NASMI and Advances in Clinical Education

From Sports Medicine Research: In the Lab & In the Field Blog Written by:  Mark Rice Reviewed by:  Stephen Thomas Core stability exercises in individuals with and without chronic nonspecific low back pain Marshall PW, Desai I, Robbins DW. J Strength Cond Res. 2011 Dec;25(12):3404-11. http://www.ncbi.nlm.nih.gov/pubmed/22080309 Quite simply, low-back pain (LBP) can be one of the most debilitating conditions that a patient has to experience, not to mention one of the most frustrating conditions to treat  as a clinician.  From early on in our training, we are taught to have our patients engage their core musculature throughout their rehabilitation exercises in an effort help alleviate the pain and/or prevent injury.  But what if what all we have been taught, and practiced, for years has been ineffective at best and deleterious at worst?  In this study Marshall et al. a examined the differences in muscle activation of the trunk in patients with and without LBP while performing common rehabilitation exercises under 2 conditions: with and without abdominal muscle bracing (defined as an active abdominal contraction where neither abdominal hollowing nor expansion were present).  They hypothesized that trunk muscle activity during selected rehabilitation exercises would be increased in individuals experiencing LBP, when compared to healthy controls, and that all subjects would see an increase in trunk muscle activation when performing abdominal bracing.  The authors also examined lumbar range of motion (LROM) in each subject while they performed each exercise.  The rectus abdominis (RA), external oblique (EO), and lumbar erector spinae (ES) were analyzed through surface electromyography with the data represented as percent maximum voluntary isometric contraction. Twenty subjects were recruited (LBP n=10; controls n=10) to perform 5 rehabilitation exercises: quadruped/bird-dog with alternating opposite arm/ leg raise, side bridge, modified push-up, squat to 70° of knee flexion, weighted shoulder flexion to 90° with a load representing 60% of their 1 rep max.  All subjects underwent 2 sessions timed one week apart.  Session 1 focused on abdominal brace training along with exercise familiarization; while session two focused on data collection.  In session 2, 3 single-repetition sets of each exercise were executed under both conditions (braced and unbraced).  After analysis, the authors were only able to partially support their primary hypothesis, compared to control patients muscle activity was higher in the RA and EO muscles for the side bridge but lower in the ES muscle for the quadruped exercises among patients with LBP.  The authors were able to support their second hypothesis in regards to abdominal bracing increasing muscle activation.  Muscle activation was greater for all exercises and in both groups during the braced condition compared to the non-braced condition.  In addition, during the braced condition each exercise selectively activated certain muscles more than others.  Lastly, there was no difference between groups, conditions, and exercises when examining LROM. There are a handful of items to take into consideration clinically from the results of this study.  First off, this study had a very limited number of participants and to try to blanket our entire patient population with these results is not feasible nor is it encouraged.  One item that can be taken from this study and utilized is the fact that no patient experienced worsening of their LBP, which indicates that these exercises can be utilized safely for these individuals.  Another point that should be noted is that abdominal bracing did not have an effect on range of motion.  The authors state that utilizing abdominal bracing for LBP patients where spinal instability isn’t present might not be necessary.  They suggest that since bracing is associated with an increase in spinal compression, LBP patients that can perform the exercises with no pain may not need to perform the brace technique.  Coincidentally, the same might be able to be said for the healthy individual performing a low-back injury prevention program.  Perhaps they don’t need to perform the brace to still get the maximum result out of the intervention.  One area where abdominal bracing may have a positive influence is in patients with LBP due to muscular weakness.  This study focused on subjects with non-specific LBP, but some patients will present with weak core and hip musculature with a resultant pressure increase in the lumbar spine and ultimately pain. What are your thoughts on the use of abdominal bracing?  Are we using it too much in our everyday practice?

