Orthopaedic rehabilitation is a unique subspecialty of orthopaedic
surgery that incorporates surgeons and allied health professionals
from several disciplines and regional subspecialties. The subspecialty
deals with problems associated with neuromuscular disorders (stroke,
brain injury, cerebral palsy, and poliomyelitis), spinal
injury and deformity, total joint reconstruction, sports injury,
pediatric orthopaedic surgery, hand surgery, and foot and ankle
surgery. The diversity of orthopaedic rehabilitation is reflected
by the many diverse subspecialists found in the membership of the
Orthopaedic Rehabilitation Association (ORA). Because of the diverse
nature of this orthopaedic subspecialty, a discussion on advances
in orthopaedic rehabilitation can be accomplished by coverage
or separate discussions of several topics. The following report
highlights some of the advancements in orthopaedic rehabilitation within
the last year. It reviews several of the topics presented at the
most recent Annual Meetings of the ORA as well as topics covered
on ORA Specialty Day during the American Academy of Orthopaedic
Surgeons (AAOS) Annual Meeting. In addition, recent information from
published abstracts and manuscripts pertinent to orthopaedic rehabilitation
is included. This information covers diverse topics, such as neuromuscular
disorders (stroke and brain injury as well as poliomyelitis), spine surgery
(vertebroplasty and kyphoplasty), adult reconstruction
(total knee arthroplasty and associated rehabilitation),
and several aspects of hand rehabilitation after surgery.
We conclude the discussion with "What’s New in
the Orthopaedic Rehabilitation Association," including
a brief background and an update on the society.
Stroke and Traumatic Brain Injury
Several new operative procedures for the management of patients
with acquired spasticity and paralysis have been recently discussed1-3. The shoulder, which has traditionally
received relatively little attention in patients with
stroke or traumatic brain injury, was among the main topics covered at
the recent ORA Specialty Day held in San Francisco on March 3, 20011-3. There were discussions on evaluation,
management of muscle weakness and spasticity, and osseous problems and
overuse syndromes2. Keenan2 pointed out the continued usefulness
of dynamic polyelectromyography to assess motor control of the shoulder
and to help with preoperative planning. Electromyography
is particularly useful in the spastic shoulder because it is difficult
to evaluate this joint clinically. The deep-seated muscles are difficult
to palpate for spasticity or to test for weakness.
Fuller and Keenan1 presented
promising results of several new operative procedures for shoulder
weakness and for muscle spasticity. Stabilization with use of the
biceps as a suspension sling was found to be effective for the treatment
of weakness and associated inferior subluxation of the humeral head.
Transfer of the pectoralis major to the scapula and transfer of
the teres major to the ribs was helpful in stabilizing the scapula
in patients with scapular weakness. Transfer of the upper portion
of the trapezius to the humerus was performed to reestablish active motion
in patients with weakness of humeral abduction. Elbow extensor weakness
was managed with transfer of the posterior part of the deltoid to
the triceps. Pectoralis-to-biceps transfer was described
for the treatment of elbow flexion weakness.
Several procedures were described for the treatment of muscle
spasticity and associated contracture. Spastic abduction of the
shoulder, caused by overactivity of the supraspinatus, was managed
successfully with a slide (recession) of the supraspinatus. In patients
with limited forward flexion of the shoulder due to spasticity,
selective lengthening of the long head of the triceps, the teres major,
and the latissimus dorsi was carried out. Lengthening of the pectoralis
major was successful in patients with limited shoulder abduction
and external rotation caused by spasticity of that muscle1.
Poliomyelitis
Post-poliomyelitis syndrome continues to present difficult problems
that require reconstruction and rehabilitation. Fixed flexion deformity
of the knee secondary to muscle loss and imbalance is not an uncommon
problem. Bracing is difficult when a patient has a fixed
flexion contracture of 15°. A knee-ankle-foot orthosis is poorly
tolerated by these patients, and it can cause problems with skin
breakdown. Hsu et al.4 recently
reported the successful use of a wedge osteotomy of the
distal part of the femur in nine patients to help correct the deformity.
Varus or valgus deformity was also corrected as needed. Following
femoral healing, patients could be fitted with a new knee-ankle-foot orthosis.
