Roeland Lysens

The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction

This study was undertaken to demonstrate that the deep inferior epigastric perforator (DIEP) flap can provide the well-known advantages of autologous breast reconstruction with lower abdominal tissue while avoiding the abdominal wall complications of the transverse rectus abdominis myocutaneous (TRAM) flap. Eighteen unilateral free DIEP flap breast reconstruction patients were assessed 12-30 months (mean 17.8 months) after surgery. Clinical examination, physical exercises and isokinetic dynamometry were performed preoperatively and two months and one year postoperatively. Intraoperative segmental nerve stimulation, visual evaluation and postoperative CT scans were also used to quantify the damage to the rectus muscle. The 18 patients were then compared with 20 free TRAM flap patients and 20 non-operated controls. Two DIEP flap patients presented with abdominal asymmetry. A limited decrease of trunk flexing strength was noticed but rotatory function was intact. Ten of the TRAM flap patients had umbilical or abdominal asymmetry, bulging or hernias. TRAM flap patients showed a statistically significant reduction in strength to flex and to rotate the upper trunk compared to both the one year postoperative DIEP flap group and the control group. The answers to a questionnaire revealed impairment of activities of daily living for some TRAM flap patients while the activities of all DIEP flap patients were unaffected. Our data demonstrate that the free DIEP flap can limit the surgical damage to the rectus abdominis and oblique muscles to an absolute minimum. We believe it is worthwhile to spend extra operative time, the main disadvantage of this technique, to limit late postoperative weakness of the lower abdominal wall.

Intrinsic Risk Factors for the Development of Anterior Knee Pain in an Athletic Population: A Two-Year Prospective Study*:

Many variables have retrospectively been associated with the presence of anterior knee pain. Very few prospective data exist, however, to determine which of these variables will lead to the development of anterior knee pain. It was our purpose in this study to determine the intrinsic risk factors for the development of anterior knee pain in an athletic population over a 2-year period. Before the start of training, 282 male and female students enrolled in physical education classes were evaluated for anthropometric variables, motor performance, general joint laxity, lower leg alignment characteristics, muscle length and strength, static and dynamic patellofemoral characteristics, and psychological parameters. During this 2-year follow-up study, 24 of the 282 students developed patellofemoral pain. Statistical analyses revealed a significant difference between those subjects who developed patellofemoral pain and those who did not concerning quadriceps and gastrocnemius muscle flexibility, explosive strength, thumb-forearm mobility, reflex response time of the vastus medialis obliquus and vastus lateralis muscles, and the psychological parameter of seeking social support. However, only a shortened quadriceps muscle, an altered vastus medialis obliquus muscle reflex response time, a decreased explosive strength, and a hypermobile patella had a significant correlation with the incidence of patellofemoral pain. We concluded that the latter four parameters play a dominant role in the genesis of anterior knee pain and we therefore deem them to be risk factors for this syndrome.

The Role of Paraspinal Muscle Spindles in Lumbosacral Position Sense in Individuals With and Without Low Back Pain

Study Design. A two-group experimental design with repeated measures on one factor was used. Objectives. To investigate the role of paraspinal muscle spindles in lumbosacral position sense in individuals with and without low back pain. Summary of Background Data. Proprioceptive deficits have been identified in patients with low back pain. The underlying mechanisms, however, are not well documented. Methods. Lumbosacral position sense was determined before, during, and after lumbar paraspinal muscle vibration in 23 young patients with low back pain and in 21 control subjects. Position sense was estimated by calculating the mean absolute error, constant error, and variable error between six criterion and reproduction sacral tilt angles. Results. Repositioning accuracy was significantly lower in the patient group than in healthy individuals (absolute error difference between groups = 2.7°, P < 0.0001). Multifidus muscle vibration induced a significant muscle-lengthening illusion that resulted in an undershooting of the target position in healthy individuals (constant error = −3.1°, P < 0.0001). Conversely, the position sense scores of the patient group did not display an increase in negative directional error but a significant improvement in position sense during muscle vibration (P < 0.05). No significant differences in absolute error were found between the first and last trial in the healthy individuals (P ≥ 0.05) and in the patient group (P > 0.05). Conclusions. Patients with low back pain have a less refined position sense than healthy individuals, possibly because of an altered paraspinal muscle spindle afference and central processing of this sensory input. Furthermore, muscle vibration can be an interesting expedient for improving proprioception and enhancing local muscle control.

