The effects of cryotherapy on quadriceps electromyographic activity and isometric strength in patient in the early phases following knee surgery.

PURPOSE: To determine the effects of cryotherapy on quadriceps electromyographic (EMG) activity and isometric strength in early postoperative knee surgery patients. METHODS: Twenty-two volunteers with recent knee surgeries were included. EMG readings of the vastus medialis (VM), rectus femoris (RF), and vastus lateralis (VL) from the surgical leg were collected during a maximal voluntary quadriceps setting (QS) activity. Maximum isometric knee extension force measurements were also recorded. Subjects were randomly assigned to receive an ice bag or a sham room-temperature bag to the front of their postsurgical knee for 20 min. After treatment, the subjects repeated the above mentioned maximum QS and isometric knee extension force measurements. The subjects returned 24 h later to conduct the same test protocol but received the treatment (ice or sham) not applied during their first test session. RESULTS: A 38% increase in VM EMG activity during QS and a 30% increase in maximum isometric knee extension strength were found after cryotherapy treatment. No significant differences were found in RF or VL EMG activity during QS after cryotherapy. No significant differences were found in any measurements after the sham treatment. CONCLUSION: Clinicians should consider applying ice to knee joints prior to exercise for patients following knee surgery with inhibited quadriceps.

THE MUSCULOSKELETAL READINESS SCREENING TOOL- ATHLETE CONCERN FOR INJURY & PRIOR INJURY ASSOCIATED WITH FUTURE INJURY.

BACKGROUND: The Musculoskeletal Readiness Screening Tool (MRST) was developed in an effort to consistently predict injury among military personnel. Current injury prediction tools have not consistently predicted injury in this population. The MRST is comprised of the weight bearing forward lunge, modified deep squat, closed kinetic chain upper extremity stability test (CKCUEST), forward step down with eyes closed, stationary tuck jump, unilateral wall sit hold, and subjective, individual perceived level of risk for injury. The Feagin hop and self-reported history of injury were also included in this study protocol. The Feagin hop was a functional test used consistently by the orthopedic department located at the testing site as well as used in a recent study aimed at defining a return to duty screen; self-reported history of injury has been identified as a potential predictor of injury. PURPOSE: To examine whether MRST scores, as a composite as individual components, were predictive of a United States Military Academy Preparatory School (USMAPS) student athlete sustaining a future musculoskeletal injury. STUDY DESIGN: Prospective Cohort Study. METHODS: MRST scores were collected for 141 student athletes (mean age 18.63 ± 1.31) at USMAPS. The injury surveillance period was nine months. Students participated in regularly occurring military specific training and various sports. Mean scores were compared between injured and uninjured groups; binary logistic regression model was also completed. RESULTS: Seventy students sustained an injury. The top activities resulting in injury included football (36%) and basketball (11%) with injuries predominantly located in the lower extremity including the knee (24%), hip (15%), and ankle (14%). Composite MRST scores were not statistically different between injured (12.58 ± 2.16) and uninjured (13 ± 2.27) groups. There was an association between those with a personal concern for future injury and actual injury (p = .04). There was an association between those reporting a prior injury in the preceding 12 months and those incurring an injury at USMAPS (p = .04). CONCLUSION: The MRST composite scores were not predictive of injury in this population. Previous injury and personal concern for injury were significant injury predictors. LEVEL OF EVIDENCE: 2a.

Real time interrater reliability of a novel musculoskeletal readiness screening tool.

