Differences In Functional Improvement Research Articles

Outcomes of the My Therapy self-management program in people admitted for rehabilitation: A stepped wedge cluster randomized clinical trial

BackgroundSelf-management programs can increase the time spent on prescribed therapeutic exercises and activities in rehabilitation inpatients, which has been associated with better functional outcomes and shorter hospital stays. ObjectivesTo determine whether implementation of a self-management program (‘My Therapy’) improves functional independence relative to routine care in people admitted for physical rehabilitation. MethodsThis stepped wedge, cluster randomized trial was conducted over 54 weeks (9 periods of 6-week duration, April 2021 - April 2022) across 9 clusters (general rehabilitation wards) within 4 hospitals (Victoria, Australia). We included all adults (≥18 years) admitted for rehabilitation to participating wards. The intervention included routine care plus ‘My Therapy’, comprising a sub-set of exercises and activities from supervised sessions which could be performed safely, without supervision or assistance. The primary outcomes were the proportion of participants achieving a minimal clinically important difference (MCID) in the Functional Independence Measure, (FIM™) and change in total FIM™ score from admission to discharge. Results2550 participants (62 % women) were recruited (control: n = 1458, intervention: n = 1092), with mean (SD) age 77 (13) years and 37 % orthopedic diagnosis. Under intervention conditions, participants reported a mean (SD) of 29 (21) minutes/day of self-directed therapy, compared to 4 (SD 14) minutes/day, under control conditions. There was no evidence of a difference between control and intervention conditions in the odds of achieving an MCID in FIM™ (adjusted odds ratio 0.93, 95 % CI 0.65 to 1.31), or in the change in FIM™ score (adjusted mean difference: -0.27 units, 95 % CI -2.67 to 2.13). ConclusionsMy Therapy was delivered safely to a large, diverse sample of participants admitted for rehabilitation, with an increase in daily rehabilitation dosage. However, given the lack of difference in functional improvement with participation in My Therapy, self-management programs may need to be supplemented with other strategies to improve function in people admitted for rehabilitation. Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12621000313831), https://www.anzctr.org.au/

Treatment of Insertional Achilles Tendinopathy Using Adjunct Electroacupuncture Therapy: A Randomized Controlled Trial.

Achilles tendinopathy is a common musculoskeletal condition associated with decreased functionality. The insertional variant (<2cm from the calcaneus) is less responsive to eccentric-exercise therapy. This study looked at the effect of electroacupuncture (EA) + eccentric exercise for treating insertional Achilles tendinopathy. Fifty-two active duty and Department of Defense beneficiaries older than 18 years of age with insertional Achilles tendinopathy were randomized to treatment with either eccentric exercise or eccentric exercise with EA. They were evaluated at 0, 2, 4, 6, and 12 weeks. The treatment group received EA treatment in the first 4 visits. The Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A; scored 0-100; higher score = increased function) was used to assess the patients and patient-reported pain (0-10, increasing pain with score) pre- and post-demonstration of the exercises during each visit. Both the treatment group (53.6% reduction; confidence interval [CI]: 2.1, 3.9; P < 0.001) and the control group (37.5% reduction; CI: 0.4, 2.9; P = 0.023) reported decreased pain between the first and last visit. The treatment group had reduced pain (mean difference [MD] = 1.0; P < 0.01) between pre- and post-eccentric-exercise performance at each visit, while the control group did not (MD = -0.3; P = 0.065). VISA-A scores did not show a difference in functional improvement between the groups (P = 0.296). EA as an adjunct to eccentric therapy significantly improves short-term pain control for insertional Achilles tendinopathy.

Operative management of midshaft clavicle fractures demonstrates better long-term outcomes: A systematic review and meta-analysis of randomised controlled trials

