Effects of neuromuscular and proprioceptive training on self-reported wellness and health scores and knee sensorimotor characteristics in active seniors

INTRODUCTION

Athletes regularly engage in comprehensive neuromuscular and proprioceptive training (NPT) to prevent musculoskeletal (MSK) injuries. NPT exercises such as movement technique, agility, balance, and posture as well as yoga-based stretching and slow/deep breathing have shown added benefits in psychological and other well-being. This study aimed to examine the effects of NPT on knee sensorimotor characteristics and multi-domain wellness and health scores in active seniors.

METHODS

Twenty seniors participated in the NPT intervention (15-20min session twice a week for 10 weeks) while the control group did not receive any intervention. All participants completed surveys (general health, frailty, anxiety, stress, mindfulness, optimism, and sleep quality) and laboratory testing before and after intervention. Laboratory testing included frailty tests (grip strength, 4-m walk speed, and calcaneal ultrasound-based bone density) and knee sensorimotor characteristics (peak force, visual-motor reaction time, and force steadiness).

RESULTS

There was significant increase in general mental health (Short Form 36 Mental Health; p = 0.005) and decrease in stress (Perceived Stress Scale; p = 0.010) and sleep disturbances (Pittsburgh Sleep Quality Index; p = 0.019) post-intervention while no significant changes were observed in the control group (p = 0.310-0.654). Peak knee forces in all directions and some visual-motor reaction time and force steadiness were significantly improved post-intervention only in the experimental group (p = 0.001-0.038).

CONCLUSION

A simple, yet, comprehensive NPT has potential to improve MSK health as well as various domains of well-being among active seniors.

At-Home High-Intensity Interval Training for Individuals with Paraplegia Following Spinal Cord Injury: A Pilot Study

Objective

This pilot study aimed to assess the efficacy of a 16-week at-home high-intensity interval training (HIIT) program among individuals with spinal cord injury (SCI).

Methods

Eight individuals (age: 47±11 (SD) years, 3 females) with SCI below the sixth thoracic vertebrae participated in a 16-week at-home HIIT program using an arm ergometer. Participants completed baseline graded exercise tests to determine target heart rate zones. HIIT was prescribed thrice per week. Each training session consisted of six one-minute bouts with a target heart rate ~80% heart rate reserve (HRR), interspersed with two minutes of recovery at ~30% HRR. A portable heart rate monitor and phone application provided visual feedback during training and allowed for measurements of adherence and compliance. Graded exercise tests were completed after 8 and 16 weeks of HIIT. Surveys were administered to assess participation, self-efficacy, and satisfaction.

Results

Participants demonstrated a decrease in submaximal cardiac output (P=0.028) and an increase in exercise capacity (peak power output, P=0.027) following HIIT, indicative of improved exercise economy and maximal work capacity. An 87% adherence rate was achieved during the HIIT program. Participants reached a high intensity of 70% HRR or greater during ~80% of intervals. The recovery HRR target was reached during only ~35% of intervals. Self-reported metrics of satisfaction and self-efficacy with at-home HIIT scored moderate to high.

Conclusion

Participants demonstrated an improvement in exercise economy and maximal work capacity following at-home HIIT. Additionally, participant adherence, compliance, satisfaction, and self-efficacy metrics suggest that at-home HIIT was easily implemented and enjoyable.

The Telemedicine Musculoskeletal Examination

Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform.

Hop tests can result in higher limb symmetry index values than isokinetic strength and leg press tests in patients following ACL reconstruction

PURPOSE

Quadriceps weakness is a common clinical sign following anterior cruciate ligament injury and reconstruction surgery (ACLR). The aim of this study was to compare strength deficits and the limb symmetry index (LSI) from three different types of functional tests: isokinetic dynamometry, hop test, and leg press.

METHODS

A total of 26 subjects with ACLR (average 8.3 months post-operation) participated in the study. The peak knee extension torque was tested with isokinetic dynamometry at 60/180/300 °/s (ISO60/180/300). Hop distance was tested during single hop (SH) and triple hop (TH). Unilateral peak leg power (POWER) was tested during a bilateral leg press test. LSI was calculated as the ratio of the involved limb over the uninvolved limb values. Pearson correlation coefficients and paired t-tests were used to establish relationships among ISO60/180/300, SH/TH, and POWER values and compare these values between the limbs, respectively. Within-subject one-way analysis of variance (ANOVA) with post hoc analyses was used to compare LSI values among different tests.

RESULTS

ISO60/180/300 values were significantly positively correlated with SH/TH and POWER (P < 0.05), while SH/TH and POWER values were not significantly correlated. Significant limb differences were found in all tests (P = 0.001-0.008). ANOVA revealed significant LSI differences among different tests. Specifically, post hoc analyses revealed that LSI during SH was significantly higher than LSI during ISO60. Similarly, LSI during TH was significantly higher than LSIs from ISO60, ISO180, and POWER tests.

CONCLUSIONS

Peak knee extension torque values were positively associated with hop distance and leg power during the leg press test. However, LSI values should be interpreted with caution as hop tests provided significantly higher LSI values than isokinetic testing. Both isokinetic dynamometry and unilateral leg press machine could be used to isolate and strengthen the quadriceps in the involved limb. The current "gold standard" isokinetic testing at slow speed (ISO60) provided the lowest LSI value among all functional tests; therefore, the current study supported a continued use of isokinetic testing when examining individual's readiness and return-to-sport.

LEVEL OF EVIDENCE

III.

