Ericka N. Merriwether

Minimum detectable change in gait velocity during acute rehabilitation following hip fracture.

Purpose: Early ambulation and rehabilitation are recommended for patients undergoing surgical fixation of hip fracture. Gait velocity may be used as an outcome measure for these patients during acute rehabilitation. As an outcome measure, an estimate of meaningful change (responsiveness) in gait velocity for these patients, however, has not been described. The minimum detectable change (MDC) is a value that represents true change in a measure beyond that accounted for by measurement error. The purpose of this study was to quantify MDC in gait velocity as an index of responsiveness for persons in the acute stage of rehabilitation following hip fracture. Methods: The study design was a descriptive cohort study with one repeated measure. A volunteer sample of 16 subjects over the age of 65, at a mean of 4.7 days postsurgical fixation of unilateral hip fracture, participated in the study. The study was conducted in an acute care rehabilitation practice in a large, tertiary care hospital. We measured gait velocity with the 10‐meter walk test, estimated test‐retest reliability with an intraclass correlation coefficient and quantified responsiveness of gait velocity as the MDC at a 95% level of confidence. Results: Mean gait velocity was 15 cm/s and the test‐retest reliability coefficient was equal to 0.823. The MDC in gait velocity during acute rehabilitation following surgical repair for hip fracture was 8.2 cm/s. Conclusions: Self‐selected gait velocity in patients during acute rehabilitation following surgical fixation for hip fracture must improve by 8.2 cm/s or more to designate the change as being real change beyond the bounds of measurement error.

Sarcopenic indices in community-dwelling older adults

Background:Sarcopenic (SP) indices are used to estimate loss of skeletal lean mass and function and to determine the prevalence of SP in older adults. It is believed that older women and men with lower skeletal lean mass will be weaker and have more functional limitations. Purpose:(1) To classify community-dwelling older adults using 2 common SP indices: appendicular lean mass/height2 (ALM/ht2) and skeletal muscle index (SMI), and (2) to determine each indices value as indicators of lower extremity strength and physical function. Methods:The sample consisted of 154 community-dwelling older adults (111 women and 43 men; mean age = 82.4, SD = 3.6 years; mean body mass index = 25.8, SD = 4.4 kg/m2). Each underwent whole-body dual-energy x-ray absorptiometry to assess lean mass. The 9-item modified Physical Performance Test and self-selected walking speed were used to evaluate function. Lower extremity strength was measured bilaterally using isokinetic dynamometry. Results:The ALM/ht2 index classified 75 participants (49%) as SP and 79 (51%) as nonsarcopenic (NSP). The SMI classified 129 participants (84%) as SP and 25 (16%) as NSP. There were no differences in functional measures between groups by gender using either index after classification. The ALM/ht2 index was more strongly correlated with peak torque of all lower extremity muscle groups (r = 0.276–0.487) compared with the SMI (r = 0.103–0.344). There was no relationship between SP index and physical function. Discussion:There were marked differences in how 2 SP indices classified community-dwelling older adults. Lower extremity strength was lower in older women classified as SP than NSP using the ALM/ht2 index, but LE strength was not different in older men. However, no lower extremity strength differences were observed between SP and NSP men or women using the SMI classification. None of the SP index uniformly identified community-dwelling older adults with functional or strength deficits. Conclusions:Detection of strength deficits using SP indices alone may be gender-specific and may not reflect strength or functional decline in community-dwelling men aged 80 years or older. Given associations between lower extremity strength and physical function, strength measures remain a better predictor of physical performance than SP indices for community-dwelling older men and women.

Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain

We conducted a systematic review and meta‐analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non‐specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non‐specific CLBP or CNP. Primary outcomes were for self‐reported pain intensity and back‐specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta‐analysis (655 participants). For CLBP, meta‐analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1–3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability. This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high‐quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged.

Perceived function and physical performance are associated with pain and fatigue in women with fibromyalgia

BackgroundFibromyalgia is a condition characterized by chronic widespread muscle pain and fatigue and associated with significant impairment in perceived function and reduced physical performance. The purpose of this study was to determine the degree to which pain and fatigue are associated with perceived function and physical performance in women with fibromyalgia.MethodsHierarchical linear regression determined the contribution of pain and fatigue (Numeric Rating Scale (NRS) for resting, movement and combined) to perceived function (Fibromyalgia Impact Questionnaire Revised - Function Subscale, FIQR-Function), Multidimensional Assessment of Fatigue - Activities of Daily Living (MAF-ADL) and SF-36 Physical Function Subscale (SF-36-PF) and physical performance (6-Minute Walk Test, 6MWT and Five Time Sit To Stand, 5TSTS) while controlling for age, body mass index, pain catastrophizing, fear of movement, anxiety, and depression in women with fibromyalgia (N = 94).ResultsFor perceived function, movement pain and movement fatigue together better predicted FIQR-function (adjusted R2 = 0.42, p ≤ 0.001); MAF-ADL (adjusted R2 = 0.41, p ≤ 0.001); and SF-36-PF function (adjusted R2 = 0.34, p ≤ 0.001). For physical performance measures, movement pain and fatigue together predicted 6MWT distance (adjusted R2 = 0.42, p ≤ 0.001) and movement fatigue alone predicted performance time on the 5TSTS (adjusted R2 = 0.20, p ≤ 0.001).ConclusionsPain and fatigue are significantly associated with and explain more than one-third of the variance in perceived function and physical performance in women with fibromyalgia.Trial registrationNIH Clinicaltrials.gov Registration: NCT01888640. Registered 13 June 2013.

