International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study

BACKGROUND

There is a lack of standardized criteria for diagnosing rotator cuff related shoulder pain (RCRSP).

OBJECTIVE

To identify the most relevant clinical descriptors for diagnosing RCRSP.

METHODS

A Delphi study was conducted through use of an international physical therapists expert panel. A 3-round Delphi survey involving an international panel of physical therapists experts with extensive clinical, teaching, and research experience was conducted. A search query was performed in Web of Science, along with a manual search, to find the experts. The first round was composed of items obtained from a previous pilot Delphi study along with new items proposed by the experts. Participants were asked to rate items across six clinical domains using a five-point Likert scale. An Aiken's Validity Index ≥ 0.7 was considered indicative of group consensus.

RESULTS

Fifteen experts participated in the Delphi survey. After the three rounds, consensus was reached on 18 clinical descriptors: 10 items were included in the "subjective examination" domain, 1 item was included in the "patient-reported outcome measures" domain, 3 items in the "diagnostic examination" domain, 2 items in the "physical examination" domain", and 2 items in the "functional tests" domain. No items reached consensus within the "special tests" domain. The reproduction of symptoms in relation to the application of load, the performance of overhead activities, and the need of active and resisted movement assessment were some of the results with greatest consensus.

CONCLUSION

In this Delphi study, a total of 18 clinical descriptors across six clinical domains were agreed upon for diagnosing RCRSP.

Identifying Risk Factors of Upper Extremity Injuries in Collegiate Baseball Players: A Pilot Study

BACKGROUND

Repetitive pitching places tremendous forces on the shoulder and elbow which can lead to upper extremity (UE) or lower extremity (LE) overuse injuries.

PURPOSE

The purpose of this study was to evaluate pre-season physical measurements in collegiate baseball players and track in-season baseball throwing volume to determine which factors may predict throwing overuse injuries.

STUDY DESIGN

Retrospective Cohort study.

METHODS

Baseline preseason mobility, strength, endurance, and perception of function were measured in 17 collegiate baseball pitchers. Participants were then followed during the course of the season to collect rate of individual exposure, estimated pitch volume, and rating of perceived exertion in order to determine if changes in workload contributed to risk of injury using an Acute-to-Chronic Workload ratio (ACWR).

RESULTS

Participants developing an injury had greater shoulder internal rotator strength (p=0.04) and grip strength in a neutral position (p=0.03). A significant relationship was identified between ACWR and UE injuries (p <0.001). Athletes with an ACWR above or below 33% were 8.3 (CI95 1.8-54.1) times more likely to suffer a throwing overuse injury occurring to the upper or lower extremity in the subsequent week.

CONCLUSION

ACWR change in a positive or negative direction by 33% was the primary predictor of subsequent injury. This finding may assist sports medicine clinicians by using this threshold when tracking pitch volume to ensure a safe progression in workload during a baseball season to reduce the risk of sustaining overuse upper or lower extremity injuries.

LEVEL OF EVIDENCE

3b.

Muscle activity during maximal isometric forearm rotation using a power grip

This study aimed to provide quantitative activation data for muscles of the forearm during pronation and supination while using a power grip. Electromyographic data was collected from 15 forearm muscles in 11 subjects while they performed maximal isometric pronating and supinating efforts in nine positions of forearm rotation. Biceps brachii was the only muscle with substantial activation in only one effort direction. It was significantly more active when supinating (µ = 52.1%, SD = 17.5%) than pronating (µ = 5.1%, SD = 4.8%, p < .001). All other muscles showed considerable muscle activity during both pronation and supination. Brachioradialis, flexor carpi radialis, palmaris longus, pronator quadratus and pronator teres were significantly more active when pronating the forearm. Abductor pollicis longus and biceps brachii were significantly more active when supinating. This data highlights the importance of including muscles additional to the primary forearm rotators in a biomechanical analysis of forearm rotation. Doing so will further our understanding of forearm function and lead to the improved treatment of forearm fractures, trauma-induced muscle dysfunction and joint replacements.

