Background: Individuals with acute-onset central nervous system (CNS) injury, including stroke, motor incomplete spinal cord injury, or traumatic brain injury, often experience lasting locomotor defi cits, as quantifi ed by decreases in gait speed and distance walked over a specifi c duration (timed distance). The goal of the present clinical practice guideline was to delineate the relative effi cacy of various interventions to improve walking speed and timed distance in ambulatory individuals greater than 6 months following these specifi c diagnoses. Methods: A systematic review of the literature published between 1995 and 2016 was performed in 4 databases for randomized controlled clinical trials focused on these specifi c patient populations, at least 6 months postinjury and with specifi c outcomes of walking speed and timed distance. For all studies, specifi c parameters of training interventions including frequency, intensity, time, and type were detailed as possible. Recommendations were determined on the basis of the strength of the evidence and the potential harm, risks, or costs of providing a specifi c training paradigm, particularly when another intervention may be available and can provide greater benefi t. Results: Strong evidence indicates that clinicians should offer walking training at moderate to high intensities or virtual reality-based training to ambulatory individuals greater than 6 months following acuteonset CNS injury to improve walking speed or distance. In contrast, weak evidence suggests that strength training, circuit (ie, combined) training or cycling training at moderate to high intensities, and virtual reality-based balance training may improve walking speed and distance in these patient groups. Finally, strong evidence suggests that body weight-supported treadmill training, robotic-assisted training, or sitting/standing balance training without virtual reality should not be performed to improve walking speed or distance in ambulatory individuals greater than 6 months following acute-onset CNS injury to improve walking speed or distance.

Late fracture of the acetabuluni after total hip replacement.

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Background: Foods containing strong-gelling fibers may provide a safe and efficacious strategy for reducing food intake by stimulating endogenous satiety signaling. Objective: A novel, 2-part beverage, consisting of alginate-pectin and calcium components, that forms a stable, fibrous gel in the stomach was tested to determine its effects on subjective satiety and food intake in overweight and obese women. Design: The investigation was a within-subjects, double-blind, placebo-controlled study. Subjects (n ҃ 29) ingested a 2-part beverage twice per day (once before breakfast and once midafternoon) for 7 d. Three alginate-pectin formulations were tested: 1.0 g, 2.8 g, and control (no fiber). Subjective satiety and ad libitum food intake were measured on days 1 and 7 of each 1-wk treatment period with a 1-wk washout between testings. Results: A significant reduction in food intake was observed at dinner for both formulations compared with the control formulation. The effects of the gel beverage differed as a function of rigid dietary restraint status. Women in the lower 50th percentile of rigid restraint consumed 12% less energy during the day and 22% less for the evening snack in the 2.8-g condition compared with the control condition. No effect was found for women in the upper 50th percentile of rigid restraint. Conclusions: Consumption of a postingestion, calcium-gelled fiber beverage twice daily reduced energy intake in overweight and obese women with low rigid restraint scores. Use of foods designed to enhance satiety may be an effective adjunctive therapy for weight loss; however, more research is needed to determine how dietary restraint alters this response.Am J Clin Nutr 2007;86: 1595-602.

