Subjective Measures Of Function Research Articles

Responsiveness of Subjective and Objective Measures of Pain and Function Following Operative Interventions for Musculoskeletal Conditions: A Narrative Review.

Musculoskeletal (MSK) disorders affect ~50% of US adults and 75% of those over the age of 65, representing a sizable economic and disability burden. Outcome measures, both objective and subjective, help clinicians and investigators determine whether interventions to treat MSK conditions are effective. This narrative review qualitatively compared the responsiveness of different types of outcome measures, a key measurement characteristic that assesses an outcome measure's ability to detect change in patient status. We evaluated elective orthopedic interventions as a model for assessing responsiveness because the great majority of patients improves following surgery. We searched for articles reporting responsiveness (quantified as effect size [ES]) of subjective and objective outcome measures after orthopedic surgery and included 16 articles reporting 17 interventions in this review. In 14 of 17 interventions, subjective function measures had an ES 10% greater than that of objective function measures. Two reported a difference in ES of <10%. The sole intervention that demonstrated higher ES of objective function used a composite measure. Sixteen interventions reported measures of subjective pain and/or mixed measures and subjective function. In nine interventions, subjective pain had a higher ES than subjective function by >10%, in three, subjective function had a higher ES than subjective pain by >10%, and in the remaining four, the difference between pain and function was <10%. These findings reinforce the clinical observation that subjective pain generally changes more than function following elective orthopedic surgery. They also suggest that subjective function measures are more responsive than objective function measures, and composite scores may be more responsive than individual performance tests.

Selected Frailty Testing Can Predict for Risk of Febrile Neutropenia in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplant

Introduction: Validated myeloma-specific frailty assessment tools, such as the IMWG geriatric assessment tool (IMW GAT) and the revised myeloma co-morbidity index (R-MCI), can be useful to tailor treatment intensity in MM patients (pts). To date, most MM studies of frailty have focused on older, transplant-ineligible populations, with less known about the utility of frailty assessments to guide therapeutic decision-making in younger, transplant pts. We previously reported that frailty scores largely validated in older MM cohorts correlate well with each other, but generally lack ability to discriminate between unfit and fit patients, when applied to a younger transplant population (Devasia et al ASH 2022). Here, we evaluate the use of pre-transplant frailty assessment, using a battery of subjective and objective tools, for predicting common post-transplant toxicities, such as febrile neutropenia (FN) and organ complications. Methods: 162 consecutive MM pts preparing for ASCT and consented for an ongoing prospective frailty study were included. Prior to ASCT, patients underwent comprehensive frailty assessments including: 1) objective measures of fitness [hand grip strength, 6-min walk test (6MWT), Timed Up and Go (TUG), 2) subjective measures of function (Fried Frailty Phenotype (FFP), Rockwood Frailty, KPS, ECOG, HSCT-CI, ESAS), 3) scoring systems integrating both objective and subjective measures (R-MCI, IMWG geriatric assessment tool (IMWG-GAT), and 4) routine screening for organ function (CrCl, serum albumin, hemoglobin, BNP, PFT, and cardiac imaging). Following ASCT, acute grade 3-4 organ-specific toxicities (including FN) occurring from stem cell infusion through engraftment to discharge were prospectively collected (NCI-CTCAE criteria V5.0). Patient/disease characteristics, stem cell dose, engraftment, and transfusion requirements were also collected from electronic patient records. Chi-square and/or Fisher's exact test, as appropriate, were used to assess the association of categorical covariates with frailty scores/measures. Logistic regression was used to assess the association of potential predictors to binary outcomes. All p-values were 2-sided and p&amp;lt;0.05 was considered statistically significant. Results: In total, 162 pts were included in this analysis, median age 62 yrs (range 35-73). Most pts received melphalan 200 mg/m2 conditioning, with 10 pts (6%) dose-reduced to 140mg/m2. All patients received antibiotic prophylaxis. Median stem cell dose was 2.82 x 10 6 CD34+ cells/kg Median neutrophil and platelet engraftment times were 13(10-17) and 14(8-45) days, respectively. 104(64%) pts developed FN post-transplant. Other grade 3-4 toxicities included: GI (41 pts; 25.3%), cardiac (12 pts; 7.4%), lung (4 pts; 2.4%). When correlating with pre-transplant frailty assessments, ECOG performance status and R-MCI appeared to predict for risk of FN, but not for specific organ toxicity (GI, cardiac) nor presence of &amp;gt;1 grade 3-4 toxicity (Table 1). In pts with ECOG 1-2 at baseline, the incidence of FN was 70.9% (83/117) compared to ECOG 0 pts 46.7% (21/45)(p=0.0039). There were no patients with ECOG 3-4 on study. Similarly, 58% (59/101) with baseline low risk frailty as per R-MCI developed FN, compared to 73.8% (45/61) in either R-MCI intermediate or high risk groups (p=0.050). We then evaluated the combined effect of ECOG and R-MCI on prediction of FN. Patients with ECOG 0 plus R-MCI low risk were grouped as “Low risk FN”, patients with ECOG 1-2 plus R-MCI intermediate/high risk were grouped as “High risk FN”. All other patients were grouped as “Intermediate risk FN” (Table 2). By using 2 scores, we could better predict for FN, with 72.5% in “High risk FN” compared with only 37% in “Low risk FN” (p=0.0008)]. Conclusions: This preliminary analysis of an ongoing frailty study in MM patients undergoing ASCT suggests potential utility of combining ECOG and R-MCI in predicting for development of FN. In pts with both ECOG 0 and R-MCI low risk (21% of total cohort), FN occurred in only 37%. Although further validation in a larger cohort is required, this finding may help to select at-risk patients for prophylactic peri-transplant antibiotics whilst avoiding routine use in all patients. This has clinical significance, given the emerging recognition of potentially detrimental effect on the gut microbiota and risk of antibiotic resistance in this setting.

