online 14 November 2017

KEYWORDSWhole bodycryotherapy;Myofascial painsyndrome;Analgesic effect

AbstractObjective: To determine the analgesic effect of whole body cryotherapy (WBC) in patients withtrapezius myofascial pain syndrome.Methods: Twenty patients from an outpatient rehabilitation clinic were recruited. Patients wererequired to have clinical data for their diagnosis of myofascial pain syndrome in the trapezius.Twenty WBC sessions (160 C) were prescribed at four sessions per week for five weeks. Avisual analog scale for pain (VAS) and algometry at trigger points (TPs) were applied before andafter each session to measure the Pressure Pain Threshold (PPT). Six blood samples per patientwere obtained during the study to measure the serum concentration of pro-inflammatory andanti-inflammatory cytokines.Results: A significant decrease in pain immediately after WBC was found from session 1(p < 0.001) onwards. Furthermore, a significant difference was observed in VAS at baseline com-pared to the value before each cryotherapy session starting from session 6 (p < 0.001). Significantdifferences were found in algometry at each session (p < 0.001) and when comparing the ini-tial and pre-session values starting from session 6 (p < 0.001). No significant differences werefound in the concentrations of inflammatory or anti-inflammatory factors throughout the study(p > 0.05).Conclusions: WBC is useful as an analgesic treatment for myofascial pain syndrome in trapez-ius. 2017 Universidad Autonoma de Nuevo Leon. Published by Masson Doyma Mexico S.A. This isan open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Corresponding author at: Departamento de Medicina del Deporte y Rehabilitacin, Hospital Universitario Dr. Jos Eleuterio Gonzlez,Universidad Autnoma de Nuevo Len, Ave. Gonzalitos, Colonia Mitras Centro, C.P. 64460 Monterrey, Nuevo Len, Mexico. Tel.: +52 8183294207.

E-mail address: dr.garciaoscar@gmail.com (.A. Garca-Espinoza).

http://dx.doi.org/10.1016/j.rmu.2017.07.0041665-5796/ 2017 Universidad Autonoma de Nuevo Leon. Published by Masson Doyma Mexico S.A. This is an open access article under theCC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

dx.doi.org/10.1016/j.rmu.2017.07.004http://www.elsevier.es/rmuanlhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.rmu.2017.07.004&domain=pdfhttp://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/mailto:dr.garciaoscar@gmail.comdx.doi.org/10.1016/j.rmu.2017.07.004http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/http://creativecommons.org/licenses/by-nc-nd/4.0/

116 .A. Garca-Espinoza et al.

Introduction

Musculoskeletal processes are the most common