 

From Sports Medicine Research: In the Lab & In the Field Blog Written by: Kimberly Rupp Reviewed by: Jeffrey Driban Should Athletes Return to Sport After Applying Ice? A Systematic Review of the Effect of Local Cooling on Functional Performance Bleakley CM, Costello JT, Glasgow PD.  Sports Med 2012; 42 (1). http://www.ncbi.nlm.nih.gov/pubmed/22121908

Topical cooling, using ice or other forms of cryotherapy, is a common treatment for acute athletic injuries to provide cold-induced analgesia to reduce pain before athletes return to play. A recent systematic review suggested that athletes should use caution when returning to play immediately after joint cooling because there is insufficient evidence to explain the effects of cooling on joint position sense. Without an understanding of the effects of cooling on joint position sense, athletes returning to play immediately after cooling could potentially be predisposed to injury or impaired performance. The purpose of the current systematic review was to examine the effect of tissue cooling on outcomes relating to functional performance, and to discuss their relevance to the sporting community. Thirty-five studies were included in this review, with outcome measures including strength, power, vertical jump, endurance, agility, speed, performance accuracy, and dexterity. Studies included healthy human participants who were treated with local cooling (studies using whole-body cryotherapy in environmental chambers and cold water immersion above the waist were excluded). Subjects must have completed at least one of the previously mentioned outcome measures both before and after a cooling intervention. There was a wide variation in the type (ice bags, ice towels, ice massage, and cold water immersion) and length of ice application in these 35 studies, but most studies used cooling times greater than 20 minutes. Overall, it appears that muscle strength was reduced after ice application, although some studies reported small increases in muscle strength. Similarly, muscle endurance results were conflicting with some studies reporting decreases and others reporting increases. Five studies reported decreases in endurance used cold water immersion for less than 45 minutes with temperatures ranging from 10 to 18°C. Four studies reported increases in endurance used cold gel packs, ice towels, or cold water immersion for less than 30 minutes with temperatures ranging from 3 to 17°C. Cooling had a negative effect on vertical jump, sprint, and agility, as well as hand dexterity and throwing accuracy.

This systematic review highlights some common inconsistencies of cryotherapy treatment. Because there are few guidelines for ice application, many clinicians and athletes follow the “20 minute” prescription, regardless of desired physiological outcome or without considering potential negative effects of returning to play while still cold. Cold-induced analgesia can be attained in about 10 minutes; so if the goal of ice is to temporarily reduce pain, a longer treatment may not be the most appropriate treatment. During athletic competitions, ice may be applied during short breaks in play or during half-time, but the effects on proprioception remain unclear. In one of the included studies, short ice applications (3 minutes) did not affect vertical jump, agility, or sprint performance. This may indicate that clinicians should avoid using ice for longer periods of time during competitions to limit declines in performance. Until more research using better-developed prescriptions of cryotherapy is completed, we are not able to fully understand the effects of muscle or joint cooling on return to play. The authors of this systematic review recommend short cold applications combined with a progressive warm up before continuing athletic activity. Do you consider the desired physiological outcome before deciding on a treatment time? Have you noticed decreased performance when athletes return to competition immediately after ice application?

From Sports Medicine Research: In the Lab & In the Field

Written by: Stephen Thomas

Reviewed by: Jeffrey Driban

Synergy of tendon stem cells and platelet-rich plasma in tendon healing.

Chen L, Dong SW, Liu JP, Tao X, Tang KL, Xu JZ. J Orthop Res. 2011 Dec 12. doi: 10.1002/jor.22033. [Epub ahead of print] (link to abstract)