Correlation Amongst Scoring of Various Frailty Tools in Myeloma Patients Undergoing Autologous Stem Cell Transplantation

Introduction: With the growing array of treatment options for multiple myeloma (MM) patients, it is important to individualize the approach at each point in the patient's treatment journey. Frailty scores such as the Revised Myeloma Comorbidity Index (R-MCI) can help match therapeutic intensity to patient fitness, particularly important in the elderly. The R-MCI has been prospectively validated in transplant patients and found to be predictive for PFS and OS outcomes. At our centre, we are enrolling patients deemed transplant-eligible by standard institutional criteria into a prospective study applying a variety of frailty tools, including objective measures of comorbidity/function and subjective measures based on patient self-assessment and physician opinion. These tools are applied at time of transplant clearance, not at diagnosis as previously studied, to take into consideration changes in frailty that occur during the initial treatment phase. The primary objective is to identify normative frailty scores at this timepoint and correlate with severity of transplant-related toxicity. In this analysis, we present data on the first 101 enrolled patients, reporting the various frailty scores and their inter-correlation. Patients and Methods: The first 101 consecutive MM patients preparing for autologous transplant (ASCT) and consented for the frailty study were included. Patients underwent comprehensive frailty assessments including: 1) objective measures of fitness [hand grip strength, 6-min walk test (6MWT), Timed Up and Go (TUG), 2) subjective measures of function (abbreviated Fried Frailty Phenotype Score (FFP), Rockwood Clinical Frailty Score, KPS, ECOG, HSCT-CI, ESAS), 3) scoring systems integrating both objective and subjective measures (R-MCI, International Myeloma Working Group geriatric assessment tool (IMWG-GAT), and 4) routine screening for organ function (creatinine clearance, serum albumin, hemoglobin, BNP, PFT, and cardiac imaging). Demographics including disease and treatment details were obtained from electronic medical records. Measures were evaluated with Chi-square/Fischer's exact test/Kruskal-Wallis test to assess the association between the various frailty scores. In addition, frailty scores were compared against R-MCI as baseline. All p values were 2-sided and p≥0.05 was considered statistically significant. Results: From Feb 2020 to July 2022, 101 patients consented for the frailty study and were included in this analysis. Patient characteristics and frailty scores are summarised in Table 1. ASCT was part of upfront treatment in 87 patients (86%), with 14 patients (14%) receiving salvage transplant at relapse. Median age was 63 years (35-75), with 9(9%) age 70 and above. In general, our transplant-eligible population tested well on most frailty scores, mostly falling within the fit or intermediate-fit categories, as expected. Notable exceptions were significantly poorer handgrip strength and 6MWT than observed in the literature. Only 2 of 101 patients in our analysis were able to walk >400 metres, a threshold for fitness cited in prior transplant studies. Most scoring systems in our analysis correlated in designating our cohort as "fit” or "intermediate fit". When using the transplant-validated R-MCI scores as our gold standard, we observed correlations with the IMWG-GAT and Rockwood scores (p=0.0014 and <0.0001 respectively). The simple-to-perform ECOG and HCT-CI indices also correlated highly with R-MCI.(Table 2) That said, the R-MCI lacked discrimination in our patient population, with almost all patients clustered into the fit or pre-fit categories (98/101; 98%). Conclusions: In this analysis of various frailty assessments applied at ASCT for MM, we report that most scoring systems correlated but generally lacked discrimination in this relatively fit cohort. Even the widely cited R-MCI which is validated in both myeloma and transplant, has limited utility in discriminating within this more homogeneously fit population. We will hence focus next on identifying scoring systems or individual tools that can further define the less fit or mildly frail within the "fit” category, allowing us to identify subgroups for medical optimization pre-ASCT. We also note that physical function testing such as handgrip and 6MWT may have limited utility in myeloma where disease-related disability may prevent full engagement. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Study design for a randomized clinical trial of cognitive-behavioral therapy for posttraumatic headache

