Phillip M. Stevens

Deformational Plagiocephaly Associated With Ocular Torticollis : A Clinical Study and Literature Review

The etiology of craniofacial asymmetry secondary to positional plagiocephaly with or without concomitant congenital muscular torticollis has been well established. It has been proposed that the craniofacial asymmetry secondary to congenital superior oblique palsy involves a similar etiology. The causal relationship has been thought to be a result of the adoption of certain head and neck positioning, which predisposes the infant to develop preferential resting positions during supine sleep. We present a single subject with ocular torticollis and resulting plagiocephaly, and we distinguish the resultant craniofacial findings from those seen in patients with congenital muscular torticollis-associated deformational plagiocephaly. The distinctions that exist between the resultant asymmetries observed in ocular torticollis with superior oblique palsy and those found with congenital muscular torticollis suggest that the facial hemihypoplasia observed in conjunction with ocular torticollis may be the result of gravitational forces rather than compressive forces.

Lower Limb Orthotic Management of Duchenne Muscular Dystrophy: A Literature Review

Although currently incurable, Duchenne muscular dystrophy remains treatable. The characteristic gradual loss of functional muscle and the concurrent developments of progressive contracture are often indications for orthotic interventions. As the disease progresses through the abbreviated life of the young man, he will encounter three functional stages: independent ambulation, assisted ambulation, and wheelchair mobility. Although controversy continues as to the appropriate role of orthoses during each of these stages, some generalities may be gleaned from a review of published literature. Specific patterns of weakness, accommodation, and contracture development characterize the initial stage of independent ambulation. Orthotic intervention is often confined to nighttime splints to slow the development of equinus contracture. As weakness and contracture progress, balance becomes increasingly precarious, and independent ambulation is ultimately precluded. Many authors have suggested that a degree of ambulation may be maintained during this phase by combinations of surgery, knee-ankle-foot orthoses and aggressive rehabilitation. The popularity of such procedures has declined since its peak in the 1970s and 1980s. Appropriate timing, patient selection, and rehabilitation appear to be essential in obtaining optimal outcomes. Weakness and contracture continue to progress until even assisted ambulation is precluded and wheelchair confinement ensues. Some authors have suggested a limited role of orthotic intervention in the form of postoperative positional ankle-foot orthoses to prevent recurrence of deformities. The relevance of corticosteroids, fracture incidence, and cognitive ability are also discussed.

Post-operative use of remoulding orthoses following cranial vault remodelling: A case series

The use of external orthoses following surgical cranial vault remodelling in infants with craniosynostosis was first described in the 1980s. While a few preliminary reports have been published on its use, there are no reports outlining specific orthotic considerations. The purpose of this paper is to present the orthotic community with an introduction to the various craniosynostoses, the resultant cranial morphologies, and specific orthotic considerations associated with these morphologies, including trigocephaly, frontal plagiocephly, brachycephaly, scapholocephaly, and occipital plagiocephaly. For each presentation, guidelines are presented as to where the cranial remoulding orthosis should maintain contact, thereby discouraging cranial growth, and where the voids should be established and maintained to allow for corrective cranial growth. Principles are supported by photographs of representative cases.

A Preliminary Investigation of Postoperative Molding to Improve the Result of Cranial Vault Remodeling

Craniosynostoses most frequently require correction by craniotomy and cranial vault remodeling to facilitate neurologic development and normal cranial shape. Although the skull can be fairly accurately contoured intraoperatively, the final shape is dependent on many factors, including bone and brain growth and bone resorption. Although molding helmets have been used for positional head molding and in the management of endoscopic suturectomy, very few studies have evaluated their use in the postoperative care of patients undergoing open cranial remodeling. The authors sought to evaluate the use of postoperative helmet therapy after surgical correction for nonsyndromic single suture craniosynostosis. A retrospective review of six patients with nonsyndromic craniosynostosis who underwent cranial remodeling by a single surgeon with postoperative helmet therapy in 2003 and 2004 was performed. The four female and two male patients ranged in age from 5 months to 13 months at the time of surgery. All the patients were seen and measured by the same orthotist, and helmet therapy was begun 2 to 4 weeks after surgery. Postoperative helmet therapy lasted for 6 months. All patients showed an improved cephalic index when compared with the initial postoperative measurements. There were no adverse consequences associated with helmet therapy. Helmet therapy after craniosynostosis surgery improves cephalic index and skull shape beyond the results obtained at surgery. The authors conclude that postoperative helmet therapy is an effective treatment adjunct to craniosynostosis surgery for patients with nonsyndromic single suture synostosis.

