An Article A Week...

Title: Shoulder Electromyography Measurements During Activities of Daily Living and Routine Rehabilitation Exercises Authors: Gurney A, Mermier C, Laplante M, Majumdar A, O’Neill K, Shewman T, Gurney J Journal: Journal of Orthopedic and Sport Physical Therapy Year: 2016

Protocols vary from super conservative to more aggressive approaches after rotator cuff surgeries. The usual progression of exercises is PROM to AAROM to AROM to resistance training, but how much do you really use each muscle of the shoulder during these beginner, phase 1 exercises? This study looked at the activation of specific rotator cuff muscles through EMG during common phase 1 shoulder exercises, as well as during common post surgical ADLs. 

Nitty Gritty

Who: 28 volunteers What: Electromyography measures of Biceps, Upper Trapezius, Middle Deltoid, Teres Minor, Supraspinatus, Infraspinatus, Subscapularis. How: 28 healthy volunteers were chosen for this study. The participants were instructed how to properly perform the following exercises and EMG data were collected during:

AAROM pulleys in sagittal plane and in scapular plane

Pendulums

AAROM Wand/Dowel Flexion

AAROM Self Ranging (interlocked fingers) Flexion

The shoulder muscle activity was also measured while walking 10 steps, donning and doffing a button down shirt, donning and doffing a shoulder sling

Results: (see table below for more detailed information)

High supraspinatus, infraspinatus and subscapularis activity during ambulation.

Donning/Doffing sling yielded high infraspinatus, subscapularis and biceps activation. 

Donning/Doffing shirt showed high supraspinatus, infraspinatus, subscapularis and teres minor activation.

Higher rotator cuff activation during scapular plane pulleys than sagittal plane pulley

Pendulum exercise had more muscle activation than AAROM with interlocking fingers.

Limitation: healthy individuals be pathological individuals. After surgery people may be even less inclined to activate those muscles during their daily activities in attempt to protect themselves or avoid pain so the recruitment may differ.

Clinical Relevance

Logical progression of pulleys is to start a patient using the pulleys in the sagittal plane and then gradually progress to scapular plane exercise due to increased activation of RTC in scapular plane.

As new grads especially, PTs are sometimes overly cautious when prescribing exercises to patients in order to protect the healing tissues. Some PTs may be nervous to give 1-2# dumbbells to grandma in fear of hurting her, when in reality grandma is lifting 1-2# objects around her home doing every day chores without even realizing it. This leads me to the interesting finding of this study. The ADLs listed in this study yielded the higher activation of rotator cuff muscles than any of the exercises performed. This further supports the safety of the phase 1 exercises given to post surgical patients. If the patient is taking his/her sling off and shirts off independently than they are able to do some gentle AAROM exercises without over stressing the healing muscles.

Title: A Literature Review of Studies Evaluating Gluteus Maximus and Gluteus Medius Activation During Rehabilitation Exercises Authors: Reiman M, Bolgla L, Loudon J Journal: Physiotherapy Theory and Practice Year: 2012

Sooooo, about the butt.....

Glute muscle weakness is seen in a lot of patient populations and contribute to low back, knee and hip pain. Exercises are frequently prescribed during PT and included in HEP to address weakness but which exercises are best?

This study was pretty straight forward and also very insightful. It was a meta-analysis of studies that investigated the best exercises for gluteus maximus (gMax) and medius (gMed) activation based on EMG data.

Nitty Gritty

Who: 6 studies gathered for gMax and 4 studies for gMed. The subjects included in these studies were HEALTHY subjects.

What: Not going to bore you with specifics but there was a bunch of inclusion and exclusion criteria looked at when picking the studies. The different exercises looked at were:

Bridge

Single Limb Bridge

Bridge on Swiss Ball

Plank

Quadruped Opposite Arm/Leg Lift

Side Lying Hip Abduction

Side Bridge

Clams at 60 and 30 degrees hip flexion

Pelvic Drop

Forward Lunge in neutral and with forward and backwards trunk lean

Side Lunge

Forward Lunge with Trunk Rotation

Single Limb Deadlift

Single Limb Squat and Mini Squat

Forwards, Lateral and Backwards Step Up

Results: They separated the results into different categories: low, moderate high and very high levels of activation. The results were as follows....

gMax:

Very High: Forward Step Up,

High: Side Lunge, Lateral and Backwards Step Up, Lunge with Trunk Twist, Quadruped with Opposite Arm/Leg Lift, Single Leg Mini Squat and Squat, Wall Squat, Single Leg Dead Lift

Moderate: Side Lying Hip Abduction, Lunge in Neutral and with Forward Trunk Lean, Bridging and Single Leg Bridge, Clam 30 and 60 Degrees

Low: Plank, Lunge with Backwards Trunk Lean, Bridge on Swiss Ball

gMed

Very High: Single Leg Squat and Side Bridge

High:  Lateral Step Up, Quadruped Opposite Arm/Leg Lift, Forward Step Up, Single Leg Bridge, Lunge w/ Trunk Rotation, Wall Squat, Side lying Hip Abduction, Pelvic Drop, Single Leg Dead Lift

Moderate: Plank, Bridge, Lunge (neutral trunk), Single Leg Mini Squat, Backwards Step Up

Low: None

Clinical Relevance

The results of this study can give clinicans ideas for glute strengthening progression from easy to hard when making an exercise program for a patient. These different exercises give them a variety of position options for those patients who tolerate certain positions better than others.

Specifically when looking at the bridge exercise a straight leg bridge tends to target the hamstrings more and decreases glute activation based on these results.

These results also suggest that trunk position can increase or decrease the glute activation. Increasing trunk extension during a lunge moves the center of mass behind the hip joint decreasing the activation required of glute. The further forward the trunk is the higher demands on the glutes.

The exercises that required higher glute med activation were exercises that required more pelvic stabilization.

If you want to target BOTH the glute max and med simultaneously the sideways lunge, lunge with trunk twist and the clam exercise at both 30 and 60 degrees had even amounts of activation.

They did not mention if the side lying hip abduction exercise was performed with slight hip extension and internal rotation to target glute med. If this position was maintained throughout testing I wonder if the glute medius activation would have been classified as “Very High” instead of “High”

Food for thought!

