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Luke M. Mueller, Ben A. Bloomer and Chris J. Durall

Clinical Scenario:

Anterior cruciate ligament (ACL) injuries are associated with a lengthy recovery time, decreased performance, and an increased rate of reinjury. To improve performance of the injured knee, affected athletes often undergo surgical reconstruction and rehabilitation. Determining when an athlete is ready to safely return to play (RTP), however, can be challenging for clinicians. Although various outcome measures have been recommended, their ability to predict a safe RTP is questionable.

Focused Clinical Question:

Which outcome measures should be used to determine readiness to return to play after ACL reconstruction?

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Laura C. Reid, Jason R. Cowman, Brian S. Green and Garrett F. Coughlan

Global positioning systems (GPS) are widely used in sport settings to evaluate the physical demands on players in training and competition. The use of these systems in the design and implementation of rehabilitation and return-to-running programs has not yet been elucidated.

Objective:

To demonstrate the application of GPS technology in the management of return to play in elite-club Rugby Union.

Design:

Case series.

Setting:

Professional Rugby Union club team.

Participants:

8 elite Rugby Union players (age 27.86 ± 4.78 y, height 1.85 ± 0.08 m, weight 99.14 ± 9.96 kg).

Intervention:

Players wore GPS devices for the entire duration of a club game.

Main Outcome Measures:

Variables of locomotion speed and distance were measured.

Results:

Differences in physical demands between playing positions were observed for all variables.

Conclusions:

An analysis of the position-specific physical demands measured by GPS provides key information regarding the level and volume of loads sustained by a player in a game environment. Using this information, sports-medicine practitioners can develop rehabilitation and return-to-running protocols specific to the player position to optimize safe return to play.

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Robert J. Delmore, Kevin G. Laudner and Michael R. Torry

Context:

Hip-adductor strains are among the most common lower-extremity injuries sustained in athletics. Treatment of these injuries involves a variety of exercises used to target the hip adductors.

Objective:

To identify the varying activation levels of the adductor longus during common hip-adductor exercises.

Design:

Descriptive study.

Setting:

Laboratory.

Participants:

24 physically active, college-age students.

Intervention:

None.

Main Measurement Outcomes:

Peak and average electromyographic (EMG) activity of the adductor longus muscle during the following 6 hip-adductor rehabilitation exercises: side-lying hip adduction, ball squeezes, rotational squats, sumo squats, standing hip adduction on a Swiss ball, and side lunges.

Results:

The side-lying hip-adduction exercise produced more peak and average activation than any other exercise (P < .001). Ball squeezes produced more peak and average activation than rotational squats, sumo squats, and standing adduction on a Swiss ball (P < .001). Ball squeezes had more average activation than side lunges (P = .001). All other variables for peak activation during the exercises were not statistically significant (P > .08). These results allowed the authors to provide an overall ranking system (highest to lowest muscle activation): side-lying hip adduction, ball squeezes, side lunges, standing adduction on a Swiss ball, rotational squats, and sumo squats.

Conclusion:

The study provides a ranking system on the activation levels of the adductor longus muscle for 6 common hip-adductor rehabilitation exercises, with the side-lying hip-adduction and ball-squeeze exercises displaying the highest overall activation.

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Jay R. Ebert and Peter K. Edwards

Autologous chondrocyte implantation (ACI) has demonstrated good clinical success in the repair of articular cartilage defects in the knee. Postoperative rehabilitation after ACI is considered critical in returning the patient to an optimal level of function by attempting to create the appropriate mechanical environment for cartilage regrowth, and it involves a progressive program that emphasizes full motion, progressive partial weight bearing (PWB), and controlled exercises. While evidence-based research is clearly lacking in all components of ACI rehabilitation, one important element in this treatment algorithm that has been subjected to some early scientific study is the gradual progression of the patient back to full weight-bearing (WB) gait after surgery. With the continual advancement of ACI surgical techniques, along with clinical experience and improved knowledge of histology and of the maturation process of chondrocytes, proposed postoperative WB protocols have evolved to better reflect the nature of the specific ACI surgery. The purpose of this article is to present the varied PWB programs that have been practiced alongside the evolving ACI surgical technique, the experimental basis for such protocols, the issues pertinent to the accurate prescription of WB, and future directions for developing such methods to best return patients to an optimal level of function after ACI.

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Lynne Halley Johnston and Douglas Carroll

Twelve seriously injured athletes were asked to describe the provision of eight functional types of support during their rehabilitation. NUD*IST (Nonnumerical Unstructured Data Indexing Searching and Theorizing) was used to organize the data. Overall, the provision of social support largely matched demand. Emotional and practical forms of support decreased with time, while varieties of informational support were increasingly received and preferred over time. The provision of informational and emotional support appeared to be dictated by four temporally sequential appraisals: injury severity, rehabilitation progress, recovery/readiness to return, and sports performance. Practical support in the form of personal assistance greatly depended upon the visibility of the injury and the mobility of the injured athlete. Physiotherapists, doctors, and other currently or previously injured athletes were most likely to provide informational support requiring expert medical knowledge, whereas coaches provided informational support requiring sport-specific expertise. Friends and family were the main source of emotional and practical support. The situational and temporal context of the provision of support is represented diagrammatically.

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Carrie B. Scherzer, Britton W. Brewer, Allen E. Cornelius, Judy L. Van Raalte, Albert J. Petitpas, Joseph H. Sklar, Mark H. Pohlman, Robert J. Krushell and Terry D. Ditmar

Objective:

To examine the relationship between self-reported use of psychological skills and rehabilitation adherence.

