This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF) Free
Right arrow Letters to the Editor: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow Rights and Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Botte, M. J.
Right arrow Articles by Colwell, C. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Botte, M. J.
Right arrow Articles by Colwell, C. W., Jr.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Facebook   Add to Technorati   Add to Twitter  
What's this?
The Journal of Bone and Joint Surgery (American) 83:1920-1926 (2001)
© 2001 The Journal of Bone and Joint Surgery, Inc.

Specialty Update

What's New in Orthopaedic Rehabilitation

Michael J. Botte, MD, Darryl D. D'Lima, MD, Matthew J. Meunier, MD, James D. Bruffey, MD, Michael E. Brage, MD and Clifford W. Colwell, Jr., MD

Michael J. Botte, MD
Darryl D. D’Lima, MD
James D. Bruffey, MD
Clifford W. Colwell Jr., MD
Division of Orthopaedic Surgery, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037

Matthew J. Meunier, MD
Michael E. Brage, MD
Department of Orthopaedic Surgery, University of California, San Diego, School of Medicine, 200 West Arbor Drive, San Diego, CA 92103

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.

Orthopaedic rehabilitation is a unique subspecialty of orthopaedic surgery that incorporates surgeons and allied health professionals from several disciplines and regional subspecialties. The subspecialty deals with problems associated with neuromuscular disorders (stroke, brain injury, cerebral palsy, and ­poliomyelitis), spinal injury and deformity, total joint reconstruction, sports injury, pediatric orthopaedic surgery, hand surgery, and foot and ankle surgery. The diversity of orthopaedic rehabilitation is reflected by the many diverse subspecialists found in the membership of the Orthopaedic Rehabilitation Association (ORA). Because of the diverse nature of this orthopaedic subspecialty, a discussion on advances in orthopaedic ­rehabilitation can be accomplished by coverage or separate discussions of several topics. The following report highlights some of the advancements in orthopaedic rehabilitation within the last year. It reviews several of the topics presented at the most recent Annual Meetings of the ORA as well as topics covered on ORA Specialty Day during the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting. In addition, recent information from published abstracts and manuscripts pertinent to orthopaedic rehabilitation is included. This information covers diverse topics, such as neuromuscular disorders (stroke and brain injury as well as poliomyelitis), spine surgery (vertebroplasty and kypho­plasty), adult reconstruction (total knee arthroplasty and ­associated rehabilitation), and several aspects of hand re­habilitation after surgery. We conclude the discussion with "What’s New in the Orthopaedic Rehabilitation Association," including a brief background and an update on the society.

Neuromuscular Disorders

Stroke and Traumatic Brain Injury
Several new operative procedures for the management of patients with acquired spasticity and paralysis have been recently discussed1-3. The shoulder, which has traditionally received r­elatively little attention in patients with stroke or traumatic brain injury, was among the main topics covered at the recent ORA Specialty Day held in San Francisco on March 3, 20011-3. There were discussions on evaluation, management of muscle weakness and spasticity, and osseous problems and overuse syndromes2. Keenan2 pointed out the continued usefulness of dynamic polyelectromyography to assess motor control of the shoulder and to help with pre­operative planning. Electromyography is particularly useful in the spastic shoulder because it is difficult to evaluate this joint clinically. The deep-seated muscles are difficult to palpate for spasticity or to test for weakness.

Fuller and Keenan1 presented promising results of several new operative procedures for shoulder weakness and for muscle spasticity. Stabilization with use of the biceps as a suspension sling was found to be effective for the treatment of weakness and associated inferior subluxation of the humeral head. Transfer of the pectoralis major to the scapula and transfer of the teres major to the ribs was helpful in stabilizing the scapula in patients with scapular weakness. Transfer of the upper portion of the trapezius to the humerus was performed to reestablish active motion in patients with weakness of humeral abduction. Elbow extensor weakness was managed with transfer of the posterior part of the deltoid to the triceps. ­Pectoralis-to-biceps transfer was described for the treatment of elbow flexion weakness.

Several procedures were described for the treatment of muscle spasticity and associated contracture. Spastic abduction of the shoulder, caused by overactivity of the supraspinatus, was managed successfully with a slide (recession) of the supraspinatus. In patients with limited forward flexion of the shoulder due to spasticity, selective lengthening of the long head of the triceps, the teres major, and the latissimus dorsi was carried out. Lengthening of the pectoralis major was successful in patients with limited shoulder abduction and external rotation caused by spasticity of that muscle1.

