Context: Anatomical and in vivo studies suggest that muscles function synergistically as part of a myofascial chain. A related theory is that certain myofascial techniques have a remote and clinically important effect on range of motion (ROM). Objective: To determine if remote myofascial techniques can effectively increase the range of motion at a distant body segment. Evidence Acquisition: In November 2018, the authors searched 3 electronic databases (CENTRAL, MEDLINE, and PEDro) and hand-searched journals and conference proceedings. Inclusion criteria were randomized controlled trials comparing remote myofascial techniques with passive intervention (rest/sham) or local treatment intervention. The primary outcome of interest was ROM. Quality assessment was performed using the PEDro Scale. Three authors independently evaluated study quality and extracted data. RevMan software was used to pool data using a fixed-effect model. Evidence Synthesis: Eight randomized controlled trials, comprising N = 354 participants were included (mean age range 22–36 y; 50% female). Study quality was low with PEDro scores ranging from 2 to 7 (median scores 4.5/10). None of the studies incorporated adequate allocation concealment and just 2 used blinded assessment of outcomes. In all studies, treatments and outcomes were developed around the same myofascial chain (superficial back line). Five studies included comparisons between remote interventions to sham or inactive controls; pooled results for ROM showed trends in favor of remote interventions (standard mean difference 0.23; 95% confidence intervals; −0.09 to 0.55; 4 studies) at immediate follow-ups. Effects sizes were small, corresponding to mean differences of 9% or 5° in cervical spine ROM, and 1 to 3 cm in sit and reach distance. Four studies compared remote interventions to local treatments, but there were few differences between groups. Conclusions: Remote exercise interventions may increase ROM at distant body segments. However, effect sizes are small and the current evidence base is limited by selection and measurement bias.
Connor Burk, Jesse Perry, Sam Lis, Steve Dischiavi, and Chris Bleakley
Hiroshi Takasaki, Yu Okubo, and Shun Okuyama
Context: Accurate joint position sense (JPS) is necessary for effective motor learning and high performance in activities that require fine motor control. Proprioceptive neuromuscular facilitation (PNF) can be a promising intervention. Objective: To examine existing peer-reviewed original studies that have investigated the effect of PNF techniques on the JPS in terms of the methodological quality, PNF techniques, outcomes, and participant characteristics. Evidence Acquisition: A systematic literature search was performed using PubMed, EMBASE, MEDLINE, CINAHL, SocINDEX, Scopus, and Cochrane Library from inception to January 2018. The following inclusion criteria were used: (1) assessment of the JPS; (2) peer-reviewed original studies with a randomized controlled trial or quasi-randomized controlled trial design; (3) participants with musculoskeletal disorders or healthy individuals (ie, neither animal studies nor those involving neurological problems); and (4) no cointervention with PNF, except for warm-up procedures. The methodological quality was assessed using PEDro scale and 5 additional criteria. Effect size (η 2) was calculated where a positive value indicated an increased JPS after PNF as compared with other approaches including the wait-and-see method. Evidence Synthesis: Nine studies were examined for their methodological quality, and only one study scored >6 on the PEDro scale. Positive and large effect size (η 2 > .14) was detected in 2 studies where JPS of the knee with contract-relax and replication techniques was assessed in healthy individuals. However, the methodological quality of these studies was poor (PEDro scores of 3 and ≤5 in the total quality score out of 16, respectively). Conclusions: The current study did not find multiple studies with high methodological quality and similar PNF techniques, outcomes, and characteristics of participants. More high-quality studies are required to achieve a comprehensive understanding of the effect of PNF on the JPS.
