Pain-Related Fear Contributes to Self-Reported Disability in Patients With Foot and Ankle Pathology

Lentz TA, Sutton Z, Greenberg S, Bishop MD. Pain-related fear contributes to self-reported disability in patients with foot and ankle pathology.

Objective

To determine the unique influence of pain-related fear of movement on foot and ankle disability, after accounting for pain, demographic, and physical impairment variables.

Design

Cross-sectional study using retrospective chart review.

Setting

Outpatient rehabilitation clinic.

Participants

Referred sample of subjects with foot- and ankle-related disability (N=85, 40 men; mean age, 33y; range, 16-77y).

Interventions

Not applicable.

Main Outcome Measures

Lower Extremity Functional Scale (LEFS), Shortened Tampa Scale of Kinesiophobia (TSK-11).

Results

Hierarchical regression analysis determined the proportions of explained variance in disability (LEFS). Demographic variables were entered into the model first, followed by pain intensity and range-of-motion (ROM) deficit, and finally, TSK-11. Demographics collectively contributed 9% (P=.015) of the variance in disability scores. Pain intensity and overall ROM deficit contributed an additional 11% (P<.001) of the variance, and TSK-11 scores contributed an additional 14% (P<.001). In the overall model, age (β=−.29, P=.004), chronicity of symptoms (β=.23, P=.024), ROM deficit (β=−.28, P=.003), and TSK-11 (β=−.41, P<.001) explained 34% of the variance in the LEFS score (P<.001).

Conclusions

Age, chronicity of symptoms, ROM deficit, and TSK-11 scores all significantly contributed to baseline foot and ankle self-reported disability. Pain-related fear of movement was the strongest single contributor to disability in this group of patients.     

Segmental spinal reflex adaptations associated with chronic ankle instability

Sefton JM, Hicks-Little CA, Hubbard TJ, Clemens MG, Yengo CM, Koceja DM, Cordova ML. Segmental spinal reflex adaptations associated with chronic ankle instability.

Objective

To further understanding of the role that segmental spinal reflexes play in chronic ankle instability (CAI).

Design

A 2 × 2 repeated-measures case-control factorial design. The independent variables were ankle group with 2 levels (healthy, CAI) and stance with 2 levels (single, double legged).

Setting

University research laboratory.

Participants

Twenty-two participants with CAI and 21 matched healthy controls volunteered.

Interventions

Not applicable.

Main Outcome Measures

The dependent variables were 2 measures of motoneuron pool excitability: paired reflex depression (PRD) and recurrent inhibition.

Results

A 2 × 2 repeated-measures multivariate analysis of variance revealed a significant interaction between group and stance on the linear combination of PRD and recurrent inhibition variables (Wilks λ=.808, F_2,40=4.77, P=.014). Follow-up univariate F tests revealed an interaction between group and stance on the PRD (F_1,41=9.74, P=.003). Follow-up dependent t tests revealed a significant difference between single- and double-legged PRD in the healthy participants (t₂₀=-3.76, P=.001) with no difference in CAI participants (t₂₁=-0.44, P=.67). Finally, there was a significant difference in recurrent inhibition between healthy (mean, 83.66) and CAI (mean, 90.27) (P=.004).

Conclusions

This study revealed that, compared with healthy participants, CAI participants were less able to modulate PRD when going from a double- to a single-legged stance. Additionally, CAI participants showed higher overall levels of recurrent inhibition when compared with healthy matched controls.     

Factor Structure and Predictive Validity of Somatic and Nonsomatic Symptoms From the Patient Health Questionnaire-9: A Longitudinal Study After Spinal Cord Injury

Krause JS, Reed KS, McArdle JJ. Factor structure and predictive validity of somatic and nonsomatic symptoms from the Patient Health Questionnaire-9: a longitudinal study after spinal cord injury.

Objective

To investigate the factor structure and predictive validity of somatic and nonsomatic depressive symptoms over the first 2.5 years after spinal cord injury (SCI) using the Patient Health Questionnaire-9 (PHQ-9).

