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The Journal of Bone and Joint Surgery (American). 2008;90:2301-2311. doi:10.2106/JBJS.H.00943 © 2008 The Journal of Bone and Joint Surgery, Inc. What's New in Orthopaedic Rehabilitation1 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Two Silverstein, Philadelphia, PA 19104. E-mail address for M.A. Keenan: maryann.keenan{at}uphs.upenn.edu
Specialty Update has been developed in collaboration with the Council of Musculoskeletal Specialty Societies (COMSS) of the American Academy of Orthopaedic Surgeons.
Orthopaedic rehabilitation involves the care of patients who have complex musculoskeletal problems, which are global in nature rather than being limited to one or two anatomic locations. It is a specialty that combines biomechanics and biology in a unique manner with an approach that focuses on improving the functional outcome for individuals with musculoskeletal disability through surgical and nonsurgical management. This specialty encompasses patients of all ages, a broad range of anatomic locations, and a variety of musculoskeletal dysfunctions. Orthopaedic rehabilitation comprises all of the traditional orthopaedic subspecialties, including amputation surgery, prosthetic and orthotic management, neuromuscular diseases, and a variety of other neurologic disorders, with a focus on the musculoskeletal system as a whole as well as on the linkages and couplings between bones, joints, muscles, and the nervous system. This update highlights presentations and advances in several areas of orthopaedic rehabilitation that were discussed at meetings of the Orthopaedic Rehabilitation Association, the American Academy of Orthopaedic Surgeons, and other specialty organizations over the past year. The review also highlights the papers that received the Jacquelin Perry Award and the Vernon Nickel Award, the two prestigious awards in orthopaedic rehabilitation that are presented annually by the Orthopaedic Rehabilitation Association.
Motion analysis and dynamic electromyography are important tools in the analysis of movement and lower extremity function. These modalities can be utilized by the surgeon to create both operative and nonoperative treatment protocols. There have been several developments in the use of treadmills for gait analysis. Riley et al.1 examined the differences between overground and treadmill running in terms of kinematics and kinetics. With the advent of instrumented treadmills that permit the measurement of ground-reaction force, the instrumented treadmill has become an important tool that can be used by the clinician for high-velocity gait analysis. The authors examined twenty healthy, young joggers who ran at least fifteen miles (24.1 km) per week. Subjects ran on both instrumented treadmills and on an overground 15-m runway at their 10-km-race pace. Instrumented treadmill running led to a higher cadence (p = 0.0086), shorter stride length (p = 0.0001), shorter stride time (p = 0.0011), decreased maximum knee flexion (p = 0.005), increased minimum knee flexion (p = 0.006), and decreased ground-reaction forces (p < 0.02). In addition, differences between the two forms of running were identified for joint moment and joint power trajectories. The authors concluded that parameters measured with an adequate, instrumented treadmill are comparable with but not directly equivalent to those of overground running. Yet, the instrumented treadmill is still an important clinical tool that can be utilized for high-velocity gait analysis if the differences between overground and treadmill running are recognized. The authors extrapolated that with a stiffer treadmill surface and better regulation of belt speed, the differences between treadmill and overground running analysis can be bridged. Stoquart et al.2 further examined treadmills by analyzing the effect of speed on kinematic, kinetic, electromyographic, and energetic reference values during treadmill walking (as opposed to running). Whereas kinematic, kinetic, and electromyographic data are classically obtained during overground walking, energetic data are obtained on treadmills. The limitation of overground testing is that it is very often done at self-selected speeds, whereas the treadmill allows control of speed. The purpose of that study was to assess the feasibility of extended gait analysis on a treadmill, allowing multiple steps to be recorded at a constant speed for young healthy subjects. In addition, the authors attempted to develop speed-specific kinematic, kinetic, electromyographic, and energetic reference values that could be utilized in future studies. Twenty young volunteers walked on a force-measuring treadmill at six speeds ranging from 1 to 6 km/hr. Hip, knee, and ankle kinematics and kinetics were analyzed, as were electromyographic muscle activity and energy cost (on the basis of oxygen-consumption measurements). The authors found that all variables were speed-dependent. With increased walking speed, kinematics and kinetic peak amplitude increased and occurred earlier during the walking cycle. Furthermore, muscle activity timing changed with speed, and energy cost produced a U-shaped curve (with minimum values at 4 km/hr). The authors concluded that their data provide kinematic, kinetic, and electromyographic reference data for healthy subjects based on the speed of the subject while walking on the treadmill, allowing for extrapolation to other studies based on subject speed. Sturnieks et al.3 provided a connection between gait analysis and clinical sports medicine by examining knee strength and knee adduction moments following arthroscopic partial medial meniscectomy. One hundred and two patients who had undergone meniscectomy were compared with forty-two age-matched controls who had not had an operation. The patients and controls underwent strength testing (with use of isometric, isokinetic, and concentric knee strength measurements) as well as three-dimensional gait analysis at each subject's self-selected walking speed. Hip, knee, and ankle kinetic and kinematic data were collected. From the strength-testing data, patients were also divided into weak and normal subgroups. The authors