Intensive Functional Rehabilitation Research Articles

Effect of Low-Level Laser Therapy on Knee Range of Motion and Functional Abilities After Total Knee Arthroplasty.

The aim of this study was to determine the effectiveness of combined low-level laser therapy (LLL) and rehabilitation in patients following recent total knee replacement (TKR). A double-blind randomized controlled study was conducted at the Orthopedic Department of Mansoura University Hospital. Forty-four patients were chosen from a total of 58 patients who met the inclusion criteria and were assigned randomly into control and experimental groups of equal size. Ultimately, 40 patients completed the study (20 from each group). Both groups participated in an intensive functional rehabilitation program, and the experimental group also received LLL therapy around the knee at the incisional line, the medial and lateral intra-articular space, above and below the patella, and at the popliteal fossa at low fluence (6 J/cm2, 650 nm continuous wave) and 60 s per point with a total dose of 48 J per session over 12 treatment sessions for six weeks. Knee range of motion (ROM) was measured with a digital goniometer, and functional abilities were assessed with the Arabic version of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index. There were significant differences in all variables pre- and post-treatment within each group. Before treatment, there was no significant difference in any of the measured variables between the groups (P>0.05). After treatment, there were significant differences in knee flexion ROM and WOMAC index (P<0.05)but no significant difference in knee extension ROM between the groups (P>0.05). The addition of low-level laser therapy to a rehabilitation program post-TKR resulted in substantial enhancements in knee flexion range of motion and the WOMAC index.

Parents’ Challenges and Needs after Inpatient Intensive Functional Rehabilitation Treatment of their Child with a Physical Disability

FLM Helmerich1*, MRJB Goossens2,3, Functional Intensive Therapy Team Adelante#1, YJM Janssen Potten3,4, AMCF Verbunt3,4 and EAA Rameckers1,3-5 Author Affiliations 1Adelante Rehabilitation centre for Children, Valkenburg, The Netherlands 2Department of Clinical Psychological Science, Maastricht University, The Netherlands 3Centre of Expertise in Rehabilitation and Audiology, Hoensbroek, The Netherlands 4Department of Rehabilitation Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, The Netherlands 5Faculty Rehabilitation Science, Pediatric Rehabilitation, Hasselt University, Belgium #Functional Intensive Therapy Team: Ingrid Meeuwsen, Marcel Coenen, Lidia Caponi, Ruud Roijen, Lizette Teeuwen, Gina van den Berge, Coen de Haan, Catherine Steinbusch, Boukje Knops, Cis Knols and Stefan Knoops Received: October 13, 2020| Published: October 22, 2020 Corresponding author: FLM Helmerich, Adelante Rehabilitation centre for Children, Valkenburg, The Netherlands DOI: 10.26717/BJSTR.2020.31.005092

Factors associated with discharge destination following inpatient functional rehabilitation in patients with traumatic spinal cord injury.

Retrospective review of data from a prospective database of a Level 1 trauma center. This project aims to identify factors collected during the acute and rehabilitative care following a traumatic spinal cord injury (TSCI) associated with success and failure to return home after inpatient intensive functional rehabilitation (IFR). Level 1 trauma center specialized in TSCI care in Montreal, Canada. All eligible patients from our prospective database were separated into two groups according to discharge destination following IFR. Clinical variables collected during the acute and rehabilitative care as well as demographic variables were compared between patients who managed to return home (Group 1) and those who were discharged elsewhere (Group 2). Multivariable regression analyses were conducted with variables that were significant at the univariate level. Out of the 193 patients included, 22 (11%) failed to return home following IFR. Six variables were associated with failure to return home at the univariate level: longer acute length of stay (LOS), longer rehabilitation LOS, living alone, higher neurological level of injury, having comorbidities, and having a pressure injury (PI) during acute care. Three variables remained significant at the multivariate level: living alone, increasing acute LOS and presenting a high cervical (C1-C4) neurological level of injury. It is important that acute care clinicians recognize the aforementioned factors early after TSCI in order to optimize patients for community reintegration.

