Reliability of lower extremity girth measurements after anterior cruciate ligament reconstruction

Time course of Quadriceps thickness changes over six months post-anterior cruciate ligament reconstruction: Unveiling critical impairments in vastii muscles

Vastii muscle adaptation caused by Quadriceps weakness observed after an Anterior Cruciate Ligament reconstruction (ACLr) remain debatable. We described the time course of changes in Quadriceps thickness, strength, and thigh circumference over six months following an ACLr. Quadriceps thicknesses, Quadriceps strength, and thigh circumference were measured preoperative, 3, and 6 months post-ACLr surgery in 103 patients (77 men and 26 women). Limbs and time were compared with repeated-measures ANOVA and the Intra-class correlation coefficient was determined (α = 5 %). From 0 to 3 months post-surgery, Quadriceps strength (p < 0.05), and VI (p < 0.05) and VL (p < 0.001) thicknesses were reduced. From 3 to 6 months, Quadriceps strength (p < 0.05), total Quadriceps thickness (p < 0.001), and VI (p < 0.001) and VL (p < 0.05) thicknesses increased. VM and RF thicknesses increase to 3 months after ACLr (p < 0.05). Quadriceps strength, circumference at 5 cm, VI, VL, VM, and total Quadriceps thickness remain lower than the contralateral limb 6 months following an ACLr (p < 0.05). Quadriceps thickness adapts heterogeneously, with VI and VL atrophying for up to three months, developing the highest Quadriceps weakness. By 6 months, VI does not recover its thickness proportion, and VI and VL do not return to pre-surgery conditions. Both vastii muscles align with Quadriceps strength changes over six months posterior ACLr.

Nutritional intervention to enhance recovery after arthroscopic knee surgery in adults: a randomized controlled pilot trial

BACKGROUND

Essential amino acid (EAA) and omega-3 fatty acid ingestion independently attenuate leg skeletal muscle disuse atrophy in uninjured persons. However, no data exist regarding the effectiveness of combined EAA and omega-3 fatty acid ingestion to mitigate skeletal muscle disuse atrophy in response to anterior cruciate ligament reconstruction (ACLR) surgery. This pilot trial will explore the feasibility of recruitment and retention of ACLR outpatients from a single center across 18 months to consume either a combination of omega-3 fatty acids and EAAs, or a placebo control, for 4 weeks before and 2 weeks after surgery.

METHODS

Thirty adult (≥ 18 years old) ACLR outpatients will be recruited for this single center, double-blind, two-arm randomized controlled feasibility pilot trial. Participants will consume either 5 g⋅day-1 of omega-3 fatty acids (fish oil) and 40 g⋅day-1 of EAAs or 5 g⋅day-1 of a control fatty acid mixture (safflower oil) and 40 g⋅day-1 of non-essential amino acids (NEAAs). Fatty acid supplements will be consumed 4 weeks before and for 2 weeks after ACLR surgery, whereas the EAAs and NEAAs will be consumed 1 week before and for 2 weeks after ACLR surgery. The primary outcomes are feasibility of recruitment and retention, with the goal to recruit 30 outpatients across 18 months and retain 22 participants upon completion of the study protocol following 12 weeks of data collection. These results will be reported using descriptive statistics, along with reasons and timepoints for study dropout. Secondary exploratory outcomes will be reported using inferential statistics for purposes of hypothesis generation and elucidation of mechanistic targets for future work; no inferences to clinical efficacy will be made. These outcomes include integrated rates of skeletal muscle protein synthesis, skeletal muscle protein content and expression of translation factors, skeletal muscle and erythrocyte phospholipid composition, and measures of skeletal muscle mass, strength, and power.

IMPACT

This work will set the foundation for a future randomized controlled trial powered to detect an effect of EAA + omega-3 fatty acid intake on skeletal muscle size or function in response to ACLR surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06233825. Registered 31 January 2024. https://clinicaltrials.gov/study/NCT06233825?term=NCT06233825&rank=1.

Safety and Effects of a Four-Week Preoperative Low-Load Resistance Training With Blood Flow Restriction on Pre- and Postoperative Quadriceps Strength in Patients Undergoing Total Knee Arthroplasty: A Single-Blind Randomized Controlled Trial

Background/Objectives Enhancing preoperative quadriceps strength and mitigating quadriceps strength loss due to total knee arthroplasty (TKA) is crucial for post-TKA recovery. This study compared the safety and effect of a four-week preoperative regimen of low-load resistance training with blood flow restriction (LLRT-BFR) with those of low-intensity resistance training with slow movement and tonic force generation (LST) on the pre- and postoperative quadriceps strength in patients undergoing TKA. Methods In this randomized controlled trial, 22 patients were assigned to either the LLRT-BFR (n=11) or LST (n=11) group. Primary outcomes included changes in quadriceps strength before and after the intervention and surgery. To assess safety, we monitored D-dimer and high-sensitivity C-reactive protein levels pre- and post-intervention. Statistical analysis involved independent samples t-tests and Mann-Whitney U tests for group comparisons of quadriceps strength changes. Additionally, a two-way repeated-measures analysis of variance was used to assess safety parameters. Results No significant differences were observed between the BFR and LST groups in terms of the rate of increase in quadriceps strength pre- and post-intervention (BFR: median 12.1%, interquartile range -0.8% to 19.5%; LST: median 6.2%, interquartile range 2.7% to 14.7%; p>0.99) or in the rate of reduction in quadriceps strength pre- and post-surgery (BFR: mean -72.4%, standard deviation ±11.2%; LST: mean -75.3%, standard deviation ±12.2%; p=0.57). Safety assessments showed no significant main effects of time, group, or interaction on the safety parameters (all p>0.05). Conclusions LLRT-BFR and LST demonstrated comparable effects on quadriceps strength before and after intervention and surgery in patients undergoing TKA. The lack of significant changes in the safety parameters supports the safety profile of both interventions, indicating their suitability for preoperative conditioning in patients scheduled for TKA.

The Use of Biomarkers to Quantify Clinical Response to Total Knee Arthroplasty Interventions: A Systematic Review

The primary objective of this review was to determine whether the attenuation of the postoperative inflammatory response (PIR) after total knee arthroplasty (TKA) leads to a notable improvement in clinical outcome scores. The secondary objective of this review was to determine the optimal approach in using inflammatory biomarkers, clinical inflammatory assessments, and imaging to quantify the PIR. A systematic literature search of eight major databases was conducted using a predetermined search strategy. C-reactive protein (CRP), interleukin-6 (IL-6), erythrocyte sedimentation rate (ESR), knee surface temperature (KST), and clinical outcome data were collected and graphically displayed. Eighty-six percent of the studies that reported a statistically significant decrease in inflammatory biomarkers in their treatment group demonstrated a concordant notable improvement in clinical outcome scores. Mean CRP, IL-6, ESR, and KST values peaked on postoperative day (POD) 2, POD1, POD7, and POD 1-3, respectively. The PIR is correlated with early pain and function recovery outcomes. Future studies comparing TKA surgical methodologies and perioperative protocols should assess PIR by incorporating inflammatory biomarkers, such as CRP and IL-6, and clinical inflammatory assessment adjuncts, to provide a more comprehensive comparison.

Inter- and intra-observer reliability of thoracic limb circumference measurement methods in sound dogs

Objective

The primary objectives of this study are to (1) compare the inter- and intra-observer reliability of thoracic limb circumference measurement methods in sound dogs, and (2) determine the most reliable thoracic limb positioning and location on the thoracic limb for performing circumferential measurements.

Methods

Thoracic limbs of 10 apparently sound dogs (20 limbs) were blindly and independently measured by 3 observers. Triplicate measurements were performed with dogs in lateral recumbency at 50 and 70% brachial (Br) length (length between the greater tubercle and lateral humoral epicondyle) and 25% ABr length (length between the lateral humeral epicondyle and ulnar styloid process), both with the elbow extended and at an approximate weight-bearing (WB) angle. Intra-class correlation coefficients (ICC) with a 95% confidence interval (CI) were used for data analysis with a p < 0.05 being significant.

Results

All measures had significantly good to excellent intra- (ICC 0.836-0.994, p < 0.001) and inter-observer reliability (ICC 0.834-0.996, p < 0.001). Inter-observer reliability was excellent at 25% ABr extended and WB positions, and at 50% Br WB position, with a wider confidence interval at the latter location. Intra-observer reliability was excellent across all observers for 25% ABr extended and WB, and 50% Br WB positions, also with a wider confidence interval at the latter location.

