Showing papers in "Pm&r in 2021"

Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC) patients.

Abstract: Large numbers of individuals who have been infected with SARS‐CoV‐2, the virus responsible for COVID‐19, continue to experience a constellation of symptoms long past the time that they have recovered from the acute stages of their illness. Often referred to as “long COVID,” these symptoms, which can include fatigue, shortness of breath, palpitations, cognitive dysfunction (“brain fog”), sleep disorders, fevers, gastrointestinal symptoms, anxiety, depression, and others, can persist for months and can range from mild to incapacitating. Although still being defined, these effects can be collectively referred to as postacute sequelae of SARS‐CoV‐2 infection (PASC).1 The magnitude of this problem is not yet known, but given the millions of individuals worldwide who have had, or will have, COVID‐19, the societal impacts are likely to be profound and long lasting.2, 3, 4, 5 It is widely acknowledged that systematic study is needed to develop an evidence‐based approach for caring for patients with PASC. At present, there is a dearth of rigorous scientific evidence regarding effective assessment and treatment of PASC that prevents the creation of evidence‐based clinical guidelines. However, the U.S. health system is currently seeing an increase in the number of patients presenting with PASC, and there is an urgent need for clinical guidance in treating these patients. The goal of this, and future statements, is to provide practical guidance to clinicians in the assessment and treatment of patients presenting with PASC. This Consensus Guidance Statement on fatigue is the first of a series focused on the most prominent PASC symptoms. PASC consensus guidance statement methods The American Academy of Physical Medicine and Rehabilitation (AAPM&R) Multi‐Disciplinary PASC Collaborative (“PASC Collaborative”) was created, in part, to develop expert recommendations and guidance from established PASC centers with extensive experience in managing patients with PASC. The PASC Collaborative is following an iterative, development approach to achieve consensus on assessment and treatment recommendations for a series of Consensus Guidance Statements focused on the most prominent PASC symptoms. These statements were developed by a diverse team of experts, with input from patient representatives with a history of PASC, and integrate current experience and expertise with available evidence to provide tools to clinicians treating patients. There is an intentional focus on health equity as disparities in care and outcomes are critically important to address. Beyond patient care, the hope is that a broadened understanding of current patient care practices will help identify areas of future research. A full description of the methodology is also published in this issue.6 We acknowledge that the definition of PASC is evolving, and there are various factors that contribute to diagnosis. The PASC Collaborative sought input from patient representatives with a history of PASC and patient‐led research initiatives to inform recommendations. For example, previous literature has suggested that PASC be defined as the continuation of symptoms beyond 3 or 4 weeks from the onset of acute infection.7 Other definitions of PASC include symptoms lasting longer than 3 months.8 Based on feedback of patient representatives that earlier evaluation, diagnosis, and management can improve access to beneficial interventions, for the purpose of this Consensus Guidance Statement, we recommend expanded assessment if symptoms are not improving 1 month after acute symptom onset. These Consensus Guidance Statements are intended to reflect current practice in patient assessment, testing, and treatments. They should not preclude clinical judgment and must be applied in the context of the specific patient, with adjustments for patient preferences, comorbidities, and other factors.

Disparities in health care for Black patients in physical medicine and rehabilitation in the United States: a narrative review

Abstract: Racial health disparities continue to disproportionately affect Black persons in the United States. Black individuals also have increased risk of worse outcomes associated with social determinants of health including socioeconomic factors such as income, education, and employment. This narrative review included studies originally spanning a period of approximately one decade (December 2009-December 2019) from online databases and with subsequent updates though June 2020. The findings to date suggest pervasive inequities across common conditions and injuries in physical medicine and rehabilitation for this group compared to other racial/ethnic groups. We found health disparities across several domains for Black persons with stroke, traumatic brain injury, spinal cord injury, hip/knee osteoarthritis, and fractures, as well as cardiovascular and pulmonary disease. Although more research is needed, some contributing factors include low access to rehabilitation care, fewer referrals, lower utilization rates, perceived bias, and more self-reliance, even after adjusting for hospital characteristics, age, disease severity, and relevant socioeconomic variables. Some studies found that Black individuals were less likely to receive care that was concordant with clinical guidelines per the reported literature. Our review highlights many gaps in the literature on racial disparities that are particularly notable in cardiac, pulmonary, and critical care rehabilitation. Clinicians, researchers, and policy makers should therefore consider race and ethnicity as important factors as we strive to optimize rehabilitation care for an increasingly diverse U.S. population.

Patient and Provider-Reported Satisfaction of Cancer Rehabilitation Telemedicine Visits During the COVID-19 Pandemic.

Abstract: Introduction The coronavirus disease 2019 (COVID-19) pandemic has accelerated the growth of telemedicine services across the United States. In this study, we examined cancer rehabilitation patient and physician satisfaction with telemedicine visits. We also sought to evaluate the types of provider services that are given during telemedicine visits. Objective To assess overall patient and provider satisfaction with telemedicine visits and explore whether satisfaction varied by contact method (phone or video) and encounter type (new problem, worsening problem, stable/improving problem). Design Prospective survey study. Setting Cancer rehabilitation program at an academic medical center. Participants Three cancer rehabilitation providers and 155 unique patients participated in the study. Interventions Not applicable. Main outcome measures Provider and patient satisfaction measured by customized surveys. Results One hundred eighty-four encounters with 169 unique patients were scheduled. Of these, 14 were new visits and 170 were follow-up visits. Eighteen encounters (9.8%) were either no shows or rescheduled, making for 166 encounters with 155 unique patients. Patient and provider responses comprised the following: 94.8% of patient responses reported "quite a bit" or "very much" for the telemedicine visit being a good experience; 63.1% of patient responses reported "quite a bit" or "very much" for interest in using telemedicine visits in the future; and 83.9% of provider responses reported "quite a bit" or "very much" for the patient's main problem being addressed by the visit. Providers were more likely to prefer an in-person visit for a new or worsening problem versus a stable/improving problem. The most common services provided were medication prescription/titration and education/counseling. The least common services provided were making of new diagnoses, ordering interventional procedures, and making referrals. Conclusion Telemedicine visits were well received by both patients and providers in a cancer rehabilitation medicine clinic setting. However, in the case of a new or worsening problem, satisfaction declined. These data support that telemedicine visits should be considered essential as part of comprehensive cancer rehabilitation care, especially during a public health crisis.