Response to: Comments regarding: Mobility Analysis of AmpuTees (MAAT I): quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis by Wurdeman et al.:

Thank you for providing the opportunity to respond to the comments directed at our recently published manuscript, ‘Mobility Analysis of AmpuTees (MAAT I): Quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis’. We appreciate the comments regarding the advancement of outcomes collection and reporting in lower limb prosthetics as this represents a shift in common practice within care facilities that provide lower limb prostheses. In order to fully address the question posed at the end of the letter which starts, ‘as long as the patient is present’, it is imperative to keep in mind this shift in common practice. Implementation of routine outcomes collection within care facilities is not as simple as a mandate that can be passed down. There are multiple barriers to implementation which have been previously identified.1,2 These barriers fall within the domains of clinician and administration running the clinics, but also includes the patient. Specifically, perceived value is a barrier to both clinician and patient, where value can be represented as reward or results divided by effort or cost. These can be either real or perceived. And, while the burden of time to administer physical performance tests such as sit-to-stand and stair climb test, is debatable, these tests increase the effort for the patient and the clinician. Thus, the increased effort decreases the perceived value, which increases this barrier unless such effort is offset with increased reward or results, both to the patient and the clinician. Unfortunately, the perceived rewards to the patients and clinicians are lacking. However, we believe that the continued efforts of the scientific community to highlight the rewards of doing physical performance measures are growing. This will be beneficial in future efforts to implement routine physical performance measures in prosthetics rehabilitation care facilities. As such we would argue the mere presence of a patient in the clinic, which is markedly different from a research subject in a laboratory, does not always represent an ‘opportunity’ to collect physical performance measures. We should not confuse or diminish the value of selfreport measures of mobility such as the Prosthetic Limb Users Survey of Mobility (PLUS-M). The reference to ‘better applicability’ within the letter denotes a higher level of importance on what the authors have noted as physical capacity or activity performance monitors. Notably, the labelling of questionnaires, physical tests and activity monitors as perception, capacity and performance, respectively, is uncertain and is not drawn from the referenced study. Physical performance measures and self-report measures quantify different constructs, the value of one construct over another should not be assumed. It seems somewhat paradoxical to suggest increased value of physical performance measures over self-report measures in the same letter that refers to the use of goal attainment scaling (GAS) as having identified mobility as a primary concern. When a self-report instrument is used to identify the most valuable domain within rehabilitation, it would seem appropriate to place at least equal value on the results of a self-report instrument used to measure that domain. Furthermore, Kayes and McPherson3 elegantly outline that the nature of physical performance measures has wrongly led to the misguided belief that such measures are superior when in reality they face as many and sometimes more limitations. One such limitation aligns with comments from Bussman and Stam4 noting the various levels of outcome measures, remarking that physical performance measures may have weak relationships with complex activity and role fulfilment, both of which can however be explored through self-report questionnaires such as PLUS-M. Thus, while we agree that there is likely a wealth of information yet to be explored from the additional collection of physical performance measures or perhaps activity monitors, this should not take away from the value of the findings of this study or any study investigating mobility captured via self-report instruments. The commenters surmise the findings to be ‘unsurprising’. Respectfully, although rehabilitation professionals are historically trained to place emphasis on the restoration of mobility following lower limb amputation, changes in healthcare dynamics are placing increased emphasis on the limb loss patient’s quality of life and general satisfaction. Response to: Comments regarding: Mobility Analysis of AmpuTees (MAAT I): quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis by Wurdeman et al. 774058 POI0010.1177/0309364618774058Prosthetics and Orthotics InternationalWurdeman et al. letter2018

Mobility Analysis of AmpuTees (MAAT I): Quality of life and satisfaction are strongly related to mobility for patients with a lower limb prosthesis:

