Nintendo Wii Fit as an adjunct to physiotherapy following lower limb fractures: preliminary feasibility, safety and sample size considerations.

OBJECTIVE: The Nintendo Wii Fit integrates virtual gaming with body movement, and may be suitable as an adjunct to conventional physiotherapy following lower limb fractures. This study examined the feasibility and safety of using the Wii Fit as an adjunct to outpatient physiotherapy following lower limb fractures, and reports sample size considerations for an appropriately powered randomised trial. METHODOLOGY: Ambulatory patients receiving physiotherapy following a lower limb fracture participated in this study (n=18). All participants received usual care (individual physiotherapy). The first nine participants also used the Wii Fit under the supervision of their treating clinician as an adjunct to usual care. Adverse events, fracture malunion or exacerbation of symptoms were recorded. Pain, balance and patient-reported function were assessed at baseline and discharge from physiotherapy. RESULTS: No adverse events were attributed to either the usual care physiotherapy or Wii Fit intervention for any patient. Overall, 15 (83%) participants completed both assessments and interventions as scheduled. For 80% power in a clinical trial, the number of complete datasets required in each group to detect a small, medium or large effect of the Wii Fit at a post-intervention assessment was calculated at 175, 63 and 25, respectively. CONCLUSIONS: The Nintendo Wii Fit was safe and feasible as an adjunct to ambulatory physiotherapy in this sample. When considering a likely small effect size and the 17% dropout rate observed in this study, 211 participants would be required in each clinical trial group. A larger effect size or multiple repeated measures design would require fewer participants.

Anthropometric measurements of the scapula, humerus, radius and ulna in Labrador dogs with and without elbow dysplasia.

OBJECTIVE: To determine if anthropometric measurements of the Labrador scapula, humerus, ulna and radius, or their ratios, are related to the presence of elbow dysplasia (ED). METHODS: Digital calliper measurements of the lengths of the left scapula, humerus, radius and ulna, and their ratios, were analysed by gender in 103 volunteer Labradors (41 dogs, 62 bitches) against the ED radiological scores derived by the International Elbow Working Group (IEWG). The IEWG score is an umbrella score used to classify for ED and includes fragmented coronoid process, osteochondritis dessicans, incongruity and ununited anconeal process, the last of which occurs rarely in Labradors. RESULTS: Of the 103 Labradors studied, 31 were diagnosed radiographically with ED (20 bitches (32%), 11 (27%) dogs). Scapula length was significantly shorter for bitches with ED (P = 0.02), but not for dogs with ED. However, dogs showed a trend for a difference in the ulna:radius ratio (P = 0.06), which bitches did not. Although a greater percentage of bitches than dogs had ED in this study, the difference was not statistically significant. CONCLUSIONS: Labrador bitches diagnosed with ED have a shorter scapula, which is a new finding associated with this condition. The difference in presentation associated with gender is unexpected and further research is recommended.

Cervical musculoskeletal impairment in frequent intermittent headache. Part 2: subjects with concurrent headache types.

A pattern of musculoskeletal impairment inclusive of upper cervical joint dysfunction, combined with restricted cervical motion and impairment in muscle function, has been shown to differentiate cervicogenic headache from migraine and tension-type headache when reported as single headaches. It was questioned whether this pattern of cervical musculoskeletal impairment could discriminate a cervicogenic headache as one type of headache in more complex situations when persons report two or more headaches. Subjects with two or more concurrent frequent intermittent headache types (n = 108) and 57 non-headache control subjects were assessed using a set of physical measures for the cervical musculoskeletal system. Discriminant and cluster analyses revealed that 36 subjects had the pattern of musculoskeletal impairment consistent with cervicogenic headache. Isolated features of physical impairment, e.g. range of movement (cervical extension), were not helpful in differentiating cervicogenic headache. There were no differences in measures of cervical musculoskeletal impairment undertaken in this study between control subjects and those classified with non-cervicogenic headaches.

Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches.

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

The effectiveness of a pre-operative home-based physiotherapy programme for chronic anterior cruciate ligament deficiency.