Treatment Recommendations for Phantom Limb Pain in People with Amputations: An Expert Consensus Delphi Study.

Abstract: Background Phantom limb pain (PLP) is common and often accompanied by serious suffering. Current systematic-review evidence suggests that recommended treatments are no more effective than placebo for reducing PLP. Given the difficulty in conducting a meta-analysis for nonpharmacological treatments and the weak evidence for pharmacological treatments for PLP, consensus on the first-line management of PLP needs to be reached using alternative methods. Objective To reach expert consensus and make recommendations on the effective management of PLP. Design A three-round Delphi design was used. Setting The study was conducted using e-mail and Google survey tool as the main methods of communication and providing feedback. Participants The study included 27 clinicians and researchers from various health disciplines who are experts in PLP management. Method Data were collected using three sequential rounds of anonymous online questionnaires where experts proposed and ranked the treatments for PLP. A consensus was reached on the treatments that were endorsed by 50% or more of the experts. Results Thirty-seven treatments were proposed for the management of PLP at the beginning of the study. Consensus was reached on seven treatments that were considered effective for managing PLP and on two treatments that were considered ineffective. Graded motor imagery, mirror therapy, amitriptyline, sensory discrimination training, and use of a functional prosthesis were endorsed by most experts because of the available backing scientific evidence and their reported efficacy in clinical practice. Cognitive behavioral therapy and virtual reality training were endorsed by most experts because of their reported efficacy in clinical practice despite indicating a dearth of scientific evidence to support their ranking. Citalopram and dorsal root ganglion pulsed radiofrequency were rejected owing to a lack of relevant scientific evidence. Conclusion The results of this study suggest that the nonpharmacological treatments endorsed in this study may have an important role in the management of PLP.

Outcomes of a COVID-19 recovery program for patients hospitalized with SARS-CoV-2 infection in New York City: A prospective cohort study.

Abstract: Background In the spring of 2020, New York City was an epicenter of coronavirus disease 2019 (COVID-19). The post-hospitalization needs of COVID-19 patients were not understood and no outpatient rehabilitation programs had been described. Objective To evaluate whether a virtual rehabilitation program would lead to improvements in strength and cardiopulmonary endurance when compared with no intervention in patients discharged home with persistent COVID-19 symptoms. Design Prospective cohort study. Setting Academic medical center. Patients Between April and July 2020, 106 patients discharged home with persistent COVID-19 symptoms were treated. Forty-four patients performed virtual physical therapy (VPT); 25 patients performed home physical therapy (HPT); 17 patients performed independent exercise program (IE); and 20 patients did not perform therapy. Interventions All patients were assessed by physiatry. VPT sessions were delivered via secure Health Insurance Portability and Accountability Act compliant telehealth platform 1-2 times/week. Patients were asked to follow up 2 weeks after initial evaluation. Main outcome measures Primary study outcome measures were the change in lower body strength, measured by the 30-second sit-to-stand test; and the change in cardiopulmonary endurance, measured by the 2-minute step test. Results At the time of follow-up, 65% of patients in the VPT group and 88% of patients in the HPT group met the clinically meaningful difference for improvement in sit-to-stand scores, compared with 50% and 17% of those in the IE group and no-exercise group (P = .056). The clinically meaningful difference for improvement in the step test was met by 74% of patients in the VPT group and 50% of patients in the HPT, IE, and no-exercise groups (P = .12). Conclusions Virtual outpatient rehabilitation for patients recovering from COVID-19 improved lower limb strength and cardiopulmonary endurance, and an HPT program improved lower limb strength. Virtual rehabilitation seems to be an efficacious method of treatment delivery for recovering COVID-19 patients.

Validating wearable sensors using self‐reported instability among patients with knee osteoarthritis

Abstract: BACKGROUND Self-perceived instability among patients with knee osteoarthritis (OA) is defined as giving way, buckling, or shifting of the knee during activities, especially walking. Although instability is a leading cause of mobility decline with knee OA, methods for quantifying the symptom, determining the mechanisms, and establishing effective interventions remain unclear. Recently, data outputs (ie, linear acceleration and its time-derivative, jerk) from wearable sensors are showing strong associations with self-perceived instability among patients with other knee pathologies and may offer insight into OA-related instability. OBJECTIVE To examine discriminant and convergent validity of using data outputs from wearable sensors to quantify self-reported instability among patients with knee OA. DESIGN Secondary analysis of a cross-sectional study. SETTING Primary recruitment from an institutional outpatient physical therapy clinic and collection completed in an institutional research laboratory. PATIENTS Thirty-nine total participants. The OA group included 26 participants with radiographic evidence of moderate to severe knee OA in the medial compartment; knee pain >3 out of 10, and a walking speed of ≥1.0 m/s. The control group included 13 participants with no history of knee OA. Participants with current or history of low back, hip, or foot/ankle injury; knee replacement; skeletal realignment surgery; or comorbidities that limit walking, pregnancy, and inability to walk without an assistive device were excluded. INTERVENTIONS N/A MAIN OUTCOME MEASURES: Data output from wearable sensors at the tibia. RESULTS Midstance acceleration (P = .01) and jerk (P = .04) were significantly greater for those with than without knee OA. Acceleration was significantly associated with self-reported instability (Spearman's rho = -0.63, P < .01). CONCLUSIONS Data from wearable sensors are a valid measurement for exploring the mechanisms and risks of instability among patients with knee OA.

Evaluation of a Game Based Tele Rehabilitation Platform for In-Home Therapy of Hand-Arm Function Post Stroke: Feasibility Study.

