Mobilising the patient: With emphasis on innovative technologies.

Treatment of trauma patients and fractures has changed dramatically throughout the years. From conservative methods to nowadays various kinds of screws, pins, plates and nails for optimal fixation of fractures. This lead to changes in post-operative management as well, from bedrest to (partial) weight bearing. Some patients however have very limited to no ability to mobilise, such as critical ill patients on the Intensive Care Unit, amputees or spinal cord injured patients. Due to innovations such as hydrotherapy, osseointegrated prosthesis and exoskeletons, even these people can mobilise. Thanks to innovations like these an increasing number of trauma patients are able to fully reintegrate into community life and get back to an active and independent life style.

Wide-Awake Surgical Management of Hand Fractures: Technical Pearls and Advanced Rehabilitation.

Most unstable metacarpal and phalangeal fractures for which operative treatment is indicated can be reduced and stabilized with either open or closed techniques using local anesthetic with epinephrine instead of intravenous sedation or general anesthesia. With the patient wide-awake during surgery, the hand can be taken through active range of motion to assess fracture stability. In this article, the authors review the rationale and technique for wide-awake, local anesthesia, no tourniquet surgery in the treatment of phalangeal and metacarpal fractures and impart pearls to optimize the patient experience and illustrate common fixation techniques using percutaneous Kirschner wires. The intraoperative assessment of fracture stability permits an accelerated, protected-range-of-motion protocol that minimizes postoperative stiffness and facilitates expedient recovery.

Passive Hydrotherapy WATSU® for Rehabilitation of an Accident Survivor: A Prospective Case Report.

BACKGROUND: WaterShiatsu (WATSU) is a passive form of hydrotherapy in warm water (35 °C) that aims at relaxation, pain relief, and a sense of security. This case report focuses on a patient's experience of integrating WATSU into her rehabilitative care. CASE REPORT: A 52-year-old woman survived a severe motorcycle accident in which she sustained several fractures on the right side of her body, including ribs, the pelvis, and the femur. After discharge from stationary care, she independently scheduled 8 weekly WATSU sessions with an experienced WATSU therapist also trained in physiotherapy and psychosomatics. Quantitative and qualitative data obtained from the patient's diary and the therapist's notes is presented. RESULTS: The patient associated WATSU with physical and emotional release, reconciliation with her body, and trunk mobilization (followed by ameliorated breath). She ascribed WATSU lasting effects on her body image and reported continuous improvement by the Patient-Specific Functional Scale. The therapist employed WATSU to equalize awareness throughout the body and for careful mobilization. Due to complications (elevated inflammation markers), only 6 of 8 scheduled sessions were administered. CONCLUSIONS: WATSU was experienced as helpful in approaching a condition that the patient felt insufficiently covered by conventional physiotherapy alone. In early rehabilitation, additional medical/physiotherapeutic skills of contributing complementary therapists are advocated.

Real-time visual biofeedback during weight bearing improves therapy compliance in patients following lower extremity fractures.

BACKGROUND: Individuals with lower extremity fractures are often instructed on how much weight to bear on the affected extremity. Previous studies have shown limited therapy compliance in weight bearing during rehabilitation. In this study we investigated the effect of real-time visual biofeedback on weight bearing in individuals with lower extremity fractures in two conditions: full weight bearing and touch-down weight bearing. METHODS: 11 participants with full weight bearing and 12 participants with touch-down weight bearing after lower extremity fractures have been measured with an ambulatory biofeedback system. The participants first walked 15m and the biofeedback system was only used to register the weight bearing. The same protocol was then repeated with real-time visual feedback during weight bearing. The participants could thereby adapt their loading to the desired level and improve therapy compliance. RESULTS: In participants with full weight bearing, real-time visual biofeedback resulted in a significant increase in loading from 50.9±7.51% bodyweight (BW) without feedback to 63.2±6.74%BW with feedback (P=0.0016). In participants with touch-down weight bearing, the exerted lower extremity load decreased from 16.7±9.77kg without feedback to 10.27±4.56kg with feedback (P=0.0718). More important, the variance between individual steps significantly decreased after feedback (P=0.018). CONCLUSIONS: Ambulatory monitoring weight bearing after lower extremity fractures showed that therapy compliance is low, both in full and touch-down weight bearing. Real-time visual biofeedback resulted in significantly higher peak loads in full weight bearing and increased accuracy of individual steps in touch-down weight bearing. Real-time visual biofeedback therefore results in improved therapy compliance after lower extremity fractures.

