Effectiveness of Mechanical Treatment for Plantar Fasciitis: A Systematic Review.

CONTEXT: Plantar fasciitis is one of the most common foot injuries. Several mechanical treatment options, including shoe inserts, ankle-foot orthoses, tape, and shoes are used to relieve the symptoms of plantar fasciitis. OBJECTIVES: To investigate the effectiveness of mechanical treatment in the management of plantar fasciitis. EVIDENCE ACQUISITION: The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A systematic search was performed in PubMed, CINAHL, Embase, and Cochrane up to March 8, 2018. Two independent reviewers screened eligible articles and assessed risk of bias using the Cochrane Collaboration's risk of bias tool. EVIDENCE SYNTHESIS: A total of 43 articles were included in the study, evaluating 2837 patients. Comparisons were made between no treatment and treatment with insoles, tape, ankle-foot orthoses including night splints and shoes. Tape, ankle-foot orthoses, and shoes were also compared with insoles. Follow-up ranged from 3 to 5 days to 12 months. Cointerventions were present in 26 studies. CONCLUSIONS: Mechanical treatment can be beneficial in relieving symptoms related to plantar fasciitis. Contoured full-length insoles are more effective in relieving symptoms related to plantar fasciitis than heel cups. Combining night splints or rocker shoes with insoles enhances improvement in pain relief and function compared with rocker shoes, night splints, or insoles alone. Taping is an effective short-term treatment. Future studies should aim to improve methodological quality using blinding, allocation concealment, avoid cointerventions, and use biomechanical measures of treatment effects.

A Passive Polycentric Mechanism to Improve Active Mediolateral Balance in Prosthetic Walking.

Prosthetic legs are typically passive systems without active ankle control, restricting mediolateral balancing to a hip strategy. Resulting balance control impairments for persons with a lower extremity amputation may be mitigated by increasing hip strategy effectiveness, in which relatively small hip moments of force are adequate for mediolateral balancing. To increase hip strategy effectiveness we have developed a prosthetic leg prototype based on the Peaucellier mechanism, the Sideways Balance Mechanism (SBM). This polycentric mechanism adds a frontal plane degree of freedom, reducing mediolateral body displacements. Adding a passive joint alone introduces instability, in which mediolateral body rotation leads to CoM height loss, ultimately resulting in a fall. The SBM however provides stability typically absent by lengthening under rotation, thereby compensating for CoM height loss. By allowing for both foot rotation (in-/eversion), and increased mediolateral ground reaction force the SBM increases hip strategy effectiveness. We aimed to provide proof of principle that the SBM can improve active mediolateral balance control in prosthetic walking by increasing hip strategy effectiveness compared to a typical set-up. Comparison between a typical set-up and the SBM showed an increased mediolateral ground reaction force at equal hip moments of force for a 2D forwards dynamics computer simulation, and a reduced hip moment of force at equal mediolateral ground reaction force for a case study. Results validate increased hip strategy effectiveness of the SBM compared to a typical set-up, providing proof of principle that adding an SBM to a prosthetic set-up improves mediolateral balance control in prosthetic walking.

Development and psychometric properties of the DCDDaily: a new test for clinical assessment of capacity in activities of daily living in children with developmental coordination disorder.

OBJECTIVE: To develop the DCDDaily, an instrument for objective and standardized clinical assessment of capacity in activities of daily living (ADL) in children with developmental coordination disorder (DCD), and to investigate its usability, reliability, and validity. SUBJECTS: Five to eight-year-old children with and without DCD. MAIN MEASURES: The DCDDaily was developed based on thorough review of the literature and extensive expert involvement. To investigate the usability (assessment time and feasibility), reliability (internal consistency and repeatability), and validity (concurrent and discriminant validity) of the DCDDaily, children were assessed with the DCDDaily and the Movement Assessment Battery for Children-2 Test, and their parents filled in the Movement Assessment Battery for Children-2 Checklist and Developmental Coordination Disorder Questionnaire. RESULTS: 459 children were assessed (DCD group, n = 55; normative reference group, n = 404). Assessment was possible within 30 minutes and in any clinical setting. For internal consistency, Cronbach's α = 0.83. Intraclass correlation = 0.87 for test-retest reliability and 0.89 for inter-rater reliability. Concurrent correlations with Movement Assessment Battery for Children-2 Test and questionnaires were ρ = -0.494, 0.239, and -0.284, p < 0.001. Discriminant validity measures showed significantly worse performance in the DCD group than in the control group (mean (SD) score 33 (5.6) versus 26 (4.3), p < 0.001). The area under curve characteristic = 0.872, sensitivity and specificity were 80%. CONCLUSIONS: The DCDDaily is a valid and reliable instrument for clinical assessment of capacity in ADL, that is feasible for use in clinical practice.