See you next week :)

Title: Baseline Examination Factors Associated with Clinical Improvement After Dry Neddling In Individuals With Low Back Pain Authors: Koppenhaver S, Walker M, Smith R, Booker J, Walkup I, Su J, Hebert J, Flynn T Journal: Journal of Orthopedic and Sports Physical Therapy Year: 2015

Dry needling is picking up speed in the rehabilitation and wellness world. Not every state is on board for this modality however clinically it is getting decent results. Whether it is just a placebo effect or it is something more concrete is an issue still up in the air, but at the end of the day does it really matter? An effective treatment is an effective treatment regardless.

This study decided to take a closer look at the effectiveness of one dry needling session on patients with back pain and specifically what deficits or signs/symptoms to look for during the evaluation that may make a person a better candidate for dry needling:

Nitty Gritty

Who: 72 patients with MECHANICAL back pain

How: Once included and exclusion criteria were considered, participants underwent a thorough evaluation of their back pain. They were also given several questionnaires:

Modified Oswestry

Pain Scale

Fear Avoidance Beliefs Questionnaire

Likert Scale on Personal Opinion on Effectiveness of Acupuncture/Dry Needling

How (continued): They then underwent 1 dry needling session targeting the multifidus and any other trigger points found in low back region. One week later they reassessed low back pain using the Modified Oswestry. Clinically significant improvement needed to be > or = to 30% improvement in questionnaire score.

Results: Participants with positive Multifidus Lift Test, patients who were not exacerbated by prolonged standing, patients without leg pain, had improved symptoms after dry needling session. 26 participants had clinically significant improvement of Modified Oswestry Score.

Clinical Relevance

Not everyone with back pain is a candidate for dry needling. You first have to narrow down where the pain is coming from......is the pain coming from myofascial structures or something else like narrowing of canals or facet arthritis? If it is of myofascial origin, chances are dry needling is a viable option for decreasing back pain.

This study suggests that dry needling is most beneficial when pain is from muscular or fascial structures, however there were no serious adverse effects of dry needling in any subject involved. If you have tried everything else in your toolbox and you cannot help relieve a patient’s pain, why not try dry needling? Even if it is not of myofascial origin, the placebo effect is a very real-fake thing :P

I would be interested to see a study comparing dry needling alone vs. dry needling with exercises because at the end of the day dry needling is a quick fix. If you do not fix the postural abnormality or the muscular weakness responsible for the muscular or fascial tightness/trigger point it will just come back over time after the dry needling treatment. That being said, these researches waited 1 week after the dry needling treatment to follow up with the patients. I would be interested to see how they felt 2 days after the treatment because over the course of the week the trigger points/symptoms may have returned.

Sorry for the delay folks! Getting back on track now with my entries :)

Howdy followers!

As some of you may have noticed already the change in name.....

I decided to change ‘An Article a Day’ (www.anarticleaday.tumblr.com) to ‘An Article a Week’ (www.anarticleaweek.tumblr.com) because between a full time job, paperwork, volunteer work AND reviewing a research article a day, it is safe to say I bit off more than I could chew. I apologies for the confusion!! 

The premise is basically the same with the change in frequency. Each week I will review one article and sum up it’s clinical relevance. I will try to incorporate a variety of orthopedic topics to keep things interesting. The article write up should be posted by Thursday every week......SHOULD BE being the operative words in that sentence ;)

Title: A comparison in the muscle activity of the abductor hallucis and the medial longitudinal arch angle during toe curl and short foot exercises. Authors: Jung DY, Kim MH, Koh EK, Kwon OY, Cynn HS, Lee WH. Journal: Physical Therapy in Sport Year: 2011

While the exercises seem elementary and sometimes silly, physical therapists have been prescribing towel curls and marble pick ups for years to strengthen intrinsic muscles in patient’s with plantar facitis, posterior tibialis dysfunction, achilles tendonitis etc..... The short foot exercise is also commonly performed in a foot pathology rehab, especially in those patients with “flat feet”.

Excessive pronation is something that is considered to contribute to over use and foot tendonitis. Studies have shown that maintaining a good medial longitudinal arch (MLA) is key to help this type of tendonitis and the abductor hallucis (AbH) is a muscle that contributes to this arch support.

Toe curls strengthen foot flexors and intrinsics but does it support the MLA and does it play a role in the arch angle during the exercise? How about the Short Foot exercise? Between the 2 exercises, which one activates the Abd H more?Also, how did doing these exercises in different positions change the muscle activation of AbH and the angle of MLA? The authors of this study wanted to know this information too.....

Nitty Gritty

Purpose: To see if the short foot exercise and toe curl exercise fire the AbH and change the MLA angle while in the sitting and single limb stance position.

Methods: 20 subjects with neutral foot alignment were chosen for the study. These subjects performed SF exercise and Toe Curl Exercise while the EMG of AbH was taken and video camera program measured angle of MLA. The maximum voluntary isometric contraction (MVIC) for the AbH was gathered as well in order to properly interpret the results of the EMG.

Results: 

AbH activation was significantly higher in short foot exercise compared to tow curl exercise in sitting and single leg stance

SITTING short foot exercise had LOWER AbH activation compared to standing. No change in activation based on position during toe curl exercise.

MLA angle was smaller during short foot exercise compared to toe curl exercise

MLA angle was larger during single limb stance toe curl vs. sitting toe curls

Clinical Relevance:

Since AbH activation was higher AND the MLA angle was smaller during the short foot exercise we can make a case that increased AbH strength/endurance contributes to a ‘good’ arch/not a ‘flat foot’.

Since AbH activation increased from sitting to single limb stance position it suggests a good exercise progression from easier to more advanced

Sitting --> Standing --> Single Limb

Based on the results of this study (showing that the MLA angle decreases with short foot exercise) the short foot is the way to go when focusing on increasing arch support and decreasing a flat foot. This is a good neuromuscular control exercise, because much like postural exercises for cervical spine and shoulder, the more you strengthen and repeat the desired position/motion, the more likely the patient will carry over the posture/position throughout their daily routine. As they get more familiar with the exercise you can have them maintain the short foot exercise during functional activities such as squats or sit to stands to reinforce proper foot posture.

