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BACKGROUND: Knee arthritis is a destructive disorder that affects the knee joints and causes pain and reduced mobility. Drug treatments, weight loss, and exercise control the symptoms of the disease, but these methods only delay the disease process and eventually, knee joint replacement surgery will be needed. After surgery, with the help of a proper physiotherapy program, full recovery takes an average of 6-12 months. However, currently, there is no similar tool to facilitate this process in Iran. OBJECTIVE: The purpose of this research is to design and develop the prototype of a rehabilitation system for patients after knee replacement surgery, which provides patients with information and appropriate physiotherapy programs. METHODS: This study was development-applied and was done in three stages. In the first stage, the needs and content of education and therapeutic exercises were prepared in the form of a checklist, and then the necessity of each item was checked in the evaluation sessions. In the second stage, the prototype of the system was developed using Adobe XD software and based on the requirements approved from the previous stage. In the third stage, the usability of the program was analyzed from the point of view of experts using the exploratory evaluation method with Nielsen's 13 principles of usability. RESULTS: At first, the system requirements were extracted and prepared in two checklists of content (51 exercises) and capabilities (60 items). Then after a survey of experts based on the Delphi technique, content information (43 exercises) and functional and non-functional requirements (53 items) were obtained. A survey of experts helped to finalize the information elements, categorize them, and prepare the final version of the checklists. Based on this, the system requirements were classified into 11 categories, and the training content was classified into 3 training periods. Finally, the design and development of the system was done. This system has admin, physician, and patient user interfaces. The result of usability showed that this system is efficient and there are only a few problems in the feature of helping users to detect and recover from errors. CONCLUSION: It seems necessary to develop a system based on the principles of usability by therapists and rehabilitation specialists to train and monitor the remote rehabilitation process of patients after knee joint replacement at home. And the importance of involving stakeholders in the design and development of remote rehabilitation systems is not hidden from anyone. Kara system has all of the above.

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CONTEXT: Contralateral training in the early stages after surgery can improve the balance of the reconstructed knee, which is impaired following anterior cruciate ligament reconstruction (ACLR). However, little is known about the neuromuscular cross exercise after ACLR. OBJECTIVE: To investigate the effects of an 8-week cross exercise on balance and function of the reconstructed knee following ACLR. DESIGN: A single-blind randomized clinical trial. PARTICIPANTS: Thirty athletic males who underwent ACLR were randomly divided into intervention (n = 15) and control groups (n = 15). INTERVENTION: The intervention and control groups received a routine physiotherapy program. In addition, the intervention group performed neuromuscular exercises on the nonoperated limb. OUTCOME MEASURES: Before and 9 weeks after ACLR, dynamic and static balance, function, and pain in the reconstructed knee were measured by Star Excursion Balance Test (SEBT), stork balance stand test, balance error scoring system (BESS), Lysholm questionnaire, and visual analog scale. Data were analyzed by SPSS using 2-independent sample t test, paired t test, and analysis of covariance. RESULTS: Between-group comparison showed that, contralateral knee neuromuscular exercises significantly increased in the reaching distance in SEBT in the anterior (P < .001), posterior (P < .001), posteromedial (P = .010), and posterolateral directions (P = .007), decreased the number of errors in 4 stance positions of BESS including single stance on the firm (P ≤ .001) and foam surface (P ≤ .001), and tandem stance on the firm (P = .028) and foam surface (P ≤ .001). It also increased the time of standing of the stork stand test (P = .044) and decreased the pain intensity (P = .014). CONCLUSION: Neuromuscular exercise of the nonsurgical knee could improve the dynamic and static balance, and pain in the early stages following ACLR in the surgical leg. These findings may be potentially valuable for current rehabilitation protocols.

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Recently, a short form of the Fullerton Advanced Balance (SF-FAB) scale was reported as a good predictor of falls in older adults. However, we found no evidence regarding its reliability in non-American older adults. Therefore, we aimed to analyze the reliability and homogeneity of the SF-FAB scale to measure postural balance in Iranian older adults. Eighty-five community-dwelling older adults (70.75 ± 4.97 years) performed the SF-FAB test on two occasions 1 week apart. In both instances, four raters assessed the performance on the test. The SF-FAB scale (mean total score: 12.46 ± 3.53) revealed acceptable internal consistency (Cronbach's α = .77), excellent intrarater reliability (intraclass correlation coefficient = .94-.99), and excellent interrater reliability (intraclass correlation coefficient = .92-.99). The overall prediction success rate was 83.5% with correctly classifying 95.6% of nonfallers and 35.3% of fallers. The SF-FAB scale can provide a quick screen of balance status in older adults to trigger referral to clinicians for a more comprehensive assessment.