Conclusion

Circumferential measurement of the canine thoracic limb was most reliable at 25% ABr length with the elbow either in an extended or WB position.

A Tissue Dielectric Constant Evaluation of Knee Edema: A Retrospective Intra-rater Reliability and Association Study of Repeated Measures

BACKGROUND

This research compared the reliability and association of tissue dielectric constant (TDC) measures of knee edema to circumferential measurements of knee girth recorded as part of a physical therapy examination.

METHODS

Twenty adults having observable unilateral knee edema were enrolled. A single examiner measured edematous knee swelling with a TDC device and a tape measure across two visits. The presence of edema was recorded as a positive number in reporting side-to-side differences and a positive percentage in documenting change over time. Intra-rater reliability of the measures was assessed with an intra-class correlation coefficient (ICC). Percent change in edema was evaluated independently for both methods using a paired t-test, and the association between measures was assessed by a Pearson's statistic.

RESULTS

Both measures were reliable (ICC ≥ 0.81), and both detected a significant percentage decrease (p < 0.05) in edema across visits. The TDC measure changed by 8.3%, an amount nearly four times larger compared to knee girth (2.4%). The subsequent follow-up comparison revealed an inverse relationship (p = 0.049; r = -0.44) between the two percent change measurements of edema.

CONCLUSION

The two methods capture different physical attributes of edema. The TDC records the water content of the tissue, while the use of a tape measure records circumferential limb girth. The TDC measurement was reliable and more responsive in detecting a percentage decrease in knee edema in comparison to a circumferential measure of knee girth. The TDC method may have wider use in directly measuring edema in other tissue structures and regions of the body.

Effects of n-3 polyunsaturated fatty acid supplementation on quadriceps weakness immediately after total knee arthroplasty: a pilot, randomized, open-label clinical trial

[Purpose] Severe quadriceps weakness immediately after total knee arthroplasty can be problematic. The n-3 long-chain polyunsaturated fatty acids have antioxidant and anti-inflammatory effects against ischemia-reperfusion injury, whereas n-6 long-chain polyunsaturated fatty acids exert pro-inflammatory effects, thereby promoting ischemia-reperfusion injury. [Participants and Methods] We explored the efficacy of preoperative n-3 long-chain polyunsaturated fatty acid supplementation against early quadriceps weakness among 20 patients scheduled for total knee arthroplasty (intervention group, n=10; control group, n=10). The intervention group received 645 mg of eicosapentaenoic acid) and 215 mg of docosahexaenoic acid daily for 30 days preoperatively. Serum eicosapentaenoic acid, docosahexaenoic acid, and arachidonic acid levels were measured preoperatively. We compared serum derivatives of reactive oxygen metabolites as oxidative stress biomarkers, knee circumference, thigh volume, knee pain during the quadriceps strength test, and quadriceps strength preoperatively and 4 days postoperatively to quantify the change. [Results] Preoperative n-3 long-chain polyunsaturated fatty acid supplementation significantly increased the (eicosapentaenoic acid+docosahexaenoic acid)/arachidonic acid ratio in the intervention group. A significantly lower increase in quadriceps weakness was exhibited in the intervention group than in the control group. However, changes in oxidative stress, knee/thigh swelling, and knee pain during strength testing did not significantly differ between the two groups. [Conclusion] Preoperative n-3 long-chain polyunsaturated fatty acid supplementation exhibited beneficial effects on quadriceps weakness immediately after total knee arthroplasty.

Pulsed electromagnetic fields improve pain management and clinical outcomes after medial unicompartmental knee arthroplasty: A prospective randomised controlled trial

BACKGROUND

To assess pain relief and clinical outcomes in patients undergoing unicompartmental knee arthroplasty (UKA) stimulated with pulsed electromagnetic fields (PEMFs) compared to a control group.

METHODS

A prospective randomised controlled trial (RCT) was performed in which 72 patients undergoing medial UKA were randomised into a control group or an experimental PEMFs group. The patients allocated to the experimental group were instructed to use PEMFs for 4 h per day for 60 days. They were evaluated before a surgery and then during the time points corresponding to 1 month, 2 months, 6 months, 12 months, and 36 months after the surgery. No placebo group was included in the RCT. Clinical assessment included the Visual Analogue Scale (VAS) for pain, Oxford Knee Score (OKS), the Short Form 36 (SF-36) health survey questionnaire, and joint swelling. During each follow-up visit, the consumption of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) was recorded.

RESULTS

The VAS decreased on follow-up visits in both the groups; a statistically significant difference between the groups was observed during the 6 (p = 0.0297), 12 (p = 0.0003), and 36 months (p = 0.0333) follow-ups in favour of the PEMFs group. One month after UKA, the percentages of patients using NSAIDs in the PEMFs and control group were 71% and 92%, respectively (p = 0.0320). At the 2 months point, 15% of the patients in the PEMFs group used NSAIDs compared to 39% in the control group (p = 0.0317). The objective knee girth evaluation showed a statistically significant difference at 6 (p = 0.0204), 12 (p = 0.0005), and 36 (p = 0.0005) months with improved values observed in the PEMFs group. The subjective assessment of the swelling demonstrated a statistically significant difference at 2 (p = 0.0073), 6 (p = 0.0006), 12 (p = 0.0001), and 36 (p = 0.0011) months with better values noted in the PEMFs group. Last, the OKS result was significant higher in the experimental group during all the follow-ups (1mth: p = 0.0295; 2mths: p = 0.0012; 6mths: p = 0.0001; 12mths: p < 0.0001; 36mths: p = 0.0061).

CONCLUSIONS

The use of PEMFs leads to significant pain relief, better clinical improvement, and lower NSAIDs consumption after medial UKA when compared to the control group.

LEVEL OF EVIDENCE

II.

Tranexamic Acid Use in Anterior Cruciate Ligament Reconstruction Decreases Bleeding Complications: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PURPOSE

To systematically review all available randomized controlled trials (RCTs) in the literature that examine outcomes following tranexamic acid (TXA) use in anterior cruciate ligament reconstruction (ACLR) to determine its effectiveness.

METHODS

PubMed/MEDLINE, Embase, Science Direct, Web of Science, CINAHL, and The Cochrane Library databases were systematically searched for RCTs comparing TXA versus no TXA in ACLR with a 4-week minimum follow-up. Quality was assessed using Risk of Bias 2. Pooled analyses were conducted using inverse variance for continuous variables and Mantel-Haenszel for dichotomous variables. The Grading of Recommendations, Assessment, Development and Evaluation guidelines were used to evaluate primary outcomes.

RESULTS

A total of 807 patients (632 male, 175 female) from 7 RCTs were included. Mean age was 28.4 years. Bias was graded "low" in 4 RCTs, "some concerns" in 2 RCTs, and "high" in 1 RCT. Visual analog scale was found to be not significantly different with TXA use at day 1-3 (mean difference [MD] -0.92, I² = 96%, P = .14) and 12 weeks (MD -0.03, I² = 0%, P = .73). Visual analog scale was significantly decreased at week 2 (MD -1.18, I² = 56%, P < .00001) and weeks 3-6 (MD -0.38, I² = 73%, P < .010). Lysholm scores were greater with TXA use at week 2 (MD 9.04, I² = 74%, P = .002) and weeks 4-6 (MD 6.17, I² = 73%, P = .0004) but not significantly different at 12 weeks (MD 6.13, I² = 98%, P = .28). Need for aspiration was less with TXA use (odds ratio 0.40, I² = 49%, P = 0.0009). Considerable heterogeneity was seen in many results. Certainty was low for 2 primary outcomes, moderate for 2, and high for 5.

CONCLUSIONS

Pooled data suggest that the use of TXA in ACLR reduces the need for aspiration, hemarthrosis, drain output, and knee swelling in the postoperative period. While early improvements in pain and function were observed, the clinical relevance is questionable. The risk of complications does not increase with TXA use, and the use of intravenous TXA over intra-articular TXA may improve and prolong hemarthrosis reduction, although the evidence is weak.

LEVEL OF EVIDENCE

Level II, systematic review of therapeutic Level I-II studies.

