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1.  Should Athletes Return to Activity After Cryotherapy? 
Journal of Athletic Training  2014;49(1):95-96.
Reference/Citation
Bleakley CM, Costello JT, Glasgow PD. Should athletes return to sport after applying ice? A systematic review of the effect of local cooling on functional performance. Sports Med. 2012; 42(1):69–87.
Clinical Question
Does local tissue cooling affect immediate functional performance outcomes in a sport situation?
Data Sources
Studies were identified by searching MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE, each from the earliest available record through April 2011. Combinations of 18 medical subheadings or key words were used to complete the search.
Study Selection
This systematic review included only randomized controlled trials and crossover studies published in English that examined human participants who were treated with a local cooling intervention. At least 1 functional performance outcome that was measured before and after a cooling intervention had to be reported. Excluded were studies using whole-body cryotherapy or cold-water immersion above the waist and studies that measured strength or force production during evoked muscle contraction.
Data Extraction
Data were extracted by 2 authors using a customized form to evaluate relevant data on study design, eligibility criteria, detailed characteristics of cooling protocols, comparisons, and outcome measures. Disagreement was resolved by consensus or third-party adjudication. To perform an intent-to-treat analysis when possible, data were extracted according to the original allocation groups, and losses to follow-up were noted. The review authors were not blinded to the study author, institution, or journal. For each study, mean differences or standardized mean differences and 95% confidence intervals were calculated for continuous outcomes using RevMan (version 5.1; The Nordic Cochrane Centre, Copenhagen, Denmark). Treatment effects were based on between-groups comparisons (cryotherapy versus control) using postintervention outcomes or within-group comparisons (precryotherapy versus postcryotherapy). If continuous data were missing standard deviations, other statistics including confidence intervals, standard error, t values, P values, or F values were used to calculate the standard deviation. The Cochrane risk-of-bias tool was used to assess the methodologic quality of included studies. Each study was evaluated for sequence generation, allocation concealment, assessor blinding, and incomplete outcome data. Studies were graded as low or high based on the criteria met, but the risk of bias across the studies was consistently high, so meaningful subgroup classifications were not possible. Differences in study quality and intervention details, including duration of cryotherapy interventions and time periods after intervention before follow-up, were potential sources of bias and considered for a subgroup analysis.
Main Results
Using the search criteria, the authors originally identified 1449 studies. Of these, after title and abstract review, 99 studies were deemed potentially relevant and kept for further analysis (1350 studies were excluded). Of the 99 potentially relevant studies, 35 were included in the final review (64 studies were excluded), with relevant outcomes of strength, power, vertical jump, endurance, agility, speed, performance accuracy, and dexterity reported. The 64 excluded studies were rejected due to intervention relevancy, outcome relevancy, and non-English language. In the 35 studies meeting the inclusion criteria, 665 healthy participants were assessed. Muscle strength (using an isokinetic dynamometer, cable tensiometer, strain-gauge device, or load cell) was assessed in 25 studies, whole-body exercise (vertical jump height, power, timed hop test, sprint time, and time taken to complete running-based agility tests, including carioca runs, shuttle sprints, T-shuttle, and cocontraction tests) was assessed in 6, performance accuracy (throwing or shooting) was assessed in 2, and hand dexterity was assessed in 2. Outcomes before and immediately after cryotherapy intervention were reported in all studies; additional outcome assessments at times ranging from 5 to 180 minutes postintervention were recorded in 11 studies. The review authors reported a high risk of bias: selection bias (poor randomization and concealment of group allocation), performance and detection bias (poor blinding of assessors), and attrition bias (incomplete data). Because of the diversity of studies, particularly with respect to cryotherapy protocols and the potential for rewarming before the posttest, the effects of cryotherapy on functional performance were mixed. From the included studies, the authors concluded that cryotherapy treatment reduced upper and lower extremity muscle strength immediately after cryotherapy. However, increases in force output after cryotherapy were reported in 5 studies. Regardless of the effect of cryotherapy on strength, the clinical meaningfulness of most of the data may not be important due to variability and small effects. Studies reporting outcomes of muscle endurance resulted in conflicting evidence: endurance increased immediately after cryotherapy in 6, whereas muscle endurance decreased in 3 . These conflicting results limit the ability to draw clinically relevant conclusions about the effect of cryotherapy on muscle endurance. The majority of studies evaluating whole-body exercise demonstrated decreases in performance after cryotherapy; these outcomes included vertical jump, sprint, and agility, even when cryotherapy was applied only to a body part. Additionally, cryotherapy appeared to decrease hand dexterity and throwing accuracy immediately after intervention, although an increase in shooting performance postintervention was reported in 1 study .
Conclusions
The authors suggested that the available evidence indicates that athletic performance may be adversely affected when athletes return to play immediately after cryotherapy treatments. Many of the included studies used variable cooling protocols, reflecting differences in time, temperature, and mode of cryotherapy. The majority of the included studies used cryotherapy for at least 20 minutes. However, when considering an immediate return to activity, this cooling duration may not be clinically relevant because cryotherapy applications during practice and competitions usually last less than 20 minutes. When immediate return to activity occurs after cryotherapy, short-duration cold applications or progressive warm-ups should be implemented to prevent a deleterious effect on functional performance.
doi:10.4085/1062-6050-48.3.13
PMCID: PMC3917303  PMID: 23724775
cold modalities; functional performance; strength; endurance
2.  INFLUENCE OF PATTERNED ELECTRICAL NEUROMUSCULAR STIMULATION ON QUADRICEPS ACTIVATION IN INDIVIDUALS WITH KNEE JOINT INJURY 
Background:
Neuromuscular Electrical Stimulation is a common intervention to address muscle weakness, however presents with many limitations such as fatigue, muscle damage, and patient discomfort that may influence its effectiveness. One novel form of electrical stimulation purported to improve neuromuscular re‐education is Patterned Electrical Neuromuscular Stimulation (PENS), which is proposed to mimic muscle‐firing patterns of healthy individuals. PENS provides patterned stimulating to the agonist muscle, antagonist muscle and then agonist muscle again in an effort to replicate firing patterns.