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BACKGROUND: Patellofemoral pain (PFP) is among the most common orthopedic complications afflicting active young people. Diminished coordination of the vastii, delayed activation of the vastus medialis obliquus (VMO), and decreased VMO-to-vastus lateralis (VL) activity ratio are well documented as underlying causes of PFP. This study compares the effects of VMO facilitatory kinesio tape (KT) versus VL inhibitory KT on electromyographic (EMG) activity of the vastii, balance, and pain in athletes with PFP. METHODS: In this single-blind randomized clinical trial, thirty-two female athletes with PFP (mean age 26.33 ± 5.93 years) were randomly assigned to VMO facilitatory KT (n = 16) or VL inhibitory KT (n = 16) groups. In the facilitatory group, a Y-shaped strip of KT at 25% of its available tension was attached from the origin of the VMO to its insertion and in the inhibitory group, an insertion-to-origin Y-shaped strip of KT at 15% of its available tension was applied on the VL. Pain intensity, dynamic balance, and EMG data were assessed respectively with a visual analogue scale, the modified Star Excursion Balance Test, and an EMG telemetry system, before and immediately after KT application. RESULTS: Pain intensity decreased and dynamic balance improved significantly after taping in both groups, and VMO: VL activity ratio increased significantly in the VL group. However, none of the parameters differed significantly between groups. CONCLUSIONS: Both VMO facilitatory and VL inhibitory KT can improve pain and balance, while the inhibitory technique might be more effective in regulating the VMO to VL activity ratio in athletes with PFP.

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BACKGROUND: Virtual reality training (VRT) is a new method for the rehabilitation of musculoskeletal impairments. However, the clinical and central effects of VRT have not been investigated in patients with patellofemoral pain (PFP). To comprehensively assess the effects of VRT on clinical indices and brain function, we used a randomized clinical trial based on clinical and brain mapping assessment. METHODS: Twenty-six women with PFP for more than 6 months were randomly allocated to 2 groups: intervention and control. The intervention consisted of lifestyle education + 8 weeks VRT, in 24 sessions each lasting 40 min of training, whereas the control group just received lifestyle education. The balance was the primary outcome and was measured by the modified star excursion balance test. Secondary outcomes included pain, function, quality of life, and brain function which were assessed by visual analogue scale, step down test and Kujala questionnaire, SF-36, and EEG, respectively. Pre-intervention, post-intervention and follow-up (1 month after the end of the intervention) measurements were taken for all outcome measures except EEG, which was evaluated only at pre-intervention and post-intervention). Analyses of variance was used to compare the clinical outcomes between the two groups. The independent t-test also was used for between group EEG analyses. RESULTS: Balance score (P < 0.001), function (P < 0.001), and quality of life (P = 0.001) improved significantly at post-intervention and 1 month follow-up in the VRT group compared with the control group. VRT group showed a significantly decreased pain score (P = 0.004). Alpha (P < 0.05) and theta (P = 0.01) power activity also increased in the brain of the VRT group. CONCLUSION: This study demonstrated that long term VRT was capable of improving both clinical impairments and brain function in patients with PFP. Therefore, therapists and clinicians can use this method as a more holistic approach in the rehabilitation of PFP. TRIAL REGISTRATION: IRCT, IRCT20090831002391N40 . Registered 23 / 10 / 2019.

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BACKGROUND: Forward head posture (FHP) is the most common malposition in the head and neck area. With the growing use of digital devices, the prevalence of FHP may be expected to increase dramatically. Thus far, FHP has been evaluated only in the sagittal plane. OBJECTIVE: The objective of this study was to measure angles and indices from anatomical landmarks in the frontal plane and determine the possible correlations between these variables and craniovertebral angle (CVA) as an index of FHP in the sagittal plane. METHODS: Fifty eight healthy individuals (29 men, 29 women) between 18 and 40 years old participated in this cross-sectional study. Participants were evaluated with an 8-camera motion analysis system. After markers were placed on predetermined landmarks, the participants were asked to maintain their head and neck in the neutral position for 5 seconds. Then participants induced FHP by flexing and lowering their head. The correlation between CVA and a set of angles and indices was calculated at the moment of FHP induction. RESULTS: A moderate correlation was observed between 3-D CVA and the angle formed between the sternum and both tragi for the whole sample and separately in both sexes. A moderate negative correlation was observed between 3-D CVA and height, weight, and BMI in women. A moderate negative correlation was observed between 3-D CVA and height, weight, BMI, and hours on digital devices in men. CONCLUSIONS: Changes in CVA in the sagittal plane can be predicted from changes in the angle formed between the midpoint of the sternum and the left and right tragi in the frontal plane.

