Persistent Functional Limitations Research Articles

Indirect calorimetry directed feeding and cycling in the older ICU population: a pilot randomised controlled trial

BackgroundOlder critically ill patients experience rapid muscle loss during stay in an intensive care unit (ICU) due to physiological stress and increased catabolism. This may lead to increased ICU length of stay, delayed weaning from ventilation and persistent functional limitations. We hypothesized that with optimal nutrition and early physical therapy acting in synergism, we can reduce muscle mass loss and improve functional outcomes.MethodsThis was a prospective, single blinded randomized, controlled single-center pilot study to compare the lean muscle mass (measured at bilateral quadriceps femoris using ultrasound) of older ICU patients at 4 time points over 14 days between the control and intervention groups. The control group received standard weight-based empiric feeding and standard ICU physiotherapy. The intervention group received indirect calorimetry directed feeding adjusted daily and 60 min per day of cycle ergometry. 21 patients were recruited and randomized with 11 patients in the control arm and 10 patients in the intervention arm. Secondary outcome measures included ICU and hospital mortality, length of stay, functional assessments of mobility and assessment of strength.ResultsMedian age was 64 in the control group and 66 in the intervention group. Median calories achieved was 24.5 kcal/kg per day in the control group and 23.3 kcal/kg per day in the intervention group. Cycle ergometry was applied to patients in the intervention group for a median of 60 min a day and a patient had a median of 8.5 sessions in 14 days. Muscle mass decreased by a median of 4.7cm2 in the right quadriceps femoris in the control group and 1.8cm2 in the intervention group (p = 0.19), while the left quadriceps femoris decreased by 1.9cm2 in the control group and 0.1cm2 in the intervention group (p = 0.51).ConclusionIn this pilot study, we found a trend towards decrease muscle loss in bilateral quadriceps femoris with our combined interventions. However, it did not reach statistical significance likely due to small number of patients recruited in the study. However, we conclude that the intervention is feasible and potentially beneficial and may warrant a larger scale study to achieve statistical significance.Trial RegistrationThis study was registered on Clinicaltrials.gov on 30th May 2018 with identifier NCT03540732.

Predicting pain and function with the neutrophil-to-lymphocyte ratio in patients following primary reverse total shoulder arthroplasty

BackgroundGlenohumeral joint osteoarthritis is prevalent in the middle-aged and elderly population, affecting approximately 16%-20% of individuals. Total shoulder arthroplasty has become a common treatment for osteoarthritis, with a notable rise in the use of reverse total shoulder arthroplasty (rTSA) over the past decade. Despite improvements in surgical technique and prostheses, 22% of patients continue to experience chronic pain following shoulder arthroplasty. Currently, medical practitioners lack a reliable method for identifying which patients will suffer from persistent pain and functional limitations after surgery. In this context, the neutrophil-to-lymphocyte ratio (NLR), known for measuring immune-inflammatory reactions and neuroendocrine stress, has gained significant attention. Therefore, the purpose of this study was to explore the predictive potential of the NLR in identifying patients who will experience elevated pain and functional limitations after primary rTSA. MethodsThis study was a retrospective cohort design. Patient data were collected retrospectively between 2019 and 2021 and grouped based on preoperative NLR (≥2.5 and <2.5). Primary outcome measures assessed were the American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS), Pittsburgh Sleep Quality Index, and Single Assessment Numeric Evaluation score. Secondary outcomes included active shoulder elevation and external rotation range of motion. Outcome measures were captured before surgery and at 6 and 12 months after surgery. ResultsAt 6 months following surgery, patients with an NLR ≥2.5 scored significantly worse on the VAS (P = .0171), ASES (P = .0015), and Single Assessment Numeric Evaluation (P = .0226). Differences in Pittsburgh Sleep Quality Index scores were not significant (P = .2705). Forward elevation and external rotation range of motion were similar between groups at 6 months (P = .7777 and P = .2630, respectively). There was no statistically significant difference between groups at 12 months across all variables. Multivariate analysis showed that an NLR <2.5 had a significant positive effect on the ASES score (P = .0011) at 6 months after adjusting for age, gender, body mass index, depression, low back pain, and diabetes. ConclusionsManagement of patients with chronic pain continues to be challenging with limited high-value interventions. Early identification of patients likely to have a protracted recovery following rTSA would allow for a multidisciplinary approach earlier in the recovery phase. Based on our results, patients who had a preoperative NLR value greater than 2.5 reported higher levels of pain, more functional limitations, and perceived poorer function at 6 months following rTSA. However, these effects were relatively small and not observed at the 12-month mark.

