Jason Peeler

Accuracy and reliability of anterior cruciate ligament clinical examination in a multidisciplinary sports medicine setting.

Objective: To investigate the accuracy and reliability of anterior cruciate ligament (ACL) clinical examination in a multidisciplinary sports medicine setting. Design: Retrospective review of patient charting. Setting: Community-based multidisciplinary sports medicine clinic. Patients: One hundred twelve patients with surgically confirmed ACL tear. Interventions: Review of therapist, physician, and orthopedic surgeon charting. Main Outcome Measures: Scoring for the anterior drawer, Lachman, and pivot shift tests completed during clinical examination. Coefficient of agreement (Po) was calculated for each assessment technique to determine the interrater reliability. Sensitivity of assessment was determined by comparing patients arthroscopic surgical results against clinicians scoring. Results: On average, Po values indicated only moderate levels of interrater reliability (anterior drawer, &OV0335; = 0.57; Lachman, &OV0335; = 0.45; pivot shift, &OV0335; = 0.53), with great variation observed between clinicians scoring for each assessment technique. Accuracy testing demonstrated that the Lachman test had the highest level of sensitivity when administered by orthopedic surgeons (&OV0335; = 86%) and that sensitivity varied greatly among clinician groups and by assessment technique (range, 15%-87%). Conclusions: In sports medicine, unreliable or inaccurate clinical examination confounds the clinicians ability to make informed decisions regarding appropriate patient referral and treatment interventions. Our results indicate that levels of accuracy and reliability for clinical examination of the ACL within a multidisciplinary sports medicine setting may be much lower than previously reported within the literature. Further research is needed to clarify whether a standardized approach to ACL clinical examination could enhance levels of accuracy and reliability among clinicians working in a multidisciplinary setting.

Exercise-induced muscle growth is muscle-specific and age-dependent

Introduction: Sarcopenia, and the importance of satellite cells (SCs) in muscle growth led us to examine the effects of exercise and age on SC activation and gene expression. Methods: Eight‐ and 18‐month‐old mice were either sedentary or underwent 3 weeks of exercise (N = 24). Body mass, distance traveled, and grip strength were recorded at weekly intervals. The extensor digitorum longus (EDL), tibialis anterior (TA), gastrocnemius (GAST), and quadriceps (QUAD) muscles were analyzed along with muscle fiber area, SC activation, neuronal nitric oxide synthase (NOS‐I), MyoD, and myostatin protein content. Results: Older mice demonstrated decreased body mass, grip strength, and fiber area, but these changes were not affected by exercise. The QUAD muscle from young mice demonstrated an exercise‐induced increase in SC activation and NOS‐I and downregulation of myostatin. Conclusions: Exercise‐induced activation of SCs and regulation of gene expression are muscle‐specific and age‐dependent. Perturbed sensitivity to exercise in older mice provides insight into sarcopenia and potential treatments. Muscle Nerve, 2011

A cadaveric study of the structural anatomy of the sternoclavicular joint.

Pathologies of the sternoclavicular (SC) joint are infrequent and effective management is often hindered by a limited understanding of the anatomy. In this study, we did macroscopic evaluations of the ligaments, the intra‐articular disc, and the articulating surfaces of 25 SC joints. After removal of the joint capsule, the articulating surfaces of the sternal end of clavicle and the sternum were evaluated and the intra‐articular disc was macroscopically examined. The anterior SC ligament covered the intra‐articular disc, which divided the joint into a clavicular and a sternal part. A thin capsule, relatively lateral and medial from the anterior SC ligament, covered the two intra‐articular parts. This means that the anterior SC ligament can be used as a landmark to enter into clavicular or sternal part of the SC joint. Posteriorly, there was a thick capsule without soft‐spot or clear posterior SC ligament. Only the antero‐inferior surface of the sternal end of every clavicle was covered by cartilage. Of the intra‐articular discs 56% were incomplete. All of these incomplete discs displayed a central hole with signs of degeneration and fraying. This was associated with increased cartilage degeneration at the clavicular side. By experimental design (past and present), it would seem reasonable to assume that the incomplete types are caused by degeneration and are not developmental. Clin. Anat. 25:903–910, 2012.

Lower body positive pressure: an emerging technology in the battle against knee osteoarthritis?

