Estimating Minimal Clinically Important Differences for Knee Range of Motion after Stroke

Validation of inertial measurement units based on waveform similarity assessment against a photogrammetry system for gait kinematic analysis

When assessing gait analysis outcomes for clinical use, it is indispensable to use an accurate system ensuring a minimal measurement error. Inertial Measurement Units (IMUs) are a versatile motion capture system to evaluate gait kinematics during out-of-lab activities and technology-assisted rehabilitation therapies. However, IMUs are susceptible to distortions, offset and drifting. Therefore, it is important to have a validated instrumentation and recording protocol to ensure the reliability of the measurements, to differentiate therapy effects from system-induced errors. A protocol was carried out to validate the accuracy of gait kinematic assessment with IMUs based on the similarity of the waveform of concurrent signals captured by this system and by a photogrammetry reference system. A gait database of 32 healthy subjects was registered synchronously with both devices. The validation process involved two steps: 1) a preliminary similarity assessment using the Pearson correlation coefficient, and 2) a similarity assessment in terms of correlation, displacement and gain by estimating the offset between signals, the difference between the registered range of motion (∆ROM), the root mean square error (RMSE) and the interprotocol coefficient of multiple correlation (CMCP). Besides, the CMCP was recomputed after removing the offset between signals (CMCPoff). The correlation was strong (r > 0.75) for both limbs for hip flexion/extension, hip adduction/abduction, knee flexion/extension and ankle dorsal/plantar flexion. These joint movements were studied in the second part of the analysis. The ∆ROM values obtained were smaller than 6°, being negligible relative to the minimally clinically important difference (MCID) estimated for unaffected limbs, and the RMSE values were under 10°. The offset for hips and ankles in the sagittal plane reached -9° and -8°, respectively, whereas hips adduction/abduction and knees flexion/extension were around 1°. According to the CMCP, the kinematic pattern of hip flexion/extension (CMCP > 0.90) and adduction/abduction (CMCP > 0.75), knee flexion/extension (CMCP > 0.95) and ankle dorsi/plantar flexion (CMCP > 0.90) were equivalent when captured by each system synchronously. However, after offset correction, only hip flexion/extension (CMCPoff = 1), hip adduction/abduction (CMCPoff > 0.85) and knee flexion/extension (CMCPoff > 0.95) satisfied the conditions to be considered similar.

Thompson Versus Judet Techniques for Quadricepsplasty: A Systematic Review and Meta-analysis of Outcomes and Complications

Background

Quadricepsplasty has been used for over half a century to improve range of motion (ROM) in knees with severe arthrofibrosis. Various surgical techniques for quadricepsplasty exist, including Judet and Thompson, as well as novel minimally invasive approaches. The goal of this review was to compare outcomes between quadricepsplasty techniques for knee contractures.

Methods

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Available databases were queried for all articles on quadricepsplasty. Outcomes included postoperative ROM, outcome scores, and complication rates. Secondarily, we summarized rehabilitation protocols and descriptions of all modified and novel techniques.

Results

Thirty-three articles comprising 797 patients were included in final analysis. Thirty-five percent of patients underwent Thompson quadricepsplasty, 36% underwent Judet, and 29% underwent other techniques. After Judet and Thompson quadricepsplasty, patients achieved a mean postoperative active flexion of 92.7° and 106.4°, respectively (p < 0.01). Complication rates after Judet and Thompson were 17% and 24%, respectively. Wound infection was the most frequently recorded complication after Judet, whereas extension lag predominated for Thompson.

Conclusion

Both the Thompson and Judet quadricepsplasty techniques offer successful treatment options to restore functional knee ROM. Although the Thompson technique resulted in greater postoperative knee flexion compared with the Judet, the difference may be attributable to differences in preoperative flexion and time from injury to quadricepsplasty. Overall, the difference in flexion gained between the 2 techniques is comparable and clinically negligible.

Level of Evidence

Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does arthroscopic or open washout in native knee septic arthritis result in superior post-operative function? A systematic review and meta-analysis of randomised controlled trials and observational studies

AIMS

Septic arthritis (SA) of the native knee joint is associated with significant morbidity. This review compared post-operative functional outcomes (patient-reported outcome measures (PROMs) and range of movement (ROM)) following arthroscopic washout (AW) and open washout (OW) amongst adult patients with SA of the native knee. The need for further operative intervention was also considered.

METHODS

Electronic databases of PubMed, MEDLINE, Embase, Cochrane, Web of Science and Scopus were searched between 16 February 2023 and 18 March 2023. Randomised controlled trials (RCTs) and comparative observational analytic studies comparing function (reflected in PROMs or ROM) at latest follow-up following AW and OW were included. A narrative summary was provided concerning post-operative PROMs. Pooled estimates for mean ROM and re-operation rates were conducted using the random-effects model. The risk of bias was assessed using the Cochrane risk-of-bias assessment tool-2 for RCTs and the Risk of Bias in Non-Randomized Studies of Interventions tool for observational analytic studies.

RESULTS

Of 2580 retrieved citations, 7 articles (1 RCT and 6 cohort studies) met the inclusion criteria. Of these, five had some concerns/moderate risk of bias, and two had serious risk. There was a slight tendency for superior mean PROMs following AW compared with OW, but due to small effect sizes, this was unlikely clinically relevant. Additionally, the use of four different PROMs scales made direct comparisons impossible. AW was associated with superior ROM (mean difference 20.18° (95% CI 14.35, 26.02; p < 0.00001)), whilst there was a tendency for lower re-operation requirements following AW (OR 0.64, 95% CI 0.26, 1.57, p = 0.44).

