Clinical evaluation of micro-fragmented adipose tissue as a treatment option for patients with meniscus tears with osteoarthritis: a prospective pilot study.

PURPOSE: The management of knee pain secondary to meniscal tears with osteoarthritis is limited by the poor inherent healing potential of the meniscus. Previous studies have reported on the benefit of autologous micro-fragmented fat as a therapeutic for various knee pathologies. The goal of this prospective pilot study was to determine the safety and potential treatment effect of micro-fragmented adipose tissue injection for patients with knee pain secondary to osteoarthritis and meniscal tears who have failed conservative management. METHODS: Twenty subjects with knee pain secondary to osteoarthritis with associated meniscal tear after failed conservative management were enrolled in the study. Numeric Pain Scale (NPS) and Knee Injury and Osteoarthritis Outcome Scale (KOOS) following ultrasound-guided intra-meniscal and intra-articular micro-fragmented adipose tissue injections were examined at three, six and 12 months. RESULTS: The mean NPS revealed a significant decrease in patient pain at the 1-year time point compared with baseline (5.45 to 2.21, p < .001). Similarly, overall, mean KOOS symptoms significantly improved from 57.7 to 78.2 (p < .001), with all 4 KOOS subscales demonstrating significant improvement at the final one year follow-up. One subject developed uncomplicated cellulitis at the harvest site which was treated with oral antibiotics. Other complications were minor and mostly limited to adipose harvest. CONCLUSION: This study demonstrated that micro-fragmented adipose tissue injected directly into a torn meniscus and knee joint using ultrasound guidance represents a safe and potentially efficacious treatment option for patients with knee pain suffering from degenerative arthritis and degenerative meniscal tears. A larger, randomized, controlled trial is warranted to determine efficacy. TRIAL REGISTRATION: Clinicaltrials.org Identifier: NCT03714659.

Investigating the Efficacy of Web-Based Transfer Training on Independent Wheelchair Transfers Through Randomized Controlled Trials.

OBJECTIVES: To determine the efficacy of a web-based transfer training module at improving transfer technique across 3 groups: web-based training, in-person training (current standard of practice), and a waitlist control group (WLCG); and secondarily, to determine subject factors that can be used to predict improvements in transfer ability after training. DESIGN: Randomized controlled trials. SETTING: Summer and winter sporting events for disabled veterans. PARTICIPANTS: A convenience sample (N=71) of manual and power wheelchair users who could transfer independently. INTERVENTIONS: An individualized, in-person transfer training session or a web-based transfer training module. The WLCG received the web training at their follow-up visit. MAIN OUTCOME MEASURE: Transfer Assessment Instrument (TAI) part 1 score was used to assess transfers at baseline, skill acquisition immediately posttraining, and skill retention after a 1- to 2-day follow-up period. RESULTS: The in-person and web-based training groups improved their median (interquartile range) TAI scores from 7.98 (7.18-8.46) to 9.13 (8.57-9.58; P<.01), and from 7.14 (6.15-7.86) to 9.23 (8.46-9.82; P<.01), respectively, compared with the WLCG that had a median score of 7.69 for both assessments (baseline, 6.15-8.46; follow-up control, 5.83-8.46). Participants retained improvements at follow-up (P>.05). A lower initial TAI score was found to be the only significant predictor of a larger percent change in TAI score after receiving training. CONCLUSIONS: Transfer training can improve technique with changes retained within a short follow-up window, even among experienced wheelchair users. Web-based transfer training demonstrated comparable improvements to in-person training. With almost half of the United States population consulting online resources before a health care professional, web-based training may be an effective method to increase knowledge translation.

Wheelchair Breakdowns Are Associated With Pain, Pressure Injuries, Rehospitalization, and Self-Perceived Health in Full-Time Wheelchair Users With Spinal Cord Injury.

