THE RELIABILITY AND DIAGNOSTIC ACCURACY OF ASSESSING THE TRANSLATION ENDPOINT DURING THE LACHMAN TEST

Background

Interpretation of Lachman testing when evaluating the status of the anterior cruciate ligament (ACL) typically includes a numerical expression classifying the amount of translation (Grade I, II, III) in addition to a categorical modifier (Grade A [firm] or B [absent]) to describe the quality of the passive anterior tibial translation''s endpoint. Most clinicians rely heavily on this tactile sensation and place value in this judgment in order to render their diagnostic decision; however, the reliability and accuracy of this endpoint assessment has not been well established in the literature.

Purpose

The purpose of this study was to determine the intertester reliability of endpoint classification during the passive anterior tibial translation of a standard Lachman test and evaluate the classification''s ability to accurately predict the presence or absence of an ACL tear.

Study design

Prospective, blinded, diagnostic reliability and accuracy study.

Methods

Forty‐five consecutive patients with a complaint of knee pain were independently evaluated for the endpoint classification during a Lachman test by two physical therapists before any other diagnostic assessment. The 21 men and 24 women ranged in age from 20 to 64 years (mean +/‐ SD age, 40.7 +/‐ 14) and in acuity of knee injury from 30 to 365 days (mean +/‐ SD, 238 +/‐157).

Results

17 of the 45 patients had a torn ACL. The agreement between examiners on A versus B endpoint classification was 91% with a kappa coefficient of 0.72. In contrast, classification agreement based on the translational amount had an agreement of 65% with a weighted kappa coefficient of 0.52. The sensitivity of the endpoint grade alone was 0.81 with perfect specificity resulting in a positive likelihood ratio of 6.2 and a negative likelihood ratio of 0.19. The overall accuracy of the Lachman test using the endpoint assessment grade alone was 93% with a number needed to diagnose of 1.2.

Conclusions

Nominal endpoint classification (A or B) from a Lachman test is a reliable and accurate reflection of the status of the ACL. The true dichotomous nature of the test''s interpretation (positive vs. negative) is well‐served by the quality of the endpoint during passive anterior tibial translation.

Level of Evidence

2     

CLINICAL RELIABILITY AND DIAGNOSTIC ACCURACY OF VISUAL SCAPULOHUMERAL MOVEMENT EVALUATION IN DETECTING PATIENTS WITH SHOULDER IMPAIRMENT

Background

Clinical investigation of shoulder injuries commonly utilizes visual evaluation of scapular movement to determine if abnormal or asymmetrical movements are related to the injury. To date, the intrarater reliability and diagnostic accuracy of visual evaluation of scapular movement among physical therapists are not known.

Purpose

The aims of this study were to determine the clinical reliability and diagnostic accuracy of physical therapists visual evaluation of scapulohumeral movements when used to diagnose shoulder impairment.

Study Design

University based laboratory and an internet based survey.

Methods

Thirty‐three physical therapists and 12 patient participants participated in this study. Reliability was measured as percent agreement and using the free marginal kappa statistic (κ) and Cronbach''s alpha (α) for interrater and intrarater reliability respectively. Diagnostic accuracy variables such as sensitivity, specificity, likelihood ratios were calculated from contingency table analysis.

Results

Visual evaluation yielded the following (95% CI): diagnostic accuracy 49.5%, specificity 60% (56 – 64), and sensitivity 35% (29 – 41), positive and negative likelihood ratios were 0.87 (0.66 – 1.14) and 1.09 (0.92 – 1.27) respectively. Percent agreements of evaluation findings between sessions for static and dynamic symmetry were 69% and 68%, respectively. The alpha statistics for static and dynamic symmetry were both 0.51. Percentage agreement in determining the injured shoulder was 59%, with an alpha statistic of 0.35.

Conclusion

Visual evaluation of scapular movements, without additional clinical information, demonstrated a poor to fair reliability and poor to fair diagnostic accuracy.

Clinical Relevance

The clinical utility of the use of isolated visual scapular evaluation is cautioned. More reliable and valid objective measures are needed for diagnosing shoulder impairment.

Level of Evidence

2b, Exploratory cohort study     

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     

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     

Differential diagnosis and management of a patient with peripheral vestibular and central nervous system disorders: a case study

Background

Clinical examination and management of patients with meningiomas is primarily dependent upon appropriate diagnosis of tumor type and surgical intervention. Physical therapists should be able to identify patients presenting with signs and symptoms suggestive of potential central nervous system (CNS) disorders and refer the patient appropriately.