Exergaming for balance training of elderly: state of the art and future developments.

Fall injuries are responsible for physical dysfunction, significant disability, and loss of independence among elderly. Poor postural control is one of the major risk factors for falling but can be trained in fall prevention programs. These however suffer from low therapy adherence, particularly if prevention is the goal. To provide a fun and motivating training environment for elderly, exercise games, or exergames, have been studied as balance training tools in the past years. The present paper reviews the effects of exergame training programs on postural control of elderly reported so far. Additionally we aim to provide an in-depth discussion of technologies and outcome measures utilized in exergame studies. Thirteen papers were included in the analysis. Most of the reviewed studies reported positive results with respect to improvements in balance ability after a training period, yet few reached significant levels. Outcome measures for quantification of postural control are under continuous dispute and no gold standard is present. Clinical measures used in the studies reviewed are well validated yet only give a global indication of balance ability. Instrumented measures were unable to detect small changes in balance ability as they are mainly based on calculating summary statistics, thereby ignoring the time-varying structure of the signals. Both methods only allow for measuring balance after the exergame intervention program. Current developments in sensor technology allow for accurate registration of movements and rapid analysis of signals. We propose to quantify the time-varying structure of postural control during gameplay using low-cost sensor systems. Continuous monitoring of balance ability leaves the user unaware of the measurements and allows for generating user-specific exergame training programs and feedback, both during one game and in timeframes of weeks or months. This approach is unique and unlocks the as of yet untapped potential of exergames as balance training tools for community dwelling elderly.

Prevalence and factors associated with musculoskeletal complaints and disability in individuals with brachial plexus injury: a cross-sectional study.

PURPOSE: (1) To determine the prevalence of musculoskeletal complaints (MSCs) in the non-affected bodily structures in individuals with brachial plexus injury (BPI) and (2) to analyse factors associated with MSCs and disability. METHODS: Survey among individuals with BPI and a control group. Multivariable logistic and linear regression analyses were used to identify factors associated with MSCs or disability. RESULTS: Forty-nine percent of individuals (34/70) with BPI experienced MSC, which was not significantly different from controls (35%, n = 40/113). Complaints were most often located in high back (OR = 3.6) or non-affected limb (OR = 2.2) or neck (OR = 2.1). Greater disability was associated with the presence of MSC in individuals with BPI (OR = 1.1, 95% confidence interval (95% CI) = 1.0; 1.1). Those with no or a low level of education (B = -10.2, 95% CI = -19.6; -1.4), a history of nerve surgery (B = 11.1, 95% CI = -0.2; 20.9), and moderately affected active range of motion (AROM) of the affected limb (B = 20.7, 95% CI = 8.8; 31.0) experienced most disability. Individuals with severely affected AROM showed a wide range of experienced disability. CONCLUSIONS: Clinicians should be aware that almost half of individuals with BPI have MSCs in the non-affected bodily structures, which was associated with increased disability.Implications for rehabilitationMusculoskeletal complaints of the non-affected limb, back and neck are common among individuals with brachial plexus injury, and are associated with more disability.Disability was associated with loss of active range of motion (AROM) in the affected limb, although there was a wide variation in experienced disability among individuals with no or a very limited AROM.

What influences a patient's decision to use custom-made orthopaedic shoes?

