Aerobic Capacity,Orthostatic Tolerance,and Exercise Perceptions at Discharge From Inpatient Spinal Cord Injury Rehabilitation

Objective

To describe physical capacity, autonomic function, and perceptions of exercise among adults with subacute spinal cord injury (SCI).

Design

Cross-sectional.

Setting

Two inpatient SCI rehabilitation programs in Canada.

Participants

Participants (N=41; mean age ± SD, 38.9±13.7y) with tetraplegia (TP; n=19), high paraplegia (HP; n=8), or low paraplegia (LP; n=14) completing inpatient SCI rehabilitation (mean ± SD, 112.9±52.5d postinjury).

Interventions

Not applicable.

Main Outcome Measures

Peak exercise capacity was determined by an arm ergometry test. As a measure of autonomic function, orthostatic tolerance was assessed by a passive sit-up test. Self-efficacy for exercise postdischarge was evaluated by a questionnaire.

Results

There was a significant difference in peak oxygen consumption and heart rate between participants with TP (11.2±3.4;mL·kg⁻¹·min⁻¹ 113.9±19.7beats/min) and LP (17.1±7.5mL·kg⁻¹·min⁻¹; 142.8±22.7beats/min). Peak power output was also significantly lower in the TP group (30.0±6.9W) compared with the HP (55.5±7.56W) and LP groups (62.5±12.2W). Systolic blood pressure responses to the postural challenge varied significantly between groups (−3.0±33.5mmHg in TP, 17.8±14.7mmHg in HP, 21.6±18.7mmHg in LP). Orthostatic hypotension was most prevalent among participants with motor complete TP (73%). Results from the questionnaire revealed that although participants value exercise and see benefits to regular participation, they have low confidence in their abilities to perform the task of either aerobic or strengthening exercise.

Conclusions

Exercise is well tolerated in adults with subacute SCI. Exercise interventions at this stage should focus on improving task-specific self-efficacy, and attention should be made to blood pressure regulation, particularly in individuals with motor complete TP.     

Maximal Cardiorespiratory Fitness Testing in Individuals With Chronic Stroke With Cognitive Impairment: Practice Test Effects and Test-Retest Reliability

Objectives

To evaluate, for individuals with chronic stroke with cognitive impairment, (1) the effects of a practice test on peak cardiorespiratory fitness test results; (2) cardiorespiratory fitness test-retest reliability; and (3) the relationship between individual practice test effects and cognitive impairment.

Design

Cross-sectional.

Setting

Rehabilitation center.

Participants

A convenience sample of 21 persons (men [n=12] and women [n=9]; age range, 48–81y; 44.9±36.2mo poststroke) with cognitive impairments who had sufficient lower limb function to perform the test.

Interventions

Not applicable.

Main Outcome Measure

Peak oxygen consumption (Vo₂peak, ml·kg⁻¹·min⁻¹).

Results

Test-retest reliability of Vo₂peak was excellent (intraclass correlation coefficient model 2,1 [ICC_2,1]=.94; 95% confidence interval [CI], .86–.98). A paired t test showed that there was no significant difference for the group for Vo₂peak obtained from 2 symptom-limited cardiorespiratory fitness tests performed 1 week apart on a semirecumbent cycle ergometer (test 2–test 1 difference, −.32ml·kg⁻¹·min⁻¹; 95% CI, −.69 to 1.33ml·kg⁻¹·min⁻¹; P=.512). Individual test-retest differences in Vo₂peak were, however, positively related to general cognitive function as measured by the Mini-Mental State Examination (ρ=.485; P<.026).

Conclusions

Vo₂peak can be reliably measured in this group without a practice test. General cognitive function, however, may influence the effect of a practice test in that those with lower general cognitive function appear to respond differently to a practice test than those with higher cognitive function.     

Improvement in aerobic fitness during rehabilitation after hip fracture

Mendelsohn ME, Overend TJ, Connelly DM, Petrella RJ. Improvement in aerobic fitness during rehabilitation after hip fracture.

Objective

To evaluate the effect of an upper-body exercise program on cardiorespiratory fitness in older adults with hip fracture during inpatient rehabilitation.

Design

Randomized controlled trial using a convenience sample.

Setting

An inpatient rehabilitation unit.

Participants

Twenty older patients (age, 81.3±7.2y; 14 women).

