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Application of an ankle foot orthosis (AFO) has proven to be an effective means of improving functional ambulation in the hemiparetic individual. Although many custom-fabricated AFO designs are commonly used to improve different gait parameters, application of the pressure relief AFO (PRAFO) has empirically been shown to offer similar improvements in ambulatory potential in this patient population. Computerized gait analyses of eight hemiparetic patients were conducted for barefoot ambulation and in the PRAFO to compare kinetic and kinematic changes when wearing the PRAFO as a functional orthosis. The data demonstrated statistically significant improvements in the sagittal plane ankle kinematics for all subjects who demonstrated excessive equinus during barefoot ambulation-thus substantiating the observations that the PRAFO can provide effective control of the ankle foot complex during hemiparetic gait. [ABSTRACT FROM AUTHOR]

The validity of the 24‐hour recall (24 HR) for estimating group aggregate and individual daily energy, protein, calcium, iron, zinc and vitamin C intakes of 29 rural Malawian children (4–6 years) was assessed by comparing weighed record (WR) and 24 HR dietary data collected for the same day of food intake. There were no significant differences comparing group median energy and nutrient intakes estimated using the two techniques. The percentage differences between group mean intakes ranged from 1% (vitamin C) to 16% (Ca). In general, these differences were reduced when morning meal intakes were omitted to eliminate the systematic bias affecting estimates of porridge intake. Spearmans and intra‐class correlation coefficients ranged from 0.28 (vitamic C) to 0.55 (Zn), and from 0.14 (vitamin C) to 0.51 (Zn), respectively. Less than 35% of the nutrient intakes estimated using the 24 HR were within ± 10% of those estimated via the WR (range = 12% for vitamin C and Ca to 33% for protein), and over 50% of the subjects consumed more than ± 20% of the 24 HR estimates for most nutrients. Reasons for the low percentage agreement between the WR and 24 HR results included errors in reporting snack food consumption, the use of average recipes, and imprecision in the recall of quantities of main meal dishes consumed. These data suggest that the 24 HR could be substituted for the WR, when estimates to within ± 10% of actual group mean intakes of energy, protein, iron, and zinc are required. [ABSTRACT FROM PUBLISHER]

Background: Aging is associated with a reduction in gait velocity, which is due to a shortened step length. This study investigated the relationship between joint kinetics and step length.Methods: Three-dimensional gait kinematics and kinetics were measured during usual pace gait in 26 older subjects (average age 79) and in 32 young subjects (average age 26). Gait measures were obtained at maximal velocity in five older subjects. Lower extremity strength was measured in the older subjects on an isokinetic dynamometer.Results: Older persons had a 10% shorter step length during usual gait, when corrected for leg length (.65 +/- .07, .74 +/- .04/leg length, respectively, p < .001). Older persons had reduced ankle plantarflexion during late stance (13 +/- 5 degrees, 17 +/- 5 degrees, p = .02) and lower ankle plantarflexor power (2.9 +/- 0.9 W kg-1, 3.5 +/- 0.9 W kg-1, respectively, p = .007). Ankle strength was associated with plantarflexor power developed during late stance (r = .49, p < .001). When gait kinetics were corrected for step length, the older subjects developed 16% greater hip flexor power during late stance than younger subjects (estimate of effect: .15 W kg-1, p = .002). Older subjects were unable to increase ankle plantarflexor power at maximal pace, but increased hip flexor power 72% (1.1 +/- 0.3 W kg-1 to 1.9 +/- 1.0 W kg-1, p = .02).Conclusions: Older subjects had lower ankle plantarflexor power during the late stance phase of gait and appeared to compensate for reductions in plantarflexor power by increasing hip flexor power. Appropriate training of ankle plantarflexor muscles may be important in maintaining step length in advanced age. [ABSTRACT FROM AUTHOR]