BACKGROUND: Despite potential benefits, some patients decide not to use their custom-made orthopaedic shoes (OS). Factors are known in the domains 'usability', 'communication and service', and 'opinion of others' that influence a patient's decision to use OS. However, the interplay between these factors has never been investigated. The aim of this study was to explore the interplay between factors concerning OS, and the influences thereof on a patient's decision to use OS. METHODS: A mixed-methods design was used, combining qualitative and quantitative data by means of sequential data analysis and triangulation. Priority was given to the qualitative part. Qualitative data was gathered with a semi-structured interview covering the three domains. Data was analysed using the framework approach. Quantitative data concerned the interplay between factors and determining a rank-order for the importance of factors of 'usability'. RESULTS: A patient's decision to use OS was influenced by various factors indicated as being important and by acceptance of their OS. Factors of 'usability' were more important than factors of 'communication'; the 'opinion of others' was of limited importance. An improvement of walking was indicated as the most important factor of 'usability'. The importance of other factors (cosmetic appearance and ease of use) was determined by reaching a compromise between these factors and an improvement of walking. CONCLUSIONS: A patient's decision to use OS is influenced by various factors indicated as being important and by acceptance of their OS. An improvement of walking is the most important factor of 'usability', the importance of other factors (cosmetic appearance and ease of use) is determined by reaching compromises between these factors and an improvement of walking. Communication is essential to gain insight in a patient's acceptance and in the compromises they are willing to reach. This makes communication the key for clinicians to influence a patient's decision to use OS.

Proprioceptive deficits after ACL injury: are they clinically relevant?

OBJECTIVE: To establish the clinical relevance of proprioceptive deficits reported after anterior cruciate ligament (ACL) injury. MATERIAL AND METHODS: A literature search was done in electronic databases from January 1990 to June 2009. Inclusion criteria for studies were ACL deficient (ACL-D) and ACL reconstruction (ACL-R) articles written in English, Dutch or German and calculation of correlation(s) between proprioception tests and clinical outcome measures. Clinical outcome measures were muscle strength, laxity, hop test, balance, patient-reported outcome, objective knee score rating, patient satisfaction or return to sports. Studies included in the review were assessed on their methodological quality. RESULTS: In total 1161 studies were identified of which 24 met the inclusion criteria. Pooling of all data was not possible due to substantial differences in measurement techniques and data analysis. Most studies failed to perform reliability measurements of the test device used. In general, the correlation between proprioception and laxity, balance, hop tests and patient outcome was low. Four studies reported a moderate correlation between proprioception, strength, balance or hop test. CONCLUSION: There is limited evidence that proprioceptive deficits as detected by commonly used tests adversely affect function in ACL-D and ACL-R patients. Development of new tests to determine the relevant role of the sensorimotor system is needed. These tests should ideally be used as screening tests for primary and secondary prevention of ACL injury.

Active video gaming to improve balance in the elderly.

The combination of active video gaming and exercise (exergaming) is suggested to improve elderly people's balance, thereby decreasing fall risk. Exergaming has been shown to increase motivation during exercise therapy, due to the enjoyable and challenging nature, which could support long-term adherence for exercising balance. However, scarce evidence is available of the direct effects of exergaming on postural control. Therefore, the aim of the study was to assess the effect of a six-week videogame-based exercise program aimed at improving balance in elderly people. Task performance and postural control were examined using an interrupted time series design. Results of multilevel analyses showed that performance on the dot task improved within the first two weeks of training. Postural control improved during the intervention. After the intervention period task performance and balance were better than before the intervention. Results of this study show that healthy elderly can benefit from a videogame-based exercise program to improve balance and that all subjects were highly motivated to exercise balance because they found gaming challenging and enjoyable.

Frontal plane roll-over analysis of prosthetic feet.

