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Corey A. Pew, Sarah A. Roelker, Glenn K. Klute, and Richard R. Neptune

The coupling between the residual limb and the lower-limb prosthesis is not rigid. As a result, external loading produces movement between the prosthesis and residual limb that can lead to undesirable soft-tissue shear stresses. As these stresses are difficult to measure, limb loading is commonly used as a surrogate. However, the relationship between limb loading and the displacements responsible for those stresses remains unknown. To better understand the limb motion within the socket, an inverse kinematic analysis was performed to estimate the motion between the socket and tibia for 10 individuals with a transtibial amputation performing walking and turning activities at 3 different speeds. The authors estimated the rotational stiffness of the limb-socket body to quantify the limb properties when coupled with the socket and highlight how this approach could help inform prosthetic prescriptions. Results showed that peak transverse displacement had a significant, linear relationship with peak transverse loading. Stiffness of the limb-socket body varied significantly between individuals, activities (walking and turning), and speeds. These results suggest that transverse limb loading can serve as a surrogate for residual-limb shear stress and that the setup of a prosthesis could be individually tailored using standard motion capture and inverse kinematic analyses.

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Svend Erik Mathiassen

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Devin S. Kielur and Cameron J. Powden

Context: Impaired dorsiflexion range of motion (DFROM) has been established as a predictor of lower-extremity injury. Compression tissue flossing (CTF) may address tissue restrictions associated with impaired DFROM; however, a consensus is yet to support these effects. Objectives: To summarize the available literature regarding CTF on DFROM in physically active individuals. Evidence Acquisition: PubMed and EBSCOhost (CINAHL, MEDLINE, and SPORTDiscus) were searched from 1965 to July 2019 for related articles using combination terms related to CTF and DRFOM. Articles were included if they measured the immediate effects of CTF on DFROM. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The level of evidence was assessed using the Strength of Recommendation Taxonomy. The magnitude of CTF effects from pre-CTF to post-CTF and compared with a control of range of motion activities only were examined using Hedges g effect sizes and 95% confidence intervals. Randomeffects meta-analysis was performed to synthesize DFROM changes. Evidence Synthesis: A total of 6 studies were included in the analysis. The average Physiotherapy Evidence Database score was 60% (range = 30%–80%) with 4 out of 6 studies considered high quality and 2 as low quality. Meta-analysis indicated no DFROM improvements for CTF compared with range of motion activities only (effect size = 0.124; 95% confidence interval, −0.137 to 0.384; P = .352) and moderate improvements from pre-CTF to post-CTF (effect size = 0.455; 95% confidence interval, 0.022 to 0.889; P = .040). Conclusions: There is grade B evidence to suggest CTF may have no effect on DFROM when compared with a control of range of motion activities only and results in moderate improvements from pre-CTF to post-CTF. This suggests that DFROM improvements were most likely due to exercises completed rather than the band application.

Open access

Robert J. Reyburn and Cameron J. Powden

Context: Ankle braces have been theorized to augment dynamic balance. Objectives: To complete a systematic review with meta-analysis of the available literature assessing the effect of ankle braces on dynamic balance in individuals with and without chronic ankle instability (CAI). Evidence Acquisition: Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to October 2019 using combinations of keywords related to dynamic balance, ankle braces, Star Excursion Balance Test (SEBT), Y-Balance Test (YBT), and Time to Stabilization. Inclusion criteria required that studies examined the effects of ankle braces on dynamic balance. Studies were excluded if they evaluated other conditions besides CAI, did not access dynamic balance, or did not use an ankle brace. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The level of evidence was assessed using the Strength of Recommendation Taxonomy. The magnitude of brace effects on dynamic balance was examined using Hedges g effect sizes (ESs) and 95% confidence intervals (CIs). Random-effects meta-analysis was performed to synthesize SEBT/YBT and Time to Stabilization data separately. Data Synthesis: Seven studies were included with a median Physiotherapy Evidence Database score of 60% (range 50%–60%), and 4 were classified as high quality. Overall meta-analysis indicated a weak to no effect of braces on SEBT/YBT (ES = 0.117; 95% CI, −0.080 to 0.433; P = .177) and Time to Stabilization (ES = −0.064; 95% CI, −0.211 to 0.083, P = .083). Subanalysis of SEBT/YBT measures indicated a weak negative effect in healthy participants (ES = −0.116; 95% CI, −0.209 to −0.022, P = .015) and a strong positive effect in individuals with CAI (ES = 0.777; 95% CI, 0.418 to 1.136; P < .001). Conclusion: The current literature supports a strong effect of ankle braces on the SEBT/YBT in those with CAI. However, little to no dynamic balance changes were noted in healthy participants. Future research should include consistent ankle brace types, pathologic populations, and the examination of dynamic balance changes contribution to injury risk reduction.