A prospective analysis of factors associated with decreased physical activity in patients with cirrhosis undergoing transplant evaluation

BACKGROUND

Physical activity (PA) has been associated with improved recovery time after transplantation. Handgrip strength has been related to post-transplant outcomes.

AIM

To evaluate predictors of PA and grip strength in patients with cirrhosis undergoing liver transplant evaluation.

METHODS

Single-center, prospective analysis.

RESULTS

One hundred patients were evaluated (54% male, mean age 53 ± 9). Common etiologies of liver disease were non-alcoholic steatohepatitis (27%), hepatitis C (22%) and alcoholic liver disease (21%). Mean model of end-stage liver disease (MELD) score was 13.5. Forty-one percent had a history of smoking. Ninety-three patients completed the International Physical Activity Questionnaire (IPAQ). The median total PA score was 33 metabolic equivalent (MET)-min/wk. The mean total grip strength was 62.1 ± 22 lb. Total grip strength was found to be an independent predictor of low-moderate PA (OR 4.7, 95% CI 1.4-16.2, p = 0.038), and smoking was the only significant factor associated with reduced grip strength (OR 3.4, 95% CI 1.4-8, p = 0.005).

CONCLUSIONS

Patients with end-stage liver disease undergoing liver transplant evaluation have reduced total PA by IPAQ. Total grip strength was found to be a significant predictor of low-moderate PA in patients with cirrhosis. Smoking is a risk factor for reduced grip strength, an important indicator of muscle wasting in cirrhotics.

Hybrid diffuse optical techniques for continuous hemodynamic measurement in gastrocnemius during plantar flexion exercise

Occlusion calibrations and gating techniques have been recently applied by our laboratory for continuous and absolute diffuse optical measurements of forearm muscle hemodynamics during handgrip exercises. The translation of these techniques from the forearm to the lower limb is the goal of this study as various diseases preferentially affect muscles in the lower extremity. This study adapted a hybrid near-infrared spectroscopy and diffuse correlation spectroscopy system with a gating algorithm to continuously quantify hemodynamic responses of medial gastrocnemius during plantar flexion exercises in 10 healthy subjects. The outcomes from optical measurement include oxy-, deoxy-, and total hemoglobin concentrations, blood oxygen saturation, and relative changes in blood flow (rBF) and oxygen consumption rate (rV̇O2). We calibrated rBF and rV̇O2 profiles with absolute baseline values of BF and V̇O2 obtained by venous and arterial occlusions, respectively. Results from this investigation were comparable to values from similar studies. Additionally, significant correlation was observed between resting local muscle BF measured by the optical technique and whole limb BF measured concurrently by a strain gauge venous plethysmography. The extensive hemodynamic and metabolic profiles during exercise will allow for future comparison studies to investigate the diagnostic value of hybrid technologies in muscles affected by disease.

Reliability of clinical office-based laryngeal electromyography in vocally healthy adults

OBJECTIVE

This study aimed to conduct a 3-session reliability assessment of the laryngeal electromyography (LEMG) signal in healthy participants during intensity controlled vocalization tasks. We hypothesized that vocal intensity level and testing session would affect LEMG measures.

METHODS

This prospective study used a 2-factor repeated measures design. Seven participants underwent bipolar needle LEMG of the right thyroarytenoid muscle. Data were collected over 3 testing sessions using vocalization tasks performed with visually guided intensity feedback targets (65 and 75 dB SPL). Root mean square amplitudes in microvolts were analyzed for within-session and between-session reliability.

RESULTS

The main effect for intensity was found to approach significance (F = 5.71, P = .054). However, intraclass correlation coefficients (ICCs) using a 2-factor mixed random effect model indicated poor to fair signal reliability between testing sessions (ICC = 0.56 at 65 dB, 0.40 at 70 dB). Intraclass correlation coefficients for within-session data indicated excellent reliability for all testing conditions (0.84-0.98).

