Journal of Orthopaedic & Sports Physical Therapy - Arthur J. Nitz, PT, PhD, ECS, OCS

A Comparison of Select Trunk Muscle Thickness Change Between Subjects With Low Back Pain Classified in the Treatment-Based Classification System and Asymptomatic Controls

Kyle B. Kiesel, Carl G. Mattacola, Arthur J. Nitz, Terry R. Malone, Frank B. Underwood
STUDY DESIGN: Cross-sectional descriptive. OBJECTIVES: To investigate if muscle thickness change, as measured with rehabilitative ultrasound imaging (RUSI), is different across subgroups of patients with low back pain (LBP) classified in the Treatment-Based Cassification (TBC) system when compared to controls. BACKGROUND: Researchers have demonstrated that subgroups of patients with LBP exist and respond differently to treatment, challenging the assertion that LBP is "nonspecific." The TBC system uses 4 categories (stabilization, mobilization, direction-specific exercise, or traction) to subgroup patients. Recently, researchers have demonstrated impairments of the transverse abdominis (TrA) and lumbar multifidus (LM) in those with LBP, regardless of classification. Although distinct differences in impairments have been identified between sub-groups, TrA and LM impairments have not been studied and may be present across categories of the TBC system. METHODS AND MEASURES: RUSI was utilized to measure percent thickness change from rest to contracted state during a voluntary task of the TrA and during an upper extremity task known to activate the LM in 56 subjects classified in the TBC system and 20 controls. RESULTS: During the prone upper extremity lifting task with a hand weight, there was a significant group difference for the LM at L4-L5 (P = .03) and at L5-S1 (P = .04), and during volitional activation for the TrA (P<.01). Post-hoc testing revealed the differences were between controls and both the direction-specific and stabilization categories at the L4-L5 level, between control and direction-specific category for the L5-S1 level, and between controls and all 3 categories for the TrA. CONCLUSION: Deficits in the ability to generate muscle thickness changes in the TrA and LM occurred across categories of the TBC system. Intervention studies should be performed to determine if intervention can correct these deficits and if deficit corrections are related to outcomes.

J Orthop Sports Phys Ther. 2007;37(10):596-607, published online 28 August 2007. doi:10.2519/jospt.2007.2574. The original article was corrected in March 2008, and the amended article PDF is provided here. Please see Correction: A comparison of select trunk muscle thickness change between subjects with low back pain classified in the treatment-based classification system and asymptomatic controls. J Orthop Sports Phys Ther. 2008;38(3):161.

KEY WORDS: multifidus, sonography, spine stabilization, therapeutic exercise, transverse abdominis

Measures of Accuracy for Active Shoulder Movements at 3 Different Speeds With Kinesthetic and Visual Feedback

Timothy J. Brindle, Arthur J. Nitz, Timothy L. Uhl, Edward Kifer, Robert Shapiro

Study Design: Repeated-measures experiment. Objective: To compare measures of end point accuracy (EPA) for 2 feedback conditions: (1) visual and kinesthetic feedback and (2) kinesthetic feedback alone, during shoulder movements, at 3 different speeds. Background: Shoulder joint kinesthesia is typically reported with EPA measures, such as constant error. Reporting multiple measures of EPA, such as variable error and absolute error, could provide a more detailed description of performance. Methods and Measures: Subjects were seated with the shoulder abducted 90° in the scapular plane and externally rotated 75°, with the forearm placed in a custom shoulder wheel. Subjects internally rotated the shoulder 27° to a target position at 48° of shoulder external rotation for both conditions. Motion analysis was used to determine peak angular velocity and 3 EPA measures for shoulder movements. Each EPA measure was compared between the 2 feedback conditions and among the 3 speeds with a separate 2-way analysis of variance. Results: Movements performed with kinesthetic feedback alone, measured by constant error (P<.01), variable error (P<.01), and absolute error (P<.01), were less accurate than movements performed with visual and kinesthetic feedback. Faster movements were less accurate when measured by constant error (P = .01) and absolute error (P<.01) than slower movements. Subjects tended to overshoot the target in the absence of visual feedback; however, movement speed played minimal role in the overshooting. Conclusions: Multiple measures of EPA, such as constant, variable, and absolute error during simple restricted shoulder movements may provide additional information regarding the evaluation of a motor performance or identify different central nervous system control mechanisms for joint kinesthesia.