Revision Patellar Tendon Reconstruction Using Hamstring Tendon Autograft

Background: Patellar tendon ruptures presenting in a chronic setting are rare events that impose technical surgical challenges due to proximal retraction of the patella, quadriceps muscle atrophy and contracture, and peripatellar adhesions. Various reconstruction techniques have been described using different grafts and fixation methods; however, there is a paucity of reported outcomes and there is no consensus on standard of care. Indications: The patient is a 36-year-old man who presented with a failed patellar tendon reconstruction 14 months after his initial surgery (performed 1 year after the initial injury) with functional weakness and loss of extension. The patient was indicated for a revision patellar tendon reconstruction due to persistent functional limitations. Technique Description: The revision patellar tendon reconstruction was performed with gracilis and semitendinosus tendon autografts harvested from the ipsilateral limb. Hardware was removed from the initial graft tunnels in the tibial tubercle and patella. Patellar height was estimated using fluoroscopic measurement of the contralateral patellar tendon length. The graft is first passed through the patellar tunnel, and the individual limbs of the graft are then both placed through the tibial tubercle tunnel. A sternal wire in a figure-of-eight configuration was used to progressively distalize the patella to match the native patellar height, and the graft was then tensioned and secured together. Results: The patient regained full range of motion at 2-year follow-up and was able to return to work and activities without functional limitations. Recent case series also using ipsilateral hamstring tendon autograft for chronic patellar tendon reconstruction report improved patient outcome scores, normal Insall-Salvati index, improved quadriceps strength, and high levels of patient satisfaction. Discussion/Conclusion: Chronic patellar tendon ruptures are technically challenging to treat, especially in the context of revision of a failed reconstruction. The technique presented in this video may aid orthopaedic surgeons in treating this rare but debilitating injury. Given the lack of high-quality evidence, future studies are needed to explore graft choices, graft fixation techniques, and postoperative protocols. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Co-production of a structured integrated post pulmonary embolism care model (Attend-PE)

Abstract Background More than half of patients with pulmonary embolism (PE) develop persistent functional limitation and experience lower quality of life (1). To mitigate long-term complications, the European Society of Cardiology clinical guidelines on PE management recommends an integrated model for patient care after PE. However, there is currently no consensus on what such an optimal follow-up strategy should include, and high-quality evidence to provide guidance is lacking (1,2). Purpose To describe the co-production of a structured model for PE follow-up. Methods This study is part of the project - A structured Integrated post PE care model (Attend-PE) aimed at developing and testing the effectiveness of a structured, integrated and patient-centred follow-up care model for patients with PE in Denmark. The co-production of the Attend-PE model was conducted from October 2021 till June 2022, featuring user-centred and participatory design techniques. This methodology was combined with a structural stepwise approach based on Intervention Mapping, to ensure the developed model was founded on evidence and theory (3). Results In accordance with the Intervention Mapping protocol, a national panel of stakeholders was formed, and a needs assessment was conducted. The needs assessment comprised a mapping of PE follow-up at all main sites treating PE in Denmark (18 hospitals), based on a co-design process with patients and health care professionals inspired by the patient journey method. To supplement this, a literature search was conducted to identify further knowledge concerning the follow-up care needs and preferences of patients with PE, as well as the optimal clinical management of PE follow-up. Based on this, the overall goal and performance objectives of a structured follow-up care model were formulated, laying the foundation for co-production workshops. In two full-day workshops, patient representatives and healthcare professionals, as well as experts in the field of PE, developed the components, scope, and sequence of the Attend-PE model. Subsequently, the structure and organization of the follow-up model were refined during online workshops, and a working group produced patient education material. The Attend-PE model (Figure 1), outlines a systematic strategy for post-PE in-hospital follow-up, involving patient education, the content and frequency of individual follow-up consultations, and the application of patient reported outcome measures to actively assess physical and psychological well-being. This model supports an individualized post-hospitalization follow-up care plan tailored to the patient's specific needs. Conclusion(s) The co-production process was successful in developing a structured follow-up model for patients with PE which was based on patients’ needs and preferences, as well as the clinical experience and perspectives of healthcare providers, and was in line with current clinical guidelines.Attend-PE model

MRI of Temporomandibular Joint Disorders: A Comparative Study of 0.55 T and 1.5 T MRI.

