Reviewed by Austin Mowrey PT, DPT

Introduction:

ACL injuries are one of the most common sports-related injuries. After someone suffers an ACL injury they can be classifies as either a coper or non-coper.  The term “coper” is utilized to describe someone that can return to prior levels of activity after an ACL rupture without dynamic instability. Previous studies have shown that you are classified as a coper or non-coper based on the Knee Outcome Survey- Activities of Daily Living Scale score ≥80%, global rating scale ≥60%, ≥80% symmetry on the timed hop and ≤ 1 recent episode of giving was during activities of daily living. Non-copers fail to meet one of these criteria. The purpose of this study was to evaluate the consistency of early coper classification before and after 10 sessions of progressive neuromuscular training and strength testing (NMST) in athletes early after acute ACL rupture and to evaluate the association of early coper classification with two-year outcomes.

 Methods and Interventions:

This study was the primary analysis of the Delaware-Oslo ACL cohort, a prospective study evaluating athletes after ACL Rupture. 300 subjects participated in the study after the met the following criteria: unilateral ACL rupture confirmed by MRI within seven months of enrollment and regularly participated in level I/II sports prior to injury, had full knee range of motion, minimal effusion, minimal pain, and quadriceps limb symmetry index ≥70% . Participants were excluded if they had a previous injury or surgery on the contralateral knee or significant concomitant injuries.  Prior to NMST, participants were identified as copers and non-copers based on the following criteria: Knee Outcome Survey- Activities of Daily Living Scale score ≥80%, global rating scale ≥60%, ≥80% symmetry on the timed hop and ≤ 1 recent episode of giving was during activities of daily living. Non-copers fail to meet one of these criteria. All athletes participated in a 10-session NMST program over approximately 5 weeks, consisting of progressive strengthening, plyometric, and neuromuscular exercises with the goal of restoring muscle strength and neuromuscular control. After the exercise interventions, participants were re-assessed if they classified as copers or non-copers.  Success two years after ACLR or non-op rehabilitations was defined as meeting or exceeding sex and age-matched norms on the International Knee Documentation Committee Subjective Knee Form, no ACL graft ruptures and ≤ 1 episode of giving way within the last year.

Results:

Of the 300 athletes who enrolled in the study, 271 completed the post-training data collection. Of the 271 participants that completed the post-training data collection, 219 returned for the two-year follow up. Out of the 219 participants that returned, 93 were ACLR potential copers, 61 were ACLR non-copers, 51 were non-op potential copers and 14 were non-op non-copers.

55% were potential copers at screening and 68% were potential copers at the end of training. 45% of initial potential non-copers become potential copers post-training, while only 13% of initial potential copers become non-copers after training. About 25% of the athletes were non-copers at screening and remained non-copers at the end of training.

At the two year follow-up, 64% of the ACLR group and 74% of the non-op group were successful per the previously described criteria.  Using coper classifications at screening, ACLR potential copers had a 2.3 times the odds of success compared to the ACLR non-copers. Non-op potential copers and non-copers did not significantly differ from ACLR non-copers. Using coper classification post-training, ACLR and non-op potential copers had 2.7 and 2.9 times the odds of success compared with ACLR non-copers. The non-op non-copers had 0.51 times the odds of success compared to ACLR non-copers, however it was not statistically significant.

Conclusion:                                                                                                        

Nearly 45% of non-copers become potential copers following NMST, while conversion from potential coper to non-coper was 13%. Athletes who were potential copers post-training were more likely to have a successful two-year outcome regardless of operative management compared to the non-copers who received ACLR.

Take Home Message:

• Coper classification can change after NMST.
• Coper classification after a challenge to the neuromuscular system improves insight into two-years outcomes.
• Brief prehabilitation improves long term success.
• Dynamic stability may be more important than mechanical stability for two-year success.
• Alternative strategies are needed for persistent non-copers.