Somatic symptom presentations in women with fibromyalgia are differentially associated with elevated depression and anxiety

This study examined whether depression and anxiety differentially relate to fatigue, sleep disturbance, pain catastrophizing, fear of movement, and pain severity in women with fibromyalgia. Baseline data from the Fibromyalgia Activity Study with Transcutaneous Electrical Nerve Stimulation were analyzed. Of 191 participants, 50 percent reported high anxiety and/or depression (17% high anxiety, 9% high depression, and 24% both). Fatigue and sleep impairment were associated with high depression (p < 0.05). Pain severity, pain catastrophizing, and fear of movement were associated with high anxiety and high depression (p < 0.05). Possible implications for underlying mechanisms and the need for targeted treatments are discussed.

Impact of foot progression angle modification on plantar loading in individuals with diabetes mellitus and peripheral neuropathy.

Aims To determine if participants can reduce foot progression angle (FPA), and if FPA reduction decreases regional plantar stresses and forces in individuals with diabetes. Methods Design Three-group cross-sectional design with repeated measures. subjects twenty-eight participants either with diabetes mellitus (DM), diabetes and peripheral neuropathy with (DMPN+NPU) or without a prior history of ulceration (DMPN−NPU) were studied. Intervention Participants were first instructed to walk over a 3.6 m walkway at their preferred FPA, and then to walk with their foot aligned parallel with the line of gait progression at their self-selected speed. Dynamic plantar kinetics in six masked regions were collected using an EMED-st-P-2 pedobarograph. Main measures Primary outcome measures were FPA, peak plantar pressure (PPP), and force-time integral (FTI). A repeated measures ANOVA was conducted to determine group differences in FPA for both walking conditions. Regional differences in PPPs and FTIs between preferred and corrected walking conditions were analyzed using repeated measures ANCOVA. Results Participants showed a reduction in FPA magnitude on the ‘Involved’ foot between the preferred and corrected walking conditions (p<0.01). There were no differences in PPPs or FTIs in any mask between walking conditions (p>0.05). Conclusion Results from this investigation offer important evidence that people with diabetes can modify their FPA with a simple intervention of visual and verbal cueing. Future research should examine if gait retraining strategies in regular footwear more effectively offload areas of elevated regional plantar stresses and forces in adults with diabetes mellitus and peripheral neuropathy.

Development of a method to maximize the transcutaneous electrical nerve stimulation intensity in women with fibromyalgia

Introduction Transcutaneous electrical nerve stimulation (TENS) is a non-pharmacological intervention clinically used for pain relief. The importance of utilizing the adequate stimulation intensity is well documented; however, clinical methods to achieve the highest possible intensity are not established. Objectives Our primary aim was to determine if exposure to the full range of clinical levels of stimulation, from sensory threshold to noxious, would result in higher final stimulation intensities. A secondary aim explored the association of pain, disease severity, and psychological variables with the ability to achieve higher final stimulation intensity. Methods Women with fibromyalgia (N=143) were recruited for a dual-site randomized controlled trial – Fibromyalgia Activity Study with TENS (FAST). TENS electrodes and stimulation were applied to the lumbar area, and intensity was increased to sensory threshold (ST), then to “strong but comfortable” (SC1), then to “noxious” (N). This was followed by a reduction to the final stimulation intensity of “strong but comfortable” (SC2). We called this the Setting of Intensity of TENS (SIT) test. Results There was a significant increase from SC1 (37.5 mA IQR: 35.6–39.0) to SC2 (39.2 mA IQR: 37.1–45.3) (p<0.0001) with a mean increase of 1.7 mA (95% CI: 1.5, 2.2). Linear regression analysis showed that those with the largest increase between SC1 and N had the largest increase in SC2–SC1. Further, those with older age and higher anxiety were able to achieve greater increases in intensity (SC2–SC1) using the SIT test. Conclusion The SC2–SC1 increase was significantly associated with age and anxiety, with greater mean increases associated with older age and higher anxiety. Thus, although all patients may benefit from this protocol, older women and women with elevated anxiety receive the greatest benefit.