Background Knee osteoarthritis (OA) is the most prevalent medical condition in individuals over the age of 65 years, and is a progressive joint degenerative condition with no known cure. Research suggests that there is a strong relationship between knee pain and loss of physical function. The resulting lifestyle modifications negatively impact not only disease onset and progression but also overall health, work productivity, and quality of life of the affected individual. Purpose The goal of this investigation was to examine the feasibility of using an emerging technology called lower body positive pressure (LBPP) to simulate weight loss and reduce acute knee pain during treadmill walking exercise in overweight individuals with radiographically confirmed symptomatic knee OA. Design Prospective case series. Methods Twenty-two overweight individuals with knee OA completed two 20-minute treadmill walking sessions (one full weight bearing and one LBPP supported) at a speed of 3.1 mph, 0% incline. Acute knee pain was assessed using a visual analog scale, and the percentage of LBPP support required to minimize knee pain was evaluated every 5 minutes. Knee Osteoarthritis Outcome Scores were used to quantify knee pain and functional status between walking sessions. The order of testing was randomized, with sessions occurring a minimum of 1 week apart. Results A mean LBPP of 12.4% of body weight provided participants with significant pain relief during walking, and prevented exacerbation of acute knee pain over the duration of the 20-minute exercise session. Patients felt safe and confident walking with LBPP support on the treadmill, and demonstrated no change in Knee Osteoarthritis Outcome Scores over the duration of the investigation. Conclusion Results suggest that LBPP technology can be used safely and effectively to simulate weight loss and reduce acute knee pain during weight-bearing exercise in an overweight knee OA patient population. These results could have important implications for the development of future treatment strategies used in the management of at-risk patients with progressive knee OA.

Managing Knee Osteoarthritis: The Effects of Body Weight Supported Physical Activity on Joint Pain, Function, and Thigh Muscle Strength.

Objective:To determine the effect of a 12-week lower body positive pressure (LBPP)-supported low-load treadmill walking program on knee joint pain, function, and thigh muscle strength in overweight patients with knee osteoarthritis (OA). Design:Prospective, observational, repeated measures investigation. Setting:Community-based, multidisciplinary sports medicine clinic. Patients:Thirty-one patients aged between 55 and 75 years, with a body mass index ≥25 kg/m2 and mild-to-moderate knee OA. Intervention:Twelve-week LBPP-supported low-load treadmill walking regimen. Main Outcome Measures:Acute knee joint pain (visual analog scale) during full weight bearing treadmill walking, chronic knee pain, and joint function [Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire] during normal activities of daily living, and thigh muscle strength (isokinetic testing). Appropriate methods of statistical analysis were used to compare data from baseline and follow-up evaluation. Results:Participants reported significant improvements in knee joint pain and function and demonstrated significant increases in thigh muscle strength about the degenerative knee. Participants also experienced significant reductions in acute knee pain during full weight bearing treadmill walking and required dramatically less LBPP support to walk pain free on the treadmill. Conclusions:Data suggest that an LBPP-supported low-load exercise regimen can be used to significantly diminish knee pain, enhance joint function, and increase thigh muscle strength, while safely promoting pain-free walking exercise in overweight patients with knee OA. These findings have important implications for the development of nonoperative treatment strategies that can be used in the management of joint symptoms associated with progressive knee OA in at-risk patient populations. Clinical Relevance:This research suggests that LBPP-supported low-load walking is a safe user-friendly mode of exercise that can be successfully used in the management of day-to-day joint symptoms associated with knee OA, helping to improve the physical health, quality of life, and social well-being of North Americas aging population.

Using digital photography to document rectus femoris flexibility: A reliability study of the modified Thomas test

Background: Research indicates that rectus femoris muscle flexibility assessment techniques suffer from multiple sources of measurement error. Objective: To examine whether scoring of rectus femoris muscle flexibility from digital photographs of clinical examination using the modified Thomas test would be highly reliable. Methods: Twenty-eight individuals were digitally photographed while having their rectus femoris muscle flexibility evaluated using the modified Thomas test. Therapists were then asked to view these digital photographs and score participants flexibility using modified Thomas test scoring criteria. A retest session was completed approximately 1-week later. Results: Kappa values for positive/negative scoring (intra-rater experienced X¯  =  0.86, in-experienced X¯  =  0.98; interrater experienced X¯  =  0.95, in-experienced X¯  =  0.99) and ICC values for goniometer scoring (intra-rater experienced X¯  =  0.98, in-experienced X¯  =  0.98; interrater experienced X¯  =  0.97, in-experienced X¯  =  0.98) indicated very high levels of reliability. Measurement error values (SEM  =  1.0°, ME  =  1.53°, and CV  =  3%) and Bland and Altman plots (with 95% limits of agreement) further illustrated the very small degree of scoring variance. Conclusions: Results indicate that goniometer and positive/negative scoring of rectus femoris muscle flexibility from digital photographs of clinical examination using the modified Thomas test were highly reliable. This finding suggests that using digital photography as a means to document patient function during clinical examination may serve as a method to help standardize physical assessment, minimize error measurement, and assist the clinician/researcher in establishing whether an observed change between testing sessions is clinically significant.

