Recommendations to Increase Neuromuscular Electrical Stimulation Training Intensity During Quadriceps Treatments for Orthopedic Knee Conditions.

ABSTRACT: Neuromuscular electrical stimulation (NMES) is often used by clinicians as a therapeutic adjunct to improve quadriceps strength deficits following orthopedic knee conditions. The efficacy of NMES treatments is primarily dependent on the NMES training intensity, which is a direct result of NMES-induced torque production. The importance of NMES training intensity is well known, yet adequate NMES training intensities are often difficult to achieve due to a variety of limitations associated with NMES (eg, fatigue and patient discomfort). This article provides recommendations that a clinician can use to increase NMES training intensity when strengthening the quadriceps with NMES for orthopedic knee conditions. These recommendations should allow forceful contractions that can be sustained over a treatment with multiple repetitions without the rapid decline in force that is typically seen when NMES is used.

Religious Fundamentalism, Humor, and Treatment Outcomes in Individuals in Court-Mandated Substance Abuse Outpatient Treatment.

The relationship between religious fundamentalism, humor, and psychological well-being was examined with a sample of individuals ( n = 109) being treated for drug abuse in a court-mandated AA outpatient program. Three separate factors of religious fundamentalism were found through exploratory factor analysis of the Revised Religious Fundamentalism Scale, and these were named Righteous-Evil Worldview, True Religion, and Scriptural Literalism. Psychological well-being of individuals in court-mandated outpatient substance abuse treatment was found to be correlated with high levels of humor but not religious fundamentalism. Psychological well-being and humor were found to be related to satisfaction with services; no relationship was found between religious fundamentalism and satisfaction with services. One factor of religious fundamentalism, Scriptural Literalism, was found to be associated with high levels of depression and paranoia/hostility. Implications of these relationships for treatment and understanding of religious fundamentalism and psychological well-being are discussed.

The Effectiveness of Neuromuscular Electrical Stimulation in Improving Voluntary Activation of the Quadriceps: A Critically Appraised Topic.

Clinical Scenario: Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established. CLINICAL QUESTION: Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions? Summary of Key Findings: Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs. Clinical Bottom Line: Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions. Strength of Recommendation: There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).

National Athletic Trainers' Association Position Statement: Management of Acute Skin Trauma.

OBJECTIVE: To present recommendations for the cleansing, debridement, dressing, and monitoring of acute skin trauma in patients. BACKGROUND: Acute skin trauma is common during participation in athletic and recreational activities. Clinical decisions and intervention protocols after injury vary among athletic trainers and are often based on ritualistic practices. An understanding of cleansing, debridement, and dressing techniques; clinical features of infection and adverse reactions; and monitoring of acute skin trauma is critical for certified athletic trainers and other allied health and medical professionals to create a local wound environment that promotes healing and lessens the risk of complications. RECOMMENDATIONS: These guidelines are intended to provide the certified athletic trainer and others participating in athletic health care with specific knowledge about and recommendations for the management of acute skin trauma.

Effects of crushed ice and wetted ice on hamstring flexibility.

Flexibility, which is the ability to move freely through a full range of motion (ROM), is desired to enhance the performance and decrease the likelihood of muscle injury. There are different techniques used to increase ROM and cryotherapy techniques to facilitation flexibility gains. However, the combination of stretching and type of cryotherapy agents are still confounding. The purpose was to determine which type of cryotherapy, crushed or wetted ice, would produce the greatest gains in hamstring ROM when followed by proprioceptive neuromuscular facilitation (PNF) stretching. Fifteen healthy subjects underwent 3 treatment conditions: crushed ice bag (crushed ice), wetted ice bag (wetted ice), and no ice bag (no ice). Subject's hamstring ROM was measured at baseline, then again after a 20-minute cryotherapy treatment session. Subjects were then stretched using a slow-reversal-hold-relax PNF technique followed by a final ROM measurement. A repeated measures analysis of variance showed significant differences between cryotherapy and measurement conditions. Post hoc testing indicated that no ice (75.49 ± 12.19° C) was significantly different from wetted ice (81.73 ± 10.34° C) and crushed ice (81.62 ± 13.19° C) at the end of the treatment session, and that no ice (85.27 ± 13.83° C) was significantly different than wetted ice (89.44 ± 11.31° C) and crushed ice (89.16 ± 13.78° C) after the stretching session. However, there were no differences between wetted ice and crushed ice. Results indicate that strength and conditioning specialists can increase ROM with both forms of ice in combination with PNF stretching more so than when using no ice at all.