In prosthetic walking mediolateral balance is compromised due to the lack of active ankle control, by moments of force, in the prosthetic limb. Active control is reduced to the hip strategy, and passive mechanical stability depends on the curvature of the prosthetic foot under load. Mediolateral roll-over curvatures of prosthetic feet are largely unknown. In this study we determined the mediolateral roll-over characteristics of various prosthetic feet and foot-shoe combinations. Characteristics were determined by means of an inverted pendulum-like apparatus. The relationship between the centre of pressure (CoP) and the shank angle was measured and converted to roll-over shape and effective radius of curvature. Further, hysteresis (i.e., lagging in CoP displacement due to material compliance or slip) at vertical shank angle was determined from the hysteresis curve. Passive mechanical stability varied widely, though all measured foot-shoe combinations were relatively compliant. Mediolateral motion of the CoP ranged between 4 mm and 40 mm, thereby remaining well within each foot's physical width. Derived roll-over radii of curvature are also small, with an average of 102 mm. Hysteresis ranges between 20% and 115% of total CoP displacement and becomes more pronounced when adding a shoe. This may be due to slipping of the foot core in its cosmetic cover, or the foot in the shoe. Slip may be disadvantageous for balance control by limiting mediolateral travel of the CoP. It may therefore be clinically relevant to eliminate mediolateral slip in prosthetic foot design.

Effects of lower limb amputation on the mental rotation of feet.

What happens to the mental representation of our body when the actual anatomy of our body changes? We asked 18 able-bodied controls, 18 patients with a lower limb amputation and a patient with rotationplasty to perform a laterality judgment task. They were shown illustrations of feet in different orientations which they had to classify as left or right limb. This laterality recognition task, originally introduced by Parsons in Cognit Psychol 19:178-241, (1987), is known to elicit implicit mental rotation of the subject's own body part. However, it can also be solved by mental transformation of the visual stimuli. Despite the anatomical changes in the body periphery of the amputees and of the rotationplasty patient, no differences in their ability to identify illustrations of their affected versus contralateral limb were found, while the group of able-bodied controls showed clear laterality effects. These findings are discussed in the context of various strategies for mental rotation versus the maintenance of an intact prototypical body structural description.

Patients' expectations and actual use of custom-made orthopaedic shoes.

OBJECTIVE: To investigate the association between patients' expectations and the actual use of custom-made orthopaedic shoes. DESIGN: A prospective cohort study with internal comparison. SETTING: Twelve orthopaedic shoe companies. PATIENTS: During six months, consecutive patients who were provided with their first ever pair of orthopaedic shoes and aged 16 years or older were recruited. A total of 339 patients with different pathologies were included (response 67%). Mean (SD) age of the patients was 63 (15) years, and 129 patients (38%) were male. MAIN MEASURES: A practical and reproducible questionnaire, measuring: frequency of use of orthopaedic shoes, patients' expectations and experiences of aspects of the usability of orthopaedic shoes, and communication about patients' expectations. RESULTS: Patients' expectations were not associated with the use of orthopaedic shoes (P-values range: 0.106 to 0.607), but the difference between expectations and experiences was (P-values range: <0.001 to 0.012). The expectations of patients who frequently used their orthopaedic shoes were in concordance with their experiences, whereas the expectations of patients who did not use their orthopaedic shoes were much higher than their experiences. There was no communication of patients' expectations with the medical specialist or orthopaedic shoe technician in 34% and 25% of the patients respectively. CONCLUSIONS: In relation to the actual use of orthopaedic shoes, it is crucial that patients' expectations are not much higher than their experiences.

Manipulative therapy in addition to usual medical care accelerates recovery of shoulder complaints at higher costs: economic outcomes of a randomized trial.

