Greater Functional Improvement Research Articles

Role of Total Ankle Arthroplasty in Stiff Ankles.

The decision tree for the operative treatment of end-stage ankle arthritis involves either ankle arthrodesis (AA) or total ankle arthroplasty (TAA). Although both have documented success providing diminished pain, improved patient-centered outcomes, and improved objective measures of function, arthroplasty is unique in its ability to preserve motion at the tibiotalar joint. Arthroplasty procedures are normally thought of as a motion-sparing surgery rather than a motion-producing procedure, which may limit its success in patients with stiff ankles. Our hypothesis was that there would be improvements in parameters of gait even in patients with a low degree of preoperative total sagittal range of motion. A retrospective review was conducted on patients who underwent total ankle arthroplasty with greater than 1-year follow-up. Seventy-six patients were available who underwent isolated TAA for end-stage ankle arthritis with greater than 1-year follow-up. Patient demographics and preoperative and postoperative gait analyses were evaluated. Using a linear regression model, the effect sizes for the variables of age, gender, BMI, preoperative diagnosis, and preoperative total sagittal range of motion were calculated. Multivariate analysis was used to determine the influence each individual variable had on the many parameters of preoperative gait, postoperative gait, and change in gait after surgery. A post hoc analysis was conducted in which patients were divided into 4 quartiles according to preoperative range of motion. A 1-way analysis of variance (ANOVA) was used to compare improvement in parameters of gait for the 4 subgroups. Although a greater degree of preoperative sagittal range of motion was predictive of greater postoperative sagittal range of motion, patients with limited preoperative range of motion experienced a greater overall improvement in range of motion, and clinically meaningful absolute improvements in range of motion, and other parameters of gait. The post hoc analysis demonstrated that patients in the lowest quartile of preoperative motion had both statistically and clinically significant greater improvements across numerous parameters of gait, although the absolute values were lower than in the patients with higher preoperative ROM. Age, gender, BMI, and preoperative diagnosis did not correlate with changes in parameters of gait after total ankle arthroplasty. Preoperative range of motion was predictive of overall postoperative gait function. On one hand, a low preoperative range of motion resulted in a lower absolute postoperative function. On the other hand, patients with stiff ankles preoperatively had a statistically and clinically greater improvement in function as measured by multiple parameters of gait. This suggests that total ankle arthroplasty can offer clinically meaningful improvement in gait function and should be considered for patients with end-stage tibiotalar arthritis even in the setting of limited sagittal range of motion. Level IV, retrospective case series.

Obese (Body Mass Index >30) Patients Have Greater Functional Improvement and Reach Equivalent Outcomes at 12 Months Following Decompression Surgery for Symptomatic Lumbar Stenosis.

To evaluate effect of obesity on 12-month functional outcomes after surgery for lumbar stenosis in adult patients. Data were collected on patients treated with lumbar laminectomy for symptomatic lumbar spinal stenosis as part of an observational registry and analyzed using a retrospective cohort study design. Patients with body mass index (BMI) >30 were compared with patients with BMI <30 with respect to baseline, 3-month, and 12-month functional status, adjusted for potential confounders. There were 101 patients. At baseline, patients with BMI >30 had significantly more back pain (P < 0.001), more leg pain (P < 0.001), lower EuroQol 5 dimensions questionnaire (EQ-5D) scores (P < 0.001), and higher Oswestry Disability Index (ODI) scores (P < 0.001). Both low- and high-BMI groups had significant improvement in back pain, leg pain, EQ-5D scores, and ODI scores after decompression (all P < 0.001). At 3 months postoperatively, high-BMI patients continued to report greater leg pain (P= 0.063) and higher ODI score (P= 0.064) relative to low-BMI patients. By 12 months, there was no difference between low- and high-BMI patients in back pain (P= 0.929), leg pain (P= 0.638), EQ-5D score (P= 0.733), or ODI score (P= 0.214). The difference between low- and high-BMI patients trended toward significance for leg pain and ODI score at 3 months, but this difference disappeared by 12 months. This suggests that obese patients with symptomatic lumbar spinal stenosis may require longer to recover after decompression but can expect to reach equivalent outcomes of similarly treated patients with BMI<30.

