Background Lifestyle medicine aims to improve whole-person health, but unique implementation challenges exist when applying lifestyle medicine to address musculoskeletal pain.Objectives (1) To identify patient-perceived factors that affect patients' ability to make and maintain lifestyle changes in the context of having chronic musculoskeletal pain. (2) To summarize specific, patient-reported key strategies for success that clinicians can efficiently discuss with patients to facilitate lifestyle change.Design Mixed methods study.Setting Musculoskeletal lifestyle medicine program within a tertiary care academic center.Participants A purposively sampled, sociodemographically diverse group of adult patients who presented to a musculoskeletal-oriented lifestyle medicine program to address chronic musculoskeletal pain and coexisting metabolic disease.Interventions Not applicable.Main Outcome Measures Participants' semistructured interview responses were triangulated with their final program disposition and mean (SD) change on Patient-Reported Outcomes Measurement Information System (PROMIS) physical and mental health measures from initial to final program visit.Results Among 38 patients (median age 59 [range 31-74] years, 28 [74% women]), chronic pain and impaired mobility were common barriers to lifestyle change. Nevertheless, with instruction regarding how to move safely, increasing physical activity was also frequently described as patients' most impactful lifestyle change. Patients reported a wide variety of effective facilitators and motivators for change, some of which were affected by patients' gender, childhood food culture, and other life circumstances. Patients with depression commonly described clinician investment and accountability via the lifestyle medicine program as key facilitators. Although mean PROMIS score changes were modest, patients nearly universally made at least one lifestyle change and perceived related clinical benefits, even among patients whose success was not perceived by the clinical team.Conclusions Patients with chronic musculoskeletal pain can successfully make lifestyle changes. They commonly cite clinician support as a key facilitator to safely increasing physical activity and identifying tailored strategies to overcome barriers to change.
BACKGROUND:Fatigue is recognized as one of the most persistent and debilitating symptoms of long COVID, affecting both functionality and quality of life. However, its long-term effects, especially beyond the first year after infection, remain poorly understood. OBJECTIVE:To investigate self-reported fatigue and muscle fatigability in individuals with severe long COVID compared to matched healthy controls at 18 and 24 months post infection. DESIGN:Longitudinal observational study. SETTING:The study was conducted at the Laboratory of Muscle and Tendon Plasticity at the University of Brasília. PARTICIPANTS:Twenty survivors of severe-COVID and 20 age- and gender-matched controls underwent repeat assessments at 18 and 24 months following hospital discharge. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:Perceived fatigue was measured using the Fatigue Severity Scale, functionality with the 30-second sit-to-stand test, muscular dimensions and quality assessment were evaluated through ultrasound-derived thickness and echogenicity, and muscle fatigability was assessed using torque, torque-time integral, and rate of force development. The generalized estimating equations method was used with "group" and "assessments" as factors, with the least significant difference test identifying specific differences. Chi-square test compared categorical variables. RESULTS:The severe-COVID group showed consistently poorer functional performance (mean difference: 2.65 [0.45-4.85], p = .018), higher perceived fatigue (2.25 [1.54-2.95], p < .001) and lower rate of force development (-103.68 [-177.22 to -30.13], p = .006) compared to controls. No significant differences were observed in muscle thickness or echogenicity between groups. CONCLUSION:Long COVID is associated with sustained fatigue, impaired neuromuscular function, and reduced physical performance up to 2 years after infection. These findings underscore the need for long-term, mechanism-based rehabilitation strategies targeting central fatigue and neuromuscular function. TRIAL REGISTRATION:NCT04961255.
BACKGROUND:Youth and young adults with spina bifida (SB) are at risk for neurocognitive challenges and face substantial medical needs, including neurogenic bowel management. Little is known about the relationship between neurocognitive functioning and independently managing a bowel program. Understanding these associations could help tailor interventions that promote independence and long-term quality of life. OBJECTIVE:To examine whether performance-based measures of intellectual functioning, academic achievement, and executive functioning are associated with bowel management program (BMP) independence in a clinical sample of youth and young adults with SB. We hypothesized that better neurocognitive and academic functioning would be associated with greater BMP independence. DESIGN:Cross-sectional study using secondary analysis of an institutional clinical registry. Binary logistic regression using weighted least squares mean and variance estimation tested predictors of bowel management independence, including a latent academic functioning factor and observed full-scale IQ, adjusting for age and ambulation status. SETTING:Outpatient hospital pediatric rehabilitation clinic. PARTICIPANTS:A total of 79 individuals with SB (ages 10-25 years; 50.6% female) with data on BMP status and neuropsychological testing. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURE:BMP independence, as measured by a parent-reported (if under 18 years) or self-reported (if older than 18 years) questionnaire. RESULTS:After adjusting for age and ambulation status, higher full-scale IQ (odds ratio [OR] = 1.32 [95% CI, 1.04-1.67], p = .025) and academic functioning (as defined as a latent variable including reading, writing, and math performance) (OR = 1.35 [95% CI, 1.08-1.69], p = .009) were associated with greater BMP independence. Executive functioning (as defined by a latent variable including tasks assessing planning, problem-solving, initiation, and cognitive flexibility) was not a significant predictor. When both full-scale IQ and academic functioning were included in a multivariable model, only full-scale IQ remained a significant independent predictor (OR = 1.45 [95% CI, 1.04-1.68], p = .004), suggesting that overall intellectual ability accounts for much of the variance in self-management. CONCLUSIONS:Higher intellectual functioning is associated with BMP independence in youth and young adults with SB, indicating that key cognitive abilities support self-management. These findings highlight the importance of considering general intellectual ability when designing individualized treatment plans and emphasize the need to address broader contextual barriers to promote successful self-management.
