Physical Therapist Management of Total Knee Arthroplasty.

A clinical practice guideline on total knee arthroplasty was developed by an American Physical Therapy (APTA) volunteer guideline development group that consisted of physical therapists, an orthopedic surgeon, a nurse, and a consumer. The guideline was based on systematic reviews of current scientific and clinical information and accepted approaches to management of total knee arthroplasty.

Feasibility of Three Novel Forms of Passive Exercise in a Multisensory Environment in Vulnerable Institutionalized Older Adults with Dementia.

BACKGROUND: Increasing physical activity levels in patients with dementia can reduce pathology severity and progression of the disease. However, physical activity programs can be challenging to adhere to for this vulnerable population. Three novel forms of passive exercise in a multisensory environment may be feasible alternatives for patients who can no longer be involved in physical activity. OBJECTIVE: To determine the feasibility of three different forms of passive exercise in a multisensory environment in inactive institutionalized older adults with dementia. METHODS: 120 patients with dementia participated in this single blind randomized controlled trial (64.5% female, age 85.3±6.8 years Mini-Mental State Examination range 0-29). Ninety participants were randomly assigned to one of the three intervention groups: Therapeutic Motion Simulation (TMSim), Whole Body Vibration (WBV), and TMSim + WBV. Participants received 6 weeks of passive exercise, 4 sessions a week, 4 (WBV) to 12 (TMSim and TMSim + WBV) minutes per session. Feasibility of the novel forms of passive exercise was evaluated based on attendance, compliance, (proxy) experience scores, adverse events and drop-out rates. RESULTS: On average 87.9% of the offered intervention sessions were attended. All three forms of passive exercise were well appreciated by the participants (7.3 on a scale from 0 to 10). Intervention related drop-out rates were reasonable (12.2%) and no serious adverse events occurred. CONCLUSION: The novel passive exercise interventions TMSim, WBV, and TMSim + WBV are feasible to apply in patients at all stages of dementia. More research is needed to establish effectiveness of passive exercise to limit adverse effects of dementia.

Passive accessory joint mobilization in the multimodal management of chronic dysesthesia following thalamic stroke.

Study design: Case Report. Purpose: Stroke is the most common cause of long-term disability. Dysesthesia, an unpleasant sensory disturbance, is common following thalamic stroke and evidence-based interventions for this impairment are limited. The purpose of this case report was to describe a decrease in dysesthesia following manual therapy intervention in a patient with history of right lacunar thalamic stroke. Case description: A 66-year-old female presented with tingling and dysesthesia in left hemisensory distribution including left trunk and upper/lower extremities, limiting function. Decreased left shoulder active range of motion, positive sensory symptoms but no sensory loss in light touch was found. She denied pain and moderate shoulder muscular weakness was demonstrated. Laterality testing revealed right/left limb discrimination deficits and neglect-like symptoms were reported. Passive accessory joint motion assessment of glenohumeral and thoracic spine revealed hypomobility and provoked dysesthesia. Interventions included passive oscillatory joint mobilization of glenohumeral joint, thoracic spine, ribs and shoulder strengthening. Results: After six sessions, shoulder function, active range of motion, strength improved and dysesthesia decreased. Global Rating of Change Scale was +5 and QuickDASH score decreased from 45% to 22% disability. Laterality testing was unchanged. Conclusion: Manual therapy may be a beneficial intervention in management of thalamic stroke-related dysesthesia. Implications for Rehabilitation While pain is common following thalamic stroke, patients may present with chronic paresthesia or dysesthesia, often in a hemisensory distribution. Passive movement may promote inhibition of hyperexcitable cortical pathways, which may diminish aberrant sensations. Passive oscillatory manual therapy may be an effective way to treat sensory disturbances such as paresthesias or dysesthesia.

Developing a Wearable Ankle Rehabilitation Robotic Device for in-Bed Acute Stroke Rehabilitation.

