Literature Review
Anne Benjaminse, Alli Gokeler, Cees P. van der Schans
Study Design: Meta-analysis.
Objectives: To define the accuracy of clinical tests for assessing anterior cruciate ligament (ACL) ruptures.
Background: The cruciate ligaments, and especially the ACL, are among the most commonly injured structures of the knee. Given the increasing injury prevalence, there is undoubtedly a growing need for clinical decision making of health care providers. We reviewed the literature to analyze the diagnostic accuracy of the clinical examination for assessing ACL ruptures.
Methods and Measures: MEDLINE (1966 to April 2005), EMBASE (1989 to April 2005), and CINAHL (1982 to April 2005) searches were performed. Also reference lists of the included studies were reviewed. Studies selected for data extraction were those that addressed the accuracy of at least 1 physical diagnostic test for ACL rupture and compared the performance of the clinical examination of the knee with a reference standard, such as arthroscopy, arthrotomy, or MRI. Searching was limited to English, German, and Dutch languages.
Results: Twenty-eight studies that assessed the accuracy of clinical tests for diagnosing ACL ruptures met the inclusion criteria. Study results were, however, heterogeneous. The Lachman test is the most valid test to determine ACL tears, showing a pooled sensitivity of 85% (95% confidence interval [CI], 83-87) and a pooled specificity of 94% (95% CI, 92-95). The pivot shift test is very specific, namely 98% (95% CI, 96-99), but has a poor sensitivity of 24% (95% CI, 21-27). The anterior drawer test shows good sensitivity and specificity in chronic conditions, respectively 92% (95% CI, 88-95) and 91% (95% CI, 87-94), but not in acute conditions.
Conclusion: In case of suspected ACL injury, it is recommended to perform the Lachman test. Because the pivot shift test is very specific both in acute as well as in chronic conditions, it is recommended to perform the pivot shift test as well. J Orthop Sports Phys Ther. 2006;36(5):267-288. doi:10.2519/jospt.2006.2011
Key Words: accuracy, anterior cruciate ligament, examination, knee
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Research Report
Barbara A. Springer, Billie J. Mielcarek, Tiffany K. Nesfield, Deydre S. Teyhen
Study Design: Exploratory.
Objectives: To explore whether hand dominance, gender, and body mass index (BMI) influence the thickness of the lateral abdominal muscles as measured by ultrasound imaging. To document the extent of improvement in response stability when an average of multiple measures was utilized.
Background: Ultrasound imaging is a relatively new tool used to assess the lateral abdominal muscles. A better understanding of how these muscles contract in a healthy population can provide a reference for comparison to patients with low back pain (LBP).
Methods and Measures: Thirty-two healthy participants (17 males, 15 females) aged 18 to 45 years (mean ± SD, 31.9 ± 7.8 years) were studied. Measurements of muscular thickness of the lateral abdominal muscles were obtained bilaterally while the subjects were at rest, and while they performed the abdominal drawing-in maneuver. To determine the possible influence of hand dominance and gender on muscle thickness, t tests were used. Correlation coefficients were used to assess the relationship between BMI and muscle thickness. Standard error of the measurement was used to assess response stability of the ultrasound imaging technique.
Results: No differences in the thicknesses of the transversus abdominis (TrA) muscle were measured during rest or while contracted, based on hand dominance (P≥.73). Men had greater muscular thickness (P<.01), while the TrA in women represented a greater proportion of the total lateral abdominal muscles (P<.01). BMI was positively associated with muscle thickness (r≥.66). Compared to a singular measurement, response stability improved by greater than 50% when an average of 3 measurements was used.
Conclusions: Future researchers should assess the need to control for gender and BMI as potential covariates in ultrasound imaging studies of the lateral abdominal muscles. Asymmetry in the lateral abdominal muscles in those with LBP would be in direct contrast to the bilateral symmetry measured in those without LBP. J Orthop Sports Phys Ther. 2006;36(5):289-297. doi:10.2519/ jospt.2006.2217
Key Words: low back pain, lumbar stabilization, real-time ultrasound imaging, sonography, transversus abdominis
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Case Report
J. Parry Gerber, Robin L. Marcus, Leland E. Dibble, Patrick E. Greis, Paul C. LaStayo
Study Design: Case report.