BACKGROUND AND PURPOSE: Little evidence supports the prescription of pre-operative rehabilitation in the treatment of chronic anterior cruciate ligament-deficient (ACLD) subjects. The aim of the present study was to assess the effectiveness of a specific six-week pre-operative exercise programme on ACLD knees. METHOD: A single, masked, controlled study was designed. This comprised two matched groups of 12 chronically ACLD patients awaiting reconstruction and a group of 12 matched uninjured control subjects. Only one ACLD group received a home-based exercise and educational programme. Assessment before and after the exercise intervention included: knee joint stability (clinical and KT1000 evaluation); muscle strength (Cybex II); standing balance and functional performance (agility, [corrected] and subjective tests). RESULTS: At the time of initial assessment there were no statistically significant differences in any measures for the two ACLD groups but both ACLD groups were significantly different from the uninjured control group as regards quadriceps strength and function. Measures taken after six weeks showed no significant improvement in the untreated ACLD group or in the uninjured control group. The treated ACLD group showed significant improvement in the following measures: quadriceps strength measured at 60 degrees and 120 degrees per second (p < 0.001); single leg standing balance with eyes closed (p < 0.001); instrumented passive stability at 20 lb (89 N) force (p = 0.003); agility and subjective performance (p < 0.001). The incidence of unstable episodes had decreased in the treated ACLD group, reducing further damage to the joint. CONCLUSION: This study leaves little doubt that pre-operative physiotherapy had a positive effect on motor function in ACLD subjects and should be prescribed routinely to maximize muscle stabilizing potential prior to reconstruction. Patients report improved stability and, in certain cases, may avoid surgery. The finding that exercise increased the passive stability of the joint was unexpected and requires further investigation.

Measuring range of active cervical rotation in a position of full head flexion using the 3D Fastrak measurement system: an intra-tester reliability study.

Most external assessments of cervical range of motion assess the upper and lower cervical regions simultaneously. This study investigated the within and between days reliability of the clinical method used to bias this movement to the upper cervical region, namely measuring rotation of the head and neck in a position of full cervical flexion. Measurements were made using the Fastrak measurement system and were conducted by one operator. Results indicated high levels of within and between days repeatability (range of ICC2,1 values: 0.85-0.95). The ranges of axial rotation to right and left, measured with the neck positioned in full flexion, were approximately 56% and 50%, respectively of total cervical rotation, which relates well to the proportional division of rotation in the upper and lower cervical regions. These results suggest that this method of measuring rotation would be appropriate for use in subject studies where movement dysfunction is present in the upper cervical region, such as those with cervicogenic headache.

The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction.

Functional stability of the knee is dependent on an intact ligamentous system and the timely and efficient contraction of supporting musculature. The aim of this study was to assess the relationship between muscle strength and functional stability in 31 patients pre- and post-operatively, following a unilateral anterior cruciate ligament rupture. All subjects underwent reconstructive surgery using semitendonosis and gracilis tendons. Isokinetic strength assessment of quadriceps and hamstring muscles was performed at a rate of movement of 60 degrees /s and 120 degrees /s. Functional stability was determined by performance during five functional stability tests that included the shuttle run, side step, carioca, single and triple hop tests. Pearson's correlation coefficient statistics were applied to pre-operative and post-operative data respectively. These analyses demonstrated a significant positive correlation between quadriceps strength indices at both testing speeds and the two hop tests pre-operatively (p's<0.007) and between quadriceps strength indices at both speeds and all five functional tests post-operatively (p's<0.01). Assessed using Steiger's formula, there was a significant increase in the correlation between quadriceps strength indices and three functional tests post-operatively compared to pre-operatively (p<0.05). No significant correlation between hamstring strength indices and functional scores existed pre- or post-operatively. This study has shown a significant correlation exists between quadriceps strength indices and functional stability both before and after surgery, this relationship does not reach significance between hamstring strength indices and functional stability.

Repeatability of maximal voluntary force and of surface EMG variables during voluntary isometric contraction of quadriceps muscles in healthy subjects.