Ankle movement training is important in motor recovery post stroke and early intervention is critical to stroke rehabilitation. However, acute stroke survivors receive motor rehabilitation in only a small fraction of time, partly due to the lack of effective devices and protocols suitable for early in-bed rehabilitation. Considering the first few months post stroke is critical in stroke recovery, there is a strong need to start motor rehabilitation early, mobilize the ankle, and conduct movement therapy. This study seeks to address the need and deliver intensive passive and active movement training in acute stroke using a wearable ankle robotic device. Isometric torque generation mode under real-time feedback is used to guide patients in motor relearning. In the passive stretching mode, the wearable robotic device stretches the ankle throughout its range of motion to the extreme dorsiflexion forcefully and safely. In the active movement training mode, a patient is guided and motivated to actively participate in movement training through game playing. Clinical testing of the wearable robotic device on 10 acute stroke survivors over 12 sessions of feedback-facilitated isometric torque generation, and passive and active movement training indicated that the early in-bed rehabilitation could have facilitated neuroplasticity and helped improve motor control ability.

The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review.

PURPOSE: There is a wide array of device modalities available for post-operative treatment following arthroscopic knee surgery; however, it remains unclear which types and duration of modality are the most effective. This systematic review aimed to investigate the efficacy of device modalities used following arthroscopic knee surgery. METHODS: A systematic search of the literature was performed on: PubMed; Scopus; MEDLINE; EMBASE; PEDro; SportDiscus; and CINAHL databases (1995-2015) for clinical trials using device modalities following arthroscopic knee surgery: cryotherapy, continuous passive motion (CPM), neuromuscular electrical stimulation (NMES), surface electromyographic (sEMG) biofeedback and shockwave therapy (ESWT). Only level 1 and 2 studies were included and the methodological quality of studies was evaluated using Physiotherapy Evidence Database (PEDro) scores. Outcome measures included: muscle strength, range of motion, swelling, blood loss, pain relief, narcotic use, knee function evaluation and scores, patient satisfaction and length of hospital stay. RESULTS: Twenty-five studies were included in this systematic review, nineteen of which found a significant difference in outcomes. For alleviating pain and decreasing narcotic consumption following arthroscopic knee surgery, cryocompression devices are more effective than traditional icing alone, though not more than compression alone. CPM does not affect post-operative outcomes. sEMG biofeedback and NMES improve quadriceps strength and overall knee functional outcomes following knee surgery. There is limited evidence regarding the effects of ESWT. CONCLUSION: Cryotherapy, NMES and sEMG are recommended for inclusion into rehabilitation protocols following arthroscopic knee surgery to assist with pain relief, recovery of muscle strength and knee function, which are all essential to accelerate recovery. CPM is not warranted in post-operative protocols following arthroscopic knee surgery because of its limited effectiveness in returning knee range of motion, and additional studies are required to investigate the effects of ESWT. LEVEL OF EVIDENCE: II.

The Effect of Passive Movement for Paretic Ankle-Foot and Brain Activity in Post-Stroke Patients.

BACKGROUND: This study aims at investigating the short-term efficacy of the continuous passive motion (CPM) device developed for the therapy of ankle-foot paresis and to investigate by fMRI the blood oxygen level-dependent responses (BOLD) during ankle passive movement (PM). METHODS: Sixty-four stroke patients were investigated. Patients were assigned into 2 groups: 49 patients received both 15 min manual and 30 min device therapy (M + D), while the other group (n = 15) received only 15 min manual therapy (M). A third group of stroke patients (n = 12) was investigated by fMRI before and immediately after 30 min CPM device therapy. There was no direct relation between the fMRI group and the other 2 groups. All subjects were assessed using the Modified Ashworth Scale (MAS) and a goniometer. RESULTS: Mean MAS decreased, the ankle's mean plantar flexion and dorsiflexion passive range of motion (PROM) increased and the equinovalgus improved significantly in the M + D group. In the fMRI group, the PM of the paretic ankle increased BOLD responses; this was observed in the contralateral pre- and postcentral gyrus, superior temporal gyrus, central opercular cortex, and in the ipsilateral postcentral gyrus, frontal operculum cortex and cerebellum. CONCLUSION: Manual therapy with CPM device therapy improved the ankle PROM, equinovalgus and severity of spasticity. The ankle PM increased ipsi- and contralateral cortical activation.