Posttraumatic headache (PTH) is a common debilitating condition arising from head injury and is highly prevalent among military service members and veterans with traumatic brain injury (TBI). Diagnosis and treatment for PTH is still evolving, and surprisingly little is known about the putative mechanisms that drive these headaches. This manuscript describes the design of a randomized clinical trial of two nonpharmacological (i.e., behavioral) interventions for posttraumatic headache. Design of this trial required careful consideration of PTH diagnosis and inclusion criteria, which was challenging due to the lack of standard clinical characteristics in PTH unique from other types of headaches. The treatments under study differed in clinical focus and dose (i.e., number of treatment sessions), but the trial was designed to balance the treatments as well as possible. Finally, while the primary endpoints for pain research can vary from assessments of pain intensity to objective and subjective functional measures, this trial of PTH interventions chose carefully to establish clinically relevant endpoints and to maximize the opportunity to detect significant differences between groups with two primary outcomes. All these issues are discussed in this manuscript.

Claudication Distances, the Walking Impairment Questionnaire, and Muscle Heme-Oxygen Saturation Best Describe the Home Daily Activity of Claudicating Patients With Peripheral Artery Disease

There is increasing interest in daily activity as a relevant index of impairment in patients with peripheral artery disease (PAD). However, correlations with other objective and subjective measures of function in PAD are not known. Ninety-six claudicating patients were recruited. Ankle-brachial index resting and with stress was determined, and patients completed the Walking Impairment Questionnaire (WIQ), a 6-minute walk test (6MWT), and a Gardner treadmill test (GTT) with concurrent near-infrared spectroscopy of gastrocnemius heme-oxygen saturation (Sto2). A wearable accelerometer was used to measure total daily steps. Mean daily activity was 4050 ± 2631 steps (n = 96). Peak walking time (r = 0.385), 6MWT (r = 0.53), and WIQ (speed r = 0.370 and distance r = 0.405) correlated with daily activity (P < .001), whereas resting and stress ankle-brachial index did not (P > .05). Three subanalyses were performed. For 6MWT, patients were grouped into those who stopped to rest and those who did not. For the GTT, fuzzy clustering analysis of time to minimum Sto2 of the more symptomatic leg grouped patients into those who reached an Sto2 minimum before (n = 44; 91 ± 12 seconds) and after (n = 12; 625 ± 76 seconds) 5 minutes. Finally, patients were grouped into those who reported bilateral or unilateral intermittent claudication. Our Results (Table) demonstrate less at-home daily activity and less walking distance on average among patients who stop to rest during the 6MWT, reach a minimum Sto2 before 5 minutes during GTT, or experience bilateral claudication. Furthermore, all patients with a time to minimum Sto2 >5 minutes had >5000 steps daily activity. Walking performance and the WIQ (distance and speed subscales) correlated with daily activity, whereas hemodynamics did not. Optimal measures of functional status in PAD need to be further explored so that PAD impairments can be better understood.TableDaily activity subanalysisCategorical groupsDaily activity, steps6-minute walk distance, metersGardner maximum walk time, secondsAnalysis based on 6MWT Rest(s) during 6MWT (n = 40)2490 ± 453237.8 ± 15211.6 ± 37 No rest during 6MWT (n = 52)4706 ± 372339.9 ± 12416.5 ± 28Analysis based on NIRS measurement during GTT Time to minimum Sto2 > 5 minutes (n = 12)7715 ± 1093367.4 ± 21735.2 ± 62 Time to minimum Sto2 < 5 minutes (n = 44)3286 ± 273256.8 ± 20251.0 ± 37Analysis based on claudication symptoms Unilateral symptoms (n = 42)5135 ± 359328.4 ± 12382.9 ± 28 Bilateral symptoms (n = 54)3341 ± 332297.3 ± 9a291.5 ± 22bGTT, Gardner treadmill test; NIRS, near-infrared spectroscopy; 6MWT, 6-minute walk test; Sto2, tissue heme-oxygen saturation.Group differences are significant at P < .001 in all comparisons except where noted.aP < .05.bP < .01. Open table in a new tab

Relationship of Knee Forces to Subjective Function Pre- and Post-ACL Reconstruction.

