Empowering Physiatrists in Training to the Peer-Review Process No abstract available

Gait Velocity and Joint Power Generation After Stroke: Contribution of Strength and Balance Objective The aim of the study was to assess the degree to which isometric strength of multiple lower limb muscle groups and balance is associated with gait velocity and joint power generation during gait after stroke. Design Sixty-three participants in a multisite, multinational, cross-sectional, observational study underwent assessment of gait velocity (10-m walk test), standing balance (computerized posturography), and isometric strength (hand-held dynamometry). Twenty-seven participants had joint power generation assessed (three-dimensional gait analysis). Bivariate associations were examined using Spearman’s correlations. Regression models with partial F tests were used to compare the contribution to gait between measures. Results Although all muscle groups demonstrated significant associations with gait velocity (ρ = 0.40–0.72), partial F tests identified that ankle plantar flexor and hip flexor strength made the largest contribution to gait velocity. Ankle plantar flexor strength also had strong associations with habitual and fast-paced ankle power generation (ρ = 0.65 and 0.75). Balance had significant associations with habitual and fast gait velocity (ρ = −0.57 and −0.53), with partial F tests showing that the contribution was independent of strength. Conclusions Ankle plantar flexor and hip flexor strength had the largest contribution to gait velocity. Future research may wish to refocus strength assessment and treatment to target the ankle plantar flexors and hip flexors. To Claim CME Credits Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives Upon completion of this article, the reader should be able to: (1) Differentiate the contribution that lower limb strength of each muscle group has on gait velocity after stroke; (2) Appraise the relationship between isometric strength and joint power generation during gait; and (3) Interpret the contribution of both strength and balance to gait after stroke. Level Advanced Accreditation The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Does a Web-Based Exercise Programming System Improve Home Exercise Adherence for People With Musculoskeletal Conditions?: A Randomized Controlled Trial Objective The aim of the study was to evaluate whether a web-based exercise programming system improves adherence to a home exercise program for people with musculoskeletal conditions. Design Eligible patients with a musculoskeletal condition presenting to a physical therapist in private practice were randomized to the following: (a) control (home exercise prescribed by therapist’s usual methods) or (b) intervention (home exercise prescribed using a web-based exercise programming system). The primary outcome was self-rated exercise adherence measured at week 3 via 11-point Numeric Rating Scales. Secondary outcomes were satisfaction with exercise delivery and confidence in ability to undertake prescribed exercise. Process measures were also included. Results We enrolled 305 participants, with loss to follow-up of 14.5% (22/152) and 13.7% (21/153) in intervention and control groups, respectively. Compared with controls, the intervention group reported higher exercise adherence (mean difference Numeric Rating Scale units (95% confidence intervals): adherence overall −1.0 [−1.6 to −0.3] and regarding number of exercises in session −0.7 [−1.3 to −0.1], number of repetitions −0.8 [−1.4 to −0.2], and number of sessions −1.0 [−1.6 to −0.3]). The intervention group showed greater confidence to exercise than control, with no difference in satisfaction. Conclusions A web-based exercise programming system improved home exercise adherence and confidence in ability to undertake exercise, although the clinical relevance of the results needs to be established.

Head Motion Predicts Transient Loss of Consciousness in Human Head Trauma: A Case-Control Study of Mixed Martial Artists Objective Concussion with transient loss of consciousness is a commonly observed but poorly understood phenomenon with mounting clinical significance. This study aimed to examine the relationship between head motion in varying planes and transient loss of consciousness in athletes with brain injuries. Study Design A case-control design was used. The Ultimate Fighting Championship database was screened for events ending with knockouts from 2013 to 2016. Time of strike, striking implement, strike location, and head motion were recorded for all knockout strikes (cases) and for a subset of nonknockout strikes (controls). Characteristics of winners and losers were compared using two-tailed t tests. Multivariate logistic regression was used to determine odds ratios for strike characteristics associated with transient loss of consciousness. The Kaplan-Meier estimate was used to describe the temporal distribution of knockouts. Results One hundred thirty-six fights were identified and 110 videos were included. Head motion in the axial plane was strongly associated with transient loss of consciousness (odds ratio, 45.3; 95% confidence interval, 20.8–98.6). Other predictors of transient loss of consciousness were head motion in sagittal and coronal planes, nonfist striking implements, and strikes to the mandible or maxilla. The Kaplan-Meier survival curve demonstrated a decreasing rate of knockouts through time. Conclusions Rotational head acceleration, particularly in the axial plane, is strongly associated with transient loss of consciousness.