Berkiye Kirmizigil, Jeffry Roy Chauchat, Omer Yalciner, Gozde Iyigun, Ender Angin, and Gul Baltaci
Context: Kinesio taping (KT) is a popular taping technique used in the recovery process; however, in the relevant literature, there is no real consensus on its efficacy. Objective: To investigate whether rectus femoris KT application after delayed onset muscle soreness enhances recovery of muscle soreness, edema, and physical performance. Participants: A total of 22 healthy amateur male athletes participated in this study. Design: Randomized, crossover study. Setting: Human performance laboratory of the university. Interventions: Participants performed an exercise protocol inducing delayed onset muscle soreness. They accomplished 2 distinct trials, with or without KT. The washout period between trials was 6 weeks. For the KT condition, KT inhibition technique was used and applied immediately after exercise bilaterally on rectus femoris. Main Outcome Measures: Range of motion, muscle soreness, and edema were measured at baseline, 30 minutes, 24, 48, and 72 hours postexercise. Dynamic balance, sprint, and horizontal jump were evaluated at similar time frame except for 30-minute postexercise. Results: The findings showed that there were no significant differences between the KT group (KTG) and control group for all outcome variables (P > .05). Muscle soreness returned to baseline values 72 hours postexercise only within the KTG (P > .05). Although the horizontal jump performance decreased substantially from baseline to 24 and 48 hours postexercise only within the control group (P < .05), the performance increased significantly from 24 to 72 hours postexercise within the KTG (P < .05). Balance increased significantly from baseline to 48 hours postexercise (P < .05) in both groups. Balance also increased significantly from baseline to 72 hours postexercise only within the KTG (P < .05). The effect size of soreness which is our primary outcome was large in both groups (r > .5). Conclusions: KT is favorable in the recovery of muscle soreness after delayed onset muscle soreness. KT has beneficial effects on horizontal jump performance and dynamic balance.
Dorianne Schuitema, Christian Greve, Klaas Postema, Rienk Dekker, and Juha M. Hijmans
Context: Plantar fasciitis is one of the most common foot injuries. Several mechanical treatment options, including shoe inserts, ankle-foot orthoses, tape, and shoes are used to relieve the symptoms of plantar fasciitis. Objectives: To investigate the effectiveness of mechanical treatment in the management of plantar fasciitis. Evidence Acquisition: The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. A systematic search was performed in PubMed, CINAHL, Embase, and Cochrane up to March 8, 2018. Two independent reviewers screened eligible articles and assessed risk of bias using the Cochrane Collaboration’s risk of bias tool. Evidence Synthesis: A total of 43 articles were included in the study, evaluating 2837 patients. Comparisons were made between no treatment and treatment with insoles, tape, ankle-foot orthoses including night splints and shoes. Tape, ankle-foot orthoses, and shoes were also compared with insoles. Follow-up ranged from 3 to 5 days to 12 months. Cointerventions were present in 26 studies. Conclusions: Mechanical treatment can be beneficial in relieving symptoms related to plantar fasciitis. Contoured full-length insoles are more effective in relieving symptoms related to plantar fasciitis than heel cups. Combining night splints or rocker shoes with insoles enhances improvement in pain relief and function compared with rocker shoes, night splints, or insoles alone. Taping is an effective short-term treatment. Future studies should aim to improve methodological quality using blinding, allocation concealment, avoid cointerventions, and use biomechanical measures of treatment effects.
Louisa D. Raisbeck, Jed A. Diekfuss, Dustin R. Grooms, and Randy Schmitz
Context: Although the beneficial effects of using an external focus of attention are well documented in attainment and performance of movement execution, neural mechanisms underlying external focus’ benefits are mostly unknown. Objective: To assess brain function during a lower-extremity gross motor movement while manipulating an internal and external focus of attention. Design: Cross-over study. Setting: Neuroimaging center Participants: A total of 10 healthy subjects (5 males and 5 females) Intervention: Participants completed external and internal focus of attention unilateral left 45° knee extension/flexion movements at a rate of 1.2 Hz laying supine in a magnetic resonance imaging scanner for 4 blocks of 30 seconds interspersed with 30-second rest blocks. During the internal condition, participants were instructed to “squeeze their quadriceps.” During the external condition, participants were instructed to “focus on a target” positioned above their tibia. Main Outcome Measures: T1 brain structural imaging was performed for registration of the functional data. For each condition, 3T functional magnetic resonance imaging blood oxygenation level dependent data representing 90 whole-brain volumes were acquired. Results: During the external relative to internal condition, increased activation was detected in the right occipital pole, cuneal cortex, anterior portion of the lingual gyrus, and intracalcarine cortex (Z max = 4.5–6.2, P < .001). During the internal relative to external condition, increased activation was detected in the left primary motor cortex, left supplementary motor cortex, and cerebellum (Z max = 3.4–3.5, P < .001). Conclusions: Current results suggest that an external focus directed toward a visual target produces more brain activity in regions associated with vision and ventral streaming pathways, whereas an internal focus manipulated through instruction increases activation in brain regions that are responsible for motor control. Results from this study serve as baseline information for future prevention and rehabilitation investigations of how manipulating focus of attention can constructively affect neuroplasticity during training and rehabilitation.