No Effect of Creatine Monohydrate Supplementation on Inflammatory and Cartilage Degradation Biomarkers in Individuals with Knee Osteoarthritis

The study purpose was to evaluate the effectiveness of creatine monohydrate supplementation (20 grams/day for 1 week and then 5 grams/day for 11 weeks) on inflammation (C-reactive protein, interleukin-1β, interleukin-6, s100 A8/A9, and tumor necrosis factor-α) and cartilage degradation (serum cartilage oligomeric matrix protein) in patients with knee osteoarthritis. We hypothesized that supplementing with creatine monohydrate for 12 weeks would lower biomarkers of inflammation and cartilage degradation in patients with knee osteoarthritis when compared to placebo. A total of 18 patients with mild to moderate knee osteoarthritis were recruited and randomized in a double blind fashion to either a creatine supplementation group (N = 9) or a placebo (N = 9). At baseline and after 12 weeks of supplementation patients had inflammatory and cartilage degradation biomarkers measured in the systemic blood. Further, patients completed the Knee injury and Osteoarthritis Outcome (KOOS) questionnaire as well as had their isometric thigh strength evaluated using an isokinetic dynamometer at both time points. Results indicated that there was no difference between the creatine and placebo groups at 12 week follow up in the inflammatory biomarkers measured nor was there any difference between the groups for cartilage degradation (all P>.05). No statistical differences were noted for the KOOS questionnaire subscales or total score (all P>.05). Muscle strength testing indicated a main effect of time for both groups where isometric thigh strength at 0° of knee flexion was lowered significantly (P=.047). No other significant differences were found in the strength data. We conclude that 12 weeks of supplementation with creatine monohydrate does not affect inflammatory biomarkers, cartilage degradation, KOOS scores, or muscle strength in patients with mild to moderate knee osteoarthritis.

Surgeon – Therapist Communication: Do All Members See Eye-to-Eye?

Abstract Background. Poor interprofessional collaboration has been shown to negatively affect patient care within many fields of medicine. Growing evidence is suggesting that improved interprofessional collaboration can positively affect patient care. Postoperative rehabilitation of many orthopedic conditions necessitates the combined efforts of surgeons, and therapists. There is a paucity of literature examining collaboration among orthopedic surgeons and therapists regarding postoperative rehabilitation. Objectives. The following study examines the perceived quality of communications between orthopedic surgeons and therapists employing an online survey. We hypothesized that collaborative practice patterns result in improved perceptions of communication. Methods. Ethics board approval was obtained. Subjects consisted of orthopedic surgeons, licensed physiotherapists and certified athletic therapists. The online survey was distributed through the Canadian Orthopaedic Association (COA), the Canadian Physiotherapy Association (CPA) and the Canadian Athletic Therapists Association (CATA). Data analysis was performed using Stata/IC 12.1 (Stata Corp, College Station, TX, USA). Descriptive statistics were calculated to determine the median responses and ranges. Median responses were compared using the Kruskal–Wallis one-way analysis of variance. Qualitative analysis regarding text responses was performed by three reviewers. Results. Reponses were received from all specialties (COA 164, CPA 524, CATA 163). There were significant differences in the perceived quality of communication by quantitative and qualitative analysis (p < 0.001). Analysis of communication within practice patterns of stand-alone versus collaborative revealed improved perception of communication quality with increased contact. 65.6% of responders that practiced as stand-alone had a negative view of interprofessional communication. 48.4% of responders in a collaborative practice had a positive view of interprofessional communication. Analysis of the preferred form of communication found that orthopedic surgeons felt the most useful referral information was a pre-printed consult sheet (odds ratio [OR] = 1.56, p < 0.001), whereas therapists were more likely to rank consult notes (OR = 1.27, p < 0.042) and operative reports (OR = 1.20, p < 0.092) as a more useful form of communication. Conclusions. Collaborative practice shows improved perceptions of communication between specialties. Orthopedic surgeons perceive a higher quality of communication than therapists. Therapists and orthopedic surgeons also do not agree on the information that should be relayed between the specialties regarding postoperative rehabilitation.BACKGROUND Poor interprofessional collaboration has been shown to negatively affect patient care within many fields of medicine. Growing evidence is suggesting that improved interprofessional collaboration can positively affect patient care. Postoperative rehabilitation of many orthopedic conditions necessitates the combined efforts of surgeons, and therapists. There is a paucity of literature examining collaboration among orthopedic surgeons and therapists regarding postoperative rehabilitation. OBJECTIVES The following study examines the perceived quality of communications between orthopedic surgeons and therapists employing an online survey. We hypothesized that collaborative practice patterns result in improved perceptions of communication. METHODS Ethics board approval was obtained. Subjects consisted of orthopedic surgeons, licensed physiotherapists and certified athletic therapists. The online survey was distributed through the Canadian Orthopaedic Association (COA), the Canadian Physiotherapy Association (CPA) and the Canadian Athletic Therapists Association (CATA). Data analysis was performed using Stata/IC 12.1 (Stata Corp, College Station, TX, USA). Descriptive statistics were calculated to determine the median responses and ranges. Median responses were compared using the Kruskal-Wallis one-way analysis of variance. Qualitative analysis regarding text responses was performed by three reviewers. RESULTS Responses were received from all specialties (COA 164, CPA 524, CATA 163). There were significant differences in the perceived quality of communication by quantitative and qualitative analysis (p < 0.001). Analysis of communication within practice patterns of stand-alone versus collaborative revealed improved perception of communication quality with increased contact. 65.6% of responders that practiced as stand-alone had a negative view of interprofessional communication. 48.4% of responders in a collaborative practice had a positive view of interprofessional communication. Analysis of the preferred form of communication found that orthopedic surgeons felt the most useful referral information was a pre-printed consult sheet (odds ratio [OR] = 1.56, p < 0.001), whereas therapists were more likely to rank consult notes (OR = 1.27, p < 0.042) and operative reports (OR = 1.20, p < 0.092) as a more useful form of communication. CONCLUSIONS Collaborative practice shows improved perceptions of communication between specialties. Orthopedic surgeons perceive a higher quality of communication than therapists. Therapists and orthopedic surgeons also do not agree on the information that should be relayed between the specialties regarding postoperative rehabilitation.