Hospital-at-home Integrated Care Program for Older Patients With Orthopedic Processes: An Efficient Alternative to Usual Hospital-Based Care.

OBJECTIVE: To compare outcomes and costs for patients with orthogeriatric conditions in a home-based integrated care program versus conventional hospital-based care. DESIGN: Quasi-experimental longitudinal study. SETTING: An acute care hospital, an intermediate care hospital, and the community of an urban area in the North of Barcelona, in Southern Europe. PARTICIPANTS: In a 2-year period, we recruited 367 older patients attended at an orthopedic/traumatology unit in an acute hospital for fractures and/or arthroplasty. INTERVENTION: Patients were referred to a hospital-at-home integrated care unit or to standard hospital-based postacute orthogeriatric unit, based on their social support and availability of the resource. MEASUREMENTS: We compared home-based care versus hospital-based care for Relative Functional Gain (gain/loss of function measured by the Barthel Index), mean direct costs, and potential savings in terms of reduction of stay in the acute care hospital. RESULTS: No differences were found in Relative Functional Gain, median (Q25-Q75) = 0.92 (0.64-1.09) in the home-based group versus 0.93 (0.59-1) in the hospital-based group, P =.333. Total health service direct cost [mean (standard deviation)] was significantly lower for patients receiving home-based care: €7120 (3381) versus €12,149 (6322), P < .001. Length of acute hospital stay was significantly shorter in patients discharged to home-based care [10.1 (7)] than in patients discharged to the postacute orthogeriatric hospital-based unit [15.3 (12) days, P < .001]. CONCLUSION: The hospital-at-home integrated care program was suitable for managing older patients with orthopedic conditions who have good social support for home care. It provided clinical care comparable to the hospital-based model, and it seems to enable earlier acute hospital discharge and lower direct costs.

Longstanding pain and social strain: patients' and health care providers' experiences with fracture management by skeletal traction; a qualitative study from Malawi.

AIM: The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi. METHODS: The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams. RESULTS: Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement. CONCLUSION: The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.

Laser Treatment on Acupuncture Points Improves Pain and Wrist Functionality in Patients Undergoing Rehabilitation Therapy after Wrist Bone Fracture. A Randomized, Controlled, Blinded Study.

The objective of this study was to determine whether application of laser beam on acupuncture points has a positive effect on the rehabilitation of patients with a diagnosis of distal radius fracture (1.5 inches proximal to distal articular surface of the radius) when applied with active conventional physical therapy exercises. Patients with a distal radius fracture treated with closed reduction, percutaneous pinning, and a short cast for six weeks was included and were assigned to one of two study groups. The control group was given simulated laser acupuncture with the laser off, while the experimental group received laser beam on acupuncture points. A low power infrared 980 nm, 50 mW laser (Diller & Diller Laser Performance) electric energy, was used; each acupuncture point was irradiated for 30 seconds at 8,000 Hz at each therapy session. In both groups, treatment was applied to the following points: Ipsilateral- Yanggu (S15), Yangchi (SJ4), Waiguan (SJ15), Yangxi (LI5), Daling (PC7); Bilateral- Hegu (L14); Contralateral- Shenmail (VL62), Kulun (V60), Taixi (KID3). All of the patients underwent a total of 10 sessions, at a frequency of three times per week. They were evaluated using the VAS, the Patient-Rated Wrist Evaluation (PRWE), and wrist mobility ranges at the beginning of treatment, at the end of the fifth session, at the 10th session, and a week after the 10th session. The patients treated with laser beam exposure on acupuncture points showed 44% reduction in pain and 33% of improvement in the functional status of the wrist compared with the control group. Application of laser beam on acupuncture points combined with active rehabilitation exercises show benefits in the rehabilitation of patients with a distal radius fracture managed with percutaneous pinning and a short cast.