IntroductionMidshaft clavicular fractures are common amongst young adults. Conservative or surgical treatment for definitive fracture management has been widely debate, both with their pros and cons. Previous meta-analyses compared the clinical outcomes between conservative and surgical treatment options of midshaft clavicular fractures but failed to elucidate any difference in functional improvement. We postulate that functional improvement after fracture union plateaus and the clinical outcome after treatment varies at different time points. This meta-analysis will focus on the synthesis comparison of outcomes at early, short-term results (3 months), intermediate-term (6 to 12 months) and long-term (>24 months) clinical outcomes.MethodsA systematic search was done on databases (Pubmed, Embase, Medline, Cochrane) in June 2021. Search keywords were: midshaft clavicular fractures and clinical trials. Clinical trials fulfilling the inclusion criteria were selected for comparison and the clinical outcomes of midshaft clavicular fractures using surgical and non-surgical interventions in terms of improvement in the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley Score (CMS), time to union and risk ratio of treatment related complications were analysed in correlation with post-treatment timeframe.ResultsOf the 3094 patients of mean age 36.7 years in the 31 selected studies, surgical intervention was associated with improved DASH score (standard-mean difference SMD -0.22, 95% CI -0.36 to -0.07, p = 0.003; mean difference MD -1.72, 95% CI -2.93 to -0.51, p = 0.005), CMS (SMD 0.44, 95% CI 0.17–0.72, p = 0.001; MD 3.64, 95% CI 1.09 to 6.19, p = 0.005), time to union (non-adjusted SMD -2.83, 95% CI -4.59 to -1.07, p = 0.002; adjusted SMD -0.69, 95% CI -0.97 to -0.41, p<0.001) and risk ratio of bone-related complications including bone non-union, malunion and implant failure (0.21, 95% CI 0.1 to 0.42; p<0.001). Subgroup analysis based on time period after treatment showed that surgical intervention was far superior in terms of improved DASH score at the intermediate-term results (6–12 months later, SMD -0.16, 95% CI -0.30 to -0.02, p = 0.02; and long term results (>24 months SMD -4.24, 95% CI -7.03 to -1.45, p = 0.003) and CMS (>24 months, SMD 1.03, 95% CI 0.39 to 1.68, p = 0.002; MD 5.77, 95% CI 1.63 to 9.91, p = 0.006). Surgical outcome is independent of fixation with plates or intra-medullary nails.ConclusionSurgical intervention was associated with better clinical outcomes compared with non-surgical approach for midshaft clavicular fractures in terms of improvement in functional scores DASH, CMS, time to union and fracture related complications, although not to the minimal clinically significant difference. Benefits in the long-term functional improvements are more pronounced.

Low level Laser Therapy versus Ultrasonic therapy for the Treatment of Shoulder Impingement Syndrome A Systematic Review of randomized controlled trials

Abstract Background Shoulder impingement syndrome is a common cause of shoulder pain in primary health care settings. Many physical modalities of treatment are available in clinical practice, however there is insufficient evidence on their relative effectiveness. This review compares the effectiveness of Low Level Laser Therapy (LLLT) with ultrasonic therapy. Objectives To assess the effectiveness of LLLT vs. ultrasonic therapy in patients with subacromial impingement syndrome Search methods We searched Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE (Pubmed), Embase, Scopus. We searched trials registries on ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) Search Portal (apps.who.int/trialsearch/). We also hand-searched reference lists of all included primary studies, relevant conference proceedings and academic literature, and relevant systematic reviews (both Cochrane and non Cochrane), to identify additional studies missed from the original electronic searches (e.g., unpublished or in press citations). We did not use date or language restrictions. Selection criteria Randomized controlled trials comparing LLLT vs. US therapy in adult patients with subacromial impingement syndrome. Data collection Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected our primary outcomes information from the trials and assessed the quality of evidence for key outcomes using GRADE. Results We included 2 RCTs, contributing 67 participants to our qualitative synthesis. The overall risk of bias is high for both studies. Very low-quality evidence from 1 RCT shows slightly increased mean change in pain severity after LLLT compared to ultrasonic therapy in the short term (3 months) (MD 4.69, 95% CI -5.76 to -3.62).[13]. Very low-quality evidence from 1 RCT shows little to no difference in functional improvement after LLLT compared to ultrasonic therapy in the short term (after 3 months) (MD -0.63, 95% CI -5.53 to 4.27) [13]. No studies investigated Range of Motion in the short term. Verylow certainty evidence showed little to no difference in pain severity and function in the immediate post-treatment phase (up to 1 month). No studies addressed long term follow-up. conclusion There is insufficient evidence regarding the difference in effects between LLLT and Ultrasonic therapy for the treatment of shoulder impingement syndrome.

Prognosis prediction of the effect of botulinum toxin therapy and intensive rehabilitation on the upper arm function in post-stroke patients using hierarchical cluster analysis

Purpose We analysed the effect of botulinum neurotoxin A therapy (BoNT-A) with intensive rehabilitation on the upper limb (UL) spasticity in post-stroke patients by classifying function by UL movement and examining differences in functional improvement. Materials and methods In this non-randomized, controlled study. The patient function was classified into groups from the score of the sub-categories of the Fugl–Meyer Assessment (FMA-UE) before treatment in the Intervention group by hierarchical cluster analysis. Results A total of 139 patients in the Intervention group were classified into six groups. All groups showed a significant improvement in FMA-UE after the intervention. In the group scoring 19–31 points on the FMA-UE and with the voluntary movement of shoulder, elbow, forearm, and finger, a significant improvement was observed compared to the Control group. Further, in the group scoring 26–47 points on the FMA-UE and with the voluntary movement of shoulder, elbow, forearm, wrist, and finger, a significant improvement was observed compared to the Control group. Conclusions In this study, BoNT-A and intensive rehabilitation showed improvement in spasticity and UL function. A high therapeutic effect is expected in patients with moderate impairment levels who have voluntary movement in whole UL or in UL except for the wrist. IMPLICATIONS FOR REHABILITATION Hierarchical cluster analysis focusing on the Fugl–Meyer Assessment of the Upper Extremity sub-categories may be useful for studies aimed to improve the upper arm function. Botulinum Neurotoxin A therapy (BoNT-A) and intensive rehabilitation in post-stroke patients showed improvement in spasticity and upper arm function. The degree of the upper arm function before the intervention may affect the improvement effect of BoNT-A and intensive rehabilitation. In the motor function, the post-stroke patients with a moderate impairment level who have voluntary movement of the whole upper limb or upper limb except for the wrist are most likely to receive these therapeutic effects.

