Joint Stability Characteristics of the Ankle Complex in Female Athletes With Histories of Lateral Ankle Sprain,Part II: Clinical Experience Using Arthrometric Measurement

Context:

This is part II of a 2-part series discussing stability characteristics of the ankle complex. In part I, we used a cadaver model to examine the effects of sectioning the lateral ankle ligaments on anterior and inversion motion and stiffness of the ankle complex. In part II, we wanted to build on and apply these findings to the clinical assessment of ankle-complex motion and stiffness in a group of athletes with a history of unilateral ankle sprain.

Objective:

To examine ankle-complex motion and stiffness in a group of athletes with reported history of lateral ankle sprain.

Design:

Cross-sectional study.

Setting:

University research laboratory.

Patients or Other Participants:

Twenty-five female college athletes (age = 19.4 ± 1.4 years, height = 170.2 ± 7.4 cm, mass = 67.3 ± 10.0 kg) with histories of unilateral ankle sprain.

Intervention(s):

All ankles underwent loading with an ankle arthrometer. Ankles were tested bilaterally.

Main Outcome Measure(s):

The dependent variables were anterior displacement, anterior end-range stiffness, inversion rotation, and inversion end-range stiffness.

Results:

Anterior displacement of the ankle complex did not differ between the uninjured and sprained ankles (P = .37), whereas ankle-complex rotation was greater for the sprained ankles (P = .03). The sprained ankles had less anterior and inversion end-range stiffness than the uninjured ankles (P < .01).

Conclusions:

Changes in ankle-complex laxity and end-range stiffness were detected in ankles with histories of sprain. These results indicate the presence of altered mechanical characteristics in the soft tissues of the sprained ankles.Key Words: ankle instability, joint laxity measurement, ankle sprains

Key Points

• Ankles with histories of lateral sprain showed more ankle-complex inversion rotation and less anterior and inversion stiffness than uninjured ankles.
• The mechanical property of stiffness might be important to understanding how lateral ankle sprain affects ligamentous elasticity and joint stability.
• These clinically important findings indicate that increased ankle-complex laxity is not the only identifiable mechanical tissue characteristic that changes after lateral ankle sprain.

Ankle sprain is one of the most common injuries encountered during sporting activity.¹ Lateral ankle sprain injury can result in changes to the ligaments and surrounding soft tissues that often lead to mechanical instability and functional insufficiencies.^2–7 Equally concerning is the recurrence rate after an initial sprain.⁸ A search of epidemiologic and cohort studies identified history of lateral ankle sprain as a consistent risk factor associated with ankle sprain in sport.^8–12 Our understanding of the connection between history of ankle sprain and mechanical measures of ankle stability is unclear because not all ankles develop mechanical instability after 1 or more ankle sprains.^7,13Increased ligament laxity can result from a tear or lengthening of the involved ligamentous structures supporting the joint or less-than-optimal healing of the injured tissues.² Individuals with histories of ankle sprain present with increased joint laxity and persistent symptoms, such as the feeling of or actual giving way of the ankle during jumping and cutting activities.^14–16 However, some authors have not reported findings of increased laxity in the sprained ankles despite the presence of functional insufficiencies, such as impaired proprioception, altered neuromuscular control, strength deficits, and diminished postural control.^6,17The passive stiffness characteristics of a joint are created in part by the viscoelastic properties of the soft tissues that surround and support the joint.¹⁸ Leardini et al¹⁹ reported that passive stiffness provided by the soft tissue structures is a vital component of joint stability. Thus, the mechanical property of stiffness may be important to understanding joint stability after injury. Only Wikstrom et al²⁰ have investigated passive ankle-joint stiffness in people who reported experiencing ankle sprains. They found no differences in anterior laxity or anterior stiffness of the ankle between individuals with or without reported functional ankle instability. In a later study, Wikstrom et al⁷ reported that patients who had histories of ankle sprain and presented with no signs or symptoms of chronic ankle instability (CAI) and patients with CAI had increased anterior ankle-joint stiffness relative to uninjured control participants. When jointly examined, these previous reports appear specious because laxity and stiffness are inversely related. We wanted to build on the work of Wikstrom et al^7,20 and also examine the effects of previous lateral ankle sprain on inversion ankle-complex motion and stiffness. Therefore, the purpose of our clinically based study was to determine ankle-complex motion and stiffness in a group of athletes with a reported history of lateral ankle sprain. We hypothesized that ankles with histories of lateral sprain would demonstrate altered motion and stiffness characteristics when compared with the uninjured ankles.     

