Clinical Scenario: Anterior cruciate ligament (ACL) ruptures are one of the most common injuries in young athletic populations. The leading treatment for these injuries is ACL reconstruction (ACL-r); however, nonoperative treatments are also utilized. Following ACL-r, patients experience prolonged muscle weakness and atrophy of the quadriceps muscle group, regardless of rehabilitation. Nonoperative treatment plans following ACL injury exist, but their outcomes are less familiar, in spite of providing insight as a nonsurgical “control” for postsurgical rehabilitation outcomes. Therefore, the purpose of this critically appraised topic was to evaluate quadriceps strength and function following nonoperative ACL rehabilitation using objective and subjective measures including isokinetic dynamometry, the single-leg hop test, and the International Knee Documentation Committee (IKDC) subjective knee form. Focused Clinical Question: What are the effects of nonoperative treatment on peak isokinetic knee-extensor torque, the single-leg hop tests, and the IKDC in patients who have sustained an ACL rupture? Summary of Key Findings: Patients who underwent nonsurgical ACL treatment produced limb symmetry index, with the side-to-side torque difference expressed as a percentage, and values at or above 90% for all 4 single-leg hop tests and strength tests similar to ACL-r patients. All studies showed individuals had higher IKDC scores at baseline collection when compared with patients who underwent ACL-r but showed lower IKDC scores at long-term follow-up compared with ACL-r patients. Clinical Bottom Line: Nonoperative treatments of ACL injuries yield similar long-term results in quadriceps strength as ACL-r. Due to the quality of evidence and the absence of randomized controlled trials on this topic, these outcomes should be considered with caution. Strength of Recommendation: The Oxford Centre for Evidence-Based Medicine taxonomy recommends a grade of B for level 2 evidence with consistent findings.
Emily R. Hunt, Cassandra N. Parise and Timothy A. Butterfield
Nickolai Martonick, Kimber Kober, Abigail Watkins, Amanda DiEnno, Carmen Perez, Ashlie Renfro, Songah Chae and Russell Baker
Clinical Scenario: Joint instability is a common condition that often stems from inadequate muscle activation and results in precarious movement patterns. When clinicians attempt to mechanically treat the unstable joint rather than attending to the underlying cause of the instability, patient outcomes may suffer. The use of kinesiology tape (KT) on an unstable joint has been proposed to aid in improving lower-extremity neuromuscular control. Clinical Question: Does KT improve factors of neuromuscular control in an athletic population when compared with no-tape or nonelastic taping techniques? Summary of Key Findings: The current literature was searched, and 5 randomized controlled studies were selected comparing the effects of KT with no-tape or nonelastic taping techniques on lower-extremity neuromuscular control in an athletic population. Primary findings suggest KT is not more effective than no-tape or nonelastic tape conditions at improving lower-extremity neuromuscular control in a healthy population. Clinical Bottom Line: The current evidence suggests that KT is ineffective for improving neuromuscular control at the ankle compared with nonelastic tape or no-tape conditions. KT was also found to be ineffective at improving hip and knee kinematics in healthy runners and cyclists. However, preliminary research has demonstrated improved neuromuscular control in a population displaying excessive knee valgus during a drop jump landing, after the application of KT. Clinicians should be cautious of these conflicting results and apply the best available evidence to their evaluation of the patient’s status. Strength of Recommendation: There is grade B evidence that the use of KT on an athletic population does not improve biomechanical measures of ankle stability. There is inconclusive, grade B evidence that KT improves neuromuscular control at the knee in symptomatic populations.
Justin L. Rush, Lindsey K. Lepley, Steven Davi and Adam S. Lepley
Context: Altered quadriceps activation is common following anterior cruciate ligament reconstruction (ACLR), and can persist for years after surgery. These neural deficits are due, in part, to chronic central nervous system alterations. Transcranial direct current stimulation (tDCS) is a noninvasive modality, that is, believed to immediately increase motor neuron activity by stimulating the primary motor cortex, making it a promising modality to use improve outcomes in the ACLR population. Objective: To determine if a single treatment of tDCS would result in increased quadriceps activity and decreased levels of self-reported pain and dysfunction during exercise. Design: Randomized crossover design. Setting: Controlled laboratory. Patients: Ten participants with a history of ACLR (5 males/5 females, 22.9 [4.23] y, 176.57 [12.01] cm, 80.87 [16.86] kg, 68.1 [39.37] mo since ACLR). Interventions: Active tDCS and Sham tDCS. Main Outcome Measures: Percentage of maximum electromyographic data of vastus medialis and lateralis, voluntary isometric strength, percentage of voluntary activation, and self-reported pain and symptom scores were measured. The 2 × 2 repeated-measures analysis of variance by limb were performed to explain the differences between time points (pre and post) and condition (tDCS and sham). Results: There was a significant time main effect for quadriceps percentage of maximum electromyographic of vastus medialis (F 9,1 = 11.931, P = .01) and vastus lateralis (F 9,1 = 9.132, P = .01), isometric strength (F 9,1 = 5.343, P = .046), and subjective scores for pain (F 9,1 = 15.499, P = .04) and symptoms (F 9,1 = 15.499, P = .04). Quadriceps percentage of maximum electromyographic, isometric strength, and voluntary activation showed an immediate decline from pre to post regardless of tDCS condition. Subjective scores improved slightly after each condition. Conclusions: One session of active tDCS did not have an immediate effect on quadriceps activity and subjective scores of pain and symptoms. To determine if tDCS is a valid modality for this patient population, a larger scale investigation with multiple treatments of active tDCS is warranted.