Abstract: Background There is a need for innovation to improve compliance and accessibility of rehabilitation programs for individuals with acquired brain injuries. A computer game-assisted tele-rehabilitation platform (GTP) has been developed to address this need. With the novel application of a miniature inertial computer mouse and taking advantage of the wide variety of computer games, the GTP can provide engaging exercises for rehabilitation of upper extremity motor skills. Objective To determine the feasibility and acceptability of the game-assisted home exercise program for upper extremity rehabilitation for people with stroke. The treatment effect was also measured after 16 weeks of intervention. Design A feasibility study. Setting College of Rehabilitation Science, University of Manitoba. Participants Ten stroke clients. Intervention Participants received three to four initial clinically supervised therapy sessions for training with the game assisted therapy program. Once trained, participants continued the program at the home for 16 weeks, four times per week. Main outcome measures Feasibility was evaluated based on retention rate and compliance. Semistructured interviews after the completion of the program were done to assess acceptability of the program. Quantitative analysis included (1) the Wolf Motor Function Test A and B and (2) a computerized performance-based assessment of specific object manipulation tasks that required a combination of finger, wrist, elbow and shoulder motion. Results Findings demonstrated the feasibility and acceptability of the home tele-rehab program. Eight of the 10 participants fully complied with the 16-week exercise program. Two participants had difficulty with computer operations and did not complete the program. For the eight participants who completed the program, there was a substantial improvement from pre- to postintervention. Conclusion Although some difficulties with the technology were reported, the findings demonstrate feasible trial procedures, acceptable game-assisted task-oriented home training with a high compliance rate and positive outcomes. These findings and the theoretical evidence direct the next phase of a full-scale randomized controlled trial.

Exergaming for Quality of Life in Persons Living with Chronic Diseases: A Systematic Review and Meta-analysis.

Abstract: OBJECTIVE To evaluate the evidence of effectiveness of exergame-based rehabilitative interventions on health-related quality of life (HRQoL) in persons with chronic diseases. TYPE: Systematic review and meta-analysis. LITERATURE SURVEY Randomized and nonrandomized controlled trials of exergame rehabilitation interventions in populations with chronic diseases reporting HRQoL outcomes were identified by searching PubMed, Scopus, Physiotherapy Evidence Database (PEDro), Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar, using keywords and MeSH terms for papers published between January 2005 and March 2019. METHODOLOGY Risk of bias was assessed by using the PEDro scale. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to score the quality of evidence. Pooled effects were reported as standardized mean differences (SMDs) or weighted mean difference (MDs) and 95% confidence intervals (CIs), using a random-effects model. Heterogeneity was weighted by inconsistency I2 tests. SYNTHESIS Thirty-four trials were identified (1594 participants). Overall, the evidence was low quality. Exergames significantly improved HRQoL in populations with chronic diseases, with a small effect size (32 studies; 1544 participants; SMD 0.24; 95% CI 0.1 to 0.4; I2 = 27%) and specifically in people with neurological disorders (20 studies, 956 participants, SMD 0.22; 95% CI 0.2 to 0.4; I2 = 49%), rheumatologic diseases (four studies, 210 participants, SMD 0.39; 95% CI 0.1 to 0.7; I2 = 4%), and cardiorespiratory and chronic metabolic conditions (five studies, 309 participants, SMD 0.23; 95% CI 0.0 to 0.5; I2 = 0%). Exergaming interventions in health care settings demonstrated similarly small but positive effects (22 studies, 905 participants, SMD 0.30; 95% CI 0.1 to 0.5; I2 = 41%), whereas those carried out in home-based contexts did not. CONCLUSIONS Exergame-based rehabilitative interventions performed in health care settings led to small but statistically significant improvements in HRQoL in persons with chronic diseases.

How Physician Compensation and Education Debt Affects Financial Stress and Burnout: A Survey Study of Women in Physical Medicine and Rehabilitation

Abstract: Objective To investigate the contribution of financial stress to physician burnout and satisfaction among women physiatrists. Relationships among education debt and compensation with demographic, sociologic, and workplace factors were also assessed. Design This was a cross-sectional survey study of women physicians in the field of physical medicine and rehabilitation (PM&R) in the United States. The survey consisted of 51 questions covering demographic information (current and maximum education debt, race/ethnicity, years out of training, practice type and setting, hours worked, family structure, and domestic duties), work/life satisfaction, and burnout. The association between current/maximum debt and demographic characteristics, work/life satisfaction, and physician burnout were examined. Results Of the 245 U.S. women attending physiatrists who met inclusion criteria, 222 (90.6%) reported ever having education debt (median category $101 000-150 000) and 162 (66.1%) reported current debt (median category ≤ $50 000). Of these participants, 218 (90.5%) agreed that they would have fewer burnout symptoms if they were able to do more work that is core to their professional mission and 226 (92.2%) agreed that feeling undervalued at work is linked to physiatrists' burnout symptoms. Greater debt was seen in those who identified as Black/African American, were fewer years out of training, practiced general physiatry, and had both inpatient and outpatient responsibilities. Greater current debt had a significant relationship with measurements of work/life dissatisfaction. Burnout was associated with higher debt, lower compensation, more hours worked per week, and fewer hours of exercise performed per week. Conclusions This study examined women physiatrists' perceptions of financial stress and found that greater education debt was associated with personal life dissatisfaction, career regret, and burnout. Further research is needed to address related causes and solutions.

Menstrual Irregularity, Hormonal Contraceptive Use, and Bone Stress Injuries in Collegiate Female Athletes in the United States.