Patient characteristics

In this case report, a 52-year-old female was referred to physical therapy after 18 months of unresolved dizziness.

Examination

Oculomotor examination revealed evidence of peripheral vestibular and potential CNS disorders. The physical therapist referred the patient to a physician who ordered magnetic resonance imaging (MRI).

Intervention

The patient received five physical therapy sessions while waiting for the MRI which revealed a meningioma. The meningioma was surgically removed and the patient was subsequently relieved of all symptoms.

Outcomes

Despite the presence of the meningioma, the patient reported improved stability during work-related activities and decreased dizziness as a result of physical therapy intervention pre-operatively.

Discussion

This case report emphasizes the importance of a physical therapists ability to perform and interpret an oculomotor examination in a patient presenting with signs consistent with peripheral vestibular and CNS disorders. It also demonstrates the role of physical therapy in collaboration with physicians in order to provide appropriate patient care management.     

THE EFFECTS OF ANTICIPATION ON THE MECHANICS OF THE KNEE DURING SINGLE‐LEG CUTTING TASKS: A SYSTEMATIC REVIEW

Background

ACL injuries are common in sports, which has resulted in the development of risk screening and injury prevention programs to target modifiable neuromuscular risk factors. Previous studies which have analyzed single‐leg cutting tasks have reported that the anticipation status of the task (pre‐planned vs. unanticipated) has a significant effect on the mechanics of the knee.

Hypothesis/Purpose

The purpose of this systematic review is to assess the effect of anticipation on the mechanics of the knee in the sagittal, frontal, and transverse planes during tasks which athletes frequently perform during competition.

Study Design

Systematic Review

Methods

The following databases were searched using relevant key words and search limits: Pub Med, SPORTDiscus, CINAHL, and Web of Science. A modified version of the Downs and Black checklist was used to assess the methodological quality of the articles by two independent reviewers.

Results

284 articles were identified during the initial database search. After a screening process, 34 articles underwent further review. Of these articles, 13 met the criteria for inclusion in this systematic review.

Conclusions

It appears that tasks which do not allow a subject to pre‐plan their movement strategy promote knee mechanics which may increase an athlete''s risk of injury.

Clinical Relevance

Clinicians involved in the development and implementation of ACL injury risk screening and prevention programs may want to consider incorporating tasks which do not allow time for pre‐planning. These unanticipated tasks may more closely mimic the demands of the sports environment and may promote mechanics which increase the risk of injury.

Level of Evidence

Level 1b     

RELIABILITY OF VIDEO‐BASED QUANTIFICATION OF THE KNEE‐ AND HIP ANGLE AT FOOT STRIKE DURING RUNNING

Introduction:

In clinical practice, joint kinematics during running are primarily quantified by two‐dimensional (2D) video recordings and motion‐analysis software. The applicability of this approach depends on the clinicians’ ability to quantify kinematics in a reliable manner. The reliability of quantifying knee‐ and hip angles at foot strike is uninvestigated.

Objective:

To investigate the intra‐ and inter‐rater reliability within and between days of clinicians’ ability to quantify the knee‐ and hip angles at foot strike during running.

Methods:

Eighteen recreational runners were recorded twice using a clinical 2D video setup during treadmill running. Two blinded raters quantified joint angles on each video twice with freeware motion analysis software (Kinovea 0.8.15)

Results:

The range from the lower prediction limit to the upper prediction limit of the 95% prediction interval varied three to eight degrees (within day) and nine to 14 degrees (between day) for the knee angles. Similarly, the hip angles varied three to seven degrees (within day) and nine to 11 degrees (between day).

Conclusion:

The intra‐ and inter rater reliability of within and between day quantifications of the knee‐ and hip angle based on a clinical 2D video setup is sufficient to encourage clinicians to keep using 2D motion analysis techniques in clinical practice to quantify the knee‐ and hip angles in healthy runners. However, the interpretation should include critical evaluation of the physical set‐up of the 2D motion analysis system prior to the recordings and conclusions should take measurement variations (3‐8 degrees and 9‐14 degrees for within and between day, respectively) into account.