Injury Rate and Patterns in Group Strength-Endurance Training Classes

OBJECTIVE

To identify the injury rate during high-intensity functional training.

PARTICIPANTS AND METHODS

Adults (N=100; 82 [82%] female) in group strength-endurance training at the Dan Abraham Healthy Living Center from January 9, 2017, through April 19, 2018, were recruited for the study. Participants were recruited before the class start date. Those who consented received a preclass survey and another survey 6 weeks after the class started to obtain data on demographic characteristics, baseline joint problems or pain, injuries in the preceding 6 weeks, class satisfaction, and exercise habits. Classes lasted 6 weeks and were led by a trainer for 60 minutes, once weekly. Participants were encouraged to perform similar exercise on 2 additional nonconsecutive days throughout the week. Injury was self-reported and defined as experiencing new pain or sustaining injury while exercising during the 6-week time frame. The primary outcome measure was the number of injuries per 1000 training hours.

RESULTS

The injury rate was 9.0 injuries per 1000 training hours (95% CI, 5.8-13.4 injuries per 1000 training hours) during the 6-week training and 5.0 injuries per 1000 training hours (95% CI, 2.8-8.2 injuries per 1000 training hours) during the 6 weeks preceding enrollment (P=.08). Injury occurred in 18 (18%) of participants during the 6-week training, and 9 of 24 injuries (37.5%) occurred during a training class. The most commonly injured regions were knees (n=7) and back (n=6). Burpees and squats were the most common movements causing injury.

CONCLUSION

The increased injury rate during the study was not statistically significant. It was higher than rates reported in previous retrospective studies of high-intensity functional training, weight lifting, or power lifting but comparable with rates reported in prospective studies of novice and recreational runners.

Youth Sport-Related Concussions: Perceived and Measured Baseline Knowledge of Concussions Among Community Coaches, Athletes, and Parents

OBJECTIVE

To assess concussion knowledge of athletes, coaches, and parents/guardians in a community setting and to understand trends/gaps in knowledge among subgroups to tailor efforts toward creating educational interventions.

PARTICIPANTS AND METHODS

This prospective cross-sectional study involved 262 individuals (142 [55%] female): 115 athletes participating in noncontact and contact sports (ages 13-19 years), 15 coaches, and 132 parents. Recruitment occurred from August 30, 2015, through August 30, 2016, at 3 local high schools. Participants completed a questionnaire developed by the investigators to assess concussion experience and basic knowledge.

RESULTS

Females, health care employees, and parents showed stronger concern for potential long-term sequelae of concussion, whereas athletes were most concerned about not being able to return to sport. Those with higher perceived concussion knowledge were slightly older (median age, 42.5 vs 33 years), more educated (college or higher: 42 [70%] vs 100 [50%]), and more likely to be health care workers (22 [37.9%] vs 34 [17.7%]) and scored higher on knowledge questions (average correct: 75.5% vs 60%). Most participants could identify potential concussion sequelae, but only 86 (34.3%) identified a concussion as a brain injury. Of the subgroups, coaches scored highest on knowledge questions. Those with a concussion history tended to consider themselves more knowledgeable but were also less concerned about sequelae. Overall, those with a concussion history scored slightly higher on knowledge questions (average correct: 69.8% vs 61.9%). Participants involved in contact sports were more likely to have had a concussion vs those in noncontact sports (57 [26%] vs 4 [10.3%]).

CONCLUSION

Significant differences in perceived and actual concussion knowledge across different subgroups of study participants involved in high school sports were identified.

Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program

OBJECTIVE

To prospectively study the effects of an incentivized exercise program on physical activity (PA), quality of life (QOL), and burnout among residents and fellows (RFs) in a large academic medical center.

PARTICIPANTS AND METHODS

In January 2011, all RFs at Mayo Clinic in Rochester, Minnesota (N=1060), were invited to participate in an elective, team-based, 12-week, incentivized exercise program. Both participants and nonparticipants had access to the same institutional exercise facilities. Regardless of participation, all RFs were invited to complete baseline and follow-up (3-month) assessments of PA, QOL, and burnout.

RESULTS

Of the 628 RFs who completed the baseline survey (59%), only 194 (31%) met the US Department of Health and Human Services recommendations for PA. Median reported QOL was 70 on a scale of 1 to 100, and 182 (29%) reported at least weekly burnout symptoms. A total of 245 individuals (23%) enrolled in the exercise program. No significant differences were found between program participants and nonparticipants with regard to baseline demographic characteristics, medical training level, PA, QOL, or burnout. At study completion, program participants were more likely than nonparticipants to meet the Department of Health and Human Services recommendations for exercise (48% vs 23%; P<.001). Quality of life was higher in program participants than in nonparticipants (median, 75 vs 68; P<.001). Burnout was lower in participants than in nonparticipants, although the difference was not statistically significant (24% vs 29%; P=.17).

CONCLUSION

A team-based, incentivized exercise program engaged 23% of RFs at our institution. After the program, participants had higher PA and QOL than nonparticipants who had equal exercise facility access. Residents and fellows may be much more sedentary than previously reported.

