Archives of Physical Medicine and Rehabilitation

Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches

2008-12-01

Abstract: Vanderploeg RD, Schwab K, Walker WC, Fraser JA, Sigford BJ, Date ES, Scott SG, Curtiss G, Salazar AM, Warden DL, for the Defense and Veterans Brain Injury Center Study Group. Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.Objectives: To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations.Design: Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches.Setting: Four Veterans Administration acute inpatient TBI rehabilitation programs.Participants: Adult veterans or active duty military service members (N=360) with moderate to severe TBI.Interventions: One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities–accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant.Main Outcome Measures: The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale.Results: The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean ± SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3±6.2) than to functional treatment (25.6±6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm.Conclusions: Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.)

A Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain Injury

2008-12-01

Abstract: Cicerone KD, Mott T, Azulay J, Sharlow-Galella MA, Ellmo WJ, Paradise S, Friel JC. A randomized controlled trial of holistic neuropsychologic rehabilitation after traumatic brain injury.Objective: To evaluate the effectiveness of comprehensive, holistic neuropsychologic (NP) rehabilitation compared with standard, multidisciplinary rehabilitation for people with traumatic brain injury (TBI).Design: Randomized practical controlled trial.Setting: Postacute brain injury rehabilitation center within a suburban rehabilitation hospital.Participants: Participants with TBI were recruited from clinical referrals and referrals from the community. Sixty-eight participants who met inclusion criteria were randomly allocated to treatment conditions. Most participants (88%) had sustained moderate or severe TBI, and greater than half (57%) were more than 1 year postinjury at the beginning of treatment.Interventions: Treatment was conducted 15 hours per week for 16 weeks. Standard neurorehabilitation consisted primarily of individual, discipline specific therapies (n=34). Intensive cognitive rehabilitation emphasized the integration of cognitive, interpersonal, and functional interventions within a therapeutic environment (n=34).Main Outcome Measures: Primary outcomes were the Community Integration Questionnaire (CIQ) and Perceived Quality of Life scale (PQOL). Secondary outcomes included NP functioning, perceived self-efficacy, and community-based employment.Results: NP functioning improved in both conditions. Intensive cognitive rehabilitation participants showed greater improvements on the CIQ (effect size [ES]=0.59) and PQOL (ES=0.30) as well as improved self-efficacy for the management of symptoms (ES=0.26) compared with standard neurorehabilitation treatment. These gains were maintained at the 6-month follow-up. Standard neurorehabilitation participants showed improved productivity at the 6-month follow-up associated with the need for continued rehabilitation.Conclusions: Improvements seen after intensive cognitive rehabilitation may be related to interventions directed at the self-regulation of cognitive and emotional processes and the integrated treatment of cognitive, interpersonal, and functional skills. The results show the effectiveness of comprehensive holistic NP rehabilitation for improving community functioning and quality of life after TBI compared with standard rehabilitation.

Assessment of the Effects of Aquatic Therapy on Global Symptomatology in Patients With Fibromyalgia Syndrome: A Randomized Controlled Trial

Diego Munguía-Izquierdo, Alejandro Legaz-Arrese — 2008-12-01

Abstract: Munguía-Izquierdo D, Legaz-Arrese A. Assessment of the effects of aquatic therapy on global symptomatology in patients with fibromyalgia syndrome: a randomized controlled trial.Objectives: To evaluate the effects of a 16-week exercise therapy in a chest-high pool of warm water through applicable tests in the clinical practice on the global symptomatology of women with fibromyalgia (FM) and to determine exercise adherence levels.Design: A randomized controlled trial.Setting: Testing and training were completed at the university.Participants: Middle-aged women with FM (n=60) and healthy women (n=25).Intervention: A 16-week aquatic training program, including strength training, aerobic training, and relaxation exercises.Main Outcome Measures: Tender point count (syringe calibrated), health status (Fibromyalgia Impact Questionnaire); sleep quality (Pittsburgh Sleep Quality Index); physical (endurance strength to low loads tests), psychologic (State Anxiety Inventory), and cognitive function (Paced Auditory Serial Addition Task); and adherence 12 months after the completion of the study.Results: For all the measurements, the patients showed significant deficiencies compared with the healthy subjects. Efficacy analysis (n=29) and intent-to-treat analysis (n=34) of the exercise therapy was effective in decreasing the tender point count and improving sleep quality, cognitive function, and physical function. Anxiety remained unchanged during the follow-up. The exercise group had a significant improvement of health status, not associated exclusively with the exercise intervention. There were no changes in the control group. Twenty-three patients in the exercise group were exercising regularly 12 months after completing the program.Conclusions: An exercise therapy 3 times a week for 16 weeks in a warm pool could improve most of the symptoms of FM and cause a high adherence to exercise in unfit women with heightened FM symptomatology. The therapeutic intervention's effects can be assessed through applicable tests in the clinical practice.

Effect of Magnetic Knee Wrap on Quadriceps Strength in Patients With Symptomatic Knee Osteoarthritis

