Prospective cohort study.To characterize knee cartilage change in individuals with knee osteoarthritis (KOA) who have completed a therapeutic exercise program.While therapeutic exercise is frequently used successfully to improve pain and function in individuals with KOA, no studies have reported the volume of cartilage change or individual factors that may impact volume of cartilage change in those completing an exercise program for KOA.Thirteen individuals with KOA underwent magnetic resonance imaging to quantify cartilage volume change in the weight-bearing regions of the medial and lateral femoral condyles and the entire surface of the tibial plateaus from baseline to 1-year follow-up. Body structure and function measures were taken for body mass index, knee axis alignment, knee motion, and knee strength. Activity limitations and activity levels were also measured prior to the therapeutic exercise program, using the Western Ontario and McMaster Universities Osteoarthritis Index and the Physical Activity Scale for the Elderly. At 6 months from baseline, follow-up clinical measurements of knee strength and motion were performed. At 1 year from baseline, imaging of the knee cartilage and knee alignment were performed, and participants completed the Western Ontario and McMaster Universities Osteoarthritis Index and Physical Activity Scale for the Elderly.The central region of the medial femoral condyle (cMF) had a median volume of cartilage loss of 3.8%. The other 3 knee tibiofemoral articular surfaces had minimal median cartilage volume change. Individuals were dichotomized into progressors (n = 6) and nonprogressors (n = 7), based on the standard error of measurement of cartilage volume change for the cMF. Progressors were younger, had a larger body mass index, had a higher Kellgren-Lawrence grade in the medial compartment of the knee, and had a greater increase in knee varus alignment from baseline to 1-year follow-up. The progressors also had frontal plane hip and knee kinetics during baseline gait analysis that potentially increased medial knee joint loading.The loss of cMF cartilage volume was highly variable and the median loss of cartilage was within the range previously reported. Seven of the 13 individuals did not have cMF cartilage volume loss greater than the standard error of measurement. Change in cartilage volume of the cMF may be influenced to a greater extent by personal factors than by completion of a therapeutic exercise program. Additional research is needed to decipher the interactions among therapeutic exercise and personal characteristics that impact knee cartilage loss.
Purpose: Minimal research has examined the prognostic ability of shoulder examination data or psychosocial factors in predicting patient-reported disability following surgery for rotator cuff pathology. The purpose of this study was to examine these factors for prognostic value in order to help clinicians and patients understand preoperative factors that impact disability following surgery.Methods: Sixty-two patients scheduled for subacromial decompression with or without supraspinatus repair were recruited. Six-month follow-up data were available for 46 patients. Patient characteristics, history of the condition, shoulder impairments, psychosocial factors, and patient-reported disability questionnaires were collected preoperatively. Six months following surgery, the Western Ontario Rotator Cuff Index (WORC) and global rating of change dichotomized subjects into responders versus nonresponders. Logistic regression quantified prognostic ability and created the most parsimonious model to predict outcome.Results: Being on modified job duty (OR = .17, 95%CI: 0.03–0.94), and having a worker's compensation claim (OR = 0.08, 95%CI: 0.01–0.74) decreased probability of a positive outcome, while surgery on the dominant shoulder (OR = 11.96, 95%CI: 2.91–49.18) increased probability. From the examination, only impaired internal rotation strength was a significant univariate predictor. The Fear-avoidance Beliefs Questionnaire (FABQ) score (OR = 0.95, 95%CI: 0.91–0.98) and the FABQ_work subscale (OR = 0.92, 95%CI: 0.87–0.97) were univariate predictors. In the final model, surgery on the dominant shoulder (OR = 8.9, 95%CI 1.75–45.7) and FABQ_work subscale score ≤25 (OR = 15.3, 95%CI 2.3–101.9) remained significant.Discussion: Surgery on the dominant arm resulted in greater improvement in patient-reported disability, thereby increasing the odds of a successful surgery. The predictive ability of the FABQ_work subscale highlights the potential impact of psychosocial factors on patient-reported disability.Implications for RehabilitationImpairment-based shoulder measurements were not strong predictors of patient-reported outcome.Having high fear-avoidance behavior scores on the FABQ, especially the work subscale, resulted in a much lower chance of responding well to rotator cuff surgery as measured by self-reported disability.Having surgery on the dominant shoulder, as compared to the nondominant side, resulted in larger improvements in disability levels.