Tendon injuries occur frequently among both recreational and competitive athletes. The Achilles tendon and rotator cuff tears are by far the most common especially in athletes over the age of 30. Advances in tissue engineering and biologic growth factors have helped in developing ways to improve tendon healing. The use of platelet rich plasma (PRP) and stem cells have recently become popular and SMR has written several posts on this topic (see related posts below). However, the combined use of tendon stem cells and PRP has not been studied for its effect on tendon healing. Therefore, the purpose of this study was to examine the combined effect of PRP and tendon stem cells on Achilles tendon healing in both a loaded and unloaded condition in a rat model. Chen et al. used 96 rats which were divided into two groups (loaded and unloaded) and both groups were divided into 4 additional treatment subgroups (tendon stem cells, PRP, PRP and tendon stem cells, saline control). The unloaded groups were injected with botulinum toxin to inhibit muscle activity. All rats underwent a surgical Achilles tendon transection (near the attachment) without repair. The rats were then allowed normal activity until they were evaluated at 3 or 14 days following surgery. The tendons were examined for both protein and gene expression of several tendon healing markers (collagen I, collagen III, Tenascin C, and Smad8). The authors found that loaded tendons treated with control saline had higher collagen I gene expression and protein content at 3 and 14 days post injury compared to the unloaded tendons. Loaded tendons treated with just PRP had higher collagen I gene expression and protein content at 3 days post injury compared to unloaded tendons (gene expression was increased at 14 days post injury but the protein content was not). When examining the loaded tendons, the combination of PRP and tendon stem cells was the only intervention that had higher collagen I gene expression than the saline controls with loading.

Previous research has demonstrated that the loading tendons improve tendon healing by increasing the production of several growth factors and proteins that are required for tendon’s mechanical strength. Loading also helps to align collagen in the direction of loading which further improves tendon strength. The results of this study agree with these previous findings that loading improves tendon healing regardless of the treatment. This is demonstrated by the enhanced expression of collagen I in the loaded control saline group compared to the unloaded. The benefits of loading give further support for a previous post describing a new acronym (POLICE) which incorporates optimal loading with PRICE. Based off the results of this study, the optimal environment for tendon healing is a combination of tendon loading, PRP, and tendon stem cells. Clinically this may be a viable option in the future to augment tendon repair. By using the patient’s own biologic factors we can potentially get athletes back on the field faster and with less reoccurring injuries. Much more research is required to determine the effects in humans and the optimal combination of biologic factors and tendon loading. However, this study provides us with additional evidence to support the use of PRP and other biologic factors to improve healing. Has anyone seen patients receive other biologic factors to improve tendon healing besides PRP? Do you think this will ever significantly speed recovery time?

 

 

From Sports Medicine Research: In the Lab & In the Field

Written by: Jeffrey Driban

Reviewed by: Kyle Harris

Effect of neuromuscular warm-up on injuries in female soccer and basketball athletes in urban public high schools: cluster randomized controlled trial.

LaBella CR, Huxford MR, Grissom J, Kim KY, Peng J, Christoffel KK. Arch Pediatr Adolesc Med. 2011 Nov;165(11):1033-40. (link to abstract)

Knee injuries account for a large amount of season-ending injuries and surgeries among high school female basketball and soccer players. Furthermore, injuries increase the risk for adverse long-term outcomes; for example, osteoarthritis. One way of reducing the acute and long-term implications of injuries would be to implement injury prevention programs. There is, however, only limited data about the effectiveness of coach-led neuromuscular training among mixed-ethnicity, predominately low-income, urban populations (a population that often does not have an athletic trainer). Therefore, the purpose of this cluster randomized control trial was to determine the effectiveness of one season of coach-led neuromuscular warm-ups on reducing lower extremity injuries among female soccer and basketball athletes in urban public high schools (Chicago). Ninety-five coaches (37% of the invited coaches) were randomized by school and 90 coaches completed the study (with 1492 athletes). Coaches assigned to the intervention group attended a 2-hour training session that instructed them on how to implement the 20-minute neuromuscular warm-up before practices and a shorter version before games. The warm-up consisted of jogging, dynamic motion (e.g., skipping, side shuffle), strengthening exercises (e.g., heel raises, squats), plyometrics (e.g., squat jumps, tuck jumps), and agility runs. The athletes were instructed to avoid dynamic knee valgus and to land from jumps with flexed hips and knees. Coaches were also taught to distinguish proper and improper form, and how to use verbal cues to promote proper techniques. Finally, coaches were provided a tool kit with DVDs, laminated cards, and printed educational materials. Research assistants attended practices biweekly to collect exposure and injury data (coaches kept record of who participated in games/practices), observe warm-up, and answer questions. Control coaches were advised to perform their usual warm-up routines. Injuries during games and practices were recorded if they resulted in time loss from practice or game. The intervention coaches used the neuromuscular warm-up in ~80% of practices (only 6 of 53 coaches used the neuromuscular warm-up at < 50% of practices). Athletes performing the neuromuscular warm-up had lower rates of gradual-onset lower extremity injuries, acute-onset noncontact lower extremity injuries, noncontact ankle sprains, and lower extremity injuries treated surgically. Further analyses showed that the athletes performing the neuromuscular training warm-up had lower incidence rate ratios (incidence among intervention group divided by incidence among control group) for acute-onset noncontact lower extremity injuries (ratio = 0.33), noncontact ankle sprains (ratio = 0.38), noncontact knee sprains (ratio = 0.30), and noncontact anterior cruciate ligament (ACL) injuries (ratio = 0.20). The number of athletes needed to treat to prevent 1 injury ranged from 46 athletes for acute, noncontact lower extremity injuries to 191 athletes for noncontact ACL injuries.