Assistive Control System for Upper Limb Rehabilitation Robot.

This paper presents an assistive control system with a special kinematic structure of an upper limb rehabilitation robot embedded with force/torque sensors. A dynamic human model integrated with sensing torque is used to simulate human interaction under three rehabilitation modes: active mode, assistive mode, and passive mode. The hereby proposed rehabilitation robot, called NTUH-ARM, provides 7 degree-of- freedom (DOF) motion and runs subject to an inherent mapping between the 7 DOFs of the robot arm and the 4 DOFs of the human arm. The Lyapunov theory is used to analyze the stability of the proposed controller design. Clinical trials have been conducted with six patients, one of which acts as a control. The results of these experiments are positive and STREAM assessment by physical therapists also reveals promising results.

Effectiveness of Music Listening in Patients With Total Knee Replacement During CPM Rehabilitation.

AIM: This study investigated the effects of music listening on the anxiety, heart rate variability (HRV), and joint range of motion (ROM) of patients undergoing continuous passive motion (CPM) after total knee replacement surgery. METHOD: An experimental design was used. Participants in the experimental group (n = 49) listened to music from 10 min before receiving CPM until the end of the session (25 min in total) on the first and second day following surgery, whereas participants in the control group (n = 42) did not listen to music but rested quietly in bed starting 10 min before and throughout CPM. RESULTS: Compared with the control group, the experimental group exhibited significantly lower anxiety levels (p < .05) and increased CPM angles (p < .05) during treatment and increased active flexion ROM (p < .05) upon discharge. The low-frequency (LF)/high-frequency (HF) power ratio, normalized LF HRV, and normalized HF HRV of the two groups differed significantly, indicating that the patients in the experimental group had greater parasympathetic activity compared with those in the control group. CONCLUSION: Music listening can effectively reduce patient anxiety and enhance the ROM of their joints during postoperative rehabilitation. Health-care practitioners should consider including music listening as a routine practice for postoperative rehabilitation following orthopedic surgery.

[Complex decongestive therapy]. / Komplexe physikalische Entstauungstherapie.

The amount of physical pressure plays an important role in complex decongestive therapy (CDT). As a function of pressure, microcirculation takes place between blood vessels and tissue. As part of the total lymphatic system, lymphatic vessels transport the lymphatic load from the interstitial space to the blood stream. The lymphatic vessel system, characterized by specific anatomical conditions like initial lymphatic vessels, precollectors, collectors, and lymphatic strains, is the therapeutic target of complex decongestive therapy. Components of CDT include manual lymphatic drainage, compression therapy, decongestive kinesitherapy, and good skin care, which increase the transport capacity of the lymphatic vessel system. Currently, CDT is acknowledged as the main conservative treatment of lymphedema of primary and secondary genesis, lipolymphedema, and phlebolymphedema. In clinical practice, we are increasingly confronted with edema of multifactorial genesis requiring a critical discussion and stocktaking of comprehensive clinical findings in terms of the indication for CDT. Therapeutic success depends on a joint application of all CDT components and patient compliance. To an increasing extent, medical research tries to combine successfully CDT with adjunct treatment options.

Biofeedback relaxation for pain associated with continuous passive motion in Taiwanese patients after total knee arthroplasty.

Effective pain management is crucial for patient recovery after total knee arthroplasty (TKA). Biofeedback therapy, which encourages relaxation and helps alleviate various conditions associated with stress, may help to decrease postoperative pain in patients undergoing TKA. A quasi- experimental design was used to investigate the efficacy of a biofeedback relaxation intervention in reducing pain associated with postoperative continuous passive motion (CPM) therapy. Sixty-six patients admitted to a general hospital in Taiwan for TKA were recruited and randomly assigned to the intervention or control group. The intervention group received biofeedback training twice daily for 5 days, concurrent with CPM therapy, whereas the control group did not receive the biofeedback intervention. Pain was measured using a numeric rating scale before and after each CPM therapy session on postoperative days 1 through 5. The CPM-elicited pain score was calculated by subtracting the pre-CPM pain score from the post-CPM pain score. Results of repeated-measures analysis of variance showed intervention group reported significantly less pain caused by CPM than did the control group (f = 29.70, p < 0.001). The study results provide preliminary support for biofeedback relaxation, a non-invasive and non-pharmacological intervention, as a complementary treatment option for pain management in this population.