Design

Somatic and nonsomatic symptoms were assessed at baseline during inpatient hospitalization (average of 50 days after onset) and during 2 follow-ups (average of 498 and 874 days after onset).

Setting

Data were collected at a specialty hospital in the Southeastern United States and analyzed at a medical university. We performed time-lag regression between inpatient baseline and follow-up somatic and nonsomatic latent factors of the PHQ-9.

Participants

Adults with traumatic SCI (N=584) entered the study during inpatient rehabilitation.

Interventions

Not applicable.

Main Outcome Measure

PHQ-9, a 9-item measure of depressive symptoms.

Results

The inpatient baseline nonsomatic latent factor was significantly predictive of the nonsomatic (r=.40; P=.000) and somatic latent factors at the second follow-up (r=.29; P=.006), whereas the somatic factor at inpatient baseline did not significantly predict either factor. In contrast, when regressing latent factors between the 2 follow-ups, the nonsomatic factor predicted only the nonsomatic factor (r=.66; P=.002), and the somatic factor predicted only future somatic symptoms (r=.66; P=.000). In addition, the factor structure was not stable over time. Item analysis verified the instability of somatic items between inpatient baseline and follow-up and also indicated that self-harm at inpatient baseline was highly predictive of future self-harm.

Conclusions

Nonsomatic symptoms are better predictors of future depressive symptoms when first assessed during inpatient rehabilitation, whereas somatic symptoms become stable predictors only after inpatient rehabilitation. Self-harm (suicidal ideation) is the most stable symptom over time. Clinicians should routinely assess for suicidal ideation and use nonsomatic symptoms when performing assessments during inpatient rehabilitation.     

Action Observation Treatment Improves Recovery of Postsurgical Orthopedic Patients: Evidence for a Top-Down Effect?

Bellelli G, Buccino G, Bernardini B, Padovani A, Trabucchi M. Action observation treatment improves recovery of postsurgical orthopedic patients: evidence for a top-down effect?

Objective

To assess whether action observation treatment (AOT) may also improve motor recovery in postsurgical orthopedic patients, in addition to conventional physiotherapy.

Design

Randomized controlled trial.

Setting

Department of rehabilitation.

Participants

Patients (N=60) admitted to our department postorthopedic surgery were randomly assigned to either a case (n=30) or control (n=30) group. Exclusion criteria were age 18 years or younger and 90 years or older, Mini-Mental State Examination score of 21 of 30 or lower, no ambulating order, advanced vision impairment, malignancy, pneumonia, or heart failure.

Interventions

All participants underwent conventional physiotherapy. In addition, patients in the case group were asked to observe video clips showing daily actions and to imitate them afterward. Patients in the control group were asked to observe video clips with no motor content and to execute the same actions as patients in the case group afterward. Participants were scored on functional scales at baseline and after treatment by a physician blinded to group assignment.

Main Outcomes Measures

Changes in FIM and Tinetti scale scores, and dependence on walking aids.

Results

At baseline, groups did not differ in clinical and functional scale scores. After treatment, patients in the case group scored better than patients in the control group (FIM total score, P=.02; FIM motor subscore, P=.001; Tinetti scale score, P=.04); patients in the case group were assigned more frequently to 1 crutch (P=.01).

Conclusions

In addition to conventional physiotherapy, AOT is effective in the rehabilitation of postsurgical orthopedic patients. The present results strongly support top-down effects of this treatment in motor recovery, even in nonneurologic patients.     

Immediate Effects of 2 Different Whole-Body Vibration Frequencies on Muscle Peak Torque and Stiffness

Siu PM, Tam BT, Chow DH, Guo J-Y, Huang Y-P, Zheng Y-P, Wong SH. Immediate effects of 2 different whole-body vibration frequencies on muscle peak torque and stiffness.

Objective

To examine the immediate effects of 2 vibration protocols with different vibration frequencies that yielded the same maximum acceleration (106.75ms⁻²) on muscle peak torque and stiffness of knee extensor and flexor.