This is an exciting study that demonstrates the potential effectiveness of a coach-led injury prevention program to reduce the risk of lower extremity injuries. A common concern about injury prevention program is how can they be implemented on a large scale. This study demonstrates that it can be done in an urban public school district that typically has limited access to athletic trainers. As the authors note, this study only followed the teams for one season so it is unclear if the coaches can implement the warm-up over several seasons or if they will require retraining. While more research will help answer key questions (e.g., do coaches need to be retrained? do these programs work in other sports?) perhaps it is time that we ask ourselves an important question as clinicians: Is it time to start talking to our coaches, athletic directors, and school districts about implementing injury prevention programs? Have you initiated an injury prevention program in your school?

 

 

 

From Sports Medicine Research: In the Lab & In the Field

Blog Written by: Mark Rice

Reviewed by: Stephen Thomas

Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment?

Lawrence JT, Argawal N, Ganley TJ. Am J Sports Med. 2011 Dec;39(12):2582-7. (link to abstract)

With nearly 38 million children playing organized sports annually in the United States, and countless more engaging in recreational sports, the opportunity for serious knee injury is more prevalent than ever. While much research has been done to determine the best approach for treating anterior cruciate ligament (ACL) injuries in adults, the same cannot be said for skeletally immature patients. Therefore, Lawrence et al. compared the effect of immediate ACL reconstruction and a delayed ACL reconstruction on meniscal and chondral injuries among patients 14 years of age or younger. The authors performed a retrospective review to identify 70 ACL reconstructed knees in 69 patients with an average age of 12.9 years (range 10 to 14 years). All patients were treated by 1 of 2 physicians utilizing similar reconstructive techniques, however one of the physicians favored delaying treatment until the patient was more skeletally mature. The timing of the surgery was ultimately determined by the attending physician and the patient’s family. Meniscal and chondral injuries were identified and graded through operative reports and intraoperative imaging review. Independent variables that were examined for each patient were time from injury to surgery, the grade of medial meniscal tear (0 to 5, where 0 = no tear and 5 = irreparable tear), and the degree of chondral damage in the affected knee (0 to 4 using the Outerbridge scale). Other risk factors that were investigated for their relationship to medial meniscal tears and chondral defects included age, sex, side, time to reconstruction, Lachman test, pivot shift test, subjective sense of instability after initial injury, and return to sports while awaiting reconstruction. The authors were able to determine that patients undergoing surgery after waiting 12 or more weeks were 4 times more likely to have medial meniscus tears. Patients experiencing instability, regardless of the surgical intervention timeframe, were 11 times more likely to have a medial meniscus tear. More irreparable medial meniscus tears were identified in patients having waited longer than 12 weeks for surgery. The authors also discovered that there was also an associated 11-fold increase in lateral femoral and 3-fold increase in patellotrochlear chondral injuries when the patients waited 12 weeks or longer for surgery. These cartilage defects were also noted to be greater in severity as well as depth.