Background: The Foot Posture Index-6 (FPI6) is an assessment of foot position that can be useful for patients with orthopaedic complaints. The FPI6 rates six components of foot position from -2 to +2, resulting in a total score on a continuum between -12 (severe cavus or supination) to +12 (severe planus or pronation). The subscores are ratings made by the examiner and are subjective assessments of deformity severity. The FPI6 requires palpation of bony structures around the foot and therefore must be administered live during physical examination. Because it is sometimes impractical to perform these assessments live, such as for retrospective research, a valid and reliable video-based tool would be very useful., Questions/purposes: This study examines a version of the FPI using three of the original six components to determine: (1) Are scores from the three-component version of the FPI (FPI3) associated with those from the original six-component version (FPI6)? (2) Is the three-component FPI3 as reliable as the original six-component FPI6? (3) Are FPI3 assessments done retrospectively from video as reliable as those done live?, Methods: A retrospective group of 155 participants (106 males; mean age 13 ± 4 years) was studied. All had undergone gait analysis including videotaping and in-person assessment using the FPI6. Ratings for three components (calcaneus inversion/eversion, medial arch congruence, and forefoot abduction/adduction) were extracted yielding an FPI3 score ranging from -6 to +6. The other three components of the FPI6 (talar head palpation, curves above and below the lateral malleolus, talonavicular joint bulge) were excluded from the FPI3. FPI6 and FPI3 scores and side-to-side asymmetry were compared for all participants and for diagnosis subgroups (cerebral palsy and Charcot-Marie-Tooth disease) using a Pearson correlation. Agreement for foot posture categorization between the FPI6 and FPI3 was assessed using weighted kappa. Intra- and interrater reliability of live and video-based assessments for the FPI3 and its components were examined using intraclass correlation coefficients (ICCs) and Bland-Altman analysis., Results: Scores from the FPI3 and FPI6 are highly associated with each other, suggesting the FPI3 is an adequate substitute for the FPI6. FPI6 and FPI3 scores (r = 0.98) and asymmetry (r = 0.96) were highly correlated overall and within the cerebral palsy (r = 0.98 for scores; r = 0.98 for asymmetry) and Charcot-Marie-Tooth (r = 0.96 for scores; r = 0.90 for asymmetry) subgroups (all p < 0.001). Agreement between the FPI6 and FPI3 was high for foot posture categorization (weighted agreement = 95%, weighted κ = 0.88; p < 0.001). Interrater reliability for live ratings was similar for FPI3 and FPI6 and high for both measures (ICC = 0.95 for FPI6 and 0.94 for FPI3; both p < 0.001). High reliability was seen in video versus live ratings for the FPI3 total score and each of its components regardless of whether they were performed by the same (ICC = 0.98) or different (ICC = 0.97) raters (both p < 0.001), and interrater reliability remained high when the FPI3 was scored from video recordings (ICC = 0.96; p < 0.001)., Conclusion: The FPI3 is valid and reliable when done live or from video or by the same or different examiners. It is suitable for retrospective and multicenter research studies, provided videos are done using standardized protocols. Further research is recommended investigating possible ceiling and floor effects in patients with pathologic conditions.Level of Evidence Level III, diagnostic study., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

Physical activity avoidance and fear of movement (FOM) is often observed in individuals with chronic musculoskeletal pain, along with difficulties coping with pain. There is little research regarding how FOM may also relate to reduced physical strength and altered movement patterns that may perpetuate a cycle of pain, FOM, and disability. The objective of this observational study was to compare how adolescents with juvenile fibromyalgia (JFM) exhibiting high versus low FOM (Tampa Scale of Kinesiophobia-11) differed on patient-reported measures of pain, fatigue, catastrophizing and pain interference, and performance-based measures of strength, postural control, and biomechanical function. Participants were youth with JFM (N = 135, Mean age = 15.6 years, 88.9% female) enrolled in an ongoing clinical trial who completed self-report questionnaires and standardized tests, including knee and hip strength, the Star Excursion Balance Test, and the Drop Vertical Jump (with 3 dimensional motion capture). Participants were categorized into Low, Medium, and High FOM groups based on Tampa Scale of Kinesiophobia-11 tertile scores. Relative to the Low FOM group, the High FOM group reported significantly greater fatigue, pain interference and catastrophizing, as well as reduced dominant leg knee strength. Additionally, those with high FOM showed altered lower-extremity movement patterns. This preliminary study highlights the importance of combining self-reported measures of symptoms and functioning with physical assessments to gain a more comprehensive view of the impact of FOM in patients with chronic musculoskeletal pain. The results could inform the development of more precise interventions to reduce FOM using a combination of behavioral and exercise-based interventions., Perspective: The results of this study demonstrate the association between FOM, fatigue and pain interference in adolescents with JFM, as well as preliminary evidence for altered movement patterns in that may predispose them to further pain/injury and activity avoidance., Gov Registration: NCT03268421., (Copyright © 2024 United States Association for the Study of Pain, Inc. Published by Elsevier Inc. All rights reserved.)

