Physical Medicine & Rehabilitation

Energy Cost of Slow and Normal Gait Speeds in Low and Normally Functioning Adults Objective Slow walking speed paired with increased energy cost is a strong predictor for mortality and disability in older adults but has yet to be examined in a heterogenous sample (i.e. age, gender, disease status). The purpose of this study was to examine energy cost of slow and normal walking speeds among low- and normal-functioning adults. Design Adults 20-90 years old were recruited for this study. Participants completed a 10-m functional walk test at a self-selected normal walking speed, and were categorized as low-functioning (LF) or normal-functioning (NF) based upon expected age and gender adjusted average gait speed. Participants completed two successive 3-minute walking stages, at slower than normal and normal walking speeds, respectively. Gas exchange was measured, and energy cost per meter (ml.kg-1.m-1) was calculated for both walking speeds. Results Energy cost per meter was higher (p<0.0001) in the LF group (n=76; female=59.21%; age 61.13±14.68 years (mean±SD)) during the slower than normal and normal (p<0.0001) walking speed bouts compared with the NF group (n=42; female=54.76%; age 51.55±19.51 years). Conclusion Low-functioning adults rely on greater energy cost per meter of walking at slower and normal speeds. This has implications for total daily energy expenditure in low-functioning, adult populations. Corresponding Author: Scott J. Strath; sstrath@uwm.edu Author Disclosures: The authors have no competing interests. This work was supported by funding from the NIH 1R21HD080828. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

The Feasibility and Effects of Acupuncture on Muscle Soreness and Sense of Well-being in an Adolescent Football Population Objective To assess the feasibility of performing acupuncture on multiple adolescent athletes in a warm weather, high intensity training environment. To measure perceived effects of acupuncture on delayed-onset muscle soreness (DOMS) and sense of well-being. Design Prospective feasibility study, registered clinical trial (NCT03478800). 42 healthy male participants, ages 13-18 years, were involved in at least one of five treatment days for a total of 147 individual treatment sessions. Fifteen-minute treatments of traditional needle acupuncture were administered at the football field. Time, cost, side effects, and participant to provider ratio were observed. Effect on DOMS and sense of well-being were measured via pre- and posttreatment VAS (0-10) rating analyses. Results Time required by research staff on treatment days, 75 minutes; total cost, $700 temperature range, 21-28°C; largest participant to acupuncturist ratio, 7-10:1. No major side effects occurred; 55% reported minimal side effects such as mild focal numbness or tingling. Overall pre- to posttreatment effect on DOMS (average over 5 days) demonstrated significantly improved posttreatment scores (pre 4.6 ± 2.0; post 2.9 ± 2.2, p<.001). There was no significant effect on sense of well-being (p=0.12). Conclusion Effectively providing acupuncture to multiple adolescent football players in their training environment is feasible with appropriate staff and resources. Despite mild side-effects, treatment was well tolerated. This study provides guidance on acupuncture delivery to other athletes in their training environments. Please address correspondence to: Edward Laskowski M.D. Department of Sports Medicine Mayo Clinic 200 1st Street SW Rochester, MN 55905 Email: Laskowski.Edward@mayo.edu Disclosures: The authors have nothing to disclose. This study was funded by the Department of Integrative Medicine and Health at Mayo Clinic, Rochester, MN. Acknowledgements: We thank acupuncturists Molly J. Mallory L.Ac. and Sarah E. Bublitz L.Ac. for helping to make this study possible. We thank the Department of Integrative Medicine and Health for their financial and secretarial support, volunteers for assisting with treatment station set-up, and coaching staff for their collaboration and cooperation. We also thank biostatistician Tina Wood-Wentz M.S. for her statistical support and Dr. Kristin L. Garlanger D.O. for contributions from the previous study design. May 9, 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Traumatic Dislocation Of The Tibialis Posterior Tendon No abstract available

