John F. Kramer

EFFECT OF ISOKINETIC STRENGTH‐TRAINING ON FUNCTIONAL ABILITY AND WALKING EFFICIENCY IN ADOLESCENTS WITH CEREBRAL PALSY

This study investigated changes in knee extensor and flexor strength of 17 mildly involved adolescents with cerebral palsy in response to an eight‐week isokinetic strength‐training program. Peak torque and work were used as strength outcome measures. Subsequent changes in gross motor function and walking efficiency were evaluated. The significant strength gains of 21 to 25 per cent observed were similar in magnitude to those previously reported for able‐bodied individuals. A significant number of subjects showed an increase in gross motor ability. However, walking velocity and walking efficiency were unchanged. Strength gains of 15 to 17 percent were maintained for three months after the cessation of isokinetic training.

What is the best way of assessing outcome after total knee replacement

Variable definitions of outcome have been used in the past to assess the results after total joint replacement surgery. These differ in their approach to the measurement of outcome but all must be valid (they measure what they are designed to measure), reliable (the consistently produce the same score), and responsive (able to detect changes that may occur during a period). Responsiveness is crucial to distinguish those patients who benefit from a procedure from those who do not, and a more responsive test will theoretically be able to identify more subtle changes in patient status. The responsiveness of 6 different scoring systems was compared. The results are based on a cohort of 71 patients undergoing total knee arthroplasty in a 7-month period. Responsiveness was determined by performing a paired t test among each patients scores at 0, 3, and 6 months. The size of the resulting t value represented the comparative responsiveness of the 6 tests. The highest value achieved was with the Western Ontario and McMaster Universities osteoarthritis index and the Knee Society clinical rating scale. The worst scores were achieved by Short Form-36 and time trade off, a utility method of measurement. If small differences between groups of patients are to be shown, measures of outcome that are more responsive to patient change should be used.

Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty.

One hundred sixty patients (mean age, 68 ± 8 years) having primary total knee arthroplasty were assigned randomly to two rehabilitation programs: (1) clinic-based rehabilitation provided by outpatient physical therapists; or (2) home-based rehabilitation monitored by periodic telephone calls from a physical therapist. Both rehabilitation programs emphasized a common home exercise program. Before surgery, and at 12 and 52 weeks after surgery, no statistically significant differences were observed between the clinic- and the home-based groups on any of the following measures: (1) total score on the Knee Society clinical rating scale; (2) total score on the Western Ontario and McMaster Universities Osteoarthritis Index; (3) total score on the Medical Outcomes Study Short Form; (4) pain scale of the Knee Society clinical rating scale; (5) pain scale of the Western Ontario and McMaster Universities Osteoarthritis Index; (6) functional scale of the Western Ontario and McMaster Universities Osteoarthritis Index; (7) distance walked in 6 minutes; (8) number of stairs ascended and descended in 30 seconds; and (9) knee flexion range of motion, on either the per protocol or the intent-to-treat or the analyses. After primary total knee arthroplasty, patients who completed a home exercise program (home-based rehabilitation) performed similarly to patients who completed regular outpatient clinic sessions in addition to the home exercises (clinic-based rehabilitation). Additional studies need to determine which patients are likely to benefit most from clinic-based rehabilitation programs.

Reliability of a patient-rated forearm evaluation questionnaire for patients with lateral epicondylitis

PURPOSE To determine the reliability of a questionnaire designed to assess forearm pain and function in patients with lateral epicondylitis. METHODS Forty-seven patients with unilateral lateral epicondylitis completed a patient-related forearm evaluation questionnaire (PRFEQ) on two occasions. Intraclass correlation coefficients (ICC 2,1), standard error of measurement (SEM), and 95% confidence intervals (CIs) were determined for the whole group and for three subgroup comparisons of male vs. female subjects, subacute vs. chronic lateral epicondylitis, and work-related vs. non-work-related lateral epicondylitis. RESULTS The test-retest reliability for the overall PRFEQ (ICC, 0.89), and its pain (ICC, 0.89) and function (ICC, 0.83) subscales was excellent. Test-retest reliability for patients with work-related lateral epicondylitis (ICC, 0.80) was significantly (p = 0.018) less than for patients with non-work-related lateral epicondylitis (ICC, 0.94). CONCLUSIONS The PRFEQ can provide a simple, quick, and reliable estimate of arm pain and function in patients with lateral epicondylitis. However, large SEM and 95% CIs limit its ability to accurately predict individual scores.