The role of exercise in the treatment of obesity

The United States is in the midst of a significant public health problem that relates to obesity and inactivity. This epidemic has far-ranging consequences for our workforce and our children and shows no signs of slowing in the near future. Significant research has been performed on the effects of exercise for the reduction of body weight; results of most studies indicate that exercise alone has a small effect on body-weight reduction independent of caloric restriction. However, when combined with dietary restriction, exercise has a synergistic effect and enhances weight loss beyond the effect of diet alone. In addition, exercise has been shown to have significant beneficial effects on cardiovascular and metabolic risk factors independent of actual weight loss, and losing just a small amount of weight can have a significant beneficial effect on these parameters. Genetic factors related to obesity have been found to be positively modified when persons incorporate physical activity into their lifestyle. Sitting time appears to be an independent risk factor for the development of metabolic risk factors; persons who spend more time sitting and watching television have worse metabolic profiles, even if they achieve the recommended amount of physical activity per week, than do those who move about throughout the day. Exercise also is essential for the prevention of weight gain over a life span, although the amount required to prevent weight gain may be closer to twice the amount of exercise recommended by the current Physical Activity Guidelines for Americans (www.health.gov/paguidelines). In many ways, the physiatrist is the most well prepared of all the specialists to address the complex, multidimensional problems of obesity and inactivity.

Effect of partial wrist denervation on wrist kinesthesia: wrist denervation does not impair proprioception

PURPOSE

To evaluate the potential effect of partial wrist denervation on wrist kinesthesia, we hypothesized that anesthetizing the anterior interosseous nerve and the posterior interosseous nerve does not impair the kinesthesia.

METHODS

We performed a double-blinded, prospective, randomized study on 80 healthy volunteers (20-54 y old) to compare the ability to detect active and passive wrist movement in 2 conditions. The test group received an anesthetic block of the anterior and posterior interosseous nerves, and the control group subjects received an injection of saline. The kinesthesia of the 2 groups was then tested in 2 conditions by measuring the error in an active and passive wrist repositioning task. Results were analyzed using a repeated measures analysis of variance.

RESULTS

In both active and passive conditions, there was no difference in the repositioning errors between the test group and the control group.

CONCLUSIONS

Our results show that kinesthesia is not impaired by blocking the anterior and posterior interosseous nerves. These findings are consistent for both active and passive motion. The study gives strong evidence that partial denervation does not impair wrist kinesthesia. However, because only kinesthesia was studied, we cannot conclude that partial denervation is a totally safe procedure for all aspects of proprioception.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

New method of measuring wrist joint position sense avoiding cutaneous and visual inputs

BACKGROUND

Aspects of afferent inputs, generally termed proprioception, are being increasingly studied. Extraneous factors such as cutaneous inputs can dramatically interfere while trying to design studies in order to determine the participation of the different structures involved in proprioception in the wrist position sense. We tried to determine validity and repeatability of a new wrist joint position measurement device using methodology designed to minimize extraneous factors and isolate muscle and joint inputs.

METHODS

In order to test the reliability of the system, eighty young-adult subjects without musculoskeletal or neurologic impairments affecting the right upper extremity were tested using a custom made motion tracking system. Testing consisted of two conditions: active reproduction of active placement and passive reproduction of passive placement. Subjects performed two repetitions of each target position (10, 20, and 30 degrees of flexion and extension) presented in a random order. Test- retest reliability was then tested.

RESULTS

The average constant error in the passive condition was -0.7 degrees +/- 4.7 degrees as compared to the active condition at 3.7 degrees +/- 5.1 degrees. Average absolute error in the passive condition was 4.9 degrees +/- 2.9 degrees compared to the active condition in which absolute error was 5.9 degrees +/- 3.5 degrees.

DISCUSSION

Test-retest repeatability in both conditions was less than the 5 degrees magnitude typical of clinical goniometry. Errors in the active condition (less than 2 degrees ) were slightly smaller than the passive condition, and the passive condition was also associated with poorer consistency between apparatus sensors and skin sensors.

CONCLUSIONS

The current system for measurement of wrist joint proprioception allows the researcher to decrease extraneous influences that may affect joint position sense awareness, and will help in future study aiming to determine precisely the role of the different structure involved in proprioception.

Septic sternoclavicular joint: a case report

A 23-year-old man presented to our sports medicine clinic with a history of nontraumatic left anterior chest pain. Prior to presentation, a magnetic resonance image (MRI) had been performed that showed increased signal in the soft tissues around the sternoclavicular joint, primarily in the pectoralis major, and a small amount of fluid in the joint, thought possibly consistent with sympathetic effusion from a muscle tear. On examination, the patient was toxic appearing and had severe pain with virtually any left upper-extremity movement and with walking. There was swelling, redness, warmth, and tenderness over the left sternoclavicular joint. Vital signs were normal, but due to concerns of possible septic arthritis, he was admitted to the hospital. After discontinuation of prednisone and hydrocodone-acetaminophen that he had been receiving, the patient became febrile. Blood and sternoclavicular joint aspirate cultures grew methicillin-sensitive Staphylococcus aureus. On re-review of the MRI, subtle abnormal signal compatible with the patient's joint infection was seen. The patient was treated with intravenous antibiotics and, eventually, surgical resection of the left sternoclavicular joint, proximal clavicle, and lateral manubrium with subsequent muscle flap. No predisposing factor for this infection was found. Septic sternoclavicular joint is rare, accounting for 1% of all septic joints. Infection or other unusual pathology should be suspected when clinical findings are not consistent with simple musculoskeletal injury.

Chronic exertional compartment syndrome of the lower extremities: improved screening using a novel dual birdcage coil and in-scanner exercise protocol

OBJECTIVE

The purpose of this study was to design and evaluate an MRI screening protocol for chronic exertional compartment syndrome (CECS) of the lower legs using an in-scanner exercise protocol and novel dual birdcage coil design for improved imaging.

