Continuous passive motion for osteoarthritis of the hip: a pilot study.

OBJECTIVE: To evaluate whether extended use of continuous passive motion (CPM) may allay the pain of walking, diminish disease effect, and increase the usual walking speed in patients with osteoarthritis (OA) of the hip. METHODS: This pilot study comprised 21 patients with Kellgren-Lawrence grade 2-4 OA of the hip who used CPM for periods of 1.2 to 7.6 h daily throughout a 12 week trial. RESULTS: Significant improvements were found in the patients' assessment of pain on visual analog scale, Sickness Impact Profile, self-selected walking speed, and the number of subjects who decreased their medication usage. None of these improvements was related to the radiographic grade of the patients' OA or the daily duration of CPM. CONCLUSION: Although regular exercise is now routinely recommended to patients with OA, there has been relatively little study of specific exercise programs. As such investigations are undertaken, we believe CPM should be included among the options that are studied.

Exercise: effects on physical functional performance in independent older adults.

BACKGROUND: Age-related loss in physiologic capacities contributes to the decline in physical function in the elderly population. Despite the beneficial effects of exercise interventions on maximal physiologic capacity measures, the functional benefits have not been shown in independently living older adults. The objective of this study was to evaluate exercise in independent older adults for significant and meaningful improvements in physical function, not detected by commonly used measures of physical function. METHODS: In a randomized controlled study, 49 independently living men and women were assigned to either a nonexercise control group (Control; n = 26) or an exercise training group (Exercise; n = 23). Participants (age = 76+/-4) in good general health were recruited from retirement communities or apartments. The combined endurance and strength training was performed at 75% to 80% intensity; the groups met 3 times/week for 6 months of supervised sessions. Outcome measures included physical capacity, health status, and physical function using a newly developed performance test--the Continuous Scale-Physical Functional Performance test (CS-PFP). RESULTS: Compared to the Control group, the Exercise group showed significant increases in maximal oxygen consumption (11%) and muscle strength (33%). No significant differences were found between groups for changes in the Sickness Impact Profile, SF-36 scales, or the 6-minute walk. However, the CS-PFP score improved significantly in the Exercise group (14%, effect size 0.80). CONCLUSIONS: Independent older adults gain meaningful functional benefits from several months of exercise training. The public health importance of physical activity may relate not just to its role in preventing decline, but also to its role in enhancing physical function.

Mass and mass distribution of below-knee prostheses: effect on gait efficacy and self-selected walking speed.

OBJECTIVE: To study mass and mass distribution effect on function of below-knee prostheses. DESIGN: Design modifications were done to produce proximal center of mass location versus distal center of mass location variations, and prosthesis weight was modified from 42% to 70% of normal limb weight. Work across joints of affected and unaffected extremities was compared to assess the ability of the prosthesis to substitute for function loss. SETTING: University biomechanics laboratory. PARTICIPANTS: Fifteen volunteers with below-knee amputations, residual limb length greater than 8.3 cm, but excluding Syme amputations. INTERVENTIONS: Patients walked with all configurations at self-selected walking speeds and 120 m/min. MAIN OUTCOME MEASURES: Self-selected walking speed and metabolic efficiency. Work across the joints of affected and unaffected sides was compared. RESULTS: Proximal center of mass location produced a more efficient gait. Weight change from 42% to 70% of normal had no significant effect. Mechanical studies show that the prosthesis is a relatively poor substitute for the normal limb; most work is done by the nonamputated side. Particularly, the prosthesis failed to produce effective forward impulses on the body, resulting from push-off and deceleration of the swing leg. CONCLUSIONS: For a proximal center of mass, lightweight distal components (e.g., feet) should be used; it is questionable whether further expenditure to develop ultralightweight prostheses would be cost effective for level walking.

Continuous-scale physical functional performance in healthy older adults: a validation study.