Does manual therapy improve pain and function in patients with plantar fasciitis? A systematic review

Objective: To assess if manual therapy (MT) in the treatment of plantar fasciitis (PF) patients improves pain and function more effectively than other interventions.Methods: A systematic review of all randomized control trials (RCTs) investigating the effects of MT in the treatment of human patients with PF, plantar fasciosis, and heel pain published in English on PubMed, CINAHL, Cochrane, and Web of Science databases was conducted. Research quality was appraised utilizing the PEDro scale. Cohen’s d effect sizes (ES) and associated 95% confidence intervals (CI) were calculated between treatment groups.Results: Seven RCTs were selected that employed MT as a primary independent variable and pain and function as dependent variables. Inclusion of MT in treatment yielded greater improvement in function (6 of 7 studies, CI that did not cross zero in 14 of 25 variables, ES = 0.5–21.5) and algometry (3 of 3 studies, CI that did not cross zero in 9 of 10 variables, ES = 0.7–3.0) from 4 weeks to 6 months when compared to interventions such as stretching, strengthening, or modalities. Though pain improved with the inclusion of MT, ES calculations favored MT in only 2 of 6 studies (3 of 13 variables) and was otherwise equivalent in effectiveness to comparison interventions.Discussion: MT is clearly associated with improved function and may be associated with pain reduction in PF patients. It is recommended that clinicians consider use of both joint and soft tissue mobilization techniques in conjunction with stretching and strengthening when treating patients with PF.Level of Evidence: Treatment, level 1a.

Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial

ObjectivesTo investigate the efficacy of shoe orthotics with and without chiropractic treatment for chronic low back pain compared with no treatment. DesignRandomized controlled trial. SettingIntegrative medicine teaching clinic at a university. ParticipantsAdult subjects (N=225) with symptomatic low back pain of ≥3 months were recruited from a volunteer sample. InterventionsSubjects were randomized into 1 of 3 treatment groups (shoe orthotic, plus, and waitlist groups). The shoe orthotic group received custom-made shoe orthotics. The plus group received custom-made orthotics plus chiropractic manipulation, hot or cold packs, and manual soft tissue massage. The waitlist group received no care. Main Outcome MeasuresThe primary outcome measures were change in perceived back pain (numerical pain rating scale) and functional health status (Oswestry Disability Index) after 6 weeks of study participation. Outcomes were also assessed after 12 weeks and then after an additional 3, 6, and 12 months. ResultsAfter 6 weeks, all 3 groups demonstrated significant within-group improvement in average back pain, but only the shoe orthotic and plus groups had significant within-group improvement in function. When compared with the waitlist group, the shoe orthotic group demonstrated significantly greater improvements in pain (P<.0001) and function (P=.0068). The addition of chiropractic to orthotics treatment demonstrated significantly greater improvements in function (P=.0278) when compared with orthotics alone, but no significant difference in pain (P=.3431). Group differences at 12 weeks and later were not significant. ConclusionsSix weeks of prescription shoe orthotics significantly improved back pain and dysfunction compared with no treatment. The addition of chiropractic care led to higher improvements in function.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery.

Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93). Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

Predictors of Patient-Reported Outcomes of Total Joint Arthroplasty in a Developing Country

BackgroundIn response to the growing burden of joint disease, developing countries are starting to create their own total joint arthroplasty (TJA) programs. To date, there has been limited research on predictors of TJA outcomes in a developing country. This investigation uses patient-reported outcome measures collected by a medical mission to assess predictors of TJA outcomes in the Dominican Republic. MethodsBaseline and postoperative information from 156 of the mission's recipients of hip and knee TJA was used. Demographics were abstracted from clinical notes, and self-reported pain and functional status were assessed using Western Ontario and McMaster University Osteoarthritis Index and Short-Form 36 measures. Bivariate analysis identified variables to include in multivariable regression models of factors associated with function and pain outcomes and improvement in these domains 1 or 2 years postoperatively. ResultsThe cohort had a mean age of 61.3 years, 82% were female, 79% had total knee arthroplasty, and 42% of the procedures were bilateral. In multivariate analyses, at P < .05, male sex, better preoperative function, and use of bilateral procedure were associated with better functional outcome. Male sex and worse preoperative pain were associated with better pain outcome. Worse preoperative pain and function, as well as bilateral surgery were associated with greater improvement in function. Additionally, a greater number of bothersome joints was associated with greater pain reduction. ConclusionOur findings of better follow-up pain scores among patients with worse pain preoperatively and better functional improvement among those undergoing bilateral replacements contrast with study results from developed countries. The explanations for these observations merit further study.