BACKGROUND: Shoulder complaints are common in primary care and have unfavourable long term prognosis. Our objective was to evaluate the clinical effectiveness of manipulative therapy of the cervicothoracic spine and the adjacent ribs in addition to usual medical care (UMC) by the general practitioner in the treatment of shoulder complaints. METHODS: This economic evaluation was conducted alongside a randomized trial in primary care. Included were 150 patients with shoulder complaints and a dysfunction of the cervicothoracic spine and adjacent ribs. Patients were treated with UMC (NSAID's, corticosteroid injection or referral to physical therapy) and were allocated at random (yes/no) to manipulative therapy (manipulation and mobilization). Patient perceived recovery, severity of main complaint, shoulder pain, disability and general health were outcome measures. Data about direct and indirect costs were collected by means of a cost diary. RESULTS: Manipulative therapy as add-on to UMC accelerated recovery on all outcome measures included. At 26 weeks after randomization, both groups reported similar recovery rates (41% vs. 38%), but the difference between groups in improvement of severity of the main complaint, shoulder pain and disability sustained. Compared to the UMC group the total costs were higher in the manipulative group (€1167 vs. €555). This is explained mainly by the costs of the manipulative therapy itself and the higher costs due sick leave from work. The cost effectiveness ratio showed that additional manipulative treatment is more costly but also more effective than UMC alone. The cost-effectiveness acceptability curve shows that a 50%-probability of recovery with AMT within 6 months after initiation of treatment is achieved at €2876. CONCLUSION: Manipulative therapy in addition to UMC accelerates recovery and is more effective than UMC alone on the long term, but is associated with higher costs. INTERNATIONAL STANDARD RANDOMIZED CONTROLLED TRIAL NUMBER REGISTER: ISRCTN11216.

Manipulative therapy in addition to usual care for patients with shoulder complaints: results of physical examination outcomes in a randomized controlled trial.

OBJECTIVE: The purpose of this study was to examine the effect of manipulative therapy on the shoulder girdle, in addition to usual care provided by the general practitioner, on the outcomes of physical examination tests for the treatment of shoulder complaints. METHODS: This was a randomized controlled trial in a primary care setting in the Netherlands. A total of 150 participants were recruited from December 2000 until December 2002. All patients received usual care by the general practitioner. Usual care included one or more of the following depending on the needs of the patient: information/advice, oral analgesics or nonsteroidal antiinflammatory drugs, corticosteroid injections, exercises, and massage. In addition to usual care, the intervention group received manipulative therapy, up to 6 treatment sessions in a 12-week period. Twenty-four physical examination tests were done at baseline and after 6, 12, and 26 weeks. Factor analysis was done to reduce the number of outcome measures. RESULTS: The factor analysis resulted in 4 factors: "shoulder pain," "neck pain," "shoulder mobility," and "neck mobility." At 6 weeks, no significant differences between groups were found. At 12 weeks, the mean changes of all 4 factors favored the intervention group; the factors "shoulder pain" and "neck pain" reached statistical significance (95% confidence interval [CI], 0.1-2.1). At 26 weeks, differences in the factors "shoulder pain" (95% CI, 0.0-2.6), "shoulder mobility" (95% CI, 0.2-1.7), and "mobility neck" (95% CI, 0.2-1.3) statistically favored the intervention group. CONCLUSION: In this pragmatic study, manipulative therapy, in addition to usual care by the general practitioner, diminished severity of shoulder pain and neck pain and improved shoulder and neck mobility.

Effect of awareness of being monitored on wearing of orthopaedic footwear.

OBJECTIVE: To investigate the effect of awareness of being monitored on wearing time and adherence to wearing orthopaedic footwear. Quantitative assessment of wearing time was made using direct measurement with temperature sensors during the first 3 months after provision of footwear. DESIGN: Randomized controlled trial. INTERVENTION: Awareness that the temperature sensor is used for measuring wearing time. METHODS: All 55 participants had a temperature sensor built into the medial arch of the left insole of their orthopaedic footwear. Participants were assigned randomly to either an "awareness group" (n = 25, mean age 67 years) and knew they were being monitored for wearing time, or a "no awareness group" (n = 30, mean age 65 years) and only knew their shoe temperature was being measured. Differences were assessed with a linear mixed model. RESULTS: Mean (standard deviation; SD) wearing time in the intervention group was 7.32 h/day (SD 4.2), and 6.11 h/day (SD 4.1) in the control group (p = 0.017). A significant interaction effect was found between awareness and pathology group on wearing time (p = 0.036). The difference was especially large (7.0 (SD 4.7) vs 2.4 (SD 2.2) h/day) in the subgroup of people with diabetes. CONCLUSION: Awareness of being monitored increases wearing time and wearing of orthopaedic footwear.

A toolkit for prosthetists and orthotists to facilitate progress in professional communication over the next 50 years.