CONCLUSIONS

AW was associated with equivalent to superior post-operative function and lower requirement for further intervention compared with OW. Results need to be interpreted cautiously, taking into consideration the methodological and clinical heterogeneity of the included studies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2022, CRD42022364062.

Minimal Clinically Important Difference of Scales Reported in Stroke Trials: A Review

There is a growing awareness of the significance of using minimum clinically important differences (MCIDs) in stroke research. An MCID is the smallest change in an outcome measure that is considered clinically meaningful. This review is the first to provide a comprehensive summary of various scales and patient-reported outcome measures (PROMs) used in stroke research and their MCID values reported in the literature, including a concise overview of the concept of and methods for determining MCIDs in stroke research. Despite the controversies and limitations surrounding the estimation of MCIDs, their importance in modern clinical trials cannot be overstated. Anchor-based and distribution-based methods are recommended for estimating MCIDs, with patient self-evaluation being a crucial component in capturing the patient's perspective on their health. A combination of methods can provide a more comprehensive understanding of the clinical relevance of treatment effects, and incorporating the patient's perspective can enhance the care of stroke patients.

A comparison of three-dimensional kinematics between markerless and marker-based motion capture in overground gait

Vision-based methods using RGB inputs for human pose estimation have grown in recent years but have undergone limited testing in clinical and biomechanics research areas like gait analysis. The purpose of the present study was to compare lower extremity kinematics during overground gait between a traditional marker-based approach and a commercial multi-view markerless system in a sample of subjects including young adults, older adults, and adults diagnosed with Parkinson's disease. A convenience sample of 35 adults between the age of 18-85 years were included in this study, yielding a total of 114 trials and 228 gait cycles that were compared between systems. A total of 30 time normalized waveforms, including three-dimensional joint centers, segment angles, and joint angles were compared between systems using root mean-squared error (RMSE), range of motion difference (ΔROM), Pearson correlation coefficients (r), and interclass correlation coefficients (ICC). RMSEs for joint center positions were less than 28 mm in all joints with correlations indicating good to excellent agreement. RMSEs for segment and joint angles were in range of previous results, with highest agreement between systems in the sagittal plane. ΔROM differences were within reference values that characterize clinical groups like Parkinson's disease, stroke, or knee osteoarthritis. Further improvements in pelvis tracking, markerless keypoint model definitions, and standardization of comparison study protocols are needed. Nevertheless, markerless solutions seem promising toward unrestricted motion analysis in biomechanics research and clinical settings.

Virtual reality-enhanced walking in people post-stroke: effect of optic flow speed and level of immersion on the gait biomechanics

BACKGROUND

Optic flow-the apparent visual motion experienced while moving-is absent during treadmill walking. With virtual reality (VR), optic flow can be controlled to mediate alterations in human walking. The aim of this study was to investigate (1) the effects of fully immersive VR and optic flow speed manipulation on gait biomechanics, simulator sickness, and enjoyment in people post-stroke and healthy people, and (2) the effects of the level of immersion on optic flow speed and sense of presence.

METHODS

Sixteen people post-stroke and 16 healthy controls performed two VR-enhanced treadmill walking sessions: the semi-immersive GRAIL session and fully immersive head-mounted display (HMD) session. Both consisted of five walking trials. After two habituation trials (without and with VR), participants walked three more trials under the following conditions: matched, slow, and fast optic flow. Primary outcome measures were spatiotemporal parameters and lower limb kinematics. Secondary outcomes (simulator sickness, enjoyment, and sense of presence) were assessed with the Simulator Sickness Questionnaire, Visual Analogue Scales, and Igroup Presence Questionnaire.

RESULTS

When walking with the immersive HMD, the stroke group walked with a significantly slower cadence (-3.69strides/min, p = 0.006), longer stride time (+ 0.10 s, p = 0.017) and stance time for the unaffected leg (+ 1.47%, p = 0.001) and reduced swing time for the unaffected leg (- 1.47%, p = 0.001). Both groups responded to the optic flow speed manipulation such that people accelerated with a slow optic flow and decelerated with a fast optic flow. Compared to the semi-immersive GRAIL session, manipulating the optic flow speed with the fully immersive HMD had a greater effect on gait biomechanics whilst also eliciting a higher sense of presence.

CONCLUSION

Adding fully immersive VR while walking on a self-paced treadmill led to a more cautious gait pattern in people post-stroke. However, walking with the HMD was well tolerated and enjoyable. People post-stroke altered their gait parameters when optic flow speed was manipulated and showed greater alterations with the fully-immersive HMD. Further work is needed to determine the most effective type of optic flow speed manipulation as well as which other principles need to be implemented to positively influence the gait pattern of people post-stroke.

TRIAL REGISTRATION NUMBER

The study was pre-registered at ClinicalTrials.gov (NCT04521829).

Combined Ankle Robot Training and Robot-assisted Gait Training Improved the Gait Pattern of a Patient with Chronic Traumatic Brain Injury

Background

: Walking disability caused by central nervous system injury often lingers. In the chronic phase, there is great need to improve walking speed and gait, even for patients who walk independently. Robot-assisted gait training (RAGT) has been widely used, but few studies have focused on improving gait patterns, and its effectiveness for motor function has been limited. This report describes the combination of "RAGT to learn the gait pattern" and "ankle robot training to improve motor function" in a patient with chronic stage brain injury.