BACKGROUND:Hip adductor spasticity is a common affliction among patients with disorders of the central nervous system. Cryoneurolysis is a novel intervention for spasticity involving the application of extreme cold to a nerve. This induces axonal breakdown, relieving spasticity. OBJECTIVE:To evaluate the effect of cryoneurolysis on hip spasticity in adults. DESIGN:This study was an observational, single-center, prospective cohort study. PARTICIPANTS:Twenty adult patients who had been scheduled to receive cryoneurolysis for hip adductor spasticity as part of their standard treatment were included. Patients with a history of previous nerve procedures, cryoneurolysis, or surgery of obturator nerves were excluded. INTERVENTIONS:Cryoneurolysis of anterior and posterior branches of the obturator nerve was performed. MAIN OUTCOME MEASURES:The primary outcome was spasticity severity on the Modified Ashworth Scale. Additional outcomes included passive and active ranges of motion and the goal attainment scale. RESULTS:There was a large reduction in Modified Ashworth Scale scores at 3 months on the right side (Wilcoxon W [W] = 6.0, p < .01; rank-biserial correlation [rrb] = -0.89, 95% confidence interval [CI] = -1.00, -0.63) and the left (W = 0.0, p < .001; rrb = -1.00, 95% CI = -1.00, -1.00). The decreases persisted at 1 year on the right (W = 0.00, p < .001; rrb = -1.00, 95% CI = -1.00, -1.00) and the left (W = 12.0, p < .05; rrb = -0.69, 95% CI = -1.00, -0.10). Maximum passive range of motion increased on the right side 1 year after treatment (repeated measures analysis of variance p < .05, ηp2 = 0.14, 95% CI = 0.07-0.26]) but not on the left side (p = .24, ηp2 = 0.07, 95% CI = 0.04-0.21). CONCLUSIONS:Cryoneurolysis resulted in decreased spasticity severity lasting for 1 year. Cryoneurolysis merits further investigation as a potential long-lasting, minimally invasive, drug-free intervention for hip adductor spasticity.
INTRODUCTION:Young female gymnasts had high prevalence of lower-extremity and lower-back injuries during training. OBJECTIVE:To examine the prevalence of injuries and their potential association with anthropometric measurements, puberty, and training intensity in gymnasts during a period of 24 months. METHODS:A total of 274 competitive female gymnasts (aged 12.1 ± 1.9 years) were clinically evaluated every 6 months for the presence of injuries, as well as anthropometrics, training characteristics, and pubertal status. RESULTS:During the first and third assessments, a high prevalence and incidence rate (IR)/1000 practice hours were found for suspected spondylolysis (IR 1.027 and 1.547, respectively), Achilles tendon injuries (IR = 1.169 and 1.630, respectively), and patellar tendon injuries (IR = 0.822 and 1.753, respectively). Compared to healthy gymnasts, those who experienced ≥2 episodes of tendon injuries and tibial injuries practiced fewer hours/week in the past year (p < .05); those with ≥2 episodes of back injuries and tibial injuries had higher body mass; while those with ≥2 episodes of Achilles tendon injuries had lower body mass (p < .05). Prepubertal gymnasts had a lower prevalence of ≥2 episodes of back injuries, suspected spondylolysis, and hip injuries compared to pre-to-postpubertal and postpubertal gymnasts (p < .001, <.001, .028, respectively); postpubertal gymnasts had a lower prevalence of ≥2 episodes of Achilles and patellar tendon injuries and tibial injuries compared to prepubertal and pre-to-postpubertal gymnasts (p = .034, .010, .028, respectively). CONCLUSIONS:High prevalence and high IR/1000 hours of practice were found in injured gymnasts mainly at baseline and after 1 year. Compared to healthy gymnasts, those with ≥2 episodes of injuries practiced less the past year year and differed in body mass. Prepubertal gymnasts had a lower prevalence of ≥2 episodes of injuries such as back injuries, compared to pre-to-postpubertal and compared with postpubertal gymnasts. Professional trainers and medical teams should be aware of important data regarding common diagnosis of injuries in female gymnasts.