Use of Kinesio® taping and manual lymphatic drainage to manage traumatic edema and ecchymosis post arthroscopic meniscectomy in a recreational weightlifter: A case report

BACKGROUND

Previous studies have reported success of edema management with manual lymphatic drainage (MLD) or Kinesio® taping. However, there is limited evidence investigating the use of a combination of the two postoperatively and evidence is conflicting due to limitations of published trials. The purpose of this case report was to describe the utilization of MLD and Kinesio® taping in the physical therapy (PT) management of edema and ecchymosis post-arthroscopic meniscectomy.

CASE DESCRIPTION

A 51 year-old male was referred to PT 10 days after meniscectomy. He presented with increased edema that was not atypical secondary to a suspected saphenous vein injury. Severe edema and ecchymosis began 24 hours after surgery, which led to pain and decreases in range of motion (ROM) and difficulty with gait. Interventions for edema management consisted of MLD, Kinesio® taping and therapeutic exercise.

OUTCOMES

The patient was seen for five visits over 10 days for edema management that resulted in decreases in girth and pain and increases in ROM and the Lower Extremity Functional Scale, and Patient Specific Functional Scale. He was able to sleep, return to the gym, and squat without pain.

DISCUSSION

Following MLD and Kinesio® taping in conjunction with therapeutic exercises, edema and ecchymosis were reduced allowing for improved function acutely. Early and aggressive edema management postoperatively should be considered to optimize patient outcomes. This case demonstrated early management of edema facilitated increases in ROM and ease of patient-specific activities and decreased pain in five visits.

The Effect of Blood Flow Restriction Training on Muscle Atrophy Following Meniscal Repair or Chondral Restoration Surgery in Active Duty Military: A Randomized Controlled Trial

CONTEXT

Recently, blood flow restriction (BFR) training has gained popularity as an alternative to high-load resistance training for improving muscle strength and hypertrophy. Previous BFR studies have reported positive treatment effects; however, clinical benefits to using BFR following meniscal repair or chondral surgery are unknown. The purpose of this study was to determine the effect of resistance exercises with BFR training versus exercises alone on self-reported knee function, thigh circumference, and knee flexor/extensor strength postmeniscal or cartilage surgery.

DESIGN

Single-blinded randomized controlled trial in an outpatient military hospital setting. Twenty participants were randomized into 2 groups: BFR group (n = 11) and control group (n = 9).

METHODS

Participants completed 12 weeks of postoperative thigh strengthening. The BFR group performed each exercise with the addition of BFR. Both groups continued with the prescribed exercises without BFR from 12 weeks until discharged from therapy. Thigh circumference and self-reported knee function were measured at 1, 6, 12, and 24 weeks postoperatively along with knee extensor and flexor strength at 12 and 24 weeks. Change scores between time points were calculated for knee function. Limb symmetry indices (LSI) were computed for thigh circumference and knee strength variables.

RESULTS

Seventeen participants were included in the final analyses (BFR = 8 and control = 9) due to COVID-19 restrictions. There were no interactions or main effects for group. Time main effects were established for change in knee function scores, thigh circumference LSI, and knee extensor strength LSI. However, knee flexor strength LSI had no main effect for time.

CONCLUSION

The outcomes of this trial suggest that resistance exercises with and without BFR training may result in similar changes to function, thigh atrophy, and knee extensor strength postmeniscus repair/chondral restoration, though further study with larger sample sizes is needed.

Would high-dose corticosteroid addition to multimodal cocktail periarticular injection contribute to prolonged pain control and better recovery following total knee arthroplasty?: study protocol for a randomized controlled trial

BACKGROUND

Enhanced recovery following total knee arthroplasty (TKA) has been advocated to enhance postoperative recovery. Multimodal cocktail periarticular injection (MCPI) use for pain control in TKA has gained wide acceptance. MCPI-containing corticosteroids are believed to be an effective solution owing to their local anti-inflammatory effects and ability to reduce the local stress response postoperatively. However, there is conflicting evidence regarding its benefits. This trial aims to compare MCPI with a high dose of corticosteroid, normal dose of corticosteroid, and non-corticosteroid during TKA, to assess the effectiveness of MCPI containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and side effects and provide evidence that high-dose corticosteroids result in prolonged pain control and better recovery following TKA.

METHODS

This is a double-blinded, randomized, placebo-controlled study. A total of 234 patients scheduled for TKA will be recruited. During surgery, before wound closure, 80 ml of the cocktail analgesic will be injected into the muscle and joint capsule for local infiltration analgesia; the participants will be randomly assigned to three groups to receive a high dose of betamethasone MCPI (group H), normal dose of betamethasone MCPI (group N), and non-betamethasone MCPI (group C). The following indices will be recorded and analyzed: the strongest knee pain experienced during 90° flexion at 6 h, 24 h, 48 h, 72 h, 5 days, 14 days, and 30 days after surgery; 1 min walking ability; and circumference around the patella at 2, 5, 14, and 30 days after surgery; Knee Society knee score at 14 days and 30 days after surgery; C-reactive protein and blood sedimentation; blood sugar 2, 5, 14, and 30 days following surgery; rescue analgesic consumption; and adverse events. If any participant withdraws from the trial, an intention-to-treat analysis will be performed.

DISCUSSION

The results of this study will provide clinical evidence on the effectiveness of MCPI-containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and adverse events, as well as provide evidence on the efficacy of high-dose corticosteroids in prolonged pain control and better recovery following TKA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2000038671 . Registered on September 27, 2020.

The use of an alternating magnetic field in the resorption of postoperative joint effusion following anterior cruciate ligament reconstruction: A randomized double-blind controlled trial

CONTEXT

There are no scientific reports unambiguously describing the efficacy of alternating magnetic field therapy in patients after anterior cruciate ligament (ACL) reconstruction in the early postoperative period.

OBJECTIVE

This study aims to evaluate the efficacy of using an alternating magnetic field in the resorption of postoperative joint effusion in patients after ACL reconstruction.

STUDY DESIGN

A randomized, double-blind placebo-controlled study.

SETTING

Inpatients.

PARTICIPANTS

Forty patients were enrolled in the trial. However, the final study group consisted of 38 patients (28 men and 10 women) after ACL reconstruction who were randomly divided into an experimental group (19 patients) and a control group (19 patients).

INTERVENTION

Each group received magnetic field therapy in the postoperative period, but only 1 apparatus emitted a magnetic field (the experimental group). Patients used the apparatus every day for 30 minutes for the next 11 days. The parameters in both devices were the same-3 mT and 10 Hz.

MAIN OUTCOME MEASURES

The measurement of the knee circumference and range of motion were made. The knee circumference measurement was performed before magnetic field therapy began and for 11 days after magnetic field treatment. The active knee range of motion was evaluated before and after magnetic field therapy was completed.

RESULTS

There were no statistically significant differences between the groups in the reduction of post-operative joint effusion or knee joint function.

CONCLUSION

In patients after ACL reconstruction, in whom an alternating magnetic field was used to treat postoperative joint effusion, there were no beneficial effects on the analyzed variables compared to the control group.

Effects of TheraBand and Theratube Eccentric Exercises on Quadriceps Muscle Strength and Muscle Mass in Young Adults

Purpose

This study was aimed at comparing the effects of TheraBand and theratube eccentric exercises on quadriceps muscle strength in young adults.

Methods

Thirty young adults (19 females, 11 males) participated in this pretest-posttest experimental study. Participants were randomly assigned to one of the two groups: TheraBand and theratube groups. They received the training intervention 3 times a week for 4 weeks (12 sessions) with progression after 2 weeks. Maximum eccentric quadriceps strength was assessed using the Biodex isokinetic dynamometer system. Additionally, quadriceps muscle mass was measured using a tape.

Results

Both groups showed a significant improvement in the peak torque of the eccentric isokinetic quadriceps' strength after weeks 2 and 4. Strength change in the quadriceps was nonsignificant in the theratube group compared to the TheraBand group after 4 weeks of training (p < 0.05). There was no increase in muscle mass during the 4 weeks of training in any group (p > 0.05).

Conclusion

Both the TheraBand and theratube are equally effective in the strengthening of the quadriceps muscle in young adults. Therefore, either the TheraBand or theratube may be used according to the availability and feasibility of the subjects for training intervention.

Evaluating the effects of embedded self-massage practice on strength performance: A randomized crossover pilot trial

Background

Self-administered massage interventions with a roller massager are commonly used as part of warm-ups and post-workout recovery routines. There is yet no clear consensus regarding the practical guidelines for efficient embedded interventions.