Purpose:
The purpose of this study was to determine the effect of a single PENS treatment on knee extension torque and quadriceps activation in individuals with quadriceps inhibition.
Methods:
18 subjects (10 males and 8 females: 24.2±3.4 years, 175.3±11.8cm, 81.8±12.4kg) with a history of knee injury/pain participated in this double‐blinded randomized controlled laboratory trial. Participants demonstrated quadriceps inhibition with a central activation ratio of ≤90%. Maximal voluntary isometric contraction of the quadriceps and central activation ratio were measured before and after treatment. The treatment intervention was a 15‐minute patterned electrical stimulation applied to the quadriceps and hamstring muscles with a strong motor contraction or a sham group, who received an identical set up as the PENS group, but received a 1mA subsensory stimulation. A 2×2 (group × time) ANCOVA was used to determine differences in maximal voluntary isometric contraction and central activation ratio between groups. The maximal voluntary isometric contraction was selected as a covariate due to baseline differences.
Results:
There were no differences in change scores between pre‐ and post‐intervention for maximal voluntary isometric contraction: (PENS: 0.09±0.32Nm/kg and Sham 0.15±0.18Nm/kg, p=0.713), or central activation ratio:(PENS: ‐1.22±6.06 and Sham: 1.48±3.7, p=0.270).
Conclusions:
A single Patterned Electrical Neuromuscular Stimulation treatment did not alter quadriceps central activation ratio or maximal voluntary isometric contraction. Unlike other types of muscle stimulation, PENS did not result in a reduction of quadriceps torque.
Level of Evidence:
Level III
PMCID: PMC4275196  PMID: 25540707
Electrical stimulation; muscle inhibition; quadriceps torque
3.  RELIABILITY OF AND THE RELATIONSHIP BETWEEN ULTRASOUND MEASUREMENT AND THREE CLINICAL ASSESSMENTS OF HUMERAL TORSION 
Purpose/Background:
Differences in humeral torsion have been observed between overhead athletes and non‐athletes. Although humeral torsion may be an adaptive process for athletic performance, it may be associated with injury. Methods for measuring humeral torsion have consisted of radiography, computer tomography, and ultrasound imaging. However, diagnostic imaging may be costly and not available to all clinicians. The implementation of clinical assessments may be an alternative way to measure humeral torsion. Before clinical measures can be recommended, these assessments need to be evaluated for validity and reliability of each test. The purpose of this study was to assess the intratester and intertester reliability of three clinical tests, intratester reliability of ultrasound measures, and the validity of each clinical test to ultrasound measures.
Methods
Thirty participants (male: 12, female: 18; age: 20±2 years; height: 174.24±9.35 cm; mass: 70.53±11.06 kg; body mass index: 23.13±2.47 kg/m2; years in sport: 9±4 years) with experience in overhead sports were assessed for humeral torsion, bilaterally. Humeral torsion was assessed using musculoskeletal ultrasound by a single assessor, and using three separate clinical assessments by two independent assessors. Clinical assessments included the angle of rotation during both the bicipital tuberosity palpation with the shoulder abducted at 90 degrees (Palp90) or 45 degrees (Palp45), and the angle of external rotation during horizontal adduction (HADD).
Results
Intratester reliability for the ultrasound measure was good (ICC=0.907), along with intratester reliability for both assessors across each clinical assessment (ICC's > 0.769). Poor to moderate reliability was observed between assessors for each clinical assessment (ICC=0.256 Palp90, ICC=0.419 Palp45, ICC=0.243 HADD. Only the Palp90 measure had a fair but significant (r=0.326, p=0.011) relationship with ultrasound measures.
Conclusion
Individual assessors can achieve reliable ultrasound, bicipital tuberosity palpation and HADD values across multiple trials; however, these measures are not consistent between assessors. Additionally, only one clinical test had a fair but significant relationship with ultrasound measures. Improved testing procedures may be needed to increase between assessor reliability and strength of relationships to ultrasound measures. Current application of clinical assessments to measure humeral torsion is limited.
Level of Evidence:
3b; Grade of Recommendation C
PMCID: PMC4275198  PMID: 25540709
athletes; overhead; shoulder
4.  Exergaming and Static Postural Control in Individuals With a History of Lower Limb Injury 
Journal of Athletic Training  2013;48(3):314-325.
Context:
Therapeutic exercise programs that incorporate real-time feedback have been reported to enhance outcomes in patients with lower extremity joint injuries. The Wii Fit has been purported to improve balance, strength, flexibility, and fitness.
Objective:
To determine the effects of Wii Fit rehabilitation on postural control and self-reported function in patients with a history of lower limb injury.
Design:
Single-blinded, randomized controlled trial.
Setting:
Laboratory.
Patients or Other Participants:
Twenty-eight physically active participants with a history of lower limb injuries were randomly assigned to 1 of 3 groups (9 Wii Fit, 10 traditional, 9 control).
Intervention(s):
Intervention groups performed supervised rehabilitation 3 d/wk for a total of 12 sessions.
Main Outcome Measure(s):
Time to boundary (TTB) and the Star Excursion Balance Test (SEBT) were conducted at baseline, 2 weeks, and 4 weeks. Self-reported function was measured at baseline and 4-week follow-up. Between-groups differences were compared using repeated-measures multivariate analysis of variance.
Results:
With the eyes open, both intervention groups improved (P < .05) in the mean and the SD of the TTB anterior-posterior minima. In the eyes-closed condition, a time main effect (P < .05) for absolute TTB medial-lateral minima was observed. A time main effect was also noted in the posteromedial and posterolateral reach directions of the SEBT. When the scores for each group were pooled, improvement (P < .05) in self-reported function was demonstrated at 4-week follow-up.
