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Volume 21 Number 12 Published by Physicians December 5, 2013 In Physical Medicine and Rehabilitation

PHYSICAL AND COGNITIVE COGNITIVE IMPAIRMENT AFTER Conclusion: This study found FUNCTIONING OF CRITICAL ILLNESS that cognitive impairment following NONAGENARIANS ICU admission is common, with the Previous studies have length of ICU delirium associated with In high income countries, the demonstrated that survivors of critical more severe cognitive deficits at population of individuals living into illness often have poorly understood three and 12 months. their tenth decade is rapidly cognitive dysfunction. These data expanding. This study compared the largely derive from small cohort Pandharipande, T., et al. Long-Term physical and cognitive function of two, studies, restricted to a single disease Cognitive Impairment after Critical complete Danish birth cohorts of process. This study was designed to Illness. N Engl J Med. 2013, October nonagenarians, born 10 years apart. better understand the prevalence of 3; 369(14): 1306-1316. The 1905 cohort study took place long-term cognitive impairment after from August to October 1998, critical illness. including all Danes born in 1905, The Bringing to Light the Risk LEG COMPRESSION AND (n=3,600), 92 to 93 years of age at Factors and Incidence of SKI PERFORMANCE the time of the survey. The 1915 Neuropsychological Dysfunction in cohort study took place 12 years ICU Survivors (BRAIN-ICU) study Given the uneven surfaces and later, and included 2,509 Danes, 94 included adults admitted to a medical high speeds involved in Alpine to 95 years of age at the time of the or surgical ICU with respiratory downhill skiing, athletes are subjected survey. All were assessed for basic failure, cardiogenic shock or septic to strong passive vibrations and activities of daily living, physical shock. Two primary independent risk shocks, activating a large number of performance, cognitive function and factors were studied, including the motor neurons. This can cause an depressive symptomatology. duration of delirium, and the use of early onset of muscle fatigue. As The chance of surviving from birth sedative or analgesic medications compression garments have been to 93 years of age was 20% higher in during hospitalization. The patients shown to attenuate longitudinal and 1915 than in 1905, and that of were assessed for cognitive function anterior – posterior oscillation of reaching 95 years of age was 32% by trained psychology professionals muscles, this study was designed to higher in 1915. The 1915 cohort completing assessments of global investigate whether compression performed better than did the 1905 cognition at three and 12 months garments might positively affect cohort in cognitive function in both after hospital discharge. The primary performance. Cognitive Composite Scores assessment tool was the Repeatable Twelve competitive elite male (p=0.0003) and on the Mini-Mental Battery for the Assessment of skiers were recruited to participate. State exam (p<0.0001), as well as in Neuropsychological Status (RBANS). All were initially tested with 3-min assessments of activities of daily Of the 821 patients recruited, six trials in a downhill tuck position living (p<0.0001). No consistent percent had cognitive impairment involving the simulation of skiing differences were noted between prior to ICU admission. While in the using the application of passive cohorts on physical performance ICU, 74% demonstrated delirium. Of vibration to the soles of both feet. The tests. those able to participate in the three- skiers then performed three trials in Conclusion: This Danish study, month follow-up, 40% displayed random order, one each wearing leg comparing two cohorts of cognition scores equal to those with garments that exerted zero, 20 mm nonagenarians, one born in 1915 and moderate traumatic brain injury, and Hg or 40 mm Hg compression. Data one in 1905, found that those born 26% had scores similar to those with were recorded including the later had a better chance of surviving mild Alzheimer's disease. At 12 electromyographic activities of to their 90s, and when they did, had months, 34% had scores similar to different muscles, cardiorespiratory better cognitive and activities of daily moderate traumatic brain injury and data, changes in total hemoglobin, living function. 24% to those with mild Alzheimer's tissue oxygenation and oscillator disease. The duration of delirium was movement of the vastus lateralis, Christiansen, K., et al. Physical and associated with poorer cognition, blood lactate and perceptual data. Cognitive Function of People Older including executive function, at three The knee angle during the exercise than 90 Years: A Comparison of Two and 12 months. The use of sedative was 10° less when subjects were in Danish Cohorts Born 10 Years Apart. or analgesic medication was not the 20 or 40 mmHg compression Lancet. 2013, November 2; 382: associated with cognitive function at protocol compared with no 1507–1513. follow up. compression(p=0.01). During passive vibration, the EMG activities of the

© Rehab in Review Editor-in-Chief David T. Burke, M.D., M.A. tibialis anterior, gastroc medialis, similar improvements in pain and Emory University, Atlanta, GA rectus femoris and vastus medialis disability scores.