2008-12-01

Abstract: Chen C-Y, Chen C-L, Hsu SC-C, Chou S-W, Wang K-C. Effect of magnetic knee wrap on quadriceps strength in patients with symptomatic knee osteoarthritis.Objective: To determine the effects of magnetic knee wrap on isokinetic quadriceps strength in patients with painful knee osteoarthritis (OA).Design: Randomized, double-blinded, placebo-controlled and before-after trial.Setting: Rehabilitation clinic in a tertiary hospital.Participants: Eligible patients (N=50) (mean age ± SD, 66.0±8.6y) with mild to moderate knee OA were recruited from the outpatient department and 37 (74%) completed the trial. Only 3 (6%) withdrew due to study-related adverse effects.Interventions: Wearing the active (n=24) or sham (n=26) magnetic knee wrap for 12 weeks.Main Outcome Measures: The primary outcome measure was isokinetic quadriceps strength. Secondary outcome measures included the Health Assessment Questionnaire Disability Index (HAQ-DI) and the Health Assessment Questionnaire (HAQ) Pain Scale.Results: Using intention-to-treat analyses, the peak isokinetic quadriceps strength increased significantly in the treated leg at 30°/s (P=.007) and 60°/s (P=.022) after wearing the magnetic knee wrap. Compared with baseline, the median strength increase for the treated leg in the study group significantly exceeded that in the control group at week 4 (.05Nm/kg vs −.09Nm/kg at 60°/s, P=.038) and week 12 (30°/s, .09Nm/kg vs .04Nm/kg, P=.044; 60°/s, .17Nm/kg vs .02Nm/kg, P=.031). The HAQ-DI and HAQ Pain Scales improved significantly in both groups. Compared with baseline, the improvement at week 12 in terms of the HAQ-DI in the study group significantly exceeded that in the control group.Conclusions: Magnetic knee wrap may significantly facilitate isokinetic quadriceps strength in patients with mild to moderate knee OA.

Low-Frequency Electric Muscle Stimulation Combined With Physical Therapy After Total Hip Arthroplasty for Hip Osteoarthritis in Elderly Patients: A Randomized Controlled Trial

2008-12-01

Abstract: Gremeaux V, Renault J, Pardon L, Deley G, Lepers R, Casillas J-M. Low-frequency electric muscle stimulation combined with physical therapy after total hip arthroplasty for hip osteoarthritis in elderly patients: a randomized controlled trial.Objective: To assess the effects of low-frequency electric muscle stimulation associated with usual physiotherapy on functional outcome after total hip arthroplasty (THA) for hip osteoarthritis (OA) in elderly subjects.Design: Randomized controlled trial; pre- and posttreatment measurements.Setting: Hospital rehabilitation department.Participants: Subjects (N=29) referred to the rehabilitation department after THA for hip OA.Interventions: The intervention group (n=16; 78±8y) received simultaneous low-frequency electric muscle stimulation of bilateral quadriceps and calf muscles (highest tolerated intensity, 1h session, 5 d/wk, for 5 weeks) associated with conventional physical therapy including resistance training. The control group (n=13; 76±10y) received conventional physical therapy alone (25 sessions).Main Outcome Measures: Maximal isometric strength of knee extensors, FIM instrument, before and after; a six-minute walk test and a 200m fast walk test, after; length of stay (LOS).Results: Low-frequency electric muscle stimulation was well tolerated. It resulted in a greater improvement in strength of knee extensors on the operated side (77% vs 23%; P<.01), leading to a better balance of muscle strength between the operated and nonoperated limb. The low-frequency electric muscle stimulation group also showed a greater improvement in FIM scores, though improvements in the walk tests were similar for the 2 groups, as was LOS.Conclusions: Low-frequency electric muscle stimulation is a safe, well-tolerated therapy after THA for hip OA. It improves knee extensor strength, which is one of the factors leading to greater functional independence after THA.

Apparent Changes in Inpatient Rehabilitation Facility Outcomes Due to a Change in the Definition of Program Interruption

2008-12-01

Abstract: Deutsch A, Granger CV, Russell C, Heinemann AW, Ottenbacher KJ. Apparent changes in inpatient rehabilitation facility outcomes due to a change in the definition of program interruption.Objective: To describe changes in inpatient rehabilitation facility (IRF) outcomes due to the program interruption definitional change, from 30 days to 3 days, in 2002.Design: Secondary data analysis of the Uniform Data System for Medical Rehabilitation (UDSMR) database.Setting: Four hundred eleven IRFs that submitted data to the UDSMR database in each of the years 1998 through 2003.Participants: Patient assessment data for 772,584 Medicare fee-for-service beneficiaries.Interventions: None.Main Outcome Measures: The number of IRF patient discharges, percent of IRF patients discharged to the community, percent of IRF patients discharged to acute care, percent of IRF patients with program interruptions, percent of IRF inpatient deaths, and average IRF length of stay (LOS).Results: IRF outcomes appeared to change because of the program interruption redefinition, with changes varying by impairment group. The largest changes due to the redefinition occurred for patients with traumatic spinal cord injury, including the largest percentage increase in patients (5.16%), the largest decrease in program interruptions (5.14%), the largest increase in acute care discharges (5.04%), and the largest mean decrease in LOS (1.27d). Community discharge showed the largest decrease for patients with Guillain-Barré syndrome (4.03%).Conclusion: The change in the definition of program interruptions creates the appearance of changes in IRF performance and is important to consider when comparing the preprospective payment system (PPS) and PPS assessment data.

Which Impairments Are Most Associated With High Mobility Performance in Older Adults? Implications for a Rehabilitation Prescription

