Correlation of muscle and bone parameters, daily function and participation in women with generalized joint hypermobility: a descriptive evaluation.

OBJECTIVES: Generalized joint hypermobility (GJH) has a prevalence in women of 15% to 35%. GJH may lead to impaired movement control, frequent sprains or subluxations and pain, and can be associated with early osteoarthritis or chronic fatigue. Aim of this project was to analyse muscle strength, muscle cross-sectional area (mCSA) and daily function in women with GJH and to analyse correlations between these measurements. METHODS: Descriptive cross-sectional study of women with GJH, defined by Beighton score ≥6/9. Assessments included muscle strength, mCSA by peripheral Quantitative Computed Tomography (pQCT), stair climbing, as well as two questionnaires. Spearman's correlations between parameters were calculated. RESULTS: 51 women with a mean age of 26.5 years participated, whereof 18 (35%) had a Beighton score of 9/9 and 17 (33%) attained 8/9. Internal correlations between strength measurements were high, whereas pQCT parameters were less correlated. Strength was moderately correlated with mCSA, while correlations with stair climbing and SF-36 were not significant. CONCLUSIONS: This study provides insight into the muscle and bone properties of women with GJH. Only slight differences were seen compared to normative values. Correlations between various dimensions were middle or low, indicating the complex relationship between strength, muscle properties and function.

Cardiorespiratory response to early rehabilitation in critically ill adults: A secondary analysis of a randomised controlled trial.

INTRODUCTION: Early rehabilitation is indicated in critically ill adults to counter functional complications. However, the physiological response to rehabilitation is poorly understood. This study aimed to determine the cardiorespiratory response to rehabilitation and to investigate the effect of explanatory variables on physiological changes during rehabilitation and recovery. METHODS: In a prospectively planned, secondary analysis of a randomised controlled trial conducted in a tertiary, mixed intensive care unit (ICU), we analysed the 716 physiotherapy-led, pragmatic rehabilitation sessions (including exercise, cycling and mobilisation). Participants were previously functionally independent, mechanically ventilated, critically ill adults (n = 108). Physiological data (2-minute medians) were collected with standard ICU monitoring and indirect calorimetry, and their medians calculated for baseline (30min before), training (during physiotherapy) and recovery (15min after). We visualised physiological trajectories and investigated explanatory variables on their estimated effect with mixed-effects models. RESULTS: This study found a large range of variation within and across participants' sessions with clinically relevant variations (>10%) occurring in more than 1 out of 4 sessions in mean arterial pressure, minute ventilation (MV) and oxygen consumption (VO2), although early rehabilitation did not generally affect physiological values from baseline to training or recovery. Active patient participation increased MV (mean difference 0.7l/min [0.4-1.0, p<0.001]) and VO2 (23ml/min [95%CI: 13-34, p<0.001]) during training when compared to passive participation. Similarly, session type 'mobilisation' increased heart rate (6.6bpm [2.1-11.2, p = 0.006]) during recovery when compared to 'exercise'. Other modifiable explanatory variables included session duration, mobilisation level and daily medication, while non-modifiable variables were age, gender, body mass index and the daily Sequential Organ Failure Assessment. CONCLUSIONS: A large range of variation during rehabilitation and recovery mirrors the heterogenous interventions and patient reactions. This warrants close monitoring and individual tailoring, whereby the best option to stimulate a cardiorespiratory response seems to be active patient participation, shorter session durations and mobilisation. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) identification number: DRKS00004347, registered on 10 September 2012.

Effect of resistance training on muscle properties and function in women with generalized joint hypermobility: a single-blind pragmatic randomized controlled trial.