BACKGROUND: In this celebratory issue of Prosthetics and Orthotics International, we review professional communication skills in the field of prosthetics and orthotics. OBJECTIVE: We aim to reflect on communication skills in the past 50 years, to discuss developments in the coming 50 years, and to create a toolkit and research agenda to facilitate progress in professional communication in the next 50 years. RESULTS: Despite being a key area in prosthetics and orthotics training programmes, we found no studies on professional communication with an experimental design published in Prosthetics and Orthotics International. As an alternative, we provide clinical reflections on the changes in professional communication in the past 50 years, and we discuss questionnaire-based and qualitative studies that provide evidence for the importance of communication in pedorthic footwear provision. In the coming 50 years, professional communication in the field of prosthetics and orthotics may be impacted by aging populations, global mobility, information technology, technological advances and emphasis on prevention. We discuss each of these topics. To facilitate progress in professional communication, we have created a toolkit with resources for prosthetics and orthotics professionals, prosthetics and orthotics students and other interested professionals. CONCLUSIONS: We hope this toolkit will inspire others to use, extend and implement it in their daily practice. As a research agenda, we strongly recommend undertaking research on interventions to improve professional communication and to study its effect on clinically meaningful outcomes.

Mechanical Noise Improves the Vibration Perception Threshold of the Foot in People With Diabetic Neuropathy.

BACKGROUND: Mechanical noise may improve somatosensation at the dorsal side of the foot, but the effect at the plantar side of the foot, the side most at risk for foot ulceration, is unknown. Moreover, techniques used in research so far have several problems that limit applicability in daily practice. Piezoelectric actuators may provide mechanical noise with better clinical applicability. We assessed the effects of piezoelectric actuators generating mechanical noise on the vibration perception threshold (VPT) at the plantar side of the foot in people with diabetic neuropathy. METHODS: Double-blind within-subjects design in a controlled laboratory setting including participants with diabetic neuropathy (N = 40; 18 male; mean age 69.6 years; mean duration of diabetes 14.1 years; mean BMI 30.5). VPT was measured at three plantar foot locations with and without mechanical noise applied via piezoelectric actuators. RESULTS: Mechanical noise improved VPT at metatarsophalangeal joint (MTP) 1 (left 39.3V vs 43.5V; right 39.0 vs 42.6 V), MTP5 (left 37.5V vs 41.7V; right 34.5V vs 40.8V) and the heel (left 40.0V vs 44.0V; right 39.3V vs 41.0V), all P < .001. CONCLUSIONS: Mechanical noise improves VPT at the plantar side of the foot in people with diabetic neuropathy. This is an important step for further development of insoles using mechanical noise that may have the potential to improve VPT and decrease the risk of foot ulceration.

More evidence that depressive symptoms predict mortality in COPD patients: is type D personality an alternative explanation?

BACKGROUND/PURPOSE: The present study attempted to replicate our previous finding that depressive symptoms are a risk factor for mortality in stable chronic obstructive pulmonary disease (COPD), but in a different population with a different measure of depressive symptoms. We further investigated whether type D personality is associated with mortality in patients with COPD and whether it explains any relationship observed between depressive symptoms and mortality. METHODS: In 122 COPD patients, mean age 60.8 +/- 10.3 years, 52% female, and mean forced expiratory volume in 1 s (FEV(1)) 41.1 +/- 17.6%pred, we assessed body mass index, post bronchodilator FEV(1), exercise capacity, depressive symptoms with the Hospital Anxiety and Depression Scale, and type D with the Type D Scale. RESULTS: In the 7 years follow-up, 48 (39%) deaths occurred. The median survival time was 5.3 years. Depressive symptoms (hazard ratio = 1.07, 95% confidence intervals = 1.00-1.14) were an independent risk factor for mortality. Type D was not associated with mortality. CONCLUSIONS: We can rule out type D as an explanation for the relationship between depressive symptoms and mortality observed in this sample. However, ambiguity remains as to the interpretation of the value of depressive symptoms in predicting death.

Improving rehabilitation treatment in a local setting: a case study of prosthetic rehabilitation.

