Tissue adaptation to physical stress: a proposed "Physical Stress Theory" to guide physical therapist practice, education, and research

Examination and physical therapy management of a young gymnast with bilateral wrist pain: A case report

BACKGROUND

Wrist pain associated with weight-bearing gymnastic activities may be linked to musculoskeletal impairments, faulty movement patterns, and poor training techniques. Inadequate proximal control may adversely impact the loading mechanics throughout the upper extremities and contribute to a gymnast's complaint of wrist pain. The purpose of this case report is to describe the management of a young gymnast with primary complaint of bilateral wrist pain associated with upper extremity weight-bearing activities.

CASE DESCRIPTION

A 10 year-old male gymnast presented with a 6-month history of bilateral wrist pain aggravated by weight-bearing gymnastic activities. Based on the findings from a physical therapy examination, a 3-stage progressive rehabilitation program was designed using an impairment-based, multi-modal approach to treat key musculoskeletal impairments and movement deficiencies. Consistent with the principle of activity simulation, treatment targeted areas of weakness considered key to activity performance and included a progression of exercises and techniques that simulated activities reported by the gymnast to be painful.

OUTCOMES

The gymnast was treated for 11 visits over 8 weeks. He demonstrated improved strength, motor control, and self-reported outcome scores that allowed pain-free return to all gymnastic activities.

Relationship of shoulder activity and skin intrinsic fluorescence with low level shoulder pain and disability in people with type 2 diabetes

AIM

People with type 2 diabetes (T2DM) have a high incidence of musculoskeletal disorders thought to be influenced by high non-enzymatic advanced glycated end-products (AGEs). The goals of this study were to determine differences in shoulder activity level and AGEs in people with T2DM compared to matched controls, and to determine factors associated with shoulder pain and disability.

METHODS

Eighty-one participants, T2DM (n=52) and controls (n=29), were examined for magnitude and duration of shoulder activity (measured using accelerometers), skin intrinsic florescence (SIF) as a surrogate measure of AGE level, and the Shoulder Pain and Disability Index (SPADI) as a self-report of shoulder pain and disability.

RESULTS

Compared with controls, T2DM participants had 23% less shoulder activity (p=0.01), greater SIF level (3.6±1.7 vs 2.7±0.6AU, p=0.01), less shoulder strength (p<0.05), and the duration of their shoulder activity was moderately associated (r=0.40; p<0.01) with reported shoulder pain and disability. Shoulder pain and disability were not related to SIF level.

CONCLUSIONS

Persons with T2DM have higher SIF levels and shoulder symptoms and disability indices than controls. Research is needed to determine if a shoulder mobility intervention to increase strength and mobility can help decrease shoulder pain and disability.

Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review

Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks. Physical activity is not contraindicated for those at risk of diabetic foot ulcer, yet patients at risk present with unique barriers to initiating increases in physical activity. This review focuses upon the physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers. Offloading, diabetic peripheral neuropathy, depression, pain, self-efficacy and social support, diabetic foot ulcer risk-specific beliefs and emotions, and research to date on exercise interventions in this population are all discussed. Additionally, recommendations for implementing and researching physical activity interventions for individuals at risk for diabetic foot ulcer are provided. Copyright © 2016 John Wiley & Sons, Ltd.

Comparison of the different kinematic patterns during lateral bending between subjects with and without recurrent low back pain

BACKGROUND

Lateral bending is a prerequisite for various functional activities of daily life, which require combined three-dimensional motion. Even though a number of studies have evaluated spinal kinematic changes during lateral bending, the literature reveals a lack of data based on limb dominance. The purpose of this study was to compare kinematic angular displacement of the spinal regions for dominant and non-dominant lateral bending in subjects with and without recurrent low back pain.

METHODS

Forty-four right hand dominant individuals with recurrent low back pain (43.1 [17.4] years) and without low back pain (39.7 [18.7] years) participated in this study. All participants were asked to perform trunk lateral bending to the dominant and non-dominant sides with a bar, three times repeatedly. The outcome measures included three-dimensional angular displacements for the three regions of the spine (upper thorax, lower thorax, and lumbar spine).

FINDINGS

Lumbar rotation (degrees) increased to the dominant side in the low back pain group (9.29 [1.06]) compared to the control group (6.20 [1.02]) with increased rotation in the upper thorax as well (t=-2.09, p=0.04). However, the upper thorax rotation increased in the low back pain group to the non-dominant side (t=2.08, p=0.03) and to the dominant side (t=-2.35, p=0.02). There was a group interaction with planes (F=5.82, p=0.02) during lateral bending.

INTERPRETATION

Although lower thorax motion was not different between groups, increased lumbar spine and upper thorax rotations to the dominant side in the low back pain group were evident during lateral bending. This directional asymmetry should be carefully monitored to understand increased lumbar rotation to the dominant side in subjects with recurrent low back pain. The interactions between group and plane explain compensation strategies through increased lumbar rotation to the dominant side with decreased lateral bending of the upper thorax in subjects with recurrent low back pain.

Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus

AIM

The Royal Dutch Society for Physical Therapy (KNGF) instructed a multidisciplinary group of Dutch anterior cruciate ligament (ACL) experts to develop an evidence statement for rehabilitation after ACL reconstruction.

DESIGN

Clinical practice guideline underpinned by systematic review and expert consensus.

