Validated Wearable Device Shows Acute Postoperative Changes in Sleep Patterns Consistent With Patient-Reported Outcomes and Progressive Decreases in Device Compliance After Shoulder Surgery.

Purpose: To assess the utility of a validated wearable device (VWD) in examining preoperative and postoperative sleep patterns and how these data compare to patient-reported outcomes (PROs) after rotator cuff repair (RCR) or total shoulder arthroplasty (TSA). Methods: Male and female adult patients undergoing either RCR or TSA were followed up from 34 days preoperatively to 6 weeks postoperatively. Sleep metrics were collected using a VWD in an unsupervised setting. PROs were assessed using the following validated outcome measures: Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function questionnaire; American Shoulder and Elbow Surgeons self-evaluation questionnaire; visual analog scale assessing pain; and Disabilities of the Arm, Shoulder and Hand questionnaire. Data were analyzed preoperatively and at 2-week intervals postoperatively with χ2 analysis to evaluate device compliance. Sleep metrics and PROs were evaluated at each interval relative to preoperative values within each surgery type with an analysis of variance repeated on time point. The relation between sleep metrics and PROs was assessed with correlation analysis. Results: A total of 57 patients were included, 37 in the RCR group and 20 in the TSA group. The rate of device compliance in the RCR group decreased from 84% at surgery to 46% by 6 weeks postoperatively (P < .001). Similarly, the rate of device compliance in the TSA group decreased from 81% to 52% (P < .001). Deep sleep decreased in RCR patients at 2 to 4 weeks (decrease by 10.99 ± 3.96 minutes, P = .021) and 4 to 6 weeks postoperatively (decrease by 13.37 ± 4.08 minutes, P = .008). TSA patients showed decreased deep sleep at 0 to 2 weeks postoperatively (decrease by 12.91 ± 5.62 minutes, P = .045) and increased rapid eye movement sleep at 2 to 4 weeks postoperatively (increase by 26.91 ± 10.70 minutes, P = .031). Rapid eye movement sleep in the RCR group and total sleep in the TSA group were positively correlated with more favorable PROs (P < .05). Conclusions: VWDs allow for monitoring components of sleep that offer insight into potential targets for improving postoperative fatigue, pain, and overall recovery after shoulder surgery. However, population demographic factors and ease of device use are barriers to optimized patient compliance during data collection. Level of Evidence: Level IV, diagnostic case series.

Shear wave elastography of the ulnar collateral ligament in division IA pitchers across a competitive collegiate season.

Background: The ulnar collateral ligament (UCL) is a commonly injured elbow stabilizer during throwing. Shear wave elastography (SWE) is a technique that may reveal structural changes in the UCL that are indicative of ligament health and injury risk. The purpose of this study was to assess preseason and inseason shear wave velocity (SWV) in the UCL of collegiate pitchers and to asses repeatability of this measurement technique in healthy volunteers. Methods: Seventeen collegiate baseball pitchers and 11 sex-matched volunteers were recruited. Two-dimensional SWE of the UCL was performed by a single radiologist. In pitchers, SWV was measured at the proximal, midsubstance, and distal UCL for dominant and nondominant elbows preseason, midseason, and postseason, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow questionnaire scores were recorded. In volunteers, SWV was measured at UCL midsubstance in dominant elbows at 3 separate occasions over 1 week. An independent samples t-test was used to compare preseason midsubstance measures between pitchers and the healthy volunteers. A mixed-model analysis of covariance (covaried on preseason measures) was used to compare SWV measures at the preseason, midseason, and postseason time points. A similar generalized linear model for nonparametric data was used to compare KJOC scores. Type-I error was set at P < .05. Results: Mean preseason midsubstance dominant arm UCL SWV did not significantly differ between the pitchers (5.40 ± 1.65 m/s) compared to the healthy volunteers (4.35 ± 1.45 m/s). For inseason measures among the pitchers, a decrease in midsubstance (-1.17 ± 0.99 m/s, P = .021) and proximal (-1.55 ± 0.91 m/s, P = .001) SWV was observed at midseason compared to preseason. The proximal measure was also observed to be significantly lower than the nondominant arm (-1.97 ± 0.95 m/s, P < .001). Proximal SWV remained reduced relative to the preseason and the postseason mark (-1.13 ± 0.91 m/s, P = .015). KJOC scores decreased at midseason compared to preseason (P = .003) but then increased to a similar preseason value at the postseason measurement (preseason = 92 ± 3, midseason = 87 ± 3, postseason = 91 ± 3). The repeatability coefficient of SWE in the volunteer cohort was 1.98 m/s. Conclusion: Decreased SWV in the proximal and midsubstance of the dominant arm UCL at midseason suggests structural changes indicative of increasing laxity or 'softening' of the UCL. Associated decline in KJOC scores suggests that these changes are associated with functional decline. Future studies with more frequent sampling would be invaluable to further explore this observation and its significance for predicting and managing UCL injury risk.

