Donor Limb Functional Restoration via a Novel Clinical Care Pathway following Fibula Free Flap Harvest for Head and Neck Reconstruction.

Patients undergoing head and neck skeletal reconstruction (HNR) often require free tissue transfer from the extremities to ensure proper restoration of form and function. This requires a team-based, highly reliable medical system centered around the patient needs. Surgical intervention across multiple sites and harvesting of donor tissue results in short- and long-term physical impairments. There is a paucity of research objectively measuring impairments resulting from the graft donor site. There is a lack of research that objectively measures impairments and protocols for the management of these patients postoperatively. Patients undergo little, if any, formal approach to dealing with the vast impairments, which are sequelae to this surgery. This leads to large discrepancies in proposed functional progressions, return to duty timelines, and utilization of rehabilitative resources. At a major military medical center, an innovative clinical care pathway for patients undergoing HNR using free tissue transfer was implemented using a multidisciplinary model that focuses on early engagement with rehabilitation. This model, paired with a single surgery, will attempt to return service members to duty months earlier than the traditional approach. This report describes the conceptual framework and implementation of a new criteria-based, multidisciplinary clinical care pathway for HNR patients. The collaboration amongst the multidisciplinary care team has optimized the holistic health of the patient and communication with their support network, yielding faster return to normalization of daily life activities. The long-term goal is to further develop and formalize this pathway to best serve this patient population.

The association between kinesiophobia and functional limitations in service members with knee pain.

BACKGROUND: Knee diagnoses account for more than 50% of lower extremity musculoskeletal conditions in non-deployed US Service members. However, there is limited information regarding kinesiophobia in Service members with non-operative knee diagnoses. HYPOTHESES: The objectives of this study were to determine the prevalence of high levels of kinesiophobia in US military Service members with knee pain across different knee diagnoses, and to determine the relationships between kinesiophobia and lower extremity function and/or specific functional limitations in Service members with knee pain. It was hypothesized Service members with knee pain would exhibit high levels of kinesiophobia across all knee diagnoses examined, and higher levels of both kinesiophobia and pain would be associated with worse self-reported function in this population. It was also hypothesized higher levels of kinesiophobia would be associated with functional activities with high knee loading. DESIGN: Retrospective cohort study. LEVEL OF EVIDENCE: IV. METHODS: Sixty-five US Service members presenting to an outpatient physical therapy clinic were included in this study (20 females; age = 30.8 ± 7.7 years; height = 1.74 ± 0.9 m; mass = 80.7 ± 16.2 kg). Inclusion criterion was the presence of knee pain (duration = 50 ± 59 months); exclusion criterion was knee pain as a sequela of knee surgery. Data regarding demographic, pain chronicity, pain by Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia (TSK), and Lower Extremity Functional Scale (LEFS) were retrospectively obtained from patients' medical records. A high level of kinesiophobia was defined as a TSK score of greater than 37 points. Patient diagnoses included: osteoarthritis (n = 16); patellofemoral pain syndrome (n = 23); and other non-operative knee diagnoses (n = 26). Commonality analysis was utilized to determine the effects of age, height, mass, NRS, and TSK on LEFS score. Predictor values were interpreted as <1% = negligible, >1% = small; >9% = moderate, >25% = large. Additionally, exploratory item-specific analyses examined the strength of the relationships between kinesiophobia and LEFS item responses. Binary logistic regression determined if difficulty with an individual LEFS item could be predicted from either NRS or TSK score. Statistical significance was set at P < 0.05. RESULTS: High levels of kinesiophobia were identified in 43 individuals (66%). NRS and TSK explained 19.4% and 8.6% of the unique variance in LEFS, and 38.5% and 20.5% of total variance, respectively. Age, height, and mass explained negligible to small proportions of the unique variance in LEFS. TSK and NRS were independent predictors for 13/20 individual LEFS items, with odds ratios ranging from 1.12 to 3.05 (P < 0.05). CONCLUSION: The majority of US Service members in this study exhibited high levels of kinesiophobia. Kinesiophobia was significantly related to self-reported functional scores and performance on individual functional tasks in Service members with knee pain. CLINICAL RELEVANCE: Treatment strategies addressing both fear of movement and pain reduction in patients with knee pain may help optimize functional outcomes.

