Search

Introduction: Rehabilitation medicine in a tertiary care hospital involves attending to many patients affected by intensive care unit (ICU)-associated weakness (ICU-AW) and hospital-associated deconditioning (HAD). These conditions contribute to poor long-term functional outcomes and increased mortality. We explored the role of short-term adjunctive androgen therapy in this group of patients in improving the rehabilitative outcomes., Methods: This was a retrospective analysis of five patients with either ICU-AW or HAD who were given testosterone replacement therapy (TRT) or oxandrolone for a total of 2 weeks during the period from April to November 2020 was undertaken. During the 2-week trial period, the subjects underwent standard rehabilitation therapy., Results: Grip strength was used as the primary outcome measure, and the mean improvement was 4.2 kg (+24.9%), which is encouraging in a 2-week timeframe. This was matched with good functional recovery in terms of distance ambulated and less assistance needed for ambulation. Sex hormone analysis was also done before initiation of TRT, and it showed that four out of five of the subjects were biochemically hypogonadal. None of the subjects dropped out or experienced any significant adverse events over the 2-week trial period. All the subjects except one improved to full independence at 3 months post-discharge., Conclusion: TRT has the potential to be used as a useful adjunct to standard rehabilitation in enhancing functional recovery in critically ill patients. A multidisciplinary approach would ensure that suitable patients benefit from optimal nutrition, optimal rehabilitation and synergistic testosterone therapy in a clinically sound and resource-efficient fashion., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

Purpose: This study aimed to investigate the respiratory physiological changes resulting from short-term inspiratory resistance training (R-IMT) and inspiratory threshold training (T-IMT) in patients with chronic obstructive pulmonary disease (COPD) and to compare the mechanisms of the two training methods., Patients and Methods: A total of 75 stable patients with COPD combined with inspiratory muscle weakness were randomly allocated to three groups: R-IMT (n = 26), T-IMT (n = 24), and control (n = 25). Before and after 8 weeks of inspiratory muscle training(IMT), cardiopulmonary exercise tests were conducted to assess respiratory patterns, respiratory central drive, exercise tolerance, and ventilation efficiency., Results: After 8 weeks of IMT, Inspiratory muscle strength, represented by MIP (maximum inspiratory mouth pressure) and exercise capacity increased during exercise in both IMT groups (P < 0.05). In the R-IMT group, inspiratory time (Ti) prolonged (P < 0.05), tidal volume (Vt) increased (P < 0.05), ventilation efficiency (represented by ventilation-center coupling) increased (P < 0.05) during exercise. Conversely, the T-IMT group did not exhibit any of these changes after IMT (P > 0.05)., Conclusion: In summary, the improvement in exercise tolerance was associated with an increase in inspiratory muscle reserve in both R-IMT and T-IMT. However, only R-IMT was associated with deeper and slower breathing, as well as improved ventilation efficiency., Competing Interests: Declaration of competing interest The authors declare no competing financial interests., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To integrate the best evidence for early rehabilitation of mechanically ventilated ICU-acquired weakness (ICU-AW) patients using evidence-based methods, providing evidence-based basis for standardized evaluation and intervention of early exercise therapy for mechanically ventilated ICU-AW patients., Methods: A systematic search was conducted on the American Thoracic Society (ATS) Clinical Practice Guidelines, Registered Nurses' Association of Ontario (RNAO), Guidelines International Network (GIN), Canadian Medical Association Clinical Practice Guideline Library (CMACPGL), BMJ Clinical Evidence, UpToDate, Scottish Intercollegiate Guidelines Network (SIGN), PubMed, Cochrane Library, National Guideline Clearinghouse (NGC), Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), UM-library, Physiotherapy Evidence Database (PEDro), National Institute for Health and Care Excellence (NICE), New Zealand Guidelines Group (NZGG), Chinese Medical Pulse Guidelines Website, CNKI and Wanfang data and other Chinese and English databases, professional team websites, and guideline websites for expert consensus, guidelines, randomized collected trial (RCT), systematic reviews and other evidence on early exercise rehabilitation for mechanically ventilated ICU-AW patients. The search time limit was from the establishment of the database to December 31, 2023. Literature search, screening, evaluation, information extraction was independently conducted by two evaluators with cross checking, and quality evaluation of the included literature was conducted., Results: A total of 21 literatures were enrolled, including 5 guidelines, 5 systematic reviews, 4 expert consensuses, and 7 RCT, all of which with high evidence level and all were enrolled. They were summarized into seven aspects with assessment screening, exercise safety standards, precautions, setting of exercise time, exercise intensity, exercise sequence, and recommended exercise content as the core, and 32 best evidences., Conclusions: The evidence summarized can provide evidence-based basis for standardized assessment and intervention of early exercise rehabilitation in mechanically ventilated ICU-AW patients. ICU medical practitioners need to combine the actual clinical environment, individual differences and rehabilitation goals of patients, to provide targeted health guidance and intervention for the prevention of ICU-AW in mechanically ventilated patients.

Background: Motor impairments are common consequences of traumatic brain injury (TBI). It affects the individuals' participation in activities of daily living (ADLs). Dry needling treatment (DNT) uses a specialized needle to alter cortical activity. This case study aims to examine the effects of DNT on spasticity, balance, gait, and self-independence in a single patient with TBI., Case Description: A twenty-six-year-old male with a history of TBI, resulting in muscle weakness on the right side of the body, spasticity, distributed balance, and difficulties with independent gait participated in this study. The Berg balance scale (BBS), 6-min walk test (6MWT), Modified Ashworth Scale (MAS), and Functional Independence Measure (FIM) were used to evaluate balance, gait, spasticity, and functional performance, respectively., Outcome: After 36 DNT sessions extended over 12 weeks, the patient demonstrated improvements in spasticity, balance, gait, and functional capacity both immediately after the intervention and at the 4-week follow-up., Conclusion: This case study demonstrates that DNT is considered a novel intervention for treating spasticity and improving balance, gait, and functional capacity post-TBI. Further research is recommended to verify these findings., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Poliomyelitis is a global disabling disease affecting 12-20 million of people. Post poliomyelitis syndrome (PPS) may affect up to 80% of polio survivors: increased muscle weakness, pain, fatigue, functional decline. It relies on aging of an impaired neuro-muscular system with ongoing denervation processes. A late involvement of humoral or cellular pro-inflammatory phenomena is also suspected., Aim: To assess the dysimmune hypothesis of PPS by comparing lymphocyte subpopulations and humoral immune factors between PPS patients and controls., Design: Cross-sectional study., Setting: Montpellier University Hospital., Population: Forty-seven PPS and 27 healthy controls., Methods: PPS patients and controls were compared on their lymphocyte subpopulations and humoral immune factors (IL-1β, IL-6, IL-8, IL-17, IL-21, IL-22, IL-23, IFN-γ, TNF-α, GM-CSF, RANTES, MCP1, MIP-3a, IL-10, TGF-β, IL4, IL13). Patients were further compared according to their dominant clinical symptoms. Sample size guaranteed a power >90% for all comparisons., Results: PPS patients and controls were comparable in gender, age and corpulence. Most patients had lower limb motor sequelae (N.=45, 95.7%), a minority had upper limb motor impairment (N.=16, 34.0%). Forty-five were able to walk (94%), 35/45 with technical aids. The median of the two-minute walking test was 110 meters (interquartile range 55; 132). Eighteen (38%) required help in their daily life. Their quality of life was low (SF36). All described an increased muscular weakness, 40 (85%) a general fatigue, and 39 (83%) muscular or joint pain. Blood count, serum electrolytes, T and B lymphocyte subpopulations and cytokines were comparable between patients and controls, except for creatine phospho kinase that was significantly higher in PPS patients. None of these variables differed between the 20/47 patients whose late main symptoms were pain or fatigue, and other patients., Conclusions: Our results suggest that PPS is not a dysimmune disease., Clinical Rehabilitation Impact: Our results do not sustain immunotherapy for PPS. Our work suggest that PPS may be mostly linked to physiological age-related phenomena in a disabled neuromuscular condition. Thus, our results emphasize the role of prevention and elimination of aggravating factors to avoid late functional worsening, and the importance of rehabilitation programs that should be adapted to patients' specific conditions.