BACKGROUND: Generalized joint hypermobility is defined as an excessive range of motion in several joints. Having joint hypermobility is not a pathology, but when associated with pain and other symptoms, it might affect health and function. Evidence for physiotherapy management is sparse and resistance training might be a possible intervention. Thus, the effects of 12-week resistance-training on muscle properties and function in women with generalized joint hypermobility were evaluated. METHODS: In this single-blind randomized controlled trial women between 20 and 40 years with generalized joint hypermobility (Beighton score at least 6/9) were included. Participants were randomly allocated to 12-week resistance training twice weekly (experimental) or no lifestyle change (control). Resistance training focused on leg and trunk muscles. Primary outcome was muscle strength; additional outcomes included muscle properties, like muscle mass and density, functional activities, pain and disability. Training adherence and adverse events were recorded. RESULTS: Of 51 participating women 27 were randomised to training and 24 into the control group. In each group 11 women had joint hypermobility syndrome, fulfilling the Brighton criteria, while 24 (89%) in the training group and 21 (88%) in the control group mentioned any pain. The mean strength of knee extensors varied in the training group from 0.63 (sd 0.16) N/bm before training to 0.64 (sd 0.17) N/bm after training and in the control group from 0.53 (sd 0.14) N/bm to 0.54 (sd 0.15) N/bm. For this and all other outcome measures, no significant differences between the groups due to the intervention were found, with many variables showing high standard deviations. Adherence to the training was good with 63% of participants performing more than 80% of sessions. One adverse event occurred during training, which was not clearly associated to the training. Four participants had to stop the training early. CONCLUSIONS: No improvement in strength or muscle mass by self-guided resistance training was found. Low resistance levels, as well as the choice of outcome measures were possible reasons. A more individualized and better guided training might be important. However, program adherence was good with few side effects or problems triggered by the resistance training. TRIAL REGISTRATION: This trial was prospectively registered in the ISRCTN registry ( www.isrctn.com , BMC, Springer Nature) on July 16, 2013 as ISRCTN90224545 . The first participant was enrolled at October 25, 2013.

Standardized, comprehensive, hospital-based circuit training in people with multiple sclerosis: results on feasibility, adherence and satisfaction of the training intervention.

BACKGROUND: We developed a standardized, comprehensive, ambulatory, hospital-based neurorehabilitation program ("MS-Fit") to improve disability, activities of daily living and quality of life in people with multiple sclerosis (PwMS). AIM: The aim of this study was to assess feasibility, adherence and satisfaction of the training intervention. DESIGN: Prospective multicenter cohort study analysis. SETTING: Ambulatory, hospital-based study. POPULATION: PwMS, aged 18 to 75 years, complaining about multiple sclerosis-related disability affecting activities of daily living and/or quality of life. METHODS: A standardized, ambulatory, hospital-based circuit training consisting of six workstations (aerobic exercise training, strength upper limbs, balance, manual dexterity, reactivity, strength and flexibility lower limbs) was performed two hours, twice weekly, for two months in groups of two to six participants supervised by experienced physiotherapists. Physiotherapists adapted the type and intensity of training according to the participants' individual performance using a training booklet. Program satisfaction and adherence were evaluated using a questionnaire and the attendance rate (clinicaltrials.gov Identifier: NCT02440516). RESULTS: Fifty-five participants started (mean age 52.82 years±10.68 standard deviation, range 29-74; 69% female; median Expanded Disability Status Scale 3.5, range 1.0-7.0) and 49 (89%) finished the training program. Main reasons to drop out during the training were lack of time, travel problems, social issues or Uthoff's phenomenon during the summer. All participants finalizing the training achieved >80% (mean 92.26%, ±7.59) attendance rate and sent back the questionnaire. Overall participant's satisfaction was high with a median of 9 points (range 4-10) on a Likert Scale from 0-10. Program quality was rated "good" with an overall median score of 39/50 points (range 26-50) and 95% of the participants would recommend the program to others. CONCLUSIONS: MS-Fit is a feasible training program with high patient satisfaction and adherence. It enables high intensity ambulatory training and can be easily reproduced due to its standardized nature. CLINICAL REHABILITATION IMPACT: MS-FIT enables a standardized ambulatory high intensity training that is easily reproducible. Participants benefit from group training and from individual adaption of the training through professional supervision.

