Long-term effects on body functions, activity and participation of hemiplegic patients in equino varus foot deformity surgical correction followed by immediate rehabilitation. A prospective observational study.

Background: Functional surgery is an effective approach in the treatment of the rigid equinovarus foot deformity (EVFD). This must be associated with early rehabilitation treatments (ERTs) to prevent muscle rearrangements due to immobilization. Objectives: To assess the effects of EVFD surgical correction in adult stroke patients, when assessed according to the ICF domains. Methods: Variables from 24 adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55 ± 13 years, affected side 12L/12R, time from lesion 5 ± 4 years were analyzed. Body function domain: pain (NPRS), walking speed, clinical global impression of change (cGIC). Activity domain: Rivermead Mobility Index (RMI), FAC, and 6 min walking test (6MWT). Participation domain: Walking Handicap Scale (WHS). Patients were assessed before (T0), one (T1), three (T2) and twelve (T3) months after surgery by a single assessor. Results: All variables but the 6MWT significantly improved (Wilcoxon test, p < .05) at T1 or T2 and this remained until the 12-months mark. Since T1, all patients reached and maintained a supervised independent walking (FAC≥3) and all those wearing an AFO stopped using it. The median cGCI was "much improved" at T1, with a "further minimal improvement" at T3. This was not associated with the improvement measured by both FAC, and WHS (Chi-square test, p = .20 and p = .36, respectively). Conclusions: Functional surgery combined with ERT is effective in improving the patients' condition according to all ICF domains. Both subjective and objective assessments have to be used when assessing these patients.

Safety and long-term effects on gait of hemiplegic patients in equinovarus foot deformity surgical correction followed by immediate rehabilitation: a prospective observational study.

BACKGROUND: Equinovarus foot deformity (EVFD) is the most common lower limb deformity in stroke patients. Immobilization following EVFD surgical correction is known to have a negative impact on muscle rearrangement with possible loss of walking ability in stroke patients. In a previous study, safe and positive effects at one-month follow-up after surgery were obtained with an early rehabilitation treatment (ERT) characterized by immediate walking and training. AIM: To determine long-term safety and efficacy of functional surgery followed by early rehabilitation (FSER). DESIGN: A 12 months prospective observational study. SETTING: Outpatients clinic, Gait and Motion Laboratory, Sol et Salus Hospital, Rimini, Italy. POPULATION: Twenty-four adult chronic stroke survivors with EVFD surgical correction followed by ERT, age 55±13 years, affected side 12L/12R, time from lesion 5±4 years. METHODS: Patients received clinical and instrumental evaluation by gait analysis (GA) before (T0), one, three and twelve months after surgery. Safety was defined as the absence of any complication consequent to FSER. Efficacy was assessed by the recovery in ankle kinematics, walking speed and space-time parameters. RESULTS: No clinical complication (thrombosis, surgical wound infection, muscle or tendon injury, muscle hematoma) arose in the sample during the follow-up year. Variables relating to ankle kinematics improved towards their normal values at one month after surgery. These were maintained at 3 and 12 months, with a significant difference between follow-ups and pre-surgical values (Durbin-Conover Test, P<0.01). Gait speed, cadence, anterior step length and stride length of the affected side showed a statistical improvement at 3 and 12 months (Wilcoxon test, P=0.012 and P=0.001, respectively). Stride width decreased at 1 month after surgery and showed a further stable reduction at 3 months (P=0.008). CONCLUSIONS: The ERT protocol with immediate rehabilitation starting on the first day after surgical correction was safe and effective in providing a long-term correction of EVFD. Ankle dorsiflexion improved both in stance and swing, allowing for a significative improvement in walking speed. CLINICAL REHABILITATION IMPACT: FSER can be considered an encouraging approach in the management of EVFD, with durable results.

Electromyographic activity of the vastus intermedius muscle in patients with stiff-knee gait after stroke. A retrospective observational study.

Stiff-knee gait (SKG) in hemiplegic patients is often due to an inappropriate activity of the quadriceps femoris. However, there are no studies in literature addressing the vastus intermedius (VI) involvement in SKG. In this study, VI activity was analyzed in a sample of 46 chronic stroke patients with SKG, during spontaneous gait. VI activity was recorded by fine-wire electrodes inserted under ultrasound guidance then confirmed by electrical stimulation. The measured VI activity was compared to the normal reference pattern reported in literature and classified (e.g. premature, prolonged). The occurrences of abnormal activations during each sub-phase of the gait cycle were assessed. VI activity presented an abnormal timing in 96% of the sample. The most common pathological pattern (in 46% of the sample) was the combination of premature and prolonged VI activation. Nearly 20% of patients presented a continuous activity. A pathological activation in patients was found for 91% in mid stance, for more than 50% in terminal stance and pre-swing and for 37% and 70% in initial- and mid-swing. Results indicate that abnormal VI activity is frequent in patients with SKG. Hence, VI activity should be included in the assessment of SKG to assist in the clinical decision-making processes.