This article only focuses on the AbH however it brings up many other muscles that have been found to help support the arch during activities and in stance so lets not forget the exercises that strengthen:

Anterior Tibialis

Posterior Tibialis

Peroneous Longus

Flexor Digitorum Brevis

Interossei

I end up having to demonstrate the short foot exercise to people because it is difficult to describe. Being my own worst patient, I am awful at the exercise, ultimately confusing my patients even more. This study gives good instructions to the participants of how to perform the exercise:

“Shorten foot bringing [knuckle of big toe] closer to heel without [curling toes]”

Citation: Jung DY, Kim MH, Koh EK, Kwon OY, Cynn HS, Lee WH. A comparison in the muscle activity of the abductor hallucis and the medial longitudinal arch angle during toe curl and short foot exercises. Phys Ther Sport. 2011;12(1):30-5.

:) Thanks to my guest author Adam for whipping this one up tonight so I could do much needed paperwork.......

Title: Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 2: glenohumeral joint. Authors: Lawrence RL, Braman JP, Staker JL, Laprade RF, Ludewig PM. Journal: J Orthop Sports Phys Ther. Year: 2014

Shoulder kinematics are a hotly debated topic in the physical therapy world. They seem to come up during any conversation about shoulder pathology and treatment, and rightfully so.  This article takes an invasive look (using bone pins) at each piece of the complex shoulder joint and tries to once again break down the movements occurring inside.

Nitty Gritty

Purpose:  To investigate Glenohumeral (GH), Scapulothoracic (ST), Sternoclavicular (SC), and Acromioclavicular (AC) motion during simple shoulder motions (flexion, abduction, and scapular plane elevation)

How:  Bone pins were inserted into the clavicle, scapula, and humerus of 12 asymptomatic and 10 symptomatic participants.  Patients performed the basic motions listed above, and motions at the tested joints were calculated using electromagnetic sensors.

Results of Part 1: 

Symptomatic individuals consistently demonstrated:

Less SC posterior rotation regardless of shoulder motion

Less ST upward rotation between 30-60 degrees of shoulder abduction, and shoulder elevation

Results of Part 2:

Symptomatic individuals consistently demonstrated:

6-7 degrees more GH superior translation between 30-60 degrees shoulder elevation (correlating to the same ROM as the decreased ST motion)

1.4mm more anterior translation between 90-120 degrees of flexion

An average of 1mm more inferior humeral head translation throughout shoulder abduction

Clinical Relevance:

Though the differences between the symptomatic and asymptomatic group were not HUGE numbers, the results still give us some food for thought when treating a painful shoulder.

The correlation between decreased scapular upward rotation and increased GH superior translation during the same ROM (30-60 degrees of elevation) could be very important in determining treatment in some impingement cases. A decrease in upward rotation decreases sub-acromial space…. As does any superior translation of the GH joint.  On top of this data, studies have also found that even in most pain FREE shoulders the sub-acromial space is smallest between 45-60 degrees of shoulder elevation (Ludewig et al).  Add it all up and maybe we have “compression” of the rotator cuff tendon.

Looking at the increased anterior translation of the humeral head between 90-120 degrees of elevation may correlate to another form of shoulder impingement…Internal aka posterior impingement.  As we know, internal impingement is said to occur above 90 degrees of elevation, which is where this translation takes place.  Therefore it is possible (not 100% definite) to relate the pain of internal impingement to this anterior translation.  Why??? Well, now you have an arm being raised above 90 degrees, this GH joint moves anteriorly, and insto-facto we have a sheer force being placed on our rotator cuff tendons.

The above points 1 & 2 may help us target exercises that stay out of these ranges of motion in order to limit the chance of further tendon damage.

Consider mobilizations at the SC joint to help address the decreased posterior rotation found in the asymptomatic group. (Also, tightness in the clavicular portion of Pec Major may relate to decreased SC rotation)

Lastly, the common idea that the humeral head must translate superiorly in order to impinge the rotator cuff was not proven.  Though the GH joint itself did elevate, the humeral head itself actually translated inferiorly.  This is theorized by the author to be because most studies examining humeral head translation, only examine patients with current rotator cuff tears (not just impingement)

Thanks again Adam for the write up!

Title: Low Back and Lower Limb Muscle Performance in Male and Female Recreational Runners With Chronic Low Back Pain Authors: C Cai, PW Kong Journal: JOSPT Year: 2015

The “Facts”

Back pain is not only one of the most common pathologies out there, but it is relatively common in runners too.

Popular deficits thought to lead to back pain according to research:

Decreased lumbar extensor strength

Decreased Multifidus Size

Delayed Transverse Abdominis Activation

Decreased lumbar extensor and gluteus maximus endurance

Decreased Knee/Hip Flexor flexibility

Inhibition of knee extensor maximum voluntary contraction

The spine is subjected to high compressive/loading forces due to high impact activity, especially if trunk/core and lower extremity muscles are weaker than they should be.

Nitty Gritty

Purpose: compare lumbar extensor endurance, stabilization muscle activation and leg strength between male and female runners with and without low back pain

How: 18 healthy runners and 18 runners with low back pain (9 men and women in each group) were chosen for the study. The following outcome measures were used: 

Patient Specific Functional Scale (PSFS) and pain scale

Sorensen Test with EMG over iliocostalis and longissimus muscles (pictured below)

Ultrasound scanner measured thickness of multifidus and transverse abdominis during rest and submax contraction

Strength of hip extensors, abductors, knee extensors measured with dynamometer

Results: 

Runners with Low Back Pain= lower PSFS score, higher fear avoidance beliefs and older, LOWER knee extensor peak torque, 

MALE Runners with Low Back Pain= decreased multifidus thickness/activation

Limitations: the biomechanics of each individual’s running form and their “usual” running speeds were not considered, no “non running” LBP group, small sample size w/ narrow age range and high functional ability

Clinical Relevance

The authors explain that knee extensors are responsible for shock absorption when lower extremity hits the floor. The weaker the extensors, the stiffer the joint is, the less shock is absorbed in the leg and is transmitted to the spine instead.

