Effects of neuromuscular and proprioceptive training on self-reported wellness and health scores and knee sensorimotor characteristics in active seniors.

INTRODUCTION: Athletes regularly engage in comprehensive neuromuscular and proprioceptive training (NPT) to prevent musculoskeletal (MSK) injuries. NPT exercises such as movement technique, agility, balance, and posture as well as yoga-based stretching and slow/deep breathing have shown added benefits in psychological and other well-being. This study aimed to examine the effects of NPT on knee sensorimotor characteristics and multi-domain wellness and health scores in active seniors. METHODS: Twenty seniors participated in the NPT intervention (15-20min session twice a week for 10 weeks) while the control group did not receive any intervention. All participants completed surveys (general health, frailty, anxiety, stress, mindfulness, optimism, and sleep quality) and laboratory testing before and after intervention. Laboratory testing included frailty tests (grip strength, 4-m walk speed, and calcaneal ultrasound-based bone density) and knee sensorimotor characteristics (peak force, visual-motor reaction time, and force steadiness). RESULTS: There was significant increase in general mental health (Short Form 36 Mental Health; p = 0.005) and decrease in stress (Perceived Stress Scale; p = 0.010) and sleep disturbances (Pittsburgh Sleep Quality Index; p = 0.019) post-intervention while no significant changes were observed in the control group (p = 0.310-0.654). Peak knee forces in all directions and some visual-motor reaction time and force steadiness were significantly improved post-intervention only in the experimental group (p = 0.001-0.038). CONCLUSION: A simple, yet, comprehensive NPT has potential to improve MSK health as well as various domains of well-being among active seniors.

At-Home High-Intensity Interval Training for Individuals with Paraplegia Following Spinal Cord Injury: A Pilot Study.

Objective: This pilot study aimed to assess the efficacy of a 16-week at-home high-intensity interval training (HIIT) program among individuals with spinal cord injury (SCI). Methods: Eight individuals (age: 47±11 (SD) years, 3 females) with SCI below the sixth thoracic vertebrae participated in a 16-week at-home HIIT program using an arm ergometer. Participants completed baseline graded exercise tests to determine target heart rate zones. HIIT was prescribed thrice per week. Each training session consisted of six one-minute bouts with a target heart rate ~80% heart rate reserve (HRR), interspersed with two minutes of recovery at ~30% HRR. A portable heart rate monitor and phone application provided visual feedback during training and allowed for measurements of adherence and compliance. Graded exercise tests were completed after 8 and 16 weeks of HIIT. Surveys were administered to assess participation, self-efficacy, and satisfaction. Results: Participants demonstrated a decrease in submaximal cardiac output (P=0.028) and an increase in exercise capacity (peak power output, P=0.027) following HIIT, indicative of improved exercise economy and maximal work capacity. An 87% adherence rate was achieved during the HIIT program. Participants reached a high intensity of 70% HRR or greater during ~80% of intervals. The recovery HRR target was reached during only ~35% of intervals. Self-reported metrics of satisfaction and self-efficacy with at-home HIIT scored moderate to high. Conclusion: Participants demonstrated an improvement in exercise economy and maximal work capacity following at-home HIIT. Additionally, participant adherence, compliance, satisfaction, and self-efficacy metrics suggest that at-home HIIT was easily implemented and enjoyable.

The Telemedicine Musculoskeletal Examination.

Telemedicine uses modern telecommunication technology to exchange medical information and provide clinical care to individuals at a distance. Initially intended to improve health care for patients in remote settings, telemedicine now has a broad clinical scope with the general purpose of providing convenient, safe, and time- and cost-efficient care. The coronavirus disease 2019 pandemic has created marked nationwide changes in health care access and delivery. Elective appointments and procedures have been canceled or delayed, and multiple states still have some degree of shelter-in-place orders. Many institutions are now relying more heavily on telehealth services to continue to provide medical care to individuals while also preserving the safety of health care professionals and patients. Telemedicine can also help reduce the surge in health care needs and visits as restrictions are lifted. In recent weeks, there has been a significant amount of information and advice on how to best approach telemedicine visits. Given the frequent presentation of individuals with musculoskeletal complaints to the medical practitioner, it is important to have a framework for the virtual musculoskeletal physical examination. This will be of importance as telemedicine continues to evolve, even after coronavirus disease 2019 restrictions are lifted. This article will provide the medical practitioner performing a virtual musculoskeletal examination with a specific set of guidelines, both written and visual, to enhance the information obtained when evaluating the shoulder, hip, knee, ankle, and cervical and lumbar spine. In addition to photographs, accompanying videos are included to facilitate and demonstrate specific physical examination techniques that the patient can self-perform.