Objectives

The present randomized crossover pilot trial aimed at examining the effects of a rolling intervention with a roller massager embedded within the rests periods of a resistance training protocol. The rolling intervention targeted quadriceps muscles.

Setting

Participants (n = 14) performed two resistance training protocols expected to elicit momentary muscle failure. The protocol consisted in 10 sets of 10 rest-pause repetitions of back squats, with a poundage set up at 50% of the maximal one-repetition. Two min were allocated to recovery between sets. During the recovery periods, participants completed a rolling routine with a roller massager for 60 s (Roller-massager), or underwent passive recovery (Control). The total workload, concentric power, thigh circumference rate of perceived exertion (RPE) and delayed onset of muscle soreness (DOMS) from 24 h to 120 h after completion of the protocol were the dependent variables.

Results

Roller-massager was associated with a reduction in total workload (-11.6%), concentric power (-5.1%) and an increase in perceived exertion compared to Control (p < 0.05). Roller-massager was also associated with reduced thigh circumference after the resistance training protocol, indicating reduced muscle swelling, and reduced DOMS 24 h to 120 h post-workout (p < 0.001).

Conclusion

These findings support that embedded rolling with a roller massager hinders performance and increases effort perception. Embedded interventions may not be suitable during conditioning periods designed to maximize training intensity.

Effects of preoperative low-intensity training with slow movement on early quadriceps weakness after total knee arthroplasty in patients with knee osteoarthritis: a retrospective propensity score-matched study

Background

Severe and early quadriceps weakness (QW) after total knee arthroplasty (TKA), which is caused by acute inflammation resulting from surgical trauma and tourniquet-induced ischemia-reperfusion (IR) injury, can be especially problematic. We focused on tourniquet-induced IR injury, because it has been shown to be preventable through ischemic and exercise preconditioning. Low-intensity resistance exercise with slow movement and tonic force generation (LST) share some similarities with ischemic and exercise preconditioning. The present study primarily aimed to clarify the efficacy of preoperative LST program as prehabilitation for early QW among patients with TKA using propensity score matching analysis.

Methods

This single-center retrospective observational study used data from patients with knee osteoarthritis (n = 277) who were scheduled to undergo unilateral TKA between August 2015 and January 2017. Those with missing outcome data due to their inability to perform tests were excluded. The LST group included participants who performed LST and aerobic exercise (LST session) more than seven times for three months prior to surgery. The control group included participants who performed less than eight LST sessions, a general and light exercise or had no exercise for three months prior to surgery. Knee circumference, thigh volume, knee pain during quadriceps strength test (QST) and timed up and go test (TUG), quadriceps strength, and TUG were measured before and 4 days after surgery. Knee swelling, thigh swelling, Δknee pain, QW, and ΔTUG were determined by comparing pre- and postoperative measurements.

Results

Propensity score matching generated 41 matched pairs who had nearly balanced characteristics. The LST group had a significantly lower knee and thigh swelling, QW, and ΔTUG compared to the control group (all, p < 0.05). No significant differences in Δknee pain during the QST and TUG were observed between both groups (both, p > 0.05).

Conclusions

The present study demonstrated the beneficial effects of preoperative LST program on knee swelling, thigh swelling, QW, and walking disability immediately after TKA.

Effect of Nonelastic Compression With an Adjustable Wrap After Total Knee Arthroplasty

Swelling is a common phenomenon after total knee arthroplasty, with potential for negative impact on the rehabilitation process and final outcome. The aim of this study was to investigate the effectiveness of a new compression protocol with a self-adjustable, nonelastic compression wrap for the knee region. This study was conducted as a prospective comparative study. Total leg volume and the circumference of the knee at three levels were compared between groups. The results of our study suggest that the application of the new compression protocol has no effect on swelling in the acute postoperative phase (0-2 days) but reduces swelling at Day 14 within the subacute phase. The observed positive effect of the compression protocol could be of clinical importance in the subacute phase as well as for a subgroup of patients suffering from aberrant quadriceps weakness concomitant with knee swelling.

Effect of Body Weight-Supported Exercise on Symptoms of Knee Osteoarthritis: A Follow-up Investigation

OBJECTIVE

To examine the long-term effect of participation in a 12-week lower-body positive pressure (LBPP)-supported low-load treadmill exercise regime on knee joint pain, physical function, and thigh muscle strength in patients with knee osteoarthritis (OA).

DESIGN

Prospective, observational, repeated measures.

SETTING

Clinical orthopedic setting.

PATIENTS

Nineteen overweight patients with knee OA.

INTERVENTION

Participants exercised under low-load treadmill walking conditions 2×/week for 12 weeks using an amount of LBPP support that minimized knee pain while walking for a period of 30 minutes at a set speed of 3.1 mph at 0-degree incline.

MAIN OUTCOME MEASURES

Knee pain, function, thigh muscle strength, and body anthropometry were reassessed a minimum of 6 months after completion of the initial exercise regime and compared with results from baseline and postexercise evaluation.

RESULTS

Data suggested that: (1) patients were able to maintain improvements in knee joint pain and symptoms; (2) patients continued to report enhanced joint function and improved quality of life; and (3) patients maintained thigh muscle strength gains. Finally, a majority of patients continued to experience significant reductions in acute knee pain during full weight-bearing treadmill walking.

CONCLUSIONS

Data suggest that improvements in knee pain, joint function, and thigh muscle strength associated with participation in a 12-week LBPP-supported low-load exercise regime were maintained well after cessation of the program. These findings have important implications for the development and refinement of exercise strategies and interventions used in the long-term management of joint symptoms associated with knee OA in overweight patients.

Importance of anthropometric features to predict physical performance in elite youth soccer: a machine learning approach

The present study aimed to determine the contribution of soccer players' anthropometric features to predict their physical performance. Sixteen players, from a professional youth soccer academy, were recruited. Several anthropometric features such as corrected arm muscle area (AMA_corr), arm muscle circumference (AMC) and right and left suprapatellar girths (RSPG and LSPG) were employed in this study. Players' physical performance was assessed by the change of direction (COD), sprint (10-m and 20-m), and vertical jump (CMJ) tests, and Yo-Yo Intermittent Recovery Test level 1 (Yo-Yo IRT1). Using an extra tree regression (ETR) model, the anthropometric features permitted to accurately predict 10-m sprint, 20-m sprint and Yo-Yo IRTL 1 performance (p < 0.05). ETR showed that upper-body features as AMA_corr, and AMC affected 10-m and 20-m sprint performances, while lower-body features as RSPG and LSPG influenced the Yo-Yo IRTL 1 (Overall Gini importance ≥ 0.22). The model predicting COD and CMJ presented a poor level of prediction, suggesting that other factors, rather than anthropometric features, may concur to predict their changes in performance. These findings demonstrated that the upper- and lower-body anthropometric features are strictly related to sprint and aerobic fitness performance in elite youth soccer.

Effect of sedation or general anesthesia on elbow goniometry and thoracic limb circumference measurements in dogs with naturally occurring elbow osteoarthritis

OBJECTIVE

To evaluate the effect of sedation or general anesthesia (GA) on elbow goniometry and thoracic limb circumference (TLC) measurements in dogs with elbow osteoarthritis (OA).

STUDY DESIGN

Prospective study.

ANIMALS

Twenty-four client-owned dogs with radiographically confirmed elbow OA.

METHODS

Elbow goniometry and TLC measurements were made before and after either sedation or GA by using a hand-held goniometer and spring tension measuring tape, respectively. Observers were not allowed to review their pre-sedation or pre-GA measurements at the time of obtaining measurements on dogs under sedation or GA. Mixed analysis of variance models were used to compare elbow goniometry and TLC measurements before and after sedation or GA.

RESULTS

Eleven and thirteen dogs were included in the sedation and GA groups, respectively. Mean elbow flexion decreased by 5° and 3° and mean elbow extension increased by 6° and 2° under sedation and GA, respectively. Total range of motion increased by 11° under sedation and by 5° under GA. Each of these changes was statistically significant (P < .05) except elbow extension under GA (P = .129). Sedation and GA did not influence TLC measurements (P > .05).

CONCLUSION

Sedation or GA led to slight and similar increase in elbow flexion and extension but did not influence TLC measurements in dogs with elbow OA.

CLINICAL SIGNIFICANCE

Sedation or GA can cause slight alterations to goniometric measurements in canine elbows with OA. The protocols used in this study for sedation and GA seem interchangeably acceptable for goniometry and TLC measurements in dogs with elbow OA.