Functional recovery of patients with intracerebral haemorrhage and cerebral infarction after rehabilitation.

To investigate potential differences in functional recovery after rehabilitation between intracerebral haemorrhage and cerebral infarction, we retrospectively compared the outcomes of patients with intracerebral haemorrhage (N = 208) and cerebral infarction (N = 480) who were consecutively discharged from our convalescent rehabilitation hospital between January 2013 and December 2018. Functional improvement was estimated by functional independence effectiveness measurements (proportion of potential for improvement achieved) upon discharge. Univariate analysis showed no significant differences in functional improvement between the two groups possibly because of the demographic variations upon admission. Multiple regression analysis demonstrated that the impact and type of factors related to functional improvement (functional independence measure upon admission, age, length of hospital stay, and time to admission after onset) were similar in both groups. Nevertheless, stratified analysis revealed, compared with patients with cerebral infarction, better improvement in patients with intracerebral haemorrhage that were admitted early after onset (<20 days), which exhibited high or moderate severity upon admission (functional independence measure: 36-89), or had a long hospital stay (>129 days). The present study showed differences as well as similarities in functional recovery between two stroke subtypes and suggests that better functional improvement might be expected in patients with intracerebral haemorrhage compared with those with cerebral infarction through an earlier start of intensive rehabilitation or longer rehabilitation in the hospital even if they exhibited relatively severe impairment upon admission. The type of stroke should be taken into consideration when predicting functional recovery and planning rehabilitation management in stroke patients.

Impact of childhood maltreatment on outcomes of antidepressant medication in chronic and/or recurrent depression

BackgroundWhile childhood maltreatment (CMT) is associated with higher rates of chronicity and recurrence in depression, whether CMT results in poorer outcomes with antidepressant medication remains unclear. MethodsWe performed secondary analyses with data from the large, representative, multisite trial Combining Medications to Enhance Depression Outcomes (CO-MED). CO-MED was a randomized, single-blinded, placebo-controlled study with 665 individuals (663 assessed for CMT) with chronic and/or recurrent Major Depressive Disorder (MDD). CMT was determined by a brief self-reported questionnaire assessing the four types of CMT defined by the Centers for Disease Control and Prevention: sexual abuse, emotional abuse, physical abuse, and neglect. Repeated measures and logistic regression analyses were used. ResultsIndividuals with CMT did not have a differential improvement of depressive symptoms when compared to those without CMT (adjusted p=.203 for continuous analysis; adjusted p=.320 for remission rates). Neither type of antidepressant medication (adjusted p=.302) nor the age at which CMT occurred (adjusted p=.509) affected depressive symptom outcomes. There was no difference in functional improvement between individuals with and without CMT (adjusted p=.228). A history of CMT was associated with greater antidepressant side effects (p=.009). LimitationsThis study investigated treatment-seeking individuals with chronic and/or recurrent MDD. Intensity and duration of CMT were not assessed. ConclusionIn a sample of treatment-seeking outpatients with chronic and/or recurrent MDD, a history of CMT was not associated with differential symptomatic or functional response to pharmacological treatment. However, those with CMT reported greater antidepressant side effect burden.

Treatment of femoroacetabular impingement by arthroscopy versus anterior mini-open approach: Case-control study of a continuous series of 91 cases at a mean 4.6 years’ follow-up