ImportanceFor walking rehabilitation after stroke, training intensity and duration are critical dosing parameters that lack optimization.ObjectiveTo assess the optimal training intensity (vigorous vs moderate) and minimum training duration (4, 8, or 12 weeks) needed to maximize immediate improvement in walking capacity in patients with chronic stroke.Design, Setting, and ParticipantsThis multicenter randomized clinical trial using an intent-to-treat analysis was conducted from January 2019 to April 2022 at rehabilitation and exercise research laboratories. Survivors of a single stroke who were aged 40 to 80 years and had persistent walking limitations 6 months or more after the stroke were enrolled.InterventionsParticipants were randomized 1:1 to high-intensity interval training (HIIT) or moderate-intensity aerobic training (MAT), each involving 45 minutes of walking practice 3 times per week for 12 weeks. The HIIT protocol used repeated 30-second bursts of walking at maximum safe speed, alternated with 30- to 60-second rest periods, targeting a mean aerobic intensity above 60% of the heart rate reserve (HRR). The MAT protocol used continuous walking with speed adjusted to maintain an initial target of 40% of the HRR, progressing up to 60% of the HRR as tolerated.Main Outcomes and MeasuresThe main outcome was 6-minute walk test distance. Outcomes were assessed by blinded raters after 4, 8, and 12 weeks of training.ResultsOf 55 participants (mean [SD] age, 63 [10] years; 36 male [65.5%]), 27 were randomized to HIIT and 28 to MAT. The mean (SD) time since stroke was 2.5 (1.3) years, and mean (SD) 6-minute walk test distance at baseline was 239 (132) m. Participants attended 1675 of 1980 planned treatment visits (84.6%) and 197 of 220 planned testing visits (89.5%). No serious adverse events related to study procedures occurred. Groups had similar 6-minute walk test distance changes after 4 weeks (HIIT, 27 m [95% CI, 6-48 m]; MAT, 12 m [95% CI, −9 to 33 m]; mean difference, 15 m [95% CI, −13 to 42 m]; P = .28), but HIIT elicited greater gains after 8 weeks (58 m [95% CI, 39-76 m] vs 29 m [95% CI, 9-48 m]; mean difference, 29 m [95% CI, 5-54 m]; P = .02) and 12 weeks (71 m [95% CI, 49-94 m] vs 27 m [95% CI, 3-50 m]; mean difference, 44 m [95% CI, 14-74 m]; P = .005) of training; HIIT also showed greater improvements than MAT on some secondary measures of gait speed and fatigue.Conclusions and RelevanceThese findings show proof of concept that vigorous training intensity is a critical dosing parameter for walking rehabilitation. In patients with chronic stroke, vigorous walking exercise produced significant and meaningful gains in walking capacity with only 4 weeks of training, but at least 12 weeks were needed to maximize immediate gains.Trial RegistrationClinicalTrials.gov Identifier: NCT03760016

Background: Decreasing length of stay (LOS) following primary total knee arthroplasty (TKA) has been an important focus by all the stakeholders involved in the delivery of care. LOS is dictated by both the patient and hospital-related factors. The purpose of this study was to determine if early mobilization on postoperative day 0 (POD 0) following primary TKA has an effect on hospital LOS and discharge to home vs. rehabilitation facilities. Methods: An analysis was performed of consecutive primary TKAs performed at a single institution over one year. Patients were assigned to two groups: POD 0 or POD 1, based on their day of mobilization. Patients were mobilized following surgery based on time of arrival to the orthopaedic floor and availability of physical therapy (PT) resources. The two groups were compared for LOS and discharge disposition using univariate analysis. A total of 408 consecutive TKAs were evaluated and from this group, a total of 143 patients who were mobilized on POD 0 were then matched to 143 patients mobilized on POD 1. There were no significant differences in age, sex, American Society of Anesthesiologists score, or body mass index (BMI) between POD 0 and POD 1 groups. Results: There was a significant difference in LOS between POD 0 and POD 1 groups, 2.44 vs. 2.80 days (P=0.002). There were also differences in discharge to home vs. rehabilitation, 70.63% of the POD 0 cohort were discharged home compared to 58.74% in POD 1 (P=0.035). Conclusions: There was a significant reduction in LOS and there were differences in discharge disposition between patients who mobilized on POD 0 vs. POD 1, with more patients mobilized on POD 0 discharged home. Hospitals should work with their total joint arthroplasty programs to mobilize close to 100% of the patients undergoing primary TKA on POD 0 in order to decrease LOS and healthcare expenditure.

Metal to metal prostheses give satisfactory results in 90% of patients. About half of the failure rate may be due to allergic reaction to the metals involved, particularly cobalt. A total of 35 patients in this unsatisfactory group have been patch-tested; 16 were positive to metals, 13 to cobalt, 4 to nickel, and 2 to chromate. Only two patients showed any skin lesions - one a localized dermatitis round the knee joint from nickel sensitivity, and one to cobalt who had a widespread scattered circular erythematous lesion suggestive of a generalized allergic vasculitis. Patients requiring a metal/metal prosthesis should have a careful history taken for metal sensitivity and be patch-tested with the metals. All the patients in this investigation had metal/metal prostheses and no reaction was seen after metal/high density polyethylene implants. Titanium 318 may be a satisfactory substitute for cobalt chrome alloy if reactions are encountered.