This is suggesting that not only should knee extensor strength be emphasized in runners with LBP but that eccentric knee extensor strengthening should be a main focus. Functional strengthening and neuromuscular control exercises should also be implemented to prevent stiffer landings during hops and jumps, similar to the ground contact made when running.

In my opinion there were far too many limitations to this study to generalize the results. There are many other studies out there supporting the importance of hip strengthening and core endurance strengthening in low back pain patients. Therefore, at the initial evaluation, if deficits in the hip and core are noted, they should not be ignored just based on the results of this one study.

Almost to hump day people! We can do it :)

Title: The Effect of Knee Braces on Quadriceps Strength and Inhibition in Subjects With Patellofemoral Osteoarthritis Authors: MJ Callaghan, MJ Parkes, DT Felson. Journal: JOSPT Year: 2016

Patella femoral knee arthritis (PFOA) is a very common orthopedic problem. Soft neoprene sleeves are sold relatively cheaply at drug stores and sporting supply stores as a viable product to provide more knee support and to help relieve knee pain during activity. Many physical therapists are hesitant to recommend these braces because they may cause weakness in the quad muscles. Is this true? Well, these authors set out to answer this question.... 

Nitty Gritty 

Purpose(s):

Compare quad function in patient’s with PFOA by measuring Maximum Voluntary Contraction (MVC) and Arthrogenous Muscle Inhibition (AMI) in people who wear flexible knee brace for 6 weeks for those who do not.

Look into the effects on quad activity after wearing brace for 12 weeks

Hypothesis: those wearing the brace will have decreased MVC and greater incidence of AMI (greater AMI=worse)

Methods: AMI and MVC measurements were gathered at the start of the experiment for the knee being studied. Bioskin Q brace (flexibile free range of motion brace with straps) used on 53 participants for 6 weeks. 55 participants used no brace for 6 weeks. NO ADDITIONAL TREATMENT OR THERAPY USED. After measurements were taken at 6 weeks, the braced group continued wearing brace for another 6 weeks (total of 12 weeks) and the non-braced group wore the brace for 12 weeks. AMI and MVC were measured at the end of each 12 week period as well.

MVC: dynamometer

AMI: Digitimer High Voltage Stimulator (electrodes) w/ equation

Results: 

There was no significant change in NON-BRACE group after 6 weeks however there was a significant DECREASE (aka improvement) in AMI in people who wore the brace.

After 12 weeks of brace wearing there was a significant increase in MVC and decrease in AMI

Limitations:  only PFOA patients were used in this study and no other types of OA or knee pain were looked at, only one type of brace was used so it is hard to generalize the results for other braces, no intervention was used in conjunction with the brace; I would have loved to seen a group that used the brace AND therapy.

Clinical Relevance

Flexible knee braces in patients with PFOA demonstrated no negative effects on quad strength/activation. As a matter of fact there were POSITIVE outcomes to knee brace wearing. How? Well, the brace could have made the patients feel more secure and comfortable, therefore causing them to be more active and the support may have also prompted the participants to move in a less 

 way using lower extremity musculature the way it is supposed to be used.

Another interesting point, a study as done suggesting that anesthetic knee injections decrease AMI by 10%. Wearing a knee brace decreased AMI by 8.42% in this study. Since those values are similar, knee braces can offer a more non-invasive and less expensive way to improve quad AMI. The authors do state that the results were significant but the clinical effects were small, but hey...it is worth a try, aint it??

Happy Monday Y’all!

Citation: Callaghan MJ, Parkes MJ, Felson DT. The Effect of Knee Braces on Quadriceps Strength and Inhibition in Subjects With Patellofemoral Osteoarthritis. J Orthop Sports Phys Ther. 2016;46(1):19-25.

Title: Stretching Before or After Exercise Does Not Reduce Delayed Onset Muscle Soreness Authors: N Henschke, CC Lin Journal: British Journal of Sports Medicine Year: 2011

A Cochrane systematic review was done in 2007 looking at the effects that stretching has on muscle soreness after a workout. They expected that stretching would decrease delayed onset muscle soreness (DOMS). The article I read was an updated version/summary of this review published in 2011. 

Nitty Gritty

 After taking into consideration all of the inclusion and exclusion criteria for the review, 12 out of 43 studies were used. These are the details of these 12 studies: 

10 were done in lab settings w/ standardized exercises 

3 stretched before, 7 stretched after, 2 stretched both before and after exercising

 11 performed static stretching, 1 performed Proprioceptive Neuromuscular Facilitation Technique (PNF) stretching (hold relax)

Among these studies different muscles were targeted and stretched 

Duration of stretch varied from 40 seconds to 900 seconds 

Visual Analog Scale for soreness or 10 point pain scale used across the board to measure soreness 

Conclusion: Stretching did not decrease soreness enough across these studies to be deemed significant. In other words, there was no correlation between stretching and decreased DOMS. 

 Granted, the writers of the review admitted that the level of evidence is 'poor' based on how these studies were conducted, however because the results were all similar across the board, the authors believed the results could more or less be generalized. 

 My Opinion

Static stretching may not be the way to go to prevent DOMS, however static stretching may still have a place in rehab. For example, if my goal for a patient is to increase ROM I am still going to include static stretching in regimen. 

There are other studies out there building a case against the benefits of static stretching for injury prevention. Some also argue that stretching may in fact decrease performance levels. With all of this in mind, if I am training an athlete and want to include stretching as part of a warm-up, DYNAMIC STRETCHING is the way to go. Why not stretch the body in a way that the athlete will be moving during their sport or work out? Performing dynamic stretching allows these muscles to be stretched out and warmed up in a more functional, yet controlled way. 

Only one study in this Cochrane review includes PNF stretching. Just based on this one study I do not think we can completely rule out PNF from decreasing DOMS. Is it likely that based on the other results, PNF has no effect....yes. But I do not believe one study can be enough to make a general statement for all of PNF stretching. 

 This all being said, I have not done much reading on the different research out there on PNF vs. Static vs. Dynamic stretching so this is my opinion as of now....it may change the more I read...stay tuned.....

 Citation: Henschke N, Lin CC. Stretching before or after exercise does not reduce delayed-onset muscle soreness. Br J Sports Med. 2011;45(15):1249-50.

