V10N4 Cover

August 2015

The Efficacy of Taping for Rotator Cuff Tendinopathy: A Systematic Review and Meta-Analysis

Authors:  Desjardins-Charbonneau A, Roy JS, Dionne CE, Desmeules F
Rotator cuff (RC) tendinopathy is a highly prevalent musculoskeletal disorder. Non-elastic taping (NET) and kinesiology taping (KT) are common interventions used by physiotherapists. However, evidence regarding their efficacy is inconclusive.  The purpose of this research was to examine the current evidence on the clinical efficacy of taping, either NET or KT, for the treatment of individuals with RC tendinopathy.  Ten trials were included in the present review. Most RCTs had a high risk of bias. There is inconclusive evidence for NET, either used alone or in conjunction with another intervention. Based on pooled results of two studies (n=72), KT used alone resulted in significant gain in pain free flexion (MD: 8.7° 95%CI 8.0° to 9.5°) and in pain free abduction (MD: 10.3° 95%CI 9.1° to 11.4°). Based on qualitative analyses, there is inconclusive evidence on the efficacy of NET or KT when used alone or in conjunction with other interventions on overall pain reduction or improvement in function.  Therefore the authors concluded that although KT significantly improved pain free range of motion, there is insufficient evidence to arrive at a formal conclusion regarding the efficacy of KT or NET used alone or in conjunction with other interventions in patients with RC tendinopathy.
IJSPT-10_4-01-Desjardins_abs  |  Full article (subscribers only)

The Relationship between Passive Glenohumeral Total Rotation and the Strength of the Internal and External Rotator Muscles:  A Preliminary Study  
Authors:   Cibulka MT,  Enders G, Jackson A, Maines S, Von der Haar J, Bennett J
There is little research on how the amount of shoulder joint range of motion, specifically glenohumeral rotation, may be related to the strength of the rotator cuff muscles. A long held belief is that a joint with excessive range of motion needs sufficient muscular strength for stability to exist. However, no studies have examined this concept. Therefore, the purpose of this study was to see if total arc of glenohumeral joint rotation (External rotation [ER] + Internal rotation [IR]) could predict peak isometric muscle strength of the IR or ER muscles of the shoulder. The authors found that those with an increased total arc of motion of glenohumeral rotation (greater than 165.0°) had less isometric rotator cuff muscle strength in all test positions than those with less glenohumeral rotation.  Decreased force of the ER and IR muscles of the shoulder was noted in those with increased total arc glenohumeral rotation (> 165.0°); specifically those with increased glenohumeral internal rotation (> 80.0°) when compared to those with glenohumeral rotation < 165.0° and glenohumeral internal rotation < 80.0°.  
IJSPT-10_4-02-Cibulka_abs  |  Full article (subscribers only)

Comparison of Eccentric and Concentric Exercise Interventions in Adults with Subacromial Impingement Syndrome.
Authors:  Blume C, Wang SS, Trudelle-Jackson E, Ortiz A
Researchers have demonstrated moderate evidence for the use of exercise in the treatment of subacromial impingement syndrome (SAIS). Recent evidence also supports eccentric exercise for patients with lower extremity and wrist tendinopathies. However, few investigators have examined the effects of eccentric exercise on patients with rotator cuff tendinopathy.   The purpose of this study was to compare the effectiveness of an eccentric progressive resistance exercise (PRE) intervention to a concentric PRE intervention in adults with SAIS.  Thirty-four participants with SAIS were randomized into concentric (n = 16, mean age: 48.6 ± 14.6 years) and eccentric (n = 18, mean age: 50.1 ± 16.9 years) exercise groups. Supervised rotator cuff and scapular PRE’s were performed twice a week for eight weeks. A daily home program of shoulder stretching and active range of motion (AROM) exercises was performed by both groups. The outcome measures of the Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain-free arm scapular plane elevation AROM, pain-free shoulder abduction and external rotation (ER) strength were assessed at baseline, week five, and week eight of the study.  The authors found that both eccentric and concentric PRE programs resulted in improved function, AROM, and strength in patients with SAIS. However, no difference was found between the two exercise modes, suggesting that therapists may use exercises that utilize either exercise mode in their treatment of patients with SAIS.
IJSPT-10_4-03-Blume_abs  |  Full article (subscribers only)