Jonathan F. Bean, Dan K. Kiely, Sharon LaRose, Suzanne G. Leveille — 2008-12-01

Abstract: Bean JF, Kiely DK, LaRose S, Leveille SG. Which impairments are most associated with high mobility performance in older adults? Implications for a rehabilitation prescription.Objective: To test which rehabilitative impairments are associated with higher mobility performance among community-dwelling, mobility-limited older adults.Design: Cross-sectional analysis of baseline data from participants within a randomized controlled trial.Setting: Outpatient rehabilitation research center.Participants: Community-dwelling older adults (N=138; mean age, 75.4y) with mobility limitations as defined by the Short Physical Performance Battery (SPPB).Interventions: Not applicable.Main Outcome Measures: Balance measured via the Berg Balance Scale, leg strength, leg velocity, submaximal aerobic capacity, body mass index (BMI), and mobility performance as measured by the SPPB.Results: Each of the 5 physiologic attributes (unipedal balance, leg strength, leg velocity, submaximal aerobic capacity, BMI) was categorized into tertiles by using lower values as reference for impairment status. Within an adjusted model, measures associated with higher SPPB performance (>9) included a BBS score greater than or equal to 54 (odds ratio [OR]=4.54; 95% confidence interval [CI], 1.11–18.60), leg strength greater than or equal to 21.5N/kg (OR=30.35; 95% CI, 5.48–168.09), leg velocity .0101 to .0129m·s−1·kg−1 (OR=5.31; 95% CI, 1.25–22.57), and leg velocity greater than or equal to .0130m·s−1·kg−1 (OR=22.86; 95% CI, 3.88–134.75).Conclusions: Our investigation highlights the importance of rehabilitative impairments in leg strength, leg velocity, and balance as being associated with mobility status as measured by the SPPB. In our sample of participants within an exercise trial, submaximal aerobic capacity and BMI status were not associated with mobility performance. These findings suggest that the augmentation of not only leg strength and balance but also leg velocity may be important in the rehabilitative care of mobility-limited older adults.

Change in Life Satisfaction of Adults With Pediatric-Onset Spinal Cord Injury

2008-12-01

Abstract: Chen Y, Anderson CJ, Vogel LC, Chlan KM, Betz RR, McDonald CM. Change in life satisfaction of adults with pediatric-onset spinal cord injury.Objectives: To examine the change in life satisfaction over time and potential contributing factors among adults with pediatric-onset spinal cord injury (SCI).Design: Prospective dynamic cohort study.Setting: Community.Participants: Individuals who sustained a SCI before age 19 years (N=278) were initially interviewed at age 24 years or older and followed on an annual basis between 1996 and 2006.Interventions: Not applicable.Main Outcome Measures: A structured telephone interview was conducted to obtain the measures of Satisfaction with Life Scale (SWLS), physical independence, participation, and psychologic functioning. The hierarchical linear modeling was performed to characterize individual person-specific time paths and estimate the average rate of change in SWLS over time.Results: A total of 1171 interviews were conducted among 184 men and 94 women (89% white; baseline age, 27.1±3.4y; baseline years since injury, 12.8±4.9). The initial SWLS score averaged 24.2 and was estimated to increase by 0.14 a year (P=.10). After adjusting for potential confounding factors, the overall life satisfaction was significantly higher for women and those who were married/living with a partner; were employed/students; did not use illicit drugs; and scored high in the FIM, the mental health component of the Short Form-12, and the social integration subscale of the Craig Handicap Assessment and Reporting Technique. The rate of change in life satisfaction did not differ significantly by any personal, medical, and psychosocial characteristics under investigation.Conclusions: The study findings suggest that people who feel unsatisfied with life initially are likely to stay unsatisfied over time if the critical determinant factors remain unchanged in their life. To minimize the risk of decreasing life satisfaction, several modifiable risk factors identified in the present study could be targeted for intervention.

The Reliability and Validity of Measures of Gait Variability in Community-Dwelling Older Adults

Jennifer S. Brach, Subashan Perera, Stephanie Studenski, Anne B. Newman — 2008-12-01

Abstract: Brach JS, Perera S, Studenski S, Newman AB. The reliability and validity of measures of gait variability in community-dwelling older adults.Objective: To examine the test-retest reliability and concurrent validity of variability of gait characteristics.Design: Cross-sectional study.Setting: Research laboratory.Participants: Older adults (N=558) from the Cardiovascular Health Study.Interventions: Not applicable.Main Outcome Measures: Gait characteristics were measured using a 4-m computerized walkway. SD determined from the steps recorded were used as the measures of variability. Intraclass correlation coefficients (ICC) were calculated to examine test-retest reliability of a 4-m walk and two 4-m walks. To establish concurrent validity, the measures of gait variability were compared across levels of health, functional status, and physical activity using independent t tests and analysis of variances.Results: Gait variability measures from the two 4-m walks demonstrated greater test-retest reliability than those from the single 4-m walk (ICC=.22–.48 and ICC=.40–.63, respectively). Greater step length and stance time variability were associated with poorer health, functional status and physical activity (P<.05).Conclusions: Gait variability calculated from a limited number of steps has fair to good test-retest reliability and concurrent validity. Reliability of gait variability calculated from a greater number of steps should be assessed to determine if the consistency can be improved.

Type of Hip Fracture in Patients With Parkinson Disease is Associated With Femoral Bone Mineral Density

2008-12-01

Abstract: Di Monaco M, Vallero F, Di Monaco R, Tappero R, Cavanna A. Type of hip fracture in patients with Parkinson disease is associated with femoral bone mineral density.Objective: To investigate the association between bone mineral density (BMD) and hip fracture type (cervical or trochanteric) in a sample of fallers with Parkinson disease (PD).Design: Observational study.Setting: Rehabilitation hospital in Italy.Patients: We investigated 1040 of 1120 white fallers consecutively admitted to a rehabilitation hospital for hip fracture. Thirty-eight (3.65%) of the 1040 patients suffered from PD secondarily. Thirty-eight controls matched for sex, age, and hip fracture type were found among the 1002 non-PD fallers.Interventions: Not applicable.Main Outcome Measures: BMD was assessed by dual-energy x-ray absorptiometry at a mean ± SD of 21.9±7.5 days after fracture occurrence in the 38 PD patients and 21.6±5.9 days after fracture occurrence in the 38 controls.Results: BMD assessed at total femur, trochanter, and intertrochanteric region was significantly lower in the 15 PD patients with trochanteric fractures than in the 23 with cervical fractures; the mean T score differences were 0.57 (95% confidence interval [CI], 0.07–1.08; P=.028), 0.66 (95% CI, 0.04–1.28; P=.037), and 0.63 (95% CI, 0.11–1.15; P=.019), respectively. A significant association between femoral BMD and hip fracture type was found at logistic regression after adjustment for several confounders. Results in the 38 controls were similar to those obtained in the 38 PD fallers.Conclusions: In a sample of PD fallers as in a control group of non-PD fallers, BMD levels assessed at 3 femoral sites were significantly lower in the patients who sustained trochanteric fractures than in those with cervical fractures of the hip.