Kinetic chain revisited: consensus expert opinion on terminology, clinical reasoning, examination, and treatment in people with shoulder pain.

BACKGROUND: The purpose of this study was to reach consensus on the most appropriate terminology and issues related to clinical reasoning, examination, and treatment of the kinetic chain (KC) in people with shoulder pain among an international panel of experts. METHODS: A 3-round Delphi study that involved an international panel of experts with extensive clinical, teaching, and research experience in the study topic was conducted. A search equation of terms related to the KC in Web of Science and a manual search were used to find the experts. Participants were asked to rate items across 5 different domains (terminology, clinical reasoning, subjective examination, physical examination, and treatment) using a 5-point Likert-type scale. An Aiken coefficient of validity (V) ≥0.7 was considered indicative of group consensus. RESULTS: The participation rate was 30.2% (n = 16), whereas the retention rate was high throughout the 3 rounds (100%, 93.8%, and 100%). A total of 15 experts from different fields and countries completed the study. After the 3 rounds, consensus was reached on 102 items: 3 items were included in the "terminology" domain; 17 items, in the "rationale and clinical reasoning" domain; 11 items, in the "subjective examination" domain; 44 items, in the "physical examination" domain; and 27 items, in the "treatment" domain. Terminology was the domain with the highest level of agreement, with 2 items achieving an Aiken V of 0.93, whereas the domains of physical examination and treatment of the KC were the 2 areas with less consensus. Together with the terminology items, 1 item from the treatment domain and 2 items from the rationale and clinical reasoning domain reached the highest level of agreement (V = 0.93 and V = 0.92, respectively). CONCLUSION: This study defined a list of 102 items across 5 different domains (terminology, rationale and clinical reasoning, subjective examination, physical examination, and treatment) regarding the KC in people with shoulder pain. The term "KC" was preferred and a agreement on a definition of this concept was reached. Dysfunction of a segment in the chain (ie, weak link) was agreed to result in altered performance or injury to distal segments. Experts considered it important to assess and treat the KC in particular in throwing or overhead athletes and agreed that no one-size-fits-all approach exists when implementing shoulder KC exercises within the rehabilitation process. Further research is now required to determine the validity of the identified items.

Implementation of an Injury Prevention Program in NCAA Division I Athletics Reduces Injury-Related Health Care Costs.

BACKGROUND: The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs. PURPOSE: To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers. RESULTS: Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P = .049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P = .032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P < .01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P = .027). CONCLUSION: This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs.

Critical review of the impact of core stability on upper extremity athletic injury and performance

BACKGROUND: Programs designed to prevent or rehabilitate athletic injuries or improve athletic performance frequently focus on core stability. This approach is based upon the theory that poor core stability increases the risk of poor performance and/or injury. Despite the widespread use of core stability training amongst athletes, the question of whether or not sufficient evidence exists to support this practice remains to be answered.OBJECTIVES: 1) Open a dialogue on the definition and components of core stability. 2) Provide an overview of current science linking core stability to musculoskeletal injuries of the upper extremity. 3) Provide an overview of evidence for the association between core stability and athletic performance.DISCUSSION: Core stability is the ability to control the position and movement of the trunk for optimal production, transfer, and control of forces to and from the upper and lower extremities during functional activities. Muscle capacity and neuromuscular control are critical components of core stability. A limited body of evidence provides some support for a link between core stability and upper extremity injuries amongst athletes who participate in baseball, football, or swimming. Likewise, few studies exist to support a relationship between core stability and athletic performance.CONCLUSIONS: A limited body of evidence exists to support the use of core stability training in injury prevention or performance enhancement programs for athletes. Clearly more research is needed to inform decision making when it comes to inclusion or emphasis of core training when designing injury prevention and rehabilitation programs for athletes.