Scott F. Nadler

The relationship between lower extremity injury, low back pain, and hip muscle strength in male and female collegiate athletes.

ObjectiveTo determine the relationship of previous lower extremity (LE) injury and/or low back pain (LBP) on hip abduction and extension strength. DesignCohort study of college athletes at time of preparticipation screening physical. SettingAn NCAA Division I college. ParticipantsTwo hundred ten college athletes (140 males and 70 females) from an NCAA Division I school. Main Outcome MeasuresMean and maximal hip abduction and extension strengths were recorded using a specially designed dynamometer anchoring station. Previous injury to the LE or LBP in the past year was recorded via personal interview at the time of screening and verified by review of previous injury records. ResultsA significant difference in side-to-side symmetry of maximum hip extension strength was observed in female subjects who reported LE injury or LBP as compared to those who did not. Side-to-side difference in hip strength, however, did not differ between male athletes, regardless of reported LE injury or LBP status. ConclusionFemale athletes appear to have a differing response of the proximal hip musculature to LE injury or LBP, as compared with their male counterparts. Research is under way to further validate these findings. Clinical RelevanceThis study provides some reasoning to support the screening of hip strength during the preparticipation physical, as it may be important in the prevention of LE injury and LBP in collegiate athletes.

Hip muscle imbalance and low back pain in athletes: influence of core strengthening

PURPOSE The influence of a core-strengthening program on low back pain (LBP) occurrence and hip strength differences were studied in NCAA Division I collegiate athletes. METHODS In 1998, 1999, and 2000, hip strength was measured during preparticipation physical examinations and occurrence of LBP was monitored throughout the year. Following the 1999-2000 preparticipation physicals, all athletes began participation in a structured core-strengthening program, which emphasized abdominal, paraspinal, and hip extensor strengthening. Incidence of LBP and the relationship with hip muscle imbalance were compared between consecutive academic years. RESULTS After incorporation of core strengthening, there was no statistically significant change in LBP occurrence. Side-to-side extensor strength between athletes participating in both the 1998-1999 and 1999-2000 physicals were no different. After core strengthening, the right hip extensor was, on average, stronger than that of the left hip extensor (P = 0.0001). More specific gender differences were noted after core strengthening. Using logistic regression, female athletes with weaker left hip abductors had a more significant probability of requiring treatment for LBP (P = 0.009) CONCLUSION The impact of core strengthening on collegiate athletes has not been previously examined. These results indicated no significant advantage of core strengthening in reducing LBP occurrence, though this may be more a reflection of the small numbers of subjects who actually required treatment. The core program, however, seems to have had a role in modifying hip extensor strength balance. The association between hip strength and future LBP occurrence, observed only in females, may indicate the need for more gender-specific core programs. The need for a larger scale study to examine the impact of core strengthening in collegiate athletes is demonstrated.

Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study.

Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik TP, DePrince M: Relationship between hip muscle imbalance and occurrence of low back pain in collegiate athletes: a prospective study. Am J Phys Med Rehabil 2001;80:572–577. ObjectiveTo assess whether athletes with strength imbalance of the hip musculature would be more likely to require treatment for low back pain (LBP) over the ensuing year. DesignThe study population included 163 National Collegiate Athletic Association Division I college athletes (100 males and 63 females) undergoing preparticipation sports physicals. Institutional review board approval was obtained to acquire and analyze hip muscle strength data. A commercially available dynamometer (Chatillon, Lexington, KY) incorporated into a specially designed anchoring station was used for testing the hip extensors and abductors. The maximum force generated for the hip abductors and extensors was used to calculate a percentage difference between the right and left hip extensors and abductors. Treatment of athletes by the athletic trainers for LBP unrelated to blunt trauma over the ensuing year was recorded. ResultsOf all athletes, 5 of 63 females and 8 of 100 males required treatment for LBP. Logistic regression analysis indicated that for female athletes, the percentage difference between the right and left hip extensors was predictive of whether treatment for LBP was required over the ensuing year (P = 0.05). There was no significant association noted for the percentage difference between the right and left hip abductors in females and for the percentage difference between both the right and left hip abductors and right and left hip extensors in males requiring treatment for LBP. ConclusionsThese data support our results from our previous cohort study, adding validity to the concept of hip muscle imbalance being associated with LBP occurrence in female athletes. This research further supports the need for the assessment and treatment of hip muscle imbalance in individuals with LBP.

