Rehabilitation Protocol Research Articles

StrokeCog-R: Protocol for a Pilot Randomised Controlled Trial Of A Novel Cognitive Rehabilitation Intervention For Post-Stroke Cognitive Impairment

Abstract Background Post-stroke cognitive impairment (PSCI) affects 50% of patients six months post-stroke and is associated with increased disability, reduced quality of life, diminished independence, and a higher risk of long-term care and dementia. Addressing cognitive impairment is crucial to maximise patient recovery, facilitate the return to pre-stroke activities, and optimise secondary prevention efforts. However, cognitive rehabilitation is underrepresented in standard stroke rehabilitation protocols. This pilot randomised controlled trial (RCT) aims to evaluate a novel cognitive rehabilitation intervention, StrokeCog-R, designed to enhance cognitive function in stroke survivors with PSCI. The primary aims are to assess the feasibility of patient recruitment and retention and to determine the statistical power needed for a definitive trial. A secondary aim is to evaluate the efficacy and acceptability of the intervention for individuals with mild-to-moderate PSCI. Methods Sixty-four consecutive stroke patients with mild-to-moderate PSCI will be recruited and randomly assigned to either the intervention group (StrokeCog-R) or the control group (usual care). The intervention involves five weeks of group-based cognitive rehabilitation using “Rehearsal-Based” and “Compensatory-Based” strategies, supplemented with tailored home activities. Cognitive function, self-efficacy, and caregiver psychological wellbeing will be assessed pre- and post-intervention (or control) and at a four-month follow-up. Intervention acceptability will be documented through focus groups following each intervention. Recruitment is ongoing, and the first intervention group has concluded. Results Recruitment and retention rates, the feasibility of randomisation, patient acceptability, and resource utilisation will be evaluated. Additionally, the effectiveness of various communication techniques for retaining participants between the intervention period and the four-month follow-up will be assessed. These data will inform recruitment strategies and the determination of necessary effect sizes to power a definitive trial. Conclusion This study will provide critical insights for a definitive trial, potentially making a substantial contribution to the evidence base for cognitive rehabilitation in stroke patients.

The Effectiveness of the Modified Side-Locking Loop Suture Technique with Early Accelerated Rehabilitation for Acute Achilles Tendon Rupture in Athletes

Background/Objectives: An early accelerated rehabilitation is generally recommended after surgery for acute Achilles tendon ruptures (ATRs). The modified side-locking loop suture (MSLLS) is a surgical technique that provides high tensile strength to the repaired Achilles tendon and allows for a safe, early accelerated rehabilitation protocol without requiring postoperative immobilization. However, there are no reports investigating the clinical outcomes of the MSLLS technique with early accelerated rehabilitation for ATRs. To clarify the effectiveness of the MSLLS technique with an early accelerated rehabilitation protocol for ATR in athletes. Methods: We retrospectively analyzed 27 athletes (Tegner activity score ≥ 6) who underwent surgical treatment using the MSLLS technique for ATR between April 2017 and August 2022. All patients underwent an early accelerated rehabilitation protocol without immobilization. Outcome measures included the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (AOFAS) score taken preoperatively and one year postoperatively, the time required to perform 20 continuous double-leg heel raises (DHR) and single-leg heel raises (SHR), the time to return to the original sport, and the presence of any complications. Results: The mean AOFAS score significantly improved from 37.2 ± 9.7 preoperatively to 96.3 ± 5.3 one year postoperatively. The mean time to be able to perform 20 continuous DHR and SHR was 7.7 ± 1.2 weeks and 11.3 ± 1.6 weeks, respectively. All patients were able to return to their original sport at their pre-injury level in an average of 22.7 ± 3.7 weeks without complication. Conclusions: The MSLLS technique in conjunction with an early accelerated rehabilitation protocol for ATR in athletes produced satisfactory results, with all patients able to return to their original sport at their preinjury level without complication.