Comparing the Effectiveness of Blood Flow Restriction and Traditional Heavy Load Resistance Training in the Post-Surgery Rehabilitation of Anterior Cruciate Ligament Reconstruction Patients: A UK National Health Service Randomised Controlled Trial

BACKGROUND

We implemented a blood flow restriction resistance training (BFR-RT) intervention during an 8-week rehabilitation programme in anterior cruciate ligament reconstruction (ACLR) patients within a National Health Service setting.

OBJECTIVE

To compare the effectiveness of BFR-RT and standard-care traditional heavy-load resistance training (HL-RT) at improving skeletal muscle hypertrophy and strength, physical function, pain and effusion in ACLR patients following surgery.

METHODS

28 patients scheduled for unilateral ACLR surgery with hamstring autograft were recruited for this parallel-group, two-arm, single-assessor blinded, randomised clinical trial following appropriate power analysis. Following surgery, a criteria-driven approach to rehabilitation was utilised and participants were block randomised to either HL-RT at 70% repetition maximum (1RM) (n = 14) or BFR-RT (n = 14) at 30% 1RM. Participants completed 8 weeks of biweekly unilateral leg press training on both limbs, totalling 16 sessions, alongside standard hospital rehabilitation. Resistance exercise protocols were designed consistent with standard recommended protocols for each type of exercise. Scaled maximal isotonic strength (10RM), muscle morphology of the vastus lateralis of the injured limb, self-reported function, Y-balance test performance and knee joint pain, effusion and range of motion (ROM) were assessed at pre-surgery, post-surgery, mid-training and post-training. Knee joint laxity and scaled maximal isokinetic knee extension and flexion strength at 60°/s, 150°/s and 300°/s were measured at pre-surgery and post-training.

RESULTS

Four participants were lost, with 24 participants completing the study (12 per group). There were no adverse events or differences between groups for any baseline anthropometric variable or pre- to post-surgery change in any outcome measure. Scaled 10RM strength significantly increased in the injured limb (104 ± 30% and 106 ± 43%) and non-injured limb (33 ± 13% and 39 ± 17%) with BFR-RT and HL-RT, respectively, with no group differences. Significant increases in knee extension and flexion peak torque were observed at all speeds in the non-injured limb with no group differences. Significantly greater attenuation of knee extensor peak torque loss at 150°/s and 300°/s and knee flexor torque loss at all speeds was observed with BFR-RT. No group differences in knee extensor peak torque loss were found at 60°/s. Significant and comparable increases in muscle thickness (5.8 ± 0.2% and 6.7 ± 0.3%) and pennation angle (4.1 ± 0.3% and 3.4 ± 0.1%) were observed with BFR-RT and HL-RT, respectively, with no group differences. No significant changes in fascicle length were observed. Significantly greater and clinically important increases in several measures of self-reported function (50-218 ± 48% vs. 35-152 ± 56%), Y-balance performance (18-59 ± 22% vs. 18-33 ± 19%), ROM (78 ± 22% vs. 48 ± 13%) and reductions in knee joint pain (67 ± 15% vs. 39 ± 12%) and effusion (6 ± 2% vs. 2 ± 2%) were observed with BFR-RT compared to HL-RT, respectively.

CONCLUSION

BFR-RT can improve skeletal muscle hypertrophy and strength to a similar extent to HL-RT with a greater reduction in knee joint pain and effusion, leading to greater overall improvements in physical function. Therefore, BFR-RT may be more appropriate for early rehabilitation in ACLR patient populations within the National Health Service.

Reliability and precision of single frequency bioelectrical impedance assessment of lower extremity swelling following total knee arthroplasty

Total knee arthroplasty (TKA) is the most common elective orthopedic surgery performed in the United States. Following surgery patients experience significant lower extremity swelling that is related to poor satisfaction with surgery and is hypothesized to contribute to functional decline. However, in practice, precise and reliable methods for measuring lower extremity swelling do not exist. The purpose of this study was to provide reliability and precision parameters of an innovative approach, single frequency bioelectrical impedance assessment (SF-BIA), for measuring post-TKA lower extremity swelling. Swelling in 56 patients (64.3 ± 9.3 years; 29 males) was measured before and after TKA using SF-BIA and circumferential measures (CM). Reliability of the measures was calculated using Intraclass Correlation Coefficients (ICC). Precision of the measures was provided using standard error of the measurement and minimal detectable change (MDC90). Change values between time points for SF-BIA and CM are provided. SF-BIA was found to have greater reliability following surgery compared to CM (ICC = 0.99 vs 0.68). SF-BIA was found to have an MDC90 = 2% following surgery, indicating improved ability to detect minute fluctuations in swelling compared to CM (MDC90 = 6%) following surgery. These results indicate that SF-BIA improves the precision and reliability of swelling measurement compared to CM.

Variables Affecting Thigh Girth Measurement and Observer Reliability in Dogs

Objective: The purpose of the study reported here was to describe variables affecting thigh girth measurements preoperatively and 2 weeks after surgical stabilization of the stifle and to examine inter- and intra-observer reliability.

Animals: Ten hound-type dogs with experimental, unilateral, cranial cruciate ligament transection, and surgical stabilization.

Procedures: Dogs were placed in lateral recumbency for measurements of thigh circumference after the stifle was placed in flexed (F), estimated standing (S), and extended (E) positions. Measurements were made at 50 and 70% of thigh length (TL), with hair unclipped and then clipped prior to surgery, before and 2 weeks after cruciate ligament transection and stifle stabilization, and with and without sedation. A spring tension measuring tape was used to determine thigh girth that allowed a consistent amount of end-tension to be applied to the tape. All measurements were made by two blinded individuals in triplicate, data were recorded for each set of measurements and the mean of the three measurements for each condition was used for analysis.

Results: Thigh girth was significantly greater at the more proximal site of 50% TL (36.7 ± 2.6 cm) when compared to the 70% TL (31.7 ± 2.7 cm) (P = 0.001). Sedation did not significantly affect thigh girth at any stifle position at the 70% and 50% TL. Although there were no differences in thigh circumference between the flexion and standing positions at 50% TL (F 38.2 ± 2.8 cm, S 38.1 ± 2.9 cm) and 70% TL (F 33.6 ± 1.6 cm; S 33.6 ± 1.8 cm), full extension of the stifle resulted in significantly less thigh girth (50% TL 36.6 ± 2.6 cm, P = 0.006; 70% TL 31.7 ± 2.6 cm, P = 0.006). Significant decreases in thigh girth were seen after surgery in all limb positions at both measurement sites. The highest correlations between Observer 1 (OB1) and Observer 2 (OB2) with least differences in measurements were with the stifle in the extended position. Agreement between two observers using standard measuring technique was significant at both the 50% (OB1: 34.10 ± 2.93 cm, OB2: 34.08 ± 2.65 cm, P = 0.007, ICC = 0.984) and 70% (OB1: 29.89 ± 2.43 cm, OB2: 30.04 ± 2.30 cm, P = 0.004, ICC = 0.981) TL positions with the stifle placed in extended position.

Conclusion and Clinical Importance: Thigh girth measurement may be useful as an outcome measure when appropriate measuring technique is used. It is recommended that thigh girth be obtained at a distance of 70% thigh length, with the leg in an extended position while in lateral recumbency, and the dog relaxed or under sedation. Further studies should be performed in a variety of clinical situations.

The effect of eccentric exercise and delayed onset muscle soreness on the homologous muscle of the contralateral limb

High intensity eccentric exercise induces muscle fiber damage and associated delayed-onset muscle soreness (DOMS) resulting in an impaired ability of the muscle to generate voluntary force. This study investigates the extent to which DOMS, induced by high intensity eccentric exercise, can affect the activation and performance of the non-exercised homologous muscle of the contralateral limb. Healthy volunteers performed maximal voluntary contractions of knee extension and sustained isometric knee extension at 50% of maximal force until task failure on both the ipsilateral exercised limb and the contralateral limb. Surface electromyography (EMG) was recorded from the ipsilateral and contralateral knee extensor muscles (vastus medialis, rectus femoris, and vastus lateralis). Maximal isometric knee extension force (13.7% reduction) and time to task failure (38.1% reduction) of the contralateral non-exercised leg decreased immediately after eccentric exercise, and persisted 24 h and 48 h later (p < 0.05). Moreover, the amplitude of muscle activity recorded from the contralateral knee extensor muscles was significantly lower during the post exercise maximal and submaximal contractions following high intensity eccentric exercise of the opposite limb (p < 0.05). Unilateral high intensity eccentric exercise of the quadriceps can contribute to reduced neuromuscular activity and physical work capacity of the non-exercised homologous muscle in the contralateral limb.

