Recommendations to Increase Neuromuscular Electrical Stimulation Training Intensity During Quadriceps Treatments for Orthopedic Knee Conditions.

ABSTRACT: Neuromuscular electrical stimulation (NMES) is often used by clinicians as a therapeutic adjunct to improve quadriceps strength deficits following orthopedic knee conditions. The efficacy of NMES treatments is primarily dependent on the NMES training intensity, which is a direct result of NMES-induced torque production. The importance of NMES training intensity is well known, yet adequate NMES training intensities are often difficult to achieve due to a variety of limitations associated with NMES (eg, fatigue and patient discomfort). This article provides recommendations that a clinician can use to increase NMES training intensity when strengthening the quadriceps with NMES for orthopedic knee conditions. These recommendations should allow forceful contractions that can be sustained over a treatment with multiple repetitions without the rapid decline in force that is typically seen when NMES is used.

The Effectiveness of Neuromuscular Electrical Stimulation in Improving Voluntary Activation of the Quadriceps: A Critically Appraised Topic.

Clinical Scenario: Orthopedic knee conditions are regularly treated in sports-medicine clinics. Rehabilitation protocols for these conditions are often designed to address the associated quadriceps strength deficits. Despite these efforts, patients with orthopedic knee conditions often fail to completely regain their quadriceps strength. Disinhibitory modalities have recently been suggested as a clinical tool that can be used to counteract the negative effects of arthrogenic muscle inhibition, which is believed to limit the effectiveness of therapeutic exercise. Neuromuscular electrical stimulation (NMES) is commonly accepted as a strengthening modality, but its ability to simultaneously serve as a disinhibitory treatment is not as well established. CLINICAL QUESTION: Does NMES effectively enhance quadriceps voluntary activation in patients with orthopedic knee conditions? Summary of Key Findings: Four randomized controlled trials (RCTs) met the inclusion criteria and were included. Of those, 1 reported statistically significant improvements in quadriceps voluntary activation in the intervention group relative to a comparison group, but the statistical significance was not true for another study consisting of the same sample of participants with a different follow-up period. One study reported a trend in the NMES group, but the between-groups differences were not statistically significant in 3 of the 4 RCTs. Clinical Bottom Line: Current evidence does not support the use of NMES for the purpose of enhancing quadriceps voluntary activation in patients with orthopedic knee conditions. Strength of Recommendation: There is level B evidence that the use of NMES alone or in conjunction with therapeutic exercise does not enhance quadriceps voluntary activation in patients with orthopedic knee conditions (eg, anterior cruciate ligament injuries, osteoarthritis, total knee arthroplasty).

Effects of crushed ice and wetted ice on hamstring flexibility.

Flexibility, which is the ability to move freely through a full range of motion (ROM), is desired to enhance the performance and decrease the likelihood of muscle injury. There are different techniques used to increase ROM and cryotherapy techniques to facilitation flexibility gains. However, the combination of stretching and type of cryotherapy agents are still confounding. The purpose was to determine which type of cryotherapy, crushed or wetted ice, would produce the greatest gains in hamstring ROM when followed by proprioceptive neuromuscular facilitation (PNF) stretching. Fifteen healthy subjects underwent 3 treatment conditions: crushed ice bag (crushed ice), wetted ice bag (wetted ice), and no ice bag (no ice). Subject's hamstring ROM was measured at baseline, then again after a 20-minute cryotherapy treatment session. Subjects were then stretched using a slow-reversal-hold-relax PNF technique followed by a final ROM measurement. A repeated measures analysis of variance showed significant differences between cryotherapy and measurement conditions. Post hoc testing indicated that no ice (75.49 ± 12.19° C) was significantly different from wetted ice (81.73 ± 10.34° C) and crushed ice (81.62 ± 13.19° C) at the end of the treatment session, and that no ice (85.27 ± 13.83° C) was significantly different than wetted ice (89.44 ± 11.31° C) and crushed ice (89.16 ± 13.78° C) after the stretching session. However, there were no differences between wetted ice and crushed ice. Results indicate that strength and conditioning specialists can increase ROM with both forms of ice in combination with PNF stretching more so than when using no ice at all.