Case

: A 34-year-old woman suffered a traumatic brain injury 5 years ago. She had residual right hemiplegia [Fugl-Meyer Assessment-Lower Extremity (FMA-LE): 18 points] and mild sensory impairment, but she walked independently with a short leg brace and a cane. Her comfortable gait speed was 0.57 m/s without an orthosis, and her 6-m walk test distance was 240 m. The Gait Assessment and Intervention Tool (G.A.I.T.) score was 35 points. After hospitalization, ankle robot training was performed daily, with RAGT performed 10 times in total. Post-intervention evaluation performed on Day 28 showed: FMA-LE, 23 points; comfortable walking speed, 0.69 m/s; G.A.I.T., 27 points; and three-dimensional motion analysis showed ankle dorsiflexion improved from 3.22° to 12.59° and knee flexion improved from 1.75° to 16.54° in the swing phase.

Discussion

: This is one of few studies to have examined the combination of two robots. Combining the features of each robot improved the gait pattern and motor function, even in the chronic phase.

Establishing minimal clinically important differences for the Quality of Life Instrument of Chronic Gastritis QLICD-CG(V2.0) based on distribution-based methods

BACKGROUND

To establish the lowest score reflecting meaningful changes from the perspective of patients is very important for explaining the results of patient reports. The measurement scale of quality of life in patients with chronic gastritis has been used in clinical practice, but the minimal clinically important difference (MCID) has not been worked out. In this paper, we use a distribution-based method to calculate the MCID of the scale QLICD-CG (Quality of Life Instruments for Chronic Diseases- Chronic Gastritis) (V2.0).

METHODS

The QLICD-CG(V2.0) scale was used to evaluate the quality of life in patients with chronic gastritis. Since the methods for developing MCID were diverse and there was no uniform standard, we took MCID developed by anchor-based method as the gold standard, and compared the MCID of QLICD-CG(V2.0) scale developed by various distribution-based methods for selection. Standard deviation method (SD), effect size method (ES), standardized response mean method (SRM), standard error of measurement method (SEM) and reliable change index method (RCI) are given in the distribution-based methods.

RESULTS

A total of 163 patients, with an average age of (52.37 ± 12.96) years old, were calculated according to the various methods and formulas given by the distribution-based method, and the results were compared with the gold standard. It was suggested that the results of the SEM method at the moderate effect (1.96) should be taken as the preferred MCID of the distribution-based method. And thus the MCID of the physical domain, psychological domain, social domain, general module, specific module and total score of the QLICD-CG(V2.0) scale were 9.29, 13.59, 9.27, 8.29, 13.49 and 7.86, respectively.

CONCLUSIONS

With anchor-based method as the gold standard, each method in distribution-based method has its own advantages and disadvantages. In this paper, 1.96SEM was found to have a good effect on the minimum clinically significant difference of the QLICD-CG(V2.0) scale, and it is recommended as the preferred method to establish MCID.

Inter-rater and intra-rater reliability of isotonic exercise monitoring device for measuring active knee extension

Background

The goal of this study was to assess the reliability of electromyography and range of motion measurements obtained using a knee exercise monitoring system. This device was developed to collect data on knee exercise activities.

Methods

Twenty healthy individuals performed isotonic quadriceps exercises in this study. The vastus medialis surface electromyography (sEMG) and range of motion (ROM) of the knee were recorded during the exercise using the isotonic knee exercise monitoring device, the Mobi6-6b, and a video camera system. Each subject underwent a second measuring session at least 24 h after the first session. To determine reliability, the intraclass correlation coefficients (ICCs) and standard error of measurement (SEM) at the 95% confidence interval were calculated, and a Bland-Altman analysis was performed.

Results

For inter-rater reliability, the ICCs of the mean absolute value (MAV) and root mean square (RMS) of sEMG were 0.73 (0.49, 0.86) and 0.79 (0.61, 0.89), respectively. ROM had an ICC of 0.93 (0.02, 0.98). The intra-rater reliability of the MAV of the sEMG was 0.89 (0.71, 0.96) and the intra-rater reliability of RMS of the sEMG was 0.88 (0.70, 0.95). The ROM between days had an intra-rater reliability of 0.82 (0.54, 0.93). The Bland-Altman analysis demonstrated no systematic bias in the MAV and RMS of sEMG, but revealed a small, systematic bias in ROM (-0.8311 degrees).

Conclusion

For sEMG and range of motion measures, the isotonic knee exercise monitoring equipment revealed moderate to excellent inter- and intra-rater agreement. However, the confidence interval of ROM inter-rater reliability was quite large, indicating a small agreement bias; hence, the isotonic knee exercise monitor may not be suitable for measuring ROM. This isotonic knee exercise monitor could detect and collect information on a patient's exercise activity for the benefit of healthcare providers.

