Abstract. Objective. There is no specific framework for the clinical management of sports related brachial plexus injuries. Necessarily, rehabilitation is based on injury presentation and clinical diagnostics but it is unclear what the underlying evidence base to inform rehabilitative management. Methods. A systematic review of the literature was undertaken in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We applied the PEO criteria to inform our search strategy to find articles that reported the rehabilitative management of brachial plexus injuries sustained while playing contact sports. An electronic search of Medline, CINAHL, SPORTDiscus and Web of Science from inception to 3rd November 2022 was conducted. MESH terms and Boolean operators were employed. We applied an English language restriction but no other filters. Manual searches of Google Scholar and citation searching of included manuscripts were also completed. All study types were considered for inclusion provided they were published as peer-reviewed primary research articles and contained relevant information. Two investigators independently carried out the searches, screened by title, abstract and full text. Two researchers independently extracted the data from included articles. Data was cross-checked by a third researcher to ensure consistency. To assess internal validity and risk of bias, the Joanna Briggs Institute (JBI) critical appraisal tools were utilised. Results. The search generated 88 articles. Following removal of duplicates, 43 papers were evaluated against the eligibility criteria. Nine were eligible for full text review, with the majority of exclusions being expert opinion articles. Eight case reports were included. One article reported three individuals, resulting in data for ten athletes. The mean age was 19.8 years (±4.09). Injuries occurred in five American football players, two wrestlers, two rugby players, and a basketball player. No two studies applied the same diagnostic terminology and the severity of injury varied widely. Burning pain and altered sensation was the most commonly reported symptom, alongside motor weakness in the upper limb. Clinical presentation and management differed by injury pattern. Traction injuries caused biceps motor weakness and atrophy of the deltoid region, whereas compression injuries led to rotator cuff weakness. In all cases treatment was separated into acute and rehabilitative management phases, however the time frames related to these differed. Acute interventions varied but essentially entailed soft tissue inflammation management.
Background. Proximal femoral fracture is a common, major health problem resulting in loss of functional independence and a high cost burden on society.
ACL injured patients show variability in the ability to perform functional activities (Button et al., 2006). It is unknown whether this is due to differences in physical capability or whether fear of re-injury plays a role. Fear of re-injury is not commonly addressed in rehabilitation. This study aimed to investigate whether fear of re-injury impacts rehabilitation of ACL injured patients. An initial group of five ACL reconstructed participants (ACLR, age: 30±11 years, weight: 815±115 N, height: 1.74±0.07 m, all male), five ACL deficient participants (ACLD, age: 31±12 years, weight: 833±227 N, height: 1.80±0.11 m, four male and one female), and five healthy controls (age: 30±3 years, weight: 704±126 N, height: 1.70±0.09 m, three male and two female) were compared. Fear of re-injury was assessed using the Tampa Scale for Kinesiophobia (Kvist, 2004). Quadriceps strength was measured on a Biodex dynamometer. Functional activity was assessed by a single legged maximum distance hop (on the injured leg for ACL patients). Motion analysis was performed with a VICON system, and a Kistler force plate. Hop distance was calculated using the ankle position. The peak knee extension moment during landing, and the knee angle at this peak moment were calculated in VICON Nexus. The ACLD group scored worse on the Tampa scale for Kinesiophobia than the ACLR group (32±4 and 26±4). The ACLD patients did not hop as far as the ACLR and control groups (1.0±0.3, 1.3±0.1 and 1.4±0.3 m). The peak knee extension moments during landing were lowest in the ACLD group (263±159 Nm), slightly higher in the control group (354±122 Nm) and highest in the ACLR group (490±222 Nm), while knee flexion angles at these moments were similar (ACLD: 28±11, ACLR: 33±7 and control: 36±13 degrees). The ACLD group had weaker quadriceps than the control group, while the ACLR group was stronger (143±44 Nm, 152±42, and 167±50 Nm respectively). Fear of re-injury and decreased quadriceps strength potentially both impact on the functional performance of ACL injured patients.