CONCLUSION

Using a quantitative analysis protocol to inform an essentially qualitative technique, our results indicated that there was generally poor to fair reliability in the LEMG signal over testing sessions. Vocal intensity was an important variable that affected LEMG signal reliability. Standardization of LEMG protocols using vocal control parameters and quantitative analyses may help improve LEMG reliability in clinical settings.

Thickness of the lower trapezius and serratus anterior using ultrasound imaging during a repeated arm lifting task

The purposes of this study were to establish the reliability for measuring scapular muscle thickness, and to examine how scapular muscle thickness changes with respect to external loads. Participants were asymptomatic subjects recruited from a sample of convenience. Thickness Measures were taken using rehabilitative ultrasound imaging (RUSI) under 11 conditions, rest and 10 progressive loads, for the Lower Trapezius (LT) and Serratus Anterior (SA). The procedures were repeated 1 week later to determine reliability. Bland and Altman limits of agreement and Interclass correlation coefficients (ICC) were used to determine reliability. Separate repeated measure ANOVAs were performed to determine differences in muscle thickness for both muscles across 3 conditions; rest and the 2 loaded conditions that represented the lowest and highest torque values. Results demonstrate good within and between day reliability for the LT (ICC = .86 to .99) and SA (ICC = .88 to .99). For the LT and SA, there were significant differences between the resting thickness and 2 lifting conditions (p ≤ .01) but not between the two lifting conditions. It was concluded that RUSI is reliable in measuring scapular muscle thickness. RUSI is sensitive enough to detect absolute changes in thickness from resting to a contracted state but unable to detect differences between loads imposed on the shoulder.

The effects of fish oil and isoflavones on delayed onset muscle soreness

INTRODUCTION/PURPOSE

Fish oils (FO) have been shown to modulate the inflammatory response through alteration of the eicosanoid pathway. Isoflavones (ISO) appear to reduce the inflammatory pathway through their role as a tyrosine kinase inhibitor. Delayed onset muscle soreness (DOMS) develops after intense exercise and has been associated with an inflammatory response. Therefore, we hypothesized that physical parameters associated with DOMS could be decreased via the modulation of the inflammatory response by supplementing subjects with either FO or ISO.

METHODS

22 subjects were recruited and randomly assigned to one of three treatment groups: FO (1.8 g of omega-3 fatty acids x d(-1)), ISO (120 mg soy isolate x d(-1)), or placebo (PL) (Western fat blend and/or wheat flour). All treatment groups received 100-IU vitamin E x d(-1) to minimize lipid peroxidation of more highly unsaturated fatty acids. Subjects were supplemented 30 d before the exercise and during the week of testing and were instructed to refrain from unusual exercise. DOMS was induced by 50 maximal isokinetic eccentric elbow flexion contractions. Strength parameters, pain, arm circumference, and relaxed arm angle (RANG) were measured at 48, 72, and 168 h post exercise. Cortisol, creatine kinase (CK), interleukin-6 (IL-6), tumor necrosis factor (TNFalpha), malondialdehyde (MDA), and serum iron were measured before supplementation, after supplementation, and post exercise.

RESULTS

Significant decreases were observed in RANG and strength 48 h postexercise among all groups, and there were significant increases in pain and arm circumference. There were no significant changes among all groups from baseline at 168 h (7 d) post exercise. There were no significant treatment effects between groups for the physical parameters or for cortisol, CK, IL-6, TNFalpha, MDA, or serum iron.

CONCLUSION

These data indicate FO or ISO, at the doses supplemented, were not effective in ameliorating DOMS with the above-cited protocol.

Shoulder rehabilitation strategies, guidelines, and practice

This framework for rehabilitation is consistent with the proximal-to-distal kinetic chain biomechanical model and applies current concepts of motor control and closed chain exercises. This framework approaches the final goal--glenohumeral motion and function-through facilitation by scapular control, and scapular control through facilitation by hip and trunk activation. This article supplies guidelines for rehabilitation and practices to implement the guidelines that have proved effective in our hands. Other protocols may be effective, as long as they adhere to several basic concepts of kinetic chain-based shoulder rehabilitation: 1. Functional shoulder rehabilitation requires that the muscle activations and joint motions follow a proximal-to-distal pathway along the appropriate kinetic chain. 2. Muscles around the shoulder function in an integrated fashion and should be rehabilitated in integrated patterns. Specific muscles may need isolated activation, but this activation should be facilitated by placing the proximal segments in a facilitating function. 3. Scapular control and coupled rotator cuff activation is vital to normal shoulder function. 4. Closed chain axial loading exercises are the primary means of early shoulder rehabilitation and are the mainstays of functional rehabilitation protocols.