Individuals with neurological disorders often exhibit altered manual dexterity and muscle weakness in their upper limbs. These motor impairments with tremor lead to severe difficulties in performing Activities of Daily Living (ADL). There is a critical need for ADL-focused robotic training that improves individual's strength when engaging with dexterous ADL tasks. This research introduces a new approach to training ADLs by employing a novel robotic rehabilitation system, Spherical Parallel INstrument for Daily Living Emulation (SPINDLE), which incorporates Virtual Reality (VR) to simulate ADL tasks. The study results present the feasibility of training individuals with movements similar to ADLs while interacting with the SPINDLE. A new game-based robotic training paradigm is suggested to perform ADL tasks at various intensity levels of resistance as needed. The proposed system can facilitate the training of various ADLs requiring 3-dimensional rotational movements by providing optimal resistance and visual feedback. We envision this system can be utilized as a table-top home device by restoring the impaired motor function of individuals with tremor and muscle weakness, guiding to improved ADL performance and quality of life.

Objective: To describe clinical and early shoulder-girdle MR imaging findings in severe COVID-19-related intensive care unit-acquired weakness (ICU-AW) after ICU discharge., Methods: A single-center prospective cohort study of all consecutive patients with COVID-19-related ICU-AW from November 2020 to June 2021. All patients underwent similar clinical evaluations and shoulder-girdle MRI within the first month and then 3 months (± 1 month) after ICU discharge., Results: We included 25 patients (14 males; mean [SD] age 62.4 [12.5]). Within the first month after ICU discharge, all patients showed severe proximal predominant bilateral muscular weakness (mean Medical Research Council total score = 46.5/60 [10.1]) associated with bilateral, peripheral muscular edema-like MRI signals of the shoulder girdle in 23/25 (92%) patients. At 3 months, 21/25 (84%) patients showed complete or quasi-complete resolution of proximal muscular weakness (mean Medical Research Council total score > 48/60) and 23/25 (92%) complete resolution of MRI signals of the shoulder girdle, but 12/20 (60%) patients experienced shoulder pain and/or shoulder dysfunction., Conclusions: Early shoulder-girdle MRI findings in COVID-19-related ICU-AW included muscular edema-like peripheral signal intensities, without fatty muscle involution or muscle necrosis, with favorable evolution at 3 months. Precocious MRI can help clinicians distinguish critical illness myopathy from alternative, more severe diagnoses and can be useful in the care of patients discharged from intensive care with ICU-AW., Key Points: • We describe the clinical and shoulder-girdle MRI findings of COVID-19-related severe intensive care unit-acquired weakness. • This information can be used by clinicians to achieve a nearly specific diagnosis, distinguish alternative diagnoses, assess functional prognosis, and select the more appropriate health care rehabilitation and shoulder impairment treatment., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

Objective: Intensive care unit-acquired muscle weakness (ICUAW) in critically ill patients is frequent and associated with negative outcomes. Early rehabilitation is a strategy to improve outcomes. The aim was to assess the effects of a rehabilitation nursing programme at discharge from intensive care unit., Methods: Quasi-experimental study with the comparison between two groups: one enrolled in a systematized nursing rehabilitation program and the other with usual nursing rehabilitation care. A non-probabilistic sample, sequential, of 42 critically ill ventilated patients, 21 patients in the control group and 21 patients the intervention group (June 2017 to June 2019), in three intensive care units of one large Portuguese teaching hospital. Mann-Whitney test was performed to compare Medical Research Council Sum Score (MRC-SS) values between groups., Results: Patients undergoing the rehabilitation program had a decrease in ICUAW (at ICU discharge mean MRC-SS = 38 vs. mean MRC-SS = 42.7, p = 0.043, U = 152,5). There was a decrease in severe muscle weakness (9.5% vs. 28.6%) and significant muscle weakness (42.9% vs. 52.4%) and an increase without muscle weakness (47,6% vs. 19%)., Conclusions: The systematic rehabilitation nursing program can improve muscle strength and reduce functional disability at the time of discharge from intensive care., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Rehabilitation engineering is playing a more vital role in the field of healthcare for humanity. It is providing many assistive devices to diplegia patients (The patients whose conditions are weak in terms of muscle mobility on both sides of the body and their paralyzing effects are high either in the arms or in the legs). Therefore, in order to rehabilitate such types of patients, an intelligent healthcare system is proposed in this research. The electric sticks and chairs are also a type of this system which was used previously to facilitate the diplegia patients. It is worth noting that a voice recognition system along with wireless control feature has been integrated intelligently in the proposed healthcare system in order to replace the common and conventional assistive tools for diplegia patients. These features will make the proposed system more user friendly, convenient and comfortable. The voice recognition system has been used for movements of system in any desired direction along with the ultrasonic sensor and light detecting technology. These sensors detect the obstacles and low light environment intelligently during the movement of the wheelchair and then take the necessary actions accordingly.

Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article.