Laboratory Diagnosis of Prosthetic Joint Infection, Part I

Prosthetic joint infection (PJI), although a rare complication of primary or revision arthroplasty, is reported more frequently as the number patients undergoing arthroplasty increases. Accurate diagnosis of PJI is essential for adequate management and outcome. Although multiple tests have been applied, in some cases, differentiation of PJI from aseptic loosening of the prosthesis remains a challenge. Here, we review the current diagnostic laboratory modalities used for the diagnosis PJI. In Part I of this two-part article, components of the preoperative evaluation of the patient and the histology of the intraoperative evaluation is discussed.     

Laboratory Measures of Postural Control During the Star Excursion Balance Test After Acute First-Time Lateral Ankle Sprain

Context

No researchers, to our knowledge, have investigated the immediate postinjury-movement strategies associated with acute first-time lateral ankle sprain (LAS) as quantified by center of pressure (COP) and kinematic analyses during performance of the Star Excursion Balance Test (SEBT).

Objective

To analyze the kinematic and COP patterns of a group with acute first-time LAS and a noninjured control group during performance of the SEBT.

Design

Case-control study.

Setting

University biomechanics laboratory.

Patients or Other Participants

A total of 81 participants with acute first-time LAS (53 men, 28 women; age = 23.22 ± 4.93 years, height = 1.73 ± 0.09 m, mass = 75.72 ± 13.86 kg) and 19 noninjured controls (15 men, 4 women; age = 22.53 ± 1.68 years, height = 1.74 ± 0.08 m, mass = 71.55 ± 11.31 kg).

Intervention

Participants performed the anterior (ANT), posterolateral (PL), and posteromedial (PM) reach directions of the SEBT.

Main Outcome Measure(s)

We assessed 3-dimensional kinematics of the lower extremity joints and associated fractal dimension (FD) of the COP path during performance of the SEBT.

Results

The LAS group had decreased normalized reach distances in the ANT, PL, and PM directions when compared with the control group on their injured (ANT: 58.16% ± 6.86% versus 64.86% ± 5.99%; PL: 85.64% ± 10.62% versus 101.14% ± 8.39%; PM: 94.89% ± 9.26% versus 107.29 ± 6.02%) and noninjured (ANT: 60.98% ± 6.74% versus 64.76% ± 5.02%; PL: 88.95% ± 11.45% versus 102.36% ± 8.53%; PM: 97.13% ± 8.76% versus 106.62% ± 5.78%) limbs (P < .01). This observation was associated with altered temporal sagittal-plane kinematic profiles throughout each reach attempt and at the point of maximum reach (P < .05). This result was associated with a reduced FD of the COP path for each reach direction on the injured limb only (P < .05).

Conclusions

Acute first-time LAS was associated with bilateral deficits in postural control, as evidenced by the bilateral reduction in angular displacement of the lower extremity joints and reduced reach distances and FD of the COP path on the injured limb during performance of the SEBT.Key Words: ankle joint, biomechanics, kinematics, kinetics, postural balance

Key Points

• Individuals with acute, first-time lateral ankle sprain injuries exhibited bilateral deficits in dynamic postural control as assessed using the reach distances achieved during the anterior, posterolateral, and posteromedial directions of the Star Excursion Balance Test.
• These deficits are underpinned by both local and global modifications in the movement patterns adopted at the point of maximum reach by the joints of the lower extremity.
• A trend toward reduced sagittal-plane range-of-motion displacement was also noted at the hip, knee, and ankle joints throughout each reach attempt in the injured group.
• These deficits were associated with an apparently reduced capacity to exploit the available base of support, as illustrated by a reduced fractal dimension of the stance-limb center-of-pressure path of the injured limb.
• Researchers need to determine if some deficits observed in the acute phase of lateral ankle sprain precede or predispose an athlete to the initial injury and to clarify whether these deficits are central to the onset of chronic injury.