The Effect of Simulating Weight Gain on the Energy Cost of Walking in Unimpaired Children and Children With Cerebral Palsy

Frank Plasschaert, Kim Jones, Malcolm Forward — 2008-12-01

Abstract: Plasschaert F, Jones K, Forward M. The effect of simulating weight gain on the energy cost of walking in unimpaired children and children with cerebral palsy.Objective: To examine the effect of simulating weight gain on the energy cost of walking in children with cerebral palsy (CP) compared with unimpaired children.Design: Repeated measures, matched subjects, controlled.Setting: University hospital clinical gait and movement analysis laboratory.Participants: Children (n=42) with CP and unimpaired children (n=42).Interventions: Addition of 10% of body mass in weight belt.Main Outcome Measures: Energy cost of walking parameters consisting of walking speed, Physiological Cost Index, Total Heart Beat Index, oxygen uptake (V̇o2), gross oxygen cost, nondimensional net oxygen cost, and net oxygen cost with speed normalized to height were measured by using a breath-by-breath gas analysis system (K4b2) and a light beam timing gate system arranged around a figure 8 track. Two walking trials were performed in random order, with and the other without wearing a weighted belt.Results: Children with CP and their unimpaired counterparts responded in fundamentally different ways to weight gain. The unimpaired population maintained speed and V̇o2 but the children with CP trended toward a drop in their speed and an increase in their V̇o2. The oxygen consumption of children with CP showed a greater dependence on mass than the unimpaired group (P=.043).Conclusions: An increase of a relatively small percentage in body mass began to significantly impact the energy cost of walking in children with CP. This result highlights the need for weight control to sustain the level of functional walking in these children.

Predicting Which Older Adults Will or Will Not Fall Using the Fullerton Advanced Balance Scale

Danielle Hernandez, Debra J. Rose — 2008-12-01

Abstract: Hernandez D, Rose DJ. Predicting which older adults will or will not fall using the Fullerton Advanced Balance Scale.Objective: The purpose of this study was to determine if the Fullerton Advanced Balance (FAB) scale can predict faller status in a group of independently functioning older adults.Design: A cross-sectional design was used to establish the sensitivity and specificity of the FAB scale to predict faller status based on a retrospective self-reported fall history. For the purpose of this study, a faller was classified as an older adult with a history of 2 or more falls in the previous 12 months.Setting: Multipurpose senior centers in an urban community.Participants: A sample of independently functioning older adults (N=192; mean age ± SD, 77±6.5y).Interventions: Not applicable.Main Outcome Measures: FAB scale, a retrospective history of falls.Results: Binary logistic regression analysis indicated that the total FAB scale score could be used to predict faller status (as determined by a retrospective self-reported fall history). In the present sample, the probability of falling increased by 8% with each 1-point decrease in total FAB scale score. Receiver operating characteristic analysis determined that a cut-off score of 25 out of 40 on the FAB scale produced the highest sensitivity (74.6%) and specificity (52.6%) in predicting faller status. Five individual test items on the FAB scale were particularly predictive of faller status and could be combined to form a short version of the scale that may be even more predictive of faller status and require less time to administer.Conclusions: The FAB scale is a predictive measure of faller status when used with independently functioning older adults. A practitioner can be confident in more than 7 out of 10 cases that an older adult who scores 25 or lower on the FAB scale is at high risk for falls and in need of immediate intervention.

Prevalence and Risk Factors of Asymptomatic Lower Extremity Deep Venous Thrombosis in Asian Neurorehabilitation Admissions in Singapore

Karen Chua, Keng He Kong, Siew Pang Chan — 2008-12-01

Abstract: Chua K, Kong KH, Chan SP. Prevalence and risk factors of asymptomatic lower extremity deep venous thrombosis in Asian neurorehabilitation admissions in Singapore.Objective: To determine the local prevalence and risk factors of asymptomatic lower limb deep venous thrombosis (DVT) among neurorehabilitation admissions.Design: A prospective observational single-center study.Setting: Tertiary rehabilitation center affiliated to a public hospital.Participants: A total of 419 Asian neurorehabilitation admissions with a mean of 26 days to rehabilitation.Intervention: Admission screening protocol included quantitative D-dimer assay within 24 to 48 hours of rehabilitation admission and targeted hemiplegic/weaker lower-extremity venous duplex ultrasonography was performed if D-dimer assay level was elevated at 0.34 μg/mL or higher.Main Outcome Measures: There were 251 (59.9%) men, and the subjects were predominantly Chinese (76.6%). Subjects had a mean age of 59±15 years. Admitting diagnoses included ischemic stroke (212), hemorrhagic stroke and subarachnoid hemorrhage (129), traumatic brain injury (59), and nontraumatic brain injury (19). The screening protocol included a quantitative D-dimer assay within 24 to 48 hours of rehabilitation admission, and hemiplegic/weaker lower-extremity venous duplex ultrasonography was performed if D-dimer assay level was elevated at 0.34 μg/mL or higher.Results: Altogether, 247 (58.9%) patients had an elevated D-dimer assay, and all underwent venous duplex ultrasonography. The incidence of lower-limb DVT was 5.01% (21), including 11 proximal and 10 distal DVT. No patients had clinical pulmonary embolism. Using 247 venous duplex ultrasonography results for analyses of correlates with logistic regression analyses, no significant demographic or clinical predictive factors for DVT were found.Conclusions: This study confirms that asymptomatic lower limb DVT is indeed uncommon in Asian neurorehabilitation admissions. Possible reasons include genetic or ethnic protective factors, early walking initiated at rehabilitation, and timing of the admission protocol (median of 14 days postevent) when the maximal thrombotic risk was on the decline.