Pier Paolo Mariani, Luca Laudani, Jacopo E. Rocchi, Arrigo Giombini, and Andrea Macaluso
Context: All rehabilitative programs before anterior cruciate ligament (ACL) reconstructive surgery, which are focused on recovery of proprioception and muscular strength, are defined as prehabilitation. While it has shown that prehabilitation positively affects the overall outcome after ACL reconstruction, it is still controversial whether preoperatively enhancing quadriceps strength has some beneficial effect on postoperative strength, mainly during the first period. Objective: To determine whether there is any relationship between preoperative and early postoperative quadriceps strength. Design: Case control. Setting: University research laboratory. Participants: Fifty-nine males (18–33 y; age: 23.69 [0.71] y) who underwent ACL reconstruction with patellar-tendon autograft were examined the day before surgery, and at 60 and 90 days after surgery. Main Outcome Measures: The limb symmetry index (LSI) was quantified for maximal voluntary isometric contraction of the knee extensor muscles and of the knee flexor muscles at 90° joint angle. A k-means analysis was performed on either quadriceps or hamstrings LSI before surgery to classify the patients in high and low preoperative LSI clusters. Differences in postoperative LSI were then evaluated between the high and low preoperative LSI clusters. Results: Following surgery, there were no differences in the quadriceps LSI between patients with high and low preoperative quadriceps LSI. Sixty days after surgery, the hamstrings LSI was higher in patients with high than low preoperative hamstrings LSI (84.0 [13.0]% vs 75.4 [15.9]%; P < .05). Conclusions: Findings suggest that quadriceps strength deficit is related to the ACL injury and increases further after the reconstruction without any correlation between the preoperative and postoperative values. Therefore, it appears that there is no need to delay surgery in order to increase the preoperative quadriceps strength before surgery.
Lauren A. Brown, Eric E. Hall, Caroline J. Ketcham, Kirtida Patel, Thomas A. Buckley, David R. Howell, and Srikant Vallabhajosula
Context: Sports often involve complex movement patterns, such as turning. Although cognitive load effects on gait patterns are well known, little is known on how it affects biomechanics of turning gait among athletes. Such information could help evaluate how concussion affects turning gait required for daily living and sports. Objective: To determine the effect of a dual task on biomechanics of turning while walking among college athletes. Design: Cross-sectional study. Setting: University laboratory. Participants: Fifty-three participants performed 5 trials of a 20-m walk under single- and dual-task conditions at self-selected speed with a 180° turn at 10-m mark. The cognitive load included subtraction, spelling words backward, or reciting the months backward. Interventions: Not applicable. Main Outcome Measures: Turn duration, turning velocity, number of steps, SD of turn duration and velocity, and coefficient of variation of turn duration and velocity. Results: Participants turned significantly slower (155.99 [3.71] cm/s vs 183.52 [4.17] cm/s; P < .001) and took longer time to complete the turn (2.63 [0.05] s vs 2.33 [0.04] s; P < .001) while dual tasking, albeit taking similar number of steps to complete the turn. Participants also showed more variability in turning time under the dual-task condition (SD of turn duration = 0.39 vs 0.31 s; P = .004). Conclusions: Overall, college athletes turned slower and showed more variability during turning gait while performing a concurrent cognitive dual-task turning compared with single-task turning. The slower velocity increased variability may be representative of specific strategy of turning gait while dual tasking, which may be a result of the split attention to perform the cognitive task. The current study provides descriptive values of absolute and variability turning gait parameters for sports medicine personnel to use while they perform their concussion assessments on their college athletes.