Background: While rehabilitation professionals are historically trained to place emphasis on the restoration of mobility following lower limb amputation, changes in healthcare dynamics are placing an increased emphasis on the limb loss patient’s quality of life and general satisfaction. Thus, the relationship between these constructs and mobility in the patient with lower limb loss warrants further investigation. Objectives: To determine the relationship between mobility of the patient with lower limb loss and both (1) general satisfaction and (2) quality of life. Study design: Retrospective chart analysis. Methods: A retrospective chart review of the Prosthetic Limb Users Survey of Mobility and the Prosthesis Evaluation Questionnaire—Well-Being subsection. Pearson correlations were used to test relationships. Results: Data from 509 patients with a lower limb prosthesis were included. Mobility was found to be positively correlated with quality of life (r = 0.511, p < 0.001, 95% confidence interval (0.443, 0.569)) and general satisfaction (r = 0.475, p < 0.001, 95% confidence interval (0.403, 0.542)), as well as their arithmetic mean (i.e. Prosthesis Evaluation Questionnaire—Well-Being) (r = 0.533, p < 0.001, 95% confidence interval (0.466, 0.592)). Conclusion: This study provides evidence of a strong positive correlation between mobility and both quality of life and general satisfaction. Thus, in the holistic care of a patient with lower limb loss, maximizing mobility would correlate with greater quality of life and general satisfaction. Clinical relevance There is growing emphasis on the quality of life and general satisfaction experienced by patients undergoing prosthetic rehabilitation. The results of this study underscore the importance of providing prosthetic rehabilitation that maximizes the patient’s mobility, noting that these individuals also report greater quality of life and general satisfaction.

Poster 2: Matching Individuals Based on Comorbid Health Reveals Improved Function for Above-Knee Prosthesis Users with Modern Knee Technology

Provided here are the abstracts of scientific papers and posters to be presented at the 2018 Annual Assembly of the American Academy of Physical Medicine and Rehabilitation in Orlando, FL. Papers and posters were chosen by members of the Academy’s Evidence Committee. The abstracts have not been subjected to formal peer review by the Editorial Board of PM&R. Levels of Evidence are self-disclosed by authors. Posters will be displayed Friday, October 26, and Saturday, October 27.

Poster 1: Quality of Life and Satisfaction are Strongly Related to Mobility for Patients with a Lower Limb Prosthesis

Provided here are the abstracts of scientific papers and posters to be presented at the 2018 Annual Assembly of the American Academy of Physical Medicine and Rehabilitation in Orlando, FL. Papers and posters were chosen by members of the Academy’s Evidence Committee. The abstracts have not been subjected to formal peer review by the Editorial Board of PM&R. Levels of Evidence are self-disclosed by authors. Posters will be displayed Friday, October 26, and Saturday, October 27.

Poster 3: Comorbidities and Mobility in Lower Limb Prosthesis Users

Disclosures: Melody Lee: I Have No Relevant Financial Relationships To Disclose Objective: The purpose of this study was to identify predictors of activity limitations, living setting, and functional gain 3 months after inpatient stroke rehabilitation. Design: The outcome measures were collected by institutions reporting data to the Uniform Data System for Medical Rehabilitation for individuals dismissed from inpatient rehabilitation for stroke between 2002 and 2010. For continuous variables, generalized additive models were used to allow for non-linear associations. Variables with a concordance of at least 0.55 were considered for multivariable models. Setting: Large, nationally representative data set for individuals hospitalized for rehabilitation after stroke in the U.S. Participants: Telephone follow-up was completed in 16,346 individuals at 3 months after rehabilitation discharge from a sample of 148,367 individuals with the diagnosis of stroke in the UDSMR data set during the years 2005 through 2007. Interventions: Not applicable. Main Outcome Measures: FIM total and FIM subscale scores, living setting, and FIM gain at 3 months after rehabilitation discharge. Results: Ninety-two percent (92%) of this follow-up sample was living in a private residence at 3 months. Models using information available at rehabilitation discharge, rather than at admission, performed best and models reduced to a single predictor performed as well as models using multiple variables. Discharge FIM scores predicted follow-up FIM scores and FIM gain at 3 months, and discharge living setting predicted living setting at 3 months. Conclusions: As previously shown, the degree of assistance needed to independently function continues to dominate prediction of functional status at 3 months, with over 90% of individuals discharged from rehabilitation hospitalization in this sample residing in a private residence. These data support the development of individualized rehabilitation plans of care to maximize functional independence during inpatient care and offers confidence in predicting functional gain and communitybased living at 3 months to providers, individuals with stroke and their families based on data known at rehabilitation discharge. Level of Evidence: Level III

Removable Rigid Dressings for Postoperative Management of Transtibial Amputations: A Review of Published Evidence

Forty years of clinical experience and peer‐reviewed research studies support the use of nonweight‐bearing removable rigid dressings (RRDs) as an effective means of postoperative management of transtibial amputations. We reviewed the published medical evidence regarding the use of RRDs as a postoperative management strategy, culminating in an evidence‐based practice recommendation. Published peer‐reviewed literature on the topic was searched and classified by level of evidence based on the research design using the scale recommended by the PM&R (level I through V). The search uncovered a total of 15 articles, including 5 level I randomized controlled trials, 6 level III retrospective matched controlled trials, and 4 level V case reports.