Comparison of mental fatigue using EEG signals and task performance in normal and slump posture adults during computer typing

ObjectivesSlump sitting at workstations has been focused on by clinicians and researchers nowadays; however, there is limited evidence to date that improper positioning affects the mental state. Accordingly, the main objective of this research was to examine the impact of slump posture on mental fatigue and task performance. MethodsA sample of 60 participants, 30 in each group including those with normal and slump postures were recruited to perform an hour of typing on the computer. Mental fatigue through EEG and task performances were considered as outcome measures and then were analyzed statistically in the first and last 3 min of typing. ResultsThe EEG showed a significant increasing trend in theta rhythm at different brain regions during 60 min of typing (P < 0.05). Besides, an interaction between time and posture was observed; it can mean the increasing trend of theta rhythm is different in normal and slump posture acquired sets (P < 0.05).Interestingly the speed of typing was found to be better (P < 0.05) in the normal posture group while no difference found between the groups in terms of errors (P > 0.05). ConclusionOur results showed poor posture can induce more mental fatigue during the given task, than the normal posture. These findings have provided evidence to indicate that in addition to the peripheral and biomechanical component, the assessment of the cortex as the central component should be considered in poor posture individuals. Besides, for any possible physical therapy rehabilitation protocol for the management of poor posture, the peripheral and central components should be focused. Trial registrationRegistered on the Iranian Registry of Clinical Trials on September 21, 2022, IRCT Identifier: IRCT20161026030516N2.

Study on correlation between Chinese medicine syndromes in stroke and neurological deficits during recovery phase: Perspective.

Stroke is a leading cause of long-term disability and mortality worldwide, necessitating effective rehabilitation strategies for successful recovery. Traditional Chinese medicine (TCM) has gained recognition as a complementary and alternative approach in stroke rehabilitation, owing to its unique syndromes that offer valuable insights for personalized treatment plans. This study aims to elucidate the correlation between TCM syndromes observed during the recovery phase of stroke and the associated neurological deficits. Syndromes such as Blood stasis, Phlegm-dampness, Qi deficiency, and Yin deficiency were systematically examined, while standardized neurological assessments, encompassing motor function, sensory perception, and cognitive abilities, were employed to evaluate the extent of neurological impairment. Rigorous statistical analyses were conducted to discern potential correlations between TCM syndromes and the severity of neurological deficits. The results revealed statistically significant positive associations between certain TCM syndromes, particularly Blood stasis and Phlegm-dampness, and heightened neurological deficits during the recovery phase post-stroke. These findings suggest that these syndromes may serve as indicators of more severe brain injury post-stroke, thereby guiding the development of tailored rehabilitation strategies. By establishing robust connections between TCM syndromes and neurological deficits, this study contributes to advancing our understanding of stroke recovery through an integrated approach that incorporates TCM principles. Moreover, it underscores the potential benefits of integrating TCM into conventional rehabilitation protocols, offering valuable insights for healthcare professionals and potentially improving patient outcomes.

Standardized treatment of infection after anterior cruciate ligament reconstruction

Infection after anterior cruciate ligament reconstruction (ACLR) is a rare and catastrophic postoperative complication. The aims of this study were to investigate the diagnostic, treatment and rehabilitation measures for postoperative infection following after ACLR. A retrospective study was conducted on 1500 patients who underwent ACLR between January 2011 and January 2022. Twenty patients who met the criteria for summarizing the incidence patterns and treatment experiences were selected for a complete investigation of their diagnostic, therapeutic, and rehabilitation processes, as well as outpatient follow-up results. Among the 20 patients who developed postoperative infections, Staphylococcus aureus was the main pathogen (80%). The clinical manifestations mainly included fever (80%) and knee joint pain (100%). Laboratory tests demonstrated that C-reactive protein (CRP) levels were greater than 50 mmol/L in fifteen patients (75%). All of the patients received intravenous antibiotic therapy. Five patients (25%) of tendon socket infection were treated with continuous negative pressure suction irrigation, whereas the other fifteen patients with intra-articular infection were treated with arthroscopic debridement and continuous flushing. The Lysholm score of the affected knee was compared before treatment and 6 months after treatment, and the difference was statistically significant (t = 20.78, P < 0.001). The success rate of treatment was 100%, and there were no significant differences between patients who received secondary treatment and functional exercise and those who underwent ACLR in terms of knee joint function or range of motion during the same time period. Infection was rare after ACLR, however it was fatal, and the main pathogen was Staphylococcus aureus. Early diagnosis and a comprehensive treatment approach are pivotal for the successful management of postoperative infections following ACLR. The results of this study contribute valuable clinical insights for further refining surgical procedures, enhancing infection prevention measures, and optimizing rehabilitation protocols.