Functional ability and quality of life in critical illness survivors with intensive care unit acquired weakness: A secondary analysis of a randomised controlled trial.

INTRODUCTION: Intensive care unit acquired weakness (ICUAW) may contribute to functional disability in ICU survivors, yet performance-based data for general ICU patients are lacking. This study explored functional outcomes of (1) and risk factors for (2) weakness at ICU discharge. METHODS: Data from a randomised controlled trial that investigated two early exercise regimes in previously independent, ventilated adults (n = 115) without any significant outcome-differences were used for the present analysis. ICUAW was clinically diagnosed in cooperative participants (n = 83) at ICU discharge with the Medical Research Council sum-score (MRC-SS) using a cut-off <48 for moderate or <36 for severe weakness. Primary outcomes were the 6-Minute Walk Test and Functional Independence Measure at hospital discharge. Secondary outcomes included health-related quality of life after six months. Risk factors during the ICU stay were explored for their effect on MRC-SS with linear regression. RESULTS: Functional outcomes and length of hospital stay significantly differed in patients with severe, moderate to no weakness (6-Minute Walk test: p = 0.013; 110m [IQR 75-240], 196m [90-324.25], 222.5m [129-378.75], Functional Independence Measure: p = 0.001; 91[IQR 68-101], 113[102.5-118.5], 112[97-123], length of stay after ICU discharge: p = 0.008; 20.9d [IQR 15.83-30.73], 16.86d [13.07-27.10], 11.16d [7.35-19.74]). However, after six months participants had similar values for quality of life regardless of their strength at ICU discharge (Short-Form 36 sum-scores physical health: p = 0.874, mental health: p = 0.908). In-bed immobilisation was the most significant factor associated with weakness at ICU discharge in the regression models (MRC-SS: -24.57(95%CI [-37.03 to -12.11]); p<0.001). CONCLUSIONS: In this general, critically ill cohort, weakness at ICU discharge was associated with short-term functional disability and prolonged hospital length of stay, but not with quality of life, which was equivalent to the values for patients without ICUAW within six months. Immobilisation may be a modifiable risk factor to prevent ICUAW. Prospective trials are needed to validate these results. TRIAL REGISTRATION: German Clinical Trials Register (DRKS) identification number: DRKS00004347, registered on September 10, 2012.

Early Assessment and Management of Dysphagia After Lung Resection: A Randomized Controlled Trial.

BACKGROUND: Aspiration resulting from oropharyngeal dysphagia has been recognized as a serious complication after lung resection. The primary aim of this study was to determine whether early detection of postoperative dysphagia would reduce pneumonia among these patients. The median length of hospital stay was assessed. METHODS: In this single-center, randomized controlled trial, the experimental group underwent clinical assessment of dysphagia before the initiation of oral intake after surgery. Therapeutic interventions were implemented immediately for patients diagnosed with dysphagia. The risk of pneumonia and the median length of hospital stay were compared between the 2 groups. RESULTS: Between February 2014 and May 2016, 438 patients were randomized. Complete data from all randomized patients were analyzed. Eight cases out of 219 (3.7%) with postoperative dysphagia were detected in the experimental group. Pneumonia occurred in 14 cases out of 219 (6.4 %) in the experimental group and in 27 cases out of 219 (12.3 %) in the control group. The resulting risk reduction for pneumonia was 5.9% in the experimental group (95% confidence interval, 0.44-11.56; P = .033). The median length of hospital stay was 6 (5-8 [25th-75th percentile]) days in the experimental group and 7 (5-10 [25th-75th percentile]) days in the control group (P = .083). CONCLUSIONS: Early detection of postoperative dysphagia can significantly decrease the risk of postoperative pneumonia in patients undergoing lung resection.

Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: A randomised controlled trial.

INTRODUCTION: Neuromuscular weakness resulting in severe functional impairment is common in critical care survivors. This study aimed to evaluate effects of an early progressive rehabilitation intervention in mechanically ventilated adults at risk. METHODS: This was a parallel, two-arm, assessor-blinded, randomised controlled trial with 6-months follow-up that was conducted in a mixed ICU of an academic centre in Switzerland. Previously independent, mechanically ventilated, critically ill adults with expected critical care stay ≥72 hours (n = 115) were randomised to a control group receiving standard physiotherapy including early mobilisation or to an experimental group with early endurance and resistance training combined with mobilisation. Primary endpoints were functional capacity (6-Minute Walk Distance) and functional independence (Functional Independence Measure) at hospital discharge. Secondary endpoints including muscle strength were assessed at critical care discharge. Safety was monitored closely by standard monitoring and predefined adverse events. RESULTS: Physiotherapy started within 48 hours of critical care admission while 97% of participants were still ventilated and 68% on inotropes. Compared to the control group (n = 57), the experimental group (n = 58) received significantly more physiotherapy (sessions: 407 vs 377, p<0.001; time/session: 25min vs 18min, p<0.001) and had less days with sedation (p<0.001). Adverse events were rare (0.6%) and without consequences. There were no significant between-group differences in 6-Minute Walk Distance (experimental 123m (IQR 25-280) vs control 100m (IQR 0-300); p = 0.542) or functional independence (98 (IQR 66-119) vs 98 (IQR 18-115); p = 0.308). Likewise, no differences were found for the secondary outcomes, except a trend towards improved mental health in the experimental group after 6 months (84 (IQR 68-88) vs 70 (IQR 64-76); p = 0.023). CONCLUSIONS: Early endurance and resistance training in mechanically ventilated, intensive care patients does not improve functional capacity or independence at hospital discharge compared to early standard physiotherapy but may improve mental health 6-months after critical care discharge. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00004347, registered on 10 September 2012.

Passive anterior tibial translation in women with and without joint hypermobility: an exploratory study.

AIM: Generalized joint hypermobility (GJH) is a frequent entity, which is still not fully understood. Symptoms associated with GJH are musculoskeletal disorders, decreased balance, impaired proprioception and chronic pain. The purpose of this study was to compare the passive anterior tibial translation (TT) in terms of distance and corresponding force between normomobile (NM) and hypermobile (HM) as well as between NM, symptomatic (HM-s) and asymptomatic (HM-as) hypermobile women. METHODS: A total of 195 women, 67 NM and 128 HM, whereof 56 were further classified as HM-s and 47 as HM-as, participated in this study. Passive TT was measured using an adapted Rolimeter. A manual traction force was applied and the distance of the translation measured. For the analysis, maximal translation (TTmax) and the respective force as well as the distance at 40N (TTF40) and 80N (TTF80) traction force were determined. The NM and HM groups were compared using independent samples t-tests, whereas the NM, HM-s and HM-as groups were compared using one-way analyses of variance with Tukey post hoc tests (significance level P ≤ 0.05). RESULTS: Comparisons revealed higher values for the variables TTmax, TTF40 and TTF80 in the HM compared to the NM group. In addition, TTmax and TTF80 were found to be higher in the HM-s compared to the NM group. CONCLUSIONS: HM women showed significantly higher TT distances, which were even more accentuated in those having symptoms. The findings point toward less passive stability of the knee joint and thus maybe a need of higher muscle activation in order to stabilize the joint.

Effects of early, combined endurance and resistance training in mechanically ventilated, critically ill patients: a study protocol for a randomised controlled trial.

