SYSTEMATIC REVIEW AND META‐ANALYSIS: A PRIMER

The use of an evidence‐based approach to practice requires “the integration of best research evidence with clinical expertise and patient values”, where the best evidence can be gathered from randomized controlled trials (RCTs), systematic reviews and meta‐analyses. Furthermore, informed decisions in healthcare and the prompt incorporation of new research findings in routine practice necessitate regular reading, evaluation, and integration of the current knowledge from the primary literature on a given topic. However, given the dramatic increase in published studies, such an approach may become too time consuming and therefore impractical, if not impossible. Therefore, systematic reviews and meta‐analyses can provide the “best evidence” and an unbiased overview of the body of knowledge on a specific topic. In the present article the authors aim to provide a gentle introduction to readers not familiar with systematic reviews and meta‐analyses in order to understand the basic principles and methods behind this type of literature. This article will help practitioners to critically read and interpret systematic reviews and meta‐analyses to appropriately apply the available evidence to their clinical practice.     

HYPNOTIZABILITY AND PAIN MODULATION: A Body–Mind Perspective

The study investigated whether the cardiac activity and cognitive–emotional traits sustained by the behavioral inhibition/activation system (BIS/BAS) may contribute to hypnotizability-related pain modulation. Nociceptive stimulation (cold-pressor test) was administered to healthy participants with high (highs) and low (lows) hypnotizability in the presence and absence of suggestions for analgesia. Results showed that heart rate increased abruptly at the beginning of nociceptive stimulation in all participants. Then, only in highs heart rate decreased for the entire duration of hand immersion. During stimulation with suggestions of analgesia, pain threshold negatively correlated with heart rate. BIS/BAS activity partially accounted for the observed hypnotizability-related differences in the relation between cardiac interoception and pain experience.     

A PILOT STUDY OF CORE STABILITY AND ATHLETIC PERFORMANCE: IS THERE A RELATIONSHIP?

Study Design:

Correlation study

Objectives:

To objectively evaluate the relationship between core stability and athletic performance measures in male and female collegiate athletes.

Background:

The relationship between core stability and athletic performance has yet to be quantified in the available literature. The current literature does not demonstrate whether or not core strength relates to functional performance. Questions remain regarding the most important components of core stability, the role of sport specificity, and the measurement of core stability in relation to athletic performance.

Methods:

A sample of 35 volunteer student athletes from Asbury College (NAIA Division II) provided informed consent. Participants performed a series of five tests: double leg lowering (core stability test), the forty yard dash, the T-test, vertical jump, and a medicine ball throw. Participants performed three trials of each test in a randomized order.

Results:

Correlations between the core stability test and each of the other four performance tests were determined using a General Linear Model. Medicine ball throw negatively correlated to the core stability test (r –0.389, p=0.023). Participants that performed better on the core stability test had a stronger negative correlation to the medicine ball throw (r =–0.527). Gender was the most strongly correlated variable to core strength, males with a mean measurement of double leg lowering of 47.43 degrees compared to females having a mean of 54.75 degrees.

Conclusions:

There appears to be a link between a core stability test and athletic performance tests; however, more research is needed to provide a definitive answer on the nature of this relationship. Ideally, specific performance tests will be able to better define and to examine relationships to core stability. Future studies should also seek to determine if there are specific sub-categories of core stability which are most important to allow for optimal training and performance for individual sports.     

KINESIOLOGY TAPING AND THE WORLD WIDE WEB: A QUALITY AND CONTENT ANALYSIS OF INTERNET‐BASED INFORMATION

Background:

Due to limited regulation of websites, the quality and content of online health‐related information has been questioned as prior studies have shown that websites often misrepresent orthopaedic conditions and treatments. Kinesiology tape has gained popularity among athletes and the general public despite limited evidence supporting its efficacy. The primary objective of this study was to assess the quality and content of Internet‐based information on Kinesiology taping.

Methods:

An Internet search using the terms “Kinesiology tape” and “kinesiology tape” was performed using the Google search engine. Websites returned within the first two pages of results, as well as hyperlinks embedded within these sites, were included in the study. These sites were subsequently classified by type. The quality of the website was determined by the Health On the Net (HON) score, an objective metric based upon recommendations from the United Nations for the ethical representation of health information. A content analysis was performed by noting specific misleading versus balanced features in each website.

