PM&R最新文献

Background: Research on older adults who sustain a traumatic brain injury (TBI) has predominantly been on civilian, nonveteran populations. Military populations experience higher rates of TBI and often experience the additive effects of TBI and other comorbid disorders, including posttraumatic stress disorder and/or substance use that may increase disability over time.

Objective: To investigate predictors of functional independence trajectories over the 5 years after TBI in veterans 55 years or older at injury.

Setting: Five Veterans Affairs (VA) polytrauma rehabilitation center (PRC) inpatient rehabilitation programs.

Participants: Veterans who experienced their TBI at 55 years or older and had completed one or more Functional Independence Measure (FIM) Motor and Cognitive measure at 1, 2, or 5 years after TBI (n = 184) from the VA TBI Model Systems national database.

Design: Retrospective analysis of observational data using hierarchical linear models.

Main measures: FIM Motor and Cognitive scores at 1, 2, and 5 years after TBI.

Results: Motor and cognitive functioning decreased over time. Lower FIM Motor trajectories occurred in participants who had pre-TBI functional limitations in going out of the home and with longer posttraumatic amnesia (PTA). FIM Motor scores decreased over time, and the decrease was steeper for those with a moderate or severe injury. Lower FIM Cognitive trajectories occurred in participants who had problematic substance use at baseline and among those with longer PTA. FIM Cognitive scores decreased at a steeper rate for participants with greater injury severity.

Conclusions: Similar to previously published studies in civilian populations, older veterans with TBI may be at risk for functional and cognitive decline. This study's findings increase the field's understanding of functional trajectories after TBI in older adults and may help identifty those who are at risk for lower functional outcomes.

Objective: To review and synthesize existing evidence on the effect of mirror therapy (MT) on motor and functional recovery and the effect of unimanual and bimanual MT in individuals with subacute stroke.

Methodology: PubMed, Physiotherapy Evidence Database, Cochrane, and Airiti Library were searched for relevant studies. Randomized and pilot randomized controlled trials comparing MT with sham MT or conventional therapy were included. Three researchers independently reviewed eligible studies for study design, participants' characteristics, intervention, and outcome measures and assessed study quality. The Physiotherapy Evidence Database scale was used to evaluate the methodological quality of included studies, and the Cochrane Risk of Bias Tool was used to assess the risk of bias.

Synthesis: Fifteen studies with 546 participants were included. An overall effect of MT was found for motor impairment (effect size [95% confidence interval]: 0.473 [0.274-0.673], p < .001), motor function (0.266 [0.059-0.474], p = .012), and activities of daily living (ADL) (0.461 [0.25-0.671], p < .001), compared with controls. There was a significant difference in motor impairment (0.39 [0.134-0.647], p = .003), motor function (0.298 [0.003-0.593], p = .048), and ADL (0.461 [0.157-0.766], p = .003) in favor of bimanual MT compared with controls. No significant effect was found for unimanual MT.

Conclusion: MT, specifically bimanual MT, is an effective intervention for improving motor recovery, motor function, and ADL in individuals with subacute stroke, whereas unimanual MT does not show significant benefits in these areas.

Orthobiologic injections including platelet-rich plasma (PRP) and cell-based injections are becoming increasingly popular. Evidence suggests that these therapies can be effective in certain situations. The efficacy of these injections may be more dependent on the quality of the injectate, which given their autologous nature, may be dependent on lifestyle choices like exercise, diet, and supplements. The literature describing PRP injections shows that the number and activity of platelets can improve their efficacy. A multitude of lifestyle modifications can affect those factors. Exercise intensity appears to increase platelet count and increases adhesion as well as release of growth factors. Low inflammatory diets increase platelet counts and activity overall. Stress, some supplements, high cholesterol, or processed sugar diets can increase inflammation and potentially decrease platelet counts as well as quality of PRP injectate. Similarly, cell-based therapies can be affected by mesenchymal stromal cell (MSC) number and quality. Cell-based therapy is based upon limiting cellular senescence and increasing replication and differentiation. Exercise may limit senescence and improve replication and differentiation of these cell-based therapies, especially in older adult populations. There are a multitude of supplements that may potentiate these types of injections and patients should discuss the potential benefits and concerns when starting a supplement regimen. Certain foods as well as changes in oxygenation may limit cellular senescence and lower calorie intake may affect MSC viability and function as well. Overall, the current state of literature describes biologic plausibility of how exercise, diet and supplements might affect orthobiologic injection efficacy. Further translational research needs to be completed to describe the effect size and improve recommendations for clinical implementation.