Walking was improved, knee pain was resolved, and in many patients
leg lengths were equalized.
Vertebroplasty and Kyphoplasty
There are new and promising techniques to stabilize painful and
disabling vertebral compression fractures. These techniques include
the minimally invasive procedures of vertebroplasty and kyphoplasty,
which are being used to stabilize fractures associated with osteoporosis
and other vertebral pathologic and metastatic processes, thus relieving
pain and restoring function5-12.
The problems of osteoporosis and its sequelae are appreciable.
An estimated twenty-eight million patients in the United States
have osteoporosis or clinically relevant osteopenia, and approximately
700,000 vertebral compression fractures are attributable to these
conditions. Approximately one-half of these fractures are clinically
relevant, requiring medical attention and treatment. The estimated
cost of osteoporosis to the United States health-care system is
at least five to ten billion dollars, and costs are expected to
increase appreciably as the population ages12,13.
The acute pain associated with vertebral compression fracture
usually lasts from two weeks to three months. Traditional treatment
involves analgesic and nonsteroidal pain medication, bed rest, immobilization,
bracing, and slow resumption of prefracture activities. Approximately
16% of patients require hospitalization for pain management
and other care. Prolonged immobilization and bed rest exacerbate
the problem by causing further deconditioning and bone demineralization.
Perhaps the greatest long-term consequence of vertebral compression
fracture is the increased risk of additional fractures. Women who
have low bone mass but who have not sustained a fracture have a
sevenfold increase in the risk of fracture compared with a twenty-fivefold
increase in women with low bone mass and a single fracture13. The chronic pain associated with
vertebral compression fracture is thought to be secondary to the
inherent mechanical instability of the spine at the site of fracture. This
pain is believed to stimulate nociceptors in the periosteum and
joint capsules13. Vertebroplasty
involves the percutaneous injection of polymethylmethacrylate
into the site of the vertebral fracture. The cement hardens, stabilizing
the fracture. Kyphoplasty involves a similar technique. However,
the collapse and wedging of the compression fracture is initially "reduced" by
the placement of an inflatable balloon catheter into the vertebral
body. The balloon is inflated, restoring vertebral height and diminishing anterior
wedging of the vertebral body. Inflation of the balloon also creates
a cavity within the vertebral body that can then be filled with
injected polymethylmethacrylate8.
The early results of both of these techniques have been quite
promising. Deramond et al.7 reported
that 90% of their eighty patients managed with vertebroplasty
experienced relief of pain within twenty-four hours after treatment.
Similarly, Jensen et al.10 reported
that 90% of their twenty-nine patients had relief of pain
after vertebroplasty. Additionally, Barr et al.5 reported
that 95% of their forty-seven patients with eighty-four
fractures had moderate-to-complete relief of pain after vertebroplasty.
The results remained promising with longer-term follow-up. Twenty-five
patients with thirty-four fractures who were followed for as long as
eighty-four months reported that pain relief, which they experienced
immediately after treatment, was maintained at the follow-up examination.
No important complications were reported, but it was noted that
the patients appeared to be at an increased risk of sustaining new
compression fractures in vertebrae adjacent to the cement-treated
levels9.
Kyphoplasty seems to be effective in relieving the pain and disability
associated with vertebral compression fractures. It may also minimize
the risk of adjacent-segment compression fractures as well as diminish
the deleterious effects of progressive thoracic kyphosis by restoring
vertebral body height. Kyphoplasty has been shown to be associated
with early clinical reduction of pain and improvement in function,
and it can restore approximately 50% of lost vertebral
body height in 70% of treated levels. No important complications
were reported11.
This ability to treat symptomatic vertebral compression fractures
in an aggressive manner is an exciting advance in the management
and rehabilitation of patients with spinal disorders. Disability
is minimized early in the disease process, and long-term functional rehabilitation
is greatly improved. A minimally invasive, safe, and effective treatment
has a substantial long-term effect on the costs associated with
prolonged disability. Both vertebroplasty and kyphoplasty
are relatively new, and longer-term follow-up is needed. Early results
of their use indicate substantial benefits to patients, and the
long-term outlook appears promising.