Design:

Prospective correlational design.

Setting:

Outpatient physical-therapy clinic specializing in sports medicine.

Patients:

Fifty-four patients (17 women and 37 men) undergoing rehabilitation after anterior-cruciate-ligament reconstruction.

Main Outcome Measures:

An abbreviated version of the Sports Injury Survey (Ievleva & Orlick, 1991) was administered approximately 5 weeks after surgery to assess use of goal setting, imagery, and positive self-talk. Four adherence measures were obtained during the remainder of rehabilitation: attendance at rehabilitation sessions, practitioner ratings of patient adherence at rehabilitation sessions, patient self-reports of home exercise completion, and patient self-reports of home cryotherapy completion.

Results:

Goal setting was positively associated with home exercise completion and practitioner adherence ratings. Positive self-talk was positively correlated with home exercise completion.

Conclusions:

Use of certain psychological skills might contribute to better adherence to sport-injury rehabilitation protocols.

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Britton W. Brewer, Joshua B. Avondoglio, Allen E. Cornelius, Judy L. Van Raalte, John C. Brickner, Albert J. Petitpas, Gregory S. Kolt, Tania Pizzari, Adrian M.M. Schoo, Kelley Emery and Stephen J. Hatten

Context:

Adherence to clinic-based rehabilitation might influence outcomes.

Objective:

To examine the construct validity and interrater agreement of a measure of adherence to clinic-based rehabilitation.

Design:

Repeated-measures in both study 1 and study 2.

Participants:

43 student rehabilitation practitioners in study 1 and 12 patients undergoing rehabilitation after anterior cruciate ligament reconstruction in study 2.

Interventions:

Participants in study 1 rated the adherence of a simulated videotaped patient exhibiting high, moderate, and low adherence. Two certified athletic trainers rated the adherence of patients at 4 consecutive appointments in study 2.

Main Outcome Measure:

The Sport Injury Rehabilitation Adherence Scale.

Results:

In study 1, adherence ratings increased in a linear fashion across the 3 levels of adherence, and r WG(J) and rater-agreement-index values ranging from .84 to .95 were obtained. In study 2, the rater-agreement index was .94.

Conclusions:

Strong support was found for the construct validity and interrater agreement of the Sport Injury Rehabilitation Adherence Scale.

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David J. Ralston

The RAMP system of athletic-injury rehabilitation, its name an acronym representing its component phases, has its foundation in the frequent reassessment of the injury condition. The patient is progressed systematically through a sequence of rehabilitation goals: management of the acute responses to injury, restoration of mobility, and successful completion of performance goals. The RAMP system designates the current highest-priority rehabilitation goal as the primary objective and any other goals as secondary. This ensures that the pursuit of 1 rehabilitation goal is not at the expense of another, more currently relevant goal. The RAMP system provides a systematic format to help less-experienced clinicians progress injured athletes through the phases of recovery from injury. Daily reassessment of an injury allows the rehabilitation plan to be current and appropriate. The goal-based progression of the system ensures maximum resolution of each rehabilitation objective, contributing to athletes’ optimal return to sport or activity

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Joanne M. Daly, Britton W. Brewer, Judy L. Van Raalte, Albert J. Petitpas and Joseph H. Sklar

Cognitive appraisal models of adjustment to sport injury hold that cognitive appraisals of the injury determine emotional responses to the injury, which in turn influence behavioral responses (e.g., adherence to rehabilitation). To test this model, recreational and competitive athletes undergoing rehabilitation following knee surgery (N = 31) appraised their ability to cope with their injury and completed a measure of mood disturbance. Adherence to rehabilitation was measured in terms of attendance at rehabilitation sessions and physical therapist/athletic trainer ratings of patient behavior during rehabilitation sessions. As predicted, cognitive appraisal was associated with emotional disturbance. Emotional disturbance was inversely related to one measure of adherence (attendance) but was unrelated to the other measure of adherence (physical therapist/athletic trainer ratings). The results of this study provide support for cognitive appraisal models and suggest that emotional disturbance may be a marker for poor adherence to sport injury rehabilitation regimens.

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Jorg Teichmann, Edin K. Suwarganda, Claudia Lendewig, Barry D. Wilson, Wee Kian Yeo, Ramlan Abdul Aziz and Dietmar Schmidtbleicher

Context:

The Unexpected-Disturbance Program (UDP) promotes exercises in response to so-called involuntary short- to midlatency disturbances.

Objective:

This study investigated the effectiveness of the UDP in the last 6 wk of rehabilitation.

Design:

Pre–post study with 2-tailed paired t tests for limited a priori comparisons to examine differences.

Setting:

National Sports Institute of Malaysia.

Participants:

24 Malaysian national athletes.

Interventions:

7 sessions/wk of 90 min with 3 sessions allocated for 5 or 6 UDP exercises.

Main Outcomes:

Significant improvements for men and women were noted. Tests included 20-m sprint, 1-repetition-maximum single-leg press, standing long jump, single-leg sway, and a psychological questionnaire.

Results:

For men and women, respectively, average strength improvements of 22% (d = 0.96) and 29% (d = 1.05), sprint time of 3% (d = 1.06) and 4% (d = 0.58), and distance jumped of 4% (d = 0.59) and 6% (d = 0.47) were noted. In addition, athletes reported improved perceived confidence in their abilities. All athletes improved in each functional test except for long jump in 2 of the athletes. Mediolateral sway decreased in 18 of the 22 athletes for the injured limb.

Conclusion:

The prevention training with UDP resulted in improved conditioning and seems to decrease mediolateral sway.