Inter-limb kinetic asymmetries during sit-to-stand performance persist following unilateral total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Kinetic asymmetries during sit-to-stand have been consistently observed early after total knee arthroplasty; however, the longer-term outcomes are less clear. The purpose of this systematic review and meta-analysis was to analyze the results of studies examining inter-limb kinetic symmetry during sit-to-stand performance among individuals who were at least one-year post unilateral total knee arthroplasty. METHODS: PubMed, SPORTDiscus, CINAHL, and Health Source databases were searched. Studies were included if they were published in a peer-reviewed journal, included subjects who had undergone unilateral total knee arthroplasty at least one-year prior, and examined vertical ground reaction forces and/or knee extension moments for the involved and uninvolved limbs during sit-to-stand performance. Data were transformed into a limb symmetry index, which expressed the ratio of the peak forces/moments for the involved limb, relative to the uninvolved limb (1.0 reflects perfect symmetry). These ratios were meta-analyzed using the ratio of means method. FINDINGS: Seven studies were deemed eligible for inclusion. Ground reaction force data was pooled from seven studies and knee extension moment data was pooled from two studies. For the peak vertical ground reaction forces, the pooled limb symmetry index was 0.96 (CI95% = [0.93, 0.99]). For the peak knee extension moments, the pooled limb symmetry index was 0.91 (CI95% = [0.84, 0.98]). In both cases this reflects greater limb/knee loading for the uninvolved limb, relative to the involved limb. INTERPRETATION: Asymmetries in limb/knee loading persist beyond the one-year post-operative period following total knee arthroplasty, potentially contributing to degenerative changes for the uninvolved limb.

Deficits in Dynamic Balance and Hop Performance Following ACL Reconstruction Are Not Dependent on Meniscal Injury History.

Background: Athletes often exhibit persistent deficits in dynamic balance and hop performance in their involved limb following ACL reconstruction. However, it is unclear how meniscal injury history affects inter-limb asymmetry. Purpose: The purpose of this study was to compare inter-limb asymmetry in dynamic balance and hop performance in athletes with and without a history of concomitant meniscal injury. Study Design: Cross-sectional study. Methods: Dynamic balance and hop test data were analyzed for 34 adolescent athletes who had undergone ACL reconstruction; 19 athletes had sustained an isolated ACL tear, while 15 had sustained an ACL tear along with a meniscus injury. Athletes who had sustained a meniscus injury were sub-divided into those who underwent a meniscal repair (n = 9) versus a partial meniscectomy (n = 6). Dynamic balance was assessed using the Y-Balance Test, while hop performance was assessed using the single and triple hop tests. Data were recorded at the time of return-to-sport testing (5-11 months post-surgery). For each variable, mixed-model analysis of variance, with a between-subjects factor of group (isolated ACL tear, meniscal repair, partial meniscectomy) and a within-subjects factor of limb (involved, uninvolved), was conducted. Results: The groups exhibited similar degrees of inter-limb asymmetry in dynamic balance and hop test performance, as there was not a group-by-limb interaction effect for the Y-Balance Test distances (p ≥ 0.43) or hop test distances (p ≥ 0.96). However, there was a main effect of limb for the anterior and posteromedial Y-Balance Test distances and the single and triple hop test distances (p ≤ 0.004). For each variable, performance was worse for the involved limb, compared to the uninvolved limb. Conclusion: It appears that deficits in dynamic balance and hop performance among adolescent athletes who have undergone ACL reconstruction are not dependent on meniscal injury/surgery history. Level of Evidence: 3.

Evidence of Generalized Muscle Stiffness in the Presence of Latent Trigger Points Within Infraspinatus.

OBJECTIVE: To evaluate stiffness of infraspinatus muscle tissue, both with and without latent trigger points, using ultrasound shear wave elastography (SWE). The primary hypothesis is that muscle with a latent trigger point will demonstrate a discrete region of increased shear wave speed. The secondary hypothesis is that shear wave speed (SWS) in the region with the trigger point will be higher in patients compared with controls, and will be similar between the two groups in the uninvolved regions. DESIGN: Case-control. SETTING: Hospital-based outpatient physical therapy center. PARTICIPANTS: Convenience sample (N=18) of patients (6 female, 3 male, mean age=44) (range=31-61y) diagnosed with latent trigger points in infraspinatus and matched controls without trigger points. MAIN OUTCOME MEASURES: Shear wave speed (m/s). RESULTS: SWS of the latent trigger point (mean=4.09±SD1.4 m/s) did not differ from the adjacent muscle tissue (3.92±1.6 m/s, P>.05), but was elevated compared to corresponding tissue in controls (2.8±0.75 m/s, P=.02). SWS was generally greater in patients' uninvolved tissue (3.83±1.6 m/s) when compared to corresponding tissue in controls (2.62±0.2 m/s, P=.05). CONCLUSION: Although discrete regions of increased SWS corresponding to the trigger point were not observed in patients, evidence of generally increased muscle stiffness in infraspinatus was exhibited compared to healthy controls. Further study of additional muscles with SWE is warranted.

Reliability, Responsiveness, and Criterion Validity of the Kiio Sensor, a New Tool for Assessment of Muscle Function.