Hyperbaric oxygen improves functional recovery of the injured spinal cord by inhibiting inflammation and glial scar formation Background Inflammation and glial scar formation determine the recovery process after spinal cord injury (SCI). Hyperbaric oxygen (HBO) is used as a rehabilitation therapy for various clinical diseases, including SCI. However, the relationship between HBO therapy and inflammation or glial scar is not fully understood. Objective The aim of this study was to investigate the therapeutic effect and molecular mechanism of HBO on SCI. Methods A total of 54 developing female Sprague-Dawley (SD) rats were randomly divided into sham group, SCI group and HBO group, with 18 rats in each group. The model of SCI was established using Allen's method. HBO therapy was administered once a day until the rats were sacrificed. Results The results demonstrated inflammation and glial scar formation are involved in secondary SCI. After HBO treatment, there was a notable improvement of the locomotor function in rats. HBO reduced the inflammatory reaction and glial scar formation by inhibiting inflammation-related factors iNOS and COX-2, and glial scar-related components GFAP and NG2. This process may be achieved by inhibiting AKT and NF-kB pathways. Conclusion HBO effectively promotes the recovery of SCI by inhibiting inflammation and glial scar formation. To whom correspondence should be addressed: Dong Liu, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang road, Suzhou (China). Tel. 13451604878. E-Mail: 32982950@qq.com; Yongming Sun, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang road, Suzhou (China). Tel. 13182605276. E-Mail: sun-ym@21cn.com. Yue Zhou and Qirong Dong The authors contributed to this work equally. Author Disclosures: This study was supported by three Planned Science and Technology Project of Suzhou city (SS201611) (SYSD2016066) (2017Q010). The authors declare no conflict of interesting and no competing financial interests. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cognitive characteristics associated with device adoption, skill retention, and early withdrawal from a study of an advanced upper limb prosthesis Objective To examine the role of cognition in device adoption, skill retention, and withdrawal from a study of an advanced upper limb prosthesis (the DEKA Arm). Design T-tests and Wilcoxon rank-sum tests were used to compare test performance among study completers and non-completers. Multivariable regression analyses were used to predict study withdrawal and DEKA Arm skill retention. Results Compared to self-withdrawn participants, those who were withdrawn by study staff performed significantly worse on tests indexing processing speed, set-shifting, and memory encoding. DEKA Arm configuration (transradial, transhumeral, shoulder – based on amputation level), was a stronger predictor of skill retention than neuropsychological test performance. Conclusion Frontally-mediated cognitive skills may influence the successful adoption of the DEKA Arm. DEKA arm configurations at higher amputation levels (e.g., shoulder) appear to be more strongly associated with prosthetic skill retention than users' cognitive status. This may be due to non-cognitive user demands (e.g., device weight) statistically masking the discrete influence of cognitive status on skill retention at higher configuration levels. Neuropsychological assessment warrants consideration as a valuable tool in rehabilitation settings to assist in functional device candidacy evaluations. Corresponding Author: Jacob Lafo, PhD - Providence Veterans Affairs Medical Center, 830 Chalkstone Ave., Providence, RI 02908; Phone: 401-273-7100; Email: jacob_lafo@brown.edu Funding Sources: VA RR&D A9226, VA RR&D A9264A-S, VA RR&D, A9280-N Financial Disclosure Statement: None Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Trunk and Head Control During Walking in Patients with Unilateral Vestibular Hypofunction: Effect of Lower Limb Somatosensory Input Objectives To investigate (1) postural control, especially trunk and head control, in patients with unilateral vestibular hypofunction (UVH) and healthy controls (HCs) during walking on firm and foam surface; (2) the difference between the impact of left and right-side UVH, and correlation between trunk/head control and vestibular function in the patients. Design 13 patients and 13 HCs were recruited. Vestibular function was examined based on the canal paresis value. Participants walked on a