The management of postamputation pain remains a significant clinical challenge, with existing therapeutic approaches often yielding inconsistent outcomes. Neuromodulation techniques, particularly peripheral nerve stimulation (PNS), have emerged as promising interventions. However, the evidence supporting their effectiveness in treating phantom limb pain (PLP) and residual limb pain (RLP) remains limited. This narrative review consolidates previous findings of PNS as a postamputation agent and amasses the most recent data on its effectiveness in clinical settings. A literature review was conducted using MEDLINE via PubMed, EMBASE, and Cochrane Library, yielding 115 references. After removing duplicates and applying inclusion criteria, three studies were included. The studies reviewed demonstrate that PNS can offer varying degrees of sustained pain relief, mood enhancement, reduction in opioid use, and functional improvement. However, discrepancies in study design, patient demographics, devices used, and methodological approaches significantly limit the generalizability and reliability of these findings. Currently, the evidence supporting PNS for the treatment of RLP and PLP is limited, with minimal data affirming its efficacy in alleviating postamputation pain and related symptoms. More studies, especially larger, well-designed comparative and observational studies are needed to extrapolate these conclusions for PNS and postamputation pain.

Background: Individuals with spinal cord injury (SCI) commonly have autonomic dysreflexia (AD) with increased sympathetic activity. After SCI, individuals have decreased baroreflex sensitivity and increased vascular responsiveness.

Objective: To evaluate the relationship between baroreflex and blood vessel sensitivity with AD symptoms.

Design: Case control.

Setting: Tertiary academic center.

Patients: 14 individuals with SCI, 17 matched uninjured controls.

Interventions: All participants quantified AD symptoms using the Autonomic Dysfunction Following SCI (ADFSCI)-AD survey. Participants received three intravenous phenylephrine boluses, reproducibly increasing systolic blood pressure (SBP) 15-40 mmHg. Continuous heart rate (R-R interval, ECG), beat-to-beat blood pressures (Finapres), and popliteal artery flow velocity were recorded. Vascular responsiveness (α1 adrenoreceptor sensitivity) and heart rate responsiveness to increased SBP (baroreflex sensitivity) were calculated.

Main outcome measures: Baroreflex sensitivity after increased SBP; Vascular responsiveness through quantified mean arterial pressure (MAP) 2-minute area under the curve and change in vascular resistance.

Results: SCI and control cohorts were well matched with mean age 31.9 and 29.6 years (p = .41); 21.4% and 17.6% female, respectively. Baseline MAP (p = .83) and R-R interval (p = .39) were similar. ADFSCI-AD scores were higher following SCI (27.9 ± 22.9 vs. 4.2 ± 2.9 in controls, p = .002). To quantify SBP response, MAP area under the curve was normalized to dose/body weight. Individuals with SCI had significantly larger responses (0.26 ± 0.19 mmHg*s/kg*μg) than controls (0.06 ± 0.06 mmHg*s/kg*μg, p = .002). Similarly, leg vascular resistance increased after SCI (24% vs. 6% to a normalized dose, p = .007). Baroreflex sensitivity was significantly lower after SCI (15.0 ± 8.3 vs. 23.7 ± 9.3 ms/mmHg, p = .01). ADFSCI-AD subscore had no meaningful correlation with vascular responsiveness (R² = 0.008) or baroreflex sensitivity (R² = 0.092) after SCI.

Conclusions: Although this confirms smaller previous studies suggesting increased α1 adrenoreceptor sensitivity and lower baroreflex sensitivity in individuals with SCI, contrary to our hypothesis these differences lacked correlation to increased symptoms of AD. Further research into physiologic mechanisms is needed to explain why some individuals with SCI develop symptoms.

Background: The Sarasota Memorial Health Care System (SMHCS) Acute Care Rehabilitation Team began implementing the Keep Your Move in the Tube (KYMITT) protocol in February 2023 to improve patient mobility and offer an alternative to traditional sternal precautions. The goal of KYMITT is for patients to remain within a safe zone (referred to as "the tube") rather than complying with time and weight restrictions, which are the cornerstone of traditional sternal precautions. In previous studies, KYMITT was associated with greater independence after surgery without placing patients at an increased risk of experiencing a surgical site infection.

Objective: To test the hypothesis that KYMITT is associated with greater patient mobility and independence, without increasing the risk of surgical complications.

Methods: Researchers at SMHCS analyzed records of 614 open-heart surgery patients (n = 293 in the traditional sternal precautions group and n = 321 in the KYMITT protocol group) to determine the differences in their Activity Measure for Post-Acute Care (AM-PAC) mobility scores.

