Steven Scott

Kinetic Chain Exercise in Knee Rehabilitation

SummaryRehabilitation is recognised as a critical component in the treatment of the anterior cruciate ligament (ACL) injured athlete, and has been the subject of intense research over the past decade. As a result, sound scientific principles have been applied to this realm of sports medicine, and have improved the outcome of both surgical and nonsurgical treatment. Possibly the most intriguing of these principles is the use of the kinetic chain concept in exercise prescription following ACL reconstruction.The hip, knee, and ankle joints when taken together, comprise the lower extremity kinetic chain. Kinetic chain exercises like the squat recruit all 3 links in unison while exercises such as seated quadriceps extensions isolate one link of the chain. Biomechanical assessment with force diagrams reveals that ACL strain is reduced during kinetic chain exercise by virtue of the axial orientation of the applied load and muscular co-contraction.Additionally, kinetic chain exercise through recruitment of all hip, knee, and ankle extensors in synchrony takes advantage of specificity of training principles. More importantly, however, it is the only way to reproduce the concurrent shift of ‘antagonistic’ biarticular muscle groups that occurs during simultaneous hip, knee, and ankle extension. Incoordination of the concurrent shift fostered by exercising each muscle group in isolation may ultimately hamper complete recovery. Modifying present day leg press and isokinetic equipment will allow clinicians to make better use of kinetic chain exercise and allow safe isokinetic testing of the ACL reconstructed knee. Reconstruction of the ACL with a strong well placed graft to restore joint kinematics, followed by scientifically sound rehabilitation to improve dynamic control of tibial translation, will improve the outcome after ACL injury.

Characteristics and Rehabilitation Outcomes Among Patients With Blast and Other Injuries Sustained During the Global War on Terror

OBJECTIVE To describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror. DESIGN Observational study based on chart review and Department of Veterans Affairs (VA) administrative data. SETTING The 4 VA polytrauma rehabilitation centers (PRCs). PARTICIPANTS Service members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom. INTERVENTION Multidisciplinary comprehensive rehabilitation program. MAIN OUTCOMES MEASURES Cognitive and motor FIM instrument gain scores and length of stay (LOS). RESULTS Most war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group. CONCLUSIONS Blasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.

Evidence for posttranscriptional regulation of C/EBPalpha and C/EBPbeta isoform expression during the lipopolysaccharide-mediated acute-phase response.

The mRNAs of the CCAAT/enhancer-binding trans-activator proteins (C/EBPalpha and C/EBPbeta) serve as templates for the differential translation of several isoforms which have specific transcriptional regulatory functions. By using an oligonucleotide corresponding to the C/EBP binding site of the mouse alpha1-acid glycoprotein promoter, we detected multiple forms of C/EBPalpha and C/EBP++ beta proteins in the mouse liver that have DNA-binding activity. By using specific antisera, we detected C/EBPalphas with molecular masses of 42, 38, 30, and 20 kDa that have DNA-binding activity. The pool levels of the 42- and 30-kDa isoforms were high in control nuclear extracts and decreased significantly after lipopolysaccharide (LPS) treatment. The binding activity and protein levels of the 20-kDa isoform are low in controls and increase dramatically after LPS treatment. C/EBPbeta isoforms with molecular masses of 35, 20, and 16 kDa were also detected. The 35-kDa pool level did not change whereas the 20-kDa isoform was strongly induced in response to LPS. Western (immunoblot) and Southwestern (DNA-protein) analyses show that p42 C/EBPalpha forms specific complexes with the alpha1-acid glycoprotein oligonucleotide in control nuclear extract and that p20 C/EBP beta forms complexes in LPS-treated liver. Our studies suggest that synthesis of specific C/EBPalpha and C/EBPbeta isoforms occurred in the normal liver in vivo and that LPS mediated a differential initiation and inhibition of translation at specific AUG sites within each mRNA. The qualitative and quantitative changes in C/EBPalpha and C/EBPbeta isoform pool levels suggest that LPS or an LPS-stimulated factor can regulate the selection of AUG start sites for both activation and repression of translation. This regulation appears to involve an LPS-mediated down-regulation of initiation at the first AUG codon of the 42-kDa C/EBPalpha and dramatic translational up-regulation at the fifth AUG codon of the 20-kDa C/EBPalpha and the third AUG codon of the 20-kDa C/EBPbeta. These regulatory events suggest the existence of proteins that may act as translational trans-acting factors.