Design

Randomized crossover study with repeated measures.

Setting

Laboratory setting.

Participants

Recreationally active male adults (N=10).

Intervention

Participants performed 10 bouts of 60-second static half squats intermitted with a 60-second rest period between bouts on a platform with no vibration (control) and a vibration frequency of 26Hz or 40Hz.

Main Outcome Measures

Concentric and eccentric peak torques of knee extensor and flexor were examined within 5 minutes before and after vibration by isokinetic test. Young's modulus as an index of tissue stiffness was determined at quadriceps and hamstring pre- and postvibration by using an ultrasound indentation method.

Results

The 2-way repeated-measures analysis of variance indicated a significant interaction effect between vibration and vibration frequency for knee extensor concentric peak torque (P=.003). The vibration-induced changes of knee extensor concentric peak torque in vibration frequency of 26Hz (14.5Nm) and 40Hz (12.0Nm) were found to be significantly greater than that in controls (−29.4Nm) (P<.05). The change in eccentric peak torque of knee flexor after vibration tended to be greater in 26Hz of vibration frequency when compared with controls (26Hz of vibration frequency vs controls: 13.9±7.1 vs −11.4±5.3Nm, P=.08). No statistically significant differences were obtained in tissue stiffness in the quadriceps and hamstring with any of the conditions.

Conclusions

Our data suggest that whole-body vibration at a frequency of 26Hz and 40Hz preclude the decline in concentric peak torque of knee extensor observed after 10 bouts of 60 seconds of static half squats. A change in muscle mechanical stiffness property as induced by whole-body vibration is not supported by our data.     

Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement

Bell DR, Padua DA, Clark MA. Muscle strength and flexibility characteristics of people displaying excessive medial knee displacement.

Objective

To determine differences in strength and range of motion (ROM) between participants who exhibit medial knee displacement (MKD) during a squat that is corrected by a heel lift and those who do not.

Design

Case control.

Setting

Sports medicine research laboratory.

Participants

Thirty-seven healthy subjects (control, 19; MKD, 18) with no lower-extremity injury in the past 6 months volunteered to participate.

Interventions

Not applicable.

Main Outcome Measures

Peak force was measured in newtons using a hand-held dynamometer and passive ROM was measured in degrees with a goniometer. Separate multivariate analyses of variance were used to determine differences in strength and ROM between groups. Post hoc testing was used to elucidate differences between groups.

Results

The MKD group had the following: greater hip external rotation strength (P=.03), increased hip extension strength (P=.01), less plantarflexion strength (P=.007), and increased hip external rotation ROM (P=.008).

Conclusions

The MKD group exhibited tight and weak ankle musculature. Interventions focusing on improving strength and ROM of the ankle may improve kinematics during a squat.     

Feasibility and Outcomes of a Home-Based Exercise Program on Improving Balance and Gait Stability in Women With Lower-Limb Osteoarthritis or Rheumatoid Arthritis: A Pilot Study

Williams SB, Brand CA, Hill KD, Hunt SB, Moran H. Feasibility and outcomes of a home-based exercise program on improving balance and gait stability in women with lower-limb osteoarthritis or rheumatoid arthritis: a pilot study.

Objective

To evaluate the feasibility and gait stability and balance outcomes of a 4-month individualized home exercise program for women with arthritis.

Design

Pre-post interventional study.

Setting

General community.

Participants

Women (N=49) (volunteers) with lower-limb osteoarthritis or lower-limb rheumatoid arthritis were enrolled. Only 39 subjects were eligible and completed the study.

Intervention

After completion of the initial assessment, all participants received home balance exercises from an experienced physiotherapist based on assessment findings and exercises available from commercially available kits. All measures were repeated 4 months later.

Main Outcome Measures

Falls risk (Falls Risk of Older People—Community Setting) and balance measures.

