The Value of Participating in International Physical Medicine and Rehabilitation No abstract available

Caloric Intake Relative to Total Daily Energy Expenditure Using a Spinal Cord Injury–Specific Correction Factor: An Analysis by Level of Injury Objective The aims of the study were to evaluate the influence of level of spinal cord injury (SCI) on caloric intake relative to total daily energy expenditure (TDEE) and body composition, and to develop a SCI–specific correction factor for the TDEE estimation. Design Individuals with paraplegia (PARA, n = 28) and tetraplegia (TETRA, n = 13) were analyzed. Daily caloric intake, basal metabolic rate, and TDEE were obtained using dietary recall, indirect calorimetry, and prediction equations, respectively. Caloric intake and TDEE were adjusted to bodyweight. Body composition was assessed using dual-energy x-ray absorptiometry. Results Total caloric (PARA 1516.4 ± 548.4, TETRA 1619.1 ± 564.3 kcal/d), fat (PARA 58.6 ± 27.4, TETRA 65.8 ± 29.7 g), and protein (PARA 62.7 ± 23.2, TETRA 71.5 ± 30.9 g) intake were significantly higher in TETRA versus PARA (P < 0.05) when adjusted for bodyweight. Adjusted and unadjusted TDEE (unadjusted: PARA 1851.0 ± 405.3, TETRA 1530.4 ± 640.4 kcal/d) and basal metabolic rate (unadjusted: PARA 1516.6 ± 398.0, TETRA 1223.6 ± 390.2 kcal/d) were significantly higher in PARA versus TETRA (P < 0.05). Bone mineral content (PARA 3.17 ± 0.6, TETRA 2.71 ± 0.5 g), lean body mass (PARA 50.0 ± 8.6, TETRA 40.96 ± 8.8 kg), and regional percent body fat (PARA 36.45 ± 8.0, TETRA 41.82 ± 9.1) were different between groups (P < 0.05). The SCI–specific correction factor was 1.15. Conclusions A dichotomy exists in caloric intake, TDEE, and body composition among TETRA and PARA. The SCI–specific correction factor of 1.15 is a promising tool to estimate TDEE in SCI. 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) Understand the influence of spinal cord level of injury on energy expenditure and body composition; (2) Appreciate that equations used to estimate total daily energy expenditure overestimate energy expenditure in individuals with spinal cord injury; and (3) Understand the importance of normalizing caloric intake to bodyweight after spinal cord injury. 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)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Impact of a Stroke Recovery Program Integrating Modified Cardiac Rehabilitation on All-Cause Mortality, Cardiovascular Performance and Functional Performance Objective Using a feasibility analysis and matched subgroup analysis, this study investigated the implementation/safety/outcomes of a stroke recovery program (SRP) integrating modified cardiac rehabilitation for stroke survivors. Design This prospective cohort study of 783 stroke survivors were discharged from an inpatient rehabilitation facility to an outpatient setting; 136 SRP-participants completed a feasibility study and received the SRP including modified cardiac rehabilitation, 473 chose standard of care rehabilitation (nonparticipants), and a group (n = 174) were excluded. The feasibility study assessed the following: safety/mortality/pre-post cardiovascular performance/pre-post function/patient/staff perspective. In addition to the feasibility study, a nonrandomized subgroup analysis compared SRP-participants (n = 76) to matched pairs of nonparticipants (n = 66, with 10 nonparticipants used more than once) for mortality/pre-post function. Results The feasibility study showed the SRP to have the following (a) excellent safety, (b) markedly low 1-yr poststroke mortality from hospital admission (1.47%) compared with national rate of 31%, (c) improved cardiovascular performance over 36 sessions (103% increase in metabolic equivalent of tasks times minutes), (d) improved function in Activity Measure of Post-Acute Care domains (P < 0.001), (e) positive reviews from SRP-participants/staff. Subgroup analysis showed the SRP to (a) positively impact mortality, nonparticipants had a 9.09 times higher hazard of mortality (P = 0.039), and (b) improve function in Activity Measure of Post-Acute Care domains (P < 0.001). Conclusions Stroke survivors receiving a SRP integrating modified cardiac rehabilitation may potentially benefit from reductions in all-cause mortality and improvements in cardiovascular performance and function.