treadmill on firm and foam surface. Peak-to-peak trunk (Troll and Tpitch) and head roll and pitch angle (Hroll and Hpitch) were calculated as primary outcome measures. Results In the UVH group but not HCs, Troll was significantly higher on foam than firm surface (p=0.03). Tpitch was significantly higher on foam than firm surface in both groups (p=0.02). Patients had significantly lower Hroll (p=0.03), Hpitch (p=0.02) and lower head-trunk correlation in both medio-lateral (p=0.05) and antero-posterior direction (p=0.03) than those in the HC group. Conclusion Patients with UVH appeared to rely more on lower limb somatosensory input for trunk control especially in the medio-lateral direction compared to HCs. Lower head sway and head-trunk correlation may suggest a more independent and successful head control strategy in patients. The two authors contributed equally to this study, Fang Zhang, Peng Liu All correspondence should be addressed to Dr Zulin Dou and Dr Yiqing Zheng. Corresponding authors: Zulin Dou, Department of Rehabilitation Medicine, The Third Affiliated Hospital, Sun Yat-sen University, 600 Yianhe Road, Guangzhou, People's Republic of China, Tel: +8602085252357, E-mail: douzul@163.com; Yiqing Zheng, Department of Otolaryngology-HNS, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, 107 Yanjiang West Road, Guangzhou, People's Republic of China. Tel: +8602034070287, E-mail: zhengyiq@mail.sysu.edu.cn Disclosure: The author(s) declared no potential conflicts of interest related to this work. Funding: This study was financially supported by Technology Program of Guangdong Province (No.2014A020212097), National Natural Science Foundation of China (No. 81771018), Guangdong Science and Technology Planning Project (Grant Nos. 2014B090901056 and 2015B020214003), Guangzhou Research Collaborative Innovation Projects (Grant No. 201604020108) and National Science & Technology Pillar Program during the 12th Five-year Plan Period of China (No. 2012BAI12B02). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Bilateral Quadriceps Muscle Strength and Pain Correlate with Gait Speed and Gait Endurance Early after Unilateral Total Knee Arthroplasty : A Cross-Sectional Study Objective The objective of this study was to determine the correlations between objective performance-based physical function, self-reported physical function, quality of life, and gait function at 1 month after unilateral total knee arthroplasty (TKA). Design Cross-sectional data from 195 patients who underwent unilateral primary TKA were analyzed. The isometric knee extensor and flexor strength of both knees, gait parameters, 6 minute walk test (6MWT), timed up-and-go (TUG) test, timed stair climbing test (SCT), knee flexion and extension range of motion (ROM) of surgical knee, Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) pain, stiffness, and functional levels, EuroQol five-dimensions (EQ-5D) questionnaire and visual analog scale (VAS) for knee pain were assessed. Results In bivariate analyses, both postoperative gait speed and gait endurance hadsignificant positive correlations with postoperative peak torque (PT) of the extensor and flexor of both knees, cadence, stride length, and significant negative correlation with TUG, SCT-ascent, SCT-descent, VAS, WOMAC pain, stiffness, and function levels.In the linear regression analyses, postoperative PT of the extensors of both knees and VAS for knee pain were factors correlated with postoperative gait speed and gait endurance. Conclusion Quadriceps muscle strength of both knees and knee pain were important factors correlated with gait function early after TKA. Please address all correspondence to: Bo Ryun Kim, MD. Ph. D., Department of Rehabilitation Medicine, Jeju National University School of Medicine, Regional Rheumatoid and Degenerative Arthritis Center, Jeju National University Hospital, Aran 13 gil 15, Jeju 63241, Republic of Korea, Phone: +82-64-717-2711, FAX: +82-64-717-1131, E-mail: brkim08@gmail.com Author disclosures Competing Interests: The aurthors certify that no party having a direct interest in the results of the research supporting this article has or will confer a benefit on them or on any organization with which they are associated Funding or grants or equipment provided for the project from any source: The authors received no funding for this work. Financial benefits to the authors; 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.

