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Maja Zamoscinska, Irene R. Faber and Dirk Büsch

Clinical Scenario: Reduced bone mineral density (BMD) is a serious condition in older adults. The mild form, osteopenia, is often a precursor of osteoporosis. Osteoporosis is a pathological condition and a global health problem as it is one of the most common diseases in developed countries. Finding solutions for prevention and therapy should be prioritized. Therefore, the critically appraised topic focuses on strength training as a treatment to counteract a further decline in BMD in older adults. Clinical Question: Is strength training beneficial in increasing BMD in older people with osteopenia or osteoporosis? Summary of Key Findings: Four of the 5 reviewed studies with the highest evidence showed a significant increase in lumbar spine BMD after strength training interventions in comparison with control groups. The fifth study confirmed the maintenance of lumbar spine density due to conducted exercises. Moreover, 3 reviewed studies revealed increasing BMD at the femoral neck after strength training when compared with controls, which appeared significant in 2 of them. Clinical Bottom Line: The findings indicate that strength training has a significant positive influence on BMD in older women (ie, postmenopausal) with osteoporosis or osteopenia. However, it is not recommended to only rely on strength training as the increase of BMD may not appear fast enough to reach the minimal desired values. A combination of strength training and supplements/medication seems most adequate. Generalization of the findings to older men with reduced BMD should be done with caution due to the lack of studies. Strength of Recommendation: There is grade B of recommendation to support the validity of strength training for older women in postmenopausal phase with reduced BMD.

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Robson Dias Scoz, Cesar F. Amorim, Bruno O.A. Mazziotti, Rubens A. Da Silva, Edgar R. Vieira, Alexandre D. Lopes and Ronaldo E.C.D. Gabriel

Objective: To assess the diagnostic validity of an isokinetic testing to detect partial injuries on the anterior cruciate ligament (ACL). Design: Prospective diagnostic study. Settings: Orthopedic clinic, physiotherapy clinic, orthopedic hospital, and diagnostic/image clinic. Participants: Consecutive patients (n = 29) with unilateral knee complaint submitted to physical examination, magnetic resonance images (MRIs), and isokinetic testing prior to surgery of ACL reconstruction. Interventions: Not applicable. Main Outcome Measures: The isokinetic torque curves data from extensor and flexor muscles were converted to frequency domain by fast Fourier transformation and compared with healthy contralateral limb. Differences were categorized as unstable knees and these conclusions were compared with patient’s physical examinations (doctor’s conclusion on ACL integrity) and MRIs (as the radiologist conclusions on ACL integrity). After surgery, all intraoperatively confirmed partial injured patient’s data were collected. The diagnostic accuracy measures to compare the conclusions of all 3 professionals included sensitivity, specificity, positive predictive value, negative predictive value, disease prevalence, positive likelihood ratio, and accuracy—all using a confidence interval of 95%. Results: Compared with MRI, the sensitivity of isokinetic test for an ACL partial injury was 90.00%, specificity 83.33%, positive predictive value 52.94%, negative predictive value 97.56%, and accuracy 84.48%. Compared with physical examination, the sensitivity of isokinetic test for an ACL partial injury was 85.71%, specificity 78.43%, positive predictive value 35.29%, negative predictive value 97.56%, and accuracy 79.31%. Conclusions: This method of isokinetic data analysis through fast Fourier transformation can be used to improve diagnostic accuracy of a difficult detection injury. Even present, a partial ACL injury can produce a stable knee during isokinetic testing and could be used to detect candidates for conservative treatment based on strengthening exercises, reducing surgery risks, and financial and social impact on patient’s life.

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Christian A. Clermont, Andrew J. Pohl and Reed Ferber

Context: The risk of experiencing an overuse running-related injury can increase with atypical running biomechanics associated with neuromuscular fatigue and/or training errors. While it is important to understand the changes in running biomechanics within a fatigue-inducing run, it may be more clinically relevant to assess gait patterns in the days following a marathon to better evaluate the effects of inadequate recovery on injury. Objective: To use center of mass (CoM) acceleration patterns to investigate changes in running patterns prior to (PRE) and at 2 (POST2) and 7 (POST7) days following a marathon race. Design: Pre–post intervention study. Setting: A 200-m oval track surface. Participants: Seventeen recreational marathon runners (10 females, age = 34.2 [5.67] y; 7 males, age = 47.41 [15.32] y). Intervention: Marathon race. Main Outcome Measures: An inertial measurement unit was placed near the CoM to collect triaxial acceleration data during overground running for PRE, POST2, and POST7 sessions. Twenty-two features were extracted from the acceleration waveforms to characterize different aspects of running gait. Lower-limb musculoskeletal pain was also recorded at each session with a visual analog scale. Results: At POST2, runners reported higher self-reported pain and exhibited elevated peak mediolateral acceleration with an increased mediolateral ratio of acceleration root mean square compared with PRE. At POST7, pain was reduced and more similar to PRE, with runners demonstrating increased stride regularity in the vertical direction and decreased peak resultant acceleration. Conclusions: The observed changes in CoM motion at POST2 may be associated with atypical running biomechanics that can translate to greater mediolateral impulses, potentially increasing the risk of injury. This study demonstrates the use of an accelerometer as an effective tool to detect atypical CoM motion for runners due to fatigue, recovery, and musculoskeletal pain in real-world environments.