Patterns and predictors of functional recovery from the subacute to the chronic phase following a traumatic spinal cord injury: a prospective study.

Prospective cohort study. To determine the extent of functional recovery between 6 and 12 months following a traumatic spinal cord injury (TSCI) and to identify individuals achieving a small clinical functional improvement during this period. A single level-1 trauma center specialized in SCI care. A cohort of 125 patients sustaining TSCI was studied. The Spinal Cord Independence Measure (SCIM) version III at 6 and 12 months post injury was used as the main outcome measure. The observed functional improvement for the final cohort did not reach a clinically significant level between 6 and 12 months post injury. However, 30.4% of individuals achieved this level (≥4 points in the SCIM-III total score). This group showed a higher proportion of motor-complete TSCI (AIS grade A or B) and showed a tendency toward older age and higher trauma severity. Longer duration of intensive functional rehabilitation was the single factor associated with reaching a small clinically important improvement in the SCIM-III total score. Functional status between 6 and 12 months following a TSCI may be considered clinically similar, regardless of the level of injury. However, 30% may reach a small clinical functional improvement in the subacute to chronic phase following TSCI, particularly individuals sustaining severe deficits and older age, which may highlight the importance of functional compensation during this period for these patients.

Effect of an intensive functional rehabilitation program on the recovery of activities of daily living after total knee arthroplasty: A multicenter, randomized, controlled trial

BackgroundPostoperative exercise is effective for improving activities of daily living (ADL) in patients undergoing total knee arthroplasty (TKA), and exercise has been included in standard care after surgery provided in Japan. However, it is unknown whether standard care has room to develop for improving ADL. The goal of this study was to investigate the effect of an intensive functional rehabilitation (IFR) program in addition to standard care on the recovery of ADL following surgery. MethodsA total of 104 inpatients with knee osteoarthritis undergoing TKA were randomly assigned to either the experimental or the control group. The experimental group (n = 57) were given standard care and participated in the IFR program immediately after surgery (e.g., stand up and sit down, strengthen the knee extensor muscle, climbing onto a platform, and walking laterally). The control group (n = 47) were given standard care only. Primary outcomes were the score of Functional Independence Measure (FIM) and the Barthel Index (BI) at 2 weeks postoperatively. Matching using the propensity score was performed to control the influence of the patient characteristic on the outcome. ResultsAs a result of matching, 42 patients were extracted. The averages (standard deviation) of the FIM motor score were 79.0 (10.8) for the experimental group and 80.5 (9.4) for the control group. The BI scores were 88.1 (13.3) for the experimental group and 91.0 (10.1) for the control group. The experimental and control groups did not show significant intergroup differences in either score. ConclusionsOur study shows that as compared to standard care, IFR program for 2 weeks in addition to standard care after surgery did not significantly improve ADL in patients undergoing TKA.

Adapted dance used in subacute rehabilitation post-stroke: impacts perceived by patients, relatives and rehabilitation therapists

Purpose: To examine the perceived impacts of an adapted-dance group intervention when added to intensive functional rehabilitation post-stroke.Method: In this exploratory qualitative case study, semi-structured interviews were analyzed using a deliberative inductive logic and referring to the International Classification of Functioning, Disability and Health. Participants were patients in rehabilitation post-stroke (≤25 days) (n = 6), relatives (n = 4) and rehabilitation therapists (n = 12). Selection was on a voluntary basis. The intervention added to the patients’ rehabilitation program consisted of 55-minute bi-weekly sessions for 10 weeks.Results: Three categories of perceived positive impacts emerged from the data: (1) mobility, (2) mental functions and personal factors (emotional functions, motivation and self-efficacy) and (3) interpersonal interactions and social life. A fourth category of perceived impacts involving exercise tolerance was both positive, in terms of general physical endurance, and negative, in terms of a feeling of increased fatigue.Conclusion: Such an adapted-dance intervention holds promise in subacute rehabilitation post-stroke. Its main strength lies in its perceived positive impact on mental functions, personal factors, and interpersonal and social interactions.Implications for rehabilitationAn adapted-dance group intervention could offer an innovative means of contributing to intensive functional rehabilitation post-stroke by potentially generating positive perceived impacts on emotional functions, motivation and self-efficacy, as well as on interpersonal and social interactions.Adapted dance could be added to inpatients’ rehabilitation with only minor impacts on fatigue.

