Gustavo J. Almeida

A Balance Exercise Program Appears to Improve Function for Patients With Total Knee Arthroplasty: A Randomized Clinical Trial

Background Patients with total knee arthroplasty (TKA) have impaired balance and movement control. Exercise interventions have not targeted these impairments in this population. Objectives The purposes of this study were: (1) to determine the feasibility of applying a balance exercise program in patients with TKA, (2) to investigate whether a functional training (FT) program supplemented with a balance exercise program (FT+B program) could improve physical function compared with an FT program alone in a small group of individuals with TKA, and (3) to test the methods and calculate sample size for a future randomized trial with a larger study sample. Design This study was a double-blind, pilot randomized clinical trial. Setting The study was conducted in the clinical laboratory of an academic center. Participants The participants were 43 individuals (30 female, 13 male; mean age=68 years, SD=8) who underwent TKA 2 to 6 months prior to the study. Interventions The interventions were 6 weeks (12 sessions) of a supervised FT or FT+B program, followed by a 4-month home exercise program. Measurements Feasibility measures included pain, stiffness, adherence, and attrition. The primary outcome measure was a battery of physical performance tests: self-selected gait speed, chair rise test, and single-leg stance time. Secondary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index and the Lower Extremity Functional Scale. Results Feasibility of the balance training in people with TKA was supported by high exercise adherence, a relatively low dropout rate, and no adverse events. Both groups demonstrated clinically important improvements in lower-extremity functional status. The degree of improvement seemed higher for gait speed, single-leg stance time, and stiffness in the FT+B group compared with the FT group. Limitations Due to the pilot nature of the study, differences between groups did not have adequate power to show statistical significance. Conclusions There is a need for conducting a larger randomized controlled trial to test the effectiveness of an FT+B program after TKA.

Physical Activity Measured by the SenseWear Armband in Women With Rheumatoid Arthritis

Background Individuals with rheumatoid arthritis (RA) often are sedentary and have an increased risk of developing comorbid conditions. Women with RA are more likely to experience challenges in maintaining an active lifestyle over their life span than men with RA or people who are healthy. As the benefits of physical activity (PA) are well known, measuring PA accurately in this population is important. Objectives The purposes of this study were: (1) to characterize PA as measured with the SenseWear Armband (SWA) in women with RA and (2) to determine the measurement time frame to obtain consistent estimates of PA and daily energy expenditure (EE) in women with RA. Design This was a cross-sectional study. Methods Participants wore the SWA for 7 days. Measurements of daily total energy expenditure (TEE), physical activity energy expenditure (PAEE) during activities at or above 1 metabolic equivalent (MET) level (PAEE≥1MET), PAEE during activities at or above 2 METs (PAEE≥2METs), PAEE during activities at or above 3 METs (PAEE≥3METs), and number of steps were obtained. Results Fifty-three women participated. Complete data were obtained for 47 participants (89%). Daily usage of the SWA was 98% of the time (23:31 hours/24 hours). Means (SD) were 2,099 (340) kcal/d for TEE, 1,050 (331) kcal/d for PAEE≥1MET, 642 (309) kcal/d for PAEE≥2METs, 239 (178) kcal/d for PAEE≥3METs, and 7,260 (2,710) for number of steps. Results of intraclass correlation coefficient analyses and multiple linear regressions indicated that 2 days were needed to reliably estimate TEE; 3 days for PAEE≥1MET, PAEE≥2METs, and number of steps; and 4 days for PAEE≥3METs. Limitations The sample was composed of well-educated women with RA who had mild to moderate difficulty performing daily activities. Conclusion The SWA may be useful to quantify PA in women with RA and to monitor effectiveness of interventions aiming to increase PA levels. Minimizing the number of days necessary for data collection will reduce the individuals burden and may improve adherence in studies of PA behaviors.

