Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA),... more Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <...
BackgroundTo evaluate changes in pain, function, and quality of life after treatment with injecte... more BackgroundTo evaluate changes in pain, function, and quality of life after treatment with injected micro-fragmented adipose tissue (MFAT) for knee osteoarthritis in a large cohort of individuals treated at multiple centers. MethodsOne hundred ten individuals were recruited from three private outpatient clinics. Participants had to be diagnosed with symptomatic knee OA (defined by persistent knee pain associated with clinical symptoms of OA and/ or classic imaging findings) and who had not received prior knee surgery or treatment with platelet-rich plasma, cortisone, or hyaluronic acid within the previous 6 weeks. Data from 120 knees were included in the analysis. Outcome measures included Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, activities of daily living [ADL], sports and recreation, quality of life [QOL]) and an 11-point Numerical Rating Scale (NRS) for average knee pain over the past week. Outcomes were collected at baseline and 3, 6, and 12 ...
Myofascial pain syndrome (MPS) is difficult to treat. The efficacy and safety of tizanidine, an a... more Myofascial pain syndrome (MPS) is difficult to treat. The efficacy and safety of tizanidine, an alpha2-adrenergic agent with effects on spasticity and pain, in treating MPS was evaluated. Female subjects (n = 29) with MPS of 9 to > 52 weeks' duration and mean age 37.5 (range 20-51) years, who also had reduced pressure thresholds, were enrolled. Subjects were titrated up to 12 mg of tizanidine over 3 weeks and maintained for 2 weeks. Sleep was assessed via visual analog scale (VAS), pain intensity via short form McGill questionnaire including VAS, disability/level of function, and pressure threshold (tested by algometry) at baseline, weeks 3 and 5, and 1 week after tizanidine was discontinued. Patient and physician global assessments of treatment were reported at week 5. Twenty-four subjects completed the study. Pain intensity and disability decreased significantly from baseline at weeks 3 and 5 and after washout (P < .001). Pressure threshold and sleep improved for all stu...
Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoar... more Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.
American Journal of Physical Medicine & Rehabilitation, 2007
To characterize graduating physical medicine and rehabilitation (PM&amp;amp;amp;amp;amp;amp;a... more To characterize graduating physical medicine and rehabilitation (PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R) residents physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of their current musculoskeletal (MSK) training, to identify barriers perceived by resident physicians to improving MSK education experiences, and to compare the views of resident physicians with those of PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residency program directors. Fourth-year PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents graduating in 2004 whose program directors attended the 2004 Association of Academic Physiatrists annual meeting were asked to complete an MSK education survey developed by the authors. Data were compared with a previous MSK education survey that had been completed by PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residency program directors. Ninety-three of 156 (61%) fourth-year PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents responded after multiple contacts. According to residents, the most frequently used MSK education formats during residency were MSK lecture series, MSK journal clubs, and MSK workshops. Potential barriers to improved MSK education during residency included staff, money, and time. If given unlimited resources, most residents would greatly increase the use of visiting lecturers, MSK workshops, and MSK lecture series. Graduating PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents as well as residency program directors indicated a strong interest in expanding resident MSK education through the use of visiting lecturers. Differences were noted with respect to the use of hands-on learning (i.e., MSK workshops [residents]) vs. passive learning (i.e., CD ROMS/DVDs and videos [program directors]). Both groups described how limited resources including staff, money, and time are barriers to resident MSK education.