Musculoskeletal injuries are a leading cause of disability in both the general population and military, and the ability to effectively quantify musculoskeletal function remains problematic. The aim of the current study is to investigate the reliability, responsiveness, and criterion validity of the kiio Sensor for measurement of muscle strength, a key aspect of comprehensive functional assessment. Forty-four (24 male, 20 female) physically active civilian adults (mean [SD] = 21.2 [1.5] years of age) with no history of upper extremity injuries in the last year and no current complaints of pain, weakness, or functional limitation completed two sessions of maximum shoulder external rotation contractions. The forces were measured with a kiio Sensor and isokinetic dynamometer. The devices showed strong correlation (r = 0.89) and no significant mean difference (0.3 ± 3.3 lb, p = 0.47). Intrasession reliability for both devices was analyzed using intraclass correlation coefficients (ICC3,1 = 0.96 [95% confidence interval = 0.93-0.98)], with the kiio Sensor having slightly less standard error and trial-to-trial variability. The kiio Sensor 7-day reliability was ICC3,3 = 0.97 (95% confidence interval = 0.94-0.98). The kiio Sensor demonstrates excellent reliability, responsiveness, and validity compared with a gold standard isokinetic dynamometer. Several key attributes contributing to this technology's military relevance are discussed.

Multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: A retrospective analysis on safety and feasibility.

OBJECTIVE: Demonstrate implementation, safety and feasibility of multimodal, impairment-based physical therapy (PT) combining vestibular/oculomotor and cervical rehabilitation with sub-symptom threshold exercise for the treatment of patients with post-concussion syndrome (PCS). SETTING: University hospital outpatient sports medicine facility. PARTICIPANTS: Twenty-five patients (12-20 years old) meeting World Health Organization criteria for PCS following sport-related concussion referred for supervised PT consisting of sub-symptom cardiovascular exercise, vestibular/oculomotor and cervical spine rehabilitation. DESIGN: Retrospective cohort. MAIN MEASURES: Post-Concussion Symptom Scale (PCSS) total score, maximum symptom-free heart rate (SFHR) during graded exercise testing (GXT), GXT duration, balance error scoring system (BESS) score, and number of adverse events. RESULTS: Patients demonstrated a statistically significant decreasing trend (p < 0.01) for total PCSS scores (pre-PT M = 18.2 (SD = 14.2), post-PT M = 9.1 (SD = 10.8), n = 25). Maximum SFHR achieved on GXT increased 23% (p < 0.01, n = 14), and BESS errors decreased 52% (p < 0.01, n = 13). Two patients reported mild symptom exacerbation with aerobic exercise at home, attenuated by adjustment of the home exercise program. CONCLUSIONS: Multimodal, impairment-based PT is safe and associated with diminishing PCS symptoms. This establishes feasibility for future clinical trials to determine viable treatment approaches to reduce symptoms and improve function while avoiding negative repercussions of physical inactivity and premature return to full activity.

Management of a Patient With Acute Acetabular Labral Tear and Femoral Acetabular Impingement With Intra-articular Steroid Injection and a Neuromotor Training Program.

Study Design Case report. Background Intra-articular hip pathologies can be difficult to diagnose, and evidence to guide physical therapy interventions is lacking. The purpose of this case report is to describe a clinical pathway for conservative management of a patient with an acute acetabular labral tear and femoroacetabular impingement. Case Description The patient was an 18-year-old woman with recent onset of right groin pain who underwent intra-articular corticosteroid injection and therapeutic exercise for the management of an acute acetabular labral tear identified on radiographic imaging. Prior to physical therapy, the patient received an intra-articular hip injection for diagnostic purposes and pain relief. Upon initial evaluation, the patient presented with improved pain but with continued kinesthetic deficits, inflexibility, muscle imbalances, and reproduction of symptoms with end-range hip motions. A physical therapy plan was implemented using neuromuscular re-education to address her continued impairments. Outcomes Marked improvements were noted at discharge and 6-month follow-up for pain, strength, and function as demonstrated on the Patient-Specific Functional Scale, global rating of change scale, and International Hip Outcome Tool-33. Discussion This case demonstrates a clinical pathway for collaborative medical management of a patient with confirmed intra-articular pathology. Details illustrate the clinical reasoning and rationale used to guide the clinical decision-making process. Level of Evidence Therapy, level 4. J Orthop Sports Phys Ther 2016;46(11):965-975. Epub 29 Sep 2016. doi:10.2519/jospt.2016.6573.

Perturbation of object location during bimanual prehension: the role of visual feedback.

In this series of studies on the coordination of the two hands during a bimanual perturbation task, 10 right-handed volunteers were asked to reach to grasp and lift two illuminated cubic objects. Upon initiation of the reach a perturbation could occur by extinguishing one or both objects and illuminating new objects located directly away from the start position in the para-sagittal plane (Experiment 1) or toward the start position in the para-sagittal plane (Experiment 2). In Experiment 2 we also manipulated position of the targets within the visual span by having the targets move toward the midline or away from the midline. Dependent measures included kinematic data for the reach movement as well as the timing of eye movements. Results of both experiments indicated little interference between the hands when one object was perturbed while the other remained stationary. We hypothesize that when visual feedback about limb movement is available, participants can independently reorganize the trajectory of the perturbed limb with minimal interference on the non-perturbed limb. Furthermore, results of Experiment 2 indicated that the position of the targets within the visual span at the final target location dictates the number of eye movements made to acquire both targets and can lead to asynchronies at movement termination in a task-dependent manner. Finally, we found that when targets were perturbed away from the body movement time results indicated a right-hand advantage for dealing with a single perturbation. In contrast, perturbations toward the body abolished the movement time advantage. We suggest that differences in the use of visual feedback when working in the upper versus lower visual fields may influence hand advantages.