The impact of early spasticity on the intensive functional rehabilitation phase and community reintegration following traumatic spinal cord injury

Context/Objectives: To determine the impact of spasticity presenting during the acute care hospitalization on the rehabilitation outcomes following a traumatic spinal cord injury (TSCI). Design: Retrospective cohort study. Setting: A single Level 1 trauma center specialized in SCI care. Participants: 150 individuals sustaining an acute TSCI. Interventions: Not applicable. Outcome Measures: The total inpatient functional rehabilitation length of stay. The occurrence of medical complications and the discharge destination from the inpatient functional rehabilitation facility were also considered. Results: 63.3% of the cohort presented signs and/or symptoms of spasticity during acute care. Individuals with early spasticity developed medical complications during acute care and during intensive functional rehabilitation in a higher proportion. They were also hospitalized significantly longer and were less likely to return home after rehabilitation than individuals without early spasticity. Early spasticity was an independent factor associated with increased total inpatient rehabilitation length of stay. Conclusion: The development of signs and symptoms of spasticity during acute care following a TSCI may impede functional rehabilitation outcomes. In view of its association with the occurrence of early spasticity, higher vigilance towards the prevention of medical complications is recommended. Early assessment of spasticity during acute care is recommended following TSCI.

Effects of gait-like vibration training on gait intralimb coordination in individuals with incomplete traumatic spinal cord injury

Gait training is a key element of intensive functional rehabilitation to improve mobility and participation after an incomplete spinal cord injury (iSCI). Gait-like vibration training is an emerging approach that may improve intralimb coordination as shown by preliminary data gathered in a person with a chronic iSCI. The effects of gait training on intralimb coordination have not been studied extensively. This study aimed to analyse the effects of gait-like vibration training on intralimb coordination in individuals with iSCI. Six participants with iSCI were evaluated pre- ( n = 4/6; missing data for 2 participants) and post–intervention ( n = 6). The intervention consisted of a gait-like vibration program encompassing 15 training sessions during which multiple vibrators reproduced typical sensory activity associated with gait movements in standing ( Fig. 1 ). During pre-intervention evaluation, participants received twelve minutes of vibrations whereas they received 27 minutes of vibrations during the post-intervention evaluation. During these two evaluations, lower limb kinematics during gait was recorded in standing without vibration before and after the vibrations with a three-dimensional motion analysis system. Intralimb coordination, characterized using hip-knee cyclograms, was compared between the beginning and the end of each evaluation conducted pre and post-intervention, respectively, using a qualitative gait classification. Gait cycles variability and cyclograms shape improved mostly at weight acceptance after heel strike ( n = 6) and for knee excursion during swing phase ( n = 5). Knee extension at heel strike was also greater in participants with a crouched gait pattern after one pre-intervention evaluation. One participant changed from the resilient to the regular gait pattern. Gait-like vibration training seems to be beneficial and could improve gait quality through a facilitation of gait movements and a better intralimb coordination. These preliminary results support the potential of gait-like vibration training to improve gait performance after iSCI.

Does the Acute Care Spinal Cord Injury Setting Predict the Occurrence of Pressure Ulcers at Arrival to Intensive Rehabilitation Centers?