Gait Variability in Women With Hip Osteoarthritis Before and After Total Hip Replacement: A Prospective Cohort Study Objective Gait variability changes before and after total hip arthroplasty are unclear. This study aimed to investigate gait variability changes in hip osteoarthritis patients before and after total hip arthroplasty and to examine the relationships between gait variability changes and hip function. Design Twenty-three female patients with hip osteoarthritis (61.0 ± 7.1 yrs) and 10 healthy female participants (57.8 ± 3.9 yrs) were assessed 1 mo before and 12 mos after surgery. Heel and lower trunk accelerations were measured using two triaxial accelerometers. The coefficient of variation of stride time for gait variability of lower limb motions and the harmonic ratio for trunk variability were calculated. Radiographic leg-length discrepancy, hip abductor strength, hip abduction, extension range of motion, and pain level during gait were measured. Results The coefficient of variation was significantly decreased after total hip arthroplasty and was comparable with that in healthy individuals. Although postoperative harmonic ratios were greater than preoperative harmonic ratios, they were not comparable with those in healthy individuals. The coefficient of variation changes were associated with pain relief during gait. Harmonic ratio changes were associated with hip abductor strength, extension range of motion, and limb lengthening. Conclusion Gait variability improved after total hip arthroplasty due to improved hip function. However, trunk variability was insufficient compared with that in healthy individuals.

Time Effect of Intra-articular Injection With Triamcinolone Hexacetonide and Its Correlations: A Case-Control Prospective 12-Month Study Objective The aim of the study was to assess the time effect of intra-articular injection with triamcinolone hexacetonide in rheumatic patients. Design A prospective case-control study with patients submitted to one intra-articular injection with triamcinolone hexacetonide. Patients were followed monthly (12 mos) for pain and swelling. Results Two hundred sixty-two joints were assessed in 158 patients with mean ± SD age of 60 ± 13.7 yrs. Remission was observed at 3, 6, and 12 mos in 142 (54.19%), 111 (42.36%), and 105 (40.07%) joints, respectively. The mean ± SD time effect were 8 ± 4.0 mos; 8.4 ± 3.9 for rheumatoid arthritis patients and 6.9 ± 4.0 for osteoarthritis patients (P = 0.012) and 10.4 ± 2.7 mos for small, 7.7 ± 4.1 for medium, and 6.8 ± 4.0 for large joints. The joints were divided into two groups: long-term group (time effect of intra-articular injection longer than 6 mos) and short-term group. The following are the variables associated (P < 0.05) with long-term group: rheumatoid arthritis, small and medium-sized joints, female sex, lower pain and swelling visual analog scale scores, and use of leflunomide. The following are the variables associated with short-term group: receiving only one intra-articular injection, hypertension, diabetes mellitus, and biological therapy. Conclusions The mean ± SD time effect of intra-articular injection with triamcinolone hexacetonide was 8.0 ± 4.0 mos. The associated predictors were rheumatoid arthritis, small and medium joints, lower pain/swelling visual analog scale scores, and use of leflunomide.

Cognitive Characteristics Associated With Device Adoption, Skill Retention, and Early Withdrawal From a Study of an Advanced Upper Limb Prosthesis Objective The aim of the study was to examine the role of cognition in device adoption, skill retention, and withdrawal from a study of an advanced upper limb prosthesis (the DEKA Arm). Design T tests and Wilcoxon rank-sum tests were used to compare test performance among study completers and noncompleters. Multivariable regression analyses were used to predict study withdrawal and DEKA Arm skill retention. Results Compared with self-withdrawn participants, those who were withdrawn by study staff performed significantly worse on tests indexing processing speed, set-shifting, and memory encoding. The DEKA Arm configuration (transradial, transhumeral, shoulder—based on amputation level) was a stronger predictor of skill retention than neuropsychological test performance. Conclusions Frontally-mediated cognitive skills may influence the successful adoption of the DEKA Arm. The DEKA Arm configurations at higher amputation levels (e.g., shoulder) appear to be more strongly associated with prosthetic skill retention than users’ cognitive status. This may be due to noncognitive user demands (e.g., device weight) statistically masking the discrete influence of cognitive status on skill retention at higher configuration levels. Neuropsychological assessment warrants consideration as a valuable tool in rehabilitation settings to assist in functional device candidacy evaluations.