Although basic objective measures (e.g., knee laxity, strength, and hop tests) have been related to subjective measures of function, associations between knee-specific objective and subjective measures have yet to be completed. The objective was to determine if knee joint contact and ligament forces differ between pre- and post-anterior cruciate ligament (ACL) reconstructed states and if these forces relate to their patient's respective subjective functional ability scores. Twelve patients performed a hopping task before and after reconstruction. Magnetic resonance images and OpenSim were used to develop patient-specific models in static optimization and joint reaction analyses. Questionnaires concerning each patient's subjective functional ability were also collected and correlated with knee joint contact and ligament forces. No significant differences were observed between deficient and reconstructed groups with respect to knee joint contact or ligament forces. Nevertheless, there were several significant (P < 0.05) moderate to strong correlations between subjective and objective measures including Tegner activity level to contact force in both states (r = 0.67-0.76) and International Knee Documentation Committee to compressive and anterior shear forces (r = 0.64-0.66). Knee-specific objective measures of a patient's functional capacity can represent their subjective ability, which explains this relationship to a greater extent than past anatomical and gross objective measures of function. This consolidation is imperative for improving the current rehabilitation schema as it allows for external validation of objective and subjective functional measures. With poor validation of subjective function against objective measures of function, the reinjury rate is unlikely to diminish, continuing the heavy financial burden on health care systems.

Bilateral asymmetry improved accuracy when assessing glaucomatous vision-related quality of life impairment.

Bilateral asymmetry has been used in optical coherence tomography tests to find early damage to the optic nerve. However, limited studies have quantitatively evaluated bilateral asymmetry in electrophysiological disorders in patients with glaucoma. The aim of the study was to evaluate bilateral asymmetry in pattern visual evoked potentials (PVEPs) and conventional clinical markers as well as its potential use in detecting glaucomatous impairment. After investigating 60 glaucomatous patients (120 eyes) and 65 age and sex-matched normal control subjects (130 eyes) using uni- and multivariable analysis, we found that vision-related quality of life (VRQOL) impairment was significantly associated with larger bilateral asymmetry index (BAI) of clinical markers. Rasch-calibrated National Eye Institute Visual Function Questionnaire-25 scores were significantly associated with the BAI in PVEPs latency in 15 minutes check size (β = -0.478, 95% confidence interval [CI], -0.708 to -0.248, P < .001) and the BAI in visual field mean deviation (β = -0.249, 95% CI, -0.454 to -0.044, P = .018) according to multivariable analysis. Bilateral asymmetry in objective and subjective functional measurements was quantitatively associated with glaucomatous VRQOL impairment. This finding may help bridge the gap in understanding between patients and clinicians, and increase awareness of how glaucomatous neuropathic progression may interfere with patients' daily life.

(313) Association between Measures of Function and Pain Perception in Older Adults with Chronic Low Back Pain

This investigation examined the association between measures of function and pain perception in older individuals with chronic low back pain (CLPB). Data from eight subjects older than 65 were analyzed. Measures of function included the 2-minute walk test (2-MWT) and the Oswestry Disability Index (ODI). Pain perception was examined by pressure pain threshold (PPT). Clinical pain was obtained with the visual analogue scale (VAS). PPT was assessed bilaterally at T12, L5, and S2. Values obtained during PPT were averaged together to quantify local PPT. Descriptive statistics were collected and Pearson correlation moment was performed to identify correlations. A stepwise regression model was used to identify the stronger predictor of PPT, (PPT was used as the dependent variable and ODI and 2-MWT were entered as the independent variables). Results showed that local PPT was significantly correlated with both objective and subjective measures of function (2-MWT r2=0.800, p=0.017, ODI r2=-0.866, p=0.005). Correlation analysis showed that clinical pain measured with the VAS scale was not associated with measures of disability used in this study (p>0.05). Stepwise regression model revealed that ODI alone was responsible for 70% of the variability in PPT (r2=0.708, β=-0.866, p=0.005). 2-MWT explained an additional 22% of the variability in PPT (r2=0.923, β=0.502 p=0.008). Results from this modest sample of participants with CLBP suggest that perception of disability and level of activity as evaluated by the 2-MWT have a strong influence in experimental pain perception. Surprisingly, clinical pain was not associated with measures of disability which indicates that the use of the VAS alone may not be enough to assess pain in older individuals with CLBP. Moreover, the 2-MWT could be a simple and easy way to assess changes in physical activity in older individuals.