DATA SOURCES

A multidisciplinary working group and steering group systematically reviewed the literature and wrote the guideline. MEDLINE and the Cochrane Library were searched for meta-analyses, systematic reviews, randomised controlled trials and prospective cohort studies published between January 1990 and June 2015.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Included literature must have addressed 1 of 9 predetermined clinical topics: (1) preoperative predictors for postoperative outcome, (2) effectiveness of physical therapy, (3) open and closed kinetic chain quadriceps exercises, (4) strength and neuromuscular training, (5) electrostimulation and electromyographic feedback, (6) cryotherapy, (7) measurements of functional performance, (8) return to play and (9) risk for reinjury.

SUMMARY

Ninety studies were included as the basis for the evidence statement. Rehabilitation after ACL injury should include a prehabilitation phase and 3 criterion-based postoperative phases: (1) impairment-based, (2) sport-specific training and (3) return to play. A battery of strength and hop tests, quality of movement and psychological tests should be used to guide progression from one rehabilitation stage to the next. Postoperative rehabilitation should continue for 9-12 months. To assess readiness to return to play and the risk for reinjury, a test battery, including strength tests, hop tests and measurement of movement quality, should be used.

Exercise and Movement-based Therapies in Geriatric Pain Management

Exercise is often recommended for older adults with pain, but pain itself is often a barrier to increased activity. This article reviews the evidence on the impact of various forms of exercise and related movement therapies on older adults with pain problems. The literature is reviewed with respect to published guidelines. When prescribing exercise, it is important to consider appropriate intensity, type, and duration of exercise as well as incorporating a plan for progression. Strategies to ensure adherence to exercise programs are also important.

A programme of static positional stretches does not reduce hemiplegic shoulder pain or maintain shoulder range of motion -a randomized controlled trial

Objective: To evaluate the effectiveness of a programme of static positional stretches and positioning of the stroke-affected shoulder for maintaining shoulder external rotation and decreasing hemiplegic shoulder pain.

Design: Randomized controlled trial with pretest and posttest design.

Setting: Inpatient rehabilitation unit.

Subjects: Thirty-two participants (17 treatment, 15 comparison) with a first time stroke who were admitted for rehabilitation.

Interventions: Treatment participants completed a programme of static positional stretches of the stroke-affected shoulder twice daily and positioned the stroke affected upper limb in an armrest support at all other times when seated.

Main measures: The main outcome measures were pain-free range of motion into external rotation, pain in the stroke-affected shoulder at rest and with movement, motor recovery and functional independence.

Results: All participants demonstrated a significant loss of external rotation (P=0.005) with no significant group differences. All participants demonstrated a significant improvement in motor recovery (P<0.01) and functional independence (P<0.01) with no significant group differences. There were no significant effects for pain. The comparison group recorded a decrease in mean pain reported with movement from admission to discharge, and the treatment group recorded an increase.

Conclusions: Participation in the management programme did not result in improved outcomes. The results of this study do not support the application of the programme of static positional stretches to maintain range of motion in the shoulder. The effect of increasing pain for the treatment group requires further investigation.

Mechanotransduction: Relevance to Physical Therapist Practice-Understanding Our Ability to Affect Genetic Expression Through Mechanical Forces

Mechanotransduction, the mechanism by which mechanical perturbation influences genetic expression and cellular behavior, is an area of molecular biology undergoing rapid exploration and discovery. Cells are sensitive to forces such as shear, tension, and compression, and they respond accordingly through cellular proliferation, migration, tissue repair, altered metabolism, and even stem cell differentiation and maturation. The study of how cells sense and respond to mechanical stimulation is under robust expansion, with new scientific methods and technologies at our disposal. The application of these technologies to physical therapist practice may hold answers to some of our age-old questions while creating new avenues for our profession to optimize movement for societal health. Embracing this science as foundational to our profession will allow us to be valuable scientific collaborators with distinctive knowledge of the effects of loading. These partnerships will be key to augmenting the clinical utility of emerging therapies such as regenerative medicine, tissue engineering, and gene therapy. Collaboration with other scientific disciplines in these endeavors, along with the inclusion and application of these discoveries in our academic programs, will enhance the understanding of the impact of our practice on biologic and genetic processes. A basic understanding of mechanotransduction and its relevance to physical therapist practice is warranted to begin the conversation.

Are Pressure Time Integral and Cumulative Plantar Stress Related to First Metatarsophalangeal Joint Pain? Results From a Community-Based Study

OBJECTIVE

To examine the relationship between plantar stress over a step, cumulative plantar stress over a day, and first metatarsophalangeal (MTP) joint pain among older adults.

METHODS

Plantar stress and first MTP pain were assessed within the Multicenter Osteoarthritis Study. All included participants were asked if they had pain, aching, or stiffness at the first MTP joint on most days for the past 30 days. Pressure time integral (PTI) was quantified as participants walked on a pedobarograph, and mean steps per day were obtained using an accelerometer. Cumulative plantar stress was calculated as the product of regional PTI and mean steps per day. Quintiles of hallucal and second metatarsal PTI and cumulative plantar stress were generated. The relationship between predictors and the odds ratio of first MTP pain was assessed using a logistic regression model.

RESULTS

Feet in the quintile with the lowest hallux PTI had 2.14 times increased odds of first MTP pain (95% confidence interval [95% CI] 1.42-3.25, P < 0.01). Feet in the quintile with the lowest second metatarsal PTI had 1.50 times increased odds of first MTP pain (95% CI 1.01-2.23, P = 0.042). Cumulative plantar stress was unassociated with first MTP pain.