Open access

Diulian Muniz Medeiros, César Marchiori, and Bruno Manfredini Baroni

Context: Nordic hamstring exercise (NHE) has been widely employed to prevent hamstring strain injuries. However, it is still not clear which adaptations are responsible for the NHE preventive effects. Objectives: The aim of this study was to investigate the effects of NHE on knee flexors eccentric strength and fascicle length. Evidence Acquisition: The search strategy included MEDLINE, PEDro, and Cochrane CENTRAL from inception to April 2020. Randomized clinical trials that have analyzed the effects of NHE training on hamstring eccentric strength and/or fascicle length were included. Evidence Synthesis: From the 1932 studies identified, 12 were included in the systematic review, and 9 studies presented suitable data for the meta-analysis. All studies demonstrated strength increments in response to NHE training (10%–15% and 16%–26% in tests performed on the isokinetic dynamometer and on the NHE device, respectively), as well as significant enhancement of biceps femoris long head fascicle length (12%–22%). Meta-analysis showed NHE training was effective to increase knee flexors eccentric strength assessed with both isokinetic tests (0.68; 95% confidence interval, 0.29 to 1.06) and NHE tests (1.11; 95% confidence interval, 0.62 to 1.61). NHE training was also effective to increase fascicle length (0.97; 95% confidence interval, 0.46 to 1.48). Conclusions: NHE training has the potential of increasing both knee flexors eccentric strength and biceps femoris long head fascicle length.

Open access

Chee Vang and Alexander Niznik

Clinical Scenario: Patellar tendinopathy is a common musculoskeletal disorder affecting the lower-extremities and a difficult condition to manage for athletes that are in season. To facilitate improvement in function and to decrease pain, initial treatment for patellar tendinopathy is typically conservative. Traditional interventions may include eccentric training, cryotherapy, patellar counterforce straps, oral anti-inflammatories, injectable agents, phonophoresis, iontophoresis, orthotics, therapeutic ultrasound, and extracorporeal shockwave. In addition, recent literature suggests that implementing isometric and isotonic contractions may be effective in reducing patellar tendon pain. Focused Clinical Question: How effective are isometric contractions compared with isotonic contractions in reducing pain for in-season athletes with patellar tendinopathy? Summary of Key Findings: Implementation of isometric and isotonic exercises statistically reduced pain levels in the short term of 4 weeks for in-season athletes; however, isometric contractions provided statistically greater pain relief immediately for up to 45 minutes postintervention compared with isotonic contractions. Clinical Bottom Line: Current evidence supports the use of isometric and isotonic contractions to reduce pain for in-season athletes with patellar tendinopathy. Based on the reviewed literature, clinicians should consider utilizing heavy loaded isometrics or progressive heavy loaded isotonic exercises, which showed reduction in pain levels immediately after intervention and at 4-week follow-up for both intervention groups. Isometric contractions appear to provide greater pain relief immediately after intervention. Strength of Recommendation: There is Grade B evidence from 2 level 2 randomized controlled trials and 1 level 3 randomized crossover study supporting the use of isometric and isotonic contractions to reduce patellar tendon pain for in-season athletes.

Open access

Katherine L. Helly, Katherine A. Bain, Phillip A. Gribble, and Matthew C. Hoch

Clinical Scenario: Patients with chronic ankle instability (CAI) demonstrate deficits in both sensory and motor function, which can be objectively evaluated through static postural control testing. One intervention that has been suggested to improve somatosensation and, in turn, static postural control is plantar massage. Clinical Question: Does plantar massage improve static postural control during single-limb stance in patients with CAI relative to baseline? Summary of Key Findings: A search was performed for articles exploring the effect of plantar massage on static postural control in individuals with CAI. Three articles were included in this critically appraised topic including 1 randomized controlled trial and 2 crossover studies. All studies supported the use of plantar massage to improve static postural control in patients with CAI. Clinical Bottom Line: There is currently good-quality and consistent evidence that supports the use of plantar massage as an intervention that targets the somatosensory system to improve static postural control in patients with CAI. Future research should focus on incorporating plantar massage as a treatment intervention during long-term rehabilitation protocols for individuals with CAI. Strength of Recommendation: In agreement with the Center of Evidence-Based Medicine, the consistent results from 2 crossover studies and 1 randomized controlled trial designate that there is level B evidence due to consistent, moderate- to high-quality evidence.

