http://www.jospt.org/issue/type.2,year.2008,month.5/pastissues.asp Wed, 30 Apr 2008 09:05:25 EST 0 http://www.jospt.org/issues/articleID.1416/article_detail.asp The patient was a 44-year-old male with a 5-month history of lumbar radiculopathy following a golf injury. Following magnetic resonance imaging, he received a spinal epidural injection consisting of corticosteriods from his spine surgeon 2 weeks prior to physical therapy evaluation. Five weeks postinjection, the patient noted a progressive and significant worsening of his local lumbar and radicular symptoms. Magnetic resonance imaging revealed a lumbar subcutaneous abscess, for which the patient underwent open debridement and intravenous antibiotic therapy for methicillin sensitive staphylococcus aureus. He subsequently returned to physical therapy for successful management of his residual disablement.J Orthop Sports Phys Ther., 2008;38(5):287. doi:10.2519/jospt.2008.0405KEY WORDS: infection, magnetic resonance imaging, staphylococcus aureus http://www.jospt.org/issues/articleID.1416/article_detail.asp http://www.jospt.org/issues/articleID.1415/article_detail.asp Concerns for the environment and the broader issue of "sustainability" abound. As are other organizations, including nonprofits, the Journal of Orthopaedic & Sports Physical Therapy is wrestling with the implications of these issues for how we do business. While we have yet to hammer out a clear statement of the Journal's position, policy, and metrics for tracking our performance in these areas, we are mindful of our many stakeholders' sustainability concerns and want to acknowledge them. With this editorial, we aim to begin a dialog with, and a periodic report to, our authors, reviewers, editors, readers, advertisers, Board of Directors, and Section owners about where we are on the path to sustainable publishing and what we are doing to address these issues.J Orthop Sports Phys Ther., 2008;38(5):226-227. doi:10.2519/jospt.2008.0106 http://www.jospt.org/issues/articleID.1415/article_detail.asp http://www.jospt.org/issues/articleID.1401/article_detail.asp STUDY DESIGN: Controlled laboratory study. OBJECTIVE: To compare postural performance measures of athletes with those of nonathletes when completing the standard Sensory Organization Test (SOT) and a modified SOT that included dynamic head tilts (DHT-SOT). BACKGROUND: Authors of recently published research have suggested that modifications to the SOT protocol (eg, introduction of pitch and roll head tilts) may enhance the test's sensitivity when assessing postural stability in individuals with higher balance capabilities or with well-compensated sensory deficits. METHODS AND MEASURES: Nineteen athletes and 19 nonathletes (group) completed both the SOT and DHT-SOT (protocol). During the SOT, participants stood upright as steadily as possible for 20 seconds during each of 6 different sensory conditions. As a variation of the SOT, the DHT-SOT incorporated active pitch and roll head tilts into the SOT protocol. Four 2-way mixed-model analyses of variance (with protocol as the repeated factor) were performed to determine if the composite equilibrium score or the visual, vestibular, or somatosensory ratio scores differed between the 2 groups across the 2 testing protocols. RESULTS: Significant group-by-protocol interaction effects were present for both the composite equilibrium score and visual ratio. Follow-up simple main-effects analyses indicated that these measures did not differ between groups for the SOT protocol but were significantly different on the DHT-SOT. CONCLUSIONS: The addition of dynamic head tilts to the SOT protocol resulted in subtle differences in balance function between athletes and nonathletes. Athletes demonstrated an increased ability to adapt to sensory disruptions during the DHT-SOT. Therapists should consider including active pitch and roll head tilts to the SOT when evaluating individuals with higher balance function or to detect subtle deficits in balance function. LEVEL OF EVIDENCE: Diagnosis, level 3b. J Orthop Sports Phys Ther. 2008;38(5):262-268, published online 12 March 2008. doi:10.2519/jospt.2008.2406KEY WORDS: balance, postural stability, sensory information http://www.jospt.org/issues/articleID.1401/article_detail.asp http://www.jospt.org/issues/articleID.1389/article_detail.asp STUDY DESIGN: Case report. BACKGROUND: Management of glenohumeral joint osteoarthritis