The Role of Brain Plasticity in Neuromuscular Disorders: Current Knowledge and Future Prospects.

Background/Objectives: Increasing evidence shows an involvement of brain plasticity mechanisms in both motor and central manifestations of neuromuscular disorders (NMDs). These mechanisms could be specifically addressed with neuromodulation or rehabilitation protocols. The aim of this scoping review is to summarise the evidence on plasticity mechanisms' involvement in NMDs to encourage future research. Methods: A scoping review was conducted searching the PubMed and Scopus electronic databases. We selected papers addressing brain plasticity and central nervous system (CNS) studies through non-invasive brain stimulation techniques in myopathies, muscular dystrophies, myositis and spinal muscular atrophy. Results: A total of 49 papers were selected for full-text examination. Regardless of the variety of pathogenetic and clinical characteristics of NMDs, studies show widespread changes in intracortical inhibition mechanisms, as well as disruptions in glutamatergic and GABAergic transmission, resulting in altered brain plasticity. Therapeutic interventions with neurostimulation techniques, despite being conducted only anecdotally or on small samples, show promising results; Conclusions: despite challenges posed by the rarity and heterogeneity of NMDs, recent evidence suggests that synaptic plasticity may play a role in the pathogenesis of various muscular diseases, affecting not only central symptoms but also strength and fatigue. Key questions remain unanswered about the role of plasticity and its potential as a therapeutic target. As disease-modifying therapies advance, understanding CNS involvement in NMDs could lead to more tailored treatments.

The use of the 360 MD Huber platform in rehabilitation of lumbar radiculopathies, chronic period

Low back pain (LBP) is a common medical condition with a negative impact on quality of life and work. It also leads to financial costs for the health system by increasing the costs of medical treatment. Numerous studies have focused on the effects of exercise, with some highlighting the role of protective studies in LBP while other studies have shown no beneficial. There is moderate-certainty evidence that therapeutic exercise is beneficial in the treatment of chronic low back pain compared with other treatment modalities. Muscle strengthening and the creation of spinal mobility through specific exercise is a recognized therapeutic approach to the prevention and treatment of LBP. The main objecvtive is to evaluate the effectiveness of a physi-cal therapy program utilizing the 360 Huber platform on the quality of life for individuals with chronic lumbar radiculopathy. A randomized controlled trial was conducted with 30 participants diagnosed with chronic lumbar radiculopathy. Participants were divided into an ex-perimental group (n=20) receiving the 360 Huber platform-based rehabilitation protocol, and a control group (n=10) continuing standard care. The intervention included 15 sessions of physical therapy on the 360 Huber platform, complemented by electrotherapy and therapeutic massage. The Oswestry Disability Index (ODI) was administered pre- and post-intervention to assess changes in functional outcomes and quality of life. The experimental group demonstrat-ed a significant reduction in ODI scores, with an average decrease of 1.85 points (10.11%) from 18.30 to 16.45. The paired t-test analysis revealed a statistically significant difference (p &lt; 0.001) and a very large effect size (1.11), indicating substantial improvements in functional outcomes. The control group showed no significant changes. The rehabilitation protocol using the 360 Huber platform, combined with electrotherapy and therapeutic massage, effectively im-proves functional outcomes and quality of life for patients with chronic lumbar radiculopathy. The study highlights the potential of integrating advanced technology with traditional physical therapy methods to enhance treatment efficacy. Future research with larger sample sizes and longer follow-up periods is recommended to confirm these findings and explore additional therapeutic modalities.

