Literature Review
Kyung-Min Kim, Jay Hertel, Theodore Croy, Susan A. Saliba
STUDY DESIGN: Systematic literature review. OBJECTIVE: To perform a systematic review of randomized controlled trials assessing the effects of neuromuscular electrical stimulation (NMES) on quadriceps strength, functional performance, and self-reported function after anterior cruciate ligament reconstruction. BACKGROUND: Conflicting evidence exists regarding the effectiveness of NMES following anterior cruciate ligament reconstruction. METHODS: Searches were performed for randomized controlled trials using electronic databases from 1966 through October 2008. Methodological quality was assessed using the Physiotherapy Evidence Database Scale. Between-group effect sizes and 95% confidence intervals (CIs) were calculated. RESULTS: Eight randomized controlled trials were included. The average Physiotherapy Evidence Database Scale score was 4 out of possible maximum 10. The effect sizes for quadriceps strength measures (isometric or isokinetic torque) from 7 studies ranged from –0.74 to 3.81 at approximately 6 weeks postoperatively; 6 of 11 comparisons were statistically significant, with strength benefits favoring NMES treatment. The effect sizes for functional performance measures from 1 study ranged from 0.07 to 0.64 at 6 weeks postoperatively; none of 3 comparisons were statistically significant, and the effect sizes for self-reported function measures from 1 study were 0.66 and 0.72 at 12 to 16 weeks postoperatively; both comparisons were statistically significant, with benefits favoring NMES treatment. CONCLUSION: NMES combined with exercise may be more effective in improving quadriceps strength than exercise alone, whereas its effect on functional performance and patient-oriented outcomes is inconclusive. Inconsistencies were noted in the NMES parameters and application of NMES. LEVEL OF EVIDENCE: Therapy, level 1a–.
J Orthop Sports Phys Ther 2010;40(7):383-391, Epub 15 April 2010. doi:10.2519/jospt.2010.3184
KEY WORDS: ACL, electromodality, postsurgical knee rehabilitation, randomized clinical trials
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Research Report
Suzanne J. Snodgrass, Darren A. Rivett, Val J. Robertson, Elizabeth Stojanovski
STUDY DESIGN: Clinical measurement, cross-sectional. OBJECTIVES: To compare cervical mobilization forces applied by physiotherapists and students, and the factors associated with forces for each group. BACKGROUND: Cervical spine joint mobilization is a common manual technique for treating patients with mechanical neck pain. But little is known about the forces applied during this technique. Potential variability between therapists may result from clinical experience or may be due to factors present in individuals prior to clinical practice exposure. METHODS: One hundred sixteen practicing physiotherapists and 120 physiotherapy students without clinical experience applied grades I through IV posteroanterior mobilization to the premarked C2 and C7 spinous and articular processes of 1 of 67 asymptomatic subjects. An instrumented table recorded applied forces (N), force amplitudes (N), and oscillation frequencies (Hz), and a custom device measured subjects’ spinal stiffness (N/mm). Independent t tests were used to compare the forces applied by therapists and students, intraclass correlation coefficients were used to determine variability, and linear regression was used to establish factors associated with applied forces. RESULTS: Students’ forces were generally lower (mean difference, 15.7 N for grades III and IV; P<.001) and applied with slower oscillation frequencies (0.12 Hz; P<.001) than therapists’ forces. Similar factors were associated with applied forces for both groups: male gender and greater subject body weight were associated with higher applied forces, and greater C2 stiffness with lower forces. Having thumb pain was associated with lower applied forces for therapists but higher ones for students. CONCLUSIONS: Students apply lower forces than therapists. Similar factors appear to affect applied forces regardless of clinical experience.