Conclusions:
Rehabilitation using the Wii Fit and traditional exercises improved static postural control in patients with a history of lower extremity injury.
doi:10.4085/1062-6050-48.2.04
PMCID: PMC3655744  PMID: 23675790
balance; rehabilitation; time to boundary; virtual reality
5.  ASSOCIATION BETWEEN QUADRICEPS STRENGTH AND SELF‐REPORTED PHYSICAL ACTIVITY IN PEOPLE WITH KNEE OSTEOARTHRITIS 
ABSTRACT
Purpose/Background:
Physical inactivity is common in patients with knee osteoarthritis (OA) and has been linked to serious comorbidities such as cardiovascular disease, obesity, and diabetes. The purpose of this study was to examine the association between quadriceps strength and self‐reported physical activity in patients with radiographically confirmed knee OA. Secondarily, the authors' sought to determine if there were differences in quadriceps strength between knee OA patients with low physical activity (LPA) and knee OA patients with higher physical activity (HPA). A tertiary aim of this study was to examine the effect of gender on physical activity and quadriceps strength in patients with knee OA.
Methods:
Thirty‐six patients with radiographically diagnosed tibiofemoral knee OA participated (15 males, 21 females; age = 59.9±11.6 yrs; height = 171.2±9.2 cm; mass = 84.3±18.9 kg; body mass index (BMI)= 28.9±6.9;Godin Leisure‐Time questionnaire =32.5±25.01). Maximal isometric knee extensor strength was assessed with a Isokinetic dynamometer in 70° of knee flexion. Knee extension torque values were normalized to body mass (Nm*kg−1). Physical activity was evaluated using the Godin Leisure‐Time questionnaire. A Godin‐Leisure time score of 32.5, which was the mean score in the current dataset, was what was used to categorize subjects into LPA and HPA subgroups. Independent t‐tests were used to determine differences in strength between HPA and LPA subgroups, as well as differences in strength and physical activity between genders. Pearson Product Moment and Spearman rank correlations were used to analyze associations between normally and non‐normally distributed variables.
Results:
Quadriceps strength was positively correlated with physical activity (r=0.44, r2=0.18, p=0.01). The HPA subgroup had significantly greater quadriceps strength (n=15, 2.01±0.84) compared to the LPA subgroup (n=21, 1.5±0.59, p=0.04). Strength was significantly correlated with physical activity in the HPA subgroup (ρ=0.53, p=0.04), but not in the LPA subgroup (ρ=−0.21,p=0.35). Males reported significantly more physical activity (43.0±28.5 vs 25.1±19.64; p=0.03) and greater strength than females in the entire cohort (2.15±0.73 Nm*kg−1 vs 1.40±0.57 Nm*kg−1; p= 0.002), and the HPA subgroup (2.4±0.65 Nm*kg−1 vs 1.4± 0.68 Nm*kg−1; P=0.02). There were no gender differences for strength in the LPA subgroup.
Conclusion:
Higher levels of quadriceps strength correlate with higher physical activity in knee OA patients. The association between higher strength and increased physical activity is stronger in the HPA subgroup compared to the entire sample. Additionally, the HPA subgroup demonstrated greater quadriceps strength compared to the LPA subgroup.
Level of Evidence:
3
PMCID: PMC4060309  PMID: 24944850
Inactivity; maximum voluntary isometric contraction; physical function; quadriceps
6.  Cocontraction of Ankle Dorsiflexors and Transversus Abdominis Function in Patients With Low Back Pain 
Journal of Athletic Training  2012;47(4):379-389.
Context
The abdominal draw-in maneuver (ADIM) with cocontraction has been shown to be a more effective method of activating the transversus abdominis (TrA) in healthy adults than the ADIM alone. Whether such an augmented core stabilization exercise is effective in managing low back pain (LBP) remains uncertain.
Objective
To determine the effect of 2 weeks of ADIM and cocontraction training on abdominal muscle thickness and activation timing and to monitor pain and function in patients with LBP.
Design
Case-control study.
Setting
Local orthopaedic clinic and research laboratory.
Patients or Other Participants
Twenty patients with mechanical LBP (age = 27.20 ± 6.46 years, height = 166.25 ± 8.70 cm, mass = 58.10 ± 11.81 kg) and 20 healthy, age-matched people (age = 24.25 ± 1.59 years, height = 168.00 ± 8.89 cm, mass = 60.65 ± 11.99 kg) volunteered for the study.
Intervention(s)
Both the LBP and control groups received ten 30-minute sessions of ADIM and cocontraction training of the tibialis anterior (TA) and rectus femoris (RF) muscles over a 2-week period.
Main Outcome Measure(s)
A separate, mixed-model analysis of variance was computed for the thicknesses of the TrA, internal oblique (IO), and external oblique muscles. The differences in mean and peak electromyographic (EMG) amplitudes, onset time, and latency were compared between the groups. The visual analog pain scale, Pain Disability Index, and LBP rating scale were used to assess pain in the LBP group before and after the intervention.
Results
We found an interaction between the LBP and control groups and a main effect from pretest to posttest for only TrA muscle thickness change (F1,38 = 6.57, P = .01). Reductions in all pain measures were observed after training (P < .05). Group differences in peak and mean EMG amplitudes and onset time values for TrA/IO and TA were achieved (P < .05). The RF peak (t38 = −3.12, P = .003) and mean (t38 = −4.12, P = .001) EMG amplitudes were different, but no group difference was observed in RF onset time (t38 = 1.63, P = .11) or the cocontracted TrA/IO peak (t38 = −1.90, P = .07) and mean (t38 = −1.81, P = .08). The test-retest reliability for the muscle thickness measure revealed excellent correlations (intraclass correlation coefficient range, 0.95–0.99).
Conclusions
We are the first to demonstrate that a cocontraction of the ankle dorsiflexors with ADIM training might result in a thickness change in the TrA muscle and associated pain management in patients with chronic LBP.
PMCID: PMC3396297  PMID: 22889653
core stability; electromyographic sequencing; ultrasound imaging
7.  Microvascular Perfusion and Intramuscular Temperature of the Calf During Cooling 
Purpose
To examine how the microvascularity of the gastrocnemius changed after a cryotherapy intervention based on subcutaneous tissue thickness. A secondary purpose was to compare intramuscular temperature change to subcutaneous tissue thickness.
