Neal R. Glaviano

Comparison of rectal and aural core body temperature thermometry in hyperthermic, exercising individuals: a meta-analysis.

OBJECTIVE To compare mean differences in core body temperature (T(core)) as assessed via rectal thermometry (T(re)) and aural thermometry (T(au)) in hyperthermic exercising individuals. DATA SOURCES PubMed, Ovid MEDLINE, SPORTDiscus, CINAHL, and Cochrane Library in English from the earliest entry points to August 2009 using the search terms aural, core body temperature, core temperature, exercise, rectal, temperature, thermistor, thermometer, thermometry, and tympanic. Study Selection: Original research articles that met these criteria were included: (1) concurrent measurement of T(re) and T(au) in participants during exercise, (2) minimum mean temperature that reached 38°C by at least 1 technique during or after exercise, and (3) report of means, standard deviations, and sample sizes. DATA EXTRACTION Nine articles were included, and 3 independent reviewers scored these articles using the Physiotherapy Evidence Database (PEDro) scale (mean = 5.1 ± 0.4). Data were divided into time periods pre-exercise, during exercise (30 to 180 minutes), and postexercise, as well as T(re) ranges <37.99°C, 38.00°C to 38.99°C, and >39.00°C. Means and standard deviations for both measurement techniques were provided at all time intervals reported. Meta-analysis was performed to determine pooled and weighted mean differences between T(re) and T(au). DATA SYNTHESIS The T(re) was conclusively higher than the T(au) pre-exercise (mean difference [MD] = 0.27°C, 95% confidence interval [CI] = 0.15°C, 0.39°C), during exercise (MD = 0.96°C, 95% CI = 0.84°C, 1.08°C), and postexercise (MD = 0.71°C, 95% CI = 0.65°C, 0.78°C). As T(re) measures increased, the magnitude of difference between the techniques also increased with an MD of 0.59°C (95% CI = 0.53°C, 0.65°C) when T(re) was <38°C; 0.79°C (95% CI = 0.72°C, 0.86°C) when T(re) was between 38.0°C and 38.99°C; and 1.72°C (95% CI = 1.54°, 1.91°C) when T(re) was >39.0°C. CONCLUSIONS The T(re) was consistently greater than T(au) when T(core) was measured in hyperthermic individuals before, during, and postexercise. As T(core) increased, T(au) appeared to underestimate T(core) as determined by T(re). Clinicians should be aware of this critical difference in temperature magnitude between these measurement techniques when assessing T(core) in hyperthermic individuals during or postexercise.

Patellofemoral pain: epidemiology, pathophysiology, and treatment options.

Patients with anterior knee pain present a complex and common problem to health care providers. The diagnosis and treatment of these patients often involve a comprehensive evaluation that includes assessing the chronicity of the pain, the specific location of the complaint, and the previous treatment modalities attempted by the patient. This common diagnosis includes a wide variety of different pathologic abnormalities that can be present independently or concomitantly and cause a spectrum of disabilities for the patient.

Supervised Rehabilitation Versus Home Exercise in the Treatment of Acute Ankle Sprains: A Systematic Review

In competitive sports medicine, supervised rehabilitation is the standard of care; in the general population, unsupervised home exercise is more common. We systematically reviewed randomized, controlled trials comparing outcomes for supervised rehabilitation versus home exercise programs. Supervised rehabilitation programs resulted in (1) less pain and subjective instability, (2) greater gains in ankle strength and joint position sense, and (3) inconclusive results regarding prevention of recurrent ankle sprains. We recommend supervised rehabilitation over home exercise programs owing to the improved short-term patient-recorded evidence with a strength-of-recommendation taxonomy level of evidence of 2B.