Evaluación de la adherencia al tratamiento con calcio y vitamina D en ancianos de una zona básica de salud / Evaluation of adherence to treatment with calcium and vitamin D in the elderly in a basic health area

Introducción y objetivo. El déficit de vitamina D en los ancianos es elevado. Complementar con suplementos de calcio y vitamina D es una práctica habitual en individuos con riesgo de caídas y/o fracturas que, sin embargo, obtiene un bajo grado de cumplimiento. El objetivo es determinar la adherencia al calcio y vitamina D en ancianos con hipovitaminosis D en una zona urbana de Madrid. Pacientes y métodos. Estudio de intervención en 438 individuos ≥ 65 años con hipovitaminosis D procedentes de la «Cohorte Peñagrande». Se les pautó calcio y vitamina D y se valoró la adherencia a los 3 y 12 meses mediante el test de Morisky-Green y el recuento de recetas prescritas. Resultados. Se analizaron 413 de los 438 individuos con hipovitaminosis D (18 casos no se trataron por contraindicaciones y 7 se perdieron). A los 3 y 12 meses el 63,9 y el 47,2%, respectivamente, fueron adherentes. El 19,3% de los no adherentes a los 3 meses fueron buenos cumplidores al año tras una intervención educativa breve. La comorbilidad se asoció con menor adherencia al año (46,3% versus 35,2%, p = 0,027). La principal causa de no adherencia al calcio fue la intolerancia digestiva, y a la vitamina D, los olvidos. Se observó concordancia entre valorar la adherencia con el test de Morisky y recuento de recetas prescritas (índice Kappa = 69,8%). Conclusiones. La falta de adherencia a tratamientos crónicos con calcio y vitamina D es un problema relevante en ancianos. Es importante evaluar la adherencia y aplicar estrategias de educación sanitaria en la práctica clínica (AU)

Background and objective. The vitamin D deficiency is high in the elderly population. Calcium and vitamin D supplements is a frequently used measure in individuals at risk for falls and/or fractures. However, this practice has achieved a low level of compliance. The aim is to assess the adherence to treatment with calcium and vitamin D in elders with hypovitaminosis D in an urban area of Madrid. Patients and methods. Intervention study performed on 438 individuals ≥ 65 years from the ‘Peñagrande Cohort’ with hypovitaminosis D that were treated with calcium and vitamin D. Adherence at 3 and 12 months was assessed using the Morisky-Green and counting of prescriptions written. Results. A total of 413 of the 438 individuals with hypovitaminosis D were analysed (18 patients were not treated because of contraindications, and 7 were considered lost). At 3 and 12 months, 63.9% and 47.2%, respectively, were adherents. After a brief educational intervention, 19.3% of individuals without adherence at 3 months became good compliers when measured at one year. Comorbidity was associated with lower rates of adherence to treatment after one year (46.3% versus 35.2%, P = .027). The main cause of non-adherence to calcium was digestive intolerance, and due to oversights for vitamin D. Concordance between adherence assessed by the Morisky test and counting of prescriptions written was high (Kappa index = 69.8%). Conclusions. Non-adherence to chronic treatment with calcium and vitamin D is a relevant problem in elderly. It is important to assess adherence and implement health education strategies in clinical practice (AU)

Effects of Progressive Muscle Relaxation Intervention in Extremity Fracture Surgery Patients.