BACKGROUND:People with spinal cord injury (SCI) experience sensory and motor impairments that often require exercise-based treatments. However, these interventions are challenging due to limited active mobility. Novel rehabilitation approaches, such as those targeting the mirror neuron system, could offer additional benefits. OBJECTIVE:To assess the effect of combining virtual walking (VW) therapy with a therapeutic physical exercise (PE) program compared to PE alone on gait and balance in people with incomplete SCI. DESIGN:Single-blinded randomized controlled trial. SETTING:Exercise laboratory. PATIENTS:Thirty-eight people with chronic incomplete SCI. INTERVENTIONS:Participants were randomized to two groups: (1) experimental intervention (EI): VW combined with PE or (2) control intervention (CI): placebo VW combined with PE. Both groups performed 18 sessions over 6 weeks (3 sessions/week). MAIN OUTCOME MEASURES:Gait performance (assessed by the 10 Meter Walk Test [10MWT, primary outcome], Walking Index for SCI [WISCI], and Center of Mass [CoM] movement during the modified Timed Up and Go test) were assessed. Moreover, static balance (assessed by CoM movement in the standing position) and dynamic balance (assessed by CoM movement during turning, sitting, and getting up tasks) were also evaluated. The assessments were performed before (T1) and after (T2) the intervention and at 4- (T3) and 12-week (T4) follow-up. The assessment points were compared through a mixed factorial analysis of variance. RESULTS:The EI group reduced the time to perform 10MWT at T2 (-36.5%, p < .05), T3 (-42.6%, p < .05), and T4 (-42.1%, p < .05), the total time to execute the modified Timed Up and Go at T3 (-18.5%, p < .05) and CoM movement during standing position at T2 (-56.1%, p < .05) and T3 (-54.1%, p < .05). The EI group also improved time to standing up at T3 (-34.9%, p < .05) and smoothness at T2 (34.8%, p < .05), and time to sitting down at T3 (-43.1%, p < .05). By contrast, the CI group improved balance only at T2 (-13.0%, p < .05), without maintaining the improvement at T3 and T4, and time to standing up at T3 (-28.8%, p < .05). No significant improvement in gait was demonstrated. CONCLUSIONS:Adding a VW intervention to a PE program could improve gait and balance in people with incomplete SCI.
BACKGROUND:Traditional rehabilitation measures, such as the Functional Independence Measure for Children (WeeFIM II), designed to measure the need for assistance and severity of disability in children with developmental disabilities, may not be an optimal indicator of physical function among pediatric patients with chronic pain undergoing rehabilitation. A better understanding of the ability of physical outcome measures to detect change over time would improve evaluation of patient response to pain interventions such as intensive interdisciplinary pain treatment (IIPT). OBJECTIVE:To investigate the responsiveness to intervention of commonly used functional assessments among pediatric patients with pain undergoing IIPT. DESIGN:This retrospective cohort study collected self-reported and performance-based measures at admission and discharge from an IIPT program. The institutional review board approved study procedures. SETTING:IIPT program in an inpatient pediatric rehabilitation unit at a major midwestern children's hospital in the United States. PARTICIPANTS:Demographics and clinical outcomes from 210 patients admitted between January 2014 and December 2022 were abstracted from the medical record. Patients were 9-19 years old (average age = 15), 75% were female, and 91% were White. The most common diagnosis was amplified musculoskeletal pain syndrome (26%). INTERVENTIONS:Patients attended an IIPT program for an average of 17 days and completed measures at admission and discharge. MAIN OUTCOME MEASURES:Four performance-based measures, WeeFIM II, Bruininks-Oseretsky Test of Motor Proficiency (BOT-2), 30-second step test (30SST), grip strength, and 6-minute walk test (6MWT), and one self-report measure, Canadian Occupational Performance Measure (COPM). RESULTS:Self-reported COPM and performance-based 6MWT and 30SST scores showed the greatest responsiveness to intervention. The WeeFIM II and BOT-2 scores were the least responsive to intervention. CONCLUSIONS:The COPM, 6MWT, 30SST were the most responsive measures to intervention, capturing improvement among children with chronic pain completing an IIPT program; the WeeFIM II and BOT-2 were the least responsive measures to intervention for this population.
BACKGROUND:High-level competitive golfers often have access to interventions and support systems that include physical, nutritional, and behavioral health. Much focus has been directed to training on the course. There are limited studies describing what competitive golfers do off the course for performance optimization. OBJECTIVES:To describe the training, resources, and lifestyle modifications that competitive golfers use off the course in order to optimize performance on the golf course. DESIGN:Cross-sectional survey study. SETTING:Online survey. PARTICIPANTS:One hundred one high-level competitive golfers (56 collegiate, 45 touring professional; mean age: 25 ± 8 years; 55% male) completed the online survey and were included in the study. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURES:Information on golf play, exercise, lifestyle (nutrition, sleep), and alternative interventions was collected from the survey. RESULTS:Participants averaged 4.1 ± 3.5 years of collegiate/professional golf play. Most golfers reported working with swing coaches (78.2%) and athletic trainers (71.3%), and 86.1% participated in golf-specific resistance training for 2.9 ± 2.0 days/week. Massage and Theragun were the most common alternative interventions used to optimize performance. Almost half of all golfers reported working with a sports psychologist. Furthermore, 64.4% of golfers reported changing diet to optimize golf performance, and 41.1% had consulted with nutrition experts. Most golfers reported ≥6 hours of sleep/night (92.1%), and 23.7% had consulted with sleep experts. Compared to collegiate golfers, touring professionals were more likely to make changes to diet, report <6 hours of sleep/night, consult with sleep experts, and use wearable devices to track sleep. CONCLUSIONS:Multiple golf-specific and lifestyle interventions were used by high-level competitive golfers off the course to optimize their performance.
