Gretchen B. Salsich

Differences in the gait characteristics of people with diabetes and transmetatarsal amputation compared with age-matched controls

Although qualitative reports in the surgical literature suggest that people with diabetes mellitus (DM) and transmetatarsal amputation (TMA) walk well with regular shoes and a toe-filler, recent data indicates that this population has multiple complications and difficulty with functional mobility. A thorough description of their gait characteristics may provide insights to the cause of these difficulties. The purpose of this study was to compare selected gait characteristics of people with DM and TMA to age-matched controls. We studied 15 subjects with DM and a TMA, and 15 age-matched controls with an overall mean age of 62.3+/-9.2 years. Data were collected with computer assisted video as subjects walked across a force platform. Range-of-motion (ROM), moments, and power were estimated at the ankle, knee, and hip in the sagittal plane using standard link-segment methods. People with DM and TMA had decreased ROM excursion, peak moments, and peak power at the ankle. At the hip, people with DM and a TMA had decreased ROM excursion, an earlier onset of the hip flexor moment, but no differences in peak moments or peak power. Since people with DM and TMA have reduced ability to generate plantar flexor power at the ankle, they appear to rely more heavily on pulling their leg forward from the hip using their hip flexor muscles. This compensation is not complete, however, as people with DM and a TMA take shorter steps and walk slower than controls. Additional research is needed to determine methods to improve or better compensate for these gait deviations during late stance phase. Copyright 1998 Elsevier Science B.V. All rights reserved

The Effects of Movement Pattern Modification on Lower Extremity Kinematics and Pain in Women With Patellofemoral Pain

STUDY DESIGNnControlled laboratory study.nnnOBJECTIVESnTo compare hip and knee kinematics and pain during a single-limb squat between 3 movement conditions (usual, exaggerated dynamic knee valgus, corrected dynamic knee valgus) in women with patellofemoral pain.nnnBACKGROUNDnAltered kinematics (increased hip adduction, hip medial rotation, knee abduction, and knee lateral rotation, collectively termed dynamic knee valgus) have been proposed to contribute to patellofemoral pain; however, cross-sectional study designs prevent interpreting a causal link between kinematics and pain.nnnMETHODSnThe study sample included 20 women with patellofemoral pain, who demonstrated observable dynamic knee valgus. Participants performed single-limb squats under usual, exaggerated, and corrected movement conditions. Pain during each condition was assessed using a 0-to-100-mm visual analog scale. Hip and knee frontal and transverse plane angles at peak knee flexion and pain levels were compared using repeated-measures 1-way analyses of variance. Pearson correlation coefficients were used to determine within-condition associations between kinematic variables and pain.nnnRESULTSnIn the exaggerated compared to the usual condition, increases were detected in hip medial rotation (mean ± SD difference, 5.8° ± 3.2°; P<.001), knee lateral rotation (5.5° ± 4.9°, P<.001), and pain (8.5 ± 10.8 mm, P = .007). In the corrected compared to the usual condition, decreases were detected in hip adduction (mean ± SD difference, 3.5° ± 3.7°; P = .001) and knee lateral rotation (1.6° ± 2.8°, P = .06); however, average pain was not decreased (1.2 ± 14.8 mm, P = 1.0). Pain was correlated with knee lateral rotation in the usual (r = -0.47, P = .04) and exaggerated (r = -0.49, P = .03) conditions. In the corrected condition, pain was correlated with hip medial rotation (r = 0.44, P = .05) and knee adduction (r = 0.52, P = .02).nnnCONCLUSIONnAvoiding dynamic knee valgus may be an important component of rehabilitation programs in women with patellofemoral pain, as this movement pattern is associated with increased pain.