Open Versus Closed Kinetic Chain Exercises for Patellofemoral Pain A Prospective, Randomized Study

The goal of this prospective study was to evaluate the efficacy of open versus closed kinetic chain exercises in the nonoperative management of patellofemoral pain. Sixty patients were randomized into a 5-week program that consisted of only closed kinetic chain exercises or only open kinetic chain exercises. Muscle characteristics, subjective symptoms, and functional performance were evaluated in this study at the time of the initial physical examination, at the end of the treatment period, and 3 months later. Both groups experienced a statistically significant decrease in pain and an increase in functional performance. This study shows that both open and closed kinetic chain exercise programs lead to an improved subjective and clinical outcome in patients with anterior knee pain. The few significantly better functional results for some of the tested parameters in the closed kinetic chain group suggest that this type of treatment is a little more effective than the open kinetic chain program in the treatment of these patients.

Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations

AbstractFormerly known as ‘jumper’s knee’, patellar tendinopathy gives rise to considerable functional deficit and disability in recreational as well as professional athletes. It can interfere with their performance, often perseveres throughout the sporting career and may be the primary cause to end it. The diagnosis of patellar tendinopathy is primarily a clinical one but new imaging techniques, such as Doppler ultrasonography, may provide additional diagnostic value. Current therapeutic protocols are characterised by wide variability ensuing from anecdotal experience rather than evidence. Moreover, numerous reports in recent years have shattered previous doctrines and dogmatic belief on tendon overuse. Histopathological and biochemical evidence has indicated that the underlying pathology of tendinopathy is not an inflammatory tendinitis but a degenerative tendinosis. Consequently, pain in chronic patellar tendinopathy is not inflammatory in nature, but its exact origin remains unexplained. In pursuit of pathology- and evidence-based management, conservative therapy should be shifted from anti-inflammatory strategies towards a complete rehabilitation with eccentric tendon strengthening as a key element. If conservative management fails, surgery is opted for. However, considering the heterogeneity of surgical procedures and the absence of randomised studies, no conclusive evidence can be drawn from the literature regarding the effectiveness of surgical treatment for patellar tendinopathy. Parallel with the improved knowledge on the pathophysiology and pain mechanisms in patellar tendinopathy, new treatment strategies are expected to emerge in the near future.

Intrinsic Risk Factors for the Development of Patellar Tendinitis in an Athletic Population A Two-Year Prospective Study*

Retrospective studies have suggested various factors that might cause a disposition to develop patellar tendinitis, but no prospective data exist to determine any relationships. The purpose of this study was to determine the intrinsic risk factors for the development of patellar tendinitis in an athletic population. Before the study, 138 male and female students of physical education were evaluated for anthropometric variables, leg alignment characteristics, and muscle tightness and strength parameters. During the 2-year study, 19 of the 138 students developed patellar tendinitis. In all cases the diagnosis was confirmed by the presence of a hypoechogenic nodular lesion in the proximal region of the patellar tendon. Univariate and stepwise discriminant function analyses were performed comparing the various measurements. These analyses revealed that the only significant determining factor was muscular flexibility, with the patellar tendinitis patients being less flexible in the quadriceps and hamstring muscles (P<0.05). The results of this study demonstrate that lower flexibility of the quadriceps and hamstring muscles may contribute to the development of patellar tendinitis in an athletic population. Therefore, the prevention of this condition in athletes should be focused on screening for and treating poor quadriceps and hamstring muscle flexibility.

Predictors of 6-minute walk test results in lean, obese and morbidly obese women.

The aim of this study was first, to assess the presence of medical conditions that might interfere with walking; second, to assess the differences in walking capacity, perceived exertion and physical complaints between lean, obese and morbidly obese women; and third, to identify anthropometric, physical fitness and physical activity variables that contribute to the variability in the distance achieved during a 6‐minute walk test in lean and obese women.

