Context: What is the correct resistive load to start resistive training with elastic resistance to gain strength? This question is typically answered by the clinician’s best estimate and patient’s level of discomfort without objective evidence. Objective: To determine the average level of resistance to initiate a strengthening routine with elastic resistance following isometric strength testing. Design: Cohort. Setting: Clinical. Participants: 34 subjects (31 ± 13 y, 73 ± 17 kg, 170 ± 12 cm). Interventions: The force produced was measured in Newtons (N) with an isometric dynamometer. The force distance was the distance from center of joint to location of force applied was measured in meters to calculate torque that was called “Test Torque” for the purposes of this report. This torque data was converted to “Exercise Load” in pounds based on the location where the resistance was applied, specifically the distance away from the center of rotation of the exercising limb. The average amount of exercise load as percentage of initial Test Torque for each individual for each exercise was recorded to determine what the average level of resistance that could be used for elastic resistance strengthening program. Main Outcome Measures: The percentage of initial test torque calculated for the exercise was recorded for each exercise and torque produced was normalized to body weight. Results: The average percentage of maximal isometric force that was used to initiate exercises was 30 ± 7% of test torque. Conclusions: This provides clinicians with an objective target load to start elastic resistance training. Individual variations will occur but utilization of a load cell during elastic resistance provides objective documentation of exercise progression.
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Kyle Matsel, Claire Davies, and Tim Uhl
Clinical Scenario: Shoulder pain is a very common symptom encountered in outpatient physical therapy practice. In addition to therapeutic exercise and manual therapy interventions, trigger point dry needling (TDN) has emerged as a possible treatment option for reducing shoulder pain and improving function. Dry needling consists of inserting a thin stainless-steel filament into a myofascial trigger point with the intention of eliciting a local twitch response of the muscle. It is theorized that this twitch response results in reduced muscle tension and can aid in reduced pain and disability. To this point, multiple studies have found TDN to be effective at reducing pain and improving function in the short-term, but the long-term outcomes remain unknown. Clinical Question: Does the addition of TDN to an exercise program result in better long-term pain intensity and disability reduction in patients with shoulder pain? Summary of Findings: Improvement in long-term pain and function can be expected regardless of the addition of TDN to an evidence-based exercise program for patients with shoulder pain. Clinical Bottom Line: Either TDN or an evidence-based therapeutic exercise program elicits improved long-term pain and disability reduction in patients with shoulder pain, which suggests that clinicians can confidently use either approach with their patients. Strength of Recommendation: Strong evidence (level 2 evidence with PEDro scores >8/10) suggesting that TDN does not outperform therapeutic exercise regarding long-term pain reduction.
Mark Kluemper, Tim Uhl, and Heath Hazelrigg
Context:
Imbalanced shoulder muscles might cause poor posture in swimmers, which has been implicated as potential cause of injury.
Objective:
To determine whether a training program can reduce forward shoulder posture.
Design:
Prospective pseudorandomized.
Setting:
College swimming pool.
Participants:
39 competitive swimmers (age 16 ± 2 years) divided into an exercise group (n = 24) and a control group (n = 15).
Intervention:
The experimental group performed a partner-stretching program on the anterior shoulder muscles and a strengthening regimen focusing on the posterior shoulder muscles for 6 weeks. The control group participated in normal swim-training activities.
Main Outcome Measures:
Shoulder posture was measured as the distance from the anterior acromion to a wall using a double-square method.
Results:
The experimental group significantly reduced the distance of the acromion from the wall in a resting posture (–9.6 ± 7.3 mm) as compared with the control group (–2.0 ± 6.9 mm).
Conclusions:
A training routine might reduce the forward shoulder posture present in most competitive swimmers.
Elizabeth Lawinger, Tim L. Uhl, Mark Abel, and Srinath Kamineni
Objective:
The overarching goal of this study was to examine the use of triaxial accelerometers in measuring upper-extremity motions to monitor upper-extremity-exercise compliance. There were multiple questions investigated, but the primary objective was to investigate the correlation between visually observed arm motions and triaxial accelerometer activity counts to establish fundamental activity counts for the upper extremity.
Study Design:
Cross-sectional, basic research.
Setting:
Clinical laboratory.
Participants:
Thirty healthy individuals age 26 ± 6 y, body mass 24 ± 3 kg, and height 1.68 ± 0.09 m volunteered.
Intervention:
Participants performed 3 series of tasks: activities of daily living (ADLs), rehabilitation exercises, and passive shoulder range of motion at 5 specific velocities on an isokinetic dynamometer while wearing an accelerometer on each wrist. Participants performed exercises with their dominant arm to examine differences between sides. A researcher visually counted all arm motions to correlate counts with physical activity counts provided by the accelerometer.
Main Outcome Measure:
Physical activity counts derived from the accelerometer and visually observed activity counts recorded from a single investigator.
Results:
There was a strong positive correlation (r = .93, P < .01) between accelerometer physical activity counts and visual activity counts for all ADLs. Accelerometers activity counts demonstrated side-to-side difference for all ADLs (P < .001) and 5 of the 7 rehabilitation activities (P < .003). All velocities tested on the isokinetic dynamometer were shown to be significantly different from each other (P < .001).