American Journal of Physical Medicine & Rehabilitation, 2001
To assess whether athletes with strength imbalance of the hip musculature would be more likely to... more To assess whether athletes with strength imbalance of the hip musculature would be more likely to require treatment for low back pain (LBP) over the ensuing year. The study population included 163 National Collegiate Athletic Association Division I college athletes (100 males and 63 females) undergoing preparticipation sports physicals. Institutional review board approval was obtained to acquire and analyze hip muscle strength data. A commercially available dynamometer (Chatillon, Lexington, KY) incorporated into a specially designed anchoring station was used for testing the hip extensors and abductors. The maximum force generated for the hip abductors and extensors was used to calculate a percentage difference between the right and left hip extensors and abductors. Treatment of athletes by the athletic trainers for LBP unrelated to blunt trauma over the ensuing year was recorded. Of all athletes, 5 of 63 females and 8 of 100 males required treatment for LBP. Logistic regression analysis indicated that for female athletes, the percentage difference between the right and left hip extensors was predictive of whether treatment for LBP was required over the ensuing year (P = 0.05). There was no significant association noted for the percentage difference between the right and left hip abductors in females and for the percentage difference between both the right and left hip abductors and right and left hip extensors in males requiring treatment for LBP. These data support our results from our previous cohort study, adding validity to the concept of hip muscle imbalance being associated with LBP occurrence in female athletes. This research further supports the need for the assessment and treatment of hip muscle imbalance in individuals with LBP.
American Journal of Physical Medicine & Rehabilitation, 1993
Continuous passive motion (CPM) has been commonly used in the postoperative rehabilitation of pat... more Continuous passive motion (CPM) has been commonly used in the postoperative rehabilitation of patients after total knee arthroplasty. In the acute care hospital, most studies have found CPM to be useful in improving range of motion and reducing length of stay. The benefit of CPM in the rehabilitation hospital has not been studied. The charts of 61 patients who had undergone total knee arthroplasty and subsequently were admitted to the East facility of the Kessler Institute for Rehabilitation were reviewed. Patients were separated into two groups: Group 1 received CPM for 3 to 4 hours/day and physical therapy for 2 hours/day. Group 2 received only physical therapy. There was no significant difference in passive range of motion or length of stay between Group 1 and Group 2. An analysis of the 16 patients who underwent bilateral replacement was undertaken. Patients in Group 1 (n = 7) achieved an average increase in passive range of motion of 20.1 degrees, whereas those in Group 2 (n = 9) achieved an increase of 12.7 degrees (P = 0.18). Power analysis demonstrated the need for 50 patients per subgroup to achieve significance. The lack of statistical significance in this subgroup may be a reflection of the small study population (n = 16). The following conclusions can be drawn concerning the use of CPM in the rehabilitation setting: (1) CPM was of no added benefit to those patients admitted after single knee replacement, and (2) CPM may be beneficial to those patients admitted after bilateral knee replacement.
Platelet-rich plasma (PRP) is an orthobiologic treatment that has gained popularity as a potentia... more Platelet-rich plasma (PRP) is an orthobiologic treatment that has gained popularity as a potential alternative treatment for various musculoskeletal conditions. The physiologic role of platelets in the healing cascade provides clarity regarding its potential as it releases various growth factors such as platelet-derived growth factor (PDGF), transforming growth factor beta-1 (TGF-β1), and vascular endothelial growth factor (VEGF). However, there are various characteristics of PRP treatments including platelet count, presence or absence of leukocytes and red blood cells, as well as the use of an activating agent that introduces heterogeneity among preparations. This aim of this article is to provide clarity, where available, regarding the optimal characteristics for PRP treatments regarding tendon and ligament injuries as well as articular and muscular pathology.
The majority of the provocative tests described for physical examination of the neck and cervical... more The majority of the provocative tests described for physical examination of the neck and cervical spine relate to identification of radiculopathy, spinal cord, or brachial plexus pathology. These tests are often performed routinely by many providers with variable methods and interpreted in a variety of ways. Several commonly performed provocative tests include Spurling's Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L'hermitte's Sign, Hoffmann's Sign and Adson's Test. This review describes some specialized provocative tests with comprehensive literature review. The goal of this review is to develop standardization in the performance and clinical use of these tests. Each of the tests described in this manuscript apparently originated from the anecdotal observations of experienced, well respected clinicians. However, only few studies have been performed addressing the interexaminer reliability or validity of these tests. The existi...