Abstract: BACKGROUND Menstrual irregularity (MI) is common in female athletes and is a component of the Female Athlete Triad (Triad). Many athletes with the Triad are started on hormonal contraceptives (HC) for MI, but this interferes with the ability to monitor menstrual cycle regularity and can mask other causes of MI. There are limited studies investigating the relationship between MI, HC use, and injury in female collegiate athletes. OBJECTIVE To examine the prevalence of and relationship between HC use, MI, and bone stress injuries in female collegiate athletes in the United States. DESIGN Cross-sectional study. SETTING Online survey. PARTICIPANTS 1020 U.S. female collegiate athletes (age ≥ 18 years). METHODS OR INTERVENTIONS Assessment of risk factors for menstrual irregularity and bone stress injuries was conducted via a one-time survey. MAIN OUTCOME MEASURES HC use, MI, history of stress fractures. RESULTS Current HC use prevalence was 65% (95% confidence interval [CI], 61.9%, 67.8%). Of all athletes, 47% reported past MI. Of the athletes who were not currently using HCs, 32% had current MI. Compared with athletes without past MI, more athletes with past MI reported current HC use (73% vs. 57%) and indicated menstrual cycle consistency as the primary reason for use (24% vs. 4%) (P < .001). Additionally, 25% of athletes reported a history of stress fractures, which was associated with lean/aesthetic sports participation (odds ratio [95% CI]: 1.9 [1.4, 2.5]; P < .001) and less oral contraceptive pill (OCP) use (0.7 [0.5, 1.0]; P = .043). Compared with OCPs, injectable HCs were associated with greater odds of a history of stress fractures (4.5[1.6, 12.3]; P = .004). CONCLUSIONS HC use was prevalent among this cohort of female collegiate athletes, and almost half of the athletes reported past MI. A goal of menstrual cycle regularity was cited by 24% of athletes as a primary reason to use HCs, which shows that more athlete education is needed to avoid masking MI and the Triad with HCs. Further studies elucidating the relationship between HC use, MI, and sports-related injury are warranted.

Randomized, Placebo-Controlled Analysis of the Knee Synovial Environment Following Platelet-Rich Plasma Treatment for Knee Osteoarthritis.

Abstract: Background Platelet-rich-plasma (PRP) is used to treat knee osteoarthritis; however, mechanistic evidence of PRP effectiveness for pain relief is limited. Objective To assess molecular biomarkers and mesenchymal stem cells (MSCs) in synovial fluid during PRP treatment of the osteoarthritic knee joint. Design Single blinded, randomized, placebo controlled pilot study. Setting Veterans Affairs Medical Center. Participants Seventeen participants with mild to moderate knee osteoarthritis were randomized in a 2:1 placebo-controlled ratio, receiving PRP or saline (placebo) intra-articular injection into the knee joint. Methods Knee synovial fluid was analyzed before the respective injections and again 10 days following injection. Participants were followed up to 12 months completing visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaires at intervals over that period. Main outcome measures The effects of PRP on synovial protein and MSC gene expression levels were measured by multiplex enzyme-linked immunosorbent assay and quantitative polymerase chain reaction. Results Novel biomarkers including levels of interleukin (IL)-5, IL-6, IL-10, and tumor necrosis factor-α were measured in synovial fluid 10 days after PRP treatment. Altered gene expression profiles in MSCs from patients treated with PRP were observed for matrix metalloproteinases and inflammatory markers (IL-6, IL-8, CCL2, TNF-α). A2M protease was significantly increased following PRP treatment (P = .005). WOMAC scores declined for up to 3 months from baseline levels and remained low at 6 and 12 months in the PRP group. In contrast, WOMAC scores for patients receiving the saline injection were relatively unchanged for up to 12 months. Conclusions We report significant changes for the biomarker A2M (P = .005) as well as differences in expression of cellular markers and postulate that PRP modulates the local knee synovial environment by altering the inflammatory milieu, matrix degradation, and angiogenic growth factors. The PRP treatment group had less pain and stiffness and improved function scores.

An Updated Review of the Epidemiology of Swimming Injuries.

Abstract: Objective To carry out a systematic review to update the scientific evidence on the incidence and prevalence of injuries in the swimming discipline, as well as the location, type, and mechanism of the injuries, and to assess whether studies are meeting methodological recommendations for data collection and injury surveillance. TYPE: Analytical-Systematic review. Literature survey The databases of PubMed and Sportdiscus were used to search for studies that describe the epidemiology of injuries in adult swimmers between 2010 and March 2020. Methodology Of the 864 articles identified, 14 studies were finally included in this review. The methodological quality of the studies was analyzed with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scale and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Synthesis The results showed a high prevalence of shoulder, knee, and lower back injuries among swimmers due to overuse. These injuries were mainly short-term tendon muscles; there were reported data differences between genders. Conclusions Despite the publication of an injury surveillance single and multisport events document and a consensus on data collection and injury surveillance in swimming, there are huge methodological limitations that do not allow firm conclusions. As such, more epidemiological studies following guidelines for data collection and injury surveillance are needed to establish differences by gender, age group, and swimming stroke.

Spasticity Management in Persons with Disorders of Consciousness

Abstract: INTRODUCTION Spasticity is one of the most frequent neurological impairments affecting persons with disorders of consciousness (DoC). If left untreated, it can mask signs of consciousness by inhibiting one's ability to interact with the environment. The lack of information about spasticity specific to patients with DoC may result in insufficient or even inappropriate treatment. OBJECTIVE To report spasticity characteristics and management in a large dedicated DoC rehabilitation program. DESIGN Retrospective chart review. SETTING An inpatient rehabilitation hospital. PARTICIPANTS Patients admitted to the DoC rehabilitation program from 1 January 2014 to 31 October 2018. MAIN OUTCOME MEASUREMENTS Spasticity characteristics; impact of interventions on spasticity as well as other clinical measures. RESULTS A total of 146 patients were included, of whom 95.2% were affected by spasticity; 52.7% had spasticity affecting all four limbs. The most commonly affected muscle groups were shoulder internal rotators (72.6%) in the upper extremity and ankle plantar flexors (59.8%) in the lower extremity. The more commonly affected muscle groups were also more spastic (R = 0.993 and 0.989 in the upper and lower extremity, respectively; P < .01). Atypical posture patterns were also commonly observed, making positioning difficult. Chemoneurolytic injections (botulinum toxin and/or phenol) were performed in over 69.9% patients, and 26.7% had intrathecal baclofen (ITB) pump placement. All patients received individualized physical modalities and therapies. With focal managements, systemic spasmolytic medications, including enteral baclofen, were reduced by at least 50.0%, which appeared to be associated with improvements in the level of consciousness. CONCLUSIONS Almost all DoC patients were affected by spasticity, often to a moderate or severe degree. Extensive use of focal spasticity interventions allowed for weaning of systemic spasmolytic medications, which seemed to result in improvements in the level of consciousness.