J Orthop Sports Phys Ther. 2004;34(8):468-478. doi:10.2519/jospt.2004.1151

Key Words: kinesthesia, proprioception, target accuracy, upper extremity

Relationship Between Ankle Invertor H-Reflexes and Acute Swelling Induced by Inversion Ankle Sprain

Maj Robert C. Hall, Darren L. Johnson, John A. Nyland, Arthur J. Nitz, Jase J. Pinerola
Study Design: Single group, post-test design using the uninvolved lower extremity as the experimental control. Objectives: To determine relationships between ankle swelling and flexor digitorum longus and peroneus longus H-reflex amplitude and latency. Background: Primary capsuloligamentous injury, neural injury, and joint effusion and swelling may contribute to H-reflex changes following inversion ankle sprain. The relationship between ankle swelling and invertor or evertor H-reflexes has not been reported. Methods and Measures: Fifteen subjects with acute grade I or II inversion ankle sprains (mean � SD) 6.5 � 3 days after onset participated in this study. Swelling was estimated using a tape measure and the figure-of-eight girth assessment method. H-reflexes were determined using standard techniques. Paired t-tests were used to compare mean differences in ankle girth (swelling) and ankle invertor or evertor H-reflex amplitude and latency between the involved and uninvolved limbs. Pearson product moment correlations were used to assess relationships between swelling and H-reflex variables. Results: Involved limb ankle girth was increased with respect to the uninvolved limb (1.5 � 0.9 cm) and the involved ankle flexor digitorum longus latency was delayed (0.72 � 0.7 ms). There was a moderate positive association (r = 0.73) between the latency delay in the involved ankle flexor digitorum longus and swelling. There were no significant differences in H-reflex amplitude and peroneus longus latency between ankles. Conclusions: Grade I or II inversion sprains and the related swelling appear to delay involved ankle flexor digitorum longus latency to a greater extent than peroneus longus latency. Clinicians need to direct greater attention to the ankle invertors when designing and implementing ankle rehabilitation programs, particularly during the swelling management phase of treatment. J Orthop Sports Phys Ther. 1999;29(6):339-344. Key Words: neuromuscular inhibition, electromyography, latency

Intrarater Reliability of Selected Clinical Outcome Measures Following Anterior Cruciate Ligament Reconstruction

Joseph A. Brosky, David N. M. Caborn, Terry R. Malone, Mary Kay Rayens, Arthur J. Nitz
Study Design: Single group repeated measures following anterior cruciate ligament (ACL) reconstruction. Objectives: The purpose of this study was to evaluate the intrarater reliability of selected clinical outcome measures in patients having ACL reconstruction. Background: Several investigations have reported the reliability of isokinetic testing and knee ligament arthrometry. Fewer studies have examined the reliability of lower extremity functional tests, with most of these studies evaluating normal subjects. Methods and Measures: Fifteen physically active males with unilateral ACL-reconstructed knees were evaluated with the KT-1000, Biodex isokinetic dynamometer, and 3 functional hop tests on 5 occasions. Results: lntraclass correlation coefficients (ICCs) revealed good to high intrarater reliability (ICC >0.80) of the functional hop tests and isokinetic peak torque values. ICCs were higher for the involved limb than the uninvolved limb using the scores from the KT-1000 Manual Maximum Test. Conclusions: The outcome measures examined in this investigation have been shown to be reliable in patients with ACL reconstructions and support previous investigations in nonimpaired populations. Further research is needed to examine the validity of these postoperative outcome measures in patients with ACL reconstructions. J Orthop Sports Phys Ther. 1999;29(1):39-48. Key Words: functional outcomes measures, functional testing