This study is important for many reasons; but especially because it shows that adolescents who suffer an ACL injury may be at a greater risk for meniscus tears and chondral lesions when the ACL reconstruction is delayed for more than 12 weeks. While the authors note that this study does not determine causality, it is concerning that an adolescent’s knee is at greater risk for considerable damage when treatment is delayed. This study illustrated that there are some serious items to consider when deciding on which treatment to select. While there may be the potential for growth complications resulting from ACL reconstruction, are those risks outweighed by a future of knee degradation, early osteoarthritis, and potential/eventual knee arthroplasty that could result from delaying surgery? Truly, this is a topic where the future isn’t seen through the lens of return to sport. Are you surprised by the dramatic increase in medial meniscus and chondral cartilage injuries seen in younger patients when delaying surgery for greater than 12 weeks? What are you and your team physician doing currently to minimize knee degeneration when your younger athletes sustain an ACL tear?

To learn more about ACL injury/rehabilitation as post-op management, check out our Upper and Lower Quarter course!

 

From Sports Medicine Research: In the Lab & In the Field

Written by: Kris Fayock & Marc Harwood

Reviewed: Jeffrey Driban

Hart L. Corticosteroid and other injections in the management of tendinopathies: a review. Clin J Sport Med 2011 Nov;21(6):540-1. (link to abstract)

Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010 Nov 20;376(9754):1751-67. Epub 2010 Oct 21. (link to abstract)

Overuse disorders of tendons, or tendinopathies, affect many people and can be frustrating for both the patient and provider. Since most studies question the presence of inflammation in the affected tendons, the use of corticosteroids has been questioned and more studies have investigated other types of injections. Coombes et al reviewed the literature to determine the efficacy and risk of adverse effects of peritendinous corticosteroids and other injections. This article was recently revisited by Hart in the Clinical Journal of Sports Medicine. The criteria for inclusion into this review were randomized controlled trials that compared greater than one peritendinous injection with placebo or other nonsurgical intervention. From these studies, the data extracted included duration of follow-up, outcomes (pain, function), and frequency of adverse events. Follow-up was defined as short term (< 12 weeks), intermediate term (12 to 52 weeks), and long term (> 52 weeks).Twelve trials assessed the efficacy of corticosteroid injections for lateral epicondylalgia. When compared to no intervention, physiotherapy, or orthotic devices, corticosteroid injections were more effective in the short-term for pain reduction, function, and overall improvement, but were less effective in the long term. The same was found in trials comparing non-operative management to platelet-rich plasma injection. Also, a history of repeated corticosteroid injections (range of 3 to 6 in 6 to 18 months) was associated with a poorer long-term effect on pain reduction than interventions with one injection. There were 12 trials included in this review that examined rotator cuff tendinopathy. Corticosteroid injections improved pain and function in the short term compared to placebo. There was no difference in effectiveness compared to NSAID’s and physiotherapy, except one study that showed short-term benefit compared to physiotherapy. Only one study has enough data for lower leg tendinopathies (patellar and Achilles). There was a benefit in the short term for corticosteroids when compared to placebo, but not in the long term. Multiple other types of injections were assessed as well, including platelet-rich plasma, aprotinin, sclerosant, glycosaminoglycan polysulfate, sodium hyaluronate, prolotherapy, and botulinum toxin. No clear evidence of benefit was found with any of these injections except for sodium hyaluronate. Sodium hyaluronate injections provide much better pain relief in the short and long term when compared to placebo injection for lateral epicondylalgia.