OBJECTIVES: To evaluate the relation between wheelchair breakdowns, their immediate consequences, and secondary health complications after spinal cord injury. "Immediate consequences" occur when part of a wheelchair breaks and leaves an individual stranded or injured, or causes him or her to miss medical appointments, work, or school. DESIGN: Survey, cross-sectional. SETTING: Spinal Cord Injury Model Systems Centers. PARTICIPANTS: Full-time wheelchair users (N=771) with SCI from 9 Spinal Cord Injury Model Systems Centers, with data collected between 2011 and 2016. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Incidence of self-reported wheelchair breakdowns within the past 6 months that did or did not result in immediate consequences (ie, injury, being stranded, missing a medical appointment, or an inability to attend school/work); self-perceived health status scale; pain severity numerical rating scale; rehospitalizations; and self-reported pressure injury development within the past 12 months. RESULTS: A total of 610 participants with complete data sets were included in the analyses. When compared to those who reported no breakdowns, participants who reported 1 or more immediate consequences had worse secondary complications: higher self-perceived health status and pain scores (partial -η2=.009-.012, P<.05), and higher odds of rehospitalization (odds ratio: 1.86, P<.05) and pressure injury development (odds ratio: 1.73, P<.05). Secondary health complications were not different in those who reported no immediate consequences compared to those who reported no breakdown. CONCLUSIONS: Wheelchair breakdowns that resulted in injury, being stranded, missing medical appointments, and/or an inability to attend work/school appear to have far-reaching impacts on health and secondary injury. Preventing wheelchair breakdowns, through either better maintenance or manufacturing, may be a means of decreasing secondary disability.

Longitudinal Prediction of Quality-of-Life Scores and Locomotion in Individuals With Traumatic Spinal Cord Injury.

OBJECTIVES: To examine (1) differences in quality-of-life scores for groups based on transitions in locomotion status at 1, 5, and 10 years postdischarge in a sample of people with spinal cord injury (SCI); and (2) whether demographic factors and transitions in locomotion status can predict quality-of-life measures at these time points. DESIGN: Retrospective case study of the National SCI Database. SETTING: Model SCI Systems Centers. PARTICIPANTS: Individuals with SCI (N=10,190) from 21 SCI Model Systems Centers, identified through the National SCI Model Systems Centers database between the years 1985 and 2012. Subjects had FIM (locomotion mode) data at discharge and at least 1 of the following: 1, 5, or 10 years postdischarge. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: FIM-locomotion mode; Severity of Depression Scale; Satisfaction With Life Scale; and Craig Handicap Assessment and Reporting Technique. RESULTS: Participants who transitioned from ambulation to wheelchair use reported lower participation and life satisfaction, and higher depression levels (P<.05) than those who maintained their ambulatory status. Participants who transitioned from ambulation to wheelchair use reported higher depression levels (P<.05) and no difference for participation (P>.05) or life satisfaction (P>.05) compared with those who transitioned from wheelchair to ambulation. Demographic factors and locomotion transitions predicted quality-of-life scores at all time points (P<.05). CONCLUSIONS: The results of this study indicate that transitioning from ambulation to wheelchair use can negatively impact psychosocial health 10 years after SCI. Clinicians should be aware of this when deciding on ambulation training. Further work to characterize who may be at risk for these transitions is needed.

Transfer Technique Is Associated With Shoulder Pain and Pathology in People With Spinal Cord Injury: A Cross-Sectional Investigation.

OBJECTIVES: To evaluate how transfer technique and subject characteristics relate to ultrasound measures of shoulder soft tissue pathology and self-reported shoulder pain during transfers in a sample of wheelchair users with spinal cord injury (SCI). DESIGN: Cross-sectional observational study. SETTING: Research laboratory, national and local veterans' wheelchair sporting events. PARTICIPANTS: A convenience sample of wheelchair users (N=76) with nonprogressive SCI. Participants were aged >18 years, >1 year postinjury, and could complete repeated independent wheelchair transfers without the use of their leg muscles. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Transfer pain items from the Wheelchair User's Shoulder Pain Index; transfer technique assessed using the Transfer Assessment Instrument (TAI); and shoulder pathology markers examined using the Ultrasound Shoulder Pathology Rating Scale (USPRS). RESULTS: Better transfer technique (higher TAI) correlated with less injury (lower USPRS) (partial η(2)=.062, P<.05) and less pain during transfers (partial η(2)=.049, P<.10). Greater age was the strongest predictor of greater pathology (USPRS total: partial η(2)=.225, supraspinatus grade: partial η(2)=.174, P<.01). An interaction between technique and weight was found (P<.10): participants with lower body weights showed a decrease in pathology markers with better transfer technique (low weight: R(2)=.422, P<.05; middle weight: R(2)=.200, P<.01), while those with higher weight showed little change with technique (R(2)=.018, P>.05). CONCLUSIONS: Participants with better transfer technique exhibited less shoulder pathology and reported less pain during transfers. The relationship between technique and pathology was strongest in lower-weight participants. While causation cannot be proven because of study design, it is possible that using a better transfer technique and optimizing body weight could reduce the incidence of shoulder pathology and pain.