Military service members receive regular screenings for a variety of health conditions, but a field-expedient and military-specific screening tool that identifies an individual's risk for injury has not yet been identified. The purpose of this study is to describe the conduct of a novel musculoskeletal readiness screening tool (MRST) and evaluate the real-time interrater reliability of the MRST when scored by raters with differing levels of medical experience. MATERIALS/METHODS: This study included a convenience sample of 40 active duty military participants (30 male, 10 female, mean age 29.3±6.9 years) without any current musculoskeletal injury or pain at the time of enrollment. The MRST consisted of 5 physical performance tests and one self-report question as follows: (1) weight-bearing lunge (WBL), (2) overhead squat, (3) closed kinetic chain upper extremity stability test (CKCUEST), (4) eyes closed forward step down, (5) repeated tuck jump, and (6) individual perceived level of risk for MSK injury. Three raters (a board certified physical therapist with 15 years of experience, a physical therapy student with less than one year didactic training, and a physical therapy technician with approximately 10 years of experience) independently scored each event as 0, 1, or 2 based on the quality of the participant's performance. This scoring system allows for a cumulative score ranging from 0 to 12, with lower scores thought to indicate higher risk for future injury. Descriptive, reliability, and chance-corrected agreement statistics were calculated using IBM SPSS. This study was approved by the Brooke Army Medical Center Institutional Review Board at Fort Sam Houston, Texas. RESULTS: The mean composite MRST score for all graders was 7.79±1.41. Among all 3 raters the overall reliability was moderate (ICC (2,1)=0.75 (0.62, 0.85)). Chance-corrected agreement values for the individual events ranged from slight to almost perfect as follows: WBL (κ=0.33-0.44), overhead squat (κ=0.57-0.65), CKCUEST (κ=0.89-1.0), eyes-closed forward step down (κ=0.10-0.42), repeated tuck jump (κ=0.39-0.61), individual perceived level of risk for MSK injury (κ=1.0). CONCLUSIONS: The MRST showed moderate interrater reliability for the overall composite score with varied levels of agreement for individual events scores. Future research should investigate test-retest reliability and interrater reliability among medical personnel from different disciplines.

Effects of technique-focused training in conjunction with physical readiness training on Army physical fitness test performance.

The Army Physical Fitness Test (APFT) is a semiannual requirement. While conducting physical readiness training (PRT) is a requirement for all Soldiers, there is no requirement to train Soldiers on techniques that may help to optimize their performance on the APFT. A cohort of 34 officers that attended the Army Medical Department Basic Officer Leadership Course completed a technique-focused training program in conjunction with their required PRT program subsequent to failing one or more events on their initial APFT. The training consisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physical therapist. Upon retest 10 days after the initial test, 27 (79.4%) participants passed the APFT with a mean improvement of 22.3 points on their overall APFT score. When evaluating change in performance by event based on failing the event initially, the observed improvement was an increase of over 9 push-ups, over 11 sit-ups, and nearly 2 minutes on the run event. The addition of a technique-focused training program to an existing PRT program can result in significant short-term improvement for those with substandard APFT performance.

Reliability of a Novel Return to Duty Screening Tool for Military Clinicians.

PURPOSE/HYPOTHESIS: Lower extremity and low back injuries represent a significant financial burden on the military healthcare system. Subsequent injuries often occur during the recuperation period or in the period directly after physical therapy ends when the patient returns to full duty. Medical providers have relatively few objective tools with which to determine if someone is ready for return to duty (RTD). The purpose of this study is to assess interrater and test-retest reliability of a novel gender-neutral RTD screening tool that requires minimal training, equipment, and time. SUBJECTS: This study included 34 active duty military participants (male=22, female=12, age=28.5 ± 5.9). 23 subjects (male=14, female=9, age=28.7 ± 6.3) returned for follow-up testing within one week. MATERIALS/METHODS: After answering a medical questionnaire, all participants completed the RTD screening tool consisting of: (1) modified anterior reach, (2) modified deep squat, (3) modified trunk stability push-up, (4) modified hip abduction test, (5) forward step-down under low-light conditions, (6) modified Feagin hop test, and (7) perceived risk of future injury. Each individual event was qualitatively scored from 0 to 2 or 3. The composite score ranged from 0 to 16 with higher scores indicating better performance. RESULTS: For the primary rater, the mean score was 11.26 ± 2.35 during the first trial session and 12.43 ± 1.47 during the second trial session. For the secondary rater, the mean score during the first trial session was 11.38 ± 2.51 and 12.61 ± 1.73 during the second session. There was good interrater reliability for the composite score (intraclass correlation coefficient [ICC] (2,1)=0.88 (0.78, 0.94)). The test-retest reliability was moderate (ICC (3,1)=0.57, (0.21, 0.79)). The chance-corrected agreement was acceptable for all individual events except the modified hip abduction test. There were no significant differences between male and female composite scores. CONCLUSIONS: This novel RTD screening tool showed good overall interrater reliability, suggesting that entry-level clinicians trained on the grading requirements are able to reliably administer the tool. In addition, the screen showed gender-neutrality with no significant differences between men and women. However, the RTD screening tool had only moderate test-retest reliability, suggesting the possible presence of a learning effect. The modified hip abduction test demonstrated poor chance-corrected agreement. Future research should consider including a longer practice session to ameliorate any possible learning effect and to modify the hip abduction test to improve reliability. CLINICAL RELEVANCE: This study has demonstrated that a novel RTD screening tool can reliably be administered to an active duty population to assist clinicians in making RTD decisions. However, at this time, it cannot be determined if a certain composite or individual event score will indicate increased risk for injury.