OBJECTIVE: The continuous-scale physical functional performance test (CS-PFP) is an original instrument designed to provide a comprehensive, in-depth measure of physical function that reflects abilities in several separate physical domains. It is based on a concept of physical function as the integration of physiological capacity, physical performance, and psychosocial factors. SETTING: The test was administered under standard conditions in a hospital facility with a neighborhood setting. The CS-PFP consists of a battery of 15 everyday tasks, ranging from easy to demanding, that sample the physical domains of upper and lower body strength, upper body flexibility, balance and coordination, and endurance. Participants are told to work safely but at maximal effort, and physical functional performance was measured as weight, time, or distance. Scores were standardized and scaled 0 to 12. The test yields a total score and separate physical domain scores. DESIGN: The CS-PFP was evaluated using 148 older adults-78 community dwellers, 31 long-term care facility residents living independently, and 39 residents with some dependence. MAIN OUTCOME MEASURES: Maximal physical performance assessment included measures of maximal oxygen consumption (VO2max), isokinetic strength, range of motion, gait, and balance. Psychosocial factors were measured as self-defined health status using the Sickness Impact Profile (SIP), self-perceived function using the Health Survey (SF36), and Instrumental Activities of Daily Living (IADL). RESULTS: IADL scores were not significantly different among the groups. Test-retest correlations ranged from .84 to .97 and inter-rater reliability from .92 to .99 for the CS-PFP total and 5 domains. Internal consistency was high (Cronbach's alpha, .74 to .97). Both total and individual domain CS-PFP scores were significantly different for the three groups of study participants, increasing with higher levels of independence, supporting construct validity. CS-PFP domain scores were significantly correlated with measures of maximal physical performance (VO2max, strength, etc) and with physical but not emotional aspects of self-perceived function. CONCLUSION: The CS-PFP is a valid, reliable measure of physical function, applicable to a wide range of functional levels, and having minimal floor and ceiling effect. The total and physical domains may be used to evaluate, discriminate, and predict physical functional performance for both research and clinical purposes.

The stretch reflex response in the normal and spastic ankle: effect of ankle position.

OBJECTIVE: The influence of stretch of the gastrocnemiussoleus muscle on the stretch reflex activity was studied, by varying the ankle angle in steps from 10 degrees of plantarflexion (PF) to 5 degrees of dorsiflexion (DF). DESIGN: Nonrandomized control trial. SETTING: Department of Rehabilitation Medicine of a university medical center. PATIENTS: Sixteen subjects with and 16 subjects without spasticity. MAIN OUTCOME MEASURES: The passive elastic stiffness and active reflex response, expressed by the total and elastic path lengths, were determined at each ankle angle as a sinusoidal displacement of 5 degrees was applied to the joint at frequencies from 3 to 12 Hz. RESULTS: The elastic stiffness showed no difference between the spastic and normal subjects for all ankle angles (p > .05). The elastic stiffness increased linearly similarly in both groups when the ankle was dorsiflexed. The reflex response was significantly greater in the spastic group for all positions (p < or = .01). The total and elastic path lengths showed a linear increase in both groups when the ankle angle was varied from PF to DF. The spastic group, however, had a significantly faster increase (p < or = .005). Between-group comparison showed a significant quadratic trend in the elastic path length for the spastic group (p < or = .05), with a maximum at 2.5 degrees of DF. CONCLUSIONS: This study showed that the stretch reflex activity varies with the ankle position. This must be considered when performing spasticity tests subsequent to an intervention that has changed the available range of motion and when comparing subjects measured at different ankle positions.

Comprehensive analysis of energy storing prosthetic feet: Flex Foot and Seattle Foot Versus Standard SACH foot.

This study compared the mechanical and biomechanical functions, metabolic demand, and shock absorption of two dynamic elastic response (DER) prosthetic foot designs with the SACH foot. Nine individuals who had undergone unilateral below knee amputation were studied. Mechanical properties of the feet were related to gait biomechanics. Forefoot compliance is greatest for the Flex Foot and least for the SACH foot, hence, Flex Foot demonstrates (1) the longest midstance phase, (2) the greatest ankle angle range, and (3) greater forward movement of the center of pressure. There was some evidence that the DER feet produced a better push-off. However, neither the self-selected walking speed nor the metabolic rate or efficiency over a spectrum of walking speeds (73 to 120m/min) and running speeds (140 to 200m/min) was significantly different. Because no energy savings resulted for the DER feet, the release of stored energy in the flexible feet may not occur at the proper time to assist in ambulation as a result of the natural frequency of oscillation.

Comprehensive analysis of dynamic elastic response feet: Seattle Ankle/Lite Foot versus SACH foot.

This study evaluated biomechanical and metabolic performance differences between two prosthetic foot designs in light of their mechanical properties. Ten unilateral below-knee amputee subjects, at least 1 year after amputation, capable of walking and running, were studied. Differences in heel and forefoot compliance explained differences in gait events and alignment. Increased efficiency of pushoff in the Seattle Ankle/Lite Foot exists as evidenced by the decrease loading on the opposite limb during double support and a less shortened step length on the sound side compared to the SACH foot. The natural frequency of oscillation for the prosthetic feet was determined to be too high to provide energy storage and release synchronized with kinematic requirements because neither metabolic cost savings nor differences in metabolic efficiency were found. Comfortable walking speed and the nadir of metabolic rate and efficiency are not different. Via accelerometer measurement, it was found that the more compliant and lossy SACH foot heel was less likely to transmit high frequency vibration.