In a recent meta-analysis, we¹ elucidated that ankle sprain is an injury risk for participants of all ages during a wide variety of activity types. Decreased physical activity,² the potential for the development of posttraumatic ankle arthritis,³ and medical costs⁴ are immediate concerns associated with the acute ankle-joint injury, which has substantial potential for recurrence.⁵Investigators^6,7 have hypothesized that the chronic sequelae associated with ankle-sprain injury result from the emergence of inappropriate postinjury-movement strategies. The success or failure of these strategies depends on a process of sensorimotor reorganization, whereby structurally different components of the neurobiological system, known as degeneracies, combine toward a common motor output. These degeneracies in available degrees of freedom at affected joints are exploited to satisfy the demands of morphologic and task constraints.⁸ An acute lateral ankle sprain (LAS) injury can be conceptualized as a morphologic constraint that challenges the human sensorimotor system to optimally organize altered peripheral sensorimotor inputs and the influence of higher brain centers.⁹Clinicians frequently use postural-control assessments to evaluate the movement deficits associated with injury. Dynamic postural-control tasks seek to mimic the demands of physical activity by dictating movement around the supporting base.¹⁰ The Star Excursion Balance Test (SEBT) is a dynamic postural-control task that has gained attention in clinical and research settings.¹⁰ Whereas the primary outcome variable during SEBT performance in the clinical setting is the magnitude of the achieved reach distance, the movement patterns associated with this distance have also been evaluated in the laboratory.^11–13 With regard to the SEBT, instrumented analysis enhances the assessment of reach-distance magnitude in isolation. In particular, 3-dimensional kinematic analyses, combined with measures of force-plate stabilometry, provide insight into the causative mechanisms underpinning the test outcome, thus allowing the movement insufficiencies linked with acute injury, such as LAS, to be identified.Analysis of center of pressure (COP) is a branch of stabilometry that has been combined with kinematic assessment in ankle-sprain research.¹⁴ A newly applied measure called fractal dimension (FD) characterizes the complexity of a given COP signal by describing its shape with a discrete value ranging from 1 (straight line) to 2 (line so convoluted that it fills the plane it occupies).^15,16 A larger FD of the COP path has been associated with greater activity of the sensorimotor system in fulfilling the demands of balance. However, FD scores do not indicate on a linear scale where more or less is better or worse; an FD that is too large may reflect an inability of the sensorimotor system to synergistically modulate sensory afferents in producing an appropriate efferent response,¹⁷ and an FD that is too small may reflect a deficit in using the base of support available^16,18 secondary to the demands of morphologic and task constraints.¹⁹Previous researchers^7,20 have revealed contrasting movement patterns during dynamic postural-control tasks in groups presenting with chronic injury and full recovery in the months after an ankle sprain. Investigations^21–23 of acute LAS cohorts have typically been restricted to the evaluation of COP measures during static postural-control tasks. To our knowledge, no one has assessed the immediate postinjury-movement strategies associated with LAS using combined COP and kinematic analyses during a dynamic postural-control task. Therefore, the purpose of our study was to examine the movement-pattern characteristics of participants with acute LAS and noninjured participants serving as a control group during the performance of the SEBT using instrumented 3-dimensional kinematic and COP analyses. We hypothesized that the group with acute LAS (1) would report reduced function secondary to injury, (2) would display bilateral impairment of dynamic balance as assessed using SEBT reach-distance scores compared with the control group, and (3) would exhibit altered kinematic and COP measures during performance of selected reach directions of the SEBT compared with the control group.     

The Effects of Sex,Joint Angle,and the Gastrocnemius Muscle on Passive Ankle Joint Complex Stiffness

OBJECTIVE: To assess the effects of sex, joint angle, and the gastrocnemius muscle on passive ankle joint complex stiffness (JCS). DESIGN AND SETTING: A repeated-measures design was employed using sex as a between-subjects factor and joint angle and inclusion of the gastrocnemius muscle as within-subject factors. All testing was conducted in a neuromuscular research laboratory. SUBJECTS: Twelve female and 12 male healthy, physically active subjects between the ages of 18 and 30 years volunteered for participation in this study. The dominant leg was used for testing. No subjects had a history of lower extremity musculoskeletal injury or circulatory or neurologic disorders. MEASUREMENTS: We determined passive ankle JCS by measuring resistance to passive dorsiflexion (5 degrees.s(-1)) from 23 degrees plantar flexion (PF) to 13 degrees dorsiflexion (DF). Angular position and torque data were collected from a dynamometer under 2 conditions designed to include or reduce the contribution of the gastrocnemius muscle. Separate fourth-order polynomial equations relating angular position and torque were constructed for each trial. Stiffness values (Nm.degree(-1)) were calculated at 10 degrees PF, neutral (NE), and 10 degrees DF using the slope of the line at each respective position. RESULTS: Significant condition-by-position and sex-by-position interactions and significant main effects for sex, position, and condition were revealed by a 3-way (sex-by-position, condition-by-position) analysis of variance. Post hoc analyses of the condition-by-position interaction revealed significantly higher stiffness values under the knee-straight condition compared with the knee-bent condition at both ankle NE and 10 degrees DF. Within each condition, stiffness values at each position were significantly higher as the ankle moved into DF. Post hoc analysis of the sex-by-position interaction revealed significantly higher stiffness values at 10 degrees DF in the male subjects. Post hoc analysis of the position main effect revealed that as the ankle moved into dorsiflexion, the stiffness at each position became significantly higher than at the previous position. CONCLUSIONS: The gastrocnemius contributes significantly to passive ankle JCS, thereby providing a scientific basis for clinicians incorporating stretching regimens into rehabilitation programs. Further research is warranted considering the cause and application of the sex-by-position interaction.     

