JOSPT Express
JOSPT Express provides immediate electronic publication of manuscripts that have been accepted for publication in the print edition of the Journal. These peer-reviewed manuscripts are posted in PDF format as submitted by their authors. They have not been edited or formatted and thus do not reflect the editorial standards to which the JOSPT holds its published material. JOSPT Express was created to give authors the opportunity to present their evidence to the musculoskeletal rehabilitation community many weeks or even months before it appears in print, and to give readers immediate access to the results of evidence-based research that can affect clinical practice and new research designs.
For more information, please see About JOSPT Express. To see the list of articles initially published in JOSPT Express and since finalized in a print issue of the Journal, please visit JOSPT Express Index.
DISCLAMER: Manuscripts published in JOSPT Express have not yet been edited or proofread and so may contain errors for which the Journal is not responsible.
Accepted Manuscripts Posted as of June 3, 2008
Clinical Commentary
Joshua A. Cleland, J. Timothy Noteboom, Julie M. Whitman, Stephen C. Allison
SYNOPSIS: The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps including formulating an appropriate question, performing an efficient literature search, critically appraising the best available evidence, applying the best evidence to clinical practice, assessing outcomes of care. This first commentary in a 2-part series will review principles relating to steps 1,2 and 3 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in formulating foreground questions, searching for the best available evidence, and determining validity of results in studies of interventions for orthopaedic and sports physical therapy.
J Orthop Sports Phys Ther., Epub 27 June 2008. doi:10.2519/jospt.2008.2722
KEY WORDS: critical appraisal, evidence-based practice, treatment effectiveness
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Clinical Commentary
J. Timothy Noteboom, Stephen C. Allison, Joshua A. Cleland, Julie M. Whitman
SYNOPSIS: The process of evidence-based practice (EBP) guides clinicians in the integration of individual clinical expertise, patient values and expectations, and the best available evidence. Becoming proficient with this process takes time and consistent practice, but should ultimately lead to improved patient outcomes. The EBP process entails 5 steps including formulating an appropriate question, performing an efficient literature search, critically appraising the best available evidence, applying the best evidence to clinical practice, assessing outcomes of care. This second commentary in a 2-part series will review principles relating to steps 4 and 5 of this 5-step model. The purpose of this commentary is to provide a perspective to assist clinicians in interpreting results, applying the evidence to patient care, and evaluating proficiency with EBP skills in studies of interventions for orthopaedic and sports physical therapy.
J Orthop Sports Phys Ther., Epub 27 June 2008. doi:10.2519/jospt.2008.2725
KEY WORDS: critical appraisal, evidence-based practice, treatment effectiveness
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Clinical Commentary
James M. Elliott, J. Timothy Noteboom, Timothy W. Flynn, Michele Sterling
SYNOPSIS: The development of chronic pain and disability following whiplash injury is common and contributes substantially to personal and economic costs related with this condition. Emerging evidence demonstrates the clinical presence of alterations in the sensory and motor systems including psychological distress in all individuals with a whiplash injury, regardless of recovery. However, individuals who transition to the chronic state present with a more complex clinical picture characterized by the presence of widespread sensory hypersensitivity as well as significant post-traumatic stress reactions. Based on the diversity of the signs and symptoms experienced by individuals with a whiplash condition, clinicians must take into account the more readily observable/measurable differences in motor, sensory and psychological dysfunction. The implications for the assessment and management of this condition are discussed. Further review into the pathomechanical, pathoanatomical, pathophysiological features of the condition also will be discussed.