IntroductionFemoroacetabular impingement is a frequent cause of hip pain, and can be managed by conservative surgery. Many studies assessed postoperative course, but none compared operative techniques within a given population. We therefore conducted a retrospective case-control study comparing the minimally invasive anterior Hueter approach versus arthroscopy, assessing difference in 1) functional gain and 2) complications and 3) analyzing the impact of labral or cartilage lesions on functional scores. HypothesisClinical results do not differ between the mini-open and arthroscopic approach. Material and methodBetween 2007 and 2018, 91 hips in 84 patients were treated for femoroacetabular impingement: 69/91 (75.8%) cam effect, 6/91 pincer effect (6.6%) and 16/91 mixed (17.6%). Fifty-five were treated by arthroscopy and 36 by the Hueter mini-open approach. There were 20 female and 71 male hips. Mean age at surgery was 32 years (range, 17–55 years). Potential predictive factors comprised Nötzli alpha angle, labral/cartilage lesion and type of surgery. ResultsMean follow-up was 4.6 years (range, 1–16 years), with no loss to follow-up. The arthroscopy and Hueter groups showed no differences in functional improvement on Oxford-12 score (gain, −6.7±5.9 versus −6.2±8.1 (p=0.73), Postel Merle d’Aubigné (PMA) score (gain, 1.3±1 versus 1.1±0.9; p=0.41), operative time (75 versus 67min; p=0.16), or alpha angle correction (−10.9±12.9 versus −9.8±7.1; p=0.22). Complications did not differ: 1/55 severe complications after arthroscopy (1 definitive femoral nerve palsy) versus 4/36 non-severe complications after Hueter (3 cases of dysesthesia in the lateral cutaneous nerve of the thigh, 1 rectus femoris enthesopathy) (p=0.15). Labral lesions (37/91) did not affect clinical outcome: gain, 1.2±1 versus 1.3±0.9 on PMA (p=0.514) and −7.3±6 versus −6±7.3 on Oxford-12 (p=0.366). Cartilage lesions (27/91) were associated with poorer outcome on PMA (gain, 1±1.1 versus 1.3±0.9; p=002) but not on Oxford-12 (gain, −6.1±7.3 versus −6.7±6.6; p=0.288). ConclusionImpingement correction by the minimally invasive anterior Hueter approach gave clinical results comparable to those of hip arthroscopy in terms of Oxford and PMA scores, alpha angle correction, operative time and complications. Cartilage lesions were associated with poorer clinical results. Level of evidenceIII; retrospective case-control study.

Epidural steroid injection versus conservative treatment for patients with lumbosacral radicular pain: A meta-analysis of randomized controlled trials.

Previous systemic reviews have examined the efficacy of individual therapeutic agents, but which type of treatment is superior to another has not been pooled or analyzed. The objective of the current study was to compare the clinical effectiveness of epidural steroid injection (ESI) versus conservative treatment for patients with lumbosacral radicular pain. A systematic search was conducted with MEDLINE, EMBASE, and CENTRAL databases with a double-extraction technique for relevant studies published between 2000 and January 10, 2019. The randomized controlled trials which directly compared the efficacy of ESI with conservative treatment in patients with lumbosacral radicular pain were included. Outcomes included visual analog scale, numeric rating scale, Oswetry disability index, or successful events. Two reviewers extracted data and evaluated the methodological quality of papers using the Cochrane Collaboration Handbook. A meta-analysis was performed using Revman 5.2 software. The heterogeneity of the meta-analysis was also assessed. Of 1071 titles initially identified, 6 randomized controlled trials (249 patients with ESI and 241 patients with conservative treatment) were identified and included in this meta-analysis. The outcome of the pooled analysis showed that ESI was beneficial for pain relief at short-term and intermediate-term follow-up when compared with conservative treatment, but this effect was not maintained at long-term follow-up. Successful event rates were significantly higher in patients who received ESI than in patients who received conservative treatment. There were no statistically significant differences in functional improvement after ESI and conservative treatment at short-term and intermediate-term follow-up. The limitations of this meta-analysis resulted from the variation in types of interventions and small sample size. According to the results of this meta-analysis, the use of ESI is more effective for alleviating lumbosacral radicular pain than conservative treatments in terms of short-term and intermediate-term. Patients also reported more successful outcomes after receiving ESI when compared to conservative treatment. However, this effect was not maintained at long-term follow-up. This meta-analysis will help guide clinicians in making decisions for the treatment of patients with lumbosacral radicular pain, including the use of ESI, particularly in the management of pain at short-term.

Anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allograft is effective for chronic acromioclavicular joint injuries at mid-term follow-up.

To evaluate the clinical and radiographic outcomes of patients undergoing anatomic coracoclavicular ligament reconstruction (ACCR) using free tendon allografts for the treatment of chronic acromioclavicular joint (ACJ) injuries with a minimum 1-year follow-up. Patients who underwent ACCR for chronic ACJ injuries between 2003 and 2017 were analyzed. Clinical outcome measures included American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM), Simple Shoulder Test (SST), and Single Assessment Numerical Evaluation (SANE) scores. Radiographic loss of reduction during follow-up was evaluated by calculating the difference (mm) in the coracoclavicular distance (CCD) of the involved side immediately postoperatively and at terminal follow-up. Forty-two patients (mean age: 42.7 ± 12.8years) were included in the study with an average follow-up of 3.8 ± 3.1years (range: 1.1-11.5years). Patients achieved significant improvement in ASES (50.2 ± 20.1 pre to 85.2 ± 16.3 post), CM (60.2 ± 18.5 pre to 88.2 ± 9.1 post), SST (6.1 ± 3.2 pre to 9.5 ± 3.7 post), and SANE (24.0 ± 25.7 pre to 89.0 ± 12.7 post) scores (P < 0.001, respectively). There were no significant differences in functional improvement when comparing type III and V injuries (n.s.). Mean increase in CCD of the involved side from immediately postoperative to final radiographic follow-up was 4.1 ± 3.9mm, with no significant correlation to clinical outcomes scores. Complications occurred in 33.3% of cases, with postoperative heterotopic ossification being most frequent (14.3%). Patients undergoing ACCR using free tendon allografts for chronic ACJ injuries achieved significant improvement in shoulder function at a mean follow-up of 3.8years. No correlation was observed between the amount of loss of reduction and clinical outcome scores. Free tendon allografts may be a reliable alternative to autografts in the treatment of chronic ACJ dislocations. IV.

