Who's Afraid of Electrical Stimulation? Let's Revisit the Application of NMES at the Knee.

BACKGROUND: Restoring quadriceps strength is essential for successful rehabilitation of knee injuries, but many athletes return to their previous activity with persisting muscle weakness. Strong evidence supports using neuromuscular electrical stimulation (NMES) to improve quadriceps strength; however, there is a lack of widespread clinical implementation. We believe there is a critical need to provide clinical approaches that promote using NMES to improve patients' quadriceps strength and ensuring clinicians provide high-value rehabilitation care. CLINICAL QUESTION: What is best practice when using NMES to facilitate strength after injury, what are barriers to its use, and how can they be addressed? KEY RESULTS: We discuss the low clinical implementation of NMES, perceived barriers to using NMES, and provide recommendations for setup and dosage parameters for effective use of NMES. CLINICAL APPLICATION: We aim for this commentary, with accompanying videos, to serve as a resource for clinicians who are using commercially available NMES units in clinical practice. J Orthop Sports Phys Ther 2024;54(2):1-6. Epub 31 October 2023. doi:10.2519/jospt.2023.12028.

ACL Reconstruction Rehabilitation: Clinical Data, Biologic Healing, and Criterion-Based Milestones to Inform a Return-to-Sport Guideline.

CONTEXT: Anterior cruciate ligament (ACL) reconstruction (ACLR) and postoperative rehabilitation continues to be a multidisciplinary focus in both research and clinical environments. Recent research on ACLR warrants a reexamination of clinicians' current rehabilitation practices to optimize the strikingly variable clinical outcomes after ACLR and return to sport. The purpose of the article and updated guidelines is to use contemporary evidence to systematically revisit our practice guidelines and validate our clinical milestones with data from our university-based practice. EVIDENCE ACQUISITION: Using the PubMed search engine, articles that reported on ACLR rehabilitation and protocols, guidelines, graft type, healing and strain, return to sport, psychological considerations, and secondary injury prevention published from 1979 to 2020 were identified using the search terms ACLR protocols, guidelines, ACLR rehabilitation, ACL graft, ACL open kinetic chain (OKC) exercise and closed kinetic chain (CKC) exercise, ACLR return to sport, ACLR psychological factors, and ACL injury prevention. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 5. RESULTS: Clinical milestones after ACLR were validated using clinical data collected from 2013 to 2017 at a university-based practice. Variables including knee joint range of motion, effusion, Knee Outcome Survey-Activities of Daily Living Scale, and quadriceps strength index were tracked throughout rehabilitation and analyzed to help inform an updated ACLR rehabilitation guideline. CONCLUSION: Incorporating the latest research, combined with direct clinical data, provides a current, realistic, and clinically benchmarked strategy for ACLR rehabilitation. Commonly held clinical beliefs regarding rehabilitation after ACL injury must be challenged by the latest research to improve patient outcomes and decrease the risk of reinjury. Key updates to the practice guidelines include the use of frequent and accurate quadriceps strength testing, delayed return-to-sport timeline, immediate use of open kinetic chain exercise, criterion-based progressions for running, sprinting, plyometrics, agility, cutting/pivoting, return to competition, and the inclusion of a secondary prevention program after return to sport. STRENGTH OF RECOMMENDATION TAXONOMY (SORT): B.

Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury.

Over the last decade, numerous concussion evidence-based clinical practice guidelines (CPGs), consensus statements, and clinical guidance documents have been published. These documents have typically focused on the diagnosis of concussion and medical management of individuals post concussion, but provide little specific guidance for physical therapy management of concussion and its associated impairments. Further, many of these guidance documents have targeted specific populations in specific care contexts. The primary purpose of this CPG is to provide a set of evidence-based recommendations for physical therapist management of the wide spectrum of patients who have experienced a concussive event. J Orthop Sports Phys Ther 2020;50(4):CPG1-CPG73. doi:10.2519/jospt.2020.0301.

How Do We Meet the Challenges of Assessing and Managing Concussion?

Despite advances in the assessment, diagnosis, prognosis, and management of the patient with mild traumatic brain injury (mTBI) or concussion, the condition continues to frustrate clinicians and researchers. The November 2019 special issue of the Journal of Orthopaedic & Sports Physical Therapy (JOSPT) supports and represents an interdisciplinary approach to assessment, management, and treatment of mTBI/concussion. The articles further highlight the evolving role of the physical therapist throughout the clinical course post concussion. It is with gratitude to the authors who contributed to this special issue of JOSPT that we present the evidence and practices currently available to clinicians in the assessment and treatment of mTBI/concussion. J Orthop Sports Phys Ther 2019;49(11):766-767. doi:10.2519/jospt.2019.0107.