CONCLUSION

Lower PTI was modestly associated with increased prevalence of frequent first MTP pain at both the hallux and second metatarsal. Lower plantar loading may indicate the presence of an antalgic gait strategy and may reflect an attempt at pain avoidance. The lack of association with cumulative plantar stress may suggest that patients do not limit their walking as a pain-avoidance mechanism.

Addressing Neuroplastic Changes in Distributed Areas of the Nervous System Associated With Chronic Musculoskeletal Disorders

Present interventions utilized in musculoskeletal rehabilitation are guided, in large part, by a biomedical model where peripheral structural injury is believed to be the sole driver of the disorder. There are, however, neurophysiological changes across different areas of the peripheral and central nervous systems, including peripheral receptors, dorsal horn of the spinal cord, brain stem, sensorimotor cortical areas, and the mesolimbic and prefrontal areas associated with chronic musculoskeletal disorders, including chronic low back pain, osteoarthritis, and tendon injuries. These neurophysiological changes appear not only to be a consequence of peripheral structural injury but also to play a part in the pathophysiology of chronic musculoskeletal disorders. Neurophysiological changes are consistent with a biopsychosocial formulation reflecting the underlying mechanisms associated with sensory and motor findings, psychological traits, and perceptual changes associated with chronic musculoskeletal conditions. These changes, therefore, have important implications in the clinical manifestation, pathophysiology, and treatment of chronic musculoskeletal disorders. Musculoskeletal rehabilitation professionals have at their disposal tools to address these neuroplastic changes, including top-down cognitive-based interventions (eg, education, cognitive-behavioral therapy, mindfulness meditation, motor imagery) and bottom-up physical interventions (eg, motor learning, peripheral sensory stimulation, manual therapy) that induce neuroplastic changes across distributed areas of the nervous system and affect outcomes in patients with chronic musculoskeletal disorders. Furthermore, novel approaches such as the use of transcranial direct current stimulation and repetitive transcranial magnetic stimulation may be utilized to help renormalize neurological function. Comprehensive treatment addressing peripheral structural injury as well as neurophysiological changes occurring across distributed areas of the nervous system may help to improve outcomes in patients with chronic musculoskeletal disorders.

An effective repetitive training schedule to achieve skill proficiency using a novel robotic virtual reality simulator

PURPOSE

A robotic virtual reality simulator (Mimic dV-Trainer) can be a useful training method for the da Vinci surgical system. Herein, we investigate several repetitive training schedules and determine which is the most effective.

METHODS

A total of 30 medical students were enrolled and were divided into 3 groups according to the training schedule. Group 1 performed the task 1 hour daily for 4 consecutive days, group II performed the task on once per week for 1 hour for 4 consecutive weeks, and group III performed the task for 4 consecutive hours in 1 day. The effects of training were investigated by analyzing the number of repetitions and the time required to complete the "Tube 2" simulation task when the learning curve plateau was reached. The point at which participants reached a stable score was evaluated using the cumulative sum control graph.

RESULTS

The average time to complete the task at the learning curve plateau was 150.3 seconds in group I, 171.9 seconds in group II, and 188.5 seconds in group III. The number of task repetitions required to reach the learning curve plateau was 45 repetitions in group I, 36 repetitions in group II, and 39 repetitions in group III. Therefore, there was continuous improvement in the time required to perform the task after 40 repetitions in group I only. There was a significant correlation between improvement in each trial interval and attempt, and the correlation coefficient (0.924) in group I was higher than that in group II (0.899) and group III (0.838).

CONCLUSION

Daily 1-hour practice sessions performed for 4 consecutive days resulted in the best final score, continuous score improvement, and effective training while minimizing fatigue. This repetition schedule can be used for effectively training novices in future.

The proliferation and tenogenic differentiation potential of bone marrow-derived mesenchymal stromal cell are influenced by specific uniaxial cyclic tensile loading conditions

It has been previously demonstrated that mechanical stimuli are important for multipotent human bone marrow-derived mesenchymal stromal cells (hMSCs) to maintain good tissue homeostasis and even to enhance tissue repair processes. In tendons, this is achieved by promoting the cellular proliferation and tenogenic expression/differentiation. The present study was conducted to determine the optimal loading conditions needed to achieve the best proliferation rates and tenogenic differentiation potential. The effects of mechanical uniaxial stretching using different rates and strains were performed on hMSCs cultured in vitro. hMSCs were subjected to cyclical uniaxial stretching of 4, 8 or 12 % strain at 0.5 or 1 Hz for 6, 24, 48 or 72 h. Cell proliferation was analyzed using alamarBlue[Formula: see text] assay, while hMSCs differentiation was analyzed using total collagen assay and specific tenogenic gene expression markers (type I collagen, type III collagen, decorin, tenascin-C, scleraxis and tenomodulin). Our results demonstrate that the highest cell proliferation is observed when 4 % strain [Formula: see text] 1 Hz was applied. However, at 8 % strain [Formula: see text] 1 Hz loading, collagen production and the tenogenic gene expression were highest. Increasing strain or rates thereafter did not demonstrate any significant increase in both cell proliferation and tenogenic differentiation. In conclusion, our results suggest that 4 % [Formula: see text] 1 Hz cyclic uniaxial loading increases cell proliferation, but higher strains are required for superior tenogenic expressions. This study suggests that selected loading regimes will stimulate tenogenesis of hMSCs.