The long-term impact of rehabilitation in upper limb plexopathies

The main objective of the research consists in providing evidence that a long-term rehabilitation protocol is favorable for the patient. In adult brachial plexus (BP) palsies, after several surgical attempts, the lack of results in the upper limb’s functionality leads to less compliance to rehabilitation therapy. The upper limb’s functionality of 22 patients with posttraumatic operated chronic BP paresis (either on the right or left, regardless the dominant limb) was assessed retrospectively. The patients were evaluated regarding MRC scaling, dynamometric tests and electroneuromyographic examination. All patients have gone through at least one rehabilitation interval (10 days) after an initial evaluation, and were evaluated again, by same methods, at a second session, at least 6 months later, but no more than one year.. Mild and inconstant improvements were obtained in a total of 9 patients, especially in better dynamometric results and improved amplitudes of motor and sensory action potentials. The electrodiagnosis correlates with dynamometric parameters (muscle strength) and slight amelioration of the motor deficit. Given the small sample size as a limitation, as well as no standardized therapeutic protocol, it should be noted that the 9 patients were the only ones who either attended more than one interval or did more procedures as frequency in time (more often meaning 3 times weekly for 6 months, in 6 patients). Although the most frequent procedures were neuromuscular electrical stimulation (NMES) and proprioceptive neuromuscular facilitation (PNF), the results suggest that regardless of the techniques, the more active patients had better results. Proving the need for long-term rehabilitation, even contrary to the less visible results, can be the trigger point for future research and therapy strategies, as the results suggest central mechanisms involved, adding the cortical ongoing plasticity into the equation.

A rare case of total hip replacement in an 11-year-old female: rehabilitation goals and challenges - a case report

This case report describes a unique pediatric patient, the first and youngest in India, who underwent total hip replacement (THR) for right ankylosed hip. Patient presented with preoperative musculoskeletal deformities, posing challenges for postoperative rehabilitation. This 11-year-old female presented with non-traumatic insidious right hip pain, limping, right hip flexion and abduction deformity. Patient was diagnosed with idiopathic chondrolysis of the hip through exclusion and clinico-radiological findings. Patient underwent surgery for ceramic-on-ceramic THR. Fusion of triradiate cartilage and epiphysis and Risser’s skeletal maturity staging were confirmed. Postoperative examination revealed right hip flexion and abduction deformity resulting in pelvic obliquity, which led to limb length discrepancy and functional scoliosis. There was increased anterior pelvic tilt, altering the gait pattern. Adhering to THR restrictions, rehabilitation strategies were tailored to restore normal pelvic orientation and address deformities through manual stretching of right hip abductor, tensor fascia latae, iliopsoas and rectus femoris. A left-sided shoe raise was also given. Lumbar segmental muscle activation, pelvic floor muscle training and gait training were crucial parts of the rehabilitation protocol. At ten-week, prodigious outcomes were achieved in the form of complete pain relief, complete correction of abduction and flexion deformity, normal pelvic alignment in the frontal plane and independent, stable full weight-bearing ambulation after two years of disabling ordeal suffering. However, minimal compensation of the anterior pelvic tilt persisted. Rehabilitation of this challenging patient with multiple deformities achieved excellent outcomes at ten-week post-rehabilitation. Thus, a tailored meticulous rehabilitation program can significantly improve quality of life.

Muscle recruitment during gait in individuals with unilateral transfemoral amputation due to trauma compared to able-bodied controls.

Individuals with transfemoral lower limb amputations walk with adapted gait. These kinetic and kinematic compensatory strategies will manifest as differences in muscle recruitment patterns. It is important to characterize these differences to understand the reduced endurance, reduced functionality, and progression of co-morbidities in this population. This study aims to characterize muscle recruitment during gait of highly functional individuals with traumatic transfemoral amputations donning state-of-the-art prosthetics compared to able-bodied controls. Inverse dynamic and static optimisation methods of musculoskeletal modelling were used to quantify muscle forces of the residual and intact limb over a gait cycle for 11 individuals with traumatic transfemoral amputation and for 11 able-bodied controls. Estimates of peak muscle activation and impulse were calculated to assess contraction intensity and energy expenditure. The generalized estimation equation method was used to compare the maximum values of force, peak activation, and impulse of the major muscles. The force exhibited by the residual limb's iliacus, psoas major, adductor longus, tensor fasciae latae and pectineus is significantly higher than the forces in these muscles of the intact contralateral limb group and the able-bodied control group (p < 0.001). These muscles appear to be recruited for their flexor moment arm, indicative of the increased demand due to the loss of the plantar flexors. The major hip extensors are recruited to a lesser degree in the residual limb group compared to the intact limb group (p < 0.001). The plantar flexors of the intact limb appear to compensate for the amputated limb with significantly higher forces compared to the able-bodied controls (p = 0.01). Significant differences found in impulse and peak activation consisted of higher values for the limbs (residual and/or intact) of individuals with transfemoral lower limb amputations compared to the able-bodied controls, demonstrating an elevated cost of gait. This study highlights asymmetry in hip muscle recruitment between the residual and the intact limb of individuals with transfemoral lower limb amputations. Overall elevated impulse and peak activation in the limbs of individuals with transfemoral amputation, compared to able-bodied controls, may manifest in the reduced walking endurance of this population. This demand should be minimised in rehabilitation protocols.