Poliomyelitis
Post-poliomyelitis syndrome continues to present difficult problems that require reconstruction and rehabilitation. Fixed flexion deformity of the knee secondary to muscle loss and imbalance is not an uncommon problem. Bracing is ­difficult when a patient has a fixed flexion contracture of 15°. A knee-ankle-foot orthosis is poorly tolerated by these patients, and it can cause problems with skin breakdown. Hsu et al.4 recently reported the successful use of a wedge ­osteotomy of the distal part of the femur in nine patients to help correct the deformity. Varus or valgus deformity was also corrected as needed. Following femoral healing, patients could be fitted with a new knee-ankle-foot orthosis. Walking was improved, knee pain was resolved, and in many patients leg lengths were equalized.

Rehabilitation for Spinal Disorders

Vertebroplasty and Kyphoplasty
There are new and promising techniques to stabilize painful and disabling vertebral compression fractures. These techniques include the minimally invasive procedures of vertebroplasty and kyphoplasty, which are being used to stabilize fractures associated with osteoporosis and other vertebral pathologic and metastatic processes, thus relieving pain and restoring function5-12.

The problems of osteoporosis and its sequelae are appreciable. An estimated twenty-eight million patients in the United States have osteoporosis or clinically relevant osteopenia, and approximately 700,000 vertebral compression fractures are attributable to these conditions. Approximately one-half of these fractures are clinically relevant, requiring medical attention and treatment. The estimated cost of osteoporosis to the United States health-care system is at least five to ten billion dollars, and costs are expected to increase appreciably as the population ages12,13.

The acute pain associated with vertebral compression fracture usually lasts from two weeks to three months. Traditional treatment involves analgesic and nonsteroidal pain medication, bed rest, immobilization, bracing, and slow resumption of prefracture activities. Approximately 16% of patients require hospitalization for pain management and other care. Prolonged immobilization and bed rest exacerbate the problem by causing further deconditioning and bone de­mineralization. Perhaps the greatest long-term consequence of vertebral compression fracture is the increased risk of additional fractures. Women who have low bone mass but who have not sustained a fracture have a sevenfold increase in the risk of fracture compared with a twenty-fivefold increase in women with low bone mass and a single fracture13. The chronic pain associated with vertebral compression fracture is thought to be secondary to the inherent mechanical instability of the spine at the site of fracture. This pain is believed to stimulate nociceptors in the periosteum and joint capsules13. Vertebroplasty involves the percutaneous injection of poly­methylmethacrylate into the site of the vertebral fracture. The cement hardens, stabilizing the fracture. Kyphoplasty involves a similar technique. However, the collapse and wedging of the compression fracture is initially "reduced" by the placement of an inflatable balloon catheter into the vertebral body. The balloon is inflated, restoring vertebral height and diminishing anterior wedging of the vertebral body. Inflation of the balloon also creates a cavity within the vertebral body that can then be filled with injected polymethylmethacrylate8.

The early results of both of these techniques have been quite promising. Deramond et al.7 reported that 90% of their eighty patients managed with vertebroplasty experienced relief of pain within twenty-four hours after treatment. Similarly, Jensen et al.10 reported that 90% of their twenty-nine patients had relief of pain after vertebroplasty. Additionally, Barr et al.5 reported that 95% of their forty-seven patients with eighty-four fractures had moderate-to-complete relief of pain after vertebroplasty. The results remained promising with longer-term follow-up. Twenty-five patients with thirty-four fractures who were followed for as long as eighty-four months reported that pain relief, which they experienced immediately after treatment, was maintained at the follow-up examination. No important complications were reported, but it was noted that the patients appeared to be at an increased risk of sustaining new compression fractures in vertebrae adjacent to the ­cement-treated levels9.

Kyphoplasty seems to be effective in relieving the pain and disability associated with vertebral compression fractures. It may also minimize the risk of adjacent-segment compression fractures as well as diminish the deleterious effects of progressive thoracic kyphosis by restoring vertebral body height. Kyphoplasty has been shown to be associated with early clinical reduction of pain and improvement in function, and it can restore approximately 50% of lost vertebral body height in 70% of treated levels. No important complications were reported11.

This ability to treat symptomatic vertebral compression fractures in an aggressive manner is an exciting advance in the management and rehabilitation of patients with spinal disorders. Disability is minimized early in the disease process, and long-term functional rehabilitation is greatly improved. A minimally invasive, safe, and effective treatment has a substantial long-term effect on the costs associated with prolonged disability. Both vertebroplasty and kypho­plasty are relatively new, and longer-term follow-up is needed. Early ­results of their use indicate substantial benefits to patients, and the long-term outlook appears promising.