Motion Analysis of Balance Pre and Post Sensorimotor Exercises to Enhance Elderly Mobility: A Case Study

Quantitative assessment of movement using motion capture provides insights on mobility which are not evident from clinical evaluation. Here, in older individuals that were healthy or had suffered a stroke, we aimed to investigate their balance in terms of changes in body kinematics and muscle activity. Our research question involved determining the effects on post- compared to pre-sensorimotor training exercises on maintaining or improving balance. Our research hypothesis was that training would improve the gait and balance by increasing joint angles and extensor muscle activities in lower extremities and spatiotemporal measures of stroke and elderly people. This manuscript describes a motion capture-based evaluation protocol to assess joint angles and spatiotemporal parameters (cadence, step length and walking speed), as well as major extensor and flexor muscle activities. We also conducted a case study on a healthy older participant (male, age, 65) and an older participant with chronic stroke (female, age, 55). Both participants performed a walking task along a path with a rectangular shape which included tandem walking forward, right side stepping, tandem walking backward, left side stepping to the starting location. For the stroke participant, the training improved the task completion time by 19 s. Her impaired left leg had improved step length (by 0.197 m) and cadence (by 10 steps/min) when walking forward, and cadence (by 12 steps/min) when walking backward. The non-impaired right leg improved cadence when walking forward (by 15 steps/min) and backward (by 27 steps/min). The joint range of motion (ROM) did not change in most cases. However, the ROM of the hip joint increased significantly by 5.8 degrees (p = 0.019) on the left leg side whereas the ROMs of hip joint and knee joint increased significantly by 4.1 degrees (p = 0.046) and 8.1 degrees (p = 0.007) on the right leg side during backward walking. For the healthy participant, the significant changes were only found in his right knee joint ROM having increased by 4.2 degrees (p = 0.031) and in his left ankle joint ROM having increased by 5.5 degrees (p = 0.006) during the left side stepping.

[Knee range of motion as a marker of the effectiveness of medical intervention in multiple sclerosis]

OBJECTIVE

To measure the knee range of motion (ROM) in the sagittal plane by video analysis in patients with multiple sclerosis (MS) after a course of medical rehabilitation and determine the minimal clinically important differences (MCID).

MATERIAL AND METHODS

We examined 45 patients (37 women, 8 men) with relapsing-remitting (n=38) and secondary-progressive MS before and after a course of medical rehabilitation. Gait parameters were recorded on video analysis system Physiomed Smart («Physiomed», Germany, the Davis protocol).

RESULTS

The course of complex medical rehabilitation contributes to an increase knee ROM in MS patients in a wide range of disability (EDSS <6.5 points). MCID is estimated as 7.14° in mild (EDSS ≤4.0) and as 7.67° in moderate (EDSS=4.5-5.5) gait impairment.

CONCLUSION

The results will assist clinicians and researchers in interpreting the significance of observed kinematic changes in the knee joint in MS patients after medical intervention.

Concurrent validity and reliability of a smartphone-based application for the head repositioning and cervical range of motion

Objectives

To evaluate the validity and reliability of a smartphone-based application against inertial sensors to measure head repositioning (by using joint position sense –JPS) and cervical range of motion (ROM).

Methods

JPS and cervical ROM were evaluated for neck flexion, extension and both-sides lateral flexion in thirty-one volunteers. Participants were simultaneously evaluated with inertial sensors and the smartphone application. A total of 248 angles were compared for concurrent validity. Inter-tester and intra-tester reliability were evaluated through scoring of images with the smartphone application by two testers, and re-scoring images by the same tester.

Results

Very high correlation was observed between both methods for ROM in all neck movements and JPS in left-side lateral flexion (r>0.9), and high for JPS in the rest of movements (r>0.8). Bland-Altman plots always demonstrated absolute agreement. Inter-and intra-tester reliability was perfect for JPS and ROM in all the neck movements (ICC>0.81).

Conclusions

This smartphone-based application is valid and reliable for evaluating head repositioning and cervical ROM compared with inertial sensors in healthy and young adults. Health professionals could use it in an easier and portable way in field conditions.

Patellofemoral Arthroplasty Results in Better Time-weighted Patient-reported Outcomes After 6 Years than TKA: A Randomized Controlled Trial

BACKGROUND

In a previous study, we reported the 2-year outcomes of a parallel-group, equivalence, randomized controlled trial (RCT; blinded for the first year) comparing patellofemoral arthroplasty (PFA) and TKA for isolated patellofemoral osteoarthritis (PF-OA). We found advantages of PFA over TKA for ROM and various aspects of knee-related quality of life (QOL) as assessed by patient-reported outcomes (PROs). Register data show increases in PFA revision rates from 2 to 6 years after surgery at a time when annual TKA revision rates are decreasing, which suggests rapidly deteriorating knee function in patients who have undergone PFA. We intended to examine whether the early advantages of PFA over TKA have deteriorated in our RCT and whether revision rates differ between the implant types in our study after 6 years of follow-up.

QUESTIONS/PURPOSES

(1) Does PRO improvement during the first 6 postoperative years differ between patients who have undergone PFA and TKA? (2) Does the PRO improvement at 3, 4, 5, and 6 years differ between patients who have undergone PFA and TKA? (3) Do patients who have undergone PFA have a better ROM after 5 years than patients who have had TKA? (4) Does PFA result in more revisions or reoperations than TKA during the first 6 postoperative years?

