Is the AO guideline for postoperative treatment of tibial plateau fractures still decisive? A survey among orthopaedic surgeons and trauma surgeons in the Netherlands.

INTRODUCTION: The standard aftercare treatment (according to the AO guideline) for surgically treated trauma patients with fractures of the tibial plateau is non-weight bearing or partial weight bearing for 10-12 weeks. The purpose of this study was to investigate the current state of practice among orthopaedic surgeons and trauma surgeons in choosing the criteria and the time period of restricted weight bearing after surgically treated tibial plateau fractures. MATERIALS AND METHODS: A web-based survey was distributed among members of the Dutch Trauma Society and Dutch Orthopaedic Society to identify the most commonly applied protocols in terms of the post-operative initiation and level of weight bearing in patients with tibial plateau fractures. RESULTS: One hundred and eleven surgeons responded to the survey. 72.1% of the respondents recommended starting weight bearing earlier than the 12 weeks recommended by the AO guideline; 11.7% recommended starting weight bearing immediately, 4.5% after 2 weeks and 55.9% after 6 weeks. Moreover, 88.7% of the respondents reported deviating from their own local protocol. There is little consensus about the definition of 100% weight bearing and how to build up weight bearing over time. CONCLUSION: This study demonstrates that consensus about the weight bearing aftercare for tibial plateau fractures are limited. A large majority of surgeons do not follow the AO guideline or their own local protocol. More transparent criteria and predictors are needed to design optimal weight-bearing regimes for the aftercare of tibial plateau fractures.

Fear of pain changes movement: Motor behaviour following the acquisition of pain-related fear.

BACKGROUND: According to current fear-avoidance models, changes in motor behaviour (e.g. avoidance) are a key component in the development and maintenance of chronic pain complaints. Yet, experimental research assessing actual behavioural changes following painful events is relatively sparse. This study investigated the effects of pain anticipation on changes in motor behaviour using a fear conditioning paradigm and robot-generated standardized movement trajectories of the upper extremities. METHODS: Pain-free participants (N = 20) performed clockwise and counterclockwise fixed, circular movements with a robotic arm without receiving visual feedback. During fear acquisition, moving in one direction (CS+) was paired with a painful stimulus (pain-US) whereas moving in the other direction (CS-) was not. During the subsequent extinction phase, the pain-US was omitted. We assessed self-reported pain-related fear and urge to avoid the movement, as well as several behavioural measures: Velocity, acceleration, exerted force and force direction. RESULTS: Movements that were paired with pain were associated with increased self-reported pain-related fear and urge to avoid. Moreover, movements that were associated with pain were performed faster, more forcefully and more accurately than movements that were not associated with pain. All these differences diminished during the extinction phase. CONCLUSIONS: The present study demonstrates the utility of robot-generated force feedback in the study of pain-related fear and associated changes in motor behaviour. SIGNIFICANCE: Fear of pain changes movement: Movements associated with pain are performed faster, with more force and higher accuracy than movements that are not associated with pain. These changes can inform us how fear of pain translates into avoidance and escape behaviour, two important constructs in the maintenance of chronic pain.

Robot-assisted task-oriented upper extremity skill training in cervical spinal cord injury: a feasibility study.

