THE CLINICAL UTILITY OF FUNCTIONAL PERFORMANCE TESTS WITHIN ONE-YEAR POST-ACL RECONSTRUCTION: A SYSTEMATIC REVIEW

Introduction:

A tear of the anterior cruciate ligament (ACL) represents a significant injury for an athlete that requires substantial time away from sport, and significant rehabilitation after reconstruction. The physical therapist is responsible to determine when a patient is capable of tolerating the physical demands of daily activities and to attempt to prevent re-injury. Physical or functional performance tests (FPTs) are one mechanism used to evaluate the athlete''s physical skills and capabilities prior to returning to sports participation. The purpose of this systematic review is to critically examine the clinical utility of functional performance tests used with patients less than or equal to one year post ACL reconstruction.

Methods:

A systematic review of the relevant literature was performed using PRISMA guidelines. A total of twelve studies were included for analysis.

Results:

Two independent blinded reviewers then analyzed and rated the final included articles (n=12) utilizing the Newcastle-Ottawa Scale (NOS). Percent overall agreement between raters for the NOS was 88% with a fixed-marginal kappa (κ) of 0.80. Of the 12 included articles, the FPTs were utilized as an outcome measure within the study design (41.7%) or studied as a measure of function (58.3%). Among those studies that used FPTs as a “measure of function” 71.4% studied a battery of FPTs, while 28.6% studied a single test. None of the studies utilized FPTs as a measure to determine readiness to return to sport.

Discussion:

FPTs are being utilized with patients, less than or equal to one year post ACL reconstruction, either as an assessment of functional performance or as an outcome measure. No studies identified a FPT or test battery that has construct or predictive validity for “return to sport” in athletic population one-year post-ACL reconstruction. The identification of the critical elements within the return to sport construct may allow lower extremity performance tests to be developed or test batteries assembled to incorporate the appropriate tests to examine all of these elements deemed critical. Additionally the current FPTs should undergo content and predictive validation to assist the sports physical therapist in determining the readiness of the athlete for return to sport.     

FUNCTIONAL PERFORMANCE TESTING OF THE HIP IN ATHLETES: A SYSTEMATIC REVIEW FOR RELIABILITY AND VALIDITY

Purpose/Background:

The purpose of this study was to systematically review the literature for functional performance tests with evidence of reliability and validity that could be used for a young, athletic population with hip dysfunction.

Methods:

A search of PubMed and SPORTDiscus databases were performed to identify movement, balance, hop/jump, or agility functional performance tests from the current peer-reviewed literature used to assess function of the hip in young, athletic subjects.

Results:

The single-leg stance, deep squat, single-leg squat, and star excursion balance tests (SEBT) demonstrated evidence of validity and normative data for score interpretation. The single-leg stance test and SEBT have evidence of validity with association to hip abductor function. The deep squat test demonstrated evidence as a functional performance test for evaluating femoroacetabular impingement. Hop/Jump tests and agility tests have no reported evidence of reliability or validity in a population of subjects with hip pathology.

Conclusions:

Use of functional performance tests in the assessment of hip dysfunction has not been well established in the current literature. Diminished squat depth and provocation of pain during the single-leg balance test have been associated with patients diagnosed with FAI and gluteal tendinopathy, respectively. The SEBT and single-leg squat tests provided evidence of convergent validity through an analysis of kinematics and muscle function in normal subjects. Reliability of functional performance tests have not been established on patients with hip dysfunction. Further study is needed to establish reliability and validity of functional performance tests that can be used in a young, athletic population with hip dysfunction.

Level of Evidence:

2b (Systematic Review of Literature)     

EFFECTIVENESS OF PHYSICAL THERAPIST ADMINISTERED SPINAL MANIPULATION FOR THE TREATMENT OF LOW BACK PAIN: A SYSTEMATIC REVIEW OF THE LITERATURE

Background Context:

Low back pain (LBP) is a prevalent disorder in society that has been associated with increased loss of work time and medical expenses. A common intervention for LBP is spinal manipulation, a technique that is not specific to one scope of practice or profession.

Purpose:

The purpose of this systematic review was to examine the effectiveness of physical therapy spinal manipulations for the treatment of patients with low back pain.