Clinical Reliability and Diagnostic Accuracy of Visual Scapulohumeral Movement Evaluation in Detecting Patients with Shoulder Impairment   
Authors:  Wassinger CA, Williams DA, Milosavljevic S, Hegedus EJ
Clinical investigation of athletes with shoulder injuries commonly utilizes visual evaluation of scapular movement to determine if abnormal or asymmetrical movements are related to the injury. To date, the intrarater reliability and diagnostic accuracy of visual evaluation of scapular movement among physical therapists are not known.  Therefore, the aims of this study were to determine the clinical reliability and diagnostic accuracy of physical therapists visual evaluation of scapulohumeral movements when used to diagnose shoulder impairment. Thirty-three physical therapists and 12 patient participants participated in this study. Reliability was measured as percent agreement and using the free marginal kappa statistic (К) and Cronbach’s alpha (α) for interrater and intrarater reliability respectively. Diagnostic accuracy variables such as sensitivity, specificity, likelihood ratios were calculated from contingency table analysis.   Visual evaluation yielded the following (95% CI): diagnostic accuracy 49.5%, specificity 60% (56 – 64), and sensitivity 35% (29 – 41), positive and negative likelihood ratios were 0.87 (0.66 – 1.14) and 1.09 (0.92 – 1.27) respectively. Percent agreements of evaluation findings between sessions for static and dynamic symmetry were 69% and 68%, respectively. The alpha statistics for static and dynamic symmetry were both 0.51. Percentage agreement in determining the injured shoulder was 59%, with an alpha statistic of 0.35.   Therefore the authors concluded that visual evaluation of scapular movements, without additional clinical information, demonstrated a poor to fair reliability and poor to fair diagnostic accuracy.
IJSPT-10_4-04-Wassinger_abs  |  Full article (subscribers only)

Knowledge of Injury Prevention and Prevalence of Risk Factors for Throwing Injuries in a Sample of Youth Baseball Players

Authors:  Bohne C, George SZ, Zeppieri G
Information on baseball injury prevention and pitch count recommendations is growing, however, the incidence of throwing injuries continues to rise. This study is the first to assess knowledge of safe throwing guidelines and risk factors from the perspective of youth athletes.  The purpose of this study wass two-fold: (1) to evaluate knowledge of safe throwing guidelines and (2) to assess the reporting of risk factors for throwing injuries in a sample of youth baseball players.  A 35-question survey was developed with questions related to knowledge of injury prevention, presence of risk factors associated with throwing injuries, and understanding and compliance with USA Baseball Medical & Safety Advisory Committee (USA BMSAC) overhead throwing guidelines.  Respondents demonstrated variability in their knowledge of the USA BMSAC guidelines related to throwing frequencies. The 13-16 year old age group displayed the least knowledge of USA BMSAC guidelines. The 9-10 and 11-12 year old age groups demonstrated the greatest knowledge of recommended BMSAC guidelines. Eighty-five (82/98) percent of the respondents reported that they had never heard of the USA BMSAC guidelines. Sixty-two percent (59/98) disagreed with the statement, “The more you throw, the more likely you are to get an injury”. Fifty-seven percent of respondents (39/98) indicated that they would not seek medical help if they experienced a tired or sore arm during a game. The results of this study suggest that young baseball players demonstrate the need for education on the following topics: the USA Baseball Medical and Safety Advisory Committee throwing guidelines, risk factors for developing throwing-related injuries, the long-term implications of playing with an injured or fatigued arm, and the benefit of seeking medical help when fatigue or soreness is experienced in the throwing arm.
IJSPT-10_4-05-Bohne_abs  |  Full article (subscribers only)