Evacuation preparedness in full-time wheelchair users with spinal cord injury.

OBJECTIVE: To analyze and evaluate the efficacy of evacuation plans described by individuals with spinal cord injury (SCI). DESIGN: Descriptive study from a convenience sample. SETTING: Outpatient population center in Pittsburgh, PA, USA. METHODS: Twenty-one individuals with SCI who previously indicated that they had a plan of evacuation from either their homes, places of work, or towns/cities were contacted via telephone and asked to describe their evacuation plans. The number of critical elements (scale of 0-10 with 10 indicating a more thorough plan) and assistive technology (AT) devices were recorded. OUTCOME MEASURES: The number of critical elements (scale of 0-10 with 10 indicating a more thorough plan) and AT devices were recorded. RESULTS: Median home and town/city evacuation scores were both 3.00 (ranges: 1.0-4.0 and 0.0-8.0, respectively). Median evacuation scores of individuals with paraplegia were higher in home (P = 0.05, r = 0.44) and town/city (P = 0.045, r = 0.63) than individuals with tetraplegia. Median evacuation scores of subjects who were employed were higher in home (P = 0.036, r = 0.47) and town/city (P = 0.064, r = 0.59) than unemployed. CONCLUSION: Low scores indicate that individuals with SCI who believe that they have plans are not adequately prepared for an emergency evacuation. Interventions are needed to improve evacuation readiness and lack of preparedness in a catastrophe should be considered by emergency personnel when responding.

Ultrasound-guided platelet-rich plasma injection for the treatment of recalcitrant rotator cuff disease in wheelchair users with spinal cord injury: A pilot study.

Context/Objective: Wheelchair users with spinal cord injury (SCI) have a high risk of developing shoulder pain, caused by rotator cuff disease. Platelet-rich plasma (PRP) is a potential treatment after conservative treatments fail and prior to surgical intervention; however, it has not been tested in wheelchair users who have recalcitrant shoulder pain associated with rotator cuff disease. The objective of this pilot project was to test the safety and potential treatment effect of an ultrasound-guided PRP injection for shoulder pain in the aforementioned population.Design: Prospective, quasi-experimental.Setting: Clinical research center.Participants: Six wheelchair users with SCI (3 paraplegia, 3 tetraplegia) who had chronic shoulder pain due to rotator cuff disease (presence of anterior shoulder pain, positive physical examination tests for rotator cuff disease, and tendinopathy demonstrated by ultrasound) and failed at least six months of conservative treatment.Interventions: Ultrasound-guided PRP injection into pathological shoulder tendons, targeting the supraspinatus. Subjects were provided a standardized stretching and strengthening program and were followed for 4, 8, 12, and 24 weeks post-intervention with outcomes collected at each time-point.Outcome Measures: Wheelchair User's Shoulder Pain Index (WUSPI); pain Numerical Rating Scale (NRS); physical and ultrasound examinations for supraspinatus tendinopathy; 5-point patient global impression of change (PGIC).Results: WUSPI (69.9%, P < 0.001), NRS (49.6%, P < 0.01), and physical exam scores (35.7%, P < 0.01) decreased 24 weeks after treatment. Participants reported overall improvement in their status as a result of the treatment. No adverse events were noted, and no changes in ultrasound markers for tendinopathy were observed.Conclusion: A single, ultrasound-guided PRP injection into the supraspinatus tendon, followed by a stretching and strengthening exercise program, was safe and provided improvements in shoulder pain outcome measures in this sample for 24 weeks. Lack of blinding, short-term follow-up, and a suitable control group warrant a larger randomized controlled trial.Trial Registration: NCT01355549.

Start-up propulsion biomechanics changes with fatiguing activity in persons with spinal cord injury.