Plantar pressures, plantar forces, and their influence on the pathogenesis of diabetic foot ulcers: a review

BACKGROUND

Clinical recommendations for the prevention and healing of diabetic foot ulcers (DFUs) are somewhat clear. However, assessment and quantification of the mechanical stress responsible for DFU remain complex. Different pressure variables have been described in the literature to better understand plantar tissue stress exposure. This article reviews the role of pressure and shear forces in the pathogenesis of plantar DFU.

METHODS

We performed systematic searches of the PubMed and Embase databases, completed by a manual search of the selected studies. From 535 potentially relevant references, 70 studies were included in the full-text review.

RESULTS

Variables of plantar mechanical stress relate to vertical pressure, shear stress, and temporality of loading. At this time, in-shoe peak plantar pressure (PPP) is the only reliable variable that can be used to prevent DFU. Although it is a poor predictor of in-shoe PPP, barefoot PPP seems complementary and may be more suitable when evaluating patients with diabetes mellitus and peripheral neuropathy who seem noncompliant with footwear. An in-shoe PPP threshold value of 200 kPa has been suggested to prevent DFU. Other variables, such as peak pressure gradient and peak maximal subsurface shear stress and its depth, seem to be of additional utility.

CONCLUSIONS

To better assess the at-risk foot and to prevent ulceration, the practitioner should integrate quantitative models of dynamic foot plantar pressures, such as in-shoe and barefoot PPPs, with the regular clinical screening examination. Prospective studies are needed to evaluate causality between other variables of mechanical stress and DFUs.

Plantar loading asymmetry in American Indians with diabetes and peripheral neuropathy, with diabetes only, and without diabetes

BACKGROUND

We investigated plantar loading asymmetry during gait in American Indians with and without diabetes and with diabetes and peripheral neuropathy.

METHODS

A convenience sample of 96 American Indians with and without diabetes was divided into three groups: 20 with diabetes and peripheral neuropathy, 16 with diabetes without peripheral neuropathy, and 60 with no history of diabetes (control group). Plantar loading was measured during barefoot walking across a pressure platform. Five trials were collected per foot during level walking at a self-selected speed using the two-step method. Asymmetry in peak pressure-time integral and peak plantar pressure were calculated from ten plantar regions and compared among groups.

RESULTS

Significant pressure-time integral asymmetry occurred across the forefoot regions in American Indians with diabetes and peripheral neuropathy compared with the other two groups. Significant peak plantar pressure asymmetry occurred in the third metatarsal region in both groups with diabetes (with and without peripheral neuropathy) compared with the control group.

CONCLUSIONS

Overall, American Indians with diabetes seemed to show greater asymmetry in plantar loading variables across the forefoot region compared with those in the control group. Specifically, individuals with diabetes and peripheral neuropathy had the greatest amount of forefoot pressure-time integral asymmetry. Significant peak plantar pressure asymmetry occurred in the third metatarsal region of the forefoot in those with diabetes with and without peripheral neuropathy. Loading asymmetry may play a role in the development of foot ulcers in the forefoot region of American Indians with peripheral neuropathy and diabetes.

Influence of second-degree flatfoot on spinal and pelvic mechanics in young females

Objective:

To investigate the effect of bilateral flexible second-degree flatfoot on pelvic and spinal mechanics in young females.

Methods:

A case-control trial was conducted at the Faculty of Physical Therapy, Cairo University, Egypt, on 60 female participants who were assigned into two groups. Group A (the control group) included 31 healthy subjects, and group B (the study group) included 29 subjects with bilateral flexible second-degree of flatfoot deformity. For each subject in both groups, using lateral weight-bearing radiographs, foot assessments were performed bilaterally to measure the talus–first metatarsal angle. Using the formetric-II device, 3D assessments of the pelvis were performed on the frontal and sagittal planes in addition to lumbar and thoracic curvatures on the sagittal plane. Outcome measures were pelvic inclination, pelvic tilt, and lumbar lordotic and thoracic kyphotic angles.

Results:

There was a significant difference in pelvic inclination and in lumbar and thoracic angles (P=0.012, 0.009, and 0.028, respectively) between both groups. There was no significant difference between both groups in pelvic tilt (P=0.688).

Conclusion:

Subjects with bilateral flexible second-degree flatfoot demonstrated increased pelvic inclination, lumbar lordotic and thoracic kyphotic angles than normal subjects. Foot assessments should be performed as an essential part of the evaluation of female patients with spine and pelvic problems. Bilateral flexible second-degree flatfoot may act as a predictor for pelvic organs prolapse in their later lives.

Variables associated with performance of an active limb movement following within-session instruction in people with and people without low back pain

Modification of a movement pattern can be beneficial in decreasing low back pain (LBP) symptoms. There is variability, however, in how well people are able to modify performance of a movement. What has not been identified is the factors that may affect a person's ability to modify performance of a movement. We examined factors related to performance of active hip lateral rotation (HLR) following standardized instructions in people with and people without LBP. Data were collected during performance of HLR under 3 conditions: passive, active, and active instructed. In people with LBP, motion demonstrated during the passive condition (r = 0.873, P < 0.001), motion demonstrated during the active condition (r = 0.654, P = 0.008), and gender (r = 0.570, P = 0.027) were related to motion demonstrated during the active-instructed condition. Motion demonstrated during the passive condition explained 76% (P < 0.001) of the variance in motion demonstrated during the active-instructed condition. A similar relationship did not exist in people without LBP. The findings of the study suggest that it may be important to assess motion demonstrated during passive HLR to determine how difficult it will be for someone with LBP to modify the performance of HLR. Prognosis should be worst for those who display similar movement patterns during passive HLR and active-instructed HLR.