Systematic Review of Postural Control and Lateral Ankle Instability,Part II: Is Balance Training Clinically Effective

Objective:

To answer the following clinical questions: (1) Can prophylactic balance and coordination training reduce the risk of sustaining a lateral ankle sprain? (2) Can balance and coordination training improve treatment outcomes associated with acute ankle sprains? (3) Can balance and coordination training improve treatment outcomes in patients with chronic ankle instability?

Data Sources:

PubMed and CINAHL entries from 1966 through October 2006 were searched using the terms ankle sprain, ankle instability, balance, chronic ankle instability, functional ankle instability, postural control, and postural sway.

Study Selection:

Only studies assessing the influence of balance training on the primary outcomes of risk of ankle sprain or instrumented postural control measures derived from testing on a stable force plate using the modified Romberg test were included. Studies had to provide results for calculation of relative risk reduction and numbers needed to treat for the injury prevention outcomes or effect sizes for the postural control measures.

Data Extraction:

We calculated the relative risk reduction and numbers needed to treat to assess the effect of balance training on the risk of incurring an ankle sprain. Effect sizes were estimated with the Cohen d for comparisons of postural control performance between trained and untrained groups.

Data Synthesis:

Prophylactic balance training substantially reduced the risk of sustaining ankle sprains, with a greater effect seen in those with a history of a previous sprain. Completing at least 6 weeks of balance training after an acute ankle sprain substantially reduced the risk of recurrent ankle sprains; however, consistent improvements in instrumented measures of postural control were not associated with training. Evidence is lacking to assess the reduction in the risk of recurrent sprains and inconclusive to demonstrate improved instrumented postural control measures in those with chronic ankle instability who complete balance training.

Conclusions:

Balance training can be used prophylactically or after an acute ankle sprain in an effort to reduce future ankle sprains, but current evidence is insufficient to assess this effect in patients with chronic ankle instability.     

Ultrasound and Joint Mobilizations for Achieving Normal Wrist Range of Motion After Injury or Surgery: A Case Series

Context:

Regaining full, active range of motion (AROM) after trauma to the wrist is difficult.

Objective:

To report the cases of 6 patients who lacked full range of motion (ROM) in the wrist due to trauma. The treatment regimen was thermal 3-MHz ultrasound and joint mobilizations.

Design:

Case series.

Setting:

University therapeutic modalities laboratory.

Patients or Other Participants:

Six patients (2 women, 4 men) from the university population lacked a mean AROM of 21.7° of flexion and 26.8° of extension approximately 2.1 years after trauma or surgery.

Main Outcome Measure(s):

I assessed changes in flexion and extension AROM before and after each treatment. Treatment consisted of 6 minutes of 3-MHz continuous ultrasound at an average intensity of 1.4 W/cm² on the dorsal and volar aspects of the wrist, immediately followed by approximately 10 minutes of joint mobilizations. After posttreatment ROM was recorded, ice was applied to the area for about 20 minutes. Once the patient achieved full AROM or did not improve on 2 consecutive visits, he or she was discharged from the study.

Results:

By the sixth treatment, 5 participants achieved normal flexion AROM, and 3 exceeded the norm. All 6 achieved normal extension AROM, and 4 exceeded the norm. All returned to normal activities and normal use of their hands. One month later, they had, on average, maintained 93% of their final measurements.

Conclusions:

A combination of thermal ultrasound and joint mobilizations was effective in restoring AROM to wrists lacking ROM after injury or surgery.     