Relationships Among Measures of Walking Efficiency, Gross Motor Ability, and Isokinetic Strength In Adolescents With Cerebral Palsy

The purpose of this study was to determine the relationships among measures of knee extensor and flexor strength, walking efficiency, and gross motor abilities in adolescents with cerebral palsy. Seventeen adolescents (mean age 16 ± 3 years) completed isokinetic tests for knee extension and flexion

Resurfacing versus not resurfacing the patella in total knee arthroplasty

Patellar resurfacing in total knee arthroplasty is a topic debated in the literature. Concerns include fracture, dislocation, loosening, and extensor mechanism injury. Residual anterior knee pain has been reported when the patella is not resurfaced. One hundred patients with osteoarthritic knees were prospectively randomized to either have their patella resurfaced or left not resurfaced. All patients were treated with a single prosthesis that featured an anatomically designed patellofemoral articulation (Anatomic Medullary Knee, DePuy, Warsaw, IN) Two patients in the unresurfaced group and one in the resurfaced group required repeat surgery for patellofemoral complications. At 8- to 10-year follow-up evaluations, Knee Society Clinical Ratings scores were not different between the 2 groups. Rates of anterior knee pain with walking and stair climbing were significantly less in the resurfaced group. Eighty percent of patients with a resurfaced patella were extremely satisfied with their total knee arthroplasty versus 48% without patellar resurfacing. When satisfied and extremely satisfied patients were grouped together, there was no difference between the 2 groups.

Interrater Reliability of Pinch and Grip Strength Measurements in Patients with Cumulative Trauma Disorders

The purposes of this study were to examine the interrater reliabilities of grip, lateral pinch, and tripod pinch measurements in patients with cumulative trauma disorders. Thirty-eight patients with unilateral (n = 28) or bilateral (n = 10) cumulative trauma disorders were tested independently by two hand therapists, during a one-hour period. The tests were completed in a normal hand clinic environment using the standard protocol recommended by the American Society of Hand Therapists. Interrater reliability coefficients for the scores obtained using either a single repetition or the mean of three repetitions were very high (intraclass correlation coefficient [ICC] > 0.87) for all strength measurements. As a result, strength determination in this patient group, when performed by different hand therapists, may be considered reliable.

Knee bracing after ACL reconstruction : effects on postural control and proprioception

PURPOSE To evaluate the effects an anterior cruciate ligament (ACL) brace has on various measures of knee proprioception and postural control. METHODS Thirty subjects (mean age 27 +/- 11 yr) having undergone unilateral ACL reconstruction were tested with and without wearing their own custom-fit brace on their involved limb. Proprioception was assessed using joint angle replication tests completed on an isokinetic dynamometer. Postural control was assessed using a series of single-limb standing balance tests completed on a force platform. The balance tests included: 1) standing on the stable platform with eyes open, 2) standing on a foam mat placed over the platform with eyes open, 3) standing on the platform with eyes closed, and 4) standing on the platform after landing from a maximal single-limb forward hop. RESULTS The brace provided a small but statistically significant improvement in proprioception (mean reduction in error scores between target and reproduced angles = 0.64 +/- 1.4 degrees, P = 0.02). For the postural control tests, there was a significant brace condition by test situation interaction (P = 0.02), with the brace providing a small but statistically significant improvement during the test completed on the stable platform with eyes open (mean reduction in center of pressure path length = 4.2 +/- 8.4 cm, P = 0.02) but not during the other more challenging test situations. Additional post hoc analyses indicated that the relationship between knee proprioception and postural control measures were low and not significant (r = 0.003 to 0.19, P > 0.32), consistent with the suggestion that changes in knee proprioception can occur in the absence of substantial changes in postural control. Also, standing balance tests that challenged the somatosensory contribution to postural control (i.e., those completed on foam, or with eyes closed) were significantly related to single-limb forward hop distances (r = -0.4, P < 0.05), whereas performance during the proprioception test was not (r = 0.1, P > 0.50). CONCLUSIONS In general, bracing appears to improve performance during tasks characterized by relatively limited somatosensory input but not during tasks characterized by increased somatosenory input. The small magnitude of the improvements, coupled with their apparent lack of carry over to more difficult and functionally relevant tasks, questions the clinical benefit of the present effects of bracing.

