Thiru M. Annaswamy

The Effects of Peroneal Nerve Functional Electrical Stimulation Versus Ankle-Foot Orthosis in Patients With Chronic Stroke A Randomized Controlled Trial

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle-foot orthoses (AFO) for treatment of foot drop poststroke, but few randomized controlled comparisons exist. Objective. To compare changes in gait and quality of life (QoL) between FES and an AFO in individuals with foot drop poststroke. Methods. In a multicenter randomized controlled trial (ClinicalTrials.gov #NCT01087957) with unblinded outcome assessments, 495 Medicare-eligible individuals at least 6 months poststroke wore FES or an AFO for 6 months. Primary endpoints: 10-Meter Walk Test (10MWT), a composite of the Mobility, Activities of Daily Living/Instrumental Activities of Daily Living, and Social Participation subscores on the Stroke Impact Scale (SIS), and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test, GaitRite Functional Ambulation Profile (FAP), Modified Emory Functional Ambulation Profile (mEFAP), Berg Balance Scale (BBS), Timed Up and Go, individual SIS domains, and Stroke-Specific Quality of Life measures. Multiply imputed intention-to-treat analyses were used with primary endpoints tested for noninferiority and secondary endpoints tested for superiority. Results. A total of 399 subjects completed the study. FES proved noninferior to the AFO for all primary endpoints. Both the FES and AFO groups improved significantly on the 10MWT. Within the FES group, significant improvements were found for SIS composite score, total mFEAP score, individual Floor and Obstacle course time scores of the mEFAP, FAP, and BBS, but again, no between-group differences were found. Conclusions. Use of FES is equivalent to the AFO. Further studies should examine whether FES enables better performance in tasks involving functional mobility, activities of daily living, and balance.

Rectus femoris: its role in normal gait

OBJECTIVE To analyze the role of the rectus femoris muscle in nondisabled gait at various walking velocities using fine-wire dynamic electromyography. DESIGN Descriptive study. Fine-wire electromyography data were collected from the rectus femoris during level walking at four walking speeds. Rectus femoris activity patterns in the loading response phase and the pre- and initial-swing phase of the gait cycle were compared using paired t tests. SETTING A gait laboratory. SUBJECTS Ten nondisabled adult volunteers. MAIN OUTCOME MEASURES Amplitude of rectus femoris activity in the loading response phase and the pre- and initial-swing phase during walking at four speeds. RESULTS There was a bimodal pattern of rectus femoris activity in all subjects, at all speeds, in both phases, with high variability in the onsets, durations, and amplitudes of activity, and paired t tests revealed no significant differences (p > .05) between phases at any walking speed. CONCLUSION Activity in the rectus femoris in the pre- and initial-swing phase in nondisabled individuals at all speeds suggests that similar activity detected in individuals with stiff-legged gait may not be inappropriate.

Emerging Concepts in the Treatment of Myofascial Pain: A Review of Medications, Modalities, and Needle-based Interventions

Significant developments and changes in the use of interventions and treatments for the management of myofascial pain syndrome have occurred in the past 10 years. These emerging concepts have changed the approach for clinicians who manage these pain disorders. However, wide variations in practice patterns prevail, and no clear consensus exists regarding when and how to use these interventions; in addition, awareness of the evidence basis behind their use is limited. This review examines the most recent advances in the treatment of myofascial pain syndromes. Specifically, the evidence basis of various emerging interventions is reviewed and recommendations for routine clinical practice and their rationale are provided. The purpose of this review is to provide the clinician with a better understanding of emerging concepts in the interventions used for myofascial pain syndromes.

Long-Term Follow-up to a Randomized Controlled Trial Comparing Peroneal Nerve Functional Electrical Stimulation to an Ankle Foot Orthosis for Patients With Chronic Stroke:

