Short-term Progressive Exercise Program Improves Knee Function Following ACL Injury

Eitzen et al from Oslo University Hospital, Norway evaluated the effects of a detailed, 5-week progressive exercise program either to optimize patients' preoperative function or as a the first step in a continuum of nonoperative management in patients with anterior cruciate ligament (ACL) injuries. The investigators evaluated both copers (those with good knee stability who compensate well) and noncopers (those with poor knee stability who and less able to compensate) and also assessed any adverse effects with treatment.

The study enrolled 100 patients (mean age, 26 years, 44 males, 56 females) who had suffered complete unilateral and isolated ACL rupture within the previous 3 months. The pre- and posttest outcome measure evaluated were isokinetic strength testing for quadriceps and hamstrings, 4 single-leg hop tests, 2 self-assessment questionnaires and a global rating of knee function.

Patients who did not demonstrate knee joint effusion and had a full range of motion were considered appropriate candidates to begin rehabilitation. The exercise program (2-4 sessions/week) emphasized heavy-resistance muscle strength training, plyometric exercises and advanced neuromusclular exercises. Guidelines from the American College of Sports Medicine were used to record progression of resistance training. Perturbation training, including balance and stability exercises, was incorporated in the neuro-muscular-enhancement program.

The 5-week progressive exercise program resulted in significant improvement in strength, function and self-reported knee functions for patients classified as both copers and noncopers. In particular, the changes from pretest to posttest in muscle strength and single-leg hop measures were considered clinically relevant (Figure 1). Surprisingly, noncopers did not show more improvement than copers. Adverse effects seen in 4.1% of participants included progressively more swelling and pain during training. This study's findings suggested that a short-term progressive and intensive program for patients with an isolated ACL injury significantly improves knee function before reconstructive surgery is considered. Eitzen I, Moksnes H, Snyder-Makler I, Risberg MA. A progressive 5-week exercise therapy program leads to signifigant improvement in knee function early after anterior cruciate ligamnet injury. J Orthop Sports Pyhs Ther 2010;40:707-721

Progressive Resistance Training Improves Function in Older Adults

The age related muscle loss of sarcopenia is a problem for both older men and women showing a more dramatic increase in muscle loss after menopause. Not only is sarcopenia associated with loss of muscle strength but there is an associated reduction in ambulatory function and risk of falling. A Cochrane systematic review published in 2009 reported that progressive resistance strength training (PRST) performed 2-3x/week effectively reduced physical disability and improved function in older adults.

Mangione et al from Arcadia University, Pennsylvania, applied the evidence from this systematic review to a clinical scenario that evaluated the effect of PRST on changes in function in an elderly woman with sarcopenia and multiple comorbidites.

An 86-year-old woman with a history of hypertension, cardiomegaly, osteoarthritis, spinal stenosis and ambulatory dysfunction was considered an appropriate candidate for a home-based PRST program. The PRST program was conducted 2x/week. Quadriceps resistance training (2 sets of 6-10 repetitions) was performed until fatigue; weights were progressively increased as indicated. Also included in the training program were

After 3.5 weeks of PRST (7 visits total), clinically meaningful changes were reported for functional activities, including faster walking speed and time to get up from a chair. Strength increased 100% for the quadriceps during this time. Over this period, the PRST contributed to the patient's independence in her activities of daily living.

The findings from this case report concurred with the evidence from the Cochrane systematic review that older adults who participate in PRST are likely to show meaningful gains and reduction in functional disability.

The findings from this case report concurred with the evidence from the Cochrane systematic review that older adults who participate in PRST are likely to show meaningful strength gains and reduction in functional disability. This report also provided a demonstration of how the evidence from systematic reviews can effectively be applied to clinical practice.

Mangione KK, Miller AH, Nauughton IV. Cochrane Review: improving physical function and performance with progressive resistance strength training.in older adults. Phys Ther 2010;90:1711-1715.

Hip-strengthening Exercises Helpful for Patellofemoral Pain

Patellofemoral pain syndrome (PFPS) is one of the most common knee disorders affecting women, particularly those who are physically active. Clinical; interventions have focused primarily on the knee, with the goal of correcting patella tracking and motion. Recent evidence suggests that hip muscle weakness and poor hip control are also found in women with PFPS; however; information regarding the effectiveness of hip-strengthening programs in these individuals is limited.