MATERIALS AND METHODS

Coil and phantom studies: a custom-made dual birdcage coil designed for this protocol was evaluated for uniformity and signal-to-noise ratio (SNR) compared with a conventional phased-array receive-only torso coil and the body coil. Phantom and normal subject studies were performed to confirm coil performance. In-vivo studies: eight unaffected subjects and 42 patients with lower extremity symptoms suggestive of CECS were imaged with the dual birdcage coil and an in-scanner exercise protocol which included imaging at rest, during isometric resisted dorsi flexion, at rest (recovery), during isometric resisted plantar flexion and, again, at rest. Of 42 patients, 14 had confirmed CECS and 28 had lower extremity anomalies attributable to other causes. Ratios of relative T2-weighted signal intensities were calculated for exercise and recovery images compared to baseline after processing of images, including re-registration for motion, smoothing and segmentation to remove bone and pulsation artifacts from blood vessels.

RESULTS

Receiver operating characteristic (ROC) analysis showed a threshold for the ratio of relative T2-weighted signal intensity of 1.54 to have a sensitivity of 96%, specificity of 90% and accuracy of 96% for CECS. Patients with CECS had their peak ratio of signal intensity compared with baseline during the first recovery period after isometric dorsi flexion, whereas unaffected subjects and patients with other causes of exercise-induced lower extremity pain reached their peak values during exercise (P<0.001).

CONCLUSION

We have developed the first in-scanner MRI exercise protocol for the assessment of patients with suspected CECS. The technique shows high accuracy, sensitivity and specificity for diagnosis in this small cohort of patients with CECS. Further study may allow this non-invasive test to be used as a triage tool for invasive intracompartmental pressure measurements in patients with suspected CECS.

Clinical management after bariatric surgery: value of a multidisciplinary approach

Comprehensive and collaborative longitudinal care is essential for optimal outcomes after bariatric surgery. This approach is important to manage the many potential surgical and medical comorbidities in patients who undergo bariatric surgery. Medical management programs require prompt and often frequent adjustment as the nutritional program changes and as weight loss occurs. Familiarity with the recommended nutritional program, monitoring and treatment of potential vitamin and mineral deficiencies, effects of weight loss on medical comorbid conditions, and common postoperative surgical issues should allow clinicians to provide excellent care. Patients must understand the importance of regularly scheduled medical follow-up to minimize potentially serious medical and surgical complications. Because the long-term success of bariatric surgery relies on patients' ability to make sustained lifestyle changes in nutrition and physical activity, we highlight the role of these 2 modalities in their overall care. Our guidelines are based on clinical studies, when available, combined with our extensive clinical experience. We present our multidisciplinary approach to postoperative care that is provided after bariatric surgery and that builds on our presurgical evaluation.

Electromyographic Activity in the Immobilized Shoulder Girdle Musculature During Scapulothoracic Exercises

OBJECTIVE

To quantify the electromyographic activity in the shoulder girdle musculature during scapulothoracic exercises performed in a shoulder immobilizer in asymptomatic men.

DESIGN

Descriptive.

SETTING

Motion analysis laboratory at a tertiary care center.

PARTICIPANTS

Five asymptomatic male volunteers ages 24 to 32 years.

INTERVENTION

Fine-wire (supraspinatus, infraspinatus, upper subscapularis) and surface (deltoids, trapezii, biceps, serratus anterior) electrodes recorded electromyographic activity from each muscle during scapular clock, elevation, depression, protraction, and retraction exercises completed during a single testing session in random order.

MAIN OUTCOME MEASURE

Mean peak normalized (percentage of maximal voluntary contraction [MVC]) electromyographic activity of each muscle during each exercise.

RESULTS

Biceps activity was uniformly low (<20% MVC), whereas upper subscapularis activity was uniformly high (40%-63% MVC). Both scapular depression and protraction elicited low activity (<20% MVC) in the supraspinatus, infraspinatus, anterior deltoid, and biceps brachii muscles, while generally producing greater than 20% MVC activity in the trapezii and serratus. Scapular depression produced the largest serratus anterior activity (47% MVC).

CONCLUSIONS

These data are the first to describe the electromyographic activity during scapulothoracic exercises while in a shoulder immobilizer. Based on electrophysiologic data in normal volunteers, our findings suggest that during periods of shoulder immobilization: (1) scapular depression and protraction exercises could potentially be safely performed after rotator cuff repair to facilitate scapulothoracic rehabilitation, (2) all exercises studied could potentially be safe after superior labral anteroposterior shoulder repair, and (3) all exercises studied should be avoided after subscapularis repair. Further investigation in symptomatic individuals may facilitate refinement of these recommendations.

Effect of magnetic vs sham-magnetic insoles on nonspecific foot pain in the workplace: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To determine whether magnetic insoles are effective for relieving nonspecific subjective foot pain in the workplace, resulting in improved job satisfaction.

SUBJECTS AND METHODS

A prospective, randomized, double-blind, placebo-controlled study of health care employees who experienced nonspecific foot pain for at least 30 days, which occurred more days than not, was conducted between February 2001 and January 2002 at the Mayo Clinic in Rochester, Minn. Participants were asked to wear either magnetic or sham-magnetic cushioned insoles for at least 4 hours daily, 4 days per week for 8 weeks. The primary outcome variable was reported foot pain (by categorical response of change from baseline and by visual analog scale) at 4 and 8 weeks. Secondary outcome variables included graded intensity of pain experienced during various daily activities and the effect of insoles on job performance and enjoyment.