Demographic and Lifestyle Factors Associated with Patient-Reported Acute COVID-19 Vaccine Reactivity.

Patient-reported vaccine reactivity (PRVR) is a major contributor to COVID-19 vaccine hesitancy. PRVR responses to the COVID-19 vaccine may be affected by several modifiable and non-modifiable factors that influence immune function. Understanding the effects of these factors on PRVR can aid in better educating patients on expectations, as well as formulating public health strategies to increase the levels of community vaccination.

Rotator cuff training with upper extremity blood flow restriction produces favorable adaptations in division IA collegiate pitchers: a randomized trial.

BACKGROUND: Recent evidence indicates that combined upper extremity blood flow restriction (BFR, applied distally to the shoulder) and low-load resistance exercise (LIX) augments clinically meaningful responses in shoulder region tissues proximal to the occlusion site. The purpose of this investigation was to determine the efficacy of BFR-LIX for the shoulder when added to standard offseason training in Division IA collegiate baseball pitchers. We hypothesized that BFR-LIX would augment training-induced increases in shoulder-region lean mass, rotator cuff strength, and endurance. As secondary outcomes, we sought to explore the impact of BFR-LIX rotator cuff training on pitching mechanics. METHODS: Twenty-eight collegiate baseball pitchers were randomized into 2 groups (BFRN = 15 and non-BFR [NOBFR]N = 13) that, in conjunction with offseason training, performed 8 weeks of shoulder LIX (Throwing arm only; 2/week, 4 sets [30/15/15/fatigue], 20% isometric max) using 4 exercises (cable external and internal rotation [ER/IR], dumbbell scaption, and side-lying dumbbell ER). The BFR group also trained with an automated tourniquet on the proximal arm (50% occlusion). Regional lean mass (dual-energy x-ray absorptiometry), rotator cuff strength (dynamometry: IR 0 & 90, ° ER 0 & 90, ° Scaption, Flexion), and fastball biomechanics were assessed pre and post-training. Achievable workload (sets × reps × resistance) was also recorded. An ANCOVA (covaried on baseline measures) repeated on training timepoint was used to detect within-group and between-group differences in outcome measures (α = 0.05). For significant pairwise comparisons, effect size (ES) was calculated using a Cohen's d statistic and interpreted as: 0-0.1, negligible; 0.1-0.3, small; 0.3-0.5, moderate; 0.5-0.7, large; >0.7, and very large (VL). RESULTS: Following training, the BFR group experienced greater increases in shoulder-region lean mass (BFR: ↑ 227 ± 60g, NOBFR: ↑ 75 ± 37g, P = .018, ES = 1.0 VL) and isometric strength for IR 90 ° (↑ 2.4 ± 2.3 kg, P = .041, ES = 0.9VL). The NOBFR group experienced decreased shoulder flexion ↓ 1.6 ± 0.8 kg, P = .007, ES = 1.4VL) and IR at 0 ° ↓ 2.9 ± 1.5 kg, P = .004, ES = 1.1VL). The BFR group had a greater increase in achievable workload for the scaption exercise (BFR: ↑ 190 ± 3.2 kg, NOBFR: ↑ 90 ± 3.3 kg, P = .005, ES = 0.8VL). Only the NOBFR group was observed to experience changes in pitching mechanics following training with increased shoulder external rotation at lead foot contact (↑ 9.0° ± 7.9, P = .028, ES = 0.8VL) as well as reduced forward ↓ 3.6° ± 2.1, P = .001, ES = 1.2VL) and lateral ↓ 4.6° ± 3.4, P = .007, ES = 1.0VL) trunk tilt at ball release. CONCLUSION: BFR-LIX rotator cuff training performed in conjunction with a collegiate offseason program augments increases in shoulder lean mass as well as muscular endurance while maintaining rotator cuff strength and possibly pitching mechanics in a manner that may contribute to favorable outcomes and injury prevention in baseball pitching athletes.