Results

Thirty-nine women (mean age, 69.3y; 95% confidence interval, 65.7-72.9) completed the 4-month program. At baseline, 64% of participants reported falling in the preceding 12 months, and the average falls risk (Falls Risk of Older People—Community Setting) score was 14.5, with 42% rated as moderate risk (16-23). Participants achieved improved performance on most balance and related measures after the exercise program, including falls risk (P=.01), activity levels (P=.015), fear of falling (P=.022), functional reach test (P=.001), rising index for sit to stand (P=.001), step width in walking (P=.001), and body mass index (P=.006).

Conclusions

An individualized balance training home exercise program is feasible for older women with osteoarthritis or rheumatoid arthritis and may improve stability during walking and other functional activities.     

A Study of Bone Mineral Density in Adults With Disability

Smith ÉM, Comiskey CM, Carroll ÁM. A study of bone mineral density in adults with disability.

Objectives

To examine prevalence of low bone mineral density (BMD) among adults with disability, using World Health Organization diagnostic categories.

Design

Cross-sectional study.

Setting

National Rehabilitation Hospital, Dublin, Ireland.

Participants

Patients (N=255; 178 men, 77 women) who were disabled for at least 3 months because of acquired brain injury, spinal cord injury, other neurologic condition, or lower-limb amputation.

Interventions

None.

Main Outcome Measures

Laboratory investigations including intact parathyroid hormone, 25-hydroxyvitamin D (25-OHD), and sex hormones; and BMD of lumbar spine and at least 1 hip, measured by dual-energy x-ray absorptiometry and expressed as T scores and z scores.

Results

Mean age ± SD of participants was 48.7±15.6 years. Vitamin D deficiency, 25-OHD level 50nmol/L or less, occurred in 154 (62.9%); insufficiency, a level between 51 and 72nmol/L, occurred in 36 (14.7%). Based on T scores, 108 participants (42.4%) had osteopenia, and 60 (23.5%) had osteoporosis. A z score of −1 or less but more than −2 occurred in 76 (29.8%); a further 52 (20.4%) had a z score of −2 or less. On multiple linear regression analysis, ambulatory status and duration of disability were independent predictors of BMD at neck of femur (β=.152, P=.007; β=−.191, P=.001, respectively) and total proximal femur (β=.170, P=.001; β=−.216, P<.001, respectively).

Conclusions

Osteopenia and osteoporosis are very common in adults with disability participating in rehabilitation, compared with the general young adult population. Duration since onset of disability and mobility status are independent predictors of BMD at the hip. Bone health monitoring should form part of the long-term follow-up in adults with newly acquired disabilities.     

Association of Dynamic Joint Power With Functional Limitations in Older Adults With Symptomatic Knee Osteoarthritis

Segal NA, Yack HJ, Brubaker M, Torner JC, Wallace R. Association of dynamic joint power with functional limitations in older adults with symptomatic knee osteoarthritis.

Objectives

To determine which lower-limb joint moments and powers characterize the level of gait performance of older adults with symptomatic knee osteoarthritis (OA).

Design

Cross-sectional observational study.

Setting

University motion analysis laboratory.

Participants

Community-dwelling adults (N=60; 27 men, 33 women; age 50-79y) with symptomatic knee OA.

Interventions

Not applicable.

Main Outcome Measures

Physical function was measured using the long-distance corridor walk, the Short Physical Performance Battery, and the Late Life Function and Disability Instrument (LLFDI Function). Joint moments and power were estimated using an inverse dynamics solution after 3-dimensional computerized motion analysis.

Results

Subjects aged 64.2±7.4 years were recruited. Ranges (mean ± SD) for the 400-m walk time and the LLFDI Advanced Lower-Limb Function score were 215.3 to 536.8 (304.1±62.3) seconds and 31.5 to 100 (57.0±14.9) points, respectively. In women, hip abductor moment (loading response), hip abductor power (midstance), eccentric hamstring moment (terminal stance), and power (terminal swing) accounted for 41%, 31%, 14%, and 48% of the variance in the 400-m walk time, respectively (model R²=.61, P<.003). In men, plantar flexor and hip flexor power (preswing) accounted for 19% and 24% of the variance in the 400-m walk time, respectively (model R²=.32, P=.025).