Diagnosis and Management of a Patient With Knee Pain Using the Movement System Impairment Classification System

STUDY DESIGNnCase report.nnnBACKGROUNDnSelecting the most effective conservative treatment for knee pain continues to be a challenge. An understanding of the underlying movement system impairment that is thought to contribute to the knee pain may assist in determining the most effective treatment. Our case report describes the treatment and outcomes of a patient with the proposed movement system impairment (MSI) diagnosis of tibiofemoral rotation.nnnCASE DESCRIPTIONnThe patient was a 50-year-old female with a 3-month history of left anteromedial knee pain. Her knee pain was aggravated with sitting, standing, and descending stairs. A standardized clinical examination was performed and the MSI diagnosis of tibiofemoral rotation was determined. The patient consistently reported an increase in pain with activities that produced abnormal motions or alignments of the lower extremity in the frontal and transverse planes. The patient was educated to modify symptom-provoking functional activities by restricting the abnormal motions and alignments of the lower extremity. Exercises were prescribed to address impairments of muscle length, muscle strength, and motor control proposed to contribute to the tibiofemoral rotation. Tape also was applied to the knee in an attempt to restrict tibiofemoral rotation.nnnOUTCOMESnThe patient reported a cessation of pain and an improvement in her functional activities that occurred with correction of her knee alignment and movement pattern. Pain intensity was 2/10 at 1 week. At 10 weeks, pain intensity was 0/10 and the patient reported no limitations in sitting, standing, or descending stairs. The patients score on the activities of daily living scale increased from 73% at the initial visit to 86% at 10 weeks and 96% at 1 year after therapy was discontinued.nnnDISCUSSIONnThis case report presented a patient with knee pain and an MSI diagnosis of tibiofemoral rotation. Diagnosis-specific treatment resulted in a cessation of the patients pain and an improved ability to perform functional activities.

Relationships between measures of function, strength and walking speed in patients with diabetes and transmetatarsal amputation

Objective: To determine the correlation between strength and functional measures, and the intercorrelation between the functional measures themselves, in a group of subjects with diabetes mellitus (DM) and transmetatarsal amputation (TMA). Design: Correlational study. Setting: The subjects were tested in the Applied Kinesiology Laboratory of the Program in Physical Therapy at Washington University School of Medicine, St Louis, MO, USA. Subjects: Thirty subjects with DM and TMA (mean age 61.7 ± 11.3 years) were studied. Main outcome measures: Function was measured using the Functional Reach Test (FR), the Physical Performance Test (PPT), the Sickness Impact Profile (SIP), and walking speed (WS) for 15.24 m. Strength measurements were taken using a hand-held dynamometer. Results: Highest correlations were found between hip extension strength and PPT: r = 0.69, FR: r = 0.45, and WS: r = 0.76, between knee extension strength and PPT: r = 0.48, and WS: r = 0.51, between hip flexion strength and PPT: r = 0.51, FR: r = 0.47, and WS: r = 0.59, between knee flexion strength and PPT: r = 0.57, and WS: r = 0.63, and between dorsiflexion strength and PPT: r = 0.49, and WS: r = 0.63. The following intercorrelations between functional measures were significant; PPT and FR: r = 0.66, PPT and SIP: r = -0.54, PPT and WS: r = 0.77, FR and WS: r = 0.54, SIP and WS: r = -0.47. Conclusions: The relationship between measures of hip and knee muscle strength and function provides some evidence that rehabilitation should focus on strengthening hip and knee extensors and flexors to improve function. The relationships between walking speed and strength, PPT, FR and SIP suggest that the simple measure of walking speed is a useful functional test in the clinic.