The purpose of this study was to evaluate the impact of progressive muscle relaxation on state anxiety and self-efficacy in hospitalized patients admitted for an extremity fracture receiving elective surgery. Eighty four patients met the inclusion criteria and all were randomly assigned to either the progressive muscle relaxation group or the control group. The control group received standard orthopedic nursing care, and the experimental group received standard care along with daily progressive muscle relaxation throughout their hospitalization. The State Anxiety Inventory and Self-Efficacy Scales were administered before and after the intervention. Both paired-sample t tests and independent t tests showed that progressive muscle relaxation is effective in reducing state anxiety and enhancing the self-efficacy of patients with extremity fracture undergoing an elective surgery.

Hinged external fixation for complex fracture-dislocation of the elbow in elderly people.

The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.

Rehabilitation of an osteochondral fracture using blood flow restricted exercise: a case review.

OBJECTIVES: In this case review we report on a bodybuilder who used a practical model of blood flow restriction (BFR) training to successfully rehabilitate himself following an injury to his right knee. RESULTS: The patient originally thought he had torn his meniscus however repeat radiographs and magnetic resonance imaging (MRI) confirmed an osteochondral fracture. The patient initially sought out a low load alternative to help with the maintenance of skeletal muscle mass. However, following rehabilitation with low load BFR resistance training, radiographs indicated that the bone had begun to heal suggesting that this type of training may also benefit bone. CONCLUSIONS: In conclusion, this case review provides evidence that practical BFR using knee wraps can serve as an effective stimulus during rehabilitation from a knee injury.

Rehabilitation for ankle fractures in adults.

BACKGROUND: Rehabilitation after ankle fracture can begin soon after the fracture has been treated, either surgically or non-surgically, by the use of different types of immobilisation that allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation, including the use of physical or manual therapies, may start following the period of immobilisation. This is an update of a Cochrane review first published in 2008. OBJECTIVES: To assess the effects of rehabilitation interventions following conservative or surgical treatment of ankle fractures in adults. SEARCH METHODS: We searched the Specialised Registers of the Cochrane Bone, Joint and Muscle Trauma Group and the Cochrane Rehabilitation and Related Therapies Field, CENTRAL via The Cochrane Library (2011 Issue 7), MEDLINE via PubMed, EMBASE, CINAHL, PEDro, AMED, SPORTDiscus and clinical trials registers up to July 2011. In addition, we searched reference lists of included studies and relevant systematic reviews. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included quality of life, patient satisfaction, impairments and adverse events. DATA COLLECTION AND ANALYSIS: Two review authors independently screened search results, assessed risk of bias and extracted data. Risk ratios and 95% confidence intervals (95% CIs) were calculated for dichotomous variables, and mean differences or standardised mean differences and 95% CIs were calculated for continuous variables. End of treatment and end of follow-up data were presented separately. For end of follow-up data, short term follow-up was defined as up to three months after randomisation, and long-term follow-up as greater than six months after randomisation. Meta-analysis was performed where appropriate. MAIN RESULTS: Thirty-eight studies with a total of 1896 participants were included. Only one study was judged at low risk of bias. Eight studies were judged at high risk of selection bias because of lack of allocation concealment and over half the of the studies were at high risk of selective reporting bias.Three small studies investigated rehabilitation interventions during the immobilisation period after conservative orthopaedic management. There was limited evidence from two studies (106 participants in total) of short-term benefit of using an air-stirrup versus an orthosis or a walking cast. One study (12 participants) found 12 weeks of hypnosis did not reduce activity or improve other outcomes.Thirty studies investigated rehabilitation interventions during the immobilisation period after surgical fixation. In 10 studies, the use of a removable type of immobilisation combined with exercise was compared with cast immobilisation alone. Using a removable type of immobilisation to enable controlled exercise significantly reduced activity limitation in five of the eight studies reporting this outcome, reduced pain (number of participants with pain at the long term follow-up: 10/35 versus 25/34; risk ratio (RR) 0.39, 95% confidence interval (CI) 0.22 to 0.68; 2 studies) and improved ankle dorsiflexion range of motion. However, it also led to a higher rate of mainly minor adverse events (49/201 versus 20/197; RR 2.30, 95% CI 1.49 to 3.56; 7 studies).During the immobilisation period after surgical fixation, commencing weight-bearing made a small improvement in ankle dorsiflexion range of motion (mean difference in the difference in range of motion compared with the non-fractured side at the long term follow-up 6.17%, 95% CI 0.14 to 12.20; 2 studies). Evidence from one small but potentially biased study (60 participants) showed that neurostimulation, an electrotherapy modality, may be beneficial in the short-term. There was little and inconclusive evidence on what type of support or immobilisation was the best. One study found no immobilisation improved ankle dorsiflexion and plantarflexion range of motion compared with cast immobilisation, but another showed using a backslab improved ankle dorsiflexion range of motion compared with using a bandage.Five studies investigated different rehabilitation interventions following the immobilisation period after either conservative or surgical orthopaedic management. There was no evidence of effect for stretching or manual therapy in addition to exercise, or exercise compared with usual care. One small study (14 participants) at a high risk of bias found reduced ankle swelling after non-thermal compared with thermal pulsed shortwave diathermy. AUTHORS' CONCLUSIONS: There is limited evidence supporting early commencement of weight-bearing and the use of a removable type of immobilisation to allow exercise during the immobilisation period after surgical fixation. Because of the potential increased risk of adverse events, the patient's ability to comply with the use of a removable type of immobilisation to enable controlled exercise is essential. There is little evidence for rehabilitation interventions during the immobilisation period after conservative orthopaedic management and no evidence for stretching, manual therapy or exercise compared to usual care following the immobilisation period. Small, single studies showed that some electrotherapy modalities may be beneficial. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