Thrombolysis Guided by Perfusion Imaging up to 9 Hours after Onset of Stroke

BackgroundThe time to initiate intravenous thrombolysis for acute ischemic stroke is generally limited to within 4.5 hours after the onset of symptoms. Some trials have suggested that the treatment window may be extended in patients who are shown to have ischemic but not yet infarcted brain tissue on imaging.MethodsWe conducted a multicenter, randomized, placebo-controlled trial involving patients with ischemic stroke who had hypoperfused but salvageable regions of brain detected on automated perfusion imaging. The patients were randomly assigned to receive intravenous alteplase or placebo between 4.5 and 9.0 hours after the onset of stroke or on awakening with stroke (if within 9 hours from the midpoint of sleep). The primary outcome was a score of 0 or 1 on the modified Rankin scale, on which scores range from 0 (no symptoms) to 6 (death), at 90 days. The risk ratio for the primary outcome was adjusted for age and clinical severity at baseline.ResultsAfter 225 of the planned 310 patients had been enrolled, the trial was terminated because of a loss of equipoise after the publication of positive results from a previous trial. A total of 113 patients were randomly assigned to the alteplase group and 112 to the placebo group. The primary outcome occurred in 40 patients (35.4%) in the alteplase group and in 33 patients (29.5%) in the placebo group (adjusted risk ratio, 1.44; 95% confidence interval [CI], 1.01 to 2.06; P=0.04). Symptomatic intracerebral hemorrhage occurred in 7 patients (6.2%) in the alteplase group and in 1 patient (0.9%) in the placebo group (adjusted risk ratio, 7.22; 95% CI, 0.97 to 53.5; P=0.05). A secondary ordinal analysis of the distribution of scores on the modified Rankin scale did not show a significant between-group difference in functional improvement at 90 days.ConclusionsAmong the patients in this trial who had ischemic stroke and salvageable brain tissue, the use of alteplase between 4.5 and 9.0 hours after stroke onset or at the time the patient awoke with stroke symptoms resulted in a higher percentage of patients with no or minor neurologic deficits than the use of placebo. There were more cases of symptomatic cerebral hemorrhage in the alteplase group than in the placebo group. (Funded by the Australian National Health and Medical Research Council and others; EXTEND ClinicalTrials.gov numbers, NCT00887328 and NCT01580839.)

Distinct skeletal muscle molecular responses to pulmonary rehabilitation in chronic obstructive pulmonary disease: a cluster analysis

BackgroundPulmonary rehabilitation (PR) is a cornerstone in the management of chronic obstructive pulmonary disease (COPD), targeting skeletal muscle to improve functional performance. However, there is substantial inter‐individual variability in the effect of PR on functional performance, which cannot be fully accounted for by generic phenotypic factors. We performed an unbiased integrative analysis of the skeletal muscle molecular responses to PR in COPD patients and comprehensively characterized their baseline pulmonary and physical function, body composition, blood profile, comorbidities, and medication use.Methods Musculus vastus lateralis biopsies were obtained from 51 COPD patients (age 64 ± 1 years, sex 73% men, FEV1, 34 (26–41) %pred.) before and after 4 weeks high‐intensity supervised in‐patient PR. Muscle molecular markers were grouped by network‐constrained clustering, and their relative changes in expression values—assessed by qPCR and western blot—were reduced to process scores by principal component analysis. Patients were subsequently clustered based on these process scores. Pre‐PR and post‐PR functional performance was assessed by incremental cycle ergometry and 6 min walking test (6MWT).ResultsEight molecular processes were discerned by network‐constrained hierarchical clustering of the skeletal muscle molecular rehabilitation responses. Based on the resulting process scores, four clusters of patients were identified by hierarchical cluster analysis. Two major patient clusters differed in PR‐induced autophagy (P < 0.001), myogenesis (P = 0.014), glucocorticoid signalling (P < 0.001), and oxidative metabolism regulation (P < 0.001), with Cluster 1 (C1; n = 29) overall displaying a more pronounced change in marker expression than Cluster 2 (C2; n = 16). General baseline characteristics did not differ between clusters. Following PR, both 6 min walking distance (+26.5 ± 8.3 m, P = 0.003) and peak load on the cycle ergometer test (+9.7 ± 1.9 W, P < 0.001) were improved. However, the functional improvement was more pronounced in C1, as a higher percentage of patients exceeded the minimal clinically important difference in peak workload (61 vs. 21%, P = 0.022) and both peak workload and 6 min walking test (52 vs. 8%, P = 0.008) upon PR.ConclusionsWe identified patient groups with distinct skeletal muscle molecular responses to rehabilitation, associated with differences in functional improvements upon PR.

