Systematic Review and Meta-Analysis of Nonoperative Platelet-Rich Plasma Shoulder Injections for Rotator Cuff Pathology.

BACKGROUND: Platelet-rich plasma (PRP) injections have been introduced to augment the recovery of patients with shoulder pathology. Although multiple studies have been published, no large-scale trials or meta-analyses have assessed the efficacy of nonoperative shoulder PRP injection. OBJECTIVE: To assess the efficacy of nonoperative PRP shoulder injection in rotator cuff pathology for pain as measured by the visual analog scale (VAS) and range of motion (ROM). DESIGN: Two authors independently screened the Medline and Cochrane databases to include prospective studies that reported VAS and ROM outcomes for nonoperative shoulder PRP injections for rotator cuff pathology. Study quality was assessed using the revised Cochrane Collaboration risk-of-bias tool and modified Downs and Black checklist. Subsequent meta-analysis was performed to determine the effect of nonoperative PRP injections on pain and ROM 3 to 12 months after intervention. RESULTS: Six studies met systematic review criteria. The included studies used different PRP formulations (concentration, leukocyte count), injection protocols (approach, injection number), and varied study designs. Three studies concluded that PRP provided no significant benefit for pain and ROM when compared to physical therapy. Within-group meta-analysis of six fairly heterogeneous studies (I2 77.8%) demonstrated a statistically significant (P < .001) improvement in pain 3 to 12 months after PRP injection. Within-group meta-analysis for four studies for shoulder flexion and abduction was found to be too heterogeneous to derive meaningful results. CONCLUSION: There is a limited quantity of high-quality studies that assess the efficacy of nonoperative PRP shoulder injection for pain and ROM. Systematic review of PRP injections did not demonstrate an improvement in pain or ROM compared to physical therapy. Although within-group meta-analysis of nonoperative PRP statistically showed that nonoperative PRP improved pain, the lack of adequate negative controls precludes the ability to conclude whether improvements were due to natural recovery or nonoperative PRP.

Prior muscle activation affects the compound muscle action potential.

INTRODUCTION: This study was performed to evaluate the effect of prior voluntary activation of a muscle on the subsequently-recorded compound muscle action potential (CMAP). METHODS: The CMAPs from the hypothenar, thenar, and extensor digitorum brevis muscles were recorded in 6 healthy volunteers at rest and for up to 30 min following 5 separate epochs of up to 20 s of voluntary muscle activation. RESULTS: There was consistent, significant (P < 0.02) enhancement of the negative area, amplitude, and duration of the CMAP after activation. The enhancement was maximal, up to 144% of baseline, within about 1 min post-activation; thereafter, the CMAP gradually returned to baseline over about 15 min. DISCUSSION: Activation of a muscle within several minutes prior to testing enhances the subsequently-recorded CMAP. This observation highlights prior muscle activation as a physiological variable that influences the size of the CMAP during motor nerve conduction studies. Muscle Nerve, 2019.

Effects of Patient Preinjury and Injury Characteristics on Acute Rehabilitation Outcomes for Traumatic Brain Injury.

OBJECTIVE: To examine associations of patient and injury characteristics with outcomes at inpatient rehabilitation discharge and 9 months postdischarge for patients with traumatic brain injury (TBI). DESIGN: Prospective, longitudinal observational study. SETTING: Inpatient rehabilitation centers. PARTICIPANTS: Consecutive patients (N=2130) enrolled between 2008 and 2011, admitted for inpatient rehabilitation after index TBI, and divided into 5 subgroups based on rehabilitation admission FIM cognitive score. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rehabilitation length of stay, discharge to home, and FIM at discharge and 9 months postdischarge. RESULTS: Severity indices increased explained variation in outcomes beyond that accounted for by patient characteristics. FIM motor scores were generally the most predictable. Higher functioning subgroups had more predictable outcomes then subgroups with lower cognitive function at admission. Age at injury, time from injury to rehabilitation admission, and functional independence at rehabilitation admission were the most consistent predictors across all outcomes and subgroups. CONCLUSIONS: Findings from previous studies of the relations among patient and injury characteristics and rehabilitation outcomes were largely replicated. Discharge outcomes were most strongly associated with injury severity characteristics, whereas predictors of functional independence at 9 months postdischarge included both patient and injury characteristics.