Level of evidence:

3     

THE EFFECTS OF CONVENTIONAL PHYSICAL THERAPY AND ECCENTRIC STRENGTHENING FOR INSERTIONAL ACHILLES TENDINOPATHY

Study Design:

Single‐blind, randomized, clinical trial.

Background:

The effect of eccentric training for mid‐portion Achilles tendinopathy is well documented; however, its effect on insertional Achilles tendinopathy is inconclusive. The primary purpose of this study was to investigate the effect of eccentric training on pain and function for individuals with insertional Achilles tendinopathy.

Methods:

All patients received a 12‐week conventional strengthening protocol. Patients who were randomly assigned to the experimental group received additional eccentric exercises. Patients completed the Short Form‐36 Health and Bodily Pain Surveys, the Foot and Ankle Outcomes Questionnaire, and the Visual Analog Scale at initial evaluation, after 6 weeks of therapy, and at 12 weeks after therapy.

Results:

Thirty‐six patients (20 control and 16 experimental; average age 54 years; 72% women) completed the study. Both groups experienced statistically significant decreases in pain and improvements in function. No statistically significant differences were noted between the groups for any of the outcome measures.

Conclusion:

Conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches, ice massage on the Achilles tendon, and use of heel lifts and night splints with or without eccentric training is effective for treating insertional Achilles tendinopathy.

Level of Evidence:

Level 2     

AN ELASTIC EXERCISE BAND MOUNTED WITH A BANDCIZER? CAN DIFFERENTIATE BETWEEN COMMONLY PRESCRIBED HOME EXERCISES FOR THE SHOULDER

Background

Home‐exercise is commonly prescribed for rehabilitation of the shoulder following injury. There is a lack of technology available to monitor if the patient performs the exercises as prescribed.

Purpose

The purpose of this study was to investigate the validity of using three dimensional (3D) gyroscope data recorded with the Bandcizer™ sensor to differentiate between three elastic band exercises performed in the shoulder joint: abduction, flexion, and external rotation.

Design

Concurrent validity study.

Methods

This study was performed over two phases. In the first phase, 20 subjects performed three sets of 10 of shoulder abduction, external rotation and flexion exercises with a Thera‐Band mounted with a Bandcizer, while supervised by a physical therapist. The Bandcizer has an inbuilt three‐dimensional gyroscope, capable of measuring angular rotation. Gyroscope data were analyzed in Matlab, and a one‐way ANOVA was used to test for significant differences between each of the three exercises. An algorithm was then created in Matlab based on the exercise‐data from the gyroscope, to enable differentiation between the three shoulder exercises. Twenty new subjects were then recruited to cross‐validate the algorithm and investigate if the algorithm could differentiate between the three different shoulder exercises.

Results

A blinded assessor using the Matlab algorithm could correctly identify 56 out of 60 exercise sets. The kappa agreement for the three exercises ranged between 0.86‐0.91.

Conclusion

The ability to differentiate between the home exercises performed by patients after shoulder injury has great implications for future clinical practice and research. When home exercises are the treatments‐of‐choice, clinicians will be able to quantify if the patient performed the exercise as intended. Further research should be aimed at investigating the feasibility of using the Bandcizer™ in a home‐based environment.

Word count

2429

Level of Evidence

2     

REHABILITATION OF A SURGICALLY REPAIRED RUPTURE OF THE DISTAL BICEPS TENDON IN AN ACTIVE MIDDLE AGED MALE: A CASE REPORT

Background:

Complete rupture of the distal tendon of the biceps brachii is relatively rare and there is little information to guide therapists in rehabilitation after this injury. The purposes of this case report are to review the rehabilitation concepts used for treating such an injury, and discuss how to modify exercises during rehabilitation based on patient progression while adhering to physician recommended guidelines and standard treatment protocols.

Case Presentation:

The patient was an active 38‐year old male experienced in weight‐training. He presented with a surgically repaired right distal biceps tendon following an accident on a trampoline adapted with a bungee suspension harness. The intervention focused on restoring range of motion and strengthening of the supporting muscles of the upper extremity without placing undue stress on the biceps brachii.

Outcomes:

The patient was able to progress from a moderate restriction in ROM to full AROM two weeks ahead of the physician''s post‐operative orders and initiate a re‐strengthening protocol by the eighth week of rehabilitation. At the eighth post‐operative week the patient reported no deficits in functional abilities throughout his normal daily activities with his affected upper extremity.