BACKGROUND:Hypovitaminosis D is associated with adverse health outcomes, including increased mortality in patients with cancer. Although vitamin D insufficiency (23%-72%) and deficiency (20%-71%) are common among patients admitted to inpatient rehabilitation, their prevalence and predictors in cancer-specific inpatient rehabilitation populations remain uncharacterized. OBJECTIVE:To determine the prevalence of hypovitaminosis D in adults with cancer admitted to acute inpatient rehabilitation and to identify demographic, clinical, laboratory, and functional predictors. DESIGN:Retrospective observational cohort study. SETTING:An inpatient rehabilitation service within a tertiary cancer hospital. PATIENTS:Consecutive adults with a cancer diagnosis admitted for acute inpatient rehabilitation between December 1, 2023, and May 24, 2024. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURE(S):The primary outcome was the prevalence of hypovitaminosis D (25-hydroxyvitamin D ≤ 29 ng/mL). Secondary outcomes included predictors of hypovitaminosis D and evaluation of the timing and frequency of vitamin D supplementation upon index hospital admission, upon admission to inpatient rehabilitation, and at 3 and 6 months post discharge. RESULTS:Of 126 patients, 78 (62%) had hypovitaminosis D. Significant predictors included relatively younger age (median 66.0 vs 71.5 years; effect size, 5.5 with 95% confidence interval [CI], 1.60-9.40, p = .006) and presence of neurogenic bladder or bowel (16.7% vs 2.4%; odds ratio, 0.12 with 95% CI, 0.003-0.924, p = .019). At hospital admission, 29% (n = 36) were receiving supplementation, and 40% (n = 51) initiated supplementation during inpatient rehabilitation. At 3 and 6 months post discharge, 48% (n = 61) and 39% (n = 49), respectively, had records of continued supplementation. Vitamin D supplementation was generally well tolerated during inpatient rehabilitation, with only minor side effects that were managed in three patients. CONCLUSIONS:Hypovitaminosis D was highly prevalent among adult patients with cancer undergoing inpatient rehabilitation. Identified predictors, including relatively younger age and neurogenic bladder or bowel, may help guide targeted screening.
INTRODUCTION:Anaerobic threshold (AT), a crucial indicator of submaximal exercise capacity and cardiorespiratory function, has been reported to be impaired in individuals with long COVID. However, the predictors of reduced AT during exercise in this population and its impacts on patient-reported outcomes, including sleep quality and health-related quality of life (HRQL), remain unknown. This study aims to identify factors associated with low AT and examine its relationship with patient-reported outcomes. OBJECTIVE:To investigate the predictors of low AT and compare patient-reported outcomes (sleep quality and HRQL) between individuals with normal and low AT among those with long COVID. DESIGN:Cross-sectional study. SETTING:Post-COVID integrated outpatient clinic at a medical center in northern Taiwan. PATIENTS (OR PARTICIPANTS):Eligible patients aged 20-80 years with long COVID were recruited. INTERVENTIONS:Not applicable. MAIN OUTCOME MEASURE(S):AT, peak oxygen consumption (peak VO2), and patient-reported outcomes, including sleep quality and HRQL, assessed using the Taiwanese version of the World Health Organization Quality of Life-BREF and Pittsburgh Sleep Quality Index. RESULTS:Factors associated with low AT included younger age (odds ratio [OR] = 0.904, 95% confidence interval [CI]: 0.867-0.942, p < .001) and lower peak VO2 (OR = 0.737, 95% CI: 0.659-0.842, p < .001). Participants with low AT exhibited impaired patient-reported outcomes including poorer sleep quality (p = .008), and lower HRQL scores across all domains, as compared to those with normal AT. After adjustment for significant covariates, only the psychological domain of HRQL remained statistically significant (adjusted p = .035). CONCLUSIONS:Low AT in individuals with long COVID was associated with younger age and lower peak VO2. Its independent impact on sleep quality and HRQL appears limited, suggesting that patient-reported outcomes may be influenced by multiple interacting factors and warrant further investigation.
