J. E. Bullock-Saxton

Factors Involved in the Development of Osteoarthritis after Anterior Cruciate Ligament Surgery

Background The incidence of osteoarthritis after anterior cruciate ligament reconstruction is disturbingly high, with reports of nearly 50% of patients developing mild to moderate osteoarthritis 6 years after surgery. Few studies have assessed the factors involved in the development of osteoarthritis. Hypothesis: The following 10 factors will be found to be predictive of osteoarthritis meniscectomy, chondral damage, patellar tendon grafting, age at surgery, time delay between injury and surgery, type and intensity of postsurgery sport, quadriceps strength, hamstring strength, quadriceps-to-hamstring strength ratio, and residual joint laxity. Study Design Cohort study (prognosis); Level of evidence, 1. Methods Fifty-six subjects with anterior cruciate ligament reconstruction were followed for 6 years after surgery. Assessment included KT-1000 arthrometer testing, isokinetic strength testing, a return-to-sport questionnaire, and a radiograph assessment. A discriminant analysis was performed to assess which of the 10 factors could discriminate between those patients who developed tibiofemoral and patellofemoral osteoarthritis and those who did not. Results Five factors were found to be predictive of tibiofemoral osteoarthritis. Meniscectomy (r = .72) and chondral damage (r = .41) were the strongest discriminators, followed by patellar tendon grafting (r = .37) (χ2 [7, n = 56] = 25.48; P = .001). Weak quadriceps (r = .39) and low quadriceps-to-hamstring strength ratios (r = .6) were very close discriminators (χ2 [8, n = 42] = 15.02; P = .059). For patellofemoral osteoarthritis, meniscectomy (r = .45), chondral damage (r = .75), and age at surgery (r = .65) were predictors or close predictors (χ2 [7, n = 54] = 13.30; P = .065). Conclusion As not all 10 factors studied were predictive of osteoarthritis, the hypothesis was only partially proven. Preventing further meniscal and chondral damage in patients with anterior cruciate ligament deficiency is critical. Grafting using the hamstring tendons and restoration of quadriceps-to-hamstring strength balance are associated with less osteoarthritis.

A 6-Year Follow-up of the Effect of Graft Site on Strength, Stability, Range of Motion, Function, and Joint Degeneration After Anterior Cruciate Ligament Reconstruction Patellar Tendon Versus Semitendinosus and Gracilis Tendon Graft

Background The choice of graft material for anterior cruciate ligament reconstruction remains controversial. Despite the need for well-controlled, long-term outcome studies comparing patellar tendon with hamstring grafting, few studies have followed results for more than 5 years. Hypothesis Graft source will not affect outcome 6 years after reconstruction. Study Design Cohort study; Level of evidence, 2. Methods Sixty-two patients with anterior cruciate ligament reconstruction and 18 uninjured control subjects were studied over 6 years. Thirty-one patients received patellar tendon grafts, and 31 received hamstring tendon grafts. Assessment included knee joint stability, range of motion, muscle strength, subjective function, objective function (running, sidestepping, carioca, and hop tests), and joint degeneration. Results Clinical stability was restored to all patients other than to the 2 hamstring graft recipients who suffered reinjuries. The KT-1000 arthrometer side-to-side differences were similar in the patellar tendon (1.9 mm) and hamstring tendon (2.0 mm) groups but were significantly greater than that of uninjured control subjects (P < .001). There were no significant strength differences between surgical and control groups, although a 6% quadriceps deficit existed after patellar tendon grafting. In the more demanding functional tests (hop and triple-hop indices and carioca), the hamstring graft recipients performed similarly to the control group, whereas a significant difference (P < .05) existed between the patellar tendon graft and the control group. The incidence of early tibiofemoral osteoarthritis was significantly greater after reconstruction using patellar tendon (62%) than after hamstring tendon grafting (33%; P = .002). Conclusion Six-year outcomes were very satisfactory irrespective of graft source. However, reconstruction using the hamstring tendons resulted in improved functional performance and a lower incidence of osteoarthritis.