Executive Editor were lower, and the gluteus maximus Conclusion: This study of Randolph L. Roig, M.D. was higher in the compression patients with chronic subacromial Emory University, Atlanta, GA groups than in the control group. bursitis found similar improvements in Copy Editor Immediately after 3 minutes of pain and function between groups Roberta Alysoun Bell, Ph.D. Emory University, Atlanta, GA passive vibration, with compression, receiving palpation guided, and those the tissue saturation index was lower receiving ultrasound guided, steroid Contributing Editors *Amy Cao, M.D. than without compression, while re- injections. BCM/UT Alliance, Houston, TX oxygenation after 90 seconds of

*Jennifer Knowlton, M.D. recovery was enhanced by Hsieh, L., et al. Is Ultrasound Guided East Carolina University, Greenville, NC compression. The Borg scale Injection More Effective in Chronic Subacromial Bursitis? Med Sci Sport *Mikhail Zhukalin, D.O. reflected less perceived exertion in Anna Cruz, M.D. the compression groups than in the Exer. 2013, Dec; 45(12): 2205-2213. Chukwuemeka Ibekwe, M.D. Mitchel Leavitt, M.D. control group. Cleo D. Stafford II, M.D., M.S. Conclusion: This study of alpine Donnie Staggs, M.D. COMBINATION TRAMADOL, Christopher Williams, M.D. skiers found that leg compression Emory University, Atlanta, GA allowed the athletes to maintain a PARACETAMOL, CAFFEINE AND deeper tuck position with less TAURINE FOR BACK PAIN *Cyrus Kao, M.D. *Pablo Vazquez, M.D. perceived exertion and with no Nicole Hanrahan, M.D. differences in whole-body oxygen Michael J. Ingraham, M.D. Acute low back pain (LBP) is a Rajat Mathur, M.D. consumption or blood lactate common complaint in the clinical Georgetown/MedStar National Rehab, Washington, DC concentration. setting. Guidelines for first-line care include analgesic medications and *Alexander Drakh, D.O. Christine Cao, M.D. Sperlich, B et al Is Leg Compression advice to stay active. Clinical use of Lindsay T. Elliot, D.O. Beneficial for Alpine Skiers? BMC combination analgesic drugs has Jerry Miller, M.D. LSU Medical Center, New Orleans, LA Sports Science, Medicine and been studied, including tramadol 37.5 Rehabilitation. 2013, 5:18 mg/paracetamol 325mg. This study *Joshua S. Sole, M.D. Mayo Clinic, Rochester, MN evaluated the efficacy of a novel combination drug including tramadol *Richard Chang, M.D., MPH Mount Sinai Med. Ctr., New York, NY ULTRASOUND GUIDANCE 37.5 mg/paracetamol 325 mg/caffeine FOR CHRONIC 30 mg/taurine 250 mg. *Arpit A. Patel, D.O. SUBACROMIAL BURSITIS Nassau University Med Center The study included 500 patients with acute LBP, randomized to one of *Christina Marciniak, M.D. Ashwin Babu, M.D. Chronic, subacromial bursitis is a two groups. Group A received the Mary Caldwell, D.O. common clinical condition which can study combination medication, and Leda Ghannad, M.D. Amy Mathews, M.D. be treated with corticosteroid group B received the tramadol/ Nicole Rup, M.D. injections. Traditionally, these paracetamol tablet. Both groups took N.W.U../R.I.C., Chicago, IL injections have been administered their medications every six hours for *David Woznica, M.D. using the palpation guided technique, five consecutive days. On day six, the NYP, Columbia-Cornell, NY, NY although the accuracy of these patients returned to the clinic, with *Samaira Khan, D.O. injections is not ideal. This study assessments including self-reported NYU/Rusk Inst. of Rehab Med, NY, NY assessed the functional effect of pain relief scales and pain intensity *Craig Best, D.O. using ultrasound (US) to aid with scales. *Kashif Saeed, M.D. Rush Univ. Medical Center, Chicago, IL these injections. The study group obtained 81% Eligible patients with chronic treatment satisfaction scores, as *Alice Hon, M.D. Arpit Arora, M.D. subacromial bursitis were randomized compared with 45% in the tramadol/ Priya Bolikal, M.D. to one of two treatment groups. paracetamol group (p<0.001). Pain Lawrence P. Lai, M.D., MS Victoria Lin, M.D. Group 1 received corticosteroid intensity was decreased by 83% in Rutgers/Kessler Rehab, Newark, NJ injections with US guidance, while the treatment group, and by 66% in

*Alan Vo, D.O. group 2 received the same injections the tramadol/paracetamol group Sinai Hospital, UMD, Baltimore, MD with palpation guidance. The primary (p<0.001). Conclusion: This study of *Vikram Arora, D.O. outcome measures were a visual Ron Avraham, M.D. analogue scale for pain and active patients with acute low back pain Shivani Dua, M.D. Matthew Santiago, M.D. and passive range of motion of the found that treatment with a Reed Williams, M.D. affected shoulder. The outcome medication combining tramadol, Temple Univ./UPenn., Philadelphia, PA assessors were held blind to the paracetamol, caffeine and taurine *Anupam Sinha, D.O. treatment assignment. resulted in better patient satisfaction Thomas Jefferson Univ/Rothman Inst., Philadelphia, PA A total of 46 subjects were and pain relief than treatment with randomized to the US group and 46 tramadol/paracetamol alone. *Usman F. Ahmad, D.O. Joshua Rothenberg, D.O. to the palpation group. Both groups University of Miami, Miami, FL had increased active and passive Madhusudhan, S., et al. A Novel

*Seth Swank, D.O. range of motion after the injections. Analgesic Combination, Tramadol, Tony Kopp, D.O. The US guided group realized Paracetamol, Caffeine and Taurine, University of Michigan, Ann Arbor, MI significantly greater improvements in in the Management of Moderate to *Chulhyun Ahn, M.D., MS passive shoulder abduction, with Moderately Severe, Acute Low Back UPenn Health System, Phil., PA