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Neal R. Glaviano, Ashley N. Marshall, L. Colby Mangum, Joseph M. Hart, Jay Hertel, Shawn Russell and Susan Saliba

Context: Patellofemoral pain (PFP) is a challenging condition, with altered kinematics and muscle activity as 2 common impairments. Single applications of patterned electrical neuromuscular stimulation (PENS) have improved both kinematics and muscle activity in females with PFP; however, the use of PENS in conjunction with a rehabilitation program has not been evaluated. Objective: To determine the effects of a 4-week rehabilitation program with PENS on lower-extremity biomechanics and electromyography (EMG) during a single-leg squat (SLS) and a step-down task (SDT) in individuals with PFP. Study Design: Double-blinded randomized controlled trial. Setting: Laboratory. Patients of Other Participants: Sixteen females with PFP (age 23.3 [4.9] y, mass 66.3 [13.5] kg, height 166.1 [5.9] cm). Intervention: Patients completed a 4-week supervised rehabilitation program with or without PENS. Main Outcome Measures: Curve analyses for lower-extremity kinematics and EMG activity (gluteus maximus, gluteus medius, vastus medialis oblique, vastus lateralis, biceps femoris, and adductor longus) were constructed by plotting group means and 90% confidence intervals throughout 100% of each task, before and after the rehabilitation program. Mean differences (MDs) and SDs were calculated where statistical differences were identified. Results: No differences at baseline in lower-extremity kinematics or EMG were found between groups. Following rehabilitation, the PENS group had significant reduction in hip adduction between 29% and 47% of the SLS (MD = 4.62° [3.85°]) and between 43% and 69% of the SDT (MD = 6.55° [0.77°]). Throughout the entire SDT, there was a decrease in trunk flexion in the PENS group (MD = 10.91° [1.73°]). A significant decrease in gluteus medius activity was seen during both the SLS (MD = 2.77 [3.58]) and SDT (MD = 4.36 [5.38]), and gluteus maximus during the SLS (MD = 1.49 [1.46]). No differences were seen in the Sham group lower-extremity kinematics for either task. Conclusion: Rehabilitation with PENS improved kinematics in both tasks and decreased EMG activity. This suggests that rehabilitation with PENS may improve muscle function during functional tasks.

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Megan Q. Beard, Samantha A. Boland and Phillip A. Gribble

Decreased hip strength is often present in patients with chronic overuse lower extremity injuries. The hand-held dynamometer (HHD) can be used in a clinical setting to quantify hip strength; however, reliability of the device remains unclear. The purpose of this study was to determine the interexaminer and intersession reliability of a HHD when measuring isometric hip abduction (HABD) and external rotation (HER) strength, both with and without a fixed strap. The HHD had good to high reliability regardless of examiner, session, or stabilization when measuring HABD (ICC = 0.885–0.977) and HER (ICC = 0.879–0.958) isometric strength. HHD is an appropriate instrument for measuring isometric hip strength.

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Robert S. Thiebaud, Takashi Abe, Jeremy P. Loenneke, Tyler Garcia, Yohan Shirazi and Ross McArthur

Context: Blood flow restriction (BFR) increases muscle size and strength when combined with low loads, but various methods are used to produce this stimulus. It is unclear how using elastic knee wraps can impact acute muscular responses compared with using nylon cuffs, where the pressure can be standardized. Objective: Investigate how elastic knee wraps compare with nylon cuffs and high-load (HL)/low-load (LL) resistance exercise. Design: A randomized cross-over experimental design using 6 conditions combined with unilateral knee extension. Setting: Human Performance Laboratory. Participants: A total of 9 healthy participants (males = 7 and females = 2) and had an average age of 22 (4) years. Intervention: LL (30% of 1-repetition maximum [1-RM]), HL (70% 1-RM), BFR at 40% of arterial occlusion pressure (BFR-LOW), BFR at 80% of arterial occlusion pressure (BFR-HIGH), elastic knee wraps stretched by 2 in (PRACTICAL-LOW), and elastic knee wraps stretched to a new length equivalent to 85% of thigh circumference (PRACTICAL-HIGH). BFR and practical conditions used 30% 1-RM. Main Outcome Measures: Muscle thickness, maximum voluntary isometric contraction, and electromyography amplitude. Bayesian statistics evaluated differences in changes between conditions using the Bayes factor (BF10), and median and 95% credible intervals were reported from the posterior distribution. Results: Total repetitions completed were greater for BFR-LOW versus PRACTICAL-HIGH (BF10 = 3.2, 48.6 vs 44 repetitions) and greater for PRACTICAL-LOW versus BFR-HIGH (BF10 = 717, 51.8 vs 36.3 repetitions). Greater decreases in changes in maximum voluntary isometric contraction were found in PRACTICAL-HIGH versus HL (BF10 = 1035, ∼103 N) and LL (BF10 = 45, ∼66 N). No differences in changes in muscle thickness were found between LL versus PRACTICAL-LOW/PRACTICAL-HIGH conditions (BF10 = 0.32). Greater changes in electromyography amplitude were also found for BFR-LOW versus PRACTICAL-HIGH condition (BF10 = 6.13, ∼12%), but no differences were noted between the other BFR conditions. Conclusions: Overall, elastic knee wraps produce a more fatiguing stimulus than LL or HL conditions and might be used as an alternative to pneumatic cuffs that are traditionally used for BFR exercise.