Intervention

Patients were randomly assigned to a control group (n=10) or a training group (n=10). Both groups attended physical and occupational therapy sessions 5 times a week during rehabilitation (mean length of stay, 32.9±5.3d). Patients in the training program used an arm crank ergometer 3 times a week for 4 weeks.

Main Outcome Measure

Peak oxygen consumption (Vo₂peak).

Results

Vo₂peak increased significantly in the training group (8.9±1.4 to 10.8±1.7mL·kg⁻¹·min⁻¹) and did not change in the control group (8.9±1.2 to 8.8±1.6mL·kg⁻¹·min⁻¹). At discharge, both groups were significantly improved in all functional outcome measures (Timed Up & Go [TUG] test, Berg Balance Scale [BBS], FIM instrument, two-minute walk test [2MWT], and ten-minute walk test [10MWT]). The training group performed significantly better in mobility (TUG, 2MWT, 10MWT) and balance (BBS) compared with the control group. There was a significant correlation between Vo₂peak and the 2MWT (r=.81) and 10MWT (r=.85) in the training group at discharge.

Conclusions

The upper-body exercise program had a significant effect on aerobic power. Our results suggest that aerobic endurance exercise should be integrated into standard rehabilitation to enhance patients’ aerobic fitness and mobility after hip fracture surgery.     

The use of a lateral wedge insole to reduce knee loading when ascending and descending stairs in medial knee osteoarthritis patients

Background

Stair climbing is a challenging task to the elderly being the task with the first complaint in patients with mild to moderate knee osteoarthritis. Stair climbing results in around six times more compressive load transmitted through the knee joint than walking on level ground. The purpose of this study was to assess whether lateral wedge insoles would reduce medial compartment knee loading when ascending and descending stairs in patients with medial knee osteoarthritis.

Methods

Eight patients with medial knee osteoarthritis were tested in random order with and without a pair of 5° off-the-shelf lateral wedge insoles for two separate activities (stair ascent and stair descent). Kinematic and kinetic data were collected for the lower extremity using a sixteen camera motion capture system and two force plates. Primary outcome measures were the external knee adduction moment and the knee adduction angular impulse.

Findings

During stair ascent and descent, lateral wedge insoles significantly (P < 0.05) reduced the 1st peak external knee adduction moment in early stance (ascent 6.8%, descent 8.4%), the trough in mid stance (ascent 13%, descent 10.7%), 2nd peak in the late stance (ascent 15%, descent 8.3%) and the knee adduction angular impulse compared to the control (standard shoe) with large effect sizes (0.75–0.95).

Interpretation

In this first study on stairs, lateral wedge insoles consistently reduced the overall magnitude of medial compartment loading during stair ascent and descent. Further research is needed to determine the relationship of this with clinical results when ascending and descending stairs with lateral wedge insoles.     

Influence of dexmedetomidine therapy on the management of severe alcohol withdrawal syndrome in critically ill patients

Purpose

Although benzodiazepines are first-line drugs for alcohol withdrawal syndrome (AWS), rapidly escalating doses may offer little additional benefit and increase complications. The purpose of this study was to evaluate dexmedetomidine's impact on benzodiazepine requirements and hemodynamics in AWS.

Materials and Methods

This retrospective case series evaluated 33 critically ill adults with a primary diagnosis of AWS from 2006 to 2012 at an academic medical center.

Results

Dexmedetomidine began a median (interquartile range) of 11 (2, 32) hours into intensive care unit admission and was titrated to an infusion rate of 0.7 (0.4, 0.7) μg kg^− 1 h^− 1 to achieve the desired depth of sedation. In the 12 hours after dexmedetomidine began, patients experienced a 20-mg reduction in median cumulative benzodiazepine dose used (P < .001), a 14-mm Hg lower mean arterial pressure (P = .03), and a 17-beats/min reduction in median heart rate (P < .001). Four (12%) patients experienced hypotension (systolic blood pressure < 80 mm Hg) during therapy, and there were no cases of bradycardia (heart rate < 40 beats/min).

Conclusion

Dexmedetomidine decreased benzodiazepine requirements and improved the overall hemodynamic profile of patients with severe AWS. These results provide promising evidence about the potential benefit of dexmedetomidine for AWS.     

Effect of Balance Support on the Energy Cost of Walking After Stroke

Objective

To examine the influence of balance support on the energy cost of treadmill and overground walking in ambulatory patients with stroke.