Making Patients Fit for Surgery: Introducing a Four Pillar Multimodal Prehabilitation Program in Colorectal Cancer Background Considering the relation between preoperative functional capacity and postoperative complications, enhancing patients’ functional capacity before surgery with a prehabilitation program may facilitate faster recovery and improve quality of life. However, time before surgery is short, mandating a multimodal and high-intensity training approach. This study investigated feasibility and safety of a prehabilitation program for colorectal cancer. Methods Multimodal prehabilitation was offered to patients eligible for participation and they were assigned to an intervention or control group by program availability. The prehabilitation program consisted of the following four interventions: in-hospital high-intensity endurance and strength training, high-protein nutrition and supplements, smoking cessation, and psychological support. Program attendance, patient satisfaction, adverse events, and functional capacity were determined. Results Fifty patients participated in this study (prehabilitation 20, control 30). Program evaluation revealed a high (90%) attendance rate and high level of patient satisfaction. No adverse events occurred. Endurance and/or strength were improved. Eighty-six percent of patients with prehabilitation recovered to their baseline functional capacity 4 weeks postoperatively, 40% in the control group (P < 0.01). Conclusions Multimodal prehabilitation including high-intensity training for colorectal cancer patients is feasible, safe, and effective. A randomized controlled trial (NTR5947) was initiated to determine whether prehabilitation may lower morbidity and mortality rates in colorectal surgery.

Bilateral Quadriceps Muscle Strength and Pain Correlate With Gait Speed and Gait Endurance Early After Unilateral Total Knee Arthroplasty: A Cross-sectional Study Objective The aim of this study was to determine the correlations between objective performance-based physical function, self-reported physical function, quality of life, and gait function at 1 mo after unilateral total knee arthroplasty. Design Cross-sectional data from 195 patients who underwent unilateral primary total knee arthroplasty were analyzed. The isometric knee extensor and flexor strength of both knees, gait parameters, 6-min walk test, timed up-and-go test, timed stair-climbing test, knee flexion and extension range of motion of surgical knee, Western Ontario McMaster Universities Osteoarthritis Index pain, stiffness, and functional levels, EuroQol five-dimensions questionnaire, and visual analog scale for knee pain were assessed. Results In bivariate analyses, both postoperative gait speed and gait endurance had significant positive correlations with postoperative peak torque of the extensor and flexor of both knees, cadence, stride length, and significant negative correlation with timed up-and-go, stair-climbing test ascent, stair-climbing test descent, visual analog scale, Western Ontario McMaster Universities Osteoarthritis Index pain, stiffness, and function levels. In the linear regression analyses, postoperative peak torque of the extensors of both knees and VAS for knee pain were factors correlated with postoperative gait speed and gait endurance. Conclusions Quadriceps muscle strength of both knees and knee pain were important factors correlated with gait function early after total knee arthroplasty.

Trunk and Head Control During Walking in Patients With Unilateral Vestibular Hypofunction: Effect of Lower Limb Somatosensory Input Objectives The aim of the study was to investigate (a) postural control, especially trunk and head control, in patients with unilateral vestibular hypofunction and healthy controls during walking on firm and foam surface and (b) the difference between the impact of left and right unilateral vestibular hypofunction, and correlation between trunk/head control and vestibular function in the patients. Design Thirteen patients and 13 healthy controls were recruited. Vestibular function was examined based on the canal paresis value. Participants walked on a treadmill on firm and foam surface. Peak-to-peak trunk (Troll and Tpitch) and head roll and pitch angle (Hroll and Hpitch) were calculated as primary outcome measures. Results In the unilateral vestibular hypofunction group but not healthy controls, Troll was significantly higher on foam than firm surface (P = 0.03). Tpitch was significantly higher on foam than firm surface in both groups (P = 0.02). Patients had significantly lower Hroll (P = 0.03) and Hpitch (P = 0.02) and lower head-trunk correlation in both medio-lateral (P = 0.05) and anteroposterior direction (P = 0.03) than those in the healthy control group. Conclusions Patients with unilateral vestibular hypofunction seemed to rely more on lower limb somatosensory input for trunk control especially in the medio-lateral direction compared with healthy controls. Lower head sway and head-trunk correlation may suggest a more independent and successful head control strategy in patients.