Emotional Responses of Athletes to Injury

Increased participation in sports is associated with increased related injuries. This study was conducted to identify the emotional responses of athletes to injury and to determine which responses might interfere with rehabilitation and necessitate psychologic or psychiatric intervention. In 72 patients, follow-up surveillance was continued from the time of injury until resumption of sports activity. Patients completed the Emotional Responses of Athletes to Injury Questionnaire and the Profile of Mood States (POMS) test, and significant differences were found when the POMS scales of depression and anger were compared with college norms. Mean POMS scores were compared (by multivariate analysis of variance) by sex, age, and severity of injury. No gender differences were found, and only for anger were age groups significantly different (younger athletes were most angered). Three severity-of-injury groups (based on the duration of time the athlete was unable to participate in sports) were also compared. The most seriously injured group experienced significantly more tension, depression, and anger and less vigor than college norms, a mood disturbance that lasted 1 month. Emotional disturbance can occur after a sports-related injury, and its prompt recognition may facilitate the athletes optimal rehabilitation and a safe return to participation in sports.

Health Outcomes Associated with Military Deployment: Mild Traumatic Brain Injury, Blast, Trauma, and Combat Associations in the Florida National Guard

OBJECTIVES To determine the association between specific military deployment experiences and immediate and longer-term physical and mental health effects, as well as examine the effects of multiple deployment-related traumatic brain injuries (TBIs) on health outcomes. DESIGN Online survey of cross-sectional cohort. Odds ratios were calculated to assess the association between deployment-related factors (ie, physical injuries, exposure to potentially traumatic deployment experiences, combat, blast exposure, and mild TBI) and current health status, controlling for potential confounders, demographics, and predeployment experiences. SETTING Nonclinical. PARTICIPANTS Members (N=3098) of the Florida National Guard (1443 deployed, 1655 not deployed). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Presence of current psychiatric diagnoses and health outcomes, including postconcussive and non-postconcussive symptoms. RESULTS Surveys were completed an average of 31.8 months (SD=24.4, range=0-95) after deployment. Strong, statistically significant associations were found between self-reported military deployment-related factors and current adverse health status. Deployment-related mild TBI was associated with depression, anxiety, posttraumatic stress disorder (PTSD), and postconcussive symptoms collectively and individually. Statistically significant increases in the frequency of depression, anxiety, PTSD, and a postconcussive symptom complex were seen comparing single to multiple TBIs. However, a predeployment TBI did not increase the likelihood of sustaining another TBI in a blast exposure. Associations between blast exposure and abdominal pain, pain on deep breathing, shortness of breath, hearing loss, and tinnitus suggested residual barotrauma. Combat exposures with and without physical injury were each associated not only with PTSD but also with numerous postconcussive and non-postconcussive symptoms. The experience of seeing others wounded or killed or experiencing the death of a buddy or leader was associated with indigestion and headaches but not with depression, anxiety, or PTSD. CONCLUSIONS Complex relationships exist between multiple deployment-related factors and numerous overlapping and co-occurring current adverse physical and psychological health outcomes. Various deployment-related experiences increased the risk for postdeployment adverse mental and physical health outcomes, individually and in combination. These findings suggest that an integrated physical and mental health care approach would be beneficial to postdeployment care.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