Design

Cross-sectional.

Setting

Research laboratory at a rehabilitation center.

Participants

Patients with stroke depending on a walking aid in daily life (n=12; walking aid dependent ambulators) and walking aid independent ambulators (n=12), all able to walk for at least 5 minutes.

Interventions

Not applicable.

Main Outcome Measures

Energy cost (J·kg⁻¹·m⁻¹) and temporal gait parameters (walking speed, mean and coefficient of variation of stride time, and symmetry index) were obtained during 4 walking trials at preferred walking speed: overground with and without a cane and on a treadmill with and without handrail support.

Results

On the treadmill, handrail support resulted in a significant decrease in energy cost of 16%, independent of the group. Although walking aid dependent ambulators had on average a larger reduction in energy cost than walking aid independent ambulators (19% vs 14%), this interaction did not reach statistical significance (P=.11). Interestingly, overground walking with support resulted in an 8% reduction in energy cost for walking aid dependent ambulators, but a 6% increase for walking aid independent ambulators. The reduction in energy cost with support was accompanied by changes in temporal gait parameters, most notably an increase in stride time and symmetry and a decrease in stride time variability.

Conclusions

Balance support can result in a significant reduction in the energy cost of walking in stroke patients, the magnitude of which depends on walking ability and the walking task. Impaired balance control should not be overlooked as a contributing factor to the increased energy cost of walking in patients with stroke, and improving or assisting balance control should be considered to reduce the energy cost of hemiplegic gait.     

Comparison between dexmedetomidine and midazolam for sedation of eclampsia patients in the intensive care unit

Purpose

This study compares the effectiveness of midazolam and dexmedetomidine for the sedation of eclampsia patients admitted to our intensive care unit (ICU).

Patients and Methods

Forty women with eclampsia requiring termination of pregnancy by caesarean delivery were randomized in to 2 groups of 20 to receive either midazolam or dexmedetomidine. The midazolam group received a loading dose of 0.05 mg/kg followed by an infusion of 0.1 mg kg⁻¹ h⁻¹. The dexmedetomidine group loading dose was 1 μg/kg per 20 minutes, followed by continuous infusion at 0.7 μg kg⁻¹ h⁻¹. Heart rate, blood pressure, Ramsey sedation score, antihypertensive need, convulsion fits, and duration in ICU were monitored and recorded all through the ICU stay.

Results

Dexmedetomidine markedly reduced heart rates for the first 24 hours (P < .05) compared with midazolam, but there were no differences at 48 and 72 hours. Mean arterial blood pressures were similar in the 2 groups (P > .05), although in the dexmedetomidine group, it was lower at 5, 6, 12, and 24 hours compared with the first 4 hours (P < .05). Moreover, fewer patients given dexmedetomidine required nitroglycerine and nitroprusside (P < .05). The duration of ICU stay was less in the dexmedetomidine group, 45.5 hours (range, 15-118 hours), than in the midazolam group, 83 hours (minimum-maximum, 15-312 hours).

Conclusion

Dexmedetomidine sedation in eclampsia patients is effective in reducing the demand for antihypertensive medicine and duration of ICU stay.     

Article 11: Aerobic exercise improves work capacity and functional mobility in spinal cord injury above T6

Objective: To determine if adults with low-cervical and high-thoracic spinal cord injury (SCI) significantly improve work capacity and functional mobility after a structured aerobic exercise. Design: Pre- and posttest interventional trial. Setting: Exercise laboratory. Participants: 6 subjects (4 men, 2 women; mean age ± SD, 37.7±12.1y; mean weight, 74.1±21.2kg; mean time since injury, 5.9±5.6y) with motor complete SCI between C7 and T5 completed the intervention. Interventions: Subjects performed arm crank ergometry at 70% of peak power output for 30min/d, 3d/wk for 10 weeks. Main Outcome Measures: Peak oxygen consumption (Vo₂peak), peak power output, and 12-minute wheelchair propulsion (12WCP). Results: Vo₂peak significantly increased, from 10.8±3.6mL·kg⁻¹·min⁻¹ to 12.6±4.2mL·kg⁻¹·min⁻¹ (P<.05) after the intervention, while peak power output and 12WPC increased from 40.8±15.3W to 54.2±18.9W and 1260±344ft to 1358±312ft, respectively (P<.005). Conclusions: Structured aerobic exercise can significantly improve work capacity and functional mobility in persons with motor complete SCI between C7 and T5.     