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BACKGROUND: Fatigue is the most disabling symptom in patients with multiple sclerosis (MS). Although there is no standard tool to evaluate fatigue in clinical settings, the Fatigue Impact Scale (FIS), Fatigue Severity Scale (FSS), and Multidimensional Assessment of Fatigue (MAF) scale are popular instruments for this purpose. The aim of this study was to compare the psychometric properties of the Persian versions of these scales. METHODS: One hundred thirty adult patients with MS and 60 controls participated in this study. They completed the scales on two occasions 3 days apart. Reproducibility and internal consistency were evaluated as intraclass correlation coefficients (ICCs) and Cronbach α. Convergent validity was assessed by evaluating the association of the fatigue scales with age, sex, Expanded Disability Status Scale (EDSS) score, disease duration, and sleep quality. Dimensionality was evaluated using confirmatory factor analysis. Acceptability and known-group validity were investigated. The effect size of each scale was computed. RESULTS: The ICC of all instruments was 0.99. Internal consistency was 0.97 for the MAF scale, 0.93 for FSS, and 0.83 for FIS. The instruments showed moderate-to-good correlations with Pittsburgh Sleep Quality Index, EDSS score, and disease duration. Acceptability was acceptable. The FIS had three dimensions, and the FSS and MAF scale were unidimensional. All scales were able to discriminate patients with MS from controls. CONCLUSIONS: The Persian version of the MAF scale seems to be the most suitable instrument to evaluate fatigue in patients with MS based on its time efficiency, effect size, and detailed data about various aspects of fatigue.

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BACKGROUND: Hemodialysis is considered a major therapeutic method for patients with chronic kidney disease. Pruritus is a common complaint of hemodialysis patients. The 5-D pruritus scale is amongst the most common tools to evaluate several dimensions of itch. Psychometric properties of the 5-D scale have not been evaluated in Persian speaking population with hemodialysis; hence, the objective of this study was to assess reliability and validity of the Persian version of the scale. METHODS: Ninety hemodialysis patients (men: 50, women: 40, mean age: 54.4 years) participated in this cross-sectional study. The final Persian version of 5-D scale was given to the participants. Tests Compared: One-third of the participants completed the scale twice within 3-7 days apart to evaluate test- retest reliability. Other psychometric properties including internal consistency, absolute reliability, convergent, discriminative and construct validity, floor/ceiling effects were also evaluated. RESULTS: The Persian 5-D scale has strong test-retest reliability (ICC= 0.98) and internal consistency (Cronbach's alpha= 0.99). Standard error of measurement and minimal detectable change were 0.33 and 0.91, respectively. Regarding convergent validity, the scale had moderate correlation with numeric rating scale (r =0.67) and quality of life questionnaire related to itch (r = 0.59). Exploratory factor analysis revealed two factors within the scale. No floor or ceiling effect was found for the scale. CONCLUSION: The Persian version of 5-D the itching scale is a brief instrument with acceptable reliability and validity. Therefore, the scale could be used by experts, nurses, and other health service providers to evaluate pruritus among Persian speaking hemodialysis patients.

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BACKGROUND: In patients with chronic nonspecific low back pain (NCLBP), brain function changes due to the neuroplastic changes in different regions. AIM: The current study aimed to evaluate the brain metabolite changes after spinal manipulation, using proton magnetic resonance spectroscopy (1H-MRS). METHODS: In the current study, 25 patients with NCLBP aged 20-50 years were enrolled. Patients were randomly assigned to lumbopelvic manipulation or sham. Patients were evaluated before and 5 weeks after treatment by the Numerical Rating Scale (NRS), the Oswestry Disability Index (ODI), and 1H-MRS. RESULTS: After treatment, severity of pain and functional disability were significantly reduced in the treatment group vs. sham group (p < 0.05). After treatment, N-acetyl aspartate (NAA) in thalamus, insula, dorsolateral prefrontal cortex (DLPFC) regions, as well as choline (Cho) in the thalamus, insula, and somatosensory cortex (SSC) regions, had increased significantly in the treatment group compared with the sham group (p < 0.05). A significant increase was further observed in NAA in thalamus, anterior cingulate cortex (ACC), and SCC regions along with Cho metabolite in thalamus and SCC regions after treatment in the treatment group compared with the baseline measures (p < 0.05). Also, a significant increase was observed in Glx (glutamate and glutamine) levels of thalamus (p = 0.03). There was no significant difference in terms of brain metabolites at baseline and after treatment in the sham group. CONCLUSION: In the patient with low back pain, spinal manipulation affects the central nervous system and changes the brain metabolites. Consequently, pain and functional disability are reduced.