Enteral Nutrition for Patients With Traumatic Brain Injury in the Rehabilitation Setting: Associations With Patient Preinjury and Injury Characteristics and Outcomes.

OBJECTIVE: To determine the association of enteral nutrition (EN) with patient preinjury and injury characteristics and outcomes for patients receiving inpatient rehabilitation after traumatic brain injury (TBI). DESIGN: Prospective observational study. SETTING: Nine rehabilitation centers. PARTICIPANTS: Patients (N=1701) admitted for first full inpatient rehabilitation after TBI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM at rehabilitation discharge, length of stay, weight loss, and various infections. RESULTS: There were many significant differences in preinjury and injury characteristics between patients who received EN and patients who did not. After matching patients with a propensity score of >40% for the likely use of EN, patients receiving EN with either a standard or a high-protein formula (>20% of calories coming from protein) for >25% of their rehabilitation stay had higher FIM motor and cognitive scores at rehabilitation discharge and less weight loss than did patients with similar characteristics not receiving EN. CONCLUSIONS: For patients receiving inpatient rehabilitation after TBI and matched on a propensity score of >40% for the likely use of EN, clinicians should strongly consider, when possible, EN for ≥25% of the rehabilitation stay and especially with a formula that contains at least 20% protein rather than a standard formula.

Rehospitalization During 9 Months After Inpatient Rehabilitation for Traumatic Brain Injury.

OBJECTIVE: To assess the frequency of, causes for, and factors associated with acute rehospitalization during 9 months after discharge from inpatient rehabilitation for traumatic brain injury (TBI). DESIGN: Multicenter observational cohort. SETTING: Community. PARTICIPANTS: Individuals with TBI (N=1850) admitted for inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Occurrences of proxy or self-report of postrehabilitation acute care rehospitalization, as well as length of and causes for rehospitalizations. RESULTS: A total of 510 participants (28%) had experienced 775 acute rehospitalizations. All experienced 1 admission (510 participants [66%]), whereas 154 (20%) had 2 admissions, 60 (8%) had 3, 23 (3%) had 4, 27 had between 5 and 11, and 1 had 12. The most common rehospitalization causes were infection (15%), neurological (13%), neurosurgical (11%), injury (7%), psychiatric (7%), and orthopedic (7%). The mean time from rehabilitation discharge to first rehospitalization was 113 days. The mean rehospitalization duration was 6.5 days. Logistic regression analyses revealed that older age, history of seizures before injury or during acute care or rehabilitation, history of brain injuries, and non-brain injury medical severity increased the risk of rehospitalization. Injury etiology of motor vehicle collision and high motor functioning at discharge decreased rehospitalization risk. CONCLUSIONS: Approximately 28% of patients with TBI were rehospitalized within 9 months of TBI rehabilitation discharge owing to various medical and surgical reasons. Future research should evaluate whether some of these occurrences may be preventable (such as infections, injuries, and psychiatric disorders) and should evaluate the extent to which persons at risk may benefit from additional screening, surveillance, and treatment protocols.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. OBJECTIVE: Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. METHODS: Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). RESULTS: A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. CONCLUSIONS: At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

The effects of peroneal nerve functional electrical stimulation versus ankle-foot orthosis in patients with chronic stroke: a randomized controlled trial.

BACKGROUND: Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. OBJECTIVE: To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. METHODS: In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. RESULTS: A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. CONCLUSIONS: Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Inpatient rehabilitation for traumatic brain injury: the influence of age on treatments and outcomes.

BACKGROUND: Elderly persons with traumatic brain injury (TBI) are increasingly admitted to inpatient rehabilitation, but we have limited knowledge of their characteristics, the treatments they receive, and their short-term and medium-term outcomes. This study explored these issues by means of comparisons between age groups. METHODS: Data on 1419 patients admitted to 9 inpatient rehabilitation facilities for initial rehabilitation after TBI were collected by means of (1) abstraction from medical records; (2) point-of care forms completed by therapists after each treatment session; and (3) interviews at 3 months and 9 months after discharge, conducted with the patient or a proxy. RESULTS: Elderly persons (65 or older) had a lower brain injury severity, and a shorter length of stay (LOS) in acute care. During rehabilitation, they received fewer hours of therapy, due to a shorter LOS and fewer hours of treatment per day, especially from psychology and therapeutic recreation. They regained less functional ability during and after inpatient rehabilitation, and had a very high mortality rate. CONCLUSIONS: Elderly people can be rehabilitated successfully, and discharged back to the community. The treatment therapists deliver, and issues surrounding high mortality need further research.