J Orthop Sports Phys Ther., Epub 3 June 2008. doi:10.2519/jospt.2008.2826
KEY WORDS: cervical spine, motor, sensory
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Case Report
Terry L. Grindstaff, Kate R. Jackson, J. Craig Garrison, David R. Diduch, Christopher D. Ingersoll, Joe H. Gieck
STUDY DESIGN: Case Report. BACKGROUND: Decreased quadriceps activation has been shown to be present following anterior cruciate ligament (ACL) injury, but its presence prior to ACL injury is unknown. The purpose of this case report was to describe the level of quadriceps activation measured hours before a non-contact ACL injury in an individual who previously demonstrated known biomechanical risk factors for ACL injury. CASE DESCRIPTION: A 23 year old female (height= 176.9 cm, mass= 72.4 kg), sustained a left non-contact ACL injury while landing from a jump-stop during a recreational basketball game. This case was unique because data regarding landing biomechanics and quadriceps force and activation were gathered in 2 separate, unrelated studies prior to injury. OUTCOMES: Peak external knee abduction moment (-65.3 Nm) during a drop jump landing, 8 months prior to injury, indicated elevated risk for ACL injury. Involved quadriceps central activation ratios (CAR) were obtained 1 week (CAR =0.81) and 4 hours (CAR =0.77) prior to injury. Strength and CAR (0.76) measurements changed very little within 36 hours of injury and both strength and activation (CAR =0.90) improved following surgical reconstruction and formal rehabilitation. DISCUSSION: An individual with known biomechanical risk factors for ACL injury may compound their risk for non-contact ACL injury if decreased quadriceps activation is also present.
J Orthop Sports Phys Ther., Epub 25 April 2008. doi:10.2519/jospt.2008.2761
KEY WORDS: ACL, biomechanics, knee, muscle inhibition
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Literature Review
Christian J. Barton, Kate E. Webster, Hylton B. Menz
STUDY DESIGN: Systematic literature review. OBJECTIVE: To evaluate the quality and scope of recently published systematic reviews on the topic of patellofemoral pain syndrome (PFPS) and provide an overview of their findings. BACKGROUND: PFPS is a commonly treated condition. There is a large body of literature on conservative non-pharmacological interventions for PFPS, including multiple systematic reviews which require critiquing and summarising. METHODS AND MEASURES: A systematic review of systematic reviews on conservative non-pharmacological treatment strategies for PFPS was performed. Published systematic reviews were identified by searching MEDLINE, EMBASE, CINAHL, SPORTDISCUS, Current Contents, The Cochrane Library, and PEDro electronic databases from the year 2000 until May 2007. Cited reference searches of each author in the Web of Science complemented this search. Review quality was evaluated by a specifically designed scale and only high quality reviews were retained to validate and summarize reported findings. RESULTS: Ten reviews met the inclusion criteria. Among them, only 3 were considered to be high quality, covering exercise, foot and knee orthoses, and ultrasound intervention for PFPS. None of the 3 reviews included literature published after the year 2001. Some limited evidence for the use of exercise, exercise combined with taping, and exercise combined with the use of a Protonics® brace was found for treatment of individuals with PFPS. CONCLUSION: Published systematic reviews and clinical trials need to be conducted with more rigorous methodological design. There are no up-to-date high quality systematic reviews covering conservative non-pharmacological treatments for individuals with PFPS, indicating updates in all areas are needed. LEVEL OF EVIDENCE: Therapy, level 1a.
J Orthop Sports Phys Ther., Epub 3 June 2008. doi:10.2519/jospt.2008.2861
KEY WORDS: exercise, literature, orthoses, physical therapy, ultrasound
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Research Report
Emmy K. L. Wong, Gabriel Y. F. Ng
STUDY DESIGN: Cross-sectional, 2 group comparison, experimental laboratory study. OBJECTIVES: Examining and comparing the work profiles of the shoulder flexors and extensors between sport climbers and non-climbers. BACKGROUND: Sport climbing places high demands on the shoulder, which could lead to unique work profiles of the agonist/antagonist muscle groups. METHODS AND MEASURES: Isokinetic work output of the dominant shoulder flexors and extensors of 31 sport climbers and 27 non-climbers were measured from 0o to 180o of flexion at a test speed of 60o/s. Profiles for work data (concentric flexion [conFlex], eccentric flexion [eccFlex], concentric extension [conExt], eccentric extension [eccExt]) normalized to body mass, conventional work ratios (conFlex/conExt and eccFlex/eccExt), and functional work ratios (eccFlex/conExt and eccExt/conFlex) were developed for both climbers and non-climbers. RESULTS: All work profiles were different between the 2 groups (P<.001). All normalized work data were higher in climbers than non-climbers especially for conExt and eccExt. In the climbers, the conventional ratios were smaller than 1 for conFlex/conExt (0.74) and eccFlex/eccExt (0.74), whereas for the non-climbers, the ratios were 1.13 and 1.05, respectively. For the functional work data, the eccFlex/conExt ratio was 0.9 for the climbers compared to 1.46 for the non-climbers. Conversely, the eccExt/conFlex ratio was much higher in the climbers (1.73) compared to the non-climbers (1.28). CONCLUSION: The differences in work profiles for the shoulder flexors and extensors between the climbers and non-climbers suggest training-induced adaptations, stronger shoulder flexors and especially extensors, resulting from the sports of climbing.