Physiotherapy After Breast Cancer Surgery: Results of a Randomised Controlled Study to Minimise Lymphoedema

The development of secondary arm lymphoedema after the removal of axillary lymph nodes remains a potential problem for women with breast cancer. This study investigated the incidence of arm lymphoedema following axillary dissection to determine the effect of prospective monitoring and early physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were made preoperatively, at day 5 and at 1, 3, 6, 12 and 24 months postoperatively. Three measurements were used for the detection of arm lymphoedema: arm circumferences (CIRC), arm volume (VOL) and multi-frequency bioimpedance (MFBIA). Clinically significant lymphoedema was confirmed by an increase of at least 200 ml from the preoperative difference between the two arms. Using this definition, the incidence of lymphoedema at 24 mo. was 21%, with a rate of 11% in the TG compared to 30% in the CG. The CIRC or MFBIA methods failed to detect lymphoedema in up to 50% of women who demonstrated an increase of at least 200 ml in the VOL of the operated arm compared to the unoperated arm. The physiotherapy intervention programme for the TG women included principles for lymphoedema risk minimisation and early management of this condition when it was identified. These strategies appear to reduce the development of secondary lymphoedema and alter its progression in comparison to the CG women. Monitoring of these women is continuing and will determine if these benefits are maintained over a longer period for women with early lymphoedema after breast cancer surgery.

The relationship between knee strength and functional stability before and after anterior cruciate ligament reconstruction.

Functional stability of the knee is dependent on an intact ligamentous system and the timely and efficient contraction of supporting musculature. The aim of this study was to assess the relationship between muscle strength and functional stability in 31 patients pre‐ and post‐operatively, following a unilateral anterior cruciate ligament rupture. All subjects underwent reconstructive surgery using semitendonosis and gracilis tendons. Isokinetic strength assessment of quadriceps and hamstring muscles was performed at a rate of movement of 60°/s and 120°/s. Functional stability was determined by performance during five functional stability tests that included the shuttle run, side step, carioca, single and triple hop tests. Pearsons correlation coefficient statistics were applied to pre‐operative and post‐operative data respectively. These analyses demonstrated a significant positive correlation between quadriceps strength indices at both testing speeds and the two hop tests pre‐operatively (ps<0.007) and between quadriceps strength indices at both speeds and all five functional tests post‐operatively (ps<0.01). Assessed using Steigers formula, there was a significant increase in the correlation between quadriceps strength indices and three functional tests post‐operatively compared to pre‐operatively (p<0.05). No significant correlation between hamstring strength indices and functional scores existed pre‐ or post‐operatively. This study has shown a significant correlation exists between quadriceps strength indices and functional stability both before and after surgery, this relationship does not reach significance between hamstring strength indices and functional stability.

Shoulder Movement After Breast Cancer Surgery: Results of a Randomised Controlled Study of Postoperative Physiotherapy

Breast screening programmes have facilitated more conservative approaches to the surgical and radiotherapy management of women diagnosed with breast cancer. This study investigated changes in shoulder movement after surgery for primary, operable breast cancer to determine the effect of elective physiotherapy intervention. Sixty-five women were randomly assigned to either the treatment (TG) or control group (CG) and assessments were completed preoperatively, at day 5 and at 1 month, 3, 6, 12 and 24 months postoperatively. The CG only received an exercise instruction booklet in comparison to the TG who received the Physiotherapy Management Care Plan (PMCP). Analyses of variance revealed that abduction returned to preoperative levels more quickly in the TG than in the CG. The TG women had 14° more abduction at 3 months and 7° at 24 months. Functional recovery at 1 month was greater in those randomised to the TG, with a dominant operated arm (OA) or receiving breast-conserving surgery. However, it was not possible to predict recovery over the 2 years postoperatively on the basis of an individual womans recovery at 1 month postoperatively. The eventual recovery of abduction or flexion range of movement was not related to the dominance of the OA nor to the surgical procedure performed. The PMCP provided in the early postoperative period is effective in facilitating and maintaining the recovery of shoulder movement over the first 2 years after breast cancer surgery.

Cervical Musculoskeletal Impairment in Frequent Intermittent Headache. Part 1: Subjects With Single Headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A dicriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.

Strength and function before and after anterior cruciate ligament reconstruction.