Improving the Efficiency of Electrical Stimulation Activities After Spinal Cord Injury.

In order to enhance spinal cord injury (SCI) rehabilitation programs using neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) it is important to examine the manner in which muscle fibers are recruited and the dose-response relationship. A review of the literature suggests that premature force decline and early fatigue with NMES and FES activities may be alleviated with decreased current frequency and increased current intensity. Dose-response relationships with NMES and FES are dependent on the goals of interest as reversing muscle atrophy can be achieved with activities 2-3 times per week for 6 or more weeks while increasing bone mass is more limited and requires more intense activity with greater exercise frequency and duration, e.g., 3-5 days per week for at least 6-12 months. The best known protocol to elicit neurological improvement is massed practice activities-based restorative therapies (ABRT) (3-5 h per day for several weeks).

Effects of transducer mass on intramuscular temperature during ultrasound treatments.

CONTEXT: A potential variable that could affect rate of temperature elevation with ultrasound is the pressure (mass) that is applied to the transducer head during application. Added pressure could compress the tissue, affecting density and the transmission of ultrasound energy. Little research has been completed to determine the effects of the amount of pressure applied during therapeutic ultrasound in vivo. OBJECTIVE: To determine the effects of different applied transducer mass on intramuscular temperature during an ultrasound treatment within the left triceps surae. DESIGN: Crossover clinical trial. SETTING: Human performance research laboratory. PARTICIPANTS: Convenience sample of thirteen healthy, college-age students. INTERVENTIONS: Three separate 3-MHz, 1.0-W/cm2 ultrasound treatments were administered 1.5 cm within the triceps surae. The independent variables were the linear temperature standards (0.5°C, 1.0°C, 1.5°C, and 2.0°C above baseline) and the 3 different applied pressures measured in grams (200 g, 600 g, and 800 g). MAIN OUTCOME MEASURES: A thermocouple probe was used to measure triceps surae temperature, and time to reach the temperature standards was recorded during the ultrasound treatments. A 4 × 3 repeated-measures analysis of variance (RM-ANOVA) was used to analyze the differences for temperature points (0.5°C, 1.0°C, 1.5°C, and 2.0°C) and transducer mass (200 g, 600 g, and 800 g) and with respect to time. RESULTS: The results of the RM-ANOVA showed no temperature-point and transducer-mass interaction (F6,72 = 1.69, P = .137) or main effect for mass (F2,24 = 1.23, P = .309). The time required to raise temperature 2°C was 209.1 ± 68.10 s at 200 g, 181.5 ± 61.50 s at 600 g, and 194.9 ± 75.54 s at 800 g. CONCLUSIONS: Under the conditions of this study, the amount of mass applied with the transducer during an ultrasound treatment does not ultimately affect the rate of tissue heating.

The effect of plyometric training on power and kicking distance in female adolescent soccer players.

The purpose of this study was to measure the effects of low-frequency, low-impact plyometric training on vertical jump (VJ) and kicking distance in female adolescent soccer players. Sixteen adolescent soccer players were studied (age 13.4 ± 0.5 years) across 14 weeks. The control group (general soccer training only) had 6 subjects, and the plyometric training (general soccer training plus plyometric exercise) group had 10 subjects. All subjects were tested for VJ and kicking distance on 3 occasions: pre-test, 7 weeks, and 14 weeks. Data were analyzed using a 2 (Training) × 3 (Test) analysis of variance (ANOVA) with repeated measures on the factor test. No significant difference in kicking distance was found between groups at pre-test (p = 0.688) or 7 weeks (p = 0.117). The plyometric group had significantly greater kicking distance after 14 weeks (p < 0.001). No significant difference in VJ height was found between groups at pre-test (p = 0.837) or 7 weeks (p = 0.108). The plyometric group had a significantly higher VJ after 14 weeks (p = 0.014). These results provide strength coaches with a safe and effective alternative to high-intensity plyometric training. Based on these findings, to increase lower-body power resulting in increased VJ and kicking distance, strength coaches should implement once-weekly, low-impact plyometric training programs with their adolescent athletes.