BACKGROUND: Prolonged need for intensive care is associated with neuromuscular weakness, termed Intensive Care Unit Acquired Weakness. Those affected suffer from severe functional impairment that can persist for years. First studies suggest a positive effect of physiotherapy and early mobilisation. However, the ideal intervention for a preferential functional outcome is not known. So far no randomised controlled trial has been conducted to specifically evaluate an early endurance and resistance training in the mechanically ventilated, critically ill patient. METHODS/DESIGN: A randomised controlled trial with blinded assessors and 6-month follow-up will be conducted in a tertiary, interdisciplinary intensive care unit in Switzerland. Participants (n = 115; expected dropouts: n = 15) will be randomised to a control group receiving standard physiotherapy and to an experimental group that undergoes early mobilisation combined with endurance and resistance training. The inclusion criteria are being aged 18 years or older, expected mechanical ventilation for more than 72 h and qualitative independence before the illness. Primary endpoints are functional capacity (6-Minute Walk Test) and the ability to perform activities of daily living (Functional Independence Measure) measured at hospital discharge. Secondary endpoints include muscle strength (Medical Research Council sum score, handgrip strength and handheld dynamometry for quadriceps muscle), joint contractures (range of motion), exercise capacity (Timed 'Up & Go' Test) and health-related quality of life (Short Form 36). Safety will be monitored during interventions by indirect calorimetry and continuous intensive care standard monitoring. All previously defined adverse events will be noted. The statistical analysis will be by intention-to-treat with the level of significance set at p < 0.05. DISCUSSION: This prospective, single-centre, allocation-concealed and assessor-blinded randomised controlled trial will evaluate participant's function after an early endurance and resistance training compared to standard care. Limitations of this study are the heterogeneity of the critically ill and the discontinuity of the protocol after relocation to the ward. The strengths lie in the pragmatic design and the clinical significance of the chosen outcome measures. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00004347 , registered on 10 September 2012.

Stair climbing - an insight and comparison between women with and without joint hypermobility: a descriptive study.

Generalized joint hypermobility (GJH) is a frequent entity in rheumatology with higher prevalence among women. It is associated with chronic widespread pain, joint dislocations, arthralgia, fibromyalgia and early osteoarthritis. Stair climbing is an important functional task and can induce symptoms in hypermobile persons. The aim of this study was to compare ground reaction forces (GRF) and muscle activity during stair climbing in women with and without GJH. A cross-sectional study of 67 women with normal mobility and 128 hypermobile women was performed. The hypermobile women were further divided into 56 symptomatic and 47 asymptomatic. GRFs were measured by force plates embedded in a six step staircase, as well as surface electromyography (EMG) of six leg muscles. Parameters derived from GRF and EMG were compared between groups using t-test and ANOVA. For GRF no significant differences were found. EMG showed lower activity for the quadriceps during ascent and lower activity for hamstrings and quadriceps during descent in hypermobile women. For symptomatic hypermobile women these differences were even more accentuated. The differences in EMG may point towards an altered movement pattern during stair climbing, aimed at avoiding high muscle activation. However, differences were small, since stair climbing seems to be not demanding.

Neuromechanical gait adaptations in women with joint hypermobility--an exploratory study.

BACKGROUND: Joint hypermobility is known to be associated with joint and muscle pain, joint instability and osteoarthritis. Previous work suggested that those individuals present an altered neuromuscular behavior during activities such as level walking. Therefore, the aim of this study was to explore the differences in ground reaction forces, temporal parameters and muscle activation patterns during gait between normomobile and hypermobile women, including symptomatic and asymptomatic hypermobile individuals. METHODS: A total of 195 women were included in this cross-sectional study, including 67 normomobile (mean 24.8 [SD 5.4] years) and 128 hypermobile (mean 25.8 [SD 5.4] years), of which 56 were further classified as symptomatic and 47 as asymptomatic. The remaining 25 subjects could not be further classified. Ground reaction forces and muscle activation from six leg muscles were measured while the subjects walked at a self-selected speed on an instrumented walkway. Temporal parameters were derived from ground reaction forces and a foot accelerometer. The normomobile and hypermobile groups were compared using independent samples t-tests, whereas the normomobile, symptomatic and asymptomatic hypermobile groups were compared using one-way ANOVAs with Tukey post-hoc tests (significance level=0.05). FINDINGS: Swing phase duration was higher among hypermobile (P=0.005) and symptomatic hypermobile (P=0.018) compared to normomobile women. The vastus medialis (P=0.049) and lateralis (P=0.030) and medial gastrocnemius (P=0.011) muscles showed higher mean activation levels during stance in the hypermobile compared to the normomobile group. INTERPRETATION: Hypermobile women might alter their gait pattern in order to stabilize their knee joint.