Abstract: Juvenile fibromyalgia (JFM) is a chronic condition characterized by symptoms of pain and fatigue and is associated with sedentary behavior and functional disability. Adults with fibromyalgia exhibit deficits in physical fitness as evidenced by lower aerobic capacity and physical endurance, but it is unknown whether these impairments are apparent in adolescents with JFM. Furthermore, the extent to which functional disability and pain interference relate to measures of physical fitness has not been investigated in a pediatric pain population. During a baseline assessment for a clinical trial, 321 adolescents with juvenile fibromyalgia (M age = 15.14, 85.2% female) completed measures of pain intensity, fatigue, JFM symptom severity, functional disability, and pain interference. They also completed 2 validated fitness tasks: (1) the Harvard step test, which assesses aerobic fitness, and (2) the 6-minute walk test, a simple submaximal test of endurance. We examined associations among self-report measures and fitness assessments using bivariate correlations. We then employed hierarchical regression analyses to determine the unique contributions of physical fitness assessments to self-reported functional disability and pain interference. Results indicated that youth with JFM exhibited deficits in aerobic capacity and physical endurance. However, physical fitness explained negligible variance in functional disability and pain interference beyond that accounted for by pain, fatigue, and JFM symptom severity. Scores on available functional disability measures may reflect perceived difficulties in coping with symptoms during physical tasks rather than actual physical capability. Rigorous and sensitive assessments of physical fitness and endurance are needed to determine whether rehabilitation interventions for pediatric pain improve physical functioning., (Copyright © 2023 International Association for the Study of Pain.)