RESULTS

Among 89 enrolled participants, 6 either withdrew before wearing insoles or were noncompliant with follow-up questionnaires; 83 participants remained for full statistical analysis. Participants in both treatment groups reported improvements in foot pain during the study period. No significant differences in categorical response to pain or pain intensity were seen with use of magnetic vs sham-magnetic insoles.

CONCLUSIONS

The magnetic insoles used in this study by a heterogeneous population with chronic nonspecific foot pain were not clinically effective. Findings confirmed that nonspecific foot pain significantly interferes with some employees' ability to enjoy their jobs and that treatment of that pain improves job satisfaction.

Implementation of Formal Learning Objectives During a Physical Medicine and Rehabilitation Sports Medicine Rotation

OBJECTIVE

To develop and implement formal learning objectives during a physical medicine and rehabilitation sports medicine rotation and characterize resident experiences with the objectives over a 16-mo period.

DESIGN

Prospective, including learning objective development, implementation, and postrotation survey.

RESULTS

A total of 69 learning objectives were developed by physical medicine and rehabilitation staff physician consensus, including 39 core objectives. Eighteen residents completed 4-wk sports medicine rotations from January 2003 through April 2004. Residents completed an average of 31 total objectives (45%; range, 3-52), of which 24 (62%; range, 3-35) were core. Residents completed the highest percentage of knee (60%), shoulder (57%), and ankle-foot (57%) objectives and reported that objectives related to these areas were most effective to facilitate learning. In general, residents reported that objective content was good and that the objectives delineated important concepts to learn during the rotation. Seventeen of 18 residents indicated that the objectives should be permanently implemented into the sports rotation and that similar objectives should be developed for other rotations. Based on our experience and the recommendations of residents, the average resident should be able to complete approximately 30 objectives during a typical 4-wk rotation.

CONCLUSIONS

Successful implementation of specific, consensus-derived learning objectives is possible within the context of a busy clinical practice. Our initial physician staff and resident experience with the objectives suggests that this model may be useful as a supplementary educational tool in physical medicine and rehabilitation residency programs.

Effect of magnetic vs sham-magnetic insoles on plantar heel pain: a randomized controlled trial

CONTEXT

Despite anecdotal reports, rigorous scientific evidence of the effectiveness of magnetic insoles for the pain of plantar fasciitis is lacking.

OBJECTIVE

To determine whether magnetic insoles provide greater subjective improvement for treatment of plantar heel pain compared with identical nonmagnetized insoles.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind, placebo-controlled trial conducted from February 12, 2001, to November 9, 2001, of a volunteer sample of 101 adults with diagnoses of plantar heel pain for at least 30 days from a multispecialty group practice clinic in Rochester, Minn. Daily pain diaries were kept for 8 weeks.

INTERVENTIONS

Cushioned insoles, with either active bipolar magnets or sham magnets, which were worn daily by the participants for 8 weeks.

MAIN OUTCOME MEASURES

Reported average daily foot pain (by metered visual analog scale [VAS] and by categorical response of change from baseline) at 4 and 8 weeks, and impact of insoles on employment performance and enjoyment.

RESULTS

No significant between-group differences were found on any outcome variables studied when comparing active vs sham magnets. Both the nonmagnetic and magnetic groups reported significant improvements in morning foot pain intensity, with mean (SD) VAS scores improving from 6.9 (2.3) and 6.7 (2.0), respectively, at baseline to 3.9 (2.6) for each group at 8 weeks (P =.94). At 8 weeks, 33% of the nonmagnetic group and 35% of the magnetic group reported being all or mostly better (P =.78). At baseline, foot pain interfered moderately with participants' employment enjoyment (mean VAS, 4.2) and improved in both groups by 8 weeks (1.3 and 1.5, respectively; P =.68).

CONCLUSION

Static bipolar magnets embedded in cushioned shoe insoles do not provide additional benefit for subjective plantar heel pain reduction when compared with nonmagnetic insoles.

The effect of static stretching of the calf muscle-tendon unit on active ankle dorsiflexion range of motion

STUDY DESIGN

Masked randomized trial.

OBJECTIVE

To examine the effects of a 6-week program of static stretching of the calf muscle-tendon unit (MTU) on active ankle dorsiflexion range of motion (ADFROM) in healthy subjects.

BACKGROUND

Static stretching of the calf MTU is often prescribed to increase flexibility in patients with shortened connective tissues or to maintain ADFROM in healthy individuals. Presently, physical therapists lack specific information on the optimal dosage of calf MTU stretching necessary to produce improvement in ADFROM.

METHODS AND MEASURES

One hundred one adults (63 women, 38 men; mean age +/- SD, 40.0 +/- 10.9 years; range, 21-59) with no visual evidence of gait impairment due to lower-extremity dysfunction participated in the study. Active ADFROM was measured with a universal goniometer. Participants were randomly assigned to group 1, no stretch controls (n = 24), or to 1 of 3 experimental groups carrying out a 6-week program of standing wall stretches once per day: individuals in group 2 stretched for 30 seconds (n = 26); individuals in group 3 stretched for 1 minute (n = 24); individuals in group 4 stretched for 2 minutes (n = 27).

RESULTS

After 6 weeks, the results of an analysis of variance found no effect of treatment on active ADFROM.

CONCLUSION

The results of this study show that a 6-week program of once-per-day static stretching for up to 2 minutes is not sufficient to increase active ADFROM in healthy subjects.