J Orthop Sports Phys Ther., Epub 29 May 2008. doi:10.2519/jospt.2008.2779
KEY WORDS: climbing, glenohumeral joint, muscles, strength
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Research Report
Tracy A. Dierks, Kurt T. Manal, Joseph Hamill, Irene S. Davis
STUDY DESIGN: Experimental correlation study. OBJECTIVES: To investigate the relationships between hip strength and hip kinematics, and between arch structure and knee kinematics during prolonged treadmill running in runners with and without patellofemoral pain syndrome (PFPS). BACKGROUND: Hip weakness can lead to excessive femoral motions that adversely affect patellofemoral joint mechanics. Similarly, foot mechanics, which are influenced by foot structure, are also known to influence patellofemoral joint mechanics. Thus, proximal and distal factors should be considered when studying individuals with PFPS. METHODS AND MEASURES: Twenty recreational runners with PFPS (5 male, 15 female) and 20 matched uninjured runners participated in the study. Hip abduction and hip external rotation isometric strength measurements were collected before and after a prolonged run, while the arch height index was recorded on all runners before the run. Lower extremity kinematic data were collected at the beginning and end of the run. Two-way repeated measures ANOVAs were used for analysis. RESULTS: Both groups displayed decreases in hip abductor and external rotator strengths at the end of the run. The PFPS group displayed significantly lower hip abduction strength (kg*cm/body weight) compared to controls (PFPS begin 15.3, end 13.5; uninjured begin 17.3, end 15.4). At the end of the run, the level of association between hip abduction strength and the peak hip adduction angle for the PFPS group was statistically significant indicating a strong relationship (r = -0.74). No other associations with hip strength were observed in either group. Arch height did not differ between groups and no significant association was observed between arch height and peak knee adduction angle during running. CONCLUSIONS: Runners with PFPS displayed weaker hip abductor muscles that were associated with an increase in hip adduction during running. This relationship became more pronounced at the end of the run.
J Orthop Sports Phys Ther., Epub 15 April 2008. doi:10.2519/jospt.2008.2490
KEY WORDS: arch height index, hip abductor muscle strength, hip external rotator muscle strength, knee valgus
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Research Report
Alice B. Aiken, Lucie Pelland, Robert Brison, William Pickett, Brenda Brouwer
STUDY DESIGN: Prospective cohort study. OBJECTIVES: To examine the natural recovery from grade I and II ankle injuries over a 1 month period. BACKGROUND: There is a high rate of injury recurrence and persistence of symptoms following ankle sprains suggesting that these injuries may not be adequately managed. However, little is known about the recovery process after discharge from emergency departments. METHODS AND MEASURES: Clinical assessment of ankle swelling, strength, and joint mobility and laboratory assessment of peak torque and joint range of motion (ROM) were performed 4 and 30 days following initial clinical assessment in the emergency department. Analyses for repeated measures determined change over time and differences between injured and non-injured ankles. Self-assessed ankle function was evaluated on day 4 and day 30 and the relationship with clinical and laboratory assessments determined. RESULTS: Forty-six subjects entered the study and complete datasets were obtained from 28. Significant swelling, weakness, and mobility restrictions were evident on initial assessment. Symptoms improved over time and while clinical variables were normal by day 30, laboratory assessment indicated weakness of plantar flexors and limited active and passive ROM at 1 month. Swelling and reduced passive ROM were associated with overall function and limitations in sports and recreation activities as well as quality of life 1 month post-injury. CONCLUSION: Clinically assessed strength and dorsiflexion mobility suggested full recovery at 1 month post injury, yet more sensitive measures of ankle impairment and performance detected residual deficits. Persistent impairment and incomplete recovery of self-assessed function suggest the need for management beyond standard emergency department care. Associations between impairment measures and function may provide guidance for treatment intervention.