The purpose of this dissertation was to systematically review the prognostic evidence for factors that may predict clinical outcome in individuals undergoing rotator cuff repair, determine preoperative factors that can accurately predict outcome in individuals having arthroscopic subacromial decompression with or without rotator cuff repair, and calculate responsiveness for the Western Ontario Rotator Cuff Index and the Disabilities of the Arm, Shoulder and Hand Questionnaire in these individuals.
A preoperative evaluation collected demographic information, history of the shoulder condition, measures of shoulder impairment, shoulder activity level, fear-avoidance levels, depressive symptomatology, and anxiety. Patient-reported outcomes (PROs) included a disease-specific PRO, the Western Ontario Rotator Cuff Index (WORC), and a region-specific PRO, the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH). Six months postoperatively, the WORC, DASH and global rating of change were collected.
Logistic regression analysis determined which preoperative variables were able to predict responders from nonresponders. Responders were determined based on a minimum improvement of 17-points on the WORC score and a global rating of change score of at least “quite a bit better” at the 6-month postoperative time point. Linear regression, with the WORC change score used as the dependent variable, provided a secondary analysis to allow comparison of the logistic and linear models. Effect sizes, standardized response means and the sensitivity and specificity of the minimal clinically important difference for both the WORC and DASH were calculated.
Surgery on the dominant shoulder and a score of 25 or less on the work subscale of the Fear-Avoidance Beliefs Questionnaire were the significant predictors in the final logistic model. The accuracy of the model for correctly predicting responders from nonresponders was excellent. Fear-avoidance, as a predictor of outcome, provides a modifiable factor that can be targeted by specific rehabilitation interventions. In the linear model, the WORC change score was predicted by surgery on the dominant arm, modified job duty, and age. Both the WORC and DASH demonstrated high levels of internal responsiveness while external responsiveness could not be accurately assessed due to the preponderance of responders to nonresponders.
Background: Understanding preoperatively available factors that predict valid, patient-reported outcomes following rotator cuff repair can assist clinicians and their patients in making an informed, shared-decision on rotator cuff repair, and assist in setting an evidence-based prognosis.Objectives: To perform a systematic review of the preoperative factors related to patient-reported outcome following rotator cuff repair.Methods: A systematic review of the literature was performed to identify studies analyzing the relationship of preoperative factors to valid, patient-reported outcome measures. To be included in the review, outcome had to be measured by at least one valid upper extremity or shoulder-specific patient-reported outcome.Results: Twenty-three studies met the criteria for inclusion. Of these, 15 studies scored 3 or less on a 7-point scale of study quality indicating a paucity of strong trials investigating these prognostic factors. Prognostic factors reviewed included age, sex, worker’s compensation status, involvement of dominant arm, fatty infiltration of the cuff musculature, duration of symptoms, comorbidities, and smoking status. Increasing age predicted worse Disabilities of Arm, Shoulder and Hand Scores (DASH) but did not predict outcome of any other patient-reported outcome. A worker’s compensation claim predicted a negative impact on patient-reported outcome. Evidence for the remaining factors indicated they do not predict patient-reported outcome.Conclusion: Six of the eight preoperative factors reviewed did not show a relationship with patient-reported outcome following rotator cuff repair. Evidence indicates a worker’s compensation claim negatively impacts patient-reported outcomes and increasing age resulted in a less favorable DASH score. However, age was not predictive of other patient-reported outcomes such as the Constant score or American Shoulder and Elbow Surgeons Shoulder Score. Overall quality of the included studies was low and future studies with stronger methodologies should be conducted.
To compare balance, mobility, and functional outcomes across 3 age groups of older adults with traumatic brain injury; to describe differences between those discharged to private residences versus institutional care.Acute inpatient rehabilitation facility.One hundred adults, mean age of 78.6 ± 7.9 years (range = 65-95 years), with an admitting diagnosis of traumatic brain injury.Retrospective case series.Functional Independence Measure (FIM) for Cognition and Mobility; Berg Balance Scale; Timed Up and Go; and gait speed, at admission to and discharge from an inpatient rehabilitation facility.Statistically significant improvements (P < .01) were made on the Timed Up and Go, Berg Balance Scale, and gait speed for young-old, mid-old, and old-old adults, with no differences among the 3 age groups. Substantial balance and mobility deficits remained. The FIM cognition (P = .013), FIM Walk (P = .009), and FIM Transfer (P = .013) scores were significantly better in individuals discharged home or home with family versus those discharged to an institution.Preliminary outcome data for specific balance and mobility measures are reported in 3 subgroups of older adults following traumatic brain injury, each of which made significant and similar improvements. Some FIM item scores discriminated between those discharged to a private residence versus a higher level of care.