Rehabilitation and Total Joint Arthroplasty

Among the several areas of adult reconstruction, total knee ­arthroplasty is one in which rehabilitation protocols have unique applications. New understandings of biomechanics, new implant designs, and the use of specific rehabilitation protocols such as continuous passive motion have contributed to the successful nature of this area of adult reconstruction. Therefore, for this report, we have elected to focus on advances in rehabilitation as related specifically to total arthroplasty of the knee. Total knee arthroplasty is recognized as a successful procedure resulting in substantial reduction of pain, improvement in mobility, and prosthetic survival rates of >95% at ten years or more14-16. Although the technical component of the operative procedure contributes greatly to the outcome, perioperative rehabilitation remains a vital adjunct. Successful rehabilitation involves the collaborative efforts of the surgeon, physical therapist, nursing staff, and patient. Rehabilitation protocols should be specific to reduce ambiguity, yet flexible to accommodate differences in patient parameters. Several recent publications have given insight into aspects of rehabilitation in patients undergoing total knee arthroplasty.

Total Knee Arthroplasty
Patient Expectations and Assessment
Patient expectation of knee surgery is often overlooked. A typical "surgically successful" knee arthroplasty may be deemed a failure because the outcome did not match the expectations of the patient. Mancuso et al.17 documented multiple expectations that varied by diagnosis, patient characteristics, and functional status. A seventeen-item survey for patients who underwent total knee arthroplasty disclosed that 52% expected complete relief of pain and 65% expected to be able to walk more than a mile (1.6 km). Another important expectation was the return to sports, especially tennis, skiing, golfing, jogging, and swimming. However, Jones et al.18 reported that, regardless of age, patients who had undergone total knee arthroplasty did not have comparable overall physical health when matched with the general population for age and gender. Salmon et al.19 recently found that patient-assessed re­covery with regard to pain and function after total knee arthroplasty was not as great as that after total hip arthroplasty, even though the quality-of-life improvements that the patients recorded after knee arthroplasty matched those recorded after hip arthroplasty. Patient satisfaction with the result of the procedure may therefore be expected to increase if the goals and limitations of rehabilitation and clinical outcome are clearly communicated.

Preoperative Factors
Jorn et al.20 attempted to identify preoperative factors that would predict patient satisfaction, function, and working capacity. The authors found a positive association between the duration of preoperative and postoperative sick leave of patients who returned to work. Overall satisfaction was greater among patients who went back to work after the operation. Forrest et al.21 looked for correlations between patient age, gender, marital status, body mass index, and comorbid illness and the length of stay in the surgical unit and the need for inpatient rehabilitation. Age was the only factor that correlated with the length of stay in the surgical unit, and age and diabetes mellitus correlated with the need for inpatient rehabilitation. Conversely, Jones et al.18 found no age-related differences in joint pain, function, or quality-of-life measures either before the operation or six months after it.

Although rehabilitation is usually targeted at postoperative recovery, the efficacy of preoperative physical therapy has been investigated in some studies22,23. In a controlled prospective randomized study, D’Lima et al.22 demonstrated no improvement in the outcome of total knee arthroplasty when patients had been managed with a preoperative physical therapy strengthening protocol or a cardiovascular conditioning program for six weeks compared with the outcome when patients had had no preoperative exercise. A similar study by Rodgers et al.23 also failed to demonstrate substantial differences in postoperative outcome. Those authors postulated that patients with chronic musculoskeletal disease may not benefit from a few weeks of physical therapy or that age and overall health status prevented them from obtaining a major long-lasting benefit. Knee replacement may also provide such dramatic improvement that it can overshadow more modest gains from physical therapy, or the deconditioning in the immediate postoperative period could counter any gains made in the preoperative period.