Injury Rate and Patterns in Group Strength-Endurance Training Classes.

OBJECTIVE: To identify the injury rate during high-intensity functional training. PARTICIPANTS AND METHODS: Adults (N=100; 82 [82%] female) in group strength-endurance training at the Dan Abraham Healthy Living Center from January 9, 2017, through April 19, 2018, were recruited for the study. Participants were recruited before the class start date. Those who consented received a preclass survey and another survey 6 weeks after the class started to obtain data on demographic characteristics, baseline joint problems or pain, injuries in the preceding 6 weeks, class satisfaction, and exercise habits. Classes lasted 6 weeks and were led by a trainer for 60 minutes, once weekly. Participants were encouraged to perform similar exercise on 2 additional nonconsecutive days throughout the week. Injury was self-reported and defined as experiencing new pain or sustaining injury while exercising during the 6-week time frame. The primary outcome measure was the number of injuries per 1000 training hours. RESULTS: The injury rate was 9.0 injuries per 1000 training hours (95% CI, 5.8-13.4 injuries per 1000 training hours) during the 6-week training and 5.0 injuries per 1000 training hours (95% CI, 2.8-8.2 injuries per 1000 training hours) during the 6 weeks preceding enrollment (P=.08). Injury occurred in 18 (18%) of participants during the 6-week training, and 9 of 24 injuries (37.5%) occurred during a training class. The most commonly injured regions were knees (n=7) and back (n=6). Burpees and squats were the most common movements causing injury. CONCLUSION: The increased injury rate during the study was not statistically significant. It was higher than rates reported in previous retrospective studies of high-intensity functional training, weight lifting, or power lifting but comparable with rates reported in prospective studies of novice and recreational runners.

Hop tests can result in higher limb symmetry index values than isokinetic strength and leg press tests in patients following ACL reconstruction.

PURPOSE: Quadriceps weakness is a common clinical sign following anterior cruciate ligament injury and reconstruction surgery (ACLR). The aim of this study was to compare strength deficits and the limb symmetry index (LSI) from three different types of functional tests: isokinetic dynamometry, hop test, and leg press. METHODS: A total of 26 subjects with ACLR (average 8.3 months post-operation) participated in the study. The peak knee extension torque was tested with isokinetic dynamometry at 60/180/300 °/s (ISO60/180/300). Hop distance was tested during single hop (SH) and triple hop (TH). Unilateral peak leg power (POWER) was tested during a bilateral leg press test. LSI was calculated as the ratio of the involved limb over the uninvolved limb values. Pearson correlation coefficients and paired t-tests were used to establish relationships among ISO60/180/300, SH/TH, and POWER values and compare these values between the limbs, respectively. Within-subject one-way analysis of variance (ANOVA) with post hoc analyses was used to compare LSI values among different tests. RESULTS: ISO60/180/300 values were significantly positively correlated with SH/TH and POWER (P < 0.05), while SH/TH and POWER values were not significantly correlated. Significant limb differences were found in all tests (P = 0.001-0.008). ANOVA revealed significant LSI differences among different tests. Specifically, post hoc analyses revealed that LSI during SH was significantly higher than LSI during ISO60. Similarly, LSI during TH was significantly higher than LSIs from ISO60, ISO180, and POWER tests. CONCLUSIONS: Peak knee extension torque values were positively associated with hop distance and leg power during the leg press test. However, LSI values should be interpreted with caution as hop tests provided significantly higher LSI values than isokinetic testing. Both isokinetic dynamometry and unilateral leg press machine could be used to isolate and strengthen the quadriceps in the involved limb. The current "gold standard" isokinetic testing at slow speed (ISO60) provided the lowest LSI value among all functional tests; therefore, the current study supported a continued use of isokinetic testing when examining individual's readiness and return-to-sport. LEVEL OF EVIDENCE: III.