A prospective model of care for breast cancer rehabilitation: bone health and arthralgias.

Musculoskeletal health can be compromised by breast cancer treatment. In particular, bone loss and arthralgias are prevalent side effects experienced by women treated with chemotherapy and/or adjuvant endocrine therapy. Bone loss leads to osteoporosis and related fractures, while arthralgias threaten quality of life and compliance to treatment. Because the processes that lead to these musculoskeletal problems are initiated when treatment begins, early identification of women who may be at higher risk of developing problems, routine monitoring of bone density and pain at certain stages of treatment, and prudent application of therapeutic interventions are key to preventing and/or minimizing musculoskeletal sequelae. Exercise may be a particularly suitable intervention strategy because of its potential to address a number of impairments; it may slow bone loss, appears to reduce joint pain in noncancer conditions, and improves other breast cancer outcomes. Research efforts continue in the areas of etiology, measurement, and treatment of bone loss and arthralgias. The purpose of this review is to provide an overview of the current knowledge on the management and treatment of bone loss and arthralgias in breast cancer survivors and to present a framework for rehabilitation care to preserve musculoskeletal health in women treated for breast cancer.

Low acceptance of treatment in the elderly for the secondary prevention of osteoporotic fracture in the acute rehabilitation setting.

BACKGROUND AND AIMS: Given the high risk of subsequent fracture among elderly persons with fracture, it is important to initiate secondary treatment for osteoporosis. Acute rehabilitation centers may offer a unique opportunity to introduce treatment. Therefore, we evaluated willingness-to-participate and compliance with evidence-based interventions for the secondary prevention of osteoporotic fracture in a non-randomized study conducted in the acute rehabilitation setting. We also described differences in baseline characteristics between study participants and non-participants. METHODS: All consecutive, community dwelling admissions to an acute rehabilitation unit (Boston, MA) with the diagnosis of fracture were screened for enrollment. Eligible subjects were offered a free, 6-month supply of alendronate/cholecalciferol (70 mg/2800 IU weekly), calcium and vitamin D supplements, and fall prevention strategies. Six-month compliance (> or =75% consumption of medication or supplement) with the interventions was determined at a home visit. RESULTS: Among 62 eligible subjects, 25 agreed to participate. Non-participants were older than participants (86 vs 80 yrs, p<0.01). There was no significant difference between other characteristics of participants and non-participants including sex, weight, type of fracture, cognitive status, and functional status. The most common reason for non-participation was reluctance to take another medication. Among participants, only 52% were compliant with alendronate and 58% were compliant with calcium and vitamin D supplementation at 6 months. CONCLUSIONS: Willingness- to-participate and compliance with secondary prevention strategies for osteoporosis was low in the acute rehabilitation setting, even when medications were provided free of cost. Educating individuals with fracture and their families on the consequences and treatment of osteoporosis may help to decrease the risk of sustaining a second fracture by accepting secondary preventive measures.

Early breast and prostate cancer and clinical outcomes (fracture).