Page 2 December 5, 2013 Volume 21 Number 12 Pain. J Ortho. 2013, September; 10 designed to determine whether One hundred forty-four rats (3): 144–140. combining the benefits of vibration underwent induced SAH. The animals with a wobble board can accelerate were randomized to receive either the treatment efficacy. sham, vehicle only, or OPN, ULTRASOUND EVALUATION Thirty-three, male, amateur administered by nasal route, 30 OF FOOT AND ANKLE TRAUMA soccer players with self-reported minutes after the SAH. The subjects unilateral functional ankle instability were evaluated for neurologic scores Ankle injuries are common, often were studied. The subjects were and for brain water content at 24 and resulting in strain, sprain or, less randomized to a wobble board group, 72 hours after the SAH. In addition, frequently, fracture. As ultrasound a vibration plus wobble board group quantification of OPN in the brain and (US) imaging is cheap and radiation or a control group. The two neuronal cell death were determined. free, its use in diagnosing intervention groups underwent a six- At 24 hours after surgery, musculoskeletal injuries has week, progressive rehabilitation neurologic scores were poorer in the increased in past years. This study program, while the control group was vehicle group than in the sham group, was designed to determine the asked to continue with normal with significant improvement noted in accuracy of US in patients with foot activity. The wobble board groups the 5 µg OPN group (p<0.05, and ankle trauma, admitted to the performed identical exercises on an compared with the vehicle group). At emergency department. identical apparatus, with the addition 72 hours, brain water content was This prospective study included of vibration in one group. similar among all groups, although patients with foot or ankle injuries Measurements of the absolute center neurologic scores were worse in the presenting to the emergency of mass distribution, the Modified Star vehicle group than in the sham group, department. Eligible patients were 16 Excursion Balance Test and the with this finding reversed by 5 µg years of age or older, had an Single Leg Triple Hop for distance OPN (p<0.05). Neuronal cell death absence of penetrating trauma, open were recorded before and after the was significantly reduced in the fractures, dislocations or major six-week treatment. cerebral cortex in the 5 µg OPN trauma, were positive according to Compared with the wobble board group compared to the sham group. the Ottawa Ankle Rules and had an group, the vibration plus wobble Conclusion: This animal study of absence of osteomyelitis. All board group had a reduced center of induced subarachnoid hemorrhage participants underwent US mass distribution (p=0.001), improved found that the nasal administration of examination of the whole foot and Modified Star Excursion Balance Test osteopontin can reduce neuronal cell ankle, prior to radiographic (p=0.01) and increased Single Leg death and improve neurologic evaluation. The US results were Triple Hop test distance scores outcome. compared with those of the (p=0.001). radiographs. Conclusion: This study found Topkoru, B., et al. Nasal A total of 131 patients with foot or that combining vibration with wobble Administration of Recombinant ankle injuries were included in the board training can enhance outcomes Osteopontin Attenuates Early Brain study, with an average age of 37.2 as compared to wobble board training Injury after Subarachnoid years. Fractures were detected in 20 alone. Hemorrhage. Stroke. 2013, of the patients by radiography, all of November; 44: 3189–3194. those also identified by US. The Cloak, R., et al. Combined Vibration sensitivity and specificity of US in and Wobble Board Training on detecting fractures were 100% and Balance and Stability in Footballers VITAMIN D FOR 99.1%, respectively. with Functional Ankle Instability. Clin OSTEOARTHRITIS OF THE KNEE Conclusion: This study of J Sport Med. 2013, September; 23 patients presenting to the emergency (5): 384–391. Current management of room with ankle trauma, Ottawa osteoarthritis (OA) of the knee Ankle Rules positive, found that includes nonpharmacological, ultrasound can be an effective tool for NASAL OSTEOPONTIN AFTER pharmacological and surgical diagnosing foot or ankle fractures. SUBARACHNOID HEMORRHAGE interventions. Although vitamin D insufficiency has been linked to Ekinci, S., et al. The Accuracy of Aneurysmal subarachnoid osteoporosis and fractures, the role of Ultrasound Evaluation in Foot and hemorrhage (SAH) has a high vitamin D insufficiency in the Ankle Trauma. A J Emer Med. 2013, mortality and disability rate. Past pathogenesis of OA remains November; 31(11): 1551–1555. research has focused primarily on the controversial. This study further treatment of SAH-induced investigated the role of vitamin D for vasospasm as a means to reduce the treatment of OA of the knee. VIBRATION delayed neurological deficits. This randomized, controlled trial AND WOBBLE BOARDS Osteopontin (OPN) is an extracellular included 103 vitamin D deficient FOR ANKLE INSTABILITY matrix protein which has been patients with knee OA. The subjects implicated in the reduction of were randomly assigned to receive Ankle injuries are common among apoptotic cell death. This animal vitamin D at 60,000 IU per day for 10 soccer players, with functional ankle study was designed to determine days, and then once monthly, or to a instability occurring in a large group whether nasal administration of OPN placebo group, receiving pills of of these patients. The use of wobble can reduce SAH-induced early brain similar appearance. The primary boards for rehabilitation of these injury. outcome measures were knee pain injuries is common. This study was and function, assessed using a visual