Current Trends in the Management of Lateral Ankle Sprain in the United States

Objective: To characterize trends in the acute management (within 30 days) after lateral ankle sprain (LAS) in the United States. Design: Descriptive epidemiology study. Patients: Of note, 825 718 ankle sprain patients were identified; 96.2% were patients with LAS. Seven percent had an associated fracture and were excluded from the remaining analysis. Setting: Primary and tertiary care settings. Interventions: We queried a database of national health insurance records for 2007 to 2011 by ICD-9 codes for patients with LAS while excluding medial and syndesmotic sprains and any LAS with an associated foot or ankle fracture. Main Outcome Measures: The percentage of patients to receive specific diagnostic imaging, orthopedic devices, or physical therapy treatments within 30 days of the LAS diagnosis and the associated costs. Results: Over two-thirds of patients with LAS without an associated fracture received radiographs, 9% received an ankle brace, 8.1% received a walking boot, 6.5% were splinted, and 4.8% were prescribed crutches. Only 6.8% received physical therapy within 30 days of their LAS diagnosis, 94.1% of which performed therapeutic exercise, 52.3% received manual therapy, and 50.2% received modalities. The annual cost associated with physician visits, diagnostic imaging, orthopedic devices, and physical therapy was 152 million USD, 81.5% was from physician evaluations, 7.9% from physical therapy, 7.2% from diagnostic imaging, and 3.4% from orthopedic devices. Conclusions: Most patients with LAS do not receive supervised rehabilitation. The small proportion of patients with LAS to receive physical therapy get rehabilitation prescribed in accordance with clinical practice guidelines. The majority (>80%) of the LAS financial burden is associated with physician evaluations.

Can the Use of Neuromuscular Electrical Stimulation Be Improved to Optimize Quadriceps Strengthening

Context: Neuromuscular electrical stimulation (NMES) is a common modality used to retrain muscles and improve muscular strength after injury or surgery, particularly for the quadriceps muscle. There are parameter adjustments that can be made to maximize the effectiveness of NMES. While NMES is often used in clinical practice, there are some limitations that clinicians should be aware of, including patient discomfort, muscle fatigue, and muscle damage. Evidence Acquisition: PubMed was searched through August 2014 and all articles cross-referenced. Study Design: Clinical review. Level of Evidence: Level 3. Results: Clinicians can optimize torque production and decrease discomfort by altering parameter selection (pulse duration, pulse frequency, duty cycle, and amplitude). Pulse duration of 400 to 600 µs and a pulse frequency of 30 to 50 Hz appear to be the most effective parameters to optimize torque output while minimizing discomfort, muscle fatigue, or muscle damage. Optimal electrode placement, conditioning programs, and stimulus pattern modulation during long-term NMES use may improve results. Conclusion: Torque production can be enhanced while decreasing patient discomfort and minimizing fatigue.

Utilization of Physical Therapy Intervention Among Patients With Plantar Fasciitis in the United States

• STUDY DESIGN: Retrospective observational study. • BACKGROUND: Plantar fasciitis is responsible for 1 million ambulatory patient care visits annually in the United States. Few studies have investigated practice patterns in the treatment of patients with plantar fasciitis. • OBJECTIVE: To assess physical therapist utilization and employment of manual therapy and supervised rehabilitation in the treatment of patients with plantar fasciitis. • METHODS: A retrospective review of the PearlDiver patient record database was used to evaluate physical therapist utilization and use of manual therapy and supervised rehabilitation in patients with plantar fasciitis between 2007 and 2011. An International Classification of Diseases code (728.71) was used to identify plantar fasciitis, and Current Procedural Terminology codes were used to identify evaluations (97001), manual therapy (97140), and rehabilitation services (97110, 97530, 97112). • RESULTS: A total of 819 963 unique patients diagnosed with plantar fasciitis accounted for 5 739 737 visits from 2007 to 2011, comprising 2.7% of all patients in the database. Only 7.1% (95% confidence interval: 7.0%, 7.1%) of patients received a physical therapist evaluation. Of the 57 800 patients evaluated by a physical therapist (59.8% female), 50 382 (87.2% ± 0.4%) received manual therapy, with significant increases in utilization per annum. A large proportion (89.5% ± 0.4%) received rehabilitation following physical therapist evaluation. • CONCLUSION: Despite plantar fasciitis being a frequently occurring musculoskeletal condition, a small proportion of patients with plantar fasciitis were seen by physical therapists. Most patients who were evaluated by a physical therapist received manual therapy and a course of supervised rehabilitation as part of their plan of care. • LEVEL OF EVIDENCE: Treatment, level 2a.