METHODS

We considered patients who had debilitating symptoms and PF-OA as eligible for this randomized trial. Screening initially identified 204 patients as potentially eligible; 7% (15) were found not to have sufficient symptoms, 21% (43) did not have isolated PF-OA, 21% (43) declined participation, and 1% (3) were not included after the target number of 100 patients had been reached. The included 100 patients were randomized 1:1 to PFA or TKA between 2007 and 2014. Of these, 9% (9 of 100) were lost before the 6-year follow-up; there were 12% (6 of 50) and 0% (0 of 50) deaths (p = 0.02) in the PFA and TKA groups, respectively, but no deaths could be attributed to the knee condition. There were no differences in baseline parameters for patients who had PFA and TKA, such as the proportion of women in each group (78% [39 of 50] versus 76% [38 of 50]; p > 0.99), mean age (64 ± 9 years versus 65 ± 9 years; p = 0.81) or BMI (28.0 ± 4.7 kg/m 2 versus 27.8 ± 4.1 kg/m 2 ; p = 0.83). Patients were seen for five clinical follow-up visits (the latest at 5 years) and completed 10 sets of questionnaires during the first 6 postoperative years. The primary outcome was SF-36 bodily pain. Other outcomes were reoperations, revisions, ROM, and PROs (SF-36 [eight dimensions, range 0 to 100 best, minimum clinically important difference {MCID} 6 to 7], Oxford Knee Score [OKS; one dimension, range 0 to 48 best, MCID 5], and Knee Injury and Osteoarthritis Outcome Score [KOOS; five dimensions, range 0 to 100 best, MCID 8 to 10]). Average PRO improvements over the 6 years were determined by calculating the area under the curve and dividing by the observation time, thereby obtaining a time-weighted average over the entire postoperative period. PRO improvements at individual postoperative times were compared for the patients who had PFA and TKA using paired t-tests. Range of movement changes from baseline were compared using paired t-tests. Reoperation and revision rates were compared for the two randomization groups using competing risk analysis.

RESULTS

Patients who underwent PFA had a larger improvement in the SF-36 bodily pain score during the first 6 years than those who underwent TKA (35 ± 19 vs. 23 ± 17; mean difference 12 [95% CI 4 to 20]; p = 0.004), and the same was true for SF-36 physical functioning (mean difference 11 [95% CI 3 to 18]; p = 0.008), KOOS Symptoms (mean difference 12 [95% CI 5 to 20]; p = 0.002), KOOS Sport/recreation (mean difference 8 [95% CI 0 to 17]; p = 0.048), and OKS (mean difference 5 [95% CI 2 to 8]; p = 0.002). No PRO dimension had an improvement in favor of TKA. At the 6-year time point, only the SF-36 vitality score differed between the groups being in favor of PFA (17 ± 19 versus 8 ± 21; mean difference 9 [95% CI 0 to 18]; p = 0.04), whereas other PRO measures did not differ between the groups. At 5 years, ROM had decreased less from baseline for patients who underwent PFA than those who had TKA (-4° ± 14° versus -11° ± 13°; mean difference 7° [95% CI 1° to 13°]; p = 0.02), but the clinical importance of this is unknown. Revision rates did not differ between patients who had PFA and TKA at 6 years with competing risk estimates of 0.10 (95% CI 0.04 to 0.20) and 0.04 (95% CI 0.01 to 0.12; p = 0.24), respectively, and also reoperation rates were no different at 0.10 (95% CI 0.04 to 0.20) and 0.12 (95% CI 0.05 to 0.23; p = 0.71), respectively.

CONCLUSION

Our RCT results show that the 2-year outcomes did not deteriorate during the subsequent 4 years. Patients who underwent PFA had a better QOL throughout the postoperative years based on several of the knee-specific outcome instruments. When evaluated by the 6-year observations alone and without considering earlier observations, we found no consistent difference for any outcome instruments, although SF-36 vitality was better for patients who underwent PFA. These combined findings show that the early advantages of PFA determined the results by 6 years. Our findings cannot explain the rapid deterioration of results implied by the high revision rates observed in implant registers, and it is necessary to question indications for the primary procedure and subsequent revision when PFA is in general use. Our data do not suggest that there is an inherent problem with the PFA implant type as otherwise suggested by registries. The long-term balance of advantages will be determined by the long-term QOL, but based on the first 6 postoperative years and ROM, PFA is still the preferable option for severe isolated PF-OA. A possible high revision rate in the PFA group beyond 6 years may outweigh the early advantage of PFA, but only detailed analyses of long-term studies can confirm this.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Comparison of Open Versus Arthroscopic Repair for Subscapularis Tendon Tears With or Without Concomitant Supraspinatus Tendon Tears

Background:

The literature comparing open and arthroscopic repair of subscapularis tendon (ST) tears is insufficient.

Purpose:

To compare the clinical results of open versus arthroscopic repair of ST tears with or without concomitant supraspinatus tears.

Study Design:

Retrospective cohort study.

Methods:

We retrospectively evaluated 70 patients treated for isolated ST tears and ST tears with concomitant supraspinatus tendon tears at a single center between 2011 and 2019. Patients were divided into 2 groups: those who underwent open ST repairs (group O) and those with an arthroscopic ST repair (group A). Range of motion (ROM), liftoff and belly-press tests, and Constant-Murley (CM) scores were included in the pre- and postoperative functional evaluations. The minimal clinically important difference was calculated using the anchor-based method for changes in CM score. Tear size was evaluated according to the Lafosse classification. The categorical data were assessed using the Pearson chi-square, Fisher exact, and Fisher-Freeman-Halton tests. The parametric and nonparametric data were evaluated using the Student t test and Mann-Whitney U test, respectively. The dependent groups (for nonnormally distributed data) were evaluated using the Wilcoxon signed rank test.

Results:

Group O included 34 patients, and group A included 36 patients. The mean age was 62.9 years, and the mean follow-up period was 66.7 months. Even though group O exhibited a significantly better preoperative CM score (53.7 ± 4.6 vs 48.9 ± 6.8 [mean ± SD]; P = .001), group A had a significantly better postoperative CM score (88.7 ± 4.7 vs 84.6 ± 2.9; P < .001). Our measurements revealed a minimal clinically important difference of 11.5 points for the CM score. Group A had significantly greater postoperative ROM in abduction (153° vs 143.9°; P = .005) and forward elevation (159.1° vs 149.7°; P = .005), as well as significantly greater postoperative improvement in positive belly-press test results (P = .028). Complications occurred in 4 patients in group O and in 1 patient in group A.

