Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain.

Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP

Kinematic assessment of upper limb function in progressive multiple sclerosis

Upper limb dysfunction is common in multiple sclerosis (MS) with current evaluation methods relying on capacity assessments and a subjective evaluation of impairment. Kinematic techniques allow the quantification of upper limb dysfunction and may provide a useful marker in the prognosis of those affected. The aim of this thesis was to develop and use kinematic assessment techniques to characterise the extent and progression of upper limb dysfunction in people with MS (pwMS). Forty-two patients with progressive MS and 15 healthy controls reached-and-grasped objects while movement trajectories were captured with a kinematic assessment system. Clinical measures including the nine hole peg test (9HPT), Expanded Disability Status Scale (EDSS), and patient reported outcomes were administered at baseline and six months. PwMS had longer reaction and reach times, took longer to pick-up objects and move them between pre-defined positions, and spent more time placing objects, compared to controls. PwMS had lower peak wrist velocities when reaching towards and moving objects. Kinematic assessment demonstrated consistent differences between the mildly and severely affected patients, driven by object grasp dimensions, which weren’t captured by 9HPT. There was no correlation between upper limb performance and EDSS, with wide variation in upper limb performance as measured by the kinematic assessment across a narrow EDSS range. There was moderate correlation between kinematic assessment and 9HPT. There was a significant change in some kinematic parameters at 6 months follow-up capturing predicted change in function. This study developed and evaluated a novel upper limb function assessment tool and found better sensitivity and behaviour capture than the EDSS and 9HPT. For the first time, we have quantified the spatiotemporal patterns of hand function impairment in people with progressive MS

Rehabilitation Outcome Following Acute Stroke: Considering Ideomotor Apraxia

Stroke is a leading cause of death and the leading cause of adult disability in the United States affecting approximately 795,000 people yearly. Stroke sequelae often span multiple domains, including motor, cognitive, and sensory subsystems. Impairments can contribute to difficulty participating in activities of daily living (ADLs) and translate into disability - a concern for patients and occupational therapists alike. The role of ideomotor apraxia (IMA) in stroke rehabilitation is unclear. Thus, the purpose of these two studies is to investigate stroke rehabilitation outcome while considering the presence of ideomotor apraxia. Stroke causes dysfunctional movement patterns arising from an array of potential etiologies. Agreement exists that understanding the patient's functioning serves as the basis for the rehabilitation process and it is insufficient for clinicians simply to determine functional movement problems without knowing how underlying impairments contribute. Stroke-induced paresis is a prevalent impairment and frequent target of traditional rehabilitation. Stroke rehabilitation often addresses paresis narrowly with little consideration for other stroke consequences. Ideomotor apraxia is one such disorder after stroke that could conceivably limit rehabilitation benefit of otherwise efficacious treatment interventions aimed at remediating paresis. This led us to an initial study of a subject who experienced a single left, ischemic stroke with paresis of his right upper extremity and comorbid ideomotor apraxia. The subject participated in combined physical and mental practice for six consecutive weeks to improve use of his right arm. After intervention, the subject demonstrated clinically significant improvements in functional performance of his more-affected right upper extremity and reported greater self-perception of performance. The subject continued to demonstrate improvements after four weeks with no intervention and despite persistent IMA. This single case report highlights the importance of recognizing that ideomotor apraxia does present after stroke, and traditional stroke rehabilitation efforts directed at paresis can be efficacious for subjects with IMA. Traditional beliefs suggested that ideomotor apraxia does not translate to disability in everyday life and that IMA resolves spontaneously. Despite accumulating evidence of the influence of IMA on functional ability, this topic remains relatively neglected. It is unclear how ideomotor apraxia affects the rehabilitation process. The second study reports rehabilitation outcomes of a group of subjects following acute stroke. The Florida Apraxia Battery gesture-to-verbal command test was used to detect IMA in subjects. Level of independence with a set of ADLs and motor impairment of the more-affected upper extremity was documented at admission and discharge. Study subjects participated in standard of care stroke rehabilitation in the inpatient rehabilitation units. A total of fifteen subjects who sustained a left hemisphere stroke participated in this study - ten with IMA and five without IMA. After rehabilitation, subjects with IMA improved ADL independence and displayed decreased motor impairment of their right upper extremity. Subjects with and without IMA exhibited comparable improvements in ADL independence, but subjects with IMA exhibited less ADL independence upon when compared to subjects without IMA. Additional findings suggested that subjects with IMA were not different with respect to motor impairments and length of stay; however, additional studies with larger sample sizes are needed. In summary, these two studies aid to elucidate the implications of ideomotor apraxia on traditional stroke rehabilitation efforts. Study subjects with ideomotor apraxia after acute stroke still derive benefit from traditional rehabilitation. Because traditional rehabilitation interventions narrowly target motor impairment, these findings support the need for considering IMA as a factor in developing interventions tailored to patients with IMA and possibly as a specific focus for interventions. A step toward addressing this need is to assess whether IMA is present after stroke on a regular basis. This work provides a framework for researchers and clinicians to investigate further how ideomotor apraxia translates into disability. These findings are important since consideration of ideomotor apraxia could influence selection and design of rehabilitation interventions to optimize patient daily functioning after stroke