Fast rehabilitation does not worsen clinical, radiological, and arthroscopic outcomes after medial meniscus posterior root repair: A retrospective comparative study

Background/ObjectiveThe main surgical treatment for medial meniscus posterior root tear (MMPRT) has shifted from meniscectomy to meniscus repair; however, there is no clear consensus regarding the optimal postoperative management strategy after MMPRT repair. This study aimed to perform a comparative analysis of patients who received conventional rehabilitation or fast rehabilitation following MMPRT repair. MethodsThe current retrospective cohort study compared clinical, radiological, and arthroscopic outcomes after conventional rehabilitation (group A, January 2020 to April 2020, 24 patients) with those after fast rehabilitation (group B, May 2020 to August 2020, 24 patients) in patients who underwent pullout repair for MMPRT. Partial weight-bearing and range of motion exercises were allowed 2 weeks postoperatively in group A and 1 week postoperatively in group B. In patients with an average weight of approximately 60 kg, full weight bearing was allowed 4 weeks postoperatively in group A and 3 weeks postoperatively in group B. ResultsAt 12 months postoperatively, the clinical scores, including International Knee Documentation Committee and Japanese Knee Injury and Osteoarthritis Outcome Score, significantly improved in both groups (p < 0.01). Although meniscus healing was achieved in both groups, medial meniscus extrusion significantly progressed by 0.9 mm in group A and 0.8 mm in group B (p < 0.01, compared with preoperative extrusion). There were no significant differences in clinical scores, arthroscopic meniscal healing status, or medial meniscus extrusion progression on magnetic resonance images between the groups. ConclusionA fast rehabilitation protocol can be safely implemented without compromising patient outcomes after pullout repair for MMPRT.

A Statistical Approach for Functional Reach-to-Grasp Segmentation Using a Single Inertial Measurement Unit.

The aim of this contribution is to present a segmentation method for the identification of voluntary movements from inertial data acquired through a single inertial measurement unit placed on the subject's wrist. Inertial data were recorded from 25 healthy subjects while performing 75 consecutive reach-to-grasp movements. The approach herein presented, called DynAMoS, is based on an adaptive thresholding step on the angular velocity norm, followed by a statistics-based post-processing on the movement duration distribution. Post-processing aims at reducing the number of erroneous transitions in the movement segmentation. We assessed the segmentation quality of this method using a stereophotogrammetric system as the gold standard. Two popular methods already presented in the literature were compared to DynAMoS in terms of the number of movements identified, onset and offset mean absolute errors, and movement duration. Moreover, we analyzed the sub-phase durations of the drinking movement to further characterize the task. The results show that the proposed method performs significantly better than the two state-of-the-art approaches (i.e., percentage of erroneous movements = 3%; onset and offset mean absolute error < 0.08 s), suggesting that DynAMoS could make more effective home monitoring applications for assessing the motion improvements of patients following domicile rehabilitation protocols.

Early implementation of MAK robotic device in total knee arthroplasty rehabilitation: A proof-of-concept study.

Effective rehabilitation following total knee arthroplasty (TKA) is crucial for enhancing both range of motion (ROM) and functional outcomes. While robotics has demonstrated its potential in various medical contexts, the evidence on its application in TKA rehabilitation is still scarce. The marsi active knee (MAK), a robotic device that has already proven to be safe and beneficial in people with neurological disease, has been tested to facilitate the rehabilitation of TKA patients. This study aims to evaluate the safety, patient satisfaction, and clinical impact of integrating the MAK into an early rehabilitation regimen for TKA patients. The intervention comprised 14 one-hour sessions administered thrice a week, utilizing the MAK within 48h post-TKA surgery. The rehabilitation sessions incorporated exercises involving passive mobilizations, sit-to-stand transitions, and gait training. Comprehensive data encompassing safety parameters, patient satisfaction, and clinical outcomes were meticulously collected and analyzed. Six participants successfully completed the rehabilitation protocol with the MAK device. Notably, no significant adverse events were documented. Application of the device corresponded to perceptible reductions in self-reported pain levels. Vital signs remained within minimal variance pre- and post-rehabilitation. Participants proficiently engaged in all assisted exercises facilitated by the device, culminating in a high overall satisfaction rating of 4.6±0.5 out of 5. The findings indicate that the MAK device exhibits a commendable level of safety while obtaining considerable patient satisfaction during the early rehabilitation phase following TKA, suggesting this device may be a reliable adjunct to TKA protocols.