Conclusion:

The study findings indicated that arthroscopic ST repair was more advantageous than open repair in terms of ROM and functional outcomes.

Effect of Unilateral Knee Extension Restriction on the Lumbar Region during Gait

Unilateral knee extension restriction might change trunk alignment and increase mechanical load on the lumbar region during walking. We aimed to clarify lumbar region mechanical load during walking with restricted knee extension using a musculoskeletal model simulation. Seventeen healthy adult males were enrolled in this study. Participants walked 10 m at a comfortable velocity with and without restricted right knee extension of 15° and 30° using a knee brace. L4-5 joint moment, joint reaction force, and muscle forces around the lumbar region during walking were calculated for each condition. Peaks of kinetic data were compared among three gait conditions during 0%-30% and 50%-80% of the right gait cycle. Lumbar extension moment at early stance of the bilateral lower limbs was significantly increased in the 30° restricted condition (p ≤ 0.021). Muscle force of the multifidus showed peaks at stance phase of the contralateral side during walking, and the erector spinae showed force peaks at early stance of the bilateral lower limb. Muscle force of the multifidus and erector spinae increased with increasing degree of knee flexion (p ≤ 0.010), with a large effect size (η ² = 0.273-0.486). The joint force acting on L4-5 showed two peaks at early stance of the bilateral lower limbs during the walking cycle. The anterior and vertical joint force on L4-5 increased by 14.2%-36.5% and 10.0%-23.0% in walking with restricted knee extension, respectively (p ≤ 0.010), with a large effect size (η ² = 0.149-0.425). Restricted knee joint extension changed trunk alignment and increased the muscle force and the vertical and anterior joint force on the L4-5 joint during walking; this tendency became more obvious with increased restriction angle. Our results provide important information for therapists engaged in the rehabilitation of patients with knee contracture.

Outcomes after ORIF of Bicondylar Schatzker VI (AO type C) Tibial Plateau Fractures in an Elderly Population

BACKGROUND

The surgical management of bicondylar tibial plateau (BTP) fractures in elderly patients aims to restore knee stability while minimizing soft tissue complications. The purpose of this study was to compare injury characteristics and surgical outcomes after ORIF of BTP fractures (AO/OTA 41-C (Schatzker VI)) in young (< 50 years) versus elderly (> 65 years) patients.

METHODS

A retrospective cohort study was conducted using data from two American College of Surgeons (ACS) level I trauma centers. Inclusion criteria were: (1) age 18 years or older, (2) bicondylar tibial plateau fracture (AO/OTA 41-C or Schatzker VI), (3) treatment with ORIF, and (4) minimum of 6 months follow-up. Patients between 50 and 65 years of age were excluded. Data collection was performed by reviewing electronic medical records, operative reports, and radiology reports.

RESULTS

We identified 323 patients (61% male) with 327 BTP fractures and a median follow-up of 685 days. There were 230 young patients (71%) < 50 years and 93 elderly patients (29%) >6 5 years at time of presentation. Elderly patients were significantly more likely to have a low energy mechanism of injury (44.6 vs. 16.2%, p < 0.001), and present with diabetes (19.4 vs. 4.4%, p < 0.001) or coronary artery disease (12.9 vs. 1.3%, p < 0.001). Elderly patients were also significantly less likely to undergo staged management with initial knee-spanning external fixation followed by delayed ORIF (19.2 vs. 33.9%, p = 0.008). Elderly patients had a lower arc of motion at final follow-up (105 vs. 113°, p < 0.001) and reduced PROMIS-10 function scores (43.8 vs. 49.8, p = 0.013). No differences were observed in rates of superficial infection, deep infection, reoperation, or EQ-5D scores between age groups.

CONCLUSIONS

This is the largest study to compare injury characteristics and outcomes after ORIF of BTP fractures according to age. Elderly patients (age > 65 years) sustained BTP fractures by lower energy mechanisms than their younger counterparts with similar fracture patterns and were often managed with ORIF. The results of this study suggest that ORIF of BTP fractures in elderly patients is associated with similar complication rates and outcomes as in younger patients despite higher comorbidities and poorer bone quality in the elderly population.

A Robot-Assisted Therapy to Increase Muscle Strength in Hemiplegic Gait Rehabilitation

This study examines the feasibility of using a robot-assisted therapy methodology based on the Bobath concept to perform exercises applied in conventional therapy for gait rehabilitation in stroke patients. The aim of the therapy is to improve postural control and movement through exercises based on repetitive active-assisted joint mobilization, which is expected to produce strength changes in the lower limbs. As therapy progresses, robotic assistance is gradually reduced and the patient's burden increases with the goal of achieving a certain degree of independence. The relationship between force and range of motion led to the analysis of both parameters of interest. The study included 23 volunteers who performed 24 sessions, 2 sessions per week for 12 weeks, each lasting about 1 h. The results showed a significant increase in hip abduction and knee flexion strength on both sides, although there was a general trend of increased strength in all joints. However, the range of motion at the hip and ankle joints was reduced. The usefulness of this platform for transferring exercises from conventional to robot-assisted therapies was demonstrated, as well as the benefits that can be obtained in muscle strength training. However, it is suggested to complement the applied therapy with exercises for the maintenance and improvement of the range of motion.