The Sensorimotor System, Part II: The Role of Proprioception in Motor Control and Functional Joint Stability

Objective: To discuss the role of proprioception in motor control and in activation of the dynamic restraints for functional joint stability.Data Sources: Information was drawn from an extensive MEDLINE search of the scientific literature conducted in the areas of proprioception, motor control, neuromuscular control, and mechanisms of functional joint stability for the years 1970-1999.Data Synthesis: Proprioception is conveyed to all levels of the central nervous system. It serves fundamental roles for optimal motor control and sensorimotor control over the dynamic restraints.Conclusions/Applications: Although controversy remains over the precise contributions of specific mechanoreceptors, proprioception as a whole is an essential component to controlling activation of the dynamic restraints and motor control. Enhanced muscle stiffness, of which muscle spindles are a crucial element, is argued to be an important characteristic for dynamic joint stability. Articular mechanoreceptors are attributed instrumental influence over gamma motor neuron activation, and therefore, serve to indirectly influence muscle stiffness. In addition, articular mechanoreceptors appear to influence higher motor center control over the dynamic restraints. Further research conducted in these areas will continue to assist in providing a scientific basis to the selection and development of clinical procedures.     

Review: IgA anaphylactic transfusion reactions. Part I. Laboratory diagnosis, incidence, and supply of IgA-deficient products

Despite yielding a definitive diagnosis in fewer than 20 percent of anaphylactic transfusion reactions, investigation for IgA deficiency and the presence of presumably pathogenic IgG anti-IgA is useful in patient management. Individuals with demonstrated anti-IgA are thereafter committed to receiving IgA-depleted cellular products or IgA-deficient plasma and derivatives to prevent recurrent severe reactions. Unfortunately, in populations of IgA-deficient individuals screened for anti-IgA, the predictive value of the test in the absence of a prior reaction is quite low. Anti-IgA testing is complex and limited to a few reference laboratories, many of which still employ a labor-intensive hemagglutination assay developed in the late 1960s. Timely decisions regarding further transfusion management of patients experiencing anaphylaxis often rely upon more rapidly obtained assays of the IgA concentration as an indicator of the likelihood of subsequent demonstration of anti-IgA. The scarcity of IgA-deficient banked plasma products and dedicated plateletpheresis donors has led to the development of American Rare Donor Program policies designed to appropriately allocate these precious resources. The test methods used to establish the diagnosis of IgA deficiency and identify the approximately one third of these individuals with anti-IgA are discussed, along with the incidence of abnormal tests in various populations. Also presented are testing recommendations for the identification of an IgA-mediated mechanism for transfusion-associated anaphylaxis and qualification of patients to receive rare IgA-deficient plasma-containing products.     

Feedback in Clinical Education,Part I: Characteristics of Feedback Provided by Approved Clinical Instructors

Context

Providing students with feedback is an important component of athletic training clinical education; however, little information is known about the feedback that Approved Clinical Instructors (ACIs; now known as preceptors) currently provide to athletic training students (ATSs).

Objective

To characterize the feedback provided by ACIs to ATSs during clinical education experiences.

Design

Qualitative study.

Setting

One National Collegiate Athletic Association Division I athletic training facility and 1 outpatient rehabilitation clinic that were clinical sites for 1 entry-level master''s degree program accredited by the Commission on Accreditation of Athletic Training Education.

Patients or Other Participants

A total of 4 ACIs with various experience levels and 4 second-year ATSs.

Data Collection and Analysis

Extensive field observations were audio recorded, transcribed, and integrated with field notes for analysis. The constant comparative approach of open, axial, and selective coding was used to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study.

Results

The ACIs gave 88 feedback statements in 45 hours and 10 minutes of observation. Characteristics of feedback categories included purpose, timing, specificity, content, form, and privacy.

Conclusions

Feedback that ACIs provided included several components that made each feedback exchange unique. The ACIs in our study provided feedback that is supported by the literature, suggesting that ACIs are using current recommendations for providing feedback. Feedback needs to be investigated across multiple athletic training education programs to gain more understanding of certain areas of feedback, including frequency, privacy, and form.Key Words: assessment, evaluation, pedagogy, preceptors

Key Points

• Feedback had several different components that made each feedback exchange unique.
• The feedback that the Approved Clinical Instructors (ACIs) provided mostly was aligned with recommendations in the literature, suggesting our ACIs provided effective feedback to athletic training students and current recommendations are applicable to athletic training clinical education.
• Researchers should continue to assess the feedback that is occurring in different athletic training education programs to gain more understanding of the current use of feedback across several programs so they can guide ACI training and evaluation, including the development of recommendations for the appropriate frequency of feedback.