[Functional deficits and self-perceived performance after surgical hip dislocation]. / Funktionelle Defizite und Selbsteinschätzung der Leistungsfähigkeit nach chirurgischer Hüftluxation.

BACKGROUND: Surgical hip dislocation (SHD) is a common procedure to treat several hip problems, namely femoroacetabular impingements. After surgery patients are required to walk with reduced weight-bearing for six to eight weeks. The literature describes important changes in general health and functional state after immobilization but little is known about physical and functional recovery of these deficits. The aim of the study was to investigate the conditional deficits and changes of patients 3 and 12 months after SHD, and to compare them to healthy subjects. MATERIALS AND METHODS: A prospective cross-sectional study with three groups was performed: 29 patients 3 months after SHD (G3), 28 patients 12 months after SHD (G12) and 34 healthy persons (G0). Strength, endurance, gait, stair climbing and balance were measured and self-perceived performance and satisfaction with daily-life activities was evaluated with questionnaires. Group differences were tested with Kruskal-Wallis test and post-hoc with the Mann-Whitney U test. RESULTS: Significant differences were found for G3 compared to G0 in strength and endurance parameters, as well as for gait and self-perceived performance. G12 also showed significant differences compared to G0 and only little differences were found compared to G3. CONCLUSION: The remaining deficits in patients twelve month after SHD with regard to conditional and functional parameters indicate that full recovery for activities of daily life has not been achieved by these patients. A specific therapy program may be able to improve the patient's strength, endurance and functional performance and may possibly lead to effective protection of the joint and enhanced performance in daily life.

Isometric rate of force development, maximum voluntary contraction, and balance in women with and without joint hypermobility.

OBJECTIVE: To determine differences between hypermobile subjects and controls in terms of maximum strength, rate of force development, and balance. METHODS: We recruited 13 subjects with hypermobility and 18 controls. Rate of force development and maximal voluntary contraction (MVC) during single leg knee extension of the right knee were measured isometrically for each subject. Balance was tested twice on a force plate with 15-second single-leg stands on the right leg. Rate of force development (N/second) and MVC (N) were extracted from the force-time curve as maximal rate of force development (= limit Deltaforce/Deltatime) and the absolute maximal value, respectively. RESULTS: The hypermobile subjects showed a significantly higher value for rate of force development (15.2% higher; P = 0.038, P = 0.453, epsilon = 0.693) and rate of force development related to body weight (16.4% higher; P = 0.018, P = 0.601, epsilon = 0.834) than the controls. The groups did not differ significantly in MVC (P = 0.767, P = 0.136, epsilon = 0.065), and MVC related to body weight varied randomly between the groups (P = 0.921, P = 0.050, epsilon = 0.000). In balance testing, the mediolateral sway of the hypermobile subjects showed significantly higher values (11.6% higher; P = 0.034, P = 0.050, epsilon = 0.000) than that of controls, but there was no significant difference (4.9% difference; P = 0.953, P = 0.050, epsilon = 0.000) in anteroposterior sway between the 2 groups. CONCLUSION: Hypermobile women without acute symptoms or limitations in activities of daily life have a higher rate of force development in the knee extensors and a higher mediolateral sway than controls with normal joint mobility.