The 'yips' in golf: a continuum between a focal dystonia and choking

The definition of the 'yips' has evolved over time. It is defined as a motor phenomenon of involuntary movements affecting golfers. In this paper, we have extended the definition to encompass a continuum from the neurologic disorder of dystonia to the psychologic disorder of choking. In many golfers, the pathophysiology of the 'yips' is believed to be an acquired deterioration in the function of motor pathways (e.g. those involving the basal ganglia) which are exacerbated when a threshold of high stress and physiologic arousal is exceeded. In other golfers, the 'yips' seems to result from severe performance anxiety. Physically, the 'yips' is manifested by symptoms of jerks, tremors or freezing in the hands and forearms. These symptoms can result in: (i) a poor quality of golf performance (adds 4.9 strokes per 18 holes); (ii) prompt use of alcohol and beta-blockers; and (iii) contribute to attrition in golf. Golfers with the 'yips' average 75 rounds per year, although many 'yips'-affected golfers decrease their playing time or quit to avoid exposure to this embarrassing problem. While more investigation is needed to determine the cause of the 'yips', this review article summarises and organises the available research. A small study included in this paper describes the 'yips' phenomenon from the subjective experience of 'yips'-affected golfers. The subjective experience (n = 72) provides preliminary support for the hypothesis suggesting that the 'yips' is on a continuum. Based on the subjective definitions of 72 'yips'-affected golfers, the 'yips' was differentiated into type I (dystonia) and type II (choking). A theoretical model provides a guide for future research on golfers with either type I or type II 'yips'.

A valid and reliable method for measuring the kicking accuracy of soccer players

Kicking accuracy is an important component of soccer performance. We constructed a plywood target measuring 243.5cm wide x 122cm high. Carbon paper applied to the surface of the target allowed measurement by 2 raters from a bull's-eye to 10 ball marks left by kicks. Intraclass correlation coefficients with 95% confidence intervals were used to determine the intra- and interrater reliability of the measurement to each ball mark. Mean and median distances from bulls-eye to ball mark were 89.9cm and 97.9cm, respectively (range, 25.7 to 150.75cm). The intraclass correlation coefficients for intra- and interrater reliability were 0.99. The root mean square error of measurement indicated that accuracy of measurement was within 0.15cm. These results suggest that our method of assessing kicking accuracy is a valid and reliable tool for analysing performance. Because this tool closely replicates kicking into a soccer goal, we feel that it also has validity. To our knowledge, no other tool or measure (e.g.. number of shots on goal or number of goals per game) has comparable validity and reliability. This method can be used as a training tool and for future investigations of kicking accuracy.

Corticosteroid injection in early treatment of lateral epicondylitis

OBJECTIVE

To analyze whether a corticosteroid injection in combination with rehabilitation early in the course of lateral epicondylitis (LE) alters the outcome up to 6 months after injection compared with a control injection and rehabilitation.

DESIGN

Randomized, controlled, double-blind study.

SETTING

Sports medicine center in a tertiary care center.

PARTICIPANTS

Subjects with a diagnosis of LE whose symptoms had been present less than 4 weeks were included. Subjects were recruited by word of mouth and through advertising. The 39 subjects who were recruited were 18 to 65 years old.

INTERVENTIONS

19 subjects were randomized to receive rehabilitation and a sham injection, and 20 were randomized to receive rehabilitation and a corticosteroid injection. At 4 and 8 weeks, they were reevaluated and their treatment programs were modified, if indicated.

MAIN OUTCOME MEASURES

Outcome measurements were performed at baseline, 4 weeks, 8 weeks, and 6 months, and included a functional pain questionnaire and a visual analogue pain scale. Painless grip strength on the affected side and maximal grip strength bilaterally were measured at baseline, 4 weeks, and 8 weeks.

RESULTS

There were no significant differences in outcome between the two groups with the exception of an improvement in the visual analogue pain scale in the corticosteroid group from 8 weeks to 6 months. Outcome measurements in both groups improved significantly over time; more than 80% of subjects reported improvements from baseline to 6 months for all scales.

CONCLUSION

A corticosteroid injection does not provide a clinically significant improvement in the outcome of LE, and rehabilitation should be the first line of treatment in patients with a short duration of symptoms.

Neurophysiologic influences on hamstring flexibility: a pilot study

OBJECTIVE

To examine the potential contribution of neurologic influences on hamstring length during passive range of motion.

DESIGN

Prospective study.

SETTINGS

Academic sports medicine center.

PATIENTS

15 subjects undergoing arthroscopic surgery for unilateral knee injuries without previous injury to the contralateral knee.

INTERVENTIONS

Subjects received: 1) spinal anesthesia with bupivacaine, 2) epidural anesthesia with lidocaine, 3) general anesthesia, or 4) femoral nerve block of injured leg only.

MAIN OUTCOME MEASURES

Noninjured leg popliteal angle preoperatively, intraoperatively under anesthesia, and postoperatively after recovery from anesthesia.

RESULTS

The overall mean popliteal angle was 132.5 +/- 3.1 degrees preoperatively, 134.31 +/- 11.6 degrees intraoperatively, and 130.7 +/- 10.2 degrees postoperatively. Overall, the intraoperative angle was significantly greater than the postoperative angle (p = 0.02). The mean change in popliteal angle was 8.1 +/- 2.2 degrees (Group 1), -0.4 +/- 1.9 degrees (Group 2), 0.9 +/- 1.4 degrees (Group 3), and -2.4 +/- 3.8 degrees (Group 4). There was no significant change in pre- to postoperative popliteal angle in relation to postoperative pain. Females had a greater mean popliteal angle (139.84 degrees ) compared with males (128.84 degrees ) (p = 0.04).