Persons With Chronic Hip Joint Pain Exhibit Reduced Hip Muscle Strength

STUDY DESIGNnControlled laboratory cross-sectional study. Objectives To assess strength differences of the hip rotator and abductor muscle groups in young adults with chronic hip joint pain (CHJP) and asymptomatic controls. A secondary objective was to determine if strength in the uninvolved hip of those with unilateral CHJP differs from that in asymptomatic controls.nnnBACKGROUNDnLittle is known about the relationship between hip muscle strength and CHJP in young adults.nnnMETHODSnThirty-five participants with CHJP and 35 matched controls (18 to 40 years of age) participated. Using handheld dynamometry, strength of the hip external rotators and internal rotators was assessed with the hip flexed to 90° and 0°. To assess external rotator and internal rotator strength, the hip was placed at the end range of external rotation and internal rotation, respectively. Strength of the hip abductors was assessed in sidelying, with the hip in 15° of abduction. Break tests were performed to determine maximum muscle force, and the average torque was calculated using the corresponding moment arm. Independent-sample t tests were used to compare strength values between (1) the involved limb in participants with CHJP and the corresponding limb in the matched controls, and (2) the uninvolved limb in participants with unilateral CHJP and the corresponding limb in the matched controls.nnnRESULTSnCompared to controls, participants with CHJP demonstrated weakness of 16% to 28% (P<.01) in all muscle groups tested in the involved hip. The uninvolved hip of 22 subjects with unilateral CHJP demonstrated weakness of 18% and 16% (P<.05) in the external rotators (0°) and abductors, respectively, when compared to the corresponding limb of the matched controls.nnnCONCLUSIONnThe results of the present study demonstrate that persons with CHJP have weakness in the hip rotator and hip abductor muscles. Weakness also was found in the uninvolved hip of persons with CHJP.

Classification of Lower Extremity Movement Patterns Based on Visual Assessment: Reliability and Correlation With 2-Dimensional Video Analysis

CONTEXTnAbnormal movement patterns have been implicated in lower extremity injury. Reliable, valid, and easily implemented assessment methods are needed to examine existing musculoskeletal disorders and investigate predictive factors for lower extremity injury.nnnOBJECTIVEnTo determine the reliability of experienced and novice testers in making visual assessments of lower extremity movement patterns and to characterize the construct validity of the visual assessments.nnnDESIGNnCross-sectional study.nnnSETTINGnUniversity athletic department and research laboratory.nnnPATIENTS OR OTHER PARTICIPANTSnConvenience sample of 30 undergraduate and graduate students who regularly participate in athletics (age = 19.3 ± 4.5 years). Testers were 2 experienced physical therapists and 1 novice postdoctoral fellow (nonclinician).nnnMAIN OUTCOME MEASURE(S)nWe took videos of 30 athletes performing the single-legged squat. Three testers observed the videos on 2 occasions and classified the lower extremity movement as dynamic valgus, no change, or dynamic varus. The classification was based on the estimated change in frontal-plane projection angle (FPPA) of the knee from single-legged stance to maximum single-legged squat depth. The actual FPPA change was measured quantitatively. We used percentage agreement and weighted κ to examine tester reliability and to determine construct validity of the visual assessment.nnnRESULTSnThe κ values for intratester and intertester reliability ranged from 0.75 to 0.90, indicating substantial to excellent reliability. Percentage agreement between the visual assessment and the quantitative FPPA change category was 90%, with a κ value of 0.85.nnnCONCLUSIONSnVisual assessments were made reliably by experienced and novice testers. Additionally, movement-pattern categories based on visual assessments were in excellent agreement with objective methods to measure FPPA change. Therefore, visual assessments can be used in the clinic to assess movement patterns associated with musculoskeletal disorders and in large epidemiologic studies to assess the association between lower extremity movement patterns and musculoskeletal injury.

Movement-Pattern Training to Improve Function in People With Chronic Hip Joint Pain: A Feasibility Randomized Clinical Trial

Study Design Feasibility randomized clinical trial. Background Rehabilitation may be an appropriate treatment strategy for patients with chronic hip joint pain; however, the evidence related to the effectiveness of rehabilitation is limited. Objectives To assess feasibility of performing a randomized clinical trial to investigate the effectiveness of movement-pattern training (MPT) to improve function in people with chronic hip joint pain. Methods Thirty-five patients with chronic hip joint pain were randomized into a treatment (MPT) group or a control (wait-list) group. The MPT program included 6 one-hour supervised sessions and incorporated (1) task-specific training for basic functional tasks and symptom-provoking tasks, and (2) strengthening of hip musculature. The wait-list group received no treatment. Primary outcomes for feasibility were patient retention and adherence. Secondary outcomes to assess treatment effects were patient-reported function (Hip disability and Osteoarthritis Outcome Score), lower extremity kinematics, and hip muscle strength. Results Retention rates did not differ between the MPT (89%) and wait-list groups (94%, P = 1.0). Sixteen of the 18 patients (89%) in the MPT group attended at least 80% of the treatment sessions. For the home exercise program, 89% of patients reported performing their home program at least once per day. Secondary outcomes support the rationale for conduct of a superiority randomized clinical trial. Conclusion Based on retention and adherence rates, a larger randomized clinical trial appears feasible and warranted to assess treatment effects more precisely. Data from this feasibility study will inform our future clinical trial. Level of Evidence Therapy, level 2b-. J Orthop Sports Phys Ther 2016;46(6):452-461. Epub 26 Apr 2016. doi:10.2519/jospt.2016.6279.

