Physical Medicine & Rehabilitation

Painful Foot Disorders in the Geriatric Population: A Narrative Review Painful foot disorders are highly prevalent among older adults causing a significant impact on mobility, function, and risk of falls. Despite its significance, foot pain is often interpreted as a normal part of aging and relatively ignored by health care providers as well as by the elderly themselves. Accurate diagnosis of the cause of foot pain is possible for most cases via clinical evaluation without a costly workup. Clinicians should consider, not only musculoskeletal pathologies, but also vascular and neurological disorders in older patients with foot pain. Fortunately, a majority of patients improve with physiatric, non-operative interventions involving biomechanical analysis, function oriented rehabilitation programs and therapeutic exercise, the use of proper footwear and orthoses, and selected percutaneous interventions, as indicated. In this review, we discuss the physiologic changes of the aging foot relevant to foot pain, the impact of painful foot disorders on function and other key outcomes, and principles of diagnosis and intervention. We also briefly describe painful foot disorders of the elderly commonly encountered in a physiatric practice. Previous presentation of the data: not applicable Financial support: none Corresponding author: Mooyeon Oh-Park, M.D. Address: Burke Rehabilitation Hospital, 785 Mamaroneck Av, White Plains, NY, 10605, U.S.A. Email: mohpark@burke.org Painful Foot Disorders in the Geriatric Population: A Narrative Review Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Use of Platelet Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study Objective This study aims to assess whether ultrasound guided injection of platelet rich plasma (PRP) can safely and effectively treat symptoms associated with acetabular hip labral tears. Design Institutional Review Board (IRB) approval was gained for a prospective study of eight patients (N=8), who have previously failed conservative management, to receive ultrasound-guided injection of PRP at the site of hip labrum tear. We assessed pain reduction and functional ability at baseline, and then 2, 6, and 8 weeks after injection, using the Visual Analogue Scale (VAS) and Harris Hip Score (HHS), respectively. Results Statistically significant differences in HHS were seen two (86.5 +/- 10.8, p<0.01), six (88.0 +/- 10.7) p<0.01), and eight weeks (92.1 +/- 11.6, p<0.01) after injection as compared to baseline (76.0 +/- 13.4). Corresponding improvements were seen in VAS two (1.0, p<0.01 at rest, 2.5, p<0.01 with activity), six (0.9, p<0.01 at rest, 2.3, p<0.01 with activity), and eight weeks (0.5, p<0.01 at rest, 1.3, p<0.01 with activity) compared to baseline (3.8 at rest, 5.4 with activity). Conclusions Ultrasound-guided injection of PRP holds promise as an emerging, minimally-invasive technique toward symptom relief, reducing pain, and improving function in patients with hip labral tears. Correspondence: Arthur Jason De Luigi, DO, MHSA, 10825 N. 140th Way, Scottsdale, AZ 85259301793-2136. ajweege@yahoo.com Author Disclosures: Arthur Jason De Luigi, DO, MHSA Daniel Blatz, MD Christopher Karam, MD Zachary Gustin, MD Andrew H. Gordon, MD Competing Interests-None for any author Funding or grants or equipment provided for the project from any source-None for any author Financial benefits to the authors-None to any author Details of any previous presentation of the research, manuscript, or abstract in any form: Please note that we have presented this research at both national and local conferences. This research was selected as a Scientific Paper Presentation at the 2015 Association for Academic Physiatrists conference held in San Antonio, Texas. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Administration of Platelet Rich Plasma to Hip Labral Tears Reduces Pain and Improves Function.Scientific Paper (Podium) Presentation, Annual Meeting of the Association of Academic Physiatrists. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Improved Hip Function and Pain Alleviation after Single Administration of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Oral Poster Presentation, Annual Meeting of the American Medical Society for Sports Medicine. 2015. Gordon, A.H., C. Karam, D. Blatz, Z. Gustin, A.J. De Luigi. Functional Improvement and Pain Reduction after Single Injection of Platelet Rich Plasma for Hip Labral Tears: A Prospective Cohort Study.Poster Presentation, MedStar Health Research Institute Research Symposium. 2015. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A NEW THRESHOLD FOR APPENDICULAR LEAN MASS DISCRIMINATES MUSCLE WEAKNESS IN WOMEN WITH HIP FRACTURE: A CROSS-SECTIONAL STUDY. Objective To investigate the relationship between measures of muscle mass and grip strength in women with subacute hip fracture. Firstly, we aimed to assess the capability of the current thresholds for appendicular lean mass (aLM), aLM-to-body-mass-index ratio and aLM/height2 to separate weak and non-weak women. Secondly, we aimed to explore alternative thresholds for the 3 measures of muscle mass to discriminate weakness. Design Cross-sectional study of 160 women with hip fracture admitted to a rehabilitation hospital. We assessed aLM by dual-energy x-ray absorptiometry and grip strength by a Jamar hand dynamometer. Weakness was defined as grip strength <16 kg. Results Weakness was not significantly associated with aLM <15.02 kg, aLM-to-body-mass-index ratio <0.512 or aLM/height2 <5.67 kg/m2. For aLM (but not for the other 2 measures of muscle mass) an