Thomas Bandholm

Loss of Knee-Extension Strength Is Related to Knee Swelling After Total Knee Arthroplasty

OBJECTIVE To examine whether changes in knee-extension strength and functional performance are related to knee swelling after total knee arthroplasty (TKA). DESIGN Prospective, descriptive, hypothesis-generating study. SETTING A fast-track orthopedic arthroplasty unit at a university hospital. PARTICIPANTS Patients (N=24; mean age, 66y; 13 women) scheduled for primary unilateral TKA were investigated 1 week before surgery and on the day of hospital discharge 2.4 days postsurgery. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES We assessed all patients for knee-joint circumference, knee-extension strength, and functional performance using the Timed Up & Go, 30-second Chair Stand, and 10-m fast speed walking tests, together with knee pain during all active test procedures. RESULTS All investigated variables changed significantly from pre- to postsurgery independent of knee pain. Importantly, knee circumference increased (knee swelling) and correlated significantly with the decrease in knee-extension strength (r=-.51; P=.01). Reduced fast-speed walking correlated significantly with decreased knee-extension strength (r=.59; P=.003) and decreased knee flexion (r=.52; P=.011). Multiple linear regression showed that knee swelling (P=.023), adjusted for age and sex, could explain 27% of the decrease in knee-extension strength. Another model showed that changes in knee-extension strength (P=.009) and knee flexion (P=.018) were associated independently with decreased performance in fast-speed walking, explaining 57% of the variation in fast-speed walking. CONCLUSIONS Our results indicate that the well-known finding of decreased knee-extension strength, which decreases functional performance shortly after TKA, is caused in part by postoperative knee swelling. Future studies may look at specific interventions aimed at decreasing knee swelling postsurgery to preserve knee-extension strength and facilitate physical rehabilitation after TKA.

Reliability of knee joint range of motion and circumference measurements after total knee arthroplasty: does tester experience matter?

BACKGROUND AND PURPOSE Two of the most utilized outcome measures to assess knee joint range of motion (ROM) and intra-articular effusion are goniometry and circumference, respectively. Neither goniometry nor circumference of the knee joint have been examined for both intra-tester and inter-tester in patients with total knee arthroplasty (TKA). The purpose of this study was to determine the intra-tester and inter-tester reliability of active and passive knee joint ROM and circumference in patients with TKA when administered by physiotherapists (testers) with different clinical experience. METHOD The design was an intra-tester, inter-tester and intra-day reliability study. Nineteen outpatients (10 females) having received a TKA were examined by an inexperienced and an experienced physiotherapist. Following a standardized protocol, active and passive knee joint ROM and circumference measurements were obtained using a universal goniometer and a tape measure, respectively. To establish reliability, intraclass correlation coefficients (ICC(2,1)) and smallest real difference (SRD) were calculated. RESULTS The knee joint ROM and circumference measurements were generally reliable (ICC > 0.8) within and between physiotherapists (except passive knee extension). Changes in knee joint ROM of more than 6.6 degrees and 10 degrees (except active knee flexion) and knee joint circumference of more than 1.0 cm and 1.63 cm represent a real clinical improvement (SRD) or deterioration for a single individual within and between physiotherapists, respectively. Generally, the experienced tester recorded larger knee joint ROM and lower circumference values than that of the inexperienced tester. CONCLUSIONS In clinical practice, we suggest that repeated knee goniometric and circumferential measurements should be recorded by the same physiotherapist in individual patients with TKA. Tester experience appears not to influence the degree of reliability.

FORCE STEADINESS, MUSCLE ACTIVITY, AND MAXIMAL MUSCLE STRENGTH IN SUBJECTS WITH SUBACROMIAL IMPINGEMENT SYNDROME

We investigated the effects of the subacromial impingement syndrome (SIS) on shoulder sensory‐motor control and maximal shoulder muscle strength. It was hypothesized that both would be impaired due to chronic shoulder pain associated with the syndrome. Nine subjects with unilateral SIS who remained physically active in spite of shoulder pain and nine healthy matched controls were examined to determine isometric and isokinetic submaximal shoulder‐abduction force steadiness at target forces corresponding to 20%, 27.5%, and 35% of the maximal shoulder abductor torque, and maximal shoulder muscle strength (MVC). Electromyographic (EMG) activity was assessed using surface and intramuscular recordings from eight shoulder muscles. Force steadiness was impaired in SIS subjects during concentric contractions at the highest target force level only, with muscle activity largely unaffected. No between‐group differences in shoulder MVC were observed. The present data suggest that shoulder sensory‐motor control is only mildly impaired in subjects with SIS who are able to continue with upper body physical activity in spite of shoulder pain. Thus, physical activity should be continued by patients with SIS, if possible, to avoid the loss in neural and muscle functions associated with inactivity. Muscle Nerve, 2006

High inter-tester reliability of the new mobility score in patients with hip fracture.