Open access

Mackenzie Holman, Madeline P. Casanova, and Russell T. Baker

Context: Patient-reported outcomes are widely used in health care. The Disablement in the Physically Active (DPA) Scale Short Form-8 (SF-8) was recently proposed as a valid scale for the physically active population. However, further psychometric testing of the DPA SF-8 has not been completed, and scale structure has not been assessed using a sample of adolescent athletes. Objective: To assess scale structure of the DPA SF-8 in a sample of adolescent high-school athletes. Main Outcome Measure(s): Adolescent athletes (n = 289) completed the DPA SF-8. Confirmatory factor analysis (CFA) was conducted to assess the psychometric properties of the scale. Results: The CFA of the DPA SF-8 indicated that the model exceeded recommended fit indices (Comparative Fit Index = .976, Tucker–Lewis Index = .965, Root Mean Square Error of Approximation = .061, and Bollen’s Incremental Fit Index = .976). All factor loadings were significant and ranged from .62 to .86. Modification indices did not suggest that meaningful cross-loadings were present or additional specifications that could further maximize fit or parsimony. Conclusions: The CFA of the DPA SF-8 met contemporary model fit recommendations in the adolescent athlete population. The results confirmed initial findings supporting the psychometric properties of the DPA SF-8 as well as the uniqueness of the quality-of-life and physical summary factors in an adolescent population. Further research (eg, reliability, invariance between groups, minimal clinically important differences, etc) is warranted to inform scale use in clinical practice and research.

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Kate N. Jochimsen, Carl G. Mattacola, Brian Noehren, Kelsey J. Picha, Stephen T. Duncan, and Cale A. Jacobs

Context: Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS. Objective: (1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety. Design: Cross-sectional. Setting: University health center. Participants: Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2). Main Outcome Measures: Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann–Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function. Results: The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = −.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = −.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = −.43, P = .002) and pain during activity (ρ = −.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01). Conclusion: Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.

Open access

Caitlin Brinkman, Shelby E. Baez, Carolina Quintana, Morgan L. Andrews, Nick R. Heebner, Matthew C. Hoch, and Johanna M. Hoch

Context: Fast visuomotor reaction time (VMRT), the time required to recognize and respond to sequentially appearing visual stimuli, allows an athlete to successfully respond to stimuli during sports participation, while slower VMRT has been associated with increased injury risk. Light-based systems are capable of measuring both upper- and lower-extremity VMRT; however, the reliability of these assessments are not known. Objective: To determine the reliability of an upper- and lower-extremity VMRT task using a light-based trainer system. Design: Reliability study. Setting: Laboratory. Patients (or Other Participants): Twenty participants with no history of injury in the last 12 months. Methods: Participants reported to the laboratory on 2 separate testing sessions separated by 1 week. For both tasks, participants were instructed to extinguish a random sequence of illuminated light-emitting diode disks, which appeared one at a time as quickly as possible. Participants were provided a series of practice trials before completing the test trials. VMRT was calculated as the time in seconds between target hits, where higher VMRT represented slower reaction time. Main Outcome Measures: Separate intraclass correlation coefficients (ICCs) with corresponding 95% confidence intervals (CIs) were calculated to determine test–retest reliability for each task. The SEM and minimal detectable change values were determined to examine clinical applicability. Results: The right limb lower-extremity reliability was excellent (ICC2,1 = .92; 95% CI, .81–.97). Both the left limb (ICC2,1 = .80; 95% CI, .56–.92) and upper-extremity task (ICC2,1 = .86; 95% CI, .65–.95) had good reliability. Conclusions: Both VMRT tasks had clinically acceptable reliability in a healthy, active population. Future research should explore further applications of these tests as an outcome measure following rehabilitation for health conditions with known VMRT deficits.