Novel continuous passive motion device for self-treatment of chronic lower back pain: a randomised controlled study.

OBJECTIVE: To evaluate the efficacy of a novel, angular, continuous passive motion device for self-treatment at home in patients with mild-to-moderate, non-specific, chronic low back pain (LBP). DESIGN: Prospective, randomised, waiting-list-controlled (WLC) trial. SETTING: Recruitment and assessment were conducted at the Koren Centre for Physical Therapy. Self-treatment was performed at home. PARTICIPANTS: Thirty-six patients with a score ≤6 on the numeric rating scale (NRS) for pain were enrolled. Twenty-eight patients completed treatment. INTERVENTIONS: Participants were randomised to receive the Kyrobak (Radiancy, Hod-hasharon, Israel) at enrolment [immediate treatment (IT) group] or 3 weeks later (WLC group). Self-treatment was prescribed for 10minutes, one to three times per day, for 3 weeks. The treatment period was followed by a 3-week follow-up period. MAIN OUTCOME MEASURES: Primary outcome was self-reported pain level (NRS). RESULTS: Three weeks of self-treatment with the Kyrobak reduced pain levels significantly in the IT group compared with the WLC group {mean [standard deviation (SD)] ΔNRS score from baseline to post-treatment: IT group, 1.4 (1.5), 95% confidence interval (CI) 0.5 to 2.3; WLC group, -0.1 (2.2), 95% CI -1.1 to 1.2; effect mean difference 1.5}. This benefit was maintained over the follow-up period [from baseline to end of follow-up, mean (SD) ΔNRS score 1.1 (1.8), 95% CI 0.4 to 1.8]. Multi-linear regression analysis found that higher baseline pain resulted in greater pain reduction (P=0.003). Eighty-three percent of participants with a baseline NRS score >4.35 (threshold determined by logistic regression, P=0.01) achieved the minimal important change criterion of ΔNRS score ≥2. Daily NRS score reduced gradually over the treatment period [regression slope -0.052 (0.01), 95% CI -0.07 to -0.03]. CONCLUSIONS: Preliminary evidence suggests that the Kyrobak may be beneficial for short-term relief of non-specific, chronic LBP, particularly in participants with a moderate level of pain. A longer treatment period may lead to a further reduction in pain.

Immediate effects of active versus passive scapular correction on pain and pressure pain threshold in patients with chronic neck pain.

OBJECTIVE: The purpose of this study was to investigate the effect of active vs passive scapular correction on pain and pressure pain threshold at the most symptomatic cervical segment in patients with chronic neck pain. METHODS: Twenty-three volunteers with chronic, idiopathic neck pain were recruited (age, 38.9 ± 14.4 years; sex [man/woman], 3/20; Neck Disability Index, 28.1% ± 9.9%). Subjects were randomly allocated to 2 groups: active scapular correction or passive scapular correction. Pressure pain threshold and pain intensity rated on a numerical rating scale during a posteroanterior glide over the most symptomatic cervical segment were measured before and immediately after the active or passive scapular intervention. RESULTS: Only the active scapular correction produced a reduction in pain (pre, 6.3 ± 1.2; post, 3.7 ± 2.4; P < .05) and increase in pressure pain threshold (pre, 8.7 ± 4.2 kg/cm(2); post, 10.1 ± 3.8 kg/cm(2); P < .05) at the most painful cervical segment. CONCLUSIONS: An active scapular correction exercise resulted in an immediate reduction of pain and pressure pain sensitivity in patients with chronic neck pain and scapular dysfunction.