Adam E. Jagodinsky, Christopher Wilburn, Nick Moore, John W. Fox and Wendi H. Weimar
Context: Ankle bracing is an effective form of injury prophylaxis implemented for individuals with and without chronic ankle instability, yet mechanisms surrounding bracing efficacy remain in question. Ankle bracing has been shown to invoke biomechanical and neuromotor alterations that could influence lower-extremity coordination strategies during locomotion and contribute to bracing efficacy. Objective: The purpose of this study was to investigate the effects of ankle bracing on lower-extremity coordination and coordination dynamics during walking in healthy individuals, ankle sprain copers, and individuals with chronic ankle instability. Design: Mixed factorial design. Setting: Laboratory setting. Participants: Forty-eight recreationally active individuals (16 per group) participated in this cross-sectional study. Intervention: Participants completed 15 trials of over ground walking with and without an ankle brace. Main Outcome Measures: Coordination and coordination variability of the foot–shank, shank–thigh, and foot–thigh were assessed during stance and swing phases of the gait cycle through analysis of segment relative phase and relative phase deviation, respectively. Results: Bracing elicited more synchronous, or locked, motion of the sagittal plane foot–shank coupling throughout swing phase and early stance phase, and more asynchronous motion of remaining foot–shank and foot–thigh couplings during early swing phase. Bracing also diminished coordination variability of foot–shank, foot–thigh, and shank–thigh couplings during swing phase of the gait cycle, indicating greater pattern stability. No group differences were observed. Conclusions: Greater stability of lower-extremity coordination patterns as well as spatiotemporal locking of the foot–shank coupling during terminal swing may work to guard against malalignment at foot contact and contribute to the efficacy of ankle bracing. Ankle bracing may also act antagonistically to interventions fostering functional variability.
Ashley L. Santo, Melissa L. Race and Elizabeth F. Teel
Context: Convergence dysfunction following concussion is common. Near point of convergence (NPC) is a quick and easy assessment that may detect oculomotor dysfunction such as convergence insufficiency (CI), but NPC measurements are rarely reported. Convergence dysfunction is treatable in otherwise healthy patients; the effectiveness of oculomotor therapy following concussion is unclear. Objectives: The purpose of this article was to systematically review the literature and answer the following clinical questions: (1) Is performance on NPC negatively affected in patients diagnosed with a concussion compared with pre-injury levels or healthy controls? (2) In patients diagnosed with concussion, what is the effect of oculomotor/vision therapy on NPC break measurements? Evidence Acquisition: The search was conducted in CINAHL, SPORTDiscus, MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, convergence, vision, and rehabilitation. Literature considered for review included original research publications that collected measures of NPC break in concussion patients, with a pretest–posttest comparison or comparison with a healthy control group. A literature review was completed; 242 relevant articles were reviewed, with 18 articles meeting criteria for inclusion in the review. Evidence Synthesis: Articles were categorized according to the clinical question they addressed. The patient or participant sample (number, sex, age, and health status), study design, instrumentation, or intervention used, and main results were extracted from each article. Conclusions: The authors' main findings suggest that there is a moderate level of evidence that patients have impaired NPC up to several months postconcussion, and a low level of evidence that impairments can be successfully treated with oculomotor therapy. These findings should be cautiously evaluated; the studies are limited by weak/moderate quality, small sample sizes, varied methodology, and nonrandomized treatment groups. Future research should explore factors affecting convergence postconcussion and include randomized, controlled studies to determine if performing vision therapy improves visual measures and promotes recovery.
Elshan Najafov, Şeyda Özal, Ahmet Yiğit Kaptan, Coşkun Ulucaköy, Ulunay Kanatlı, Baybars Ataoğlu and Selda Başar
Introduction: Long head of biceps (LHB) pathologies are an important cause of pain and dysfunction. As LHB pathologies have specific components from other underlying or related pathologies, the LHB score is designed for an accurate assessment. The aim of this study was to adapt the LHB score into Turkish and to assess its validity and reliability. Materials and Methods: LHB score was translated and culturally adapted from English to Turkish, and then it was applied to 62 patients with biceps long head pathology. The reliability of the scale was checked through internal consistency and test–retest methods. Internal consistency was computed with Cronbach alpha value. Test–retest reliability was assessed using an intraclass correlation coefficient. American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form and modified Constant–Murley score were used to analyze concurrent validity. Results: The Cronbach alpha value of the scale was found as .640. When the subsections of LHB score were computed separately, Cronbach alpha levels of pain/cramps and cosmesis sections were found as .753 and .774, respectively. The intraclass correlation coefficient value of the scale was found to be excellent (.940; P < .001). The total LHB score was determined to have a good positive correlation with the American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form (.527) and Constant–Murley score (.516). But an excellent correlation was revealed between the pain/cramps section of LHB score and other pain sections in American Shoulder and Elbow Surgeons Standard Shoulder Assessment Form (.811) and Constant–Murley score (.816) (P < .001). There was an excellent correlation (.916) between cosmesis section and Popeye sign (P < .001). There was a moderate correlation (.469) between elbow-flexion strength section of LHB score and the digital handheld dynamometer outcomes (P < .001). Conclusion: The Turkish version of the LHB is a valid and reliable tool, especially for biceps pathologies.
Kailin C. Parker, Rachel R. Shelton and Rebecca M. Lopez
Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient’s core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14–0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.
Nicholas Hattrup, Hannah Gray, Mark Krumholtz and Tamara C. Valovich McLeod
Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.