The Feasibility and Effects of Acupuncture on Muscle Soreness and Sense of Well-being in an Adolescent Football Population.

OBJECTIVE: The aims of the study were to assess the feasibility of performing acupuncture on multiple adolescent athletes in a warm weather, high-intensity training environment and to measure perceived effects of acupuncture on delayed-onset muscle soreness and sense of well-being. DESIGN: This is a prospective feasibility study (registered clinical trial NCT03478800). Forty-two healthy male participants, aged 13-18 yrs, were involved in at least 1 of 5 treatment days for a total of 147 individual treatment sessions. Fifteen-minute treatments of traditional needle acupuncture were administered at the football field. Time, cost, adverse effects, and participant/provider ratio were observed. Effect on delayed-onset muscle soreness and sense of well-being were measured via pretreatment and posttreatment visual analog scale (0-10) rating analyses. RESULTS: The results are as follows: time required by research staff on treatment days, 75 mins; total cost, US $700; temperature range, 21°C-28°C; and largest participant to acupuncturist ratio, 7-10:1. No major adverse effects occurred; 55% reported minimal adverse effects, such as mild focal numbness or tingling. Overall pretreatment to posttreatment effect on delayed-onset muscle soreness (average over 5 days) demonstrated significantly improved posttreatment scores (pre 4.6 ± 2.0; post 2.9 ± 2.2, P < 0.001). There was no significant effect on sense of well-being (P = 0.12). CONCLUSIONS: Effectively providing acupuncture to multiple adolescent football players in their training environment is feasible with appropriate staff and resources. Despite mild adverse effects, treatment was well tolerated. This study provides guidance on acupuncture delivery to other athletes in their training environments.

Youth Sport-Related Concussions: Perceived and Measured Baseline Knowledge of Concussions Among Community Coaches, Athletes, and Parents.

OBJECTIVE: To assess concussion knowledge of athletes, coaches, and parents/guardians in a community setting and to understand trends/gaps in knowledge among subgroups to tailor efforts toward creating educational interventions. PARTICIPANTS AND METHODS: This prospective cross-sectional study involved 262 individuals (142 [55%] female): 115 athletes participating in noncontact and contact sports (ages 13-19 years), 15 coaches, and 132 parents. Recruitment occurred from August 30, 2015, through August 30, 2016, at 3 local high schools. Participants completed a questionnaire developed by the investigators to assess concussion experience and basic knowledge. RESULTS: Females, health care employees, and parents showed stronger concern for potential long-term sequelae of concussion, whereas athletes were most concerned about not being able to return to sport. Those with higher perceived concussion knowledge were slightly older (median age, 42.5 vs 33 years), more educated (college or higher: 42 [70%] vs 100 [50%]), and more likely to be health care workers (22 [37.9%] vs 34 [17.7%]) and scored higher on knowledge questions (average correct: 75.5% vs 60%). Most participants could identify potential concussion sequelae, but only 86 (34.3%) identified a concussion as a brain injury. Of the subgroups, coaches scored highest on knowledge questions. Those with a concussion history tended to consider themselves more knowledgeable but were also less concerned about sequelae. Overall, those with a concussion history scored slightly higher on knowledge questions (average correct: 69.8% vs 61.9%). Participants involved in contact sports were more likely to have had a concussion vs those in noncontact sports (57 [26%] vs 4 [10.3%]). CONCLUSION: Significant differences in perceived and actual concussion knowledge across different subgroups of study participants involved in high school sports were identified.

The Feasibility and Effects of Acupuncture in an Adolescent Nordic Ski Population.