found that the arthroscopic partial medial meniscectomy group had weaker concentric knee extension and flexion strength (p < 0.001 and p = 0.033, respectively). Furthermore, the weak meniscectomy subgroup had increased average (p < 0.033) and peak knee adduction moments (p < 0.032) during stance when compared with both the normal-strength meniscectomy subgroup and the controls. In addition, the normal strength meniscectomy subgroup had a larger peak knee adduction moment in early and late stance (p = 0.005) as compared with the controls. The authors concluded that, in order to resume normal frontal plane loading of the knee during walking, the achievement of normal muscle strength is paramount. Continuing with the use of gait analysis to evaluate clinical conditions, Lai et al.4 performed three-dimensional gait analysis of obese patients in order to better characterize the role of obesity in walking. Fourteen obese subjects (average body mass index, 33.06) were compared with fourteen non-obese subjects (average body mass index, 21.33) in terms of kinematic and kinetic data that were obtained with use of a self-selected walking speed and a three-dimensional motion-analysis system. The authors found that obese patients spent more time during stance (p < 0.05) and double support (p < 0.01) and had a lower self-selected walking speed (p < 0.01), shorter stride length (p < 0.01), greater hip adduction during terminal stance (p < 0.01) and pre-swing (p < 0.05), greater knee adduction angles (p < 0.05), increased ankle eversion angles (p < 0.05), increased ankle inversion moments (p < 0.05), and reduced peak ankle plantar flexor moments (p < 0.01). The authors concluded that the differences in the three-dimensional gait analysis between the obese and non-obese subjects were adaptations of the obese patients to their heavy body weight, particularly attempts by the obese patients to reduce moments about the knee and energy expenditure.
Interest in amputation surgery and prosthetics has been in the international spotlight with controversy regarding South African double amputee sprinter Oscar Pistorius's ambitions to compete in the able-bodied Olympics and the purported advantage (or disadvantage) that his prosthetic limbs confer to him. This dialogue has raised awareness of the tremendous technological advances that are now available to individuals who have undergone amputation surgery, allowing patients to return to a high level of function. This has been of particular importance to the large numbers of young soldiers who have experienced traumatic amputations in conflicts across the globe. Hagberg et al.5 performed the first prospectively designed outcomes study on tumor and trauma patients with transfemoral osseointegrated (i.e., bone anchored) prostheses. The main purpose of their study was to analyze general and condition-specific health-related quality-of-life changes in eighteen consecutive patients prior to, and two years after, treatment with an osseointegrated prosthesis. The Short Form-36 (SF-36) health survey and the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) were administered preoperatively and postoperatively. The authors found that there was a significant improvement in the physical functioning, role functioning physical, bodily pain, and physical component subscores of the SF-36 as well as the prosthetic use, prosthetic mobility, problems, and general health scores of the Q-TFA at the time of follow-up (after placement of an osseointegrated prosthesis) as compared with the preoperative status. These improvements in SF-36 and Q-TFA scores were extrapolated to superior quality of life, increased prosthetic use, better prosthetic mobility, decreased problems, and a better overall amputation condition. The authors concluded that osseointegrated prostheses are a promising development for individuals with transfemoral amputations that can lead to an improved quality of life at the time of the two-year follow-up. Whereas the previous study examined the use of a specific prosthesis for transfemoral amputations, Baum et al.6 retrospectively examined the effect of residual limb length on gait parameters in patients with transfemoral and knee-disarticulation amputations. As prostheses evolve, there is a lack of objective data on the correct level for transfemoral amputations as it relates to gait as well as on the relationship between gait and knee disarticulation. The purpose of that study was to determine how temporal-spatial, kinematic, and kinetic trends correlate with the length of the residual femur in patients with transfemoral and knee-disarticulation amputations. The authors retrospectively reviewed gait analysis data on thirteen active, young soldiers (mean age [and standard deviation], 30.7 ± 6.7 years) who underwent a unilateral transfemoral or knee-disarticulation amputation following a traumatic injury. To prevent variability based on the prosthesis, all individuals used the C-Leg microprocessor knee unit (Otto Bock, Duderstadt, Germany) in conjunction with their everyday foot, which in each case was an all multiaxial, energy storage and return (ESAR) foot. Residual limb lengths were measured from the greater trochanter to the distal aspect of the limb. Among the thirteen patients in the study, the residual limb ratio, as compared with the contralateral, intact limb, ranged from 57% (transfemoral level) to 100% (knee disarticulation). The authors found that after the removal of one outlier, pelvic tilt excursion was inversely related to residual limb length (R2 = 0.465). Otherwise, the authors found no correlation between residual limb ratio and velocity, cadence, step length or stance time of the prosthetic limb, step length or stance time of the intact limb, step width, hip flexion, trunk lateral flexion, and trunk forward lean. The authors concluded that if the length of the amputated femur is at least 57% of that of the contralateral femur, dramatic changes in gait are not expected. The authors noted that "This implies that surgeons may have more flexibility to amputate at a higher level to preserve soft tissue quality and improve prosthetic fitting without sacrificing gait function."