Interrater Reliability and Validity of the Stair Ascend/Descend Test in Subjects With Total Knee Arthroplasty

OBJECTIVE (1) To determine the interrater reliability and measurement error of an 11-step stair ascend/descend test (STTotal-11) and stair up (ascend) test (STUp-11); (2) to seek evidence for the STTotal-11 and STUp-11 as valid measures of physical function by determining if they relate to measures of physical function and do not relate to measures not of physical function; and (3) to explore if the STTotal-11 and STUp-11 scores relate to lower-extremity muscle weakness and knee range of motion (ROM) in subjects with total knee arthroplasty (TKA). DESIGN Cross-sectional study. SETTING Academic center. PARTICIPANTS Subjects (N=43, 30 women; mean age, 68+/-8y) with unilateral TKA. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES STTotal-11 and STUp-11 were performed twice, and scores were compared with scores on 4 lower extremity performance-based tasks, 2 patient-reported questionnaires of physical function, 3 psychologic factors, knee ROM, and strength of quadriceps, hip extensors, and abductors. RESULTS Intraclass correlation coefficient was .94 for both the STTotal-11 and STUp-11, standard error of measurements were 1.14 seconds and .82 seconds, and minimum detectable change associated with 90% confidence interval was 2.6 seconds and 1.9 seconds, respectively. Correlations between stair tests and performance-based measures and knee and hip muscle strength ranged from Pearson correlation coefficient (r)=.40 to .78. STTotal-11 and STUp-11 had a small correlation with one of the patient-reported measures of physical function. Stair tests were not associated with psychologic factors and knee extension ROM and were associated with knee flexion ROM. CONCLUSIONS STTotal-11 and STUp-11 have good interrater reliability and minimum detectable changes adequate for clinical use. The pattern of associations supports the validity of the stair tests in TKA.

Contribution of Hip Abductor Strength to Physical Function in Patients With Total Knee Arthroplasty

Background Investigating modifiable factors that contribute to functional limitations in patients with total knee arthroplasty (TKA) may guide changes in rehabilitation protocols and improve functional outcomes. Whereas quadriceps muscle weakness has been demonstrated to contribute to functional limitations in TKA, the role of hip abductor weakness has not received attention. Objective The purpose of this study was to determine whether hip abductor strength (force-generating capacity) contributes to physical function beyond what can be explained by quadriceps muscle strength in patients after a TKA. Design A cross-sectional design was used in the study. Setting The study was conducted in a clinical laboratory at an academic center. Patients Thirty-one people with TKA (74% female; mean age=68 years, SD=8; mean body mass index=31 kg/m2, SD=5) participated in the study. Measurements Strength of quadriceps muscles and hip abductors was measured using an isokinetic dynamometer. Performance-based physical function was assessed with 4 measures: self-selected walking speed, the Figure-of-8 Walk Test, the Stair Ascend/Descend Test, and the 5-Chair Rise Test. Self-reported physical function was assessed with the Western Ontario and McMaster Universities Osteoarthritis Index Physical Function Subscale. Results In hierarchical regression models, after accounting for demographic and anthropometric factors, quadriceps muscle strength was associated with performance on the Stair Ascend/Descend Test. After accounting for demographic, anthropometric, and quadriceps strength, hip abductor strength was associated with performance on the Stair Ascend/Descend Test, the Figure-of-8 Walk Test, and the 5-Chair Rise Test. Limitations The study design precluded ascertainment of causal relationships. Conclusions After TKA, hip abductor strength influenced physical function in participants more than did demographic or anthropometric measures or quadriceps strength. Longitudinal studies with larger samples are warranted. If findings are replicated, they will justify targeting the hip abductors during rehabilitation after TKA.

Classifying human motion quality for knee osteoarthritis using accelerometers

In this paper, we describe methods for assessment of exercise quality using body-worn tri-axial accelerometers. We assess exercise quality by building a classifier that labels incorrect exercises. The incorrect performances are divided into a number of classes of errors as defined by a physical therapist. We focus on exercises commonly prescribed for knee osteoarthritis: standing hamstring curl, reverse hip abduction, and lying straight leg raise. The methods presented here will form the basis for an at-home rehabilitation device that will recognize errors in patient exercise performance, provide appropriate feedback on the performance, and motivate the patient to continue the prescribed regimen.

Association of physical function and physical activity in women with rheumatoid arthritis

To explore the associations between measures of physical activity (PA) and measures of physical function (PF) in women with rheumatoid arthritis (RA). We hypothesized that the strength of the associations between PA and PF would be moderate, and that after controlling for social and biomedical characteristics, the associations would decrease.