Objective: Juvenile-onset fibromyalgia (JFM) is a chronic debilitating pain condition that negatively impacts physical, social and academic functioning. Cognitive-behavioral therapy (CBT) is beneficial in reducing functional disability among adolescents with JFM but has only a modest impact on pain reduction and does not improve physical exercise participation. This randomized controlled trial (RCT) aims to test whether a novel intervention that combines CBT with specialized neuromuscular exercise training (the Fibromyalgia Integrative Training program for Teens "FIT Teens") is superior to CBT alone or a graded aerobic exercise (GAE) program., Design/methods: This 3-arm multi-site RCT will examine the efficacy of the FIT Teens intervention in reducing functional disability (primary outcome) and pain intensity (secondary outcome), relative to CBT or GAE. All interventions are 8-weeks (16 sessions) in duration and are delivered in small groups of 4-6 adolescents with JFM. A total of 420 participants are anticipated to be enrolled across seven sites with approximately equal allocation to each treatment arm. Functional disability and average pain intensity in the past week will be assessed at baseline, post-treatment and at 3-, 6-, 9- and 12-month follow-up. The 3-month follow-up is the primary endpoint to evaluate treatment efficacy; longitudinal assessments will determine maintenance of treatment gains. Changes in coping, fear of movement, biomechanical changes and physical fitness will also be evaluated., Conclusions: This multi-site RCT is designed to evaluate whether the combined FIT Teens intervention will have significantly greater effects on disability and pain reduction than CBT or GAE alone for youth with JFM. Clinical trials.gov registration: NCT03268421., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Research suggests that dynamic balance in adolescents is compromised following concussion and may worsen if patients return to sport (RTS) too soon. Understanding if there are ongoing dynamic balance deficits in adolescents at the time of RTS clearance would determine if more complex motor tasks are necessary to facilitate safe RTS decisions., Research Question: The purpose of this study was to determine if there were remaining dynamic balance deficits in concussed adolescents at the time of clearance for RTS., Methods: Sixteen concussed adolescent athletes (age 14.6 ± 1.8 years; 9 males; 57 ± 46 days post injury) performed a simple walking task as well as two split attention gait tasks (reciting months backwards and audio Stroop). The center of mass (COM) movement and walking velocity during these tasks was compared to a control group of 15 healthy non-concussed adolescent athletes (age 13.8 ± 1.4 years; 9 male)., Results: The results indicated that there were no statistically significant differences between the two groups for any of the tasks. Height-normalized walking speed did not differ between groups during walking alone (control: 0.757 ± 0.119, concussed: 0.739 ± 0.108, p = 0.34), with the recitation task (control: 0.555 ± 0.095, concussed: 0.557 ± 0.143, p = 0.72), or with the Stroop task (control: 0.589 ± 0.129, concussed: 0.567 ± 0.141, p = 0.43). Similarly, height-normalized medial-lateral COM displacement did not differ between groups during walking alone (control: 0.027 ± 0.007, concussed: 0.028 ± 0.007, p = 0.98, with the recitation task (control: 0.037 ± 0.012, concussed: 0.0.037 ± 0.016, p = 0.82), or with the Stroop task (control: 0.032 ± 0.014, concussed: 0.033 ± 0.009, p = 0.891)., Significance: These findings indicate that the patients were returned to sport when their dynamic balance was similar to controls suggesting that this cohort had recovered from their concussion. However, large variability in dynamic balance measures in both the patient and control groups may reflect ongoing neuromuscular development and requires further exploration., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Cognitive-behavioral therapy (CBT) is effective in reducing disability among youth with juvenile fibromyalgia (FM); however, engagement in moderate to vigorous physical activity remains poor, even after CBT. The purpose of this study was to evaluate the feasibility and preliminary outcomes of an innovative program combining CBT with specialized neuromuscular exercise: the Fibromyalgia Integrative Training for Teens (FIT Teens) program., Methods: Adolescents with juvenile FM (n = 22, all female, ages 12-18 years) from 2 urban children's hospitals participated in the 8-week FIT Teens intervention. Participants completed measures of pain intensity, functional disability, depressive symptoms, pain catastrophizing, fear of movement, and readiness to change at baseline and after the intervention., Results: The feasibility of the intervention across 2 sites was documented, including high retention rates (80%). Participants showed significant decreases in functional disability (P < 0.05), depression (P < 0.001), fear of movement (P < 0.01), and pain catastrophizing (P < 0.001) from pre- to postintervention. Results of the readiness to change measure indicated a significant decrease in precontemplation (P < 0.01) and increase in action/maintenance scores (P < 0.001). All results demonstrated medium to large effect sizes., Conclusion: Adolescents with juvenile FM reported significant improvements in physical function and reduced fear of movement following the intervention. Improvement in physical function was achieved in a shorter time frame than in a prior trial of CBT without an exercise component. Further work is needed to compare the FIT Teens program with existing approaches and determine whether objective changes in exercise participation are achieved., (© 2016, American College of Rheumatology.)

Heritable diseases of the peripheral nerves (Charcot-Marie-Tooth disease [CMT]) affect the motor units and sensory nerves, and they are among the most prevalent genetic conditions in the pediatric patient population. The typical clinical presentation includes distal muscle weakness and atrophy, but the severity and progression are largely variable. Improvements in supportive treatment have led to better preservation of patients' motor functions. More than 80 genes have been associated with CMT. These genetic discoveries, along with the developments of cellular and transgenic disease models, have allowed clinicians to better understand the disease mechanisms, which should lead to more specific treatments., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Current pitching literature focuses primarily on the elbow and glenohumeral joints. This has led to a paucity of information regarding the forearm and wrist, and the limited data available are inconsistent. Therefore, this article seeks to provide a comprehensive description of the kinematics and kinetics of the wrist and forearm for the fastball, curveball, slider/cutter, and change-up for college-level baseball pitchers. Thirty-six collegiate pitchers were evaluated using motion analysis techniques. Results indicated that pitching the curveball generated the greatest forearm supination (16 ± 13°) compared with the other three pitch types (p < 0.05). The curveball and slider/cutter were pitched with less wrist extension and greater ulnar deviation compared with the fastball and change-up. The curveball was found to produce the greatest ulnar moment (7.3 ± 2.2 Nm) and was significantly different from the moments noted when pitching the fastball and change-up (5.1 ± 1.9 and 4.9 ± 1.9 Nm, respectively; p < 0.05). These results indicate that it may be possible to objectively determine pitch type from kinematic data of the wrist and forearm. It may also be possible that coaches may be able to identify abnormal pitching mechanics from more proximal segments by understanding the motion of the wrist.