Immediate Effect of Patterned Electrical Neuromuscular Stimulation on Pain and Muscle Activation in Individuals With Patellofemoral Pain

CONTEXT For individuals with patellofemoral pain (PFP), altered muscle activity and pain are common during functional tasks. Clinicians often seek interventions to improve muscle activity and reduce impairments. One intervention that has not been examined in great detail is electrical stimulation. OBJECTIVE To determine whether a single patterned electrical neuromuscular stimulation (PENS) treatment would alter muscle activity and pain in individuals with PFP during 2 functional tasks, a single-legged squat and a lateral step down. DESIGN Cohort study. SETTING Sports medicine research laboratory. PATIENTS OF OTHER PARTICIPANTS: A total of 22 individuals with PFP (15 women, 7 men; age = 26.0 ± 7.9 years, height = 173.8 ± 8.1 cm, mass = 75.1 ± 17.9 kg). INTERVENTION(S) Participants were randomized into 2 intervention groups: a 15-minute PENS treatment that produced a strong motor response or a 15-minute 1-mA subsensory (sham) treatment. MAIN OUTCOME MEASURE(S) Before and immediately after the intervention, we assessed normalized electromyography amplitude, percentage of activation time across functional tasks, and onset of activation for the vastus medialis oblique, vastus lateralis, gluteus medius, adductor longus, biceps femoris, and medial gastrocnemius muscles during a single-legged squat and a lateral step down. Scores on the visual analog scale for pain were recorded before and after the intervention. RESULTS After a single treatment of PENS, the percentage of gluteus medius activation increased (0.024) during the lateral step down. Visual analog scores decreased during both the single-legged squat (PENS: preintervention = 2.7 ± 1.9, postintervention = 0.9 ± 0.7; sham: preintervention = 3.2 ± 1.6, postintervention = 2.8 ± 1.9; group × time interaction: P = .041) and lateral step down (PENS: preintervention = 3.4 ± 2.4, postintervention = 1.1 ± 0.8; sham: preintervention = 3.9 ± 1.7, postintervention = 3.3 ± 2.0; group × time interaction: P = .023). No changes in electromyography or pain measures were noted in the sham group. CONCLUSIONS The PFP participants who received PENS had immediate improvement in gluteus medius activation and a reduction in pain during functional tasks.

Impairment based rehabilitation for patellofemoral pain patients

ABSTRACT Patellofemoral pain is a common knee pathology that affects a wide range of active individuals. These individuals often seek medical care, with 25% of all patients seen in sports medicine clinics being treated for patellofemoral pain. While conservative treatment produce beneficial short-term results, individuals with patellofemoral pain often have long-term pain and decreased quality of life for many years following their diagnosis. One of the challenges for treating this chronic condition is the heterogeneous presentation of impairments across patients, ranging from soft tissue restriction, muscle weakness, altered movement patterns during functional tasks, and weak core stability. Clinicians need to identify these impairments and develop an individualized impairment-based model for treating patients with PFP. The aim of this review it to provide guidance and recommendations for clinicians who treat PFP in hopes to improve long-term outcomes for the conservative treatment of PFP.

Improvements in kinematics, muscle activity and pain during functional tasks in females with patellofemoral pain following a single patterned electrical stimulation treatment.

BACKGROUND Individuals with patellofemoral pain present with altered hip muscle activation, faulty movement patterns, and pain during functional tasks. Examining new treatment options to address these impairments may better treat those with patellofemoral pain. The purpose of this study was to determine if patterned electrical stimulation to the lower extremity affects muscle activity, movement patterns, and pain following a single treatment. METHODS Fifteen females with patellofemoral pain were randomized to receive a single 15-minute treatment of either a patterned electrical neuromuscular stimulation or a sham. Peak kinematics of the knee, hip, and trunk, electromyography and pain were examined pre and post-intervention during a single leg squat and lateral step-down task. Group means and pre/post reduced kinematic values were also plotted during the entire task with 90% confidence intervals to identify differences in movement strategies. FINDINGS No baseline differences were found in peak kinematics between groups. No pre to post-intervention differences in peak knee, hip and trunk kinematics were found, however differences were seen when the quality of movement across the entire tasks was assessed. The electrical stimulation group had improved knee flexion and hip abduction during the lateral step-down. A significant improvement in gluteus medius activation following patterned electrical neuromuscular stimulation occurred during the step-down (P=0.039). Significant pain improvements were also seen in both the single leg squat (P=0.025) and lateral step-down (P=0.006). INTERPRETATION A single treatment of patterned electrical neuromuscular stimulation improved muscle activation, lower extremity kinematics during functional tasks, and pain.