Amputation and cardiac comorbidity: analysis of severity of cardiac risk.

OBJECTIVE: To evaluate population-based cardiovascular risk scores and coronary artery calcification scores (CACS) in amputees. DESIGN: A retrospective cohort study of 1300 veterans in a cardiac computed tomography database. SETTING: 1B Veterans Administration medical center. PARTICIPANTS: A total of 76 amputees and similar number of age-, gender-, and Framingham Risk Scores (FRS)-matched control subjects. METHODS: The amputee population was identified and compared for CACS and traditional cardiac risk factors. Two control groups were used: control group 1, with known risk factors including diabetes mellitus, and control group 2, with all risk factors without diabetes mellitus. MAIN OUTCOME MEASURES: Statistical associations between amputee and control group FRS scores, CACS, and other cardiac risk factors were assessed. RESULTS: The study included 57 nontraumatic and 19 traumatic amputees with an average age of 62.4 years. Sixty-six amputees were in the low-to-intermediate cardiac risk groups according to FRS. Despite this classification, the mean CACS were significantly higher in amputees (1285 ± 18) than in either of the control groups: control group 1 (540 ± 84) and control group 2 (481 ± 11), P < .001. CACS also were significantly higher in the nontraumatic subject group (1595 ± 12) compared with the traumatic group (356 ± 57; P < .001). Upon categorization of CACS based on probability of coronary artery disease (CAD), 76% of amputees had a CACS >100 and 38% of amputees had a CACS >1000. Interestingly, CACS were almost the same in finger/toe amputations compared with an above-knee amputation, indicating an already ongoing CAD process irrespective of level of amputation. The predominant clinical significant cardiac risk factors in amputees are hypertension (89.5%), P < .005; chronic kidney disease (31.6%), P < .001; dyslipidemia (72.4%), P < .04; and insulin resistance. Total cholesterol, low-density lipoprotein, and high-density lipoprotein levels were nonsignificantly low in all amputees. Triglycerides were particularly higher in traumatic patients compared with nontraumatic patients, with the triglycerides/high-density lipoprotein ratio >7. CONCLUSION: This study demonstrates that amputees have a much greater burden of underlying atherosclerotic disease as detected by CACS than do control subjects matched by Framingham risk stratification. Early screening for CAD and aggressive targeted interventions may be an important part of management to reduce early mortality after amputation.

A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities.

UNLABELLED: McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. OBJECTIVE: To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States. DESIGN: Prospective observational cohort study. SETTING: Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ. PARTICIPANTS: Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18 y) after acute stroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Change in FIM score and discharge destination. RESULTS: NZ participants were older than U.S. participants (mean: 74.1 y vs 66.0 y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0 d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores. CONCLUSIONS: U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke.

Swallowing, nutrition, and hydration during acute stroke care.

Dysphagia occurs in up to half of patients after an acute stroke and may cause dehydration, undernutrition, and aspiration pneumonia. Current evidence suggests that a systematic program of diagnosis and treatment of dysphagia in an acute stroke management plan may yield dramatic reductions in aspiration pneumonia rates. There is also some evidence that nutritional supplementation and proper hydration may reduce morbidity and mortality in acute stroke patients. This article focuses on the recent advances in the evaluation and management of dysphagia, undernutrition, and dehydration related to acute stroke. A summary of pertinent studies in the area of stroke dysphagia and nutrition is also included.

Rehabilitation interventions during acute care of stroke patients.

The immediate care of a stroke patient admitted to hospital is best provided in a dedicated stroke unit, within which all of the key components of care can be coordinated. Neurologic diagnosis and intervention and general medical care are essential elements of acute stroke management. However, optimal outcome requires a comprehensive and multidisciplinary approach, which includes rehabilitation interventions. During the initial phases of care, rehabilitation interventions are mostly passive and emphasize prevention of secondary co-impairments such as contractures, pressure ulcers, and deconditioning. Rehabilitation interventions should be incorporated into care protocols for all patients and should begin immediately. As the patient becomes stable, more intensive therapy can be initiated in preparation for transition into the postacute phase of active rehabilitation.