Systemic and microcirculatory effects of dobutamine in patients with septic shock

Purpose

The aim of this study was to characterize the cardiovascular responses to dobutamine and their predictors. Our hypotheses were that dobutamine mainly produces tachycardia and vasodilation and fails to improve the microcirculation of patients with septic shock.

Materials and Methods

Systemic hemodynamics and sublingual microcirculation were evaluated with dobutamine (0, 2.5, 5.0, and 10.0 μg kg^− 1 min^− 1) in 23 patients with septic shock.

Results

Dobutamine increased heart rate, cardiac index, and stroke volume index (SVI). Mean blood pressure was unchanged, and systemic vascular resistance decreased. Individual responses were heterogeneous. Stroke volume index increased in 52% of the patients. These patients showed lower changes in mean blood pressure (3 ± 16 mm Hg vs − 10 ± 6 mm Hg, P < .05) and higher increases in cardiac index (1.47 ± 0.93 L m^− 1 m^− 2 vs 0.20 ± 0.5 L m^− 1 m^− 2) than did nonresponders. Changes in SVI significantly correlated with echocardiographic left ventricular ejection fraction (r = 0.55). In the whole group, perfused capillary density remained unchanged (14.0 ± 4.3 mm/mm² vs 14.8 ± 3.7 mm/mm²), but improved if basal values were 12 mm/mm² or less (9.1 ± 4.3 mm/mm² vs 12.5 ± 4.8 mm/mm²).

Conclusions

Dobutamine produced variable hemodynamic effects. Systolic dysfunction was the only variable associated with increases in SVI. Finally, dobutamine only improved sublingual microcirculation when severe alterations were found at baseline.     

Are written advance directives helpful to guide end-of-life therapy in the intensive care unit? A retrospective matched-cohort study

Purpose

The purpose of the study was to determine whether treatment preferences in patients' advance directives (ADs) are associated with life-supporting treatments received during end-of-life care in the intensive care unit (ICU).

Material and methods

This is a retrospective cohort study, including patients who died in 4 ICUs of a university hospital in Germany. Patients with ADs were matched with 2 patients each without ADs using propensity scores.

Results

Sixty-four (13%) of 477 patients had ADs, written a median of 109 weeks before admission. Five categories of applicability conditions were identified, most of them difficult to interpret in the ICU (eg, “advanced brain impairment” or “imminent death”). Advance directives contained a number of treatment refusals. Specifically, 63 of 64 refused “life-sustaining measures.” Compared to patients without ADs, patients with ADs were less likely to receive cardiopulmonary resuscitation (9% vs 23%, P = .029) and more likely to have do-not-resuscitate orders (77% vs 56%, P = .007). Therapy-limiting decisions and ICU length of stay did not differ between those with or without ADs.

Conclusions

Patients with ADs are less likely to receive cardiopulmonary resuscitation but otherwise receive similar life-sustaining treatments compared to matched patients without ADs. More research is needed to explore reasons for potential noncompliance with patient preferences.     

Geometric and architectural contributions to hamstring musculotendinous stiffness

Background

Greater hamstring musculotendinous stiffness is associated with lesser anterior cruciate ligament loading mechanisms during both controlled joint perturbations and dynamic tasks, suggesting a potential protective mechanism. Additionally, lesser hamstring stiffness has been reported in females, potentially contributing to their greater risk of anterior cruciate ligament injury. However, the factors which contribute to high vs. low stiffness are unclear. Muscle geometry and architecture influence force production and may, therefore, influence stiffness. The purpose of this investigation was to evaluate the contributions of geometric and architectural muscle characteristics to hamstring stiffness.

Methods

Thirty healthy individuals (15 males, 15 females) volunteered for participation. Biceps femoris long head cross-sectional area, pennation angle, fiber length, tendon stiffness, and posterior thigh fat thickness were assessed via ultrasound imaging, and strength was measured via isometric contraction. Stiffness was assessed via the damped oscillatory technique.

Findings

Following normalization to anthropometric factors, only strength (r = 0.535) and posterior thigh fat thickness (Spearman ρ = − 0.305) were correlated with stiffness. Normalized tendon stiffness (0.06 vs. 0.10 N/m · kg^− 1) and strength (7.1 vs. 10.0 N · kg^− 1) were greater in males, while posterior thigh fat thickness (10.4 vs. 5.0 mm) was greater in females.