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OBJECTIVES: To evaluate the added value of isolated core postural control training on knee pain and function in women with patellofemoral pain syndrome (PFPS). DESIGN: Randomized controlled trial. SETTING: Rehabilitation sciences research center. PARTICIPANTS: Women (N=33) between 18 and 30 years of age with PFPS were randomly assigned to a control group (n=16) or the experimental group (n=17). INTERVENTIONS: Participants in both groups received the same stretching and strengthening exercises during 4 weeks (12 sessions 3 days per week). The experimental group also received isolated core postural training with an unstable seat apparatus. MAIN OUTCOME MEASURES: Center of pressure (CoP) trajectories in sitting postural control, pain intensity, and function were recorded before and after the 4-week intervention period. Functional capacity and pain intensity were reassessed 3 months after the intervention. RESULTS: After treatment, both groups had significant improvements in pain, function (P<.001), and CoP trajectories in sitting postural control (control group P<.05, experimental group P<.001). Between-group comparisons demonstrated greater improvements in pain, function, and CoP trajectories in the experimental group (P<.001). This group also had significantly greater improvements in pain and Kujala Anterior Knee Pain Scale score at 3-month follow-up compared to the control group (P<.001). CONCLUSIONS: Adding isolated core postural control training to physiotherapy exercises was associated with significantly greater improvements in pain, function, and CoP trajectories than physiotherapy exercises alone. Therefore, unstable sitting postural control training is potentially useful to enhance rehabilitation management in patients with PFPS.

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Patients with low back pain (LBP) have reduced core muscle geometry and impaired postural balance. Impaired trunk control was shown to be associated with poor balance and limited functional mobility in these patients. However, the relationship between muscle geometry and postural balance is unclear. This study aimed to determine the correlation of core muscle geometry with pain intensity, functional disability and postural balance in patients with chronic nonspecific mechanical LBP. Thirty patients aged 20-50 years were enrolled. Ultrasound imaging was used to assess their muscle geometry. The participants completed a numerical rating scale (NRS) for pain severity, and the Persian version of the Roland-Morris Disability Questionnaire (PRMDQ). To estimate static balance, they were asked to perform the single leg stance test. Dynamic balance was assessed with the Y-balance test. Significant correlations were found between NRS scores and bilateral multifidus cross-sectional area during rest (r ≥ - 0.31, P ≤ 0.04) and contraction (r ≥ - 0.37, P ≤ 0.02). NRS scores correlated significantly with bilateral multifidus thickness during rest (r ≥ - 0.31, P ≤ 0.04) and contraction (r ≥ - 0.28, P ≤ 0.04). Significant correlations were also observed for PRMDQ scores with thickness (r ≥ - 0.35, P = 0.04) and cross-sectional area of the multifidus muscles (r ≥ - 0.33, P = 0.04) bilaterally during contraction. A significant correlation was found between Y-balance scores and right abdominal muscle thickness during rest and contraction (r ≥ 0.34, P ≤ 0.04). Core muscle geometry correlated with pain, functional disability indices and dynamic balance in these patients.

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OBJECTIVE: The purpose of this study was to compare the efficacy of 4 weeks of whole body vibration training on balance in older adults who word two different types of shoes: unstable (unstable group) versus standard shoes (stable group). DESIGN: Randomized, single-blind clinical trial. PARTICIPANTS: Seventy eight eligible older adults were initially enrolled; 59 participants (mean age 69.7±5.3 years) completed the program. INTERVENTION: Participants were randomized 1:1 to an intervention group that received whole body vibration with unstable shoes, and a control group that received whole body vibration with standard shoes. OUTCOME MEASURES: The Fullerton Advanced Balance scale, preferred gait speed, maximum gait speed, and Fall Efficacy Scale were recorded at baseline, after the 4-week intervention, and 1 month after the end of the training program. RESULTS: Both groups showed improvement in all outcome measures at 4 weeks (p < 0.01) with no significant between-group differences. In the unstable group, the gains were maintained at follow-up (p < 0.01) whereas the scores returned to baseline values in the stable group. At follow-up, significant between-group differences were found for Fullerton Advanced Balance scale (p < 0.001), preferred gait speed (p = 0.007) and maximum gait speed (p = 0.007), and all were in favor of the unstable group. CONCLUSION: Combining whole body vibration with unstable shoes can be proposed as a beneficial method with relatively long-term effects to improve balance measures in older people.