Low Back Pain in College Athletes: A Prospective Study Correlating Lower Extremity Overuse or Acquired Ligamentous Laxity With Low Back Pain

Study Design. A prospective evaluation of the incidence of low back pain in college athletes was under‐taken. Objectives. To evaluate prospectively leg length discrepancy, hip flexor tightness, and lower extremity acquired laxity or overuse as predictive factors for low back pain in college athletes. Summary of Background Data. A pilot study found an association between low back pain and the factors to be studied. Several allusions to the kinetic chain theory appear in the literature, but little prospective research has been done in examining the effects of lower extremity involvement on the back. Methods. Two‐hundred fifty‐seven college athletes representing nine varsity sports were screened during a preseason sports physical examination. Measures of flexibility, ligamentous stability, leg length discrepancy, and overuse syndromes were recorded. Athletes were observed throughout the ensuing year for low back pain requiring treatment by the athletic trainer. Those athletes with low back pain as the result of direct trauma to the region were excluded from the data. Results. Twenty‐four athletes (9.3%) received treatment for low back pain. Thirteen of 87 women (15%) compared with 11 of 170 men (6%) required treatment for low back pain (P = 0.048). Of 57 athletes with lower extremity acquired laxity or overuse, low back pain developed in 14 (P < 0.001). Conclusions. Athletes with lower extremity acquired ligamentous laxity or overuse may be at risk for the development of noncontact low back pain during athletic competition. Female athletes with lower extremity involvement appeared to have a higher incidence of low back pain treatment compared with their male counter‐parts. Inflexibility of the lower extremities or leg length discrepancy were not associated with future low back pain treatment.

Continuous Low-Level Heat Wrap Therapy Provides More Efficacy Than Ibuprofen and Acetaminophen for Acute Low Back Pain

Study Design. A prospective, randomized, single (investigator) blind, comparative efficacy trial was conducted. Objective. To compare the efficacy of continuous low-level heat wrap therapy (40 C, 8 hours/day) with that of ibuprofen (1200 mg/day) and acetaminophen (4000 mg/day) in subjects with acute nonspecific low back pain. Summary of Background Data. The efficacy of topical heat methods, as compared with oral analgesic treatment of low back pain, has not been established. Methods. Subjects (n = 371) were randomly assigned to heat wrap (n = 113), acetaminophen (n = 113), or ibuprofen (n = 106) for efficacy evaluation, or to oral placebo (n = 20) or unheated back wrap (n = 19) for blinding. Outcome measures included pain relief, muscle stiffness, lateral trunk flexibility, and disability. Efficacy was measured over two treatment days and two follow-up days. Results. Day 1 pain relief for the heat wrap (mean, 2) was higher than for ibuprofen (mean, 1.51;P = 0.0007) or acetaminophen (mean, 1.32;P = 0.0001). Extended mean pain relief (Days 3 to 4) for the heat wrap (mean, 2.61) also was higher than for ibuprofen (mean, 1.68;P = 0.0001) or acetaminophen (mean, 1.95;P = 0.0009). Lateral trunk flexibility was improved with the heat wrap (mean change, 4.28 cm) during treatment (P ≤ 0.009 vs acetaminophen [mean change, 2.93 cm], P ≤ 0.001 vs ibuprofen [mean change, 2.51 cm]). The results were similar on Day 4. Day 1 reduction in muscle stiffness with the heat wrap (mean, 16.3) was greater than with acetaminophen (mean, 10.5;P = 0.001). Disability was reduced with the heat wrap (mean, 4.9), as compared with ibuprofen (mean, 2.7;P = 0.01) and acetaminophen (mean, 2.9;P = 0.0007), on Day 4. None of the adverse events were serious. The highest rate (10.4%) was reported in the ibuprofen group. Conclusion. Continuous low-level heat wrap therapy was superior to both acetaminophen and ibuprofen for treating low back pain.

Nonoperative Treatment of Low Back Pain

Low back pain is a common problem with substantial social and economic issues. Physicians continue to have difficulty managing this condition despite an increased awareness of its magnitude. In addition, there is a misperception about the outcome of patients affected with low back pain; most continue to suffer from pain. We present a nonoperative approach and review various diagnostic and treatment strategies with respect to both scientific and clinical merit. Although many treatment strategies have not been well proved in the scientific literature, thoughtful review of the available information provides a basis for the use of these treatment methods in the patient with refractory pain. This approach can be used in conjunction with existing information to assist clinicians in the management of patients with acute low back pain.

Functional performance deficits in athletes with previous lower extremity injury.