The objective of this study was to evaluate the impact of acute care in specialized spinal cord injury (SCI) trauma centers on the prevalence of pressure ulcers (PU) upon arrival at a functional rehabilitation center after a traumatic SCI. This is a retrospective cohort study among 123 patients with traumatic SCI referred to intensive functional rehabilitation between January 1, 2009, and December 31, 2011. Group 1 (n = 90) was referred from a level 1 specialized SCI trauma center and group 2 (n = 33) was referred from seven trauma centers not specialized in SCI. The total prevalence of patients with PU at admission to functional rehabilitation was 33.3% (26.7% in group 1 and 51.5% in group 2, P = 0.017). There were also more patients with multiple PU in group 2 (24.2% vs. 2.2%, P = 0.0001). A binary logistic regression showed a significant relationship between the occurrence of PU and the type of acute care facility as well as the ASIA (American Spinal Injury Association) Impairment Scale grade. Receiving acute care at the specialized SCI trauma center was associated with a decrease in the number of patients developing one and multiple PU. These results highlight the importance of specialized SCI trauma centers in acute care of patients with traumatic SCI in reducing PU at their admission to functional rehabilitation settings.

Physiotherapy in the first three months after allograft face transplantation – case report

AbstractObjective: The aim of the study was to present physiotherapy procedures of the patient with von Recklinhausen’s disease in the first three months after allograft face transplantation (PT).Methods: During hospitalization lasting 2.5 months intensive functional rehabilitation was conducted. It ran in two stages: early (up to 30 days after surgery) and recovery (1 to 3 months). In physiotherapy the method with elements of PNF (Prioprioceptywne Neuromuscular Facilitation) was used. During 2 months from PT an electrostimulation of orbicularis oris muscles was included. Physiotherapists did not focus only on rehabilitation of the face transplant, but also paid attention to functional problems caused by von Recklinhausen’s disease. When planning therapy, they took into consideration personal, physical and emotional features. In therapy we used exercises in different starting positions, such as rollers, elastic bands, balls and sensory rings were employed. Lymphatic drainage of the face and neck was performed.Results: During three months of the rehabilitation an improvement of upper and lower limbs′ muscle strength was achieved; cervical spine range of motion increased, pain and discomfort caused by scar restrictions were reduced. There was also an improvement of the overall functionality of the patient. However, due to short time after PT no improvement in the functioning of facial expressions and sensory feeling was noticed, nevertheless the patient accepted the new face. In our opinion, rehabilitation is an inevitable element after face transplant (PT). The use of an individual and comprehensive program of physiotherapy, and it’s early and systematic implementation allow to achieve an improvement of the patient’s physical function after PT. Continuing rehabilitation is necessary to achieve full facial functionality and maintain physical capacity.

The Effectiveness and Efficiency of Inpatient Rehabilitation Services in Thailand: A Prospective Multicenter Study

Objective To investigate the effectiveness and efficiency of inpatient rehabilitation. Methods A total of 2,081 patients across 14 hospitals were recruited in this prospective, multicenter cohort study. Data on the diagnoses, types of admission, length of stay (LOS), and functional ability score based on a modified Barthel index (BI) at admission (BIa) and at discharge (BId) were collected. Effectiveness was defined as the difference of BI (ΔBI) and efficiency as ΔBI divided by LOS. Results The majority of patients were diagnosed with spinal cord injury and stroke (41.8% and 37.5%, respectively). The mean age was 52.4 ± 18.6 years with a mean LOS of 23.9 ± 19.9 days, BIa of 9.4 ± 6.1, and BId of 12.3 ± 5.7. The overall effectiveness and efficiency were 2.9 ± 3.4 and 0.16 ± 0.30 scores/day, respectively; stroke rehabilitation provided the most effective and efficient BI improvement compared with rehabilitation for other diseases. Most patients (54.5%) received intensive functional rehabilitation, which was the most effective and efficient program (4.4 ± 3.6 and 0.23 ± 0.32 scores/day, respectively); the efficiency of the intensive program was not different among various diseases (P = 0.726). Conclusion Stroke rehabilitation had the highest efficiency compared with rehabilitation for other neurological diseases. The most efficient type of admission was intensive rehabilitation, regardless of the disease being treated.