Objective: Limited data exist on the quantification of activity levels and functional status in critically ill patients as they transition from the intensive care unit (ICU) to the wards and, subsequently, back into the community. The physical activity of critically ill patients from their ICU stay until 7 days after hospital discharge was characterized, as well as correlate physical activity levels with an objective measure of physical function., Methods: This prospective observational study of previously independent adults aged 55 or older, undergoing mechanical ventilation for up to 7 days, recruited participants at the time of spontaneous breathing trials or less than 24 hours after extubation. Participants received an accelerometer at enrollment to wear until 1 week after discharge., Results: Twenty-two participants received accelerometers; 15 were suitable for analysis. Participants had a mean (SD) age of 68 (9.6) years; 47% were female. Mean step counts were 95 (95% CI = 15-173) in the 3 days before ICU discharge, 257 (95% CI = 114-400) before hospital discharge, 1223 (95% CI = 376-2070) in the first 3 days at home, and 1278 (95% CI = 349-2207) between day 4 and 6 post-hospital discharge. Physical activity was significantly higher post- compared with pre-hospital discharge. Short Physical Performance Battery scores were poor at ICU and hospital discharge; however, they correlated moderately with physical activity levels immediately upon return home., Conclusions: Physical activity remained low as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. Despite poor Short Physical Performance Battery scores at both ICU and hospital discharge, participants were significantly more active immediately after discharge than in their last 3 days of hospitalization. This may represent rapid functional improvement or, conversely, constrained physical activity in hospital., Impact: This study highlights the need for further evaluation of physical activity constraints in hospital and ways to augment physical activity and function upon discharge., Lay Summary: Physical activity (step counts) increased modestly as survivors of critical illness transitioned from ICU to hospital wards, but significantly increased upon return to the community. This study highlights the need for further evaluation of physical activity constraints in the hospital setting and ways to augment physical activity and function postdischarge., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Functional electrical stimulation-assisted cycle ergometry (FESCE) enables in-bed leg exercise independently of patients' volition. We hypothesised that early use of FESCE-based progressive mobility programme improves physical function in survivors of critical care after 6 months., Methods: We enrolled mechanically ventilated adults estimated to need >7 days of intensive care unit (ICU) stay into an assessor-blinded single centre randomised controlled trial to receive either FESCE-based protocolised or standard rehabilitation that continued up to day 28 or ICU discharge., Results: We randomised in 1:1 ratio 150 patients (age 61±15 years, Acute Physiology and Chronic Health Evaluation II 21±7) at a median of 21 (IQR 19-43) hours after admission to ICU. Mean rehabilitation duration of rehabilitation delivered to intervention versus control group was 82 (IQR 66-97) versus 53 (IQR 50-57) min per treatment day, p<0.001. At 6 months 42 (56%) and 46 (61%) patients in interventional and control groups, respectively, were alive and available to follow-up (81.5% of prespecified sample size). Their Physical Component Summary of SF-36 (primary outcome) was not different at 6 months (50 (IQR 21-69) vs 49 (IQR 26-77); p=0.26). At ICU discharge, there were no differences in the ICU length of stay, functional performance, rectus femoris cross-sectional diameter or muscle power despite the daily nitrogen balance was being 0.6 (95% CI 0.2 to 1.0; p=0.004) gN/m 2 less negative in the intervention group., Conclusion: Early delivery of FESCE-based protocolised rehabilitation to ICU patients does not improve physical functioning at 6 months in survivors., Trial Registration Number: NCT02864745., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Myasthenia gravis is characterized by muscle weakness and fatigue. As sustained muscle use increases the weakness, the value of physical training programs has previously been questioned. This is a review to clarify the safety and usefulness of systematic training in myasthenia gravis, based on a systematic search in available databases using the relevant key words. Ten intervention studies including 159 patients with generalized disease have been published regarding the effect of systematic physical training, three of them on respiratory muscles. Muscle strength improved, and in the majority of the studies also daily function and quality of life. The feeling of fatigue not directly related to actual muscle weakness was less influenced by physical training. Continuous training was necessary to maintain the improved function. Physical training and exercise are safe in myasthenia gravis. This can improve both muscle strength and daily function. Type and intensity of systematic training should be adapted in the individual patient. A minimum of 150 min of exercise per week is recommended for myasthenia gravis patients with mild and moderate disease., Competing Interests: Declaration of Competing Interest N.E. Gilhus has received consultant or speaker's honoraria from UCB, Ra Pharma, Argenx, Alexion, Roche, Immunovant, Merck, Octapharma, (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To determine the effect of dual tasking on trunk muscle endurance in patients after lumbar diskectomy., Design: Cross-sectional study., Setting: Rehabilitation hospital setting., Participants: Individuals (N=14) undergoing primary lumbar diskectomy., Intervention: Using a randomized design on 2 separate days, muscle endurance was evaluated during prone bridging and Biering-Sorensen tests. Each test was randomly performed under 2 cognitive conditions: single task without cognitive condition and self-regulated dual task (ie, mathematical task)., Main Outcome Measures: The primary outcomes were time to failure and pain assessed by the visual analog scale from 0 to 100 mm. The secondary outcomes were kinesiophobia assessed by the Tampa Scale and disability assessed by the Oswestry Disability Index. Associations were tested using a repeated measures analysis of variance with relevant interaction test., Results: A significant interaction between condition, endurance tests, and kinesiophobia (P=.005) was found. The post hoc comparison showed positive effects between cognitive conditions in both endurance tests (prone bridging test: mean difference, 15.7s; 95% confidence interval [CI], 7.5-24s; P=.001; Biering-Sorensen test: mean difference, 7.9s; 95% CI, 1.9-14s; P=.014). The linear regression analysis between the Tampa Scale for Kinesiophobia and the difference of time to failure between cognitive conditions showed a positive correlation only during the Biering-Sorensen test (r=0.80; P=.001)., Conclusions: A self-regulated dual task increases trunk muscle endurance in patients after lumbar diskectomy. The results suggest that the difference observed in time to failure between the single task and dual task is associated with fear avoidance, especially during back extension. This strategy seems especially relevant for patients with high levels of fear avoidance and may be used to improve trunk muscle endurance., (Copyright © 2020 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Restoring quadriceps muscle strength following anterior cruciate ligament reconstruction (ACLR) may prevent the posttraumatic osteoarthritis that affects over 50% of knees with ACLR. However, a fundamental gap exists in our understanding of how to maximize muscle strength through rehabilitation. Neurological deficits and muscle atrophy are 2 of the leading mechanisms of muscle weakness after ACLR. High-intensity neuromuscular electrical stimulation (NMES) and eccentric exercise (ECC) have been shown to independently target these mechanisms. If delivered in succession, NMES and then ECC may be able to significantly improve strength recovery. The objectives of this study were to evaluate the ability of NMES combined with ECC to restore quadriceps strength and biomechanical symmetry and maintain cartilage health at 9 and 18 months after ACLR., Methods: This study is a randomized, double-blind, placebo-controlled, single-center clinical trial conducted at the University of Michigan. A total of 112 participants between the ages of 14 and 45 years and with an anterior cruciate ligament rupture will be included. Participants will be randomly assigned 1:1 to NMES combined with ECC or NMES placebo combined with ECC placebo. NMES or NMES placebo will be delivered 2 times per week for 8 weeks beginning 10 to 14 days postoperatively and will be directly followed by 8 weeks of ECC or ECC placebo delivered 2 times per week. The co-primary endpoints are change from baseline to 9 months and change from baseline to 18 months after ACLR in isokinetic quadriceps strength symmetry. Secondary outcome measures include isometric quadriceps strength, quadriceps activation, quadriceps muscle morphology (cross-sectional area), knee biomechanics (sagittal plane knee angles and moments), indexes of patient-reported function, and cartilage health (T1ρ and T2 relaxation time mapping on magnetic resonance imaging)., Impact: The findings from this study might identify an intervention capable of targeting the lingering quadriceps weakness after ACLR and in turn prevent deterioration in cartilage health after ACLR, thereby potentially improving function in this patient population., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Acute flaccid myelitis (AFM) is characterised by rapid onset of limb weakness with spinal cord grey-matter abnormalities on MRI scan. We aimed to assess whether detection of enterovirus in respiratory or other specimens can help predict prognosis in children with AFM., Methods: In this nationwide, longitudinal study, we evaluated the significance of detection of enterovirus in any sample in predicting outcomes in a cohort of Canadian children younger than 18 years presenting with AFM to tertiary paediatric hospitals in Canada in 2014 and 2018. All patients fulfilled the 2015 US Centers for Disease Control and Prevention case definition for definite AFM or probable AFM. Clinical data, laboratory findings, treatment, and neuroimaging results were collected (follow up period up to 5 years). We assessed neurological function and motor outcomes using Kurtzke's Expanded Disability Status Scale (EDSS) and a Weakest Limb Score., Findings: 58 children with AFM (median age 5·1 years, IQR 3·8-8·3) were identified across five of Canada's ten provinces and three territories. 25 (43%) children had enterovirus detected in at least one specimen: 16 (64%) with EV-D68, two (8%) with EV-A71, two (8%) with coxsackievirus, 10 (40%) with untyped enterovirus. Children who were enterovirus positive were more likely than those that were negative to have had quadriparesis (12 [48%] of 25 vs four [13%] of 30; p=0·028), bulbar weakness (11 [44%] of 25 vs two [7%] of 30; p=0·028), bowel or bladder dysfunction (14 [56%] of 25 vs seven [23%] of 30; p=0·040), cardiovascular instability (nine [36%] of 25 vs one [3%] of 30; p=0·028), and were more likely to require intensive care unit admission (13 [52%] of 25 vs 5 [17%] of 30; p=0·028). On MRI, most children who were enterovirus positive showed brainstem pontine lesions (14 [61%] of 23), while other MRI parameters did not correlate with enterovirus status. Median EDSS of enterovirus positive (EV+) and enterovirus negative (EV-) groups was significantly different at all timepoints: baseline (EDSS 8·5, IQR 4·1-9·5 vs EDSS 4·0, IQR 3·0-6·0; p=0·0067), 3 months (EDSS 4·0, IQR 3·0-7·4 vs EDSS 3·0, IQR 1·5-4·3; p=0·0067), 6 months (EDSS 3·5, IQR 3·0-7·0 vs EDSS 3·0, IQR 1·0-4·0; p=0·029), and 12 months (EDSS 3·0, IQR 3·0-6·9 vs EDSS 2·5 IQR 0·3-3·0; p=0·0067). Kaplan-Meier survival analysis of a subgroup of patients showed significantly poorer motor recovery among children who tested positive for enterovirus than for those who tested negative (p=0·037)., Interpretation: Detection of enterovirus in specimens from non-sterile sites at presentation correlated with more severe acute motor weakness, worse overall outcomes and poorer trajectory for motor recovery. These results have implications for rehabilitation planning as well as counselling of families of children with these disorders. The findings of this study support the need for early testing for enterovirus in non-CNS sites in all cases of AFM., Funding: None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Dorsiflexion-restricting ankle-foot orthoses (DR-AFOs) are often prescribed in polio survivors with calf muscle weakness to reduce or solve gait problems. However, orthoses are sometimes not being used and/or users are dissatisfied with the usability., Aim: To compare the usability of custom-made DR-AFOs provided in clinical care between users and discontinued users who have calf muscle weakness due to polio., Design: Cross-sectional survey., Setting: Outpatient post-polio university hospital clinic in the Netherlands., Population: All polio survivors with calf muscle weakness, provided with a DR-AFO between 2004 and 2015 in our outpatient clinic., Methods: DR-AFO use and usability according to the ISO 9241-11 standard were evaluated with a questionnaire sent out by postal mail., Results: Forty of 57 questionnaires were returned. Five respondents did not fulfil the eligibility criteria. DR-AFO use among the 35 eligible respondents was 74%. Compared to discontinued users, users were significantly more often male (users: 16 of 26 vs. discontinued users: 0 of 9, P=0.001), more limited in their walking ability without DR-AFO (P=0.007), perceived more effectiveness, both overall (P=0.001) and on their personal goals of use (P=0.006), and were more satisfied with orthosis-related aspects (P=0.011), such as comfort., Conclusions: Almost three quarters of the polio survivors used their orthosis. Use was related to several aspects of usability, indicating that it is important to consider usability in the prescription process of DR-AFOs for polio survivors with calf muscle weakness., Clinical Rehabilitation Impact: When prescribing DR-AFOs, it is important to consider that the orthosis is most likely used when the experienced walking problems are large and the DR-AFO reduces these problems. We recommend discussing the patient's personal goals for DR-AFO use and the anticipated improvement on the individual's walking problems as well as possible hindrance of the orthosis during daily life activities. Furthermore, providers may need to pay extra attention to females and should particularly take care that the experienced fit and comfort are satisfactory. Incorporating these suggestions in clinical practice may further improve DR-AFO use among polio survivors with calf muscle weakness.