ObjectiveTo evaluate the influence of previously treated, though clinically resolved, lower extremity injury on performance in a timed 20-meter shuttle run. DesignCase control study. SettingNational Collegiate Athletic Association (NCAA) Division I college during the 2000/2001 preparticipation physicals. ParticipantsNCAA Division I athletes (n = 213) participated in this research study. Athletes were excluded if they presently had an unresolved lower extremity injury or low back pain. Main Outcome MeasuresTime to complete a 20-meter shuttle run was recorded. Previous lower extremity injury and college year were recorded via a short questionnaire. ResultsA significantly slower response time on the 20-meter shuttle run was observed in freshman athletes with a history of a lower extremity injury, as compared with freshmen without a previous injury (p = 0.01). No significant difference was noted in nonfreshman collegiate athletes regardless of injury history (p = 0.98). ConclusionKinetic chain deficits may exist long after symptomatic recovery from injury resulting in functional deficits, which may be missed on a standard physical assessment. The slower shuttle run times observed in freshmen with previous lower extremity injury may be a manifestation of insufficient treatment received at the high school level or the benefit of a mandatory core strengthening program in returning athletes. Further study is necessary to identify and validate the cause-and-effect relationship. Clinical RelevanceThis study may support residual functional deficits in incoming college athletes, which may be related to inadequate care in the high school setting.

Continuous passive motion in the rehabilitation setting: a retrospective study

Continuous passive motion (CPM) has been commonly used in the postoperative rehabilitation of patients after total knee arthroplasty. In the acute care hospital, most studies have found CPM to be useful in improving range of motion and reducing length of stay. The benefit of CPM in the rehabilitation hospital has not been studied. The charts of 61 patients who had undergone total knee arthroplasty and subsequently were admitted to the East facility of the Kessler Institute for Rehabilitation were reviewed. Patients were separated into two groups: Group 1 received CPM for 3 to 4 hours/day and physical therapy for 2 hours/day. Group 2 received only physical therapy. There was no significant difference in passive range of motion or length of stay between Group 1 and Group 2. An analysis of the 16 patients who underwent bilateral replacement was undertaken. Patients in Group 1 (n=7) achieved an average increase in passive range of motion of 20.1°, whereas those in Group 2 (n=9) achieved an increase of 12.7° (P=0.18). Power analysis demonstrated the need for 50 patients per subgroup to achieve significance. The lack of statistical significance in this subgroup may be a reflection of the small study population (n=16). The following conclusions can be drawn concerning the use of CPM in the rehabilitation setting: (1) CPM was of no added benefit to those patients admitted after single knee replacement, and (2) CPM may be beneficial to those patients admitted after bilateral knee replacement.

Spectral analysis during fatigue. Surface and fine wire electrode comparison.

Fine wire (FW) intramuscular electrodes and spectral analysis have not previously been used to quantify metabolic muscle fatigue in deep muscles not accessible with surface electrodes. This study compares initial median frequency (IMF) and decline in median frequency with fatigue (SLOPE) using surface and FW electrodes. Eighteen men performed isometric biceps contractions for 100 s. Electromyographic signals were collected using FW and surface electrodes. The recordings of SLOPE was greater with FW (-0.44 v -0.23 %IMF/s) and IMF was higher (195 v 69 Hz). Intrasession reliability for slope was better with FW electrode (intraclass correlation coefficient (ICC) = 0.74; P<0.0001) than with the surface electrode (ICC = 0.43; P = 0.006), but intersession reliability was best with the surface electrode (ICC = 0.50; P = 0.03). Spectral analysis using FW electrodes provides earlier detection of muscle fatigue and can be used in deep muscles, but the reliability must be improved before clinical application.

Pain, dizziness, and central nervous system blood flow in cervical extension: vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy.

Foye PM, Najar MP, Camme A Jr, Stitik TP, DePrince ML, Nadler SF, Chen B: Prospective study of pain, dizziness, and central nervous system blood flow in cervical extension: Vascular correlations to beauty parlor stroke syndrome and salon sink radiculopathy. Am J Phys Med Rehabil 2002;81:395–399. Objective Professional shampoos have previously been implicated in beauty parlor stroke syndrome and salon sink radiculopathy. The purpose of this study was to record pain, dizziness, and cervical blood flow while subjects were specifically placed into the salon sink position and to determine whether an additional cervical support would alter these symptoms and measurements. Design In 25 volunteers who reported previous dizziness from salon shampoos, we recorded subjective levels of pain and dizziness and objective measurements of blood flow within the vertebral and carotid arteries at baseline and then during cervical extension into a salon sink, with and without additional cervical support. Results When the additional cervical support was not used, there was significantly greater dizziness, neck pain, and carotid blood flow. No statistically significant differences were seen in the vertebral artery blood flow when comparing the three positions. Conclusions Pain and dizziness were commonly reproduced in this previously symptomatic population but significantly less frequently when a supplemental cervical support was used. Individuals with a history of such symptoms should probably exercise caution when deciding whether to receive a salon sink shampoo.