Baseball Players with Ulnar Collateral Ligament Tears Demonstrate Decreased Rotator Cuff Strength
Compared to Healthy Controls
Authors: Garrison JC, Johnston C, Conway JE
Ulnar Collateral Ligament (UCL) tears are common in baseball players. Alterations in rotator cuff strength are believed to be associated with injury to the shoulder and/or elbow in baseball players.  Baseball players diagnosed with a UCL tear may demonstrate decreased internal (IR) and external rotator (ER) strength in the throwing arm compared to IR and ER strength of the throwing arm in healthy baseball players. The purpose of this study was to compare isometric rotator cuff strength between a group of baseball players with a UCL tear and a group of healthy controls.   The authors found that in baseball players with UCL tears demonstrated significant rotator cuff strength deficits on their throwing arm IR (p < .001) and ER (p < .001) compared to throwing arm IR and ER in the Healthy (UCL IR = 131.3±31.6 N; Healthy IR = 174.9±20.7 N) (UCL ER = 86.4±18.3 N; Healthy ER = 122.3 ±18.3 N). On the non-throwing arm, the UCL group was weaker in both IR (135.0±31.1 N; p < .001) and ER (93.4±22.8 N; p < .001) than IR (172.1±24.1 N) and ER (122.3±19.1 N) in the Healthy group.  Overall, participants with a UCL tear exhibited lower rotator cuff strength values in both the throwing and non-throwing arms than a healthy cohort.  The results of this study indicate that rotator cuff strength in baseball players with a UCL tear is decreased compared to healthy baseball players. Although these data do not directly provide a cause and effect relationship between rotator cuff weakness and UCL tears, these results may help clinicians by providing a framework for assessment and treatment of this population of baseball players.
IJSPT-10_4-06-Garrison_abs  |  Full article (subscribers only)

Observer Rating Versus Three-Dimensional Motion Analysis of Lower Extremity Kinematics During Functional Screening Tests: A Systematic Review

Authors:  Maclachlan L, White SG, Reid D
Functional assessments are conducted in both clinical and athletic settings in an attempt to identify those individuals who exhibit movement patterns that may increase their risk of non-contact injury. In place of highly sophisticated three-dimensional motion analysis, functional testing can be completed through observation.  The purpose of this study was to evaluate the validity of movement observation assessments by summarizing the results of articles comparing human observation in real-time or video play-back and three-dimensional motion analysis of lower extremity kinematics during functional screening tests.  A computerized systematic search was conducted using Medline, SPORTSdiscus, Scopus, Cinahl, and Cochrane health databases between February and April of 2014. Validity studies comparing human observation (real-time or video play-back) to three-dimensional motion analysis of functional tasks were selected. Only studies examining uninjured, healthy subjects conducting lower extremity functional assessments were appropriate for review. Eligible observers were certified health practitioners or qualified members of sports and athletic training teams that conduct athlete screening. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) was used to appraise the literature. Results are presented in terms of functional tasks.  Six studies met the inclusion criteria. Across these studies, two-legged squats, single-leg squats, drop-jumps, and running and cutting manoeuvres were the functional tasks analysed. When compared to three-dimensional motion analysis, observer ratings of lower extremity kinematics, such as knee position in relation to the foot, demonstrated mixed results. Single-leg squats achieved target sensitivity values (> 80%) but not specificity values (> 50%). Drop-jump task agreement ranged from poor (< 50%) to excellent (> 80%). Two-legged squats achieved 88% sensitivity and 85% specificity. Mean underestimations as large as 19⁰ (peak knee flexion) were found in the results of those assessing running and side-step cutting manoeuvres. Variables such as the speed of movement, the methods of rating, the profiles of participants and the experience levels of observers may have influenced the outcomes of functional testing.  The authors concluded that slower, speed controlled movements using dichotomous ratings reach target sensitivity and demonstrate higher overall levels of agreement. As a result, their utilization in functional screening is advocated.
IJSPT-10_4-07-Maclachlan_absFull article (subscribers only)

