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Patient Adherence for Blended Physiotherapy in Patients With Chronic Pain: A Critically Appraised Topic

Cynthia Miranda, Anne C. Russ, Ryan T. Tierney, and Jamie L. Mansell

Clinical Scenario: Chronic pain conditions affect approximately 30% of the world’s population, and treatment plans are often complex. 70% of patients fail to adhere to prescribed home exercise programs. One possible solution is blended physiotherapy, which combines in-person physical therapy and web-based applications to support. Clinical Question: In patients with chronic pain, is blended physiotherapy an effective approach to patient adherence when compared to traditional rehabilitation interventions? Summary of Key Findings: The literature search included studies including any form of blended physiotherapy assessing patient adherence outcome measures. A total of 22 were identified for inclusion criteria, and three were identified for data synthesis. Two studies found significant increases in patient adherence when applying blended physiotherapy. The third study reported lower patient adherence when comparing blended physiotherapy to standard treatment methods. Clinical Bottom Line: Current low-level evidence supports the use of blended physiotherapy as an effective approach for adherence in patients with chronic pain. Blended physiotherapy reported in the literature consisted of video-supported exercises; self-management skills; pain management education; and telephone support for low-, medium-, and high-risk patients with chronic pain. Use of blended physiotherapy promotes patient engagement and may enhance a patient-centered care environment.

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Positive Experiences Among Elite Athletes in Finland: Associations With Basic Psychological Needs, Sport Conditions, and Background Factors

Satu S. Kaski and Ulla Kinnunen

This research aimed to study the prevalence of PERMA experiences (Positive emotions, Engagement, (positive) Relationships, Meaning, and Accomplishment) among elite athletes in Finland (n = 2,045) and factors that are potentially connected to these experiences. The results indicated that, depending on the PERMA component, 40%–52% of the athletes had positive experiences in sports. A total of 42% of the athletes could be classified as flourishing. Feeling competent in sports was positively related to all PERMA experiences. The safe atmosphere of the team seemed to be of greater importance for PERMA components than coach behavior. Belonging to a minority group was negatively related to all positive experiences except for Engagement. Our results suggest that strengthening of athletes’ feeling of competence is essential in promoting positive experiences in sports, which are important for athletes’ functioning and success. In addition, sports organizations should pay more attention to how to strengthen equality and equity in sports.

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Influence of Sensory Integration and Visual Performance on Postural Control Under Differing Levels of Visual Occlusion in Those With Chronic Ankle Instability

Erik A. Wikstrom, Jaeho Jang, Lilly H. VanDeMark, Cassie B. Ford, and Jason P. Mihalik

Individuals with chronic ankle instability (CAI) have postural control deficits and appear to be more reliant on visual information to maintain balance. The underlying cause of this visual reliance remains unknown. Our purpose was to determine how sensory integration and visual performance influence postural control under different visual occlusion levels in those with CAI. Sensory integration ability, as measured by the Sensory Organization Test, was not associated with postural control in those with CAI. Visual performance variables, such as perception span, depth perception, and target capture explained between 13% and 45% of postural control variance across visual occlusion levels. The results suggest that improving visual performance in those with CAI may improve postural control across levels of visual occlusion.

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Comparison of Shoulder Rotation Strength and Test–Retest Reliability in 3 Test Positions With Swimmers

Trey D.W. Job III, Matthew R. Cross, and John B. Cronin

Context: Advancements in portable load-cell technology have enabled high-quality assessment of shoulder internal (IR) and external rotation (ER) peak force (Fmax) and rate of force development (RFD). This study’s purpose was to explore the reliability and differences between IR and ER Fmax and RFD in different testing positions using a novel load-cell device. Design: A within-subjects repeated-measures design was employed to compare the intersession values and reliability of Fmax and RFD for both shoulder IR and ER across 3 positions: seated-0°, supine-0° and supine-90°. Methods: National-level swimmers (n = 19; age = 16.8 [1.0] y) completed 3 testing occasions of each condition (combination of arm, rotation, and test position) separated by 7 to 14 days. Results: IR superseded ER in all testing positions. The association between these positions across IR and ER was typically strong for both Fmax and RFD (r > .85, P < .001) except for IR RFD (r = .56–.73, P < .05). For sessions 2 to 3, Fmax intraclass correlation coefficient and CV (intraclass correlation coefficient = .89–.96, CV = 5.2%–8.8%) were typically within acceptable ranges, whereas RFD (intraclass correlation coefficient = .74–.90, CV = 11.5%–18.1%) often exhibited inflated error. Conclusion: The supine (90°) position was the most consistent position across both measures. Load-cell technology can be confidently used to assess shoulder rotation Fmax in 3 different positions, whereas RFD should be used with caution without protocol refinement.