: With the current issue, the journal continues to bring new insights from Cochrane Systematic Reviews to the readers of Obstetrics & Gynecology. This month, we focus on potential interventions to improve pregnancy outcomes for women with recurrent pregnancy loss and antiphospholipid antibodies, the utility of pelvic floor muscle training in the perinatal period to prevent incontinence, and the use of adhesion barriers in gynecologic surgery. The summaries are published below, and the complete references with hyperlinks are listed in Box 1. BOX 1. ABSTRACTS DISCUSSED IN THIS SUMMARY.

Objective: Direct strength training (DST) is effective in managing unilateral weakness in people with multiple sclerosis (MS). Its feasibility, however, is considerably reduced if one limb is too compromised to train. In this case, contralateral strength training (CST) of the unaffected side to induce a strength transfer to the untrained homologous muscles can help to establish a strength baseline in the weaker limb, eventually allowing direct training. Limited effects for CST, however, have been reported on patient functioning. We tested the effects on dynamometric, electromyographic, and functional outcomes of a sequential combination of CST and DST of the ankle dorsiflexors in a case of MS-related foot-drop., Methods: A 56-year-old man diagnosed with relapsing-remitting MS exhibited severe weakness of the right dorsiflexors impairing functional dorsiflexion. The intervention consisted of a 6-week CST of the unaffected dorsiflexors followed by 2 consecutive 6-week DST cycles targeting the weaker dorsiflexors., Results: At baseline, the participant could not dorsiflex his right ankle but could do so after CST. Maximal strength of the affected dorsiflexors increased by 80% following CST, by 31.1% following DST-1, and by a further 44.6% after DST-2. Neuromuscular recruitment was found progressively increased, with the largest changes occurring after DST-1. Improvements in mobility and walking speed were also detected, although plantar flexors' spasticity on the Modified Ashworth Scale increased from 1+ to 2., Conclusion: In this case, the sequential combination of CST and DST proved a feasible approach to manage severe unilateral weakness in a patient who was not able, at least initially, to dorsiflex his weaker ankle. In this perspective, CST may prime a minimum gain in strength necessary to allow subsequent direct training., (© The Author(s) 2020. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Locomotive syndrome is a state in which locomotive function is decreased due to musculoskeletal diseases. To extend a healthy lifespan, it is important to prevent falls and locomotive syndrome development accompanying aging by slowing the decline in walking ability. However, it is unclear whether hip flexor muscle strengthening improves walking ability and locomotive syndrome. This study aimed to examine the effect of hip flexor muscle strengthening on walking ability and the locomotive syndrome rank test., Methods: Forty participants were enrolled. Before hip flexor muscle strengthening, maximum muscle strength on the exercised side was measured, and gait analysis and the two-step test were performed simultaneously. Participants were divided into a healthy group and a locomotive syndrome group based on the two-step test and were given hip flexor muscle training at least three days a week for six weeks. After completing the training, maximum muscle strength was measured and gait analysis was performed for all participants. The difference between the two-step test conducted pre- and post-training in the locomotive syndrome group was statistically analyzed., Results: Twenty-two and 14 participants were included in the healthy and the locomotive syndrome groups, respectively. Hip flexion strength on the exercised side increased from 1.68 to 1.95 Nm/kg (p < 0.0001) and 1.04 to 1.21 Nm/kg (p = 0.0031) in the healthy and the locomotive syndrome groups, respectively. Step length, stride length and walking speed measured by gait analysis also increased in both groups. Consequently, the two-step test score improved from 1.17 to 1.30 (p = 0.0002) and the stage of locomotive syndrome improved in 9 participants (p = 0.041)., Conclusions: Strengthening of the hip flexor muscles improved walking ability and the stage of locomotive syndrome. Therefore, strengthening of the hip flexor muscles is important for the prevention and improvement of locomotive syndrome., Competing Interests: Declaration of Competing Interest None of the authors have any conflicts of interest., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Purpose of Review: We aimed to explore, through a conceptual model, how we can maximize the post-ICU recovery of patients with ICU-acquired weakness (ICU-AW). The '6 Ps' were used to structure our research questions, what are the Predisposing (pre-ICU patient characteristics), Precipitating (ICU exposures) and Perpetuating (hinder recovery) risk factors for ICU-AW (Problem) and what Protective strategies and Proactive treatment can we adopt to improve muscle mass, strength and function of these patients?, Recent Findings: Examination of the relationship between pre-ICU patient characteristics with ICU-AW and post-ICU factors that prolong recovery are limited. Our understanding of the pathophysiology of the condition is improving, however, much of the biological mechanisms of ICU-AW and persistent weakness remain unknown. Investigation into the ICU-AW phenotype and prediction tools would be of great clinical utility. Further research on ICU-AW muscle biology and recovery may permit the application of precision and personalized medicine to therapeutic interventions., Summary: A structured approach to clinical practice and future research to better understand the mechanism (Problem), and identify Predisposing, Precipitating and Perpetuating risk factors will advance the field in better managing ICU-AW through implementation of Protective strategies and Proactive multimodal treatments.

Study Design: A multi-centred, single-blinded randomised controlled trial., Objectives: To determine the effect of 10,000 voluntary contractions over 8 weeks on the strength of very weak muscles in people with spinal cord injury (SCI)., Settings: Seven hospitals in Australia and Asia., Methods: One hundred and twenty people with recent SCI undergoing inpatient rehabilitation were randomised to either a Treatment or Control Group. One major muscle group from an upper or lower limb was selected if the muscle had grade 1 or grade 2 strength on a standard six-point manual muscle test. Participants allocated to the Treatment Group performed 10,000 isolated contractions of the selected muscle group, as well as usual care in 48 sessions over 8 weeks. Participants allocated to the Control Group received usual care alone. Participants were assessed at baseline and 8 weeks by a blinded assessor. The primary outcome was voluntary muscle strength on a 13-point manual muscle test. There were three secondary outcomes capturing therapists' and participants' perceptions of strength and function., Results: The mean between-group difference of voluntary strength at 8 weeks was 0.4/13 points (95% confidence interval -0.5 to 1.4) in favour of the Treatment Group. There were no notable between-group differences on any secondary outcome., Conclusion: Ten thousand isolated contractions of very weak muscles in people with SCI over 8 weeks has either no or a very small effect on voluntary strength.