Ultrasound-guided percutaneous needle tenotomy (PNT) alone versus PNT plus platelet-rich plasma injection for the treatment of chronic tendinosis: A randomized controlled trial.

Abstract: Background Tendinosis is a chronic degenerative condition. Current research suggests both percutaneous needle tenotomy (PNT) and leukocyte-rich platelet-rich plasma (LR-PRP) may be effective treatments for chronic tendinosis, but no studies have assessed the effectiveness of PNT alone versus PNT with intratendinous LR-PRP for multiple tendon types in a single study. Objective To assess the efficacy of PNT versus PNT + LR-PRP to treat chronic tendinosis. Study design Double-blind, randomized, controlled comparative treatment study. Setting Primary academic institution. Participants A convenience sample of 40 participants who had chronic tendinosis (rotator cuff, wrist extensor, wrist flexor, hip abductor, proximal hamstring, patellar, or Achilles) confirmed via ultrasound, failed conservative treatment, and did not have tendon tears, known coagulopathy, or systemic illnesses. Interventions Participants were randomly assigned to PNT (n = 19) or PNT + LR-PRP (n = 21). Participants and outcomes assessors were blinded to treatment assignments. PNT was performed with 20-30 passes of a 22-gauge needle under ultrasound guidance, with 1% lidocaine given outside the tendon. LR-PRP was processed from whole blood (30-60 mL) and injected into the affected tendon using the same PNT technique. Main outcome measures Primary outcome was current numerical rating scale pain at 6 weeks. Secondary outcomes were average pain, function, general well-being, and sleep quality at 6, 52, and 104 weeks. Results Baseline characteristics were similar between groups. Overall, there were no significant differences between groups over time for any of the outcomes (P > .05). Between-group analyses showed significantly lower current and average pain after PNT compared to PNT + LR-PRP at 6 weeks (estimated-mean [SE]: 3.1[0.4] vs. 4.6[0.6], P = .04; 3.4[0.4] vs. 4.9[0.5], P = .03) only. Adverse event rates were low (PNT-3.9%; PNT + LR-PRP-5.0%) and related primarily to postprocedural pain and inflammation. Conclusions Although pain scores were lower after PNT compared to PNT + LR-PRP at 6 weeks, there were no between-group differences in outcomes at 52 or 104 weeks.

Center-Based Group and Home-Based Individual Exercise Programs Have Similar Impacts on Gait and Balance in People With Multiple Sclerosis: A Randomized Trial.

Abstract: Background Group and home-based exercises to improve function in people with multiple sclerosis (MS) are common but have little underpinning evidence. Objective To determine the comparative effectiveness of a center-based group versus home-based individual 8-week exercise program to improve gait and balance in people with MS. Design Prospective, randomized controlled trial. Setting Community center-based and home-based exercise program. Participants Fifty people with MS were randomized and completed allocated intervention (n = 26 center, n = 24 home), 47 completed post-assessment and 44 follow-up assessment. Methods The center- and home-based groups completed an 8-week progressive functional and balance training exercise program. The center-based groups of four to six were supervised by a physiotherapist. The home-based group was provided with telephone support. Main Outcome Measurements The primary outcome was gait speed (10-meter walk test). Secondary outcomes were gait endurance (6-minute walk test) and balance (Berg Balance Scale). Outcome assessments were conducted at baseline, immediately postintervention and at 8-week follow-up. Results There was no statistically significant difference between groups in gait speed post training, with a mean difference of 0.01 m/s, 95% CI −0.36 to 0.37. There were no group effects, time effects, or interactions for gait speed, endurance, or balance. In both groups, gait speed improved to a level that met minimal clinically important differences. Conclusions Gait speed, endurance, and balance did not statistically improve in either group; however, gait speed changes met minimally important differences.

Falls After Dysvascular Transtibial Amputation: A Secondary Analysis of Falling Characteristics and Reduced Physical Performance

Abstract: Introduction Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited. Objective To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories. Design Secondary data analysis from two randomized controlled trials. Setting Outpatient setting. Participants People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis. Intervention None. Outcome Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated. Results Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities. Conclusion Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring.

Prevalence of depression and anxiety disorders following mild traumatic brain injury.

Abstract: BACKGROUND Previous studies have identified an association between traumatic brain injuries and the development of psychiatric disorders in general. However, these studies were subject to limitations that demonstrate the need for a study of a large, clearly defined mild traumatic brain injury (mTBI) population within an integrated healthcare system. OBJECTIVE To determine the prevalence and relative risk of postinjury affective disorders over 4 years following mTBI. DESIGN Cohort study of mTBI cases and matched controls, over a 4-year period. SETTING An integrated healthcare delivery system in California. PATIENTS A total of 9428 adult health plan members diagnosed with mTBI from 2000-2007 and enrolled in the year before injury, during which no TBI was ascertained. Control participants included 18,856 individuals selected based on the following criteria: Two unexposed health plan members per each mTBI-exposed patient were randomly selected and individually matched for age, gender, race/ethnicity, and medical comorbidities. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES A diagnosis of affective disorder (depressive, anxiety, and adjustment disorders) in the 4 years after mTBI or the reference date, determined according to the International Classification of Diseases, Ninth Revision, Clinical Modification as well as the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. RESULTS Affective disorders were most prominent during the first 12 months with 23% following mTBI and 14% in the control group. Four-year aggregate adjusted odds ratios for having an affective disorder following mTBI were 1.2 (95% CI: 1.1, 1.2; p < .001) and 1.5 (95% CI: 1.5, 1.6; p < .001) for patients with and without prior affective disorders, respectively. CONCLUSION mTBI was associated with a significantly increased risk of having subsequent affective disorders. Screening for and addressing affective disorders at earlier stages following the injury is an important step to avoid persisting conditions that may pose a barrier to full recovery.