Comparing leukocyte-rich platelet-rich plasma injection with surgical intervention for the management of refractory tennis elbow. A prospective randomised trial.

Patients with ongoing symptoms after non-operative treatment of lateral epicondylosis are usually treated with surgical release. Platelet-rich plasma injection is an alternative treatment option. This study aims to determine whether there is a difference in outcome from platelet-rich plasma injection or surgical release for refractory tennis elbow. Eighty-one patients with a diagnosis of tennis elbow for a minimum of six months, treated with previous steroid injection and a minimum visual analogue scale pain score of 50/100 were randomised to open surgery release (41 patients) or leucocyte rich platelet-rich plasma (L-PRP) (40 patients). Patients completed the Patient-Rated Tennis Elbow Evaluation and Disability of the Arm Shoulder and Hand at baseline, 1.5, 3, 6 and 12 months post-intervention. The primary endpoint was change in Patient-Rated Tennis Elbow Evaluation pain score at 12 months. Fifty-two patients completed final follow-up. Functional and pain scores improved in both groups. No differences in functional improvements were found but greater improvements in Patient-Rated Tennis Elbow Evaluation pain scores were seen after surgery. Thirteen patients crossed over from platelet-rich plasma to surgery within 12 months, and one surgical patient underwent a platelet-rich plasma injection. L-PRP and surgery produce equivalent functional outcome but surgery may result in lower pain scores at 12 months. Seventy per cent of patients treated with platelet-rich plasma avoided surgical intervention.

No difference in the functional improvements between unilateral and bilateral total knee replacements

BackgroundDifferences between staged bilateral total knee replacement (TKR) and simultaneous bilateral TKR have been investigated, but few studies have investigated differences in the functional improvements resulting from these methods. Therefore, this study investigates the different functional improvements between staged bilateral total knee TKR and simultaneous bilateral TKR.MethodsAmong 144 potential bilateral TKR patients who were included in this study, 93 (64.6%) patients selected unilateral TKR and 51 (35.4%) selected bilateral TKR. Functional improvements were assessed using the Western Ontario and McMaster University osteoarthritis index (WOMAC) and the Medical Outcomes Trust Short Form-36 (SF-36), and patients were interviewed pre-operatively and after 6 months. A generalized equation was used to test for differences in functional improvements.ResultsAfter TKR, pain, stiffness, function and total WOMAC scores were significantly reduced in both groups, with mean changes from − 26.6 to − 41.4 and from − 27.5 to − 42.2.The mean health change of SF-36 scores, physical component and mental component scores changed to 45.2 ± 18.2, 74.0 ± 15.4 and 77.0 ± 9.6, respectively, in Group 1 and 47.1 ± 17.1, 74.0 ± 15.2 and 75.5 ± 12.1, respectively, in Group 2.Unilateral and simultaneous bilateral TKR produce similar functional improvements, although current work status may be a novel impact factor.ConclusionNo differences in functional improvements were identified between patients who selected unilateral versus bilateral TKR, indicating no recommendation for one procedure over the other.

Effect of Hand Dominance on Functional Status and Recovery of Hand in Stroke Patients

Stroke is characterized by hemiplegia, including motor deficits and various neurological manifestations mainly in contralateral half of the body lasting more than 24 hours with a presumed vascular cause. The goal of stroke rehabilitation is to make people independent and this is possible with appropriate functioning of the affected hand and upper extremity. Stroke patients have to depend on the nondominant hand when the effected hand is the dominant side. However this disadvantage might end up in better results with more effort for recovery of the dominant hand. In this study, we aimed to understand the effect of hand dominance on both functional loss and regain after stroke. 18 patients with right or left hemiplegia participated in the study. Patients were grouped as dominant side and nondominant side hemiplegic (groups D and ND). Patients were evaluated in the 1st week, 1st month and 3rd month. Brunnstrom stages, Motricity index, MAS and FIM, NHPT and hand grip strength were recorded for every patient in every visit. None of the parameters showed significant difference between two groups. Only NHPT used to assess fine manual dexterity revealed a significant difference in the final analysis. Correlation analysis displayed a positive correlation between hand grip strength with FIM and pinch grip strength with NHPT. We concluded that there was no significant difference in functional improvement between dominant and non-dominant side hemiplegic groups during the first three months after stroke. However longer follow ups and larger patient groups are needed to clarify the effect of hand dominance on long term functional status.