Age explains limited hip extension recovery at one year from total hip arthroplasty.

BACKGROUND: To investigate the dependency of the one-year recovery in gait after total hip arthroplasty on age and preoperative conditions. METHODS: Longitudinal retrospective study on 20 elderly patients with unilateral total hip arthroplasty consequent to hip osteoarthritis, assessed by gait analysis before surgery (T0), 2weeks (T1), 6 (T2) and 12months (T3) post-surgery. A set of variables assessing primary gait deviations and compensatory mechanisms were extracted from gait analysis data. Their variations throughout the one-year period were analyzed through a repeated measures ANOVA. Their dependency on preoperative conditions (age, hip passive limitations and Thomas Test) at one year after surgery were assessed through a correlation analysis and an ANCOVA. FINDINGS: Hip sagittal range significantly increased (P<0.05) after each measurement session from mean 21 (SD 10) degrees at T0, to 31 (6) at T1, to 34 (6) at T2 until 36 (4) degrees at T3. The peak of hip and ankle power generation significantly increased from T0 to T3, with a progressive reduction of compensatory mechanisms towards normal values. At T3, preoperative hip passive extension and Thomas Test score did not affect hip sagittal range during gait, while age did (P<0.05, R2=0.36). Ankle and hip peak powers were also correlated with age (P=0.033 and P=0.008, respectively). In our sample, age was the main cause of hip sagittal joint range limitation. INTERPRETATION: At one year from total hip arthroplasty, age affects hip joint limitations and gait recovery more than preoperative passive restrictions due to muscle shortening.

Early rehabilitation treatment combined with equinovarus foot deformity surgical correction in stroke patients: safety and changes in gait parameters.

BACKGROUND: Equinovarus foot deformity (EVFD) compromises several prerequisites of walking and increases the risk of falling. Guidelines on rehabilitation following EVFD surgery are missing in current literature. AIM: The aim of this study was to analyze safety and adherence to an early rehabilitation treatment characterized by immediate weight bearing with an ankle-foot orthosis (AFO) in hemiplegic patients after EVFD surgery and to describe gait changes after EVFD surgical correction combined with early rehabilitation treatment. DESIGN: Retrospective observational cohort study. SETTING: Inpatient rehabilitation clinic. POPULATION: Forty-seven adult patients with hemiplegia consequent to ischemic or haemorrhagic stroke (L/R 20/27, age 56±15 years, time from lesion 6±5 years). METHODS: A specific rehabilitation protocol with a non-articulated AFO, used to allow for immediate gait training, started one day after EVFD surgery. Gait analysis (GA) data before and one month after surgery were analyzed. The presence of differences in GA space-time parameters, in ankle dorsiflexion (DF) values and peaks at initial contact (DF at IC), during stance (DF at St) and swing (DF at Sw) were assessed by the Wilcoxon Test while the presence of correlations between pre- and post-operative values by Spearman's correlation coefficient. RESULTS: All patients completed the rehabilitation protocol and no clinical complications occurred in the sample. Ankle DF increased one month after surgery at all investigated gait phases (Wilcoxon Test, P<0.0001), becoming neutral at IC. Significant (P<0.05) variations were found for stride length, stride width, anterior step length of the affected side and for the duration of the double support phase of the contralateral side. The postsurgery ankle DF at St was found to be correlated (R=0.81, P<0.0001) with its pre-surgery value, thus being predictable. Weaker significant correlations were found for DF at Sw and DF at IC, where contribution from the dorsiflexor muscles is required in addition to calf muscle passive lengthening. CONCLUSIONS: An orthosis-assisted immediate rehabilitation associated with surgical procedure is safe and may be suitable to correct EVFD by restoring both the neutral heel foot-ground contact and the ankle DF peaks during stance and swing at one month from surgery. CLINICAL REHABILITATION IMPACT: The proposed protocol is a safe and potentially useful rehabilitative approach after EVFD surgical correction in stroke patients.

Effects of physical therapy for the management of patients with ankylosing spondylitis in the biological era.

Exercise is considered a fundamental tool for the management of ankylosing spondylitis (AS), in combination with pharmacological therapy that with the advent of biological therapy has improved dramatically the control of signs and symptoms of this challenging disease. Current evidence shows that a specific exercise protocol has not been validated yet. The purpose of this review is to update the most recent evidence (July 2010-November 2013) about physiotherapy in AS, analyzing the possible role and synergistic interactions between exercise and biological drugs. From 117 studies initially considered, only 15 were included in the review. The results support a multimodal approach, including educational sessions, conducted in a group setting, supervised by a physiotherapist and followed by a maintaining home-based regimen. Spa exercise and McKenzie, Heckscher, and Pilates methods seem promising in AS rehabilitation, but their effectiveness should be further investigated in future randomized controlled trials (RCTs). When performed in accordance with the American College of Sports Medicine guidelines, cardiovascular training has been proven safe and effective and should be included in AS rehabilitation protocols. Exercise training plays an important role in the biological era, being now applicable to stabilized patients, leading ultimately to a better management of AS by physiatrists and rheumatologists throughout the world. On the basis of the current evidence, further research should aim to determine which exercise protocols should be recommended.