Reference:

Thoma LM, Grindem H, Logerstedt D, et al. Coper Classification Early After Anterior Cruciate Ligament Rupture Changes With Progressive Neuromuscular and Strength Training and Is Associated With 2-Year Success: The Delaware-Oslo ACL Cohort Study. Am J Sports Med. 2019;47(4):807-814. doi:10.1177/0363546519825500

Reviewed by Mark Boyland PT, DPT, CSCS

Physical Therapists can assist with many patient complaints, and this also includes headaches.  This review specifically focused on tension type headaches but there are several headache types.  Tension type headaches are classified as headaches which present on both of sides of the head, are non pulsing, mild to moderate intensity, don’t get worse with motion, or may be associated with nausea/vomiting depending on how long you’ve had tension type headaches.  Also, those who have tension type headaches may also present with light/noise sensitivity but not both at the same time.  Those who have tension type headaches may have at least 10 episodes per year with duration of headaches lasting 30 minutes to 7 days.  In short headaches aren’t a pleasant experience especially if they can last upwards of 7 days.  Despite our ability to classify headaches we are not exactly sure what causes them which makes treating them a challenge.  This review found exactly that, and that while there is no treatment standard in physical therapy for tension type headaches interventions that address the neck, jaw, and thoracic spine are common treatment trends.  Not having a standard of treatment provides benefits for our patients as we can customize your treatment plan based on your preferences and dysfunctions as opposed to a cookie cutter model.

This systematic review examined the available trials and found that treatments benefits were divided into short, medium, and long term.  While there was no definition provided for short term effects, medium term was defined between 8 weeks and 3 months, and long term was defined as beyond 36 weeks. Treatment interventions included manual therapy including myofascial release of cervical tissues, joint mobilization/manipulation of the cervical and thoracic spine, as well as progressive relaxation of the jaw and cervicothoracic musculature which included patient education as well as other modalities. 

With al this said many of the interventions studied had improvements in headache frequency and intensity which is again a good thing for out patients. Unfortunately due to the nature of randomized control trials and systematic reviews the quality of evidence was low for several of the randomized control trials and that no specific recommendations can be made based on their findings.  This is the joy of research.  However ,with all this said, while many can have tension type headaches, not all symptoms and dysfunctions are the same between all patients and therefore our treatments should be tailored to our patients.

Patient summary: Your therapist will likely address your neck, midback, and jaw during your sessions.  You should expect interventions to include manual therapy including soft tissue and joint mobilization will be applied.  There’s also going to be some exercises including relaxation, mobilization, and stabilization will be included. 

Reviewed by: Zachary Stango, SPT; Bridget Collier, PT, DPT

The act of raising one’s arm overhead is a simple motion in theory, but biomechanically, it requires a great deal of coordinated motions between a multitude of joints that comprise the shoulder complex. Of the intra-articular motions that occur during arm elevation, upward rotation of the scapula is necessary to allow for full range of motion. Adhesive capsulitis, more commonly known as frozen shoulder, is a common condition that is associated with alterations in the kinematics of the shoulder, contributing to scapular dyskinesis and variations in the amount of upward rotation noted during these motions. Decreased motion of the shoulder is associated with alterations in proprioception of the joint, possibly further contributing to the abnormal rotational movements attributed to this condition. The randomized controlled trial conducted by Mohamed et al. (2020) aimed to analyze the effects of improving awareness of scapular motions on pain, disability, and range of motion in individuals with adhesive capsulitis.

The inclusion criteria for this study consisted of patients with the inability to raise their arm above 100 degrees of scaption, with limitations in both active and passive range of motion interfered by pain. 66 individuals aged 40-60 years old were evenly split into two groups, performing their respective routines for 40 minutes, three times a week for two months while also receiving hot packs and scapular mobilizations. Baseline measurements for shoulder flexion, abduction, external rotation, and scapular upward rotation were noted using an inclinometer. The control group performed active shoulder flexion and abduction exercises, while the experimental group performing dynamic scapular recognition utilized a ViMove motion sensor system, an audible biofeedback device that was placed on the spine of the scapula. The participants performed shoulder abduction, with greater upward rotation of the scapula increasing the sound of the device, providing feedback to the participant that they are performing the desired movement.

Follow up metrics were taken at two weeks, two months, and 6 months following the procedure and the results displayed a significant improvement in upward rotation between the dynamic scapular recognition group compared to the control group at all three timelines. The range of motion values proved to be of similar results, with significant improvements of flexion, abduction, and external rotation of the experimental group noted compared to the control group after 6 months. The Shoulder Pain and Disability Index was the validated measure used to assess pain and disability of the shoulder, with scores exhibiting significant reductions in pain and disability of the experimental group compared to the control group at two weeks and two months. Through the use of the audible biofeedback device, the participants were able to receive active interpretations of their scapular kinematics, perhaps aiding in their joint’s proprioceptive ability to decrease elevation of the scapular prior to the rotational component motions needed to successfully execute full arm elevation.