in young, active patients is challenging due to the significant functional limitations and progression of the disease, coupled with the limited lifespan of prosthetic implants presently in use. The purpose of this report is to present the detailed rehabilitation program and outcome of a patient who suffered an initial glenohumeral dislocation and, following multiple surgical interventions, required shoulder hemiarthroplasty and biologic glenoid resurfacing to return to function. CASE DESCRIPTION: An objectively based rehabilitation protocol was used for this patient following shoulder hemiarthroplasty. Data collected included passive and active range of motion, isometric rotational strength, and functional outcome scores to include the Single Assessment Numeric Evaluation (SANE) and American Shoulder Elbow Surgeons (ASES) outcome measures. OUTCOMES: Progressive improvements in active and passive range of motion were documented at numerous points during postoperative rehabilitation, including 1 and 2 years postoperatively. The patient's initial functional outcome scores improved from 2/100 to 90/100 in the SANE and from 17/100 to 85/100 for the ASES rating scales. At 2 years postsurgery the SANE score was 60/100 and ASES 68/100. DISCUSSION: Early postoperative range of motion exercises performed in a range protecting the subscapularis, coupled with a progressive program of rotator cuff and scapular strengthening exercises, resulted in decreased pain, improved range of motion, and return to work in a limited capacity following hemiarthroplasty with biologic glenoid resurfacing. Further research in series of patients following this procedure will help to establish optimal treatment guidelines and prognosis for young active patients with severe glenohumeral joint osteoarthritis. LEVEL OF EVIDENCE: Therapy, level 4.J Orthop Sports Phys Ther. 2008;38(5):277-286, published online 22 January 2008. doi:10.2519/jospt.2008.2546KEY WORDS: arthroplasty, biologic resurfacing, rehabilitation, shoulder http://www.jospt.org/issues/articleID.1389/article_detail.asp http://www.jospt.org/issues/articleID.1388/article_detail.asp STUDY DESIGN: Experimental laboratory study. OBJECTIVES: We tested the hypothesis that the muscle fibers and the connective tendinous structures, combined in series, provide the resistance to passive joint movement at the ankle. We also determined the relative association between passive joint torque and each of these 2 elements. BACKGROUND: The reason for individual variation in joint flexibility or tightness is not clearly understood, but the influence of musculotendinous stiffness has been inferred. METHODS AND MEASURES: Each of the subjects (6 women and 6 men) was seated with the right knee extended and right ankle positioned at a 30°, 20°, 10°, 0°, –10°, –20°, and –30° (0, neutral position, positive values reflecting plantar flexion) angle while passive plantar flexion torque was measured. The distal muscle-tendon junction of the medial gastrocnemius was visualized by ultrasonography, and its positional change was defined as muscle belly length change. The whole muscle-tendon unit length change was estimated from joint angle changes, from which Achilles tendon length change was estimated. RESULTS: Both the muscle belly and tendon were significantly elongated as the ankle was dorsiflexed (at 0° the mean ± SD muscle belly elongation was 10.3% ± 1.8 %, and the tendon elongation was 2.8% ± 1.2 %, of the initial length at 30° of ankle plantar flexion), from which stiffness indices were determined both for muscle belly and tendon. The passive torque at 0°, –10°, –20°, and –30° was significantly correlated with the stiffness indices of the Achilles tendon (at 0°, r2 = 0.70 and 0.62 for overall and specific stiffness, respectively; Pr2 = 0.76; Pr2 = 0.47, Pr2 = 0.32, P>.05). CONCLUSION: Results suggest that extensibility of the muscle-tendon unit of the Achilles tendon for the most part is related to passive ankle plantar flexion joint torque. J Orthop Sports Phys Ther. 2008;38(5):269-276, published online 22 January 2008. doi:10.2519/jospt.2008.2632KEY TERMS: dorsiflexion, flexibility, plantar flexors, stretching http://www.jospt.org/issues/articleID.1388/article_detail.asp http://www.jospt.org/issues/articleID.1383/article_detail.asp STUDY DESIGN: Experimental laboratory study. OBJECTIVES: To measure the transmission of dexamethasone sodium phosphate (DEX-P) using iontophoresis as a function of skinfold tissue thickness and time elapsed between treatment and tissue extraction. BACKGROUND: Iontophoresis is a modality used in physical therapy with the intent to drive medications through the skin to underlying tissues using a direct electrical current. DEX-P is the most commonly used medication with iontophoresis and is used to treat a variety of connective tissue conditions. METHODS AND MEASURES: Sixteen adults undergoing anterior cruciate ligament reconstructive surgery using the semitendinosis/gracilis autograft received a 40-mA-min dose of iontophoresis with 0.4% DEX-P superficial to a slip of the distal semitendinosis tendon prior to surgery. The tendon slip was extracted within 4 hours. Time between treatment and tissue extraction and skinfold thickness were measured. Analysis was performed on the slip of the semitendinosis using high-performance liquid chromatography mass spectrum. RESULTS: Of the 16 subjects (10 female, 6 male; mean age, 33 years), 7 had measurable amounts of DEX-P in the tendon slip (4 female, 3 male; mean age, 34 years). The average concentration in the 16 subjects was 2.9 ng/g of tendon tissue. There was no correlation between DEX-P absorbed and skinfold thickness (r = –0.08, P = .79) or time elapsed (r = 0.25, P = .38). In a subset of the 7 individuals that showed measurable levels of DEX-P absorbed, the average concentration of DEX-P was 6.6 ng/g of tendon tissue, and there was a relationship between DEX-P concentrations and time elapsed that did not reach statistical significance (r = 0.71, P = .11). CONCLUSIONS: Iontophoresis appears to facilitate the transmission of dexamethasone to connective tissues in humans with skinfold thickness up to at least 30 mm. The absorption of the dexamethasone seemed to continue to occur for up to 4 hours after delivery. It is not clear why DEX-P was measured in only 7 of the 16 subjects. LEVEL OF EVIDENCE: Therapy, level 5.J Orthop Sports Phys Ther. 2008;38(5):238-245, published online 22 January 2008. doi:10.2519/jospt.2008.2648 KEY WORDS: connective tissue, pain, tendinitis http://www.jospt.org/issues/articleID.1383/article_detail.asp http://www.jospt.org/issues/articleID.1373/article_detail.asp SYNOPSIS: The number of total knee arthroplasty (TKA) surgeries performed each year is predicted to steadily increase. Following TKA surgery, self-reported pain and function improve, though individuals are often plagued with quadriceps muscle impairments and functional limitations. Postoperative rehabilitation approaches either are not incorporated or incompletely address the muscular and functional deficits that persist following surgery. While the reason for quadriceps weakness is not well understood in this patient population, it has been suggested that a combination of muscle atrophy and neuromuscular activation deficits contribute to residual strength impairments. Failure to adequately address the chronic muscle impairments has the potential to limit the long-term functional gains that may be possible following TKA. Postoperative rehabilitation addressing quadriceps strength should mitigate these impairments and ultimately result in improved functional outcomes. The purpose of this paper is to describe these quadriceps muscle impairments and discuss how these impairments can contribute to the related functional limitations following TKA. We will also describe the current concepts in TKA rehabilitation and provide recommendations and clinical guidelines based on the current available evidence. LEVEL OF EVIDENCE: Therapy, level 5.J Orthop Sports Phys Ther. 2008;38(5):246-256, published online 14 December 2007. doi:10.2519/jospt.2008.2715KEY WORDS: electrical stimulation, quadriceps strength, rehabilitation, total knee arthroplasty, TKA http://www.jospt.org/issues/articleID.1373/article_detail.asp http://www.jospt.org/issues/articleID.1372/article_detail.asp STUDY DESIGN: Experimental laboratory study supplemented with a repeated case study. OBJECTIVE: To examine bilateral muscle activity of the deep abdominals in response to rapid arm raising, specifically to examine the laterality and directional specificity of feedforward responses of the transversus abdominis (TrA). BACKGROUND: Based on the feedforward responses of trunk muscles during rapid arm movements, authors have concluded that the deep trunk muscles have different control mechanisms