Online detection of REM sleep based on the comprehensive evaluation of short adjacent EEG segments by artificial neural networks

1. For scientific and clinical requirements the present objective is a robust automatic online algorithm to detect rapid eye movement (REM) sleep from single channel sleep EEG data without using EMG or EOG information. 2. For data preprocessing 20 seconds time periods of the continuous EEG activity are digitally filtered in 7 frequency bands. Then the RMS values of these filtered signals are calculated along segments of 2.5 seconds. The resulting matrix of RMS values is representing information on the power of the signal localized in time and frequency and serves as input to an artificial neural network. A pooled set of EEG data together with the corresponding manual evaluation of the recordings was used in the training process. 3. Afterwards more than 90% of the time periods not belonging to the training set could be correctly labeled into REM and nonREM periods. In comparison to an older algorithm based on RMS values calculated along segments of 20 seconds, the error rate could be reduced by 20%.

A musculoskeletal approach to the preparticipation physical examination. Preventing injury and improving performance

Preparticipation physical examinations provide information concerning an athlete's ability to participate safely in sports. By collecting information specific to the musculoskeletal system in addition to that from a general medical examination, information can be gained that may improve performance and help prevent certain injuries. Two thousand one hundred seven athletes from a variety of sports from the junior high to the college level were examined using specific tests for flexibility, strength, and endurance. Females were significantly more flexible than were males on all flexibility measurements, and males were significantly stronger than were females on all strength measurements. Upper-body athletes were tighter in dominant side internal rotation and significantly looser in dominant side external rotation. Lower-body athletes, especially females, were significantly tighter in the leg muscles. These results indicate that the adaptations of the musculo-skeletal system are sport specific and depend on the body area that is placed under stress.

Fitness evaluations and fitness findings in competitive junior tennis players

Elite tennis players, as well as a large number of active recreational players, are involved in a sport that applies high repetitive loads that can create tension overload situations in certain key anatomic areas of the body and add to possible overload situations in other areas of the body. This results in patterns of inflexibility and weakness that can be demonstrated on a tennis-specific musculoskeletal exam, and that can be correlated with areas of increased injury occurrence. These players report conditioning programs that are, for the most part, inadequate to confer total conditioning of all the muscular parameters important in playing tennis. All of these factors, in addition to the frequency and type of playing, contribute to the occurrence of the overload injuries noted. These aspects need to be addressed in a preventative program for injury reduction. We do not believe that major changes in the way that tennis is played should be implemented until the effects of a proper preventative conditioning program are evaluated. The "ideal" conditioning program has not yet been found. While the exact composition of the program is in doubt, our studies allow us to recommend flexibility, strength, and endurance training for all athletes playing tennis at frequent intervals. This program should be guided by the findings on the preparticipation exam.

[Erythrocyte phospholipids in Duchenne muscular dystrophy (author's transl)]

The different fractions of erythrocyte phospholipids determined in eleven patients suffering from Duchenne muscular dystrophy and in six possible or probable heterozygous carriers do not differ significantly from those observed in controls. Distribution of their fatty acids shows a reduced amount of palmitoleic acid (C16 : 1) in total fatty acids, in sphingomyelin and phosphatidylethanolamine. The same anomaly is observed, but less significant, in the heterozygous carriers. The C20 : 0 acid is increased in sphingomyelin. Some overlap occurs between results determined in hemizygous or in heterozygous carriers and in controls. These anomalies in fatty acid distribution, if confirmed, may help a better understanding of the pathogenesis of the disease and perhaps be useful to its detection.