Gait Variability and Relationships With Fear, Avoidance, and Pain in Adolescents With Chronic Pain.

OBJECTIVE: Some children with chronic pain struggle with fear of pain, avoidance behaviors, and associated disability; however, movement adaptations in the context of chronic pain in childhood is virtually unknown. Variability in adaptive movement responses previously observed between individuals might be largely explained by the presence of problematic psychological drivers (eg, fear, avoidance). The goals of this study were to quantify the variability of gait and examine relationships among pain, fear, avoidance, function (perceived and objective), and gait variability. METHODS: This study used a cross-sectional design. Eligible patients were between 8 and 17 years of age and had musculoskeletal, neuropathic, or headache pain that was not due to acute trauma (eg, active sprain) or any specific or systemic disease. Participants completed the Numeric Pain Rating Scale, Fear of Pain Questionnaire (FOPQ), Functional Disability Inventory, and 6-Minute Walk Test and received kinematic gait analysis. Relationships were analyzed among these measures, and the self-report and functional measures were examined to determine whether they predicted gait variability (GaitSD). RESULTS: The 16 participants who were evaluated (13.8 [SD = 2.2] years of age; 13 female) had high Numeric Pain Rating Scale scores (6.2 [SD = 2.1]), FOPQ-Fear scores (25.9 [SD = 12.1]), FOPQ-Avoidance scores (22.8 [SD = 10.2]), and Functional Disability Inventory scores (28.6 [SD = 9.4]) and low 6-Minute Walk Test distance (437.1 m [SD = 144.6]). Participants had greater GaitSD than age-predicted norms. Fear was related to self-selected GaitSD, and avoidance was related to both self-selected and standardized GaitSD. Avoidance predicted 43% and 47% of the variability in self-selected and standardized GaitSD, respectively. CONCLUSION: GaitSD was significantly related to both fear of pain and avoidance behaviors, suggesting the interplay of these psychological drivers with movement. FOPQ-Avoidance was robust in accounting for GaitSD. IMPACT: This study offers preliminary evidence in understanding movement adaptations associated with adolescents with chronic pain. They may lend to more directed interventions.

An isokinetic training program for reducing falls in a community-dwelling older adult: a case report.

BACKGROUND: With the population older than 65 years, projected to double by the year 2030, falls in older adults are a substantial health concern. Muscle strength deficits are one of the multifactorial components linked to increased fall risk, and decreasing these deficits has been one of the goals of interventions designed to decrease fall risk. These interventions have traditionally focused on improving peak torque; however, recent research suggests that exercise protocols that focus on the rate of torque development (RTD) may be more effective in decreasing fall risk. PURPOSE: This case report examines clinical outcomes following implementation of an isokinetic strengthening protocol coupled with a balance program designed to reduce fall risk in a community-dwelling older adult. METHODS: The individual was a 70-year-old woman with a history of 3 falls over the past 8 months and no related medical etiology who had self-limited her activities because of fear of another fall. She was classified as having substantial risk for future falls because of fall history, increased fear of falling, and below age norms on the Berg Balance Scale (BBS), and the Timed Up and Go (TUG). The treatment program consisted of 12 weeks of high-intensity isokinetic knee extensor training, high challenge dynamic gait and balance activities, and core strengthening. The isokinetic protocol consisted of 4 sets of 10 concentric-only repetitions at speeds of 240°/sec and 300°/sec for a total of 8 work sets. Dynamic gait activities incorporating directional and obstacle drills, and rocker and balance boards were used for balance training activities. Progressive theraband exercises were used for core strengthening. As her home program, the participant was encouraged to return to line dancing twice per week. During the 12-week protocol, the participant completed two 90-minute therapy sessions and two 90-minute dance classes per week. RESULTS: After the 12 weeks of treatment, knee extensor peak torque at 150 ms improved on the right from 67.8 N to 107.1 N (57.9% increase), and on the left from 65.1 N to 97.6 N (49.9% increase). The BBS score improved from 45 to 52; and the TUG improved from 14.0 to 8.6 seconds. Both final scores exceeded fall risk cutoffs (BBS = 48; TUG = 13.5 seconds) and the change score exceeded minimal detectable change (BBS = 7; TUG 5.4 seconds). CONCLUSIONS: The treatment program produced improvements in knee extensor peak torque and RTD, but more importantly, the final scores on the clinical outcome measures placed the participant above established fall-risk cutoff scores. Although future research with increased numbers of participants and a control group should be conducted to confirm this study's results, these findings support the use of isokinetic training to reduce fall risk in older adults.