Temporomandibular disorders (TMDs) are common and may cause persistent functional limitations and pain. Magnetic resonance imaging (MRI) at 1.5 and 3 T is commonly applied for the evaluation of the temporomandibular joint (TMJ). No evidence is available regarding the feasibility of modern low-field MRI for the assessment of TMDs. The objective of this prospective study was to evaluate the image quality (IQ) of 0.55 T MRI in direct comparison with 1.5 T MRI. Seventeen patients (34 TMJs) with suspected intraarticular TMDs were enrolled, and both 0.55 and 1.5 T MRI were performed on the same day. Two senior readers independently evaluated the IQ focusing on the conspicuity of disc morphology (DM), disc position (DP), and osseous joint morphology (OJM) for each joint. We analyzed the IQ and degree of artifacts using a 4-point Likert scale (LS) at both field strengths. A fully sufficient IQ was defined as an LS score of ≥3. Nonparametric Wilcoxon test for related samples was used for statistical comparison. The median IQ for the DM and OJM at 0.55 T was inferior to that at 1.5 T (DM: 3 [interquartile range {IQR}, 3-4] vs 4 [IQR, 4-4]; OJM: 3 [IQR, 3-4] vs 4 [IQR 4-4]; each P < 0.001). For DP, the IQ was comparable (4 [IQR 3-4] vs 4 [IQR 4-4]; P > 0.05). A sufficient diagnostic IQ was maintained for the DM, DP, and OJM in 92% of the cases at 0.55 T and 100% at 1.5 T. Minor image artifacts (LS score of ≥3) were more prevalent at 0.55 T (29%) than at 1.5 T (12%). Magnetic resonance imaging of the TMJ at 0.55 T yields a lower IQ than does MRI at 1.5 T but maintains sufficient diagnostic confidence in the majority of patients. Further improvements are needed for reliable clinical application.

Mental Health and Quality of Life in Pulmonary Embolism: A Literature Review

Pulmonary embolismis an acute disease with chronic complications and, although it is not considered a chronic disease, it requires close follow-up. The scope of the present literature review is to decode the existing data concerning quality of life and the mental health impact of PE during the acute and long-term phases of the disease. The majority of studies reported impaired quality of life in patients with PE when compared to population norms, both in the acute phase and >3 months after PE. Quality of life improves over time, irrespectively of the measurement used. Fear of recurrences, elderly, stroke, obesity, cancer and cardiovascular comorbidities are independently associated with worse QoL at follow-up. Although disease specific instruments exist (e.g., the Pulmonary Embolism Quality of Life questionnaire), further research is required in order to develop questionnaires that may fulfil international guideline requirements. The fear of recurrences and the development of chronic symptoms, such as dyspnea or functional limitations, may further impair the mental health burden of PE patients. Mental health may be implicated by post-traumatic stress disorder, anxiety and depressive symptoms present following the acute event. Anxiety may persist for 2 years following diagnosis and may be exaggerated by persistent dyspnea and functional limitations. Younger patients are at higher risk of anxiety and trauma symptoms while elderly patients and patients with previous cardiopulmonary disease, cancer, obesity or persistent symptoms exhibit more frequently impaired QoL. The optimal strategy for the assessment of mental health in this patient pool is not well defined in the literature. Despite mental burden being common following a PE event, current guidelines have not incorporated the assessment or management of mental health issues. Further studies are warranted to longitudinally assess the psychological burden and elucidate the optimal follow-up approach.

The Post-Venous Thromboembolism Functional Status Scale: From Call to Action to Application in Research, Extension to COVID-19 Patients, and Its Use in Clinical Practice.

A broad spectrum of long-term sequelae may be present in venous thromboembolism (VTE) survivors, affecting their quality of life and functioning. To monitor recovery and improve the prognosis of patients with persistent functional limitations, the development of a new outcome measure that could better capture the consequences of VTE was an unmet need. Starting as a call to action, the Post-VTE Functional Status (PVFS) scale was developed to meet this need. The PVFS scale is an easy-to-use clinical tool to measure and quantify functional outcomes after VTE by focusing on key aspects of daily life. As the scale was considered useful in coronavirus disease 2019 (COVID-19) patients as well, the Post-COVID-19 Functional Status (PCFS) scale was introduced early in the pandemic after slight adaptation. The scale has been well incorporated into both the VTE and COVID-19 research communities, contributing to the shift of focus toward patient-relevant functional outcomes. Psychometric properties have been evaluated, mainly for the PCFS scale but recently also for the PVFS scale, including validation studies of translations, showing adequate validity and reliability. In addition to serving as outcome measure in studies, guidelines and position papers recommend using the PVFS and PCFS scale in clinical practice. As broad use of the PVFS and PCFS scale in clinical practice is valuable to capture what matters most to patients, widespread implementation is a crucial next step. In this review, we discuss the development of the PVFS scale and introduction in VTE and COVID-19 care, the incorporation of the scale in research, and its application in clinical practice.