The repeatability of initial values and rate of change of EMG signal mean spectral frequency (MNF), average rectified values (ARV), muscle fiber conduction velocity (CV) and maximal voluntary contraction (MVC) was investigated in the vastus medialis obliquus (VMO) and vastus lateralis (VL) muscles of both legs of nine healthy male subjects during voluntary, isometric contractions sustained for 50 s at 50% MVC. The values of MVC were recorded for both legs three times on each day and for three subsequent days, while the EMG signals have been recorded twice a day for three subsequent days. The degree of repeatability was investigated using the Fisher test based upon the ANalysis Of VAriance (ANOVA), the Standard Error of the Mean (SEM) and the Intraclass Correlation Coefficient (ICC). Data collected showed a high level of repeatability of MVC measurement (normalized SEM from 1.1% to 6.4% of the mean). MNF and ARV initial values also showed a high level of repeatability (ICC>70% for all muscles and legs except right VMO). At 50% MVC level no relevant pattern of fatigue was observed for the VMO and VL muscles, suggesting that other portions of the quadriceps might have contributed to the generated effort. These observations seem to suggest that in the investigation of muscles belonging to a multi-muscular group at submaximal level, the more selective electrically elicited contractions should be preferred to voluntary contractions.

Muscle strength and function before and after anterior cruciate ligament reconstruction using semitendonosus and gracilis.

This study assessed the quadriceps and hamstring strength before and 6 months after anterior cruciate ligament (ACL) reconstructive surgery using the hamstrings and related the findings to functional performance. Six months after surgery is a critical time for assessment as this is when players are returning to sport. Maximum isokinetic strength of 31 patients with complete unilateral ACL ruptures was measured at speeds of 60 degrees and 120 degrees per second. Functional assessment included the single hop, the triple hop, the shuttle run, side-step and carioca tests. All patients underwent a controlled quadriceps emphasized home-based physiotherapy program both before and after surgery. Results show that before surgery there was a 7.3% quadriceps strength deficit at 60 degrees per second compared to the uninjured leg but no hamstring strength deficit. After surgery there was a statistically significant but relatively small loss of muscle strength. The quadriceps strength deficit had increased to 12% and there was a 10% hamstring deficit. Post-operatively there was an 11% and 6.3% improvement in the hop tests, a 9% (P < 0.01) improvement in the shuttle run, a 15% (P < 0.001) improvement in the side step and a 24% (P < 0.001) improvement in the carioca tests (P < 0.001) despite the loss of muscle strength.

The influence of age on weight-bearing joint reposition sense of the knee.

Knee joint-position sensitivity has been shown to decline with increasing age, with much of the research reported in the literature investigating this age effect in non-weight-bearing (NWB) conditions. However, little data is available in the more functional position of weight-bearing conditions. The objective of this study was to identify the influence of age on the accuracy and nature of knee joint-position sense (JPS) in both full weight-bearing (FWB) and partial weight-bearing (PWB) conditions and to determine the effect of lower-extremity dominance on knee JPS. Sixty healthy subjects from three age groups (young: 20-35 years old, middle-aged: 40-55 years, and older: 60-75 years) were assessed. Tests were conducted on both the right and left legs to examine the ability of subjects to correctly reproduce knee angles in an active criterion-active repositioning paradigm. Knee angles were measured in degrees using an electromagnetic tracking device, Polhemus 3Space Fastrak, that detected positions of sensors placed on the test limb. Errors in FWB knee joint repositioning did not increase with age, but significant age-related increases in knee joint-repositioning error were found in PWB. It was found that elderly subjects tended to overshoot the criterion angle more often than subjects from the young and middle-aged groups. Subjects in all three age groups performed better in FWB than in PWB. Differences between the stance-dominant (STD) and skill-dominant (SKD) legs did not reach significance. Results demonstrated that for, normal pain-free individuals, there is no age-related decline in knee JPS in FWB, although an age effect does exist in PWB. This outcome challenges the current view that a generalised decline in knee joint proprioception occurs with age. In addition, lower-limb dominance is not a factor in acuity of knee JPS.

Strength and function before and after anterior cruciate ligament reconstruction.