STUDY DESIGN: Prospective multiple case study. OBJECTIVES: To test (1) the feasibility of haptic robot technology (Haptic Master (HM)) use to improve arm-hand function (AHF) and arm-hand skill performance (AHSP) in persons with a cervical spinal cord injury (C-SCI), (2) inventory participants' motivation and expectation to work with the robot technology used and (3) to descriptively report the results in individual cases. SETTING: Rehabilitation Centre. METHODS: Five C-SCI patients were trained for 6 weeks, 3 days per week, 60 min per day. Therapists filled out the Usefulness, Satisfaction and Ease-of-use questionnaire (USE). The Intrinsic Motivational Inventory (IMI) and credibility and expectancy questionnaire (CEQ) were filled out by participants. Performance at activity level was gauged using the Van Lieshout test for AHF in Tetraplegia and the Spinal Cord Independence Measure. Function level was gauged using muscle strength testing and the International Classification for Surgery of the Hand in Tetraplegia. RESULTS: As to the feasibility of the application of haptic robot technology, the mean USE score was 65%. Mean IMI and CEQ results were 67% and 60%, respectively. Participants were motivated to train with the HM. All participants rated credibility higher than expectations regarding the improvement. In the current patients, little progress was demonstrated at the International Classification of Functioning, Disability and Health function and the activity level. CONCLUSION: It is feasible to train C-SCI persons with the HM. Therapists report that working with the HM is easy to learn and easy to perform. Usability of the HM may be improved. Further research is needed to assess in which group of C-SCI and at which stage of rehabilitation HM training may be most beneficial.

Reference values for the transformed Van Lieshout hand function test for tetraplegia.

STUDY DESIGN: Longitudinal cohort study. OBJECTIVES: Previously, the Van Lieshout hand function test for tetraplegia (short form)(VLT-SF) has been transformed into an interval scale (r_VLT-SF) using the Rasch analysis, thereby fulfilling the requirements of an objective measurement. The present study aims (1) to transform r_VLT-SFlogit scores (r_VLT-SFlogit) into 0-100 scores (r_VLT-SF100) in order to facilitate communication amongst its users and (2) to describe r_VLT-SF100 reference values in order to refine the prediction of upper extremity skilled performance in persons with tetraplegia. SETTING: Eight Dutch rehabilitation centres. METHODS: The VLT-SF data of tetraplegic patients from eight Dutch rehabilitation centres, gathered at the start of the active rehabilitation (t1), 3 months after t1 (t2) and at the time of discharge (t3), have been used. The r_VLT-SF100 total score for t1 and t3 were computed, anchored on the data for t2. Reference values (medians and interquartiles) for different subgroups were calculated at different moments during the rehabilitation. RESULTS: Data at t1 (n=64), t2 (n=73) and t3 (n=69) were used. The r_VLT-SFlogit scores (-4.78-6.32) were transformed into r_VLT-SF100 (0-100) at t2. Reference values were established for persons with motor complete or incomplete lesions with either a high (C1-C6) or a low (C7-T1) lesion level at t1, t2 and t3. Significant differences (P<0.025) in r_VLT-SF100 were found for most subgroups and different time intervals. CONCLUSIONS: The r_VLT-SFlogit scores were converted into r_VLT-SF100 scores, and reference values of the r_VLT-SF100 have been established for different subgroups of tetraplegic patients at different stages during rehabilitation. The r_VLT-SF100 has been proven to be able to detect improvement over time.

Improvement of the Van Lieshout hand function test for tetraplegia using a Rasch analysis.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: The Van Lieshout hand function test for tetraplegia (VLT) measures the quality of arm-hand functioning in persons with tetraplegia. It is valid, reliable and responsive. However, it does not satisfy all the criteria for interval level measurement. The present study aims to apply the Rasch model to the VLT short form (VLT-SF) to upgrade its scale type towards interval level, and to verify if the requirements of an objective measure are satisfied in the revised version. SETTING: Eight Dutch Rehabilitation centres. METHODS: The VLT-SF data of 73 tetraplegic patients were Rasch-analysed (RUMM2030 software, RUMM Laboratory Pty Ltd, Perth, Australia) to verify the order of response categories, unidimensionality and reliability of the VLT-SF, and to assess its applicability regardless of (motor) lesion completeness. RESULTS: Seven of the ten VLT-SF items showed disordered response categories. The six original response categories were therefore recoded into three or four categories. After recoding, all items satisfied the model requirement of unidimensionality. The items were relatively well-targeted on the subjects' arm-hand skilled performance measures, leading to a good person separation index (R=0.91). The difficulty hierarchy of the VLT-SF items was invariant across patient subgroups of (motor) lesion completeness. CONCLUSIONS: Provided that response categories are recoded, VLT-SF Rasch analysis showed that the requirements of an objective measure were satisfied. This allows to compare the measurements of different patients quantitatively, and to follow their results over time.