Among the several areas of adult reconstruction, total knee arthroplasty
is one in which rehabilitation protocols have unique applications.
New understandings of biomechanics, new implant designs, and the
use of specific rehabilitation protocols such as continuous passive motion
have contributed to the successful nature of this area of adult
reconstruction. Therefore, for this report, we have elected to focus
on advances in rehabilitation as related specifically to total arthroplasty
of the knee. Total knee arthroplasty is recognized as a successful procedure
resulting in substantial reduction of pain, improvement in mobility,
and prosthetic survival rates of >95% at ten years
or more14-16. Although the technical
component of the operative procedure contributes greatly to the
outcome, perioperative rehabilitation remains a vital adjunct. Successful
rehabilitation involves the collaborative efforts of the surgeon,
physical therapist, nursing staff, and patient. Rehabilitation protocols
should be specific to reduce ambiguity, yet flexible to accommodate
differences in patient parameters. Several recent publications have given
insight into aspects of rehabilitation in patients undergoing total
knee arthroplasty.
Total Knee Arthroplasty
Patient Expectations and Assessment
Patient expectation of knee surgery is often overlooked. A typical "surgically
successful" knee arthroplasty may be deemed a failure because
the outcome did not match the expectations of the patient. Mancuso
et al.17 documented multiple expectations
that varied by diagnosis, patient characteristics, and functional
status. A seventeen-item survey for patients who underwent total knee
arthroplasty disclosed that 52% expected complete relief
of pain and 65% expected to be able to walk more than a
mile (1.6 km). Another important expectation was the return to sports,
especially tennis, skiing, golfing, jogging, and swimming. However,
Jones et al.18 reported that,
regardless of age, patients who had undergone total knee arthroplasty
did not have comparable overall physical health when matched with
the general population for age and gender. Salmon et al.19 recently found that patient-assessed
recovery with regard to pain and function after total
knee arthroplasty was not as great as that after total hip arthroplasty,
even though the quality-of-life improvements that the patients recorded
after knee arthroplasty matched those recorded after hip arthroplasty.
Patient satisfaction with the result of the procedure may therefore
be expected to increase if the goals and limitations of rehabilitation
and clinical outcome are clearly communicated.
Preoperative Factors
Jorn et al.20 attempted to
identify preoperative factors that would predict patient satisfaction,
function, and working capacity. The authors found a positive association between
the duration of preoperative and postoperative sick leave of patients
who returned to work. Overall satisfaction was greater among patients
who went back to work after the operation. Forrest et al.21 looked for correlations between
patient age, gender, marital status, body mass index, and comorbid
illness and the length of stay in the surgical unit and the need for
inpatient rehabilitation. Age was the only factor that correlated
with the length of stay in the surgical unit, and age and diabetes
mellitus correlated with the need for inpatient rehabilitation.
Conversely, Jones et al.18 found
no age-related differences in joint pain, function, or quality-of-life
measures either before the operation or six months after it.
Although rehabilitation is usually targeted at postoperative
recovery, the efficacy of preoperative physical therapy has been
investigated in some studies22,23.
In a controlled prospective randomized study, D’Lima et
al.22 demonstrated no improvement
in the outcome of total knee arthroplasty when patients had been
managed with a preoperative physical therapy strengthening protocol or
a cardiovascular conditioning program for six weeks compared with
the outcome when patients had had no preoperative exercise. A similar
study by Rodgers et al.23 also
failed to demonstrate substantial differences in postoperative outcome.
Those authors postulated that patients with chronic musculoskeletal
disease may not benefit from a few weeks of physical therapy or
that age and overall health status prevented them from obtaining a
major long-lasting benefit. Knee replacement may also provide such
dramatic improvement that it can overshadow more modest gains from
physical therapy, or the deconditioning in the immediate postoperative period
could counter any gains made in the preoperative period.