The magnitude of tissue cooling during cryotherapy with varied types of compression.

CONTEXT: Certified athletic trainers can choose different types of external compression (none, Flex-i-Wrap, and elastic wrap) when applying an ice bag to the body. However, which type facilitates the greatest magnitude of tissue cooling is unclear. OBJECTIVE: To compare the effects of 2 common types of external compression on the magnitude of surface and intramuscular cooling during an ice-bag treatment. DESIGN: Randomized controlled trial. SETTING: University research laboratory. PATIENTS OR OTHER PARTICIPANTS: Fourteen college students (10 women, 4 men; age = 22.4 +/- 1.8 years, height = 169.1 +/- 8.2 cm, mass = 73.3 +/- 18.5 kg, skinfold = 13.14 +/- 1.61 mm) with previous cryotherapy experience and a posterior lower leg skinfold equal to or less than 15 mm. INTERVENTION(S): On 3 different days separated by 24 to 48 hours, an ice bag was applied to the posterior lower leg surface of each participant for 30 minutes with no compression, with elastic wrap, or with Flex-i-Wrap. MAIN OUTCOME MEASURE(S): Posterior lower leg surface and intramuscular (2 cm) temperatures were recorded for 95 minutes. RESULTS: At 15 minutes, the elastic wrap produced greater surface temperature reduction than no compression (P = .03); this difference remained throughout the protocol (P range, .03 to .04). At 30 minutes, surface temperatures were 14.95 degrees C, 11.55 degrees C, and 9.49 degrees C when an ice bag was applied with no external compression, Flex-i-Wrap, and elastic wrap, respectively. Surface temperatures between Flex-i-Wrap and elastic wrap and between Flex-i-Wrap and no compression were never different. At 10 minutes, Flex-i-Wrap (P = .006) and elastic wrap (P < .001) produced greater intramuscular temperature reduction than no compression produced; these differences remained throughout the protocol. At 10 minutes, no compression, Flex-i-Wrap, and elastic wrap decreased intramuscular temperature by 1.34 degrees C, 2.46 degrees C, and 2.73 degrees C, respectively. At 25 minutes, elastic wrap (8.03 degrees C) produced greater temperature reduction than Flex-i-Wrap (6.65 degrees C) (P = .03) or no compression (4.63 degrees C) (P < .001 ). These differences remained throughout ice application and until 50 minutes after ice-bag removal. CONCLUSIONS: During an ice-bag application, external compression with elastic wrap was more effective than Flex-i-Wrap at reducing intramuscular tissue temperature. Elastic wraps should be used for acute injury care.

Acute effects of static and ballistic stretching on measures of strength and power.

Preactivity stretching is commonly performed by athletes as part of their warm-up routine. However, the most recent literature questions the effectiveness of preactivity stretching. One limitation of this research is that the stretching duration is not realistic for most athletes. Therefore, the purpose of this study was to determine the effects of a practical duration of acute static and ballistic stretching on vertical jump (VJ), lower-extremity power, and quadriceps and hamstring torque. Twenty-four subjects performed a 5-minute warm-up followed by each of the following three conditions on separate days with order counterbalanced: static stretching, ballistic stretching, or no-stretch control condition. Vertical jump was determined with the Vertec VJ system and was also calculated from the ground-reaction forces collected from a Kistler force plate, which also were used to calculate power. Torque output of the quadriceps and hamstrings was measured through knee extension and flexion on the Biodex System 3 Dynamometer at 60 degrees x s(-1). Data normalized for body weight were analyzed using five separate, 3 (stretch condition) x 2 (gender) analysis-of-variance procedures with repeated measures on the factor of stretch condition. The gender x stretch interaction was not significant for any of the four measures, suggesting that the stretching conditions did not affect men and women differently. The results of this study reveal that static and ballistic stretching did not affect VJ, or torque output for the quadriceps and hamstrings. Despite no adverse effect on VJ, stretching did cause a decrease in lower-extremity power, which was surprising. Because of the mixed results, strength coaches would be better served to use dynamic stretching before activity; this has been consistently supported by the literature.