The relationship of cognitive improvement after cognitive remediation with social functioning in patients with schizophrenia and severe cognitive deficits

BackgroundThis study aims to examine the effects of change in neurocognition on functional outcomes and to examine predictors of change in social functions following a 12-week course of cognitive remediation in patients with schizophrenia and schizoaffective disorder with severe cognitive impairments. MethodLevel of social functioning was assessed using a performance based measure of functional capacity (PSP) in patients prior to and after the completion of 12-week cognitive remediation treatment (CRT). Participants completed a neuropsychological battery (MCCB-MATRICS) and clinical measures at both time points. Results63 subjects with a mean age of 41.4 (SD=12.2) and with 12.2years of education (SD=2.4) were enrolled. There were significant improvements in overall PSP score from baseline to endpoint (p=0.021) as well as in PSP domain A (socially useful activities) (p≤0.001), domain B (personal and social relationships) (p=0.009), and domain D (disturbing and aggressive behaviors) (p=0.003). There was a significant improvement in the composite MCCB score (p=0.020) and the Working Memory (p<0.046). Stepwise logistic regression yielded a significant association for baseline Visual Learning (Wald=6.537, p=0.011, OR=1.195), Speed of Processing (Wald=4.112, p=0.043, OR=0.850) and level of PANSS positive symptoms (Wald=4.087, p=0.043, OR=0.739) with PSP overall improvement. ConclusionsFaster speed of processing, better visual and verbal learning and less prominent positive symptoms were associated with greater functional improvement after a systematic cognitive intervention within a rehabilitative setting.

Evaluation of Speech Intelligibility of a Cleft Palate Patient with Speech Prosthesis before and after Palatographical Analysis and Prosthesis Modification

The aim of the study was to evaluate the alterations in speech intelligibility in a cleft palate patient, before and after extending and modifying the palatal contour of the existing prosthesis using a correctable wax recording. An eight-year-old girl studying in second grade with a velopharyngeal defect using an obturator reported to the outpatient clinic complaining of lack in clarity of speech. The existing prosthesis was lacking a speech bulb hence it was decided to add the speech bulb to the existing prosthesis and evaluate the speech. Even after the use of speech bulb it was observed that she was unable to pronounce the vowels and words like shoe, vision, cheer, etc. clearly. Hence, a palatography was done using a correctable wax technique and the existing prosthesis was altered accordingly. Great improvement in speech, mastication, and velopharyngeal function was achieved after the palatography alteration of the existing prosthesis.

Osteoarthritis patients with pain improvement are highly likely to also have improved quality of life and functioning. A post hoc analysis of a clinical trial