Clinical Bottom Line:

The results of this trial serve as evidence that biofeedback markers can increase one’s awareness of their compensatory mechanisms and therefore, in this case, can assist in mitigating abnormal kinematics in order to restore proper joint biomechanics. Further research is needed to generalize this theory to other movements that also require a successful synchronicity of the surrounding joints, but this can be trialed as an intervention for those individuals who may respond well to a unique style of cueing.

References:

Mohamed AA, Jan YK, El Sayed WH, Wanis MEA, Yamany AA. Dynamic scapular recognition exercise improves scapular upward rotation and shoulder pain and disability in patients with adhesive capsulitis: a randomized controlled trial [published correction appears in J Man Manip Ther. 2020 Jun 10;:1]. J Man Manip Ther. 2020;28(3):146-158.

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

After ACL reconstruction surgery, the quadriceps muscle is commonly about 20% weaker on the surgical side than the healthy side. Recent evidence states that changes in the central nervous system can account for some of these deficits, which is why ACL rehabilitation plans need to also include strategies that address these central neural mechanisms and in turn reduce strength loss. Cross education is one such way to do this. Cross Education (CE) is the strength gain found when a patient performs a strengthening exercise program on the uninjured limb to maintain or even gain strength in the injured limb. This can be an effective strategy when a patient’s injury requires complete immobilization or has limited motion due to the recency of the injury. CE can induce structural and functional changes in the patient’s nervous system which increases their ability to activate the quadriceps muscle and thus increase its strength.

Methods:

This systematic review included 7 randomized control trials that met these specific criteria:

• Patients > 18 years old after arthroscopic ACL reconstruction
• Interventions used included unilateral strength, motor control, and balance training to the uninjured limb
• Plans utilized standard protocols of rehabilitation for ACL
• Strength testing was performed on quadriceps and hamstring muscles
• Study was a randomized control trial or controlled clinical trial.

Individuals with other ligamentous injuries of the knee were excluded from this study. Each utilized a variety of training frequencies (2,3, or 5 times per week) and for varying total weeks of training time with 8, 24, 26 weeks total being most common. Several different measures were used among each of the studies to determine the effects of the CE through unilateral training including maximal voluntary isometric contractions (MVICs) of the quadriceps, self-reported knee function, and limb symmetry index (LSI) which is a ratio of the estimated performance of the involved limb and uninvolved limb.

Conclusions of the Study:

All the studies demonstrated a significant difference in quadriceps MVIC between participants who performed standard rehabilitation and unilateral training versus standard rehabilitation alone. The self-reported knee function measures were mostly inconclusive among all the studies, but one that determined at 8 weeks of rehabilitation there was a significant difference in knee function according to the participants suggesting a potential short term benefit to the CE. The LSI scores in studies that extended to the 24 and 26 week time frames demonstrated significant difference between groups who performed the unilateral training and standard rehabilitation and those who did not perform unilateral training. However, this measure is simply and estimation and can be significantly overestimate the functional abilities of an ACL patient at 6 months post-operation. The results of the study concluded that by including unilateral training in the participant’s rehabilitation program, the loss of strength typically experienced by the patients after an ACL reconstruction was reduced by 8.52%. This same effect has been even higher in other types of patients like those with osteoarthritis, multiple sclerosis, or other limb immobilizations and therefore would be an excellent addition for most ACL reconstruction patients.

Clinical Implications:

Through stimulating the nervous system and activating the spinal nerve pathways that contribute to movement of the uninvolved limb, ACL reconstruction patients could experience a protective effect to atrophy and strength loss of the quadricep muscle on the affected side by performing unilateral training of the uninvolved limb. PTs should include this in all stages of rehabilitation, but especially in the early stages when the patient is immobilized or has restricted motion due to surgical protocols. Exercises like the single leg squats or long arc quads that require high degrees of quadriceps activation could be great options to promote this protective effect, as long as it fits within the parameters of the patient’s surgical protocol.