Cervical myelopathy: diagnosing another great impostor.

CONTEXT: Cervical myelopathy, especially during the early stages of the disorder, is very difficult to diagnose. It has the ability to mimic a number of other neurologic and musculoskeletal conditions, resulting in prolonged diagnostic delay in some cases. Excessive delay can result in permanent paralysis, gait, and genitourinary dysfunction. While most common in aging populations, it can present to military clinicians at any time. Consequently, there needs to be an increased index of clinical suspicion when evaluating Soldiers. OBJECTIVE: The purpose of this clinical review is to provide an evidence-based update regarding the diagnostic utility of both common and novel clinical tools. DATA SOURCES: English language articles published in peer reviewed journals were identified by searching the PubMed, CINAHL, and SPORTDiscus databases. RESULTS: Historically, clinicians have performed tests such as the Hoffmann or Babinski signs in order to rule out the presence of cervical myelopathy or other upper motor neuron disease. While there is some evidence to suggest their clinical usefulness, several other clinical tools should be considered as well. Specifically, the Trömner and the Wazir hand myelopathy signs are very sensitive for detecting myelopathy at or above the C5-6 level. There is sufficient evidence to suggest that any neurologic screen with the purpose of excluding cervical myelopathy needs to include the lower extremity tests such as the patellar tendon and Rossolimo reflexes. Analysis of the lateral cervical radiograph is an efficient and inexpensive method of evaluating for the presence of congenital cervical spine stenosis, a known risk factor for cervical myelopathy. Magnetic resonance imaging findings on T2, and especially the T1 weighted images, appear correlated with surgical outcomes. CONCLUSION: Military clinicians should use the most valid clinical tools when evaluating for the presence of cervical myelopathy.

Identification of a high-risk anterior tibial stress fracture.

The patient was a deployed 34-year-old female soldier with a chief complaint of bilateral anterior shin pain for the past 8 weeks. Due to concern for a stress fracture, radiographic views of the bilateral tibia and fibula were completed, which revealed cortical thickening through the anterior midtibial regions bilaterally, consistent with stress reactive changes. Furthermore, a transverse lucency through the anterior cortex of the anterior right midtibial region was noted, which was consistent with a stress fracture. The patient was immediately placed in a short leg cast and was given strict non-weight-bearing instructions for gait. She was subsequently evacuated to her home duty station for consultation with an orthopaedic surgeon to determine if surgical intervention was warranted. This report illustrates the importance of identifying stress fractures considered to be high risk.

The clinical efficacy of kinesio tape for shoulder pain: a randomized, double-blinded, clinical trial.

STUDY DESIGN: Prospective, randomized, double-blinded, clinical trial using a repeated-measures design. OBJECTIVES: To determine the short-term clinical efficacy of Kinesio Tape (KT) when applied to college students with shoulder pain, as compared to a sham tape application. BACKGROUND: Tape is commonly used as an adjunct for treatment and prevention of musculoskeletal injuries. A majority of tape applications that are reported in the literature involve nonstretch tape. The KT method has gained significant popularity in recent years, but there is a paucity of evidence on its use. METHODS AND MEASURES: Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: therapeutic KT group or sham KT group. Subjects wore the tape for 2 consecutive 3-day intervals. Self-reported pain and disability and pain-free active ranges of motion (ROM) were measured at multiple intervals to assess for differences between groups. RESULTS: The therapeutic KT group showed immediate improvement in pain-free shoulder abduction (mean +/- SD increase, 16.9 degrees +/- 23.2 degrees ; P = .005) after tape application. No other differences between groups regarding ROM, pain, or disability scores at any time interval were found. CONCLUSION: KT may be of some assistance to clinicians in improving pain-free active ROM immediately after tape application for patients with shoulder pain. Utilization of KT for decreasing pain intensity or disability for young patients with suspected shoulder tendonitis/impingement is not supported. LEVEL OF EVIDENCE: Therapy, level 1b-.