BackgroundThis analysis evaluated whether osteoarthritis patients achieving the greatest pain control and lowest pain states also have the greatest improvement in functioning and quality of life. MethodsPatients (n=419) who failed prior therapies and who were switched to etoricoxib 60mg were categorized as pain responders or non-responders at 4 weeks based on responder definitions established by the Initiative on Methods, Measurement, and Pain (IMMPACT) criteria, including changes from baseline of ≥15%, ≥30%, ≥50%, ≥70% and a final pain status of ≤3/10 (no worse than mild pain). Pain was assessed at baseline and 4 weeks using 4 questions from the Brief Pain Inventory (BPI) (worst pain, least pain, average pain, and pain right now), and also using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain subscale. We examined the relationship between pain responses with changes from baseline in two functional measures (the BPI Pain Interference questions and the WOMAC Function Subscale) as well as changes from baseline in quality of life (assessed on the SF-36 Physical and Mental Component Summaries). We also sought to understand whether these relationships were influenced by the choice of the pain instrument used to assess response. We contrast the mean difference in improvements in the functional and quality of life instruments based on pain responder status (responder versus non-responder) and the associated 95% confidence limits around this difference. ResultsPatients with better pain responses were much more likely to have improved functional responses and improved quality of life, with higher mean changes in these outcomes versus pain non-responders, regardless of the choice of IMMPACT pain response definition (e.g., using any of 15%, 30%, 50%, 70% change from baseline) or the final pain state of ≤3/10. There was an evident gradient, where higher levels of pain response were associated with greater mean improvements in function and quality of life. The finding that greater pain responses led to greater functional improvements and quality of life gains was not dependent on the manner in which pain was evaluated. Five different pain instruments (e.g., the 4 questions on pain from the BPI pain questionnaire and the WOMAC pain subscale) consistently demonstrated that pain responders had statistically significantly greater improvements in function and quality of life compared to pain non-responders. This suggests these results are likely to be generalizable to any validated pain measure for osteoarthritis. ConclusionsPain is an efficient outcome measure for predicting broader patient response in osteoarthritis. Patients who do not achieve timely, acceptable pain states over 4 weeks were less likely to experience functional or quality of life improvements. ImplicationsGood pain improvements in osteoarthritis with a valid pain instrument are a proxy for good improvements in both function and quality of life. Therefore proper osteoarthritis pain assessment can lead to efficient evaluations in the clinic.

Relationship and Classification of Plantar Heel Spurs in Patients With Plantar Fasciitis.

This study classified plantar heel spurs and their relationship to plantar fasciitis. Patients included those with plantar fasciitis who were treated from 2012 through 2013. Plantar heel spur shape and size were assessed radiographically and correlated to function and pain before and after treatment. Function and pain were scored with the Foot and Ankle Ability Measures and a visual analog scale, respectively. This study included 109 patients with plantar fasciitis. The plantar heel spur shape was classified as 0/absent in 26 patients, 1/horizontal in 66 patients, 2/vertical in 4 patients, and 3/hooked in 13 patients. The plantar heel spur size was less than 5 mm in 75 patients, 5-10 mm in 28 patients, and greater than 10 mm in 6 patients. Initially, patients with any shape or size to their spur had no difference in function and pain. With treatment, patients with horizontal and hooked spurs had the greatest improvement in function and pain (P < .05). With treatment, patients with larger spurs had the greatest improvement in function and pain (P < .05). Plantar heel spurs can be classified by shape and size in patients with plantar fasciitis. Before treatment, neither the spur shape nor size significantly correlated with symptoms. After treatment, patients with larger horizontal or hooked spurs had the greatest improvement in function and pain. These findings may be important when educating patients about the role of heel spurs with plantar fasciitis and the effect of nonsurgical treatment with certain spurs. Level III, comparative series.

Pain relief and functional improvement in patients with neuropathic pain associated with spinal cord injury: an exploratory analysis of pregabalin clinical trials.

BackgroundCharacterizing relationships between pain relief and function can inform patient management decisions. This analysis explored graphically the relationship between pain relief and functional improvement in patients with neuropathic pain associated with spinal cord injury in two clinical trials of pregabalin.MethodsThis was a post hoc analysis of two randomized, double-blind, clinical trials in patients who were treated with pregabalin (n=181) or placebo (n=172) for neuropathic pain associated with spinal cord injury. The bivariate relationship between percent pain relief and absolute change in the functional outcomes with placebo and pregabalin was evaluated graphically using scatter plots, and loess curves illustrated the extent of the relationship between pain and function. Linear trend analysis evaluated the statistical significance of these relationships using Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT)-based thresholds of pain reduction (<15%, 15% <30%, 30% to <50%, and ≥50%). Outcome measures included modified Brief Pain Inventory pain interference with function in one of the studies and the Medical Outcomes Study Sleep Scale (an 11-point Numeric Rating Scale) and the Hospital Anxiety and Depression Scale (HADS) for the pooled studies.ResultsData ellipses showed a shift with pregabalin relative to placebo toward greater improvement with increasing pain relief for all outcome measures except HADS. Loess curves suggested a relationship between increased pain relief and improved function except for HADS, with the clearest relationship observed for sleep. Linear trend analysis showed significant relationships between pain and Medical Outcomes Study Sleep Scale (P<0.0001) and between pain and function on the modified Brief Pain Inventory Interference Index and most individual items (P<0.05).ConclusionGreater functional improvements were generally achieved at higher levels of clinically significant pain reduction. Pregabalin resulted in shifts from placebo toward greater functional improvement with greater pain relief.