Title: Neuromotor Control of the Lower Limb in Achilles Tendinopathy: Implications for Foot Orthotic Therapy Authors: N Wyndow Journal: Sports Medicine Year: 2010

This article was a review of the current literature on Achilles Tendonitis. So this entry is going to be set up a bit differently and going to be a general summary on what the article talks about with some of my clinical relevance suggestions sprinkled in. 

FOOT PRONATION has been associated and clinically accepted as a possible cause for Achilles Tendinopathy (AT) but there is varied research/results of the actual contributing factors. Calf tightness and ECCENTRIC weakness have also been associated with AT.

Other possible contributors according to the research are location of plantar surface pressure and tibial external rotation however after reading this article it is hard to tease out ‘what came first the chicken or the egg?’. Were these two biomechanical findings the CAUSE of AT or possibly RESULTS from AT pain?

AT onset has been linked to excessive repetitive loads, uneven tendon loading, increased tissue temperature causes damage from repetitive joint angle changes/forces

Also the following extrinsic factors are linked to AT in the literature: insufficient stretching program, improper footwear (soft heel cup/midfoot and rearfoot stability), previous foot/ankle injury

The action of the Triceps Surae (calf muscle) was looked at more closely in certain studies. It was found to be responsible for plantar flexion and eccentric control of posture preventing anterior translation of body during standing, walking and running. Also....

Gastroc= flexes knee

Triceps Surae= pronation and supination of subtalar joint

Another interesting point on gastroc/soleus action: it is responsible mostly for forward propulsion during walking however during running its force is directed more in the vertical plane. This suggests that vertical hopping and jumps should be incorporated in later phases of rehab to prepare patient for the demands of jogging and running.

2 types of AT have been identified: Insertional, and Mid-belly; the latter being more common.

Insertional: more resistant to treatment

Mid-belly: most cases involve the medial side of muscle

In rehab you may want to focus on targeting the medial side of the calf. Perform stretches and calf exercises at different foot angles (turned in and turned out) to target the different calf areas and not just with foot pointe forward.

AT was found to be more like a DEGENERATIVE pathology rather than an INFLAMMATORY pathology so from here on out people should not use the term tendinITIS because it is a bit misleading

Only 2 studies (since 2010) have been done linking pronation during running/walking and AT; which does not seem like a lot of evidence however think about it......Pronation= rear foot eversion, foot dorsiflexion and abduction and tibial internal rotation. As stated above, AT is most commonly on medial side of muscle, so it would make sense that rear foot eversion would contribute to AT because eversion over stretches the medial achilles causing extra stress.

Orthotic use to treat/prevent AT: In the studies that are out there, success of treatment was as high as 75% but quality research is lacking in this department. These orthoses demonstrated a decrease in rear foot movement/pronation.

BOTTOM LINE: There is some interesting research on AT and the cause/treatment for it however much more QUALITY research is needed to better understand this common pathology

Citation: Wyndow, Narelle (2010). "Neuromotor Control of the Lower Limb in Achilles Tendinopathy: Implications for Foot Orthotic Therapy". Sports medicine (Auckland)(0112-1642), 40 (9), p. 715.

Title: Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula. Authors: T Pizzari, J Wickham, S Balster, C Ganderton, L Watson Journal: Clinical Biomechanics Year: 2014

Scapular dyskinesia is a condition in symptomatic and non symptomatic people characterized by a “drooping” scapula with decreased upward rotation during arm elevation. The upper trapezius is a muscle people tend to avoid during rehab because it is thought to be overactive and the culprit of causing the “shrug” compensation, thus contributing to shoulder impingement. However, upper trapezius strength contributes to upward rotation of the scapula in the beginning stages of elevation. This study proposes a different type of shrug exercise that strengthens the upper trap in the best functional way to facilitate upper trap as an upper rotator.

Nitty Gritty

Purpose: To determine the level of activation of the upper, middle, lower trapezius and the serratus anterior during a modified shrug in normal and pathological participants and to compare them to the level of activation of those muscles during a normal shrug.

Who: 23 asymptomatic participants and 14 participants with multidirectional shoulder instability

How: EMG collected muscle activation of upper, middle and lower trapezius and the serratus anterior. Max Voluntary Isometric Contraction for shoulder abduction (positioned at 90 degrees abduction) was gathered at start of study for each participant and they used a dumbbell that was 25% of their specific value. The participants performed 10 trials of regular shrug exercise (at 0 degrees abduction) and 10 trials of abducted shrug exercise (shoulder abduction at 30 degrees). They had standardized amount of time to rest in between trials.

Results: Increased activation in all 4 muscles with modified/abducted shrug compared to regular shrug. Increased activation in upper trapezius and lower trapezius during modified/abducted shrug compared to regular shrug in multidirectional instability patients.

Limitations: small-ish sample size, only performed at 30 degrees of abduction,

Clinical Significance

When making an exercise rehabilitation plan for patients with scapular dyskinesia, the abducted shrug gives clinicans a way to strengthen the upper trapezius in the most beneficial way for the patient.

Being that the middle trapezius and serratus anterior did not have significantly higher activation during the abducted shrug does not mean the exercise won’t be beneficial in strengthening the muscles because the EMG did show some activation. Based on the graphs in the article it seems that the upper and middle trap exhibited the MOST activation during the exercise with lower activation in low trap and serratus anterior. Be sure that the exercises you give the patients are well rounded exercises. For example, compliment the modified shrug with exercises like serratus punches and Prone Ts and Ys to make sure all the scapular stabilizers are addressed.

As always, I WANT MORE!!! Since the researchers already had the EMG hooked up, why didn’t they go the extra mile and perform the shrug exercise in different abduction angles. I would love to know how the shrug exercise affects the different shoulder stabilizers as the arm elevates. (30, 45, 60, 90, 120....i want to know!!)

Overall this article offers very valuable information. STRENGTHEN THE UPPER TRAP WITH MODIFIED SHRUGS AND YOU DO NOT HAVE A REASON TO BE AFRAID!!

:) Caio!!

Citation: Pizzari T, Wickham J, Balster S, Ganderton C, Watson L. Modifying a shrug exercise can facilitate the upward rotator muscles of the scapula. Clin Biomech (Bristol, Avon). 2014;29(2):201-5.