Objectives: To present a progressively increasing negative-work exercise program via eccentric ergometry early after anterior cruciate ligament reconstruction (ACL-R) and to suggest the potential of negative work to amplify the return of quadriceps size and strength.
Case Description: The patient was a 26-year-old highly active recreational athlete who sustained an ACL tear while skiing in January 2004 and then again while skiing in February 2005. This individual underwent an arthroscopically assisted ACL-R with a double-loop semitendinosusgracilis autograft initially, then a patellar tendon autograft following his ACL graft rupture. Beginning within 3 weeks after surgery, a progressive negative-work exercise program was initiated using an eccentric ergometer. The patient completed 31 training sessions of 5 to 30 minutes in duration over a 12-week period following the ACL-R and 33 training sessions of the same frequency and duration following the ACL revision.
Outcomes: Following ACL-R, quadriceps volume increased 28% (involved lower extremity) and 14% (uninvolved lower extremity) during the 12-week training program. Following revision, quadriceps volume returned to similar levels at the same postoperative period as those achieved after the initial surgery (2% less on the involved side and 2% greater on the uninvolved side). Quadriceps strength, 15 weeks after ACL-R, exceeded preoperative measures by an average of 20% (involved) and 14% (uninvolved). Quadriceps strength after ACL revision exceeded all previous measures.
Discussion: This case report suggests that if gradually and progressively applied, negative work via eccentric ergometry can be both safe and efficacious early after ACL-R. Eccentric exercise may mitigate the prevalent muscle size and strength deficits commonly observed after ACL-R. The results of this case suggest a need for continued research with early negative work interventions following ACL-R. J Orthop Phys Ther. 2006;36(5):298-307. doi:10.2519/jospt.2006.2197
Key Words: ACL, knee, muscle physiology, skiing
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Research Report
Terese L. Chmielewski, Gregory D. Myer, Douglas Kauffman, Susan M. Tillman
Plyometric exercise was initially utilized to enhance sport performance and is more recently being used in the rehabilitation of injured athletes to help in the preparation for a return to sport participation. The identifying feature of plyometric exercise is a lengthening of the muscle-tendon unit followed directly by shortening (stretch-shortening cycle). Numerous plyometric exercises with varied difficulty and demand on the musculoskeletal system can be implemented in rehabilitation. Plyometric exercises are initiated at a lower intensity and progressed to more difficult, higher intensity levels. The progression to higher-intensity plyometric exercise is thought to resolve postinjury neuromuscular impairments and to prepare the musculoskeletal system for rapid movements and high forces that may be similar to the demands imposed during sport participation, thus assisting the athlete with a return to full function.
While there is a large body of scientific literature that supports the use of plyometric exercise to enhance athletic performance, evidence is sparse regarding the effectiveness of plyometric exercise in promoting a quick and safe return to sport after injury. This review will describe the mechanisms involved in plyometric exercise, discuss the considerations for implementing plyometric exercise into rehabilitation protocols, examine the evidence supporting the use of plyometric exercises, and make recommendations for future research. J Orthop Sports Phys Ther. 2006;36(5):308-319. doi:10.2519/ jospt.2006.2013
Key Words: jump training, neuromuscular, return to sport, stretch shortening
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Research Report
Stephanie L. Weaver, Timothy J. Demchak, Marcus B. Stone, Jody B. Brucker, Phillip O. Burr
Study Design: A 3 × 2 repeated-measures design was used. The independent variables were transducer velocity (2-3 cm/s, 4-5 cm/s, and 7-8 cm/s) and time (pretreatment and posttreatment).
Objective: To determine if transducer velocity of a 1-MHz ultrasound treatment affects intramuscular tissue temperature.
Background: Most authors advocate ultrasound transducer velocities of 2 to 4 cm/s within an area of 2 to 3 times the effective radiating area or 2 times the size of the transducer head. However, a much faster rate of application (approximately 7-8 cm/s) is often observed in clinical settings.