The Use of Functional Tests to Predict Sagittal Plane Knee Kinematics in NCAA-D1 Female Athletes
Authors:  Cacolice PA, Carcia CR,  Scibek JS, Phelps AL
Landing with the knee in extension places increased loads on ligamentous restraints at the knee versus landing in flexion.  Unfortunately, existing methods to predict landing kinematics require sophisticated equipment and expertise.  The purpose of this study was to develop predictive models for sagittal plane tibiofemoral landing kinematics from the results of functional tests.  Twenty-nine female, NCAA-D1 college athletes (mean ±standard deviation, age= 19.03±1.09 mass=66.56±13.47kg; height=171.16± 7.92cm) participated in a descriptive, laboratory study. Participants performed five unilateral, dominant lower extremity (LE) landings from a 35cm platform onto a force plate.  LE three-dimensional kinematics were captured with electromagnetic sensors interfaced with motion analysis software.  Then in a randomized order, participants performed three standardized functional tests: single limb triple hop (SLTH), countermovement vertical jump (CMVJ) and the Margaria-Kalamen (MK) test.  Sagittal plane tibiofemoral joint angle at initial contact (IC) and excursion (EXC) in the first 0.1s after ground contact were entered into a statistical software package.  Multiple linear regression analyses generated one model predicting IC and one predicting EXC from the independent variables.  Alpha levels were set a priori at p≤ .05.  A two variable (MK, SLTH) linear regression model that predicted EXC was significant (Adjusted R2=.213, p=.017), however the model that predicted IC was not (p=.890).  The authors concluded that knee flexion excursion following a single leg landing task may be predicted with the MK and SLTH.  The use of functional tests provides a practical means to predict landing kinematics to clinicians working with an active, athletic population.
IJSPT-10_4-08-Cacolice_abs  |  Full article (subscribers only)

Changes in Hip Range of Motion and Strength in Collegiate Baseball Pitchers Over the Course of a Competitive Season: A Pilot Study.

Authors: Zeppieri G,  Lentz TA, Moser MW, Farmer KW
Adaptations in hip range of motion (ROM) and strength have been shown to influence performance and injury risk in overhead athletes. These adaptations in hip ROM and strength have not been examined longitudinally, and little is known regarding whether these changes are a result of pitching workload.  The authors hypothesized that hip rotation ROM and strength would change over the course of a season, and would be associated with pitching workload (number of pitches over the course of a season). The purpose of this exploratory, pilot study was twofold: 1) to examine changes in hip external rotation (ER) ROM, internal rotation (IR) ROM, isometric hip abduction and hip extension strength in pitchers occurring over the course of a competitive season, and 2) to determine the association between changes in hip ROM, strength, and pitching volume.  Bilateral hip rotation ROM and hip isometric strength was tested pre- and post-season in fourteen collegiate baseball pitchers.  Pearson correlations were calculated to determine the association between changes in hip ROM, strength, and pitching workload. Trail and lead hip ER, trail and lead hip total rotational ROM, and trail and lead hip abduction strength in all pitchers decreased from preseason to postseason (p < 0.01).  However, these changes were not significantly associated with pitching workload (p > 0.05).  This study demonstrates that changes occur in hip ROM and strength in collegiate pitchers over the course of a season.  These changes were not associated with pitching workload.
IJSPT-10_4-09-Zeppieri_abs  |  Full article (subscribers only)

Evidence for Isokinetic Knee Torque Asymmetries in Male Long Distance Trained Runners

Authors:  Dellagrana RA, Diefenthaeler F, Carpes FP, Hernandez SG, de Campos W
Strength asymmetries are related to knee injuries and such injuries are frequently observed among runners. The purpose of this study was to examine whether long-distance runners have symmetric performance during knee isokinetic testing at two angular velocities.  Twenty-three healthy and well-trained male long-distance runners performed open-chain isokinetic assessment of concentric the quadriceps and hamstrings at velocities of 60°·s-1 and 240°·s-1. Data were compared between the lower limbs at different velocities.   Peak torque and total work were similar between the limbs. Asymmetry was observed for knee flexor power at 240°·s-1 (237 ± 45 W and 205 ± 53 W, in the preferred and non-preferred limb, respectively). Asymmetry indexes for flexor power were different between the velocities tested (13.1% and 2.21% for 240°·s-1 and 60°·s-1, respectively).  A limb asymmetry was observed among runners for knee flexor power, mainly at higher angular velocities (240°·s-1). In addition, H/Q ratios were observed to be contraction velocity dependent. 
IJSPT-10_4-10-Dellagrana_abs  |  Full article (subscribers only)