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Brian W. Wiese, Kevin Miller and Eduardo Godoy

A 19-year-old African-American male Division I collegiate American football player with no prior history of shoulder injury presented with right shoulder pain after making a tackle during a game. He was initially diagnosed with a rotator cuff strain with potential underlying labral pathology. Subsequent magnetic resonance imaging arthrogram showed no labral tearing, though a Buford complex was identified. A Buford complex is a normal anatomical labral variant where the anterior labrum is absent and the middle glenohumeral ligament is “cord-like” in structure. This case was managed conservatively since surgical intervention is only recommended if there is a secondary pathology to the shoulder (e.g., type II superior labrum anterior to posterior [SLAP] lesions). Clinicians should be aware of Buford complexes because they can predispose athletes to secondary injuries and can be managed successfully with a conservative rehabilitation approach in the absence of secondary pathology.

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Timothy A. Kulpa, Jamie Mansell, Anne Russ and Ryan Tierney

Context: Patients who do not fully recover from a concussion in 7–14 days may require an impairment-based rehabilitation program. Recent evidence indicates improved outcomes with active rehabilitation compared to passive physical and cognitive rest. Clinical Question: In patients with persistent symptoms (greater than 4 weeks) following concussion, how does aerobic exercise affect postconcussion symptoms? Clinical Bottom Line: There is moderate and sufficient SORT Level B evidence to support the inclusion of subsymptom threshold (SST) exercise in the multimodal treatment plan for patients suffering from persistent symptoms after concussion. All five included studies reported moderate to very large effects ranging from d = 0.72 to d = 10.64 in reducing symptoms after the implementation of SST aerobic exercise. Additionally, two studies also identified moderate and very large effects (d = 0.77, d = 2.56) favoring aerobic exercise over stretching interventions. These results indicate that this treatment has potential clinical utility and is a viable option to reduce symptoms in patients with postconcussion syndrome and persistent symptoms following concussion.

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Fatemeh Ehsani, Rozita Hedayati, Rasool Bagheri and Shapour Jaberzadeh

Context: Chronic low back pain (CLBP) often presents with a dysfunction in deep abdominal muscles activity during standing tasks. Although some studies indicated that deep abdominal muscle activity improved during some functional tasks following stabilization exercise (SE), there is no study to evaluate the effect of SE on lateral abdominal muscles thickness during standing postural tasks. Objective: The purpose of this study was (1) to evaluate the lateral abdominal muscles thickness in the participants with CLBP while standing on a balance board and (2) to compare the effects of SE and a general exercise (GE) program on the lateral muscles thickness changes. Methods: This was a between-groups, triple-blinded randomized controlled trial design. In total, 40 females with CLBP were randomly assigned into 2 groups:  GE (control group) and supervised progressive SE (experimental group). Diagnostic ultrasound imaging was used before and after the intervention to measure lateral abdominal muscles thickness during standing on 2 different levels of platform in the Biodex Balance System. Visual analog scale and Roland–Morris Disability Questionnaire were used to evaluate changes in pain intensity and disability. Results: The results indicated significant increases in transverse abdominis muscle thickness during all standing tasks (P = .02) and significant decreases in pain intensity and disability following SE intervention (P < .001). However, the lateral abdominal muscle thicknesses were not changed after GE intervention while standing postural tasks (P > .05). The GE group revealed only significant decreases in pain intensity after intervention (P = .03). Conclusion: Supervised progressive SE improved the activity of deep abdominal muscles in standing postural tasks in the patients with CLBP.

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Erik A. Wikstrom, Kyeongtak Song, Kimmery Migel and Chris J. Hass

Aberrant loading is a mechanism by which individuals with chronic ankle instability (CAI) may negatively impact cartilage health and therefore long-term health outcomes. We aimed to quantify walking vertical ground reaction force (vGRF) component differences between those with and without CAI. Participants (n = 36) walked barefoot overground at a self-selected comfortable pace. Normalized peak vGRF, time to peak vGRF, and normalized loading rate were calculated. Higher normalized loading rates (CAI: 5.69 ± 0.62 N/BW/s; controls: 5.30 ± 0.44 N/BW/s, p = .034) and less time to peak vGRF (CAI: 1.48 ± 0.18 s; controls: 1.62 ± 0.16 s, p = .018) were observed in those with CAI. In conclusion, those with CAI demonstrate a higher normalized loading rate and less time to peak vGRF compared to controls.