Rehabilitation of patients with anterior cruciate ligament injury is a topic of interest among clinicians. Although numerous studies report the deficits after anterior cruciate ligament reconstruction, there are no data available on the changes in strength and functional performance before and 6 months after reconstruction surgery. This is when most patients are returning to sports activities. In the current study 31 patients with complete unilateral anterior cruciate ligament ruptures followed a controlled rehabilitation program emphasizing early range of motion after surgery and quadriceps strengthening before and after undergoing bone-patellar tendon-bone reconstruction. Strength of the hamstrings and quadriceps and five functional activities were assessed at 1 week before and 6 months after surgery. Preoperative strength assessments using a Cybex II dynamometer showed a 12% quadriceps deficit at 60° per second and 9% deficit at 120° per second with no hamstring deficit in the injured leg compared with the uninjured leg. Despite intensive quadriceps training, the postoperative quadriceps deficit increased to 28% at 60° per second and 22% at 120° per second in comparison with the uninjured leg. There was no change in hamstring strength in the injured leg. Most functional measures improved after surgery. The shuttle run improved by 10%, the side step test results improved by 17%, and the carioca test results improved by 23%. No significant difference was found in the results of the hop test. This study highlights the extent of the quadriceps deficits despite functional improvement and the difficulty in restoring quadriceps strength after bone-patellar tendon-bone reconstruction. It also questions the relationship of current functional tests to quadriceps strength and the role of maximum strength testing as a predictor of function and of safe sporting performance.

Muscle strength and function before and after anterior cruciate ligament reconstruction using semitendonosus and gracilis.

This study assessed the quadriceps and hamstring strength before and 6 months after anterior cruciate ligament (ACL) reconstructive surgery using the hamstrings and related the findings to functional performance. Six months after surgery is a critical time for assessment as this is when players are returning to sport. Maximum isokinetic strength of 31 patients with complete unilateral ACL ruptures was measured at speeds of 60 degrees and 120 degrees per second. Functional assessment included the single hop, the triple hop, the shuttle run, side-step and carioca tests. All patients underwent a controlled quadriceps emphasized home-based physiotherapy program both before and after surgery. Results show that before surgery there was a 7.3% quadriceps strength deficit at 60 degrees per second compared to the uninjured leg but no hamstring strength deficit. After surgery there was a statistically significant but relatively small loss of muscle strength. The quadriceps strength deficit had increased to 12% and there was a 10% hamstring deficit. Post-operatively there was an 11% and 6.3% improvement in the hop tests, a 9% (P < 0.01) improvement in the shuttle run, a 15% (P < 0.001) improvement in the side step and a 24% (P < 0.001) improvement in the carioca tests (P < 0.001) despite the loss of muscle strength.

Repeatability of maximal voluntary force and of surface EMG variables during voluntary isometric contraction of quadriceps muscles in healthy subjects

The repeatability of initial values and rate of change of EMG signal mean spectral frequency (MNF), average rectified values (ARV), muscle fiber conduction velocity (CV) and maximal voluntary contraction (MVC) was investigated in the vastus medialis obliquus (VMO) and vastus lateralis (VL) muscles of both legs of nine healthy male subjects during voluntary, isometric contractions sustained for 50 s at 50% MVC. The values of MVC were recorded for both legs three times on each day and for three subsequent days, while the EMG signals have been recorded twice a day for three subsequent days. The degree of repeatability was investigated using the Fisher test based upon the ANalysis Of VAriance (ANOVA), the Standard Error of the Mean (SEM) and the Intraclass Correlation Coefficient (ICC). Data collected showed a high level of repeatability of MVC measurement (normalized SEM from 1.1% to 6.4% of the mean). MNF and ARV initial values also showed a high level of repeatability (ICC>70% for all muscles and legs except right VMO). At 50% MVC level no relevant pattern of fatigue was observed for the VMO and VL muscles, suggesting that other portions of the quadriceps might have contributed to the generated effort. These observations seem to suggest that in the investigation of muscles belonging to a multi-muscular group at submaximal level, the more selective electrically elicited contractions should be preferred to voluntary contractions.

Reflex activation of gluteal muscles in walking : an approach to restoration of muscle function for patients with low-back pain

Gluteal activation and pelvic stability often are decreased in chronic low-back pain sufferers, but the importance of motor control and programming in treatment has not been fully evaluated. This study investigated whether gluteal muscles could be activated more affectively by stimulating the proprioceptive mechanism during walking. Labile support, through wearing “balance shoes,” offered facilitation of cerabellovestibular circuits, Electromyographic recordings of gluteus maximus and medius in 15 healthy subjects were made during barefoot and balance shoes walking before and after 1 week of facilitation. Singnificant increases (P<0.0002) in gluteal activity and significant decreases(P<0.01) In time to 75% maximum contraction, demonstrated the value of sensorimotor elicitation of subconscious and automatic responses in muscles often weakened in back pain sufferers.