The principal of “function priority, early rehabilitation, and return to sports” is now the goal for sports injury rehabilitation. Neuromuscular electrical stimulation for anterior cruciate ligament (ACL) reconstruction is a rising procedure for early rehabilitation. This paper systematically assessed the effects of neuromuscular electrical stimulation on postoperative ACL reconstruction to provide guidance for physiotherapist and patient when designing a suitable rehabilitation protocol. To evaluate the interventional outcomes of neuromuscular electrical stimulation following ACL reconstruction, we searched PubMed, EMbase, the Cochrane Library, Web of Science and CNKI to collect all randomized controlled trials (RCTs) comparing the effects with neuromuscular electrical stimulation and without intervention on rehabilitation after ACL reconstruction up to January 30, 2022. Two investigators independently performed literature screening, data extraction, bias assessment of risk, and used RevMan 5.3 software to conduct a meta-analysis. A total of six RCTs were included, and the results showed that the use of neuromuscular electrical stimulation after anterior cruciate ligament reconstruction significantly improved the International Knee Documentation Committee (IKDC) scores (MD 6.33, 95% CI [-0.43, 12.22]; I2 = 66%; p = 0.040), the Lysholm score (MD 7.94, 95% CI [6.49, 9.39]; I2 = 89%; p < 0.001), and the range of motion (ROM) (MD 9.99, 95% CI [7.97, 12.02]; I2 = 81%; p < 0.001) in the knees when compared to the control group without using neuromuscular electrical stimulation. Existing evidence show that neuromuscular electrical stimulation is beneficial for early rehabilitation after ACL reconstruction. The use of neuromuscular electrical stimulation is encouraged in the design of rehabilitation protocol. However, due to the limited number of RCT studies and the small sample size, further multi-center RCTs with more participants are needed for a higher-level evidence.
As high incidences of tendinopathies are observed particularly in those who intensively use their tendons, we assume that pathological changes are caused, at least partially, by mechanical overload. This has led to the so-called overload hypothesis, explaining the development of tendinopathies by structural failure resulting from excessive load. At the same time, tendon loading is an important part in tendon rehabilitation. Currently, exercise treatment approaches such as eccentric training or heavy load resistance training are widely applied in tendinopathy rehabilitation, with good clinical results such as an improvement in function and a reduction in pain. Particularly those rehabilitative approaches which impose high strains on the tendon may induce an adaptation of the tendon's mechanical properties such as increased tendon stiffness. An increased tendon stiffness is often interpreted as desirable, as it may protect the tendon from overloading and thus prevent future strain injuries. However, the tendinopathic tendon is not necessarily less stiff than the tendon in the contralateral leg and an improvement in tendon stiffness is not necessarily accompanied by an improvement in tendon pain or function. In addition, metabolic factors, resulting e.g. in low-level systemic inflammation, may contribute to pathological tendon tissue changes and are not necessarily affected by an exercise program, while nutritional interventions or dietary supplements may potentially affect tendon cell metabolism. Indeed, dietary supplements have been introduced as an additional therapeutic approach in the treatment of tendinopathies in recent years, and their positive curative effects have been reported for both the general population and athletes. In the management of tendinopathies, it may thus be advisable if therapeutic approaches aim to address both tendon mechanics and tendon metabolism for better treatment effectiveness and a sustainable improvement in pain and function.
Patients with bone and muscle weakness from disuse have higher risk of fracture and worse post-injury mortality rates. The goal of this current study was to better inform post-fracture rehabilitation strategies by investigating if physical remobilization following disuse by hindlimb unloading improves osteochondral callus formation compared to continued disuse by hindlimb suspension (HLS). We hypothesized that continued HLS would impair callus bone and cartilage formation and that physical rehabilitation after HLS would increase callus properties. All animal procedures were approved by the VCU IACUC. Skeletally mature, male and female C57BL/6J mice (18 weeks) underwent HLS for 3 weeks. Mice then had their right femur fractured by open surgical dissection (stabilized with 24-gauge pin). Mice were then either randomly assigned to continued HLS or allow normal physical weight-bearing remobilization (HLS + R). Mice allowed normal cage activity throughout the experiment served as controls (GC). All mice were sacrificed 14-days following fracture with 4-8 mice (male and female) per treatment. Data analyzed by respective ANOVA with Tukey post-hoc (*p< 0.05; # p < 0.10) Male and female mice showed conserved and significant decreases in hindlimb callus bone formation from continued HLS versus HLS + R. Combining treatment groups regardless of mouse sex, histological analyses using staining on these same calluses demonstrated that HLS resulted in trends toward decreased cartilage cross-sectional area and increased osteoclast density in woven bone versus physically rehabilitated mice. In support of our hypothesis, physical remobilization increases callus bone formation following fracture compared to continued disuse potentially due to increased endochondral ossification and decreased bone resorption. In all, partial weight-bearing exercise immediately following fracture may improve callus healing compared to delayed rehabilitation regimens that are frequently used.