Comparison of lumbopelvic rhythm and flexion-relaxation response between 2 different low back pain subtypes

STUDY DESIGN

A cross-sectional study to compare the kinematics and muscle activities during trunk flexion and return task in people with and without low back pain (LBP).

OBJECTIVE

To characterize the lumbopelvic rhythms during trunk flexion and return task in a group of healthy persons and 2 different subgroups of patients with LBP, identifying the flexion-relaxation (FR) responses in each group.

SUMMARY OF BACKGROUND DATA

The lumbopelvic rhythm is the coordinated movement of the lumbar spine and hip during trunk flexion and return and is a clinical sign of LBP. However, the reported patterns of lumbopelvic rhythm in patients with LBP are inconsistent, possibly because previous studies have examined a heterogeneous group of patients with LBP. To clarify the lumbopelvic rhythm patterns, it is necessary to study more homogeneous subgroups of patients with LBP.

METHODS

The study involved the following subjects: control group of healthy subjects (N = 16); lumbar flexion with rotation syndrome (LFRS) LBP subgroup (N = 17); and lumbar extension with rotation syndrome (LERS) LBP subgroup (N = 14). The kinematic parameters during the trunk flexion and return task were recorded using a 3-dimensional motion capture system, and the FR ratio of the erector spinae muscle was measured.

RESULTS

The flexion angle of the lumbar spine was larger in the LFRS subgroup than in the control group and the LERS LBP subgroup, and the hip flexion angle was larger in the LERS LBP subgroup than in the control group and LFRS subgroup. The FR response of the erector spinae muscle disappeared in the LFRS and LERS LBP subgroups.

CONCLUSION

These results show that the lumbopelvic rhythms are different among healthy subjects and patients assigned to 2 specific LBP subgroups. These results provide information on the FR response of the erector spinae muscle.

Differences between two subgroups of low back pain patients in lumbopelvic rotation and symmetry in the erector spinae and hamstring muscles during trunk flexion when standing

The present study was performed to examine lumbopelvic rotation and to identify asymmetry of the erector spinae and hamstring muscles in people with and without low back pain (LBP). The control group included 16 healthy subjects, the lumbar-flexion-rotation syndrome LBP group included 17 subjects, and the lumbar-extension-rotation syndrome LBP group included 14 subjects. Kinematic parameters were recorded using a 3D motion-capture system, and electromyography parameters were measured using a Noraxon TeleMyo 2400T. The two LBP subgroups showed significantly more lumbopelvic rotation during trunk flexion in standing than did the control group. The muscle activity and flexion-relaxation ratio asymmetries of the erector spinae muscles in the lumbar-flexion-rotation syndrome LBP group were significantly greater than those in the control group, and the muscle activity and flexion-relaxation ratio asymmetry of the hamstring muscles in the lumbar-extension-rotation syndrome LBP group were significantly greater than those in the control group. Imbalance or asymmetry of passive tissue could lead to asymmetry of muscular activation. Muscle imbalance can cause asymmetrical alignment or movements such as unexpected rotation. The results showed a greater increase in lumbopelvic rotation during trunk flexion in standing among the lumbar-flexion-rotation syndrome and lumbar-extension-rotation syndrome LBP groups compared with the control group. The differences between the two LBP subgroups may be a result of imbalance and asymmetry in erector spinae and hamstring muscle properties.

Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial

OBJECTIVE

To determine the effects of weight-bearing (WB) versus nonweight-bearing (NWB) exercise for persons with diabetes mellitus (DM) and peripheral neuropathy (PN).

DESIGN

Randomized controlled trial with evaluations at baseline and after intervention.

SETTING

University-based physical therapy research clinic.

PARTICIPANTS

Participants with DM and PN (N=29) (mean age ± SD, 64.5±12.5y; mean body mass index [kg/m(2)] ± SD, 35.5±7.3) were randomly assigned to WB (n=15) and NWB (n=14) exercise groups. All participants (100%) completed the intervention and follow-up evaluations.

INTERVENTIONS

Group-specific progressive balance, flexibility, strengthening, and aerobic exercise conducted sitting or lying (NWB) or standing and walking (WB) occurred 3 times a week for 12 weeks.

MAIN OUTCOME MEASURES

Measures included the 6-minute walk distance (6MWD) and daily step counts. Secondary outcome measures represented domains across the International Classification of Functioning, Disability and Health.

RESULTS

The WB group showed greater gains than the NWB group over time on the 6MWD and average daily step count (P<.05). The mean and 95% confidence intervals (CIs) between-group difference over time was 29m (95% CI, 6-51) for the 6MWD and 1178 (95% CI, 150-2205) steps for the average daily step count. The NWB group showed greater improvements than the WB group over time in hemoglobin A1c values (P<.05).

CONCLUSIONS

The results of this study indicate the ability of this population with chronic disease to increase 6MWD and daily step count with a WB exercise program compared with an NWB exercise program.