OBJECTIVE To assess the inter-tester reliability of the New Mobility Score in patients with acute hip fracture. DESIGN An inter-tester reliability study. SUBJECTS Forty-eight consecutive patients with acute hip fracture at a median age of 84 (interquartile range, 76-89) years; 40 admitted from their own home and 8 from nursing homes to an acute orthopaedic hip fracture unit at a university hospital. METHODS The New Mobility Score, which evaluates the prefracture functional level with a score from 0 (not able to walk at all) to 9 (fully independent), was assessed by 2 independent physiotherapists at the orthopaedic ward. Inter-tester reliability was evaluated using the intraclass correlation coefficient (ICC1.1) and the standard error of measurement (SEM). RESULTS The ICC between the 2 physiotherapists was 0.98, 95% confidence interval (CI) 0.96-0.99 and the SEM was 0.42, 95% CI -0.40-1.24 New Mobility Score points. No systematic between-rater bias was observed (p>0.05). Patients who were scored differently by the 2 physiotherapists had significantly lower mental scores (p=0.02). CONCLUSION The inter-tester reliability of the New Mobility Score is very high and can be recommended to evaluate the prefracture functional level in patients with acute hip fracture.

Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial

Background Soccer players with weak hip-adductor muscles are at increased risk of sustaining groin injuries. Therefore, a simple hip-adductor strengthening programme for prevention of groin injuries is needed. Objective We aimed to investigate the effect of an 8-week hip-adductor strengthening programme, including one hip-adduction exercise, on eccentric and isometric hip-adduction strength, using elastic bands as external load. Methods Thirty-four healthy, sub-elite soccer players, mean (±SD) age of 22.1 (±3.3) years, were randomised to either training or control. During the mid-season break, the training group performed 8 weeks of supervised, progressive hip-adduction strength training using elastic bands. The participants performed two training sessions per week (weeks 1–2) with 3×15 repetition maximum loading (RM), three training sessions per week (weeks 3–6) with 3×10 RM and three training sessions per week (weeks 7–8) with 3×8 RM. Eccentric hip-adduction (EHAD), isometric hip-adduction (IHAD) and isometric hip-abduction (IHAB) strength, and the IHAD/IHAB ratio were measured assessor-blinded preintervention and postintervention, using reliable hand-held dynamometry procedures. Results In the training group, EHAD strength increased by 30% (p<0.001). In the control group, EHAD strength increased by 17% (p<0.001), but the increase was significantly larger in the training group compared with the control group (p=0.044). No other significant between-group strength-differences in IHAD, IHAB or the IHAD/IHAB ratio existed (p>0.05). Conclusions 8 weeks of hip-adduction strength training, using elastic bands, induce a relevant increase in eccentric hip-adduction strength in soccer players, and thus may have implications as a promising approach towards prevention of groin injuries in soccer.

Hip strength assessment using handheld dynamometry is subject to intertester bias when testers are of different sex and strength.

Handheld dynamometry (HHD) is a promising tool for obtaining reliable hip strength measurements in the clinical setting, but intertester reliability has been questioned, especially in situations where testers exhibit differences in upper‐extremity muscle strength (male vs female). The purpose of this study was to examine the intertester reliability concerning strength assessments of hip abduction, adduction, external and internal rotation, flexion and extension using HHD, and to test whether systematic differences in test values exist between testers of different upper‐extremity strength. Fifty healthy individuals (29 women), aged 25 ± 5 years were included. Two physiotherapist students (one female, one male) of different upper‐extremity strength performed the measurements. The tester order and strength test order were randomized. Intraclass correlation coefficients were used to quantify reliability, and ranged from 0.82 to 0.91 for the six strength test. The female tester systematically measured lower strength values for all isometric strength tests (P < 0.05). In hip strength assessments using HHD, systematic bias exists between testers of different sex, which is likely explained by differences in upper‐extremity strength. Hence, to improve intertester reliability, the dynamometer likely needs external fixation, as this will eliminate the influence of differences in upper‐extremity strength between testers.

Acute hospitalization of the older patient: changes in muscle strength and functional performance during hospitalization and 30 days after discharge.