STUDY DESIGN A case report of unrecognized lumbarization of the S-1 vertebral body leading to wro... more STUDY DESIGN A case report of unrecognized lumbarization of the S-1 vertebral body leading to wrong-level disc surgery in a patient with acute cauda equina syndrome secondary to a large disc extrusion at the L4-L5 interspace. Laminectomy and excision were initially performed at the level of L5-L6. OBJECTIVES To review the importance of detection of lumbosacral transitional vertebrae when performing interventional procedures in the lumbar spine. SUMMARY OF BACKGROUND DATA Lumbosacraljunction transitional vertebrae have been well documented. Likewise, surgery at the wrong intervertebral level has been reported as a reason for failure of lumbar spine surgery. There is also brief mention in the literature of lumbar disc surgery performed at incorrect levels in part secondary to junctional anomalies. However, there is no recorded case of wrong-level disc surgery in acute cauda equina syndrome occurring as a result of an unrecognized lumbarization or sacralization of transitional vertebra...
Background Several nonoperative options have been recommended for the treatment of knee osteoarth... more Background Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. Objectives To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. Methods We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 ...
Significant variability exists in the literature, with no clear consensus to the optimal protocol... more Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights th...
Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA),... more Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 states, had claim history <...
BackgroundTo evaluate changes in pain, function, and quality of life after treatment with injecte... more BackgroundTo evaluate changes in pain, function, and quality of life after treatment with injected micro-fragmented adipose tissue (MFAT) for knee osteoarthritis in a large cohort of individuals treated at multiple centers. MethodsOne hundred ten individuals were recruited from three private outpatient clinics. Participants had to be diagnosed with symptomatic knee OA (defined by persistent knee pain associated with clinical symptoms of OA and/ or classic imaging findings) and who had not received prior knee surgery or treatment with platelet-rich plasma, cortisone, or hyaluronic acid within the previous 6 weeks. Data from 120 knees were included in the analysis. Outcome measures included Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales (pain, symptoms, activities of daily living [ADL], sports and recreation, quality of life [QOL]) and an 11-point Numerical Rating Scale (NRS) for average knee pain over the past week. Outcomes were collected at baseline and 3, 6, and 12 ...
Myofascial pain syndrome (MPS) is difficult to treat. The efficacy and safety of tizanidine, an a... more Myofascial pain syndrome (MPS) is difficult to treat. The efficacy and safety of tizanidine, an alpha2-adrenergic agent with effects on spasticity and pain, in treating MPS was evaluated. Female subjects (n = 29) with MPS of 9 to > 52 weeks' duration and mean age 37.5 (range 20-51) years, who also had reduced pressure thresholds, were enrolled. Subjects were titrated up to 12 mg of tizanidine over 3 weeks and maintained for 2 weeks. Sleep was assessed via visual analog scale (VAS), pain intensity via short form McGill questionnaire including VAS, disability/level of function, and pressure threshold (tested by algometry) at baseline, weeks 3 and 5, and 1 week after tizanidine was discontinued. Patient and physician global assessments of treatment were reported at week 5. Twenty-four subjects completed the study. Pain intensity and disability decreased significantly from baseline at weeks 3 and 5 and after washout (P < .001). Pressure threshold and sleep improved for all stu...
Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoar... more Aim: We studied changes in opioid prescriptions and corticosteroid injection use for knee osteoarthritis patients before and after intra-articular hyaluronic acid (HA) use and opioid prescriptions before and after knee arthroplasty (KA). Materials & methods: A total of 1,017,578 knee osteoarthritis members were ascertained from a commercial claims database (Health Intelligence Company LLC, IL, USA) using ICD9/ICD10 diagnosis codes. Results: Eighty two percent of HA patients did not fill opioid prescriptions postinjection, with 54% of opioid users discontinuing fills. Two-thirds of KA patients filled opioid prescriptions within 6 months postsurgery, with 78% of opioid users continuing fills and 62% of nonusers initiating use. Conclusion: Alternative therapies, such as HA, that reduce opioid use may alleviate opioid addiction risks for KA patients who use opioids in the pre- and postoperative periods.