Methods
This was a single-blinded crossover study; each subject received both conditions (cryotherapy or sham). Subjects had baseline measurements of blood flow, blood volume, and intramuscular temperature recorded at 1cm into the muscle belly of the medial gastrocnemius. The randomized condition was applied for 10, 25, 40, or 60min depending on subcutaneous tissue thickness. Immediate post treatment microvascular measures were taken. After a designated rewarm period, again based on subcutaneous tissue thickness, measurements were retaken. At least 48 hours separated the two conditions.
Results
There were significant condition by time interactions for blood flow (p=0.01), blood volume (p=0.022), and intramuscular temperature (p<0.001). For blood flow and volume, the cryotherapy condition maintained baseline levels, while the sham condition increased at immediate-post treatment and rewarm. For intramuscular temperature, the cryotherapy condition caused a decrease in intramuscular temperature from baseline compared to no change in the sham condition from baseline. Intramuscular temperature change was significantly correlated to subcutaneous tissue thickness (r=.49; p=0.05).
Conclusions
Cryotherapy did not decrease blood flow and blood volume from resting levels, even though the intramuscular temperature decreased. An intramuscular change of 7–9°C may not be cold enough to cause local vasoconstriction.
doi:10.1249/MSS.0b013e31823bced9
PMCID: PMC3295862  PMID: 21988932
Contrast-enhanced ultrasound; cryotherapy; skeletal muscle; thermocouple
8.  Reliability of Thoracic Spine Rotation Range-of-Motion Measurements in Healthy Adults 
Journal of Athletic Training  2012;47(1):52-60.
Context:
The reliability of clinical techniques to quantify thoracic spine rotation range of motion (ROM) has not been evaluated.
Objective:
To determine the intratester and intertester reliability of 5 thoracic rotation measurement techniques.
Design:
Descriptive laboratory study.
Setting:
University research laboratory.
Patients or Other Participants:
Forty-six healthy volunteers (age = 23.6±4.3 years, height = 171.0±9.6 cm, mass = 71.4 ±16.7 kg).
Main Outcome Measure(s):
We tested 5 thoracic rotation ROM techniques over 2 days: seated rotation (bar in back and front), half-kneeling rotation (bar in back and front), and lumbar-locked rotation. On day 1, 2 examiners obtained 2 sets of measurements (sessions 1, 2) to determine the within-session intertester reliability and within-day intratester reliability. A single examiner obtained measurements on day 2 (session 3) to determine the intratester reliability between days. Each technique was performed 3 times per side, and averages were used for data analysis. Reliability was determined using intraclass correlation coefficients, standard error of measurement (SEM), and minimal detectable change (MDC). Differences between raters during session 1 were determined using paired t tests.
Results:
Within-session intertester reliability estimates ranged from 0.85 to 0.94. Ranges for the SEM were 1.0° to 2.3° and for the MDC were 2.8° to 6.3°. No differences were seen between examiners during session 1 for seated rotation (bar in front, both sides), half-kneeling rotation (bar in front, left side), or the lumbar locked position (both sides) (all values of P > .05). Within-day intratester reliability estimates ranged from 0.86 to 0.95. Ranges for the SEM were 0.8° to 2.1° and for the MDC were 2.1 ° to 5. 9°. Between-days intratester reliability estimates ranged from 0.84 to 0.91. Ranges for the SEM were 1.4° to 2.0° and for the MDC were 3.9° to 5.6°.
Conclusions:
All techniques had good reliability and low levels of measurement error. The seated rotation, bar in front, and lumbar-locked rotation tests may be used reliably when more than 1 examiner is obtaining measurements.
PMCID: PMC3418115  PMID: 22488230
biomechanics; bubble inclinometer; goniometer; scapulothoracic joint
9.  Electrode Type and Placement Configuration for Quadriceps Activation Evaluation 
Journal of Athletic Training  2011;46(6):621-628.
Context:
The ability to accurately estimate quadriceps voluntary activation is an important tool for assessing neuromuscular function after a variety of knee injuries. Different techniques have been used to assess quadriceps volitional activation, including various stimulating electrode types and electrode configurations, yet the optimal electrode types and configurations for depolarizing motor units in the attempt to assess muscle activation are unknown.
Objective:
To determine whether stimulating electrode type and configuration affect quadriceps central activation ratio (CAR) and percentage-of-activation measurements in healthy participants.
Design:
Crossover study.
Setting:
Research laboratory.
Patients and Other Participants:
Twenty participants (13 men, 7 women; age = 26 ± 5.3 years, height = 173.85 ± 7.3 cm, mass = 77.37 ± 16 kg) volunteered.
Intervention(s):
All participants performed 4 counter-balanced muscle activation tests incorporating 2 different electrode types (self-adhesive, carbon-impregnated) and 2 electrode configurations (vastus, rectus).
Main Outcome Measure(s):
Quadriceps activation was calculated with the CAR and percentage-of-activation equations, which were derived from superimposed burst and resting torque measurements.
Results:
No differences were found between conditions for CAR and percentage-of-activation measurements, whereas resting twitch torque was higher in the rectus configuration for both self-adhesive (216 ± 66.98 Nm) and carbon-impregnated (209.1 ± 68.22 Nm) electrodes than in the vastus configuration (209.5 ± 65.5 Nm and 204 ± 62.7 Nm, respectively) for these electrode types (F1,19 = 4.87, P = .04). In addition, resting twitch torque was greater for both electrode configurations with self-adhesive electrodes than with carbon-impregnated electrodes (F1,19 = 9.33, P = .007). Bland-Altman plots revealed acceptable mean differences for agreement between electrode type and configuration for CAR and percentage of activation, but limits of agreement were wide.
Conclusions:
Although these electrode configurations and types might not necessarily be able to be used interchangeably, differences in electrode type and configuration did not seem to affect CAR and percentage-of-activation outcome measures.