ToCUEST: a task-oriented client-centered training module to improve upper extremity skilled performance in cervical spinal cord-injured persons.

OBJECTIVES: Given (a) the importance of upper extremity skill performance in persons with cervical spinal cord injury (C-SCI), (b) the limited number of studies on arm hand functioning in C-SCI and (c) the discrepancy between the importance of client centeredness and the lack of a theoretical framework and practical guidelines on how to apply client centeredness into practice, the aim of the present study is to (1) develop a training concept in which rehabilitation of the upper extremity focuses on patient's needs and wishes and (2) to put this concept into practice for tetraplegic persons. METHODS: The training concept contains two main components. The client-centered component includes both extracting individual goals and defining and objectifying these goals. The task-oriented component incorporates a task analysis and the composition of an individual training program. RESULTS: A task-oriented client-centered training aimed at improving upper extremity skilled performance in tetraplegic persons is described step by step. The Canadian Occupational Performance Measure is used to identify patient's specific needs. The Goal Attainment Scale is applied to define and objectify individual goals. A task analysis is essential to map limiting and facilitating factors of the person, the task and the environment and to identify which aspects should be trained. An individual task-oriented training program is composed, based on principles of motor learning and training physiology and the use of assistive devices. Each step is explained and illustrated using a case example.

Evaluation of a task-oriented client-centered upper extremity skilled performance training module in persons with tetraplegia.

STUDY DESIGN: Clinical intervention study. OBJECTIVE: Arm hand skilled performance (AHSP) has a major role in the rehabilitation of persons with cervical spinal cord injury (C-SCI). A task-oriented client-centered upper extremity skilled performance-training (ToCUEST) module was developed. The present study aims to evaluate effects of ToCUEST on specific and general AHSP in C-SCI, during and after rehabilitation. SETTING: Adelante Rehabilitation Centre (The Netherlands). METHODS: C-SCI persons, either during or after rehabilitation, completed the ToCUEST training; a control group of patients during rehabilitation received standard rehabilitation. The training module was focused on patient's individual needs, combining principles of motor learning and training physiology. Three self-selected goals were trained 3 days per week, in three sessions of 30 min per day for 8 weeks. Measures were taken at 3 months after the start of the active rehabilitation (T0), before training (T1), after training (T2), at follow-up (3 months post-training; T3) and at discharge. RESULTS: For both ToCUEST groups during (n=11) and after (n=12) rehabilitation, an improvement (P<0.001) on specific AHSP (using the Goal Attainment Scale and the Canadian Occupational Performance Measure (satisfaction and performance)) was found between T1-T2 and T1-T3. Also an improvement (P<0.02) in general AHSP (using the Van Lieshout Test, the QIF and the motor FIM) was found in the total ToCUEST group between T1-T2 and T1-T3. No significant difference in improvement of general AHSP was found between the ToCUEST rehab and control group. CONCLUSION: The ToCUEST module leads to improvement in AHSP, not only persons with C-SCI during rehabilitation, but also after finishing rehabilitation. These effects remain at follow-up.