Functional Tests Assessing Return to Activity after Anterior Cruciate Ligament Reconstruction

PURPOSE: A successful return to activity following anterior cruciate ligament reconstruction is the primary goal for athletes and physically active populations who underwent the surgery. However, functional tests that could be utilized for deciding return to activity are not well-described. Therefore, we reviewed currently suggesting functional tests and the effectiveness of each tests. METHODS: In this review, we summarized the patient oriented subjective functional measures, objective functional tests, a functional test battery, and a general pass and fail criteria for functional tests. RESULTS: There are various subjective and objective functional measures to assess ACLR patients’ level of knee function. The concept of a functional test battery that is the combination of various functional tests is more sensitive to detect patient’s readiness to return. Eighty-five to ninety percent of limb symmetry index score is frequently applied as the pass and fail criteria for functional test. CONCLUSIONS: Various researches suggested functional tests that clinicians could be applied to their patients for return to activity safely. Despite the use of various functional tests, the risk for subsequent knee problems remains elevated in ACLR individuals. Therefore, it is necessary to investigate the usefulness of functional tests to identify individuals that are at greatest risk for subsequent knee injury.

The 8-foot up and go test is the best way to assess physical function in the rheumatoid arthritis clinic.

ObjectivesRA is characterized by poor physical function, which compromises patients’ quality of life and outcome. Clinical assessment of function is usually performed using self-reported questionnaires, such as the Multi-Dimensional HAQ (MDHAQ) and the Short Form-36 (physical component) (SF36-PC). However, such subjective measures may not accurately reflect real functional status. This study aimed to determine: (i) which clinically practicable objective test best represents overall physical function; and (ii) the extent to which self-reported subjective functional measures reflect objectively assessed function. MethodsObjective [isometric knee extensor strength, handgrip strength, sit-to-stands in 30 s, 8-foot up and go (8′UG), 50-foot walk (50′W) and estimated aerobic capacity (V̇O2max)] and subjective (MDHAQ and SF36-PC) measures of function were correlated with one another to determine the best overall test of functional status in 82 well-controlled RA patients (DAS28 (s.d.) = 2.8 (1.0)).ResultsIn rank order of size, averaged correlations (r) to the other outcome measures were as follows: 8′UG: 0.650; 50′W: 0.636; isometric knee extensor strength: 0.502; handgrip strength: 0.449; sit-to-stands in 30 s: 0.432; and estimated V̇O2max: 0.358. The MDHAQ was weakly (0.361) and the SF36-PC moderately correlated (0.415) with objective measures.ConclusionOur results show that the most appropriate measure of objective physical function in RA patients is the 8′UG, followed by the 50′W. We found discordance between objectively and subjectively measured function. In clinical practice, an objective measure that is simple and quick to perform, such as the 8′UG, is advocated for assessing real functional status.

Multifactoral measures of fall risk in the visually impaired population: A pilot study

To determine the feasibility of taking multiple measures of visual and physical function in adults with visual impairment. A second objective was to obtain preliminary data on risk for falls in this population. Cohort feasibility study. University ambulatory patient care center and research center. Convenience sample of community-dwelling men and women over age 18 with visual impairment (n=12). Thirteen subjects were enrolled in the study; one was subsequently excluded due to self-reported cognitive decline at time of testing. Subjects were grouped by prospective fall incidence. Verbal education. Subjective measures of function; objective measures of visual and physical function. Visually impaired adults can safely complete a battery of physical functions to predict fall risk. Recent onset of visual impairment was correlated with higher fall risk [-0.53±0.22, p=0.04]. It is feasible for an interdisciplinary team to measure risk for falls in adults with a visual impairment. Further investigation is needed to identify predictors of falls in adults of all ages with visual impairment.

Effect of Anxiety and Catastrophic Pain Ideation on Early Recovery After Surgery for Distal Radius Fractures

To evaluate the effects of preoperative anxiety and catastrophic pain ideation on perceived disability and objective measures after distal radius fracture surgery. A total of 121 patients with distal radius fractures treated with volar plate fixation were enrolled. The wrist range of motion (ROM), grip strength, and perceived disability as measured by the Michigan Hand Questionnaire (MHQ) score were assessed 4, 12, and 24 weeks after surgery. To evaluate psychological factors related to pain, catastrophic pain ideation was measured using the Pain Catastrophizing Scale (PCS) and pain anxiety was measured using the Pain Anxiety Symptom Scale (PASS). Then relative contributions of pain anxiety and catastrophic pain ideation and other clinical parameters to functional recovery in terms of grip strength, ROM, and MHQ score were assessed. An increase in the PCS score was associated with the wrist ROM and grip strength only at week 4, whereas an increase in the PASS score was associated with the wrist ROM at week 4 and grip strength at weeks 4 and 12. According to a multivariate regression analysis, an increase in the PCS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4; and an increase in the PASS score was associated with a decrease in grip strength, ROM, and MHQ score at week 4 and grip strength and MHQ score at week 12. At week 24, only age and fracture severity were associated with the MHQ score. In addition, age was associated with grip strength and fracture type was associated with ROM. Preoperative PCS and PASS were significantly associated with delayed recovery as evidenced by scores on both objective and subjective measures of function. Given these relationships, it becomes important to assess preoperative PCS and PASS and address issues for patients at risk with brief psychosocial intervention early in the recovery process. Prognostic II.