Conclusions

There is evidence that men and women with higher mobility function tend to rely more on an ankle strategy rather than a hip strategy for gait. In higher functioning men, higher knee extensor and flexor strength may contribute to an ankle strategy, whereas hip abductor weakness may bias women with lower mobility function to minimize loading across the knee via use of a hip strategy. These parameters may serve as foci for rehabilitation interventions aimed at reducing mobility limitations.     

Validity of the Fingertip-To-Floor Test and Straight Leg Raising Test in Patients With Acute and Subacute Low Back Pain: A Comparison by Sex and Radicular Pain

Ekedahl KH, Jönsson B, Frobell RB. Validity of the fingertip-to-floor test and straight leg raising test in patients with acute and subacute low back pain: a comparison by sex and radicular pain.

Objective

To use self-reported disability (Roland-Morris Disability Questionnaire [RMDQ]) to assess the criterion validity of straight leg raising (SLR) test and flexion range of motion (ROM) (fingertip-to-floor test) before and after stratification by sex and presence/absence of radicular pain.

Design

Cross-sectional study.

Setting

Outpatient physical therapy clinic.

Participants

Subjects with acute/subacute low back pain with (n=40) and without (n=35) radicular pain.

Interventions

Not applicable.

Main Outcome Measures

We examined the relationship between RMDQ (reference variable) and SLR test and fingertip-to-floor test. The sample was stratified by presence/absence of radicular pain (categorized by the dichotomous slump test).

Results

In the entire sample, fair correlations were found between both physical impairment tests (ie, SLR test and flexion ROM) and self-reported disability (.27<r>.44). After stratification by sex, the correlation between RMDQ and flexion ROM and between RMDQ and nonside-specific SLR test increased in women but decreased in men. In those with radicular pain, good correlations were found between RMDQ and flexion ROM (r=.68 for men and r=.70 for women), and moderate correlation was found between the RMDQ and SLR tests of the affected side in women (r=.60), but only fair correlation was found between the RMDQ and SLR tests of the affected side in men (r=.28).

Conclusions

After stratification by sex and presence/absence of radicular pain, the present study supports a good validity of the fingertip-to-floor test for both men and women with radicular pain. The SLR test, however, was of less value as an indicator of self-reported disability after stratification, especially for men.     

The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus

Cauza E, Hanusch-Enserer U, Strasser B, Ludvik B, Metz-Schimmerl S, Pacini G, Wagner O, Georg P, Prager R, Kostner K, Dunky A, Haber P. The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus.

Objective

To compare the effects of a 4-month strength training (ST) versus aerobic endurance training (ET) program on metabolic control, muscle strength, and cardiovascular endurance in subjects with type 2 diabetes mellitus (T2D).

Design

Randomized controlled trial.

Setting

Large public tertiary hospital.

Participants

Twenty-two T2D participants (11 men, 11 women; mean age ± standard error, 56.2±1.1y; diabetes duration, 8.8±3.5y) were randomized into a 4-month ST program and 17 T2D participants (9 men, 8 women; mean age, 57.9±1.4y; diabetes duration, 9.2±1.7y) into a 4-month ET program.

Interventions

ST (up to 6 sets per muscle group per week) and ET (with an intensity of maximal oxygen consumption of 60% and a volume beginning at 15min and advancing to a maximum of 30min 3×/wk) for 4 months.

Main Outcome Measures

Laboratory tests included determinations of blood glucose, glycosylated hemoglobin (Hb A_1c), insulin, and lipid assays.

Results

A significant decline in Hb A_1c was only observed in the ST group (8.3%±1.7% to 7.1%±0.2%, P=.001). Blood glucose (204±16mg/dL to 147±8mg/dL, P<.001) and insulin resistance (9.11±1.51 to 7.15±1.15, P=.04) improved significantly in the ST group, whereas no significant changes were observed in the ET group. Baseline levels of total cholesterol (207±8mg/dL to 184±7mg/dL, P<.001), low-density lipoprotein cholesterol (120±8mg/dL to 106±8mg/dL, P=.001), and triglyceride levels (229±25mg/dL to 150±15mg/dL, P=.001) were significantly reduced and high-density lipoprotein cholesterol (43±3mg/dL to 48±2mg/dL, P=.004) was significantly increased in the ST group; in contrast, no such changes were seen in the ET group.