Feasibility and Efficacy of Function-Focused Care for Orthopedic Trauma Patients.

To overcome challenges associated with optimizing function and physical activity among hospitalized older adults, we developed function-focused care for acute care (FFC-AC). The purpose of this study was to test the feasibility and preliminary effectiveness of this intervention. We hypothesized that hospitalized trauma patients exposed to FFC-AC would (1) maintain or improve function, spend more time in physical activity, and have fewer adverse events between admission and discharge; and (2) maintain or improve function, have less fear of falling, fewer depressive symptoms, less pain, be more physically resilient, and be less likely to experience adverse events at 1 month postdischarge compared with those exposed to FFC-education only (EO). FFC-AC was implemented by a research function-focused care nurse who worked on the participating units for 20 hr a week for 16 months to implement the three components of FFC-AC. The sample included 89 older orthopedic trauma patients the majority of whom were female (N = 59, 66%), white (N = 82, 92%), and not married (N = 53, 59%). At discharge and/or 30 days postdischarge, participants in the treatment site showed greater improvement in function, less fear of falling, and better physical resilience when compared with those in the FFC-EO site. Future research is needed to continue to work on engaging staff in function-focused care approaches and optimizing the hospital environment and policies to support nurses in this type of care approach.

Physical Therapist-Delivered Pain Coping Skills Training and Exercise for Knee Osteoarthritis: Randomized Controlled Trial.

To investigate whether a 12-week physical therapist-delivered combined pain coping skills training (PCST) and exercise (PCST/exercise) is more efficacious and cost effective than either treatment alone for knee osteoarthritis (OA). This was an assessor-blinded, 3-arm randomized controlled trial in 222 people (73 PCST/exercise, 75 exercise, and 74 PCST) ages ≥50 years with knee OA. All participants received 10 treatments over 12 weeks plus a home program. PCST covered pain education and training in cognitive and behavioral pain coping skills, exercise comprised strengthening exercises, and PCST/exercise integrated both. Primary outcomes were self-reported average knee pain (visual analog scale, range 0-100 mm) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index, range 0-68) at week 12. Secondary outcomes included other pain measures, global change, physical performance, psychological health, physical activity, quality of life, and cost effectiveness. Analyses were by intent-to-treat methodology with multiple imputation for missing data. A total of 201 participants (91%), 181 participants (82%), and 186 participants (84%) completed week 12, 32, and 52 measurements, respectively. At week 12, there were no significant between-group differences for reductions in pain comparing PCST/exercise versus exercise (mean difference 5.8 mm [95% confidence interval (95% CI) -1.4, 13.0]) and PCST/exercise versus PCST (6.7 mm [95% CI -0.6, 14.1]). Significantly greater improvements in function were found for PCST/exercise versus exercise (3.7 units [95% CI 0.4, 7.0]) and PCST/exercise versus PCST (7.9 units [95% CI 4.7, 11.2]). These differences persisted at weeks 32 (both) and 52 (PCST). Benefits favoring PCST/exercise were seen on several secondary outcomes. Cost effectiveness of PCST/exercise was not demonstrated. This model of care could improve access to psychological treatment and augment patient outcomes from exercise in knee OA, although it did not appear to be cost effective.

Drug-induced toxicity and patient reported outcomes in rheumatoid arthritis patients following intensive treated-to-target strategy: does ceasing therapy due to toxicity worsen outcomes in long term?