American Journal of Physical Medicine & Rehabilitation, 2007
To characterize graduating physical medicine and rehabilitation (PM&amp;amp;amp;amp;amp;amp;a... more To characterize graduating physical medicine and rehabilitation (PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R) residents physicians&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; perceptions of their current musculoskeletal (MSK) training, to identify barriers perceived by resident physicians to improving MSK education experiences, and to compare the views of resident physicians with those of PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residency program directors. Fourth-year PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents graduating in 2004 whose program directors attended the 2004 Association of Academic Physiatrists annual meeting were asked to complete an MSK education survey developed by the authors. Data were compared with a previous MSK education survey that had been completed by PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residency program directors. Ninety-three of 156 (61%) fourth-year PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents responded after multiple contacts. According to residents, the most frequently used MSK education formats during residency were MSK lecture series, MSK journal clubs, and MSK workshops. Potential barriers to improved MSK education during residency included staff, money, and time. If given unlimited resources, most residents would greatly increase the use of visiting lecturers, MSK workshops, and MSK lecture series. Graduating PM&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;R residents as well as residency program directors indicated a strong interest in expanding resident MSK education through the use of visiting lecturers. Differences were noted with respect to the use of hands-on learning (i.e., MSK workshops [residents]) vs. passive learning (i.e., CD ROMS/DVDs and videos [program directors]). Both groups described how limited resources including staff, money, and time are barriers to resident MSK education.
American Journal of Physical Medicine & Rehabilitation, 2001
To assess whether athletes with strength imbalance of the hip musculature would be more likely to... more To assess whether athletes with strength imbalance of the hip musculature would be more likely to require treatment for low back pain (LBP) over the ensuing year. The study population included 163 National Collegiate Athletic Association Division I college athletes (100 males and 63 females) undergoing preparticipation sports physicals. Institutional review board approval was obtained to acquire and analyze hip muscle strength data. A commercially available dynamometer (Chatillon, Lexington, KY) incorporated into a specially designed anchoring station was used for testing the hip extensors and abductors. The maximum force generated for the hip abductors and extensors was used to calculate a percentage difference between the right and left hip extensors and abductors. Treatment of athletes by the athletic trainers for LBP unrelated to blunt trauma over the ensuing year was recorded. Of all athletes, 5 of 63 females and 8 of 100 males required treatment for LBP. Logistic regression analysis indicated that for female athletes, the percentage difference between the right and left hip extensors was predictive of whether treatment for LBP was required over the ensuing year (P = 0.05). There was no significant association noted for the percentage difference between the right and left hip abductors in females and for the percentage difference between both the right and left hip abductors and right and left hip extensors in males requiring treatment for LBP. These data support our results from our previous cohort study, adding validity to the concept of hip muscle imbalance being associated with LBP occurrence in female athletes. This research further supports the need for the assessment and treatment of hip muscle imbalance in individuals with LBP.
American Journal of Physical Medicine & Rehabilitation, 1993
Continuous passive motion (CPM) has been commonly used in the postoperative rehabilitation of pat... more Continuous passive motion (CPM) has been commonly used in the postoperative rehabilitation of patients after total knee arthroplasty. In the acute care hospital, most studies have found CPM to be useful in improving range of motion and reducing length of stay. The benefit of CPM in the rehabilitation hospital has not been studied. The charts of 61 patients who had undergone total knee arthroplasty and subsequently were admitted to the East facility of the Kessler Institute for Rehabilitation were reviewed. Patients were separated into two groups: Group 1 received CPM for 3 to 4 hours/day and physical therapy for 2 hours/day. Group 2 received only physical therapy. There was no significant difference in passive range of motion or length of stay between Group 1 and Group 2. An analysis of the 16 patients who underwent bilateral replacement was undertaken. Patients in Group 1 (n = 7) achieved an average increase in passive range of motion of 20.1 degrees, whereas those in Group 2 (n = 9) achieved an increase of 12.7 degrees (P = 0.18). Power analysis demonstrated the need for 50 patients per subgroup to achieve significance. The lack of statistical significance in this subgroup may be a reflection of the small study population (n = 16). The following conclusions can be drawn concerning the use of CPM in the rehabilitation setting: (1) CPM was of no added benefit to those patients admitted after single knee replacement, and (2) CPM may be beneficial to those patients admitted after bilateral knee replacement.