One of the critical tasks that the clinician faces after successful amputation is the long-term management of the patient's prosthesis. As a result, one of the important roles of the physician is to prescribe the proper prosthesis so that the patient's gait and function are not impaired. The ability to accurately determine the patient's activity level is essential in this process and was examined by Stepien et al.7. The purpose of that study was to compare the number of steps that lower-limb amputees take per day and to compare their self-reported step number (by means of an activity diary) with that recorded with the StepWatch Activity Monitor (SAM) 3.0 (Cyma, Mountlake Terrace, Washington), which has been shown to be 99.7% accurate for determining activity levels in lower-limb amputees8. Seventy-seven patients with a unilateral lower-limb amputation who had undergone at least six months of prosthetic rehabilitation were studied. Activity counts (steps/min) and self-reported activity level (rest, low, medium, high) were recorded for fifteen-minute time intervals over a total period of one week for each participant with use of both the patient's diary and the SAM (which was fitted to the patient's prosthesis and continuously recorded activity). The authors found that the participants' self-reported and measured activity strongly agreed (gamma In line with the work by Stepien et al.7 with regard to the utilization of the proper prosthetic design for patients, Adderson et al.9 examined the effect of a shock-absorbing pylon on the peak magnitude and frequency content of the heel-strike-initiated shock wave transmitted to the residual limb as well as the relationship between heel-strike transient force and function. The authors examined seven patients with unilateral transtibial amputation who walked at self-selected speeds with and without the shock-absorbing pylon. Accelerometers (mounted along the prosthetic pylon) were used to measure transmitted shock waves, force plates were used to measure ground-reaction forces, ten-minute walking tests were used to determine walking speed, and questionnaires were used to evaluate gait function and subjective preference for the shock-absorbing pylon. The authors found that the shock-absorbing pylon provided no significant shock absorption (p = 0.28) or change in frequency content. Furthermore, there were no significant differences in terms of ground-reaction force, walking speed, gait function, or subjective preference. The authors concluded that there is no evidence to suggest a significant effect of the shock-absorbing pylon, although additional study is necessary because of the high variance in the study.
The precise pathophysiology behind heterotopic ossification is unknown but is thought to be related to both local and systemic factors causing osteoblastic differentiation of pluripotent mesenchymal stem cells. The source of these mesenchymal cells is yet to be determined, and the stimulus that causes them to differentiate is still being elucidated. Exploration into the molecular and cellular basis of conditions such as fibrodysplasia ossificans progressiva can likely provide insight into the mechanism behind heterotopic ossification10,11. Bone morphogenetic protein (BMP) is believed to be an important regulator of the process, with BMP-4 in particular having been shown to be upregulated in association with fibrodysplasia ossificans progressiva. Modulation of BMP-4 by antagonists such as noggin and chordin has been shown to inhibit heterotopic ossification12, and mice lacking noggin show overactivity of BMP and display exuberant orthotopic and heterotopic ossification. Several risk factors for heterotopic ossification in patients who have sustained a head injury have been identified, and multiple authors have shown a correlation with the duration of coma, spasticity, immobility, and fractures. Hendricks et al.13, in a retrospective cohort study, investigated autonomic dysregulation, systemic infection, and various sequelae of severe brain injury as predictors for the development of heterotopic ossification. A total of seventy-six patients were followed for an average of seventeen months. Clinically relevant heterotopic ossification developed in nine patients (12%) at an average of thirty-four days after the injury. Multiple variables defining the severity of head injury were documented, including the initial Glasgow Coma Scale score, intracranial pressure, the classification of the initial computed tomography findings in the brain, the presence of diffuse axonal injury, the duration of mechanical ventilation requirement, the duration of the coma period, and the development of spasticity. Both coma duration (mean, 28.11 days compared with 7.54 days; p < 0.001) and the length of time on a mechanical ventilator (mean, 22.33 days compared with 7.25 days; p < 0.001) were significantly longer for patients who had development of heterotopic ossification than those who did not. Although there was an increase in all categories of brain injury sequelae as demonstrated by the calculation of relative risk, only autonomic dysregulation had high positive and negative predictive values for the development of heterotopic ossification (relative risk, 59.55; positive predictive value, 88.9%; negative predictive value, 98.5%). The authors concluded that comatose patients receiving mechanical ventilation after sustaining a severe traumatic brain injury who meet the criteria for autonomic dysfunction are at high risk for the development of heterotopic ossification. Simonsen et al.14, in a similar retrospective study that was performed to determine the prevalence of and possible risk factors for heterotopic