J Orthop Sports Phys Ther., Epub 29 May 2008. doi:10.2519/jospt.2008.2811
KEY WORDS: function, injury, impairment, soft tissue, strength
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Research Report
Yusaku Sugiura, Tomoyuki Saito, Keishoku Sakuraba, Kazuhiko Sakuma, Eiichi Suzuki
STUDY DESIGN: Prospective cohort study. OBJECTIVES: In this prospective cohort study of elite sprinters, muscle strength of the hip extensors, as well as of the knee extensors and flexors was measured to determine a possible relationship between strength deficits and subsequent hamstring injury within 12 months of testing. The method used for testing muscle strength simulated the specific muscle action during late swing and early contact phases when sprinting. BACKGROUND: There have been no prospective studies in elite sprinters that examined the concentric and eccentric isokinetic strength of the hip extensors and the quadriceps and hamstring muscles in a manner that reflects their actions in late swing or early contact phases of sprinting. Consequently, the causal relationship between hip and thigh muscle strength and hamstring injury in elite sprinters may not be fully understood. METHODS AND MEASURES: Isokinetic testing was performed on 30 male elite sprinters to assess hip extensors, quadriceps, and hamstring muscle strength. The occurrence of hamstring injury among the subjects was determined during the year following the muscle strength measurements. The strength of the hip extensors, quadriceps, and hamstring muscles, as well as the hamstrings/quadriceps (H/Q) and hip extensors/quadriceps ratios were compared. RESULTS: Hamstring injury occurred in 6 subjects during the 1-year period. Isokinetic testing at a speed of 60 deg/sec revealed weakness of the injured limb with eccentric action of the hamstring muscles and during concentric action of the hip extensors. When performing a side to side comparison for the injured sprinters, the hamstring injury always occurred on the weaker side. Differences in the H/Q and hip extensors/quadriceps strength ratios were also evident between uninjured and injured limbs and this was attributable to deficits in hamstring strength. CONCLUSION: Hamstring injury in elite sprinters was associated with weakness during eccentric action of the hamstrings and weakness during concentric action of the hip extensors, but only when tested at the slower speed of 60 deg/sec.
J Orthop Sports Phys Ther., Epub 15 April 2008. doi:10.2519/jospt.2008.2575
KEY WORDS: isokinetics, quadriceps, running, sprinting
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Research Report
Ashraf S. Gorgey, Gary A. Dudley
STUDY DESIGN: Controlled laboratory study OBJECTIVES: To determine the effects of pulse durations and stimulation durations on the evoked torque after controlling for the activated area by using magnetic resonance imaging (MRI). BACKGROUND: Neuromuscular electrical stimulation (NMES) is commonly used in the clinic without considering the physiological implications of its parameters. METHODS AND MEASURES: Seven able-bodied, college students (mean +/- SD age = 28 +/- 4 years) participated in this study. Two NMES protocols were applied to the knee extensor muscle group in a random order. Protocol A was 100 Hz, 450 µs pulses applied for 5 minutes in a 3 sec on 3 sec off duty cycle. Protocol B was 60 Hz, 250 µs pulses applied for 5 minutes in a10 sec on 20 sec off duty cycle. The amplitude of the current was similar in both protocols. Torque, torque time integral, and normalized torque for the knee extensors were measured for both protocols. MRI scans were taken prior to and immediately post each protocol to measure the cross-sectional area (CSA) of the stimulated muscle. RESULTS: The skeletal muscle CSA activated after both protocols were similar. The longer pulse duration in protocol A elicited 22% greater torque output than protocol B (P < .05). After considering the activated area in both protocols, the normalized torque with protocol A was 38% greater than with protocol B (P < .05). Torque-time integral was 21% greater with protocol A (P = .029). Protocol B fails to maintain torque at the start and the end of the 10 sec contraction. CONCLUSIONS: Longer pulse duration, but not contraction time, resulted in a greater evoked and normalized torque compared to the shorter pulse duration even after controlling for the activated muscular CSA with both protocols.
J Orthop Sports Phys Ther., Epub 25 April 2008. doi:10.2519/jospt.2008.2734
KEY WORDS: electrotherapy, MRI, NMES, quadriceps
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