Dynamic Restraint Capacity of the Hamstring Muscles Has Important Functional Implications After Anterior Cruciate Ligament Injury and Anterior Cruciate Ligament Reconstruction

Adam L. Bryant, Mark W. Creaby, Robert U. Newton, Julie R. Steele — 2008-12-01

Abstract: Bryant AL, Creaby MW, Newton RU, Steele JR. Dynamic restraint capacity of the hamstring muscles has important functional implications after anterior cruciate ligament injury and anterior cruciate ligament reconstruction.Objective: The purpose of this study was to investigate the relation between knee functionality of anterior cruciate ligament deficient (ACLD) and anterior cruciate ligament reconstruction (ACLR) patients and hamstring antagonist torque generated during resisted knee extension.Design: Cross-sectional.Setting: Laboratory based.Participants: Male ACLD subjects (n=10) (18–35y) and 27 matched males who had undergone ACLR (14 patella tendon [PT] grafts and 13 combined semitendinosus/gracilis tendon grafts).Interventions: Not applicable.Main Outcome Measures: Knee functionality was rated (0- to 100-point scale) by using the Cincinnati Knee Rating System. Using electromyography data from the semitendinosus (ST) and biceps femoris muscles, we created a mathematical model to estimate the opposing torque generated by the hamstrings during isokinetic knee extension in 10° intervals from 80° to 10° knee flexion.Results: Pearson product-moment correlations revealed that more functional ACLD subjects generated significantly (P<.05) higher hamstring antagonist torque throughout knee extension. In contrast, more functional PT subjects produced significantly lower hamstring antagonist torque at 80° to 70° knee flexion, whereas no significant associations were found between hamstring antagonist torque and knee functionality for the ST/gracilis tendon subjects.Conclusions: An increased hamstring antagonist torque generated by the more functional ACLD subjects, reflective of increased hamstring contractile force, is thought to represent a protective mechanism to compensate for mechanical instability. The restoration of anterior knee stability through ACLR negates the need for augmented hamstring antagonist torque.

Functional and Clinical Outcomes of Telemedicine in Patients With Spinal Cord Injury

2008-12-01

Abstract: Dallolio L, Menarini M, China S, Ventura M, Stainthorpe A, Soopramanien A, Rucci P, Fantini MP, on behalf of the THRIVE Project. Functional and clinical outcomes of telemedicine in patients with spinal cord injury.Objective: To compare the 6-month outcomes of telerehabilitation intervention with those of standard care for spinal cord injury (SCI).Design: Multicenter randomized controlled trial.Setting: Home, nursing, or unspecialized hospital care provided after discharge from a spinal cord unit.Participants: Adult patients with nonprogressive, complete, or incomplete SCI discharged for the first time from the spinal cord unit to their homes (Belgium and Italy) or to their homes or another facility (England).Interventions: All patients received the standard care they would have normally received after discharge from the spinal cord unit. In addition, patients in the telemedicine group received 8 telemedicine weekly sessions in the first 2 months, followed by biweekly telemedicine sessions for 4 months.Main Outcome Measures: Functional status at 6 months, clinical complications during the postdischarge period, and patient satisfaction.Results: No significant differences in the occurrence of clinical complications were found between the study groups. A higher improvement of functional scores in the telemedicine group was found only at the Italian site: FIM total score 3.38±4.43 (controls) versus 7.69±6.88 (telemedicine group), FIM motor score 3.24±4.38 (controls) versus 7.55±7.00 (telemedicine group; P<.05). Items contributing to this difference were grooming, dressing upper body, dressing lower body, and bed/chair/wheelchair transfer. Higher satisfaction with care was reported by patients in the telemedicine group across all sites.Conclusions: Our study provides some of the first quantitative evidence, based on results from 1 site, that telerehabilitation may offer benefits to patients discharged from a spinal cord unit compared with standard care in terms of functional improvement. Further research is warranted to confirm or disprove this finding.

Wheelchair Curb Climbing: Randomized Controlled Comparison of Highly Structured and Conventional Training Methods

R. Lee Kirby, Sean Bennett, Cher Smith, Kim Parker, Kara Thompson — 2008-12-01

Abstract: Kirby RL, Bennett S, Smith C, Parker K, Thompson K. Wheelchair curb climbing: randomized controlled comparison of highly structured and conventional training methods.Objectives: Our primary objective was to test the hypothesis that a highly structured training method for wheelchair curb-climbing requires less training time than conventional training. Our secondary objectives were to test the hypotheses that this training method increases success rate, reduces the need for spotter interventions, and reduces the participants' perceptions of difficulty.Design: Randomized controlled trial.Setting: Rehabilitation center.Participants: Able-bodied participants (N=16), randomly allocated to intervention (n=7) and control (n=9) groups.Interventions: Both groups received up to 5 training sessions. Each session included instruction, practice, and feedback. The participants in the intervention and control groups used 18- and 9-step approaches, respectively. Training in the intervention group also included video demonstration, trainer demonstrations, mirror feedback, and standardized feedback phrases.Main Outcome Measures: Total training time, success rate at climbing a 15cm-high curb, the number of spotter interventions during training, and a questionnaire.Results: The mean ± SD training times for the successful participants in the intervention and control groups were 42.5±24.4 minutes and 87.4±45.3 minutes (P=.084). The curb-climbing success rates of the intervention and control groups were 86% and 89% (P=1.000). There were no significant differences between the groups regarding the number of spotter interventions (P=.203) or for participants' perceptions of difficulty (P=.050).Conclusions: In comparison with a conventional method for curb-climbing, a highly structured method seems to require less than 50% of the training time for able-bodied participants, although this finding is only a trend statistically. This has implications for clinical training.