Conclusions

ST was more effective than ET in improving glycemic control. With the added advantage of an improved lipid profile, we conclude that ST may play an important role in the treatment of T2D.     

Effects of concurrent strength and endurance training on physical fitness and symptoms in postmenopausal women with fibromyalgia: a randomized controlled trial

Valkeinen H, Alén M, Häkkinen A, Hannonen P, Kukkonen-Harjula K, Häkkinen K. Effects of concurrent strength and endurance training on physical fitness and symptoms in postmenopausal women with fibromyalgia: a randomized controlled trial.

Objective

To examine the effectiveness of concurrent strength and endurance training on muscle strength, aerobic and functional performance, and symptoms in postmenopausal women with fibromyalgia (FM).

Design

Randomized controlled trial.

Setting

Local gym and university research laboratory.

Participants

Twenty-six women with FM.

Intervention

Progressive and supervised 21-week concurrent strength and endurance training.

Main Outcome Measures

Muscle strength of leg extensors, upper extremities, and trunk; peak oxygen uptake (Vo₂peak), maximal workload (Wmax), and work time; 10-m walking and 10-step stair-climbing time and self-reported functional capacity (Health Assessment Questionnaire); and symptoms of FM.

Results

After concurrent strength and endurance training, the groups differed significantly in Wmax (P=.001), work time (P=.001), concentric leg extension force (P=.043), walking (P=.001) and stair-climbing (P<.001) time, and fatigue (P=.038). The training led to an increase of 10% (P=.004) in Wmax and 13% (P=.004) in work time on the bicycle but no change in Vo₂peak.

Conclusions

Concurrent strength and endurance training in low to moderate volume improves the muscle strength of leg extensors, Wmax, work time, and functional performance as well as perceived symptoms, fatigue in particular. Concurrent strength and endurance training is beneficial to postmenopausal women with FM without adversities, but more extensive studies are needed to confirm the results.     

Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury

Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination findings, and pain in manual wheelchair users with spinal cord injury.

Objectives

To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathology Rating Scale (USPRS). To investigate physical examination (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight.

Design

Case series.

Setting

National Veterans' Wheelchair Games 2005 and 2006.

Participants

Volunteer sample of manual wheelchair users with SCI participating in the National Veterans' Wheelchair Games.

Interventions

Not applicable.

Main Outcome Measures

Presence of relationships between US findings, PE findings, pain, and subject characteristics.

Results

The USPRS correlated with age, duration of SCI, and weight (all P<.01), and showed a positive trend with the total Wheelchair User's Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P<.001) and duration of SCI (P<.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002).

Conclusions

PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in manual wheelchair users with SCI, and further investigation of this pain is indicated.     

Cyclic Functional Electrical Stimulation Does Not Enhance Gains in Hand Grasp Function When Used as an Adjunct to OnabotulinumtoxinA and Task Practice Therapy: A Single-Blind, Randomized Controlled Pilot Study

Weber DJ, Skidmore ER, Niyonkuru C, Chang C-L, Huber LM, Munin MC. Cyclic functional electrical stimulation does not enhance gains in hand grasp function when used as an adjunct to onabotulinumtoxinA and task practice therapy: a single-blind, randomized controlled pilot study.

Objective

To determine whether onabotulinumtoxinA injections and task practice training with or without functional electrical stimulation (FES) improve upper limb motor function in chronic spastic hemiparesis.

Design

Randomized controlled trial.

Setting

Outpatient spasticity clinic.

Participants

Participants (N=23) had chronic spastic hemiparesis with moderate-severe hand impairment based on Chedoke-McMaster Assessment greater than or equal to 2.