compared to the more superficial muscles. It has been proposed that deep trunk muscles such as TrA contribute substantially to the stability of the lumbar spine and that this is achieved through simultaneous bilateral feedforward activation. These inferences are based on unilateral fine-wire electromyographic (EMG) data and there are limited investigations of bilateral responses of the TrA during unilateral arm raising. METHODS AND MEASURES: Bilateral fine-wire and surface EMG data from the anterior deltoid, TrA, obliquus internus (OI), obliquus externus, biceps femoris, erector spinae, and rectus abdominis during repeated arm raises were recorded at 2kHz. EMG signal linear envelopes were synchronized to the onset of the anterior deltoid. A feedforward window was defined as the period up to 50 ms after the onset of the anterior deltoid, and paired onsets for bilateral muscles were plotted for both left and right arm movements. RESULTS: Trunk muscles from the group data demonstrated differences between sides (laterality), which were systematically altered when alternate arms were raised (directional specificity). This was clearly evident for the TrA but less obvious for the erector spinae. The ipsilateral biceps femoris and obliquus externus, and contralateral OI and TrA, were activated earlier than the alternate side for both right and left arm movements. This was a consistent pattern over a 7-year period for the case study. Data for the rectus abdominis derived from the case study demonstrated little laterality or directionally specific response. CONCLUSION: This is the first study to show that the feedforward activity of the TrA is specific to the direction of arm movement and not bilaterally symmetrical. The asymmetry of TrA activity during arm raising suggests that the interpretation of the role of TrA as a bilateral stabilizer during anticipatory postural adjustments needs to be revised. Future research needs to examine muscle synergies associated with the asymmetrical function of the TrA and the underlying mechanism associated with low-load stability training. LEVEL OF EVIDENCE: Therapy, level 5.J Orthop Sports Phys Ther. 2008;38(5):228-237, published online 14 December 2007. doi:10.2519/jospt.2008.2703KEY WORDS: abdominal muscles, anticipatory postural adjustments, low back pain, motor control http://www.jospt.org/issues/articleID.1372/article_detail.asp http://www.jospt.org/issues/articleID.1369/article_detail.asp STUDY DESIGN: Experimental laboratory design. OBJECTIVES: To measure the strain at the proximal origin of the extensor carpi radialis brevis (ECRB), and to determine the influence of a forearm support band. BACKGROUND: A forearm support band is often used with the intent to decrease stresses around the origin of the wrist extensors. However, the influence of the location of the band has not been studied. METHODS AND MEASURES: The forearm support band was applied on 8 cadaver arms (mean ± SD age, 78.4 ± 10.3 years) and 2 experimental conditions were performed. First, strain measurements were made without applying tension to the distal ECRB tendon, then strain measurements were made with a traction force of 21.5 N being applied to the distal ECRB tendon. Strain of the proximal origin of the ECRB, 1.0 cm distal from the lateral epicondyle, was recorded using a strain gauge. The band was mounted on the forearm at distances equal to 80%, 70%, 60%, 50%, 40%, 30%, and 20% of the forearm length as measured from the wrist. Testing order was randomized. Tension applied to the band was 19.6 N. RESULTS: When no tension was applied to the ECRB, there was no statistically significant difference (P>.05) in strain values at the ECRB origin by mounting the band at any of the forearm positions. In the tension condition, the average (SD) strain with no band was 2.40% (1.40%). The average strain value of 0.85% (0.65%), when the band was mounted 80% of the forearm length proximal to the wrist, was statistically smaller than that obtained without the band (PCONCLUSIONS: The strain on the ECRB origin was less when the forearm support band was applied 80% proximal from the wrist joint. LEVEL OF EVIDENCE: Therapy, level 5.J Orthop Sports Phys Ther. 2008;38(5):257-261, published online 7 December 2007. doi:10.2519/jospt.2008.2672KEY WORDS: cadaver, lateral epicondylalgia, tennis elbow, tennis elbow brace http://www.jospt.org/issues/articleID.1369/article_detail.asp