Core Sets of Kinematic Variables to Consider for Evaluation of Gait Post-stroke

Background

Instrumented gait analysis post-stroke is becoming increasingly more common in research and clinics. Although overall standardized procedures are proposed, an almost infinite number of potential variables for kinematic analysis is generated and there remains a lack of consensus regarding which are the most important for sufficient evaluation. The current aim was to identify a discriminative core set of kinematic variables for gait post-stroke.

Methods

We applied a three-step process of statistical analysis on commonly used kinematic gait variables comprising the whole body, derived from 3D motion data on 31 persons post-stroke and 41 non-disabled controls. The process of identifying relevant core sets involved: (1) exclusion of variables for which there were no significant group differences; (2) systematic investigation of one, or combinations of either two, three, or four significant variables whereby each core set was evaluated using a leave-one-out cross-validation combined with logistic regression to estimate a misclassification rate (MR).

Results

The best MR for one single variable was shown for the Duration of single-support (MR 0.10) or Duration of 2nd double-support (MR 0.11) phase, corresponding to an 89–90% probability of correctly classifying a person as post-stroke/control. Adding Pelvis sagittal ROM to either of the variables Self-selected gait speed or Stride length, alternatively adding Ankle sagittal ROM to the Duration of single-stance phase, increased the probability of correctly classifying individuals to 93–94% (MR 0.06). Combining three variables decreased the MR further to 0.04, suggesting a probability of 96% for correct classification. These core sets contained: (1) a spatial (Stride/Step length) or a temporal variable (Self-selected gait speed/Stance time/Swing time or Duration of 2nd double-support), (2) Pelvis sagittal ROM or Ankle plantarflexion during push-off, and (3) Arm Posture Score or Cadence or a knee/shoulder joint angle variable. Adding a fourth variable did not further improve the MR.

Conclusion

A core set combining a few crucial kinematic variables may sufficiently evaluate post-stroke gait and should receive more attention in rehabilitation. Our results may contribute toward a consensus on gait evaluation post-stroke, which could substantially facilitate future diagnosis and monitoring of rehabilitation progress.

High hip center arthroplasty in the treatment of severe hip dysplasia: Are knee and ankle compromised?

BACKGROUND

There is limited information about the effect of hip center location on gait parameters of knee and ankle. This study aimed to compare anatomical vs. high hip center arthroplasty according to gait parameters of knee and ankle and investigate whether the high hip center has any adverse effect on these joints or not.

METHODS

20 patients who underwent unilateral total hip arthroplasty (Group 1; 10 patients with anatomical reconstruction, Group 2; 10 patients with high hip center) due to Crowe type III-IV developmental dysplasia of the hip and completed 2 years of follow-up were included. The patients were examined by 3-D gait analysis.

FINDINGS

The maximum extension of the knee on the operated side was lower in Group 2 (p = 0.044). Longitudinal knee joint force was higher in Group 2 on both operated (p = 0.041) and non-operated sides (p = 0.031). Lateral knee joint force was also higher in Group 2 (p = 0.023). No significant difference was detected in ankle parameters.

INTERPRETATION

Unilateral high hip center has been shown to restrict the dynamic knee range of motion on the operated side and increase the knee load on both sides, thus putting the knees at risk for osteoarthritis.

LEVEL OF EVIDENCE

Level III, Retrospective comparative study.

Establishing the Minimal Clinically Important Differences for Sagittal Hip Range of Motion in Chronic Stroke Patients

Many researchers have pointed out that decreased sagittal range of motion (ROM) in the affected hip joint is a common consequence of stroke, and it adversely affects walking performance and walking speed. Nevertheless, the minimal clinically important differences (MCID) in hip-related kinematic gait parameters post-stroke have not yet been determined. The present study aimed to define MCID values for hip ROM in the sagittal plane i.e., flexion-extension (FE), for the affected and unaffected sides at a chronic stage post-stroke. Fifty participants with hemiparesis due to stroke were enrolled for the study. Four statistical methods were used to calculate MCID. According to the anchor-based approach, the mean change in hip FE ROM achieved by the MCID group on the affected/unaffected side amounted to 5.81°/2.86° (the first MCID estimate). The distribution-based analyses established that the standard error of measurement in the no-change group amounted to 1.56°/1.04° (the second MCID estimate). Measurements based on the third method established that a change of 4.09°/0.61° in the hip ROM corresponded to a 1.85-point change in the Barthel Index. The optimum cutoff value, based on ROC curve analysis, corresponded to 2.9/2.6° of change in the hip sagittal ROM for the affected/unaffected side (the fourth MCID estimate). To our knowledge, this is the first study to use a comprehensive set of statistical methods to determine the MCID for hip sagittal ROM for the affected and unaffected sides at a chronic stage post-stroke. According to our findings, the MCID of the hip FE ROM for the affected side amounts to 5.81° and for the unaffected side to 2.86°, in patients with chronic stroke. This indicator is extremely important because it allows clinical practitioners to assess the effects of interventions administered to patients, and to interpret the significance of improvements in sagittal kinematic parameters of the hip; ultimately, it may facilitate the process of designing effective gait reeducation programs.

Should corticosteroids be administered for local infiltration analgesia in knee arthroplasty? A meta-analysis and systematic review

WHAT IS KNOWN AND OBJECTIVE

The benefits of local infiltration analgesia (LIA) in knee arthroplasty (KA) have been well-documented. However, it is unknown whether adding a corticosteroid to the composition of the LIA is beneficial. This study aimed to investigate the efficacy and safety of administering periarticular steroids intraoperatively in patients who underwent KA through a systematic review and meta-analysis.