Tai Chi-based exercise program provided via telerehabilitation compared to home visits in a post-stroke population who have returned home without intensive rehabilitation: study protocol for a randomized, non-inferiority clinical trial

BackgroundThe incidence of strokes in industrialized nations is on the rise, particularly in the older population. In Canada, a minority of individuals who have had a stroke actually receive intensive rehabilitation because most stroke patients do not have access to services or because their motor recovery was judged adequate to return home. Thus, there is a considerable need to organize home-based rehabilitation services for everyone who has had a stroke. To meet this demand, telerehabilitation, particularly from a service center to the patient’s home, is a promising alternative approach that can help improve access to rehabilitation services once patients are discharged home.Methods/DesignThis non-inferiority study will include patients who have returned home post-stroke without requiring intensive rehabilitation. To be included in the study, participants will: 1) not be referred to an Intensive Functional Rehabilitation Unit, 2) have a Rankin score of 2 or 3, and 3) have a balance problem (Berg Balance Scale score between 46 and 54). Participants will be randomly assigned to either the teletreatment group or the home visits group. Except for the delivery mode, the intervention will be the same for both groups, that is, a personalized Tai Chi-based exercise program conducted by a trained physiotherapist (45-minute session twice a week for eight consecutive weeks). The main objective of this research is to test the non-inferiority of a Tai Chi-based exercise program provided via telerehabilitation compared to the same program provided in person at home in terms of effectiveness for retraining balance in individuals who have had a stroke but do not require intensive functional rehabilitation. The main outcome of this study is balance and mobility measured with the Community Balance and Mobility Scale. Secondary outcomes include physical and psychological capacities related to balance and mobility, participants’ quality of life, satisfaction with services received, and cost-effectiveness associated with the provision of both types of services.Study/trial registrationClinicalTrials.gov: NCT01848080

Exploring Factors in the Systematic Use of Outcome Measures: A Multi-Disciplinary Rehabilitation Team Perspective

Purpose: The implementation of routine outcome measurement was initiated as a quality improvement initiative in a unit delivering intensive functional rehabilitation for people with lower limb amputation. Two years post-implementation, completion rates remained low which raised the need to gain an indepth understanding of the factors that might impact the systematic use of Outcome Measures (OMs). Method: A qualitative exploratory study embedded in the ongoing quality improvement initiative was designed. Data were gathered through a focus group with members of a multidisciplinary rehabilitation team. A deductive content analysis was performed using Consolidated Framework for Implementation Research (CFIR) as a guide to explore factors that impact routine outcome measurement. Results: Respondents perceived OMs as valid and offering clear advantages in clinical practice. At the organizational level, lack of fit with clinical practice, loss of project leaders and lack of clear management directives had negative repercussions on the use of OMs. Conclusion: Our results suggest that a dedicated project leader throughout the implementation process and effective communication may contribute to bypassing barriers associated to practice changes leading to a more systematic use of OMs among clinicians.

Added value of an intensive multidisciplinary functional rehabilitation programme for chronic low back pain patients