J Orthop Sports Phys Ther 2010;40(7):392-401, Epub 22 April 2010. doi:10.2519/jospt.2010.3274
KEY WORDS: manipulation, manual therapy, neck, students
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Case Report
Jeffrey J. Hebert, Robin L. Marcus, Shane L. Koppenhaver, Julie M. Fritz
STUDY DESIGN: A case report and literature review. BACKGROUND: Optimizing clinical outcomes following lumbar disc surgery is a research priority; however, relatively little attention has been paid to the postoperative management of this population. The transversus abdominis and lumbar multifidus (LM) muscles appear to play a unique role in lumbar spine stability, and may relate to clinical outcome following lumbar disc surgery. The purpose of this case report was to describe the preoperative LM morphology, clinical outcome, and change in transversus abdominis and LM muscle activation in a patient following lumbar disc surgery and motor control exercise initiated in the early postoperative period. CASE DESCRIPTION: A 29-year-old female underwent an 8-week postoperative rehabilitation program emphasizing motor control exercises to restore trunk muscle function 10 days following lumbar disc surgery. OUTCOMES: The patient experienced clinically important improvements in pain and disability following the postoperative rehabilitation program. Substantial improvements in muscle activation were observed of the transversus abdominis and the LM at the L4-5 level. Minimal change in LM activation and a higher proportion of intramuscular fat was observed at the L5-S1 level. DISCUSSION: This case report represents limited evidence regarding the feasibility of instituting a rehabilitation program in the early postoperative period following lumbar disc surgery. Improvements in clinical status and muscle function were observed, and a differential change in muscle activation between the L4-5 and L5-S1 levels was noted. The literature regarding rehabilitation following lumbar disc surgery, as well as the neuromuscular changes observed in this population, was reviewed. Additionally, a novel method of examining LM morphology was described and suggestions were made for directions of future research. LEVEL OF EVIDENCE: Therapy, level 4.
J Orthop Sports Phys Ther 2010;40(7):402-412, Epub 12 April 2010. doi:10.2519/jospt.2010.3332
KEY WORDS: adipose, discectomy, exercise therapy, rehabilitation, skeletal muscle, ultrasonography
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Research Report
Jean-Sébastien Roy, Joy C. MacDermid, Kenneth J. Faber, Darren S. Drosdowech, George S. Athwal
STUDY DESIGN: Prospective cohort study with repeated measures. OBJECTIVE: To establish the responsiveness of the Simple Shoulder Test (SST) in comparison to other commonly used clinical outcomes in patients undergoing shoulder arthroplasty. BACKGROUND: Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty. METHODS: Patients undergoing shoulder arthroplasty (n = 120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST. RESULTS: The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r = 0.49). CONCLUSIONS: The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.
J Orthop Sports Phys Ther 2010;40(7):413-421, Epub 15 April 2010. doi:10.2519/jospt.2010.3209
KEY WORDS: psychometric properties, questionnaire, responsiveness, shoulder
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Research Report
Sai-Chuen Fu, Leung-Kim Hung, Wai-Ting Shum, Yuk-Wa Lee, Lai-Shan Chan, Grace Ho, Kai-Ming Chan
STUDY DESIGN: Bench research, cross-sectional. OBJECTIVE: To determine if the effects of low-intensity pulsed ultrasound (LIPUS) on matrix synthesis change at different stages of tendon healing. BACKGROUND: LIPUS is effective in promoting tendon healing by stimulation of matrix synthesis. The timing of initiation and duration of LIPUS treatment have been shown to affect its effectiveness to promote tendon healing, suggesting a change of tissue responses to LIPUS stimulation. Understanding how the cellular responses to LIPUS stimulation change during tendon healing is thus important. METHODS: In a rat model of patellar tendon donor site injury, a single sonication of LIPUS or mock sonication was delivered to the injured knee of the rats on the fourth, 14th or 28th day postinjury. Tendon samples were harvested at 4 hours and 24 hours after sonication and the mRNA expression of COL1A1, COL3A1, decorin, biglycan, and TGF-beta 1 was analyzed. RESULTS: The results showed that a single sonication of LIPUS increased COL1A1 and COL3A1 mRNA in healing patellar tendons when administered on the fourth or 14th day postinjury, but not when administered on the 28th day postinjury. Both decorin and biglycan mRNA were decreased by treatment with LIPUS on the 28th day postinjury. Our results showed that LIPUS enhanced collagen synthesis in vivo only during the granulation phase. Matrix remodeling may be affected by LIPUS with the suppressed expression of decorin and biglycan. CONCLUSION: Our findings suggest that LIPUS should be applied during the granulation phase but not during the remodeling phase, to promote tendon healing.