Making patients fit for surgery: introducing a four pillar multimodal prehabilitation program in colorectal cancer Background Considering the relation between preoperative functional capacity and postoperative complications, enhancing a patients functional capacity prior to surgery with a prehabilitation program may facilitate faster recovery and improve quality of life. However, time before surgery is short, mandating a multimodal and high-intensity training approach. This study investigated feasibility and safety of a prehabilitation program for colorectal cancer. Methods Multimodal prehabilitation was offered to patients eligible for participation. They were assigned to an intervention or control group by block randomisation. The prehabilitation program consisted of four interventions: in-hospital high-intensity endurance and strength training, high-protein nutrition, smoking cessation and psychological support. Program attendance, patient satisfaction, adverse events and functional capacity were determined. Results Fifty patients participated in this study (prehabiilitaiton 20, control 30). Program evaluation revealed a high (90%) attendance rate and high level of patient satisfaction. No adverse events occurred. Endurance and/or strength were improved. 86% of patients with prehabilitation recovered to their baseline functional capacity 4 weeks post-operatively, 40% in the control group (p<0.01). Conclusions Multimodal prehabilitation including high-intensity training for colorectal cancer patients is feasible, safe and effective. A randomized controlled trial (NTR5947) was initiated to determine whether prehabilitation may lower morbidity and mortality rates in colorectal surgery. Corresponding author + request for reprints: S.J. van Rooijen MD PhD, Máxima Medical Center, Department of Surgery, P.O. Box 7777, Veldhoven, the Netherlands, stefanvanrooijen@msn.com / prehab.resurge@mmc.nl This pilot was financially supported (MMC2620) by the National Foundation against Cancer (Nationaal Fonds tegen Kanker). FrieslandCampina provided the Refit®TMP 90 Shakes. The funding sources had no role in the design of this study and did not have any role during its execution, analyses, interpretation of the data, or decision to submit results. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Evaluating Physician Knowledge of Commonly Prescribed Inpatient Rehabilitation Unit Discharge Medication's Costs: An Observational Study The objective of this study was to assess physiatrists' knowledge of the cost of medications commonly prescribed at discharge from inpatient rehabilitation units across the spectrum of practice experience from residents to attending physicians. Investigators contacted 92 pharmacies across 4 major regions of the United States (U.S.) and averaged the cash price of each medication. An electronic survey was created highlighting 17 medications in which physicians estimated the cost of a medication per pill and per month for a 30-day supply. Surveys were sent to all ACGME-accredited programs across the U.S.; 43 participants responded to the survey. Most respondents overestimated the cost of the medications chosen for the survey. There was no significant difference between medication cost knowledge and practice experience (p = 0.497) or post-graduate year of training (p = 0.593). This raises awareness that physiatrists may not know the cost of medications they commonly prescribe at discharge, which may have implications on patient medication compliance, quality of care and patient satisfaction. Correspondence: Allison Capizzi, MD, University of Utah, 30 North 1900 East, Salt Lake City, UT, 84132. Office Phone: 801-585-2589. Mobile: 805-403-1763. Fax: 801-587-5757 Author Disclosures: No authors involved in this study have any competing interests, financial benefits, funding, grants or equipment to disclose. This material has not been presented at an AAPM&R Annual Assembly. Funding: No funding was acquired in completion of this project Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense Between 2015 and 2017, the US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) developed a Clinical Practice Guideline (CPG) for Rehabilitation of Lower Limb Amputation to address key clinical questions. A multidisciplinary workgroup of VA and DoD amputation care subject-matter-experts was formed and an extensive literature search was performed which identified 3,685 citations published from January 2007 through July 2016. Articles were excluded based upon established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded utilizing the National Academies of Science GRADE criteria. Recommendations were formulated following extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semi-rigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this CPG utilized the best available evidence from the past 10 years to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation. Corresponding Author: Joseph B. Webster, M.D.; 1201 Broad Rock Boulevard, Richmond, VA 23112, 804-675-7036, joseph.webster@va.gov Disclosure: This work represents the opinions of the authors and not necessarily those of any government agency, academic institution or healthcare agency. This work was fully funded by the Departments of Defense and Veterans Affairs. No funding was received from any commercial entity. Material was presented at the 2018 AAPM&R Annual Assembly on October 26, 2018. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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