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Impact of Reach Height on Estimated Rotator Cuff Compression Risk in Manual Wheelchair Users With Spinal Cord Injury

Kylee M. Schaffer, Stefan I. Madansingh, Emma Fortune, Melissa M. Morrow, Kristin D. Zhao, and Beth A. Cloud-Biebl

Reaching is a common daily activity requiring a range of humeral elevation that contributes to rotator cuff compression. The purpose of this study was to estimate supraspinatus and infraspinatus tendon compression risk relative to the acromion and coracoacromial ligament during reaching by manual wheelchair users with spinal cord injury. A cross-sectional design was used to evaluate 8 participants (7 males, median [range] age 36 y [23–61]). Electromagnetic motion capture recorded shoulder kinematics while participants reached for a can at 2 heights: low (0.91 m) and high (1.37 m). Using 1 set of computed tomographic-based bone models and individual glenohumeral kinematics, compression risk was evaluated as the percentage of the reach activity and number of seconds that tendon insertions were less than 5 mm from scapular landmarks. Reach conditions were compared using a Wilcoxon signed-rank test (α = .05). Although not statistically significant, the supraspinatus and infraspinatus relative to the acromion had approximately 40% of the activity duration or 0.8 seconds more time under 5 mm in low versus high reach, indicating increased risk of compression. Compression risk estimates were consistent with prior publications on planar arm movements. Estimating the risk of tendon compression using absolute time may help with understanding cumulative exposure during day-to-day activity.

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Individualization of Footwear for Optimizing Running Economy: A Theoretical Framework

Mark J. Connick and Glen A. Lichtwark

Advanced footwear technologies contain thicker, lightweight, and more resilient midsoles and are associated with improved running economy (RE) compared with traditional footwear. This effect is highly variable with some individuals gaining a greater RE benefit, indicating that biomechanics plays a mediating role with respect to the total effect. Indeed, the energy generated by contractile elements and the elastic energy recovered from stretched tendons and ligaments in the legs and feet are likely to change with footwear. Therefore, if RE is to be maximized according to individual characteristics, an individualized approach to footwear selection is required. However, current theoretical frameworks hinder this approach. Here, we introduce a framework that describes causal relationships between footwear properties, biomechanics, and RE. The framework proposes that RE changes with footwear due to (1) a direct effect of footwear properties—for example, increased or decreased energy return—and (2) a mediating effect of footwear on ankle and foot biomechanics and the spring-mass system. By describing the total effect as 2 complementary pathways, the framework facilitates research that aims to separately quantify direct and mediating effects of footwear. This may permit the development of footwear materials that can separately target the direct and individual mediating effects.

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Acquisition, Retention, and Transfer Effects of Landing Training to Increase Foot Progression Angle During Bilateral Drop Landings

Joshua T. Weinhandl, Alec M. Genter, Shelby A. Peel, Songning Zhang, and Jeffrey T. Fairbrother

Foot position during landing directly influences knee mechanics. Thus, the purpose of this study was to determine success in practicing, repeating, and transferring a desired foot progression angle (FPA) during landing, as well as changes in knee mechanics. Twenty females were randomly assigned to a control or verbal instruction group. On day 1, each group performed 40 drop landings. The verbal instruction group was instructed to “Land with 30 degrees of external rotation” before every trial. Feedback was provided on a terminal schedule in the form of knowledge of FPA error. On day 2, retention was assessed with 5 drop landings, while transfer was assessed during a 2-step stop-jump landing. Repeated-measures analyses of variance (2 × 4 [group × time]) were used to assess the influence of verbal instruction on knee mechanics. Participants who received verbal instruction exhibited increased FPA. They also demonstrated increased initial contact knee abduction during acquisition and retention. For all participants, initial contact knee flexion increased, while peak knee adduction moment decreased during acquisition. While the verbal instruction cue was effective in promoting an increase in FPA and reducing some ACL injury risk factors during practice and retention, this cue may only be effective to tasks similar to what was practiced.