PMCID: PMC3418939  PMID: 22488187
burst superimposition; interpolated twitch technique; central activation ratio; knee; motor neurons
10.  AVOIDING MANUSCRIPT MISTAKES 
Writing a scientific manuscript can be a consuming, but rewarding task with a number of intrinsic and extrinsic benefits. The ability to write a scientific manuscript is typically not an emphasized component of most entry‐level professional programs. The purpose of this overview is to provide authors with suggestions to improve manuscript quality and to provide mechanisms to avoid common manuscript mistakes that are often identified by journal reviewers and editors.
PMCID: PMC3474299  PMID: 23091784
manuscript; scientific writing
11.  Differential Ability of Selected Postural-Control Measures in the Prediction of Chronic Ankle Instability Status 
Journal of Athletic Training  2011;46(3):257-262.
Context:
Chronic ankle instability (CAI) is a term used to identify a condition associated with recurrent ankle sprains and persistent symptoms. Balance deficits, evaluated using center-of-pressure (COP) force-plate measurements, have been shown to occur in people with CAI.
Objective:
To determine the differential abilities of selected force-plate postural-control measures to assess CAI.
Design:
Case-control study.
Setting:
Laboratory.
Patients or Other Participants:
A total of 63 individuals with CAI (30 men, 33 women: age = 22.3 ± 3.7 years, height = 169.8 ± 9.6 cm, mass = 70.7 ± 14.3 kg) and 46 healthy controls (22 men, 24 women: age = 21.2 ± 4.1 years, height = 173.3 ± 9.2 cm, mass = 69.2 ± 13.2 kg) volunteered.
Intervention(s):
Participants performed 3 10-second trials of quiet, single-limb stance on a force plate under 2 conditions: eyes open and eyes closed.
Main Outcome Measure(s):
Measures of COP area, COP velocity, COP SD, COP range of excursion, percentage of COP range used, time-to-boundary absolute minimum, time-to-boundary mean of the minima, and time-to-boundary SD of the minima were calculated. All measures with the exception of COP area were calculated in both the mediolateral (ML) and anteroposterior directions. For each measure, a receiver operator curve analysis was created, and the corresponding area under the curve was tested. The optimal diagnostic threshold value for each measure was determined, and the corresponding positive and negative likelihood ratios were calculated.
Results:
Three eyes-closed, single-limb force-plate measures (COP ML SD, ML percentage of COP range used, and time-to-boundary absolute minimum) predicted CAI status. However, all 3 measures had positive likelihood ratios associated with only small shifts in the probability of a patient with a positive test having CAI and negative likelihood ratios associated with very small shifts in the probability of a patient with a negative test not having CAI.
Conclusions:
No single force-plate measure was very effective in predicting if an individual had CAI or not.
PMCID: PMC3419553  PMID: 21669094
balance; force plate; time to boundary
12.  Subcutaneous Thigh Fat Assessment: A Comparison of Skinfold Calipers and Ultrasound Imaging 
Journal of Athletic Training  2011;46(1):50-54.
Abstract
Context:
Skinfold calipers (SC) typically are used to determine subcutaneous fat thicknesses. Identifying the exact separation of muscle and fat can complicate measurements. Ultrasound imaging (USI) might provide a better technique for analyzing subcutaneous fat thicknesses.
Objective:
To compare measurements from SC and USI in assessing subcutaneous thigh fat thickness.
Design:
Descriptive laboratory study.
Setting:
Laboratory.
Patients and Other Participants:
Twenty healthy adults (13 men, 7 women; age  =  26.9 ± 5.4 years, height  =  173.9 ± 7.3 cm, mass  =  77.4 ± 16.1 kg) participated.
Intervention(s):
Participants were seated in 90° of knee flexion and 85° of trunk extension. A standardized template was used to identify measurement sites over the vastus medialis obliquus (VMO), distal rectus femoris (dRF), proximal rectus femoris (pRF), and vastus lateralis (VL). Three measurements at each of the 4 sites were made in random order and were averaged for each measurement tool by the same investigator.
Main Outcome Measure(s):
Fat thickness was measured in millimeters with SC and USI. Measurements at each site were compared using Pearson product moment correlations and Bland-Altman plots.
Results:
Strong correlations between measures were found at the VMO (r  =  .90, P < .001), dRF (r  =  .93, P < .001), pRF (r  =  .93, P < .001), and VL (r  =  .91, P < .001). Mean differences between measures ranged from 1.7 ± 2.4 mm (dRF) to 3.7 ± 2.6 mm (pRF), indicating that the SC resulted in larger thicknesses compared with USI. Limits of agreement, as illustrated by the Bland-Altman plots, were fairly wide at each site: from −3.38 mm to 7.74 mm at the VMO, from −3.04 mm to 6.52 mm at the dRF, from −1.53 mm to 8.87 mm at the pRF, and from −3.73 mm to 8.15 mm at the VL. All plots except for the VL demonstrated increasing overestimation via the SC as fat thicknesses increased.
Conclusions:
We found strong correlations between the SC and USI; however, the large limits of agreement and increasing mean differences with larger fat thicknesses were a concern in terms of using this tool. When measuring subcutaneous fat thickness of the thigh, SC tended to overestimate thickness in individuals with higher fat values.
doi:10.4085/1062-6050-46.1.50
PMCID: PMC3017489  PMID: 21214350
agreement; anthropometry; body composition
13.  Sex Differences in Concussion Symptoms of High School Athletes 
Journal of Athletic Training  2011;46(1):76-84.
Abstract
Context:
More than 1.6 million sport-related concussions occur every year in the United States, affecting greater than 5% of all high school athletes who participate in contact sports. As more females participate in sports, understanding possible differences in concussion symptoms between sexes becomes more important.
Objective:
To compare symptoms, symptom resolution time, and time to return to sport between males and females with sport-related concussions.
Design:
Descriptive epidemiology study.
Setting:
Data were collected from 100 high schools via High School RIO (Reporting Information Online).