Methods:

A search of the current literature was conducted using PubMed, CINAHL, SPORTDiscus, Pro Quest Nursing and Allied Health Source, Scopus, and Cochrane Controlled Trials Register. Studies were included if each involved: 1) individuals with LBP; 2) spinal manipulations performed by physical therapists compared to any control group that did not receive manipulations; 3) measurable clinical outcomes or efficiency of treatment measures, and 4) randomized control trials. The quality of included articles was determined by two independent authors using the criteria developed and used by the Physiotherapy Evidence Database (PEDro).

Results:

Six randomized control trials met the inclusion criteria of this systematic review. The most commonly used outcomes in these studies were some variation of pain rating scales and disability indexes. Notable results included varying degrees of effect sizes favoring physical therapy spinal manipulations and minimal adverse events resulting from this intervention. Additionally, the manipulation group in one study reported statistically significantly less medication use, health care utilization, and lost work time.

Conclusion:

Based on the findings of this systematic review there is evidence to support the use of spinal manipulation by physical therapists in clinical practice. Physical therapy spinal manipulation appears to be a safe intervention that improves clinical outcomes for patients with low back pain.     

AN UPDATE FOR THE CONSERVATIVE MANAGEMENT OF PATELLOFEMORAL PAIN SYNDROME: A SYSTEMATIC REVIEW OF THE LITERATURE FROM 2000 TO 2010

Purpose/Background:

Patellofemoral pain syndrome (PFPS) is one of the most common and clinically challenging knee pathologies. Historically, clinicians have used a myriad of interventions, many of which have benefited some but not all patients. Suboptimal outcomes may reflect the need for an evidence-based approach for the treatment of PFPS. The authors believe that integrating clinical expertise with the most current scientific data will enhance clinical practice. The purpose of this systematic review is to provide an update on the evidence for the conservative treatment of PFPS.

Methods:

The PubMed, CINAHL, and SPORTDiscus databases were searched for studies published between January 1, 2000 and December 31, 2010. Studies used were any that utilized interventions lasting a minimum of 4 weeks for subjects with PFPS. Data were examined for subject sample, intervention duration, intervention type, and pain outcomes.

Results:

General quadriceps strengthening continues to reduce pain in patients with PFPS. Data are inconclusive regarding the use of patellar taping, patellar bracing, knee bracing, and foot orthosis. Although emerging data suggest the importance of hip strengthening exercise, ongoing investigations are needed to better understand its effect on PFPS.

Conclusions:

Current evidence supports the continued use of quadriceps exercise for the conservative management of PFPS. However, inconsistent or limited data regarding the other interventions precluded the authors'' ability to make conclusive recommendations about their use. Future investigations should focus on identifying cohorts of patients with PFPS who may benefit from the other treatment approaches included in this systematic review.     

INJURY RISK IS ALTERED BY PREVIOUS INJURY: A SYSTEMATIC REVIEW OF THE LITERATURE AND PRESENTATION OF CAUSATIVE NEUROMUSCULAR FACTORS

Background:

Active adults commonly present with lower extremity (LE) injuries from a variety of professional and amateur sports activities. Decreased LE function significantly alters daily life and subsequent injuries increase this impact. The purpose of this systematic review was to examine the association between previous injury and the risk of re‐injury, and to describe the changes in kinematics and motor programming that may contribute to this relationship.

Methods:

A preliminary search was conducted to determine the four most common LE injuries on PubMed, CINAHL and Web of Science. These injuries, in a healthy active adult population, were hamstring strain (HS), anterior cruciate ligament injury (ACL), achilles tendon pathology, and ankle sprain. After these injuries were established, the search for this systematic review found evidence relating these injuries to re‐injury. Articles related to degenerative changes were excluded. Twenty‐six articles were included in the systematic review detailing the risk of re‐injury from a previous injury and were graded for quality.

Results:

ACL injury was linked to a successive injury of the same ACL, and other injuries in the LE. HS was associated with subsequent ipsilateral HS and knee injuries. Previous achilles tendon rupture increased the risk of an analogous injury on the contralateral side. An ankle sprain was associated with a re‐injury of either the ipsilateral or the contralateral ankle. Post‐injury changes were present in strength, proprioception, and kinematics, which may have led to overall changes in motor control and function.

Conclusion:

This review provides insight into the changes occurring following common LE injuries, how these changes potentially affect risk for future injury, and address the needs of the active adult population in rehabilitation.