Hart states in his commentary, “There is little robust evidence to guide the management of tendinopathies, although they are among the commonest of soft tissue conditions.” This review can help providers show their patients that corticosteroid injections might not be the best option for these conditions in the long-term, especially with repeated use. It’s important to tell patients that the other treatments, such as physical therapy and orthotic devices for lateral epicondylalgia, offer the best chance for long-term pain relief, before using a corticosteroid injection. If patients get proper patient education on expectations from treatments, this may help at follow-up visits. More studies are needed to assess the other injections that were looked at in this study. What are other strategies you have used for patients that continue to ask for repeated corticosteroid injections?

From Sports Medicine Research: In the Lab & In the Field

Blog Written By: Kathleen White

Reviewed By: Stephen Thomas

Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction

Barber-Westin SD and Noyes FR. Arthroscopy. 2011;27(12):1697-1705. (link to abstract)

Anterior Cruciate Ligament (ACL) injury occurs frequently in the US in young athletic individuals under the age of 25. Reconstruction of this ligament is frequently done with the intention of returning to playing sports. However, the rates of re-injury of the reconstructed ACL range from 4.3 to 19% and up to 24% in the contralateral knee. Limited research on an effective rehabilitation program after ACL reconstruction has been completed and there is no consensus on appropriate criteria to allow athletes to return to play. Therefore the purpose of this systematic review was to evaluate current factors that are being used to determine return to unrestricted play after surgery. Studies were included in this analysis if they had a minimum of 12 month follow-up, subjects were skeletally mature and this was the primary ACL reconstruction of any graft type (revisions were excluded). Both contact and non-contact injuries were included in this analysis. A literature search identified 264 studies that evaluated ACL reconstruction, however only 159 of these studies reported criteria for return to sport. The different criteria used in these studies included time after surgery, muscle strength, knee examination of effusion and range of motion (ROM) measures, single leg hop test measures, knee stability with a Lachman Test and measures from validated questionnaires. Of these studies, 60% included time after surgery to be a criterion for return to sport and only 32% used time after surgery as the only criterion. Differences in graft type had no effect on return to sport time point. Nine percent of studies reported muscle strength criteria. Eighty to ninety percent isokinetic strength measures of quadriceps and hamstrings compared to the uninjured limb were required. Three studies reported thigh circumference measures of 1cm difference between limbs as a requirement for return to sport. Six percent of studies required minimal to no effusion and/or full ROM measures as a return to sport criteria. Single leg hop measures of ? 90% symmetry between limbs was a requirement for return to sport in 4% of studies. Only 1 study required ? 90% for all 4 hop measures. This study by Hartigan et al also used validated questionnaires as criteria for return to sport. A ? 90% score on the KOS-ADLs and the global rating scare was required for return to sport. Objective knee stability measures using the Lachman Test was reported as criteria in only 1 study.

Continue reading “Factors Used to Determine Return to Unrestricted Sports Activities After Anterior Cruciate Ligament Reconstruction” »

From Sports Medicine Research: In the Lab & In the Field

Written by: Stephen Thomas

Reviewed by: Jeffrey Driban

An Acute Throwing Episode Decreases Shoulder Internal Rotation

Kibler WB, Sciascia A, Moore S. Clin Orthop Relat Res. 2011 Dec 17. [Epub ahead of print] (link to abstract)

Glenohumeral range of motion has been examined for decades in baseball players. It is comprised of both glenohumeral internal rotation (GIR) and glenohumeral external rotation (GER). In addition, the sum of the GIR and GER has been termed total arc of motion (TAM). It has been suggested that decreases in GIR and TAM and increases in GER are associated with shoulder and elbow injuries. However, the temporal response of an acute bout of throwing on shoulder motion is currently not known. Therefore the objectives of this study were to determine if (1) GIR and TAM would change in response to a 4-day pitching cycle; (2) the change in GIR would be slow to return to baseline; and (3) rotation magnitude and duration would differ between starters and relievers. They measured GIR, GER, and TAM in 45 professional baseball pitchers (starters = 22 and relievers = 23) before a live game pitching outing (averaged 61 pitches for starters and 41 for relievers), immediately after, 24, 48, and 72 hours after throwing. The team did not perform any stretching, ice, exercise or massage after throwing. They only perform aerobic exercise. Shoulder measures were performed using standard goniometer measurements with the scapula stabilized. They found that GIR was significantly greater prior to throwing compared to all of the post throwing time points (immediately following, 24, 48, and 72 hours). They also found that GER increased following throwing and remained elevated until 72 hours post throwing when it returned to baseline. Therefore, TAM remained the same until 72 hours post throwing when it decreased.