Objective: Shoulder pathology is a common condition in wheelchair users that can considerably impact quality of life. Shoulder muscles are prone to fatigue, but it is unclear how fatigue affects start-up propulsion biomechanics. This study determines acute changes in start-up wheelchair propulsion biomechanics at the end of a fatiguing propulsion protocol. Design: Quasi-experimental one-group pretest-postest design. Setting: Biomechanics laboratory. Participants: Twenty-six wheelchair users with spinal cord injury (age: 35.5 ± 9.8 years, sex: 73% males and 73% with a paraplegia). Interventions: Protocol of 15 min including maximum voluntary propulsion, right- and left turns, full stops, start-up propulsion, and rests. Outcome measures: Maximum resultant force, maximum rate of rise of applied force, mean velocity, mean fraction of effective force, and mean contact time at the beginning and end of the protocol during start-up propulsion. Results: There was a significant reduction in maximum resultant force (P < 0.001) and mean velocity (P < 0.001) at the end of the protocol. Also, contact time was reduced in the first stroke of start-up propulsion (P < 0.001). Finally, propelling with a shorter contact time was associated with a greater reduction in performance (maximum velocity) at the end of the protocol. Conclusion: There are clear changes in overground propulsion biomechanics at the end of a fatiguing propulsion protocol. While reduced forces could protect the shoulder, these reduced forces come with shorter contact times and lower velocity. Investigating changes in start-up propulsion biomechanics with fatigue could provide insight into injury risk.

Microdialysis to Quantify Inflammatory Cytokines in the Glenohumeral Joint: A Brief Methods Report.

Microdialysis quantifies in vivo soft-tissue biochemical concentrations via passive diffusion of interstitial molecules through a porous membrane into a dialysate. The purpose of this pilot study was to evaluate a technique to measure inflammatory cytokines associated with rotator cuff tendinopathy by inserting a microdialysis catheter into the posterior glenohumeral joint. The technique was tested in a convenience sample of six pain-free, able-bodied veterans. Complete dialysate samples were collected in two participants. Two participants' sample volumes were smaller than what was required for analysis (30 µl) and thus were diluted. Catheter failures in two participants prevented collection altogether. Three cytokine concentrations were quantified: interleukin-1 receptor antagonist, interleukin 8, and regulated on activation, normal T-cell expressed and secreted. Microdialysis is not recommended for use in the glenohumeral joint, yet quantification of glenohumeral joint cytokines could yield valuable information to better understand pathophysiology of the joint and its surrounding tissues. Another technique, such as joint lavage, may be a more attractive alternative to overcome the limitations of microdialysis in the glenohumeral joint.

Relationship between linear velocity and tangential push force while turning to change the direction of the manual wheelchair.

Wheelchair propulsion is a major cause of upper limb pain and injuries for manual wheelchair users with spinal cord injuries (SCIs). Few studies have investigated wheelchair turning biomechanics on natural ground surfaces. The purpose of this study was to investigate the relationship between tangential push force and linear velocity of the wheelchair during the turning portions of propulsion. Using an instrumented handrim, velocity and push force data were recorded for 25 subjects while they propel their own wheelchairs on a concrete floor along a figure-eight-shaped course at a maximum velocity. The braking force (1.03 N) of the inside wheel while turning was the largest of all other push forces (p<0.05). Larger changes in squared velocity while turning were significantly correlated with higher propulsive and braking forces used at the pre-turning, turning, and post-turning phases (p<0.05). Subjects with less change of velocity while turning needed less braking force to maneuver themselves successfully and safely around the turns. Considering the magnitude and direction of tangential force applied to the wheel, it seems that there are higher risks of injury and instability for upper limb joints when braking the inside wheel to turn. The results provide insight into wheelchair setup and mobility skills training for wheelchair users.

Acute Response of the Infraspinatus and Biceps Tendons to Pitching in Youth Baseball.