alternative threshold (11.87 kg instead of 15.02 kg) significantly discriminated weakness: χ2 (1, n=160)=10.77 (p=0.001). The association between aLM <11.87 kg and grip strength <16 kg persisted after adjustment for age and body mass index: odds ratio =2.50 (95% CI 1.17-5.34; p=0.018). Conclusions Data suggests that the current thresholds for measures of muscle mass do not discriminate weakness in women with subacute hip fracture. For aLM an alternative cutoff-point actually separated weak and non-weak women. CORRESPONDING AUTHOR: Dr. Marco Di Monaco, Osteoporosis Research Center, Division of Physical Medicine and Rehabilitation, Presidio Sanitario San Camillo, Strada Santa Margherita 136, 10131, Torino, Italy. Tel. 0039 011 8199411; Fax 0039 011 8193012; Email Marco.di.monaco@alice.it,m.di-monaco@h-sancamillo.to.it DISCLOSURES: All the authors have no conflicts of interest. The study was not funded. The authors had no financial benefits for the study. The results have not been previously presented. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Letter to the Editor Regarding the Article "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) lesion" No abstract available

Authors' Response to the Letter to the Editor on "Dynamic Ultrasound Imaging for the Diagnosis of Superior Labrum Anterior to Posterior (SLAP) Lesion" No abstract available

EMG Evaluation of Bodyweight Exercise Progression in a Validated ACL Injury Rehabilitation Program: Cross-sectional Study Objectives Regaining muscle strength is essential for successful outcome after anterior cruciate ligament (ACL) injury, why progression of exercise intensity in ACL injury rehabilitation is important. Thus, this study evaluated hamstring and quadriceps muscle activity progression during bodyweight exercises used in a validated ACL injury rehabilitation program. Design The study design involved single-occasion repeated measures in a randomized manner. Twenty healthy athletes (nine females) performed nine bodyweight exercises (three exercises per rehabilitation phase). Surface electromyography signals were recorded for hamstring (semitendinosus, biceps femoris) and quadriceps (vastus medialis, vastus lateralis) muscles, and normalized to isometric peak EMG (nEMG). Results Hamstring muscle activity did not increase from one rehabilitation phase to the next, ranging between 8-45% nEMG for semitendinosus and 11-54% nEMG for biceps femoris. Only one exercise (Cook hip lift) exhibited hamstring muscle activities above 60% nEMG. By contrast, quadriceps muscle activity increased, and late phase exercises displayed high nEMG (vastus lateralis >60% and vastus medialis >90% nEMG). Conclusion The examined bodyweight exercises did not progress for hamstring muscle activity but successfully progressed for quadriceps muscles activity. This study highlights the need for consensus on exercise selection when targeting the hamstring muscles in the rehabilitation after ACL injury. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Conflicts of interest None declared. Funding None declared. Corresponding author: Mette Kreutzfeldt Zebis E-mail corresponding author: mzeb@kp.dk Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Differences in the mitochondrial and lipid droplet morphology in female office workers with trapezius myalgia, compared to healthy controls. A muscle biopsy study Objective Trapezius myalgia, or more specific, myofascial dysfunction of the upper trapezius mainly affects women performing jobs requiring prolonged low level activation of the muscle. This continuous low muscle load can be accompanied by a shift to a more anaerobic energy metabolism, causing pain. To investigate whether morphological signs of an impaired aerobic metabolism are present in female office workers with trapezius myalgia. Design Muscle biopsy analysis, using electron and light microscopy, was performed to compare mitochondrial and fat droplet morphology, and irregular muscle fibers, between female office workers with (n=17) and without (n= 15) work-related trapezius myalgia. Results The patient group showed a significantly higher mean area (P=0.023) and proportion (P=0.029) for the subsarcolemmal and intermyofibrillar mitochondria respectively, compared to the control group. A significantly lower mean area of subsarcolemmal lipid droplets was found in the patient group (P=0.015), which also displayed a significantly higher proportion of lipid droplets touching the mitochondria (P=0.035). A significantly higher amount of muscle fibers with COX deficient areas were found in the patient group (P=0.030). Conclusion The results of the present study may be indicatve for an impaired oxidative metabolism in work-related trapezius myalgia. However, additional research is necessary to confirm this hypothesis. Corresponding author: Kayleigh De Meulemeester Corneel Heymanslaan 10, 9000 Ghent (Belgium) Kayleigh.demeulemeester@ugent.be No conflicts of interest were present in writing this article. Kayleigh De Meulemeester is funded by BOF- UGent 01N04215. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Rehabilitation Research Experience for Medical Students (RREMS): A 10-year review The purpose of this project was to evaluate the 10-year outcomes from the Rehabilitation Research Experience for Medical Students (RREMS). A target benchmark was 1 high quality output per student. Students were required to devise a research project and work full time with a mentor at an approved sponsor site for 8 weeks. Longitudinal surveys were used to collect data about research outputs, match results, and decisions about whether to pursue academic careers. From 2008 to 2017, 73 out of 153 (48%) applicants were awarded summer externships. Residency match results included: PM&R (45%), Internal Medicine (17%), Emergency Medicine (8%), Orthopedic Surgery (6%), Neurology (6%), Psychiatry (6%), OBGYN (6%), Pediatrics (4%), and Anesthesia (2%). The RREMS was successful in exceeding the target benchmark for quality scholarly output which included 73 oral presentations at the AAP meeting, 63 published and 20 in-review manuscripts directly related to summer research, 5 book chapters, and 51 published and 20 in-review manuscripts that were indirectly related to summer research. A total of 77% reported that the RREMS positively influenced their decision to pursue research in their future career, and 70% endorsed interest in becoming a clinician-scientist. Correspondence should be directed to: Brad E. Dicianno, MD, Human Engineering Research Laboratories, Bakery Square, 6425 Penn Avenue, Suite 400, Pittsburgh, PA 15206, 412-822-3700, (dicianno@pitt.edu) Disclosures: This manuscript has not been published and is not under consideration for publication elsewhere. Data from this manuscript was accepted as part of an abstract to be presented at the 2019 Association for Academic Physiatrists Annual Meeting in Puerto Rico. This project was funded by the Association of Academic Physiatrists, the Foundation for PM&R and the Craig H. Neilsen Foundation. 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. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Validity of the Montreal Cognitive Assessment for Moderate to Severe Traumatic Brain Injury Patients: A Pilot Study Objective To pilot the use of Montreal Cognitive Assessment (MOCA) as a quick clinical screen for cognitive assessment in traumatic brain injury (TBI) patients. Design The study recruited 61 participants with moderate to severe TBI presenting to a tertiary rehabilitation center under the Brain Injury Program. A MOCA questionnaire and neuropsychological battery (Repeatable Battery for the Assessment of Neuropsychological Status [RBANS] and Color Trails Test[CTT]) were administered to participants who had completed inpatient rehabilitation. Results Receiver Operating Characteristic (ROC) analysis for the MOCA revealed an optimal balance of sensitivity and specificity at 24/25 to discriminate participants who were classified as less than 5th centile on the Total Scale Index on the RBANS. This achieved a sensitivity, specificity, PPV and NPV of 73.9%, 86.5%, 77.3% and 84.2% respectively. ROC analysis for the trail making subtest of the MOCA achieved a sensitivity, specificity, PPV and NPV of 79.4%, 74.1%, 79.4% and 74.1% in identifying patients classified as less than 5th centile on CTT Part 2. Conclusion The use of MOCA displayed good validity in identifying patients with clinically significant impairment on a standard neuropsychological assessment battery in the study population. However, it may lack sensitivity for estimating mild levels of impairment. All correspondence and requests for reprints should be addressed to: Matthew Rong Jie Tay, Tan Tock Seng Hospital Rehabilitation Center, c/o TTSH Rehabilitation Center @ Ang Mo Kio-Thye Hua Kwan (AMK-THK), 17, Ang Mo Kio Ave 9, Singapore 569766, Republic of Singapore. The authors confirmed that with regard to this submitted article, we have none of the following disclosures: competing interests, funding or grants or equipment from any source, and financial benefits to the authors, nor have we previously published any part or whole of this original work. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Early detection of diabetic polyneuropathy using paired stimulation studies of the sensory nerves Objective This study seeks to use the RRP, a sensitive parameter for detecting early change in peripheral polyneuropathies, as a tool for early detection of diabetic polyneuropathy (DPN). Design The RRP of the median and sural sensory nerves were measured in 57 diabetic patients (male 31, female 26) and 23 healthy controls (male 16, female 7). The shortest inter-stimulus interval, where the latency of the response to the second stimulus recovers to normal, was defined as the RRP. Results The RRP of the median and sural nerves were significantly longer in diabetic patients (3.6 msec, p<0.001 and 3.8 msec, p<0.001, respectively) than in the control group (3.0 msec in both nerves). RRP values of both nerves were also significantly prolonged compared with the control group, even in diabetic patients without DPN based on conventional conduction studies (3.3 msec, p=0.002 for median nerve; 3.5 msec, p<0.001 for sural nerve) or without any clinical symptoms and signs (3.3 msec, p=0.007 for median nerve; 3.5 msec, p=0.001 for sural nerve). Conclusion The RRP was prolonged in diabetic patients even before other electrophysiologic abnormalities or clinical findings appeared. These results suggest that the RRP can be a possible early indicator of DPN. Corresponding author: Hee-Kyu Kwon, M.D., Ph.D Address: Department of Physical Medicine and Rehabilitation, Department of Medicine, Graduate School, Korea University, 73 Inchon-ro, Seongbuk-gu, Seoul 02841, Korea. E-mail: hkkwon@korea.ac.kr Disclosure statements: There is no conflicts of interest and no funding was provided for the study. The abstract of the study was presented at the 46th Annual Meeting of the Korean Academy of Rehabilitation Medicine on Oct. 27th, 2018, in Seoul, Korea. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Alexandros Sfakianakis
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