Background. Evidence supports peroneal nerve functional electrical stimulation (FES) as an effective alternative to ankle foot orthoses (AFO) for treatment of foot drop poststroke, but few long-term, randomized controlled comparisons exist. Objective. Compare changes in gait quality and function between FES and AFOs in individuals with foot drop poststroke over a 12-month period. Methods. Follow-up analysis of an unblinded randomized controlled trial (ClinicalTrials.gov #NCT01087957) conducted at 30 rehabilitation centers comparing FES to AFOs over 6 months. Subjects continued to wear their randomized device for another 6 months to final 12-month assessments. Subjects used study devices for all home and community ambulation. Multiply imputed intention-to-treat analyses were utilized; primary endpoints were tested for noninferiority and secondary endpoints for superiority. Primary endpoints: 10 Meter Walk Test (10MWT) and device-related serious adverse event rate. Secondary endpoints: 6-Minute Walk Test (6MWT), GaitRite Functional Ambulation Profile, and Modified Emory Functional Ambulation Profile (mEFAP). Results. A total of 495 subjects were randomized, and 384 completed the 12-month follow-up. FES proved noninferior to AFOs for all primary endpoints. Both FES and AFO groups showed statistically and clinically significant improvement for 10MWT compared with initial measurement. No statistically significant between-group differences were found for primary or secondary endpoints. The FES group demonstrated statistically significant improvements for 6MWT and mEFAP Stair-time subscore. Conclusions. At 12 months, both FES and AFOs continue to demonstrate equivalent gains in gait speed. Results suggest that long-term FES use may lead to additional improvements in walking endurance and functional ambulation; further research is needed to confirm these findings.

Synchronous stimulation and monitoring of soleus H reflex during robotic body weight-supported ambulation in subjects with spinal cord injury.

We evaluated the accuracy of a novel method for recording the soleus H reflex at specific points in the gait cycle during robotic locomotor training in subjects with spinal cord injury (SCI). Hip goniometric information from the Lokomat system defined midstance and midswing points within the gait cycle. Soleus H reflex stimulation was synchronized to these points during robotic-assisted ambulation at 1.8 and 2.5 km/h. Motor stimulus intensity was monitored and adjusted in real time. Analysis of 50 H reflex cycles during each speed and gait phase showed that stimulation accuracy was within 0.5 degrees of the defined hip joint position and that >85% of the H reflex cycles met the +/-10% M wave criterion that was established during quiet standing. This method allows increased consistency of afferent information into the segmental spinal and supraspinal circuitry and, thus, evaluation of H reflex characteristics during robotic ambulation in subjects with SCI.

The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Hip Fractures in the Elderly.

The AAOS Evidence-Based Guideline on Management of Hip Fractures in the Elderly includes both diagnosis and treatment. This clinical practice guideline has been endorsed by the Orthopaedic Trauma Association (OTA), the American Academy of Physical Medicine and Rehabilitation (AAPM&R), the American Society for Bone and Mineral Research (ASBMR), the United States Bone and Joint Initiative, the Hip Society, the American Association of Clinical Endocrinologists, the Orthopaedic Rehabilitation Association (ORA), and the American Geriatrics Society (AGS). This brief summary of the AAOS Clinical Practice Guideline contains a list of the recommendations and the rating of strength based on the quality of the supporting evidence. Discussion of how each recommendation was developed and the complete evidence report are contained in the full guideline at www.aaos.org/guidelines. ### ADVANCED IMAGING Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of presumed hip fracture not apparent on initial radiographs. Strength of Recommendation: Moderate ★★★☆ ### PERIOPERATIVE REGIONAL ANALGESIA Strong evidence supports regional analgesia to improve preoperative pain control in patients with hip fracture. …

Needle electromyography predicts outcome after lumbar epidural steroid injection

Introduction: Needle electromyography (NEE) would be more valuable if it could predict outcomes after lumbar epidural steroid injections (LESIs) in lumbosacral radiculopathy (LSR). Methods: We investigated the predictive value of NEE for outcome after LESI compared with other known predictive variables in 89 subjects with clinical LSR. Seventy patients completed the study, which included diagnostic lower extremity NEE and LESI. Outcome measures included changes in pain, physical function, and psychosocial function [assessed using the Pain Disability Questionnaire (PDQ)]. Results: NEE was an independent predictor of long‐term pain improvement after LESI and was not predictive of PDQ functional improvement. A regression model, with NEE as one of several independent variables, showed strong outcome‐predictive ability. Conclusions: NEE is an independent predictor of long‐term pain relief after LESI for LSR. Abnormal NEE is predictive of better outcome than normal NEE. A regression equation including NEE and other independent predictors was predictive of pain and functional outcomes. Muscle Nerve, 2012