Results: The average last-recorded AM-PAC score for the traditional sternal precautions group was significantly lower than for those receiving the KYMITT protocol (19.2 [95% CI: 18.86-19.62] vs. 20.0 [95% CI: 19.62-20.35], p = .006). For patients with at least two AM-PAC scores recorded, the difference was calculated for each patient's first to last AM-PAC score (AM-PAC delta). There was not a statistically significant difference between groups with an average improvement of 2.7 (95% CI: 2.30-3.09) for the traditional sternal precautions group compared to 3.1 (95% CI: 2.71-3.45) for the KYMITT protocol, p = .16 when comparing average AM-PAC delta.

Conclusion: Overall, during the 7 months that KYMITT was conducted hospital-wide, a significant increase in average last-recorded AM-PAC scores was observed month to month (slope = 0.45, 95% CI: 0.27-0.62, p < .001).

Background: Knee osteoarthritis (OA) and its impairments affect patients' physical and mental health. Radiographically severe knee OA is believed to respond less to conservative treatments including physical therapy (PT) but has not been compared specifically with Patient-Reported Outcomes Measurement Information System (PROMIS)-10.

Objective: To correlate baseline PROMIS-10 physical and mental health scores in patients undergoing PT for knee OA, subgrouped by radiographic severity (Kellgren-Lawrence [KL] grade and number of knee compartments involved). Additionally, to describe the relationship between radiographic severity of knee OA and the change in PROMIS-10 scores post-PT.

Design: Retrospective review.

Setting: Outpatient musculoskeletal clinics at an orthopedic specialty hospital.

Patients (or participants): One hundred nine patients (age ≥ 18 years) who presented for evaluation of knee OA from April 1, 2019 to August 1, 2021, had baseline radiographs, underwent PT, and completed PROMIS-10 at baseline and follow-up.

Interventions: PT.

Main outcome measure(s): PROMIS-10 physical and mental health scores.

Results: Participants were 60% female; average age was 66.6 ± 10.0 years. Baseline PROMIS-10 physical and mental health scores averaged 44.4 ± 7.2 and 52.8 ± 9.0. Post-PT PROMIS-10 physical and mental health scores averaged 44.7 ± 6.7 and 52.6 ± 8.7. Physical health scores improved in 39% of patients; mental health scores improved in 36% of patients (no statistical significance). There was no relationship between post-PT PROMIS-10 scores and radiographic severity of knee OA. Females exhibited osteoarthritic changes in all compartments in 72% of cases compared to 55% of males (p = .020). Females demonstrated a higher predisposition for lateral compartment involvement (83% vs. 64%; p = .021) and a higher proportion of severe OA, radiographically, with a KL grade 3-4 (92% vs. 80%; p = .051).

Conclusions: More than one third of patients with knee OA reported improved physical and mental health post-PT. The degree of benefit did not relate to radiographic severity. Although OA is characterized by radiographic measurements, there are variables beyond the radiographic imaging that may affect patient outcomes.

Background: There are no evidence based guidelines for clinicians to follow in advising pediatric patients with traumatic brain injury (TBI) on return to play (RTP).

Objective: To understand practice patterns of experts in pediatric traumatic brain injury (TBI) in relation to how they assess severity of TBI and guide return to play (RTP) decisions with their patients who sustain complicated mild, moderate, or severe TBI.

Design: Cross-sectional web-based survey.

Setting: Not applicable.

Participants: Thirty experts (defined by attesting to their clinical management of children with TBI and demonstrating a history of publication in the area of pediatric TBI including mild TBI) represented by physical medicine and rehabilitation, neurology, neurosurgery, sports medicine, and neuropsychology. Fifty-five candidates were invited, 37 responded (67% response rate), and 30 were eligible to participate.

Interventions: Not applicable.

Main outcome measure(s): Ratings of agreement as to the relative importance of a variety of factors used to assess initial severity of injury as well as to measure recovery. RTP timelines were measured for different scenarios (adjusted by level of risk of activity returned to and the severity of initial injury sustained). Finally, ratings of agreement with various factors that could influence their RTP decision making as well as a free text option.

Results: Recommendations on RTP timing varied significantly based on risk of activity returned to for all levels of TBI severity (p < .05). There was large variability of RTP timeline for any given level of injury severity. There was no significant association between medical specialty and RTP recommendations. Experts also noted a variety of factors which may inform their RTP decision making, many with high agreement.

Conclusions: These results can inform clinicians who care for these patients in their own RTP decision making. The description of these RTP trends, in combination with the variability seen in both severity determination and recovery assessment, highlight the importance of further study of outcomes related to RTP and the eventual development of standardized guidelines for this patient population.