Psychological effects of severe burn injuries.

Severe burn injuries provide researchers with an opportunity to study the effects of painful but usually transient trauma on psychological functioning. To that end, this article presents a review of the 3 main areas of this body of literature: (a) premorbid characteristics of people who sustain severe burn injuries, (b) psychological reactions during hospitalization, and (c) long-term adjustment. The general implications of these studies are discussed and then used to illuminate the circumstances under which individuals suffer the most from this type of trauma, the effects of such injuries on personality function, and how meaningful units of measurements can be defined. Potential clinical applications are also described.

Concentric versus combined concentric-eccentric isokinetic training programs: effect on peak torque of human quadriceps femoris muscle.

To determine the effects of isokinetic resistance training of the quadriceps, 25 male volunteers were randomly assigned to five training groups: Concentric Slow (CS), Concentric Fast (CF), Concentric-Eccentric Slow (MS), Concentric-Eccentric Fast (MF), and Control (C). In training, subjects performed 20 contractions of each quadriceps using either 60 degrees/sec or 180 degrees/sec, for both sides, five days per week for 12 weeks. Testing consisted of measurement of peak torque, at intervals of 60 degrees/sec across a spectrum of velocities ranging from plus to minus 240 degrees/sec, at 0, 4, 8, and 12 weeks. Repeated MANOVA using planned comparisons showed that all trained subjects made significant peak torque gains (p < .05), but that the gains made by MS and MF were greater. These findings suggest that the addition of an eccentric training component to a concentric isokinetic training program may allow greater peak torque gains regardless of the velocity.

The treatment of agitation during initial hospitalization after traumatic brain injury.

Agitation after traumatic brain injury is disruptive for patient care, distressing, and difficult to treat. The use of propranolol has been advocated to control agitation after brain injury. It reportedly lacks some of the deleterious cognitive and emotional effects of other medications and physical restraints. This study was designed to test if propranolol is effective in reducing agitated behavior. Subjects had traumatic closed-head injury treated at a combined Level I Trauma Center and Rehabilitation Center. Twenty-one subjects met the criteria of agitation and were treated with propranolol or placebo in a double-blind fashion. The intensity of agitation was significantly lower in the treatment group although the number of episodes were similar. The use of restraints was also significantly lower in the treatment group. The results support the effectiveness of propranolol in reducing the intensity of agitation during the initial hospitalization after closed-head injury.

Driving evaluation after traumatic brain injury.

Traumatic closed head injury results in a variety of cognitive and behavioral deficits that may be difficult to assess fully. Adequately evaluating driving safety is a common and important problem for health care professionals. The purpose of this study was to examine the relationship between standardized measures of cognitive function and measures of driving performance in patients with closed head injuries and in their age-matched relative or friend cohorts. Thirteen patients were evaluated. They had each sustained a closed head injury (followed by more than 1 h of coma) 3 to 6 months before testing. Their scores were analyzed along with those of seven cohorts. Assessments of cognitive function and behind-the-wheel driving performance were conducted by examiners blinded to subjects' group membership and medical condition. There was a significant relationship (r = 0.44) between the sum of rated scores of the Tactual Performance Test and Trail Making Test and the global pass/fail ratings of the behind-the-wheel driving test, but it was not related to the driving performance score. The difference between the verbal and performance IQs, and the difference between the block design and other performance tests of the Wechsler Adult Intelligence Scale-Revised were also not significantly related to driving performance. These results suggest that tests of cognitive function alone are not adequate to predict driving performance, and should be used along with standardized driving performance evaluations before recommendations are made.

Agitation and restlessness after closed head injury: a prospective study of 100 consecutive admissions.

Agitation and restlessness are two of the most striking and problematic behaviors for patients with traumatic brain injury (TBI), their caregivers, and their families. These behaviors are often treated with physical and chemical restraints which have potentially harmful side effects. There are, however, few prospective studies which clearly define agitation and restlessness in a representative sample of TBI patients. Subjects for this study were 100 consecutive patients with traumatic, closed head injury (CHI) admitted to a regional Level I Trauma Center with a Glasgow Coma Scale score of less than 8, who had more than one hour of coma, and who required more than one week of hospitalization. Agitation was defined as episodic motor or verbal behavior which interfered with patient care or clearly required physical or chemical restraints to prevent damage to persons or property. This variable was rated on the Overt Aggression Scale, a 16-item scale, in four categories: verbal aggression; physical aggression against objects; physical aggression against self; or physical aggression directed at others. Systematic direct observations, caregiver interviews, and chart reviews were used to determine the frequency and duration of agitation. Patients were also monitored for restlessness, which was defined as behavior that interfered with staff or required some action by staff, such as change of activity, but either did not meet the severity criteria for agitation, or was continuous. Only 11 of the 100 subjects exhibited episodic agitation which met the criteria. Eight subjects were agitated for one week, one for two weeks, one for three weeks, and one for four weeks. Only one subject went directly from being unresponsive to being agitated.(ABSTRACT TRUNCATED AT 250 WORDS)