Thomas G. Almonroeder, Emily Watkins, and Tricia Widenhoefer
Context: The bodyweight squat exercise is a common component for treatment and prevention of patellofemoral pain; however, it can also place a high load on the patellofemoral joint. Restricting anterior motion of the knees relative to the toes during squatting appears to reduce patellofemoral loading. However, exercise professionals typically rely on verbal instructions to alter squat technique. Objective: To evaluate the influence of verbal instructions regarding squat technique on patellofemoral joint loading. Design: Cross-sectional study. Setting: Motion analysis laboratory. Participants: Eleven uninjured females. Intervention: Participants performed bodyweight squats before (baseline) and after receiving verbal instructions to limit anterior knee motion. Two different types of verbal instruction were used, one intended to promote an internal focus of attention and the other intended to promote an external focus of attention. Three-dimensional kinematics and kinetics were recorded using a multicamera system and force plate. Main Outcome Measures: Sagittal plane patellofemoral joint forces and stress were estimated using a musculoskeletal model. Results: Participants demonstrated a reduction in patellofemoral joint forces (35.4 vs 31.3 N/kg; P = .01) and stress (10.7 vs 9.2 mPa; P = .002) after receiving instructions promoting an internal focus of attention, compared with their baseline trials. Participants also demonstrated a reduction in patellofemoral joint forces (35.4 vs 32.3 N/kg; P = .03) and stress (10.7 vs 9.6 mPa; P = .04) after receiving instructions promoting an external focus of attention (vs baseline). However, there were no significant differences in patellofemoral forces (P = .84) or stress (P = .41) for trials performed with an internal versus external attentional focus. Conclusion: It appears that verbal instruction regarding knee position influences patellofemoral joint loading during squatting.
Marissa L. Mason, Marissa N. Clemons, Kaylyn B. LaBarre, Nicole R. Szymczak, and Nicole J. Chimera
Clinical Scenario: Lower-extremity injuries in the United States costs millions of dollars each year. Athletes should be screened for neuromuscular deficits and trained to correct them. The tuck jump assessment (TJA) is a plyometric tool that can be used with athletes. Clinical Question: Does the TJA demonstrate both interrater and intrarater reliability in healthy individuals? Summary of Key Findings: Four of the 5 articles included in this critically appraised topic showed good to excellent reliability; however, caution should be taken in interpreting these results. Although composite scores of the TJA were found to be reliable, individual flaws do not demonstrate reliability on their own, with the exception of knee valgus at landing. Aspects of the TJA itself, including rater training, scoring system, playback speed, volume, and number of views allotted, need to be standardized before the reliability of this clinical assessment can be further researched. Clinical Bottom Line: The TJA has shown varying levels of reliability, from poor to excellent, for both interrater and intrarater reliability, given current research. Strength of Recommendation: According to the Centre for Evidence Based Medicine levels of evidence, there is level 2b evidence for research into the reliability of the TJA. This evidence has been demonstrated in elite, adolescent, and college-level athletics in the United Kingdom, Spain, and the United States. The recommendation of level 2b was chosen because these studies utilized cohort design for interrater and intrarater reliability across populations. An overall grade of B was recommended because there were consistent level 2 studies.
Bryan L. Riemann and George J. Davies
Context: Previous investigations have examined the reliability, normalization, and underlying projection mechanics of the seated single-arm shot-put (SSASP) test. Although the test is believed to reflect test limb strength, there have been no assessments determining whether test performance is directly associated with upper-extremity strength. Objective: To determine the relationship between isokinetic pushing force and SSASP performance and conduct a method comparison analysis of limb symmetry indices between the 2 tests. Design: Controlled laboratory study. Setting: Biomechanics laboratory. Patients (or Other Participants): Twenty-four healthy and physically active men (n = 12) and women (n = 12). Intervention(s): Participants completed the SSASP and isokinetic pushing tests using their dominant and nondominant arms. Main Outcome Measures: SSASP distance and isokinetic peak force. Results: Significant moderate to strong relationships were revealed between the SSASP distances and isokinetic peak forces for both limbs. The Bland–Altman analysis results demonstrated significantly (P < .002) greater limb symmetry indices for the SSASP (both medicine balls) than the isokinetic ratios, with biases ranging from −0.094 to −0.159. The limits of agreement results yielded intervals ranging from ±0.241 to ±0.340 and ±0.202 to ±0.221 from the biases. Conclusions: These results support the notion that the SSASP test reflects upper-extremity strength. The incongruency of the limb symmetry indices between the 2 tests is likely reflective of the differences in the movement patterns and coordination requirements of the 2 tests.