Discussion:

The results of this case report strengthen current knowledge regarding physical therapy treatment for a distal biceps tendon repair while at the same time providing new insights for future protocol considerations in active individuals. Most current protocols do not advocate aggressive stretching, AROM, or strengthening of a surgically repaired biceps tendon early in the rehabilitation process due to the fear of a re‐rupture. In the opinion of the authors, if full AROM can be achieved before the 6^th week of rehabilitation, initiating a slow transition into light strengthening of the biceps brachii may be possible.

Level of evidence:

4‐Single Case report     

CONSIDERATIONS FOR LATE STAGE ACL REHABILITATION AND RETURN TO SPORT TO LIMIT RE‐INJURY RISK AND MAXIMIZE ATHLETIC PERFORMANCE

Purpose/Background:

Despite recent advances in anterior cruciate ligament reconstruction (ACL) surgical techniques, an improved understanding of the ACL’s biomechanical role, and expanding research on optimal rehabilitation practices in ACL‐reconstructed (ACLR) patients, the re‐tear rate remains alarmingly high and athletic performance deficits persist after completion of the rehabilitation course in a large percentage of patients. Significant deficits may persist in strength, muscular activation, power, postural stability, lower extremity mechanics, and psychological preparedness. Many patients may continue to demonstrate altered movement mechanics associated with increased injury risk. The purpose of this clinical commentary and literature review is to provide a summary of current evidence to assist the rehabilitation professional in recognizing, assessing, and addressing factors which may have been previously underappreciated or unrecognized as having significant influence on ACLR rehabilitation outcomes.

Methods:

A literature review was completed using PubMed, Medline, and Cochrane Database with results limited to peer‐reviewed articles published in English. 136 articles were reviewed and included in this commentary.

Conclusions:

Barriers to successful return to previous level of activity following ACLR are multifactorial.Recent research suggests that changes to the neuromuscular system, movement mechanics, psychological preparedness, and motor learning deficits may be important considerations during late stage rehabilitation.

Level of evidence:

Level 5‐ Clinical Commentary     

EFFECTIVENESS OF THE EMERGENCY RESPONSE COURSE IN IMPROVING STUDENT PHYSICAL THERAPISTS' AND LICENSED PHYSICAL THERAPISTS' DECISION‐MAKING RELATED TO ACUTE SPORTS INJURIES AND MEDICAL CONDITIONS

Purpose:

To analyze the effectiveness of the American Red Cross Emergency Response Course (ARC ERC) in improving decision‐making skills of physical therapists (PTs) and third semester clinical doctorate student physical therapists (SPTs) when assessing acute sports injuries and medical conditions.

Methods:

An existing questionnaire was modified, with permission from the original authors of the instrument. The questionnaire was administered to PTs and SPTs before the start of and immediately after the completion of 5 different ARC ERCs. The overall percentages of “Appropriate” responses for the 17 case scenarios were calculated for each participant for the pre‐and post‐tests. Participants also rated their perceived level of preparedness for managing various conditions using a 5‐point Likert Scale (ranging from Prepared to Unprepared). The overall percentage of “Prepared/Somewhat Prepared” responses for the 16 medical conditions was calculated for each participant for the pre‐and post‐tests. In addition, mean Likert scale scores were calculated for level of perceived preparedness for each of the 16 medical conditions. Paired t‐tests, calculated with SPSS 20.0, were used to analyze the data.

Results:

37 of 37 (100.0%) of eligible PTs and 45 of 48 (93.8%) of eligible SPTs completed the pre‐ and post‐test questionnaires. The percentage of “Appropriate” responses for all 17 cases in the aggregate (PTs: 76.8% pre‐test, 89.0% post‐test; SPTs: 68.5%, 84.3%), as well as the percentage of “Prepared/Somewhat Prepared” responses for all conditions in the aggregate (PTs: 67.5%, 96.5%; SPTs: 37.1%, 90.6%) were significantly different from pre‐test to post‐test (P = .000). There was also a significant difference (P < .05) in the mean overall preparedness Likert scale scores from pre‐test to post‐test for each medical condition for the SPT''s, and 15 of the 16 medical conditions (muscle strains: P = .119) for the PTs.

Conclusions:

The ARC ERC appears to be effective in improving both PTs'' and SPTs'' decision‐making skills related to acute sports injuries and medical conditions, as both “Appropriate” responses and perceived level of preparedness improved.

Level of Evidence:

Level 3