The effect of low-load exercise on joint pain, function, and activities of daily living in patients with knee osteoarthritis

BACKGROUND Knee osteoarthritis has a lifetime risk of nearly one in two, with obese individuals being most susceptible. While exercise is universally recognized as a critical component for management, unsafe or ineffective exercise frequently leads to exacerbation of joint symptoms. AIM Evaluate the effect of a 12week lower body positive pressure (LBPP) supported low-load treadmill walking program on knee pain, joint function, and performance of daily activities in patients with knee osteoarthritis (OA). DESIGN Prospective, observational, repeated measures investigation. SETTING Community based, multidisciplinary musculoskeletal medicine clinic. PATIENTS Thirty-one patients, aged 50-75, with a BMI ≥25kg/m2 and radiographic confirmed mild to moderate knee OA. INTERVENTION Twelve week LBPP treadmill walking exercise regimen. OUTCOME MEASURES The Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Canadian Occupational Performance Measure (COPM) were used to quantify joint symptoms and patient function; isokinetic thigh muscle strength was evaluated; and a 10-point VAS was used to quantify acute knee pain while walking. Baseline and follow-up data were compared in order to examine the effect of the 12week exercise intervention. RESULTS There was a significant difference between baseline and follow-up data: KOOS and COPM scores both improved; thigh muscle strength increased; and acute knee pain during full weight bearing walking diminished significantly. CONCLUSIONS Participation in a 12week LBPP supported treadmill walking exercise regimen significantly enhanced patient function and quality of life, as well as the ability to perform activities of daily living that patients self-identified as being important, yet difficult to perform.

The systemic myokine response of decorin, interleukin-6 (IL-6) and interleukin-15 (IL-15) to an acute bout of blood flow restricted exercise

PurposeBlood flow restricted resistance exercise (BFR-RE) is an emerging hypertrophy training modality. A complete profile of its mechanisms of action has yet to be elucidated. Cytokines are universal intercellular messengers. Recent research has implicated certain cytokines (termed “myokines”) in skeletal muscle hypertrophy pathways; however, little research has been conducted on the systemic myokine response to BFR-RE as potential hypertrophic biomarkers. Therefore, this project was conducted to determine any differences in the systemic myokine response between BFR-RE and control conditions.MethodsThe appearance of systemic myokines interleukin-6 (IL-6), interleukin-15 (IL-15), and decorin were measured following acute bouts of low-load resistance exercise, BFR-RE, and high-load resistance exercise in physically active young males to determine if BFR-RE modifies the exercise-induced systemic myokine response.ResultsNo measurable levels of IL-6 were observed during the project. No significant effects were observed for IL-15. A significant time (11.91% increase pre to post exercise; p < 0.05) but no condition or condition by time effect was observed for decorin.ConclusionThese findings suggest that BFR-RE does not modify the systemic myokine appearance of IL-6, IL-15, or decorin when compared to control conditions.