Results:

A total of 31 unique websites were identified. The majority of the websites (71%) were commercial. Out of a total possible 16 points, the mean HON score among the websites was 8.9 points (SD 2.2 points). The number of misleading features was significantly higher than the balanced features (p < 0.001). Fifty‐eight percent of sites used anecdotal testimonials to promote the product. Only small percentages of websites discussed complications, alternatives, or provided accurate medical outcomes. Overall, commercial sites had a greater number of misleading features compared to non‐commercial sites (p = 0.01).

Conclusions:

Websites discussing Kinesiology tape are predominantly of poor quality and present misleading, imbalanced information. It is of ever‐increasing importance that healthcare providers work to ensure that reliable, balanced, and accurate information be available to Internet users.

Level of Evidence:

IV     

IS THERE A RELATION BETWEEN SHOULDER DYSFUNCTION AND CORE INSTABILITY?

Background:

Overhead athletes often suffer injury to the glenohumeral joint secondary to inherent instability. However, little is known about the relationship between core stability and shoulder dysfunction among athletes.

Purpose:

The purpose of this study was to analyze the difference between healthy athletes and those with shoulder dysfunction in regard to core stability measures. Secondary purpose was to explore the relationship between measures of core stability and measures of shoulder dysfunction.

Methods:

Participants consisted of NCAA Division III overhead athletes (28 males, 33 females) with a mean age of 19.3 ± (1.1) years, mean weight of 173.6 ± (36.9) pounds, mean height of 67.8 ± (3.5) inches. Functional questionnaires (the Kerlan‐Jobe Orthopaedic Clinical Scale [KJOC] and the QuickDASH sports module) as well as Single‐Leg Stance Balance Test (SLBT), Double Straight Leg Lowering Test (DLL), Sorensen Test, and Modified Side Plank Test were completed in a randomized order with consistent raters.

Results:

MANOVA was significant at (p = .038) for the comparison between the experimental group and the control group for the values of Right SLBT. The experimental group had significantly less balance than the control group with means of 10.14 ± (5.76) seconds and 18.98 ± (15.22) seconds respectively. Additionally, a positive correlation was found between the DLL and the KJOC at (r = .394, p > .05) and a negative correlation was found between the Right SLBT and the Quick DASH sports module (QD) at (r = –.271, p > .05).

Discussion and Conclusion:

Balance deficiency was found in athletes with shoulder dysfunction. According to this study, greater shoulder dysfunction is correlated with greater balance and stability deficiency. Therapists and trainers should consider incorporating balance training as an integral component of core stability into rehabilitation of athletes with shoulder dysfunction.

Level of Evidence:

3b     

HEALTH AND SPORTS

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SIDESTEP AND CROSSOVER LOWER LIMB KINEMATICS DURING A PROLONGED SPORT‐LIKE AGILITY TEST

Background:

Non‐contact anterior cruciate ligament (ACL) injuries in athletes occur more often towards the end of athletic competitions. However, the exact mechanisms of how prolonged activity increases the risk for ACL injuries are not clear.

Purpose:

To determine the effect of prolonged activity on the hip and knee kinematics observed during self‐selected cutting maneuvers performed in a timed agility test.

Methods:

Nineteen female Division I collegiate soccer players completed a self‐selected cutting agility test until they were unable to meet a set performance time (one standard deviation of the average baseline trial). Using the 3D dimensional coordinate data the cut type was identified by the principle investigators. The 3D hip and knee angles at 32ms post heel strike were analyzed using a two‐factor, linear mixed model to assess the effect of prolonged activity and cut type on the recorded mean hip and knee angles.

Results:

Athletes performed either sidestep or crossover cuts. An effect of cut type and prolonged activity was seen at the hip and knee. During the prolonged activity trials, the knee was relatively more adducted and both the hip and knee were less flexed than during the baseline trials regardless of cut type. Regardless of activity status, during sidestep cuts, the hip was more internally rotated and abducted, and less flexed than during crossover cuts while the knee was more abducted and less flexed during the sidestep than crossover cuts.