Subcutaneous tissue thickness alters the effect of NMES.

CONTEXT: No direct research has been conducted on the relationship between subcutaneous tissue thickness and neuromuscular electrical stimulation (NMES). OBJECTIVE: The purpose of this study was to determine the effects of subcutaneous tissue thickness on NMES amplitude and NMES force production of the quadriceps. DESIGN: Simple fixed design, testing the independent variable of subcutaneous thickness (skinfold) groups with the dependent variables of NMES amplitude and force production. SETTING: Athletic Training Laboratory. PARTICIPANTS: 29 healthy women. INTERVENTION: NMES to produce at least 30% of maximal voluntary isometric contractions (MVIC) of the quadriceps. MAIN OUTCOME MEASURE: Maximal NMES amplitude and percentage of MVIC using NMES. RESULTS: A significant skinfold category difference F2,28=3.92, P=.032 on NMES amplitude was found. Post hoc revealed the thinnest skinfold category tolerated less amplitude compared to the thickest category. A significant correlation was found between NMES amplitude skinfold category R=.557, P=.002. CONCLUSION: Higher NMES amplitudes are needed for the thickest skinfold category compared to the thinnest skinfold category.

A victim typology of sexual harassment.

A clinical sample of 20 sexual harassment victims who were successful in obtaining damage awards for trauma through the judicial system were sources of this descriptive study. Ratings of physical coercion of the harassment, MMPI-2 scores, and ratings on DSM-IV symptoms were analyzed. The majority of subjects met the DSM-IV criteria of Post-Traumatic Stress Disorder. A cluster analysis identified four clusters of harassment victims, described as older-mature, younger-mature, anxious-guilty, and expressive-adaptive based on MMPI-2 scores and symptoms.

Effect of hamstring-emphasized resistance training on hamstring:quadriceps strength ratios.

A decreased hamstring:quadriceps (H:Q) ratio may put the hamstrings and anterior cruciate ligament (ACL) at increased risk of injury. Therefore, the purpose of this study was to evaluate H:Q ratios of 12 female National Collegiate Athletic Association soccer players, and to test the effects of a 6-week strength training program on these ratios. Each subject completed 2 practice sessions before a pretest. Subjects then completed 6 weeks of strength training that included the addition of 2 hamstring specific exercises, followed by a posttest. Peak torque during concentric and eccentric actions for both hamstrings and quadriceps was measured with an isokinetic dynamometer. Each muscle action was tested at 3 angular velocities in the following order: concentric 240, 180, and 60 degrees x s(-1) and eccentric 60, 180, and 240 degrees x s(-1). The H:Q strength ratio was evaluated using concentric muscle actions (concentric hamstrings:concentric quadriceps). This method is commonly used and is thus called the conventional ratio. Because concentric actions do not occur simultaneously in opposing muscles, a more functional assessment compares eccentric hamstring actions to concentric quadriceps actions. This functional ratio was also analyzed. Mean conventional and functional H:Q ratio data were analyzed using separate analysis of variance procedures with repeated measures on all factors (2 [Test] x 2 [Leg] x 3 [Angular Velocity]). The results revealed a significant main effect for factor (F test) with the functional ratio (p < 0.05) but not for the conventional ratio. The mean functional ratio increased from 0.96 +/- 0.09 in pretest to 1.08 +/- 0.11 in posttest. These results suggest that 6 weeks of strength training that emphasizes hamstrings is sufficient to significantly increase the functional ratio. The functional ratio after training exceeded 1.0, which is specifically recommended for prevention of ACL injuries.

The acute effects of mechanical vibration on power output in the bench press.