J Orthop Sports Phys Ther 2010;40(7):422-429, Epub 22 April 2010. doi:10.2519/jospt.2010.3254
KEY WORDS: collagens, matrix synthesis, tendon healing, therapeutic ultrasound
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Research Report
Yung-Shen Tsai, Timothy C. Sell, James M. Smoliga, Joseph B. Myers, Kenneth E. Learman, Scott M. Lephart
STUDY DESIGN: Controlled laboratory study using a cross-sectional design. OBJECTIVES: To examine the kinematics and kinetics of the trunk and the physical characteristics of trunk and hip in golfers with and without a history of low back pain (LBP). BACKGROUND: Modified swing patterns and general exercises have been suggested for golfers with back pain. Yet we do not know what contributes to LBP in golfers. To create and validate a low back-specific exercise program to help prevent and improve back injuries in golfers, it may be valuable to understand the differences in biomechanical and physical characteristics of golfers with and without a history of LBP. METHODS: Sixteen male golfers with a history of LBP were matched by age and handicap with 16 male golfers without a history of LBP. All golfers underwent a biomechanical swing analysis, trunk and hip strength and flexibility assessment, spinal proprioception testing, and postural stability testing. RESULTS: The group with a history of LBP demonstrated significantly less trunk extension strength at 60°/s and left hip adduction strength, as well as limited trunk rotation angle toward the nonlead side. No significant differences were found in postural stability, trunk kinematics, and maximum spinal moments during the golf swing. CONCLUSION: Deficits observed in this study may affect a golfer’s ability to overcome the spinal loads generated during the golf swing over time. Exercises for improving these physical deficits can be considered, although the cause-effect of LBP in golfers still cannot be determined.
J Orthop Sports Phys Ther 2010;40(7):430-438, Epub 15 April 2010. doi:10.2519/jospt.2010.3152
KEY WORDS: balance, flexibility, golf swing, proprioception, strength
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Research Report
Amanda J. Hobbs, Roger D. Adams, Debra Shirley, Terence M. Hillier
STUDY DESIGN: Cross-sectional laboratory study. OBJECTIVE: To determine whether individuals with spinal pain and those who have undergone spinal surgery have difficulty discriminating small movement differences using a spinal proprioception test for active flexion movements. BACKGROUND: Structures contributing to proprioception may be affected during disc replacement surgery. Postsurgical assessment of proprioceptive ability to make discriminations in the range used for maintaining upright postural stability is needed to inform postoperative rehabilitation. METHODS: Proprioceptive sensitivity to differences between lumbar spine movements of 11°, 13°, 15°, 17°, and 19° of forward flexion was measured in unrestrained standing, with vision of the target obscured. Individuals after disc replacement (n = 16), with disc degeneration and discogenic back pain (n = 19), and without back pain (n = 18) performed 50 movement trials and stated the amount of movement performed for each trial (11°, 13°, 15°, 17°, or 19°). RESULTS: The pattern of discrimination scores between adjacent lumbar flexion movement pairs shown by the individuals in the discogenic back pain group differed significantly from the disc replacement and healthy control groups (P = .024), which were not significantly different from each other. Although mean discrimination scores averaged over all movement pairs did not differ significantly between the groups, participants with discogenic back pain discriminated between the 2 smallest lumbar flexion movements significantly better than those in the other 2 groups (P = .013). CONCLUSION: The greater sensitivity of the individuals with disc pain to discriminate between the 2 smallest flexion movements was interpreted as a contrast effect arising from differences between the groups in usual upright posture, with disc replacement restoring the same pattern of posture as seen for healthy controls.
J Orthop Sports Phys Ther 2010;40(7):439-446, Epub 15 April 2010. doi:10.2519/jospt.2010.3149
KEY WORDS: disc degeneration, discogenic pain, lumbar spine, movement discrimination
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Musculoskeletal Imaging
Michael S. Crowell, Ryan J. Plank
The patient was a 27-year-old male pilot referred to a physical therapist for a suspected left acromioclavicular joint injury following a fall 3 weeks prior. Physical examination revealed decreased active shoulder flexion, decreased supraspinatus strength, and a positive Hawkins test. Radiographs were ordered and the anterior-posterior radiographic view showed an incomplete nondisplaced fracture in the superior aspect of the greater tuberosity. The patient was placed in a sling for 4 weeks and performed passive range-of-motion exercises to maintain shoulder mobility. Radiographs at 7 weeks following the injury revealed a healed greater tuberosity fracture.
J Orthop Sports Phys Ther 2010;40(7):447. doi:10.2519/jospt.2010.0411
KEY WORDS: radiographs, shoulder
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Book Reviews
Tammy DeRoche, Greg Blaske, Christopher Hughes, Steve Hoffman, Evan Hellwig
The JOSPT offers invited reviews of current titles. The July 2010 column includes 5 reviews of the following books: Against the Tide: Back Pain Treatment —The Breakthrough; Solutions for Complex Upper Extremity Trauma; Biomechanical Analysis of Fundamental Human Movements; AO Manual of Fracture Management: Elbow and Forearm; and Color Atlas of Human Anatomy Volume 1: Locomotor System.
J Orthop Sports Phys Ther 2010;40(7):448-450.
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