Patients or Other Participants:
Athletes from participating schools who sustained concussions while involved in interscholastic sports practice or competition in 9 sports (boys' football, soccer, basketball, wrestling, and baseball and girls' soccer, volleyball, basketball, and softball) during the 2005–2006 and 2006–2007 school years. A total of 812 sport concussions were reported (610 males, 202 females).
Main Outcome Measure(s):
Reported symptoms, symptom resolution time, and return-to-play time.
Results:
No difference was found between the number of symptoms reported (P  =  .30). However, a difference was seen in the types of symptoms reported. In year 1, males reported amnesia (exact P  =  .03) and confusion/disorientation (exact P  =  .04) more frequently than did females. In year 2, males reported more amnesia (exact P  =  .002) and confusion/disorientation (exact P  =  .002) than did females, whereas females reported more drowsiness (exact P  =  .02) and sensitivity to noise (exact P  =  .002) than did males. No differences were observed for symptom resolution time (P  =  .40) or return-to-play time (P  =  .43) between sexes.
Conclusions:
The types of symptoms reported differed between sexes after sport-related concussion, but symptom resolution time and return-to-play timelines were similar.
doi:10.4085/1062-6050-46.1.76
PMCID: PMC3017493  PMID: 21214354
epidemiology; mild traumatic brain injuries; symptom resolution; return to play
14.  COMPARISON OF ANKLE ARTHROMETRY TO STRESS ULTRASOUND IMAGING IN THE ASSESSMENT OF ANKLE LAXITY IN HEALTHY ADULTS 
Purpose/Background:
Ultrasonography (US) may aid the assessment of the anterior talofibular ligament (ATFL) injury after lateral ankle sprains by allowing the clinician to visualize and measure talocrural laxity. Comparison of US against another objective method of ankle laxity assessment, such as ankle arthrometry (AA), is needed. The purpose was to evaluate the relationship between the ATFL length measurements measured from stress US images to the inversion and anterior drawer displacement measured with AA in healthy subjects.
Methods:
This descriptive laboratory study included 26 ankles from healthy subjects. The apparent length of the ATFL was measured using US during anterior drawer (USAD) and inversion (USINV) stress and the translation of the talocrural joint was measured using AA during anterior drawer (AAAD) and inversion (AAINV) stress. Percent change in length for USAD and USINV were quantified. Intraclass correlation coefficients and pearson product moment correlations Bland-Altman limits of agreement were calculated between relevant variables.
Results:
USAD and USINV percent change in length were positively correlated (r = .76). Bland Altman analysis revealed a mean difference of 5.38 mm (95% CI: –3.5 to 12 mm) with the AAAD producing higher values than the USAD. No significant correlations were found between the US and AA variables, however the absolute AAAD and AAINV variables were also positively correlated (r = .61).
Conclusions:
The US and AA variables were not directly correlated when measuring inversion and anterior laxity in healthy ankles. Differences between the devices that may affect this include different rates of joint loading, patient position and method of assessing laxity. The AA results demonstrated greater anterior displacement. Results may differ in ankle injured subjects who may demonstrate increases in anteroposterior and inversion laxity.
Level of Evidence:
2b. Exploratory study in healthy cohort.
PMCID: PMC3230157  PMID: 22163091
ankle laxity; anterior displacement; inversion rotation; percent length change
15.  Effect of Duration and Amplitude of Direct Current when Lidocaine Is Delivered by Iontophoresis 
Pharmaceutics  2011;3(4):923-931.
Dosage for the galvanic stimulation for iontophoresis varies. Clinicians manipulate the duration or the amplitude of the current, but it is not known which is more effective. We compared the anesthetic effect of lidocaine HCL (2%) by manipulating the current parameters on 21 healthy volunteers (age: 21.2 ± 4.2, height 170.7 ± 10.2 cm, mass 82.1 ± 19.2 kg). Three conditions were administered in a random order using a Phoresor II® with 2 mL, 2% lidocaine HCL in an iontophoresis electrode. (1) HASD (40 mA*min): High amplitude (4 mA), short duration (10 min); (2) LALD (40 mA.min): Low amplitude (2 mA), long duration (20 min); (3) Sham condition (0 mA, 20 min). Semmes-Weinstein monofilament (SWM) scores were taken pre and post intervention to measure sensation changes. Two-way ANOVA with repeated measures was used to compare sensation. Both iontophoresis treatments: LALD (4.2 ± 0.32 mm) and HASD (4.2 ± 0.52 mm) significantly increased SWM scores, indicating an increase in anesthesia, compared to the sham condition (3.6 ± 0.06 mm) p < 0.05. Neither LALD nor HASD was more effective and there was no difference in anesthesia with the sham. Lidocaine delivered via iontophoresis reduces cutaneous sensation. However, there was no benefit in either a HASD or LALD treatment.
doi:10.3390/pharmaceutics3040923
PMCID: PMC3857064  PMID: 24309314
percutaneous drug delivery; physical therapy; transdermal; electrical stimulation; electroporation
16.  Transcranial Magnetic Stimulation and Volitional Quadriceps Activation 
Journal of Athletic Training  2010;45(6):570-579.
Abstract
Context:
Quadriceps-activation deficits have been reported after meniscectomy. Transcranial magnetic stimulation (TMS) in conjunction with maximal contractions affects quadriceps activation in patients after meniscectomy.
Objective:
To determine the effect of single-pulsed TMS on quadriceps central activation ratio (CAR) in patients after meniscectomy.
Design:
Randomized controlled clinical trial.
Setting:
University laboratory.
Patients or Other Participants:
Twenty participants who had partial meniscectomy and who had a CAR less than 85% were assigned randomly to the TMS group (7 men, 4 women; age  =  38.1 ± 16.2 years, height  =  176.8 ± 11.5 cm, mass  =  91.8 ± 27.5 kg, postoperative time  =  36.7 ± 34.9 weeks) or the control group (7 men, 2 women; age  =  38.2 ± 17.5 years, height  =  176.5 ± 7.9 cm, mass  =  86.2 ± 15.3 kg, postoperative time  =  36.6 ± 37.4 weeks).
