Juliana M. Ocarino

Complex systems approach for sports injuries: moving from risk factor identification to injury pattern recognition—narrative review and new concept

Injury prediction is one of the most challenging issues in sports and a key component for injury prevention. Sports injuries aetiology investigations have assumed a reductionist view in which a phenomenon has been simplified into units and analysed as the sum of its basic parts and causality has been seen in a linear and unidirectional way. This reductionist approach relies on correlation and regression analyses and, despite the vast effort to predict sports injuries, it has been limited in its ability to successfully identify predictive factors. The majority of human health conditions are complex. In this sense, the multifactorial complex nature of sports injuries arises not from the linear interaction between isolated and predictive factors, but from the complex interaction among a web of determinants. Thus, the aim of this conceptual paper was to propose a complex system model for sports injuries and to demonstrate how the implementation of complex system thinking may allow us to better address the complex nature of the sports injuries aetiology. According to this model, we should identify features that are hallmarks of complex systems, such as the pattern of relationships (interactions) among determinants, the regularities (profiles) that simultaneously characterise and constrain the phenomenon and the emerging pattern that arises from the complex web of determinants. In sports practice, this emerging pattern may be related to injury occurrence or adaptation. This novel view of preventive intervention relies on the identification of regularities or risk profile, moving from risk factors to risk pattern recognition.

Myofascial force transmission between the latissimus dorsi and gluteus maximus muscles: An in vivo experiment

There are extensive connections between the latissimus dorsi (LD) and gluteus maximus (GMax) muscles and the thoracolumbar fascia (TLF), which suggests a possible pathway for myofascial force transmission. The present study was designed to provide empirical evidence of myofascial force transmission from LD to contralateral GMax through TFL in vivo. To accomplish this goal, we evaluated whether active or passive tensioning of the LD results in increased passive tension of the contralateral GMax, indexed by changes in the hip resting position (RP) or passive stiffness. The hip RP was defined as the angular position in which the passive joint torque equals zero, and passive hip stiffness was calculated as the change in passive torque per change in joint angle. Thirty-seven subjects underwent an assessment of their passive hip torque against medial rotation by means of an isokinetic dynamometer. These measures were carried out under three test conditions: (1) control, (2) passive LD tensioning and (3) active LD tensioning. Electromyography was used to monitor the activity of the hip muscles and the LD under all conditions. Repeated measures analyses of variance demonstrated that passive LD tensioning shifted the hip RP towards lateral rotation (p=0.009) but did not change the passive hip stiffness (p>0.05). Active LD tensioning shifted the hip RP towards lateral rotation (p<0.001) and increased the passive hip stiffness (p≤0.004). The results demonstrated that manipulation of the LD tension modified the passive hip variables, providing evidence of myofascial force transmission in vivo.

Stretching versus strength training in lengthened position in subjects with tight hamstring muscles: A randomized controlled trial

Stretching is used to modify muscle length. However, its effects seem to be temporary. There is evidence in animal models that strengthening in a lengthened position may induce long lasting changes in muscle length. The objective of this study was to compare changes in hamstrings flexibility, peak torque angle and stretch tolerance after two training programs: stretching and strengthening in a lengthened position. Forty-five subjects with tight hamstrings were randomly assigned into three groups: control, stretching and strength training in lengthened position. The interventions were performed three times a week for eight weeks. The subjects were assessed before and after the end of the programs. Data provided by an isokinetic dynamometer were used to assess hamstrings flexibility, peak torque angle, and stretch tolerance. The data analysis demonstrated that strengthening in lengthened position changed peak torque angle in the direction of knee extension (p=0.001). No change in flexibility was observed (p=0.449). Both experimental groups showed an increase in stretch tolerance (p=0.001). The results demonstrated that strengthening in a lengthened position produced a shift of the torque-angle curve, which suggests an increase in muscle length. Conversely, stretching did not produce modification of torque-angle curve and flexibility; its effects appear restricted to increases in stretch tolerance.