PURPOSE: Youth baseball frequently results in repetitive strain injuries. Quantitative ultrasound allows real-time imaging with the ability to identify acute markers of tendon change. The study objective was to determine acute quantitative ultrasound changes in the long head of the biceps and infraspinatus tendons of the throwing and nonthrowing shoulders during a pitching performance. We hypothesized the tendons of the pitching arm would exhibit an increased width and decreased echogenicity after pitching and that tendons of the nonpitching arm would not demonstrate such changes. METHODS: Fifty youth baseball players, ages 9-14 yr, engaged in a simulated pitching performance that consisted of 50 pitches. Subjects underwent serial quantitative ultrasound imaging of the infraspinatus and the long head of the biceps before pitching and after 25 and 50 pitches were thrown. RESULTS: Testing of the change in tendon width revealed the infraspinatus (0.21 mm) and long head of the biceps tendons (0.18 mm) in the throwing shoulder had statistically significant increases (P = 0.03) in tendon width as an acute response to throwing 50 pitches, without such changes in the nonthrowing shoulder (P > 0.05). No tendon width change was found at 25 pitches in either arm or tendon (P > 0.05). No associated changes in echogenicity were found at any time point (P > 0.05). CONCLUSION: The results of this study suggest that pitching acutely increases tendon width in two biomechanically important tendons of the shoulder as early as the 50 pitch mark. This change could be a normal physiological response or a potential warning sign of future pathology and requires further study.

Transfer component skill deficit rates among Veterans who use wheelchairs.

The purpose of this study was to quantify the deficit rates for transfer component skills in a Veteran cohort and explore the relationship between deficit rates and subject characteristics. Seventy-four men and 18 women performed up to four transfers independently from their wheelchair to a mat table while a therapist evaluated their transfer techniques using the Transfer Assessment Instrument. The highest deficit rates concerned the improper use of handgrips (63%). Other common problems included not setting the wheelchair up at the proper angle (50%) and not removing the armrest (58%). Veterans over 60 yr old and Veterans with moderate shoulder pain were more likely to set up their wheelchairs inappropriately than younger Veterans (p = 0.003) and Veterans with mild shoulder pain (p = 0.004). Women were less likely to remove their armrests than men (p = 0.03). Subjects with disabilities other than spinal cord injury were less inclined to set themselves up for a safe and easy transfer than the subjects with spinal cord injury (p ≤ 0.001). The results provide insight into the disparities present in transfer skills among Veterans and will inform the development of future transfer training programs both within and outside of the Department of Veterans Affairs.

Cross-Sectional Investigation of Acute Changes in Ultrasonographic Markers for Biceps and Supraspinatus Tendon Degeneration After Repeated Wheelchair Transfers in People With Spinal Cord Injury.

OBJECTIVE: The objectives of this work were to investigate how wheelchair transfers influence acute changes in ultrasound markers for biceps and supraspinatus tendon degeneration and to determine how such changes correlate with transfer technique and demographic characteristics. DESIGN: Participants underwent quantitative ultrasound examinations for markers of biceps and supraspinatus tendon degeneration (tendon width, echogenicity, variance, and contrast) before and after a stressful repeated-transfers protocol. The Transfer Assessment Instrument was completed for each participant to identify transfer skills. Linear regression tested whether demographics and transfer skills correlated with ultrasound measures. RESULTS: Sixty-two wheelchair users with spinal cord injury were included (39 with paraplegia and 23 with tetraplegia). Biceps tendon width increased after repeated transfers (P < 0.001). Participants with greater body weight experienced greater increases in biceps width after transfers (ß = 0.109, P < 0.05). Skills evaluating body position relative to the target surface and safe and stable hand and arm positions affected changes in biceps and supraspinatus width and echogenicity (P < 0.05). CONCLUSIONS: Repeated transfers caused measurable changes in biceps tendon width in a subset of participants. Changes in biceps and supraspinatus ultrasound measures were related to body weight and performance of specific transfer skills. Further testing is needed to confirm whether the clinical meaning of the observed relationships and whether using certain transfer skills and reducing body weight can attenuate the development of tendinopathy.

Ultrasonographic Median Nerve Changes After Repeated Wheelchair Transfers in Persons With Paraplegia: Relationship With Subject Characteristics and Transfer Skills.