Ambulatory Rehabilitation of Patients Hospitalized with SARS CoV-2 Infections: Early Pandemic Experience in New York City and Boston

Abstract: The current COVID-19 pandemic has rapidly affected a large number of people across the world In the US, New York and Massachusetts were two states significantly affected early on in the pandemic Many individuals infected with COVID-19 require hospitalization and following discharge, a subset develop longer-term rehabilitation needs To address the ongoing rehabilitation needs in this growing population, multidisciplinary teams at academic centers in NYC and Boston designed and implemented post-COVID outpatient clinical recovery programs In this report, we describe the local development of the outpatient programs and characteristics of the initial patient cohort referred for evaluation This article is protected by copyright All rights reserved

Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation.

Abstract: Background Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability. Objective To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later. Design Cross-sectional study. Setting General community. Participants Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Interventions Not applicable. Main outcome measures Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates. Results The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P Conclusions Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.

Functional outcomes and post-discharge care sought by patients with COVID-19 compared to matched controls after completing inpatient acute rehabilitation.

Abstract: INTRODUCTION: A subset of patients with coronavirus disease 19 (COVID-19) can develop severe illness, resulting in significant functional and cognitive deficits that require acute inpatient rehabilitation. Guidelines following discharge from acute inpatient rehabilitation have not yet been established. This study seeks to establish outcomes of rehabilitation patients with COVID-19 and characterize their need for long-term care. OBJECTIVE: To determine the functional outcomes and utilization of follow-up medical care for patients with COVID-19 90 days following discharge from acute inpatient rehabilitation, as compared to rehabilitation impairment and age-matched controls. DESIGN: Prospective, single-center cohort study. SETTING: Inpatient rehabilitation facility (IRF). PATIENTS: Sixty-four patients recovering from COVID-19 and 64 age and impairment group category controls were identified to answer survey questions following discharge from inpatient rehabilitation. A total of 36 patients participated in the study (18 patients with COVID-19 and 18 controls). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Functional outcomes at discharge (GG Self-Care and Mobility Activities items of the IRF-PAI Version 3.0), hospital readmissions, and follow-up care sought by patients. RESULTS: The COVID-19 patient group had similar improvements in functional outcomes as compared to controls. Patients with COVID-19 required fewer 0-90 day readmissions than their matched controls (22.2% vs 61.1%, P < .05), but there were no differences in 0-90 day urgent care/emergency department visits, clinic visits and use of outpatient therapies. CONCLUSIONS: Patients with functional deficits as a result of COVID-19 who require multiple therapy disciplines should be considered for acute inpatient rehabilitation as this study demonstrates their ability to participate in and benefit from IRF level care.

Knee Flexion Contractures Are Associated with Worse Pain, Stiffness, and Function in Patients with Knee Osteoarthritis: Data from the Osteoarthritis Initiative

Abstract: BACKGROUND Patients with or at risk of developing knee osteoarthritis (OA) can acquire a knee flexion contracture (FC). The prevalence, severity, and association of knee FC on OA outcomes such as pain, stiffness, and function are not well described and clinical scales may omit measuring joint range of motion. OBJECTIVE (1) To determine if the presence and severity of a knee FC was associated with worse joint pain, stiffness and/or function and (2) to determine if this association was present in participants with or at risk of knee OA. METHODS Following a detailed standardized protocol, maximum knee extension was obtained from the baseline physical examination data using a goniometer with the fulcrum over the knee joint line, the upper arm directed towards the greater trochanter and the lower arm directed towards the lateral malleolus. DESIGN Cross-sectional, using the Osteoarthritis Initiative database. SETTING AND PARTICIPANTS Baseline cross-sectional data collected from a prospective outpatient cohort study, recruiting from four academic health care centers in the United States. Three subcohorts were included: those at-risk of OA (n = 5995 knees), those with radiographic OA (n = 2610 knees), and controls (n = 62 knees). MAIN OUTCOME MEASURES We categorized knee FCs as none, mild, moderate, or severe. Pain scales included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and numeric pain rating scale; stiffness, the WOMAC stiffness subscale; and function, the WOMAC function subscale and 400-m walk time. RESULTS Participants with FC reported overall worse pain, stiffness, and function compared to those without FC in a severity-dependent manner. OA participants' scores showed between 1.8- and 11.0-fold mean relative worsening versus at-risk participants (P < .05 for all). Knee FC was independently associated in a severity-dependent manner with all outcomes (P < .01). CONCLUSIONS Knee FCs were associated with worse pain, stiffness, and function in a severity-dependent manner in a population with or at risk of knee OA. There was an interaction between OA subcohort and FC severity (P-for-interaction <.01 for all WOMAC outcomes). Evaluation of the longitudinal effects of contracture on OA and at-risk patient outcomes is necessary.

Providing Rehabilitation to Patients Recovering from COVID-19: A Scoping Review.

Abstract: Objective To synthesize the nature and extent of research on rehabilitation care provision to COVID-19 (COVID) patients. Specifically, we aimed to: (1) Describe the impact of COVID on patients and associated rehabilitation needs; (2) Outline the adaptations and preparations required to enable the provision of COVID rehabilitation; (3) Describe the types of rehabilitation services and treatments provided to COVID patients; and (4) Identify barriers and facilitators to delivering COVID rehabilitation. Literature survey We searched Medline, PsychINFO, Embase, and CINAHL on June 26th , 2020 using key words such as "rehabilitation", "physical medicine", "allied health professionals" and variations of "COVID". The search was updated on October 13th , 2020. We included articles published in English and that focused on some aspect of COVID rehabilitation for adults. We excluded articles focused on pediatric populations and those not focused (or minimally focused) on rehabilitation for COVID patients. Methodology Data were charted based on article type (i.e. primary data, secondary data, guidelines). Key information extracted included: (i) COVID sequelae; (ii) rehabilitation adaptations; (iii) structure, function and content of rehabilitation services/programs; (iv) facilitators and/or barriers to providing COVID rehabilitation; and (v) recommendations for COVID rehabilitation programming. Data were synthesized narratively. Synthesis In total, 129 articles were included in the review that reported primary data (n=33), secondary data (n=82), and clinical practice/patient self-management guidelines (n=13). Evidence begins to suggest that rehabilitation is necessary and valuable for addressing COVID-related declines in health, function, and well-being. Most articles recommended that an individualized rehabilitation program be provided across the continuum of care by an interdisciplinary team of professionals and that the nature and extent of rehabilitation be informed by the care setting and COVID severity. Most issues that challenged COVID rehabilitation delivery were directly addressed by the facilitators and adaptations identified. Conclusions Future recommendations include a greater emphasis on the psychosocial aspects of COVID rehabilitation, inclusion of families in rehabilitation planning, and the use of qualitative approaches to complement clinical data. This article is protected by copyright. All rights reserved.