Objective: To date, no attention has been devoted to the employment of eccentric contractions to manage spasticity in multiple sclerosis. This single-system case series aimed to explore the effects of eccentric training on spasticity-related resistance to passive motion in people with multiple sclerosis with elbow flexor spasticity., Methods: Six people with multiple sclerosis (median Expanded Disability Status Scale score = 4.8, range = 2.0-5.5; Modified Ashworth Scale [MAS] score ≤ 3) underwent a 6-week eccentric strength training of the spastic muscles. Before and after the intervention, the following outcomes were assessed: resistive peak torque (RPT), isometric strength, resting limb position, passive range of motion and active range of motion, severity of hypertonia by MAS, and numerical rating scale. At baseline, the primary outcome (RPT) was tested over 3 time points to ensure a stable measurement. The 2-SD method was used to test pre-post training effects at individual level. Group-level analyses were also performed., Results: Following the intervention RPT decreased by at least 2 SDs in all participants but 1, with a significant reduction at group level of 41.6 (29.6)%. Four people with multiple sclerosis reported a reduction in perceived spasticity severity. No changes in MAS score were detected. Group-level analyses revealed that maximal strength increased significantly in the trained elbow flexors (+30.9 [9.1]%). Elbow flexion at rest was found to be significantly reduced (-35.5 [12.4]%), whereas passive range of motion (+4.6%) and active range of motion (+11.8%) significantly increased., Conclusion: Eccentric training is feasible and safe to manage spasticity in people with multiple sclerosis. Preliminary data showed that this protocol can reduce resistance to passive motion, also improving strength, spasticity-free range of motion, and limb positioning., Impact: Patients with multiple sclerosis-related spasticity and moderate-to-severe disability can benefit from adding slow submaximal eccentric contractions to the conventional management of spasticity., (© 2020 American Physical Therapy Association.)

Introduction: Traditional physiotherapy is currently the best approach to manage patients with intensive care unit acquired weakness (ICUAW). We report on a patient with ICUAW, who was provided with an intensive, in-patient regimen, that is, conventional plus robot-assisted physiotherapy. Aim of this case study was to assess the efficacy of a combined approach (conventional plus robot-assisted physiotherapy), on muscle strength, overall mobility, and disability burden in a patient with ICUAW in post-ICU intensive rehabilitation setting., Patient Concerns: A 56-years-old male who was unable to stand and walk independently after hospitalization in an Intensive Care Unit. He initially was provided with daily sessions of conventional physiotherapy for 2 months, with mild results., Diagnosis: The patient was affected by ICUAW., Intervention: Given that the patient showed a relatively limited improvement after conventional physiotherapy, he was provided with daily sessions of robot-aided training for upper and lower limbs and virtual reality-aided rehabilitation for other 4 months, beyond conventional physiotherapy., Outcomes: At the discharge (6 months after the admission), the patient reached the standing station and was able to ambulate with double support., Conclusions: Our case suggests that patients with ICUAW should be intensively treated in in-patient regimen with robot-aided physiotherapy. Even though our approach deserves confirmation, the combined rehabilitation strategy may offer some advantage in maximizing functional recovery and containing disability.

Blood flow restriction therapy (BFRT) is an innovative training method for the development of muscle strength and hypertrophy in the athletic and clinical settings. Through the combination of venous occlusion and low-load resistance training, it induces muscle development through a number of proposed mechanisms including anaerobic metabolism, cellular swelling, and induction of type 2 muscle fibers. Muscle weakness and atrophy are prevalent among musculoskeletal rehabilitation patients, causing delayed return to functional activity. In traditional resistance training, muscle development requires exercise loads of 70% of one-repetition maximum (1RM), but the stress placed on connective tissues and joints can be detrimental to the elderly and rehabilitation patients. However, BFRT with loads of 20% to 40% of 1RM has been shown consistently in the literature to increase muscle strength, hypertrophy, and angiogenesis. The rate of adverse effects has not been found to be greater than that in traditional high-load resistance training, but its effects on the cardiovascular system have yet to be evaluated in long-term studies. Although further investigations are needed to determine the exact mechanism and optimal usage, current evidence is promising for the application of BFRT in athletes, rehabilitation patients, and the elderly patients.

Background: Early mobilization has been proven effective for patients in intensive care units (ICUs) to improve functional recovery. However, early mobilization of critically ill, often mechanically ventilated, patients is cumbersome because of the attachment to tubes, drains, monitoring devices and muscle weakness. A mobile treadmill with bodyweight support may help to initiate mobilization earlier and more effectively. The aim of this study is to assess the effectiveness of weight-supported treadmill training in critically ill patients during and after ICU stay on time to independent functional ambulation., Methods: In this randomized controlled trial, a custom-built bedside body weight-supported treadmill will be used and evaluated. Patients are included if they have been mechanically ventilated for at least 48 hours, are able to follow instructions, have quadriceps muscle strength of Medical Research Council sum-score 2 (MRC 2) or higher, can sit unsupported and meet the safety criteria for physical exercise. Exclusion criteria are language barriers, no prior walking ability, contraindications for physiotherapy or a neurological condition as reason for ICU admission. We aim to include 88 patients and randomize them into either the intervention or the control group. The intervention group will receive usual care plus bodyweight-supported treadmill training (BWSTT) daily. The BWSSTT consists of walking on a mobile treadmill while supported by a harness. The control group will receive usual care physiotherapy treatment daily consisting of progressive activities such as bed-cycling and active functional training exercises. In both groups, we will aim for a total of 40 minutes of physiotherapy treatment time every day in one or two sessions, as tolerated by the patient. The primary outcome is time to functional ambulation as measured in days, secondary outcomes include walking distance, muscle strength, status of functional mobility and symptoms of post-traumatic stress. All measurements will be done by assessors who are blinded to the intervention on the regular wards until hospital discharge., Discussion: This will be the first study comparing the effects of BWSTT and conventional physiotherapy for critically ill patients during and after ICU stay. The results of this study contribute to a better understanding of the effectiveness of early physiotherapy interventions for critically ill patients., Trial Registration: Dutch Trial Register (NTR) ID: NL6766. Registered at 1 December 2017.

Background: Pregnancy is one of the main risk factor of pelvic floor muscle dysfunction. Postpartum women with extremely weak muscle strength have difficulty to do voluntary pelvic floor muscle training. This study aims to evaluate the effects of different protocols of electrical stimulation in the treatment of postpartum women with extremely weak muscle strength., Methods: A total of 67 women were randomized into 2 groups: group A received transvaginal electrical stimulation (TVES) for 5 times, and group B received TVES for 3 times with electromyogram (EMG)-triggered neuromuscular stimulation twice. Subjects were evaluated before and after treatment. Pelvic muscle strength was measured by both digital vaginal palpation and EMG variables, and quality of life was investigated by 4 kinds of pelvic floor disease-related questionnaires., Results: According to the intention-to-treat principle, compared with baseline, in group A, EMG of contractile amplitude of endurance phase was significantly elevated (P = .03), variation of contractile amplitude in tonic phase was more stable after treatment (P = .004), and EMG of mean value of final rest was significantly elevated after treatment (P = .047). After 5 times treatments, the incidence of correct pelvic floor muscle contraction in group A was significantly elevated (P = .045). No significant difference of muscle strength test by digital vaginal palpation was detected between the 2 groups, so did questionnaires., Conclusion: For postpartum women with extremely weak muscle strength, TVES for 5 times might be more benefit for control ability of pelvic muscle contractions and elevating muscle strength even in short-time treatment.