Validity of the test-table-test for Nordic skiing for classification of paralympic sit-ski sports participants.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To assess the interrater reliability and validity of the test-table-test (TTT) with which paralympic sports participants involved in Nordic sit-ski sports may be classified. SETTING: Movement laboratory in a rehabilitation centre, The Netherlands. METHODS: Thirty-three persons with a spinal cord injury caudally to Th2, a leg amputation, poliomyelitis affecting the trunk and/or lower extremities, or cerebral palsy participated. Subjects were classified according to a classification system for Nordic skiing (that is, five subclasses between LW10 and LW12) by two raters, involving, among others, a combination of four balance tests called TTT. The validity of the TTT was investigated using a gold standard, involving balance perturbation tests on a force plate and centre of pressure (CoP) displacement measurements. RESULTS: As for the interrater reliability, Spearman's rank-correlation coefficient was 0.95 (P<0.001). As regards the validity of the TTT, correlation coefficients ranging from 0.61 to 0.74 (P<0.001) were found when comparing the data with the gold standard. CONCLUSION: Interrater reliability was high in both scoring and classification. With regard to TTT validity, strong positive correlations between CoP displacement and TTT classification were found. Overall, the results of this study show that the TTT is a reliable and valid test. However, the relations between TTT and CoP displacement in the LW10 and LW10.5 subclasses found in this study are somewhat vague, which could be due to the small number of participants in these subclasses. For the LW10 and LW10.5 subclasses further refinement of the four tests within the TTT is warranted.

Impact of EMG-triggered neuromuscular stimulation of the wrist and finger extensors of the paretic hand after stroke: a systematic review of the literature.

OBJECTIVE: To assess whether EMG-triggered neuromuscular electrical stimulation (EMG-NMES) applied to the extensor muscles of the forearm improves hand function after stroke. DESIGN: Systematic review of randomized controlled trials. METHODS: A computer-aided literature search up to June 2006 identified articles comparing EMG-NMES of the upper extremity with usual care. Methodological quality was rated on the Physiotherapy Evidence Database scale (PEDro), and the Hedges' g model was used to calculate the summary effect sizes (SES) using fixed or random models depending on heterogeneity. RESULTS: Eight studies, selected out of 192 hits and presenting 157 patients, were included in quantitative and qualitative analyses. The methodological quality ranged from 2 to 6 points. The meta-analysis revealed non-significant effect sizes in favour of EMG-NMES for reaction time, sustained contraction, dexterity measured with the Box and Block manipulation test, synergism measured with the Fugl-Meyer Motor Assessment Scale and manual dexterity measured with the Action Research Arm test. CONCLUSION: No statistically significant differences in effects were found between EMG-NMES and usual care. Most studies had poor methodological quality, low statistical power and insufficient treatment contrast between experimental and control groups. In addition, all studies except two investigated the effects of EMG-NMES in the chronic phase after stroke, whereas the literature suggests that an early start, within the time window in which functional outcome of the upper limb is not fully defined, is more appropriate.

Assessment of upper extremity muscle function in persons with tetraplegia.

The objective was to investigate the actual level of muscle function impairment in tetraplegic persons and, inextricably related to this, the possibilities to compensate function loss using new muscle coalitions. In this cross-sectional group study, 20 persons with a cervical spinal cord injury (SCI) at segmental levels C5C6 or C7C8 and 10 control persons participated. Activity from 21 upper extremity and trunk muscles was recorded during standardised gross upper extremity task performance. No substantial differences in main activation patterns were found between C7C8 and control subjects. In contrast, main activation patterns in C5C6 persons showed an absence of selectivity, which may be explained by the participants activating every controllable muscle in an attempt to perform maximally. In order to identify more intricate differences in muscle activation between control and C7C8 persons a fine motor function task may be necessary. Muscle activation patterns during arm task performance were stable in all three groups.

Effects of movement imagery and electromyography-triggered feedback on arm hand function in stroke patients in the subacute phase.