Effects of transducer mass on intramuscular temperature during ultrasound treatments.

CONTEXT: A potential variable that could affect rate of temperature elevation with ultrasound is the pressure (mass) that is applied to the transducer head during application. Added pressure could compress the tissue, affecting density and the transmission of ultrasound energy. Little research has been completed to determine the effects of the amount of pressure applied during therapeutic ultrasound in vivo. OBJECTIVE: To determine the effects of different applied transducer mass on intramuscular temperature during an ultrasound treatment within the left triceps surae. DESIGN: Crossover clinical trial. SETTING: Human performance research laboratory. PARTICIPANTS: Convenience sample of thirteen healthy, college-age students. INTERVENTIONS: Three separate 3-MHz, 1.0-W/cm2 ultrasound treatments were administered 1.5 cm within the triceps surae. The independent variables were the linear temperature standards (0.5°C, 1.0°C, 1.5°C, and 2.0°C above baseline) and the 3 different applied pressures measured in grams (200 g, 600 g, and 800 g). MAIN OUTCOME MEASURES: A thermocouple probe was used to measure triceps surae temperature, and time to reach the temperature standards was recorded during the ultrasound treatments. A 4 × 3 repeated-measures analysis of variance (RM-ANOVA) was used to analyze the differences for temperature points (0.5°C, 1.0°C, 1.5°C, and 2.0°C) and transducer mass (200 g, 600 g, and 800 g) and with respect to time. RESULTS: The results of the RM-ANOVA showed no temperature-point and transducer-mass interaction (F6,72 = 1.69, P = .137) or main effect for mass (F2,24 = 1.23, P = .309). The time required to raise temperature 2°C was 209.1 ± 68.10 s at 200 g, 181.5 ± 61.50 s at 600 g, and 194.9 ± 75.54 s at 800 g. CONCLUSIONS: Under the conditions of this study, the amount of mass applied with the transducer during an ultrasound treatment does not ultimately affect the rate of tissue heating.

Treating prepartum depression to improve infant developmental outcomes: a study of diabetes in pregnancy.

Whether and how the co-occurrence of depression and diabetes in pregnancy may worsen infant development has not been reported. Pregnant women with diabetes and with (n = 34) or without (n = 34) major depressive disorder (MDD) were followed during pregnancy and 6-months postpartum. The MDD subset received randomly assigned treatment with cognitive behavior therapy (CBT) or supportive counseling (SC). Depression severity was measured with the Beck Depression Inventory (BDI); infant developmental outcomes were measured with the Bayley Scales of Infant Development (BSID) and its Behavior Rating Scale (BRS). Infants of women with MDD had lower BRS scores (p = .02). Reduction in depression scores was associated with better infant outcomes on the BSID and BRS (p values <.03). These preliminary findings suggest depression occurring in pregnant women with diabetes is associated with poorer infant development and improvement in prepartum depression is associated with improvement in measures of infant development.

The effect of plyometric training on power and kicking distance in female adolescent soccer players.

The purpose of this study was to measure the effects of low-frequency, low-impact plyometric training on vertical jump (VJ) and kicking distance in female adolescent soccer players. Sixteen adolescent soccer players were studied (age 13.4 ± 0.5 years) across 14 weeks. The control group (general soccer training only) had 6 subjects, and the plyometric training (general soccer training plus plyometric exercise) group had 10 subjects. All subjects were tested for VJ and kicking distance on 3 occasions: pre-test, 7 weeks, and 14 weeks. Data were analyzed using a 2 (Training) × 3 (Test) analysis of variance (ANOVA) with repeated measures on the factor test. No significant difference in kicking distance was found between groups at pre-test (p = 0.688) or 7 weeks (p = 0.117). The plyometric group had significantly greater kicking distance after 14 weeks (p < 0.001). No significant difference in VJ height was found between groups at pre-test (p = 0.837) or 7 weeks (p = 0.108). The plyometric group had a significantly higher VJ after 14 weeks (p = 0.014). These results provide strength coaches with a safe and effective alternative to high-intensity plyometric training. Based on these findings, to increase lower-body power resulting in increased VJ and kicking distance, strength coaches should implement once-weekly, low-impact plyometric training programs with their adolescent athletes.

