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William R. Holcomb

Electrical therapy is a popular therapeutic modality for the management and rehabilitation of athletic injuries. Electrical stimulation is commonly used to elicit muscle contraction, reduce edema, and control pain. However, electrical therapy can also be a tremendous challenge for clinicians. The purpose of this paper is to present current and accurate information that will serve as a guide In the use of electrical therapy for the effective management of athletic injuries. With an understanding of the basic current types provided by various electrical stimulators and the modifications of the currents that are available, electrical therapy becomes an invaluable tool for injury management and rehabilitation.

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William R. Holcomb

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William R. Holcomb and Chris Blank

Context:

Ultrasound significantly raises tissue temperature, but the time of temperature elevation is short.

Objective:

To assess the effectiveness of superficial preheating on temperature elevation and decline when using ultrasound.

Design:

Within-subjects design to test the independent variable, treatment condition; repeated-measures ANOVAs to analyze the dependent variables, temperature elevation and decline.

Setting:

Athletic training laboratory.

Intervention:

Temperature at a depth of 3.75 cm was measured during ultrasound after superficial heating and with ultrasound alone.

Subjects:

10 healthy men.

Main Outcome Measure:

Temperature was recorded every 30 s during 15 min of ultrasound and for 15 min afterward.

Results:

Temperature elevation with ultrasound was significantly greater with preheating (4.0 ± 0.21 °C) than with ultrasound alone (3.0 ± 0.22 °C). Temperature decline was not significantly different between preheating and ultrasound alone.

Conclusions:

Superficial preheating significantly increases temperature elevation but has no effect on temperature decline during a 15-min cooling period.

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William R. Holcomb, Shahin Golestani and Shante Hill

Context:

Neuromuscular electrical stimulation (NMES) can be used to prevent the atrophy and strength loss associated with immobilization.

Objective:

To compare the effects of biphasic current and the modulated “Russian” current on muscular torque production during different contraction conditions.

Design, Setting, and Participants:

In a within-subjects design, 10 healthy subjects in an athletic training laboratory received NMES.

Interventions:

Isometric knee-extension torque was recorded with the Biodex™ under 4 conditions: maximum voluntary contraction (MVC; control), MVC superimposed with low-intensity stimulation (sham), MVC superimposed with high-intensity stimulation, and high-intensity stimulation only.

Main Outcome Measure:

Data normalized for body weight were analyzed using a 2 (current type) X 4 (condition) repeated-measures analysis of variance.

Results:

The main effect for current type was not significant, F1,9 = .03, P = .87.

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William R. Holcomb and Douglas M. Kleiner

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Mack D. Rubley, William R. Holcomb and Mark A. Guadagnoli

Context:

Cryotherapy is initially uncomfortable, but habituation is thought to occur during treatment.

Objective:

To examine pain habituation to ice-bath immersion over 5 consecutive days.

Design:

Mean Borg ratings were analyzed by ANOVA.

Setting:

Athletic training laboratory.

Intervention:

Ankle immersion in a 1 °C ice bath for 20 min.

Participants:

28 healthy individuals.

Main Outcome Measure:

Level of discomfort was rated at immersion; during treatment at 1, 3, 5, 8, 11, 14, 17, and 20 min; and 1 min posttreatment.

Results:

Analysis revealed significant main effects for day and time and a Day × Time interaction. Day 1 had higher pain ratings than days 4 and 5. From min 1 to 11 there was a progressive decline in pain rating; after that there was no significant decline.

Conclusions:

Discomfort was greatest during the first 5 min, and perception of discomfort at initial immersion was consistent across 5 days. In addition, after 3 days of treatments habituation occurred. Taken together, this suggests that treatment habituation is not the result of change in receptor sensitivity.

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William R. Holcomb

Column-editor : David O. Draper

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Daniel Krasinski, Ashley B. Thrasher, Michael G. Miller and William R. Holcomb

Context:

A potential variable that could affect rate of temperature elevation with ultrasound is the pressure (mass) that is applied to the transducer head during application. Added pressure could compress the tissue, affecting density and the transmission of ultrasound energy. Little research has been completed to determine the effects of the amount of pressure applied during therapeutic ultrasound in vivo.

Objective:

To determine the effects of different applied transducer mass on intramuscular temperature during an ultrasound treatment within the left triceps surae.

Design:

Crossover clinical trial.

Setting:

Human performance research laboratory.

Participants:

Convenience sample of thirteen healthy, college-age students.

Interventions:

Three separate MHz, 1.0-W/cm2 ultrasound treatments were administered 1.5 cm within the triceps surae. The independent variables were the linear temperature standards (0.5°C, 1.0°C, 1.5°C, and 2.0°C above baseline) and the 3 different applied pressures measured in grams (200 g, 600 g, and 800 g).

Main Outcome Measures:

A thermocouple probe was used to measure triceps surae temperature, and time to reach the temperature standards was recorded during the ultrasound treatments. A 4 × 3 repeated-measures analysis of variance (RM-ANOVA) was used to analyze the differences for temperature points (0.5°C, 1.0°C, 1.5°C, and 2.0°C) and transducer mass (200 g, 600 g, and 800 g) and with respect to time.

Results:

The results of the RM-ANOVA showed no temperature-point and transducer-mass interaction (F 6,72 = 1.69, P = .137) or main effect for mass (F 2,24 = 1.23, P = .309). The time required to raise temperature 2°C was 209.1 ± 68.10 s at 200 g, 181.5 ± 61.50 s at 600 g, and 194.9 ± 75.54 s at 800 g.

Conclusions:

Under the conditions of this study, the amount of mass applied with the transducer during an ultrasound treatment does not ultimately affect the rate of tissue heating.

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Cody B. Bremner, William R. Holcomb, Christopher D. Brown and Melanie E. Perreault

Clinical Scenario:

Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established.

Clinical Question:

Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions?

Summary of Key Findings:

Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs.

Clinical Bottom Line:

Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions.

Strength of Recommendation:

There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).

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William R. Holcomb, Mack D. Rubley, Michael G. Miller and Tedd J. Girouard

Context:

Previous studies using neuromuscular electrical stimulation (NMES) have suggested that 30-second rest intervals are too short for sufficient recovery.

Objective:

To compare the effect of rest interval on knee-extension torque production.

Design:

Counterbalanced mixed design to test independent variable, rest interval; ANOVA to analyze dependent variable, percentage decline.

Setting:

Athletic training research laboratory.

Participants:

24 healthy men and women.

Intervention:

Participants performed knee extension under 2 contraction conditions, maximum voluntary isometric contraction (MVIC) and NMES with either 30- or 120-second rest between repetitions.

Main Outcome Measure:

Peak torque produced during each repetition of a 5-repetition set.

Results:

The main effect for rest interval was significant (F 1,23 = 30.30, P = .001), as was the main effect for condition (F 1,23 = 11.18, P = .003).

Conclusions:

A 120-second rest between repetitions is recommended when using NMES in early rehabilitation because force decline across repetitions with 30-second rest during NMES is greater than with MVIC.