Footwear and posture. Compensatory strategies for heel height.

The belief that wearing high-heeled shoes increases lumbar lordosis is firmly ingrained in clinical folklore. Proponents of negative heel footwear argue that because high positive heels increase the lumbar lordosis, negative heels will decrease the lumbar lordosis. Quantitative documentation of the assumption regarding high heels is not to be found in the literature, although sporadic attempts to prove this assumption have been made throughout the 20th Century. Although other effects, such as decreased gait speed and step length, and increased knee flexion at heel strike have been found in more than one study, no increase in lumbar lordosis has been found. Where an actual decrease in lordosis has been found, authors tend to explain it away as inconsistent with what every clinician feels that he or she has observed. We felt it appropriate, then, to conduct both a static and a dynamic study to assess the effects of heel height on lumbar spine and lower limb joint kinematics in the sagittal plane, as well as other strategies to compensate for heel height. The results indicate that the greatest compensation is at the ankle and knee. Where a significant effect occurred in the lumbar spine (males, dynamic study), high heels decreased the lumbar lordosis, i.e., resulted in less swayback rather than more.

Torque development in isokinetic training.

Twenty men were randomized into three groups that performed maximal isokinetic knee extensions five days a week for 12 weeks; a fourth group was a control group. The training protocol was different for the opposite lower extremity of each subject, such that subjects in group I trained at 36 degrees/sec with 20 or 60 repetitions, group II did 20 repetitions at 36 degrees/sec with one limb and 60 repetitions at 108 degrees/sec contralaterally, and group III trained at 108 degrees/sec with 20 or 60 repetitions. Group IV did no training. Bilateral pretraining and posttraining vastus lateralis muscle biopsies were done, and maximal torque-velocity tests (0 degrees to 234 degrees/sec at 18 degrees/sec steps) were performed every two weeks. The muscle biopsies were examined for muscle-fiber area and enzyme activity. Statistical analysis of the torque-velocity curves showed that subjects who trained at 36 degrees/sec made significant overall gains in torque and significantly greater torque gains than those training at 108 degrees/sec. Torque gains were not made uniformly during the 12 weeks of training; they occurred primarily during the initial 4 to 8 weeks. There were no significant increases in muscle-fiber areas in response to training, but there were increases in glycolytic and mitochondrial enzyme activities. These findings suggest that the critical variable for developing strength (maximal torque), at least within the context of isokinetic training, is the amount of torque developed during training.

Shoulder subluxation in hemiplegia: effects of three different supports.

Shoulder subluxation in hemiplegia is a difficult problem to manage and it may be associated with pain and other complications. Measurements taken from x-rays have been used to obtain objective measures of shoulder subluxation, but have not been used to compare the effects of different shoulder supports. This study used x-ray measurements to evaluate different shoulder supports for subluxation in hemiplegia and to see if there was a significant difference between the Harris hemisling and the Bobath sling. The Harris hemisling gave good vertical correction of subluxation and compared closely to the uninvolved shoulder. The Bobath sling did not correct the subluxation as well, and the mean difference between the two slings was significant. The arm trough or lap board was less effective and tended to overcorrect. The Harris hemisling and arm trough or lap board had horizontal measurements similar to the uninvolved shoulders. The Bobath sling, however, distracted the glenohumeral joint horizontally and was more variable. The mean horizontal difference between the Harris hemisling and the Bobath sling was significant. These results support the effectiveness and specificity of shoulder support to decrease subluxation after hemiplegia.

Post-traumatic stress disorder in hospitalized patients with burn injuries.