AIM This prospective multicenter study assessed performance and changes over time, with and without surgical intervention, in the modified Timed Up and Go (mTUG) and One-Minute Walk tests (1MWT) in children with bilateral cerebral palsy (CP). Minimum clinically important differences (MCIDs) were established for these tools. METHOD Two hundred and nineteen participants with bilateral spastic CP (Gross Motor Function Classification System [GMFCS] levels I–III) were evaluated at baseline and 12 months follow-up. The non-surgical group (n=168; 54 females, 114 males; mean age 12y 11mo, [SD 2y 7mo], range 8y 1mo–19y) had no surgical interventions during the study. The surgical group (n=51; 19 females, 32 males; mean age 12y 10mo [SD 2y 8mo] range 8y 2mo–17y 5mo) underwent soft-tissue and/or bony procedures within 12 months from baseline. The mTUG and 1MWT were collected and MCIDs were established from the change scores of the non-surgical group. RESULTS Dependent walkers (GMFCS level III) required more time to complete the mTUG (p≤0.01) than independent walkers (GMFCS levels I and II). For the 1MWT, distance walked decreased with increasing impairment (p≤0.01). 1MWT and mTUG change scores were not significantly different at any GMFCS level for either the surgical or non-surgical groups (p≤0.01). INTERPRETATION Children with varying levels of function (GMFCS level) perform differently on the 1MWT and mTUG. The data and MCID values can assist clinicians in interpreting changes over time and in assessing interventions.

Background: Baseball professionals believe that pitching from a mound can increase the stresses placed on the body., Hypothesis: There is no difference in kinematics or kinetics in pitching from a mound versus flat-ground conditions in adolescent baseball pitchers., Study Design: Laboratory investigation., Methods: The fastball pitching motions of 15 adolescent baseball pitchers, including upper extremity kinematics and kinetics and lead- and trail-leg kinematics, were evaluated while pitching from the mound and flat ground. Student t tests were used to determine the differences between the 2 testing conditions., Results: Maximum external glenohumeral rotation was similar between the 2 conditions (134° ± 14° mound vs 133° ± 14° flat ground, P = 0.10). Ankle plantar flexion of the lead leg at ball release was greater in the flat-ground condition (-20° ± 10° mound vs -15° ± 12° flat ground, P = 0.01). A statistically significant increase in glenohumeral internal rotation moment (33.6 ± 12.1 Nm mound vs 31.7 ± 11.6 Nm flat ground, P = 0.01) and an increase in elbow varus moment (33.3 ± 12.3 Nm mound vs 31.4 ± 11.8 Nm flat ground, P = 0.02) was measured when pitching from the mound as compared with flat ground., Conclusion: Pitching from the mound causes increased stress on the shoulder and elbow of adolescent pitchers as compared with that from flat ground., Clinical Relevance: The differences in kinematics as well as increased moments in the shoulder and elbow are helpful for pitchers and their coaches to know at the beginning of their season or as they return from injury or surgery. Pitchers in these situations should start their pitching progression on flat ground and progress to the mound.

The aim of this systematic review was to evaluate and summarize the current evidence base related to the clinical efficacy of gait analysis. A literature review was conducted to identify references related to human gait analysis published between January 2000 and September 2009 plus relevant older references. The references were assessed independently by four reviewers using a hierarchical model of efficacy adapted for gait analysis, and final scores were agreed upon by at least three of the four reviewers. 1528 references were identified relating to human instrumented gait analysis. Of these, 116 original articles addressed technical accuracy efficacy, 89 addressed diagnostic accuracy efficacy, 11 addressed diagnostic thinking and treatment efficacy, seven addressed patient outcomes efficacy, and one addressed societal efficacy, with some of the articles addressing multiple levels of efficacy. This body of literature provides strong evidence for the technical, diagnostic accuracy, diagnostic thinking and treatment efficacy of gait analysis. The existing evidence also indicates efficacy at the higher levels of patient outcomes and societal cost-effectiveness, but this evidence is more sparse and does not include any randomized controlled trials. Thus, the current evidence supports the clinical efficacy of gait analysis, particularly at the lower levels of efficacy, but additional research is needed to strengthen the evidence base at the higher levels of efficacy., (Copyright © 2011. Published by Elsevier B.V.)