Interventions

OnabotulinumtoxinA injections followed by 12 weeks of postinjection task practice. Participants randomly assigned to FES group were also fitted with an orthosis that provided FES.

Main Outcome Measures

Motor Activity Log (MAL)-Observation was the primary outcome. Secondary outcomes were Action Research Arm Test (ARAT) and MAL-Self-Report.

Results

For the entire cohort, MAL-Observation mean item scores improved significantly from baseline to week 6 (P=.005) but did not remain significant at week 12. MAL-Self-Report mean item scores improved significantly (P=.009) from baseline to week 6 and remained significantly higher (P=.014) at week 12. ARAT total scores also improved significantly from baseline to week 6 (P=.018) and were sustained at week 12 (P=.032). However, there were no significant differences between the FES and no-FES groups for any outcome variable over time.

Conclusions

Rehabilitation strategies that combine onabotulinumtoxinA injections and task practice therapy are feasible and effective in improving upper-limb motor function and reducing spasticity in patients with chronic spastic hemiparesis. However, the cyclic FES protocol used in this study did not increase gains achieved with the combination of onabotulinumtoxinA and task practice alone.     

Subacromial Corticosteroid Injection for Poststroke Shoulder Pain: An Exploratory Prospective Case Series

Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain: an exploratory prospective case series.

Objective

To assess the effectiveness of subacromial corticosteroid injections for poststroke shoulder pain.

Design

Exploratory, prospective case series.

Setting

Ambulatory setting, university-affiliated hospital.

Participants

Stroke survivors (N=10) with pain in the hemiparetic shoulder.

Intervention

Consecutive stroke survivors with evidence of supraspinatus impingement, supraspinatus tendonitis, or subacromial bursitis received subacromial corticosteroid injections.

Main Outcome Measures

The primary outcome measure was the Brief Pain Inventory (BPI) question 12 (BPI 12), which assesses “worst pain” in the previous 7 days. Secondary measures included BPI question 15, which assesses present pain and BPI question 23 (BPI 23), which assesses pain interference with 7 daily activities. Outcomes were assessed at baseline, weekly for the first 4 weeks and then at 8 and 12 weeks postinjection.

Results

Repeated measure analysis of variance revealed significant within group time effect for BPI 12 (F=7.7, P<.001). Based on absolute means, the largest therapeutic benefit was seen by the second week postinjection with partial loss of effect thereafter. There were significant within group time effects for the general activity (F=3.2, P=.009), sleep (F=3.9, P=.003), and enjoyment of life (F=2.3, P=.044) domains of BPI 23.

Conclusions

Subacromial corticosteroid injection is associated with significant reduction in poststroke shoulder pain in patients with evidence of supraspinatus impingement, supraspinatus tendonitis, or subacromial bursitis. However, there is a gradual loss of effect with time. Controlled trials are needed to show a cause and effect relationship.     

Can four key psychosocial risk factors for chronic pain and disability (Yellow Flags) be modified by a pain management programme?: A pilot study

Objectives

To identify the extent to which an adapted pain management programme is successful in modifying pain beliefs, psychological distress, locus of control and self-efficacy using both qualitative and quantitative approaches.

Design

Prospective, observational study with questionnaires at baseline and following completion of a pain management programme.

Setting

Outpatient pain management programme in a district general hospital.

Participants

Fifteen participants experiencing chronic pain, referred from pain and rheumatology clinics within the hospital.

Outcome measures

Pain beliefs, self-efficacy, locus of control and psychological distress.

Results

Wilcoxon signed ranks tests demonstrated significant improvements in pain beliefs, self-efficacy and psychological distress. However, changes in locus of control were not found to be significant. The qualitative data supported these findings.

Conclusions

The pilot study suggested that the pain management programme successfully modified three out of four of the psychosocial risk factors (Yellow Flags) in a population with established pain and disability. A larger scale project replicating this pilot study including a comparison group, and further research to assess the extent to which modifying Yellow Flags generalises to affect quality of life and disability, are underway.     