Title: A Comparison Of The Effects of Stabilization Exercises Plus Manual Therapy To Those Of Stabilization Exercises Alone In Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial Authors: S Celenay, T Akbayrak, D Kaya Journal: Journal of Orthopedic and Sport Physical Therapy Year: 2016

So....

Two popular findings of patients with neck pain:

Overactivity of superficial cervical muscles

Scapulothoracic findings: overactive axioscapular muscles and decreased activation of lower trap and serratus

Why do we care?

Goal of rehab is to increase strength of deep cervical muscles, decrease activity of over-active muscles and to increase lost cervical ROM. One way therapists can do this is through cervical mobilizations. However, since scapulothoracic mobility and strength is linked to neck pain would scapular mobilizations contribute to a decrease in neck pain? No studies have looked at effectiveness of scapular mobilizations and neck pain in the past.

Nitty Gritty

Purpose: Compare treatment using both cervical/thoracic stabilization exercises and cervical/scapular manual therapy to treatment with just stabilization exercises alone.

Study Type: Randomized Clinical Trial

Who: 102 patients with mechanical neck pain (not including any neuro/radicular symptoms)

How: Randomized participants into 2 groups (exercise and manual therapy vs. only exercise). At baseline the following data was gathered:

Neck Disability Index

VAS

Pressure Pain Threshold (measured on bilateral upper trap)

Cervical ROM (flexion, extension, bilateral side bending and rotation)

Medical Outcomes Study 36- Item Short Form Health Survey

The same data was gathered after 4 weeks of 3x/week treatment. Treatment included:

10 reps of 10 seconds of bracing in following positions (supine, prone, quadruped, standing). And 8-12 reps of following exercises

6-10 sec hold of cervical isometrics using a band (as follows)

10-15 sec hold of 10 reps of each of the following functional activities

Thoracic bracing with 6-10 sec hold for 10 reps of following exercises; if pt can perform 15 then they increased resistance

The manual therapy group underwent 15-20 min of cervical mobilizations (bridging, manual traction, rotation and AP glides with traction and lateral glides). They also underwent 10 repetitions of bilateral scapular mobilizations of superior, inferior, bilateral rotational glides and distraction.

Results: After 4 weeks there was a greater improvement in Neck Disability Index, VAS, cervical rotation motion, QOL (SF-36) w/ both manual and stabilization exercise therapy compared to exercises alone.

Clinical Relevance

I found this article to be very insightful not only supporting the importance of manual therapy but it also gave me some great ideas for cervical exercises that are beneficial as well as functional for the patient. As a therapist, I believe it is important to know your strengths and weaknesses and I would say the cervical spine is my #1 weakness. My cervical tool box is very limited and I use the same handful of exercises for almost every patient with not a lot of creativity. I will definitely be adding the exercises (posted above) to my patient's repertoire when appropriate.

I think the frequency of therapy and the duration of manual therapy was also interesting. 3x/ a week for 4 weeks seemed to be a good plan of care duration to start with because it was successful in this particular study. I wish the study looked at the outcomes after 8 weeks to see if the improvements at some point level off or if they keep on improving from the prolonged therapy. It would have also been interesting to see if patients were able to sustain the functional improvements and decreased pain levels after the therapy sessions were over.....or if continuous manual therapy is the key. Lastly, the patients received 15-20 min of manual therapy in the assigned group. I am wondering if there would have been significant improvements in those groups with only about 8-10 min of manual therapy. In a high volume clinic, it may be difficult for some therapists to perform 20 min of hands on manual therapy, therefore I am curious if a decreased duration of manual therapy is just as beneficial.

Just some food for thought.....

Citation: Celenay ST, Akbayrak T, Kaya DO. A Comparison of the Effects of Stabilization Exercises Plus Manual Therapy to Those of Stabilization Exercises Alone in Patients With Nonspecific Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016;46(2):44-55.

Title: Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running Authors: HL Teng, C Powers Journal: Journal of Orthopedic and Sport Physical Therapy Year: 2014

Patellofemoral (PF) pain is a very common pathology especially among runners. Many studies in the past have explored what may contribute to this pain and it is understood that the 2 following conditions have a correlation with increased PF joint pain:

INCREASE in PF joint reaction force, occurs with:

INCREASE in knee extensor moment

INCREASE knee flexion angle

DECREASE in area of contact patella makes with femur, occurs with

Knee Extension; contact area increases with knee flexion

While other aspects of the running motion have been investigated, such as the area of contact the foot makes with the ground (hind foot, front foot or mid foot) there is not much research out there in relation to trunk position’s effects on LE biomechanics and PF joint pain. 

Nitty Gritty:

Type of Study: Cross Sectional Repeated Measure

Purpose(s):

Investigate the effects of sagittal plane trunk position on PF joint stress

How the change in sagittal plane trunk posture effects the kinetics/kinematics of the knee while running

Who: 24 recreational runners (½ male ½ female); runners all made contact with floor with hind foot.

How: First the athletes would run at a self selected posture and data would be gathered. Then during the last 2 trials they would run at flexed and extended posture relative to their “normal” and data was collected. Before the trials the maximum voluntary isometric contraction was determined for medial hamstrings, lateral hamstring and gastrocnemius. EMG markers were placed on these muscles during the trials. A 3D motion capture system gathered kinematic data.

The running speed and distance was consistent between all trials and all participants.

Results: 

The more trunk flexion the less PF joint stress/PF joint reaction force. The more trunk extension the more PF joint reaction force. 

Contact area of patella on femur at peak PF joint stress was increased during BOTH flexion/extension trunk trials compared to self selected trunk posture.

Limitations: no standardized trunk flexion or extension angle from their normal, small sample size, did not look at other planes of motion (just sagittal). Lastly, if runners run in a more flexed posture, what is the effect on performance (if any)?

Clinical Relevance

People who ran with more flexed posture had less PF joint stress than those who were more upright. Flexing at the trunk is a much easier adjustment to make than changing foot strike, cadence or running barefoot.

Biomechanical Results to Consider: Knee extensor moment is more influential on PF joint stress compared to knee flexion moment.

Hasta Tomorrow! 

Citation: Teng HL, Powers CM. Sagittal plane trunk posture influences patellofemoral joint stress during running. J Orthop Sports Phys Ther. 2014;44(10):785-92.