ObjectiveAcute hospitalization of older patients may be associated with loss of muscle strength and functional performance. The aim of this study was to investigate the effect of acute hospitalization as a result of medical disease on muscle strength and functional performance in older medical patients. DesignIsometric knee-extension strength; handgrip strength; and functional performance, that is, the Timed Up and Go test, were assessed at admission, at discharge, and 30 days after discharge. Twenty-four–hour mobility was measured during hospitalization. ResultsThe mean (SD) age was 82.7 (8.2) years, and the median length of stay was 7.5 days (interquartile range, 4.25–11). Knee-extension strength did not change over time (1.0 [N·m]/kg, 1.1 [N·m]/kg, and 1.1 [N·m]/kg, P = 0.138), as did handgrip strength (24.2 kg, 23.3 kg, and 23.5 kg, P = 0.265). The Timed Up and Go test improved during hospitalization, from 17.3 secs at admission to 13.3 secs at discharge (P = 0.003), but with no improvement at the 30-day follow-up (12.4 secs, P = 0.064). The median times spent in lying, sitting, and standing/walking were 17.4 hrs per day, 4.8 hrs per day, and 0.8 hrs per day, respectively. ConclusionsMuscle strength did not change during hospitalization and 30 days after discharge in the acutely admitted older medical patients. Despite a low level of mobility during hospitalization, functional performance improved significantly during hospitalization, without further improvement.

Timed up & go test score in patients with hip fracture is related to the type of walking aid.

UNLABELLED Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed Up & Go test score in patients with hip fracture is related to the type of walking aid. OBJECTIVE To determine the relationship between Timed Up & Go (TUG) test scores and type of walking aid used during the test, and to determine the feasibility of using the rollator as a standardized walking aid during the TUG in patients with hip fracture who were allowed full weight-bearing (FWB). DESIGN Prospective methodological study. SETTING An acute orthopedic hip fracture unit at a university hospital. PARTICIPANTS Patients (N=126; 90 women, 36 men) with hip fracture with a mean age +/- SD of 74.8+/-12.7 years performed the TUG the day before discharge from the orthopedic ward. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The TUG was performed with the walking aid the patient was to be discharged with: a walker (n=88) or elbow crutches (n=38). In addition, all patients also performed the TUG using a rollator. RESULTS Patients who performed the TUG with a walker were on average 13.6 (95% confidence interval [CI], 11.2-16.1) seconds faster using a rollator compared with the walker (P<.001). Correspondingly, patients who performed the TUG with crutches were on average 3.5 (95% CI, 1.5-5.4) seconds faster using a rollator compared with elbow crutches (P=.001). In both patient groups, the between walking-aid scores were strongly correlated (r>.833, P<.001). CONCLUSIONS TUG scores are significantly related to the type of walking aid used during the test in patients with hip fracture who are allowed FWB when discharged from the hospital, but all patients were able to perform the TUG using the rollator as a standardized walking aid. Our findings indicate the importance of using a standardized walking aid when evaluating changes or comparing TUG scores in patients with hip fracture.

Early Progressive Strength Training to Enhance Recovery After Fast‐Track Total Knee Arthroplasty: A Randomized Controlled Trial

To compare 7 weeks of supervised physical rehabilitation with or without progressive strength training (PST) commenced early after fast‐track total knee arthroplasty (TKA) on functional performance.

Knee-extension strength, postural control and function are related to fracture type and thigh edema in patients with hip fracture.

BACKGROUND Post-surgery thigh edema, loss of knee-extension strength, and reduced physical performance are common following a hip fracture. It is not known if knee-extension strength and physical performance are related to the edema and fracture type. The aim of this study was to examine the influence of fracture type and post-surgery edema on physical performances in patients with hip fracture. METHODS Fifteen women and five men admitted from their own home to an acute orthopedic hip fracture unit were examined. Ten had cervical and ten had intertrochanteric fractures. Correlations between fracture type and thigh edema in the fractured limb (% non-fractured) to physical performances of basic mobility, postural control (sway), and isometric knee-extension strength were examined. All measures, except those of basic mobility, were conducted at the time of discharge, 8.5 days post-surgery. FINDINGS Patients with intertrochanteric fractures had greater edema (111% non-fractured limb) compared with cervical fractures (104% non-fractured, P<0.001). Thigh edema was significantly correlated to lower scores of basic mobility (r=-0.61, P=0.004), reduced postural control (r=0.67, P=0.001), and fractured limb knee-extension strength deficit ([% non-fractured], r=-0.77, P<0.001), explaining between 32% and 59% of the variance (r(2)) in performances. INTERPRETATION Our results indicate that fracture type and the corresponding thigh edema are important factors influencing physical performances after hip fracture. These findings have important implications for rehabilitation programs and for further research in patients with hip fracture.