Osteoporosis is a skeletal disorder characterized by low bone mass that is associated with increased risk of fracture. Nearly 40% of the 12 million cancer survivors in the United States were diagnosed with breast and prostate cancer. Therapy for these two diseases is not uncommonly associated with bone loss related to hormone-ablative therapy. In women, this includes the use of endocrine therapies and chemotherapy-related premature menopause. In men, hormone-ablative therapies include gonadotropin-releasing hormone analogs and bilateral orchiectomy. Fracture risk assessment includes bone mineral density determination in appropriate populations and integration of findings with identified risk factors. Strategies to prevent and treat bone loss include nonpharmacologic and pharmacologic interventions. In the former case, regular weight-bearing and muscle-strengthening exercise is encouraged along with smoking cessation, modulation of alcohol consumption, and fall prevention. Supplementation with calcium and vitamin D decreases fracture risk in subgroups. Pharmacologic interventions include use of oral or intravenous bisphosphonates, selective estrogen receptor modulators, and calcitonin. Estrogen/menopause hormone therapies are not recommended for use in breast cancer survivors related to potential influence on recurrence. Strategies for management of bone loss in breast and prostate cancer are outlined by guidelines from the American Society of Clinical Oncology and the National Comprehensive Cancer Network.

Rehabilitation for ankle fractures in adults.

BACKGROUND: Rehabilitation after ankle fracture can begin soon after the fracture has been treated by the use of different types of immobilisation which allow early commencement of weight-bearing or exercise. Alternatively, rehabilitation may start following the period of immobilisation, with physical or manual therapies. OBJECTIVES: To compare the effectiveness of rehabilitation interventions following ankle fracture in adults. SEARCH STRATEGY: We searched two Specialised Registers of The Cochrane Collaboration, electronic databases (including MEDLINE, EMBASE and CINAHL), reference lists of included studies and relevant systematic reviews, and clinical trials registers to September 2007. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials with adults undergoing any interventions for rehabilitation after ankle fracture were considered. The primary outcome was activity limitation. Secondary outcomes included impairments and adverse events. DATA COLLECTION AND ANALYSIS: Two reviewers independently screened search results, assessed methodological quality, and extracted data. Relative risk and 95% confidence intervals (95% CI) were calculated for dichotomous variables, and weighted or standardised mean difference and 95% CI were calculated for continuous variables. A meta-analysis was performed where appropriate. MAIN RESULTS: Thirty-one studies were included. Clinical and statistical heterogeneity prevented meta-analyses in most instances. After surgical fixation, commencing exercise in a removable brace or splint significantly improved activity limitation, pain and ankle range of motion, but also led to a higher rate of adverse events. Early commencement of weight-bearing during the immobilisation period improved ankle range of motion after surgical fixation. Where it was possible to avoid ankle range of motion after surgical fixation, the use of no immobilisation compared to cast immobilisation also improved ankle range of motion. After the immobilisation period, manual therapy was beneficial in increasing ankle range of motion. There was no evidence of effect for electrotherapy, hypnosis, or stretching. AUTHORS' CONCLUSIONS: There is limited evidence supporting the use of a removable type of immobilisation and exercise during the immobilisation period, early commencement of weight-bearing during the immobilisation period, and no immobilisation after surgical fixation of ankle fracture. There is also limited evidence for manual therapy after the immobilisation period. Because of the potential increased risk, the patient's ability to comply with the use of a removable type of immobilisation and exercise is essential. More clinical trials that are well-designed and adequately-powered are required to strengthen current evidence.