Several treatments exist for chronic low back pain (cLBP) patients although none has shown superiority. Among group treatments, muscle reconditioning programmes (MRPs) are the most commonly used. Multidisciplinary functional rehabilitation programmes (MFRPs) are an alternative. To compare a MFRP with a MRP as few studies compare these treatments This was a prospective, nonrandomised, controlled study comparing cLBP patients participating in a MRP or MFRP in an outpatient setting. The predetermined primary outcome measure was the daily life activity subscale (DLA) of the Dallas Pain Questionnaire (DPQ) within one year after the end of the treatment. Twenty-one patients were included in the MRP and 24 in the MFRP. At inclusion, the groups were similar in terms of age (mean 40 years), sex (50%-60% males), sick leave duration (mean 6.0 months, standard deviation (SD) 4.4 months) and follow up (mean 9.0 months, SD 2.0 months). The DLA score decreased from 59.5% (SD 16.9) to 44.8% (SD 25.4), p <0.01, in the MFRP and from 62.3 (SD 20.3) to 58.8 (SD 20.7), p = 0.3, in the MRP. The between-groups difference at follow-up was 13.8, p = 0.05, and the difference in the mean improvement was -11.5 (5.9), p = 0.058. Seventy-eight percent of MFRP patients versus 47 % in the MRP group returned to work (p = 0.08). In a population of highly disabled cLBP patients, MFRP seems more effective in increasing function and return to work. Interpretation is limited by the small population included and by the type of trial. Randomised studies are needed to confirm these results and explore the cost-effectiveness of MFRP.

Community Needs of People Living With Spinal Cord Injury and Their Family

Returning to the community after intensive functional rehabilitation can be a challenge for people who have sustained a traumatic spinal cord injury (SCI) and for their family members.1-4 They may need different services in order to facilitate their social participation and improve their quality of life.3,5,6 Research was conducted to better understand the role of the environment in community reintegration in the first years post rehabilitation. This article focuses on the needs from the perspective of persons with SCI and their family members. A more complete understanding of unmet needs will help better address them in future intervention and policies.

Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial

Moffet H, Collet J-P, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty: a single-blind randomized controlled trial. Arch Phys Med Rehabil 2004;85:546–56. Objective To evaluate the effectiveness of a new intensive functional rehabilitation (IFR) program on functional ability and quality of life (QOL) in persons who underwent a first total knee arthroplasty (TKA). Design Randomized controlled trial. Setting Ambulatory care. Participants Seventy-seven people with knee osteoarthritis. Intervention Two months after TKA, subjects were randomly assigned to either a group with IFR (n=38), who received 12 supervised rehabilitation sessions combined with exercises at home between months 2 and 4 after TKA, or to a control group (n=39), who received standard care. All participants were evaluated by a blind evaluator at baseline (2mo after TKA), immediately after IFR (2mo later; POST1), and 2 and 8 months later (POST2 and POST3). Main outcome measures The primary outcome measure with respect to effectiveness was the 6-minute walk test (6MWT) at POST2. Secondary outcome measures were the 6MWT at the other evaluations and the Western Ontario and McMaster Universities Osteoarthritis Index and Medical Outcomes Study 36-Item Short-Form Health Survey. Results Subjects in the IFR group walked longer distances (range, 23–26m) in 6 minutes at the 3 POST evaluations than subjects in the control group. At POST1 and POST2, they also had less pain, stiffness, and difficulty in performing daily activities. Positive changes in QOL in favor of the IFR were found only at POST2. Conclusions The IFR was effective in improving the short-term and mid-term functional ability after uncomplicated primary TKA. The magnitude of the IFR effect on the primary outcome was modest but consistent. More intensive rehabilitation should be promoted in the subacute recovery period after TKA, to optimize functional outcomes in the first year after surgery.

Arm and leg impairments and disabilities after stroke rehabilitation: relation to handicap.

(1) To examine the relationships between measures of impairment and disability for the arm and leg with a measure of handicap and (2) to identify the impairment or disability most strongly related to handicap situations. Prospective cohort study. Intensive functional rehabilitation unit and community. One hundred and two persons who had a stroke. Arm and leg impairments and disabilities were evaluated with reliable and valid tests at discharge from rehabilitation. Six months later, handicap situations were evaluated with the Assessments of Life Habits (LIFE-H). Arm and leg impairments and disabilities are correlated with handicap situations. Disability of the leg is more strongly associated with handicap than arm disability. Arm and leg disabilities are not statistically more strongly related to handicap than arm and leg impairments. The high correlations found between handicap situations and the impairment and disability measures of the leg provide new information that support the importance of mobility to promote integration after stroke.