The Feasibility and Effects of Acupuncture on Muscle Soreness and Sense of Well-being in an Adolescent Football Population Objective The aims of the study were to assess the feasibility of performing acupuncture on multiple adolescent athletes in a warm weather, high-intensity training environment and to measure perceived effects of acupuncture on delayed-onset muscle soreness and sense of well-being. Design This is a prospective feasibility study (registered clinical trial NCT03478800). Forty-two healthy male participants, aged 13–18 yrs, were involved in at least 1 of 5 treatment days for a total of 147 individual treatment sessions. Fifteen-minute treatments of traditional needle acupuncture were administered at the football field. Time, cost, adverse effects, and participant/provider ratio were observed. Effect on delayed-onset muscle soreness and sense of well-being were measured via pretreatment and posttreatment visual analog scale (0–10) rating analyses. Results The results are as follows: time required by research staff on treatment days, 75 mins; total cost, US $700; temperature range, 21°C–28°C; and largest participant to acupuncturist ratio, 7–10:1. No major adverse effects occurred; 55% reported minimal adverse effects, such as mild focal numbness or tingling. Overall pretreatment to posttreatment effect on delayed-onset muscle soreness (average over 5 days) demonstrated significantly improved posttreatment scores (pre 4.6 ± 2.0; post 2.9 ± 2.2, P < 0.001). There was no significant effect on sense of well-being (P = 0.12). Conclusions Effectively providing acupuncture to multiple adolescent football players in their training environment is feasible with appropriate staff and resources. Despite mild adverse effects, treatment was well tolerated. This study provides guidance on acupuncture delivery to other athletes in their training environments.

The Validity of the Montreal Cognitive Assessment for Moderate to Severe Traumatic Brain Injury Patients: A Pilot Study Objective The aim of the study was to pilot the use of Montreal Cognitive Assessment as a quick clinical screen for cognitive assessment in traumatic brain injury patients. Design The study recruited 61 participants with moderate to severe traumatic brain injury presenting to a tertiary rehabilitation center under the Brain Injury Program. A Montreal Cognitive Assessment questionnaire and neuropsychological battery (Repeatable Battery for the Assessment of Neuropsychological Status and Color Trails Test) were administered to participants who had completed inpatient rehabilitation. Results Receiver operating characteristic analysis for the Montreal Cognitive Assessment revealed an optimal balance of sensitivity and specificity at 24/25 to discriminate participants who were classified as less than 5th centile on the Total Scale Index on the Repeatable Battery for the Assessment of Neuropsychological Status. This achieved a sensitivity, specificity, PPV, and NPV of 73.9%, 86.5%, 77.3%, and 84.2%, respectively. Receiver operating characteristic analysis for the trail making subtest of the Montreal Cognitive Assessment achieved a sensitivity, specificity, PPV, and NPV of 79.4%, 74.1%, 79.4%, and 74.1% in identifying patients classified as less than 5th centile on Color Trail Test part 2. Conclusions The use of Montreal Cognitive Assessment displayed good validity in identifying patients with clinically significant impairment on a standard neuropsychological assessment battery in the study population. However, it may lack sensitivity for estimating mild levels of impairment.

Energy Cost of Slow and Normal Gait Speeds in Low and Normally Functioning Adults Objective Slow walking speed paired with increased energy cost is a strong predictor for mortality and disability in older adults but has yet to be examined in a heterogeneous sample (ie, age, sex, disease status). The aim of this study was to examine energy cost of slow and normal walking speeds among low- and normal-functioning adults. Design Adults aged 20–90 yrs were recruited for this study. Participants completed a 10-m functional walk test at a self-selected normal walking speed and were categorized as low functioning or normal functioning based on expected age- and sex-adjusted average gait speed. Participants completed two successive 3-min walking stages, at slower than normal and normal walking speeds, respectively. Gas exchange was measured and energy cost per meter (milliliter per kilogram per meter) was calculated for both walking speeds. Results Energy cost per meter was higher (P < 0.0001) in the low-functioning group (n = 76; female = 59.21%; mean ± SD age = 61.13 ± 14.68 yrs) during the slower than normal and normal (P < 0.0001) walking speed bouts compared with the normal-functioning group (n = 42; female = 54.76%; mean ± SD age = 51.55 ± 19.51 yrs). Conclusions Low-functioning adults rely on greater energy cost per meter of walking at slower and normal speeds. This has implications for total daily energy expenditure in low-functioning, adult populations.

Early Detection of Diabetic Polyneuropathy Using Paired Stimulation Studies of the Sensory Nerves Objective This study seeks to use the relative refractory period, a sensitive parameter for detecting early change in peripheral polyneuropathies, as a tool for early detection of diabetic polyneuropathy. Design The relative refractory period of the median and sural sensory nerves was measured in 57 diabetic patients (male 31, female 26) and 23 healthy controls (male 16, female 7). The shortest interstimulus interval, where the latency of the response to the second stimulus recovers to normal, was defined as the relative refractory period. Results The relative refractory period of the median and sural nerves were significantly longer in diabetic patients (3.6 msec, P < 0.001, and 3.8 msec, P < 0.001, respectively) than in the control group (3.0 msec in both nerves). Relative refractory period values of both nerves were also significantly prolonged compared with the control group, even in diabetic patients without diabetic polyneuropathy based on conventional conduction studies (3.3 msec, P = 0.002, for median nerve; 3.5 msec, P < 0.001, for sural nerve) or without any clinical symptoms and signs (3.3 msec, P = 0.007, for median nerve; 3.5 msec, P = 0.001, for sural nerve). Conclusions The relative refractory period was prolonged in diabetic patients even before other electrophysiologic abnormalities or clinical findings appeared. These results suggest that the relative refractory period can be a possible early indicator of diabetic polyneuropathy.