To investigate changes in quadriceps and hamstrings muscle groups during sustained isokinetic knee flexion and extension. 125 paediatric participants (45 males and 80 females, mean age 14.2 years) were divided into two groups: participants with a confirmed ACL tear (ACLi, n = 64), and puberty- and activity-level matched control participants with no prior history of knee injuries (CON, n = 61). Participants completed a series of 44 repetitions of isokinetic knee flexion and extension at 90 deg/ sec using a Biodex dynamometer (Biodex Medical Systems Inc, Shirley, New York). Surface EMG sensors (Delsys Incorporated, Natick, MA) simultaneously recorded the quadriceps and hamstring activations. Muscle function was assessed as the change in quadriceps activation and extension torque were calculated using the percent difference between the mean of the first five trials, and the mean of the last five trials. ACLi participants had significantly higher percent change in quadriceps activation for both healthy and injured legs, in comparison to CON dominant leg. As such, the healthy leg of the ACLi participants is activating significantly more than their health matched controls, while also demonstrating reduced muscular endurance (less torque in later repetitions). Therefore, we conclude that the non-injured limb of the ACLi participant is not performing as a healthy limb. Since return to activity clearance following ACLi implies return to sport against age- and activity matched opponents, clearing young athletes based on the non-injured contralateral limb may put them at greater risk of reinjury.
Whilst home-based exercise rehabilitation plays a key role in determining patient outcomes following orthopaedic intervention (e.g. total knee replacement), it is very challenging for clinicians to objectively monitor patient progress, attribute functional improvement (or lack of) to adherence/non-adherence and ultimately prescribe personalised interventions. This research aimed to identify whether 4 knee rehabilitation exercises could be objectively distinguished from each other using lower body inertial measurement units (IMUs) and principle components analysis (PCA) in the hope to facilitate objective home monitoring of exercise rehabilitation. 5 healthy participants performed 4 repetitions of 4 exercises (knee flexion in sitting, knee extension, single leg step down and sit to stand) whilst wearing lower body IMU sensors (Xsens, Holland; sampling at 60 Hz). Anthropometric measurements and a static calibration were combined to create the biomechanical model, with 3D hip, knee and ankle angles computed using the Euler sequence ZXY. PCA was performed on time normalised (101 points) 3D joint angle data which reduced all joint angle waveforms into new uncorrelated PCs via an orthogonal transformation. Scatterplots of PC1 versus PC2 were used to visually inspect for clustering between the PC values for the 4 exercises. A one-way ANOVA was performed on the first 3 PC values for the 9 variables under analysis. Games-Howell post hoc tests identified variables that were significantly different between exercises. All exercises were clearly distinguishable using the PC scatterplot representing hip flexion-extension waveforms. ANOVA results revealed that PC1 for the knee flexion angle waveform was the only PC value statistically different across all exercises. Findings demonstrate clear potential to objectively distinguish between different knee rehabilitation exercises using IMU sensors and PCA. Flexion-extension angles at the hip and knee appear most suited for accurate separation, which will be further investigated on patient data and additional exercises.
Following acute ACL rupture patients are routinely referred for rehabilitation but the timing and level of functional recovery related to rehabilitation outcome are poorly defined. The primary aim of this study was to measure functional recovery following acute ACL rupture in the clinical setting using a two dimensional movement analysis system. A longitudinal research design was used; we aimed for three clinical movement analysis sessions over the course of rehabilitation. One hundred and fifteen patients were recruited. Sixty three uninjured matched controls were recorded once performing all the functional activities; walking, jogging, distance hop and run and stop. Participants were filmed in the sagittal plane using a digital camcorder to extract kinematic data. Average recovery over time was modelled using a least squares third order polynomial. The secondary aim was to define the outcome measures and treatment goals used in ACL rehabilitation by specialist knee physiotherapists. A questionnaire was distributed to 300 hospitals across the UK. From the 44 responses insight was obtained about parameters physiotherapists use to plan treatment and evaluate recovery. Repeated movement analysis showed that gait velocity took on average 85 days to recover to within the normal limits of uninjured controls. Jogging velocity took 30 days; Hop distance took 55 days for the non-injured leg and 100 days for the injured leg; Knee range during the landing phase of run and stop took 80 days to recover but demonstrated some deterioration. The questionnaire identified that specialist knee physiotherapists use 60 different outcome measures and 34 rehabilitation treatment goals, which can be sub-divided into patient reported (PR), functional activities (A) and impairments (I). The percentage usage by physiotherapists for each category of outcome measure were 55.8% (A), 62.8% (I) to 67.4% (PR) and for treatment goals 55.8% (PR), 69.8% (A) to 81.4% (I). Hopping is the most frequently evaluated functional activity but there are large differences in its utilisation. The application of functional goals and outcome measures in rehabilitation is not universal with specialist physiotherapists generally adopting an impairment approach. Repeated movement analysis in the clinical setting provided objective data on the recovery of functional activities that progressively challenge knee stability. Gait and hop distance appear to be the most useful variables for tracking performance over time but their predictive value needs to be explored further. Adaptations in the non-injured leg indicate that its use as a control needs to be done with caution. For jogging and run and stop there appears to be a threshold after which patients can perform these activities rather than a gradual recovery. Clinical movement analysis could be used to provide objective feedback on recovery levels and help guide the rehabilitation process. However, currently functional goals and milestones are not always included in the planning and evaluation of rehabilitation. Developing better rehabilitation should involve greater integration of functional activity measures into practice. This would require a shift from an impairment rehabilitation approach to focus on functional goals.