Effects of Intravesical Lactobacillus Rhamnosus GG on Urinary Symptom Burden in People with Neurogenic Lower Urinary Tract Dysfunction

Abstract: OBJECTIVE: Test the effectiveness of intravesical Lactobacillus rhamnosus GG (LGG) to reduce the burden of urinary symptoms for individuals with spinal cord injury and disease (SCI/D) with neurogenic lower urinary tract dysfunction (NLUTD) who manage their bladders with intermittent catheterization (IC). DESIGN: A 3-phase study (6 months each in baseline; intervention; and washout).Participants self-managed following the Self-Management Protocol using Probiotics (SMP-Pro), completing the online Urinary Symptom Questionnaire for Neurogenic Bladder-IC version (USQNB-IC) weekly. SETTING: Nationwide (US). PARTICIPANTS: 96 adults and 7 children with SCI/D. INTERVENTIONS: In response to one or both of the SMP-Pro trigger urinary symptoms, "cloudier" or "foul smelling" urine, subjects self-administered using a clean urinary catheter an LGG+Normal Saline instillate once or twice in a 30-hour period. MAIN OUTCOME MEASURES: Change in USQNB-IC burden was adjusted individually according to the prior phase for four symptom types. Adjusted changes in burden between the intervention and washout phases were analyzed using one-sample t-tests. Holm correction was applied for the four types of symptoms: A, clinically actionable; B1, bladder function; B2, urine quality; and C, other. RESULTS: During the intervention phase, participants met SMP-Pro instillation criteria3.83 times on average (range 1 - 20). An average of 5.6 doses of LGG were instilled.For those who instilled at least once, burdens of type A and B2 symptoms were significantly improved at washout (both adjusted p<0.05). CONCLUSIONS: Self-instilled LGGseemed to improve "clinically actionable" (A) and "urine quality" (B2) symptom burden. No changes were observed for those who did not instill. This first-in-human clinical trial supports ongoing research of intravesicalLGG, and the SMP-Pro for urinary symptoms. This article is protected by copyright. All rights reserved.

Accuracy of Wearable Devices for Measuring Heart Rate During Conventional and Nordic Walking

Abstract: INTRODUCTION Nordic walking is being used increasingly as an exercise method in many clinical disorders. To apply Nordic walking in cases of fragile or deconditioned patients, monitoring of exercise intensity such as heart rate (HR) measurement is required. The accuracy of wearable HR monitors during Nordic walking has not yet been reported. OBJECTIVE To compare the accuracy of an electrocardiography (ECG)-based HR monitor (Polar H7) and a photoplethysmography (PPG)-based HR monitor (Fitbit Charge 2) during conventional and Nordic walking. DESIGN Accuracy was assessed by comparing the HR values obtained using the wearable devices with those obtained via 12-lead ECG as a reference. SETTING Laboratory setting. PARTICIPANTS Fifteen male volunteers age 23.7 ± 3.0 years. INTERVENTIONS None. MAIN OUTCOMES MEASURES HR was simultaneously recorded via 12-lead ECG, the Polar H7, and the Fitbit Charge 2 during conventional and Nordic walking. Agreement between the devices was assessed by calculating Lin's concordance correlation coefficient (rc ), the mean absolute difference, and the limit of agreement (LoA) from Bland-Altman plots. RESULTS Regarding HR values including Nordic and conventional walking, there was a better agreement between the Polar H7 and the reference (rc = 0.96) than between the Fitbit Charge 2 and the reference (rc = 0.84). For the Polar H7, the mean absolute difference from the reference did not differ significantly between the walking methods; for the Fitbit Charge 2, the mean absolute difference was significantly higher during Nordic walking than during conventional walking (6.60 vs. 3.68 bpm, P < .001). The Fitbit Charge 2 had a wider LoA than did the Polar H7 during both walking methods. CONCLUSION ECG-based wearable devices may be better than PPG-based devices for monitoring HR during Nordic walking. However, both types of devices may adequately monitor HR during conventional walking.

Prevalence and factors associated with bone stress injury in middle school runners.

Abstract: BACKGROUND Bone stress injury (BSI) in youth runners is clinically important during times of skeletal growth and is not well studied. OBJECTIVE To evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners. DESIGN Retrospective cross-sectional study. SETTING Online survey distributed to middle school runners. METHODS Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics. MAIN OUTCOME MEASUREMENTS Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations. PARTICIPANTS 2107 runners (n = 1250 boys, n = 857 girls), age 13.2 ± 0.9 years. RESULTS One hundred five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, p = .004). The most common location was the tibia (n = 51). Most trabecular-rich BSIs (n = 16, 94% total) were sustained by girls (pelvis: n = 6; femoral neck: n = 6; sacrum: n = 4). In girls, consuming <3 daily meals (odds ratio [OR] = 18.5, 95% confidence interval [CI] = 7.3, 47.4), eating disorder (9.8, 95% CI = 2.0, 47.0), family history of osteoporosis (OR = 6.9, 95% CI = 2.6, 18.0), and age (OR = 1.6, 95% CI = 1.0, 2.6) were associated with BSI. In boys, family history of osteoporosis (OR = 3.2, 95% CI = 1.2, 8.4), prior non-BSI fracture (OR = 3.2, 95% CI = 1.6, 6.7), and running mileage (OR = 1.1, 95% CI = 1.0, 1.1) were associated with BSI. Participating in soccer or basketball ≥2 years was associated with lower odds of BSI for both sexes. CONCLUSION Whereas family history of osteoporosis and prior fracture (non-BSI) were most strongly related to BSI in the youth runners, behaviors contributing to an energy deficit, such as eating disorder and consuming <3 meals daily, also emerged as independent factors associated with BSI. Although cross-sectional design limits determining causality, our findings suggest promoting optimal skeletal health through nutrition and participation in other sports including soccer and basketball may address factors associated with BSI in this population.

