Optimising the Early-Stage Rehabilitation Process Post-ACL Reconstruction.

Outcomes following anterior cruciate ligament reconstruction (ACLR) need improving, with poor return-to-sport rates and a high risk of secondary re-injury. There is a need to improve rehabilitation strategies post-ACLR, if we can support enhanced patient outcomes. This paper discusses how to optimise the early-stage rehabilitation process post-ACLR. Early-stage rehabilitation is the vital foundation on which successful rehabilitation post-ACLR can occur. Without high-quality early-stage (and pre-operative) rehabilitation, patients often do not overcome major aspects of dysfunction, which limits knee function and the ability to transition through subsequent stages of rehabilitation optimally. We highlight six main dimensions during the early stage: (1) pain and swelling; (2) knee joint range of motion; (3) arthrogenic muscle inhibition and muscle strength; (4) movement quality/neuromuscular control during activities of daily living (5) psycho-social-cultural and environmental factors and (6) physical fitness preservation. The six do not share equal importance and the extent of time commitment devoted to each will depend on the individual patient. The paper provides recommendations on how to implement these into practice, discussing training planning and programming, and suggests specific screening to monitor work and when the athlete can progress to the next stage (e.g. mid-stage rehabilitation entry criteria).

Recommendations for Hamstring Function Recovery After ACL Reconstruction.

It is important to optimise the functional recovery process to enhance patient outcomes after major injury such as anterior cruciate ligament reconstruction (ACLR). This requires in part more high-quality original research, but also an approach to translate existing research into practice to overcome the research to implementation barriers. This includes research on ACLR athletes, but also research on other pathologies, which with some modification can be valuable to the ACLR patient. One important consideration after ACLR is the recovery of hamstring muscle function, particularly when using ipsilateral hamstring autograft. Deficits in knee flexor function after ACLR are associated with increased risk of knee osteoarthritis, altered gait and sport-type movement quality, and elevated risk of re-injury upon return to sport. After ACLR and the early post-operative period, there are often considerable deficits in hamstring function which need to be overcome as part of the functional recovery process. To achieve this requires consideration of many factors including the types of strength to recover (e.g., maximal and explosive, multiplanar not just uniplanar), specific programming principles (e.g., periodised resistance programme) and exercise selection. There is a need to know how to train the hamstrings, but also apply this to the ACLR athlete. In this paper, the authors discuss the deficits in hamstring function after ACLR, the considerations on how to restore these deficits and align this information to the ACLR functional recovery process, providing recommendation on how to recover hamstring function after ACLR.

RESTORING KNEE EXTENSOR STRENGTH AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A CLINICAL COMMENTARY.

One of the main priorities of rehabilitation after anterior cruciate ligament reconstruction (ACLR) surgery is the restoration of knee extensor muscle strength. Residual deficits in knee extensor muscle size and strength after injury are linked to poor biomechanics, reduced knee function, increased knee osteoarthritis risk, as well as heightened risk of re-injury upon return to sport. Most studies indicate that knee extensor muscle strength is typically not resolved prior to return to sport. This clinical commentary discusses strategies to optimize and accelerate the recovery of knee extensor strength post-surgery, with the purpose to support the clinician with evidence-based strategies to implement into clinical practice. Principally, two strategies exist to normalize quadriceps strength after surgery, 1) limiting strength loss after injury and surgery and 2) maximizing and accelerating the recovery of strength after surgery. Optimal preparation for surgery and a focused attempt to resolve arthrogenic muscle inhibition are essential in the pre and post-operative period prior to the inclusion of a periodized strength training program. Often voluntary strengthening alone is insufficient to fully restore knee extensor muscle strength and the use of electrical stimulation and where necessary the use of blood flow restriction training with low loads can support strength recovery, particularly in patients who are significantly load compromised and experience pain during exercise. Resistance training should employ all contraction modes, utilize open and closed kinetic chain exercise of both limbs, and progress from isolated to functional strength training, as part of a periodized approach to restoring neuromuscular function. Furthermore, thinking beyond the knee musculature and correcting core and hip dysfunction is also important to ensure an optimal knee extension strengthening program. The purpose of this clinical commentary is to provide a series of evidenced based strategies which can be implemented by clinicians responsible for the rehabilitation of patients after ACLR. LEVEL OF EVIDENCE: 5.

Intra-arterial nimodipine to treat symptomatic cerebral vasospasm following traumatic subarachnoid haemorrhage. Technical case report.

Intra-arterial Nimodipine administration can be an effective alternative to papaverine or balloon angioplasty for the treatment of cerebral vasospasm refractory to medical therapy. It has been used for intractable vasospasm due to aneurysmal subarachnoid haemorrhage (SAH) with convincing results and no significant complications in small case series. This report describes of a patient with symptomatic and angiographically documented vasospasm following traumatic SAH which was refractory to maximal medical therapy and successfully treated with intra-arterial infusion of Nimodipine. This first reported technical note is with special reference to the nimodipine administration modalities, clinical and neuroradiological criteria of selection as well as the follow up of the patient.

Vestibular impairment and cochlear implantation.