ossification in patients who had sustained a very severe brain injury (defined as a posttraumatic amnesia period of at least twenty-eight days), found a 7.9% prevalence of clinically important heterotopic ossification. Female sex and a higher Injury Severity Score showed a significant positive correlation, prompting the authors to suggest the involvement of hormonal mediators in ectopic bone formation. Recent literature has supported the role of heterotopic ossification as a cause of pain in the residual limb of amputees. Potter et al.15 evaluated the development of heterotopic ossification in a study of 187 patients (213 residual limbs) who had sustained a traumatic or combat-related amputation. The prevalence of radiographic heterotopic ossification in this population was 63% (134 of 213). A large number of patients with radiographic evidence of heterotopic ossification were asymptomatic; with the inclusion of patients without two months of radiographic follow-up, only twenty-five (6.7%) of all 373 amputations required operative excision of bone at an average of 8.2 months after the initial injury. Twenty limbs underwent local radiation therapy within twenty-four hours after excision, and twelve received nonsteroidal anti-inflammatory drugs and local radiation therapy. At the time of the twelve-month follow-up, significant decreases were noted in the requirements for narcotic consumption in twenty-four patients (p < 0.0001) and neuropathic pain medication in twenty-two patients (p = 0.002). Twenty-three limbs had no evidence of recurrent heterotopic ossification at twelve months. Two limbs had a radiographic but clinically asymptomatic recurrence. Wound-related complications necessitating a return to the operating room occurred in six patients. No significant difference was found between the use of nonsteroidal anti-inflammatory drugs and local radiation therapy for postoperative prophylaxis against recurrence. In this population, the excision of heterotopic bone was associated with a low rate of recurrence but a moderate risk of wound complications. Surgical intervention can restore motion in patients with heterotopic ossification, but the timing of excision has been controversial. Some experts believe that ossification is less likely to recur after a prolonged observation period, which allows for resolution of the acute inflammatory phase and the maturation of bone. Others have suggested that early excision allows for increased range of motion, the prevention of soft-tissue contracture, and the prevention of muscle atrophy. Chalidis et al.16 conducted a systematic review to determine the optimum timing of surgical resection for the treatment of heterotopic ossification. Only studies consisting of patients with traumatic brain injury who had undergone resection of heterotopic ossification for the first time and had a minimum of twelve months of follow-up were included in the analysis. Sixteen studies comprising 255 patients were analyzed. The recurrence rate reported in eleven of the sixteen studies was 19.8% (thirty-eight of 192). Regression analysis did not show a significant impact of the time interval before resection on the rate of recurrence (odds ratio, 1.00; 95% confidence interval, 0.98 to 1.03). The overall probability of recurrence after thirteen, twenty-one, and thirty months of waiting was 9%, 14%, and 19%, respectively. The duration of coma was the strongest predictor of recurrence, with rates of 5%, 13%, and 29% after three, six, and twelve weeks of coma, respectively. The authors concluded that, from the available data, surgical resection does not need to be postponed until there is maturation of the heterotopic bone. The elbow joint is a common site for heterotopic ossification as a result of neurologic injury, posttraumatic injury, or burns. Klein et al.17 suggested the need for increased attention on optimizing the time to wound closure after observing an increased rate of heterotopic ossification in patients with extended time to wound closure. The development of ossification around the elbow has been considered to be a poor prognostic factor for surgery designed to restore motion. Lindenhovius et al.18, in a study on the use of elbow contracture release for the treatment of elbows with and without posttraumatic heterotopic ossification, tested the hypothesis that patients with heterotopic ossification who undergo open elbow contracture release and excision of the heterotopic bone will regain less ulnohumeral motion than patients without heterotopic ossification who also undergo open elbow contracture release. A total of thirty-seven patients (sixteen patients with heterotopic ossification and twenty-one patients with a capsular contracture) were included in the study. Two of the sixteen patients in the heterotopic ossification cohort and seven of the twenty-one in the capsular contracture cohort required subsequent surgery for various reasons (repeat contracture release, ulnar nerve transposition, and removal of implants). Twenty-four months after the index procedure, there was a significant improvement in the flexion arc in the heterotopic ossification cohort as compared with the capsular contracture cohort (54° compared with 35°; p = 0.02). After all subsequent procedures, the flexion arc improvement was greater, but not significantly so, in the heterotopic ossification cohort (57° compared with 46°; p = 0.19). Although the study did not have sufficient power to show a difference in final flexion arc improvement, the authors suggested that heterotopic ossification is a positive prognostic factor for improvement after release, with better motion and with fewer repeat procedures being required.