Comparison of Results of 4 Methods of Surgery in Grade 1 Lumbosacral Spondylolisthesis

Introduction: There are 3 ways for the treatment of patients for spondylolisthesis grade 1 in lumbosacral region associating with lumbar disk herniation or lumbar stenosis: pedicular screw fixation method alone; pedicular screw with insertion of trans lumbar interbody fusion (TLIF), or with posterior lumbar interbody fusion (PLIF). Interestingly, all methods have associated with satisfactory results. However, which method is superior for the treatment of such patients still has remained controversial. Materials and Methods: Patients with clinical signs and symptoms of disk herniation or lumbar canal stenosis and also spondylolysthesis grade 1 were selected, who had randomly undergone pedicle screw and posterior fusion surgery, pedicle screw and TLIF surgery, pedicle screw and PLIF surgery, or without instrumentation and fusion, in neurosurgery section in Mashhad, from 2009 to 2011. Afterwards, clinical symptoms, radiologic study results, amount of fusion in terms of Brantigan and Stefee indices, and functional improvement by Oswestry Disability Index were recorded after 6 and 12 months from surgery, respectively. Results: Of 120 patients who were analyzed in 4 treatment groups, age and sex distribution was matched. Also, L4-L5 involvement was more common in 3 groups with a normal distribution. Statistically, Oswestry Disability Index had a significant reduction after operation, and no significant differences were observed among the 3 study groups. These groups showed no significant variation in degree of fusion and Brantigan and Stefee index, but in the group which had been undergone surgery without instrumentation and fusion, the difference was significant. Conclusions: After a 12-month follow-up, the 3 procedures of TLIF, PLIF, and posterior fusion pedicle screw did not show any difference in functional improvement of the patients, degree of fusion, and complications significantly, whereas all of them had a significant preference rather than the fourth group, in which no instrumentation and fusion was applied.

WITHDRAWN: Exercise therapy for patellofemoral pain syndrome.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a common problem among adolescents and young adults, characterised by retropatellar pain (behind the kneecap) or peripatellar pain (around the kneecap) when ascending or descending stairs, squatting or sitting with flexed knees. Etiology, structures causing the pain and treatment methods are all debated in literature, but consensus has not been reached so far. Exercise therapy to strengthen the quadriceps is often prescribed, though its efficacy is still debated. OBJECTIVES: This review aims to summarise the evidence of effectiveness of exercise therapy in reducing anterior knee pain and improving knee function in patients with PFPS. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group and Cochrane Rehabilitation and Related Therapies Field specialised registers, the Cochrane Controlled Trials Register, PEDro - The Physiotherapy Evidence Database, MEDLINE, EMBASE, CINAHL, up till December 2001 for controlled trials (randomised or not) comparing exercise therapy with control groups, or comparing different types of exercise therapy. SELECTION CRITERIA: Only trials focusing on exercise therapy in patients with PFPS were considered. Trials in patients with other diagnoses such as tendinitis, Osgood Schlatter syndrome, bursitis, traumatic injuries, osteoarthritis, plica syndrome, Sinding-Larssen-Johansson syndrome and patellar luxations were excluded. DATA COLLECTION AND ANALYSIS: From 750 publications 12 trials were selected. All included trials studied quadriceps strengthening exercises. Outcome assessments for knee pain and knee function in daily life were used in a best evidence synthesis to summarise evidence for effectiveness. MAIN RESULTS: One high and two low quality studies used a control group not receiving exercise therapy. Significantly greater pain reduction in the exercise groups was found in one high and one low quality study, though at different time points. Only one low quality study reported significantly greater functional improvement with exercise. Five studies compared exercise therapies that could be designated closed kinetic chain exercise (foot in contact with a surface) versus open kinetic chain exercise (foot not in contact with a surface). Two of these studies were of high quality, but no significant differences in improvement of function or reduction of pain were apparent between the types of exercise in any of the studies. The remaining four studies, all of which were of low quality, focused on other treatment comparisons. AUTHORS' CONCLUSIONS: The evidence that exercise therapy is more effective in treating PFPS than no exercise was limited with respect to pain reduction, and conflicting with respect to functional improvement. There is strong evidence that open and closed kinetic chain exercise are equally effective. Further research to substantiate the efficacy of exercise treatment compared to a non-exercising control group is needed, and thorough consideration should be given to methodological aspects of study design and reporting.