In patients with developmental dysplasia of the hip (DDH) chronic joint dislocation induces remodeling of the soft tissue with contractures, muscle atrophy, especially of the hip abductors muscles, leading to severe motor dysfunction, pain and disability (1). The aim pf the present work is to explore if a correct positioning of the prosthetic implants through 3D skeletal modeling surgical planning technologies and an adequate customized rehabilitation can be beneficial for patients with DDH in improving functional performance. The project included two branches: a methodology branch of software development for the muscular efficiency calculation, which was inserted in the Hip-Op surgical planning system (2), developed at IOR to allow surgical planning for patients with complex hip joint impairment; and a clinical branch which involved the use of the developed software as part of a clinical multicentric randomized trial. 50 patients with DDH were randomized in two groups: a simple surgical planning group and an advanced surgical planning with muscular study group. The latter followed a customized rehabilitation program for the strenghtening of hip abductor muscles. All patients were assessed before surgery (T0) and at 3 (T1) and 6 months (T2) postoperatively using clinical outcome (WOMAC, HHS, ROM, MMT, SF12, 10mt WT) and instrumental measures (Dynamometric MT). Pre- and post-operative musculoskeletal parameters obtained by the software (i.e., leg length discrepancy, hip abductor muscle lengths and lever arms) using Hip-Op during the surgical planning were considered. One Way ANOVA for ROM measurement showed a significant improvement at T2 in patients included in experimental group, as well as WOMAC, HHS and SF12 score. The Dynamometric MT score showed significant differences between at T2 (p<0.009). Spearman's rank correlation coefficients showed a significant correlation between both pre- and post-operative abductors lever arm (mm) and hip abductor muscle strength at T2 (ρ = −0.55 pre-op and ρ = −0.51 post-op, p p<0.012 and p<0.02 respectively) and between the operated pre-postoperative leg length variation (mm) and the hip abductor muscle strength (ρ = −0.55, p p<0.013). Results so far obtained showed an improvement of functional outcomes in patients undergoing hip replacement surgery who followed therapeutic diagnostic pathway sincluding a preoperative planning including the assessment of the abductiors lever arm and a dedicated rehabilitation program for the strenghtening of abductios. Particularly interesting is the inverse relationship between the strength of the hip abductor muscles and the variation of the postoperative abductor lever arm.