Patellar tendinopathy: preliminary surgical results.

BACKGROUND: Calcific deposits (CaDs) may be related to chronic postoperative pain and may affect function after patellar tendon surgery. STUDY DESIGN: Cross-sectional. HYPOTHESIS: We hypothesized that patients with CaDs (+CaDs) would rate lower than those without (-CaDs) on measures of knee function and quality of life. METHODS: Patients completed the Tegner Lysholm Knee Scoring Scale (Lysholm), Knee Injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Subjective Knee Form (IKDC), and the Tegner Activity Level Scale. Sixteen postsurgical and 16 age-matched controls were tested. Patients +CaDs were 5.6 years older than those patients -CaDs and had 4.2 years of longer elapse since surgery. Bilateral patellar tendons were examined for CaDs with musculoskeletal ultrasound imaging. One-way analysis of variance was used to determine if differences existed among patients +CaDs and -CaDs and healthy controls. Hierarchical logistic regressions were used to determine which variables best predicted the presence of CaDs. RESULTS: CaDs were found in 44% (7 of 16) of postsurgical patients, who scored lower than controls on all dimensions of the Lysholm, KOOS, and IKDC. Patients +CaD had lower KOOS scores than controls (symptoms, activities of daily living, and quality of life). Age and time since surgery were both moderately related to the presence of CaDs, and both correctly predicted 71% of patients +CaDs. CONCLUSION: Calcific deposits were found in the patellar tendon of 44% of postsurgical patients, who rated themselves lower on all subjective measures of knee function and quality of life following surgery. Age is an important factor for developing CaDs postsurgery. CLINICAL RELEVANCE: Calcific deposits may be present in patellar tendons following surgery, but their direct role in functional or clinical limitations remains unknown.

Relationships and responsiveness of six upper extremity function tests during the first six months of recovery after stroke.

BACKGROUND: Knowing how clinical tests are related to each other and whether tests are responsive to change are critical to evidence-based practice and sound research. OBJECTIVE: To determine (1) relationships between six clinical tests of upper extremity function and (2) responsiveness for each test during the first six months after stroke. METHODS: Grip strength test, pinch strength test, Action Research Arm Test, Jebsen-Taylor Hand Function Test, Nine-Hole Peg Test, and the Stroke Impact Scale-Hand domain were administered to 33 subjects within one, three, and six months after stroke. Spearman correlations were used to analyze relationships between tests. Responsiveness was calculated using the single population effect size method. RESULTS: All tests were correlated with each other with absolute r-values ranging from 0.54 to 0.92 at one month, 0.57 to 0.97 at three months, and 0.41 to 0.97 at six months. All tests were at least moderately responsive to change, with effect sizes ranging from 0.50 to 1.02 from one to three months, and 0.56 to 0.86 (d) from one to six months. CONCLUSIONS: Our data can assist clinicians and researchers in making decisions to use specific tests for measuring upper extremity function in people with hemiparesis in the first six months of recovery.

Recovery of thumb and finger extension and its relation to grasp performance after stroke.