The Effect of Quadriceps Femoris, Hamstring, and Placebo Eccentric Fatigue on Knee and Ankle Dynamics During Crossover Cutting

John A. Nyland, Robert Shapiro, David N. M. Caborn, Arthur J. Nitz, Terry R. Malone

This study attempted to determine the effect of eccentric quadriceps femoris, hamstring, and placebo fatigue on stance limb dynamics during the plant-and-cut phase of a crossover cut. Twenty female college students (task trained) were tested. Hamstring fatigue resulted in decreased peak impact knee flexion moments (p = .01), increased internal tibial rotation at peak knee flexion (p = .05), and decreased peak ankle dorsiflexion (p = .05). Quadriceps fatigue resulted in increased peak ankle dorsiflexion moments (p < .01), decreased peak posterior braking forces (p = .01), decreased peak knee extension moments (p = .01), delayed peak knee flexion (p = .01), delayed peak propulsive forces (p < .01), and delayed subtalar peak inversion moments (p = .05). Fatigue of either muscle group produced earlier peak ankle plantar flexion moments (p = .05) and decreased peak propulsive knee flexion moments (p = .05). Variables requiring further study (p = .1) provide discussion data. Soleus, gastrocnemius, tibialis anterior, and deep posterior compartment calf muscles serve as dynamic impact force attenuators, compensating for fatigued proximal muscles.

J Orthop Sports Phys Ther. 1997;25(3):171-184.

Key Words: women, muscle, fatigue, compensatory dynamics

The Ankle Ligaments: Consideration of Syndesmotic Injury and Implications for Rehabilitation

Tony Brosky, John A. Nyland, Arthur J. Nitz, David N. M. Caborn

Injury to the distal tibiofibular syndesmosis (DTFS) may be more common than previously reported. This injury is typically caused by external forces, which produce sudden ankle dorsiflexion or plantar flexion in combination with external rotation of the foot. Common mechanisms include direct contact with another player or uneven physical terrain. Improper diagnosis of this injury may greatly delay the return to normal functional status and promote the development of chronic instability, degenerative joint changes, and pain. The purpose of this clinical commentary is to review the ligamentous anatomy of the ankle and the incidence of injury to the lateral ligaments of the ankle, with emphasis on DTFS injury. Special tests that enhance the recognition of DTFS injury, such as the external rotation stress test and the distal tibiofibular compression test, and a rehabilitation progression are presented.

J Orthop Sports Phys Ther. 1995;21(4):197-205.

Key Words: ankle, anatomy, rehabilitation

Patellofemoral Alignment: Reliability

David A. Tomsich, Arthur J. Nitz, Mr. A. Joseph Threlkeld, Robert Shapiro

Clinical assessment of the patellofemoral alignment is frequently performed, yet the repeatability of these measurements has not been previously investigated. This study examined the reliability of measuring patellofemoral alignment. The Q angle, A angle, and patellar orientation (mediolateral tilt, mediolateral position, superoinferior tilt, and rotation) of 27 healthy subjects were measured over 3 trials using standardized positioning and operationally defined goniometric, pluri-cal caliper, and visual estimation measurement techniques. Intratester and intertester intraclass correlation coefficients of measurements obtained with the pluri-cal caliper and goniometer ranged from .52 to .86 and .003 to .61, respectively. Intratester and intertester standard errors of the instrumented measurements ranged from 1.6° to 3.5° and 3.2° to 6.8° (.28 and .55 cm for mediolateral position), respectively. Intratester kappas of visually estimating patellar orientation ranged from .40 to .57. Intertester kappas were between .03 and .30. The results suggest that both clinical estimation and instrumented measurement of patellofemoral alignment may be unreliable.