Differences in the Mitochondrial and Lipid Droplet Morphology in Female Office Workers With Trapezius Myalgia, Compared With Healthy Controls: A Muscle Biopsy Study Objective Trapezius myalgia or, more specifically, myofascial dysfunction of the upper trapezius mainly affects women performing jobs requiring prolonged low level activation of the muscle. This continuous low muscle load can be accompanied by a shift to a more anaerobic energy metabolism, causing pain. The aim of the study was to investigate whether morphological signs of an impaired aerobic metabolism are present in female office workers with trapezius myalgia. Design Muscle biopsy analysis, using electron and light microscopy, was performed to compare mitochondrial and fat droplet morphology, and irregular muscle fibers, between female office workers with (n = 17) and without (n = 15) work-related trapezius myalgia. Results The patient group showed a significantly higher mean area (P = 0.023) and proportion (P = 0.029) for the subsarcolemmal and intermyofibrillar mitochondria respectively, compared with the control group. A significantly lower mean area of subsarcolemmal lipid droplets was found in the patient group (P = 0.015), which also displayed a significantly higher proportion of lipid droplets touching the mitochondria (P = 0.035). A significantly higher amount of muscle fibers with cytochrome c oxidase–deficient areas were found in the patient group (P = 0.030). Conclusions The results of the present study may be indicative for an impaired oxidative metabolism in work-related trapezius myalgia. However, additional research is necessary to confirm this hypothesis.

Electromyography Evaluation of Bodyweight Exercise Progression in a Validated Anterior Cruciate Ligament Injury Rehabilitation Program: A Cross-Sectional Study Objectives Regaining muscle strength is essential for successful outcome after anterior cruciate ligament injury, why progression of exercise intensity in anterior cruciate ligament injury rehabilitation is important. Thus, this study evaluated hamstring and quadriceps muscle activity progression during bodyweight exercises used in a validated anterior cruciate ligament injury rehabilitation program. Design The study design involved single-occasion repeated measures in a randomized manner. Twenty healthy athletes (nine females) performed nine bodyweight exercises (three exercises per rehabilitation phase). Surface electromyography signals were recorded for hamstring (semitendinosus, biceps femoris) and quadriceps (vastus medialis, vastus lateralis) muscles and normalized to isometric peak electromyography. Results Hamstring muscle activity did not increase from one rehabilitation phase to the next, ranging between 8% and 45% normalized electromyography for semitendinosus and 11% and 54% normalized electromyography for biceps femoris. Only one exercise (Cook hip lift) exhibited hamstring muscle activities more than 60% normalized electromyography. By contrast, quadriceps muscle activity increased, and late-phase exercises displayed high normalized electromyography (vastus lateralis >60% and vastus medialis >90% normalized electromyography). Conclusions The examined bodyweight exercises did not progress for hamstring muscle activity but successfully progressed for quadriceps muscles activity. This study highlights the need for consensus on exercise selection when targeting the hamstring muscles in the rehabilitation after anterior cruciate ligament injury.

A New Threshold for Appendicular Lean Mass Discriminates Muscle Weakness in Women With Hip Fracture: A Cross-Sectional Study Objective The aim of the study was to investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass, appendicular lean mass/body mass index ratio and appendicular lean mass/height2 to separate weak and nonweak women. Secondly, we aimed to explore alternative thresholds for the three measures of muscle mass to discriminate weakness. Design This is cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed appendicular lean mass by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength of less than 16 kg. Results Weakness was not significantly associated with appendicular lean mass of less than 15.02 kg, appendicular lean mass/body mass index ratio of less than 0.512 or appendicular lean mass/height2 of less than 5.67 kg/m2. For appendicular lean mass (but not for the other 2 measures of muscle mass), an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ2 (1, n = 160) = 10.77 (P = 0.001). The association between appendicular lean mass of less than 11.87 kg and grip strength of less than 16 kg persisted after adjustment for age and body mass index (odds ratio = 2.50, 95% confidence interval = 1.17–5.34, P = 0.018). Conclusions Data suggest that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For appendicular lean mass, an alternative cutoff point actually separated weak and nonweak women.