Primary Repair of Peroneus Longus Myofascial Herniation With Symptomatic Superficial Peroneal Nerve Compression

Symptomatic myofascial herniations of the extremities occur infrequently; however, they can contribute to significant pain, weakness, and neuropathy with activity. Muscle herniation typically occurs through either a traumatic or congenital focal defect in the deep overlying fascia. Patients may present with an intermittently palpable subcutaneous mass and may have neuropathic symptoms, depending on the degree of nerve involvement. Patients are initially treated with conservative modalities, whereas surgery is reserved for patients who demonstrate persistent functional limitations and neurologic symptoms. Here, we demonstrate a technique for primary repair of a symptomatic lower-leg fascial defect.

Abcc8 (sulfonylurea receptor-1) knockout mice exhibit reduced axonal injury, cytotoxic edema and cognitive dysfunction vs. wild-type in a cecal ligation and puncture model of sepsis

Sepsis-associated brain injury (SABI) is characterized by an acute deterioration of mental status resulting in cognitive impairment and acquisition of new and persistent functional limitations in sepsis survivors. Previously, we reported that septic mice had evidence of axonal injury, robust microglial activation, and cytotoxic edema in the cerebral cortex, thalamus, and hippocampus in the absence of blood–brain barrier disruption. A key conceptual advance in the field was identification of sulfonylurea receptor 1 (SUR1), a member of the adenosine triphosphate (ATP)-binding cassette protein superfamily, that associates with the transient receptor potential melastatin 4 (TRPM4) cation channel to play a crucial role in cerebral edema development. Therefore, we hypothesized that knockout (KO) of Abcc8 (Sur1 gene) is associated with a decrease in microglial activation, cerebral edema, and improved neurobehavioral outcomes in a murine cecal ligation and puncture (CLP) model of sepsis. Sepsis was induced in 4–6-week-old Abcc8 KO and wild-type (WT) littermate control male mice by CLP. We used immunohistochemistry to define neuropathology and microglial activation along with parallel studies using magnetic resonance imaging, focusing on cerebral edema on days 1 and 4 after CLP. Abcc8 KO mice exhibited a decrease in axonal injury and cytotoxic edema vs. WT on day 1. Abcc8 KO mice also had decreased microglial activation in the cerebral cortex vs. WT. These findings were associated with improved spatial memory on days 7–8 after CLP. Our study challenges a key concept in sepsis and suggests that brain injury may not occur merely as an extension of systemic inflammation. We advance the field further and demonstrate that deletion of the SUR1 gene ameliorates CNS pathobiology in sepsis including edema, axonal injury, neuroinflammation, and behavioral deficits. Benefits conferred by Abcc8 KO in the murine CLP model warrant studies of pharmacological Abcc8 inhibition as a new potential therapeutic strategy for SABI.

1235: ABBCC8 (SULFONYLUREA RECEPTOR 1) KO CONFERS NEUROPROTECTION IN SEPSIS-ASSOCIATED BRAIN INJURY

Introduction: Sepsis-Associated Brain Injury (SABI) Is Characterized by an Acute Deterioration of Mental Status Resulting in Cognitive Impairment and Acquisition of New and Persistent Functional Limitations in Sepsis Survivors. Previously, We Reported That Septic Mice Had Evidence of Axonal Injury, Robust Microglial Activation, and Cytotoxic Edema in the Cerebral Cortex, Thalamus, and Hippocampus in the Absence of Blood-Brain Barrier Disruption. In Central Nervous System Injury, Sulfonylurea Receptor 1 (SUR1), a Member of the Adenosine Triphosphate (ATP)-Binding Cassette Protein Superfamily, Associates With the Transient Receptor Potential Melastatin 4 (TRPM4) Cation Channel to Play a Crucial Role in Cerebral Edema Development. Therefore, We Hypothesized That Knockout (KO) of Abcc8 (Sur1 Gene) Is Associated With a Decrease in Microglial Activation, Cerebral Edema, and Improved Neurobehavioral Outcomes in a Murine Cecal Ligation and Puncture (CLP) Model of Sepsis. Methods: Sepsis Was Induced in 4-6-Week-Old Abcc8 KO and Wild-Type (WT) Littermate Control Male Mice by CLP. We Used Immunohistochemistry to Define Microglial Activation Along With Parallel Studies Using Magnetic Resonance Imaging, Focusing on Cerebral Edema on Days 1 and 4 Days After CLP. Results: Abcc8 KO Mice Exhibited a Decrease in Axonal Injury and Cytotoxic Edema vs. WT on Day 1. Abcc8 KO Mice Also Had Decreased Microglial Activation in the Cerebral Cortex vs WT. These Findings Were Associated With Cognitive Improvement on Days 7–8 After CLP. Conclusions: Our Study Challenges a Key Concept in Sepsis and Suggests That Brain Injury Does Not Merely Happen as an Extension of Systemic Inflammation, but Upregulation of the SUR1-TRPM4 Channel in the Brain Directly Contributes to the CNS Pathobiology Previously Demonstrated. Benefits Conferred by Abcc8 KO in the Murine CLP Model Warrant Studies of Pharmacological Abcc8 Inhibition as a New Potential Therapeutic Strategy for SABI.