Dynamic midfoot kinematics in subjects with medial tibial stress syndrome

BACKGROUND

Medial tibial stress syndrome (MTSS) is a common diagnosis. Several studies have demonstrated that excessive static navicular drop (ND) is related to the diagnosis. However, no studies have yet investigated ND and the velocity of ND during dynamic conditions. The aim of this study was to evaluate ND characteristics in patients with MTSS in dynamic and static conditions.

METHODS

In a case-control study, 14 patients diagnosed as having MTSS were included from an orthopedic outpatient clinic. A control group consisting of 14 healthy participants was matched regarding age, sex, and typical sporting activity. Navicular drop was evaluated during treadmill walking by a two-dimensional video analysis. Static foot posture, static ND, dynamic ND (dND), and velocity of dND were compared.

RESULTS

The two groups were comparable in relation to age, sex, height, weight, and foot size. No significant difference was found in static foot posture. Static ND showed a mean difference of 1.7 mm between the groups (P = .08). During treadmill walking, patients with MTSS had, on average, a 1.5-mm-larger dND (P =.004) and a 2.4-mm/sec-larger mean velocity of dND (P = .03).

CONCLUSIONS

Patients with MTSS display a larger ND and a higher ND velocity during treadmill walking. Increased ND velocity may be important to this condition. Future studies should include velocity of dND to investigate the mechanisms of dND in relation to overuse injuries.

Effective therapeutic exercise prescription: the right exercise at the right dose

The prescription of an effective therapeutic exercise program requires the right dosage of the right exercise, at the right time for that patient. The therapist must understand and apply training principles effectively in the presence of pathology, injury, or otherwise unhealthy tissue. The intervention goal is to close the gap between current performance and the desired goal or capacity. Although there may be a preferred linear path from current performance to optimal outcome, complexities of the human body, internal factors, and external variables may create barriers to this direct path. Successful programs include key program design considerations such as ensuring a stable baseline before progression, treating the right impairments and activity limitations, understanding contextual factors, considering the principles of specificity and optimal loading, and applying dosing principles. Program progression can be achieved through increases in total exercise volume and/or through manipulation of exercise challenges at the same exercise volume. Effective application of these principles will guide patients toward their goals as quickly and efficiently as possible.

Effect of selected exercises on in-shoe plantar pressures in people with diabetes and peripheral neuropathy

BACKGROUND

In people with diabetes and peripheral neuropathy (DM+PN), injury risk is not clearly known for weight bearing (WB) vs. non-weight bearing (NWB) exercise. In-shoe peak plantar pressures (PPP) often are used as a surrogate indicator of injury to the insensitive foot.

OBJECTIVE

Compare PPPs in people with DM+PN during selected WB and NWB exercises.

METHODS

Fifteen subjects with DM+PN participated. PPPs were recorded for the forefoot, midfoot, and heel during level walking and compared to; WB exercises--treadmill walking, heel and toe raises, sit to stands, stair climbing, single leg standing; and NWB exercises--stationary bicycling, balance ball exercise and plantar flexion exercise.

RESULTS

Compared to level walking; mean forefoot PPP during treadmill walking was 13% higher, but this difference was eliminated when walking speed was used as a covariate. Mean PPPs were similar or substantially lower for other exercises, except for higher forefoot PPP with heel raise exercises.

CONCLUSIONS

Slow progression and regular monitoring of insensitive feet are recommended for all exercises, but especially for heel raises, and increases in walking speed. The remaining WB and NWB exercises pose no greater risk to the insensitive foot due to increases in PPP compared to level walking.

Prevalência e fatores associados a lesões em corredores amadores de rua do município de Belo Horizonte, MG

INTRODUÇÃO: A prática da corrida de rua tem aumentado nos últimos anos, tanto por sua facilidade quanto pelo baixo custo envolvido. Essa prática, todavia, envolve risco de lesões musculoesqueléticas. OBJETIVO: Verificar a prevalência de lesões osteomioarticulares e analisar os fatores associados em corredores de rua amadores de Belo Horizonte, MG. MÉTODOS: Foi realizado um estudo observacional do tipo transversal. A seleção da amostra foi por conveniência. Participaram da pesquisa 100 atletas amadores com pelo menos três meses de prática de corrida com frequência mínima de duas vezes por semana. Foram coletados os dados referentes à prevalência de lesões e os fatores associados através de um questionário estruturado. RESULTADOS: A prevalência de lesões entre os atletas foi de 40%. Dentre os fatores associados à lesão destacam-se a distância média diária e a variação no volume do treinamento. CONCLUSÃO: A prevalência de lesões em corredores amadores é considerável, apesar de ter sido relatada por menos da metade dos participantes. As características do treinamento podem desencadear lesões e devem ser analisadas com cautela para que a corrida seja realizada de forma segura.

Low back pain

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.

Stride activity level in young and middle-aged adults with hip disorders

OBJECTIVES

To determine the activity level, represented by total daily strides (TDS), of young and middle-aged adults with hip disorders and asymptomatic controls and to assess the association between TDS and self-report functional measures.

METHODS

Patients (age 15-50) with deep hip or groin pain (n=202) and controls (n=20) wore an accelerometer that recorded TDS. Symptomatic subjects completed self-report questionnaires. Symptomatic subjects were classified into subgroups: femoroacetabular impingement (FAI), developmental dysplasia of the hip (DDH), isolated labral tear (LT) and osteoarthritis (OA) based on intraoperative findings. Between-group comparisons of TDS were performed and correlations between TDS and questionnaires were determined.