Efficacy and safety of using a unilateral lower limb exoskeleton combined with conventional treatment in post-stroke rehabilitation: a randomized controlled trial.

The incidence of hemiplegia caused by stroke is high. In particular, lower limb dysfunction affects the daily activities of patients, and lower limb robotic devices have been proposed to provide rehabilitation therapy to improve balance function in this patient population. To assess the effectiveness of the LiteStepper® unilateral lower limb exoskeleton (ULLE) combined with conventional treatment for balance function training in patients with post-stroke hemiplegia. This multicenter randomized controlled trial, conducted in the convalescent rehabilitation ward of four hospitals, involved 92 patients in their post-stroke phase. Participants were randomized into an experimental group (EG) or a conventional group (CG). The EG adopted the LiteStepper® ULLE combined with conventional treatment for 21days. The CG underwent a standard daily rehabilitation routine for 21days. The Berg Balance Scale (BBS), Functional Ambulation Category scale (FAC), 6-min walk test (6MWT), and Barthel Index (Barthel) were used for evaluations before and after 21days of rehabilitative training. The BBS scores in EG was significantly elevated compared to CG, exhibiting a profound statistical difference (P< 0.0001). Notably, these disparities persisted at both day 21 (P < 0.0001) and day 14 (P < 0.0047) post-intervention, underscoring the efficacy of the treatment in the EG. The EG demonstrated a markedly greater improvement in BBS scores from pre-rehabilitation to 21days post-training, significantly outperforming the CG. Furthermore, at both day 14 and day 21, functional assessments including the FAC, 6MWT, and Barthel revealed improvements in both groups. However, the improvements in the EG were statistically significant compared to the CG at both time points: day 14 (FAC, P = 0.0377; 6MWT, P = 0.0494; Barthel, P = 0.0225) and day 21 (FAC, P = 0.0015; 6MWT, P = 0.0005; Barthel, P = 0.0004). These findings highlight the superiority of the intervention in the EG in enhancing functional outcomes. Regarding safety, the analysis revealed a solitary adverse event (AEs) related to the LiteStepper®ULLE device during the study period, affirming the combination therapy's safety profile when administered alongside conventional balance training in post-stroke hemiplegic patients. This underscores the feasibility and potential of incorporating LiteStepper®ULLE into rehabilitation protocols for this patient population. The LiteStepper® ULLE combined with conventional treatment is effective and safe for balance function training in patients with post-stroke hemiplegia.

Walking on different inclines affects gait symmetry differently in the anterior-posterior and vertical directions: implication for future sensorimotor training

A symmetric gait pattern in humans reflects near-identical movement in bilateral limbs during walking. However, little is known about how gait symmetry changes on different inclines. This study aimed to address this knowledge gap using the central pattern generator and internal model hypotheses. Eighteen healthy young adults underwent five 2-minute walking trials (inclines of +15%, +8%, 0%, −8%, and −15%). Dependent variables included step time, step length, step width, maximum heel clearance, time to peaks of maximum heel clearance, their corresponding coefficients of variation (CV), and respective symmetry indices (SI). Significant differences were observed in SI of step length (p = .022), step length variability (p &lt; .001), step width variability (p =.001), maximum heel clearance (p &lt; .001), and maximum heel clearance variability (p = .049). Compared to level walking, walking at −8% and −15% inclines increased SI of step length (p = .011, p = .039 respectively) but decreased SI of maximum heel clearance (p = .025, p = .019 respectively). These observations suggested that incline walking affected gait symmetry differently, possibly due to varied internal models used in locomotion. Downhill walking improved vertical gait symmetry but reduced anterior-posterior symmetry compared to level walking. Downhill walking may be a preferable rehabilitation protocol for enhancing gait symmetry, as it activates internal model controls. Even slight downhill inclines could increase active control loading, beneficial for the elderly and those with impaired gait.

A Modern-Day Algorithm for the Treatment of Multi-Ligament Knee Injuries.