Title: Return to Sport Following Surgery for a Complicated Tibia and Fibula Fracture in a Collegiate Women’s Soccer Player with a Low Level of Kinesiophobia. Authors: L Feigenbaum, M Baraga, L Kaplan, et al. Journal: International Journal of Sports Physical Therapy Year: 2015

In physical therapy school at the University of Miami, we were required to pair up with a professor and work on a research project. At the end of our last year, we presented our research to the entire class and faculty. My group also had the great experience of presenting a poster presentation at CSM 2015 in Indianapolis. And now for the cherry on top…….our study was published in the international Journal of Sports Physical Therapy!!

We did a case study following a Division 1 soccer player with low level of kinesiophobia and how it affected the outcomes of rehab after a serious injury. The following is a summary of our article that myself and the other 3 DPT students put together:

Why do we care: Much attention has been paid to physical outcome measures for return to sport in the past. However, current research shows that the psychological component of these injuries can be more predictive of return to play than physical outcome measures. 

Nitty Gritty

Purpose: to describe the successful post-surgical physical therapy management of a Division 1 collegiate women’s soccer player with a lack of pain-related fear who sustained a horrific and gruesome mid-shaft fracture of the tibia-fibula while playing in a game.

Type of Research: Case Study

Methods/Case Description: 22 year old female in her final year of collegiate eligibility sustained a traumatic mid-shaft fracture of her tibia-fibula. During a high velocity play, she slide tackled an opponent in an attempt to win a 50/50 ball. As a result of the play, her distal tibia was displaced 90 degrees to the rest of her leg. She underwent a closed reduction and tibial internal fixation. Her physical therapy intervention included effusion management, range of motion exercises, neuromuscular re-education, strengthening, gait training, and sports-specific conditioning. Outcome scores were tracked using the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tampa Scale for Kinesiophobia. The IKDC measures symptoms, function, and sport activity related to knee injuries. The TSK measures fear of movement and (re)injury which was important to assess during this case due to the gruesome nature of the injury.

Outcomes: Rehabilitation occurred at the university training facility with the team physical therapist. At four months, the athlete became symptomatic over the fibula and was diagnosed with a fibular non-union fracture. This result was unexpected due to the low incidence and asymptomatic nature of fibular non-union fractures. As a result, a second surgery was performed one month later to fixate the fibula. TSK scores ranged from 19-20 throughout the treatment process, signifying low kinesiophobia. IKDC scores improved from 8.05 to 60.92. The course of care continued for an additional four months with the athlete ultimately signing a professional soccer contract in Italy.

Clinical Relevance

The rehabilitation of this athlete was complex due to her low levels of kinesiophobia and the potential role it may have had in her fibular non-union fracture. An additional complexity was her self-guided overtraining which occurred independently. Physical therapy education was modified to emphasize safety precautions and proper rehab phase progressions to address her unusual lack of kinesiophobia. This case study demonstrates a successful outcome despite a unique injury presentation, multiple surgeries, and low levels of kinesiophobia. Despite the complications and a lack of evidence-based research supporting a rehabilitation protocol for this injury, it is possible to return an athlete to a high level of competition after a traumatic high impact tibial-fibular fracture. While a low level of kinesiophobia can be detrimental to rehabilitation compliance, her overall psychological affect may have benefited her in the long run.

Kinesiophobia should be considered when recovering from an injury. Therapists and coaches should be aware of levels of kinesiophobia because this can seriously effect compliance and rehab outcome/progression.

Shout out to my awesome research group :) Its all about THE []__[] !!!!!! Go Canes!

Citation: Feigenbaum LA, Baraga M, Kaplan LD, et al. Return to Sport Following Surgery for a Complicated Tibia and Fibula Fracture in a Collegiate Women’s Soccer Player with a Low Level of Kinesiophobia. Int J Sports Phys Ther. 2015;10(1):95-103.

Title: Ankle Bracing Decreases Vertical Jump Height and Alters Lower Extremity Kinematics Authors: B Smith, T Claiborne, V Liberi Journal: International Journal of Athletic Therapy and Training Year: 2016

Ankle braces are super common for athletes to wear during games and practices to improve stability of the joint. But how does wearing braces on your ankles affect your ability to move and perform? This study decided to take a closer look at this question....

Nitty Gritty

Purpose: To observe the effects of a soft ankle brace on vertical jump height, hip/knee/ankle motion and gastroc/soleus activation during a vertical jump

Who: 20 Division 3 College Athletes (10 males, 10 females)

How: Participants performed 5 vertical jumps with the brace on and then 5 vertical jumps without the brace on (on separate days). During jumps EMG and 3-D motion analysis data was collected to analyze hip/knee/ankle movement in sagittal plane and gastroc/soleus activation. Jump height determined by Vertec jump apparatus.

Results: With the soft ankle brace the athletes demonstrated:

Decrease in jump height

Decrease in hip flexion during loading phase of jump

Decrease peak ankle plantar flexion during propulsion phase

Decreased Soleus muscle activity.

Limitations: small sample size, athletes were not used to moving or jumping with brace since they just used it for the first time on the day of testing, just one type of brace tested, and last but not least.....athletes not wearing shoes (to minimize effects of shoes) but how realistic is this for athletes who wear these ankle braces?

Clinical Relevance

Since there are mixed research/reviews on the effectiveness of braces for injury prevention, one must ask themselves....do I want to possibly sacrifice performance for a brace that does not have much research supporting it’s benefits? Also, If athletes are demonstrating decreased vertical jump heights what else could they possibly be sacrificing? Speed.....Agility? Instead of athletes wearing braces in hopes of preventing an ankle roll, why don’t they focus on a lower extremity injury prevention plan focusing on strength, balance, proprioception and correcting poor movement patterns?

The article discusses how one of it’s limitations is that the athletes did not get to “break in” the brace/get used to wearing it before the vertical jump trials; suggesting that maybe if they had time to test out the brace beforehand the results would be different. If an athlete wants to wear a brace, perhaps they should be educated on the importance of breaking the brace in. With repetitive use and an introductory phase to brace use, maybe performance does not decline as much as this study let on.