The impact of liver transplantation on the phenotype of primary biliary cirrhosis patients in the UK-PBC cohort

Liver transplantation improves survival in end-stage primary biliary cirrhosis (PBC), but the benefit for systemic symptoms including fatigue is less clear. The aim of this study was to utilise the comprehensive UK-PBC Research Cohort, including 380 post-transplant patients and 2300 non-transplanted patients, to answer key questions regarding transplantation for PBC. Cross-sectional study of post-transplant PBC patients and case-matched non-transplanted patients. Detailed clinical information was collected, together with patient systemic symptom impact data using validated assessment tools. Over 25% of patients in the transplant cohort were grafted within 2 years of PBC diagnosis suggesting advanced disease at presentation. Transplanted patients were significantly younger at presentation than non-transplanted (mean 7 years) and >35% of all patients in the UK-PBC cohort who presented under 50 years had already undergone liver transplantation at the study censor point (>50% were treatment failures (post-transplant or unresponsive to UDCA)). Systemic symptom severity (fatigue and cognitive symptoms) was identical in female post-transplant patients and matched non-transplanted controls and unrelated to disease recurrence or immunosuppression type. In males, symptoms were worse in transplanted than in non-transplanted patients. Age at presentation is a major risk factor for progression to transplant (as well as UDCA non-response) in PBC. Although both confirmatory longitudinal studies, and studies utilising objective as well as subjective measures of function, are needed if we are to address the question definitively, we found no evidence of improved systemic symptoms after liver transplantation in PBC and patients should be advised accordingly. Consideration needs to be given to enhancing rehabilitation approaches to improve function and life quality after liver transplant for PBC.

Computerized gait analysis in Legg–Calvé–Perthes disease—Analysis of the sagittal plane

Current follow-up- and outcome-evaluations of Legg–Calvé–Perthes disease (LCPD) are based on subjective measures of function, clinical and radiological parameters. The objective of this study was to evaluate the sagittal plane kinematics and the effect on hip joint loading on the affected hip in children with LCPD. Materials and methodsComputerized gait analysis was performed in 49 LCPD patients aged ≥5 years with unilateral hip involvement. Sagittal plane kinematics and kinetics were compared to a group of healthy children (n=30). ResultsKinematics: a significantly increased anterior tilt and range of motion (ROM) of the pelvis combined with a marked reduction of the extension of the involved hip joint compared to the control group was observed. The increased ROM of the contralateral hip results from increased maximum flexion. Power generation: overall significantly decreased on the involved side during florid stage. Global hip function: significantly reduced hip flexor index of the involved hip; 46.2% of the patients in advanced stage, although having no significant changes in kinematics – except increased anterior pelvic tilt – had a pathologic HFI. ConclusionSagittal plane hip function is significantly impaired in florid and advanced LCPD. The results of this study will lead to further investigations into whether this development can be prevented by conservative or operative treatment thus improving function and long-term prognosis.

Deformity correction by Ilizarov distraction osteogenesis after distal radius physeal arrest

The aim of this study was to evaluate the results of osteotomy and distraction osteogenesis using Ilizarov circular external fixator to treat radial shortening and severe wrist deformity due to neglected post-traumatic distal radius physeal arrest. The study retrospectively reviewed 4 patients (4 males; average age: 16 years; range: 14 to 19 years) who underwent osteotomy and distraction osteogenesis to treat radial shortening and severe wrist deformity due to neglected distal radius physeal arrest. Mean interval between trauma and surgical intervention was 8 (range: 4 to 12) years and mean follow-up time was 83 (range: 40 to 126) months. Patients were evaluated with radiographic measurements (shortening and lengthening ratio, radioulnar joint leveling, distal radioulnar joint congruency), objective functional measurements (grip and pinch strength, range of motion measurements [ROM]) and subjective functional measurements (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire and Mayo wrist score). Statistical analysis was made using the Mann-Whitney U non-parametric test. Radiographic measurements were obtained preoperatively and at the final follow-up. The mean shortening ratio of the radius was 14.6% (range: 9.3% to 18.7%) and mean lengthening ratio was 15.9% (range: 13.2% to 18.3%). Normal distal radioulnar joint leveling and distal radioulnar congruency resembling a joint was established in all but one patient with four millimeters of ulna plus deformity. According to the Mann-Whitney U non-parametric test, there was no statistical difference in grip and pinch power, ROM on flexion/extension, and ulnar/radial deviation axis between the operated and non-operated sides. There was statistically significant pronation/supination restriction between the operated and non-operated sides (p<0.04). Mean DASH score was 2.07 (range: 0.0 to 8.3) and the mean Mayo wrist score was 89 (range: 75 to 100) points. According to the Mayo wrist score, results were excellent in one patient, good in two patients, and satisfactory in one patient. The use of distal metaphyseal osteotomy and Ilizarov distraction osteogenesis is a viable treatment method for neglected physeal fractures of the distal radius as it establishes acceptable deformity correction and a functional wrist joint.