Airflow Obstruction and Reversibility in Spinal Cord Injury: Evidence for Functional Sympathetic Innervation

2008-12-01

Abstract: Radulovic M, Schilero GJ, Wecht JM, Weir JP, Spungen AM, Bauman WA, Lesser M. Airflow obstruction and reversibility in spinal cord injury: evidence for functional sympathetic innervation.Objectives: The first objective was to assess group differences for specific airway conductance (sGaw) among subjects with tetraplegia, high paraplegia (HP: T2-T6), and low paraplegia (LP: T10-L4). The second objective was to determine the significance of responsiveness to ipratropium bromide (IB) by the assessment of the inherent variability of baseline measurements for impulse oscillation (IOS), body plethysmography, and spirometry.Design: Prospective cross-sectional intervention study.Setting: James J. Peters Veterans Administration Medical Center.Participants: Subjects (N=43): 12 with tetraplegia (C4-8), 11 with HP, 11 with LP, and 9 controls.Interventions: Not applicable.Main Outcome Measures: Measurement of IOS, body plethysmography, and spirometry parameters at baseline and 30 minutes after IB.Results: Baseline sGaw was significantly lower in tetraplegia (0.14±0.03) compared with HP (0.19±0.05) and LP (0.19±0.04) patients. By use of minimal difference to evaluate IB responsiveness in tetraplegia, 4 of 12 and 12 of 12 subjects had significant increases in forced expiratory volume in 1 second and sGaw, respectively, whereas 11 of 12 and 10 of 12 subjects had significant decreases in respiratory resistances measured at 5 and 20Hz (R5 and R20), respectively.Conclusions: The finding of group differences for baseline sGaw supports the hypothesis that human lung contains functional sympathetic innervation. Body plethysmography and IOS were comparable in detecting IB-induced bronchodilation in tetraplegia and significantly more sensitive than spirometry.

Six-Minute Walk Test in Persons With Transtibial Amputation

Suh-Jen Lin, Nisha Hathi Bose — 2008-12-01

Abstract: Lin S-J, Bose NH. Six-minute walk test in persons with transtibial amputation.Objective: This study was to report the within-day test-retest reliability and the measurement properties of the six-minute walk test (6MWT) in persons with lower-limb (transtibial) amputation.Design: Test-retest study design.Setting: University research laboratory.Participants: Subjects (N=13) with transtibial amputation (9 men and 4 women; mean age, 46y).Interventions: Three trials of the 6MWT were conducted within 1 day with 20 to 30 minutes of rest between consecutive trials. Timed Up & Go (TUG) test and timed one-leg balance tests were conducted on another day.Main Outcome Measures: (1) Distance, heart rate, symptoms and signs of exercise intolerance during the walk test, (2) times of the TUG test and the one-leg balance test.Results: The intraclass correlation coefficient (ICC3,1) value was .94. Bland and Altman graphs showed no systemic variations between trials and a small learning effect. The peak heart rate approximated 72% to 78% of the age-predicted maximal heart rate. Moderate degrees of correlation were observed in: (1) the 6MWT versus the TUG test (r=–.76, P<.05), and (2) the 6MWT versus the timed prosthetic-leg stance (with eyes open: r=.63, P<.05; with eyes closed: r=.61, P<.05).Conclusions: These findings suggest that the 6MWT could be considered as a reliable measure of functional capacity, involves a moderate degree of exercise intensity, and is related in a moderate degree to postural control abilities in persons with transtibial amputation.

The Reliability of Spatiotemporal Gait Data for Young and Older Women During Continuous Overground Walking

Kade L. Paterson, Keith D. Hill, Noel D. Lythgo, Wayne Maschette — 2008-12-01

Abstract: Paterson KL, Hill KD, Lythgo ND, Maschette W. The reliability of spatiotemporal gait data for young and older women during continuous overground walking.Objective: To examine the reliability and systematic bias in spatiotemporal gait parameters recorded in healthy women during repeated single and continuous overground walking trials.Design: Test-retest.Setting: University laboratory.Participants: Young (n=13) and older adult (n=14) women volunteers.Interventions: Not applicable.Main Outcome Measures: Spatiotemporal data were collected from an 8.1-m GAITRite mat during 10 trials of discrete single walks and 10 laps of a continuous circuit presented in random order over 2 separate test sessions. Paired t tests, intraclass correlation coefficients (ICCs), SE of measurement, and coefficients of variation (CV) were calculated.Results: The relative and absolute measures of reliability showed most spatiotemporal variables recorded during the single and continuous walking protocols were reliable. Step length, foot angle, and step and stance times were found to be the most reliable parameters, with ICCs ranging from 0.84 to 0.95, CVs from 2.06% to 4.02%, and SE of measurements of 1.59 to 2.04cm for step length, 1.32° to 1.71° for foot angle, and 0.011 to 0.025 seconds for step and stance times. Reliability estimates were similar for the single and continuous trial conditions and between the young and older women. Although small mean differences in the gait parameters were found across the test sessions, many of these parameters showed systematic bias (P≤.05). In the single trial condition, the majority (65%) of the gait parameters showed significant bias, whereas in the continuous condition only 19% of the parameters exhibited bias. For the young women, 54% of the parameters showed systematic bias (P≤.05) in the single trial condition, whereas 77% of the parameters exhibited bias for the older women. In the continuous walking condition, 38% of the gait parameters showed systematic bias (P≤.05) for the young women, whereas no systematic bias was found in the gait parameters of the older women.Conclusions: This study shows that both the single and continuous walking protocols are reliable methods for the collection of gait data in young and older women. It also shows that a continuous overground walking protocol produces less bias in test-retest spatiotemporal gait data. Therefore, a continuous protocol may be a better method when attempting to monitor gait changes over time, especially for older women.