Personalized Hip and Knee Joint Replacement

This open access book describes and illustrates the surgical techniques, implants, and technologies used for the purpose of personalized implantation of hip and knee components. This new and flourishing treatment philosophy offers important benefits over conventional systematic techniques, including component positioning appropriate to individual anatomy, improved surgical reproducibility and prosthetic performance, and a reduction in complications. The techniques described in the book aim to reproduce patients’ native anatomy and physiological joint laxity, thereby improving the prosthetic hip/knee kinematics and functional outcomes in the quest of the forgotten joint. They include kinematically aligned total knee/total hip arthroplasty, partial knee replacement, and hip resurfacing. The relevance of available and emerging technological tools for these personalized approaches is also explained, with coverage of, for example, robotics, computer-assisted surgery, and augmented reality. Contributions from surgeons who are considered world leaders in diverse fields of this novel surgical philosophy make this open access book will invaluable to a wide readership, from trainees at all levels to consultants practicing lower limb surger

Musculoskeletal and Sports Medicine Physical Medicine and Rehabilitation Curriculum Guidelines

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/147194/1/pmr21244.pd

Der Einfluss des postoperativen femoralen offset auf die Funktion des Hüftgelenks nach trochantärer Femurfraktur und Versorgung mittels intramedullären Marknagels

Die proximale Femurfraktur tritt hierzulande insbesondere bei älteren Patienten auf. Die trochantären Frakturen, die in dieser Doktorarbeit untersucht wurden, stellen hierbei den häufigsten Subtyp dar. Auch im Hinblick auf den demographischen Wandel wird die Bedeutung des hier untersuchten Frakturtyps immer mehr ansteigen. Meist sind Niedrigenergie-Traumta die Ursache für eine solche Fraktur. Therapien der Wahl stellen die Osteosyntheseverfahren wie die dynamische Hüftschraube (DHS) und die intramedulläre Marknagelung dar. Im Gegensatz zur traditionellen Bewertung des Behandlungsergebnisses, die sich vornehmlich an der operationsbedingten Mortalität orientierte, rückt heutzutage vermehrt das Interesse an einem möglichst optimalen und den Patienten zufriedenstellenden klinischen Ergebnis in das Zentrum der Forschung. Im Rahmen der Therapie von Hüftgelenkserkrankungen mittels Endoprothetik gibt es zahlreiche Studien und Übersichtsarbeiten, die eine postoperative Funktionalität dieses Gelenks untersucht haben. Für die intramedulläre Nagelung trochantärer Femurfrakturen ist dies hingegen nicht der Fall. Da durch Ergebnisse aus dem Bereich des Gelenkersatzes die Wichtigkeit der ordnungsgemäßen Wiederherstellung der anatomischen Größen deklariert wird, wurden diese im Rahmen dieser Doktorarbeit genauer beleuchtet. Die Bedeutung des FO für die endoprothetische Versorgung wurde ausführlich untersucht. Da die Bedeutung dieses anatomischen Parameters für die Versorgung mittels intramedullärer Marknagelung jedoch noch unklar ist, wurde in dieser Arbeit das Hauptaugenmerk auf dessen Untersuchung gelegt. Zu diesem Zweck wurden deshalb 188 Patienten, die eine per-, inter- oder subtrochantäre Femurfraktur erlitten hatten und daraufhin mit einem intramedullären Marknagel therapiert worden waren, radiologisch untersucht und mit deren bereits im Rahmen der RePrOF-Studie erhobenem klinischen Ergebnis korreliert. Da die exakte Bestimmung des FO auf den standardmäßig verwendeten Röntgenbildern zum Teil stark eingeschränkt ist, wurde zur korrekten Messung dieses Parameters eine Formel zur Rotationskorrektur verwendet. Bei der Auswertung der Ergebnisse trat eine inverse Korrelation zwischen, sowohl dem rotationskorrigierten als auch dem spezifischeren relativen, FO und den primären (Harris Hip Score) und sekundären (Barthel-Index) Messinstrumenten zur Überprüfung der Hüftfunktionalität zutage. Dies legt folglich eine verbesserte Beweglichkeit des Hüftgelenks bei vermindertem FO nahe. Diese erarbeitete Tendenz ist überraschenderweise gegensätzlich zu den bisher publizierten Ergebnissen aus der Endoprothetik, auch wenn eine neue Publikation dieses Spektrums aus dem Jahr 2014 eine ähnliche Beziehung, allerdings bezogen auf das FO und das Schmerzempfinden und nicht auf den Bewegungsumfang der Hüfte, beschrieben hat. So war ein geringes FO mit einer geringeren Schmerzintensität assoziiert, wohingegen keine Aussage über eine Auswirkung des FO auf die Hüftbeweglichkeit getroffen werden konnte. Zu beachten ist allerdings, dass die Ergebnisse dieser Doktorarbeit nur im Rahmen der univariaten Analyse eine statistische Signifikanz erreichten. Nach Berücksichtigung der untersuchten möglichen confounder zeigten sich keine statistisch signifikanten Zusammenhänge zwischen dem femoralen offset und dem postoperativen klinischen Ergebnis. Aus diesem Grunde sollten weitere wissenschaftliche Arbeiten explizit den Zusammenhang dieser beiden Größen untersuchen. Erst dann können definitive Aussagen über den Einfluss des FO auf das klinische Ergebnis nach intramedullärer Nagelung trochantärer Femurfrakturen getroffen werden. Nichtsdestotrotz zeigt diese Arbeit den Trend an, dass sich ein vermindertes postoperatives FO positiv auf das klinische Ergebnis des Patienten auswirken kann