Acute effects of static and ballistic stretching on measures of strength and power.

Preactivity stretching is commonly performed by athletes as part of their warm-up routine. However, the most recent literature questions the effectiveness of preactivity stretching. One limitation of this research is that the stretching duration is not realistic for most athletes. Therefore, the purpose of this study was to determine the effects of a practical duration of acute static and ballistic stretching on vertical jump (VJ), lower-extremity power, and quadriceps and hamstring torque. Twenty-four subjects performed a 5-minute warm-up followed by each of the following three conditions on separate days with order counterbalanced: static stretching, ballistic stretching, or no-stretch control condition. Vertical jump was determined with the Vertec VJ system and was also calculated from the ground-reaction forces collected from a Kistler force plate, which also were used to calculate power. Torque output of the quadriceps and hamstrings was measured through knee extension and flexion on the Biodex System 3 Dynamometer at 60 degrees x s(-1). Data normalized for body weight were analyzed using five separate, 3 (stretch condition) x 2 (gender) analysis-of-variance procedures with repeated measures on the factor of stretch condition. The gender x stretch interaction was not significant for any of the four measures, suggesting that the stretching conditions did not affect men and women differently. The results of this study reveal that static and ballistic stretching did not affect VJ, or torque output for the quadriceps and hamstrings. Despite no adverse effect on VJ, stretching did cause a decrease in lower-extremity power, which was surprising. Because of the mixed results, strength coaches would be better served to use dynamic stretching before activity; this has been consistently supported by the literature.

A victim typology of sexual harassment.

A clinical sample of 20 sexual harassment victims who were successful in obtaining damage awards for trauma through the judicial system were sources of this descriptive study. Ratings of physical coercion of the harassment, MMPI-2 scores, and ratings on DSM-IV symptoms were analyzed. The majority of subjects met the DSM-IV criteria of Post-Traumatic Stress Disorder. A cluster analysis identified four clusters of harassment victims, described as older-mature, younger-mature, anxious-guilty, and expressive-adaptive based on MMPI-2 scores and symptoms.

Stereotypy in young children with autism and typically developing children.

Although stereotypy is one of the key diagnostic features of autism, few studies have compared stereotypic behavior in children with autism and typically developing children. The present study employed direct observational measurement methods to assess levels of stereotypic behavior in 2-, 3- and 4-year-old children with autism or pervasive developmental disorder - not otherwise specified (PDD-NOS) and age-matched typically developing peers. Thirty children with autism or PDD-NOS and 30 typically developing children participated. Each child's performance of several early learning and play skills was assessed using a direct observational assessment protocol developed for children with autism who were entering early intensive behavioral treatment. Duration of episodes of vocal and motor stereotypy was recorded from a videotaped 10 min portion of that assessment session. Results indicated that the 2-year-old children with autism or PDD-NOS had somewhat higher levels of stereotypic behavior than the typically developing 2-year-olds, while the 3- and 4-year-old children with autism or PDD-NOS displayed substantially higher levels stereotypic behavior than their same-age peers.

Religious Fundamentalism, Humor, and Treatment Outcomes in Individuals in Court-Mandated Substance Abuse Outpatient Treatment.

The relationship between religious fundamentalism, humor, and psychological well-being was examined with a sample of individuals ( n = 109) being treated for drug abuse in a court-mandated AA outpatient program. Three separate factors of religious fundamentalism were found through exploratory factor analysis of the Revised Religious Fundamentalism Scale, and these were named Righteous-Evil Worldview, True Religion, and Scriptural Literalism. Psychological well-being of individuals in court-mandated outpatient substance abuse treatment was found to be correlated with high levels of humor but not religious fundamentalism. Psychological well-being and humor were found to be related to satisfaction with services; no relationship was found between religious fundamentalism and satisfaction with services. One factor of religious fundamentalism, Scriptural Literalism, was found to be associated with high levels of depression and paranoia/hostility. Implications of these relationships for treatment and understanding of religious fundamentalism and psychological well-being are discussed.

Behavioral assessment of joint attention: a methodological report.