References:

Cuyul-Vásquez, I., Álvarez, E., Riquelme, A., Zimmermann, R., & Araya-Quintanilla, F. (2022). Effectiveness of unilateral training of the uninjured limb on muscle strength and knee function of patients with Anterior Cruciate Ligament Reconstruction: A systematic review and meta-analysis of cross-education. Journal of Sport Rehabilitation, 31(5), 605–616. https://doi.org/10.1123/jsr.2021-0204

Reviewed by Tyler Tice, PT, DPT, OCS, ATC

Introduction:

Ankle sprains are one of the most common injuries in athletes and often leave residual effects on postural control post-injury due to the sensorimotor dysfunction. The Y-balance test is a dynamic balance test that is often utilized to assess these patient’s abilities to demonstrate sufficient dynamic postural control to return to sport or other recreational activities safely after ankle injuries. The maximal reach distance (MRD) in the posteromedial direction of the Y-balance test (PM-YBT) is often used to distinguish individuals with ankle instability from healthy people. Sensory processing and the motor output both have an effect on postural control in performance of the PM-YBT, but the amount each contributes is yet to be determined. This study investigated the contribution of eccentric dorsiflexion and plantarflexion torque control on MRD in the PM-YBT performance and therefore determine its contribution to dynamic postural control.

Methods:

            This was a cross-sectional study with 12 subjects. Exclusion criteria for subject selection included a history of lower extremity surgery, injuries in the previous 6 months, or neurological diseases with balance impairments. Subjects height (cm), weight (Kg), and limb length of dominant limb that were used for kicking a ball (cm) were taken. Subjects performed the PM direction of the YBT using the Move2Perform YBT kit with several practice attempts prior to testing. The patients also performed a 5-second maximal voluntary isometric contraction (MVIC) of plantarflexion and dorsiflexion and torque control testing of the ankle using a Biodex dynamometer system. The torque control was defined as the ability to match eccentric torque output to a target torque level. The subjects were instructed to eccentrically contract the plantar flexors at 50% of MVIC as the dynamometer moved them into dorsiflexion and contract the dorsiflexors eccentrically at 30% MVIC while being moved into plantarflexion. EMG data was also collected for tibialis anterior and the soleus as representatives to compare activation of the plantar flexors and dorsiflexors during this testing.

Conclusions of the Study:

            Statistical analysis revealed a higher torque control during eccentric dorsiflexion predicted higher MRD scores for the participants, however, higher eccentric plantarflexion torque control was not predictive for MRD performance. This is contrary to previous studies, but is likely attributable to methodological differences between the use of the Biodex compared to use of a handheld dynamometer. It was also noted higher tibialis anterior activity during the YBT test also predicted greater accuracy of torque control in the subjects, while higher soleus activity did not. Therefore, eccentric dorsiflexion torque control can be a potential predictive indicator for performance in PM-YBT. It was theorized that the lack of predictability from the plantar flexors eccentric control performance was due to it their primary usage being in single plane of motion while the dorsiflexors have greater impact on multiple planes at a time. Previous EMG data has indicated plantar flexors are activated similarly between healthy individuals and people with ankle instability, while the tibialis anterior was activated less in patients with ankle instability, continuing to support the need for strong dorsiflexors. There needs to be further investigation to confirm the data seen here, since this study was self-limited by the small sample size used.

Clinical Implications:

            This article highlights the importance of ensuring patients have sufficient eccentric dorsiflexor torque control. It seems having better motor control within the tibialis anterior and the other dorsiflexors through direct training can assist in improving the patient’s postural control before returning to recreational activities. The application of this data should not be limited to just athletes or other younger adults who are commonly assessed using the YBT. Although older adults may not be able to perform the PM-YBT, improving the eccentric control of the dorsiflexors may be an effective method for improving older adult’s dynamic balance as well, and consequently reduce their fall risk. Unless the patient has high irritability and cannot tolerate the movement or has precautions surrounding performing active dorsiflexion it would be ideal to begin strengthening this muscle group early to aid in their dynamic balance later in treatment.

References:

Nozu, S., Johnson, K. A., Tanaka, T., Inoue, M., Nishio, H., & Takazawa, Y. (2023). The accuracy of ankle eccentric torque control explains dynamic postural control during the Y-balance test. International Journal of Sports Physical Therapy, 18(5). https://doi.org/10.26603/001c.87760