285. Post-COVID-19 Functional Status (PCFS) scale in Mexican adults: a cross-sectional study

Abstract Background Over 5.74 million COVID-19 cases have been reported in Mexico as of May 1, 2022. Determining the impact of COVID-19 on functional status is essential to assess health services needs. The Post-COVID-19 Functional Status Scale (PCFS) is a patient-reported tool that evaluates functional status over time after COVID-19, listing a wide range of functional limitations. We aimed to assess the functional status of Mexican patients after recovery from COVID-19. Figure 1.Persistent Symptoms acording the PCFS scale. Methods This cross-sectional study was conducted from April 11 to May 1, 2022, through an online survey that included demographic and clinical data, PCFS grades 0-4 and persistent symptoms. We included Mexicans aged ≥18 years who recovered from COVID-19 (≥14 days since diagnosis), who resided in Mexico and agreed to participate. We posted the survey on Facebook and Twitter. We performed a descriptive analysis of demographic and clinical variables and assessed the relationship between symptoms and PCFS grade. Statistical analyses were conducted in Stata/SE 17.0. Results Of 959 respondents, 838 (87%) met inclusion and exclusion criteria. Mean age was 40 (IQR 34-46) years, 82% were female, and 40% lived in Mexico City. COVID-19 diagnosis ranged from March 21, 2020, to April 7, 2022, and mean days since diagnosis was 276 (IQR 91-480) days. Most (796, 95%) were treated as outpatients. In PCFS, 338 (40%) had no functional limitations (grade 0), 266 (32%) had negligible functional limitations (grade 1), 154 (18%) had slight functional limitations (grade 2), 44 (5%) had moderate functional limitations (grade 3), 12 (2%) had severe functional limitations (grade 4) and 24 (3%) had missing PCFS data. Overall, 654 (78%) completed the persistent symptoms section. Among them, 57% presented fatigue, 46% impaired concentration, and 10% were asymptomatic (Figure 1). Of those with &amp;gt;12 weeks since diagnosis, 88% (499/564) had at least one symptom. Conclusion Although most participants had mild COVID-19 at diagnosis, we found a high prevalence of persistent symptoms (90%) and functional limitations (60%) after recovery, revealing the devastating impact of COVID-19 on quality of life. The PCFS may be a valuable and simple tool to screen patients who could benefit from referral to rehabilitation programs, particularly in resource-limited settings. Disclosures All Authors: No reported disclosures.

Trajectory of Functional Recovery from 6 to 12 Months in Persons Hospitalized for Severe SARS-CoV-2 Illness

<h3>Research Objectives</h3> To identify distinct post-acute COVID-19 phenotypes among adults hospitalized for severe SARS-CoV-2 infection and describe multidimensional outcomes and trajectories at 6 and 12 months post-hospitalization. <h3>Design</h3> Prospective, longitudinal data collection in functional, physical, cognitive, and psychological domains at 3, 6, and 12 months post-hospitalization. Retrospective data collection from the acute care and post-acute care settings. <h3>Setting</h3> Acute care and post-acute telephone follow-up. <h3>Participants</h3> English- and Spanish- speaking adults, with decision-making capacity, admitted for inpatient rehabilitation following inpatient rehabilitation for acute COVID-19 related illness (N = 61). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Physical, cognitive, and psychological symptoms; self-reported employment status and assistance with ADLs. <h3>Results</h3> Median age 60.8 years; 59% male; 72.1% white; 72.1% non-Hispanic; 26.2% preferred assessment in Spanish. 83% required mechanical ventilation in acute care. Comorbidities were common. We found a high prevalence of persistent symptoms at 6- and 12- months across physical, cognitive, and emotional health outcome domains. Three post-acute phenotypes were identified at 6 months; a "minimally symptomatic" subgroup with minimal symptom endorsement across all domains relative to other subjects (22.95%, n = 14), a "predominantly physical symptoms" subgroup (47.54%, n = 29), and a "globally symptomatic" subgroup (29.51%, n = 18). A similar pattern for phenotypes emerges at 12-months, with 67.21% of subjects falling into the same phenotype at both time points. In the Predominantly Physical Symptom phenotype, 31.0% declined into the Globally Symptomatic Phenotype and 10.3% improved. In the Globally Symptomatic phenotype, 11.1% of participants transitioned to the Minimally Symptomatic phenotype and 16.7% to the Predominantly Physical Symptom phenotype. Compared to premorbid level of employment (50.8%), 24.6% of participants were employed at 12-months. Phenotype at 6-months was a significant predictor of employment at 12-months (B = 2.26, p = .05, OR = 9.6). <h3>Conclusions</h3> Persons with severe COVID-19 illness experience persistent functional limitations and reduced employment up to 12 months post-hospitalization. Distinct recovery subgroups were found suggesting the need for comprehensive assessment and tailored treatment for recovery. <h3>Author(s) Disclosures</h3> The authors declare no relevant conflicts of interest.