This paper describes a highly structured assessment protocol with objective behavioral measures for joint attention responding and initiation. The assessment was given to 26 children diagnosed with autism spectrum disorders and 21 typically developing children, aged two to four years. Interobserver agreement was high for all behavioral measures. Children with autism had relatively minor deficits in joint attention responding and more severe deficits in joint attention initiation, relative to typically developing children. These results replicate those reported in previous research. The protocol can be used reliably to assess behavior indicative of joint attention responding and initiation in typically developing children and children with autism.

Effect of training with neuromuscular electrical stimulation on elbow flexion strength.

Neuromuscular electrical stimulation (NMES) may be used to prevent strength loss associated with post-surgical immobilization. Most studies testing the effectiveness of NMES have trained the knee extensors. The purpose of this investigation was to test the effectiveness of NMES when training the elbow flexors. Twenty-four students were randomly assigned to one of three groups: NMES training, isometric training or control. Testing and training were completed using a Biodex™ dynamometer. After a standard warm-up, subjects were positioned on the Biodex™ with left shoulder in anatomical neutral, elbow flexed to 90(o) and forearm supinated. Subjects performed three maximum isometric contractions of 5 seconds duration, with 1 min rest between repetitions. Average peak torque during three repetitions was calculated. Subjects trained on three days per week for four weeks. Training included 15 maximum contractions of 15 seconds duration with 45 seconds recovery between repetitions. Russian current was delivered by a Forte™ 400 Combo via electrodes placed over ends of biceps brachii. A maximum tolerable ramped intensity was delivered with frequency of 90 bps and duty cycle of 15:45. After training, subjects were post-tested in a manner identical to pretest. Mean normalized strength data were analyzed using a 3 (Group) x 2 (Test) ANOVA. The Group x Test interaction was significant. Post-hoc analyses revealed that the voluntary training group (normalized means of 0.49 to 0.71 for the pretest and post-test, respectively) had a significantly greater increase than the other two groups, which were not significantly different from each other. The lack of significant strength gains with NMES was likely due to low average training intensity, which was only 20.4% of MVIC. Based on these results, NMES training may not be an effective alternative to voluntary training in healthy subjects. Key PointsTraining the elbow flexors with voluntary isometric contractions produced significantly greater strength gains than did training with NMES.Strength gains when training with NMES were no greater than with no training.The lack of strength gains with NMES was likely due to a low average training torque of 20.4% of MVIC.

National Athletic Trainers' Association Position Statement: Management of Acute Skin Trauma.

OBJECTIVE: To present recommendations for the cleansing, debridement, dressing, and monitoring of acute skin trauma in patients. BACKGROUND: Acute skin trauma is common during participation in athletic and recreational activities. Clinical decisions and intervention protocols after injury vary among athletic trainers and are often based on ritualistic practices. An understanding of cleansing, debridement, and dressing techniques; clinical features of infection and adverse reactions; and monitoring of acute skin trauma is critical for certified athletic trainers and other allied health and medical professionals to create a local wound environment that promotes healing and lessens the risk of complications. RECOMMENDATIONS: These guidelines are intended to provide the certified athletic trainer and others participating in athletic health care with specific knowledge about and recommendations for the management of acute skin trauma.

The effect of cerclage in twin gestations with short cervix: a Bayesian evaluation.

OBJECTIVE: Bayesian inference allows the revision of prior clinical estimates of treatment effectiveness based on current data. We apply it to a published dataset evaluating the effect of cerclage upon preterm delivery in twin gestations with a short cervix. STUDY DESIGN: Prior probability distributions for delivery <35 weeks gestation for the control group and the treatment (cerclage) group were constructed under assumptions ranging from treatment having no effect (prior A) to halving early deliveries (prior C). Likelihood functions were calculated based on a published meta-analysis. Posterior probability densities were derived from which risk ratios for early delivery were computed, with 95% credible intervals and the probability of cerclage benefit. RESULTS: Median posterior risk ratios (95% credible intervals) for delivery <35 weeks with cerclage are 1.51 (1.02-2.33) for prior A and 1.11 (0.72-1.77) for prior C. The probability of cerclage benefit ranged from 2.1% for prior A to 31.4% for prior C. By comparison, the conventional risk ratio (95% confidence interval) for early delivery, based on the data alone, is 2.08 (1.18-3.69). CONCLUSIONS: As might be anticipated, those with low expectation of cerclage benefit remain more convinced of the ineffectiveness (or harm) of the procedure than those with higher expectations.