CLINICAL RELEVANCE

Understanding the neuromuscular influences on muscle flexibility will assist in the development of new rehabilitative and injury preventative techniques.

CONCLUSION

The present pilot study implicates neural contributions to muscle flexibility. Further studies are needed to delineate the relative contributions of neural and muscular components and to facilitate new techniques in the rehabilitation and prevention of injury.

Development of a musculoskeletal examination skills course for a physical medicine and rehabilitation residency program

This article describes the development of a musculoskeletal physical examination skills course for a physical medicine and rehabilitation residency training program. Course objectives, structure, and modification over time based on experience and resident feedback are discussed. The current course design is adaptable to meet the needs and resources of most residency programs.

The effect of ankle disk training on muscle reaction time in subjects with a history of ankle sprain

The purpose of this study was to determine whether 8 weeks of ankle disk training alters ankle muscle onset latency of patients with a history of lateral ankle sprain. The training was completed by eight minimally symptomatic subjects with a history of nonrehabilitated, unilateral, inversion ankle sprain sustained between 6 and 16 months before entry into the study. Ankle inversion perturbations monitored by fine-wire electromyography were performed in four lower extremity muscles (anterior tibialis, posterior tibialis, peroneus longus, and flexor digitorum longus) of all subjects on both the injured (experimental) and noninjured (control) legs. Testing was performed at study entry and after 8 weeks of ankle disk training on the previously injured ankle. Results revealed a statistically significant decrease in the anterior tibialis onset latency in both the experimental (67.6 +/- 20.3 to 51.7 +/- 17.6) and control (65.5 +/- 9.8 to 53.8 +/- 23.7) ankles after the training period. These findings indicate that muscle onset latency decreases in specific ankle muscle groups after ankle disk training in previously injured ankles. Both the experimental and control ankles demonstrated a significant change, which raises the question as to whether a proprioceptive cross-training effect occurred.

The effects of a lumbar support on repositioning error in subjects with low back pain

OBJECTIVE

To determine whether a lumbar support improves trunk repositioning error (RE), an aspect of proprioception.

DESIGN

RE was measured with and without a lumbar support.

SETTING

Outpatient clinic.

PARTICIPANTS

Twenty subjects with chronic low back pain (LBP) and 20 control subjects.

INTERVENTIONS

Subjects wore the lumbar support for 2 hours and then testing was repeated.

MAIN OUTCOME MEASURES

Standing with legs and pelvis immobilized, subjects moved to a predetermined target position and then attempted to replicate the position. The 3-dimensional position of the trunk was measured with a 3Space Tracker. RE was calculated as the absolute difference between the actual target position and the subject-perceived target position. Testing was performed with and without a lumbar support both before and after wearing the support for 2 hours.

RESULTS

In subjects with LBP, RE was significantly lower with a support in flexion, extension, and right lateral bending. In control subjects, RE was significantly lower when wearing the support in left bending only, and RE was significantly higher in control subjects after wearing the support for 2 hours.

CONCLUSION

A lumbar support improves trunk RE. In subjects with LBP, this result was significant in the sagittal plane and in right lateral bending, whereas in control subjects, it was significant only in left lateral bending.

Barriers to bicycle helmet use

OBJECTIVE

To determine why people do or do not wear helmets while bicycling.

METHODS

A survey was conducted from August through October 1999. Two survey areas were chosen for this study: local public schools and paved bicycle trails. For the school arm of the study, 3 public elementary, middle, and high schools were selected from 3 different regions of Rochester, Minnesota, for participation in the study. For the bicycle arm of the study, 3 paved trails located in southeastern Minnesota were selected. A total of 2970 surveys were distributed to the public school system, and 463 surveys were collected from bicyclists on the paved bicycle trails. The survey population was split into 3 age categories for analysis: child (7-10), adolescent (11-19), and adult (older than 19).

RESULTS

Of the 2970 surveys distributed to Rochester public schools, 2039 (69%) were returned for analysis. Seventy-eight of the surveys that were completed in the public school system were discarded for the following reasons: age <10 years (35), insufficient completion (24), and selection of every reason for not wearing a bicycle helmet (19). A total of 463 surveys were completed on the 3 paved bicycle trails. One survey from the paved bicycle trail arm of the study was discarded because of insufficient completion. The total number of surveys used for statistical analysis was 2424. The distribution of male (52.7%) and female (47.3%) participants was similar. No significant difference in bicycle helmet use was found between genders. The age groups with the highest rate of bicycle helmet use were 50 to 59 years (62%) and older than 59 years (70%). The age groups with the lowest rate of bicycle helmet use were 11 to 19 years (31%) and 30 to 39 years (30%). The most common reasons given for not wearing a bicycle helmet were "uncomfortable," "annoying," "it's hot," "don't need it," and "don't own one." Bicycle helmet use was significantly influenced by peer helmet use in all 3 age groups. Children also were more likely to wear a bicycle helmet when their parents wore bicycle helmets. A majority of respondents in all 3 age groups indicated that bicycle helmets provided either "moderate" or "great" protection from head injury, although significantly more adults (65.9%) than adolescents (43.9%) believed that the protection afforded by bicycle helmets was "great." Despite this belief, a majority of adolescents and adults indicated that there was only a "slight risk" of head injury when bicycling without a helmet. Participants in all 3 categories were more likely to wear a bicycle helmet when they indicated either that there was a "great risk" of head injury when bicycling without a helmet or that helmets provided "great protection" from head injury. Adolescents and adults who believed that bicycling without a helmet put one at "great risk" for head injury also were more likely to indicate that helmets provided "great protection" from head injury.