Page 3 December 5, 2013 Volume 21 Number 12 analogue scale, and the Western by 10.58%. Participants with a history reported for ischemic stroke in other Ontario and McMaster University of chronic musculoskeletal pain were meta-analyses. Osteoarthritis Index (WOMAC). Total more likely to report current smoking calcium, 25(OH) D, alkaline (p<0.001). Associations between past Sacco, S., et al. Migraine and phosphatase and phosphorus were smoking and chronic pain were not Hemorrhagic Stroke. A Meta- documented. significant. Those with chronic Analysis. Stroke. 2013, November; At 12-month follow-up, the vitamin musculoskeletal pain demonstrated a 44: 3032–3038. D group had less knee pain than did higher usual pain intensity (p<0.001), the control group, as measured by perceived stress (p<0.01) and greater the VAS and WOMAC pain scores anxiety (p<0.001), and were more MIGRAINE HEADACHES (p<0.02 and p<0.001, respectively). likely to meet screening criteria for TRIGGERED BY SUNLIGHT WOMAC function scores worsened in depression (p<0.001), than were the placebo group and improved in those without chronic musculoskeletal A number of studies have shown the treatment group. Serum markers pain. Among twins who were that migraines can be triggered by indicated that vitamin D and total discordant for smoking, those who stress, hormonal instability, sleep calcium levels increased in the smoked had a two-fold greater odds disorders, certain foods, weather treatment group, while the placebo of chronic musculoskeletal pain than changes and exposure to sunlight. group experienced a decrease. did those who did not smoke. This study further reviewed patients Conclusion: This randomized, Conclusion: This study supports with migraine headache, with or controlled trial of patients with previous research identifying an without aura, provoked by sunlight. osteoarthritis of the knee and vitamin association between tobacco abuse Data were reviewed for 2,957 D deficiency found that vitamin D and chronic musculoskeletal pain in patients with headache, all admitted supplementation can decrease pain young adults. to a headache clinic in Turkey. From and improve function. these, 16 were identified with a Holley, A., et al. Current Smoking is a diagnosis of migraine headache Sanghi, D., et al. Does Vitamin D Predictor of Chronic Musculoskeletal onset occurring after sunlight Improve Osteoarthritis of The Knee: A Pain in Young Adult Twins. J Pain. exposure. Characteristics of these Randomized, Controlled Pilot Trial. 2013, October; 14(10): 1131–1139. patients were compared with those Clin Ortho Related Research. 2013; without migraine. 471(11): 3556-3562. Of the sunlight induced migraine MIGRAINE AND group, 14 of 19 had migraine without HEMORRHAGIC STROKE aura. The mean time to headache CURRENT SMOKING AND onset after sunlight exposure was five CHRONIC Several observational studies to 10 minutes in the summer and 60 MUSCULOSKELETAL PAIN have indicated an association minutes in the winter. These patients between migraine and ischemic never experienced any other Musculoskeletal pain is common stroke, with a stronger association triggering factors. during adolescence and young among those experiencing migraine Conclusion: This study found a adulthood. It is the chief complaint in with aura. This meta-analysis was potential subgroup of patients with approximately 30% of primary care designed to further clarify the migraine in whom the only trigger visits among those 20 to 30 years of association between migraine and the factor is sunlight exposure. age. As smoking prevalence and risk of hemorrhagic stroke. initiation is highest during young A search of studies in multiple Tekatas, A., et al. Migraine Headache adulthood, this is a behavior of databases was completed for studies Triggered Specifically by Sunlight: interest when examining contributors reviewing the association between Report of 16 Cases. Euro Neur. to chronic pain. This study was migraine and intracranial hemorrhage 2013; 70(5-6): 263-266. performed to determine the and subarachnoid hemorrhage. Of association between chronic pain in over 11,000 records identified, eight young adults and tobacco use. studies were selected, involving NATURAL HISTORY OF SMALL, From the University of 1,600 hemorrhagic strokes. UNRUPTURED ANTERIOR Washington Twin Registry, 794 pairs From the selected studies, the CIRCULATION ANEURYSMS of twins, 18 to 30 years of age, were pooled, adjusted effect estimate of identified. Participants were asked to hemorrhagic stroke in patients with Previous data concerning complete a questionnaire assessing any migraine as compared with untreated, unruptured intracranial tobacco use, mood and pain in controls was 1.48 (p=0.002). aneurysms of less than seven mm in muscles, joints and bones, lasting for However, the pooled, adjusted effect diameter has demonstrated a very more than three months. For tobacco