Intervention(s):
Participants in the experimental group received TMS over the motor cortex that was contralateral to the involved leg and performed 3 maximal quadriceps contractions with the involved leg. The control group performed 3 maximal quadriceps contractions without the TMS.
Main Outcome Measure(s):
Quadriceps activation was assessed using the CAR, which was measured in 70° of knee flexion at baseline and at 0, 10, 30, and 60 minutes posttest. The CAR was expressed as a percentage of full activation.
Results:
Differences in CAR were detected over time (F4,72  =  3.025, P  = .02). No interaction (F4,72  =  1.457, P  =  .22) or between-groups differences (F1,18  =  0.096, P  =  .76) were found for CAR. Moderate CAR effect sizes were found at 10 (Cohen d  =  0.54, 95% confidence interval [CI]  =  −0.33, 1.37) and 60 (Cohen d  =  0.50, 95% CI  =  −0.37, 1.33) minutes in the TMS group compared with CAR at baseline. Strong effect sizes were found for CAR at 10 (Cohen d  =  0.82, 95% CI  =  −0.13, 1.7) and 60 (Cohen d  =  1.06, 95% CI  =  0.08, 1.95) minutes in the TMS group when comparing percentage change scores between groups.
Conclusions:
No differences in CAR were found between groups at selected points within a 60-minute time frame, yet moderate to strong effect sizes for CAR were found at 10 and 60 minutes in the TMS group, indicating increased activation after TMS.
doi:10.4085/1062-6050-45.6.570
PMCID: PMC2978008  PMID: 21062180
central activation ratio; arthrogenic muscle inhibition; knee; meniscus
17.  CONTRALATERAL EFFECTS OF DISINHIBITORY TENS ON QUADRICEPS FUNCTION IN PEOPLE WITH KNEE OSTEOARTHRITIS FOLLOWING UNILATERAL TREATMENT 
Background:
Quadriceps activation failure is common in patients with tibiofemoral osteoarthritis (TFOA) and has been reported to occur bilaterally following acute and chronic knee injuries. Sensory transcutaneous electrical stimulation (TENS) applied to the knee has increased ipsilateral quadriceps activation, yet it remains unknown if repeated sensory TENS treatments affect activation in the contralateral quadriceps.
Objective:
To determine the effects of unilateral TENS treatment to the involved leg, in conjunction with 4-weeks of therapeutic exercise, on volitional quadriceps activation in the contralateral leg.
Methods:
Thirty-three patients with radiographically diagnosed TFOA were randomly assigned to the TENS, placebo, and the control groups. The involved leg was defined as the knee with highest degree of radiographically assessed TFOA. All participants completed a supervised 4-week lower extremity exercise program for the involved leg only. TENS and placebo TENS were worn throughout the rehabilitation sessions as well as during daily activities for those groups on the involved leg. Quadriceps central activation ratio (CAR), a measure of volitional muscular activation, was assessed in the uninvolved leg at baseline, 2-weeks and 4-weeks following the initiation of the intervention.
Results:
There were no differences between groups for quadriceps CAR (P=0.3).
Discussion:
Although significant differences were not found, strong to moderate within group effect sizes were calculated for the TENS group at 2 (d = .87) and 4 weeks (d = .54), suggesting that significant differences may be found in a larger population.
Conclusions:
Contralateral quadriceps CAR was not affected following a 4-week unilateral disinhibitory intervention in this sample.
PMCID: PMC2971644  PMID: 21589667
Voluntary activation; Arthrogenic muscle inhibition; Pain; Strength
18.  No Difference in Transverse Abdominis Activation Ratio between Healthy and Asymptomatic Low Back Pain Patients during Therapeutic Exercise 
Dysfunction of the transverse abdominis (TrA) has been associated with LBP. Several therapeutic exercises are prescribed to help target the TrA. Rehabilitative ultrasound imaging (RUSI) is used to capture activation of the TrA during exercise. The purpose was to examine TrA activation during the ADIM and quadruped exercises between healthy and nonsymptomatic LBP patients. We instructed the subjects how to perform the exercises and measured muscle thickness of the TrA at rest and during the exercises using RUSI. This allowed us to calculate TrA activation ratio during these exercises. We found no significant differences between activation ratios of the two groups during either exercise; however TrA activation during the ADIM was higher than the quadruped exercise. These exercises were capable of activating the TrA, which may be in part due to the verbal instruction they received. These exercises could be used during prevention or rehabilitation programs, since the TrA is activated.
doi:10.1155/2010/459738
PMCID: PMC3200274  PMID: 22110965
19.  Differences in Transverse Abdominis Activation with Stable and Unstable Bridging Exercises in Individuals with Low Back Pain 
Background
The transversus abdominis (TrA) is a spine stabilizer frequently targeted during rehabilitation exercises for individuals with low back pain (LBP). Performance of exercises on unstable surfaces is thought to increase muscle activation, however no research has investigated differences in TrA activation when stable or unstable surfaces are used.
Objective
The purpose of this study was to investigate whether TrA activation in individuals with LBP is greater when performing bridging exercises on an unstable surface versus a stable surface.
Methods
Fifty one adults (mean ± SD, age 23.1 ± 6.0 years, height 173.60 ± 10.5 cm, mass 74.7 ± 14.5 kg) with stabilization classification of LBP were randomly assigned to either exercise progression utilizing a sling bridge device or a traditional bridging exercise progression, each with 4 levels of increasing difficulty. TrA activation ratio (TrA contracted thickness/TrA resting thickness) was measured during each exercise using ultrasound imaging. The dependent variable was the TrA activation ratio.
Results
The first 3 levels of the sling-based and traditional bridging exercise progression were not significantly different. There was a significant increase in the TrA activation ratio in the sling-based exercise group when bridging was performed with abduction of the hip (1.48 ± .38) compared to the traditional bridge with abduction of the hip (1.22 ± .38; p<.05).