BACKGROUND: Studies investigating the use and effectiveness of acupuncture in adults after exercise have been well documented. Fewer studies involving acupuncture have been completed in the adolescent athlete population. To our knowledge, there are no published studies that investigate the use of acupuncture in adolescent athletes within their field of play. OBJECTIVE: To primarily assess the feasibility of performing acupuncture in adolescent Nordic skiers within their athletic environment, and secondarily to measure the effect of acupuncture on muscle soreness and sense of well-being. DESIGN: Prospective feasibility study. SETTING: Local outdoor cross country ski trails and indoor lodge. PARTICIPANTS: Fifteen healthy participants (80% female, 20% male; age 14-17 years) were involved on at least 1 of 5 treatment days. INTERVENTION: Fifteen-minute treatments were administered using traditional needle acupuncture following the first 5 consecutive Nordic Ski Team practices of the season in an attempt to capture the effect of acupuncture on delayed-onset muscle soreness (DOMS). Acupuncture points specific to muscle groups in the lower limbs that are commonly reported as painful during Nordic skiing were chosen. Pre- and posttreatment surveys included visual analogue scales (VAS) to track participant responses. OUTCOME MEASURES: Time, cost, side effects, and participant to provider ratio was observed to determine feasibility. Effect on muscle soreness and sense of well-being was measured via pre- and posttreatment VAS (0-10) rating analyses. RESULTS: Total time required by research staff on treatment days was 90 minutes; total cost, $1500; temperature range, -13.9°C to -2.8°C, and largest participant to acupuncturist ratio, 7:1. No major side effects occurred. The majority (73%) of participants reported minimal side effects; most common was treatment site pain. The overall pre- to posttreatment effect on muscle soreness (average over 5 days) demonstrated significantly improved posttreatment scores (P = .04). The effect of the day (average over pre- and posttreatment values) demonstrated significantly higher muscle soreness scores on day 3 versus day 1 (P = .03). At study completion, all participants indicated that they would consider acupuncture in the future and would recommend treatments to friends or teammates. CONCLUSION: Providing acupuncture to adolescent Nordic ski athletes in the practice field under extreme temperatures is feasible with the appropriate resources. Despite mild side effects, acupuncture was well received by the athletes. Lessons learned from this trial can provide a framework for delivering acupuncture to other athletes in their training environment. LEVEL OF EVIDENCE: IV.

Physical activity, quality of life, and burnout among physician trainees: the effect of a team-based, incentivized exercise program.

OBJECTIVE: To prospectively study the effects of an incentivized exercise program on physical activity (PA), quality of life (QOL), and burnout among residents and fellows (RFs) in a large academic medical center. PARTICIPANTS AND METHODS: In January 2011, all RFs at Mayo Clinic in Rochester, Minnesota (N=1060), were invited to participate in an elective, team-based, 12-week, incentivized exercise program. Both participants and nonparticipants had access to the same institutional exercise facilities. Regardless of participation, all RFs were invited to complete baseline and follow-up (3-month) assessments of PA, QOL, and burnout. RESULTS: Of the 628 RFs who completed the baseline survey (59%), only 194 (31%) met the US Department of Health and Human Services recommendations for PA. Median reported QOL was 70 on a scale of 1 to 100, and 182 (29%) reported at least weekly burnout symptoms. A total of 245 individuals (23%) enrolled in the exercise program. No significant differences were found between program participants and nonparticipants with regard to baseline demographic characteristics, medical training level, PA, QOL, or burnout. At study completion, program participants were more likely than nonparticipants to meet the Department of Health and Human Services recommendations for exercise (48% vs 23%; P<.001). Quality of life was higher in program participants than in nonparticipants (median, 75 vs 68; P<.001). Burnout was lower in participants than in nonparticipants, although the difference was not statistically significant (24% vs 29%; P=.17). CONCLUSION: A team-based, incentivized exercise program engaged 23% of RFs at our institution. After the program, participants had higher PA and QOL than nonparticipants who had equal exercise facility access. Residents and fellows may be much more sedentary than previously reported.