OBJECTIVE: To investigate the effects of movement imagery-assisted electromyography (EMG)-triggered feedback (focused on paretic wrist dorsiflexors) on the arm-hand function of stroke patients. DESIGN: Single-blinded, longitudinal, multicentre randomized controlled trial. Measurements were performed (on average) 54 days post stroke (baseline), three months later (post training) and at 12 months post baseline. SETTING: Two rehabilitation centres. SUBJECTS: Twenty-seven patients with a first-ever, ischaemic, subacute stroke. INTERVENTIONS: A reference group received conventional electrostimulation, while the experimental group received arm-hand function training based on EMG-triggered feedback combined with movement imagery. Both groups were trained for three months, 5 days/week, 30 minutes/day, in addition to their therapy as usual. MAIN MEASURES: Arm-hand function was evaluated using the upper extremity-related part of the Brunnstrom Fugl-Meyer test and the Action Research Arm test. RESULTS: During training, Brunnstrom Fugl-Meyer scores improved 8.7 points and Action Research Arm scores by 19.4 points (P < 0.0001) in both groups relative to baseline results, rising to 13.3 and 28.4 points respectively at one year follow-up (P < 0.0001). No between-group differences were found at any time. CONCLUSIONS: EMG-triggered feedback stimulation did not lead to more arm-hand function improvement relative to conventional electrostimulation. However, in contrast to many clinical reports, a significant improvement was still observed in both groups nine months after treatment ceased.

Measuring change in arm hand skilled performance in persons with a cervical spinal cord injury: responsiveness of the Van Lieshout Test.

OBJECTIVES: To asses whether the Van Lieshout Test (VLT) is responsive to measure changes in arm hand skilled performance (AHSP) over time during active rehabilitation in persons with cervical spinal cord injury (C-SCI) and in different subgroups of persons with C-SCI according to lesion completeness and to lesion level. STUDY DESIGN: Longitudinal cohort study. SETTING: Spinal Cord Injury Units in eight rehabilitation centres across the Netherlands. METHODS: In the present study, data from a national SCI cohort study are used. Data from the VLT, the Grasp Release Test (GRT), the Functional Independence Measure (FIM) and the Quadriplegia Index of Function (QIF) were recorded at three moments during active rehabilitation: at the start of active rehabilitation (t1), 3 months after t1 (t2) and at discharge (t3). Data have been analysed using three responsiveness measures, that is, the standardized response mean, the effect size and comparison of test scores measured at different times. RESULTS: The VLT is responsive for the intervals t1-3, t1-2 and t2-3. The VLT can be used to measure changes in AHSP in persons with a C-SCI with an American Spinal Injury Association Impairment Scale (AIS) A or B score or an AIS C or D score, as well as in persons with a C3-C6 lesion or a C7-T1 lesion. The responsiveness of the VLT is significantly correlated to the GRT, but not to the FIM and the QIF. CONCLUSION: The VLT is responsive in measuring changes in AHSP during rehabilitation in persons with C-SCI.

Measurement properties of the short version of the Van Lieshout test for arm/hand function of persons with tetraplegia after spinal cord injury.

STUDY DESIGN: Two validation studies. OBJECTIVES: To assess the measurement properties of the short version of the Van Lieshout test (VLT-SV), a new test for arm/hand function of persons with tetraplegia after spinal cord injury (SCI). SETTING: Two specialized rehabilitation centres in The Netherlands. METHODS: Study 1 (N=12)--assessment of inter-rater reliability (intraclass correlations (ICC); weighted kappa; Bland-Altman plots). Study 2 (N=55)--assessment of convergent validity by computing Spearman's correlations with the Grasp-Release test (GRT; criterion standard) and with motor level of injury, ASIA impairment scale, international classification for surgery of the hand, and the self-care and transfer scales of the functional independence measure. All statistics were computed separately for the right- and the left-hand scores. RESULTS: Inter-rater reliability was excellent (ICC 0.98 and 0.99). Agreement was independent of the height of the scores and the limits of agreement were +/-0.5 points on a 0-5 scale. Convergent validity was very good with a Spearman correlation of 0.87 and 0.90 between the VLT-SV and the GRT and correlations between 0.35 and 0.85 with the other indicators of arm/hand function. CONCLUSION: The VLT-SV seems a reliable and valid test to assess arm/hand function of persons with tetraplegia after SCI.