Correlação entre um questionário de desempenho funcional e capacidade física em pacientes com lombalgia

CONTEXTUALIZACAO: A lombalgia e um conjunto de manifestacoes dolorosas que pode acarretar limitacoes em varios aspectos da vida de um individuo. O modelo de Classificacao Internacional de Funcionalidade, Incapacidade e Saude (CIF) proposto pela Organizacao Mundial da Saude (OMS) fornece uma estrutura para o entendimento da funcionalidade e da incapacidade associadas aos estados de saude, possibilitando uma descricao significativa da saude de um individuo. A CIF utiliza os termos capacidade e desempenho para se referir a aspectos distintos da funcao e para diferenciar o estado funcional dos pacientes. Na pratica clinica, e necessario saber se existe uma associacao entre esses distintos aspectos. OBJETIVOS: Analisar a correlacao entre o questionario de desempenho funcional de Roland Morris e os testes de capacidade fisica (sentado para de pe e a caminhada de 15,24 metros) em pacientes com lombalgia. METODOS: Trinta pacientes com diagnostico de lombalgia, media de idade de 43,16 anos, foram avaliados com o Roland Morris e os testes de capacidade. RESULTADOS: A analise de correlacao de Pearson demonstrou correlacao significativa, porem fraca entre o escore do Roland Morris e o Teste Sentado para de Pe (r=0,38; p=0,0388). Nao foi observada uma correlacao significativa entre o escore do questionario e o teste de caminhada de 15,24 m (r=0,24; p=0,1862). CONCLUSAO: Esses resultados indicam a necessidade de se utilizarem instrumentos que avaliem ambos os aspectos (capacidade e desempenho) em pacientes com lombalgia, para que se possa definir um perfil funcional mais completo desses individuos.

Caracterização da performance muscular em atletas profissionais de futebol

INTRODUCTION AND OBJECTIVE: The association of muscular performance with risk of injury and functional performance in different sports has been reported in numerous studies in the literature. However, there is a paucity of data that characterizes the muscular performance in Brazilian professional soccer athletes. Therefore, the objective of this study was to make a descriptive analysis of parameters related to the muscular performance of this population. METHODS: The sample of this study was composed of 117 athletes belonging to professional soccer clubs in Minas Gerais State. In order to evaluate the muscular performance of the athletes, an isokinetic dynamometer was used and the tests involved maximum voluntary contractions of the selected muscles. Hip abductors and adductors were assessed at the speeds of 30o/s, 60o/s and 120o/s; knee flexors and extensors at 60o/s, 180o/s and 300o/s; and ankle dorsiflexors, plantarflexors, invertors and evertors at 30o/s, 60o/s and 180o/s. Descriptive statistics were used to present the normative data and paired t-tests were used to identify significant differences between legs considering the parameters evaluated in this study. RESULTS: This study generated normative data to characterize the profile of Brazilian professional soccer players relative to their capacity of producing torque, muscle work and power. Significant differences were observed between legs considering some of the studys variables. CONCLUSION: The established normative data can be used as reference values in the prevention, training and rehabilitation of the athletes. In addition, these data may be used as reference for future studies with the objective of testing the association between muscular performance and incidence of injury in soccer practice.

Foot and Hip Contributions to High Frontal Plane Knee Projection Angle in Athletes: A Classification and Regression Tree Approach

STUDY DESIGN Cross-sectional. OBJECTIVE To investigate predictors of increased frontal plane knee projection angle (FPKPA) in athletes. BACKGROUND The underlying mechanisms that lead to increased FPKPA are likely multifactorial and depend on how the musculoskeletal system adapts to the possible interactions between its distal and proximal segments. Bivariate and linear analyses traditionally employed to analyze the occurrence of increased FPKPA are not sufficiently robust to capture complex relationships among predictors. The investigation of nonlinear interactions among biomechanical factors is necessary to further our understanding of the interdependence of lower-limb segments and resultant dynamic knee alignment. METHODS The FPKPA was assessed in 101 athletes during a single-leg squat and in 72 athletes at the moment of landing from a jump. The investigated predictors were sex, hip abductor isometric torque, passive range of motion (ROM) of hip internal rotation (IR), and shank-forefoot alignment. Classification and regression trees were used to investigate nonlinear interactions among predictors and their influence on the occurrence of increased FPKPA. RESULTS During single-leg squatting, the occurrence of high FPKPA was predicted by the interaction between hip abductor isometric torque and passive hip IR ROM. At the moment of landing, the shank-forefoot alignment, abductor isometric torque, and passive hip IR ROM were predictors of high FPKPA. In addition, the classification and regression trees established cutoff points that could be used in clinical practice to identify athletes who are at potential risk for excessive FPKPA. CONCLUSION The models captured nonlinear interactions between hip abductor isometric torque, passive hip IR ROM, and shank-forefoot alignment.

Prestress revealed by passive co-tension at the ankle joint.