Association between personal and environmental factors and the occurrence of handicap situations following a stroke

Background and purpose : Little is known about the potential role of environmental factors in the handicap creation process following a stroke. The objective of this study was to explore the presence of a relationship between environmental factors and the occurrence of handicap following a stroke, taking into consideration age and the level of impairments and disabilities. Methods : This is a cross-sectional study where data were collected 6 months after discharge from an intensive functional rehabilitation unit. A convenience sample of 51 participants was recruited at the time of their admission to the rehabilitation unit for rehabilitation post-stroke. Perceived influence of environmental factors was measured using the Measure of the Quality of the Environment (MQE). Handicap situations were measured with the Assessment of Life Habits (LIFE-H). Impairments and disabilities comprised six domains (cognition, perception, depression, communication, sensorimotor function and comorbidity) assessed using a variety of measuring tools from which a composite score was derived. Results : Fifty-one participants aged 40-97 years old took part in this study. Perceived obstacles in the environment, together with age and the level of impairments and disabilities, explained 58.9% of the variation in the LIFE-H (handicap level). Taken alone, the perceived obstacles (total score) explained 6.2%. The perceived facilitators (total score) in the environment were not found to be related to the presence of handicap situations. Conclusion : Increased level of impairments and disabilities, advanced age and perceived barriers in the physical and social environment contribute to the handicap creation process following a stroke.

Nontraumatic glenohumeral instability and coracoacromial impingement in swimmers.

Competitive swimming is one of the most demanding and time-consuming sports. Swimmers at elite level practice 20-30 h per week. During 1 year's practice, the average top level swimmer performs more than 500,000 stroke revolutions per arm. These innumerable repetitions over many years of hard training together with an increasing muscular imbalance around the shoulder girdle seem to be the main etiological factors in the development of the over-use syndrome swimmer's shoulder. Shoulder pain in swimmers has in general been regarded as synonymous with coracoacromial impingement, i.e. anterior shoulder pain due to rotator cuff tendinitis, but new knowledge suggests that a concomitant glenohumeral instability plays an additional role. The diagnostic complexity of the problem is as challenging as the search for the gold standard of treatment. The condition should ideally be diagnosed as early as possible, and intensive functional rehabilitation of the shoulder girdle including the scapular muscles should be started in order to restore muscle balance. The surgical possibilities include subacromial decompression in cases of purely mechanical impingement. If a painful glenohumeral instability persists after intensive functional rehabilitation, anterior capsulolabral reconstruction can be performed. Still, however, short- and long-term results show that surgery is less successful in elite athletes involved in overhead sports. Prevention protocols include education of coaches in primary injury prophylaxis and the institution of resistance strength training in prepubescent swimmers. Emphasis should be made to improve muscular balance around the glenohumeral and scapulothoracic joints.

Stabilization of Fractures in the Hand and Wrist with Traumatic Soft Tissue and Bone Loss

Open type III fractures of the hand or wrist with severe bone and soft tissue loss justify aggressive treatment to restore anatomy, assure healing, and maximize functional recovery. The techniques of modern wound excision used at initial surgery predictably result in a decompressed and surgically clean wound within a few days from injury in the vast majority of cases. This allows a safe application of delayed primary internal fixation and bone grafting for fracture restoration or joint arthrodesis as well as early wound closure or coverage. The immediate or early application of stable external devices, internal fixation, or combinations of the two along with early bone grafting restores the structural integrity of the skeleton, reduces pain, protects other repaired and reconstructed tissues, promotes the healing, and supports early and intensive functional rehabilitation of the hand and wrist. Early wound closure or coverage minimizes scar formation. Together, the early sequencing of effective wound debridement with skeletal stabilization and bone grafting and early wound closure or coverage provide the most favorable circumstances for healing and functional recovery of the seriously damaged hand and wrist.