Update on the Use of Continuous Passive Motion
The effects of continuous passive motion on the range of ­motion of the knee remain controversial. The reported benefits include decreased need for knee manipulation, fewer instances of deep venous thrombosis, decreased postoperative use of analgesics, and a greater final range of motion. Reported disadvantages include increased wound complications, bleeding, and pain. Patients who undergo continuous passive motion tend to have a greater range of motion at the time of discharge, but this advantage appears to lessen during the subsequent follow-up period. Recently, MacDonald et al.24 reported the results of a prospective, randomized, clinical trial comparing continuous passive motion with physiotherapy alone after total knee arthroplasty. The authors found no statistical differences between the treatment groups regarding cumulative analgesic requirements, range of motion at any measured interval, length of stay in the hospital, or Knee S­ociety scores. Lachiewicz25 recommended continuous passive motion because it decreased the need for manipulation. However, Chen et al.26 found no improvement in range of motion of the knee with continuous passive motion compared with that with physical therapy alone in a prospective, randomized, controlled study. Beaupre et al.27 also found that adjunct therapies, such as continuous passive motion and slider-board exercises, had no positive impact on knee range of motion or arthritis index scores.

New Aspects of Implant Design
Mobile-bearing knee arthroplasty offers the advantages of increased conformity and greater mobility, which theoretically translate into improved function and range of motion. Mobile-bearing designs have demonstrated survival rates comparable with those of successful fixed-bearing designs. However, recent reviews28 of clinical outcomes do not provide conclusive evidence to support improved function and/or range of motion.

Designs of knee prostheses that increase the quadriceps moment arm can reduce quadriceps tension, facilitate activities of daily living, and enhance rehabilitation. When two designs were tested in vitro, the design with the 10-mm longer quadriceps lever arm reduced quadriceps tension by 5% to 20%29. Mahoney et al.30 compared patients who had received a posterior cruciate-substituting prosthesis with patients who had received a design that increased the patellofemoral moment arm by 30%. After the operation, more patients who had received the latter design reported no anterior knee pain and were able to rise from a chair without using their arms.

Operative Techniques and Rehabilitation
The medial parapatellar approach and the midvastus approach are the two most commonly used surgical approaches in total knee arthroplasty. White et al.31 recently reported that patients managed with both operative approaches during bilateral primary total knee arthroplasty required fewer lateral retinacular releases, had less pain at eight days and at six weeks, and were more likely to be able to perform straight-leg raises at eight days on the side managed with the midvastus approach. These advantages disappeared within six months. Keating et al.32 randomized the two approaches to either side of 100 patients undergoing bilateral knee arthroplasty and found no differences in range of motion on day two or at discharge, no differences in the performance of straight-leg raises, and no difference in terminal knee extension, extensor lag, lateral release, or any other aspects of rehabilitation. All complications, including two postoperative hematomas and one manipulation, were noted on the side treated with the muscle-splitting approach.

Rehabilitation of the Hand

Active Mobilization Compared with Passive Mobilization in Optimizing Hand Function
A recent advancement in hand rehabilitation is the increased appreciation and implementation of active motion (compared with passive motion) to maximize rapid functional restoration after injury or reconstruction. Rehabilitation of the hand has traditionally emphasized aggressive and well-organized postoperative protocols, and it has been long established that early motion after injury to the tendons and soft tissues of the hand leads to optimum results. Idler et al.33 recently showed the benefits of active-motion protocols compared with passive-motion protocols. For patients who sustained flexor tendon injuries in zone II (injuries in "no-man’s land," which are challenging in terms of repair and rehabilitation), the use of active motion resulted in a greater final total arc of motion than did a passive-motion protocol. Smoking, concomitant nerve injuries, and crush injuries were also associated with a poorer rehabilitative outcome. To facilitate early active motion, operative techniques have been modified to strengthen the tendon repair site. Use of locking loops, multistrand repairs, and a locked epitenon suture results in tendon repairs that can better withstand early active motion. Several other authors34,35 have recently noted the advantages of active motion compared with passive motion in rehabilitation of the hand, although they have also identified limitations that are particular to these methods. Although Boyer et al.34 showed improved final repair strength with the use of active motion after tendon repairs, they also reported that increasing the ­levels of applied force did not seem to provide additional ­benefit. Silva et al.35 supported the use of active motion following tendon repair; however, they also reported that additional tendon excursion did not seem to add benefit.

Active motion may also play a greater role in the therapy programs that are initiated following metacarpophalangeal joint arthroplasty with silicone implants. Traditionally, the accepted postoperative protocol after such arthroplasty has included dynamic extension splinting. Recently, similar outcomes have been obtained with use of a simple program consisting of a short period of immobilization followed by progressive active motion.