While the introduction of the treat-to-target (T2T) strategy has been an important advance in the management of rheumatoid arthritis (RA), the potential for increased toxicity due to use of concurrent drugs could adversely affect patient reported outcomes (PROs). The objective was to determine whether the cessation of therapy due to toxicity affects long-term improvement in PROs in patients treated according to T2T strategy. A total of 149 patients from an inception cohort of early RA were included. The occurrence and severity of toxicity were monitored at each visit over 3 years. PROs studied were function (measured using health assessment questionnaire); pain, fatigue and patient global assessment (PtGA) all assessed using a 100 mm visual analogue scale; helplessness and health-related quality of life (HRQoL). For each PRO, effect of drug withdrawal was measured by comparing mean change in PROs among patients with no/temporary vs. permanent withdrawal. In addition, effects of frequency of drug withdrawals, weeks to withdrawal and number of drugs withdrawn were analysed using linear regression. After 3 years, 56 (37.4%) patients ceased at least one drug permanently due to toxicity. Patients with no/temporary withdrawal (n = 93) achieved significantly greater improvement in function (mean change = -0.54 vs. -0.31, p = 0.033), pain (mean change = -39.82 vs. -5.02, p = 0.018), fatigue (mean change = -29.14 vs. -14.76, p = 0.015) and PtGA (mean change = -29.64 vs. -17.00, p = 0.018) compared with their counterparts. Higher frequency of withdrawals was associated with lesser improvements in function, pain, fatigue and PtGA, while the number of drugs withdrawn and the weeks to withdrawal had lesser effects. However, the cessation of the drugs due to their toxicity did not have a significant association with HRQoL and helplessness. Improvements in function, pain, fatigue and PtGA at 3 years were diminished for patients who ceased drugs due to toxicity while broader measures of HRQoL were not affected.

Baseline disability and poor functioning in bipolar disorder predict worse outcomes: results from the Bipolar CHOICE study.

To examine the effects of treatment on functioning impairments and quality of life and assess baseline functioning and employment status as predictors of treatment response in symptomatic individuals from the Bipolar Clinical Health Outcomes Initiative in Comparative Effectiveness (Bipolar CHOICE) study. Bipolar CHOICE was an 11-site, 6-month randomized effectiveness study comparing lithium to quetiapine, each with adjunctive personalized treatments (APTs). We examined post hoc (1) the effects of treatment on functioning, (2) how changes in functioning differed between treatment responders and nonresponders, and (3) whether functioning and employment status mediated treatment response in 482 participants with DSM-IV-TR bipolar I or II disorder from September 2010 to September 2013. Treatment was associated with significant improvements in functioning and quality of life, regardless of treatment group (P values < .0001). Responders showed greater improvements in quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire P values < .05) and functioning (Longitudinal Interval Follow-up Evaluation-Range of Impaired Functioning Tool P values < .05) than nonresponders. Unemployed or disabled participants at baseline had significantly greater illness severity at baseline than employed participants (P values < .05). Over the study duration, employed participants reported greater improvements in physical health and quality of life in leisure activities than both unemployed and disabled participants (P values < .05). Individuals who saw greater improvement in functioning and quality of life tended to show greater improvements in depressive and anxiety symptoms (P values ≤ .0001), as well as overall illness severity (P values < .001). Early (8 weeks) and very early (4 weeks) clinical changes in mood symptoms predicted changes in functioning and quality of life at 6 months (P values < .001). Prior disability status was associated with a worse treatment response and prospective illness course. Results implicate functioning and employment status as important markers of illness severity and likelihood of recovery in bipolar disorder, suggesting that interventions that target functional impairment may improve outcomes. ClinicalTrials.gov identifier for the Bipolar CHOICE study: NCT01331304.

Community-oriented family-based intervention superior to standard treatment in improving depression, hopelessness and functioning among adolescents with any psychosis-risk symptoms

The aim of the present study was to compare change in functioning, affective symptoms and level of psychosis-risk symptoms in symptomatic adolescents who were treated either in an early intervention programme based on a need-adapted Family- and Community-orientated integrative Treatment Model (FCTM) or in standard adolescent psychiatric treatment (Treatment As Usual, TAU). 28 pairs were matched by length of follow-up, gender, age, and baseline functioning. At one year after the start of treatment, the matched groups were compared on change in functioning (GAF-M), five psychosis-risk dimensions of the Structured Interview for Psychosis-Risk Syndromes (SIPS), and self-reported anxiety, depression, and hopelessness symptoms (BAI, BDI-II, BHS). FCTM was more effective in improving functioning (20% vs. 6% improvement on GAF-M), as well as self-reported depression (53% vs. 14% improvement on BDI-II) and hopelessness (41% vs. 3% improvement on BHS). However, for psychosis-risk symptoms and anxiety symptoms, effectiveness differences between treatment models did not reach statistical significance. To conclude, in the present study, we found greater improvement in functioning and self-reported depression and hopelessness among adolescents who received a need-adapted Family- and Community-orientated integrative Treatment than among those who were treated in standard adolescent psychiatry.