Neuromuscular Control During Performance of a Dynamic Balance Task in Subjects With and Without Ankle Instability

Authors:  Pozzi F, Moffat M, Gutierrez G
Lateral ankle sprains are common injuries that often lead to chronic ankle instability (CAI). Individuals who previously sustained a lateral ankle sprain, but did not develop CAI, termed “copers”, may have altered postural control strategies compared to individuals who have developed CAI. These altered postural control strategies may allow for more appropriate dynamic stabilization of the ankle joint after injury compared to those seen in patients who have developed CAI.  The objective of this study was to compare lower leg biomechanics, as well as electromyographic (EMG) activation of the tibilias anterior and peroneus longus muscles, during the posteromedial reach of the Star Excursion Balance Test (SEBT) in individuals with healthy ankles, copers, and those with CAI.   Primary outcome measures included SEBT normalized reach distance in the posteromedial direction and average integrated EMG activation of the tibialis anterior and peroneus longus muscles during the reach. Secondary outcome measures included sagittal and frontal plane ankle complex angles and moments and sagittal plane knee angles and moments. Data were analyzed between groups using a one-way ANOVA model.  No significant differences in reach distance or kinematic and kinetic outcomes were found between groups. The activation of the tibialis anterior and peroneus longus muscles was significantly different between groups (p=0.033 and p=0.014, respectively). The post-hoc analysis revealed that the coper group had significantly higher muscle activation compared to the control group, but not to the CAI group.  The authors concluded that CAI did not alter kinematic, kinetic, or reach performance during the SEBT. When compared to controls, copers appeared to have greater activation of the ankle musculature, which may serve to increase stability of the ankle complex during a dynamic balance task.
IJSPT-10_4-11-Pozzi_abs  |  Full article (subscribers only)

Rehabilitation after Hip Arthroscopy and Labral Repair in a High School Football Athlete: A 3.6 Year Follow- Up with Insight into Potential Risk Factors.

Author:  Cheatham SW,  Kolber MJ
Hip arthroscopy is a common surgical technique for the correction of intra-articular pathology. While surgical success is often determined by anatomical correction, post-operative rehabilitation serves an essential role in restoring pre-morbid activity levels. A paucity of long-term post-operative rehabilitation outcomes exists in the literature lending uncertainty to the long-standing efficacy of interventions and associated risk for future injury. This case report describes the 3.6 year follow-up for a young adult male subject after unilateral left hip arthroscopy and acetabular labral repair. The re-examination findings and risk factors identified at the follow-up may provide insight into the need for long-term surveillance among post-surgical individuals.
IJSPT-10_4-12-Cheatham_abs  |  Full article (subscribers only)

Effectiveness of Dry Needling, Stretching, and Strengthening to Reduce Pain and Improve Function in Subjects with Chronic Lateral Hip and Thigh Pain: A Retrospective Case Series