Update on the Use of Continuous Passive Motion
The effects of continuous passive motion on the range of motion
of the knee remain controversial. The reported benefits include
decreased need for knee manipulation, fewer instances of deep venous
thrombosis, decreased postoperative use of analgesics, and a greater
final range of motion. Reported disadvantages include increased
wound complications, bleeding, and pain. Patients who undergo continuous
passive motion tend to have a greater range of motion at the time
of discharge, but this advantage appears to lessen during the subsequent
follow-up period. Recently, MacDonald et al.24 reported
the results of a prospective, randomized, clinical trial comparing
continuous passive motion with physiotherapy alone after total knee
arthroplasty. The authors found no statistical differences between
the treatment groups regarding cumulative analgesic requirements,
range of motion at any measured interval, length of stay in the
hospital, or Knee Society scores. Lachiewicz25 recommended continuous passive motion
because it decreased the need for manipulation. However, Chen et al.26 found no improvement in range of
motion of the knee with continuous passive motion compared with
that with physical therapy alone in a prospective, randomized, controlled
study. Beaupre et al.27 also found
that adjunct therapies, such as continuous passive motion and slider-board
exercises, had no positive impact on knee range of motion or arthritis
index scores.
New Aspects of Implant Design
Mobile-bearing knee arthroplasty offers the advantages of increased
conformity and greater mobility, which theoretically translate into
improved function and range of motion. Mobile-bearing designs have
demonstrated survival rates comparable with those of successful
fixed-bearing designs. However, recent reviews28 of
clinical outcomes do not provide conclusive evidence to support
improved function and/or range of motion.
Designs of knee prostheses that increase the quadriceps moment
arm can reduce quadriceps tension, facilitate activities of daily
living, and enhance rehabilitation. When two designs were tested in
vitro, the design with the 10-mm longer quadriceps lever
arm reduced quadriceps tension by 5% to 20%29. Mahoney et al.30 compared
patients who had received a posterior cruciate-substituting prosthesis
with patients who had received a design that increased the patellofemoral moment
arm by 30%. After the operation, more patients who had
received the latter design reported no anterior knee pain and were
able to rise from a chair without using their arms.
Operative Techniques and Rehabilitation
The medial parapatellar approach and the midvastus approach are
the two most commonly used surgical approaches in total knee arthroplasty.
White et al.31 recently reported
that patients managed with both operative approaches during bilateral
primary total knee arthroplasty required fewer lateral retinacular
releases, had less pain at eight days and at six weeks, and were more
likely to be able to perform straight-leg raises at eight days on
the side managed with the midvastus approach. These advantages disappeared
within six months. Keating et al.32 randomized
the two approaches to either side of 100 patients undergoing bilateral
knee arthroplasty and found no differences in range of motion on
day two or at discharge, no differences in the performance of straight-leg
raises, and no difference in terminal knee extension, extensor lag,
lateral release, or any other aspects of rehabilitation. All complications,
including two postoperative hematomas and one manipulation, were
noted on the side treated with the muscle-splitting approach.
Active Mobilization Compared with Passive Mobilization
in Optimizing Hand Function
A recent advancement in hand rehabilitation is the increased
appreciation and implementation of active motion (compared with
passive motion) to maximize rapid functional restoration after injury
or reconstruction. Rehabilitation of the hand has traditionally
emphasized aggressive and well-organized postoperative protocols,
and it has been long established that early motion after injury
to the tendons and soft tissues of the hand leads to optimum
results. Idler et al.33 recently
showed the benefits of active-motion protocols compared with passive-motion
protocols. For patients who sustained flexor tendon injuries in
zone II (injuries in "no-man’s land," which
are challenging in terms of repair and rehabilitation), the use
of active motion resulted in a greater final total arc of motion
than did a passive-motion protocol. Smoking, concomitant nerve injuries,
and crush injuries were also associated with a poorer rehabilitative
outcome. To facilitate early active motion, operative techniques
have been modified to strengthen the tendon repair site. Use of
locking loops, multistrand repairs, and a locked epitenon suture
results in tendon repairs that can better withstand early active motion.
Several other authors34,35 have
recently noted the advantages of active motion compared with passive
motion in rehabilitation of the hand, although they have also identified
limitations that are particular to these methods. Although Boyer
et al.34 showed improved final
repair strength with the use of active motion after tendon repairs,
they also reported that increasing the levels of applied
force did not seem to provide additional benefit. Silva
et al.35 supported the use of
active motion following tendon repair; however, they also reported
that additional tendon excursion did not seem to add benefit.