When it comes to throwing there are both acute and chronic effects. They both have separate etiologies but help us to understand the overall adaptations that occur to the throwing shoulder. To date research hasn’t performed many studies to separate the two. This was a nice examination of the isolated acute effects of throwing and to identify what clinicians can expect to see following pitching. They found that the main motion effected following throwing is GIR and doesn’t return to baseline at the 72 hour time point. GER is also effected but does return to baseline by 72 hours. These findings suggest to me that since GIR does not return to baseline prior to 72 hours (the normal off time after a pitching session) then pitchers need to augment with stretching to regain that motion. GIR has been linked to shoulder and elbow injuries so it is important to regain this motion. If motion is not restored prior to another bout of throwing the reductions in GIR may be exasperated and continue to worsen. This main be one of the mechanisms that cause the development of glenohumeral internal rotation deficits (GIRD). The other interesting finding is that GER increased and remained increased until 72 hours post throwing. When calculating TAM these findings of decreased GIR and increased GER cause TAM to remain unchanged and would suggest that everything is normal. This stresses the importance of examining the measures separately, in addition to the sum, to identify which motion is being affected. I hope this is only the start of research examining these acute and semi-chronic effects of throwing. There are still many unanswered questions including if players do continue throwing without returning GIR to baseline does their baseline measures progressively worsen throughout the season? Is this change in motion initially from muscular stiffness and progress to capsular adaptations in a more chronic state? These are all questions that need to be answered.

Want to take your evaluation and treatment of the throwing athlete to the next level? Check out our Current Concepts in Management of Upper and Lower Quarter Injuries course.

From Sports Medicine Research: In the Lab & In the Field

Written By: Kathleen White

Reviewed By: Stephen Thomas

Kinesio Taping in Treatment and Prevention of Sports Injuries. A Meta-Analysis of the Evidence for its Effectiveness

Williams S, Whatman C, Hume P, Sheerin K. Sports Med. 2011. Nov 29. [Epub ahead of print](Link to abstract)

Since its international appearance at the 2008 Olympic Games, KinesioTape (KT) has become a popular intervention in clinical medicine. Because of its increasing popularity it has practitioners and researchers looking for the evidence to support its acclaimed therapeutic benefits. The purpose of this study was to determine the effectiveness of KT in the prevention and treatment of sports injuries based on the current published literature. Cochrane review methodology was used to complete an electronic data search of the literature. Of the 96 articles obtained, 10 were used for this meta-analysis. Papers were only included if they reported data on musculoskeletal outcomes (e.g., pain, range of motion [ROM], proprioception) and if there were at least 2 groups (KT group vs comparison group). It has been thought that some influence of the effects of KT is due to the placebo effect. The authors controlled for this by only evaluating studies that had more than 1 group. Seven of the studies involved healthy subjects while the remaining 3 had patients with shoulder impingement or whiplash disorders. For most studies, objective measures were evaluated within 24 hours of tape application. One study, Slupik et al evaluated the tape up to 72 hrs after application. This meta-analysis was grouped by outcome measure (pain, ROM, strength, proprioception and muscle activity). Gonzalez-Iglesias et al found a statistically significant improvement in pain rating after application of KT to the cervical spine in patients with whiplash. However the authors did not deem this to be clinically meaningful because the improvement was only 2 points on the Numerical Pain Rating scale (0 to 10 pain rating). Thelen et al evaluated pain free shoulder abduction ROM with glenohumeral KT taping compared to sham taping. They found a statistically significant result of an increase of 19.1° with the KT tape application. This was the only study evaluating ROM that the authors found to have a small clinical benefit despite other reports of statistical significance. The results for strength measures were more positive. Hsu et al found statistically and clinically significant improvements in lower trapezius strength with KT taping. Vithaoulka et al had significant findings when evaluating quadriceps eccentric strength with KT application. Proprioceptive changes were evaluated with force sense error during a grip strength test by Chang et al. They found that with the KT condition subjects were better able to sense the amount of force that they were generating and therefore had less error. Despite Hsu et al and Slupik et al having statistically significant results for an increase in muscle activity of the lower trapezius and vastus medialis, their measures were not clinically meaningful.