Objectives: The aim was to investigate whether patients who participated in a mobility program in the ICU performed better on functional status, muscle, mobility, and respiratory assessments upon discharge than patients who received conventional physiotherapy., Design: Randomized controlled trial., Setting: Blind evaluation., Patients: Adults with previous functional independence and without contraindications for mobilization were eligible., Interventions: The intervention group participated in an early and progressive mobility program with five levels of activity. The control group underwent the conventional treatment without a preestablished routine. We evaluated functional status, level of activity, respiratory status, muscle strength, and mobility at ICU discharge., Measurements and Main Results: We analyzed 49 patients in the control group and 50 patients in the intervention group. Our data showed patients with better functional status and more functionally independent patients in the intervention group compared with those in the control group (96% vs 44%; p < 0.001). The results of the sit-to-stand and 2-minute walk tests, as well as the results of the maximum voluntary ventilation tests, also varied between the groups. The intervention group had shorter ICU stays than the control group. Higher Barthel index scores were associated with the amount of activity and participation in the protocol. The benefits to functional status remained during follow-up., Conclusions: Patients who participated in an ICU mobility program had better functional status at discharge from the ICU. The other benefits of the program included better performance in the mobility tests and improved maximum voluntary ventilation performance.

The pathophysiology of dropped head syndrome (DHS) remains unknown, and its treatment algorithm and indication are not standardized. Here, we established a novel rehabilitation program, short and intensive rehabilitation program for DHS (SHAiR program), consisting of cervical paraspinal muscles exercise, range of motion exercise, cervical and thoracic mobilization, deep cervical flexor muscle exercise, hip lift exercise, anterior pelvic tilt exercise, and walking exercise. The aim of this study was to evaluate the clinical effectiveness of this program. We reviewed clinical outcomes for five consecutive patients with DHS who underwent the SHAiR program (SHAiR group). The outcomes were compared with those of other five patients with DHS who received exercise instruction (control group). Demographic data, the duration from onset of DHS, the apex of sagittal kyphosis on the lateral radiographs, and clinical outcomes including the ability to maintain normal horizontal gaze, chin brow vertical angle, and numerical rating scale (NRS) were evaluated at the initial visit and final follow-up at 7.5 months. There was no significant difference between the two groups in terms of demographic and radiographic data. The ability of horizontal gaze and NRS of cervical pain improved rapidly for all five patients in the SHAiR group as compared to no improvement for all patients in the control group. Rehabilitation for DHS was considered effective not only for localized rehabilitation such as exercise for training cervical extensor muscle function but also exercises for thoracolumbar posture improvement and the psoas muscle., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Sarcopenia is a physiopathological process associated with aging, caused by reduction of muscle strength, muscle quality and physical performance, and associated with an increased risk of falls, physical disability and premature death. There is no effective treatment for sarcopenia, but physical exercise seems to be highly effective at counteracting the decline in muscle mass and strength associated with aging. Recently, sarcopenia has been recognized as an emerging issue in people living with HIV (PLWH). Despite adequate treatment with combination antiretroviral therapy (cART), PLWH may exhibit an early occurrence of some aging-related conditions, including sarcopenia, frailty and falls, and this is likely resulting from high rates of comorbidities, high-risk behaviours, chronic immune activation and cART-specific factors. In this review, we discuss the potential mechanisms and the clinical relevance of sarcopenia in PLWH, and present data from longitudinal studies of physical activity in this population. Despite none of these studies having specifically addressed the benefits of physical exercise on sarcopenia, there is evidence that exercise is effective to increase aerobic capacity and muscle strength, and to improve body composition and inflammatory outcomes in PLWH. Therefore, the expected benefits of physical exercise are likely to translate into a successful and specific intervention for prevention and treatment of sarcopenia in this population., Competing Interests: The authors have no conflict of interest to declare.

Background: Although several studies have shown an association of muscle weakness with gait speed (GS), no study has explored the relationship of muscle strength with swing phase duration and GS after stroke among the elderly in Saudi Arabia., Objective: To examine the association of affected ankle dorsiflexor and hip flexor muscle strength with swing phase duration and GS in the elderly with different stroke chronicity., Methods: In this cross-sectional study, we included a total of 60 post-stroke patients aged ≥55 years who were admitted in neurorehabilitation units between May 2017 and August 2018. Linear regression was employed to examine the association of muscle strength (measured using a handheld dynamometer) with swing phase duration and GS (both measured using the computerized Zebris-Mat)., Results: The chronicity of the stroke was negatively associated (p < 0.05) with swing phase duration. The ankle dorsiflexor muscle strength was significantly associated with GS (β= 0.656, p = 0.041). In contrast, hip flexor muscle strength was significantly associated with GS (β= 0.574, p < 0.0001) even after adjusting for stroke chronicity (β= 0.561, p < 0.0001)., Conclusions: Stroke chronicity was the predictor that reduced swing phase duration. The ankle dorsiflexor muscle strength was associated with GS. However, the hip flexor muscle strength was associated with GS even after adjusting for stroke chronicity.

Background: Intensive care unit (ICU)-acquired weakness is the most important cause of failed functional outcome in survivors of critical care. Most damage occurs during the first week when patients are not cooperative enough with conventional rehabilitation. Functional electrical stimulation-assisted cycle ergometry (FES-CE) applied within 48 h of ICU admission may improve muscle function and long-term outcome., Methods: An assessor-blinded, pragmatic, single-centre randomized controlled trial will be performed. Adults (n = 150) mechanically ventilated for < 48 h from four ICUs who are estimated to need > 7 days of critical care will be randomized (1:1) to receive either standard of care or FES-CE-based intensified rehabilitation, which will continue until ICU discharge., Primary Outcome: quality of life measured by 36-Item Short Form Health Survey score at 6 months., Secondary Outcomes: functional performance at ICU discharge, muscle mass (vastus ultrasound, N-balance) and function (Medical Research Council score, insulin sensitivity). In a subgroup (n = 30) we will assess insulin sensitivity and perform skeletal muscle biopsies to look at mitochondrial function, fibre typing and regulatory protein expression., Trial Registration: ClinicalTrials.gov, NCT02864745. Registered on 12 August 2016.

Background: There is a considerable literature on arm/hand dysfunction post stroke, but little information on the participants' opinions about perceived and desired arm/hand strength, recovery, and function., Objective: The objective of this study was to examine the perceptions of individuals with stroke about arm/hand function and training devices., Methods: A 69-item survey was developed addressing: activity before and after stroke, involved arm/hand function, willingness to use a training device, and important device characteristics. The survey included items from the Hand Function and Strength Subscales of the Stroke Impact Scale (SIS). Face validity was established by physical therapists and individuals with stroke. The survey was administered via phone and online., Results: 852 registry participants were recruited. Ninety-seven responded; 83 completed the survey. Subjects were 51 males, 31 females; mean age: 65 (25-95); meantime since stroke: 13 years (1-34; SD 6.678). There was a statistically significant difference between perceived and desired arm/hand strength, recovery, and function p <0.0001. Impairment factors, such as weakness and spasticity were greater barriers to recovery than socio-economic ones. Most participants (94%) were willing to use a device; functional gains during/following use were the most important characteristics., Limitations: Participants had greater arm impairment and were more chronic than other studies., Conclusions: Participants desired more arm/hand strength, function, and recovery that they perceived they had achieved. Impairment - level factors posed more barriers to arm recovery than socioeconomic ones. Most participants were interested in using arm/hand training devices; the most important device characteristic is functional gain.