Article Found in the International Journal of Athletic Therapy & Training 21(2):39-46 · February 2016 

Title: The effect of anterior and posterior glide joint mobilization on external rotation range of motion in adhesive capsulitis patients Authors: A Johnson, J Godges, G Zimmerman, L Ounanian Journal: Journal of Orthopedic and Sport Physical Therapy Year: 2014

The concave convex rule comes directly from body biomechanics and this rule is what has driven joint mobilization treatment. If you want to gain a motion in a specific direction and you are moving a convex surface on a concave surface you mobilize in the opposite direction. Therefore, the traditional thinking would be:

Gain more Glenohumeral External Rotation= Anterior Mobilization

Gain more Glenohumeral Internal Rotation= Posterior Mobilization

While this makes sense biomechanically does this work in actuality with patients with restricted joint capsule? That is what this article investigated.

Nitty Gritty:

Purpose: To determine which direction joint mobilization yielded most improvement in external rotation ROM in adhesive capsulitis patients

Type of Research: Randomized Clinical Trial

Who: 20 subjects with adhesive capsulitis

How: Patients external rotation measurements were taken at baseline and after every treatment. 6 treatments total that were set up like this:

Ultrasound --> Joint Mobilization --> Measurement --> UBE

Results: Posterior glides had a greater and more significant improvement in external rotation glenohumeral motion compared to anterior

Downfalls:

Had additional treatments like ultrasound and UBE and did not isolate joint mobilizations

Short course of therapy

Small sample size

Clinical Relevance:

Posterior mobilizations can potentially be beneficial in all shoulder rotational deficits.

A ball and socket joint capsule is circular which means it is continuous. If one section of the capsule has an adhesion it affects the entire joint in all planes because the capsule is one continuous unit. Therefore, performing joint mobilizations in other directions (other than the standard directions we are taught in school) can benefit shoulder movement as well.

This study took patients to their end range of shoulder abduction to perform the mobilizations. In school, PTs are frequently taught to perform mobilizations in the open/”loose” packed position of the joint however this study proposes to perform rotational mobilizations at different angles of abduction. Going off of the circular joint capsule idea, why not perform mobilizations is varying degrees? You will have a better chance of breaking through adhesions rather than sticking with the same mobilization in the standard plane and ultimately beating a dead horse.

Another interesting point that this article touches on is evaluating the shoulder joint external rotation restriction to differentiate between a tight joint capsule and tight muscles. Measure ER at 0, 45 and 90 degrees of abduction (if available). If external rotation range of motion decreased (gets worse) with arm abduction, the problem is thought to be muscular tightness. If the external rotation range of motion improves with shoulder abduction it is truly capsular. Why do we care? Well, if the decrease in ROM is caused by muscular tightness we may want to pick an intervention that targets decreased tissue mobility (ie: soft tissue massage, trigger point release, PNF stretching.....) If it is truly a capsular tightness, then they are a prime candidate for joint mobilizations.

All in all, do not think of capsular restrictions as black and white. There is a lot of grey area so work where you feel a restriction, even if it goes against the biomechanical rules of a joint.

Hope everyone had a good Hump Day!! Half way through this week, we can do it!!!

Citation: Johnson AJ, Godges JJ, Zimmerman GJ, Ounanian LL. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in patients with shoulder adhesive capsulitis. J Orthop Sports Phys Ther. 2007;37(3):88-99.

Title: Postural Cueing to Increase Lumbar Lordosis Increases Lumbar Multifidus Activation During Trunk Stabilization Exercises: Electromyographic Assessment Using Intramuscular Electrodes Authors: G Beneck, J Story, S Donald Journal: Journal of Orthopedic and Sport Physical Therapy Year: 2016

So why do we care?

If you work in any outpatient setting you know back pain is pretty much in every other patient that walks into the door. If it isn’t their primary reason for being to therapy, patients often mention LBP at some point during the course of treatment.

There are global back extensors and local back extensors. Global extensors tend to be stronger on people with back pain with atrophy of local muscles.

Global: Controls the displacement of the spine (ex: longissimus thoracis)

Local: spinal stability/stiffness of the spine (ex: multifidus)

Spine stability is often goal for back pain patients but how do you isolate those spine stabilizers?

Nitty Gritty:

Purpose: To research the influence of postural cueing to increase lumbar lordosis in lumbar extensor activity during trunk stabilization/core exercises

Hypothesis: Lumbar lordosis during exercises will improve Multifidus activation without increasing global muscle (longissimus thoracis) activation

Subjects: 13 Healthy Adults

Methods: Study began with training session to ensure proper exercise form of 6 core exercises with neutral spine and increased lumbar lordosis. Then each participant performed 6 exercises with neutral spine and 6 exercises with increased lordosis and multifidus activity and longissimus thoracis activity was recorded through EMG.

6 Exercises: Alternate Arm/Leg Lift (opp) in Quadruped, Unilateral Prone Leg Extension, Sidebridge on Knees, Prone Trunk Lift, Roman Chair Trunk lift from 15 degree incline and then from 45 degree incline (pictures at end of entry for clarification if needed)

Verbal Cue for form: “Push tailbone backwards to tighten lower back muscles”

Results: 

Higher Multifidus Activation on IPSILATERAL SIDE of lifted leg during quadruped exercises; increase in Longissimus Thoracis on OPPOSITE SIDE of lifted leg.

Higher activation of both muscles on side CLOSEST TO TABLE during side bridge.

Increased Longissimus Thoracis on IPSILATERAL side of leg lift during Prone Leg Extension.

For ALL EXERCISES lumbar lordosis increased multifidus activation but not Longissimus Thoracic

Most activation was during side bridge exercise

Clinical Relevance

Key to increase spine stabilization is to find exercises that increase the ratio of Multifidus to other global spinal extensors such as Longissimus Longus. Cuing patients to maintain lumbar lordotic position during core exercises is one way to do this.

This may be the best way to strengthen spinal stability muscles because it does not increase compressive forces on lumbar facets or discs since the larger, more global muscles do not reveal an increase in activation (Longissimus Thoracis).

Since this article only looked at healthy subjects, patient’s with low back pain may struggle proprioceptively to find what is considered “lumbar lordosis” and may need extra cueing for proper form.