Manual therapy in addition to physiotherapy does not improve clinical or economic outcomes after ankle fracture.

OBJECTIVE: The primary aim of this study was to determine the effectiveness and cost-effectiveness of adding manual therapy to a physiotherapy programme for ankle fracture. DESIGN: Assessor-blinded randomized controlled trial. PARTICIPANTS: Ninety-four adults were recruited within one week of cast removal for isolated ankle fracture. Inclusion criteria were: they were able to weight-bear as tolerated or partial weight-bear, were referred for physiotherapy, and experienced pain. Ninety-one participants completed the study. METHODS: Participants were randomly allocated to receive manual therapy (anterior-posterior joint mobilization over the talus) plus a standard physiotherapy programme (experimental), or the standard physiotherapy programme only (control). They were assessed by a blinded assessor at baseline, and at 4, 12 and 24 weeks. The main outcomes were activity limitation and quality of life. Information on costs and healthcare utilization was collected every 4 weeks up to 24 weeks. RESULTS: There were no clinically worthwhile differences in activity limitation or quality of life between groups at any time-point. There was also no between-group difference in quality-adjusted life-years, but the experimental group incurred higher out-of-pocket costs (mean between-group difference = AU$200, 95% confidence interval 26-432). CONCLUSION: When provided in addition to a physiotherapy programme, manual therapy did not enhance outcome in adults after ankle fracture.

[Rehabilitation of elderly patients after fracture]. / Réhabilitation des sujets âgés après fracture ostéoporotique.

Hip fracture in the elderly is associated with increased mortality and disability. The rate of recovery of the pre-fracture functional or ambulatory level is less than 70%. Different intervention programs accelerate the recovery and decrease the mortality; these programs include early ambulation, recovery of the activities of daily living, muscle training and correction of malnutrition (protein supplements, vitamin D). Successful interventions concern patients able to walk with or without help before the fracture. Pre-fracture motor and not cognitive level is the most important predictive factor for motor recovery. The degree of involvement of the geriatric team and organization of the intervention play a major role in its efficacy.

Synthesis of nitric oxide in human osteoblasts in response to physiologic stimulation of electrotherapy.

Electrotherapy for bone healing, remodeling and wound healing may be mediated by modulation of nitric oxide (NO). Using NO-specific fluorophore (DAF-2), we report here that application of non-invasive, physiologic electrical stimulation induces NO synthesis in human osteoblasts, and that such NO generation is comparable to that induced by estrogen treatment. For example, application of a sinusoidal 1 Hz, 2 V/cm (peak to peak) electrical stimulation (ES) increases NO-bound DAF-2 fluorescence intensity by a 2-fold within 60 min exposure by activating nitric oxide synthase (NOS). Increase in the NO level is found to depend critically on the frequency and strength of ES. While the frequency of 1 Hz ES seems optimal, the ES strength >0.5 V/cm is required to induce significant NO increase, however. Nitric oxide synthesis in response to ES is completely prevented by blocking estrogen receptors using a competitive inhibitor, suggesting that NO generation is likely initiated by activation of estrogen receptors at the cell surface. Based on these findings, physiologic stimulation of electrotherapy appears to represent a potential non-invasive, non-genomic, and novel physical technique that could be used to regulate NO-mediated bone density and facilitate bone remodeling without adverse effects associated with hormone therapy.