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Association Between Lower Extremity Muscle Strength and Knee Loading During 180° Pivot Turn in Female Players

Mari Leppänen, Jari Parkkari, Tron Krosshaug, Tommi Vasankari, Pekka Kannus, and Kati Pasanen

Sufficient muscle strength is suggested to reduce frontal plane knee loading during change of direction maneuvers. However, it is currently not thoroughly understood if lower extremity strength is associated with increased frontal plane knee biomechanics during change of direction in youth female team sport players. The objective of this cross-sectional study was to investigate the influence of maximal muscle strength on knee valgus angle and knee abduction moment during 180° pivot turn in 106 youth female team sport players. Lower hip abductor strength, lower knee extensor strength, and higher knee flexor strength were associated with increased knee valgus. Higher knee flexor and leg press strength were associated with increased knee abduction moment. The study found associations between both decreased and increased lower extremity muscle strength and frontal plane knee biomechanics. However, these associations could explain only 20% of the variance in frontal plane knee biomechanics at best.

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Effects of Neuromuscular Electrical Stimulation Waveforms and Occlusion Pressures on Elicited Force and Microvascular Oxygenation

Trent E. Cayot, James W. Bellew, Estefania Zapata-Rodriguez, Justin Rutherford, Sofia Simpson, Sam Somesan, Trevor Edgerton, Dawson Labaw, Joe Northam, and Caleb Bowling

Context: Interest in the effects of concurrently using neuromuscular electrical stimulation (NMES) and blood flow restriction (BFR) to improve muscle strength has risen, but limited studies and inconsistent findings have led to more questions. The 2 current projects aimed to systematically investigate how NMES waveform shape and BFR occlusion pressure acutely influence electrically elicited force (EEF) and tissue oxygen saturation (StO2) of the knee extensors. Design: A single-session repeated-measures design was followed. Methods: EEF and StO2 were measured in 2 different groups of 15 participants during 3 sets of NMES contractions. Ten NMES contractions per set were performed with 5 minutes of passive interset recovery. In the first project, different NMES waveforms (RUS, Russian burst-modulated alternating current; VMS, biphasic pulsed current; and VMS-Burst, burst-modulated biphasic pulsed current) were administered for each set, while BFR was applied at 60% limb occlusion pressure (LOP). During the second projet, VMS was administered, while a different BFR occlusion pressure (0% LOP, 40% LOP, and 80% LOP) was used during each set. Two-way repeated-measures analysis of variance examined if repetition and/or NMES waveform (first project) or BFR occlusion pressure (second project) significantly affected (P < .05) EEF or StO2. Results: VMS (12% [7%] MVIF) and VMS-Burst (13% [10%] MVIF) led to higher EFF compared with RUS (6% [5%] MVIF) with 60% LOP; 80% LOP (20% [14%] MVIF) led to lower EEF compared with 0% LOP (29% [17%] MVIF) with VMS. No significant differences in StO2 were observed between NMES waveforms or BFR occlusion pressures. Conclusions: If a clinician wanted to concurrently use NMES and BFR, the acute findings of the current projects would suggest the use of VMS or VMS-Burst with lower BFR occlusion pressure (40% LOP). However, further investigation into how these parameters would influence muscle strength subsequent to a training/rehabilitation intervention should be performed.

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Evaluating the Relationship Between Surface and Intramuscular-Based Electromyography Signals: Implications of Subcutaneous Fat Thickness

Matthew S. Russell, Sam S. Vasilounis, Daniel Desroches, Talia Alenabi, Janessa D.M. Drake, and Jaclyn N. Chopp-Hurley

Intramuscular (iEMG) and surface electromyographic (sEMG) signals have been compared previously using predictive regression equations, finite element modeling, and correlation and cross-correlation analyses. Although subcutaneous fat thickness (SCFT) has been identified as a primary source of sEMG signal amplitude attenuation and low-pass filter equivalence, few studies have explored the potential effect of SCFT on sEMG and iEMG signal characteristics. The purpose of this study was to investigate the relationship between normalized submaximal iEMG and sEMG signal amplitudes collected from 4 muscles (rectus femoris, vastus lateralis, infraspinatus, and erector spinae) and determine whether SCFT explains more variance in this relationship. The effect of sex was also explored. Linear regression models demonstrated that the relationship between sEMG and iEMG was highly variable across the muscles examined (adjusted coefficient of determination [Adj R 2] = .02–.74). SCFT improved the model fit for vastus lateralis, although this relationship only emerged with the inclusion of sex as a covariate. Thus, this research suggests that SCFT is not a prominent factor affecting the linearity between sEMG and iEMG. Researchers should investigate other parameters that may affect the linearity between sEMG and iEMG signals.