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OBJECTIVES: The aim of this study was to investigate the immediate effects of facilitatory and inhibitory kinesiotaping on motor neuron excitability. DESIGN: Randomized cross-over trial. METHOD: Twenty healthy people received inhibitory and facilitatory kinesiotaping on two testing days. The H- and M-waves of the lateral gasterocnemius were recorded before and immediately after applying the two modes of taping. The Hmax/Mmax ratio (a measure of motor neuron excitability) was determined and analyzed. RESULTS: The mean Hmax/Mmax ratios were -0.013 (95% CI: -0.033 to 0.007) for inhibitory taping and 0.007 (95% CI: -0.013 to 0.027) for facilitatory taping. The mean difference between groups was -0.020 (95% CI: -0.048 to 0.008). The statistical model revealed no significant differences between the two interventions (P = 0.160). Furthermore, there were no within-group differences in Hmax/Mmax ratio for either group. CONCLUSIONS: Our findings did not disclose signs of immediate change in motor neuron excitability in the lateral gasterocnemius.

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BACKGROUND: Multiple sclerosis (MS) is a chronic inflammatory disorder of the central nervous system associated with a variety of symptoms and functional deficits. Balance impairment is a common concern in patients with MS. Core muscle stabilization is considered a main component of balance. The strength and endurance of core muscles have not been compared between patients with MS and healthy people. The objective of this study was to compare core muscle strength and endurance between ambulatory patients with MS and a healthy group. METHODS: Thirty-three patients with MS with Expanded Disability Status Scale scores ranging from 1.0 to 4.5 and 33 matched healthy people participated in this cross-sectional group comparison study. The primary outcome measure was endurance of core muscles assessed by functional endurance tests, and the secondary outcome was isometric strength of core muscles assessed using a dynamometer. RESULTS: Patients with MS had lower performance on endurance tests (P < .001) and strength tests (P < .05) compared with the control group. CONCLUSIONS: These results show decreased core muscle strength and endurance in ambulatory individuals with MS compared with a matched control group. Future studies are required to assess how core muscle impairment affects balance and how it would be affected by rehabilitation and exercise programs.

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Iontophoresis is the noninvasive delivery of ions using direct current. The direct current has some disadvantages such as skin burning. Interferential current is a kind of alternating current without limitations of direct current; so the purpose of this study is to investigate and compare the effects of lidocaine, interferential current and lidocaine iontophoresis using interferential current. 30 healthy women aged 20-24 years participated in this randomized clinical trial study. Pressure, tactile and pain thresholds were evaluated before and after the application of treatment methods. Pressure, tactile and pain sensitivity increased significantly after the application of lidocaine alone (p < 0.005) and lidocaine iontophoresis using interferential current (p < 0.0001). Lidocaine iontophoresis using interferential current can increase perception threshold of pain, tactile stimulus and pressure sense more significantly than lidocaine and interferential current alone.

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STUDY DESIGN: Crosscultural adaptation and psychometric measurements of the Functional Rating Index (FRI). OBJECTIVE: To develop and investigate the reliability and validity of the Persian version of the FRI when applied to patients with low back pain (LBP). SUMMARY OF BACKGROUND DATA: The FRI is a self-report questionnaire designed to assess patient's perception of function and pain. Despite the use of this outcome measure in clinical trials in Iran, it was not translated and culturally adapted. METHODS: The FRI was translated into Persian language and crossculturally adapted. The Persian FRI was administered to 100 patients with LBP (male patients/female patients = 22/78). A numerical rating scale, the Roland-Morris Disability Questionnaire, the Oswestry Disability Questionnaire, and the Quebec Back Pain Disability Scale were also recorded. The test-retest reliability (time interval = 7 days) was assessed in 50 patients. RESULTS: There were no missing responses and floor or ceiling effects. The examination of discriminative validity showed that the questionnaire discriminated clearly between patients and healthy participants (P < 0.001). The concurrent criterion validity was confirmed by the Spearman rank correlation between the Persian FRI and the numerical rating scale (0.73, P < 0.0001 for test; and 0.77 for retest, P < 0.0001). Evidence for construct validity was found with a significant Pearson correlation between the FRI and the Roland-Morris Disability Questionnaire (r = 0.61; P < 0.0001), the Oswestry Disability Questionnaire (r = 0.75; P < 0.0001), or Quebec Back Pain Disability Scale (r = 0.76; P < 0.0001). Internal consistency reliability estimates (Cronbach α) for the Persian FRI were high, with 0.89 for test and 0.92 for retest. The test-retest reliability for the total score was excellent with an intraclass correlation coefficient (agreement) (ICCagreement) of 0.81 (P < 0.0001). CONCLUSION: The Persian version of the FRI seems to have an excellent reliability and validity when applied to patients with LBP.

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