Fukuda et al from the Irmandade de Santa Casa de Misericordia de Sao Paulo, Brazil, assessed whether strengthening the knee musculature alone in improving pain and function in women with PFPS; previous studies had typically assessed female athletes.

Seventy patients (mean age, 25 years) with a history of anterior knee pain for >_ 3 months were randomly assigned to 3 groups.

Treatment protocols are summarized in Table 1. Patients in both exercise groups participate in 3 sessions/week for4 weeks. An 11-point numerical pain rating scale (NPRS) was used to assess pain during stair accent and descent, and the lower Extremity Functional Scale (LEFS), the Anterior Knee Pain Scale (AKIPS) and the single-limb hop test were used to assess function. Following interventions, both the KE (p < .05) and KHE (p < .01) groups showed significant improvement in function compared with baseline measures. These groups were also significantly different from the CO group for all measured variables. It is interesting to note that there were no differences between the KE and KHE groups for the LEFS, AKPS, and single-limb hop test (Table 2). The one difference found between the exercise groups was that the KHE group had significantly lower ratings of pain during stair descent compared with both the KE and CO groups (p < .05 and p < .01, respectively).



The findings of this study showed that both knee intervention and knee and hip intervention effectively improved pain and function in women with PFPS. For most outcome measures, enhanced clinical benefits may have been realized for the KHE group as shown by greater improved function and reduced pain during stair descent. The inclusion of a hip-strengthening program may be an effective adjunct intervention for women with PFPS.

Fukuda TY, Rossetto FM, Magalhaes E, et al. Short-term effects of hip abductors and lateral rotators strengthening in females with patellofemoral pain syndrome: a randomized controlled clinical trial. J Orthop Sports Phys Ther 2010:40: 736-742.

Isolated Eccentric Wrist Extensor Training Beneficial For Tennis Elbow

Lateral Epicondylosis, or tennis elbow, is a common condition found in individuals participating in activities involving repetitive wrist flexion and extension, such as golf and tennis or other racquet sports. Eccentric strength training has been found effective to treat other types of tendinopathies, but few studies have assessed the benefits of eccentric strength training for patients with lateral epicondylosis.

Tyler et al from the Nicholas Institute for Sports Medicine and Athletic Trauma, New York, compared the effect of an isolated wrist extensor exercise performed eccentrically with a standard treatment program for chronic lateral epicondylosis. Twenty-one patients with symptoms >6 weeks in duration were randomized to

*an eccentric training group (n = 11; mean age, 47 years)
*a standard treatment group (n = 10; mean age, 51 years)

All patients received wrist extensor stretching, ultrasound, cross friction massage, ice and heat during physical therapy. The standard group was given isotonic exercises; the eccentric group instructed in isolated eccentric wrist extensor exercises.

The novel eccentric exercise program was performed using flexible rubber bars of variable thicknesses that required the patient to slowly "untwist" the bar in a manner requiring activation from the wrist extensor muscle group. Exercises were performed daily. Outcome measures were the Disability of Arm, Shoulder and Hand Questionnaire (Dash), pain measured using a visual analog scale, strength (measured by wrist extension and middle finger extension) and tenderness distal to the lateral epicondyle.

After 7 weeks of treatment, improvements in outcome measures were noted for patients it n the eccentric muscle training group. Their DASH scores improved 76% vs a 13% mean improvement for patients in the standard group (p = .01). Pain reduction was also better for the eccentric group, with men improvements 0f 81% compared with 22% improvement for the standard group ( p= .002). In the eccentric group, wrist extension strength defects also improved from 30% to 9%, and tenderness was also reduced.

Although only short-term effects were studied, the novel exercise, using a inexpensive rubber bar to isolate the wrist extensors in an eccentric mode of training, proved to effectively reduce symptoms associated with lateral epicondylosis.

Tyler TF, Thomas GC, Nicholas SJ, McHugh MP. Addition of isolated wrist extensor eccentric exercise to standard treatment for chronic lateral epicondylosis: a prospective randomized trial. J Shoulder Elbow Surg 2010;19:917-922

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