Authors:  Pavkovich R
Chronic lateral hip and thigh pain is regularly treated by the physical therapist.  Many issues can cause pain in this region, and trigger points may contribute to pain.  Dry Needling (DN) is an intervention used by physical therapists where a monofilament needle is inserted into soft tissue to reduce pain thereby facilitating return to prior level of function.  The purpose of this case series is to report the outcomes of DN and conventional physical therapy as a treatment intervention for subjects with chronic lateral hip and thigh pain.  Four subjects with chronic lateral hip and thigh pain attended between four and eight sixty-minute sessions of dry needling and stretching/ strengthening activities over a four to eight week intervention course.   Outcomes were tested at baseline and upon completion of therapy.  A long-term follow up averaging 12.25 months (range 3 to 20 months) was also performed.  The outcome measures included the Visual Analog Scale (VAS) and the Lower Extremity Functional Scale (LEFS).   The LEFS and VAS indicated clinically meaningful improvements in disability and pain in the short term and upon long term follow up for each subject. The LEFS mean for the four subjects improved from 50.75 at baseline to 66.75 at the completion of treatment.  At long-term follow-up, the LEFS mean was 65.50. Each subject met the minimal clinically important difference (MCID) and minimal detectable change (MDC) for the LEFS and the VAS.  The VAS was broken down into best (VAS B), current (VAS C), and worst (VAS W) rated pain levels and averaged between the four subjects.  The VAS B improved from 20 mm at the initial assessment to 0 mm upon completion of the intervention duration.  The VAS C improved from 25.75 mm to 11.75 mm, and the VAS W improved from 85 mm to 32.5 mm. At the long-term follow up (average 12.25 months), the VAS B, VAS C, and VAS W scores were 0 mm, 14.58 mm, and 43.75 mm respectively.  Clinically meaningful improvements in pain and disability were noted. Subjects reported improved sleep and functional mobility, which were commensurate with their different age ranges and initial reported limitations in mobility.  The results of this case series show promising outcomes for the use of dry needling in the treatment of chronic lateral hip and thigh pain.  Further controlled clinical trials are recommended to determine the effectiveness of adding dry needling as compared to other interventions for chronic lateral hip and thigh pain.
IJSPT-10_4-13-Pavkovich_abs  |  Full article (subscribers only)

Why are Eccentric Exercises Effective for Achilles Tendinopathy?

Authors:  O’Neill S, Watson PJ, Barry S
Achilles tendinopathy is a complex problem, with the most common conservative treatment being eccentric exercises. Despite multiple studies assessing this treatment regime, little is known about the mechanism of effect. This lack of understanding may be hindering therapeutic care and preventing optimal rehabilitation. Of the mechanisms proposed, most relate to tendon adaptation and fail to consider other possibilities. The current consensus is that tendon adaptation does not occur within timeframes associated with clinical improvements, therefore the clinical benefits must occur through another unidentified pathway. This clinical commentary critically reviews each of the proposed theories and highlights that muscle alterations are observed prior to onset of Achilles tendinopathy and during the disease. Evidence shows that the observed muscle alterations change with treatment and that these adaptations may have the ability to reduce tendon load and thereby improve tendon health. The purpose of this clinical commentary is to review previous theories regarding the mechanisms by which eccentric exercise might affect Achilles tendinopathy and offer a novel mechanism by which the plantarflexor muscles may shield the Achilles tendon.
IJSPT-10_4-14-O'Neill_abs  |  Full article (subscribers only)

The Female Athlete Triad-What Every Physical Therapist Should Know.

Authors:  Stickler L, Hoogenboom BJ, Smith L
Females participating in sports have the potential of developing one or multiple parts of the Female Athlete Triad (triad), defined as the inter-relationship among energy availability, menstrual function, and bone mineral density. Energy availability, defined as dietary energy intake minus exercise energy expended, is believed to be at the cornerstone of the triad, and complications from low energy availability span many of the bodily systems and can have psychological implications. Treatment of the triad requires a comprehensive multi-disciplinary approach.  Physical therapists frequently treat injured athletes and may have prolonged interactions with athletes depending on the length of the rehabilitation process. In addition to examination, assessment, and treatment of injuries, the role of the physical therapist includes prevention, and the promotion of health, wellness, and fitness. Thus, the goal of this clinical commentary is to identify and describe essential knowledge for the physical therapist, clearly identify the role of the physical therapist as part of multi-disciplinary management team, and outline resources for the physical therapist and athletes relevant to the female athlete triad.
IJSPT-10_4-15-Stickler_abs  |  Full article (subscribers only)