Feedback is any information provided to a student that helps correct, reinforce, or suggest change in his or her performance.^1,2 It is a type of evaluation that is less formal and judgmental than structured, summative evaluation and assessment² and is an effective educational technique.^3,4 Providing feedback to students also has been described as one of the most important characteristics of clinical instructors in athletic training,^5,6 medicine,^7,8 nursing,⁹ and physical therapy.¹⁰ In addition, feedback has been shown to improve clinical performance in medical^11,12 and nursing students.^13,14Most research on feedback has been focused on the recommended characteristics of feedback, such as its specificity, timing, tone, and relation to educational and career goals.^3,4,15 Much of the existing research is based on student and instructor perceptions of whether these recommendations are followed rather than actual observed feedback.^12,16 Feedback research in athletic training is much less extensive than other areas of clinical education. Most research on feedback in athletic training education has been focused on general effective clinical instructor behaviors.^5,17,18 These investigators have identified feedback as an important behavior of Approved Clinical Instructors (ACIs),⁵ and along with evaluation, it is considered a standard for selecting, training, and evaluating ACIs.^17,18 Several authors^1,19,20 have provided suggestions for giving effective feedback to athletic training students (ATSs) in clinical education. The supervision, questioning, feedback (SQF) model of clinical teaching provides guidelines for giving feedback to ATSs at different developmental levels.¹ Stemmans²¹ compared the quantity of feedback provided by clinical instructors with different amounts of experience. The researcher found that novice clinical instructors provided less feedback to ATSs than more experienced clinical instructors did. Berry et al²² reported that students in outpatient rehabilitation clinics spent more time engaged in active learning than did students in intercollegiate and high school settings. Because learning experiences differ among clinical settings, the feedback exchange also may differ among settings.Providing feedback is considered to be one of the most important roles of ACIs during clinical education experiences.^5,6 However, feedback has been minimally explored in practitioner-based articles and research studies specific to athletic training. Little is known about the feedback ACIs provide to ATSs. Similarly, to our knowledge, no one has examined how feedback is used in different clinical education settings, such as rehabilitation clinics and collegiate athletic training facilities. Therefore, the purpose of our study was to characterize the feedback provided by ACIs to ATSs during clinical education sessions in 1 outpatient rehabilitation clinic and 1 collegiate athletic training facility.     

Pulsed Shortwave Diathermy and Joint Mobilizations for Achieving Normal Elbow Range of Motion After Injury or Surgery With Implanted Metal: A Case Series

Context:

Regaining full, active range of motion (ROM) after trauma to the elbow is difficult.

Objective:

To report the cases of 6 patients who lacked full ROM in the elbow because of trauma. The treatment regimen was thermal pulsed shortwave diathermy and joint mobilizations.

Design:

Case series.

Setting:

University therapeutic modalities laboratory.

Patients or Other Participants:

Six patients (5 women [83%], 1 man [17%]) lacked a mean active ROM of 24.5° of extension approximately 4.8 years after trauma or surgery.

Intervention(s):

Treatment consisted of 20 minutes of pulsed shortwave diathermy at 800 pulses per second for 400 microseconds (40–48 W average power, 150 W peak power) applied to the cubital fossa, immediately followed by 7 to 8 minutes of joint mobilizations. After posttreatment ROM was recorded, ice was applied to the area for about 30 minutes.

Main Outcomes Measure(s):

Changes in extension active ROM were assessed before and after each treatment. Once the patient achieved full, active ROM or failed to improve on 2 consecutive visits, he or she was discharged from the study.

Results:

By the fifth treatment, 4 participants (67%) achieved normal extension active ROM, and 2 of the 4 (50%) exceeded the norm. Five participants (83%) returned to normal activities and full use of their elbows. One month later, the 5 participants had maintained, on average, (mean ± SD) 92% ± 6% of their final measurements.

Conclusions:

A combination of thermal pulsed shortwave diathermy and joint mobilizations was effective in restoring active ROM of elbow extension in 5 of the 6 patients (83%) who lacked full ROM after injury or surgery.Key Words: deep heat, therapeutic modalities, rehabilitation

Key Points

• Pulsed shortwave diathermy can increase the viscoelastic properties of collagen.
• Combined pulsed shortwave diathermy and joint mobilizations increased active elbow range of motion in 5 of 6 patients nearly 5 years after injury or surgery.

