Objective: To assess the results of physical therapy management and surgical treatment in a prospective observational cohort of patients with neurogenic thoracic outlet syndrome (NTOS) using patient-reported outcomes measures.Methods: Of 183 new patient referrals from July 1 to December 31, 2015, 150 (82%) met the established clinical diagnostic criteria for NTOS. All patients underwent an initial 6-week physical therapy trial. Those with symptom improvement continued physical therapy, and the remainder underwent surgery (supraclavicular decompression with or without pectoralis minor tenotomy). Pretreatment factors and 7 patient-reported outcomes measures were compared between the physical therapy and surgery groups using t-tests and c 2 analyses. Follow-up results were assessed by changes in 11-item version of Disability of the Arm, Shoulder, and Hand (QuickDASH) scores and patient-rated outcomes.Results: Of the 150 patients, 20 (13%) declined further treatment or follow-up, 40 (27%) obtained satisfactory improvement with physical therapy alone, and 90 (60%) underwent surgery. Slight differences were found between the physical therapy and surgery groups in the mean 6 standard error degree of local tenderness to palpation (1.7 6 0.1 vs 2.0 6 0.1; P ¼ .032), the number of positive clinical diagnostic criteria (9.0 6 0.3 vs 10.1 6 0.1; P ¼ .001), Cervical-Brachial Symptom Questionnaire scores (68.0 6 4.1 vs 78.0 6 2.7; P ¼ .045), and Short-Form 12-item physical quality-of-life scores (35.6 6 1.5 vs 32.0 6 0.8; P ¼ .019) but not other pretreatment factors. During follow-up (median, 21.1 months for physical therapy and 12.0 months for surgery), the mean change in QuickDASH scores for physical therapy was À15.6 6 3.0 (À29.5% 6 5.7%) compared with À29.8 6 2.4 (À47.9% 6 3.6%) for surgery (P ¼ .001). The patient-rated outcomes for surgery were excellent for 27%, good for 36%, fair for 26%, and poor for 11%, with a strong correlation between the percentage of decline in the QuickDASH score and patient-rated outcomes (P < .0001). Conclusions:The present study has demonstrated contemporary outcomes for physical therapy and surgery in a wellstudied cohort of patients with NTOS, reinforcing that surgery can be effective when physical therapy is insufficient, even with substantial pretreatment disability. Substantial symptom improvement can be expected for w90% of patients after surgery for NTOS, with treatment outcomes accurately reflected by changes in QuickDASH scores. Within this cohort, it was difficult to identify specific predictive factors for individuals most likely to benefit from physical therapy alone vs surgery.

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the juxtaglomerular apparatus of the kidney. Successful treatment necessitates restoration of normal aortorenal blood flow. This study undertook computational modeling to define the effectiveness of thoracoabdominal bypass (TAB) and patch aortoplasty (PA) in achieving normal postoperative renal artery flow using retrospective data from an abdominal aortic coarctation patient treated with TAB.Methods: Patient-specific anatomic models were constructed from preoperative computed tomography angiograms (Fig 1). Fluid-structure interaction analyses of hemodynamics were performed to quantify changes in renal flow and pressure waveforms after TAB and PA.Results: Preoperative results revealed diastole-dominated renal artery flow with considerable high-frequency disturbances (Fig 2). Postoperative increases in systolic flow and decreases in high-frequency disturbances accompanied both TAB and PA. However, whereas PA resulted in nearly normal renal flow waveforms, a degree of high-frequency renal flow disturbances persisted after TAB. Furthermore, postoperative decreases in collateral flow distributions accompanied both TAB and PA. In addition, the postoperative TAB right and left kidney volumes increased by 32% and 56%, respectively, paralleling the increased volumetric renal artery flows predicted by the TAB fluid-structure interaction analysis.Conclusions: Both TAB and PA dramatically improved renal artery flow and pressure waveforms. Importantly, PA eliminated high-frequency renal flow disturbances, resulting in nearly normal aortorenal blood flow. Therefore, this study documented a superior hemodynamic performance of PA over TAB treatment for suprarenal abdominal aortic coarctations. The study also confirms the relevance of patient-specific computational modeling in planning of interventions for complex vascular diseases.

Motor vehicle impacts result in energy being transferred between the involved vehicles and subsequently to occupants within those vehicles. Similarly, when outside of a vehicle, humans constantly encounter energy transfers within their surrounding environment, inducing internal reactions within their bodies. A common method used by biomechanical engineers is to compare the exposure in a particular event to the general exposures during various activities of daily living (ADL). Such comparisons can be in terms of general inertial loading, such as accelerations, or in terms of specific joint loading (i.e., forces and/or moments). Regardless, to be comparable from the biomechanics standpoint, there needs to be sufficient correlation between the duration, magnitude and/or direction of acceleration or load application. An area of forensic science where such comparisons are common is when a biomechanical engineer is assessing an occupant’s exposure to a minor vehicle accident. In many of these events, the accelerations and loading present are found to be well below any published and accepted injury parameters and to be comparable to published exposures to various ADLs. In this study, spinal loading reported in the published literature during spinal manipulation therapy (SMT) is compared to published spinal exposures in minor vehicle accidents. Extensive research and associated publications regarding both accident reconstruction and biomechanical analyses have studied minor motor vehicle accidents. This current work does not attempt to provide a review of all the volunteer or surrogate studies of occupant exposures available. Instead, this work is the initial phase of a larger study to build on the body of literature that provides quantitative comparisons of human exposures to relatively minor real-world accidents and a wide variety of ADLs, including exposures during the application of common clinical therapies such as SMT. There is a relative lack of studies that quantify the loads applied to patients or develop within patients during various SMT inputs. However, the studies found that do provide quantification suggest that the spinal loading duration, magnitude and direction are similar to that shown to exist in many minor vehicle accidents. For example, Forand [4] reported that SMT inputs applied forces up to 1,000 Newtons (N) to a particular target site (i.e., disc) within a time duration of about 20 to 170 milliseconds (ms). By contrast, spinal loading durations in minor impacts have been shown in the biomechanics literature [9, 11 and 12] and publicly available testing [18] to have similar durations (50 to 250 ms) with distributed neck forces typically less than 500 N. This study has found that like many other ADLs, the spinal loading present during SMT may be comparable to that present in many minor vehicle impacts due to the similar duration, magnitude and direction of the joint loads.