The use of systemic hypothermia for spinal cord injury has received much attention in the past year, in large part because of the substantial neurologic recovery after the use of moderate hypothermia in the case of a professional football player who had sustained an incomplete cervical spinal cord injury19. Whether the neurologic recovery was spontaneous, was due to hypothermia, or was due to early surgical decompression is uncertain. The current theory is that decreased temperatures will minimize metabolic demands and edema during periods of spinal cord ischemia. The results from multiple studies investigating the use of hypothermia in animal models of spinal cord injury have been mixed. Morochovic et al.20 studied local transcutaneous cooling of the spinal cord. An animal model of spinal cord compression involving epidural balloon inflation was utilized in a study of forty rats. Twenty-five minutes after cord compression, the paravertebral temperature of twenty animals was maintained at 28.5°C for an hour, whereas the remaining twenty animals were kept normothermic. Functional recovery was monitored weekly for four weeks. Although there was more white matter in portions of the spinal cord in the hypothermic group, the overall volume of preserved spinal cord tissue and the overall functional improvement were not significantly different between the two groups. Nishi et al.21 studied the effect of hypothermia on experimental ischemia in spinal ventral horn neurons, which previously have been found to be vulnerable to ischemia22. Lumbosacral spinal cord slices were prepared, and an oxygen and glucose-deprived solution was superfused to simulate ischemia in the ventral horn neurons. The frequency of spontaneous excitatory postsynaptic currents was significantly decreased in a hypothermic environment, suggesting that glutamate release from presynaptic terminals onto these ventral horn neurons was inhibited by hypothermia. Because ischemia can disrupt synaptic function and can result in the accumulation of glutamate in the extracellular space, spinal ventral horn neurons can be excessively stimulated, initiating intracellular events leading to apoptosis and necrosis; hypothermia can reduce this excessive stimulation. The authors concluded that one mechanism of the neuroprotective effects of hypothermia may be through suppression of excitatory synaptic transmission and, therefore, eventual neuronal death. Other laboratory and animal studies have been inconclusive with regard to this neuroprotective effect of hypothermia; in addition, there have been no clinical case reports in the last three decades. Prospective clinical trials evaluating the effectiveness of hypothermia for the treatment of spinal cord injury are encouraged. Surgical as compared with nonsurgical treatment for acute cervical spine injury continues to be investigated. In a retrospective review over a period of nine years, Singhal et al.23 evaluated the neurologic outcomes for patients who had had surgical treatment of incomplete closed traumatic cervical spinal cord injuries; these results were then compared with those of an earlier study of conservatively managed patients. Thirty-seven patients who had been followed for at least twelve months after the surgical treatment of a traumatic closed cervical spine injury with a Frankel grade of B or better were included in the study. No significant difference was noted between the two groups with regard to the neurologic outcome or the motor recovery rate. The duration of hospital stay was also not significantly different between the groups. The results of that investigation concurred with the results of a prospective study by Vaccaro et al.24, which demonstrated no significant benefit when decompression performed earlier than seventy-two hours after the injury was compared with decompression performed more than five days after the injury. The efficacy and safety of methylprednisolone for the treatment of acute spinal cord injury continue to be controversial as the complications stemming from its use cannot be ignored. Hurlbert and Hamilton25 recently reported a reversal of practice patterns related to the use of steroids for the treatment of spinal cord injury in the past five years. At a national meeting, a total of forty-six neurosurgeons and orthopaedic surgeons actively participating in the care of patients with spinal cord injury responded to a questionnaire. Eighty-five percent reported that their view on steroid administration had changed in the last five years. When the results of those questionnaires were compared with the results of questionnaires that had been completed five years earlier, only 24% of the spinal surgeons reported that they currently prescribed steroids for spinal cord injury, in contrast to 76% in 2001. Although not as prevalent as it was five years ago, litigation is still a major factor for surgeons who choose to prescribe steroids. Review articles still present contrasting conclusions regarding the use of steroids for the treatment of acute spinal cord injury, making it difficult for clinicians to make confident evidence-based decisions. Immobilization arising from spinal cord injury leads to general bone loss, reported to be anywhere from 30% to 50%, which predisposes these patients to a high frequency of fractures. Alekna et al.26, in a prospective study, investigated the effect of weight-bearing on bone mineral density in patients with spinal cord injury. Fifty-four subjects were split evenly among two groups: one in which standing exercises were performed for more than one hour daily and one in which they were not. Bone mineral density was measured at the one-year and two-year time points. At two years after the injury, significant differences were noted between the two groups in terms of the bone mineral density of the leg (1.018 compared with 0.91 g/cm2; p = 0.0004), pelvis (1.002 compared with 0.91 g/cm2; p = 0.0144), and total body (1.116 compared with 1.077 g/cm2; p = 0.016). Age, sex, and the level of injury did not have an impact on bone mineral density. No significant difference was found between paraplegic and tetraplegic patients with regard to bone mineral density. The authors concluded that standing for more than one hour daily for at least five days a week can decrease the loss of bone mineral density in patients with a spinal cord injury. Multiple studies have suggested that substantial activity-dependent neuroplasticity is present following a spinal cord injury and that it warrants the use of locomotor training. Various strategies exist, including body weight-supported treadmill training and functional electrical stimulation. Mehrholz et al.27 systematically reviewed strategies for locomotor training in an attempt to find a superior method for improving walking function. Four randomized controlled trials involving 222 patients were included in the review; all studies compared body weight-supported treadmill training with other types of training approaches. One study also investigated robotic-assisted locomotor training, and one study included a combination of body weight-supported treadmill training along with functional electrical stimulation. Walking speed, walking capacity, and the chance of walking independently did not significantly improve in association with any of the methods. The safety of the exercises, measured on the basis of the prevalence of adverse events, was not significantly different in any of the trials. The authors concluded that there is insufficient evidence to support the use of one locomotor training strategy over another. Griffin et al.28 investigated functional electrical stimulation cycling and its effect on the metabolic, body composition, and neurologic profile of patients with paralysis resulting from spinal cord injury. Eighteen patients with a spinal cord injury were enrolled in the study. After thirty minutes of functional electrical stimulation cycling three times per week for ten weeks, a comprehensive profile, including body composition and bone mass, motor and sensory American Spinal Injury Association (ASIA) scores, plasma glucose and insulin levels, and serum inflammatory marker levels, was compiled. Lean muscle mass increased, but there was no change in bone or adipose tissue at ten weeks. Lower extremity motor, sensory, and total ASIA scores were significantly higher after functional electrical stimulation. Glucose levels were significantly lower at thirty, sixty, and ninety minutes after dextrose consumption following functional electrical stimulation cycling, and insulin levels were significantly lower. Although plasma lipid levels did not change, except for a slight increase in high-density lipoprotein levels, selected inflammatory markers were all significantly reduced after ten weeks. Significant improvements in motor and sensory ability, along with improvements in blood glucose control and lean muscle mass, are indicative of the health benefits of functional electrical stimulation cycling in patients with spinal cord injury.