RESULTS

Overall, controls recorded greater TDS than symptomatic subjects; however, between-group comparisons showed that FAI and DDH were similar to controls. OA demonstrated fewer TDS than FAI (4327 [2075] vs. 5095 [2354]). In symptomatic subjects, TDS had a low correlation with modified Harris Hip Score (r=0.33) and the University of California Los Angeles Activity Score (ρ=0.30), but no correlation with the Marx Activity Rating Scale.

CONCLUSIONS

Subjects with hip disorders demonstrate reduced TDS compared with controls; however, some subgroups demonstrated TDS similar to controls. In addition, symptomatic subjects demonstrated relatively high TDS while reporting poor function. Accelerometers can be used in clinical populations to provide additional information about activity not represented by traditional functional measures.

Need for speed: better movement quality during faster task performance after stroke

BACKGROUND

. Although slow and insufficient muscle activation is a hallmark of hemiparesis poststroke, movement speed is rarely emphasized during upper-extremity rehabilitation. Moving faster may increase the intensity of task-specific training, but positive and/or negative effects on paretic-limb movement quality are unknown.

OBJECTIVE

. To determine whether moving quickly instead of at a preferred speed either enhances or impairs paretic-limb task performance after stroke.

METHODS

. A total of 16 people with poststroke hemiparesis and 11 healthy controls performed reach-grasp-lift movements at their preferred speed and as fast as possible, using palmar and 3-finger grip types. The authors measured durations of the reach and grasp phases, straightness of the reach path, thumb-index finger separation (aperture), efficiency of finger movement, and grip force.

RESULTS

. Reach and grasp phase durations decreased in the fast condition in both groups, showing that participants were able to move more quickly when asked. When moving fast, the hemiparetic group had reach durations equal to those of healthy controls moving at their preferred speed. Movement quality also improved. Reach paths were straighter, and peak apertures were greater in both groups in the fast condition. The group with hemiparesis also showed improved efficiency of finger movement. Differences in peak grip force across speed conditions did not reach significance.

CONCLUSIONS

. People with hemiparesis who can perform reach-grasp-lift movements with a 3-finger grip can move faster than they choose to, and when they do, movement quality improves. Simple instructions to move faster could be a cost-free and effective means of increasing rehabilitation intensity after stroke.

Treadmill training induces plasticity in spinal motoneurons and sciatic nerve after sensorimotor restriction during early postnatal period: new insights into the clinical approach for children with cerebral palsy

The aim of the present study was to investigate whether locomotor stimulation training could have beneficial effects on the morphometric alterations of spinal cord and sciatic nerve consequent to sensorimotor restriction (SR). Male Wistar rats were exposed to SR from postnatal day 2 (P2) to P28. Control and experimental rats underwent locomotor stimulation training in a treadmill for three weeks (from P31 to P52). The cross-sectional area (CSA) of spinal motoneurons innervating hind limb muscles was determined. Both fiber and axonal CSA of myelinated fibers were also assessed. The growth-related increase in CSA of motoneurons in the SR group was less than controls. After SR, the mean motoneuron soma size was reduced with an increase in the proportion of motoneurons with a soma size of between 0 and 800 μm(2). The changes in soma size of motoneurons were accompanied by a reduction in the mean fiber and axon CSA of sciatic nerve. The soma size of motoneurons was reestablished at the end of the training period reaching controls level. Our results suggest that SR during early postnatal life retards the growth-related increase in the cell body size of motoneurons in spinal cord and the development of sciatic nerve. Additionally, three weeks of locomotor stimulation using a treadmill seems to have a beneficial effect on motoneurons' soma size.

Scapular and humeral movement patterns of people with stroke during range-of-motion exercises

BACKGROUND AND PURPOSE

In people with stroke, range-of-motion (ROM) exercises may contribute to hemiparetic shoulder pain, but the underlying mechanisms are unknown. This study examined scapular and humeral movement patterns in people with poststroke hemiparesis as they performed commonly prescribed ROM exercises.

METHODS

Using kinematic techniques, we studied 13 people with hemiparesis, both with and without pain, as they performed 3 commonly prescribed ROM exercises: person-assisted ROM, self-assisted ROM, and cane-assisted ROM. Their data were compared with those of a group of 12 matched control subjects performing scapular plane shoulder elevation, using mixed-model ANOVAs. Correlation analyses were used to examine the relationship between participants' ratings of pain and kinematic data.

RESULTS

The hemiparetic group had mild pain at rest that increased during the performance of the exercises. During shoulder elevation, humeral external rotation in the hemiparetic group was decreased in all 3 ROM exercises compared with that in the control group. Scapular upward rotation in the hemiparetic group was decreased for the person-assisted ROM exercise only. No differences in scapular tilt were found between groups. The extent of movement abnormalities was not related to pain severity.

DISCUSSION AND CONCLUSIONS

People with hemiparesis had altered scapular and humeral movement patterns and increased shoulder pain when performing the ROM exercises. These data can assist clinicians in making decisions regarding which exercises to prescribe to preserve shoulder motion and prevent contractures in this population.