METHODS

A systematic search was conducted to identify relevant randomized controlled trials in the PubMed, Embase, Web of Science and Cochrane databases up to January 19th, 2021 to perform a meta-analysis. Outcome variables included pain scores, total opioid consumption, knee range of motion (ROM) and postoperative complications.

RESULTS

Corticosteroid injections did not reduce pain scores at 6, 12, 24 or 72 h postoperatively, although a minimal degree of transient pain relief was achieved at 48 h postoperatively compared with those in the placebo group, nor was there a significant difference in total opioid consumption. However, patients receiving corticosteroids did exhibit a transient ROM increase on postoperative days 1, 2 and 3. Since the minimal clinically important difference (MCID) for ROM is unclear, it is unknown if the improvement in ROM is clinically significant.

WHAT IS NEW AND CONCLUSION

Our specific end-point analysis demonstrated that corticosteroid administration did not provide pain relief or reduce opioid consumption compared with placebo. However, corticosteroids might provide a statistically significant, though transient and minimal improvement in knee ROM after KA, although no firm conclusions about the benefits of administering corticosteroids in KA can be made based on the available evidence.

Task-specific training for improving propulsion symmetry and gait speed in people in the chronic phase after stroke: a proof-of-concept study

Background

After stroke, some individuals have latent, propulsive capacity of the paretic leg, that can be elicited during task-specific gait training. The aim of this proof-of-concept study was to investigate the effect of five-week robotic gait training for improving propulsion symmetry by increasing paretic propulsion in chronic stroke survivors.

Methods

Twenty-nine individuals with chronic stroke and impaired paretic propulsion (≥ 8% difference in paretic vs. non-paretic propulsive impulse) were enrolled. Participants received ten 60-min sessions of individual robotic gait training targeting paretic propulsion (five weeks, twice a week), complemented with home exercises (15 min/day) focusing on increasing strength and practicing learned strategies in daily life. Propulsion measures, gait kinematics and kinetics, self-selected gait speed, performance of functional gait tasks, and daily-life mobility and physical activity were assessed five weeks (T0) and one week (T1) before the start of intervention, and one week (T2) and five weeks (T3) after the intervention period.

Results

Between T0 and T1, no significant differences in outcomes were observed, except for a marginal increase in gait speed (+ 2.9%). Following the intervention, propulsion symmetry (+ 7.9%) and paretic propulsive impulse had significantly improved (+ 8.1%), whereas non-paretic propulsive impulse remained unchanged. Larger gains in propulsion symmetry were associated with more asymmetrical propulsion at T0. In addition, following the intervention significantly greater paretic trailing limb angles (+ 6.6%) and ankle plantarflexion moments (+ 7.1%) were observed. Furthermore, gait speed (+ 7.2%), 6-Minute Walk Test (+ 6.4%), Functional Gait Assessment (+ 6.5%), and daily-life walking intensity (+ 6.9%) had increased following the intervention. At five-week follow-up (T3), gains in all outcomes were retained, and gait speed had further increased (+ 3.6%).

Conclusions

The post-intervention gain in paretic propulsion did not only translate into improved propulsion symmetry and gait speed, but also pertained to performance of functional gait tasks and daily-life walking activity levels. These findings suggest that well-selected chronic stroke survivors may benefit from task-specific targeted training to utilize the residual propulsive capacity of the paretic leg. Future research is recommended to establish simple baseline measures for identification of individuals who may benefit from such training and confirm benefits of the used training concepts in a randomized controlled trial.

Trial registration: Registry number ClinicalTrials.gov (www.clinicaltrials.gov): NCT04650802, retrospectively registered 3 December 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00858-8.

Functional capacity assessment and Minimal Clinically Important Difference in post-acute cardiac patients: the role of Short Physical Performance Battery

BACKGROUND

The Short Physical Performance Battery (SPPB) test is a well-established tool to assess physical performance, and to identify frail patients. Assessment of the SPPB in a specific population of elder patients in cardiac rehabilitation phase after a cardiac event is missing.

AIM

The aim of this study was to correlate SPPB and the cardiac rehabilitation outcome in a group of elder patients after a cardiac event and to identify the Minimal Clinically Important Difference (MCID) of the SPPB.

METHODS

Consecutive (n = 392) patients aged ≥75 years, in the rehabilitation phase after cardiac surgery (70.1%), congestive heart failure (7.4%), or acute coronary syndrome (22.5%), were enrolled. SPPB was performed twice: on admission and discharge. The MCID was assessed with the 'anchor method', and the Patient Global Impression of Change was employed as the anchor.

RESULTS

On admission, SPPB classified 56, 117, 116, and 94 patients as severe, moderate, mild, or minimal/no limitations, respectively. Patients with the lower SPPB had the longer length of stay, and the higher complications rate. At receiver operating characteristic analysis, an SPPB improvement >1 was identified as the MCID (area-under-curve 0.77, 95% CI 0.67-0.85). Overall, 285 patients (74.2%) had a 'clinically significant' improvement in SPPB, with a rate of improvement higher in patients with severe/moderate limitations (83.0%) and lower in those with mild (78.9%) or minimal/no limitations (53.6%).

CONCLUSION

A lower SPPB score is associated with a higher complications rate in the post-acute phase. An improvement >1 point of SPPB was identified as the MCID; this reference value could serve as the goal for rehabilitation interventions.