The role of laminoplasty in cervical spine diseases. Evidences from a literature review

Anterior decompression at multiple disc spaces, multilevel corpectomy, laminectomy with or without fusion, and laminoplasty have all been performed to treat cervical diseases such as the ossification of the posterior longitudinal ligament (OPLL) and the cervical spondylotic myelopathy (CSM). Laminectomy has been the most used technique to decompress spinal cord in such conditions. Nonetheless spinal deformity, instability, progressive kyphotic deformity and late neurological deterioration are not infrequent complications after laminectomy. Laminoplasty techniques have been developed to overcome these problems but there are no definitive data supporting the superiority of laminoplasty over laminectomy in OPLL and CSM. Here we reviewed the available literature about laminoplasty, with particular attention to comparative works (laminoplasty vs laminectomy). We analyzed 38 articles. Twenty-three were papers reported the results of laminoplasty in OPLL and CSM, 7 articles compared two different types of laminoplasty technique and 8 studies were comparative works between laminoplasty and laminectomy. We found that laminoplasty was reported safe and effective in decompressing spinal cord, preserving the range of motion and the good clinical results at long follow-up. Moreover laminoplasty has been found to arrest the progression of myelopathy, also in elderly and debilitated patients, with low incidence of postoperative axial pain and kyphotic deformity at follow-up. Among different laminoplasty techniques the mini-plates fixation seems to provide the best results compared to suture fixation. Moreover most of comparative studies suggest that laminoplasty is associated with shorter hospital stay, greater functional improvement and with fewer late complications (including the need of further stabilization) compared to laminectomy. Nonetheless skip laminectomy seems a promising technique in terms of good results and low complications, although more comparative perspective studies are needed to confirm this evidence.

Severe arthritis predicts greater improvements in function following total knee arthroplasty.

Although excellent outcomes are routinely reported following total knee replacement, up to 20% of patients remain dissatisfied. The aim of this study was to determine whether pre-operative radiographic classification was associated with functional outcomes following surgery. A retrospective review of a prospective arthroplasty database identified 256 patients that fulfilled the inclusion criteria over an 18-month period. Baseline demographic data on all patients were collected prospectively. All pre-operative radiographs were assessed using the Kellgren and Lawrence (K&L) classification system. Patients were prospectively assessed using the American Knee Society Score pre-operatively and at 1, 3 and 5years post-surgery. An association was found between the pre-operative radiographic severity of arthritis and the pre-operative American Knee Society Knee (AKSK) scores, with worsening radiographic grade corresponding to worsening AKSK scores (p=0.020). There was an association between K&L classification and improvement in AKSK scores from pre-operative to 1year (p=0.003) and 3years (p=0.04), with K&L grades 3 and 4 demonstrating the most significant improvements. On multivariate regression analysis, K&L classification was the only significant predictor of improvement in AKSK at 1year (p=0.009). No correlation was found between K&L grade and the American Knee Society Functional Scores at any stage. The results of this study may help to improve satisfaction rates in total knee replacement by targeting treatment. Patients can be counselled that although radiographic severity of arthritic changes can predict knee-specific functional improvement, the extent of their global functional improvement cannot. IV.