The physiatrists' crucial role in the development and implementation of a longitudinal musculoskeletal physical examination curriculum in a medical school.

The musculoskeletal physical examination (MSK PE) is a critical clinical skill that should be mastered by all medical students. The authors believe that physiatrists should have a crucial role in undergraduate musculoskeletal education. This article outlines the successful integration of an MSK PE curriculum taught by physiatrists into the first 2 yrs of medical school. During year 1, a basic MSK PE is taught concomitantly with the human anatomy course and focuses on anatomical correlation with physical examination maneuvers. In year 2, the MSK PE is taught concomitantly with the musculoskeletal didactic block. Special musculoskeletal tests, basic neurologic evaluation, and case correlation are also added to expand on the examination skills learned in the first year. At the end of the second year and before beginning third-year clinical rotations, students take a practical test to demonstrate their competency in the MSK PE. The authors believe that an important component of their MSK PE educational sessions is a low student-to-instructor ratio (4:1), with ample hands-on supervision of physical examination skills practice. Residents in the Department of Physical Medicine and Rehabilitation assist with the teaching. With their intensive training and clinical experience in musculoskeletal medicine, physiatric staff and residents are ideal faculty for teaching the MSK PE. The authors are hopeful that this article encourages other physiatrists to construct similar programs aimed to develop MSK PE skills in medical students.

The role of exercise in the treatment of obesity.

The United States is in the midst of a significant public health problem that relates to obesity and inactivity. This epidemic has far-ranging consequences for our workforce and our children and shows no signs of slowing in the near future. Significant research has been performed on the effects of exercise for the reduction of body weight; results of most studies indicate that exercise alone has a small effect on body-weight reduction independent of caloric restriction. However, when combined with dietary restriction, exercise has a synergistic effect and enhances weight loss beyond the effect of diet alone. In addition, exercise has been shown to have significant beneficial effects on cardiovascular and metabolic risk factors independent of actual weight loss, and losing just a small amount of weight can have a significant beneficial effect on these parameters. Genetic factors related to obesity have been found to be positively modified when persons incorporate physical activity into their lifestyle. Sitting time appears to be an independent risk factor for the development of metabolic risk factors; persons who spend more time sitting and watching television have worse metabolic profiles, even if they achieve the recommended amount of physical activity per week, than do those who move about throughout the day. Exercise also is essential for the prevention of weight gain over a life span, although the amount required to prevent weight gain may be closer to twice the amount of exercise recommended by the current Physical Activity Guidelines for Americans (www.health.gov/paguidelines). In many ways, the physiatrist is the most well prepared of all the specialists to address the complex, multidimensional problems of obesity and inactivity.

Effect of partial wrist denervation on wrist kinesthesia: wrist denervation does not impair proprioception.

PURPOSE: To evaluate the potential effect of partial wrist denervation on wrist kinesthesia, we hypothesized that anesthetizing the anterior interosseous nerve and the posterior interosseous nerve does not impair the kinesthesia. METHODS: We performed a double-blinded, prospective, randomized study on 80 healthy volunteers (20-54 y old) to compare the ability to detect active and passive wrist movement in 2 conditions. The test group received an anesthetic block of the anterior and posterior interosseous nerves, and the control group subjects received an injection of saline. The kinesthesia of the 2 groups was then tested in 2 conditions by measuring the error in an active and passive wrist repositioning task. Results were analyzed using a repeated measures analysis of variance. RESULTS: In both active and passive conditions, there was no difference in the repositioning errors between the test group and the control group. CONCLUSIONS: Our results show that kinesthesia is not impaired by blocking the anterior and posterior interosseous nerves. These findings are consistent for both active and passive motion. The study gives strong evidence that partial denervation does not impair wrist kinesthesia. However, because only kinesthesia was studied, we cannot conclude that partial denervation is a totally safe procedure for all aspects of proprioception. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

New method of measuring wrist joint position sense avoiding cutaneous and visual inputs.