Cognitive Behavioural Therapy to Optimize Post-Operative Fracture Recovery (COPE): protocol for a randomized controlled trial

ImportanceChronic, non-cancer pain affects approximately 20–30% of the population in North America, Europe, and Australia, with surgery and trauma frequently cited as inciting events. Prospective studies of fracture patients have demonstrated an association between somatic pre-occupation, poor coping, and low recovery expectations following surgery with persistent pain, functional limitations, and lower rates of return to work. Psychological interventions, such as cognitive behavioural therapy (CBT), that are designed to modify unhelpful beliefs and behaviours have the potential to reduce persistent post-surgical pain and its associated effects among trauma patients.ObjectiveTo determine whether online CBT, versus usual care, reduces the prevalence of moderate to severe persistent post-surgical pain among participants with an open or closed fracture of the appendicular skeleton.Design, setting, and participantsThe Cognitive Behavioural Therapy to Optimize Post-Operative Fracture Recovery (COPE) protocol will be followed to conduct a multi-centre randomized controlled trial. Participants undergoing surgical repair of a long bone fracture will be randomized to receive either (1) online CBT modules with asynchronous therapist feedback or (2) usual care. The primary outcome will be the prevalence of moderate to severe persistent post-surgical pain over 12 months post-fracture. Secondary outcomes include the Short Form-36 Physical and Mental Component Summary scores, return to function, pain severity and pain interference over 12 months post-fracture, and the proportion of patients prescribed opioid class medications (and average dose) at 6 and 12 months post-fracture. The COPE trial will enroll 1000 participants with open and closed fractures of the appendicular skeleton from approximately 10 hospitals in North America.DiscussionIf CBT is effective in improving outcomes among patients with traumatic fractures, our findings will promote a new model of care that incorporates psychological barriers to recovery.Trial registrationClinicalTrials.gov Identifier: NCT04274530. Registered on 14 February 2020.

The effect of medium-term recovery status after COVID-19 illness on cardiopulmonary exercise capacity in a physically active adult population.

A failure to fully recover following coronavirus disease 2019 (COVID-19) may have a profound impact on high-functioning populations ranging from frontline emergency services to professional or amateur/recreational athletes. The aim of the study is to describe the medium-term cardiopulmonary exercise profiles of individuals with "persistent symptoms" and individuals who feel "recovered" after hospitalization or mild-moderate community infection following COVID-19 to an age, sex, and job-role matched control group. A total of 113 participants underwent cardiopulmonary functional tests at a mean of 159 ± 7 days (∼5 mo) following acute illness; 27 hospitalized with persistent symptoms (hospitalized-symptomatic), 8 hospitalized and now recovered (hospitalized-recovered); 34 community managed with persistent symptoms (community-symptomatic); 18 community managed and now recovered (community-recovered); and 26 controls. Hospitalized groups had the least favorable body composition (body mass, body mass index, and waist circumference) compared with controls. Hospitalized-symptomatic and community-symptomatic individuals had a lower oxygen uptake (V̇o2) at peak exercise (hospitalized-symptomatic, 29.9 ± 5.0 mL/kg/min; community-symptomatic, 34.4 ± 7.2 mL/kg/min; vs. control 43.9 ± 3.1 mL/kg/min, both P < 0.001). Hospitalized-symptomatic individuals had a steeper V̇e/V̇co2 slope (lower ventilatory efficiency) (30.5 ± 5.3 vs. 25.5 ± 2.6, P = 0.003) versus. controls. Hospitalized-recovered had a significantly lower oxygen uptake at peak (32.6 ± 6.6 mL/kg/min vs. 43.9 ± 13.1 mL/kg/min, P = 0.015) compared with controls. No significant differences were reported between community-recovered individuals and controls in any cardiopulmonary parameter. In conclusion, medium-term findings suggest that community-recovered individuals did not differ in cardiopulmonary fitness from physically active healthy controls. This suggests their readiness to return to higher levels of physical activity. However, the hospitalized-recovered group and both groups with persistent symptoms had enduring functional limitations, warranting further monitoring, rehabilitation, and recovery.NEW & NOTEWORTHY At 5 mo postinfection, community-treated individuals who feel recovered have comparable cardiopulmonary exercise profiles to the physically trained and active controls, suggesting a readiness to return to higher intensity/volumes of exercise. However, both symptomatic groups and the hospital-recovered group have persistent functional limitations when compared with active controls, supporting the requirement for ongoing monitoring, rehabilitation, and recovery.