Multiligament knee injuries (MLKI) are rare and complex, significantly impacting long-term outcomes, with risks of osteoarthritis, joint stiffness, and reduced activity levels. To explore the evolution of MLKI treatment protocols, comparing historical and modern approaches, and to present a patient-tailored, preservation-first algorithm. This article reviews the literature on MLKI management, focusing on surgical timing, techniques, and rehabilitation protocols. The proposed algorithm categorizes MLKIs based on tear location and tissue quality, incorporating options, such as primary ligament repair, augmentation, and reconstruction. The modern preservation-first algorithm provides a tailored approach to MLKI treatment, addressing the complexity and heterogeneity of these injuries, and aims to mitigate risks like postoperative arthrofibrosis. MLKI management remains complex and controversial. The presented algorithm offers a structured, individualized treatment strategy that integrates modern surgical and rehabilitation advancements.

Characterizing the Longitudinal Impact of Backward Locomotor Treadmill Training on Walking and Balance Outcomes in Chronic Stroke Survivors: A Randomized Single Center Clinical Trial.

Walking and balance impairments after stroke are a global health concern, causing significant morbidity and mortality. However, effective strategies for achieving meaningful recovery in the chronic stages are limited. Backward locomotor treadmill training (BLTT) is a novel walking rehabilitation protocol that is safe, feasible, and likely beneficial in stroke survivors; however, its efficacy has not been tested. This single-center, randomized, assessor-blind clinical trial aims to test the preliminary efficacy of BLTT compared to forward locomotor treadmill training (FLTT) on walking speed, symmetry, and postural stability. Forty stroke survivors [BLTT (N=19), FLTT (N=21); mean age= 56.3 ± 8.6 years; 53% Female; 30% Non-Hispanic Black] with mild-moderate walking impairment were enrolled. Participants underwent nine 30-minute BLTT or FLTT sessions over three weeks. The primary outcome was the mean change in the 10-meter walk test (10 MWT) at 24 hours post-training (24 hr POST). Secondary outcome measures were changes in spatiotemporal walking symmetry and postural stability during quiet standing at 24 hr POST. Retention was explored at Days 30- and 90 POST. We report clinically meaningful (≥ 0.16 m/s) improvements in overground walking speed at 24 hr POST, with retention up to Day 90 POST with BLTT and FLTT. However, contrary to our working hypothesis, no between-group differences in walking speed were observed. Nonetheless, we found that BLTT resulted in offline improvements in spatial symmetry and retention of subcomponents of the modified clinical test of sensory interaction on balance (mCTSIB), including the testing of proprio-vestibular integration up to Day 30 POST. Among chronic stroke patients with mild-moderate walking impairment, BLTT and FLTT both resulted in long-lasting and clinically meaningful improvement in walking speed. However, preliminary findings suggest that BLTT may better comprehensively target walking asymmetry and sensory systems processing and integration.

Fibro-adhesive Bursitis: A Novel Sonographic Finding in Adhesive Capsulitis Patients and a Proposal of Management.

Adhesive capsulitis, also known as "frozen shoulder," is a debilitating shoulder condition increasingly linked to fibroadhesive bursitis, particularly after COVID-19 and related vaccinations. There is no definitive gold standard for its treatment, the primary therapeutic objectives of which are the reduction of pain and the restoration of shoulder range of motion. The aim of our study was to analyze treatment outcomes based on quantitative measures of shoulder function and symptom relief. Conducted between January 2022 and April 2023, the research involved 45 patients initially diagnosed with adhesive capsulitis and associated fibroadhesive bursitis. After excluding nine patients for other concomitant pathologies (five for calcific tendinopathy and four for rotator cuff injury), 36 patients were randomized into two groups: one group was treated with glenohumeral hydrodistension, the other with glenohumeral hydrodistension combined with bursal injection. Assessments were conducted at baseline and then 2, 4, and 6months after treatment, focusing on changes in pain levels, functional scores, and range of motion in all planes. Each group followed a home-based rehabilitation protocol. Significant improvements were observed in both treatment groups, with the combined hydrodistension and bursal injection group showing notably superior outcomes. Specifically, the range of motion in flexion improved from an initial median of 80° to 155° in the combined treatment group, compared to an increase from 75.5° to 129° in the group treated with hydrodistension alone. This enhancement was statistically significant (p < 0.001). Regarding pain reduction, the combined treatment group demonstrated a dramatic decrease in visual analogue scale (VAS) scores, from a baseline median of 7 to 1 at the 6-month follow-up. In contrast, the hydrodistension-only group showed a reduction from 7 to 3, with these differences also proving statistically significant (p < 0.001). Ultrasound-guided hydrodistension of the glenohumeral joint, if combined with bursal injection and specific exercises, effectively reduces pain, decreases disability, and improves range of motion in patients with second-stage adhesive capsulitis. This study highlights the importance of a combined approach in the management of this complex condition, especially after the histological changes that occurred after COVID-19 and related vaccinations. ClinicalTrials.gov identifier NCT06062654.