The Effects of Vitamin D Supplementation on Physical Function and Quality of Life in Older Patients With Heart Failure

Background— Low 25-hydroxyvitamin D levels, commonly found in older patients with heart failure, may contribute to the chronic inflammation and skeletal myopathy that lead to poor exercise tolerance. We tested whether vitamin D supplementation of patients with heart failure and vitamin D insufficiency can improve physical function and quality of life. Methods and Results— In a randomized, parallel group, double-blind, placebo-controlled trial, patients with systolic heart failure aged ≥70 years with 25-hydroxyvitamin D levels &lt;50 nmol/L (20 ng/mL) received 100 000 U of oral vitamin D2 or placebo at baseline and 10 weeks. Outcomes measured at baseline, 10 weeks, and 20 weeks were 6-minute walk distance, quality of life (Minnesota score), daily activity measured by accelerometry, Functional Limitations Profile, B-type natriuretic peptide, and tumor necrosis factor-α. Participants in the vitamin D group had an increase in their 25-hydroxyvitamin D levels compared with placebo at 10 weeks (22.9 versus 2.3 nmol/L [9.2 versus 0.9 ng/mL]; P &lt;0.001) and maintained this increase at 20 weeks. The 6-minute walk did not improve in the treatment group relative to placebo. No significant benefit was seen on timed up and go testing, subjective measures of function, daily activity, or tumor necrosis factor. Quality of life worsened by a small, but significant amount in the treatment group relative to placebo. B-type natriuretic peptide decreased in the treatment group relative to placebo (−22 versus +78 pg/mL at 10 weeks; P =0.04). Conclusions— Vitamin D supplementation did not improve functional capacity or quality of life in older patients with heart failure with vitamin D insufficiency. Clinical Trial Registration— www.controlled-trials.com. Identifier: ISRCTN51372896.

Computerized gait analysis in Legg Calvé Perthes disease—Analysis of the frontal plane

Current follow-up and outcome studies of Legg Calvé Perthes disease (LCPD) are based on subjective measures of function, clinical parameters and radiological changes [Herring JA, Kim HT, Browne RH. Legg-Calvé-Perthes disease. Part II: prospective multicenter study of the effect of treatment on outcome. J Bone Joint Surg 2004;86A:2121-34; Aksoy MC, Cankus MC, Alanay A, Yazici M, Caglar O, Alpaslan AM. Radiological outcome of proximal femoral varus osteotomy for the treatment of lateral pillar group-C. J Pediatr Orthop 2005;14 B:88-91; Kitakoji T, Hattori T, Kitoh H, Katho M, Ishiguro N. Which is a better method for Perthes' disease: femoral varus or Salter osteotomy? Clin Orthop 2005;430:163-170; Joseph B, Rao N, Mulpuri K, Varghese G, Nair S. How does femoral varus osteotomy alter the natural evolution of Perthes' disease. J Pediatr Orthop 2005;14B:10-5; Ishida A, Kuwajima SS, Laredo FJ, Milani C. Salter innominate osteotomy in the treatment of severe Legg-Calvé-Perthes disease: clinical and radiographic results in 32 patients (37 hips) at skeletal maturity. J Pediatr Orthop 2004;24:257-64.]. The objective of this study was to evaluate the frontal plane kinematics and the effect on hip joint loading on the affected side in children with a radiographic diagnosis of LCPD. Computerized, three-dimensional gait analysis was performed in 33 individuals aged > or =5 years (mean 8.0+/-2 years) with unilateral LCPD and no history of previous surgery to the hip or any disorder leading to gait abnormality. Frontal plane kinematics and kinetics were compared to a group of healthy children (n=30, mean age 8.1+/-1.2 years). Hip joint loading was estimated as a function of the hip abductor moment. Subjects with LCPD demonstrated two distinct frontal plane gait patterns, both deviating from normal. Type 1 (n=3) was characterized by a pelvic drop of the swinging limb, a trunk lean in relation to the pelvis towards the stance limb and hip adduction during stance phase and corresponded well to the description of Trendelenburg gait caused by abductor insufficiency. Type 2 (n=12) is characterized by a trunk lean toward the affected stance limb with the pelvis stable or elevated on the swinging limb during single stance phase. The abductor moment of the involved side during single stance was significantly reduced in type 2 compared to the controls (p=0.004) indicating a hip-unloading mechanism. These results may influence the physiotherapy regimen, which may require to work towards a hip-unloading gait pattern.