[Physiotherapy and rehabilitation for low back pain]. / Physiotherapie und Rehabilitation bei unspezifischen Kreuzschmerzen.

Low back pain (LBP) continues to be a major health problem causing personal suffering and enormous socioeconomic costs. Evidence suggests that more than 85 % of individuals with LBP suffer from non-specific low back pain. Physiotherapy for non-specific LBP includes educational, physical, manual and movement therapy measures. In the acute phase, it is very important to prevent chronicity by identifying barriers for a full recovery and a quick return to everyday activities. If there is a chronicity of symptoms, the treatment must focus on improvement of the general physical activity despite the pain and promote participation in the social and work context. These aims are more important than pain relief. Therefore in the acute phase educational and activity-promoting measures are the primary treatment options. In the sub-acute and chronic phase a multidimensional treatment approach including exercise therapy with the aim of improving function, including return to work, should be applied. By now, there is scientific evidence that physiotherapy can reduce pain and disability due to LBP, and that return to usual activities including work can be achieved.

Differences in somatosensory and motor improvement during temporary functional deafferentation in stroke patients and healthy subjects.

Temporary functional deafferentation is of interest to become an additional tool in neurorehabilitative treatments. Temporary functional deafferentation is known to improve sensory and motor outcomes in chronic stroke patients and healthy subjects. The present study soughts to indicate differences in the efficiency of pharmacologically induced temporary functional deafferentation between chronic stroke patients and matched healthy subjects. 46 chronic stroke patients and 20 age- and gender-matched healthy subjects were deafferented on one forearm by an anesthetic cream. Somatosensory performance was assessed using von-Frey Hair testing and Grating orientation task; motor performance was assessed by means of a shape-sorter-drum task. Grating orientation task and shape-sorter-drum task were significantly improved during temporary functional deafferentation in stroke patients but not in healthy subjects. Von-Frey Hair testing revealed no improvement of absolute tactile thresholds during temporary functional deafferentation in both groups. Furthermore, the stroke patients showed deficits at baseline measurement in all assessments except the von-Frey Hair test. Temporary functional deafferentation of a forearm by an anesthetic cream results in improvements of motor performance and somatosensory discrimination in stroke patients but not in healthy subjects. Therefore, it is reasonable to test in a next step whether temporary functional deafferentation might become an additional tool in motor rehabilitation of post stroke patients.

Virtual reality aided training of combined arm and leg movements of children with CP.

Cerebral palsy (CP) occurs in over 2 out of 1000 live births and can impair motor control and cognition. Our goal was to create a robotic rehabilitation environment that mimics real-life situations by allowing simultaneous exercise of upper and lower limbs. We chose to use the Lokomat as a gait robot and added a novel removable arm robot, called PASCAL (pediatric arm support robot for combined arm and leg training), that was integrated into the Lokomat environment. We also added a virtual reality (VR) environment that enables the subject to perform motivating game-like scenarios incorporating combined arm and leg movements. In this paper we summarize the design of PASCAL and present the novel virtual environment including first experimental results. The next step will be to test whether a combined application of the virtual environment and the two simultaneously working robots is feasible in healthy participants, and finally to clinically evaluate the entire system on children with CP.

Arm stiffness during assisted movement after stroke: the influence of visual feedback and training.

Spasticity and muscular hypertonus are frequently found in stroke survivors and may have a significant effect on functional impairment. These abnormal neuro-muscular properties, which are quantifiable by the net impedance of the hand, have a direct consequence on arm mechanics and are likely to produce anomalous motor paths. Literature studies quantifying limb impedance in stroke survivors have focused on multijoint static tasks and single joint movements. Despite this research, little is known about the role of sensory motor integration in post-stroke impedance modulation. The present study elucidates this role by integrating an evaluation of arm impedance into a robotically mediated therapy protocol. Our analysis had three specific objectives: 1) obtaining a reliable measure for the mechanical proprieties of the upper limb during robotic therapy; 2) investigating the effects of robot-assisted training and visual feedback on arm stiffness and viscosity; 3) determining if the stiffness measure and its relationship with either training or visual feedback depend on arm position, speed, and level of assistance. This work demonstrates that the performance improvements produced by minimally assistive robot training are associated with decreased viscosity and stiffness in stroke survivors' paretic arm and that these mechanical impedance components are partially modulated by visual feedback.