Objective: The aim of this review was to evaluate and summarize the results of published studies exploring the effects of expiratory muscle strength training on swallowing and cough functions in patients with neurological diseases., Data Sources: The study used Embase, PubMed, and the Cochrane Library as data sources., Review Methods: Randomized controlled trials or pretest/posttest studies of adults with neurological diseases were included. The data included basic population characteristics, penetration-aspiration scores, peak expiratory flow rate, cough volume acceleration, and maximum expiratory pressure., Results: Ten studies were included in this meta-analysis. Compared with the control groups, expiratory muscle strength training in patients with neurological diseases significantly reduced the penetration-aspiration scores (risk ratio = -0.94, 95% confidence interval = 1.27 to -0.61, P < 0.01) but did not increase the voluntary cough peak expiratory flow rate (risk ratio = 0.57, 95% confidence interval = 0.62 to 1.77, P = 0.35), cough volume acceleration (risk ratio = 33.87, 95% confidence interval = 57.11 to 124.85, P = 0.47), or maximum expiratory pressure (risk ratio = 14.78, 95% confidence interval = 16.98 to 46.54, P = 0.36)., Conclusions: Expiratory muscle strength training might improve swallowing function in patients with neurological diseases. However, conclusive evidence supporting the use of this approach in isolation for improving cough function is unavailable. Additional multicenter, randomized clinical trials performed using reliable and valid cough function outcome measures are required to explore the effects of expiratory muscle strength training on cough function.

Study Design: Retrospective comparative case series., Objectives: Evaluation of sacral morphology in spondylolisthesis patients compared with asymptomatic controls., Summary of Background Data: Patients with spondylolisthesis are known to differ from asymptomatic controls in sagittal plane anatomy, but few studies examine the coronal and axial plane differences in these cohorts., Methods: This is a retrospective evaluation of magnetic resonance imaging of the lumbosacral spine in 29 spondylolisthesis patients and an asymptomatic cohort (n = 154). Measurements of the linear distance and angular position of L5 and sacrum were performed in the sagittal, coronal, and axial planes. Receiver operating characteristic (ROC) curve analysis quantified these associations. High- and low-grade spondylolisthesis patients were compared with two-sample t-tests. All p-values are two-sided and considered significant when p < .05., Results: Axial measurements showed the distance of the right to left anterior ala and the L5 body width did not differ between the cohorts. Sacroiliac (SI) joint angles in the spondylolisthesis cohort were closer to the true sagittal plane than in the controls 109° versus 121° (p < .001). In the sagittal plane, the linear measurement of the ratio of the midpoint anteroposterior width L5 to the sacral end plate was larger in the high-grade patients than the low-grade patients and controls. In addition, the kyphosis between S1-S2 and S2-S3 was larger in the spondylolisthesis cohort., Conclusions: The SI joints in patients with spondylolisthesis were orientated closer to the sagittal plane than in the controls. An awareness of this positioning may be important in surgical implant insertion as well as rehabilitation of hip extensor weakness. The main anatomical differences found in this study were in the sagittal plane. Sacral end plate abnormalities were well visualized and consistent with radiographic findings in the literature., Level of Evidence: Level III, diagnostic., (Copyright © 2019 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.)

Background: To improve gait, persons with calf muscle weakness can be provided with a dorsal leaf spring ankle foot orthosis (DLS-AFO). These AFOs can store energy during stance and return this energy during push-off, which, in turn, reduces walking energy cost. Simulations indicate that the effect of the DLS-AFO on walking energy cost and gait biomechanics depends on its stiffness and on patient characteristics. We therefore studied the effect of varying DLS-AFO stiffness on reducing walking energy cost, and improving gait biomechanics and AFO generated power in persons with non-spastic calf muscle weakness, and whether the optimal AFO stiffness for maximally reducing walking energy cost varies between persons., Methods: Thirty-seven individuals with neuromuscular disorders and non-spastic calf muscle weakness were included. Participants were provided with a DLS-AFO of which the stiffness could be varied. For 5 stiffness configurations (ranging from 2.8 to 6.6 Nm/degree), walking energy cost (J/kg/m) was assessed using a 6-min comfortable walk test. Selected gait parameters, e.g. maximal dorsiflexion angle, ankle power, knee angle, knee moment and AFO generated power, were derived from 3D gait analysis., Results: On group level, no significant effect of DLS-AFO stiffness on reducing walking energy cost was found (p = 0.059, largest difference: 0.14 J/kg/m). The AFO stiffness that reduced energy cost the most varied between persons. The difference in energy cost between the least and most efficient AFO stiffness was on average 10.7%. Regarding gait biomechanics, increasing AFO stiffness significantly decreased maximal ankle dorsiflexion angle (- 1.1 ± 0.1 degrees per 1 Nm/degree, p < 0.001) and peak ankle power (- 0.09 ± 0.01 W/kg, p < 0.001). The reduction in minimal knee angle (- 0.3 ± 0.1 degrees, p = 0.034), and increment in external knee extension moment in stance (- 0.01 ± 0.01 Nm/kg, p = 0.016) were small, although all stiffness' substantially affected knee angle and knee moment compared to shoes only. No effect of stiffness on AFO generated power was found (p = 0.900)., Conclusions: The optimal efficient DLS-AFO stiffness varied largely between persons with non-spastic calf muscle weakness. Results indicate this is caused by an individual trade-off between ankle angle and ankle power affected differently by AFO stiffness. We therefore recommend that the AFO stiffness should be individually optimized to best improve gait., Trial Registration Number: Nederlands Trial Register 5170. Registration date: May 7th 2015. http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5170.

Purpose: ICU acquired Weakness (ICUaW) is a common complication of critical illness. The aim of our study was the assessment of quality of life (QoL) and functional ability of patients with ICUaW, 6 months post hospital discharge., Material and Methods: Eight hundred seventy eight consecutive patients who had been discharged from the ICU were evaluated and 128 of them, 36 with ICUaW, were eligible for the study. Muscle strength was evaluated with MRC and Hand grip dynamometry. The Functional Independence Measure (FIM) was used to evaluate the functional ability while QoL was assessed with the Nottingham Health Profile and with the SF-36 questionnaire., Results: Patients with ICUaW continued to have low MRC at hospital discharge, [53(49-56) vs. 59(58-60), p < 0.05]. Patients who developed ICUaW had lower Hand grip dynamometry at ICU, hospital discharge and 6 months after (p < 0.05). Patients with ICUaW have significantly lower FIM score at hospital discharge, 3 and 6 months post hospital discharge (p < 0.05) and persistently lower QoL at 3 and 6 months post hospital discharge(p < 0.05)., Conclusions: ICUaW is associated with persistent deficiencies in functional ability and Qol leading to a prolonged period of recovery. Further research is needed in the field of prevention and targeted rehabilitation of functionality in this patient group., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Muscle weakness is one of the most prevalent symptoms in children with cerebral palsy (CP). Although recent studies show that functional power training can improve strength and functional capacity in young children with CP, effects on specific gait parameters have not previously been reported., Research Question: What are the effects of functional power training on gait in children with CP? Specifically, we investigated effects of training on gait kinematics and spatiotemporal parameters, and whether these were dependent on walking speed., Methods: Ten children with CP (age 5-10 years, GMFCS I-II) participated in a functional power training program. At the start and end of the program, children underwent 3D gait analysis on a treadmill at a gradual range of walking speeds (70-175% of their comfortable walking speed). Multilevel (linear mixed model) analysis was used to evaluate effects pre-post training at different walking velocities., Results: Although children's self-chosen comfortable walking speed improved (0.71 ± 0.25 to 0.85 ± 0.25 m/s, p < .05), effects on gait kinematics at similar speed were limited and only exceeded statistical and clinically meaningful thresholds when children walked at higher walking speed. At fast speeds, improvements up to 5° were found in knee and hip extension during stance (p < .01)., Significance: This study demonstrates that gait kinematics can improve after functional power training, but the magnitude of effects is dependent on walking speed. In this light, improvements are underestimated when evaluating gait at pre-training comfortable walking speed only., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background: Amyotrophic lateral sclerosis flail arm (ALS-FA) is a motor neuron disease form confined to the upper limbs (cervical spinal cord region), often with asymmetric onset. To date, there is no defined neurorehabilitation strategy for ALS patients, although aerobic exercises may be of some help., Case Report: A 69-year-old woman affected by ALS-FA was admitted to our research institute because of upper limb muscle weakness. She was then submitted to two different conventional physiotherapy programs, the first stand-alone and the second combined to a robotic treatment. The patient gained an important motor improvement only after a 2-month treatment of physiotherapy plus Armeo-Power (AP), a robotic rehabilitation exoskeleton for upper limbs training, providing intelligent arm support in a 3D workspace., Clinical Rehabilitation Impact: Even though this is a single case, our combined neurorehabilitation approach (i.e. conventional physiotherapy plus robotics) could be considered a promising tool in improving upper limb function in patients affected by motoneurons disease, including ALS. Further studies involving a larger cohort of ALS-FA patients and long-term follow-up are needed, in order to evaluate the efficacy of robotics in prolonging patient's independence in active daily living.