BACKGROUND: Aspects of afferent inputs, generally termed proprioception, are being increasingly studied. Extraneous factors such as cutaneous inputs can dramatically interfere while trying to design studies in order to determine the participation of the different structures involved in proprioception in the wrist position sense. We tried to determine validity and repeatability of a new wrist joint position measurement device using methodology designed to minimize extraneous factors and isolate muscle and joint inputs. METHODS: In order to test the reliability of the system, eighty young-adult subjects without musculoskeletal or neurologic impairments affecting the right upper extremity were tested using a custom made motion tracking system. Testing consisted of two conditions: active reproduction of active placement and passive reproduction of passive placement. Subjects performed two repetitions of each target position (10, 20, and 30 degrees of flexion and extension) presented in a random order. Test- retest reliability was then tested. RESULTS: The average constant error in the passive condition was -0.7 degrees +/- 4.7 degrees as compared to the active condition at 3.7 degrees +/- 5.1 degrees. Average absolute error in the passive condition was 4.9 degrees +/- 2.9 degrees compared to the active condition in which absolute error was 5.9 degrees +/- 3.5 degrees. DISCUSSION: Test-retest repeatability in both conditions was less than the 5 degrees magnitude typical of clinical goniometry. Errors in the active condition (less than 2 degrees ) were slightly smaller than the passive condition, and the passive condition was also associated with poorer consistency between apparatus sensors and skin sensors. CONCLUSIONS: The current system for measurement of wrist joint proprioception allows the researcher to decrease extraneous influences that may affect joint position sense awareness, and will help in future study aiming to determine precisely the role of the different structure involved in proprioception.

Running shoe selection criteria among adolescent cross-country runners.

OBJECTIVE: To determine which factors are most important to adolescent cross-country runners in selecting and replacing running shoes. DESIGN: A cross-sectional, descriptive survey. SETTING: Surveys were completed at 4 high schools in a southeastern Minnesota community. PARTICIPANTS: Eligible subjects included adolescents (grades 7-12) participating in cross-country running at any of the 4 high schools in Rochester, Minnesota. A total of 223 surveys were distributed and collected from of an estimated 243 eligible participants. ASSESSMENT OF RISK FACTORS: Independent variables included gender, running experience, grade, and previous injury history. MAIN OUTCOME MEASURES: A descriptive analysis of factors important in running shoe selection was performed. The assessment also included evaluation of the runners' knowledge of arch type and awareness of mileage accumulated before replacing running shoes. RESULTS: A total of 73.1% of survey participants identified arch type compatibility with shoe design as the most important factor in choosing a running shoe. However, only 57.0% reported knowing their arch type. A total of 74.0% reported not knowing how many miles they accumulated in a single pair of running shoes before replacement. CONCLUSIONS: A majority of adolescent runners in this study identified arch type and shoe design as the most important factors in choosing a running shoe.

Septic sternoclavicular joint: a case report.

A 23-year-old man presented to our sports medicine clinic with a history of nontraumatic left anterior chest pain. Prior to presentation, a magnetic resonance image (MRI) had been performed that showed increased signal in the soft tissues around the sternoclavicular joint, primarily in the pectoralis major, and a small amount of fluid in the joint, thought possibly consistent with sympathetic effusion from a muscle tear. On examination, the patient was toxic appearing and had severe pain with virtually any left upper-extremity movement and with walking. There was swelling, redness, warmth, and tenderness over the left sternoclavicular joint. Vital signs were normal, but due to concerns of possible septic arthritis, he was admitted to the hospital. After discontinuation of prednisone and hydrocodone-acetaminophen that he had been receiving, the patient became febrile. Blood and sternoclavicular joint aspirate cultures grew methicillin-sensitive Staphylococcus aureus. On re-review of the MRI, subtle abnormal signal compatible with the patient's joint infection was seen. The patient was treated with intravenous antibiotics and, eventually, surgical resection of the left sternoclavicular joint, proximal clavicle, and lateral manubrium with subsequent muscle flap. No predisposing factor for this infection was found. Septic sternoclavicular joint is rare, accounting for 1% of all septic joints. Infection or other unusual pathology should be suspected when clinical findings are not consistent with simple musculoskeletal injury.