Body mass index change between pregnancies and small for gestational age births.

OBJECTIVE: To estimate whether maternal weight changes between pregnancies influence the risk for small for gestational age (SGA) births. METHODS: SGA cases (n = 8,062) below the tenth percentile birth weight for gestational age were selected from liveborn singletons born of Missouri residents during 1989-1997. Normal weight controls (n = 8,062) were selected according to birth year. The risk of SGA from interpregnancy body mass index (BMI) change and other maternal factors was estimated using logistic regression analysis. RESULTS: An increase in BMI between pregnancies decreased SGA risk (adjusted odds ratio = 0.8; 95% confidence interval 0.7, 1.0). Other risk factors were prior SGA (4.4; 4.0, 4.8), preeclampsia/eclampsia (2.6; 2.1, 3.2), maternal cardiac disease (1.8; 1.1, 2.9), inadequate weight gain (1.9; 1.8, 2.2), and cigarette smoking (1.9; 1.7, 2.3 for 1-9 cigarettes per day; 2.5; 2.2, 2.8 for 10-19/d; and 2.8; 2.5, 3.3 for 20/d or more). CONCLUSION: Increase in interpregnancy BMI lowers SGA risk, but adequate weight gain during pregnancy is more effective.

Reduction in radioactive material use and waste generation at the National Institutes of Health.

The National Institutes of Health (NIH) has implemented an enhanced and comprehensive program to reduce the use of radioactive materials and to minimize the generation of radioactive and mixed wastes. The primary drivers for this program were increasing waste management costs, difficulties in disposing of certain types of radioactive wastes, particularly mixed wastes, and the increasing burden of managing radioactive materials in accordance with new regulatory requirements. These minimization efforts, coupled with the development of new on-site waste treatment options and the use of commercially available waste processing facilities, have resulted in significant reductions in the use of radioactive materials in bench research and the resultant amounts of radioactive and mixed waste generated and disposed off-site. A survey of users of radioactive materials was conducted to examine the reasons for this reduction and to predict future ordering trends. The primary factors contributing to reductions in ordering appear to be rapidly increasing use of non-radioactive research techniques, and increasingly burdensome safety and security regulations governing the use of radioactive material, which tend to discourage their use. The downward trends in use and disposal of radioactive materials at the NIH appear to be continuing.

Toward a behavioral analysis of joint attention.

Joint attention (JA) initiation is defined in cognitive-developmental psychology as a child's actions that verify or produce simultaneous attending by that child and an adult to some object or event in the environment so that both may experience the object or event together. This paper presents a contingency analysis of gaze shift in JA initiation. The analysis describes reinforcer-establishing and evocative effects of antecedent objects or events, discriminative and conditioned reinforcing functions of stimuli generated by adult behavior, and socially mediated reinforcers that may maintain JA behavior. A functional analysis of JA may describe multiple operant classes. The paper concludes with a discussion of JA deficits in children with autism spectrum disorders and suggestions for research and treatment.

Improving the Efficiency of Electrical Stimulation Activities After Spinal Cord Injury.

In order to enhance spinal cord injury (SCI) rehabilitation programs using neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES) it is important to examine the manner in which muscle fibers are recruited and the dose-response relationship. A review of the literature suggests that premature force decline and early fatigue with NMES and FES activities may be alleviated with decreased current frequency and increased current intensity. Dose-response relationships with NMES and FES are dependent on the goals of interest as reversing muscle atrophy can be achieved with activities 2-3 times per week for 6 or more weeks while increasing bone mass is more limited and requires more intense activity with greater exercise frequency and duration, e.g., 3-5 days per week for at least 6-12 months. The best known protocol to elicit neurological improvement is massed practice activities-based restorative therapies (ABRT) (3-5 h per day for several weeks).