Clinical Relevance:

Current research on previous injury and re‐injury is of high quality, but scarce quantity. Deficits following an injury are known, but how these deficits correlate or lead to re‐injury requires further exploration.

Level of Evidence:

1     

Bronchial Asthma in the Nigerian Savanna Region: A CLINICAL AND LABORATORY STUDY OF 106 PATIENTS WITH A REVIEW OF THE LITERATURE ON ASTHMA IN THE TROPICS

One hundred and six asthma patients were studied in Zaria inthe Nigerian savanna region. This group resembled hospital attendersin general in containing a disproportionately large number ofimmigrants from southern Nigeria and students undergoing highereducation. Childhood asthma was rare. Asthma started after theage of 19 years in 69 per cent of patients. Twenty-seven percent gave a history of rhinitis but none had had eczema. Twenty-twoper cent gave a family history of asthma. Cutaneous hypersensitivity to house dust supported by a historyof attacks being precipitated by dust was found in 41 per centof patients. Asthma was worst in the rainy season in 45 percent of patients. Mites were found in mattress dust samples;the mean count was 243 mites per g dust; Dermatophagoides farinaeformed 86.6 per cent of the total mite population. The variability of airways obstruction averaged 50 per centof maximum values for forced expiratory volume in the firstsecond (FEV₁) and peak expiratory flow (PEF). The median severityof airways obstruction measured as FEV₁/VC per cent was fourstandard deviations below predicted normal. Eighty-seven per cent of patients were positive to prick skintests with one or more allergens. The commonest reactions wereto house dust (58 per cent), house dust mite (45 per cent) andDermatophagoides farinae (44 per cent). Fifty-one per cent ofa group of controls were also positive on skin testing but thepattern of responses was different from the asthmatic patients.This high proportion of reactors is explained by high allergenload. Serum IgE levels were lower in the asthmatics than in a groupof healthy controls who showed the very high levels characteristicof some African populations. We suggest that the controls wereprotected from atopic disease by developing high blocking levelsof non-specific IgE, perhaps in response to gut helminths. The clinical pattern of asthma in Zaria is compared with othercountries in the tropical and temperate zones. The particularproblems of treating asthma in developing tropical countriesare discussed.     

AN EXAMINATION OF THE GLUTEAL MUSCLE ACTIVITY ASSOCIATED WITH DYNAMIC HIP ABDUCTION AND HIP EXTERNAL ROTATION EXERCISE: A SYSTEMATIC REVIEW

Background

A wide variety of hip abduction and hip external rotation exercises are used for training, both in athletic performance and in rehabilitation programming. Though several different exercises exist, a comprehensive understanding of which exercises best target the gluteus maximus (Gmax) and gluteus medius (Gmed) and the magnitude of muscular activation associated with each exercise is yet to be established.

Purpose

The purpose of this systematic review was to quantify the electromyographic (EMG) activity of exercises that utilize the Gmax and Gmed muscles during hip abduction and hip external rotation.

Methods

Pubmed, Sports Discuss, Web of Science and Science Direct were searched using the Boolean phrases (gluteus medius OR gluteus maximus) AND (activity OR activation) AND (electromyography OR EMG) AND (hip abduction OR hip external rotation). A systematic approach was used to evaluate 575 articles. Articles that examined injury‐free participants of any age, gender or activity level were included. No restrictions were imposed on publication date or publication status. Articles were excluded when not available in English, where studies did not normalize EMG activity to maximum voluntary isometric contraction (MVIC), where no hip abduction or external rotation motion occurred or where the motion was performed with high acceleration.

Results

Twenty‐three studies met the inclusion criteria and were retained for analysis. The highest Gmax activity was elicited during the lateral step up, cross over step up and rotational single leg squat (ranging from 79 to 113 % MVIC). Gmed activity was highest during the side bridge with hip abduction, standing hip abduction with elastic resistance at the ankle and side lying hip abduction (ranging from 81 to 103 % MVIC).

Limitations

The methodological approaches varied between studies, notably in the different positions used for obtaining MVIC, which could have dramatically impacted normalized levels of gluteal activation, while variation also occurred in exercise technique and/or equipment.

Conclusions

The findings from this review provide an indication for the amount of muscle activity generated by basic strengthening and rehabilitation exercises, which may assist practitioners in making decisions for Gmax and Gmed strengthening and injury rehabilitation programs.