Carpal Tunnel Syndrome
The method of rehabilitation and functional restoration of the hand in patients with carpal tunnel syndrome is an area of continued research and debate. The influence of surgical technique (endoscopic release compared with open release) on rehabilitative outcome and the time before the patient can return to work continue to be controversial topics. It has been shown that endoscopic carpal tunnel release usually facilitates an earlier return to work. However, by about six weeks after decompression, the functional level of patients who have undergone endoscopic or open release is similar. To the proponents of open carpal tunnel release, the suggested increased risks (such as nerve injury) associated with endoscopic release may outweigh the benefits of the earlier return to work. The optimum method remains controversial and, to an extent, probably depends on the experience and preference of the individual surgeon in conjunction with the preferences of a well-informed patient who is aware of the advantages and disadvantages of each method.

Prophylactic rehabilitation protocols have now been shown to be of benefit for patients with carpal tunnel syndrome. Seradge et al.36 found a 45% decrease in the prevalence of carpal tunnel symptoms one year after carpal tunnel decompression exercises shown on the official AAOS web page were implemented in a meatpacking plant. In addition, Barr et al.37 showed a dose-response relationship between repetitive activity and local inflammation of tendons of the upper limbs. These studies add to our understanding of the need to avoid provocative situations in the preoperative and postoperative management and rehabilitation of patients with carpal tunnel syndrome. The use of a well-organized rehabilitation program after carpal tunnel release has also been shown to be of benefit. Provinciali et al.38 noted that a hand rehabilitation program after carpal tunnel release was associated with an accelerated return to work by motivated patients; however, the rehabilitation program did not seem to improve the final functional outcome.

Accuracy of Goniometric and Grip-Strength Measurements
Evaluation of the upper extremity includes the measurement of range of motion, grip and pinch strength, and sensory evaluation as well as provocative tests. Validated outcomes measures such as the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire are new, standardized methods that are being used more commonly in the evaluation of the hand and upper extremity. In addition, recent studies39,40 have been performed to evaluate the accuracy, repeatability, and methods of functional measurements of the upper extremities. Groth et al.39 showed that the accuracy of goniometric measurement of digital motion in the hand is equal with either dorsal or lateral placement of the goniometer. However, neither measurement correlated well with radiographic measurements. Shechtman40 studied the validity of grip-strength measurement, including the range of variation associated with the sincerity of effort in manual grip testing with a Jamar dynamometer. Volunteers without a disorder or injury of the hand were asked to attempt a maximal as well as a "poor" effort in grip testing. The range of variation was found to be so great that the variation could not be used as a tool to determine sincerity of effort.

The Orthopaedic Rehabilitation Association

A Brief History of the ORA
The ORA had its beginnings at the Annual Meeting of the AAOS that was held in New Orleans in 1989. A group of approximately thirty orthopaedic surgeons who were interested in rehabilitation and in the surgical and medical management of patients with chronic neuromusculoskeletal disorders met and formed the organization.

The ORA had its first scientific meeting in San Antonio, Texas, in November 1989. After subsequent annual meetings, it applied for and became a member of the AAOS Council of Musculoskeletal Specialty Societies (COMSS). In addition to an annual meeting, the ORA has produced a scientific meeting program each year for Specialty Day at the AAOS since 1994. The members of the ORA represent several areas of orthopaedic and rehabilitative interests. The society has prepared scientific programs, exhibits, and symposia involving areas such as spinal disorders, neuromuscular disorders (brain injury, stroke, spinal cord injury, and cerebral palsy), interdisciplinary care, sports medicine, hand and upper extremity, foot and lower extremity, tumor surgery, adult reconstruction and joint arthroplasty, prosthetics, orthotic devices, robotics, and innovative scientific and engineering developments in rehabilitation. Regular membership is open to members of the AAOS who demonstrate an interest in orthopaedic rehabilitation. Other types of memberships are open to residents and fellows in orthopaedic surgery, international orthopaedic surgeons, and other physicians, scientists, and allied health-care professionals working in the field.

The twelfth Annual Meeting of the ORA was held in Coronado (San Diego), California, on April 20 and 21, 2001. As the ORA approaches its thirteenth year, the organization extends an invitation to those interested in the field to apply for membership. The thirteenth Annual Meeting will be held in Tucson, Arizona, on April 4, 5, and 6, 2002.