Analysis of Factors That Influence Patient Satisfaction After Periacetabular Osteotomy: An Asian Cohort Study

Periacetabular osteotomy (PAO) is an effective joint-preserving procedure for developmental dysplasia of the hip. However, some patients report dissatisfaction after PAO. Because patient satisfaction is increasingly used as a health care quality metric, it is important to gain a better understanding of factors associated with patient satisfaction after PAO. The goal of this study was to investigate patient satisfaction among a cohort of Asian patients undergoing PAO. This study included 227 Asian patients who had undergone PAO at our institution between 1998 and 2016. The study participants completed a questionnaire assessing patient satisfaction, reasons for dissatisfaction, and postoperative Oxford Hip Score (OHS) and University of California, Los Angeles (UCLA), activity scale score. Based on their satisfaction levels, the participants were divided into 4 subgroups, and their demographic characteristics and postoperative patient-reported outcomes were compared. Of the 227 patients, 190 expressed satisfaction that correlated with OHS-pain, OHD-activities of daily living, and UCLA activity scale scores. Primary reasons for dissatisfaction after PAO were persistent pain (24 of 49, 49%), functional limitations (14 of 49, 29%), stiffness around the hip (4 of 49, 8%), unmet expectations (4 of 49, 8%), conversion to total hip arthroplasty (2 of 49, 4%), and complications (1 of 49, 2%). Multivariate analysis showed that preoperative Kellgren-Lawrence grades 1 and 3 were the significant predictive factors for satisfaction and dissatisfaction, respectively. The potential for lower patient satisfaction associated with Kellgren-Lawrence grade 3 because of persistent pain and functional limitations postoperatively suggests that consideration of preoperative severity of osteoarthritis could enhance patient satisfaction after PAO. [Orthopedics. 20XX;4X(X):xx-xx.].

Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review.

Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation. A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis. A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation. Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data. Many patients report persistent pain and functional limitations up to 18months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Prevalence and Correlates of Depressive Symptoms Within 6 Months After First-Time Mild Traumatic Brain Injury.

Depressive symptoms are among the most common neuropsychiatric sequelae of mild traumatic brain injury (mTBI). Very few studies have compared correlates of depressive symptoms within the first 6 months of injury in cohorts experiencing their first TBI. The authors investigated whether the correlates of depressive symptoms (being female, older, lower education, having brain lesions, experiencing worse postconcussive symptoms, and incomplete functional recovery) that have been established in populations with moderate to severe TBI were the same for individuals with first-time mTBI within the first 6 months of recovery. Two hundred seventeen individuals with first-time mTBI were divided into subgroups-new-onset depressive symptoms, recurrent depressive symptoms, prior depression history only, and never depressed-and compared on clinical and demographic variables and the presence of postconcussive symptoms and functional recovery at 3 and 6 months. New-onset depressive symptoms developed in 12% of the cohort, whereas 11% of the cohort had recurrent depressive symptoms. Both depressive symptoms groups were more likely to comprise women and persons of color and were at higher risk for clinically significant postconcussive symptoms and incomplete functional recovery for the first 6 months postinjury. Presence of depressive symptoms after first-time mTBI was associated with persistent postconcussive symptoms and incomplete functional recovery in the first 6 months. Adding to the existing literature, these findings identified correlates of depressive symptom development and poor outcomes after mTBI, thus providing further evidence that mTBI may produce persistent symptoms and functional limitations that warrant clinical attention.