estimate in patients with migraine small risk for rupture. However, some abuse, participants were asked with aura versus control subjects was have suggested that these data may whether they were current smokers or noted to be statistically nonsignificant be flawed. This study was designed had smoked at least 100 cigarettes (p=0.129). to better understand this risk. over their lifetime. Conclusion: This meta-analysis Beginning in 1999, all patients Current smoking was endorsed by found an increased risk of with intracranial aneurysms seen at a 11.3% of the sample, with 19% hemorrhagic stroke among patients neurovascular center were reporting having smoked at least 100 with migraine, with the overall risk of prospectively entered into a cigarettes. A history of chronic 1.48, found to be lower than that database. Patients with aneurysms of musculoskeletal pain was identified less than seven mm of the anterior

Page 4 December 5, 2013 Volume 21 Number 12 circulation, and without previous receive edoxaban at 30 mg or 60 mg cause of readmission within 90 days subarachnoid hemorrhage, were once daily, or to receive warfarin. The was joint stiffness, seen in 23.9%, evaluated by annual surveillance with primary outcome measure was wound problems, seen in 10.5%, magnetic resonance angiography recurrent, symptomatic venous cardiovascular issues, seen in 6.6% (MRA). All patients seen between thromboembolism. The principle and venous thromboembolism, seen June 1999 and June 2012 were safety outcome measure was in 5.8%. The rate of unplanned selected for inclusion in this study. clinically relevant bleeding. readmission was greater for knees From the database, 387 A symptomatic DVT or PE than for hips at 30 and 90 days aneurysms in the anterior circulation recurred in 3.2% of the edoxaban (p=0.002 and p<0.001, respectively). were identified. Of these, follow-up group and in 3.5% of the warfarin The multivariate analysis revealed MRA found three to be enlarging. group (p<0.001). Clinically relevant that significant independent These were treated by clipping. Three bleeding occurred in 8.5% of the predictors of unplanned readmission aneurysms ruptured during the follow- edoxaban group and in 10.3% of the within 30 days included male gender, up period. The aneurysm size did not warfarin group (p=0.004). increased duration of stay, decreased differ significantly between patients Conclusion: This study of distance to the hospital and discharge who experienced a rupture and those patients with venous to an inpatient facility. who did not (p=0.6). Aneurysm size thromboembolism found that Conclusion: This study of was stable between MRAs among edoxaban is not inferior to warfarin for patients undergoing total joint those who experienced an aneurysm decreasing the amount of recurrent arthroplasty found that 3.1% required rupture. All patients who experienced symptomatic venous thrombo- readmission within 30 days, with a a rupture, and 109 of the 260 patients embolisms. higher rate among those residing without aneurysm rupture, had within 10 km. of the treating hospital. arterial hypertension (p=0.08). All of Butler, H., et al. Edoxaban versus patients with aneurysm rupture, and Warfarin for the Treatment of Zmistowski, B., et al. Unplanned 134 of the 260 without rupture, were Symptomatic Venous Readmission after Total Joint current smokers (100% versus 52%; Thromboembolism. N Eng J Med. Arthroplasty: Rates, Reasons and p=0.2). A multivariate analysis 2013, October 10; 369: 1406-1416. Risk Factors. J Bone Joint Surg. revealed that hypertension and age of 2013, October; 95(20): 1869–1876. less than 50 years were significant, independent predictors of aneurysm UNPLANNED READMISSION rupture. AFTER PROGNOSIS OF Conclusion: This study of TOTAL JOINT ARTHROPLASTY FLEXION CONTRACTURES AFTER patients with unruptured aneurysms TOTAL KNEE ARTHROPLASTY of less than seven mm in diameter, By 2030, more than three million and without a history of subarachnoid total knee, and 500,000 total hip Total knee arthroplasty (TKA) is a hemorrhage, found the overall annual arthroplasties are expected to be common orthopedic procedure. incidence of subarachnoid performed annually in the United Among reported complications, hemorrhage to be 0.2% States. Despite the success of these flexion contracture has been reported surgeries, complications are of in 1.4-17% of patients. This study Guresir, E., et al. Natural History of concern. Readmission rates of four was designed to better determine the Small, Unruptured, Anterior percent to 8.5% have been reported incidence and natural history of these Circulation Aneurysms: A within 30 days of discharge. This contractures, and their effect on Prospective, Cohort Study. Stroke. study was designed to determine the clinical outcome. 