Interpretation

Greater posterior thigh fat thickness may influence stiffness by contributing to greater intramuscular fat and shank segment mass, and lesser muscle per unit mass in the thigh segment. These findings suggest that training designed to increase hamstring strength and decrease fat mass may be beneficial for anterior cruciate ligament injury prevention.     

Effect of perioperative terlipressin infusion on systemic,hepatic, and renal hemodynamics during living donor liver transplantation

Background

End-stage liver disease is associated with marked hemodynamic disturbances that are further aggravated during liver transplantation. Terlipressin has been shown to be effective in the management of sepsis-induced hypotension and hepatorenal syndrome and recently has been tried as infusion during liver transplantation. This study assessed the effect of intraoperative and postoperative terlipressin infusion on systemic, hepatic, and renal hemodynamics during adult living donor liver transplantation.

Methods

Eighty recipients were randomly allocated into control (C group; n = 40) and terlipressin (TP group; n = 40), in which, terlipressin infusion was started at the beginning of surgery at a dose of 3 μg kg^− 1 h^− 1 to be reduced to 1.5 μg kg^− 1 h^− 1 after reperfusion and continued for 3 postoperative days; vasoactive agents were used as appropriate in all patients. Systemic hemodynamics, hepatic and renal arterial resistive indices (HARI, RARI), and portal venous blood flow (PBF) were compared between both groups intraoperatively and for 5 postoperative days.

Results

With terlipressin infusion, there were significant increases in both mean arterial pressure and systemic vascular resistance (P < .001), whereas heart rate and cardiac output decreased significantly (P < .001) throughout the study period compared with the C group. Vasoconstrictor drugs required during reperfusion were significantly lower in the TP group. There was a significant decrease in HARI, RARI, and portal venous blood flow in the TP group compared with the C group throughout the study period. There was no significant difference between both groups regarding liver function tests and serum lactate, whereas renal function tests were significantly better in the TP group.

Conclusion

Terlipressin infusion significantly decreased HARI, RARI, and portal vein flow and improved low systemic vascular resistance and mean arterial pressure. It helped to reduce intraoperative vasoactive support and might improve postoperative renal function.     

Functional performance of a total ankle replacement: thorough assessment by combining gait and fluoroscopic analyses

Background

A thorough assessment of patients after total ankle replacement during activity of daily living can provide complete evidence of restored function in the overall lower limbs and replaced ankle. This study analyzes how far a possible restoration of physiological mobility in the replaced ankle can also improve the function of the whole locomotor apparatus.

Methods

Twenty patients implanted with an original three-part ankle prosthesis were analyzed 12 months after surgery during stair climbing and descending. Standard gait analysis and motion tracking of the components by three-dimensional fluoroscopic analysis were performed on the same day using an established protocol and technique, respectively.

Findings

Nearly physiological ankle kinematic, kinetic and electromyography patterns were observed in the contralateral side in both motor activities, whereas these patterns were observed only during stair climbing in the operated side. Particularly, the mean ranges of flexion at the replaced ankle were 13° and 17° during stair climbing and descending, respectively. Corresponding 2.1 and 3.1 mm antero/posterior meniscal-to-tibial translations were correlated with flexion between the two metal components (p < 0.05). In addition, a larger tibiotalar flexion revealed by fluoroscopic analysis resulted in a physiological hip and knee moment.

Interpretation

The local and global functional performances of these patients were satisfactory, especially during stair climbing. These might be associated to the recovery of physiological kinematics at the replaced ankle, as also shown by the consistent antero/posterior motion of the meniscal bearing, according to the original concepts of this ankle replacement design.     

Medical Comorbidities in Disorders of Consciousness Patients and Their Association With Functional Outcomes

Objective

To identify, for patients in states of seriously impaired consciousness, comorbid conditions present during inpatient rehabilitation and their association with function at 1 year.

Design

Abstracted data from a prospective cross-sectional observational study with data collection occurring January 1996 through December 2007.

Setting

Four inpatient rehabilitation facilities in metropolitan areas.

Participants

The study sample of 68 participants is abstracted from a database of 157 patients remaining in states of seriously impaired consciousness for at least 28 days.

Interventions

Not applicable.