Spaulding REhabilitation and COVid Recovery study (RECOVR): Preliminary Findings at 6 Months

Research ObjectivesTo identify distinct post-acute COVID-19 phenotypes among adults hospitalized for severe SARS-CoV-2 infection and describe multidimensional outcomes at 6 months post-hospitalization.DesignProspective, longitudinal data collection in functional, physical, cognitive, and psychological domains at 3, 6, and 12 months post-hospitalization. Retrospective data collection from the acute care and post-acute care settings.SettingAcute care and post-acute telephone follow-up.ParticipantsSpanish- and English-speaking adults, with decision-making capacity, admitted for inpatient rehabilitation following inpatient hospitalization for acute COVID-19 related illness (N = 52).InterventionsN/A.Main Outcome MeasuresPhysical, cognitive, and psychological symptoms; Self-reported employment status and assistance with ADLs.ResultsMedian age was 60.96 (IQR = 20.89), with race/ethnicity representative of the US adult population (71% White; 13% Black; 27% Hispanic). Compared to premorbid status, 33% of individuals were no longer employed full-time and 23% were no longer independent in basic ADLs. Latent profile analysis identified distinct subgroups within physical, cognitive, and emotional domains of functioning. Approximately 31% were in either the moderately or most symptomatic groups for both cognitive and emotional functioning, with 88% of these also falling into the most symptomatic group for physical functioning. There were 29% in the least symptomatic group across all domains.ConclusionsPersons with severe COVID-19 illness experience persistent functional limitations that interfere with employment and ADLs up to 6 months post-hospitalization. Although symptom variability is high at 6 months, we identified distinct subgroups, including those with co-occurring emotional and cognitive symptoms, that suggest the need for comprehensive assessment and tailored treatment for physical, emotional, and cognitive symptoms.Author(s) DisclosuresThe author's declare no relevant conflict of interests.

Femoroacetabular offset restoration in total hip arthroplasty; Digital templating a short stem vs a conventional stem.

BACKGROUNDFailure in restoring individual anatomy could be a reason for persistent functional limitations post total hip arthroplasty. Femoroacetabular offset (FAO) plays an important role in anatomic restoration, as loss of offset ≥ 5 mm is associated with altered gait and decreased functional outcome. Preoperative assessment by use of digital templating has shown to be a reliable method for sizing the components in total hip arthroplasty, and can show if anatomic restoration is achieved. In recent years, short stems are growing in popularity as it could allow better restoration due to more variety in placement.AIMTo assess whether restoration of the FAO differs between a short or a conventional stem by use of digital templating. Additionally, association of the preoperative offset and caput-colllum-diaphyseal angle (CCD-angle) within restoration of both stems was investigated, and the reliability of measurements was assessed.METHODSA total of 100 standardized hip radiographs were used for digital templating. Restoration of FAO was classified into “restored” or “not restored”, when a < 5 mm or ≥ 5 mm difference from baseline value presented, respectively. Differences between the two stems concerning proportions of correct restoration of the FAO were analyzed by use of McNemar tests. To assess association between CCD-angle and preoperative FAO with absolute FAO restoration, multi-level analysis was performed by use of a linear mixed model to account for paired measurements. Through determination of the optimal point under the curve in operating curve-analysis, bootstrapping of thousand sets was performed to determine the optimal cutoff point of the preoperative FAO for restoration within the limits of 5 mm. Three observers participated for inter-observer reliability, with two observers measuring the radiographs twice for intra-observer reliability.RESULTSThe mean preoperative FAO was 79.7 mm (range 62.5-113 mm), with a mean CCD-angle of 128.6° (range 114.5°-145°). The conventional stem could only restore the FAO in 72 of the cases, whereas the short stem restored the FAO in all cases. CCD-angle was not a predictor, but the preoperative FAO was. A cut-off point of 81.25 mm (95% confidence interval of 80.75-84.75 mm) in preoperative FAO was found where the conventional stem was unable to restore the FAO. Reliability of measurements was excellent, with an intra-observer reliability of 0.99 and inter-observer reliability in baseline measurements higher than 0.9 between the three observers.CONCLUSIONIn preoperative planning of FAO restoration in total hip arthroplasty, digital templating shows that short stems with a curve following the medial calcar are potentially better at restoring the FAO compared to conventional stems if the preoperative offset is ≥ 80.0 mm.

What influences patient satisfaction after total knee replacement? A qualitative long-term follow-up study

ObjectivesTo explore whether a conceptual model of patient satisfaction previously developed 1–2 years post-total knee replacement (TKR) is still relevant 3–4 years post-TKR. Specifically, (i) what is the stability in...