BACKGROUND: Wheelchair users with spinal cord injuries are susceptible to peripheral neuropathies from overuse, yet no studies have established a relationship between median neuropathy and wheelchair transfers. A more thorough understanding of how transfers and technique contribute to pathologic conditions may guide interventions that curtail its development. OBJECTIVE: To evaluate the effects of repeated transfers on ultrasound markers for carpal tunnel syndrome (CTS) in people with spinal cord injuries and to relate changes to subject characteristics and transfer skills. DESIGN: Cross-sectional, repeated measures. SETTING: Research laboratory and national wheelchair sporting events. PARTICIPANTS: A convenience sample of 30 wheelchair users with nonprogressive paraplegia were recruited via research registries and at the 2013 National Veterans Wheelchair Games and 2014 Paralyzed Veterans of America Buckeye Games. Participants were older than 18 years and could complete transfers independently within 30 seconds without use of their leg muscles. METHODS: Demographic questionnaires and physical examinations for CTS were completed. Quantitative ultrasound techniques were used to measure changes in the median nerve after a repeated-transfers protocol. The Transfer Assessment Instrument (TAI) was completed to quantify transfer ability. MAIN OUTCOME MEASUREMENTS: Median nerve cross-sectional area at the level of the pisiform (PCSA) and swelling ratio (SR), transfer quality, and skills via the TAI. RESULTS: PCSA increased after repeated transfers (P < .025). Participants who used safe hand positions had a lower baseline SR (ß = -0.728; P < .01). Participants with a higher body weight had a lower baseline SR provided they performed higher quality transfers. Participants who scooted to the front of the seat prior to transferring (TAI item 7; ß = 0.144; P < .05) and who weighed more (ß = 0.142; P < .05) exhibited greater increases in PCSA in response to transfers. CONCLUSIONS: An acute increase was observed in median nerve CSA at the pisiform after repeated wheelchair transfers. Changes were greater in persons with higher body weight and in persons who did not perform certain transfer skills correctly (according to the TAI). It is possible that these factors contribute to chronic injury and possibly CTS.

Computer keyboarding biomechanics and acute changes in median nerve indicative of carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is a common and costly peripheral neuropathy. Occupations requiring repetitive, forceful motions of the hand and wrist may play a role in the development of carpal tunnel syndrome. Computer keyboarding is one such task, and has been associated with upper-extremity musculoskeletal disorder development. The purpose of this study was to determine whether continuous keyboarding can cause acute changes in the median nerve and whether these changes correlate with wrist biomechanics during keyboarding. METHODS: A convenience sample of 37 healthy individuals performed a 60-minute typing task. Ultrasound images were collected at baseline, after 30 and 60 min of typing, then after 30 min of rest. Kinematic data were collected during the typing task. Variables of interest were median nerve cross-sectional area, flattening ratio, and swelling ratio at the pisiform; subject characteristics (age, gender, BMI, wrist circumference, typing speed) and wrist joint angles. FINDINGS: Cross-sectional area and swelling ratio increased after 30 and 60 min of typing, and then decreased to baseline after 30 min of rest. Peak ulnar deviation contributed to changes in cross-sectional area after 30 min of typing. INTERPRETATION: Results from this study confirmed a typing task causes changes in the median nerve, and changes are influenced by level of ulnar deviation. Furthermore, changes in the median nerve are present until cessation of the activity. While it is unclear if these changes lead to long-term symptoms or nerve injury, their existence adds to the evidence of a possible link between carpal tunnel syndrome and keyboarding.

The relationship between independent transfer skills and upper limb kinetics in wheelchair users.

Transfers are one of the most physically demanding wheelchair activities. The purpose of this study was to determine if using proper transfer skills as measured by the Transfer Assessment Instrument (TAI) is associated with reduced loading on the upper extremities. Twenty-three wheelchair users performed transfers to a level-height bench while a series of forces plates, load cells, and a motion capture system recorded the biomechanics of their natural transferring techniques. Their transfer skills were simultaneously evaluated by two study clinicians using the TAI. Logistic regression and multiple linear regression models were used to determine the relationships between TAI scores and the kinetic variables on both arms across all joints. The results showed that the TAI measured transfer skills were closely associated with the magnitude and timing of joint moments (P < .02, model R(2) values ranged from 0.27 to 0.79). Proper completion of the skills which targeted the trailing arm was associated with lower average resultant moments and rates of rise of resultant moments at the trailing shoulder and/or elbow. Some skills involving the leading side had the effect of increasing the magnitude or rate loading on the leading side. Knowledge of the kinetic outcomes associated with each skill may help users to achieve the best load-relieving effects for their upper extremities.