Passive Hydrotherapy WATSU® for Rehabilitation of an Accident Survivor: A Prospective Case Report

BACKGROUND

WaterShiatsu (WATSU) is a passive form of hydrotherapy in warm water (35 °C) that aims at relaxation, pain relief, and a sense of security. This case report focuses on a patient's experience of integrating WATSU into her rehabilitative care.

CASE REPORT

A 52-year-old woman survived a severe motorcycle accident in which she sustained several fractures on the right side of her body, including ribs, the pelvis, and the femur. After discharge from stationary care, she independently scheduled 8 weekly WATSU sessions with an experienced WATSU therapist also trained in physiotherapy and psychosomatics. Quantitative and qualitative data obtained from the patient's diary and the therapist's notes is presented.

RESULTS

The patient associated WATSU with physical and emotional release, reconciliation with her body, and trunk mobilization (followed by ameliorated breath). She ascribed WATSU lasting effects on her body image and reported continuous improvement by the Patient-Specific Functional Scale. The therapist employed WATSU to equalize awareness throughout the body and for careful mobilization. Due to complications (elevated inflammation markers), only 6 of 8 scheduled sessions were administered.

CONCLUSIONS

WATSU was experienced as helpful in approaching a condition that the patient felt insufficiently covered by conventional physiotherapy alone. In early rehabilitation, additional medical/physiotherapeutic skills of contributing complementary therapists are advocated.

Effective therapy to reduce edema after total knee arthroplasty Multi-layer compression therapy or standard therapy with cool pack - a randomized controlled pilot trial

Background: After total knee arthroplasty (TKA) efficient control and reduction of postoperative edema is of great importance. Aim: The aim of this pilot study (EKNZ 2014 – 225 DRKS00006271) was to investigate the effectiveness of multi-layer compression therapy (MLCT) to reduce edema in the early period after surgery compared to the standard treatment with Cool Pack. Methods: In this randomized controlled pilot trial, sixteen patients after TKA were randomized into an intervention group (IG) or a control group (CG). Circumferential measurements were used to assess edema. Secondary outcomes were range of motion (ROM), pain (numeric rating scale, NRS) and function as measured with the fast Self Paced Walking Test (fSPWT). Results: Clinically relevant differences in edema reduction between the two groups were found in the early postoperative period and at the six weeks follow up. Six days postoperatively the group time interaction (IE) in favor of the IG were −3.8 cm (95 % CI: −5.1; −2.4) when measured 10 cm proximal to the joint space and −2.7 cm (CI: −4.1; −1.3) when measured 5 cm proximally. We further observed differences in secondary outcomes in favor of the CG. Six days postoperatively the IE for knee flexion was –8.3 ° (CI: −22.0; 5.4) and for the fSPWT it was 12.8 seconds (CI: −16.4; 41.3). Six weeks postoperatively these differences diminished. Conclusions: The findings suggest that MLCT could be an alternative treatment to reduce postoperative edema in patients after total knee arthroplasty. Eventually possible negative effects on early knee flexion and function must be considered.

How does functionality proceed in ACL reconstructed subjects? Proceeding of functional performance from pre- to six months post-ACL reconstruction

This is the first study examining functionality of subjects with anterior cruciate ligament (ACL) tears and a subsequent reconstruction comprehensively by multiple test sessions from pre- to six months post-reconstruction. The purpose was to evaluate if a generally applied rehabilitation program restores functionality to levels of healthy controls. Subjects with unilateral tears of the ACL were compared to matched healthy controls throughout the rehabilitation. 20 recreational athletes were tested: T₁ (preoperative), 6 weeks after tear; T₂, 6 weeks, T₃, 3 months, T₄, 6 months post-reconstruction. At all test sessions, subjects self-evaluated their activity level with the Tegner activity score and their knee state with the Knee Injury and Osteoarthritis Outcome Score. Passive range of motion during knee flexion and extension and leg circumference were measured as functional clinical tests. Bilateral countermovement jumps, one-leg jumps for distance and isometric force tests in knee flexion and extension with 90° and 110° knee angle were conducted as functional performance tests. For determination of functionality, leg symmetry indices (LSIs) were calculated by dividing values of the injured by the uninjured leg. In the ACL group most LSIs decreased from T₁ to T₂, and increased from T₂ and T₃ to T₄. LSIs of ACL subjects remained lower than LSIs of healthy controls at 6 months post-reconstruction in nearly all parameters. Self-evaluation of ACL subjects showed, additionally, that activity level was lower than the pre-injury level at 6 months post-reconstruction. Low LSIs and low self-evaluation indicate that knee joint functionality is not completely restored at 6 months post-reconstruction. The study shows that multiple comprehensive testing throughout the rehabilitation gives detailed images of the functional state. Therefore, the functional state of ACL reconstructed individuals should be evaluated comprehensively and continuously throughout the rehabilitation to detect persisting deficiencies detailed and adapt rehabilitation programs individually depending on the functionality.

Factors predicting quadriceps femoris muscle atrophy during the first 12weeks following anterior cruciate ligament reconstruction

BACKGROUND

Factors predicting quadriceps femoris muscle (QF) atrophy during the early period after arthroscopic ACL reconstruction have not been extensively studied. It is also yet to be confirmed whether muscle atrophy is a key determinant of postoperative QF weakness.

METHODS

Mean changes in QF volume, MVIC torque and isometric endurance time were analysed in 25 patients prior to and at four and 12 weeks after surgery. A multivariable regression model of change in QF volume was made from combination of several parameters of preoperative QF size and strength and postoperative joint recovery. The impact of QF atrophy on muscle weakness was evaluated with univariate regression and MVIC torque to volume ratio at postoperative week only.

RESULTS

The model of QF volume change was significant (P<0.01) only at postoperative week 4, explaining 57% of its variation, where isometric endurance time had a negative and knee extension ROM deficit a positive weight. Change in QF volume explained (P<0.05) 46% of the MVIC torque variation at postoperative week 12. A significant change (P<0.05) in QF MVIC torque to volume ratio was observed at postoperative week 12.

CONCLUSIONS

Good prediction of QF atrophy in the first postoperative month can be made from studied variables, with isometric endurance and knee extension ROM deficit being the most significant contributors. The atrophy explained a large part of QF muscle weakness, whereas factors contributing to the remaining portion need further research.

Bioimpedance spectroscopy for swelling evaluation following total knee arthroplasty: a validation study

BACKGROUND

The evaluation of swelling is important for the outcome of total knee arthroplasty (TKA) surgery. The circumference or volume measurements are applicable at the bedside of the patient but are altered by muscular atrophy and the post-surgical dressing. Bioimpedance spectroscopy might overcome these limitations; however, it should be validated. This study aimed to explore the validity, the reliability and the responsiveness of bioimpedance spectroscopy for measuring swelling after TKA.

METHODS

The degree of swelling in 25 patients undergoing TKA surgery was measured using bioimpedance spectroscopy (BIS R0), knee circumference and limb volume. The measurements were performed on D-1 (day before surgery), D + 2 (2 days after surgery) and D + 8 (8 days after surgery). The BIS R0 measurements were repeated twice, alternating between two evaluators. The percentage of the difference between the limbs was calculated for BIS R0, circumference and volume. The intra- and inter-observer intraclass correlation coefficients (ICCs), limits of agreement (LOA), effect size (Cohen's d), correlations between the methods and diagnostic sensitivity were calculated.

RESULTS

BIS R0, circumference and volume detected swelling < 3.5% at D-1. The swelling at D2 and D8 was greater with BIS R0 [mean (SD) 29.9% (±9.8) and 38.27 (±7.8)] than with volume [14.7 (±9.5) and 14.9 (±8.2)] and circumference [11.1 (±5.7) and 11.7 (±4.1)]. The BIS R0 intra- and inter-evaluator ICCs ranged from 0.89 to 0.99, whereas the LOA were < 5.2%. The BIS R0 correlation was 0.73 with volume and 0.75 with circumference. The BIS R0 Cohen's d was 3.32 for the D-1-D2 evolution. The diagnostic sensitivity was 83% D2 and 96% at D8.