Conclusions:

During a sport‐like agility test, prolonged activity appears to predispose the athlete to position their knee in a more extended and abducted posture and their hip in a more extended posture. This position has been suggested to place stress on the ACL and potentially increase the risk for injury. Clinicians may want to consider the effects of prolonged activity on biomechanical risk factors for sustaining ACL injuries in the design of intervention strategies to prevent ACL injuries.

Level of Evidence:

Level 4     

RETURN TO SWIMMING PROTOCOL FOR COMPETITIVE SWIMMERS: A POST‐OPERATIVE CASE STUDY AND FUNDAMENTALS

A large percentage of swimmers report shoulder pain during their swimming career. Shoulder pain in swimmers has been attributed to duration of swim practice, total yardage, and break down in stroke technique. Rehabilitation programs are generally land‐based and cannot adequately address the intricacies of the swimming strokes. Return to swimming protocols (RTSP) that address progression of yardage are scarce, yet needed. The purpose of this clinical commentary is to familiarize the clinician with the culture and vernacular of swimming, and to provide a suggested yardage based RTSP for high school and collegiate level swimmers.

Level of Evidence:

5     

THE EFFICACY OF TAPING FOR ROTATOR CUFF TENDINOPATHY: A SYSTEMATIC REVIEW AND META‐ANALYSIS

Background

Rotator cuff (RC) tendinopathy is a highly prevalent musculoskeletal disorder. Non‐elastic taping (NET) and kinesiology taping (KT) are common interventions used by physiotherapists. However, evidence regarding their efficacy is inconclusive.

Objective

To examine the current evidence on the clinical efficacy of taping, either NET or KT, for the treatment of individuals with RC tendinopathy.

Study Design

Systematic review and meta‐analysis

Methods

A literature search was conducted in four bibliographical databases to identify randomized controlled trials (RCT) that compared NET or KT to any other intervention or placebo for treatment of RC tendinopathy. Internal validity of RCTs was assessed with the Cochrane Risk of Bias tool. A qualitative or quantitative synthesis of evidence was performed.

Results

Ten trials were included in the present review on overall pain reduction or improvement in function. Most RCTs had a high risk of bias. There is inconclusive evidence for NET, either used alone or in conjunction with another intervention. Based on pooled results of two studies (n=72), KT used alone resulted in significant gain in pain free flexion (MD: 8.7 ° 95%CI 8.0 ° to 9.5 °) and in pain free abduction (MD: 10.3 ° 95%CI 9.1 ° to 11.4 °). Based on qualitative analyses, there is inconclusive evidence on the efficacy of KT when used alone or in conjunction with other interventions on overall pain reduction or improvement in function.

Conclusion

Although KT significantly improved pain free range of motion, there is insufficient evidence to formally conclude on the efficacy of KT or NET used alone or in conjunction with other interventions in patients with RC tendinopathy.

Level of Evidence

Therapy, level 1a     

ECCENTRIC AND CONCENTRIC JUMPING PERFORMANCE DURING AUGMENTED JUMPS WITH ELASTIC RESISTANCE: A META‐ANALYSIS

Introduction

The initial rapid eccentric contraction of a stretch‐shortening cycle (SSC) activity is typically reported to accentuate the subsequent concentric jump performance. Some researchers have rationalized that adding elastic resistance (ER) to explosive type activities (e.g. countermovement jumps and drop jumps) would increase excitatory stretch reflex activity and mechanical recoil characteristics of the musculotendinous tissues. The purpose of this meta‐analysis was to examine the available literature on jumping movements augmented with ER and to provide a quantitative summary on the effectiveness of this technique for enhancing acute eccentric and concentric jumping performance.

Methods

In a random‐effects model, the Hedges`s g effect size (ES) was used to calculate the biased corrected standardized mean difference between the augmented and similar non‐augmented jumps.

Results

The results demonstrated that augmented jumps provided a greater eccentric loading compared to free jumps (Hedges`s g ES = 0.237, p = 0.028). However the concentric performance was significantly impaired, particularly if the downward elastic force was used during concentric phase as well (ES = ‐2.440, p < 0.001). Interestingly, no performance decrement was observed in those studies, which released the bands at the beginning of the concentric phase (ES = 0.397, p = 0.429).