Return to Play After an Anterior Cruciate Ligament Reconstruction in the Collegiate Athlete: A Systematic Review Evaluating Return to Play Proportions and Associated Factors.

OBJECTIVE: To estimate anterior cruciate ligament reconstruction (ACLR) return-to-play (RTP) factors and proportions across all National Collegiate Athletics Association (NCAA) sports. DESIGN: Systematic review with prognosis and etiology components. LITERATURE SEARCH: Two independent reviewers searched PubMed, Cochrane Library, and Embase databases using terms related to RTP, ACLR, and NCAA for articles published up to June 30, 2023. STUDY SELECTION CRITERIA: Articles were included if RTP proportions or factors affecting RTP were reported and if the study population included NCAA collegiate athletes recovering from an ACLR. DATA SYNTHESIS: The proportion represents the total number of athletes who returned to play after ACLR over the total number of ACLR athletes from each cohort. The cumulative proportion represents the aggregated total from each included study. When eligibility information was available (ie, athletes in their final year of eligibility), RTP proportions were adjusted. The Newcastle-Ottawa Scale (NOS) was used to assess the study quality and scored by 2 raters. RESULTS: Nine studies were included. RTP criteria varied across the studies. Proportions of RTP ranged from 69% to 92%, with a cumulative RTP proportion after ACLR of 84% (628/745). The primary factors associated with the proportion of RTP were scholarship status, competitive eligibility remaining, depth chart position, and surgical graft type. CONCLUSIONS: The cumulative proportion of RTP was 84% and was associated with patient-specific and operative factors. Psychological and functional factors were not routinely reported, and rehabilitation protocols were unknown. Data were not explicitly available for any athletes outside of Division I. The criteria for RTP after ACLR varied. J Orthop Sports Phys Ther 2024;54(10):1-9. Epub 10 September 2024. https://doi.org/10.2519/jospt.2024.12483.

Pectoralis Major Muscle Tear – Effectiveness Orthobiologic Nonoperative Treatment with Platet-Rich Plasma (PRP) Injections

Introduction Pectoralis major muscle ruptures, once considered rare, are now more common, especially in young male athletes and weightlifters involved in high-intensity sports. This injury can significantly impair upper limb function, leading to pain, weakness, and potential disability. Exploring and understanding available treatment options, particularly the promising role of orthobiologic therapies like PRP, is essential for optimizing recovery and achieving the best outcomes. Purpose The purpose of this review is to evaluate the effectiveness and the role of orthobiologic treatments such as PRP in enhancing healing and functional recovery for pectoralis major muscle ruptures. Conslusions The treatment of pectoralis major muscle ruptures requires a tailored approach that considers the injury's severity, the patient's activity level, and their goals. Nonoperative treatment can be effective for partial tendinous tears, muscle belly tears, muscle origin tears, and complete tendinous tears in sedentary individuals or when surgery is not feasible. Surgical intervention generally provides superior functional outcomes, particularly for athletes and those with complete ruptures. Orthobiologic treatments, such as ultrasound-guided PRP injections, provide a promising complement to conservative management, with potential benefits in pain reduction and accelerated functional recovery. Studies indicate that PRP-treated patients report higher satisfaction and better outcomes compared to those without PRP treatment. Nevertheless, many questions remain regarding the optimal formulation, dosage, and rehabilitation protocols for PRP. To fully understand PRP's effectiveness and refine its applications in sports medicine, more rigorous and long-term studies are needed. Additionally, further research is required to improve nonoperative treatment and rehabilitation protocols, ensuring optimal outcomes for all patients.