Medium-/long-term effects of a specific exercise protocol combined with patient education on spine mobility, chronic fatigue, pain, aerobic fitness and level of disability in fibromyalgia.

OBJECTIVE: To propose a rehabilitation protocol able to produce immediate and long-term beneficial effects on level of disability and overall performance in ADLs. MATERIALS AND METHODS: Forty-one FM patients were randomized to an exercise and educational-behavioral programme group (experimental group, EG = 21) or to a control group (CG = 20). Each subject was evaluated before, at the end (T1), and after 6 months (T6) from the conclusion of the rehabilitation treatment using the Fibromyalgia Impact Questionnaire (FIQ), the visual analogue scale (VAS), the Health Assessment Questionnaire (HAQ), the fatigue severity scale (FSS), the 6-minute walking test (6MWT), tender points count (TPC), and spinal active range of motion. The exercise protocol included 20 sessions consisting in self-awareness, stretching, strengthening, spine flexibility, and aerobic exercises, which patients were subsequently educated to perform at home. RESULTS: The two groups were comparable at baseline. At T1, the EG showed a positive trend in FIQ, VAS, HAQ, and FSS scales and significant improvement in 6MWT and in most spinal active range of motion measurements (P between 0.001 and 0.04). The positive results were maintained at the follow-up. CONCLUSION: The proposed programme was well tolerated and produced immediate and medium-term beneficial effects improving function and strain endurance. This trial is registered with DRKS00005071 on DRKS.

Autologous conditioned serum for the treatment of osteoarthritis and other possible applications in musculoskeletal disorders.

INTRODUCTION: The therapeutic use of interleukin 1 (IL-1) cytokine receptor antagonists (IL-1RA) has promoted the development of new biological therapies for osteoarthritis (OA). Autologous conditioned serum (ACS) is an alternative, safe and well-tolerated treatment in OA. Sources of data We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL, Embase, SportDiscus, Pedro and Google scholar databases using keywords such as 'interleukin 1', 'osteoarthritis' and 'autologous conditioned serum'. AREAS OF AGREEMENT: ACS, containing endogenous anti-inflammatory cytokines including IL-1RA and several growth factors, could reduce pain and increase function and mobility in mild to moderate knee OA. AREA OF CONTROVERSY: Given the limited data available on the composition of ACS, the mechanisms through which ACS produces clinical improvement, the duration of its effect and the changes in cytokine levels after repeated injections are still unknown. Growing points Although previous clinical data are encouraging and confirm the safety of this modality, given the limitations of current studies, there should be additional, controlled trials to further confirm efficacy for the use of ACS in OA treatment. AREA TIMELY FOR DEVELOPING RESEARCH: ACS can lead to enhancement of tissue regeneration and to reduction of degenerative mechanisms.

Insertional tendinopathy of the adductors and rectus abdominis in athletes: a review.

Insertional tendinopathy of the adductors and rectus abdominis is common in male athletes, especially in soccer players. It may be worsened by physical activity and it usually limits sport performance. The management goal in the acute phase consists of analgesic and anti-inflammatory drugs and physical rehabilitation. In the early stages of rehabilitation, strengthening exercises of adductors and abdominal muscles, such as postural exercises, have been suggested. In the sub-acute phase, muscular strength is targeted by overload training in the gym or aquatherapy; core stability exercises seem to be useful in this phase. Finally, specific sport actions are introduced by increasingly complex exercises along with a preventive program to limit pain recurrences.

The meniscus tear. State of the art of rehabilitation protocols related to surgical procedures.

Meniscal injuries represent one of the most frequent lesions in sport practicing and in particular in soccer players and skiers. Pain, functional limitation and swelling are typical symptoms associated with meniscal tears. Epidemiological studies showed that all meniscal lesions, in different sports athletes, involves 24% of medial meniscus, while 8% of lateral meniscus and about 20-30% of meniscal lesions are associated with other ligament injuries. Meniscal tears can be treated conservatively or surgically. Surgery leads in many cases to complete resolution of symptoms and allows the return to sport activity. However many studies show that this treatment can induce more frequently the development of degenerative conditions if not correctly associated to a specific rehabilitation protocol. The aim of this article is to compare different timing in specific rehabilitation programs related to the most actual surgical options.