Orthopaedic Rehabilitation Today: New Directions
There is a consensus among the members of the ORA to emphasize that, in general, orthopaedic rehabilitation is a surgical subspecialty. Although orthopaedic rehabilitation does involve a multidisciplinary team approach and relies on the crucial medical and therapeutic management from our colleagues in several disciplines (rehabilitation nursing, physical and oc­cupational [and hand] therapy, orthotics and prosthetics, bioengineering, and social work), the ORA emphasizes that a main part of orthopaedic rehabilitation is surgical reconstruction. Surgery can be considered an important tool in rehabilitation, assisting with the management of the unique and challenging problems presented by these often complicated cases. When applied in the rehabilitation setting, operative methods are effective for many purposes, including correction of limb deformity, tendon transfer for functional restoration, contracture release for improvement of function or positioning, excision of heterotopic ossification, management of chronic infection or refractory areas of skin breakdown, treatment of associated fracture nonunions and malunions, implantation of electrodes for functional electrical stimulation in the paralytic limb, management of neuropathy secondary to limb deformity, and treatment of the many overuse syndromes that develop in this population because of the overtaxing of available muscles or joints. Orthopaedic rehabilitation usually starts in the rehabilitation setting; in fact, often it should start in the acute setting, such as when a patient has sustained multiple trauma. Rigid internal fixation to aid early motion of the limb or weight-bearing is part of orthopaedic rehabilitation. Splints, mobilization programs, and nerve blocks in a severely spastic limb can be performed in the acute or intensive care setting to initiate rehabilitation at the earliest possible time.

Since orthopaedic rehabilitation is not a specialty based on a specific anatomic region, it is perhaps one of the more difficult specialties to define in terms of domain, goals, and directions. The Board of Directors of the ORA, in conjunction with the general membership, formally established a mission statement in the fall of 2000 and announced these new areas of emphasis at the twelfth Annual Meeting of the ORA in Coronado, California41:

The mission of the Orthopaedic Rehabilitation Asso­ciation is to improve the functional outcome of persons with musculoskeletal disability utilizing surgical and nonsurgical management.

In addition, the Vision Statement of the ORA was also announced as follows42:

Rehabilitation is the restoration or improvement of functional capacities and outcomes of individuals with chronic or permanent disabilities. Orthopaedic surgery is a valuable and powerful tool in the rehabilitation armamentarium for improving musculoskeletal function. Orthopaedic ­rehabilitation uses the basic principles of our specialty to ­evaluate and treat a wide variety of potentially devastating ­injuries and disorders. Orthopaedic rehabilitation does not limit itself by the age of the person, the anatomic location of the problem, or the etiology of the musculoskeletal dysfunction. Rather, it focuses on the musculoskeletal system as a whole and understands the linkages and coupling between bones, joints, muscles and the nervous system. Orthopaedic rehabilitation includes all of the traditional orthopaedic subspecialties. It also includes amputation surgery, prosthetic and orthotic management, neuromuscular diseases, and the various neurologic disorders, which defy easy classification. The Orthopaedic Rehabilitation Association strives to be a force helping to unify the needs of our patients with the ever expanding subspecialty expertise within Orthopaedic Surgery and other medical specialties.

Today, the ORA continues to attract new members from several disciplines, both locally and abroad. Most of the members also belong to one or more of the orthopaedic subspecialty associations based on anatomic regions. Membership has expanded by approximately 10% during the last year, and the Association encourages applications from new, interested prospective members.

References

  1. Fuller DA, Keenan MA. Muscular problems of the shoulder: new technologies for managing shoulder problems in neurologic patients. Read at the Orthopaedic Rehabilitation Association Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2001 Mar 3; San Francisco, CA

  2. Keenan MA. Evaluation of the shoulder: new technologies for managing shoulder problems in neurologic patients. Read at the Orthopaedic Rehabilitation Association Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2001 Mar 3; San Francisco, CA

  3. Keenan MA, Lazarus MD. Bony problems of the shoulder: new technologies for managing shoulder problems in neurologic patients. Read at the Orthopaedic Rehabilitation Association Specialty Day at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2001 Mar 3; San Francisco, CA

  4. Hsu J, Perry J, Baumgartner M, Shandy J. Distal femoral osteotomy to ­improve use of KAFO in ambulatory polio patients. Read at the Annual Meeting of the Orthopaedic Rehabilitation Association; 2001 Apr 20-21; ­Coronado, CA

  5. Barr JD, Barr MS, Lemley TJ, McCann RM. Percutaneous vertebroplasty for pain relief and spinal stabilization. Spine, 2000;25: 923-8. [Medline]

  6. Belkoff SM, Mathis JM, Jasper LE, Deramond H. The biomechanics of ­vertebroplasty. The effect of cement volume on mechanical behavior. Spine, 2001;26: 1537-41. [Medline]