Discussion

The authors postulated that the excessive eccentric loading might trigger reflex inhibition, alter the muscle stiffness, increase downward hip displacement and dissipate mechanical recoil properties. These results suggest that the release of elastic force at the beginning of the concentric phase seems to be a critical point to avoid impairment of acute concentric performance in augmented jumps.

Level of Evidence

2a     

RADIOLOGICAL EXAMINATION OF THE HIP ‐ CLINICAL INDICATIONS,METHODS, AND INTERPRETATION: A CLINICAL COMMENTARY

There is a growing interest in musculoskeletal rehabilitation for young active individuals with non‐arthritic hip pathology. History and physical examination can be useful to classify those with non‐arthritic intra‐articular hip pathology as having impingement or instability. However, the specific type of deformity leading to symptoms may not be apparent from this evaluation, which may compromise the clinical decision‐making. Several radiological indexes have been described in the literature for individuals with non‐arthritic hip pathology. These indexes identify and quantify acetabular and femoral deformities that may contribute to instability and impingement. The aim of this paper is to discuss clinical indications, methods, and the use of hip radiological images or radiology reports as they relate to physical examination findings for those with non‐arthritic hip pathology.

Level of evidence:

5     

THE COMPARISON OF THE EMPTY CAN AND FULL CAN TECHNIQUES AND A NEW DIAGONAL HORIZONTAL ADDUCTION TEST FOR SUPRASPINATUS MUSCLE TESTING USING CROSS‐SECTIONAL ANALYSIS THROUGH ULTRASONOGRAPHY

Purpose/Background:

Several examination tests are currently used for diagnosing a supraspinatus lesion. The empty can (EC) test is currently considered the gold standard for testing, but full can (FC) testing is also utilized. Both of these tests do not fully eliminate the deltoid synergistic when resistance is applied. A new diagonal horizontal adduction (DHA) technique has been developed for evaluation of the supraspinatus that has not yet been compared with the existing techniques (EC/FC). Cross‐sectional analysis (CSA) change during contraction as an ultrasonographic means of visualizing and measuring contraction of the supraspinatus has been reported previously.

Objective:

The purpose of this study was to use diagnostic musculoskeletal ultrasound (MSK) to compare CSA of the supraspinatus during the FC, EC, and the DHA tests.

Methods:

The supraspinatus muscle of 37 healthy, uninjured volunteers (21 males and 16 females, mean age of 26.9) were visualized and CSA was captured during 4 randomly assigned test positions (including control) using MSK.

Results:

A one‐way Analysis of Variance with repeated measures of the mean CSA obtained in the testing positions was performed followed by least significant difference (LSD) for post‐hoc analysis. Significant differences (p < 0.05) were found between the mean CSA of the controls and the CSA of each of the three testing procedures analyzed using the MSK. There were no significant differences (p < 0.05) in CSA between any of the three testing procedures.

Conclusions:

In this study, MSK visualized and objectified activity of the supraspinatus muscle as evidenced through increased mean CSA when resisted. All the testing positions (FC, EC, and DHA) demonstrated significantly increased mean CSA of the muscle when isometrically contracted when compared to the resting control. The DHA procedure also elicited significant increase in CSA of the supraspinatus. However, no significant difference was found between the CSA of the DHA when compared to the FC and EC tests.

Level of Evidence:

Level 2     

THE NAVICULAR POSITION TEST – A RELIABLE MEASURE OF THE NAVICULAR BONE POSITION DURING REST AND LOADING

Background:

Lower limb injuries are a large problem in athletes. However, there is a paucity of knowledge on the relationship between alignment of the medial longitudinal arch (MLA) of the foot and development of such injuries. A reliable and valid test to quantify foot type is needed to be able to investigate the relationship between arch type and injury likelihood. Feiss Line is a valid clinical measure of the MLA. However, no study has investigated the reliability of the test.

Objectives:

The purpose was to describe a modified version of the Feiss Line test and to determine the intra- and inter-tester reliability of this new foot alignment test. To emphasize the purpose of the modified test, the authors have named it The Navicular Position Test.