CONCLUSION

Bioimpedance is a valid method for the evaluation of swelling following TKA. BIS R0 also demonstrated excellent intra- and inter-evaluator reliability. The diagnostic sensitivity and responsiveness is superior to that of concurrent methods. BIS R0 is an efficient method for post-surgical follow up at the bedside of the patient. The measurement of BIS R0 is a straightforward, valid, reliable and responsive method for lower limb swelling following TKA surgery that could be used in clinics and research.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00627770.

Short-stretch inelastic compression bandage in knee swelling following total knee arthroplasty study (STICKS): study protocol for a randomised controlled feasibility study

Background

Enhanced recovery programmes in total knee arthroplasty are well established. Post-operative knee swelling is common and impairs early post-operative function. The use of a short-stretch, inelastic compression bandage is hypothesised to reduce knee swelling and improve pain and early function. A study was designed to test feasibility with a view to informing a larger, future trial and to provide preliminary data.

Methods/design

This is a randomised controlled feasibility study. Fifty consecutive patients selected for primary total knee arthroplasty will be enrolled in the trial. Patients with a BMI >35, latex allergy or neurological or peripheral vascular disease are excluded. Patients are randomised by distance randomisation to receive a compression bandage for 24 hours after surgery or a standard wool and crepe bandage. The bandages are applied by one of two consultant surgeons who have had training with their application. Knee swelling, range of motion and pain scores will be compared pre-operatively and at day 1, day 2 and at 6 weeks between groups. The Oxford knee score and EQ-5D health status will be compared pre-operatively and at 6 months between groups. Recruitment rates, retention rates, resource allocation, completeness of data collection, and tolerance and complications with the compression bandage are recorded. Descriptive statistics are used to calculate a standard deviation for post-operative knee swelling in the groups and to perform a power calculation incorporating anticipated patient retention rates to inform a future trial. Preliminary data will be analysed using the independent samples t-test for equal distributions and the Mann-Whitney U for unequal distributions with the significance denoted at P <0.05.

Discussion

Enhanced recovery programmes have revolutionized the management of total knee arthroplasty. There is a paucity of clinical data regarding the efficacy of compression bandages. Large, randomised controlled trials are uncommon in orthopaedic surgery. The results of this study will provide feasibility and preliminary data prior to the construction of a larger, multicentre study.

Trial registration

The study was registered with Current Controlled Trials (ISRCTN86903140) on 30 May 2013.

Effect of pulsed electromagnetic field therapy in patients undergoing total knee arthroplasty: a randomised controlled trial

Purpose

It has been reported that even one year after total knee arthroplasty (TKA), a relevant percentage of patients does not attain complete recovery and indicate unfavourable long-term pain outcome. We compared the clinical outcome of 33 patients undergoing TKA randomly assigned to the control or the pulsed electromagnetic field group (I-ONE therapy).

Methods

I-ONE therapy was administered postoperatively four hours per day for 60 days. Patients were assessed before surgery and then at one, two and six months postoperatively using international scores.

Results

One month after TKA, pain, knee swelling and functional score were significantly better in the treated compared with the control group. Pain was still significantly lower in the treated group at the six month follow-up. Three years after surgery, severe pain and occasional walking limitations were reported in a significantly lower number of patients in the treated group.

Conclusions

Advantages deriving from early control of joint inflammation may explain the maintenance of results at follow-up. I-ONE therapy should be considered an effective completion of the TKA procedure.

Rehabilitation for the management of knee osteoarthritis using comprehensive traditional Chinese medicine in community health centers: study protocol for a randomized controlled trial

Background

It is becoming increasingly necessary for community health centers to make rehabilitation services available to patients with osteoarthritis of the knee. However, for a number of reasons, including a lack of expertise, the small size of community health centers and the availability of only simple medical equipment, conventional rehabilitation therapy has not been widely used in China. Consequently, most patients with knee osteoarthritis seek treatment in high-grade hospitals. However, many patients cannot manage the techniques that they were taught in the hospital. Methods such as acupuncture, tuina, Chinese medical herb fumigation-washing and t’ai chi are easy to do and have been reported to have curative effects in those with knee osteoarthritis. To date, there have been no randomized controlled trials validating comprehensive traditional Chinese medicine for the rehabilitation of knee osteoarthritis in a community health center. Furthermore, there is no standard rehabilitation protocol using traditional Chinese medicine for knee osteoarthritis. The aim of the current study is to develop a comprehensive rehabilitation protocol using traditional Chinese medicine for the management of knee osteoarthritis in a community health center.

Method/design

This will be a randomized controlled clinical trial with blinded assessment. There will be a 4-week intervention utilizing rehabilitation protocols from traditional Chinese medicine and conventional therapy. Follow-up will be conducted for a period of 12 weeks. A total of 722 participants with knee osteoarthritis will be recruited. Participants will be randomly divided into two groups: experimental and control. Primary outcomes will include range of motion, girth measurement, the visual analogue scale, and results from the manual muscle, six-minute walking and stair-climbing tests. Secondary outcomes will include average daily consumption of pain medication, ability to perform daily tasks and health-related quality-of-life assessments. Other outcomes will include rate of adverse events and economic effects. Relative cost-effectiveness will be determined from health service usage and outcome data.

Discussion

The primary aim of this trial is to develop a standard protocol for traditional Chinese medicine, which can be adopted by community health centers in China and worldwide, for the rehabilitation of patients with knee osteoarthritis.

Trial registration

Clinical Trials Registration: ChiCTR-TRC-12002538

I-ONE therapy in patients undergoing total knee arthroplasty: a prospective, randomized and controlled study

Background

Total knee arthroplasty (TKA) is often associated with a severe local inflammatory reaction which, unless controlled, leads to persistent pain up to one year after surgery. Standard and accelerated rehabilitation protocols are currently being implemented after TKA, but no consensus exists regarding the long-term effects. Biophysical stimulation with pulsed electromagnetic fields (PEMFs) has been demonstrated to exert an anti-inflammatory effect, to promote early functional recovery and to maintain a positive long-term effect in patients undergoing joint arthroscopy. The aim of this study was to evaluate whether PEMFs can be used to limit the pain and enhance patient recovery after TKA.

Methods

A prospective, randomized, controlled study in 30 patients undergoing TKA was conducted. Patients were randomized into experimental PEMFs or a control group. Patients in the experimental group were instructed to use I-ONE stimulator 4hours/day for 60days. Postoperatively, all patients received the same rehabilitation program. Treatment outcome was assessed using the Knee Society Score, SF-36 Health-Survey and VAS. Patients were evaluated pre-operatively and one, two, six and 12 months after TKA. Joint swelling and Non Steroidal Anti Inflammatory Drug (NSAID) consumption were recorded. Comparisons between the two groups were carried out using a two-tail heteroschedastic Student’s t-test. Analysis of variance for each individual subject during the study was performed using ANOVA for multiple comparisons, applied on each group, and a Dunnet post hoc test. A p value < 0.05 was considered statistically significant.

Results

Pre-operatively, no differences were observed between groups in terms of age, sex, weight, height, Knee-Score, VAS, SF-36 and joint swelling, with the exception of the Functional Score. The Knee-Score, SF-36 and VAS demonstrated significantly positive outcomes in the I-ONE stimulated group compared with the controls at follow-ups. In the I-ONE group, NSAID use was reduced and joint swelling resolution was more rapid than in controls. The effect of I-ONE therapy was maintained after use of the device was discontinued.

Conclusions

The results of the study show early functional recovery in the I-ONE group. I-ONE therapy should be considered after TKA to prevent the inflammatory reaction elicited by surgery, for pain relief and to speed functional recovery.

Trial registration

Current Controlled Trials ISRCTN10526056

Measuring functional improvement after total knee arthroplasty requires both performance-based and patient-report assessments: a longitudinal analysis of outcomes

The purpose was to explore the responsiveness of both patient-report and performance-based outcome measures to determine functional changes during the acute and long-term postoperative recovery after total knee arthroplasty (TKA). One hundred patients scheduled for unilateral TKA underwent testing preoperatively and at 1 and 12 months postoperatively using the Delaware Osteoarthritis Profile. All physical performance measures decreased initially after surgery then increased in the long term; however, the perceived function did not follow the same trend, and some showed an increase immediately after surgery. Patient-report measures were variable, with no to small response early, but had excellent long-term responsiveness that was twice as large as performance measures. Patient perception fails to capture the acute functional declines after TKA and may overstate the long-term functional improvement with surgery.