Conclusion
Both types of exercise result in activation of the TrA, however, the sling based exercise when combined with dynamic movement resulted in a significantly higher activation of the local stabilizers of the spine compared to traditional bridging exercise. This may have implications for rehabilitation of individuals with LBP.
PMCID: PMC2953390  PMID: 21589663
Core stability; rehabilitation; Rehabilitative Ultrasound Imaging
20.  Short-Term Effect of Muscle Energy Technique on Pain in Individuals with Non-Specific Lumbopelvic Pain: A Pilot Study 
Muscle energy technique (MET) is a form of manual therapy frequently used to correct lumbopelvic pain (LPP), herein the patient voluntarily contracts specific muscles against the resistance of the clinician. Studies on MET regarding magnitude and duration of effectiveness are limited. This study was a randomized controlled trial in which 20 subjects with self-reported LPP were randomized into two groups (MET or control) after magnitude of pain was determined. MET of the hamstrings and iliopsoas consisted of four 5-second hold/relax periods, while the control group received a sham treatment. Tests for current and worst pain, and pain with provocation were administered at baseline, immediately following intervention and 24 hours after intervention. Separate 2×3 ANOVAs were used to assess results as change scores. Visual analog score (VAS) for worst pain reported in the past 24 hours decreased for the MET group (4.3mm±19.9, p=.03) and increased for the sham (control) group (17.1mm±21.2, p=.03). Subjects receiving MET demonstrated a decrease in VAS worst pain over the past 24 hours, thereby suggesting that MET may be useful to decrease LPP over 24 hours.
PMCID: PMC2704351  PMID: 20046557
Inclinometer; Lumbopelvic Pain; Manual Therapy; Pain Provocation Tests
21.  Rehabilitation Considerations of a Brachial Plexus Injury with Complete Avulsion of C5 and C6 Nerve Roots in a College Football Player 
Sports Health  2009;1(5):370-375.
Severe brachial plexus injuries are rare in sports, but they have catastrophic results with a significant loss of function in the involved upper extremity. Nerve root avulsions must be timely managed with prompt evaluation, accurate diagnosis, and surgical treatment to optimize the potential for a functional outcome. This case report describes the mechanism of injury, diagnostic evolution, surgical management, and rehabilitation of a college football player who sustained a traumatic complete nerve root avulsion of C5 and C6 (upper trunk of the brachial plexus). Diagnostics included clinical evaluation, magnetic resonance imaging, computed tomography myelogram, and electromyogram. Surgical planning included nerve grafting and neurotization (nerve transfer). Rehabilitation goals were to bring the hand to the face (active biceps function), to stabilize the shoulder for abduction and flexion, and to reduce neuropathic pain. Direct current stimulation, bracing, therapeutic exercise, and biofeedback were used to maximize the use of the athlete’s upper extremity. Although the athlete could not return to sport or normal function by most standards, his results were satisfactory in that he regained an ability to perform many activities of daily living.
doi:10.1177/1941738109343544
PMCID: PMC3445178  PMID: 23015895
nerve root avulsion; preganglionic; brachial plexus; nerve graft
22.  Community-Associated Methicillin-Resistant Staphylococcus Aureus 
Methicillin resistant Staphylococcus aureus (MRSA), is a problematic infection which is becoming more common in a variety of athletic related environments. Early recognition, diagnosis, and timely management of infection can help minimize the severity of infection and decrease the rate of transmission. Since most sports physical therapists typically lack adequate knowledge and ability to identify cases of MRSA infection, the pur-pose of this review is to provide a background for associated risk factors, recognition, treatment, and prevention of community associated-MRSA in athletic environments.
PMCID: PMC2953299  PMID: 21522209
23.  Phonophoresis and the Absorption of Dexamethasone in the Presence of an Occlusive Dressing 
Journal of Athletic Training  2007;42(3):349-354.
Context: Phonophoresis is purported to represent a method to apply topical medications through the skin to treat soft tissue injuries and inflammatory conditions. Few data are available to demonstrate the clinical effectiveness of the treatment.
Objective: To determine the effect of ultrasound on the transcutaneous absorption of dexamethasone when occluded with a dressing.
Design: Crossover design.
Setting: University general clinical research center.
Patients or Other Participants: Ten healthy subjects (age = 29.2 ± 8.8 years; height = 170.0 ± 3.9 cm; mass = 67.5 ± 18.4 kg).
Intervention(s): Two grams of 0.33% dexamethasone cream were applied to a 10-cm 2 area on the anterior forearm. The drug was applied to the skin and occluded with a dressing for 30 minutes before the ultrasound and sham ultrasound treatments. The treatments were applied over the drug and occlusive dressing. Ultrasound treatments were delivered at an intensity of 1.0 W/cm 2 (50% pulsed) at an output frequency of 3 MHz for 5 minutes and compared with sham ultrasound treatments that were delivered at an intensity of 0.0 W/cm 2 (50% pulsed) at an output frequency of 3 MHz for 5 minutes. All subjects received both the ultrasound and sham treatments, and the order in which subjects received the treatments was counterbalanced.
Main Outcome Measure(s): Serum samples were drawn before treatment and immediately posttreatment and at 2, 4, 6, 8, and 10 hours posttreatment. Using high-performance liquid chromatography, we analyzed serum to determine dexamethasone concentrations.
Results: A 2-way repeated-measures analysis of variance (condition × time) revealed a significant main effect for ultrasound treatment ( P = .047). The rate of appearance and the total concentration of dexamethasone in the serum were greater in subjects after phonophoresis than after sham ultrasound. The sham group had only trace amounts of dexamethasone in the serum, indicating that drug absorption was negligible without the ultrasound energy. The effect size of the phonophoresis condition fell within a 95% confidence interval after the baseline measurement.
Conclusions: We found that a phonophoretic effect occurred with dexamethasone when its application saturated the skin.
PMCID: PMC1978471  PMID: 18059989
ultrasound; therapeutic ultrasound; skin saturation

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