Methods:

Intra- and inter-tester reliability were evaluated of The Navicular Position Test with the use of ICC (interclass correlation coefficient) and Bland-Altman limits of agreement on 43 healthy, young, subjects.

Results:

Inter-tester mean difference -0.35 degrees [–1.32; 0.62] p = 0.47. Bland-Altman limits of agreement –6.55 to 5.85 degrees, ICC = 0.94. Intra-tester mean difference 0.47 degrees [–0.57; 1.50] p = 0.37. Bland-Altman limits of agreement –6.15 to 7.08 degrees, ICC = 0.91.

Discussion:

The present data support The Navicular Position Test as a reliable test of the navicular bone position during rest and loading measured in a simple test set-up.

Conclusion:

The Navicular Position Test was shown to have a high intraday-, intra- and inter-tester reliability. When cut off values to categorize the MLA into planus, rectus, or cavus feet, has been determined and presented, the test could be used in prospective observational studies investigating the role of the arch type on the development of various lower limb injuries.     

ERYTHROPOIETIN RECEPTOR AND SIGNAL TRANSDUCTION

A group of hormones are believed to exertregulation on the development of erythrocyticprogenitors,among which erythropoietin(EPO)is the most important regulator.     

THE IMMEDIATE AND LONG-TERM EFFECTS OF KINESIOTAPE? ON BALANCE AND FUNCTIONAL PERFORMANCE

Background

The application of Kinesio Tex® tape (KT) results, in theory, in the improvement of muscle contractibility by supporting weakened muscles. The effect of KT on muscle strength has been investigated by numerous researchers who have theorized that KT facilitates an immediate increase in muscle strength by generating a concentric pull on the fascia. The effect of KT on balance and functional performance has been controversial because of the inconsistencies of tension and direction of pull required during application of KT and whether its use on healthy individuals provides therapeutic benefits.

Hypotheses/Purpose

The purpose of the present study was to investigate the immediate and long-term effects of the prescribed application (for facilitation) of KT when applied to the dominant lower extremity of healthy individuals. The hypothesis was that balance and functional performance would improve with the prescribed application of KT versus the sham application.

Study Design

Pretest-posttest repeated measures control group design.

Methods

Seventeen healthy subjects (9 males; 8 females) ranging from 18-35 years of age (mean age 23.3 ± 0.72), volunteered to participate in this study. KT was applied to the gastrocnemius of the participant''s dominant leg using a prescribed application to facilitate muscle performance for the experimental group versus a sham application for the control group. The Biodex Balance System and four hop tests were utilized to assess balance, proprioception, and functional performance beginning on the first day including pre- and immediately post-KT application measurements. Subsequent measurements were performed 24, 72, and 120 hours after tape application. Repeated measures ANOVA''s were performed for each individual dependent variable.

Results

There were no significant differences for main and interaction effects between KT and sham groups for the balance and four hop tests.

Conclusion

The results of the present study did not indicate any significant differences in balance and functional performance when KT was applied to the gastrocnemius muscle of the lower extremity.

Level of evidence

Level 1- Randomized Clinical Trial     

STUDIES OF CALCIUM AND PHOSPHORUS METABOLISM : V. A STUDY OF THE BONE TRABECUL? AS A READILY AVAILABLE RESERVE SUPPLY OF CALCIUM.

1. Bone trabeculae are easily depleted by the prolonged administration of parathormone, long continued negative calcium balance and growth. 2. A long continued high calcium diet results in a rapid accumulation of the trabeculae. 3. Alizarin red, as has previously been shown in the literature, is deposited in newly formed bone. Its use has made clear that easily mobilizable calcium is not deposited in the shafts of adult animals, but in the trabeculae of bone. 4. The bone trabeculae therefore serve as the storehouse of readily available calcium. 5. The shafts have a slow progressive exchange of inorganic salts and are not influenced except in the case of unusual body demands. 6. It is suggested that the absence of trabeculae in premature infants and their depletion at the end of 4 months in a normal baby might well be an etiological factor in rickets. 7. In our observations, parathormone administration to growing or adult cats has been without effect. 8. Daily injections of parathormone in growing rats results in an increased number of trabeculae and smaller bones.