The degree to which patients hospitalized for a major burn displayed symptoms of post-traumatic stress disorder or met the full criteria for this disorder was assessed during the course of hospitalization. Fifty-four consecutive patients were screened weekly for symptoms of post-traumatic stress disorder. Sixty-three percent showed intrusive recollections of the initial trauma (partial diagnostic criteria) and 16 (29.6%) of the sample met full criteria for post-traumatic stress disorder at some point during the hospitalization. None of the patients met the full diagnostic criteria at discharge from the hospital, although one did at follow-up. Post-traumatic stress disorder was found to be related to patients' total body surface area burn, length of hospital stay, sex (female patients), and lack of responsibility for the injury. The results suggest that although post-traumatic stress disorder in patients with burn injuries generally resolves without interventions other than standard hospital care, it might be preventable if patients who are at risk for developing it receive appropriate psychologic treatment soon after the injury.

Hypnotherapy as an adjunct to narcotic analgesia for the treatment of pain for burn debridement.

This paper presents a hypnotherapeutic intervention for controlling pain in severely burned patients while they go through dressing changes and wound debridement. The technique is based on Barber's (1977) Rapid Induction Analgesia (RIA) and involves hypnotizing patients in their rooms and having their nurses provide posthypnotic cues for analgesia during wound cleaning. Five subjects who underwent hypnotherapy showed reductions on their pain rating scores (Visual Analogue Scale) relative to their own baselines and to the pain curves of a historical control group (N = 8) matched for initial pain rating scores. Although the lack of randomized assignment to experimental and control groups limited the validity of the results, the findings provide encouraging preliminary evidence that RIA offers an efficient and effective method for controlling severe pain from burns.

Relating mental health and physical function at discharge to rehabilitation status at three months postburn.

Preinjury mental health is said to be a major predictive factor in the rehabilitation progress of burn patients. However, it is unclear which component of rehabilitation (emotional v physical) is predicted by this variable; furthermore, the predictive validity of preinjury mental health has not been compared with physical variables. The present study compared preinjury mental health, physical variables, and length of hospitalization in predicting the rehabilitation progress of 59 major burn patients at three-month follow-up. Preinjury mental health was assessed by the Rand Mental Health Form; physical status, by the Upper Extremity Index (standard measures of upper limb joint mobility); and hospital stay, by the number of days of acute hospitalization. These variables were assessed at the time of discharge. Three-month rehabilitation outcome was measured by the Sickness Impact Profile, a self-report inventory that evaluates patient outcome in 12 different areas. These areas were in turn placed in the categories of disability (ie, difficulties in functioning in activities of daily living; eating) handicap (ie, difficulties in functioning in general areas of living; employment) and mental health status. In predicting mental health status at three months, preinjury mental health was significantly correlated. In predicting physical disability, physical factors were found to be important. Conversely, physical status was not significantly related to mental health outcome, and preinjury mental health was not related to physical disability. The results indicate the importance of defining outcome when attempting to predict rehabilitation progress of burn patients.

Hypnotherapy as a treatment for pain in patients with burns: research and clinical considerations.

Hypnotherapy has increasingly been included in the management of burn patients, particularly in the area of acute pain. To better understand such issues as (1) overall efficacy of hypnotherapy to alleviate acute burn pain, (2) instances in which hypnotherapy is contraindicated, (3) interaction of hypnotherapy with medication, (4) standard induction techniques to use with various age groups, (5) role of nursing and other staff in facilitating hypnotic effects, and (6) future methodological directions, we examined the clinical and methodological merits of recent studies of hypnoanalgesia. Through a computer search of the medical literature and cross-referencing recent bibliographies, we were able to find 17 studies in which hypnotherapy was applied to the management of burns. The literature generally supports the efficacy of this approach to reduce burn pain; however, little else can be concluded from these studies. Several recent studies have applied hypnotherapy to aspects of burn care other than pain using excellent experimental designs. It is suggested that future studies of acute pain management follow suit.

Patient self-reports three months after sustaining a major burn.

As survival rates of patients with major burns increase, it is becoming more important to study the course and quality of their recovery. Few studies of the recovery of these patients exist that use a prospective design and standardized measures. This paper describes a preliminary study of the self-reported health of patients three months after sustaining a major burn. An initial analysis was conducted on selected data gathered from 29 patients as part of a more comprehensive, prospective study of burn rehabilitation outcome. Measurements analyzed included the Sickness Impact Profile (SIP), the Health-Specific Locus of Control Scale (HLC), and the total body surface area burned (TBSA). Findings showed that TBSA was related to the degree to which patients perceived they had control over their health, but few correlations were found between TBSA, and HLC scale, and the SIP scale. On the SIP, most patients reported few or no problems, but a significant minority reported major problems in one or more areas of their lives. The problems that were reported tended to cluster in the areas of vocation and emotional adjustment. These results suggest that patients with major burns should not be considered a homogeneous group with respect to rehabilitation outcome.