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Vincent H.K.,UF Orthopaedics and Sports Medicine Institute | Seay A.N.,University of Florida | Montero C.,University of Florida | Vincent K.R.,The Interdisciplinary Center
European Journal of Physical and Rehabilitation Medicine | Year: 2013

Background. Obesity is related to the development of functional and mobility impairment, musculoskeletal pain and orthopedic problems. Irrespective of age, obese children and adults have impaired walking capacity and body transfer ability, and difficulties navigating obstacle courses or community spaces. Obesity is related to relative strength deficits, musculoskeletal pain, kincsiophobia, low self-efficacy and a decline in quality of life. Aim. This review provides an update of the available evidence for the efficacy of outpatient rehabilitation programs for the treatment of disabling obesity. Results. Outpatient rehabilitation programs can effectively improve muscle strength, self-confidence and physical function. Key rehabilitation components should include aerobic exercise (AX), resistance exercise (RX) and cognitive strategies to cope with the unique challenges posed by obesity. Available high quality evidence indicates that 3-18 month rehabilitation programs that included aerobic and strengthening exercise (2-3 days per week) with caloric restriction (typically 500-750 kcal deficit/ day), elicited the best changes in functional performance measures compared with exercise or diet alone. Conclusion. Comprehensive outpatient rehabilitation interventions coupled with diet can catalyze lifestyle patterns that improve and preserve physical function over the life span.

Vincent H.K.,UF and Shands Orthopaedics and Sports Medicine Institute | Lamb K.M.,University of Florida | Day T.I.,Shands Physical Therapy | Tillman S.M.,Shands Physical Therapy | And 2 more authors.
PM and R | Year: 2010

Objective: To compare fear of movement in patients with different body mass index (BMI) values referred for rehabilitative care of the knee and to examine whether this fear contributed to self-reported knee-related function. We hypothesized that fear of movement would be elevated with increasing BMI and that fear would correspond with lower self-report knee-related function and lower quality of life (QOL). Design: Retrospective cross-sectional study. Setting: Outpatient therapy clinic affiliated with a tertiary care hospital. Patients: Patients with knee pain diagnoses (n = 278) were stratified into 4 BMI groups (in ≤25 kg/m 2 nonobese; 25-29.9 kg/m 2 overweight; 30-39.9 kg/m 2 obese; ≥40 kg/m 2 morbidly obese). Main Outcome Measurements: The Tampa Scale of Kinesiophobia (TSK; fear of movement), International Knee Documentation (IKDC; knee function), and Short-Form 8 (SF-8; QOL) scores were main outcomes. Pain and straight leg raise test scores also were collected. Methods: After review of the medical records, descriptive statistics and nonparametric tests were performed, and TSK, QOL, and SF-8 scores were compared. Hierarchical regression modeling determined the contribution of TSK scores to the variance of IKDC scores. Results: Pain scores were greatest in the nonobese group and lowest in the morbidly obese group (7.5 ± 2.6 points vs 4.8 ± 3.1 points; P < .05). TSK scores in morbidly obese patients were greater than in nonobese patients (27.1 ± 7.7 points vs 22.0 ± 6.6 points; P = .002). The SF-8 mental-physical subscores were 27% to 32% lower in the morbidly obese than nonobese patients (both P < .0001). IKDC scores were lower in the morbidly obese than nonobese patients (32.1 ± 19.2 points vs 50.9 ± 23.8 points; P = .0001). Pain severity and TSK scores contributed 28.6% and 7.1% to the variance of the IKDC scores (overall R 2 = 68.6). Conclusions: Morbid obesity is associated with elevated fear of movement. Pain was the strongest predictor of IKDC scores, and fear of movement enhanced this predictive value of the regression model. Despite lower absolute pain severity in the morbidly obese group, this fear may influence IKDC scores in this population. Morbidly obese patients might benefit from rehabilitation activities that reduce fear of movement to optimize participation in rehabilitation activity. © 2010 American Academy of Physical Medicine and Rehabilitation.