Blood Flow Restriction Therapy Preserves Lower Extremity Bone and Muscle Mass After ACL Reconstruction.

BACKGROUND: Muscle atrophy is common after an injury to the knee and anterior cruciate ligament reconstruction (ACLR). Blood flow restriction therapy (BFR) combined with low-load resistance exercise may help mitigate muscle loss and improve the overall condition of the lower extremity (LE). PURPOSE: To determine whether BFR decreases the loss of LE lean mass (LM), bone mass, and bone mineral density (BMD) while improving function compared with standard rehabilitation after ACLR. STUDY DESIGN: Randomized controlled clinical trial. METHODS: A total of 32 patients undergoing ACLR with bone-patellar tendon-bone autograft were randomized into 2 groups (CONTROL: N = 15 [male = 7, female = 8; age = 24.1 ± 7.2 years; body mass index [BMI] = 26.9 ± 5.3 kg/m2] and BFR: N = 17 [male = 12, female = 5; age = 28.1 ± 7.4 years; BMI = 25.2 ± 2.8 kg/m2]) and performed 12 weeks of postsurgery rehabilitation with an average follow-up of 2.3 ± 1.0 years. Both groups performed the same rehabilitation protocol. During select exercises, the BFR group exercised under 80% arterial occlusion of the postoperative limb (Delfi tourniquet system). BMD, bone mass, and LM were measured using DEXA (iDXA, GE) at presurgery, week 6, and week 12 of rehabilitation. Functional measures were recorded at week 8 and week 12. Return to sport (RTS) was defined as the timepoint at which ACLR-specific objective functional testing was passed at physical therapy. A group-by-time analysis of covariance followed by a Tukey's post hoc test were used to detect within- and between-group changes. Type I error; α = 0.05. RESULTS: Compared with presurgery, only the CONTROL group experienced decreases in LE-LM at week 6 (-0.61 ± 0.19 kg, -6.64 ± 1.86%; P < 0.01) and week 12 (-0.39 ± 0.15 kg, -4.67 ± 1.58%; P = 0.01) of rehabilitation. LE bone mass was decreased only in the CONTROL group at week 6 (-12.87 ± 3.02 g, -2.11 ± 0.47%; P < 0.01) and week 12 (-16.95 ± 4.32 g,-2.58 ± 0.64%; P < 0.01). Overall, loss of site-specific BMD was greater in the CONTROL group (P < 0.05). Only the CONTROL group experienced reductions in proximal tibia (-8.00 ± 1.10%; P < 0.01) and proximal fibula (-15.0±2.50%,P < 0.01) at week 12 compared with presurgery measures. There were no complications. Functional measures were similar between groups. RTS time was reduced in the BFR group (6.4 ± 0.3 months) compared with the CONTROL group (8.3 ± 0.5 months; P = 0.01). CONCLUSION: After ACLR, BFR may decrease muscle and bone loss for up to 12 weeks postoperatively and may improve time to RTS with functional outcomes comparable with those of standard rehabilitation.

Relationship Between Pitch Volume and Subjective Report of Injury in High School Female Fast-Pitch Softball Pitchers.