OBJECTIVE: To contribute to the discussion on the research-practice gap by illustrating obstacles and opportunities that arise in an evidence-informed improvement process of prosthetic rehabilitation in a local setting. SETTING: Dutch rehabilitation centre. PRESUPPOSITION: The improvement process was considered as a two-way translation process rather than a unidirectional process of knowledge transfer between science and practice. METHOD: Case study and participatory research methods comprising documentary analysis, treatment observations, individual and focus groups interviews, and literature studies. A qualitative software program (Atlas-ti) was used to triangulate the collected data. RESULTS: The main concern of local practitioners was identified to be the post-discharge decline in functional capacity in elderly amputees. This was related to a predominantly biomedical and biomechanical approach, and accompanying traditional therapist-patient interactions. The content and underpinnings of prosthetic treatments were scarcely specified in either the scientific literature or the local setting. Generic principles and practices from other fields were useful for treatment innovation for post-discharge problems, such as task- and context-specific training and self-management education. A circuit training focused on motor learning and a problem-solving training focused on social learning were developed by integrating amputation-specific knowledge. CONCLUSION: Improving rehabilitation practice with the use of available evidence is a heterogeneous and multifaceted scientific enterprise. Such an enterprise requires as much self-reflexivity from researchers as from practitioners.

Gait adjustments in obstacle crossing, gait initiation and gait termination after a recent lower limb amputation.

OBJECTIVE: To describe the adjustments in gait characteristics of obstacle crossing, gait initiation and gait termination that occur in subjects with a recent lower limb amputation during the rehabilitation process. DESIGN: Prospective and descriptive study. SUBJECTS: Fourteen subjects with a recent transfemoral, knee disarticulation or transtibial amputation. METHODS: Subjects stepped over an obstacle and initiated and terminated gait at four different times during the rehabilitation process. OUTCOME MEASURES: Success rate, gait velocity and lower limb joint angles in obstacle crossing, centre of pressure shift and peak anteroposterior ground reaction force in gait initiation and termination. RESULTS: In obstacle crossing amputees increased success rate, gait velocity and swing knee flexion of the prosthetic limb. Knee flexion in transfemoral and knee disarticulation amputees was not sufficient for safe obstacle crossing, which resulted in a circumduction strategy. In gait initiation and termination amputees increased the anteroposterior ground reaction force and the centre of pressure shift in the mediolateral direction in both tasks. Throughout the rehabilitation process the centre of pressure was shifted anteriorly before single-limb stance on the trailing prosthetic limb in gait initiation, whereas in gait termination the centre of pressure in single-limb stance remained posterior when leading with the prosthetic limb. CONCLUSION: Subjects with a recent amputation develop adjustment strategies to improve obstacle crossing, gait initiation and gait termination. Innovations in prosthetic design or training methods may ease the learning process of these tasks.

Determinants of return to work in patients with hand disorders and hand injuries.

INTRODUCTION: Return to work (RTW) in patients with hand disorders and hand injuries is determined by several determinants not directly related to the physical situation. Besides biomedical determinants, work-related and psychosocial determinants may influence RTW as well. This study is conducted to investigate the influence of these potential determinants on RTW in patients with hand disorders and hand injuries. METHODS: Included 91 patients who were operatively treated for a hand disorder or a hand injury, and who were employed prior to surgery. Patients answered several questionnaires on the aforementioned categories. Potential determinants significantly related to RTW in a univariate analysis were entered in a logistic regression for the total group and the acutely injured patients separately. RESULTS: Pain, accident location, job independence and symptoms of post-traumatic stress disorder (PTSD) were univariately associated with RTW. Pain was a determinant for late RTW in the total group and accident location and symptoms of PTSD in the acutely injured group. CONCLUSION: Pain, accident location and symptoms of PTSD were most important in resuming work in hand injured patients or in patients with a hand disorder. These findings may indicate that attention should be paid to the treatment of pain, and to the development of symptoms of PTSD during rehabilitation. It may be necessary to make extra efforts aimed at RTW in patients who sustained their injury on the job.