Recent data from the United States Centers for Disease Control and Prevention indicate an alarming increase in the incidence of diabetes, with 1.5 million new cases in 2005, and an estimated 21 million people, or 7% of the population, affected in the United States. These patients experience a multitude of lower extremity complications as a result of poor glycemic control. The prevalence of foot ulcers ranges from 4% to 10% among the diabetic population, and the lifetime prevalence is reported to be as high as 25%. These ulcers are associated with a high risk for complications such as infection, gangrene, and amputation. Diabetic patients undergoing bypass surgery for the treatment of lower limb ischemia also are at an increased risk of amputation and have a decreased time of survival as compared with nondiabetic patients29. Approximately 50% of nontraumatic amputations in the United Kingdom are reported to occur in diabetic patients, and 50% of these patients will die within three years after the amputation. The financial burden on the healthcare system is staggering, with conservative estimates of cost around $45,000 per patient. Therefore, a high standard of care, including early recognition and prevention followed by multidisciplinary treatment protocols for diabetic foot ulcers, must be instituted in order to reduce the morbidity and mortality associated with diabetes. Rerkasem et al.30 evaluated a diabetic-foot protocol involving a multidisciplinary approach for decreasing the prevalence of lower extremity amputation. A diabetic foot care team composed of endocrinologists, rehabilitation physicians, family physicians, plastic and vascular surgeons, and nurses at a university hospital met monthly to develop strategies, algorithms, and consensus guidelines to appropriately treat diabetic foot ulcers on the basis of the most recent literature. Preventive services, self-care education, routine foot care, and protective footwear were offered to each patient. A total of seventy-three patients received care under the diabetic foot care protocol, whereas 110 patients received standard foot care. The rate of minor amputations was significantly lower in the diabetic foot care protocol group (5.5% compared with 13.6%; p = 0.04), as was the rate of major amputations (4.1% compared with 13.6%; p = 0.03). The authors concluded that a diabetic foot care protocol can be useful for decreasing the rate of lower extremity amputations and, if instituted at other hospitals, should improve overall outcomes in patients with diabetes. Other studies have also demonstrated a decrease in the rate of diabetes-related lower extremity amputation after the introduction of improved diabetic foot management31,32. Total contact casting has been established as an effective treatment for diabetic foot ulceration. Frigg et al.33 reported the recurrence rate of ulcers after total contact casting in patients with diabetic foot ulcers. Twenty-eight patients with a total of thirty-four Wagner grade-1 and 2 ulcers were managed with total contact casting and were followed for an average of 2.8 years. Ulcers were débrided of all necrotic tissue before cast application, and patients were allowed full weight-bearing. After complete wound-healing, patients were fitted in custom-made orthopaedic shoes and had standard follow-up examinations every one to two months. Patients were managed with the first series of total contact casts for an average of 4.2 months, with complete healing occurring in association with twenty-nine (85%) of thirty-four ulcers. There were a total of twenty-six ulcer recurrences in sixteen patients (57%) at an average of 4.6 months after healing. Eight of these recurrences were treated with operative correction, and all of these patients remained ulcer-free after correction. The ulcer-free interval after operative correction was significantly longer than that before operative correction (twenty-eight months compared with 3.5 months; p = 0.008). Sixteen recurrences were treated with repeat total contact casting, which resulted in an ulcer recurrence rate of 50%. Patients with obvious foot deformities before total contact casting were more likely to experience recurrences and new ulcers than patients without deformities were. The authors suggested a more aggressive approach to the correction of foot deformities for ulcer prevention and recurrence, as total contact casting alone resulted in an unacceptable rate of recurrence. After noting that patients who were noncompliant with instructions against weight-bearing did not experience the harmful effects thought to be associated with weight-bearing, de Souza34 reported the results of immobilization in weight-bearing total contact casts for patients with Charcot arthropathy. Over a period of eighteen years, twenty-seven patients with a total of thirty-four feet with Charcot arthropathy were followed for an average of 5.5 years. Total contact casts were used for all patients with Eichenholtz Stage-I or early Stage-II disease, and all patients were allowed to bear weight; various types of orthoses were used as the disease progressed to latter Stage-II and Stage-III disease. On the average, patients were immobilized in a total contact cast for fourteen weeks, with the cast being changed at weekly intervals. Of the thirty-four feet, thirty had anatomic changes or disruption before the initial application of a cast, none of which progressed further or deteriorated with weight-bearing in a total contact cast. In addition, ten feet were noted to have ulcers before cast immobilization, and no new ulcers developed with weight-bearing. The author concluded that, for patients with Eichenholtz Stage-I Charcot arthropathy, weight-bearing in a total contact cast until the arthropathy clearly progresses to Stage II is an acceptable management approach. Charcot midfoot deformity is a risk factor for the development of plantar midfoot ulcerations that can lead to infection, and ultimately amputation, in diabetic patients. Bevan and Tomlinson35 investigated radiographic measures associated with skin abnormality in this population. A retrospective review of nineteen patients with diabetic Charcot midfoot neuroarthropathy was performed; a total of twenty-four feet were