Platelet-rich plasma (PRP) is an orthobiologic treatment that has gained popularity as a potentia... more Platelet-rich plasma (PRP) is an orthobiologic treatment that has gained popularity as a potential alternative treatment for various musculoskeletal conditions. The physiologic role of platelets in the healing cascade provides clarity regarding its potential as it releases various growth factors such as platelet-derived growth factor (PDGF), transforming growth factor beta-1 (TGF-β1), and vascular endothelial growth factor (VEGF). However, there are various characteristics of PRP treatments including platelet count, presence or absence of leukocytes and red blood cells, as well as the use of an activating agent that introduces heterogeneity among preparations. This aim of this article is to provide clarity, where available, regarding the optimal characteristics for PRP treatments regarding tendon and ligament injuries as well as articular and muscular pathology.
The majority of the provocative tests described for physical examination of the neck and cervical... more The majority of the provocative tests described for physical examination of the neck and cervical spine relate to identification of radiculopathy, spinal cord, or brachial plexus pathology. These tests are often performed routinely by many providers with variable methods and interpreted in a variety of ways. Several commonly performed provocative tests include Spurling's Neck Compression Test, Shoulder Abduction (Relief) Test, Neck Distraction Test, L'hermitte's Sign, Hoffmann's Sign and Adson's Test. This review describes some specialized provocative tests with comprehensive literature review. The goal of this review is to develop standardization in the performance and clinical use of these tests. Each of the tests described in this manuscript apparently originated from the anecdotal observations of experienced, well respected clinicians. However, only few studies have been performed addressing the interexaminer reliability or validity of these tests. The existi...
STUDY DESIGN A case report of unrecognized lumbarization of the S-1 vertebral body leading to wro... more STUDY DESIGN A case report of unrecognized lumbarization of the S-1 vertebral body leading to wrong-level disc surgery in a patient with acute cauda equina syndrome secondary to a large disc extrusion at the L4-L5 interspace. Laminectomy and excision were initially performed at the level of L5-L6. OBJECTIVES To review the importance of detection of lumbosacral transitional vertebrae when performing interventional procedures in the lumbar spine. SUMMARY OF BACKGROUND DATA Lumbosacraljunction transitional vertebrae have been well documented. Likewise, surgery at the wrong intervertebral level has been reported as a reason for failure of lumbar spine surgery. There is also brief mention in the literature of lumbar disc surgery performed at incorrect levels in part secondary to junctional anomalies. However, there is no recorded case of wrong-level disc surgery in acute cauda equina syndrome occurring as a result of an unrecognized lumbarization or sacralization of transitional vertebra...
Background Several nonoperative options have been recommended for the treatment of knee osteoarth... more Background Several nonoperative options have been recommended for the treatment of knee osteoarthritis (OA), with varying degrees of evidence. Adhering to the American Academy of Orthopaedic Surgeons clinical practice guidelines has been suggested to decrease direct treatment costs by 45% in the year before knee arthroplasty, but this does not consider the cost of the entire episode of care, including the cost of surgery and postsurgery care. Objectives To analyze the total treatment costs after a diagnosis of knee OA, as well as the proportion of arthroplasty interventions as part of the total knee OA-related costs, and whether the total costs differed for patients who received intra-articular hyaluronic acid and/or had knee arthroplasty. Methods We identified patients newly diagnosed with knee OA using the 5% Medicare data sample from January 2010 to December 2015. Patients were excluded if they were aged <65 years, had incomplete claim history, did not reside in any of the 50 ...
Significant variability exists in the literature, with no clear consensus to the optimal protocol... more Significant variability exists in the literature, with no clear consensus to the optimal protocol after a regenerative procedure. Given this uncertainty, the authors systematically reviewed the literature cataloging the different variables that may influence outcomes. Search was limited to randomized clinical trials and prospective cohort studies of regenerative procedures for the treatment of tendinopathy. Variables were predetermined, and included: cyrotherapy, pre- and post-procedure nonsteroidal anti-inflammatory drugs use, recommendations for alternative pain medications, immobilization and duration of rest. Variables were categorized based on the influence of the intervention on the three phases of healing. 749 studies were assessed for eligibility, and 60 studies were included. Significant variability existed in the literature. Despite the importance of rehabilitation after regenerative procedures, there is a paucity of evidence available to guide clinicians and highlights th...
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Papers by Gerard Malanga