Individuals who have reduced active range of motion (AROM) in 1 or more limbs for extended periods have their lives altered. A person who can only extend the elbow halfway will find it difficult to throw objects or to reach a high shelf to retrieve a book. The elbow should extend to a full AROM (0°) as measured by a goniometer.¹Many^1–6 are of the opinion that using heat in concert with joint mobilizations can increase accessory and physiologic movements. In 2010, I⁷ reported on the treatment protocol for 6 patients who lacked full AROM in wrist flexion and extension due to injury. The treatment regimen was thermal ultrasound followed by joint mobilization. All 6 patients had at least 90% of their wrist-flexion and -extension range of motion (ROM) restored. Another heating modality, pulsed shortwave diathermy (PSWD), uses high-frequency electromagnetic waves to heat tissues up to 5 cm deep. Heat is produced by the resistance of tissue to the passage of energy.⁸ Although it heats to the same depth as 1-MHz ultrasound, PSWD heats a much larger area than ultrasound does,⁹ making it ideal to heat larger joints, such as the elbow, shoulder, hip, knee, and ankle.^1,3,5 With today''s modern PSWD devices, tissues at the elbow can be heated up to 4°C, or a peak temperature of more than 40°C,⁴ which is ideal for increasing the viscoelastic properties of collagen.¹⁰In this case series, a unique treatment protocol is presented, which combines PSWD and joint mobilizations. I used this protocol in 6 patients who had sustained severe elbow injuries.     

Optimizing Technology Development and Adoption in Medical Imaging Using the Principles of Innovation Diffusion,Part I: Theoretical,Historical, and Contemporary Considerations

The pioneering work performed in the social sciences on diffusion of innovation can be applied to medical imaging and shed valuable insights as to how innovation is analyzed and adopted within the population of end-users. Successful innovation must take into account unique stakeholder differences, changes in communication and social interactions, and shifting priorities in market economics. The dramatic changes currently underway in current medical imaging practice provides unique innovation opportunities to those individuals and companies which can utilize this knowledge and effect change in objective and reproducible means. Successful innovation should rely upon data-driven objective analysis, which can scientifically validate the inherent strengths and weaknesses of the innovation, when compared with the idea or technology it supercedes.     

Clinical, biologic, and therapeutic aspects of malignancies associated with the acquired immunodeficiency syndrome: Part I and Part II

The incidence of malignant disease in AIDS patients is around 40%. Ninety percent of the tumors are Kaposi's sarcoma and 10% are malignant lymphomas, predominantly of B cell origin. The natural history of the AIDS-associated Kaposi's sarcoma is variable. It may remain entirely asymptomatic without treatment for many months or it may be rapidly progressive and produce life-threatening pulmonary, cardiac, or gastrointestinal symptoms requiring acute therapeutic intervention. The malignant lymphomas occurring in AIDS patients are usually very aggressive in their natural history. The treatment of choice for symptomatic Kaposi's sarcoma and malignant lymphoma is chemotherapy. In general, such treatment can alleviate symptoms and improve the quality of life in AIDS patients; however, the underlying immune defect is not improved by such treatment and the patients remain susceptible to life-threatening opportunistic infections. The ultimate control of the malignancies associated with AIDS depends upon the development of therapies capable of reversing the underlying immune defect.     

急性颅脑损伤患者血浆NT和血清hs-CRP、APN检测的临床意义

目的：探讨了急性颅脑损伤患者治疗前后血浆神经降压素（NT）和血清hs-CRP、脂联素（APN）水平的变化及临床意义。方法：应用放射免疫分析、免疫比浊法和酶联法对36例急性颅脑损伤患者进行治疗前后血浆NT和血清hs-CRP、APN检测,并与35名正常健康人作比较。结果：急性颅脑损伤患者治疗前血浆NT和血清hs—CRP水平非常显著地高于正常人组（P〈0．01）,而血清APN水平又非常显著地低于正常人组（P〈0．01）。经综合治疗2周后则与正常人组比较无显著性差异（P〉0．05）,血清APN水平与NT、hs．CRP水平呈显著负相关（r=-0．6108、-0．5984,P〈0．01）结论：检测急性颅脑损伤患者血浆NT和血清hs—CRP、APN水平的变化对了解病情、观察疗效和预后判定均有一定的临床价值。