2013, November; 44(11): 3027 3031. specific indications for these Subjects were 365 patients readmissions, and to define undergoing primary TKA between predisposing factors. January of 2006 and April of 2011. WARFARIN VERSUS EDOXABAN A total of 11,915 total joint Rehabilitation was initiated for all FOR arthroplasties were identified, patients on the day of surgery. Follow VENOUS THROMBOEMBOLISM including 6,166 total knee -up occurred at six weeks, four arthroplasties (TKAs) and 5,749 total months and one year after surgery. A Venous thromboembolism is the hip arthroplasties (THAs). All Knee Society Score (KSS) was third most common cardiovascular unplanned readmissions within 90 assigned at each visit, assessing disease after myocardial infarction days of discharge were identified. A pain, range of motion, stability and and stroke. The standard treatment multivariate logistic regression was function. The patients with for these events consists of low used to determine the independent postoperative flexion contractures molecular weight heparin, followed by predictors of readmission. were matched and paired with those vitamin k antagonists. This study Of the patients identified, 591 without a postoperative flexion compared the efficacy of a new, unplanned readmissions occurred, contracture. direct inhibitor of activated factor X, involving 5.8% of the patients. Of Of the 319 knees studied, 14 .4% with a rapid onset of action, with that these, 348 occurred within the first 30 developed a new flexion contracture of warfarin. days. The most common causes of of five degrees or more at the six- Subjects were 4,921 patients with readmission within 90 days was joint week follow-up. A residual flexion deep vein thrombosis, and 3,319 with related infection, occurring in 35.9% contracture was detected in 30% at pulmonary embolism, all of whom had of those readmitted within 30 days, four months, and in 15% at one year. initially received heparin. The and 25.4% of those readmitted within The total function KSS scores were subjects were randomly assigned to 90 days. The next most common similar between the study and control

Page 5 December 5, 2013 Volume 21 Number 12 groups. The total knee section of the flexibility and strength improved most therapy does not provide more KSS was lower in the study group in the eccentric group. superior performance outcomes or than in the control group (p= 0.02). Conclusion: This study of patient satisfaction than does group- Conclusion: This study of recreational runners with chronic based or monitored home therapy. patients undergoing total knee Achilles tendinopathy found that arthroplasty found flexion contracture eccentric training is superior to Victoria, K., et al. One-to-One in 14.4% of the patients at six weeks, strength training with vibration for Therapy Is Not Superior to Group or falling to 0.3% at one year. All newly reducing pain and increasing Home-Based Therapy after Total developed flexion contractures function. Knee Arthroplasty. J Bone Joint resolved to five degrees or less at Surg (Am). 2013, Nov 6; 95(21): one year post-surgery. Horstmann, T., et al. Whole Body 1942–1949. Vibration versus Eccentric Training or Anania, A., et al. Natural History of a Wait-and-See Approach for Chronic Newly Developed Flexion Contracture Achilles Tendinopathy: A HEMOGLOBIN A-1 C AND following Primary Total Knee Randomized, Clinical Trial. J COMPLICATIONS OF Arthroplasty. International Ortho. Orthoped Sport Phys Ther. 2013, TOTAL JOINT ARTHROPLASTY 2013; 37: 1917-1923. November; 43(11): 794–803. Among patients with diabetes, 52% have physician diagnosed ACHILLES TENDINOPATHY: ONE-ON-ONE VERSUS GROUP arthritis. As the incidence of diabetes VIBRATION VERSUS THERAPY AFTER increases, so does the number of ECCENTRIC TRAINING TOTAL KNEE ARTHROPLASTY diabetic patients who undergo hip and knee arthroplasty. This study was As a treatment for Achilles After a total knee arthroplasty designed to determine the tendinopathy, eccentric training has (TKA), outpatient physical therapy association between diabetes, control shown promise, although training may involve one-on-one therapy, of diabetes, and postoperative protocols vary widely. In addition, group-based therapy, home-based complications. whole body vibration has been exercise programs and, more This retrospective study reviewed explored as a means to enhance recently, tele-rehabilitation. This study hospital records for patients training and as an adjunct to was designed to compare the undergoing primary or revision total therapeutic exercise. This study was effectiveness of different methods of hip or total knee arthroplasty. Of the designed to compare eccentric rehabilitation. 152 patients identified as diabetic, training with strength training This multicenter study included 118 had HbA1c levels available within combined with vibration. patients undergoing primary TKA in 90 days of surgery. Based upon Subjects were recreational one of two Sydney, Australia, these results, the subjects were runners, ages 25 to 55 years, all with metropolitan hospitals. At two weeks grouped by HbA1c scores, with these chronic Achilles tendinopathy. The 12 post-surgery, the patients were compared to postoperative -week intervention phase included 36 randomized to receive one-on-one complications. sessions for each participant. The therapy, group-based therapy or Postoperative complications vibration group exercised on a monitored home therapy. increased with increasing HbA1c vibration platform, performing heel Standardized assessments were levels (R2=0.87). Those with levels rises and heel drops. The eccentric conducted before surgery, and then higher than 7.5% had postoperative exercise group slowly lowered the two, 10, 26 and 52 weeks later. The complications at a greater rate than ankle until reaching full dorsiflexion, primary outcome measure was the did those with lower levels. using the contralateral limb to return Oxford Knee Score (OKS). Conclusion: This study found a to the starting position. The control Secondary outcomes included the clear correlation between group maintained their usual Western Ontario and McMaster postoperative complications and recreational activities. Pain with Universities Osteoarthritis Index and hemoglobin A-1C levels. palpation, flexibility and strength were a visual analogue scale for pain and assessed at baseline and at follow- function. Goldstein, D., et al. Effect of up. Improvement was most marked Preoperative Hemoglobin A-1 C Level Fifty-eight runners with an between weeks two and ten on Acute Postoperative average pain duration of 3.7 years postoperatively for all groups. At 10 Complications of Total Joint completed the program. Pain weeks post-surgery, no significant Arthroplasty. Am J Ortho. 