Effectiveness of electrical stimulation on rehabilitation after ligament and meniscal injuries: a systematic review

CONTEXT AND OBJECTIVE Electrical stimulation (ES) is widely used to strengthen muscles following ligament and meniscal injuries. The aim of this study was to evaluate the effectiveness of ES for rehabilitation after soft tissue injuries of the knee treated surgically or conservatively. DESIGN AND SETTING Systematic review at the Brazilian Cochrane Center. METHODS We searched the Cochrane Central Register of Controlled Trials (2010, Issue 12), Medline (Medical Analysis and Retrieval System Online) via PubMed (1966 to December 2010), Embase (Excerpta Medica database, 1980 to December 2010), Lilacs (Literatura Latino-Americana e do Caribe em Ciências da Saúde, 1982 to December 2010), and PEDro (Physiotherapy Evidence Database, 1929 to December 2010). The studies included were randomized controlled trials using ES to increase muscle strength for rehabilitation of patients with soft tissue injuries of the knee. Two authors independently evaluated studies for inclusion and performed data extraction and methodological quality assessment. RESULTS Seventeen studies evaluating ES after anterior cruciate ligament reconstruction and two studies evaluating ES after meniscectomy were included. There was a statistically significant improvement in quadriceps strength through ES (mean difference, MD: -32.7; 95% confidence interval, CI: -39.92 to -25.48; n = 56) and in functional outcomes (MD -7; -12.78 to -1.22; n = 43) six to eight weeks after surgical reconstruction of the anterior cruciate ligament. CONCLUSION There is evidence that ES coupled with conventional rehabilitation exercises may be effective in improving muscle strength and function two months after surgery.

Patella Fracture During Rehabilitation After Bone-Patellar Tendon-Bone Anterior Cruciate Ligament Reconstruction: 2 Case Reports

STUDY DESIGN Case report. BACKGROUND Patellar fracture is a rare but significant complication following anterior cruciate ligament (ACL) reconstruction when using a bone-patellar tendon-bone (BPTB) autograft. The purpose of these case reports is to describe 2 cases in which patellar fracture occurred during rehabilitation after ACL reconstruction using a BPTB. CASE DESCRIPTION Both patients were 23-year-old males referred for rehabilitation after ACL reconstruction using a BPTB autograft. They were both progressing satisfactorily in rehabilitation until sustaining a fracture of the patella. One fracture occurred during the performance of the eccentric phase of a knee extension exercise during the sixth week of rehabilitation (7 weeks postsurgery), whereas the other fracture occurred during testing of the patient is quadriceps maximum voluntary isometric contraction in the ninth week of rehabilitation (10 weeks postsurgery). Both patients were subsequently treated with open reduction and internal fixation of the patella. DISCUSSION During rehabilitation following ACL reconstruction using BPTB autograft, clinicians should consider the need to balance the sometimes-competing goals of improving quadriceps strength while providing protection to the healing graft, minimization of patellofemoral pain, and protection of the patellar donor site.

Multi-label classification for the analysis of human motion quality

Knowing how well an activity is performed is important for home rehabilitation. We would like to not only know if a motion is being performed correctly, but also in what way the motion is incorrect so that we may provide feedback to the user. This paper describes methods for assessing human motion quality using body-worn tri-axial accelerometers and gyroscopes. We use multi-label classifiers to detect subtle errors in exercise performances of eight individuals with knee osteoarthritis, a degenerative disease of the cartilage. We present results obtained using various machine learning methods with decision tree base classifiers. The classifier can detect classes in multi-label data with 75% sensitivity, 90% specificity and 80% accuracy. The methods presented here form the basis for an at-home rehabilitation device that will recognize errors in patient exercise performance, provide appropriate feedback on the performance, and motivate the patient to continue the prescribed regimen.

Association of Light-Intensity Physical Activity With Lower Cardiovascular Disease Risk Burden in Rheumatoid Arthritis.

To characterize physical activity (PA) in individuals with rheumatoid arthritis (RA) and to determine the associations between PA participation at light to moderate intensities and cardiovascular disease risk factors, disability, and disease activity.