Aged trauma patients are at high risk for various comorbidities and loss of function following hip fracture. Consequently a multidisciplinary approach for the treatment of these patients has become more famous in order to maintain the patients” activity level and health status prior to trauma. This study evaluates the effect of a multidisciplinary inpatient rehabilitation on the short- and long-term functional status of geriatric patients following hip fracture surgery. A collective of 158 hip fracture patients (> 80 years) who underwent surgery were included in this study. An initial Barthel Index lower than 30 points was a criteria to exclude patients from this study. Two subgroups, depending on the availability of treatment spots at the rehabilitation center were made. No other item was used to discriminated between the groups. Group A (n=95) stayed an average of 21 days at an inpatient rehabilitation center specialized in geriatric patients. Group B (n=63) underwent the standard postoperative treatment. As main outcome parameter we used the Barthel Index, which was evaluated for every patient on the day of discharge and checkups after three, six and twelve months.Objectives
Methods
To aid recovery, rehabilitation is an important adjunct to surgery. Acknowledging the MRC framework for complex interventions we assessed the evidence-base for components of comprehensive rehabilitation in total hip (THR) and total knee replacement (TKR) pathways. We conducted systematic reviews and meta-analyses of randomised controlled trials (RCT) of pre-surgical exercise and education, occupational therapy and post-operative physiotherapy. In feasibility RCTs we explored acceptability of pain self-management and occupational therapy before THR, and physiotherapy after TKR. We searched trial registers for ongoing RCTs.Background
Methods
High-volume image guided injections (HVIGI) followed by structured rehabilitation have been shown to be effective in various musculoskeletal conditions including Achilles tendinopathy and shoulder impingement syndrome. The aim was to explore the effect of a HVIGI in Hoffa's fat pad impingement, a common cause of anterior knee pain. 100 consecutive subjects who received a HVIGI followed by a standardised physiotherapy rehabilitation regime for Hoffa's fat pad impingement (diagnosed using clinical history, examination and magnetic resonance imaging) at one specialist MSK centre were sent a follow-up questionnaire. The questionnaire collected demographics, symptom length and the percentage improvement in symptoms following the HVIGI. All had received HVIGI consisting of 10ml of 0.5% Marcaine and 50mg of hydrocortisone followed by a structured rehabilitation programme with a focus on lower limb alignment control, flexibility, hip and knee strengthening in line with best practice. Data was analysed using SPSS version 20 at this interim stage; data collection is continuing.Introduction
Materials and Methods
This study sought to determine whether the functional outcome of two common spinal operations could be improved by a programme of post-operative rehabilitation and/or an educational booklet each compared with usual care. This was a multi-centre, factorial, randomised controlled trial on the post operative management of spinal surgery patients, with randomisation stratified by surgeon and operative procedure. The study compared the effectiveness of a rehabilitation programme and an education booklet for the postoperative management of patients undergoing discectomy or lateral nerve root decompression surgery, each compared with “usual care” using a 2 × 2 factorial design, randomising patient to four groups; rehabilitation-only, booklet-only, rehabilitation-plus-booklet, and usual care only. The primary outcome measure was the Oswestry Disability Index (ODI) at 12 months, with secondary outcomes including visual analogue scale measures of back and leg pain. An economic analysis was also performed.Introduction
Methods
The evidence base to inform the management of Achilles tendon
rupture is sparse. The objectives of this research were to establish
what current practice is in the United Kingdom and explore clinicians’
views on proposed further research in this area. This study was
registered with the ISRCTN (ISRCTN68273773) as part of a larger
programme of research. We report an online survey of current practice in the United
Kingdom, approved by the British Orthopaedic Foot and Ankle Society
and completed by 181 of its members. A total of ten of these respondents
were invited for a subsequent one-to-one interview to explore clinician
views on proposed further research in this area.Objectives
Methods
Plantar fasciitis (PF) is one of the widespread conditions causing hindfoot pain. The most common presenting symptoms are functional limitation and pain (first step and activity) on plantar surface of the foot. The non-operative treatments provide complete resolution of pain in 90% of patients, but functional limitation still remains as a risk factor for recurrency of PF. Although the number of non-operative treatment options showing efficacy on pain and functional limitation are excessive, the evidences are limited for functional limitation. Additionally, Mulligan mobilization with movement (MMWM) in Chronic Plantar Fasciitis has been poorly studied in the literature. According to these findings, the study was aimed to determine effectiveness of Mulligan mobilization with movement on Chronic Plantar Fasciitis. A total of 25 patients (40 feet) with chronic PF were included in the study. The patients were randomly divided into Mulligan concept rehabilitation group (PF-M, n=20 feet) and Home
Falls in adults are a major problem and can lead to injuries and death. In order to better understand falls and successful recoveries, identifying kinematics, kinetics, and muscle forces during recovery from loss of balance is crucial. To obtain reactive gait patterns, participants must be subjected to unexpected perturbations such as trips and slips. Previous researchers have reported kinetics recovery data following stumbling; however, the muscle force recovery patterns remain unknown. To better target exercises to reduce the risk of falls, we must first understand which muscles, their magnitude, and their coordination patterns, play a role in a successful recovery from a trip and a slip. Additionally, knowing the successful patterns of lower limb function can help with the diagnosis of faulty movements. A total of 20 healthy adults in their twenties with similar athletic backgrounds were perturbed on a split-belt treadmill using Computer-Assisted
Introduction and Objective. Slipped Capital Femoral Epiphysis (SCFE) is one of the most common hip disorders in children and is characterized by a proximal femoral deformity, resulting in early osteoarthritis. Several studies have suggested that SCFE patients after in situ fixation show an altered gait pattern. Early identification of gait alterations might lead to earlier intervention programs to prevent osteoarthritis. The aim of this study is to analyse gait alterations in SCFE patients after in situ fixation compared to typically developed children, using the Computer Assisted