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

BACKGROUND AND PURPOSE

Two of the most utilized outcome measures to assess knee joint range of motion (ROM) and intra-articular effusion are goniometry and circumference, respectively. Neither goniometry nor circumference of the knee joint have been examined for both intra-tester and inter-tester in patients with total knee arthroplasty (TKA). The purpose of this study was to determine the intra-tester and inter-tester reliability of active and passive knee joint ROM and circumference in patients with TKA when administered by physiotherapists (testers) with different clinical experience.

METHOD

The design was an intra-tester, inter-tester and intra-day reliability study. Nineteen outpatients (10 females) having received a TKA were examined by an inexperienced and an experienced physiotherapist. Following a standardized protocol, active and passive knee joint ROM and circumference measurements were obtained using a universal goniometer and a tape measure, respectively. To establish reliability, intraclass correlation coefficients (ICC(2,1)) and smallest real difference (SRD) were calculated.

RESULTS

The knee joint ROM and circumference measurements were generally reliable (ICC > 0.8) within and between physiotherapists (except passive knee extension). Changes in knee joint ROM of more than 6.6 degrees and 10 degrees (except active knee flexion) and knee joint circumference of more than 1.0 cm and 1.63 cm represent a real clinical improvement (SRD) or deterioration for a single individual within and between physiotherapists, respectively. Generally, the experienced tester recorded larger knee joint ROM and lower circumference values than that of the inexperienced tester.

CONCLUSIONS

In clinical practice, we suggest that repeated knee goniometric and circumferential measurements should be recorded by the same physiotherapist in individual patients with TKA. Tester experience appears not to influence the degree of reliability.

Validation of the body scanner as a measuring tool for a rapid quantification of body shape

BACKGROUND

Currently, the body scanner, using laser-triangulation, is one of the most precise measuring tools for the rapid quantification of body shape. The VITUS body scanner is a laser-based system based on a principle called triangulation and the scan produced describes the distance to a surface at each point in the picture. The body scanner has multiple applications such as determining body measurements for tailoring, anthropometric investigations and cosmetic surgery. There are also intensive investigations into the effect of weight gain and thus body shape on health risks. In order to be of value, the body scanner needs to generate precise, accurate and reproducible data.

AIMS

To determine the precision and reproducibility of the VITUS XXL 3D body scanner.

METHODS

The measurements of geometric shapes (cones, columns) and human body parts (mid-thigh) were compared using a measuring tape and the body scanner.

RESULTS

The precision of the measurements of the circumferences of a truncated cone and a column was within 1 mm of the actual values (0.29%). The reproducibility of the measurements was very good. The standard deviation in the measurement of a truncated cone was only 0.13% of the actual value. Likewise, the standard deviation of the thigh measurement of 12 human subjects was <1%.

CONCLUSION

These results show that the body scanner can accurately, precisely and reproducibly measure the circumference of objects and human body parts.

Gait symmetry and walking speed analysis following lower-extremity trauma

BACKGROUND AND PURPOSE

Gait has been shown to be a major determining factor of function following limb-salvage surgery. However, little is known regarding the measures associated with gait recovery for this patient population. The purpose of this study was to identify clinical measures associated with impaired walking speed and gait asymmetry in patients with lower-extremity reconstruction.

SUBJECTS

Study subjects were 381 patients from the Lower Extremity Assessment Project (LEAP) who had undergone reconstruction following severe lower-extremity trauma.

METHODS

The LEAP study was a longitudinal study of outcomes following lower-extremity reconstruction. The present study used 24-month clinical follow-up data. A combined outcome measure of reduced walking speed and gait deviation was chosen to provide a comprehensive measure of impaired physical mobility.

RESULTS

The most significant clinical factors associated with decreased walking speed and gait deviation were impaired ankle plantar-flexion range of motion, knee flexion strength, and a nonreciprocal stair-climbing pattern.

DISCUSSION AND CONCLUSION

The findings provide clinicians with specific clinical measures associated with functional recovery in patients with lower-limb reconstruction. These measures, in turn, can be considered to inform treatment decision making and to prioritize interventions.

Effect of drain placed in the donor site in the early postoperative period after arthroscopically assisted anterior cruciate ligament reconstruction with quadrupled hamstring tendons

BACKGROUND

No scientific study has addressed the effects of the routine use of postoperative drains in the donor site after arthroscopic anterior cruciate ligament reconstruction using hamstring tendons.

HYPOTHESIS

Patients who have drains placed in their donor sites have less lower extremity edema, more motion, and more comfort in the early postoperative period.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Thirty-four patients undergoing arthroscopically assisted quadruple hamstring tendon anterior cruciate ligament reconstruction were randomly assigned to either receive a drain for 24 hours placed at the donor site (17 patients) or have no drain at the donor site (17 patients). Data were collected on postoperative days 1, 3, 5, and 7 regarding knee flexion, knee extension, thigh circumference, leg circumference, and visual analog scale (measuring pain).

RESULTS

In the study group versus the control group, there were increased knee flexion measurements on postoperative day 7 (84 degrees vs 69 degrees , P < .05); smaller thigh circumference measurements on postoperative day 7 (36.8 vs 40.1 cm, P < .05); smaller leg circumference measurements on postoperative days 3 (33.2 vs 36.4 cm, P < .05), 5 (32.7 vs 36.0 cm, P < .05), and 7 (31.8 vs 35.7 cm, P < .001); and a lower visual analog scale score on postoperative days 3 (40.38 vs 57.50, P = .001), 5 (38.46 vs 60.35, P = .001), and 7 (38.07 vs 61.43, P = .001).

CONCLUSION

Drain placement at the donor site after anterior cruciate ligament reconstruction gives more comfort to the patient and provides better flexion within the first week.

Criterion-related validity of the figure-of-eight method of measuring ankle edema

STUDY DESIGN

Single-session, prospective, repeated-measures design.

OBJECTIVE

To determine intratester reliability and criterion-related validity of the figure-of-eight method of measuring ankle edema.

BACKGROUND

The measurement of edema is often necessary when physical therapists assess patients with ankle injuries. The figure-of-eight method has been shown to be a reliable method in measuring the size of ankles in subjects without edema but not in subjects with ankle swelling. The validity of this method of measurement has not been established.

METHODS AND MEASURES

The subjects (mean age, 22.7 +/- 4.4 years) were 7 men and 8 women with observable ankle edema secondary to acute or chronic ankle sprains or injury to the lower extremity. Three figure-of-eight measurements were taken by one tester. These measurements were correlated to measurements taken by another tester using a foot volumeter.

RESULTS

The intraclass correlation coefficient (ICC [2,1]) for the figure-of-eight measurements was 0.99. The Pearson Product Moment correlation coefficients between the figure-of-eight measurements and the first volumetric measurement were 0.89 (first figure-of-eight), 0.88 (second figure-of-eight), 0.91 (third figure-of-eight), and 0.90 (mean of all 3 figure-of-eight measurements).

CONCLUSION

The figure-of-eight method was demonstrated to be a reliable and valid indirect method of measuring ankle edema in individuals with edema secondary to sprains or other lower-extremity musculoskeletal disorders.

Thigh and calf girth following knee injury and surgery

Girth measures are commonly used to assess muscle atrophy or joint effusion. Little is known, however, regarding girth measurement changes following knee injury and subsequent surgery. Therefore, the purpose of this study was to compare the thigh and calf girth measurements of involved and noninvolved extremities prior to and following knee surgery for subjects with acute and chronic knee injuries. Of the 40 subjects that were studied, 22 subjects were placed in the acute group (less than 6 months from time of injury to presurgery measurement) and 18 subjects were placed in the chronic group (greater than 6 months from time of injury to presurgery measurement). Thigh and calf girth measurements were taken prior to surgery and then prior to the initiation of outpatient rehabilitation following surgery. For the acute and chronic groups, a three-way analysis of variance (ANOVA) with repeated measures on the extremity, muscle, and time factors was used to analyze the data. For each group, the three-way ANOVA revealed a significant two-way interaction between the extremity and time factors. Post hoc analysis revealed significant differences between involved and noninvolved extremities at both the pre- and post-surgery time periods for the acute and chronic groups. While thigh and calf girth measurement differences existed between the involved and noninvolved extremities prior to and after surgery, the bulk of the girth measurement differences existed prior to surgery for both groups. Based upon the results of this study, the assessment and rehabilitation of the thigh and calf following knee injury and surgery are recommended.