BACKGROUND: The relationship between pitch volume and injury is well-represented within baseball literature. However, the impact of softball pitch volume on injury epidemiology is limited. HYPOTHESIS: The purpose was to determine if increased pitch volumes in high school-aged softball pitchers are related to increased rates of subjectively reported pain/injury. We hypothesized that pitchers with increased volumes would have higher pain/injury rates. STUDY DESIGN: Cross-sectional study. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 28 female softball pitchers (aged 14-18 years) completed an online survey of questions pertaining to pitching history, pitch volume, and subjective report of pain or injury in the back, shoulder, and elbow. An independent-samples t test was used to (1) compare pitch volumes in those who reported pain in individual body regions (shoulder, elbow, back) compared with those who did not; (2) compare pitch volumes in those who reported pain in 0 or 1 of the regions of interest compared with 2 or 3 regions; and (3) compare the reported percentage of the past year that players reported playing through pain in players who averaged >85 compared with <85 pitches per game. Chi-square analysis was used to compare those who pitched either >85 or <85 pitches per game with regard to frequency of shoulder pain, elbow pain, back pain, seeking of medical attention, and actual injury diagnosis. Type I error was set at α = 0.05. RESULTS: Weekly and yearly pitch counts were higher in those reporting pain or injury (YES) than those who did not (NO) in the shoulder (pitches per week: NO = 219 ± 35; YES = 429 ± 101; P = 0.027) (pitches per year: NO = 8876 ± 946; YES = 19,195 ± 4944; P = 0.022) and back (pitches per week: NO = 188 ± 16; YES = 426 ± 90; P = 0.014) (pitches per year: NO = 8334 ± 793; YES = 18,252 ± 4340; P = 0.027). Similar results were observed for those with pain or injury reported in 2 or 3 regions compared with 0 or 1 regions (pitches per week: NO = 220 ± 38; YES = 414 ± 95; P = 0.039) (pitches per year: NO = 8765 ± 1010; YES = 18,661 ± 4623; P = 0.028). Those reporting shoulder pain or injury also reported higher pitch counts per game (NO = 71.4 ± 5.2; YES = 83 ± 4; P = 0.049), and those reporting back pain also reported playing more games per week (NO = 2.7 ± 0.2; YES = 5.2 ± 1.1; P = 0.034). Those with pitch counts of >85/game were more than twice as likely to see a physician regarding pain/injury (P = 0.027) and reported playing through pain a higher percentage of the year (>85, 49.3% ± 10%; <85, 25.2% ± 6%; P < 0.05). CONCLUSION: High pitching volumes commonly prevalent in high school-aged softball pitchers may be associated with increased pain/injury and appear related to cumulative volume. CLINICAL RELEVANCE: This study provides recommendations for cumulative pitch volume guidelines in softball pitchers.

Limb Occlusion Pressure Versus Standard Pneumatic Tourniquet Pressure in Open Carpal Tunnel Surgery - A Randomized Trial.

INTRODUCTION: Pneumatic tourniquets are used extensively in orthopedic hand/wrist surgery. Complications, while rare, are associated with elevated pressure and duration of tourniquet use. Limb occlusion pressure (LOP) is the minimum tourniquet pressure at which arterial blood flow is restricted. Therefore, we performed a cross-sectional double-blinded randomized control trial to assess if there is a difference in post-operative pain at the surgical and tourniquet site between LOP and standard tourniquet pressure and if there is a difference in post-operative opioid usage. METHODS: A total of 44 patients (Age 60±13, 30 female, 14 male) were randomized into two groups (LOP, 191±14 mmHg | STP, 250 mmHg) of 22 patients controlling for gender (15 female, seven male). The primary outcome was a visual analog scale (VAS) for pain at the tourniquet and surgical sites, recorded for the first two weeks post-operative. Daily pain medication usage was recorded and quantified using oral morphine milligram equivalents (MME). A group-by-time generalized mixed-model ANOVA was used to detect within-group and between group (LOP vs STP) differences in VAS at the surgical and tourniquet sites as well as medication use.  Results: LOP significantly decreased post-operative pain medication usage across the first week (-50%; p<0.05). Both groups had similar VAS pain at the surgery site, but the LOP group had 80% reduced pain at the tourniquet site when averaged across the first post-operative week (p<0.05).  Conclusions: The use of LOP compared to STP elicits reduced post-operative pain at the tourniquet site and reduces post-operative pain medication use in the first post-operative week.