2013, improvement at the midsection of the difference in OKS was found between October; 42(10): E88–E90. tendon was greater in both treatment the groups. Further, one-to-one groups than in the control group. The therapy was not significantly superior vibration group did not experience to group-based therapy or a home ISOTONIC AND ISOMETRIC any change in pain at the monitored program in secondary HAND EXERCISES FOR musculotendinous junction, compared outcomes. Patient satisfaction was RHEUMATOID ARTHRITIS with a 66.6% reduction for the also not superior at 10 weeks in the eccentric group and a 73.3% increase one-on-one group as compared to Rheumatoid arthritis (RA) is a for the wait-and-see group. The other intervention groups. systemic disease with a chronic, eccentric group enjoyed a decrease Conclusion: This study of progressive course, often leading to in the pain limiting running. Muscle patients undergoing total knee erosions in the wrist, arthroplasty found that one-on-one metacarpophalangeal (MCP) and

Page 6 December 5, 2013 Volume 21 Number 12 proximal interphalangeal joints. according to BMI and were followed During the execution of the motor Studies of hand exercises in RA have prospectively for two years. task, patients were encouraged to reported various benefits, although Comparison groups were formed by pronounce words according to the methodologies have been World Health Organization semantic criteria, to count backwards, heterogeneous. This study was classifications of BMI as normal or to name figures and colors. The designed to determine whether a six- weight (< 25 kg/m²), overweight (BMI subjects were assessed for cognition, week long isotonic or isometric hand 25 to 29.9 kg/m²) or obese (BMI > 30 affect and physical activity. A force exercise program would effect pain kg/m²). platform was used to measure hand function dexterity and quality of Significant improvements in visual postural control. Functional capacity life in women with RA. analog scores for pain were noted in was evaluated using the Timed Up Subjects were females with RA all three cohort groups, with no and Go Test, the 30-Second Sit to between the ages of 40 and 70 years. significant differences among the Stand and Sit Test, the Reach Test All underwent assessments including weight groups. Patients in the and the Berg Balance Scale. pain, hand function, dexterity, quality- overweight and obese groups After four months, the training of-life, hand grip strength and disease demonstrated significantly less group had improved global function activity. The participants were then overall physical functional (p<0.01), postural control and randomized to perform either isotonic improvement, as measured by SF–36 functional capacity (p<0.01), attention or isometric hand exercise five days a Physical Component scores, as (p=0.001) and lower limb strength week. Exercises were preceded by compared with patients in the normal (p<0.01), with no significant wax dipping treatments with warming weight group, while no significant difference seen in balance scores for 15 minutes. After two weeks, the difference was found on the SF–36 Conclusion: This study of patients were instructed to perform Mental Component scores. patients with Alzheimer’s disease the exercises at home. Conclusion: This study of found that exercise associated with At the end of week six, those in patients undergoing total shoulder frontal cognitive stimulation enhances the isometric group showed an arthroplasty found that being frontal cognition and balance in increase in dominant hand strength, overweight or obese results in poorer individuals with AD. with the isotonic group showing a physical outcome, although no effect significant increase in non-dominant on pain scores was seen at two-year De Andrade, L., et al. Benefits of hand strength, as compared with follow-up. Multimodal Exercise Intervention for baseline. Other evaluation scores Postural Control and Frontal improved significantly in both groups, Li, X., et al. Functional Outcomes Cognitive Function in Individuals with with no differences between groups. after Total Shoulder Arthroplasty in Alzheimer's Disease: A Controlled Conclusion: This study of Obese Patients. J Bone Joint Surg. Trial. J Am Geriatric Soc. 2013, patients with rheumatoid arthritis 2013, November 6; 95(21): doi: November; 61(11): 1919-1926. found beneficial effects of isotonic 10.2106/JBJS.L.01145 and isometric exercise, with no difference in outcomes between the LUMBAR DISC HERNIATION IN two. EXERCISE FOR POSTURE AND ATHLETES COGNITION IN Dogu, B., et al. Effects of Isotonic and ALZHEIMER'S DISEASE Back pain from lumbar disc Isometric Hand Exercises on Pain, herniation has been found to Hand Function, Dexterity and Quality- Patients with Alzheimer’s disease decrease performance in athletes. Of-Life in Women with Rheumatoid (AD) often exhibit progressive This study was designed to clarify the Arthritis. Rheum Intern. 