Active motion may also play a greater role in the therapy programs
that are initiated following metacarpophalangeal joint arthroplasty
with silicone implants. Traditionally, the accepted postoperative
protocol after such arthroplasty has included dynamic extension splinting.
Recently, similar outcomes have been obtained with use of a simple
program consisting of a short period of immobilization followed
by progressive active motion.
Carpal Tunnel Syndrome
The method of rehabilitation and functional restoration of the
hand in patients with carpal tunnel syndrome is an area of continued
research and debate. The influence of surgical technique (endoscopic
release compared with open release) on rehabilitative outcome and
the time before the patient can return to work continue to be controversial
topics. It has been shown that endoscopic carpal tunnel release
usually facilitates an earlier return to work. However, by about
six weeks after decompression, the functional level of patients
who have undergone endoscopic or open release is similar. To the proponents
of open carpal tunnel release, the suggested increased risks (such
as nerve injury) associated with endoscopic release may outweigh
the benefits of the earlier return to work. The optimum method remains
controversial and, to an extent, probably depends on the experience
and preference of the individual surgeon in conjunction with the
preferences of a well-informed patient who is aware of the advantages
and disadvantages of each method.
Prophylactic rehabilitation protocols have now been shown to
be of benefit for patients with carpal tunnel syndrome. Seradge
et al.36 found a 45% decrease
in the prevalence of carpal tunnel symptoms one year after carpal
tunnel decompression exercises shown on the official AAOS web page were
implemented in a meatpacking plant. In addition, Barr et al.37 showed a dose-response relationship
between repetitive activity and local inflammation of tendons of
the upper limbs. These studies add to our understanding of the need
to avoid provocative situations in the preoperative and postoperative
management and rehabilitation of patients with carpal tunnel syndrome.
The use of a well-organized rehabilitation program after carpal
tunnel release has also been shown to be of benefit. Provinciali et
al.38 noted that a hand rehabilitation
program after carpal tunnel release was associated with an accelerated return
to work by motivated patients; however, the rehabilitation program
did not seem to improve the final functional outcome.
Accuracy of Goniometric and Grip-Strength Measurements
Evaluation of the upper extremity includes the measurement of
range of motion, grip and pinch strength, and sensory evaluation
as well as provocative tests. Validated outcomes measures such as
the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire
are new, standardized methods that are being used more commonly
in the evaluation of the hand and upper extremity. In addition,
recent studies39,40 have been
performed to evaluate the accuracy, repeatability, and methods of
functional measurements of the upper extremities. Groth et al.39 showed that the accuracy of goniometric
measurement of digital motion in the hand is equal with either dorsal or
lateral placement of the goniometer. However, neither measurement
correlated well with radiographic measurements. Shechtman40 studied the validity of grip-strength
measurement, including the range of variation associated with the
sincerity of effort in manual grip testing with a Jamar dynamometer.
Volunteers without a disorder or injury of the hand were asked to
attempt a maximal as well as a "poor" effort in
grip testing. The range of variation was found to be so great that
the variation could not be used as a tool to determine sincerity
of effort.
A Brief History of the ORA
The ORA had its beginnings at the Annual Meeting of the AAOS
that was held in New Orleans in 1989. A group of approximately thirty
orthopaedic surgeons who were interested in rehabilitation and in
the surgical and medical management of patients with chronic neuromusculoskeletal
disorders met and formed the organization.
The ORA had its first scientific meeting in San Antonio, Texas,
in November 1989. After subsequent annual meetings, it applied for
and became a member of the AAOS Council of Musculoskeletal Specialty
Societies (COMSS). In addition to an annual meeting, the ORA has
produced a scientific meeting program each year for Specialty Day
at the AAOS since 1994. The members of the ORA represent several
areas of orthopaedic and rehabilitative interests. The society has
prepared scientific programs, exhibits, and symposia involving areas such
as spinal disorders, neuromuscular disorders (brain injury, stroke,
spinal cord injury, and cerebral palsy), interdisciplinary care,
sports medicine, hand and upper extremity, foot and lower extremity,
tumor surgery, adult reconstruction and joint arthroplasty, prosthetics,
orthotic devices, robotics, and innovative scientific and engineering
developments in rehabilitation. Regular membership is open to members
of the AAOS who demonstrate an interest in orthopaedic rehabilitation.