Augmented reality-based exergames for rehabilitation

Rehabilitation for stroke afflicted patients, through exercises tailored for individual needs, aims at relearning basic motor skills, especially in the extremities. Rehabilitation through Augmented Reality (AR) based games engage and motivate patients to perform exercises which, otherwise, maybe boring and monotonic. Also, mirror therapy allows users to observe ones own movements in the game providing them with good visual feedback. This paper presents an augmented reality based system for rehabilitation by playing four interactive, cognitive and fun Exergames (exercise and gaming). The system uses low-cost RGB-D cameras such as Microsoft Kinect V2 to capture and generate 3D model of the person by extracting him/her from the entire captured data and immersing it in different interactive virtual environments. Animation based limb movement enhancement along with cognitive aspects incorporated in the game can help in positive reinforcement, progressive challenges and motion improvement. Recording module of the toolkit allows future reference and facilitates feedback from the physician. 10 able-bodied users, 2 psychological experts and 2 Physical Medicine and Rehabilitation physicians evaluated the user experience and usability aspects of the exergames. Results obtained shows the games to be fun and realistic, and at the same time engaging and motivating for performing exercises.

Effect of lidocaine iontophoresis on pain during needle electromyography.

Objective: Pain during needle electrode examination (NEE) is often poorly tolerated. No previous studies have evaluated the effect of lidocaine iontophoresis on pain reduction during NEE. Our objective was to determine whether pretreatment with lidocaine iontophoresis mitigates the pain felt during NEE. Design: In this prospective randomized, placebo-controlled, double-blinded study, the subjects were recruited from among patients scheduled for electromyographic evaluation of the bilateral upper limbs in a hospital-based clinic; they were randomized to receive either lidocaine (4%) or placebo (normal saline) administered through iontophoresis (40 mA/min) to the left opponens pollicis. The right opponens pollicis was untreated. A bilateral opponens pollicis NEE was then performed in standard fashion using a monopolar needle electrode, immediately after which the subjects rated their pain using a 10-cm Visual Analog Scale. Results: Fourteen subjects were studied. Paired t tests revealed that iontophoresis significantly decreased pain (untreated side: 6.61 ± 1.96, n = 7; treated side: 4.63 ± 2.90, n = 7; P < 0.05). However, there were no significant side-to-side differences in either group (lidocaine: 7.29 ± 1.56 vs. 5.63 ± 3.12; P = 0.19 and placebo: 5.93 ± 2.19 vs. 3.63 ± 2.48; P = 0.1). Conclusions: Pretreatment with iontophoresis significantly reduced pain during NEE. However, the lack of group differences between lidocaine and saline iontophoresis suggested that the analgesic effect may have been attributable primarily to the iontophoresis modality itself rather than to the medication administered with iontophoresis.

Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale.

Annaswamy T, Mallempati S, Allison SC, Abraham LD: Measurement of plantarflexor spasticity in traumatic brain injury: correlational study of resistance torque compared with the modified Ashworth scale. Am J Phys Med Rehabil 2007;86:404–411. Objectives:To examine the usefulness of a biomechanical measure, resistance torque (RT), in quantifying spasticity by comparing its use with a clinical scale, the modified Ashworth scale (MAS), and quantitative electrophysiological measures. Design:This is a correlational study of spasticity measurements in 34 adults with traumatic brain injury and plantarflexor spasticity. Plantarflexor spasticity was measured in the seated position before and after cryotherapy using the MAS and also by strapping each subject’s foot and ankle to an apparatus that provided a ramp and hold stretch. The quantitative measures were (1) reflex threshold angle (RTA) calculated through electromyographic signals and joint angle traces, (2) Hdorsiflexion (Hdf)/Hcontrol (Hctrl) amplitude ratio obtained through reciprocal inhibition of the soleus H-reflex, (3) Hvibration (Hvib)/Hctrl ratio obtained through vibratory inhibition of the soleus H-reflex, and (4) RT calculated as the time integral of the torque graph between the starting and ending pulses of the stretch. Results:Correlation coefficients between RT and MAS scores in both pre-ice (0.41) and post-ice trials (0.42) were fair (P = 0.001). The correlation coefficients between RT scores and RTA scores in both the pre-ice (0.66) and post-ice trials (0.75) were moderate (P ≤ 0.001). Conclusion:RT is a measure of the cumulative torque during an imposed stretch. The MAS is a subjective measure of the cumulative resistance perceived by the clinician during an imposed stretch. RT seems to be a fair quantitative correlate of the MAS in assessing spasticity.