Exercise capacity in lean versus obese women

The aim of this study was to assess the nature and magnitude of the differences in submaximal and maximal exercise capacity parameters between lean and obese women. A total of 225 healthy obese women 18–65 years (BMI> or=30 kg/m2) and 81 non‐athletic lean women (BMI< or=26 kg/m2) were selected. Anthropometric measurements (weight and height), body composition assessment (bioelectrical impedance method) and a maximal exercise capacity test on a bicycle ergometer were performed. Oxygen uptake (VO2), carbon dioxide production (VCO2), expired ventilation (VE), respiratory quotient (RQ), breathing efficiency (VE/VO2), mechanical efficiency (ME) and anaerobic threshold (AT) were calculated. At a submaximal intensity load of 70 W, VO2 (l/min) was larger in the obese women and was already 78% of their peak VO2, whereas in the non‐obese it was only 69% (P=0.0001). VE (l/min) was larger, VE/VO2 did not differ and ME was lower in obese compared to the lean women. AT occurred at the same percentage of peak VO2 in both lean and obese women. At peak effort, achieved load, terminal VO2 (l min−1 kg−1), VE, heart rate, RQ respiratory exchange ratio and perceived exertion were lower in obese subjects compared to the non‐obese. Obese subjects mentioned significantly more musculoskeletal pain as a reason to end the test, whereas in lean subjects it was leg fatigue. Lean women recovered better as after 2 min they were already at 35% of the peak VO2, whereas in the obese women it was 47% (P=0.0001). Our results confirm that exercise capacity is decreased in obesity, both at submaximal and peak intensity, and during recovery. Moreover, at peak effort musculoskeletal pain was an important reason to end the test and not true leg fatigue. These findings are important when designing exercise programs for obese subjects.

Study of differences in peripheral muscle strength of lean versus obese women: an allometric approach

OBJECTIVE: To investigate whether peripheral muscle strength is significantly different between lean and obese women controlled for age and physical activity, using an allometric approach.DESIGN: Cross-sectional study of isometric handgrip and isokinetic leg and trunk muscle strength.SUBJECTS: 173 obese (age 39.9±11.4 y, body mass index (BMI) 37.8±5.3 kg/m2) and 80 lean (age 39.7±12.2 y, BMI 22.0±2.2 kg/m2) women.MEASUREMENTS: Anthropometric measures (weight, height) and body composition (bioelectrical impedance method), isometric handgrip (maximal voluntary contraction on the Jamar dynamometer), isokinetic trunk flexion–extension, trunk rotation, and knee flexion–extension (Cybex dynamometers).RESULTS: Absolute isokinetic strength output (that is, strength uncorrected for fat-free mass) was larger in obese compared to lean women, except for knee flexion and isometric handgrip, which were not significantly different (P>0.05). Pearson correlation coefficients between strength measures and fat-free mass (kg) were low to moderate both in lean (r=0.28–0.53, P<0.05) and in obese (r=0.29–0.49, P<0.001) women. There was no correlation with fat mass (kg) in the lean, whereas in the obese women a weak positive relation could be observed for most isokinetic data (r=0.21–0.39, P<0.01). When correcting for fat-free mass (raised to the optimal exponent determined by allometric scaling), all strength measurements were at least 6% lower in obese when compared to the lean women, except for trunk flexion, which was at least 8% stronger in obese women.DISCUSSION: The higher absolute knee extension strength measures of leg and the similar extension strength of the trunk in the obese sample compared to the lean might be explained by the training effect of weight bearing and support of a larger body mass. However when the independent effect of fat-free mass is removed, these strength measures, as well as oblique abdominal muscle and handgrip strength, turned out to be lower in obese women. These observations could be the reflection of the overall impairment of physical fitness as a consequence of obesity and its metabolic complications.

Avoidance and Confrontation of Painful, Back-Straining Movements in Chronic Back Pain Patients

Avoidance of painful activities has been proposed to be an important nsk factor for the initiation and maintenance of chronic low back suffering, whereas exposure to these activities has been suggested to be beneficial for recovery. In a cross-sectional study, the differences between chronic patients with avoidant and confrontational styles were investigated using self-report measures and a behavioral test. Participants were first classified as avoiders or confronters. In comparison with confronters, avoiders reported greater frequency and duration of pain, higher fear of pain and injury, more disability in daily living, and more attentiorr to back sensations. Finally, avoiders reported more fear of (re)injury during the behavioral test and had a worse performance than confronters. The results suggest a close link between the fear of pain/(re)injury on one hand and avoidance behavior and physical deconditioning on the oither hand.