graded according to skin abnormality as "no ulcer," "pre-ulcerative lesion," "forefoot ulcer," or "midfoot ulcer." Radiographs of thirteen feet with no ulcers were compared with radiographs of six feet with midfoot ulcers. The lateral talar-first metatarsal angle (p < 0.001) and the calcaneal-fifth metatarsal angle (p = 0.007) were both significantly associated with plantar midfoot ulcerations. These angles are associated with a rocker-bottom deformity and are likely radiographic representations of high peak plantar pressures that lead to ulceration. Simple radiographic measurements may identify a foot that is at high risk for ulceration and may lead to earlier preventative measures designed to decrease the rate of amputation. Autonomic neuropathy and sympathetic denervation of sweat glands lead to anhidrosis and poorly hydrated skin in the diabetic foot. Autonomic neuropathy predisposes the foot to skin disruption and ulceration secondary to shear stresses applied during walking. Elisa et al.36 conducted a single-blinded randomized study evaluating the use and safety of a foot sock containing a hydrating agent composed of a nanoemulsion of liposomes. Thirty patients with peripheral neuropathy and bilateral anhidrosis of the foot were randomized into two groups: one group was managed with the application of socks with an active hydrating agent, and one was managed with the application of socks without an active agent. Patients were evaluated at baseline and after six weeks of continuous treatment with respect to multiple parameters, including skin moisture, transepidermal water loss, skin temperature, and skin hardness. Compared with the baseline findings, the group that had been managed without the active hydrating agent showed no significant changes, whereas the group that had been managed with the active hydrating agent showed a significant improvement in all parameters except for skin temperature. Senneville et al.37 conducted a retrospective cohort study to identify factors that predict remission following the nonoperative treatment of diabetic foot osteomyelitis. Fifty diabetic patients at nine different centers received antibiotic treatment for an average of 11.5 weeks. Twenty-two patients had bone culture-based therapy, whereas twenty-eight patients had swab culture-based therapy. A total of twenty-four demographic, clinical, and therapeutic variables were analyzed. After 12.8 months of antibiotic therapy, eighteen (82%) of twenty-two patients in the bone culture-based therapy group were in remission as compared with fourteen (50%) of twenty-eight patients in the swab culture-based therapy group. This difference was significant on both univariate (p = 0.02) and multivariate analysis (odds ratio, 4.78; 95% confidence interval, 1.0 to 22.7; p = 0.04). The authors recommended the use of bone biopsy to guide appropriate treatment in diabetic patients who are managed nonoperatively for osteomyelitis of the foot.
An estimated $20 billion to $25 billion is spent annually on wound care in the United States, with chronic wounds affecting millions of people and causing approximately two million lost workdays each year. It is estimated that the United States population over the age of eighty-five years will increase fourfold in the next fifteen years, likely increasing the number of patients and the costs associated with these wounds. Chronic leg wounds can be classified into four main groups on the basis of etiology: venous, arterial, diabetic, and pressure wounds. Other diseases such as cancer and vasculitis can also be complicated by chronic wound formation. The Wound Healing Society recently established guidelines for both the prevention38-41 and treatment42-45 of each type of wound. Various treatment regimens are available for chronic wounds, including débridement, pressure management, antibiotic treatment, compression therapy, and the use of specialized wound dressings. Recent advances in chronic wound therapy include cultured skin substitutes, hyperbaric oxygen therapy, and negative pressure therapy. Infected chronic wounds can be treated systemically (e.g., with antibiotics) or locally with dressings, topical applications, débriding agents, or wound cleansing. Dressings incorporating the antimicrobial effects of silver have been one of the more popular types of dressings for the treatment of chronically infected wounds. Vermeulen et al.46 systematically reviewed the literature on the use of silver dressings for the treatment of contaminated and infected wounds in order to evaluate their role in reducing infection and improving wound-healing. Three randomized controlled trials were included in the review, two of which evaluated silver-containing foam and one of which investigated silver-containing alginate. All three studies had small sample sizes, low power, and a limited follow-up period of four weeks. No trial demonstrated clear evidence supporting the effectiveness of silver-containing dressings. Two studies showed favorable outcomes with regard to odor and leakage for the silver-containing group. However, there was no difference in the number of completely healed ulcers between the two groups, and only one of the three studies showed an increased rate of wound area reduction. Furthermore, none of the trials investigated the duration of wound infection as an outcome measure. The authors concluded that there is insufficient evidence to support the use of silver-containing dressings to reduce infection and improve wound-healing and suggested future studies with longer follow-up as these wounds require a longer healing period. Thackham et al.47 reviewed the rationale and current protocols for the use of hyperbaric oxygen in the treatment of chronic wounds. Many studies have shown that oxygen is a critical element in all stages of wound-healing. Collagen production is decreased in association with reduced wound oxygen tension, and wound hypoxia inhibits the bactericidal activities of leukocytes, predisposing to bacterial infection. Oxygen is also thought to stimulate angiogenesis, which is needed for healing. Evidence supporting the use of hyperbaric oxygen for the treatment of chronic wounds has been primarily focused on diabetic wounds. The American Diabetes