A Treatment-Based Profiling Model for Physical Therapy Management of Patients Following a Concussive Event.

SYNOPSIS: Concussions are a public health concern that affects individuals across the life span. The multifaceted effects of concussion warrant an interdisciplinary management strategy that may include physical therapy. However, physical therapists may feel underprepared for clinical decision making following a concussive event. We propose a new treatment-based profiling model to help physical therapists manage patients following a concussive event. This profiling model, based on symptom type and intensity, disability status, and response to movement, prioritizes treatment emphasis on (1) symptom management, (2) movement system optimization, or (3) performance optimization. We consider contextual factors that modify treatment decision making and present examples of each treatment-based profile. J Orthop Sports Phys Ther 2019;49(11):829-841. doi:10.2519/jospt.2019.8869.

PROGRESSIVE REHABILITATION AFTER TOTAL HIP ARTHROPLASTY: A PILOT AND FEASIBILITY STUDY.

BACKGROUND: The incidence of total hip arthroplasty (THA) has increased, due in part to younger individuals undergoing the procedure. Surgical techniques and biomaterials have improved, but rehabilitation has not kept pace with the needs of a changing demographic. HYPOTHESIS/PURPOSE: The purpose of this study was to evaluate the feasibility and preliminary effectiveness of a progressive strengthening and functional retraining intervention after THA. STUDY DESIGN: Intervention study. METHODS: Twenty patients participated in the control group (n=10) or experimental group (n=10). The experimental intervention had few supervised sessions in the early phase after THA (weeks 0-12), followed by supervised, progressive, and high-level activity retraining in the later phase (weeks 12-16). Training in the experimental group was tailored to individual patient goals, which included a variety of vocational and recreational activities. The control group participated in usual rehabilitation care as prescribed by their surgeon. Therefore, the duration and content of rehabilitation of the control group therapy was not constrained. Testing included three-dimensional motion analysis of gait and a clinical evaluation prior to surgery and 16 weeks post-surgery. Change scores were calculated for pain, the Timed Up and Go (TUG), the Stair Climb Test (SCT), the Six-minute Walk Test (6MWT), the Thirty Second Chair Rise Test (30-CRT), strength, the Hip Outcome Scale (HOS), the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS Jr), ground reaction force during stance, hip abduction moment, sit to stand ground reaction force, and symmetry between limbs during stance and sit to stand and compared between groups. Patient satisfaction and number of rehabilitation visits were also compared. Safety and feasibility were assessed using descriptive analysis of the number adverse events. RESULTS: One patient dropped from the control group prior to rehabilitation. The intervention group had a significantly greater improvement for the 6MWT than the control group (p=0.011), functional questionnaires (p=0.034), hip abduction strength on the non-surgical side (p=0.01) and greater satisfaction (96 vs 84 out of 100; p=0.03) at the conclusion of the intervention. The intervention group demonstrated a significantly greater improvement in force symmetry during sit-to-stand (p=0.041) as compared to the control group. There were no other significant differences in change scores for functional measures or discrete biomechanical metrics. CONCLUSION: This physical therapy protocol, which focused on reducing supervised visits early after THA and retraining higher level activities later in the course of recovery, had a positive effect on biomechanics and functional outcomes without compromising safety. The effect of the experimental intervention was most appreciable for the 6MWT, non-surgical hip strength, satisfaction, and movement symmetry. LEVEL OF EVIDENCE: 2B.

Ultimate frisbee injuries in a collegiate setting.

PURPOSE/BACKGROUND: Ultimate Frisbee (Ultimate) is a limited-contact team sport growing in popularity, particularly as a collegiate club sport. In 2011, over 947,000 people played Ultimate. Sex, age, skill level, and physical demands of the sport place each player at risk for injury, yet there is limited information on the number of injuries with regard to clinical research. The purpose of this study is to identify injury reporting trends in Ultimate Frisbee against other collegiate club sports and examine correlation with sex, body region, and medical recommendations and to discuss associated risk of injury. METHODS: Athletes who sustained an injury related to participation in their respective club sport attended a physical therapy sports clinic, underwent screening, and were provided direction for injury management. Data was collected on various elements of each case with descriptive statistical analysis performed to catalog injury characteristics. Chi-square analyses were performed to compare proportions between sports, sex, and body region. RESULTS: Ultimate accounted for 143 (31.0%) of the 461 reported injury cases collected from all club sports. Female injuries represented 101 (70.6%) of the 143 Ultimate cases, whereas men totaled 42 (29.4%) (p<0.001). Women had significantly more foot/ankle (26) than men (4) (p<.001) and more lumbar/flank (9) injuries than men (2) (p=.022). CONCLUSIONS: Ultimate accounted for one of the highest number of reported injuries among all club sports. Women reported injuries more than twice as frequently as men. The majority of reported Ultimate injuries involved the lower extremity. Injury trends observed are similar to those previously reported in several NCAA Intercollegiate sports. LEVEL OF EVIDENCE: IV.