2013, impairment of recent memory, outcomes of a group of hockey October; 33(10): 2625–2630. semantic aphasia, agnosia, apraxia players with lumbar disc herniation and executive function. Individuals who were treated surgically versus with early-stage AD may have a nonsurgically. OBESITY AND FUNCTIONAL discrete motor function abnormality. This descriptive epidemiologic OUTCOME OF TOTAL This study assessed whether physical study utilized public record archives SHOULDER ARTHROPLASTY exercise, associated with frontal and team injury reports. From these cognitive stimulation, could improve were identified 87 National Hockey While some studies have frontal cognition and postural control. League players with back injury demonstrated that patients with This study included 30 between 1967 and 2009. obesity undergo a disproportionately participants with AD, divided into two Performance outcomes included high number of elective orthopedic groups. The treatment group received return to play rate, games played per procedures, there is little literature a multimodal exercise intervention, season, points per game and concerning those undergoing total including motor activity and frontal performance scores. Performance shoulder arthroplasty. This study was cognitive activity. The control group was compared before and after injury, designed to compare the did not participate in any activity. The with data then compared between perioperative complications and physical exercise protocol included those who underwent surgery and functional outcomes of patients by aerobic exercise, muscle those who underwent nonsurgical body mass index (BMI). strengthening, flexibility and balance intervention. Of 234 patients who underwent exercises. The exercise protocol Of the 87 NHL players diagnosed total shoulder arthroplasty, 76 were encompassed cognitive components with a symptomatic lumbar disc enrolled in a prospective registry. including executive function, attention herniation, 31 underwent These patients were grouped and language. nonoperative care, and 56 underwent

Page 7 December 5, 2013 Volume 21 Number 12 (Continued from page 2) surgical care. Of the surgeries, 48 Rehab in Review (RIR) is produced underwent a discectomy and eight a monthly by physicians in the field of *Chulhyun Ahn, M.D., MS Physical Medicine and Rehabilitation UPenn Health System, Phil., PA single-level fusion. After injury, the (PM&R), with the cooperation and return to play rate was 85% for all *Thiru Annaswamy, M.D. assistance of Emory University School Trixy Syu, D.O. players. Comparison of all seasons of Medicine, Department of Rehabilita- UTSW Medical Center, Dallas TX before and all seasons after the tion Medicine. The summaries diagnosis revealed a significant appearing in this publication are *Rachel Hallmark, M.D., Ph.D. intended as an aid in reviewing the UVA, Charlottesville, VA decrease in games played per broad base of literature relevant to this season (p<0.0001), points per game *Ryan Solinsky, M.D. field. These summaries are not University of Washington, Seattle, WA (p=0.01) and performance scores intended for use as the sole basis for (p<0.0001). No significant difference clinical treatment, or as a substitute for *Bonnie Weigert, M.D. the reading of the original research. Lauren Schatzeder, D.O. was seen in the decrease in University of Wisconsin, Madison, WI performance scores between the The Emory University School of Medicine designates this journal based *William Robbins, M.D. surgical and the nonsurgical groups. activity for a maximum of 3 AMA PRA Angel Chang, M.D. However, those treated nonsurgically Category 1 Credits™. Physicians Udayan Kulkarni, M.D. had a greater decrease in points should only claim credit commensurate James Newman, M.D. Don Tower, D.O. scored per game than did the surgery with the extent of their participation in VCU, Richmond, VA group (p=0.001). the activity. The Emory University School of Medicine is accredited by the *Adam J. Schulte, M.D. Conclusion: This study of ACCME to provide continuing medical Mark F. Adderley, D.O. national hockey league players with education for physicians. Michael Ahuja, M.D. H. Orson Setzer, D.O. disc herniation found that return to RIR is affiliated with the Association Washington University, St. Louis, MO play and post-injury performance of Academic Physiatrists, the World were comparable between athletes Health Organization, and the Chinese Executive Editor Emeritus and Indian Societies of PM&R and en- Donald F. Langenbeck, Jr., M.D. treated surgically and those treated dorsed by the International Society of nonsurgically. Subscription Manager Physical and Rehabilitation Medicine. Michael P. Burke, M.S. Private subscriptions are available Schroeder, G., et al. Performance- by email at [email protected] or by fax or phone at (800) 850-7388. Based Outcomes after Nonoperative Treatment, Discectomy and/or Fusion ISSN # 1081-1303 www.rehabinreview.com *Regional Managing Editors have for Lumbar Disc Herniation in attested that they have no financial conflict of interest when choosing National Hockey League Athletes. articles that appear in Rehab in Am J Sports Med. 2013, November; Review. 41 (11): 2604–2608.

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