Reduced Hip Adduction Is Associated With Improved Function After Movement-Pattern Training in Young People With Chronic Hip Joint Pain

•STUDY DESIGN: Ancillary analysis, time‐controlled randomized clinical trial. •BACKGROUND: Movement‐pattern training (MPT) has been shown to improve function among patients with chronic hip joint pain (CHJP). •OBJECTIVE: To determine the association among treatment outcomes and mechanical factors associated with CHJP. •METHODS: Twenty‐eight patients with CHJP, 18 to 40 years of age, participated in MPT, either immediately after assessment or after a wait‐list period. Movement‐pattern training included task‐specific training to reduce hip adduction motion during functional tasks and hip muscle strengthening. Hip‐specific function was assessed using the Modified Harris Hip Score (MHHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). Three‐dimensional kinematic data were used to quantify hip adduction motion, dynamometry to quantify abductor strength, and magnetic resonance imaging to measure femoral head sphericity using the alpha angle. Paired t tests assessed change from pretreatment to posttreatment. Spearman correlations assessed associations. •RESULTS: There was significant improvement in MHHS and HOOS scores (P≤.02), adduction motion (P = .045), and abductor strength (P = .01) from pretreatment to posttreatment. Reduction in hip adduction motion (r = ‐0.67, P<.01) and lower body mass index (r = ‐0.38, P = .049) correlated with MHHS improvement. Alpha angle and abductor strength change were not correlated with change in MHHS or HOOS scores. •CONCLUSION: After MPT, patients reported improvements in pain and function that were associated with their ability to reduce hip adduction motion during functional tasks. •LEVEL OF EVIDENCE: Therapy, level 2b.

Hip Abductor Muscle Volume and Strength Differences Between Women With Chronic Hip Joint Pain and Asymptomatic Controls

STUDY DESIGN: Secondary analysis, cross‐sectional study. BACKGROUND: Chronic hip joint pain (CHJP) can lead to limitations in activity participation, but the musculoskeletal factors associated with the condition are relatively unknown. Understanding the factors associated with CHJP may help develop rehabilitation strategies to improve quality of life of individuals with long‐term hip pain. OBJECTIVES: To compare measures of hip abductor muscle volume and hip abductor muscle strength between women with CHJP and asymptomatic controls. METHODS: Thirty women, 15 with CHJP and 15 matched asymptomatic controls (age range, 18–40 years), participated in this study. Magnetic resonance imaging was used to determine the volume of the primary hip abductor muscles, consisting of the gluteus medius, gluteus minimus, a small portion of the gluteus maximus, and the tensor fascia latae, within a defined region of interest. Break tests were performed using a handheld dynamometer to assess hip abductor strength. During the strength test, the participant was positioned in sidelying with the involved hip in 15° of abduction. Independent‐samples t tests were used to compare muscle volume and strength values between those with CHJP and asymptomatic controls. RESULTS: Compared to asymptomatic controls, women with CHJP demonstrated significantly increased gluteal muscle volume (228 ± 40 cm3 versus 199 ± 29 cm3, P = .032), but decreased hip abductor strength (74.6 ± 16.8 Nm versus 93.6 ± 20.2 Nm, P = .009). There were no significant differences in tensor fascia lata muscle volume between the 2 groups (P = .640). CONCLUSION: Women with CHJP appear to have larger gluteal muscle volume, but decreased hip abductor strength, compared to asymptomatic controls.