The Effect of Mobilization on Repaired Extensor Tendon Injuries of the Hand: A Systematic Review

Eelkje Talsma, Mirjam de Haart, Anita Beelen, Frans Nollet — 2008-12-01

Abstract: Talsma E, de Haart M, Beelen A, Nollet F. The effect of mobilization on repaired extensor tendon injuries of the hand: a systematic review.Objective: To systematically review the available evidence comparing the effectiveness of different rehabilitation regimes in repaired extensor tendon injuries of the hand.Data Sources: A systematic literature search of the Cochrane Library, MEDLINE (1950–January 2008), PEDro (up to January 2008), EMBASE (1980–January 2008) and CINAHL (1982–January 2008) databases was conducted, and reference lists were scanned for relevant studies.Study Selection: Studies on the rehabilitation of surgically repaired extensor tendon injuries of the hand in which patients received one of the following interventions: immobilization, early controlled mobilization, or early active mobilization.Data Extraction: The methodologic quality of the selected studies was assessed by 2 reviewers. All randomized controlled trials, high quality controlled clinical trials, and other design studies with sufficient quality were included in the best evidence synthesis.Data Synthesis: Four randomized controlled trials and 1 other design study were included. Short-term outcomes after immobilization were significantly inferior to outcomes after early controlled mobilization. Inconclusive findings suggested that early controlled mobilization might lead to better short-term effects (4wk postoperatively) than early active mobilization. In time, differences in effects disappeared and 3 months postoperatively no significant differences were found between early controlled mobilization and early active mobilization.Conclusions: Although strong evidence was found for the short-term superiority of early controlled mobilization over immobilization for extensor tendons, no conclusive evidence was found regarding the long-term effectiveness of the different rehabilitation regimes. High quality prospective studies should be performed to further explore the outcomes of rehabilitation of extensor tendon injuries and to substantiate the available evidence.

Prevalence of Osteoporosis in Osteoarthritic Patients Undergoing Total Hip or Total Knee Arthroplasty

2008-12-01

Abstract: Labuda A, Papaioannou A, Pritchard J, Kennedy C, DeBeer J, Adachi JD. Prevalence of osteoporosis in osteoarthritic patients undergoing total hip or total knee arthroplasty.Objective: To determine the prevalence of osteoporosis in osteoarthritic patients undergoing total hip or total knee arthroplasty.Design: Cross-sectional study.Setting: The Specialized Outpatient Rehabilitation Service's (SORS) Pre-surgical Arthroplasty Service located at the Chedoke Hospital, Hamilton Health Sciences, Hamilton, ON, Canada.Participants: SORS outpatients (N=364), from the period of March 2006 to March 2007.Interventions: Not applicable.Main Outcome Measures: Prevalence of osteoporosis was determined by review of a self-reported survey, and defined by (1) self-reported diagnosis of osteoporosis, (2) history of fragility fracture (defined by a bone fracture occuring as a result of a fall from standing height or less after the age of 50), or (3) current treatment for osteoporosis using bisphosphonates.Results: Of the study cohort, 26% were classified as having osteoporosis, according to our criteria. Of the patients with self-reported osteoporosis or a history of fragility fractures, only 37% and 17% reported current treatment with bisphosphonates, respectively.Conclusions: Osteoporosis is common in the osteoarthritic arthroplasty population, with a prevalence at least equal to that in the general population. Due to the self-reported nature of the study, the prevalence of osteoporosis in this population is likely significantly higher. Results from this study indicate need for further research, specifically in formal assessment for osteoporosis in patients undergoing a joint replacement.

Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients

Nicolas Pinsault, Nicolas Vuillerme, Paul Pavan — 2008-12-01

Abstract: Pinsault N, Vuillerme N, Pavan P. Cervicocephalic relocation test to the neutral head position: assessment in bilateral labyrinthine-defective and chronic, nontraumatic neck pain patients.Objective: To determine whether vestibular or cervical proprioceptive information influence the cervicocephalic relocation test to the neutral head position, by comparing head repositioning errors obtained in asymptomatic, unimpaired control subjects with those obtained in bilateral labyrinthine-defective patients and chronic, nontraumatic neck pain patients.Design: A group-comparison study.Setting: University medical bioengineering laboratory.Participants: Labyrinthine-defective patients (n=7; mean age ± SD, 67±15y), nontraumatic neck pain patients (n=7; 56±9y), and asymptomatic, unimpaired control subjects (n=7; 64±12y).Interventions: Participants were asked to relocate the head on the trunk, as accurately as possible, after full active cervical rotation to the left and right sides. Ten trials were performed for each rotation side.Main Outcome Measures: Absolute and variable errors were used to assess accuracy and consistency of the repositioning, respectively.Results: No significant difference in repositioning errors was observed between labyrinthine-defective patients and control subjects, whereas nontraumatic neck pain patients demonstrated significantly increased absolute errors in horizontal and global components and higher variable errors in horizontal component.Conclusions: These findings suggest that the vestibular system is not involved in the performance of the cervicocephalic relocation test to neutral head position, and further support this test as a measure of cervical proprioceptive acuity.