  7. Deramond H, Depriester C, Galibert P, Le Gars D. Percutaneous vertebroplasty with polymethylmethacrylate. Technique, indications, and results.. Radiol Clin N Am, 1998;36: 533-46. [Medline]

  8. Garfin SR, Yuan HA, Reiley MA. New technologies in spine: kyphoplasty and vertebroplasty for the treatment of painful osteoporotic compression fractures. Spine, 2001;26: 1511-5. [Medline]

  9. Grados F, Depriester C, Cayrolle G, Hardy N, Deramond H, Fardellone P. Long-term observations of vertebral osteoporotic fractures treated by percutaneous vertebroplasty. Rheumatology (Oxford), 2000;39: 1410-4. [Abstract/Free Full Text]

  10. Jensen ME, Evans AJ, Mathis JM, Kallmes DF, Colft HJ, Dion JE. Percutaneous polymethylmethacrylate vertebroplasty in the treatment of osteoporotic vertebral body compression fractures: technical aspects. AJNR Am J Neuroradiol, 1997;18: 1897-904. [Abstract]

  11. Lieberman IH, Dudeney S, Reinhardt MK, Bell G. Initial outcome and efficacy of "kyphoplasty" in the treatment of painful osteoporotic vertebral compression fractures. Spine, 2001;26: 1631-8. [Medline]

  12. Riggs BL, Melton LJ 3rd. The worldwide problem of osteoporosis: insights afforded by epidemiology. Bone, 1995;17: 505S-11S.

  13. Silverman SL. The clinical consequences of vertebral compression fracture. Bone, 1992;13 Suppl 2: 27-31.

  14. Duffy GP, Trousdale RT, Stuart MJ. Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results. Clin Orthop, 1998;356: 22-7..

  15. Ranawat CS, Flynn WF Jr, Saddler S, Hansraj KK, Maynard MJ. Long­-term results of the total condylar knee arthroplasty. A 15-year survivorship study. Clin Orthop, 1993;286: 94-102.

  16. Ritter MA, Herbst SA, Keating EM, Faris PM, Meding JB. Long-term survival analysis of a posterior cruciate-retaining total condylar total knee arthroplasty. Clin Orthop, 1994;309: 136-45.

  17. Mancuso CA, Sculco TP, Wickiewicz TL, Jones EC, Robbins L, Warren RF, Williams-Russo P. Patients’ expectations of knee surgery. J Bone Joint Surg Am, 2001;83: 1005-12. [Abstract/Free Full Text]

  18. Jones CA, Voaklander DC, Johnston DW, Suarez-Almazo ME. The effect of age on pain, function, and quality of life after total hip and knee arthroplasty. Arch Intern Med, 2001;161: 454-60. [Abstract/Free Full Text]

  19. Salmon P, Hall GM, Peerbhoy D, Shenkin A, Parker C. Recovery from hip and knee arthroplasty: patients’ perspective on pain, function, quality of life, and well­ being up to 6 months postoperatively. Arch Phys Med Rehabil, 2001;82: 360-6. [Medline]

  20. Jorn LP, Johnsson R, Toksvig-Larsen S. Patient satisfaction, function and return to work after knee arthroplasty. Acta Orthop Scand, 1999;70: 343-7. [Medline]

  21. Forrest G, Fuchs M, Gutierrez A, Girardy J. Factors affecting length of stay and need for rehabilitation after hip and knee arthroplasty. J Arthroplasty, 1998;13: 186-90. [Medline]

  22. D’Lima DD, Colwell CW Jr, Morris BA, Hardwick ME, Kozin F. The effect of preoperative exercise on total knee replacement outcomes. Clin Orthop, 1996;326: 174-82.

  23. Rodgers JA, Garvin KL, Walker CW, Morford D, Urban J, Bedard J. Pre­operative physical therapy in primary total knee arthroplasty. J Arthroplasty, 1998;13: 414-21. [Medline]

  24. MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW, Kramer J, Vaz M. Prospective randomized clinical trial of continuous passive motion after total knee arthroplasty. Clin Orthop, 2000;380: 30-5.