Other types of memberships are open to residents and fellows in
orthopaedic surgery, international orthopaedic surgeons, and other
physicians, scientists, and allied health-care professionals working
in the field.
The twelfth Annual Meeting of the ORA was held in Coronado (San
Diego), California, on April 20 and 21, 2001. As the ORA approaches
its thirteenth year, the organization extends an invitation to those
interested in the field to apply for membership. The thirteenth
Annual Meeting will be held in Tucson, Arizona, on April 4, 5, and
6, 2002.
Orthopaedic Rehabilitation Today: New Directions
There is a consensus among the members of the ORA to emphasize
that, in general, orthopaedic rehabilitation is a surgical subspecialty.
Although orthopaedic rehabilitation does involve a multidisciplinary
team approach and relies on the crucial medical and therapeutic
management from our colleagues in several disciplines (rehabilitation
nursing, physical and occupational [and hand] therapy,
orthotics and prosthetics, bioengineering, and social work), the
ORA emphasizes that a main part of orthopaedic rehabilitation is
surgical reconstruction. Surgery can be considered an important
tool in rehabilitation, assisting with the management of the unique
and challenging problems presented by these often complicated cases.
When applied in the rehabilitation setting, operative methods are
effective for many purposes, including correction of limb deformity,
tendon transfer for functional restoration, contracture release for
improvement of function or positioning, excision of heterotopic
ossification, management of chronic infection or refractory areas
of skin breakdown, treatment of associated fracture nonunions and
malunions, implantation of electrodes for functional electrical
stimulation in the paralytic limb, management of neuropathy secondary
to limb deformity, and treatment of the many overuse syndromes that
develop in this population because of the overtaxing of available
muscles or joints. Orthopaedic rehabilitation usually starts in
the rehabilitation setting; in fact, often it should start in the
acute setting, such as when a patient has sustained multiple trauma.
Rigid internal fixation to aid early motion of the limb or weight-bearing
is part of orthopaedic rehabilitation. Splints, mobilization programs,
and nerve blocks in a severely spastic limb can be performed in
the acute or intensive care setting to initiate rehabilitation at
the earliest possible time.
Since orthopaedic rehabilitation is not a specialty based on
a specific anatomic region, it is perhaps one of the more difficult
specialties to define in terms of domain, goals, and directions.
The Board of Directors of the ORA, in conjunction with the general
membership, formally established a mission statement in the fall
of 2000 and announced these new areas of emphasis at the twelfth
Annual Meeting of the ORA in Coronado, California41:
The mission of the Orthopaedic Rehabilitation Association
is to improve the functional outcome of persons with musculoskeletal
disability utilizing surgical and nonsurgical management.
In addition, the Vision Statement of the ORA was also announced
as follows42:
Rehabilitation is the restoration or improvement of functional
capacities and outcomes of individuals with chronic or permanent
disabilities. Orthopaedic surgery is a valuable and powerful tool
in the rehabilitation armamentarium for improving musculoskeletal
function. Orthopaedic rehabilitation uses the basic principles
of our specialty to evaluate and treat a wide variety
of potentially devastating injuries and disorders. Orthopaedic
rehabilitation does not limit itself by the age of the person, the
anatomic location of the problem, or the etiology of the musculoskeletal
dysfunction. Rather, it focuses on the musculoskeletal system as
a whole and understands the linkages and coupling between bones, joints,
muscles and the nervous system. Orthopaedic rehabilitation includes
all of the traditional orthopaedic subspecialties. It also includes
amputation surgery, prosthetic and orthotic management, neuromuscular diseases,
and the various neurologic disorders, which defy easy classification.
The Orthopaedic Rehabilitation Association strives to be a force
helping to unify the needs of our patients with the ever expanding
subspecialty expertise within Orthopaedic Surgery and other medical
specialties.
Today, the ORA continues to attract new members from several
disciplines, both locally and abroad. Most of the members also belong
to one or more of the orthopaedic subspecialty associations based
on anatomic regions. Membership has expanded by approximately 10% during
the last year, and the Association encourages applications from
new, interested prospective members.