SURGICAL APPLICATION OF A NOVEL BIOMATERIAL ENHANCES POST-MI FUNCTIONAL RECOVERY BY STIMULATING VASCULOGENESIS THROUGH AN ACTIVE BIO-INDUCTIVE MECHANISM

Epicardial infarct repair (EIR) using a bio-inductive extracellular matrix (ECM) biomaterial is a novel surgical approach that targets the infarcted myocardium to enhance myocardial repair and prevent ischemic HF. We previously demonstrated that EIR prevents maladaptive LV remodeling and improves post-MI functional recovery. It is unclear if these benefits are a consequence of passive biomechanical infarct restraint or secondary to active paracrine signals from within the biomaterial (bio-inductive effect). In this study we outline the mechanisms by which EIR enhances myocardial repair following ischemic injury. Epicardial infarct repair performed using a biologically active ECM-biomaterial (CorMatrix-ECM, CorMatrix Cardiovascular Inc., GA, USA) was compared to EIR performed using the same ECM-biomaterial biologically inactivated by gluteraldehyde fixation. The active (N=4) or inactive (N=6) ECM-biomaterial was surgically applied to the epicardial surface of the infarcted myocardium following permanent coronary artery ligation in a rat model. Using a conductance catheter, indices of cardiac performance were quantified by pressure volume loop analysis 14-weeks post-treatment. EIR with either biomaterial resulted in functional recovery above sham-treated (N=4) animals (ejection fraction: 42.43±13.09% vs. 25.15±6.99%, respectively; P=0.035), however we observed a trend toward greater functional improvement in active EIR-treated animals as compared to inactive EIR-treated animals (ejection fraction: 47.13±15.45% vs. 30.50±13.40%, respectively; P=0.16; stroke work: 10618±1548mmHg*uL vs. 8148±2514mmHg*uL, respectively; P=0.17). Increased vascularity was observed within the infarcted myocardium of active EIR-treated animals as compared to inactive EIR-treated animals (11.8±5.6 vs. 3.7±3.9 blood vessels per high power field, respectively; P=0.0008) potentially resulting in increased microvascular perfusion accounting for the functional recovery observed. Increased epicardial thickness, indicative of epicardial activation, was also observed in active EIR-treated animals as compared to inactive EIR-treated animals (4.6±1.6 vs. 2.9±0.7 fold increase relative to sham-treated animals, respectively; P=0.0012). An increase in the number of epicardium derived progenerator cells (EDPCs), identified by Wilms’ tumor-1 expression and nuclearization of β-catenin was also observed in active EIR-treated animals, specifically in the infarcted myocardium indicative of increased epithelial to mesenchymal transition. Vascular structures positive for both nuclear β-catenin and α-SMA identified within the infarcted myocardium of active biomaterial-treated animals indicate that EDPCs undergo EMT and differentiate into vascular smooth muscle cells (VSMCs) through vasculogenesis (Figure). These data suggest that EIR with a biologically active biomaterial enhances myocardial repair through a bio-inductive mechanism beyond passive infarct restraint. The epicardial application of ECM-biomaterial stimulates epicardial progenitor cell mobilization and increases vasculogenesis to enhance functional recovery post-MI.

Greater functional improvement in patients with diabetes after rehabilitation following cardiac surgery

Diabetes increases the risk of in-hospital complications in medical or surgical patients. Few data are available in the rehabilitation phase after cardiac surgery. To assess the influence of diabetes on outcome and complication rate in the rehabilitation phase after cardiac surgery. Data prospectively recorded in the Hospital Information System from 5261 patients consecutively admitted between 1 January 2008 and 31 May 2013 for a comprehensive cardiac rehabilitation programme directly after cardiac surgery were analysed retrospectively. The study cohort included 1285 (24%) patients with diabetes and 3976 (76%) without. Coronary artery bypass graft (CABG) was more frequent in patients with diabetes (58% vs. 37%, P<0.01), and valvular surgery was more frequent in patients without diabetes (37% vs. 22%, P<0.01). Patients with diabetes were more disabled after surgery, with severe disability (Barthel Index <60) observed in 22% (vs. 17% in patients without diabetes, P<0.001). During rehabilitation, complications were more frequent in patients with diabetes than those without (28% vs. 21%, P<0.01); in particular, patients with diabetes had more infections, heart failure and more difficult surgical wound healing. However, the improvement in the Barthel Index was greater in patients with diabetes (+16±15) than without (+13±15, P<0.001). In a large cohort of patients directly admitted to an early inpatient rehabilitation programme after cardiac surgery, those with diabetes were more disabled. Nonetheless, and despite the higher rate of complications, patients with diabetes had the greatest benefit in terms of functional improvement.