Main Outcome Measure

One-year cognitive, motor, and total FIM score.

Results

The most common medical complications during inpatient rehabilitation for the study sample are active seizures (46%), spasticity (57%), urinary tract infections (47%), and hydrocephalus with and without shunt (38%). Presence of ≥3 medical complications during inpatient rehabilitation, controlling for injury severity, is significantly (P<.05) associated with poorer total FIM and FIM motor scores 1 year after injury. The presence of hydrocephalus with and without shunt (r=−.20, −.21, −.18; P ≤.15), active seizures (r=−.31, −.22, −.42), spasticity (r=−.38, −.28, −.40), and urinary tract infections (r=−.25, −.24, −.26) were significantly (P<.10) associated with total FIM, FIM cognitive, and FIM motor scores, respectively.

Conclusions

Reported findings indicate that persons in states of seriously impaired consciousness with higher numbers of medical complications during inpatient rehabilitation are more likely to have lower functional levels 1-year postinjury. The findings indicate that persons with ≥3 medical complications during inpatient rehabilitation are at a higher risk for poorer functional outcomes at 1 year. It is, therefore, prudent to evaluate these patients for indications of these complications during inpatient rehabilitation.     

Measuring cardiac index with a focused cardiac ultrasound examination in the ED

Objectives

Noninvasive technology may assist the emergency department (ED) physician in determining the hemodynamic status in critically ill patients. The objective of our study was to show that ED physicians can accurately measure cardiac index (CI) by performing a bedside focused cardiac ultrasound examination.

Methods

A convenience sample of adult subjects were prospectively enrolled. Cardiac index, left ventricular outflow tract (LVOT) diameter, velocity time integral (VTI), stroke volume index, and heart rate were obtained by trained ED physicians and a certified cardiac sonographer. The primary outcome was percent of optimal LVOT diameter and VTI measurements as verified by an expert cardiologist.

Results

One hundred patients were enrolled, with obtainable CI measurements in 97 patients. Cardiac index, LVOT diameter, VTI, stroke volume index, and heart rate measurements by ED physician were 2.42 ± 0.70 L min⁻¹ m⁻², 2.07 ± 0.22 cm, 18.30 ± 3.71 cm, 32.34 ± 7.92 mL beat⁻¹ m⁻², and 75.32 ± 13.45 beats/min, respectively. Measurements of LVOT diameter by ED physicians and sonographer were optimal in 90.0% (95% confidence interval, 82.6%-94.5) and 91.3% (73.2%-97.6%) of patients, respectively. Optimal VTI measurements were obtained in 78.4% (69.2%-85.4%) and 78.3% (58.1%-90.3%) of patients, respectively. In 23 patients, the correlation (r) for CI between ED physician and sonographer was 0.82 (0.60-0.92), with bias and limits of agreement of −0.11 (−1.06 to 0.83) L min⁻¹ m⁻² and percent difference of 12.4% ± 10.1%.

Conclusions

Emergency department ED physicians can accurately measure CI using standard bedside ultrasound. A focused ultrasound cardiac examination to derive CI has potential use in the management of critical ill patients in the ED.     

Sagittal plane knee joint moments following anterior cruciate ligament injury and reconstruction: A systematic review

Background

Gait adaptations in persons with anterior cruciate ligament (ACL) injuries have been debated. Many studies examine high speed, 3-dimensional video gait analysis to compare knee joint torques during simulated activities of daily living.

Methods

We performed a systematic review of the literature for published clinical papers that reported sagittal plane knee joint kinetics in ACL deficient or reconstructed individuals. We calculated weighted effect sizes (Cohen’s d) to evaluate the magnitude of differences between the injured limb and the contralateral limb and healthy, uninjured limbs in control subjects.

Findings

Ten published papers reported kinetic data in ACL deficient subjects while walking for comparisons to the contralateral side (weighted average d = −0.83, range: −3.21, 1.07), and to healthy control knees (weighted average d = −1.0, range: −3.36, 0.17); four papers reported data during jogging compared to the contralateral side (weighted average d = −0.94, range: −4.15, 0.17), and to controls (weighted average d = −1.42, range: −3.83,−0.2). Four papers reported data for ACL-reconstructed patients compared to healthy controls during walking (weighted average d = −0.94, range: −0.4, −1.77) and jogging (weighted average d = −1.18).