Prevalence/Incidence of Low Back Pain and Associated Risk Factors Among Nursing and Medical Students: A Systematic Review and Meta-Analysis.

Abstract: OBJECTIVE To summarize evidence regarding the prevalence and incidence of low back pain and associated risk factors in nursing and medical students. TYPE: Systematic review and meta-analysis. LITERATURE SURVEY The protocol was registered with PROSPERO (CRD42015029729). Its reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seven databases were searched until August 2020 to identify relevant studies. METHODOLOGY Two independent reviewers screened, extracted, and evaluated the risk of bias of the selected studies. Meta-analyses were used to estimate 12-month prevalence/incidence rates of low back pain and associated risk factors in these students. Levels of evidence for risk factors were determined by the updated Guidelines for Systematic Reviews in the Cochrane Collaboration Back Review Group. SYNTHESIS Sixteen studies involving 7072 students were included. The pooled 12-month prevalence rates of low back pain for nursing and medical students were 44% (95% confidence interval [95% CI]: 27%-61%) and 53% (95% CI: 44%-62%), respectively. The 12-month incidence of low back pain in nursing students ranged from 29% to 67%. No incidence rate was reported in medical students. Strong/moderate-quality evidence supported that final year of study (pooled odds ratio [OR] from five studies, 1.96, 95% CI: 1.13-3.40), anxiety (OR ranging from 3.12 to 4.61), or high mental pressure or psychological distress (OR ranging from 1.37 to 4.52) was associated with a higher 12-month low back pain prevalence in both student groups. Moderate-quality evidence suggested that prior history of low back pain (pooled OR from two studies: 3.46, 95% CI: 1.88-6.36) was associated with a higher 12-month low back pain incidence in nursing students. Similarly, moderate-quality evidence suggested that female medical students (pooled OR from two studies: 1.77, 95% CI: 1.09-2.86) demonstrated a higher 12-month low back pain prevalence than male counterparts. CONCLUSIONS Although it is impossible to alter nonmodifiable risk factors for low back pain, universities may develop and implement proper strategies to mitigate modifiable risk factors in these students.

Systematic Review and Meta-Analysis of Nonoperative Platelet-Rich Plasma Shoulder Injections for Rotator Cuff Pathology.

Abstract: BACKGROUND Platelet-rich plasma (PRP) injections have been introduced to augment the recovery of patients with shoulder pathology. Although multiple studies have been published, no large-scale trials or meta-analyses have assessed the efficacy of nonoperative shoulder PRP injection. OBJECTIVE To assess the efficacy of nonoperative PRP shoulder injection in rotator cuff pathology for pain as measured by the visual analog scale (VAS) and range of motion (ROM). DESIGN Two authors independently screened the Medline and Cochrane databases to include prospective studies that reported VAS and ROM outcomes for nonoperative shoulder PRP injections for rotator cuff pathology. Study quality was assessed using the revised Cochrane Collaboration risk-of-bias tool and modified Downs and Black checklist. Subsequent meta-analysis was performed to determine the effect of nonoperative PRP injections on pain and ROM 3 to 12 months after intervention. RESULTS Six studies met systematic review criteria. The included studies used different PRP formulations (concentration, leukocyte count), injection protocols (approach, injection number), and varied study designs. Three studies concluded that PRP provided no significant benefit for pain and ROM when compared to physical therapy. Within-group meta-analysis of six fairly heterogeneous studies (I2 77.8%) demonstrated a statistically significant (P < .001) improvement in pain 3 to 12 months after PRP injection. Within-group meta-analysis for four studies for shoulder flexion and abduction was found to be too heterogeneous to derive meaningful results. CONCLUSION There is a limited quantity of high-quality studies that assess the efficacy of nonoperative PRP shoulder injection for pain and ROM. Systematic review of PRP injections did not demonstrate an improvement in pain or ROM compared to physical therapy. Although within-group meta-analysis of nonoperative PRP statistically showed that nonoperative PRP improved pain, the lack of adequate negative controls precludes the ability to conclude whether improvements were due to natural recovery or nonoperative PRP.

A Retrospective Analysis of Nonoperative Treatment Techniques for Idiopathic Toe Walking in Children: Outcomes and Predictors of Success.

Abstract: Background The lack of consensus regarding optimal nonoperative management of idiopathic toe walking (ITW) results in wide variation in treatment across providers and institutions. Untreated toe walking can cause persistence of abnormal gait and symptomatic foot deformity in adulthood. Objective To examine the outcomes of multiple commonly used nonoperative treatment techniques in a large cohort of children with ITW to better inform management of this condition. Design Retrospective cohort study. Setting Single tertiary care children's hospital from 2008 to 2015. Patients Two hundred four children with ITW, aged 4 to 7 years at time of diagnosis, nonoperatively managed in orthopedic surgery, rehabilitation medicine, neurodevelopmental medicine, neurology, or physical therapy clinics. Interventions Nonoperative techniques included observation, home stretching program, physical therapy program, use of ankle-foot orthoses (AFOs), and serial casting. Main outcome measures Greater than or equal to 10° of ankle dorsiflexion with the knee extended or walking on toes less than 25% of the time at last visit. Failure of treatment was defined as not achieving resolution criteria or requiring surgical intervention following failed nonoperative management. Results Only 121 children (59.3%) attended at least one follow-up visit. Of those, 55 (45.5%) had a successful outcome. Increasing severity of ITW was associated with increased rate of follow-up (P = .03) and lower rates of successful treatment (P = .03). The use of AFOs was the only treatment modality associated with a successful outcome (unadjusted/adjusted odds ratio 3.97; [95% confidence interval, 1.80-8.74] and 4.81 [95% confidence interval, 1.91-12.1], respectively; P = .001). Conclusions Loss to follow-up is common in children with ITW. Of those children who returned to clinic, less than half had a successful outcome. The only treatment technique statistically associated with short-term resolution of toe walking was the use of AFOs.