The Psychological Effects of Sports Injuries Coping

SummaryEpidemiological reports of sports injury confirm a high incidence of injuries occurring at all levels of sport participation, ranging in severity from cuts and bruises to spinal cord injury. The psychosocial dynamics accompanying sport injury should be known to ensure psychological recovery, an important aspect in rehabilitating the injured athlete. Earlier studies demonstrating psychological differences between athletes and nonathletes indicated the need for actual research on the athletes’ postinjury response in lieu of accepting the hypothesis that the emotional responses of athletes to injury parallels existing (i.e. terminally ill) ‘loss of health models’. Recent research has shown that injured athletes experience simultaneous mood disturbance and lowered self-esteem. Due to a paucity of research on the coping methods of injured athletes, studies involving the coping methods of several nonathletic patient populations were reviewed. These patients benefitted primarily from a concrete, problem-focused, behaviourally orientated programme which minimises uncertainty. This approach is theoretically ideal for injured athletes, congruent with the goal setting and performance outcome emphasis common to exercise and sport training programmes but to date the effectiveness of these strategies for injured athletes have not been fully examined. Therefore, until such research is available, these coping strategies (also used for performance enhancement) are provided as therapeutic guidelines for dealing with the emotional distress experienced by injured athletes.Individual responses of injured athletes varied from those who took injury in stride to those who required psychiatric intervention. This marked individual variation in response underscores the importance of neither assuming mood disturbance nor overlooking a serious emotional response in the injured athlete. Awareness of the emotional responses of athletes to injury and employment of appropriate coping strategies should facilitate optimal rehabilitation and return to sport.

Musculoskeletal Injuries in Competitive Swimmers

Competitive swimming is a rigorous sport being engaged in by an increasing number of young athletes. In swimmers, shoulder pain is the most common musculoskeletal complaint and is usually due to supraspinatus or biceps tendinitis. Glenohumeral instability (often multidirectional) can also be a cause of shoulder pain in swimmers and may be more common than has been reported. Surgical treatment is seldom indicated. Physical therapy modalities and training modifications are the mainstay of treatment. Medial knee pain in breaststroke swimmers and extensor tendon inflammation over the dorsum of the foot are less common injuries and respond to conservative therapy. These overuse syndromes are best prevented by proper training schedules, strength training, flexibility exercises, and avoidance of errors in stroke technique. The rehabilitation program for a competitive swimmer should be chosen with an understanding of the goals of the swimmer and the cooperation of the coach.

Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory.

Objective:To develop and cross-validate internal validity scales for the Neurobehavioral Symptom Inventory (NSI). Participants:Four existing data sets were used: (1) outpatient clinical traumatic brain injury (TBI)/neurorehabilitation database from a military site (n = 403), (2) National Department of Veterans Affairs TBI evaluation database (n = 48 175), (3) Florida National Guard nonclinical TBI survey database (n = 3098), and (4) a cross-validation outpatient clinical TBI/neurorehabilitation database combined across 2 military medical centers (n = 206). Research Design:Secondary analysis of existing cohort data to develop (study 1) and cross-validate (study 2) internal validity scales for the NSI. Main Measures:The NSI, Mild Brain Injury Atypical Symptoms, and Personality Assessment Inventory scores. Results:Study 1: Three NSI validity scales were developed, composed of 5 unusual items (Negative Impression Management [NIM5]), 6 low-frequency items (LOW6), and the combination of 10 nonoverlapping items (Validity-10). Cut scores maximizing sensitivity and specificity on these measures were determined, using a Mild Brain Injury Atypical Symptoms score of 8 or more as the criterion for invalidity. Study 2: The same validity scale cut scores again resulted in the highest classification accuracy and optimal balance between sensitivity and specificity in the cross-validation sample, using a Personality Assessment Inventory Negative Impression Management scale with a T score of 75 or higher as the criterion for invalidity. Conclusions:The NSI is widely used in the Department of Defense and Veterans Affairs as a symptom-severity assessment following TBI, but is subject to symptom overreporting or exaggeration. This study developed embedded NSI validity scales to facilitate the detection of invalid response styles. The NSI Validity-10 scale appears to hold considerable promise for validity assessment when the NSI is used as a population-screening tool.

Utility of mechanism-of-injury-based assessment and treatment: Blast Injury Program case illustration.

While medicine typically proceeds in a sequential fashion based on primary symptoms, sometimes relying on a parallel, mechanism-of-injury-based approach is advantageous, particularly when the mechanism of injury is associated with a variety of known sequelae. A mechanism-of-injury-based approach relies on knowledge of the typical sequelae associated with that mechanism of injury to guide assessment and treatment. Thus, it represents an active, rather than passive, case-finding approach. This article describes an example of a mechanism-of-injury-based program, namely, a Blast Injury Program at the James A. Haley Veterans Hospital in Tampa, Florida. Case examples illustrate the utility of this approach with regard to more comprehensive assessment and treatment, as well as the possibility for secondary prevention.