BACKGROUND:Knee osteoarthritis (OA) is a common cause of disability among older adults. Common treatments include intra-articular corticosteroids (IACS) and viscosupplementation (VS). However, many insurance carriers either decline to cover VS or require prior IACS failure. Limited data exist on whether IACS response can guide VS use. OBJECTIVE:To determine whether response to IACS predicts subsequent response to VS, and whether age, gender, body mass index (BMI), and OA severity are associated with VS outcomes. DESIGN:Retrospective cohort study. SETTING:Outpatient physical medicine and rehabilitation clinics at a tertiary-care academic medical center. PARTICIPANTS:Four hundred sixty three adult patients (≥18 years) with primary knee OA who received both IACS and VS injections. INTERVENTIONS:Primary independent variable was response to IACS. Additional variables were age, gender, BMI, and OA severity. MAIN OUTCOME MEASURES:Primary outcome was pain relief following VS, categorized as favorable (>33% relief) or unfavorable (≤ 33% relief ). RESULTS:The favorable response rate to VS among IACS nonresponders was 55% (95% confidence interval [CI]: 48%-62%) compared to 72% (95% CI: 67%-76%) in IACS responders (p < .001). IACS response was associated with higher odds of VS response (odds ratio [OR] = 2.10, 95% CI: 1.41-3.12, p < .001), which remained significant after adjusting for age, gender, BMI, and OA severity (OR = 2.25, 95% CI: 1.54-3.28, p <.001). BMI and age were not independently associated with VS response; however, both demonstrated a nonsignificant trend toward lower odds of response (BMI: OR = 0.88 per 5 kg/m2, 95% CI: 0.77-1.01, p = .08; age: OR = 0.95 per 5 years, 95% CI: 0.87-1.04, p = .24). No significant associations were observed for gender or OA severity. CONCLUSIONS:Response to IACS predicts subsequent response to VS in patients with knee OA. These findings may help guide treatment selection, though prospective studies are needed.
BACKGROUND:Osteoarthritis is a leading cause of disability worldwide, and cell-based treatments including adipose-derived and bone marrow aspirate have been sought by the lay and medical community as treatment options. OBJECTIVE:To perform a scoping review of published literature on cell-based injections allowed by the U.S. Food and Drug Administration for the treatment of osteoarthritis to synthesize existing evidence and identify research gaps for future evaluation. METHODS:A comprehensive search of five databases was executed from inception through January 2, 2025. Studies that met the inclusion criteria were original research studies written in English on Food and Drug Administration-allowed cell-based treatments in adults with osteoarthritis of any joint. RESULTS:The database search yielded 4257 unique records. After screening, 84 studies met the inclusion criteria, encompassing 9996 patients and a total of 10,508 procedures. The primary research study designs were cohort studies (n = 62), focused on treatment of knee osteoarthritis (n = 63), and described bone marrow aspirate (n = 42) and adipose-derived (n = 42) treatments. Postprocedure monitoring ranged from 6 weeks to 5 years, with most studies ≤1 year (n = 59). Patient-reported outcomes were reported in 83 of 84 studies; few provided imaging outcomes including magnetic resonance imaging (n = 9) or radiographs (n = 2). CONCLUSION:This review identified limited randomized controlled trials, limited studies outside the knee, limited description of cell-based treatments, and treatment protocols, along with inconsistent patient-reported outcomes limited to 1 year in most studies. We propose establishing reporting guidelines in research on cell-based therapies.
BACKGROUND:Intercostal nerve injury can occur after rib fractures, resulting in denervation of the abdominal musculature. Loss of innervation to the rectus abdominis and intercostal muscles can cause atrophy and subsequent eventration, pain, and cosmetic issues. Intercostal electrodiagnostic testing can diagnose and localize intercostal nerve damage after rib fractures at levels T7 and below. OBJECTIVE:To characterize rib fracture patterns associated with intercostal nerve injury and evaluate the diagnostic and surgical utility of preoperative nerve conduction study/electromyography (NCS/EMG) findings. METHODS:Eight patients with NCS/EMG-diagnosed intercostal nerve injury following rib fractures were included in the study. A total of 17 levels with intercostal nerve damage were identified on electrodiagnostic testing. Descriptive rib fracture characteristics were obtained from preoperative chest computed tomography by a single chest wall surgeon and analyzed for displacement, degree of rib separation, fracture location, and presence of intercostal muscle, lung, and retroperitoneal hernias. Preoperative electrodiagnostic testing results were correlated with computed tomography rib fracture characteristics, ultrasound measurements of rectus abdominis cross sectional thickness, and direct intraoperative intercostal nerve evaluation using an intraoperative nerve stimulator. RESULTS:At the level of NCS/EMG-diagnosed intercostal nerve injury, 50% ribs were displaced and 50% were nondisplaced. Two levels demonstrated evidence of intercostal hernia, one with lung hernia and one with retroperitoneal hernia. The average degree of separation of rib fractures was 1.45 cm with two ribs demonstrating 0 cm of separation. With regard to rib fracture location, 29% were posterior, 41% posterolateral, and 23% lateral. Seven of eight patients (total of 15 nerves) underwent surgical intervention in the form of neurolysis versus intercostal nerve reconstruction with allograft nerve tissue. Direct intraoperative intercostal nerve stimulation correlated with the presence of intercostal nerve injury identified on preoperative NCS/EMG findings in 12 of 15 cases (80%). Two intercostal nerves were not explored secondary to significant intercostal trauma. A single level discrepancy was identified between preoperative NCS/EMG and intraoperative findings in one case. Ultrasound measurements demonstrated an average rectus abdominis transverse cross-sectional thickness of 0.66 cm on the affected side, compared with 1.04 cm on the nonaffected side (p = .01) and demonstrated a decrease in cross-sectional thickness as represented as a percentage of the contralateral, nonaffected side when measured against time from rib fracture (R2 = 0.432). CONCLUSIONS:The present case series describes the rib fracture characteristics, ultrasound assessment, and interoperative intercostal nerve stimulation findings of patients with preoperative NCS/EMG-diagnosed intercostal nerve injury after rib fractures. Intercostal nerve damage resulting in rectus abdominis atrophy after rib fractures may be an underrecognized and thus undertreated complication of rib fractures. Preoperative electrodiagnostic testing demonstrates high diagnostic accuracy and can guide surgical planning. Awareness of high-risk fracture patterns may improve clinical decision-making and outcomes in rib fracture management.
BACKGROUND:Chronic low back pain with associated leg pain (CLBP-L) (whether referred or radiating) is a common, debilitating, and expensive condition. Epidural steroid injections (ESI) are commonly used, although effectiveness is often limited. Dextrose prolotherapy injections (DPT) are a potential alternative treatment to address the biomechanical and neurological causes of CLBP-L. OBJECTIVE:To assess the effectiveness of DPT compared with ESI for CLBP-L. DESIGN:Pragmatic unblinded, randomized controlled trial. SETTING:Outpatient pain clinic; ESIs were performed in an operating room, DPT in a clinic procedure room. PARTICIPANTS:Adults aged between 18 and 90 years with at least 12 weeks of CLBP-L, and at least 6 on a 0-10 point leg pain severity numerical rating scale (NRS). INTERVENTIONS:Up to three monthly injections for ESI participants; up to five monthly treatments for DPT participants. MAIN OUTCOME MEASURES:Least square mean (LSM) analysis of NRS 0-10 point pain scale (primary) and Oswestry Disability Index (secondary) at 1, 3, 6, and 12 months after treatment completion, using intention to treat analysis. RESULTS:One hundred twelve participants were enrolled; eight withdrew from the study before receiving therapy; 104 participants (53% female; 58 ± $$ \pm $$ 15 years old; body mass index 28 ± 5 kg/m2, with 19 ± $$ \pm $$ 23 months CLBP-L) were randomized (55 DPT, 49 ESI) and analyzed. No baseline differences existed between groups. DPT outperformed ESI in LSM pain scores at 6 (5.1 ± 0.7 vs. 7.2 ± 0.75 points; p < .001) and 12 m(5.2 ± 0.7 vs. 6.9 ± 0.7 points; p = .001) months. Function score LSMs also favored the DPT group at 6 (33 ± 5 vs. 45 ± 4.5 points; p < .001) and 12 (34 ± 4.5 vs. 42 ± 5 points; p = .012) months. There were no adverse events. CONCLUSIONS:For participants with CLBP-L, DPT resulted in statistically significant and clinically meaningful improvement of pain and function compared with ESI at 1 year after treatment completion. DPT may be an appropriate alternative for patients with CLBP-L. CLINICAL TRIALS:NCT01934868, registered on August 30, 2013.
BACKGROUND:Concussion surveillance in adaptive sports is essential for improving athlete safety and informing prevention strategies, yet existing data remain limited. To our knowledge, this is the first longitudinal investigation of concussion incidence in athletes with disability across multiple seasons. OBJECTIVE:To determine the incidence of sport-related concussion in collegiate wheelchair basketball across multiple seasons and compare rates with National Collegiate Athletic Association (NCAA) basketball athletes without disabilities. DESIGN:Prospective, multiseason, longitudinal surveillance cohort study. SETTING:The University of Texas at Arlington men's and women's wheelchair basketball teams. INTERVENTIONS:Repeated administration of standardized electronic injury and illness surveys pre-, intra-, and post season. Concussion reporting through both athlete self-report surveys and athletic trainer verified injuries. MAIN OUTCOME MEASURES:Concussion rates of intercollegiate wheelchair basketball athletes across seasons per 10,000 athlete exposures, injury rate ratios compared to NCAA basketball athletes without disabilities, and injury descriptive statistics on mechanism of injury, time missed, and care received. RESULTS:Twelve concussions occurred across four seasons (2021-2024, 99 athlete-seasons). Concussion rate per 10,000 athlete exposures were 6.66 (95% confidence interval, 2.44-14.49), 8.86 (3.25-19.29), and 7.60 (3.93-13.28) for men, women, and combined, respectively. Compared to NCAA basketball, injury rate ratios were 1.99 (0.88-4.49), 1.69 (0.75-3.80), and 1.79 (1.01-3.18) for men, women, and overall, indicating a significantly higher overall rate of concussion. CONCLUSIONS:Across a multiseason longitudinal study, collegiate wheelchair basketball players experienced a higher overall concussion rate than their collegiate basketball (NCAA) counterparts without disabilities. These findings emphasize the need for improved surveillance, targeted concussion prevention, and tailored response protocols in adaptive sports.
BACKGROUND:Postmenopausal female individuals are disproportionately affected by knee osteoarthritis (KOA), experiencing earlier onset and more severe pathology compared to their male counterparts. Despite this clinical disparity, the molecular mechanisms underlying female-specific vulnerability remain poorly defined. OBJECTIVE:To evaluate the mechanistic role of relaxin-2 in postmenopausal KOA. DESIGN:This was a translational research study that evaluated relaxin-2 using an in vitro postmenopausal human KOA chondrocyte culture model and in silico network medicine simulation. SETTING:Research laboratory. SPECIMENS:KOA chondrocytes isolated from a 67-year-old postmenopausal female human donor. INTERVENTIONS:Female KOA chondrocytes were treated with varying relaxin-2 concentrations (control: 0 pg/mL, low: 0.496 pg/mL, medium: 49.6 pg/mL, and high: 4960 pg/mL; n = 5-7/group), with doses based on previously reported physiologic serum levels for pre- and postmenopausal female individuals. MAIN OUTCOME MEASURE(S):Effects were evaluated by immunofluorescence analysis of chondrogenicity markers (type II collagen [Col2], aggrecan [ACAN]), fibrotic markers (type I collagen [Col1], type III collagen [Col3]), extracellular matrix degradation markers (matrix metalloproteinase-13 [MMP-13], A Disintegrin And Metalloproteinase with Thrombospondin Motifs 4 [ADAMTS4]), and mitochondrial integrity and function markers (translocase of the outer mitochondrial membrane 20 [TOMM20], Succinate Dehydrogenase Subunit A [SDHA], Peroxisome Proliferator-Activated Receptor Gamma Coactivator 1-alpha [PGC-1α]). RESULTS:Relaxin-2 increased Col2 at low and medium concentrations (p < .05), with the Col2/Col1 ratio highest at the low dose relaxin-2. MMP-13 expression was greatest for the medium compared to the control (p = .73), low (p = .002), and high relaxin-2 concentrations (p = .005), whereas ACAN and ADAMTS4 showed no differences across concentrations (p > .05). In silico analysis revealed that postmenopausal female individuals exhibit a fibrotic transcriptomic signature and that mitochondrial function is regulated by relaxin-2 in fibrotic chondrocytes. Computational analyses were validated experimentally, with TOMM20 and SDHA elevated at all relaxin-2 concentrations (p < .05), whereas PGC-1α was reduced at high concentration (p < .05). CONCLUSIONS:These findings demonstrate that relaxin-2 reprograms fibrotic osteoarthritic chondrocytes toward a healthier, less fibrotic state by restoring mitochondrial function.
BACKGROUND:Advanced footwear technology (AFT) is commonly used by runners during training and competition. Prior work has characterized improvements in running economy and performance. No prior work has explored whether running with AFT changes biomechanics associated with bone stress injury (BSI). OBJECTIVE:To measure biomechanics while running in an AFT (with a carbon fiber plate), lightweight foam (responsive foam), and neutral shoe footwear in elite distance runners. STUDY DESIGN:Cross-sectional cohort study. SETTING:Academic medical multisite hospital system. PARTICIPANTS:Healthy elite male and female distance runners. TESTING PROTOCOL:Participants ran in three different shoes (neutral, responsive foam, and AFT) in a randomized order at three self-selected speeds: training effort, a tempo run, and a 5-km race speed. MAIN OUTCOME MEASURES:Biomechanical variables associated with BSI were measured during each speed and shoe condition: rearfoot eversion excursion, rearfoot eversion velocity, vertical ground reaction force, ankle plantarflexion moment, vertical center of mass excursion, cadence, and duty factor. A two-factor repeated measures analysis of variance was performed by shoe type and running speed using a Bonferroni correction for main effects with p value <.05 defined as significant. RESULTS:Twenty-three runners (11 women, 12 men; average and SD for age: 25.4 ± 2.7) participated. Ankle plantarflexion moment was higher in neutral compared to the responsive foam or AFT. Rearfoot eversion excursion was lower in the neutral shoe compared to responsive foam and AFT. Rearfoot eversion velocity was higher in the responsive foam shoe compared to neutral and AFT. Cadence was lower in AFT compared to responsive foam and neutral. No other spatiotemporal variables were significant. CONCLUSION:Increases in several biomechanical variables associated with BSI were observed during running with AFT. The changes in biomechanics were small; however, cumulative effects to bone and the lower extremity could contribute to injury. These factors should be considered when using AFT during training and competition.
BACKGROUND:The current nonoperative standard-of-care therapies for knee osteoarthritis (OA) include weight reduction, physical therapy, analgesics, optimization of biomechanics, and intra-articular injection of corticosteroids. Platelet rich plasma (PRP) is an orthobiologic intervention that is increasingly used in patients with knee OA, primarily due to its many key mediators that can potentially reduce joint inflammation thereby improving pain and enhancing overall joint function. The American Academy of Physical Medicine and Rehabilitation (AAPM&R) convened a technical expert panel (TEP) to summarize and assess the evidence for use of PRP in patients with knee OA and synthesize current knowledge into a summary document that can serve as a resource for clinicians. We address many of the questions and decision points that practitioners need to consider for responsible use of PRP in knee OA. OBJECTIVE:To develop consensus-based practice recommendations to identify and address gaps in PRP applications in patients with knee OA. METHODS:The AAPM&R orthobiologic TEP initiated development of this consensus guidance statement in March 2023. The TEP was responsible for formulating search terms and research questions and synthesizing evidence obtained from a structured literature review that was initially completed in April 2023 and subsequently updated to reflect studies published between May 2023 and June 2025. The recommended actions and best practices in this guidance reflect consensus being achieved by the expert physiatrists and supported by best available evidence, where available. These actions and practices were conceptualized in response to common questions this expert panel frequently encounter in the use and administration of PRP. The TEP was asked to consider the strengths and limitations of available evidence and augment with expert opinion focused on closing knowledge gaps guiding the delivery of PRP in patients with knee OA. RESULTS:As a result of the structured literature review and use of a modified Delphi process to achieve consensus on clinical guidance for PRP use in patients with knee OA, the AAPM&R TEP on use of PRP in knee OA arrived at five evidence-based clinical recommendations for PRP management and 11 consensus-based best practices supported by expert opinion and limited evidence. CONCLUSION:This consensus guidance addresses common questions about the use of PRP in patients with knee OA and provides actionable recommendations and best practices based on expert opinion supported by best available evidence. Despite their growing availability as point-of-care interventions, orthobiologic therapies remain an evolving area of practice. Robust, dose-dependent randomized controlled trials are needed to more clearly establish the clinical effects of PRP on patient outcomes. Clinical judgment should be exercised and management options tailored to individual patient needs, preferences, and risk profiles.
BACKGROUND:There is a paucity of contemporary studies assessing the supply, demand, and adequacy of the physical medicine and rehabilitation (PMR) physician workforce in the United States. We hypothesized that geographic disparities in the adequacy of the PMR physician workforce would exist across the United States especially in nonmetropolitan areas. METHODS:The Health Workforce Simulation Model from the Health Resources and Services Administration was used to analyze U.S. federal government projections in the supply, demand, and adequacy of PMR physicians from 2025 to 2037. Adequacy was defined as the ratio of supply over demand and linear regression was used to analyze physician workforce trends. RESULTS:By 2037, PMR physician adequacy was projected to be lowest in nonmetropolitan areas compared to metropolitan areas (39.0% vs. 98.1%, p < .001). Additionally, PMR physician adequacy was projected to be lowest in the South (77.2%) followed by the West (92.1%), Midwest (97.2%), and Northeast (123%) (p < .001). By 2037, the states with the lowest projected PMR physician adequacy were Rhode Island (33.3%), Mississippi (40.0%), and West Virginia (42.9%). PMR ranked 16th for physician adequacy in 2025 compared with 20 other specialties. CONCLUSIONS:This study highlighted geographic disparities in the adequacy of the PMR workforce, especially in nonmetropolitan areas, the South, and certain U.S. states. Future work is needed to implement strategies that improve PMR physician adequacy in geographies with identified inadequacies.
BACKGROUND:Fear of falling (FoF) is a common concern in individuals with multiple sclerosis (MS). Understanding whether and how FoF affects activities and participation is crucial for developing effective rehabilitation programs in individuals with MS. OBJECTIVE:To examine the relationship between measures of FoF (degree of FoF and avoidance behavior due to FoF) and measures of activities and participation in ambulatory individuals with MS. We also aim to investigate whether avoidance behavior due to FoF is relevant beyond the effect of degree of FoF. DESIGN:Cross-sectional survey-based design. SETTING:Community. PARTICIPANTS:A convenience sample of 531 community-dwelling ambulatory individuals with MS. INTERVENTIONS:N/A. MAIN OUTCOME MEASURES:Activities measures included Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning and self-efficacy to manage activities of daily living (ADLs). Measures of participation included PROMIS ability to participate in social roles and activities (SRAs) and Community Participation Indicators-Control subscale. RESULTS:After controlling for age, gender, duration of MS, disability level, history of previous falls, and MS subtype, hierarchical linear regression analyses indicated participants with moderate and high FoF showed lower physical functioning and ability to participate in SRAs (B = -4.75 to -10.81, p < .01) compared to those with low FoF. Participants with high FoF also had reduced self-efficacy in managing ADLs (B = -6.29, p < .01) and less control over community participation (B = 6.77, p < .05) compared to those with low FoF. Avoidance behavior due to FoF was associated with lower self-efficacy to manage ADLs (Β = -1.59, p < .01), ability to participate in SRAs (Β = -2.62, p < .01), and control over community participation (Β = 3.34, p < .01). CONCLUSIONS:FoF is a significant predictor of activities performance and participation in individuals with MS. Our findings highlight the importance of assessing avoidance behavior due to FoF to inform rehabilitation approaches aimed at improving the participation and community integration of individuals with MS.