Background: The clinical course of motor deficits from lumbosacral radiculopathy appears to improve with or without surgery. Strength measurements have been confined to manual muscle testing (MMT) and have not been extensively followed and quantified in prior studies., Objective: To determine if motor weakness and patient-reported outcomes related to lumbosacral radiculopathy improve without surgical intervention over the course of 12 months., Design: Prospective observational cohort., Setting: Outpatient academic spine practice., Participants: Adults with acute radicular weakness due to disk herniation., Methods: Forty patients with radiculopathy and strength deficit were followed over a 12-month period. Objective strength and performance tests as well as survey-based measurements were collected at baseline and then every 3 months. Patients underwent comprehensive pain management and rehabilitation and/or surgical approaches as determined in coordination with the treating specialist. This study was approved by the institutional review board of Colorado., Main Outcome Measurements: Testing of strength was through MMT, handheld dynamometer, and performance-based testing. Furthermore, visual analog scale, modified Oswestry Disability Index, and 36-Item Short Form Health Survey (SF-36) were used to measure pain and disability outcomes., Results: Of the 40 patients, 33 (82.5%) did not have surgery; 7 (17.5%) had surgery. Twenty-four of the 33 patients (60%) did not undergo surgery and were followed for 12 months (Comprehensive Pain Management and Rehabilitation, Complete [CPM&R-C]), and 9 (22%) did not have surgery and lacked at least one follow-up evaluation (Comprehensive Pain Management and Rehabilitation, Incomplete [CPM&R-I]). No statistically significant differences were found on baseline measures of strength deficits and SF-36 domains between the CPM&R-C, Surgery, and CPM&R-I groups. Pain and disability scores in the Surgery group were significantly higher than in the CPM&R-C at baseline. There were statistically significant improvements in all areas of strength, pain, and function when comparing measurements at the 12-month follow-up to baseline in the CPM&R-C group., Conclusions: Individuals with motor deficits due to lumbosacral radiculopathy improve over time regardless of treatment choice. Most did not choose surgery, and almost all of these patients regained full strength at 1 year. Strength recovery typically occurred in the first 3 months, but there was ongoing recovery over the course of a year., Level of Evidence: II., (© 2019 American Academy of Physical Medicine and Rehabilitation.)

Study design: Case Report. Purpose: Stroke is the most common cause of long-term disability. Dysesthesia, an unpleasant sensory disturbance, is common following thalamic stroke and evidence-based interventions for this impairment are limited. The purpose of this case report was to describe a decrease in dysesthesia following manual therapy intervention in a patient with history of right lacunar thalamic stroke. Case description: A 66-year-old female presented with tingling and dysesthesia in left hemisensory distribution including left trunk and upper/lower extremities, limiting function. Decreased left shoulder active range of motion, positive sensory symptoms but no sensory loss in light touch was found. She denied pain and moderate shoulder muscular weakness was demonstrated. Laterality testing revealed right/left limb discrimination deficits and neglect-like symptoms were reported. Passive accessory joint motion assessment of glenohumeral and thoracic spine revealed hypomobility and provoked dysesthesia. Interventions included passive oscillatory joint mobilization of glenohumeral joint, thoracic spine, ribs and shoulder strengthening. Results: After six sessions, shoulder function, active range of motion, strength improved and dysesthesia decreased. Global Rating of Change Scale was +5 and QuickDASH score decreased from 45% to 22% disability. Laterality testing was unchanged. Conclusion: Manual therapy may be a beneficial intervention in management of thalamic stroke-related dysesthesia. Implications for Rehabilitation While pain is common following thalamic stroke, patients may present with chronic paresthesia or dysesthesia, often in a hemisensory distribution. Passive movement may promote inhibition of hyperexcitable cortical pathways, which may diminish aberrant sensations. Passive oscillatory manual therapy may be an effective way to treat sensory disturbances such as paresthesias or dysesthesia.

Objectives: We investigated the effectiveness of cycle ergometer training and resistance training to enhance the efficiency of standard care to improve walking ability, muscular strength of the lower limbs, cardiovascular endurance and health-related quality of life during inpatient rehabilitation in intensive care unit acquired weakness., Materials & Methods: Thirty-nine patients with severe to moderate walking disability were enrolled in one of the three experimental groups: (a) ergometer training group, (b) resistance training group and (c) control group (standard care only). Intervention was applied 5 days a week over a 4-week period during inpatient neurological rehabilitation. We evaluated walking ability (Functional Ambulation Category test, timed up and go test, 10-metre walk test and 6-minute walk test), muscle strength (Medical Research Council and maximum muscle strength tests), cardiovascular endurance and muscular endurance of the lower limbs at the fatigue threshold (physical working capacity at fatigue threshold) and quality of life (medical outcomes study SF-36 form). All tests were performed at baseline, after two weeks of treatment and at the end of the 4-week intervention period., Results: Ergometer training and resistance training enhanced the effectiveness of standard care in order to improve (a) lower limb muscle strength, (b) walking ability and (c) cardiorespiratory fitness during inpatient rehabilitation of intensive care acquired weakness. In addition, ergometer training may be superior to resistance training., Conclusions: Our data encourage more research to develop and implement these training tools in rehabilitation programmes for intensive care acquired weakness., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Exercise improves objective measures of physical function in individuals on hemodialysis, but its effect on patient-reported outcomes (PROs) is largely unknown. We performed a scoping review to characterize the existing knowledge base on exercise and PROs in dialysis patients to make recommendations for future research. We searched Medline, Embase, Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials, CINAHL, and SPORT Discus from inception to November 28, 2018 and then screened results for randomized controlled trials comparing aerobic/resistance exercise, or both, with no exercise in individuals on dialysis that reported results of any PRO. Of 1374 eligible studies, 25 studies met inclusion criteria. Study interventions included aerobic exercise (11 intradialytic and 3 home-based trials); intradialytic resistance exercise (seven studies) and combined aerobic and resistance exercise (six intradialytic and one facility-based trial). The PROs measured included health-related quality of life (n = 19), depression (n = 6), anxiety (n = 3), symptom burden (n = 4), sleep quality (n = 2), restless legs syndrome (n = 2), disability (n = 2), and self-reported physical activity level (n = 4). Only five studies included a PRO as a primary outcome. Studies primarily used broad/generic measures of health-related quality of life and the effect of exercise on symptoms remains relatively unexplored, particularly in peritoneal dialysis populations. Although limited, the role of exercise in improving restless legs was consistent and is a promising outcome for future study. A critical step to improving the quality of the research on this topic includes the use of validated and consistent PRO measures., (© 2019 Wiley Periodicals, Inc.)

Intradialytic exercise can improve physical function and health-related quality of life (HRQoL) in hemodialysis (HD) patients, but is not implemented in routine clinical practice. Virtual reality (VR) exercise has resulted in benefits in non-dialysis contexts, but implementation in HD patients has been limited. The aim of this review was to provide an overview of VR, present the results of a 12-week intradialytic VR exercise intervention, and compare VR to conventional exercise. The secondary aim was to review the effect of VR exercise during the last 30 minutes of the HD session on hemodynamic stability. We conclude that VR exercise during HD is safe and can improve physical function and HRQoL, and can be performed safely toward the end of the HD session., (© 2019 Wiley Periodicals, Inc.)