Knee flexor and extensor strength during concentric and eccentric muscle actions after anterior cruciate ligament reconstruction using the semitendinosus tendon and ligament augmentation device

The purposes of this study were to compare operated and nonoperated knees after anterior cruciate ligament reconstruction using the semitendinosus tendon and a polypropylene ligament augmentation device, and to determine the interrelationships among strength, knee stability, and current activity levels. Isokinetic tests for knee flexion (prone position) and extension (sitting po sition) strength during concentric-eccentric muscle ac tion cycles were completed at 60 and 180 deg/sec angular velocities, and passive anterior displacement were determined for 15 male and 15 female patients (mean age, 27 ± 8 years; mean time since surgery, 21 ± 3 months). With the exception of eccentric muscle actions during knee extension, peak torque and work done were significantly greater on the nonoperated leg (P < 0.05). Passive anterior displacement was signifi cantly greater in the operated than the nonoperated knee (P < 0.01). Strength measurements tended to be modestly related to current activity level ( R > 0.40 in 24 of 32 correlations; P < 0.05), whereas anterior displacement was not related to current activity level (R = -0.19, operated knee; R = - 0.09, nonoperated knee; P > 0.05). Greater emphasis should be directed toward strengthening the knee flexors and knee exten sors after this surgery. Although joint-specific tests (completed actively via isokinetic dynameter) are more related to activity levels than are knee laxity tests (completed passively via knee arthrometer), neither test should be relied on as the only predictor of activity level in this patient population.

A Randomized Controlled Trial Comparing the Effectiveness of Functional Knee Brace and Neoprene Sleeve Use After Anterior Cruciate Ligament Reconstruction

Background Despite a lack of evidence for their effectiveness, functional knee braces are commonly prescribed to patients after anterior cruciate ligament (ACL) reconstruction. Purpose This trial was conducted to compare postoperative outcomes in patients using an ACL functional knee brace and patients using a neoprene knee sleeve. Hypothesis Patients using a brace will have superior outcomes than those using a sleeve. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods One hundred fifty patients were randomized to receive a brace (n = 76) or neoprene sleeve (n = 74) at their 6-week postoperative visit after primary ACL reconstruction with hamstring autograft. Patients were assessed preoperatively, then 6 weeks and 6, 12, and 24 months postoperatively. Outcome measures included disease-specific quality of life (Anterior Cruciate Ligament–Quality of Life [ACL-QOL] Questionnaire), anterior tibial translation (KT-1000 arthrometer side-to-side difference), the single-limb forward hop test (limb symmetry index), and Tegner Activity Scale. Outcomes at 1 and 2 years were compared after adjusting for baseline scores. Subjective ratings of how patients felt while using the brace/sleeve were also collected for descriptive purposes using a questionnaire. Four a priori directional subgroup hypotheses were evaluated using tests for interactions. Results There were no significant differences between brace (n = 62) and sleeve (n = 65) groups for any of the outcomes at 1- and 2-year follow-ups. Adjusted mean differences at 2 years were as follows: −0.94 (95% confidence interval [CI], −7.52 to 5.64) for the ACL-QOL Questionnaire, −0.10 mm (95% CI, −0.99 to 0.81) for KT-1000 arthrometer side-to-side difference, −0.87% (95% CI, −8.89 to 7.12) for hop limb symmetry index, and −0.05 (95% CI, −0.72 to 0.62) for the Tegner Activity Scale. Subjective ratings of confidence in the knee provided by the brace/sleeve were higher for the brace group than the sleeve group. Subgroup findings were minimal. Adverse events were few and similar between groups. Conclusions A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction.