BACKGROUND:We aimed to examine the efficiency of fixed daily dose enoxaparin (40 mg) thromboprophylaxis strategy for patients undergoing inpatient rehabilitation. METHODS:This was an observational, prospective, cohort study that included 63 hospitalized patients undergoing rehabilitative treatment following sub-acute ischemic stroke (SAIS) or spinal cord injury (SCI), with an indication for thromboprophylaxis. Anti-Xa level measured three hours post-drug administration (following three consecutive days of enoxaparin treatment or more) was utilised to assess in vivo enoxaparin activity. An anti-Xa level between 0.2-0.5 U/ml was considered evidence of effective antithrombotic activity. RESULTS:We found sub-prophylactic levels of anti-Xa (<0.2 U/ml) in 19% (12/63). Results were within the recommended prophylactic range (0.2-0.5 U/ml) in 73% (46/63) and were supra-prophylactic (>0.5 U/ml) in 7.9% (5/63) of patients. Anti-Xa levels were found to inversely correlate with patients' weight and renal function as defined by creatinine clearance (CrCl) (p<0.05). CONCLUSIONS:Our study confirmed that a one-size-fits-all approach for venous thromboembolism (VTE) prophylaxis may be inadequate for rehabilitation patient populations. The efficacy of fixed-dose enoxaparin prophylaxis is limited and may be influenced by renal function and weight. This study suggests that anti-Xa studies and prophylactic enoxaparin dose adjustments should be considered in certain patients, such as those who are underweight, overweight and or have suboptimal renal function. TRIAL REGISTRATION:No. NCT103593291, registered August 2018.

INTRODUCTION:The use of artificial intelligence applications in medicine has been common in recent decades. Machine learning, a subfield of artificial intelligence, is a methodology that allows computers to learn from examples and draw conclusions about new data. Advances in artificial intelligence and machine learning may play a central role in making clinical decisions in rehabilitation, diagnosing functional impairments, developing, improving existing protocols and building personalized rehabilitation programs. In addition, artificial intelligence applications in rehabilitation will be integrated into rehabilitation treatment for the purpose of improving impairments in body functions and compensating for body functions that cannot be restored (using human-machine interfaces).

When losing balance, upper-body movements serve as mechanical aids to regain stability. However, it remains unclear how these movements contribute to dynamic stability during recovery from a lateral loss of balance while walking with arm restriction. We aimed to (i) quantify the effect of arm restriction on gait stability and upper-body velocities and (ii) characterize upper-body kinematic strategies in response to lateral surface translations under different arm restriction conditions. Healthy adults were exposed to lateral surface translations while walking on a computerized treadmill under three conditions: ‘free arms’, ‘1-arm restricted’ and ‘2-arms restricted’. Dynamic stability and upper-body velocities for the first step after perturbation onset were extracted. We found decreased dynamic stability in the sagittal plane and increased trunk velocity in the ‘2-arms restricted’ condition compared with the ‘free arms’ condition. Head and trunk movements in the medio-lateral plane were in opposite directions in 44.31% of responses. Additionally, significant trunk velocities were observed in the opposite direction to the perturbation-induced loss of balance. Our results support the contribution of increased upper-body velocities to balance responses following arm-restricted walking perturbations and suggest that the ‘2-arms restricted’ condition may be utilized as a perturbation-based balance training, focusing on head and trunk responses.

BACKGROUND:Foot problems and lower-limb diseases (e.g., foot ulcers, osteoarthritis, etc.), are presented with a ground reaction force (GRF) that may deviate substantially from the normal. Thus, GRF manipulation is a key parameter when treating symptoms of these diseases. In the current study, we examined the impact of footwear-generated center of pressure (COP) manipulations on the GRF components, and the ability to predict this impact using statistical models.METHODS:A foot-worn biomechanical device which allows manual manipulation of the COP location was utilized. Twelve healthy young men underwent gait analysis with the device set to convey seven COP conditions: (1) a neutral condition, (2) lateral and (3) medial offset along the medio-lateral foot axis, (4) anterior and (5) posterior offset along the antero-posterior foot axis, and (6) a dorsi-flexion and (7) plantar-flexion condition. Changes in the magnitude and the early stance-phase impulse of the GRF components across COP conditions were observed. Linear models were used to describe relationships between COP conditions and GRF magnitude and impulse.RESULTS:With respect to ANOVA, the vertical and antero-posterior components of the GRF were significantly influenced by the COP configuration throughout the different stages of the stance-phase, whereas the medio-lateral components were not. The models of vertical, antero-posterior and medio-lateral GRF components were statistically significant.SIGNIFICANCE:The study results are valuable for the development of a method and means for efficient treatment of foot and lower-limb pathologies. The ability to predict and control the GRF components along three orthogonal axes, for a given COP location, provides a strong tool for efficient treatment of foot and lower-limb diseases and may also have relevant implications in sports shoe design. This study is a preliminary investigation for our ultimate goal to develop an effective treatment method by developing an autonomous GRF manipulations device based on closed-loop feedback.

Loading/excessive loading of the hip joint has been linked to onset and progression of hip osteoarthritis. Footwear-generated biomechanical manipulation in the frontal plane has been previously shown in a cohort of healthy subjects to cause a specific gait adaption when the foot center of pressure trajectory was shifted medially, which thereby significantly reduced hip joint reaction force. The objective of the present study was to validate these results in a cohort of female bilateral hip osteoarthritis patients. Sixteen patients underwent gait analysis while using a footworn biomechanical device, allowing controlled foot center of pressure manipulation, in three para-sagittal configurations: medial, lateral, and neutral. Hip osteoarthritis patients exhibited similar results to those observed in healthy subjects in that a medial center of pressure led to an increase in inter-maleolar distance while step width (i.e., distance between right and left foot center of pressure) remained constant. This adaptation, which we speculate subjects adopt to maintain base of support, was associated with significantly greater hip abduction, significantly decreased hip adduction moment, and significantly reduced joint reaction force compared to the neutral and lateral configurations. Recommendations for treatment of hip osteoarthritis emphasize reduction of loads on the pathological joint(s) during daily activities and especially in gait. Our results show that a medially deviated center of pressure causes a reduction in hip joint reaction force. The present study does not prove, but rather suggests, clinical significance, and further investigation is required to assess clinical implications. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1762-1771, 2016.

Purpose: To evaluate the correlations between common clinical OA diagnostic tools in order to determine the value of each. A secondary goal was to investigate the influence of gender differences on the findings. Methods: Five hundred and eighteen patients with knee OA were evaluated using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire, short form 36 (SF-36) Health Survey and plain radiographs. Analysis of variance (ANOVA) was used to compare the different domains of the WOMAC and SF-36 questionnaires between genders and the radiographic scale. Results: Higher knee OA x-ray grade were associated with worse clinical outcome: for women – higher scores for the WOMAC pain, function and final scores and lower scores in the SF-36 final score; in men: lower SF-36 overall and Physical domains scores. Gender differences were found in all clinical scores that were tested, with women having worse clinical scores for similar radiographic grading (p values< 0.001). Conclusions: Knee radiographs for OA have an important role in the clinical evaluation of the patient. Patients with higher levels of knee OA in x-ray has a higher probability of having a worse clinical score in the WOMAC and SF-36 scores. The gender differences suggest that for similar knee OA x-ray grade women's clinical scores are lower.

BACKGROUND:Gait metric alterations have been previously reported in patients suffering from chronic ankle instability (CAI). Previous studies of gait in this population have been comprised of relatively small cohorts, and the findings of these studies are not uniform. The objective of the present study was to examine spatiotemporal gait metrics in patients with CAI and examine the relationship between self-reported disease severity and the magnitude of gait abnormalities.METHODS:Forty-four patients with CAI were identified and compared to 53 healthy controls. Patients were evaluated with spatiotemporal gait analysis via a computerized mat and with the Short Form (SF) - 36 health survey.RESULTS:Patients with CAI were found to walk with approximately 16% slower walking velocity, 9% lower cadence and approximately 7% lower step length. Furthermore, the base of support, during walking, in the CAI group was approximately 43% wider, and the single limb support phase was 3.5% shorter compared to the control group. All of the SF-36 8-subscales, as well as the SF-36 physical component summary and SF-36 mental component summary, were significantly lower in patients with CAI compared to the control group. Finally, significant correlations were found between most of the objective gait measures and the SF-36 mental component summary and SF-36 physical component summary.CONCLUSIONS:The results outline a gait profile for patients suffering from CAI. Significant differences were found in most spatiotemporal gait metrics. An important finding was a significantly wider base of support. It may be speculated that these gait alterations may reflect a strategy to deal with imbalance and pain. These findings suggest the usefulness of gait metrics, alongside with the use of self-evaluation questionnaires, in assessing disease severity of patients with CAI.

Background: Anterior knee pain (AKP) is a common musculoskeletal disorder affecting 25–36% of the general population with an impact on many aspects of daily life. AKP was reported as the cause of up to 40% of all visits to physiotherapy clinics as a result of knee pain and often becomes chronic, with 94% of patients continuing to experience pain up to four years after initial presentation and 25% reporting significant symptoms up to 20 years later. A wide variety of treatment methods have been proposed for the treatment of AKP. Cochrane reviews addressing the efficacy of therapeutic ultrasound, exercise therapy, pharmacotherapy, and foot orthoses for the treatment of AKP have found that evidence for the effectiveness of these interventions is limited and conflicting.

Introduction The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls. Materials and methods Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life. Results Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18 % compared to the control group ( p < 0.001), had slower cadence by 8 % compared ( p = 0.002) to the control group and had shorter step length in the involved leg by 11 % and in the uninvolved leg by 12 % compared to the control group ( p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12 % compared to the uninvolved leg and 5 % in the uninvolved leg compared to the control group ( p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65 % lower compared to healthy controls ( p < 0.001), and Mental Health Score of the patients was 40 % lower compared to healthy controls ( p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns. Conclusion Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as self-reported quality of life.

Background: Osteoarthritis (OA) is a major health concern in modern society, affecting 10% of men and 21% of women over age 65. The hip joint is the second most common lower limb site. Several articles have described locomotor deviations typical of individuals suffering from hip OA alongside increased pain and limitation in function. Treatments for OA are typically directed at the management of symptoms, with a goal of pain relief and improved function. Several studies emphasize the importance of physical therapy and biomechanical interventions for patients with hip OA, claiming that such therapies should aim to restore or maintain gait patterns close to normal, as well as improve walking efficiency and quality of life.

BACKGROUND:Footwear-generated biomechanical manipulations have been shown to alter lower limb kinetics. It has been suggested that this is due to altered trajectory of the foot's center of pressure (COP), conveying a shift in location of the ground reaction force and modifying moments and forces acting on proximal body segments. However, past studies have focused on qualitative association between footwear design and the COP locus. Moreover, this association was calculated via indirect analysis. The purpose of the present study was to directly examine and quantify the correlation between measured footwear biomechanical manipulation and the location of the COP trajectory during gait.METHODS:A novel biomechanical device allowing flexible positioning of 2 convex-shaped elements attached to its sole was utilized. A total of 20 healthy male adults underwent direct in-shoe pressure measurements while walking with the device set at 7 mediolateral configurations. COP data were collected during gait and analyzed with respect to different stance subphases.RESULTS:COP location significantly correlated with a shift of the elements medially or laterally. The linear model describing this correlation was found to be statistically significant.CONCLUSION:There was significant correlation between the plantar orientation of the shoe device configuration and the COP.CLINICAL RELEVANCE:Changes in COP trajectory may be valuable in patients suffering from multiple foot disorders elevating pressure on the foot. Accurate COP control could aid in the manipulation of the forces acting on the proximal joints during gait. In addition, these findings may have implications in the field of biomechanical apparatus design and practice.

This study aims to evaluate the correlations between common clinical osteoarthritis (OA) diagnostic tools in order to determine the value of each. A secondary goal was to investigate the influence of gender differences on the findings. Five hundred and eighteen patients with knee OA were evaluated using the Western Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire, short form 36 (SF-36) Health Survey, and plain radiographs. Analysis of variance (ANOVA) was used to compare the different domains of the WOMAC and SF-36 questionnaires between genders and the radiographic scale. Higher knee OA x-ray grade were associated with worse clinical outcome: for women, higher scores for the WOMAC pain, function and final scores and lower scores in the SF-36 final score; in men, lower SF-36 overall and physical domains scores. Gender differences were found in all clinical scores that were tested, with women having worse clinical scores for similar radiographic grading (p values < 0.001). Knee radiographs for OA have an important role in the clinical evaluation of the patient. Patients with higher levels of knee OA in x-ray have a higher probability of having a worse clinical score in the WOMAC and SF-36 scores. The gender differences suggest that for similar knee OA x-ray grade, women's clinical scores are lower.Trial registration: NCT00767780.

Retraining Program Reduces Knee Adduction Moment, Reduces Pain, and Improves Function for Individuals with Medial Compartment Knee Osteoarthritis" by Shull et al. 1 This is an important article that supports existing knowledge about the effect of non-invasive interventions, based on gait training, to establish new motor patterns for patients suffering from knee OA.The researchers examined the influence of a 6-week gait retraining program on the knee adduction moment (KAM), as well as knee pain and function, on 10 patients with medial compartment knee OA.Results demonstrated that following the 6-week program, the first peak KAM reduced by 20%, and WOMAC pain and function scores were improved by 29% and 32%, respectively.After reading this study, we would like to provide some additional information to the reader.The results of the current article support previous articles published by Erhart et al. 2 in 2010 and by Haim et al. 3 in 2012.The research methodology of all three articles was similar in that they examined the changes in KAM and WOMAC following intervention, and in all cases patients walked barefoot during examinations.Erhart et al. 2 reported a 6.6% reduction in KAM for subjects with knee OA wearing variable-stiffness shoes for six months, whereas Haim et al. 3 reported a 15.5% reduction in KAM, and an improvement of WOMAC pain and function by 61.0% and 63.0%, respectively.The importance of non-invasive biomechanical interventions, and their effect on biomechanical parameters (i.e., KAM) and clinical symptoms of pain and function has increased in the last decade.Only in the past few years it has been shown that, following training with a certain biomechanical device, 2,3 the above-mentioned parameters improve while walking barefoot.Recently, Shakoor et al. 4 evaluated the effects of 6 months of use of flat, flexible footwear (the mobility shoe) on knee loading in OA.Their findings support the results of previous publications, which showed a 10% reduction in KAM.The current article of Shull et al. and the studies of Erhart et al., Haim et al., and Shakoor et al., establish the realization of the effect of biomechanical interventions on biomechanical parameters and clinical symp-toms.These articles should serve as the supporting pillar in this field and should further be examined.The next challenge should be to examine the longterm effect of these interventions on the disease's progress.

Knee frontal (adduction/abduction) and sagittal (flexion/extension) moments have been implicated in the pathomechanics of knee osteoarthritis (OA). The aim of this study was to evaluate the change in the knee sagittal moment in a cohort of patients with knee OA undergoing a biomechanical training program. Twenty-five female patients with symptomatic medial compartment knee OA were enrolled in a customized biomechanical intervention program. All patients underwent consecutive gait analyses prior to treatment initiation, and after 3 months and 9 months of therapy. Self-evaluative questionnaires, spatiotemporal gait parameters, peak knee sagittal moments, knee sagittal impulses, and duration of knee moments were compared throughout the duration of therapy. Differences between baseline and follow-up values were examined using nonparametric tests. Peak knee flexion moment (KFM) at loading response decreased significantly with therapy (p = 0.001). Duration of KFM and impulse of knee flexion also decreased significantly (p = 0.024 and p = 0.029, respectively). These changes were accompanied by increased walking velocity, significant pain reduction, and increased functional activity. Post-training kinetic evaluation demonstrated profound alterations of knee sagittal moments at the loading response KFM. We speculate that knee sagittal moments can potentially be improved in patients with knee OA over time with a biomechanical training program.

ABSTRACTFootwear‐generated biomechanical manipulation of lower‐limb joints has been shown to influence lower‐limb biomechanics. Numerous studies report the influence of such interventions on the knee, however little is known about the influence of these interventions on the hip. The present study analyzed kinetic and kinematic changes about the hip of 12 healthy young males who underwent biomechanical manipulation utilizing the APOS biomechanical device (APOS–Medical and Sports Technologies Ltd., Herzliya, Israel) allowing controlled foot center of pressure manipulation. Subjects underwent gait testing in four para‐sagittal device configurations: Medial, lateral, neutral, and regular shoes. In the medial configuration, subjects demonstrated no change in step width (i.e., distance between right and left foot center of pressure), however inter‐malleolar distance significantly increased. Likewise with the medial setting, greater hip abduction was recorded, while hip adduction moment and joint reaction force decreased significantly. We speculate that subjects adopt a modified gait pattern aimed to maintain constant base of support. As a result, hip abductor muscle moment arm increases and adduction moment and joint reaction force decreases. To the best of our knowledge this is the first study to show this relationship. These results contribute to the understanding of lower‐limb biomechanics and warrant further investigation. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:261–269, 2015.

Purpose: The predicted increase in primary and revision total knee arthroplasty (TKA) for knee osteoarthritis is a major concern. The demand for primary TKA in the United States alone is expected to grow by 673% (3.48 million annual procedures) by 2030 and the demand for TKA revisions is expected to grow by 601%. Yet, up to 50% of patients continue to suffer from pain and disability following the surgery. In most of the cases those finding cannot be explained by implant factors or surgical technique. Additionally, physiotherapy functional exercises after discharge result in small to moderate effect sizes with no long-term benefits. Evidence shows that gait patterns after TKA do not return to healthy ranges. These pathological gait patterns may partially explain the difficulty in postoperative recovery in pain and function, as well the wear and tear of the TKA implant in the long-term. In this study we applied a biomechanical therapy program after surgery aimed at reducing pain, improving function and correcting gait patterns. Methods: We conducted a randomized, controlled, double-blind trial involving fifty patients after unilateral TKA for end-stage knee OA. The active group underwent a therapy program using a biomechanical foot-worn device, while the control group received a similar training program with a sham walking shoe. Treatment was initiated 6 weeks postoperatively. Patients were examined at baseline, 3 months, 6 months, 9 months and 12 months postoperatively. Outcomes were the Western Ontario and McMaster Osteoarthritis Index (WOMAC), the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) and three-dimensional gait analysis measurements in the frontal and sagittal planes. Comparisons of categorical variables between the intervention groups (active vs. control) were carried out with the chi-square tests. Comparisons of continuous variables such as demographic data and baseline gait data between the groups were done by the Wilcoxon-Mann-Whitney rank-sum test. A linear mixed effect model was used to determine the effect of the treatment over time in each parameter. Results: There were no differences between groups at baseline. Both groups improved with time after surgery, but the active group consistently showed significantly better outcomes in WOMAC pain (Figure 1; 91% reduction compared to 33%), function (Figure 2; 93% reduction compared to 21%) and stiffness (85% reduction compared to 32%) sub-scales (all p = 0.001), in SF-36 physical score (107.3% increase compared to 59%) and mental scores (51% increase compared to 45%) (all p<0.001). Patients from the active group also showed lower second peak knee adduction moment (Figure 3; p = 0.007) and greater peak knee extension moment (p = 0.009). Linear mixed effect models over time showed faster improvements in the active group in all clinical parameters, stride, cadence, double-limb-support, step-length, knee range of motion and impulses of the knee flexion and extension moments, as well as slower regression of the knee adduction impulse (all p<0.01). The knee varus angle did not differ between groups over time. Conclusions: A patient-specific biomechanical therapy program applied to patients after unilateral TKA may lead to a greater improvement and more rapid recovery time in pain and function, as compared to regular rehabilitation protocols after TKA. Furthermore, this biomechanical training program may lead to healthier loading patterns on the knee joint.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

BACKGROUND:Above-the-knee amputations (AKA) and below-the-knee amputations (BKA) are commonly indicated in patients with ischemia, extensive tissue loss, or infection. AKA were previously reported to have better wound-healing rates but poorer rehabilitation rates than BKA.OBJECTIVES:To compare the outcomes of AKA and BKA and to identify risk factors for poor outcome following leg amputation.METHODS:This retrospective cohort study comprised 188 consecutive patients (mean age 72 years, range 25-103, 71 males) who underwent 198 amputations (91 AKA, 107 BK 10 bilateral procedures) between February 2007 and May 2010. Included were male and female adults who underwent amputations for ischemic, infected or gangrenotic foot. Excluded were patients whose surgery was performed for other indications (trauma, tumors). Mortality and reoperations (wound debridement or need for conversion to a higher levelof amputation) were evaluated as outcomes. Patient- and surgery-related risk factors were studied in relation to these primary outcomes.RESULTS:The risk factors for mortality were dementia [hazard ratio (HR) 2.769], non-ambulatory status preoperatively (HR 2.281), heart failure (HR 2.013) and renal failure (HR 1.87). Resistant bacterial infection (HR 3.083) emerged as a risk factor for reoperation. Neither AKA nor BKA was found to be an independent predictor of mortality or reoperation.CONCLUSIONS:Both AKA and BKA are associated with very high mortality rates. Mortality is most probably related to serious comorbidities (renal and heart disease) and to reduced functional status and dementia. Resistant bacterial infections are associated with high rates of reoperation. The risk factors identified can aid surgeons and patients to better anticipate and possibly prevent severe complications.

Background: This study was devised to examine the effect of a novel biomechanical therapy for patients suffering from anterior knee pain (AKP).Methods: A retrospective analysis of 48 patients suffering from AKP was performed. Patients underwent a gait evaluation, using an electronic walkway mat, and completed the SF-36 health survey and the WOMAC questionnaire at baseline and after 3 and 6 months of therapy. A special biomechanical device was individually calibrated for each patient. AposTherapy is a functional, non-invasive rehabilitation therapy consisting of a biomechanical foot-worn device that is used during activities of daily living. Repeated measures analyses were performed to compare gait parameters and self-evaluation questionnaires between baseline, 3 months and 6 months.Results: Walking velocity significantly increased by 5.7 cm/s, cadence increased by 1.6 steps/minute, and stride length increased by 3.4 cm in relation to pretreatment testing (p < .001 for all). End-point evaluation revealed additional improvement of these parameters; however these did not significantly differ from that of mid-treatment. Pain decreased by 36.6% and 492% following 13 and 26 weeks of treatment, respectively (P<0.01) and function improved by 252% and 41.7% following 13 and 26 weeks of treatment, respectively (P = 0.01).Conclusions: Based on the current study's results it may be concluded that this therapy might have a positive effect ;or patients with AKP. (C) 2012 Elsevier B.V. All rights reserved.