Association endorsed the use of hyperbaric oxygen therapy for the treatment of diabetic wounds that fail to respond to conventional treatment, and the Centers for Medicare and Medicaid Services stated that there was adequate evidence to support hyperbaric oxygen as an effective treatment for diabetic wounds that are classified as Wagner grade 3 or higher. In 2006, the use of hyperbaric oxygen therapy for arterial insufficiency ulcers was supported by the Wound Healing Society42. The most popular advancement in wound care in the past decade has been the use of topical negative pressure therapy, also more commonly known as vacuum-assisted closure. Ubbink et al.48 conducted a systematic review based solely on randomized controlled trials to evaluate the use and effectiveness of topical negative pressure therapy. Fifteen reports on thirteen randomized controlled trials were included in the review, with a total of 573 wounds in 554 patients; seven of the thirteen trials involved chronic wounds. Aggregate data did not show any evidence of more rapid or complete wound closure. Two studies demonstrated a shorter median time to be ready for surgery in association with vacuum-assisted closure as compared with the control. Both studies demonstrated a higher complication rate in association with vacuum-assisted closure and no difference in terms of pain or quality of life. Two studies evaluating bacterial load demonstrated no reduction in bacterial load in association with topical negative pressure therapy. Three studies evaluating the cost difference between vacuum-assisted closure and conventional treatment had varied results, with two demonstrating higher costs for conventional treatment and one demonstrating the opposite. The authors reported several consistent flaws in the existing randomized trials; specifically, allocation concealment was a problem in many studies and likely resulted in selection bias, the follow-up time was too short for the evaluation of chronic wound-healing, and too many different end points and control treatments were used, which prevented meta-analysis. The authors concluded that there is insufficient evidence to support the effectiveness of topical negative pressure therapy and reported that they plan to publish a more detailed review specifically for chronic wounds in the Cochrane Database of Systematic Reviews in the near future.
Each year the Orthopaedic Rehabilitation Association holds a competition for the best original research paper by a resident or fellow. These awards are named in honor of the two pioneers in this field, Dr. Jacquelin Perry and Dr. Vernon Nickel. The Perry Award paper is presented at the Orthopaedic Rehabilitation Association Specialty Day Program held in conjunction with the annual meeting of the American Academy of Orthopaedic Surgeons. The Nickel Award paper is presented at the annual meeting of the Orthopaedic Rehabilitation Association.
The Jacquelin Perry Award Paper 2008: Orthopaedic Management Improves the Early Rate of Osteoporosis Treatment after Hip Fracture The percentage of patients who started treatment and the number of patients who had a bone mineral density scan within six months after the hip fracture were also significantly greater in the study group (p = 0.002 and p < 0.0001, respectively). The trial was stopped before the pretrial estimate of 120 patients was reached because intermediate-term analysis demonstrated a significant difference in the rate of treatment between the two groups. A post hoc power analysis demonstrated a power of 0.61.
The Vernon Nickel Award Paper 2008: The Effect of Sitting Pressure on Ischial Blood Flow in Spinal Cord Injured Patients vs. Non-Injured Controls Healthy controls exhibited stable cutaneous ischial tissue perfusion in association with sitting pressures of up to 150 mm Hg, followed by a 10% increase in blood flow at higher peak pressures. In contrast, subjects with spinal cord injuries underwent an early decrease in perfusion of 20% in association with pressures of up to 150 mm Hg, with a subsequent leveling off of blood flow at higher pressures. The patients with spinal cord injuries also demonstrated lower reperfusion values, indicative of a weaker reactive hyperemia, in response to pressure. Noiseux concluded that, compared with uninjured controls, patients with spinal cord injuries appeared to have inherent blood flow regulation differences in response to pressure in the subischial tissues, possibly because of a dysfunction in an autonomic phenomenon termed pressure-induced vasodilation. However, a threshold pressure for maintaining optimal perfusion remains elusive for both healthy subjects and patients with spinal injuries. Future steps should be directed at targeting the altered blood flow response to pressure in patients with spinal cord injuries, pharmacologically or mechanically, which may lead to a reduction in the prevalence of decubital ulcers.
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0.7) for only 34% of the participants during waking hours. The self-reported and measured activity levels also showed poor agreement for each state of activity (rest [r = 0.41], low level [r = 0.39], medium level [r = 0.26], high level [r = 0.40]). The authors did find that the transtibial amputees took more steps per day on the average than the transfemoral amputees did and that there was no bias toward over-reporting or under-reporting of the level of activity among all amputees. The authors concluded that the use of self-reported activity levels may have consequences for both patients and funding agencies (such as insurance companies) as these measurements are not accurate. Under-reporting of activity can prevent patients from being prescribed the prosthesis that will most effectively meet their activity level and walking ability. Over-reporting of activity can lead patients and funding agencies to pay for advanced prostheses that are unnecessary for patients with low activity levels. 
I. Local transcutaneous cooling of the spinal cord in the rat: effects on long-term outcomes after compression spinal cord injury. Int J Neurosci. 2008;118:555-68.| home | CME | help | feedback | subscriptions | archive | site index |
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