Continue reading “Kinesio Taping in Treatment and Prevention of Sports Injuries” »

From Sports Medicine Research: In the Lab & In the Field

Blog Written by: Hallie Labrador, MD and Peter C. Vitanzo, MD

Reviewed by: Stephen Thomas

Continued Significant Effect of Physical Training as Treatment for Overuse Injury: 8- to 12-Year Outcome of a Randomized Clinical Trial

Holmich P, Nyvold P, Larsen K. Am J Sports Med. 2011 39:2447. Epub 2011 Aug 3. (Link to abstract)

Physical therapy is a very common and effective treatment for musculoskeletal disorders; however, very little is known about the long-term effects of these treatments. The purpose of this follow-up trial was to revisit the original subjects of a randomized controlled trial studying the impact of a training program on adductor-related groin pain and test whether the effects were still statistically significant 8 to 12 years later. In the original study, 59 participants were randomized to receive either active treatment which involved strength training of the adductor, abdominal, and low back muscles combined with coordination and balance exercises, or passive treatment which involved manual therapy, electrotherapy and stretching. Of those subjects in the original study, 23 (79%) of those in the active-treatment group had an excellent outcome versus 4 (13%) of those in the passive-treatment group (p=0.001). The outcomes were assessed by the following criteria: (1) no pain at palpation of the adductor tendon and insertion points and no groin pain during resisted adduction, (2) no groin pain during or after athletic activity in the same sport and (3) return to the same sport and at the same level without groin pain. If all 3 measures were met, the result was labeled excellent; if 2 measures were met, the result was labeled good, if 1 measure was met the result was labeled fair and if no measures were met, the result was poor. Forty-seven (80%) of the original 59 subjects agreed to participate in the follow up study which consisted of a questionnaire based on a personal interview with a physician blinded to the original treatment group and an examination by the same physician using the identical protocol to the one used in the original study. During the follow-up period, most of the athletes had reduced their athletic level; however, this did not differ between the 2 treatment groups. Using similar outcome criteria as the original trial, the follow-up trial demonstrated 12 (50%) of athletes in the active-treatment group had an excellent result compared with 5 (22%) of the passive-treatment group (p=0.047). The association was even stronger in the subgroup of soccer players tested where 11 (55%) of athletes in the active-treatment group had an excellent result compared with 3 (16%) in the passive-treatment group.

This is an exciting study, because it suggests that an active training program can be used both as a treatment for acute pain and as a prevention strategy for future groin pain in athletes. However, given the long follow up period, there are many potential confounding factors when considering the authors’ conclusions. It is difficult, if not impossible, to compare return to sport at the same level following an acute injury versus after 8 to 12 years. The authors try to accommodate this by requiring return to sport in the follow-up study at the same or one level below the original level. This study implies that an active training program can make a difference in the long run, but it is unclear why this would be the case. The authors do not assess whether the athletes in the active treatment group continued any of the exercises shown to them during the training session in the years to follow as is commonly recommended after “graduation” from a physical therapy program. It is also unclear whether or not any of the athletes had recurrence of their groin symptoms during the follow-up period that may have resolved by the time the data were assessed. In general, though, this study suggests that a supervised core program and muscle-specific strengthening can have a beneficial impact on the treatment of chronic, overuse injuries both in present athletic endeavors and perhaps in the future as well. In your experience, can the proper rehabilitation program prevent future groin pain recurrences?