Rehabilitation of patients with anterior cruciate ligament injury is a topic of interest among clinicians. Although numerous studies report the deficits after anterior cruciate ligament reconstruction, there are no data available on the changes in strength and functional performance before and 6 months after reconstruction surgery. This is when most patients are returning to sports activities. In the current study 31 patients with complete unilateral anterior cruciate ligament ruptures followed a controlled rehabilitation program emphasizing early range of motion after surgery and quadriceps strengthening before and after undergoing bone-patellar tendon-bone reconstruction. Strength of the hamstrings and quadriceps and five functional activities were assessed at 1 week before and 6 months after surgery. Preoperative strength assessments using a Cybex II dynamometer showed a 12% quadriceps deficit at 60 degrees per second and 9% deficit at 120 degrees per second with no hamstring deficit in the injured leg compared with the uninjured leg. Despite intensive quadriceps training, the postoperative quadriceps deficit increased to 28% at 60 degrees per second and 22% at 120 degrees per second in comparison with the uninjured leg. There was no change in hamstring strength in the injured leg. Most functional measures improved after surgery. The shuttle run improved by 10%, the side step test results improved by 17%, and the carioca test results improved by 23%. No significant difference was found in the results of the hop test. This study highlights the extent of the quadriceps deficits despite functional improvement and the difficulty in restoring quadriceps strength after bone-patellar tendon-bone reconstruction. It also questions the relationship of current functional tests to quadriceps strength and the role of maximum strength testing as a predictor of function and of safe sporting performance.

Joint reposition sense in subjects with unilateral osteoarthritis of the knee.

OBJECTIVE: To identify the sensory deficit of partial weight-bearing joint repositioning sense in subjects with unilateral osteoarthritis (OA) of the knee. The methodology was developed to incorporate measures made easily in a clinical setting. In OA, local degenerative changes can affect the function of sensory receptors and mechanoreceptors. As a result, appreciation of limb position as well as function may be compromised. Because proprioceptive sense plays an important role in reflex muscle contraction and stabilization of the joint, functional stability and joint integrity may be at risk if proprioception is impaired. DESIGN: Twenty subjects with unilateral OA of the knee were age-matched with 20 controls for the purpose of this study. The difference in degrees between a target angle of knee flexion and a reposition angle was measured during a partial weight-bearing test. A Dualer (electronic dual inclinometer) was used to measure the joint reposition sense (JRS) of the knee. Both sides were tested with six repetitions on each side. A mixed-model ANOVA was applied to the data for analysis. RESULTS: Comparison of the JRS between groups revealed a significant difference, with OA subjects having higher JRS error (JRSE) (p <0.001) than controls. There was no significant difference in JRSE for either side, regardless of group. CONCLUSIONS: Subjects with unilateral OA of the knee demonstrated poorer performance on both legs in a partial weight-bearing reposition test than did control subjects.

Recruitment patterns of the scapular rotator muscles in freestyle swimmers with subacromial impingement.

Athletes with shoulder pathology consistently demonstrate abnormalities in scapular rotator activity, suggesting that muscle dysfunction is a factor to consider in the aetiology or recurrence of shoulder pain. However, one important measure of the coordinated activity between the scapular rotators, their timing or temporal recruitment pattern, remains undetermined. The purposes of this study were to 1. provide normative data on the temporal recruitment pattern of the scapular rotators in freestyle swimmers, 2. determine the effect of a unilateral shoulder injury on this pattern, 3. determine whether these effects extend to the non-injured side, and 4. determine the effect of injury on the consistency (variability) of muscle recruitment. Surface EMG data for the upper and lower trapezius and serratus anterior were recorded bilaterally from two groups of competitive freestyle swimmers during controlled bilateral elevation in the plane of the scapula. An injured group comprising nine swimmers with unilateral shoulder pathology and a control group of nine non-injured swimmers were included. Temporal data determined for the onset of muscle activation for each muscle were then compared between groups using an ANOVA and a one-sided F test. The results of the study indicate that in non-injured swimmers, upper trapezius is activated 217 ms prior to shoulder motion, followed by serratus anterior activation 53 ms after motion commences. Lower trapezius was not recruited until 349 ms after shoulder motion, when the arm had attained 15 degrees elevation. In injured swimmers, all three muscles on the injured side displayed significantly increased variability in the timing of activation (p < 0.05), whilst the serratus anterior was significantly delayed in its activation on the non-injured side (p < 0.05). Skill hand preference was shown to have no effect on muscle recruitment. The findings of this study indicate that a relationship does exist between shoulder injury and the temporal recruitment patterns of the scapular rotators, such that injury reduces the consistency of muscle recruitment. They further suggest that injured subjects have muscle function deficits on their unaffected side.

Sensory changes associated with severe ankle sprain.