Technologies and combination therapies for enhancing movement training for people with a disability.

There has been a dramatic increase over the last decade in research on technologies for enhancing movement training and exercise for people with a disability. This paper reviews some of the recent developments in this area, using examples from a National Science Foundation initiated study of mobility research projects in Europe to illustrate important themes and key directions for future research. This paper also reviews several recent studies aimed at combining movement training with plasticity or regeneration therapies, again drawing in part from European research examples. Such combination therapies will likely involve complex interactions with motor training that must be understood in order to achieve the goal of eliminating severe motor impairment.

The effects of electromechanical wrist robot assistive system with neuromuscular electrical stimulation for stroke rehabilitation.

An electromyography (EMG)-driven electromechanical robot system integrated with neuromuscular electrical stimulation (NMES) was developed for wrist training after stroke. The performance of the system in assisting wrist flexion/extension tracking was evaluated on five chronic stroke subjects, when the system provided five different schemes with or without NMES and robot assistance. The tracking performances were measured by range of motion (ROM) of the wrist and root mean squared error (RMSE). The performance is better when both NMES and robot assisted in the tracking than those with either NMES or robot only (P<0.05). The muscle co-contractions in the upper limb measured by EMG were reduced when NMES provided assistance (P<0.05). All subjects also attended a 20-session wrist training for evaluating the training effects (3-5 times/week). The results showed improvements on the voluntary motor functions in the hand, wrist and elbow functions after the training, as indicated by the clinical scores of Fugl-Meyer Assessment, Action Research Arm Test, Wolf Motor Function Test; and also showed reduced spasticity in the wrist and the elbow as measured by the Modified Ashworth Score of each subject. After the training, the co-contractions were reduced between the flexor carpi radialis and extensor carpi radialis, and between the biceps brachii and triceps brachii. Assistance from the robot helped improve the movement accuracy; and the NMES helped increase the muscle activation for the wrist joint and suppress the excessive muscular activities from the elbow joint. The NMES-robot assisted wrist training could improve the hand, wrist, and elbow functions.

Effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women.

INTRODUCTION: Physiological and psychological alterations in the climacteric period frequently influence women's quality of life. Hot flushes, nocturia, mood alterations, respiratory disturbances, insomnia and restless leg syndrome all affect sleep, and the altered hormonal state in this period impacts the aging process. As hormonal therapy is not indicated in some cases, the search for complementary therapies, such as massage therapy, to improve insomnia in the climacteric period is increasing. OBJECTIVE: To evaluate the effect of therapeutic massage on insomnia and climacteric symptoms in postmenopausal women. METHODS: Forty-four volunteers were randomly distributed into three groups: therapeutic massage (TM), passive movement (PM) and control (CTL). The women received 32 therapeutic massage sessions and passive movement twice a week. Questionnaires were given in the pre-trial and the 16th and 32nd sessions. The Insomnia Severity Index (ISI), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), Menopause Quality of Life questionnaire (MENQOL), Kupperman Menopausal Index and Lipp Symptoms of Stress Inventory were assessed. In addition, the women underwent polysomnography at baseline and post-treatment. Statistical analyses were calculated using Friedman and Wilcoxon non-parametric tests. The level of significance was fixed at p ≤ 0.05. RESULTS: There was an improvement in ISI in the TM group (p = 0.000) and in the PM group (p = 0.001). A decrease in the BDI occurred in the TM group (p = 0.004), and the MENQOL improved in the TM group (p = 0.015). Furthermore, there were no significant differences in polysomnography parameters in the TM group, with only an increase in minimal saturation (p = 0.053). CONCLUSION: The TM group exhibited improved subjective data considering the changes in symptoms according to the ISI and the MENQOL and a decrease in symptoms according to the BDI.