Methods and Measures: Eleven healthy screened volunteers (9 males, 2 females; mean ± SD age, 22.6 ± 1.7 years; mean ± SD height, 175.7 ± 13.7 cm; mean ± SD body mass, 82.5 ± 19.5 kg) were randomly assigned to a treatment order with all conditions administered during a single testing session. Each transducer velocity condition was administered for 10 minutes, using 1-MHz ultrasound with a 100% continuous duty cycle at an intensity of 1.5 W/cm2 over an area twice the size of the transducer head. After the first treatment, the 2 remaining subsequent velocity conditions were administered after the intramuscular temperature returned to within ±0.3°C of the initial pretreatment temperature for 5 minutes. The dependent variable was left triceps surae muscle temperature measured at 3 cm below one half the measured skinfold thickness.
Results: Temperature increase across the 3 velocities was within 0.4°C (F2,20 = 0.07, P = .93). Posttreatment values (mean ± SD) ranged from 42.7°C ± 2.3°C for the slowest velocity to 43.1°C ± 1.4°C for the fastest velocity. Temperature increase was significant for time (F1,10 = 155.68, P<.00001), increasing from 37.8°C ± 0.8°C pretreatment to 42.9°C ± 1.9°C after treatment.
Conclusion: Very similar intramuscular temperature increases can be observed among ultrasound treatments (10-minute duration, 1-MHz frequency, 100% continuous duty cycle, 1.5 W/cm2 intensity, within an area twice the size of the transducer head), with transducer velocities of 2 to 3, 4 to 5, and 7 to 8 cm/s.
J Orthop Sports Phys Ther. 2006;36(5):320-325. doi:10.2519/jospt.2006.2157
Key Words: calf heating, piezoelectric modality, therapeutic modality
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Research Report
Todd S. Ellenbecker, Eric Elmore, David S. Bailie
Study Design: Retrospective chart review.
Objectives: To measure short-term postsurgery glenohumeral internal rotation and external rotation strength, shoulder range of motion (ROM), and subjective self-report ratings following mini-open rotator cuff repair of full-thickness rotator cuff tears.
Background: Physical therapists provide rehabilitation for patients following mini-open rotator cuff repair. Long-term outcome studies have reported a high percentage of good and excellent results following surgery; however, little has been published regarding the immediate short-term results of this procedure, during which the patient is under the direct care of the physical therapist.
Materials and Methods: Charts from 11 female and 26 male patients, with a mean ± SD age of 57.3 ± 9.9 years, were reviewed following rotator cuff repair, using an arthroscopically assisted mini-open deltoid-splitting approach. All patients underwent postsurgery rehabilitation by the same therapist using a standard protocol. Retrospective chart review was used to obtain descriptive profiles of shoulder joint ROM at 6 and 12 weeks postsurgery and isokinetically assessed shoulder strength at 12 weeks postsurgery.
Results: For the postsurgical shoulder, ROM deficits ranging between 5° to 7° were measured for shoulder abduction and external rotation and internal rotation at 90° of abduction. The postsurgical extremity had greater flexion ROM (9°) compared to the contralateral side. Isokinetic external rotation strength deficits of 5% to 7% were present at 12 weeks postsurgery, with 2% to 11% greater internal rotation shoulder strength on the operative extremity, when compared to the other side. Patients completed the self-report section of the modified American Shoulder Elbow Surgeons (ASES) Rating Scale at 12 weeks postsurgery and scored a mean of 38.7/45.0 points.
Conclusion: The application of early ROM and progressive strengthening following mini-open rotator cuff repair allows for the successful return of ROM and strength 12 weeks postsurgery. The results of this study provide objective data for both shoulder ROM and strength at time points during which patients are traditionally receiving physical therapy following surgery.
J Orthop Sports Phys Ther. 2006;36(5):326-335. doi:10.2519/jospt.2006.2191
Key Words: glenohumeral joint, rotator cuff tear, surgery
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