An intact afferent nervous system is important in providing the feedback necessary for effective motor control. Joint injury may influence afferent feedback and, if the lower limb is involved, lead to a decrease in stability. Accordingly, the association between severe ankle sprain and local sensory deficit was examined. Measurements of vibration perception, two point discrimination and balance in one legged standing were made in subjects who had sustained a previous severe unilateral ankle sprain and in subjects with no history of lower limb injury. Comparisons between the two groups showed that subjects with previous severe ankle sprain had sensory deficits in all measured variables between the injured and non-injured sides. Such differences between sides was not apparent in the non-injured group. This study highlights that local sensory deficits are associated with severe ankle sprain.

The influence of ankle sprain injury on muscle activation during hip extension.

The likely influence of a localised injury in a distal joint on the function of proximal muscles is an important consideration in assessment and treatment of musculoskeletal injuries. However, little experimental evidence in humans exists in this area. Accordingly, a controlled study was carried out, in which the function of muscles at the hip was compared between subjects who had suffered previous severe unilateral ankle sprain and matched control subjects. The pattern of activation of the gluteus maximus, the hamstring muscles and the ipsilateral and contralateral erector spinae muscles was monitored through the use of surface electromyography during hip extension from prone lying. Analyses revealed that the pattern of muscle activation in subjects with previous injury differed markedly from normal control subjects, and that changes appeared to occur on both the uninjured and the injured sides of the body. A significant difference between the two groups was the delay in onset of activation of the gluteus maximus in previously injured subjects. The existence of remote changes in muscle function following injury found in this study emphasise the importance of extending assessment beyond the side and site of injury.

Local sensation changes and altered hip muscle function following severe ankle sprain.

BACKGROUND AND PURPOSE: Changes in sensory information have been shown to influence muscle function locally. Some clinicians, however, believe that the influence may be more extensive. To investigate this clinical concept, subjects with severe ankle sprain were assessed for local sensation changes and proximal hip/back muscle function. SUBJECTS: Of a total of 361 potential subjects whose medical histories were assessed, 20 men (age 18-35 years) who had previously sustained a severe unilateral ankle sprain and 11 matched "control" subjects with no previous lower-limb injury participated in the study. METHODS: Using this experimental model, tests of vibration sensation in the ankle (indicating sensation changes) as well as surface electromyography of muscle recruitment patterns for hip extension (indicating muscle function proximally) of the biceps femoris, gluteus maximus, and lumbar erector spinae muscles were made on both sides of the unilaterally injured and matched control subjects. RESULTS: Significant decreases in vibration perception and significant delays in gluteus maximus muscle recruitment during hip extension were found in the injured group. CONCLUSION AND DISCUSSION: The author concludes that both local sensory and proximal muscle function changes are associated with unilateral severe ankle sprain.

Reflex activation of gluteal muscles in walking. An approach to restoration of muscle function for patients with low-back pain.

Gluteal activation and pelvic stability often are decreased in chronic low-back pain sufferers, but the importance of motor control and programming in treatment has not been fully evaluated. This study investigated whether gluteal muscles could be activated more effectively by stimulating the proprioceptive mechanism during walking. Labile support, through wearing "balance shoes," offered facilitation of cerebellovestibular circuits. Electromyographic recordings of gluteus maximus and medius in 15 healthy subjects were made during barefoot and balance shoes walking before and after 1 week of facilitation. Significant increases (P < 0.0002) in gluteal activity and significant decreases (P < 0.01) in time to 75% maximum contraction, demonstrated the value of sensorimotor elicitation of subconscious and automatic responses in muscles often weakened in back pain sufferers.

Postural alignment in standing: A repeatability study.

Interpretation of any postural changes over time relies on the knowledge that the person's perception of comfortable erect posture remains sufficiently constant. This study measured the repeatability of sagittal spinal alignment during one day, and the degree of variability in that alignment measured subsequently four, eight and 12 days, and 16 and 24 months later. Normal women, pregnant women and women with low back pain, in the age range of 15 to 34 years, were included in the study. Spinal curvature was determined using a clinometer, while an electro-goniometer attached to callipers determined the degree of pelvic tilt. Results demonstrated that on any one day, a consistent postural alignment is assumed (in terms of spinal curvature and pelvic inclination) when an individual is asked to stand comfortably erect. In addition, in the normal, symptom-free, young adult subject, the perception of posture, and therefore postural alignment remains constant for at least two years.