Effects of the abdominal drawing-in maneuver on muscle activity, pelvic motions, and knee flexion during active prone knee flexion in patients with lumbar extension rotation syndrome

OBJECTIVE

To investigate the effects of performing an abdominal drawing-in maneuver (ADIM) during active prone knee flexion on the hamstrings and erector spinae muscle activity, the amounts of pelvic motion and knee flexion, and onset of pelvic movements.

DESIGN

Comparative, repeated-measures study.

SETTING

University research laboratory.

PARTICIPANTS

Men patients (N=18) with lumbar extension rotation syndrome.

INTERVENTION

Subjects performed prone knee flexion in 2 conditions.

MAIN OUTCOME MEASURES

To measure muscle activity, surface electromyogram (EMG) of both erector spinae and the medial and lateral hamstrings was performed. Kinematic data on the pelvic motion and knee flexion were measured using a 3-dimensional motion analysis system. Repeated 1-way analysis of variance was used for the statistical analysis.

RESULTS

Significantly decreased electromyographic activity in the right and left erector spinae and significantly increased electromyographic activity in the medial and lateral hamstrings activity were shown during prone knee flexion in ADIM condition using the pressure biofeedback unit. In addition, the amounts of anterior pelvic tilt, pelvic rotation, knee flexion, and perceived pain decreased significantly during prone knee flexion in the ADIM condition compared with the same maneuver in the non-ADIM condition. The onset of anterior pelvic tilt and pelvic rotation occurred significantly earlier in the non-ADIM condition, compared with the ADIM condition.

CONCLUSIONS

ADIM effectively increased activation of knee flexors, decreased activation of back extensors, and reduced the pelvic motions and low back pain during prone knee flexion in patients with lumbar extension rotation syndrome.

Treatment of patella alta with taping, exercise, mobilization, and functional activity modification: a case report

Knee pain associated with patella alta (PA) can limit involvement in sport or work activities and prevent an individual from performing basic functional tasks. This case report describes the use of patellar taping to treat an individual with PA. The patient was a 56 year-old female with bilateral knee pain associated with PA. The focus of treatment was to decrease pain during functional activities by using tape to correct patella alignment. The patient was also instructed on specific exercises and mobilizations. The primary outcome measure was the ADL subscale of the Knee Outcome Survey (ADL-KOS). Initially, the patient scored a 50 on the ADL-KOS and rated her function at 30% of normal. She demonstrated symptom improvement when tape was applied appropriately and was, therefore, instructed in tape application. At discharge, the patient scored a 56 on the ADL-KOS and rated her function at 70% of normal. This case demonstrates the effective use of a taping method for the treatment of pain associated with PA. Taping appears to be a safe, conservative, and cost-efficient measure to manage symptoms and to improve activity tolerance in this patient.

Enhancing muscle force and femur compressive loads via feedback-controlled stimulation of paralyzed quadriceps in humans

OBJECTIVE

To compare paralyzed quadriceps force properties and femur compressive loads in an upright functional task during conventional constant-frequency stimulation and force feedback-modulated stimulation.

DESIGN

Crossover trial.

SETTING

Research laboratory.

PARTICIPANTS

Subjects (N=13; 12 men, 1 woman) with motor-complete spinal cord injury.

INTERVENTIONS

Subjects performed 2 bouts of 60 isometric quadriceps contractions while supported in a standing frame. On separate days, subjects received constant-frequency stimulation at 20Hz (CONST) or frequency-modulated stimulation triggered by a change in force (FDBCK). During FDBCK, a computer algorithm responded to each 10% reduction in force with a 20% increase in stimulation frequency.

MAIN OUTCOME MEASURES

A biomechanical model was used to derive compressive loads on the femur, with a target starting dose of load equal to 1.5 times body weight.

RESULTS

Peak quadriceps force and fatigue index were higher for FDBCK than CONST (P<.05). Within-train force decline was greater during FDBCK bouts, but mean force remained above CONST values (P<.05). As fatigue developed during repetitive stimulation, FDBCK was superior to CONST for maintenance of femur compressive loads (P<.05).

CONCLUSIONS

Feedback-modulated stimulation in electrically activated stance is a viable method to maximize the physiologic performance of paralyzed quadriceps muscle. Compared with CONST, FDBCK yielded compressive loads that were closer to a targeted dose of stress with known osteogenic potential. Optimization of muscle force with FDBCK may be a useful tactic for future training-based antiosteoporosis protocols.

Effect of hip angle on anterior hip joint force during gait

Anterior hip or groin pain is a common complaint for which people are referred for physical therapy. We have observed that people with anterior hip pain often walk in greater hip extension than people without anterior hip pain, and that the pain is reduced when they walk in less hip extension. Therefore, we investigated anterior hip joint forces which may contribute to anterior hip pain and examined the effect of end range hip extension on the anterior hip joint force during gait. To do this, we used a 6 degree of freedom, three-dimensional musculoskeletal model to estimate hip joint forces during gait. Within subjects, the maximum anterior hip joint force for gait trials with the most hip extension was compared to the anterior hip joint force for gait trials with the least hip extension. The musculoskeletal model indicated that increasing the maximum end range hip extension when walking results in an increase in the anterior hip joint force when compared to walking in less hip extension. Walking in greater hip extension may result in an increase in the anterior hip joint force, and thereby contribute to anterior hip pain. The findings of this study provide some evidence supporting the use of gait modification to reduce anterior hip force when treating people with anterior hip pain.