Functional testing to determine readiness to discontinue brace use, one year after acl reconstruction.

BACKGROUND: While the use of functional knee braces for return to sports or high level physical activity after ACL reconstruction (ACLR) is controversial, brace use is still prevalent.(1,2,3,4,5) All active patients in the practice are braced after ACLR and must pass a battery of sports tests before they return to play in their brace. Criteria include a 90% score on 4 one-legged hop tests(9) burst superimposition strength test,(10) Knee Outcome Survey Activities of Daily Living Scale,(8) and a global rating of knee function. PURPOSE: The purpose of this study was to describe the use of criterion-based guidelines to determine if athletes who had undergone an ACLR function better with or without their functional brace, one year after surgery. STUDY DESIGN: Cross-Sectional Study. METHODS: Sixty-four patients post ACLR performed 4 one-legged hop tests,(9) burst superimposition strength test,(10) and completed the Knee Outcome Survey Activities of Daily Living Scale,(8) and a global rating of knee function one year after surgery with and without their brace. RESULTS: Participants included 35 men and 29 women with a mean age of 25 years. The Mean Knee Outcome Survey Activities of Daily Living score was 98%, and the global rating was 97%. Of the subjects, one patient failed hop testing by at least one criterion with and without the brace. Three additional patients failed the test while braced but passed un-braced, and one patient passed with the brace, but failed without the brace. Subjects performed significantly better un-braced than braced in all hop tests: single leg hop braced = 101%; un-braced = 107% (p<0.001); cross-over hop braced = 100%; un-braced = 105% (p<0.001); triple hop braced = 99%; un-braced = 101% (p=0.003); timed hop braced = 98%; un-braced = 103% (p = 0.004). CONCLUSIONS: Sixty-two of 64 patients continued to score above return to play criteria one year after ACLR. All but two subjects in the cohort performed better un-braced than braced. Based on the criterion set for this testing session, 62/64 individuals performed well enough to discontinue use of their brace. LEVEL OF EVIDENCE: 2b.

Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression.

UNLABELLED: The management of patients after anterior cruciate ligament reconstruction should be evidence based. Since our original published guidelines in 1996, successful outcomes have been consistently achieved with the rehabilitation principles of early weight bearing, using a combination of weight-bearing and non-weight-bearing exercise focused on quadriceps and lower extremity strength, and meeting specific objective requirements for return to activity. As rehabilitative evidence and surgical technology and procedures have progressed, the original guidelines should be revisited to ensure that the most up-to-date evidence is guiding rehabilitative care. Emerging evidence on rehabilitative interventions and advancements in concomitant surgeries, including those addressing chondral and meniscal injuries, continues to grow and greatly affect the rehabilitative care of patients with anterior cruciate ligament reconstruction. The aim of this article is to update previously published rehabilitation guidelines, using the most recent research to reflect the most current evidence for management of patients after anterior cruciate ligament reconstruction. The focus will be on current concepts in rehabilitation interventions and modifications needed for concomitant surgery and pathology. LEVEL OF EVIDENCE: Therapy, level 5.

Data-based interval hitting program for female college volleyball players.

CONTEXT: Interval sports programs are a critical rehabilitation element when preparing the injured athlete for a return to preinjury activities. There is currently no published interval hitting program to guide a return to unrestricted play for the volleyball athlete. Therefore, data-based, position-specific overhead hitting programs that control for intensity, time, and number of ball strikes were developed for female college volleyball players. EVIDENCE ACQUISITION: Records from a single Division I varsity women's volleyball team were examined for all matches during 7 consecutive years of team play. Data were collected for number of hitting and service attempts per game for each position and the number of games per match. RESULTS: Per game, middle hitters averaged 4.51 attacks and 2.77 service attempts; right-side hitters, 3.58 attacks and 1.26 service attempts; outside hitters, 6.37 attacks and 3.44 service attempts; and setters and defensive specialists, 0.17 attacks and 1.78 service attempts. CONCLUSION: The interval hitting program can provide rehabilitation specialists with a data-based approach that may facilitate a return to play and minimize the risk of reinjury for volleyball athletes.