This study investigated how the ability to extend the fingers and thumb recovers early after stroke and how the ability to extend all of the digits affects grasping performance. We studied 24 hemiparetic patients at 3 and 13 wk post stroke. At each visit, we tested the subjects' ability to actively extend all five digits of their contralesional, affected hand against gravity and to perform a grasp movement with the same hand. Three-dimensional motion analysis captured: 1) maximal voluntary extension excursion of each digit and 2) grasp performance variables of movement time, peak aperture, peak aperture rate, and aperture path ratio. We found that finger and thumb extension improved from 3 to 13 wk, with average improvements ranging from 12 to 19 degrees across the five digits. Grasp performance improved on two of the four variables measured. Peak apertures and peak aperture rates improved from 3 to 13 wk, but self-selected movement time and aperture path ratio did not. Stepwise multiple regression models showed that the majority of variance in grasp performance at 13 wk could be predicted by the ability to extend the index or middle finger at 3 wk, plus the change in the ability to extend the index finger from 3 to 13 wk. R2 values ranged from 0.55 to 0.89. Our data indicate that the amount of recovery in finger and thumb extension and grasping is small from 3 to 13 wk post stroke. In people with relatively pure motor hemiparesis, one important factor underlying deficits in hand shaping during grasping is the inability to extend the fingers and thumb. Without sufficient volitional control of finger and thumb extension, successful grasping of objects will not occur.

Active range of motion predicts upper extremity function 3 months after stroke.

BACKGROUND AND PURPOSE: After stroke, 80% of patients experience acute paresis of the upper extremity and only approximately one-third achieve full functional recovery. Predicting functional recovery for these patients is highly important to provide focused, cost-effective rehabilitation. Our purpose was to examine if early measures of upper extremity active range of motion (AROM) could predict recovery of upper extremity function, and to describe the trajectory of upper extremity AROM recovery over time. METHODS: Thirty-three subjects were tested at 1 month and then at 3 months after stroke. Upper extremity function was measured with 6 standardized clinical tests that were synthesized into a single, sensitive score for upper extremity function using principal component analysis. The ability to move each segment (AROM) was measured using a 3-dimensional electromagnetic tracking system. RESULTS: Stepwise multiple regression revealed that AROM of the shoulder and middle finger segments taken at 1 month could predict 71% of the variance in upper extremity function at 3 months. All segments of the upper extremity recover similarly and no evidence of a proximal to distal gradient in motor deficits appeared over time. CONCLUSIONS: Simple AROM measurements of the upper extremity taken within 1 month after stroke can be used to predict upper extremity function at 3 months. This information is important for determining the prognosis of upper extremity functional recovery.

Restricted active range of motion at the elbow, forearm, wrist, or fingers decreases hand function.

The purpose of this study was to investigate how restricting active range of motion (AROM) at various upper extremity segments influenced hand function in younger and older populations. Eighteen younger (27+/-4yr) and 15 older subjects (67+/-6yr) participated. A repeated-measures study design was used with six test conditions: one condition without AROM restrictions and five conditions with AROM restrictions (shoulder, elbow, forearm, wrist, fingers). AROM was restricted using customized braces. Hand function was measured using total time to complete the Jebsen-Taylor Test of Hand Function. We found that the older group took longer than the younger group to complete the Jebsen, and that restricting AROM at the elbow, forearm, wrist, or fingers resulted in decreased hand function for both groups. Because restricted AROM is a consequence of a variety of diseases and conditions, it is important to know how restricted AROM at multiple upper extremity segments affects hand function.

Absence of a proximal to distal gradient of motor deficits in the upper extremity early after stroke.

OBJECTIVE: Our first purpose was to determine whether there was a proximal to distal gradient in motor deficits in nine segments of the affected upper extremity (shoulder, elbow, forearm, wrist, and five fingers) post-stroke. Our second purpose was to determine which upper extremity segments made the greatest contributions to hand function. METHODS: Thirty-three subjects were tested on average 18.6 (+/-5.6) days after stroke. The ability to move each segment was measured by active range of motion (AROM). Hand function was measured by a battery of standardized clinical tests which were synthesized into a single, sensitive score for hand function using principal component analysis. RESULTS: AROM at all nine segments of the upper extremity was reduced and there was no evidence of a proximal to distal gradient in AROM values. Strength of each segment was reduced and there was also no evidence of a gradient in strength values. AROM at each segment was strongly correlated with hand function scores (range 0.76-0.94). General multiple regression analysis showed that AROM explained 82% of the variance in hand function, with most of the variance shared across proximal, middle, and distal segments. Hierarchical regression analysis showed that shoulder AROM alone could explain 88% of the variance in hand function. CONCLUSIONS: Early after stroke a proximal to distal gradient of motor deficits was not present, and loss of hand function was due to a loss of ability to move many segments of the upper extremity and not just the distal ones. SIGNIFICANCE: These results suggest that a change in the clinical perception of motor deficits post-stroke is needed. Our finding that shoulder AROM predicted almost all the variance in hand function opens up the possibility that this quick, simple measure may be predictive of future hand function. This would be of high economic and clinical utility compared to other ongoing efforts attempting to predict outcomes post-stroke (e.g. fMRI, MEG).