The purpose of this study was to determine the effects of orthopedic procedures performed after skeletal maturity on ambulatory patients with cerebral palsy. Twenty-five patients (46 sides) had pre- and postoperative computerized gait analysis. All patients underwent any one or a combination of the following procedures: hamstring lengthenings, ankle plantar flexor lengthenings, rectus femoris transfers, psoas lengthenings, and femoral derotation osteotomies. Surgical results were similar in this group of older patients to those for younger individuals with cerebral palsy. Surgical procedures were evaluated pre- versus postoperatively within the subgroups of patients that had a particular procedure. Patients experienced the following results 1 year postoperatively: (1) improved knee extension at initial contact following hamstring lengthenings (n=35 sides, preop=32+/-15 degrees, postop=22+/-13 degrees, p<0.01), (2) improved peak dorsiflexion in swing (n=23 sides, preop=-1+/-9 degrees, postop=6+/-8 degrees, p<0.01) and improved modulation with peak dorsiflexion occurring later in stance (preop=31+/-15% of gait cycle, postop=43+/-13% of gait cycle, p<0.01) following ankle plantar flexor lengthenings, (3) improved hip rotation following femoral derotational osteotomies (n=9 sides, preop=19+/-12 degrees internal, postop=0+/-12 degrees, p<0.01), (4) improved peak knee flexion in swing following rectus femoris transfers (n=23 sides, preop=47+/-11 degrees, postop=55+/-13 degrees, p=0.01), (5) a reduction in excessive hip flexion during terminal stance was found in those patients with psoas lengthening (n=8 sides, preop=18+/-21 degrees, postop=9+/-19 degrees, p=0.04).

Background: The incidence of shoulder and elbow injuries in adolescent baseball players is rapidly increasing. One leading theory about this increase is that breaking pitches (such as the curveball) place increased moments on the dominant arm and thereby increase the risk of injury., Hypothesis: There is no difference in the moments at the shoulder and elbow between fastball and curveball pitches in adolescent baseball pitchers., Study Design: Controlled laboratory study., Methods: Thirty-three adolescent baseball pitchers with a minimum of 2 years of pitching experience underwent 3-dimensional motion analysis using reflective markers aligned to bony landmarks. After a warm-up, pitchers threw either a fastball or curveball, randomly assigned, from a portable pitching mound until 3 appropriate trials were collected for each pitch technique. Kinematic and kinetic data for the upper extremities, lower extremities, thorax, and pelvis were collected and computed for both pitch types. Statistical analysis included both the paired sample t test and mixed model regression., Results: There were lower moments on the shoulder and elbow when throwing a curveball versus when throwing a fastball. As expected, speed for the 2 pitches differed: fastball, 65.8 +/- 4.8 mph; and curveball, 57.7 +/- 6.2 mph (P < .001). Maximal gle-nohumeral internal rotation moment for the fastball was significantly higher than for the curveball (59.8 +/- 16.5 N.m vs 53.9 +/- 15.5 N.m; P < .0001). Similarly, the maximum varus elbow moment for the fastball was significantly higher than for the curveball (59.6 +/- 16.3 N.m vs 54.1 +/- 16.1 N.m; P < .001). The wrist flexor moment was greater in the fastball, 8.3 +/- 3.6 N.m, than in the curveball, 7.8 +/- 3.6 N.m (P < .001), but the wrist ulnar moment was greater in the curveball, 4.9 +/- 2.0 N.m, than in the fastball, 3.2 +/- 1.5 N.m (P < .001). Relatively minor motion differences were noted at the shoulder and elbow throughout the pitching motion, while significant differences were seen in forearm and wrist motion. The forearm remained more supinated at each point in the pitching cycle for the curveball but had less overall range of motion (62 degrees +/- 20 degrees ) than with the fastball (69 degrees +/- 17 degrees ) (P < .001), and the difference in the forearm pronation and supination moment between the pitches was not significant (P = .104 for pronation and P = .447 for supination). The wrist remained in greater extension during the fastball from foot contact through ball release but did not have significantly different total sagittal range of motion (53 degrees +/- 11 degrees ) when compared with the curveball (54 degrees +/- 15 degrees ) (P = .91)., Conclusion: In general, the moments on the shoulder and elbow were less when throwing a curveball than when throwing a fastball. In each comparison, the fastball demonstrated higher moments for each individual pitcher for both joints., Clinical Relevance: The findings based on the kinematic and kinetic data in this study suggest that the rising incidence of shoulder and elbow injuries in pitchers may not be caused by the curveball mechanics. Further evaluation of adolescent and adult baseball pitchers is warranted to help determine and subsequently reduce the risk of injury.