Isolated Median Sensory Neuropathy After Acupuncture

Chang Ho Lee, Jung Keun Hyun, Seong Jae Lee — 2008-12-01

Abstract: Lee CH, Hyun JK, Lee SJ. Isolated median sensory neuropathy after acupuncture.A 47-year-old left-handed man presented with pain and numbness in his left thumb and index finger after acupuncture treatment on an acupoint in his left wrist. A technique of herbal acupuncture, involving the use of a needle coated with apricot seed extract, was used. Median nerve conduction study showed an absence of sensory nerve action potential in the left index finger, whereas the results were normal in all other fingers. The radial and ulnar nerves in the left thumb and ring finger, respectively, showed no abnormality. Infrared thermography of the left index finger showed severe hypothermia. The patient was diagnosed as having an isolated injury to the sensory nerve fibers of the median nerve innervating the index finger. This is the first case report of complications from an herbal acupuncture treatment, and it highlights the possibility of focal peripheral nerve injury caused by acupuncture.

Pain in Myotonic Muscular Dystrophy, Type 1

2008-12-01

The article by Gagnon et al in the July 2008 issue nicely identified personal and environmental factors that may influence the trajectory toward disrupted participation in individuals with myotonic muscular dystrophy type 1 (DM1). The factors they identified that were found to be independent predictors of disrupted participation included fatigue, strength, and family support. Unfortunately, this study did not address an additional issue that many individuals with DM1 must deal with: chronic pain. Pain as a cause of impaired community and social integration, as well as diminished quality of life is frequently overlooked, despite clearly being identified as a major problem for this patient population. We raise this point primarily to make readers more aware of a problem that seems to be continually overlooked. Indeed many major medical textbooks still describe this disorder, as well as other neuromuscular diseases, as being “painless,” which is clearly not the case. We congratulate the authors on an otherwise excellent study.

New Books

2008-12-01

Davis CM. Complementary Therapies in Rehabilitation: Evidence for Efficacy in Therapy, Prevention and Wellness. 3rd ed. ISBN: 9781556428661. Oct 2008. $55.95. Contact: Slack, 800-257-8290, www.slackbooks.com.

Archives Manuscript Reviewers

2008-12-01

The Editorial Board thanks the individuals listed here for their cooperation and enthusiasm in reviewing manuscripts submitted to the Archives of Physical Medicine and Rehabilitation, April 2008 through September 2008.

Journal-Based CME Evaluation and Application

2008-12-01

CME Processing Fees and Application

2008-12-01

2008-2009 ACRM Board of Governors

2008-12-01

Masthead

2008-12-01

Archives of Physical Medicine and Rehabilitation (ISSN 0003-9993) is published monthly by Elsevier Inc., 360 Park Avenue South, New York, NY 10010-1710. Business and Editorial Office: 1600 John F. Kennedy Blvd., Ste. 1800, Philadelphia, PA 19103-2899. Customer Service Office: 11830 Westline Industrial Drive, St Louis, MO 63146. Periodicals postage paid at New York, NY and additional mailing offices.

Editorial Board

2008-12-01

Selections From This Month in the Archives

2008-12-01

Rodney D. Vanderploeg, PhD Karen Schwab, PhD

Archives of Physical Medicine and Rehabilitation

Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches

A Randomized Controlled Trial of Holistic Neuropsychologic Rehabilitation After Traumatic Brain Injury

Assessment of the Effects of Aquatic Therapy on Global Symptomatology in Patients With Fibromyalgia Syndrome: A Randomized Controlled Trial

Effect of Magnetic Knee Wrap on Quadriceps Strength in Patients With Symptomatic Knee Osteoarthritis

Low-Frequency Electric Muscle Stimulation Combined With Physical Therapy After Total Hip Arthroplasty for Hip Osteoarthritis in Elderly Patients: A Randomized Controlled Trial

Apparent Changes in Inpatient Rehabilitation Facility Outcomes Due to a Change in the Definition of Program Interruption

Which Impairments Are Most Associated With High Mobility Performance in Older Adults? Implications for a Rehabilitation Prescription

Change in Life Satisfaction of Adults With Pediatric-Onset Spinal Cord Injury

The Reliability and Validity of Measures of Gait Variability in Community-Dwelling Older Adults

Type of Hip Fracture in Patients With Parkinson Disease is Associated With Femoral Bone Mineral Density

The Effect of Simulating Weight Gain on the Energy Cost of Walking in Unimpaired Children and Children With Cerebral Palsy

Predicting Which Older Adults Will or Will Not Fall Using the Fullerton Advanced Balance Scale

Prevalence and Risk Factors of Asymptomatic Lower Extremity Deep Venous Thrombosis in Asian Neurorehabilitation Admissions in Singapore

Dynamic Restraint Capacity of the Hamstring Muscles Has Important Functional Implications After Anterior Cruciate Ligament Injury and Anterior Cruciate Ligament Reconstruction

Functional and Clinical Outcomes of Telemedicine in Patients With Spinal Cord Injury

Wheelchair Curb Climbing: Randomized Controlled Comparison of Highly Structured and Conventional Training Methods

Airflow Obstruction and Reversibility in Spinal Cord Injury: Evidence for Functional Sympathetic Innervation

Six-Minute Walk Test in Persons With Transtibial Amputation

The Reliability of Spatiotemporal Gait Data for Young and Older Women During Continuous Overground Walking

The Effect of Mobilization on Repaired Extensor Tendon Injuries of the Hand: A Systematic Review

Prevalence of Osteoporosis in Osteoarthritic Patients Undergoing Total Hip or Total Knee Arthroplasty

Cervicocephalic Relocation Test to the Neutral Head Position: Assessment in Bilateral Labyrinthine-Defective and Chronic, Nontraumatic Neck Pain Patients

Isolated Median Sensory Neuropathy After Acupuncture

Pain in Myotonic Muscular Dystrophy, Type 1

New Books

Archives Manuscript Reviewers

Journal-Based CME Evaluation and Application

CME Processing Fees and Application

2008-2009 ACRM Board of Governors

Masthead

Editorial Board

Table of Contents

Selections From This Month in the Archives