Conclusion:
There is a linear relationship between arm motions counted visually and the physical activity counts generated by an accelerometer, indicating that arm motions could be potentially accounted for if monitoring arm usage. The accelerometers can detect differences in relatively slow arm-movement velocities, which is critical if attempting to evaluate exercise compliance during early phases of shoulder rehabilitation. These results provide fundamental information that indicates that triaxial accelerometers have the potential to objectively monitor and measure arm activities during rehabilitation and ADLs.
Nicole Cascia, Tim L. Uhl, and Carolyn M. Hettrich
Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. Successful RTP rates (66%–100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. Strength of Recommendation: There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.
Robert English, Mary Brannock, Wan Ting Chik, Laura S. Eastwood, and Tim Uhl
Context:
Lower extremity functional testing assesses strength, power, and neuro-muscular control. There are only moderate correlations between distance hopped and isokinetic strength measures.
Objective:
Determine if incorporating body weight in the single-leg hop for distance increases the correlation to isokinetic measures.
Study Design:
Correlational study.
Setting:
Musculoskeletal laboratory.
Participants:
30 healthy college students; 15 men and 15 women; ages 18 to 30 years.
Main Outcome Measures:
Isokinetic average peak torque and total work of quadriceps and hamstrings and single-leg hop work and distance.
Results:
Significant correlations include hop work to total-work knee extension (r = .89), average peak-torque knee extension (r = .88), distance hopped to total-work knee extension (r = .56) and average peak-torque knee extension (r = .63). Correlations involving hop work were greater than distance hopped (P < .05).
Conclusions:
Use of body weight in the assessment of distance hopped provides better information about the patient’s lower extremity strength and ability than the distance hopped alone.
Oliver Silverson, Nicole Cascia, Carolyn M. Hettrich, Matt Hoch, and Tim Uhl
Clinical Scenario: Assessing movement of the scapula is an important component in the evaluation and treatment of the shoulder complex. Currently, gold-standard methods to quantify scapular movement include invasive technique, radiation, and 3D motion systems. This critically appraised topic focuses on several clinical assessment methods of quantifying scapular upward rotation with respect to their reliability and clinical utility. Clinical Question: Is there evidence for noninvasive methods that reliably assess clinical measures of scapular upward rotation in subjects with or without shoulder pathologies? Summary of Key Findings: Four studies were selected to be critically appraised. The quality appraisal of diagnostic reliability checklist was used to score the articles on methodology and consistency. Three of the 4 studies demonstrated support for the clinical question. Clinical Bottom Line: There is moderate evidence to support reliable clinical methods for measuring scapular upward rotation in subjects with or without shoulder pathology. Strength of Recommendation: There is moderate evidence to suggest there are reliable clinical measures to quantify scapular upward rotation in patients with or without shoulder pathology.
Christopher Melton, David R. Mullineaux, Carl G. Mattacola, Scott D. Mair, and Tim L. Uhl
Context:
Dynamic shoulder motion can be captured using video capture systems, but reliability has not yet been established.
Objective:
To compare the reliability of 2 systems in measuring dynamic shoulder kinematics during forward-elevation movements and to determine differences in these kinematics between healthy and injured subjects.
Design:
Reliability and cohort.
Setting:
Research laboratory.
Participants:
11 healthy subjects and 10 post–superior labrum anteroposterior lesion patients (SLAP).
Intervention:
Contrasting markers were placed at the hip, elbow, and shoulder to represent shoulder elevation and were videotaped in 2 dimensions. Subjects performed 6 repetitions of active elevation (AE) and active assisted elevation of the shoulder, and 3 trials were analyzed using Datapac (comprehensive system) and Dartfish (basic system).
Main Outcome Measures:
Amplitudes and velocities of the shoulder angle were calculated. Intraclass correlation coefficient (ICC), standard error of measurement (SEM), and levels of agreement (LOA) were used to determine intersystem and intertrial reliability.
Results:
For AE, the amplitude maximum (ICC = .98–.99, SEM = 2–3°, LOA = −9° to 5°) and average velocity (ICC = .94–.97, SEM = 1°/s, LOA = −4° to 1°/s) indicated excellent intersystem reliability between systems. Intratrial reliability for minimum velocity was moderate for Datapac (ICC = .64, SEM = 4°/s, LOA = 7°/s) and poor for Dartfish (ICC = .52, SEM = 20°/s, LOA = 37°/s). Cohort results demonstrated for AE a greater amplitude for healthy v SLAP (139° ± 11° v 113° ± 13°; P = .001) and interaction for an average velocity increase of 2°/s in healthy and decrease of 2°/s in SLAP patients over the 3 trials (P = .02).
Conclusions:
Reliability ranges provide the means to assess the clinical meaningfulness of results. The cohort differences are supported when the values exceed the ranges of the SEM; hence the amplitude results are meaningful. For dynamic shoulder elevation measured using video, the assessment of velocity was found to produce moderate to good reliability. The results suggest that with these measures subtle changes in both measures may be possible with further investigations.