Rectus femoris transfer is frequently performed to treat stiff-knee gait in subjects with cerebral palsy. In this surgery, the distal tendon is released from the patella and re-attached to one of several sites, such as the sartorius or the iliotibial band. Surgical outcomes vary, and the mechanisms by which the surgery improves knee motion are unclear. The purpose of this study was to clarify the mechanism by which the transferred muscle improves knee flexion by examining three types of transfers. Muscle-actuated dynamic simulations were created of ten children diagnosed with cerebral palsy and stiff-knee gait. These simulations were altered to represent surgical transfers of the rectus femoris to the sartorius and the iliotibial band. Rectus femoris transfers in which the muscle remained attached to the underlying vasti through scar tissue were also simulated by reducing but not eliminating the muscle's knee extension moment. Simulated transfer to the sartorius, which converted the rectus femoris' knee extension moment to a flexion moment, produced 32+/-8 degrees improvement in peak knee flexion on average. Simulated transfer to the iliotibial band, which completely eliminated the muscle's knee extension moment, predicted only slightly less improvement in peak knee flexion (28+/-8 degrees ). Scarred transfer simulations, which reduced the muscle's knee extension moment, predicted significantly less (p<0.001) improvement in peak knee flexion (14+/-5 degrees ). Simulations revealed that improved knee flexion following rectus femoris transfer is achieved primarily by reduction of the muscle's knee extension moment. Reduction of scarring of the rectus femoris to underlying muscles has the potential to enhance knee flexion.

Background: The treatment of ischaemic stroke with neuroprotective drugs has been unsuccessful, and whether these compounds can be used to reduce disability after recurrent stroke is unknown. The putative neuroprotective effects of antiplatelet compounds and the angiotensin II receptor antagonist telmisartan were investigated in the Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) trial., Methods: Patients who had had an ischaemic stroke were randomly assigned in a two by two factorial design to receive either 25 mg aspirin (ASA) and 200 mg extended-release dipyridamole (ER-DP) twice a day or 75 mg clopidogrel once a day, and either 80 mg telmisartan or placebo once per day. The predefined endpoints for this substudy were disability after a recurrent stroke, assessed with the modified Rankin scale (mRS) and Barthel index at 3 months, and cognitive function, assessed with the mini-mental state examination (MMSE) score at 4 weeks after randomisation and at the penultimate visit. Analysis was by intention to treat. The study was registered with ClinicalTrials.gov, number NCT00153062., Findings: 20,332 patients (mean age 66 years) were randomised and followed-up for a median of 2.4 years. Recurrent strokes occurred in 916 (9%) patients randomly assigned to ASA with ER-DP and 898 (9%) patients randomly assigned to clopidogrel; 880 (9%) patients randomly assigned to telmisartan and 934 (9%) patients given placebo had recurrent strokes. mRS scores were not statistically different in patients with recurrent stroke who were treated with ASA and ER-DP versus clopidogrel (p=0.38), or with telmisartan versus placebo (p=0.61). There was no significant difference in the proportion of patients with recurrent stroke with a good outcome, as measured with the Barthel index, across all treatment groups. Additionally, there was no significant difference in the median MMSE scores, the percentage of patients with an MMSE score of 24 points or less, the percentage of patients with a drop in MMSE score of 3 points or more between 1 month and the penultimate visit, and the number of patients with dementia among the treatment groups. There were no significant differences in the proportion of patients with cognitive impairment or dementia among the treatment groups., Interpretation: Disability due to recurrent stroke and cognitive decline in patients with ischaemic stroke were not different between the two antiplatelet regimens and were not affected by the preventive use of telmisartan.