Weight Lifting in Patients With Lower-Extremity Lymphedema Secondary to Cancer: A Pilot and Feasibility Study

Katz E, Dugan NL, Cohn JC, Chu C, Smith RG, Schmitz KH. Weight lifting in patients with lower-extremity lymphedema secondary to cancer: a pilot and feasibility study.

Objective

To assess the feasibility of recruiting and retaining cancer survivors with lower-limb lymphedema into an exercise intervention study. To develop preliminary estimates regarding the safety and efficacy of this intervention. We hypothesized that progressive weight training would not exacerbate leg swelling and that the intervention would improve functional mobility and quality of life.

Design

Before-after pilot study with a duration of 5 months.

Setting

University of Pennsylvania.

Participants

Cancer survivors with a known diagnosis of lower-limb lymphedema (N=10) were directly referred by University of Pennsylvania clinicians. All 10 participants completed the study.

Intervention

Twice weekly slowly progressive weight lifting, supervised for 2 months, unsupervised for 3 months.

Main Outcome Measures

The primary outcome was interlimb volume differences as measured by optoelectronic perometry. Additional outcome measures included safety (adverse events), muscle strength, objective physical function, and quality of life.

Results

Interlimb volume differences were 44.4% and 45.3% at baseline and 5 months, respectively (pre-post comparison, P=.70). There were 2 unexpected incident cases of cellulitis within the first 2 months. Both resolved with oral antibiotics and complete decongestive therapy by 5 months. Bench and leg press strength increased by 47% and 27% over 5 months (P=.001 and P=.07, respectively). Distance walked in 6 minutes increased by 7% in 5 months (P=.01). No improvement was noted in self-reported quality of life.

Conclusions

Recruitment of patients with lower-limb-lymphedema into an exercise program is feasible. Despite some indications that the intervention may be safe (eg, a lack of clinically significant interlimb volume increases over 5mo), the unexpected finding of 2 cellulitic infections among the 10 participants suggests additional study is required before concluding that patients with lower-extremity lymphedema can safely perform weight lifting.     

A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain

Objectives

To assess the short- and long-term effectiveness of spinal manipulation therapy, and to identify the effect of manipulation on lumbar muscle endurance in patients with chronic low back pain (LBP).

Design

A randomised controlled trial comparing manipulation and exercise treatment with ultrasound and exercise treatment.

Setting

An outpatient physiotherapy department.

Participants

One hundred and twenty patients with chronic LBP were allocated at random into the manipulation/exercise group or the ultrasound/exercise group.

Interventions

Both groups were given a programme of exercises. In addition, one group received spinal manipulation therapy and the other group received therapeutic ultrasound.

Main outcome measures

Pain intensity, functional disability, lumbar movements and muscle endurance were measured shortly before treatment, at the end of the treatment programme and 6 months after randomisation using surface electromyography.

Results

Following treatment, the manipulation/exercise group showed a statistically significant improvement (P = 0.001) in pain intensity [mean 16.4 mm, 95% confidence interval (CI) 6.1-26.8], functional disability (mean 8%, 95% CI 2-13) and spinal mobility (flexion: mean 9.4 mm, 95% CI 5.5-13.4; extension: mean 3.4 mm, 95% CI 1.0-5.8). There was no significant difference (P = 0.068) between the two groups in the median frequency of surface electromyography (multifidus: mean 6.8 Hz, 95% CI 1.24-14.91; iliocostalis: mean 2.4 Hz, 95% CI 2.5-7.1), although a significant difference (P = 0.013) was found in the median frequency slope of surface electromyography in favour of spinal manipulation for multifidus alone (mean 0.3, 95% CI 0.1-0.5). A significant difference was also found between the two groups in favour of the manipulation/exercise group at 6-month follow-up.

Conclusions

Although improvements were recorded in both groups, patients receiving manipulation/exercise showed a greater improvement compared with those receiving ultrasound/exercise at both the end of the treatment period and at 6-month follow-up.