To examine the relationship among measures of gait, balance, and community integration in adults with brain injury.Two rehabilitation hospitals.Thirty-four community-dwelling individuals with brain injury, aged 18 to 61 years (mean = 32 years), who were able to walk at least 12 m independently or with supervision. Mean time post-brain injury was 52 ± 44 months.Cross-sectional study.Community Balance and Mobility Scale, Dynamic Gait Index, Ten-Meter Walk Test for gait speed, and the Community Integration Questionnaire (CIQ).Mean balance and gait scores were as follows: 54 ± 26 of 96 on the Community Balance and Mobility Scale; 19 ± 5 of 24 on the Dynamic Gait Index; and gait speed of 1.36 ± 0.88 m/s. Mean score on the CIQ was 16 ± 5 of 29. Correlations between the balance/gait measures and the total CIQ score ranged from 0.21 to 0.30 and were not significant. All 3 balance/gait measures correlated significantly with the CIQ Productivity subscale (range = 0.38-0.52).The ability of people with brain injury to engage in work/school/volunteer activity may be reduced by impairments in balance and mobility. Future research should explore this relationship and determine whether interventions that improve balance and mobility result in improved community productivity.
Abstract Objective To examine whether pretreatment magnitude of quadriceps activation (QA) helps predict changes in quadriceps strength after exercise therapy in subjects with knee osteoarthritis (OA). We hypothesized that subjects with lower magnitudes of QA (greater failure of muscle activation) would have smaller gains in strength compared with those with higher magnitudes of QA following exercise therapy. Methods One hundred eleven subjects with knee OA (70 women) participated. Baseline measures included demographic information, quadriceps muscle strength, and QA using a burst‐superimposition isometric torque test. Following baseline testing, subjects underwent a 6‐week supervised exercise program designed to improve strength, range of motion, balance and agility, and physical function. On completion of the program, quadriceps strength and QA were reassessed. Multiple regression analysis was used to determine whether baseline QA predicted quadriceps strength scores at the 2‐month followup. Results Bivariate correlations demonstrated that baseline QA was significantly associated with quadriceps strength at baseline (ρ = 0.30, P < 0.01) and 2‐month followup (ρ = 0.23, P = 0.01). Greater magnitude of baseline QA correlated with higher strength. While controlling for baseline quadriceps strength and type of exercise therapy, the level of QA did not predict quadriceps strength at the 2‐month followup (β = −0.04, P = 0.18). Conclusion Baseline QA did not predict changes in quadriceps strength following exercise therapy. Measurement of QA using the central activation ratio method does not appear to be helpful in identifying subjects with knee OA who will have difficulty improving quadriceps strength with exercise therapy.
Muscle atrophy is common in patients with rheumatoid arthritis (RA). Although neuromuscular electrical stimulation (NMES) is a viable treatment for muscle atrophy, there is no evidence about the use of NMES in patients with RA. The purposes of this multiple-patient case report are: (1) to describe the use of NMES applied to the quadriceps femoris muscles in conjunction with an exercise program in patients with RA; (2) to report on patient tolerance and changes in lean muscle mass, quadriceps femoris muscle strength (force-producing capacity), and physical function; and (3) to explore how changes in muscle mass relate to changes in quadriceps femoris muscle strength, measures of physical function, and patient adherence.Seven patients with RA (median age=61 years, range=39-80 years) underwent 16 weeks of NMES and volitional exercises. Lean muscle mass and strength of the quadriceps femoris muscle and physical function were measured before and after treatment.One patient did not tolerate the NMES treatment, and 2 patients did not complete at least half of the proposed treatment. Patients who completed the NMES and volitional exercise program increased their lean muscle mass, muscle strength, and physical function.Because of the small sample, whether NMES combined with exercises is better than exercise alone or NMES alone could not be determined. However, the outcomes from this multiple-patient case report indicate that NMES is a viable treatment option to address muscle atrophy and weakness in patients with RA. Strategies to increase tolerance and adherence to NMES are warranted.