Relating movement control at 9 upper extremity segments to loss of hand function in people with chronic hemiparesis.

BACKGROUND AND OBJECTIVE: Loss of hand function in people with hemiparesis is a major contributor to disability poststroke. To use the hand for functional activities, a person may need control of the more proximal upper extremity segments to position and orient the hand with respect to the environment and may need control of the fingers to manipulate objects within the environment. The purpose of this project was to investigate how movement control at proximal, middle, and distal upper extremity segments contributed to loss of hand function in people with chronic hemiparesis. METHODS: 32 patients with hemiparesis (avg 21.4 months postlesion) were studied making isolated movements of shoulder flexion, elbow flexion, forearm pronation/supination, wrist flexion/extension, and individual finger flexion using 3D kinematic techniques. For each segment, 3 variables were obtained: how far a segment could move (active range of motion [AROM]), how well a segment could move by itself (individuation index), and how well a segment could remain still when it was not supposed to move (stationary index). Hand function was measured with a battery of clinical tests, and principal components analysis was used to create a single hand function score for each patient from the test battery. Correlation and regression analyses were used to examine relationships between segmental movement control and hand function. RESULTS: Movement control at all 9 segments of the upper extremity was related to hand function. Of the 9 segments, the thumb tended to have the weakest relationship with hand function. Of the 3 measures of movement control, AROM had strong relationships with and predicted the most variance in hand function (73%). Most of this variance was shared across segments, such that, for AROM, there were no unique contributions provided by proximal, middle, or distal segments. CONCLUSIONS: These data support the idea that loss of movement control covaries across segments and that loss of hand function is due to loss of movement control at all segments, not just at distal ones.

A comparison of serratus anterior muscle activation during a wall slide exercise and other traditional exercises.

STUDY DESIGN: Single-group repeated-measures design. OBJECTIVES: To investigate the ability of the wall slide exercise to activate the serratus anterior muscle (SA) at and above 90 degrees of humeral elevation. BACKGROUND: Strengthening of the SA is a critical component of rehabilitation for patients with shoulder impingement syndromes. Traditional SA exercises have included scapular protraction exercises such as the push-up plus. These exercises promote activation of the SA near 90 degrees of humeral elevation, but not in positions above 90 degrees where patients typically experience pain. METHODS AND MEASURES: Twenty healthy subjects were studied performing 3 exercises: (1) wall slide, (2) plus phase of a wall push-up plus, and (3) scapular plane shoulder elevation. Three-dimensional position of the thorax, scapula, and humerus and muscle activity from the SA, upper and lower trapezius, and latissimus dorsi were recorded. The magnitudes of activation for each muscle at 90 degrees, 120 degrees, and 140 degrees of humeral elevation were quantified from EMG records. Repeated-measures analyses of variance were used to determine the degree to which the different exercises activated the SA at the 3 humeral positions. RESULTS: The intensity of SA activity was not significantly different between the 3 exercises at 90 degrees of humeral elevation (P = .40). For the wall slide and scapular plane shoulder elevation exercises, SA activity increased with increasing humeral elevation angle (P = .001), with no significant differences between the 2 exercises (P = .36). CONCLUSION: The wall slide is an effective exercise to activate the SA muscle at and above 90 degrees of shoulder elevation. During this exercise, SA activation is not significantly different from SA activation during the push-up plus and scapular plane shoulder elevation, 2 exercises previously validated in the literature.