CONCLUSIONS

The prevalence of bicycle helmet use remains low despite research indicating the high level of head injury risk when bicycling without a helmet and the significant protection afforded by bicycle helmets. With the information provided by this survey, a well-designed intervention to increase the use of bicycle helmets can be implemented. Suggestions for a campaign to promote an increase in bicycle helmet use include focusing efforts on males and females between 11 and 19 years and 30 and 39 years of age; educating the public on new bicycle helmet designs that address comfort, ventilation, and fashion; educating adolescents on the significant protection from head injury afforded by bicycle helmets; and educating the public on the risk and severity of head injury associated with bicycling without a helmet. The influence of parents and peers on bicycle helmet use may be targeted through education and statements such as, "If you wear a bicycle helmet, you are not only protecting yourself, you are also helping to protect your friends and/or children." bicycle, helmet, injury, accident, prevention.

A preliminary analysis of psychophysiological variables and nursing performance in situations of increasing criticality

OBJECTIVE

To examine the relationship between psychological, physiological, and performance variables in intensive care unit (ICU) nurses in situations of increasing criticality.

SUBJECTS AND METHODS

Psychophysiological variables and endotracheal suctioning performance were examined in a classroom, a skills laboratory, and an ICU. Situation-specific anxiety (state anxiety) and the predisposition to view situations as threatening (trait anxiety), cognitive appraisal, and heart rate were measured and compared with self-appraisal and a nurse instructor's ratings of suctioning performance. Baseline data were obtained during class on 45 novice ICU nurses.

RESULTS

Twenty-six nurses provided complete data, which included being videotaped and monitored in the classroom, in the skills laboratory performing endotracheal suctioning, and in the ICU during suctioning. High state anxiety significantly predicted poor ICU suctioning performance (P<.04). Nurses high in state and trait anxiety, worry, and heart rate performed poorly compared with less anxious nurses. Nurses in this study who performed best had a mean heart rate of 94 beats/min.

CONCLUSION

Those nurses who are high state anxious, high trait anxious, and worried and who had a faster heart rate performed less well than their more relaxed peers. Nurses with high state anxiety may be at risk for attrition, burnout, medical errors, and poor performance in other ICU nursing tasks.

A multidisciplinary study of the 'yips' phenomenon in golf: An exploratory analysis

BACKGROUND

The 'yips' is a psychoneuromuscular impediment affecting execution of the putting stroke in golf. Yips symptoms of jerks, tremors and freezing often occur during tournament golf and may cause performance problems. Yips-affected golfers add approximately 4.7 strokes to their scores for 18 holes of golf, and have more forearm electromyogram activity and higher competitive anxiety than nonaffected golfers in both high and low anxiety putting conditions. The aetiology of the yips is not clear.

OBJECTIVE

To determine whether the yips is a neurological problem exacerbated by anxiety, or whether the behaviour is initiated by anxiety and results in a permanent neuromuscular impediment.

METHODS

In phase I, golf professionals assisted investigators in developing a yips questionnaire that was sent to tournament players (<12 handicap) to establish the prevalence and characteristics of the yips. Phase II measured putting behaviour in scenarios that contribute to the yips response. Four self-reported yips and 3 nonaffected golfers putted 3 scenarios using an uncorrected grip and a standard length putter. Heart rate was superimposed on the videotape and the putter grip was instrumented with strain gauges to measure grip force. Electromyograms and relative putting performance were also measured.

RESULTS

The questionnaire was sent to 2,630 tournament players, of whom 1,031 (39%) responded (986 men and 45 women). Of these, 541 (52%) perceived they experienced the yips compared with 490 (48%) who did not. Yips-affected golfers reported that the most troublesome putts were 3, 4 and 2 feet (0.9, 1.2 and 0.6 metres) from the hole. Fast, downhill, left-to-right breaking putts and tournament play also elicited the yips response. Golfers affected by the yips had a faster mean heart rate, increased electromyogram activity patterns and exerted more grip force than nonrffected golfers and had a poorer putting performance.

CONCLUSIONS

For <10 handicap male golfers and <12 handicap female golfers, the prevalence of the yips is between 32.5% and 47.7%, a high proportion of serious golfers. This high prevalence suggests that medical practitioners need to understand the aetiology of the yips phenomenon so that interventions can be identified and tested for effectiveness in alleviating symptoms. Although previous investigators concluded that the yips is a neuromuscular impediment aggravated but not caused by anxiety, we believe the yips represents a continuum on which 'choking' (anxiety-related) and dystonia symptoms anchor the extremes. The aetiology may well be an interaction of psychoneuromuscular influences. Future research to test the effect of medications such as beta-blockers should assist in better identifying the contributions these factors make to the yips phenomenon.

Integration of physical medicine and rehabilitation into a medical school curriculum: musculoskeletal evaluation and rehabilitation

The issue of increasing awareness of the specialty of physical medicine and rehabilitation is a primary concern of physiatrists in both teaching hospitals and private practice. Over the years, exposure to this specialty in medical schools has decreased, although there is simultaneously an increasing awareness of the importance of providing adequate musculoskeletal education for medical students. The authors describe one institution's success at integrating musculoskeletal medicine education, along with exposure to patients with chronic disease and disability. Curriculum content and a unique musculoskeletal skills acquisition test are discussed. Increased exposure to the specialty of physical medicine and rehabilitation in medical school can introduce numerous benefits for both the specialty and musculoskeletal education as a whole.