This study was designed to investigate the effect of mechanical vibration on acute power output in the bench press exercise. Ten male subjects who were experienced in resistance training participated in this study. Each subject performed 3 sets of 3 repetitions in the bench press exercise using a load equal to 70% of 1 repetition maximum in each of 2 sessions separated by 3 days. One session served as the experimental (vibration) condition, whereas the other session served as the control (no vibration) condition. The intervention (vibration or control) was applied between sets 2 and 3. The vibration was applied by a vibrating barbell apparatus held by the subjects while lying supine on a bench. The only difference between the 2 conditions was the vibration of the barbell apparatus during the vibration condition. Peak and average power were calculated during each bench press set to determine whether power output differed following vibration compared to control. Average power was significantly higher for the vibration condition compared to the control (525 +/- 74 vs. 499 +/- 71 W; p = 0.01). There was also a trend toward an increase in peak power in the vibration condition (846 +/- 168 by vs. 799 +/- 149 W; p = 0.06). In general, peak and average power output were higher following the vibration intervention compared to control. However, the sets prior to vibration application during the vibration condition also demonstrated higher power outputs compared with the control condition, which contributed to the main effect for the vibration condition. These results suggest that factors other than the vibration intervention influenced task performance during the vibration condition. We suggest that psychological factors related to the novelty of the vibration intervention were involved. These factors may partially explain the conflicting results of previous investigations that examined vibration as an exercise intervention.

Investigation of vertical jump performance after completing heavy squat exercises.

The purpose of this study was to determine whether vertical jump height was influenced by completing a half squat or quarter squat exercise prior to jumping. Ten male subjects experienced with the squat exercise performed 4 warm up squat sets followed by 1 repetition with the weight of 90% of 1 repetition maximum of the half squat or quarter squat. No difference in jump heights after any of the 3 conditions, including a control group (F = 3.096, p = 0.070), was found. Correlations between the relative strength ratio and the difference in averaged jump heights before and after the half and quarter squat conditions were also tested, and no correlation was found (r = -0.128, p = 0.724, and r = -0.189, p = 0.601, respectively). Although statistical significance at the 0.05 level was not observed for the comparison of jump heights between conditions, we did observe a trend (i.e., p = 0.07). Therefore, we examined the individual responses to the exercises and determined that 5 of the subjects did increase their vertical jumps after both squat exercises. It may be that the influence of prejump exercise on jump performance may be individualized. Nevertheless, the use of a strength ratio does not appear to predict who will benefit from posttetanic potentiation in this type of exercise situation.

A Comparison of Temperature Increases Produced by 2 Commonly Used Ultrasound Units.

OBJECTIVE: To compare temperature changes produced by 2 commonly used ultrasound units. DESIGN AND SETTING: We inserted a thermistor microprobe connected to a digital monitor into the medial belly of the triceps surae muscle at a depth of 1.2 cm. We administered ultrasound with both the Omnisound 3000 and the Forte 400 Combo through 5-cm(2) sound heads. Continuous ultrasound was administered at a frequency of 3 MHz and an intensity of 1.0 W/cm(2). SUBJECTS: Ten (5 men, 5 women) healthy subjects (age = 21.9 +/- 0.87 years, height = 175 +/- 0.09 cm, mass = 74.2 +/- 13.3 kg) volunteered to participate in this study. MEASUREMENTS: We monitored temperature continuously during 10 minutes of ultrasound. Temperature was allowed to return to baseline between trials, and the treatment order was counterbalanced. RESULTS: We analyzed the mean temperature changes over baseline with a 2-within-factor (ultrasound unit) x 2-between-factor (sex) mixed-design analysis of variance. The mean temperature elevation was significantly greater with the Omnisound 3000 than with the Forte 400 Combo (P =.0001). Temperature increased by 5.81 +/- 0.41 degrees C with the Omnisound 3000 and only by 3.85 +/- 0.75 degrees C with the Forte 400 Combo. CONCLUSIONS: We concluded that the Omnisound 3000 was more effective in raising temperature in tissues at a depth of 1.2 cm.