This study was designed to test the assumption that elastic tissues of the ankle are prestressed, by investigating the presence of simultaneous opposite passive elastic moments and thus, passive co-tension, at the ankle joint. A prestressed two-spring model used to generate qualitative predictions of the effects of stretching the posterior elastic structures of the ankle on the net passive moment of this joint was used. Twenty-seven healthy individuals were subjected to passive evaluation of the net elastic moment of the ankle in the sagittal plane, with the knee positioned at 90 degrees, 60 degrees, 30 degrees and 0 degrees of flexion, in order to change the length of the posterior biarticular elastic structures. The placement of the knee in the more extended positions caused changes in the net passive moment as predicted by the prestressed model. The ankle position in which the net passive moment was equal to zero was shifted to more plantar flexed positions (p<0.001) and there was a global increase in ankle stiffness since both passive dorsiflexion stiffness (p< or =0.037) and passive plantar flexion stiffness (p< or =0.029) increased. The normalized terminal plantar flexion stiffness also increased (p< or =0.047), suggesting that biarticular posterior elastic structures are pre-strained and still under tension when the ankle is maximally plantar flexed and the knee is positioned at 60 degrees of flexion. Resting positions were indicative of equilibrium between opposite passive elastic moments. The results revealed that there is passive co-tension at the ankle, demonstrating the existence of prestress in elastic structures of this joint.

Muscle co-contraction after anterior cruciate ligament reconstruction: Influence of functional level

BACKGROUND ACL reconstruction is recommended to improve function in subjects with ligament injuries. However, after surgery, some individuals are not able to return to their pre-injury functional level. The mechanisms related to this incapacity are not well understood. STUDY DESIGN Cross-sectional study. METHODS Co-contraction levels were assessed in individuals who returned to their pre-injury functional level and in 10 individuals who were not able to return to full activity after unilateral ACL reconstruction. Electromyography of the vastus lateralis and biceps femoris muscles before and after sudden perturbations applied during the stance phase of walking was used to calculate co-contraction. RESULTS The involved limb had lower co-contraction pre-perturbation than the non-involved limb in both groups (p=0.049). The co-contraction level post-perturbation was significantly higher in the limited return group than in the full return group (p=0.03). CONCLUSION Decreased co-contraction in the involved limb before perturbation may be caused by sensorial changes resulting from surgery or injury. Increased co-contraction levels observed in the limited return group after perturbation may be a compensatory mechanism to make up for possible decreased intrinsic stability of the knee joint. CLINICAL RELEVANCE Increased co-contraction after perturbation does not contribute to knee stability.

Contributions of Cocontraction and Eccentric Activity to Stiffness Regulation

Individuals commonly adjust joint stiffness in response to changes in environmental and task demands. The objective of the present study was to evaluate the contribution of muscular cocontraction and eccentric activity to this adjustment. In all, 30 healthy volunteers participated in the present study. The authors indirectly manipulated elbow stiffness by modifying (a) the frequency of forearm movements (frequency conditions) and (b) the kinetic properties of the forearm through the addition of external mass (mass conditions). Multilevel regression models identified muscular cocontraction and eccentric activity as predictors of joint stiffness in the frequency conditions but not in the mass conditions. Results indicated that cocontraction is not the sole mechanism for stiffness regulation. Rather, the mechanisms that different participants used varied as a function of the demands of the task.

Proprioception in Individuals with ACL-Deficient Knee and Good Muscular and Functional Performance

The objective of this study was to verify whether proprioception is affected in individuals with ACL-deficient knees and good functional and muscular performances. Eleven subjects with ACL injury and 11 controls participated in the study. Functional performance was assessed using the Cincinnati Knee Rating System (CKRS), hop index, and figure-eight ratio. An isokinetic test was done to evaluate muscular performance. Proprioception was evaluated through position sense and threshold tests. Analyses of variance were used for data analysis. The injured subjects scored significantly lower in the CKRS (p = 0.001). No statistically significant differences were found in the hop index, in the figure-eight ratio, or in peak torque. There were no statistically significant differences in proprioception between groups and between legs. These results indicated that the individuals evaluated in this study with ACL injury and good functional and muscular performance did not have proprioceptive deficits, suggesting that the ligament mechanoreceptors, in some cases, might not contribute relevantly to proprioception. This work was partially supported through grants conferred to the first author by Brazilian government agencies CNPq and FAPEMIG and by the Universidade Federal de Minas Gerais (PRPq). We would also like to thank CNPq and PRPq agencies for the scholarships conferred to the second and third authors.