CONCLUSION: Cochlear implantation (CI) may induce vestibular impairment soon after surgery as well as after implant activation. This impairment seems to be independent from the cause of deafness and can be considered a possible complication from the intra-operative trauma and, to minor degree, from the ongoing electric stimulation. It would also seem that vestibular damage occurs independently from the likelihood of post-operative hearing deterioration. In unilateral selected CI cases, vestibular examination can be proposed as additional pre-operative exam for selection of the ear to be implanted. OBJECTIVES: This study has been planned in order to get evidence of eventual impairment of the vestibular apparatus after cochlear implantation as well as to verify whether the impairment could be related to different variables, such as cause of deafness, concomitant hearing deterioration, surgical trauma and duration of electrical stimulation. METHOD: Charts from two different populations of implantees have been reviewed, 21 from a prospective, 72 from a retrospective study, respectively. All the patients were implanted with Clarion(R) devices of different generation. Vestibular testing was based on rotatory, caloric (when possible) and stabilometric measurements, which were carried out pre-operatively and at the following different times: 5 weeks after CI surgery, and 30, 60 and 90 days after CI activation. Hearing thresholds were also assessed in those patients who showed signs of vestibular impairment as well as in a group of patients without vestibular disorders (control). Patients belonging to the retrospective group were all asked to fill a questionnaire regarding their balance condition. Results. In 14.3% of the prospective study group, a grade I and II spontaneous nystagmus was evidenced pre-operatively and remained unchanged during the whole assessment period. A grade II spontaneous nystagmus was present in 3 patients (21.4%) of the same group after surgery. In the immediate post-operative period, vestibular impairment was displayed as true rotational vertigo in 21.4% and unsteadiness in 42.8% of the study group. Severe unsteadiness was present during the first 2 days after activation in 14.3% of the subjects. In 21.4% of the patients a VPPB episode occured. In the retrospective study group, 26.4% of the subjects referred pre-operative dizziness and 25 patients (34.7%) referred immediate post-operative vertigo episodes, which remained in a milder form after CI activation in 12% of them. The hearing threshold showed to deteriorate in both vestibular-impaired and control CI population without significant difference.

Inhibition of the nuclear factor-kappaB activation with pyrrolidine dithiocarbamate attenuating inflammation and oxidative stress after experimental spinal cord trauma in rats.

OBJECT: The nuclear factor-kappaB (NF-kappaB) is a transcription factor that plays a pivotal role in the induction of genes involved in physiological processes and in the response to inflammation. The authors of recent studies have demonstrated that NF-kappaB and oxidative stress contribute to secondary injury after impact-induced spinal cord injury (SCI) in the rat. Dithiocarbamates are antioxidants that are potent inhibitors of NF-kappaB. The authors postulated that pyrrolidine dithiocarbamate (PDTC) would attenuate NF-kappaB-related inflammatory and oxidative events that occur after SCI. METHODS: Spinal cord injury was induced by the application of vascular clips (force of 50 g) to the dura mater after a four-level T5-8 laminectomy. The authors investigated the effects of PDTC (30 mg/kg administered 30 minutes before SCI and 6 hours after SCI) on the development of the inflammatory response associated with SCI in rats. Levels of myeloperoxidase activity were measured as an indicator of polymorphonuclear infiltration; malondialdehyde levels in the spinal cord tissue were determined as an indicator of lipid peroxidation. The following studies were performed: immunohistochemical analysis to assess levels of inducible nitric oxide synthase (iNOS), nitrotyrosine formation, poly([adenosine diphosphate]-ribose) polymerase (PARP) activity; Western blot analysis to determine cytoplasmic levels of inhibitory-kappaB-alpha (IkappaB-alpha); and electrophoretic mobility-shift assay to measure the level of DNA/NF-kappaB binding. The PDTC treatment exerted potent antiinflammatory effects with significant reduction of polymorphonuclear cell infiltration, lipid peroxidation, and iNOS activity. Furthermore, administration of PDTC reduced immunohistochemical evidence of formation of nitrotyrosine and PARP activation in the spinal cord section obtained in the SCI-treated rats. Additionally, PDTC treatment significantly prevented the activation of NF-kappaB (electrophoretic mobility-shift assay and immunoblot analysis). CONCLUSIONS: Overall, the results clearly demonstrate that PDTC-related prevention of the activation of NF-kappaB reduces the development of some secondary injury events after SCI. Therefore, inhibition of NF-kappaB may represent a novel approach in the treatment of SCIs.

Pedicle screw fixation for isthmic spondylolisthesis: does posterior lumbar interbody fusion improve outcome over posterolateral fusion?

OBJECT: Posterolateral fusion involving instrumentation-assisted segmental fixation represents a valid procedure in the treatment of lumbar instability. In cases of anterior column failure, such as in isthmic spondylolisthesis, supplemental posterior lumbar interbody fusion (PLIF) may improve the fusion rate and endurance of the construct. Posterior lumbar interbody fusion is, however, a more demanding procedure and increases costs and risks of the intervention. The advantages of this technique must, therefore, be weighed against those of a simple posterior lumbar fusion. METHODS: Thirty-five consecutive patients underwent pedicle screw fixation for isthmic spondylolisthesis. In 18 patients posterior lumbar fusion was performed, and in 17 patients PLIF was added. Clinical, economic, functional, and radiographic data were assessed to determine differences in clinical and functional results and biomechanical properties. At 2-year follow-up examination, the correction of subluxation, disc height, and foraminal area were maintained in the group in which a PLIF procedure was performed, but not in the posterolateral fusion-only group (p < 0.05). Nevertheless, no statistical intergroup differences were demonstrated in terms of neurological improvement (p = 1), economic (p = 0.43), or functional (p = 0.95) outcome, nor in terms of fusion rate (p = 0.49). CONCLUSIONS: The authors' findings support the view that an interbody fusion confers superior mechanical strength to the spinal construct; when posterolateral fusion is the sole intervention, progressive loss of the extreme correction can be expected. Such mechanical insufficiency, however, did not influence clinical outcome.