Vincent H.K.,UF Orthopaedics and Sports Medicine Institute | Vincent K.R.,The Interdisciplinary Center
PM and R | Year: 2013

Running has rapidly increased in popularity and elicits numerous health benefits, including weight loss. At present, no practical guidelines are available for obese persons who wish to start a running program. This article is a narrative review of the emerging evidence of the musculoskeletal factors to consider in obese patients who wish to initiate a running program and increase its intensity. Main program goals should include gradual weight loss, avoidance of injury, and enjoyment of the exercise. Pre-emptive strengthening exercises can improve the strength of the foot and ankle, hip abductor, quadriceps, and trunk to help support the joints bearing the loads before starting a running program. Depending on the presence of comorbid joint pain, nonimpact exercise or walking (on a flat surface, on an incline, and at high intensity) can be used to initiate the program. For progression to running, intensity or mileage increases should be slow and consistent to prevent musculoskeletal injury. A stepwise transition to running at a rate not exceeding 5%-10% of weekly mileage or duration is reasonable for this population. Intermittent walk-jog programs are also attractive for persons who are not able to sustain running for a long period. Musculoskeletal pain should neither carry over to the next day nor be increased the day after exercising. Rest days in between running sessions may help prevent overuse injury. Patients who have undergone bariatric surgery and are now lean can also run, but special foci such as hydration and energy replacement must be considered. In summary, obese persons can run for exercise, provided they follow conservative transitions and progression, schedule rest days, and heed onset of pain symptoms. © 2013 American Academy of Physical Medicine and Rehabilitation.

Offley S.,URMC Orthopaedics and Rehabilitation | Coyne E.,URMC Orthopaedics and Rehabilitation | Horodyski M.,UF Orthopaedics and Sports Medicine Institute | Rubery P.,URMC Orthopaedics and Rehabilitation | Zeidman S.,URMC Orthopaedics and Rehabilitation
Surgical Neurology International | Year: 2013

Background: Safe and effective postoperative pain control remains an issue in complex spine surgery. Spinal narcotics have been used for decades but have not become commonplace because of safety or re-dosing concerns. An extended release epidural morphine (EREM) preparation has been used successfully in obstetric, abdominal, thoracic, and extremity surgery done with epidural anesthesia. This has not been studied in open spinal surgery. Methods: Ninety-eight patients having complex posterior lumbar surgery were enrolled in a partially randomized clinical trial (PRCT) of low to moderate doses of EREM. Surgery included levels from L3 to S1 with procedures involving combinations of decompression, instrumented arthrodesis, and interbody grafting. The patients were randomized to receive either 10 or 15 mg of EREM through an epidural catheter placed under direct vision at the conclusion of surgery. Multiple safety measures were employed to prevent or detect respiratory depression. Postoperative pain scores, narcotic utilization, and adverse events were recorded. Results: There were no significant differences between the two groups as to supplemental narcotic requirements, pain scores, or adverse events. There were no cases of respiratory depression. The epidural narcotic effect persisted from 3 to 36 hours after the injection. Conclusion: By utilizing appropriate safety measures, EREM can be used safely for postoperative pain control in lumbar surgery patients. As there was no apparent advantage to the use of 15 mg, the lower 10 mg dose should be used. © 2013 Offley SC.

Vincent K.R.,UF Orthopaedics and Sports Medicine Institute | Conrad B.P.,University of Florida | Fregly B.J.,University of Florida | Vincent H.K.,University of Florida
PM and R | Year: 2012

Osteoarthritis (OA) is the most frequent cause of disability in the United States, with the medial compartment of the knee being most commonly affected. The initiation and progression of knee OA is influenced by many factors, including kinematics. In response to loading during weight-bearing activity, cartilage in healthy knees demonstrates spatial adaptations in morphology and mechanical properties. These adaptations allow certain regions of the cartilage to respond to loading; other regions are less well suited to accommodate loading. Alterations in normal knee kinematics shift loading from cartilage regions adapted for loading to regions less well suited for loading, which leads to the initiation and progression of degenerative processes consistent with knee OA. Kinematic variables that are associated with the development, progression, and severity of knee OA are the adduction moment and tibiofemoral rotation. Because of its strong correlation with disease progression and pain, the peak adduction moment during gait has been identified as a target for treatment design. Gait modification offers a noninvasive option for seeking significant reductions. Gait modification has the potential to reduce pain and slow the progression of medial compartment knee OA. © 2012 American Academy of Physical Medicine and Rehabilitation.

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