  25. Lachiewicz PF. The role of continuous passive motion after total knee arthroplasty. Clin Orthop, 2000;380: 144-50.

  26. Chen B, Zimmerman JR, Soulen L, DeLisa JA. Continuous passive motion after total knee arthroplasty: a prospective study. Am J Phys Med Rehabil, 2000;79: 421-6. [Medline]

  27. Beaupre LA, Davies DM, Jones CA, Cinats JG. Exercise combined with continuous passive motion or slider board therapy compared with exercise only: a randomized controlled trial of patients following total knee arthroplasty. Phys Ther, 2001;81: 1029-37. [Abstract/Free Full Text]

  28. D’Lima DD, Colwell CW Jr. Rotating versus fixed bearings: what should we use in the young patient. Curr Opin Orthop, 2000;12: 26-32.

  29. D’Lima DD, Poole C, Chadha H, et al.. Quadriceps moment arm and quadriceps forces after total knee arthroplasty. Unpublished data.

  30. Mahoney OM, McClung CD, Zahiri CA, Schmalzried TP, Tullos HS. Effect of surgical technique and prosthetic design on extensor mechanism function following total knee replacement. Trans Orthop Res Soc, 1999;24: 145.

  31. White RE Jr, Allman JK, Trauger JA, Dales BH. Clinical comparison of the midvastus and medial parapatellar surgical approaches. Clin Orthop, 1999;367: 117-22.

  32. Keating EM, Faris PM, Meding JB, Ritter MA. Comparison of the midvastus muscle-splitting approach with the median parapatellar approach in total knee arthroplasty. J Arthroplasty, 1999;14: 29-32. [Medline]

  33. Idler RS, Trumble TE, Strickland JW, Stern PJ. Randomized prospective trial of active vs passive motion after zone II flexor tendon repair. Read at the Annual Meeting of the American Society for Surgery of the Hand; 2000 Oct 5-7; Seattle, WA

  34. Boyer MI, Gelberman RH, Burns ME, Dinopoulos H, Hofem R, Silva MJ. Intrasynovial flexor tendon repair. An experimental study comparing low and high levels of in vivo force during rehabilitation in canines. J Bone Joint Surg Am, 2001;83: 891-9. [Abstract/Free Full Text]

  35. Silva MJ, Brodt MD, Boyer MI, Morris TS, Dinopoulos H, Amiel D, Gelberman RH. Effects of increased in vivo excursion on digital range of motion and tendon strength following flexor tendon repair. J Orthop Res, 1999;17: 777-83.. [Medline]

  36. Seradge H, Bear C, Bithell D. Preventing carpal tunnel syndrome and cumulative trauma disorder: effect of carpal tunnel decompression exercises: an Oklahoma experience. J Okla State Med Assoc., 2000;93: 150-3. [Medline]

  37. Barr AE, Fayez FF, Popoff SN, Barbe MF. Repetitive motion causes systemic inflammation and reach pattern decrements in rats. Read at the Annual ­Meeting of the American Society for Surgery of the Hand; 2000 Oct 5-7; ­Seattle, WA

  38. Provinciali L, Giattini A, Splendiani G, Logullo F. Usefulness of hand rehabilitation after carpal tunnel surgery. Muscle Nerve, 2000;23: 211-6. [Medline]

  39. Groth GN, Van Deven KM, Phillips EC, Ehretsman RL. Goniometry of the proximal and distal interphalangeal joints, Part II: placement preferences, ­interrater reliability, and concurrent validity. J Hand Ther, 2001;14: 23-9. [Medline]

  40. Shectman O. Using the coefficient of variation to detect sincerity of effort of grip strength: a literature review. J Hand Ther, 2000;13: 25-32. [Medline]

  41. Orthopaedic Rehabilitation Association. Mission of the ORA. Read at the Annual Meeting of the Orthopaedic Rehabilitation Association; 2001 Apr 20-21; Coronado, CA

  42. Orthopaedic Rehabilitation Association. Vision statement of the ORA. Read at the Annual Meeting of the Orthopaedic Rehabilitation Association; 2001 Apr 20-21; Coronado, CA


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us   Add to Facebook Facebook   Add to Technorati Technorati   Add to Twitter Twitter    What's this?



This Article
Right arrow Extract Freely available
Right arrow Full Text (PDF) Free
Right arrow Letters to the Editor: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Letters to the Editor are posted
Right arrow Alert me if a correction is posted
Services
Right arrow E-mail this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My File Cabinet
Right arrow Download to citation manager
Right arrow Rights and Permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Botte, M. J.
Right arrow Articles by Colwell, C. W.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Botte, M. J.
Right arrow Articles by Colwell, C. W., Jr.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us   Add to Facebook   Add to Technorati   Add to Twitter  
What's this?