Effects of prosthesis alignment on pressure distribution at the stump/socket interface in transtibial amputees during unsupported stance and gait.

OBJECTIVE: To assess the effects of antero-posterior realignment of the prosthesis on pressure distribution at the stump/socket interface in unilateral transtibial amputees during unsupported stance and gait. DESIGN: Cross-sectional group study. SETTING: Outpatient rehabilitation clinic. SUBJECTS: Seventeen unilateral transtibial amputees. INTERVENTION: Antero-posterior prosthesis realignment using 0.5 cm heel or forefoot wedging. MEASURES: Pressure distribution changes at several sites at the stump/socket interface, expressed as peak pressure, peak pressure time, sustained submaximal load (MP80+) and time period of MP80+ (TP80+). RESULTS: During stance, heel wedging led to a 30.4% decrease in mean pressure near the patella tendon and a 40.0% increase near the distal tibia site, whereas forefoot wedging led to a 30.0% decrease in pressure in the tibial end region. Antero-posterior ankle realignment did not lead to significant changes near the fibular head. During gait only heel wedging led to a 11.5% increase in peak pressure in the tibia end region. Mean peak pressure time increased 22.7% using heel wedging and decreased 8.8% using forefoot wedging. MP80+ increased 23.8% in the tibia end region during heel wedging and 17.0% in the subpatellar region during forefoot wedging. CONCLUSIONS: Antero-posterior realignment of the ankle joint led to an inverse loading and unloading of the subpatellar region versus tibial end region. However, results indicate that stump/socket interface pressure during stance seems not to be highly predictive as to pressure behaviour during gait. Ankle joint realignment led to significant differences in temporal sequences of tissue (un-)loading in the subpatellar area during gait.

Ankle-foot orthosis has limited effect on walking test parameters among patients with peripheral ankle dorsiflexor paresis.

The aim of this study was to determine the relationship between ankle dorsiflexor strength and performances on several walking tests and to determine the effect of ankle-foot orthosis (AFO) use on walking tests. The following tests were used: 10-metre walking test (with and without three stairs), a complex walking task (6-minute walk with cognitive loading) and a subjective evaluation (SIP68 mobility scale and questionnaire). Isometric strength of the ankle dorsiflexors was measured. All walking tests were performed with and without AFO in random order. When relating torque values to walking performances, the highest correlation was found with the "10 metre" and "10 metre with stairs" test (r = -0.51, i.e. an inverse relationship). No threshold in the degree of paresis was found below which walking disability suddenly increased. No significant improvement could be demonstrated from AFO use on the 10-metre tests. Improvement on the 6-minute test was nearly significant (p = 0.06), the questionnaire revealed a positive opinion on AFO use related to overall walking function and effort. Thus, we have to conclude that these walking tests do not aid the clinician in estimating the severity of (progression of) the paresis nor to detect differences in degree of paresis between subjects.

Evaluation of upper extremity motor function tests in tetraplegics.

OBJECTIVE: To provide an overview of arm-hand function tests useful in tetraplegic subjects. Considerations for selection of an appropriate test are also provided. DATA SOURCES: A Medline literature search was conducted covering the period from 1967 to March 2001. Relevant references cited in the selected papers were also considered, regardless of the year of publication. STUDY SELECTION: This review was restricted to strength tests, functional and ADL tests. Only general tests and tests designed specifically to test tetraplegic persons written in English, or in Dutch were included in the review. RESULTS: Information is provided on four types of strength tests, 10 general and five specific functional tests and eight ADL tests. CONCLUSION: Many tests are available to measure upper extremity motor function in tetraplegics. Selection of a test is at first determined by the outcome value in which the investigator is interested. When the type of outcome value has been determined, the most suitable test has to be selected from the range of available tests. When two tests appear to be equally suitable, the availability of information on psychometric properties of the test when used in tetraplegic patients is a decisive factor. When information on the reliability, validity and sensitivity of a test is missing, it should be gathered before using the test.