Interpretation

Effect sizes comparing knee joint moments in injured vs. healthy control subjects appear to be slightly higher while jogging than walking, and higher in ACL-deficient patients compared to reconstructions. However, magnitudes are all large. Few studies report stair climbing. Consequently, it is difficult to make inferences with confidence during these tasks.     

Impact of Physical Exercise on Reaction Time in Patients With Parkinson's Disease—Data From the Berlin BIG Study

Objective

To determine whether physical activity may affect cognitive performance in patients with Parkinson's disease by measuring reaction times in patients participating in the Berlin BIG study.

Design

Randomized controlled trial, rater-blinded.

Setting

Ambulatory care.

Participants

Patients with mild to moderate Parkinson's disease (N=60) were randomly allocated to 3 treatment arms. Outcome was measured at the termination of training and at follow-up 16 weeks after baseline in 58 patients (completers).

Interventions

Patients received 16 hours of individual Lee Silverman Voice Treatment-BIG training (BIG; duration of treatment, 4wk), 16 hours of group training with Nordic Walking (WALK; duration of treatment, 8wk), or nonsupervised domestic exercise (HOME; duration of instruction, 1hr).

Main Outcome Measures

Cued reaction time (cRT) and noncued reaction time (nRT).

Results

Differences between treatment groups in improvement in reaction times from baseline to intermediate and baseline to follow-up assessments were observed for cRT but not for nRT. Pairwise t test comparisons revealed differences in change in cRT at both measurements between BIG and HOME groups (intermediate: −52ms; 95% confidence interval [CI], −84/−20; P=.002; follow-up: 55ms; CI, −105/−6; P=.030) and between WALK and HOME groups (intermediate: −61ms; CI, −120/−2; P=.042; follow-up: −78ms; CI, −136/−20; P=.010). There was no difference between BIG and WALK groups (intermediate: 9ms; CI, −49/67; P=.742; follow-up: 23ms; CI, −27/72; P=.361).

Conclusion

Supervised physical exercise with Lee Silverman Voice Treatment-BIG or Nordic Walking is associated with improvement in cognitive aspects of movement preparation.     

A Combined Inspiratory and Expiratory Muscle Training Program Improves Respiratory Muscle Strength and Fatigue in Multiple Sclerosis

Objective

To determine the effects of a short-duration, combined (inspiratory and expiratory), progressive resistance respiratory muscle training (RMT) protocol on respiratory muscle strength, fatigue, health-related quality of life, and functional performance in individuals with mild-to-moderate multiple sclerosis (MS).

Design

Quasi-experimental before-after trial.

Setting

University rehabilitation research laboratory.

Participants

Volunteers with MS (N=21) were divided into 2 groups: RMT (n=11; 9 women, 2 men; mean age ± SD, 50.9±5.7y, mean Expanded Disability Status Scale score ± SD, 3.2±1.9) and a control group that did not train (n=10; 7 women, 3 men; mean age ± SD, 56.2±8.8y, mean Expanded Disability Status Scale score ± SD, 4.4±2.1). Expanded Disability Status Scale scores ranged from 1 to ≤6.5. No patients withdrew from the study.

Intervention

Training was a 5-week combined progressive resistance RMT program, 3d/wk, 30 minutes per session.

Main Outcome Measures

The primary outcome measures were maximal inspiratory pressure and expiratory pressure and the Modified Fatigue Impact Scale. All subjects completed secondary measures of pulmonary function, the six-minute walk test, the timed stair climb, the Multiple Sclerosis Self-Efficacy Scale, the Medical Outcomes Study 36-Item Short-Form Health Survey, and the Physical Activity Disability Scale.

Results

Maximal inspiratory pressure and expiratory pressure (mean ± SD) increased 35%±22% (P<.001) and 26%±17% (P<.001), respectively, whereas no changes were noted in the control group (12%±23% and −4%±17%, respectively). RMT improved fatigue (Modified Fatigue Impact Scale, P<.029), with no change or worsening in the control group. No changes were noted in the six-minute walk test, stair climb, Multiple Sclerosis Self-Efficacy Scale, or Physical Activity Disability Scale in the RMT group. The control group had decreases in emotional well-being and general health (Medical Outcomes Study 36-Item Short-Form Health Survey).

Conclusions

A short-duration, combined RMT program improved inspiratory and expiratory muscle strength and reduced fatigue in patients with mild to moderate MS.