Background: Recurrent stroke is a frequent, disabling event after ischemic stroke. This study compared the efficacy and safety of two antiplatelet regimens--aspirin plus extended-release dipyridamole (ASA-ERDP) versus clopidogrel., Methods: In this double-blind, 2-by-2 factorial trial, we randomly assigned patients to receive 25 mg of aspirin plus 200 mg of extended-release dipyridamole twice daily or to receive 75 mg of clopidogrel daily. The primary outcome was first recurrence of stroke. The secondary outcome was a composite of stroke, myocardial infarction, or death from vascular causes. Sequential statistical testing of noninferiority (margin of 1.075), followed by superiority testing, was planned., Results: A total of 20,332 patients were followed for a mean of 2.5 years. Recurrent stroke occurred in 916 patients (9.0%) receiving ASA-ERDP and in 898 patients (8.8%) receiving clopidogrel (hazard ratio, 1.01; 95% confidence interval [CI], 0.92 to 1.11). The secondary outcome occurred in 1333 patients (13.1%) in each group (hazard ratio for ASA-ERDP, 0.99; 95% CI, 0.92 to 1.07). There were more major hemorrhagic events among ASA-ERDP recipients (419 [4.1%]) than among clopidogrel recipients (365 [3.6%]) (hazard ratio, 1.15; 95% CI, 1.00 to 1.32), including intracranial hemorrhage (hazard ratio, 1.42; 95% CI, 1.11 to 1.83). The net risk of recurrent stroke or major hemorrhagic event was similar in the two groups (1194 ASA-ERDP recipients [11.7%], vs. 1156 clopidogrel recipients [11.4%]; hazard ratio, 1.03; 95% CI, 0.95 to 1.11)., Conclusions: The trial did not meet the predefined criteria for noninferiority but showed similar rates of recurrent stroke with ASA-ERDP and with clopidogrel. There is no evidence that either of the two treatments was superior to the other in the prevention of recurrent stroke. (ClinicalTrials.gov number, NCT00153062.), (2008 Massachusetts Medical Society)

Background: Prolonged lowering of blood pressure after a stroke reduces the risk of recurrent stroke. In addition, inhibition of the renin-angiotensin system in high-risk patients reduces the rate of subsequent cardiovascular events, including stroke. However, the effect of lowering of blood pressure with a renin-angiotensin system inhibitor soon after a stroke has not been clearly established. We evaluated the effects of therapy with an angiotensin-receptor blocker, telmisartan, initiated early after a stroke., Methods: In a multicenter trial involving 20,332 patients who recently had an ischemic stroke, we randomly assigned 10,146 to receive telmisartan (80 mg daily) and 10,186 to receive placebo. The primary outcome was recurrent stroke. Secondary outcomes were major cardiovascular events (death from cardiovascular causes, recurrent stroke, myocardial infarction, or new or worsening heart failure) and new-onset diabetes., Results: The median interval from stroke to randomization was 15 days. During a mean follow-up of 2.5 years, the mean blood pressure was 3.8/2.0 mm Hg lower in the telmisartan group than in the placebo group. A total of 880 patients (8.7%) in the telmisartan group and 934 patients (9.2%) in the placebo group had a subsequent stroke (hazard ratio in the telmisartan group, 0.95; 95% confidence interval [CI], 0.86 to 1.04; P=0.23). Major cardiovascular events occurred in 1367 patients (13.5%) in the telmisartan group and 1463 patients (14.4%) in the placebo group (hazard ratio, 0.94; 95% CI, 0.87 to 1.01; P=0.11). New-onset diabetes occurred in 1.7% of the telmisartan group and 2.1% of the placebo group (hazard ratio, 0.82; 95% CI, 0.65 to 1.04; P=0.10)., Conclusions: Therapy with telmisartan initiated soon after an ischemic stroke and continued for 2.5 years did not significantly lower the rate of recurrent stroke, major cardiovascular events, or diabetes. (ClinicalTrials.gov number, NCT00153062.), (2008 Massachusetts Medical Society)