Electrical stimulation for chronic non-specific low back pain in a working-age population: a 12-week double blinded randomized controlled trial

BackgroundNon-invasive electrotherapy is commonly used for treatment of chronic low back pain. Evidence for efficacy of most electrotherapy modalities is weak or lacking. This study aims to execute a high-quality, double-blinded randomized controlled clinical trial comparing 1) H-Wave® Device stimulation plus usual care with 2) transcutaneous electrical nerve stimulation (TENS) plus usual care, and 3) Sham electrotherapy plus usual care to determine comparative efficacy for treatment of chronic non-specific low back pain patients.Methods/DesignPatients- Chronic non-specific low back pain patients between ages of 18–65 years, with pain of at least 3 months duration and minimal current 5/10 VAS pain. Patients will have no significant signs or symptoms of lumbosacral nerve impingement, malignancy, spinal stenosis, or mood disorders.Study design- Double blind RCT with 3 arms and 38 subjects per arm. Randomization by permuted blocks of random length, stratified by Workers Compensation claim (yes vs. no), and use of opioids. The null hypothesis of this study is that there are no statistically significant differences in functional improvement between treatment types during and at the end of a 12-week week treatment period.Data collection- Subjective data will be collected using Filemaker Pro™ database management collection tools. Objective data will be obtained through functional assessments. Data will be collected at enrollment and at 1, 4, 8, and 12 weeks for each participant by a blinded assessor.Interventions- H-Wave® device stimulation (Intervention A) plus usual care, transcutaneous electrical nerve stimulation (TENS) (Intervention B) plus usual care, and sham electrotherapy plus usual care (control). Each treatment arm will have identical numbers of visits (4) and researcher contact time (approximately 15 hours).Outcomes- Primary outcome measure: Oswestry Disability Index. Secondary measures include: Rowland Morris Instrument, VAS pain score, functional evaluation including strength when pushing and pulling, pain free range of motion in flexion and extension. Outcome measures assessed at baseline, 1, 4, 8, and 12 weeks. Treatment failure will be defined if patient terminates assigned treatment arm for non-efficacy or undergoes invasive procedure or other excluded cointerventions. Data will be analyzed using intention-to-treat analysis and adjusted for covariates related to LBP (e.g. age) as needed.DiscussionStudy strengths include complex randomization, treatment group allocation concealment, double blinding, controlling for co-interventions, rigorous inclusion criteria, assessment of compliance, plans for limiting dropout, identical assessment methods and timing for each treatment arm, and planned intention-to-treat analyses.

Clinical Effects of Scalp Electrical Acupuncture in Stroke: A Sham-Controlled Randomized Clinical Trial

The majority of individuals who survive a stroke are disabled because of persisting neurological impairments. The objective of this study was to evaluate the efficacy of subcutaneous electrical stimulation of the scalp in spontaneous functional recovery of patients with chronic ischemic stroke, by evaluating clinical, neurological, and functional findings. Sixty-two (62) subjects who were at least 18 months postdiagnosis of ischemic stroke were randomized to receive 10 sessions of placebo or active low-frequency electrical stimulation (2/100 Hz) using subcutaneous acupuncture needles over the scalp. Functional and neurological evaluations were indexed by the Barthel, Rankin, and National Institutes of Health Stroke Scale (NIHSS). Results show that there was a significant difference in functional improvement between the sham and active group as indexed by NIHSS scale. The active group had a larger functional improvement after 10 sessions of scalp electrical acupuncture. The other two functional scales (Rankin and Barthel) failed to show significant differences between the two treatment groups. These results support further testing of scalp electrical acupuncture for the treatment of stroke as well further mechanistic studies to understand mechanisms associated with the observed improvement. Further studies need to consider longer follow-up assessments to investigate potential functional changes associated with electrical acupuncture.

Shoulder instability surgery in Norway

Background and purpose In January 2008, we established the Norwegian Register for Shoulder Instability Surgery. We report on the establishment, the baseline data, and the results at 1-year follow-up.Methods Primary and revision shoulder stabilization is reported by the surgeon on a 1-page paper form containing the patient's history of shoulder injury, clinical findings, and perioperative findings. The WOSI questionnaire for self-assessment of shoulder function is completed at baseline and at follow-up after 1, 2, and 5 years. To evaluate the completeness of registration, we compared our data with those in the Norwegian Patient Registry (NPR).Results The NPR reported 39 hospitals performing shoulder stabilizations. 20 of these started to report to our register during 2009, and 464 procedures (404 primary, 59 revisions) were included up to December 31, 2009, which represented 54% of the procedures reported to NPR. Of the 404 primary procedures, 83% were operations due to anterior instability, 10% were operations due to posterior instability, and 7% were operations due to multidirectional instability. Arthroscopic soft tissue techniques were used in 88% of the patients treated for primary anterior instability and open coracoid transfer was used in 10% of such patients. At 1-year follow-up of 213 patients, we found a statistically significantly improved WOSI score in all types of instability. 10% of the patients treated with arthroscopic anterior labral repair and 16% treated with arthroscopic posterior labral repair reported recurrent instability. No statistically significant difference in functional improvement or rate of recurrence was found between these groups.Interpretation The functional results are in accordance with those in previous studies. However, the incidence of recurrent instability 1 year after arthroscopic labral repair is higher than expected.