J Orthop Sports Phys Ther. 1996;23(3):200-208.

Key Words: reliability, patellofemoral, alignment

Review of the Afferent Neural System of the Knee and Its Contribution to Motor Learning

John A. Nyland, Tony Brosky, Dean Currier, Arthur J. Nitz, David N. M. Caborn

Understanding the afferent neural system of the knee is considered to be vital to rehabilitation planning. An intricate relationship exists involving the afferent neural receptors in the inert and contractile tissues of the knee. Traditional rehabilitation strategies may not exploit this extensive afferent neural system. Closed kinetic chain functional training (CKCFT) may provide a method for more effectively rehabilitating an injured or reconstructed knee. The rationale for CKCFT has traditionally focused on mechanical aspects. Sensorimotor integration through motor learning is believed to be an important component of CKCFT. The purposes of this review are to discuss: 1) the afferent neural system of the knee with emphasis on the mechanoreceptors, 2) the influence of the afferent neural system of the knee on motor learning, and 3) how CKCFT uses the afferent neural system of the knee and motor learning during knee rehabilitation. This review reinforces the use of CKCFT in knee rehabilitation plans.

J Orthop Sports Phys Ther. 1994;19(1):2-11.

Key Words: articular neurology, motor learning, knee rehabilitation

Tennis Elbow: A Review

J. Timothy Noteboom, Rob Cruver, Julie Keller, Bob Kellogg, Arthur J. Nitz

Tennis elbow is a common yet sometimes complex musculoskeletal condition affecting many patients treated by physical therapists. The purpose of this article is to review the anatomy, clinical examination, differential diagnosis, conservative care, and surgical treatment for tennis elbow, or lateral epicondylitis. Particular attention is given to determining the precise pathological cause of lateral epicondylitis, with consideration of intrinsic and extrinsic factors associated with this condition. This information should assist health care practitioners who treat patients with this disorder.

J Orthop Sports Phys Ther. 1994;19(6)357-366.

Key Words: lateral epicondylitis (tennis elbow), conservative treatment, surgical treatment

Shoulder Musculature Activation During Upper Extremity Weight-BearingExercise

Timothy L. Uhl, Thomas J. Carver, Carl G. Mattacola, Scott D. Mair, Arthur J. Nitz

Study Design: Repeated-measures design comparing 7 static weight-bearing shoulder exercises. Objective:The purpose of this study was to determine the demand on shoulder musculature during weight-bearing exercises and the relationship between increasing weight-bearing posture and shoulder muscle activation. Background: Weight-bearing shoulder exercises are commonly prescribed in the rehabilitation of shoulder injuries. Limited information is available as to the demands placed on shoulder musculature while these exercises are performed. Methods: Eighteen healthy college students volunteered for this study. Surface bipolar electrodes were applied over the infraspinatus, posterior deltoid, anterior deltoid, and pectoralis major muscles. Fine-wire bipolar intramuscular electrodes were inserted into the supraspinatus muscle. Electromyographic (EMG) root mean square signal intensity was normalized to 1 second of EMG obtained with a maximal voluntary isometric contraction (MVIC). Subjects were tested under 7 isometric exercise positions that progressively increased upper extremity weight-bearing posture. Results: There was a high correlation between increasing weight-bearing posture and muscular activity (r = 0.97, p<0.01). There was relatively little demand on the shoulder musculature for the prayer and quadruped positions (2%-10% MVIC). Muscular activation was greater for the infraspinatus than for other shoulder muscles throughout most of the exercise positions tested. Conclusion: These results indicate that alterations of weight-bearing exercises, by varying the amount of arm support and force, resulted in very different demands on the shoulder musculature. Specifically, the infraspinatus was particularly active during the weight-bearing exercises used in this study.

J Ortho Sports Phys Ther. 2003;33:109-117.

Key Words: electromyography, muscles, progressive resistive exercise, rehabilitation