Patients’ perceptions versus medical testing of function in women with lymphangioleiomyomatosis (LAM)

Lymphangioleiomyomatosis (LAM), a rare pulmonary disease that occurs primarily in women is characterized by progressive cystic lung lesions causing respiratory failure, which may require lung transplantation. It has been observed that in diseases of the lungs, objective medical tests frequently do not translate to subjective functional status. However, patient's perceptions of functional status directly impact quality of life. In order to evaluate this relationship in LAM, a cross sectional study of 31 lung transplant candidates and 43 lung transplant recipients with LAM was conducted to evaluate functional status. Objective tests (Pulmonary function tests, PFTs, 6 min walk) were obtained in 19 candidates and 23 recipients, and subjective function was assessed in all women using the Functional Performance Inventory. For both groups statistically significant relationships emerged between forced vital capacity with subjective measures of function including total, social and recreational function (P < 0.05). As well diffusing capacity related significantly to total function, ability to maintain household chores, body care, and social function (P < 0.05), where higher scores were associated with better subjective function. Forced expiratory volume in one second was not found to significantly relate to subjective function in these groups, except the physical exercise domain in transplant recipients. However, despite better PFT results in double lung transplant recipients, no differences were found in subjective measures of function between single and double lung recipients. Results suggest that clinicians need to better recognize that certain aspects of spirometry/6 min walk tests do not necessarily correlate well with patient's perceptions of their function. This has implications for the assessment and follow-up of women living with LAM; considering subjective aspects of function may help focus interventions and improve quality of life.

Cone-mediated multifocal electroretinogram in early age-related maculopathy and its relationships with subjective macular function tests

Purpose. To investigate the multifocal electroretinogram (mfERG) and subjective function in early age-related maculopathy (ARM). Methods. Seventeen subjects with early ARM with visual acuity (VA) of 6/12 or better and 20 age-matched control subjects were examined. We assessed mfERGs, high and low contrast distance VA, near VA, low luminance VA, contrast sensitivity, saturated and desaturated Panel D-15 and visual fields (mean sensitivity). The mfERG responses were analysed by comparing central-overall (method 1) and superior-inferior (method 2) ratios. Results. The mfERG did not discriminate between the groups whereas colour vision (tritan deficiency), contrast sensitivity, and high contrast and low contrast VA showed significantly reduced responses for the early ARM group compared with the control group (p ≤⃒ 0.01). The mfERG first-order kernel responses correlated significantly with the desaturated D-15 in both methods (r = −0.5, p ≤⃒ 0.05). Fundus grading was not correlated with the mfERG measures. Conclusions. Although the mfERG correlated significantly with the desaturated D-15 in early ARM, suggesting it operates at a sensitive level, it failed to discriminate between the control and ARM groups. In our sample, the subjective function measures were more sensitive than the mfERG measures.

Meniscal transplant combined withanterior cruciate ligament reconstruction

The meniscal cartilage plays a vital role in maintaining normal knee function. This important structure providesshock absorption, stabilization, lubrication, proprioception, and load sharing to the knee joint. Although it has been shown that an anterior cruciate ligament (ACL) reconstruction can provide symptomatic pain relief in the arthritic knee, the results following ACL reconstruction in a medial meniscus-deficient knee are usually worse than when the medial meniscus is intact. Given these findings, meniscal allograft transplantation with concomitant ACL reconstruction have been performed to provide patients with a more stable and functional knee as well as to forestall the degenerative process. We report our indications, preoperative considerations, surgical technique, postoperative rehabilitation protocol, and results with meniscal allograft transplantation combined with ACL reconstruction. We believe that meniscal transplantation combined with ACL reconstruction, in appropriately selected patients with meniscus- and ACL-deficient knees, offers significant advantages that cannot be accomplished with either procedure alone. Although technically challenging, careful attention to the details outlined will help to avoid pitfalls and will maximize the opportunity for a successful outcome. Our results suggest that this procedure can predictably improve subjective measures of function and symptoms while objectively restoring stability and affording protection to the articular surfaces of the transplanted knee compartment.