This week we discuss telerehabilitation vs in perosn rehab for chronic nonoperative shoulder pain. In this RCT, the digital health group performs 20 minute exercise sessions 3 times per week and is monitored via inertial units which give real time biofeedback. Physical therapists provide education through short written articles that can be accessed via an app, they also text and phone/video call to answer questions and ensure adherence. The in person group received 30 minute sessions of traditional physical therapy twice per week. After 8 weeks there was no significant difference their primary outcome measure, the QuickDASH. There were a lot of directions we took this article in the podcast, so be sure to check it out!

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/37490337/

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This week we discuss reverse engineering strength and conditioning programming. Reverse engineering is a decision-making process which starts with the end goal in mind and works backwards to determine when different athletic qualities should be emphasized in a training program. While people can have a wide range of goals, different activities rely on the development of certain physical characteristics, so it is important to know the demands of the end task. Throughout the bulk of the article, the authors discuss agility development as an example of the application of reverse engineering. Agility requires decision making and change of direction speed. An athlete must be able to quickly decide how and where to produce a large amount of force in a short period of time to achieve an appropriate degree of change of direction during in-game situations. Some component pieces of agility include: maximal strength, stretch-shortening cycle mechanics, accelerative and decelerative ability, and decision making. The authors also discuss how and why coaches should screen for movement imbalances and mobility deficits throughout training. Clinicians should examine and assess qualities which are related to a patient/client’s current injury status, but also understand which qualities are important for the patient/client to achieve their long-term goals. This can be done by screening the final movement we want to see, in this case a 180 change of direction. Analysis of the end task reveals where the patient/client is currently lacking.

The abstract can be found here: https://journals.lww.com/nsca-scj/fulltext/2022/08000/reverse_engineering_in_strength_and_conditioning_.8.aspx

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This week's article is a reivew of minimal dose resistance exercise programs among the general population from the article "Resistance exercise minimal dose strategies for increasing muscle strength in the general population: an overview." Roughly 80% of the population does not meet current weeky resistance exercise minimum guidelines with about 58% of people not participating in resistance training at all. Therefore, minimal dose resistance training programs could be a potential gateway into meeting current guidelines, or at least provide some stimulus for adaptation. Five different programs are reviewed: weekend warrior, single set resistance exercise, exercise snacks, practicing the strength test, and eccentric minimal dose. Weekend warrior programs resistance train once per week, single set programs perform a single set of various exercises a few times per week, and exercise snacks are frequently implemented multiple times every day and can be as short as 9 minutes per day of exercise. Practicing the strength test involves training sets of 1 rep at a maximal intensity of either eccentric and concentric movements or maximal isometrics. Eccentric minimal dose programs accentuate the eccentric phase of lifting, and both of these last two programs are less commonly applied to the general population. All programs have shown to benefit muscle strength and hypertrophy more than no exercise, and they are generally easy to adhere to. In particular, exercise snacks were found to have a 97% adherence when done once for 9 minutes per day, with an 81% adherence when performing 9 minute sessions three times per day for a total of 27 minutes per day. These programs improve function in older adult populations, decrease reported daytime sleepiness, and decrease pain in populations with chronic neck pain. Clinically, this is likely the most common exercise prescription to give patients. Knowledge of minimal effective dosage of resistance training is important to solidly understand as a clinician because it is very likely your patients are not already meeting resistance training minimum guidelines, and prescribing optimal dosage or even these minimum guidelines will likely result in your patients not adhering to their program with poor adherence leading to worse outcomes. Offer options between these five different minimal effective dose programs to best fit the needs of the patient before you.

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/38509414/

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This week's article is a narrative review titled "Biology and physiology of tendon healing." This article should be titled "Microbiology and physiology of tendon healing" because it goes very in-depth on the molecular and cellular components of tendons and their roles in tendon health; including tenocytes, extracellular matrix proteins, hormonal factors, and immune cells. For the most part, this goes into greater detail that physical therapists have to know, especially when describing tendon pathology to patients. However, an understanding of the phases of healing (inflammatory, proliferative, and remodeling) is crucial for physical therapists when assessing injury timelines. Unfortunately, this article does not discuss the differences in this healing process between acute and chronic overuse injuries, like tendinopathies. It is possible there is disruption in this process in tendinopathic tendons. They do say how "poor intrinsic healing ability of the tendon" and inadequate recovery can lead to accumulation of damage over time, but do not specify what constitutes poor intrinsic healing ability. There is discussion of angiogensis after injury, with a bilateral difference in number of vessels ni an injured tendon even 20 weeks after an initial injury. This could relate to chronic tendon pain, however this is not discussed. Overall, it is hard to take actionable information to the clinic from this article since it was so focused on microbiological factors.

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/38307405/

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This week's article is a systematic review of the literature investigating the impact running has on knee osteoarthritis. There were 17 studies which met inclusion criteria, with over 14,141 participants included. The presence of knee pain ranged from 10.2-35.4% in runners and 13.4%-58.8% in nonrunners, but the paper talks little about this outside of saying there is lower presence of knee pain in runners. It is possible that some of the nonrunners used to run but stopped due to knee pain, or were told to stop from radiographic imaging. There was one study which found a significantly higher prevalence of patellofemoral joint space narrowing and more osteophyte prevalence in the patellofemoral and tibiofemoral joints in runners than nonrunners, but two studies comparing radiographic knee osteoarthritis between runners and nonrunners found no difference between groups. There was no significant differences in cartilage thickness at various locations in the knee between runners and nonrunners, while total knee replacements were performed on 2.6-3.9% of runners and 4.3-4.6% of nonrunners. Overall, the evidence appears to show that there is no difference in many characteristics of osteoarthritis (pain, radiographs, cartilage thickness, and prevalence of total knee replacements) between runners and nonrunners. However, there are a few limitations to this article. We personally did not feel very impressed with the robustness nor the interpretation of the data. This is a subject that has to have a lot of nuance and grey areas, but this paper felt very black and white. A lot of the decisions around knee replacement, and even whether to keep running in the presence of joint space narrowing, are largely impacted by the words and beliefs of the provider. Additionally, there is no discussion of the impact of running volume on these factors associated with osteoarthritis. It is theorized recreational running volumes could be protective against arthritis, or at least not inherently damaging the knee joint. However, those who run at large volumes could have higher incidences of knee arthritis in line with the "wear and tear" explanation for the cause of arthritis. There is still a lot more research to be done in this area!

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/36875337/

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This week's article details the objectives from ACSM’s "Moving Through Cancer" initiative's leadership team. They outline 5 priority areas: workforce enhancement, program development, research and evaluation, stakeholder awareness, empowerment and engagement; and policy, funding, and sustainability. Workforce enhancement is targeted at both current rehab curricula and continuing education opportunities with the goal of improving knowledge and compentency with exercise prescription when working with oncological patients. Program development centers on patient support and exercise programs, with the creation of a national directory of exercise programs for cancer patients (exerciseismedicine.org/movingthroughcancer). Research and evaluation is necessary to continue to define appropriate exercise and loading parameters to guide clinicians working in this setting. While it is great to know the "optimal" dosage, we must remember to treat the patient in front of us and optimally load for their context and needs. The authors primarily focus on the patient when describing stakeholder awareness, however stakeholders also include practicioners and patiet's families. There should be resources targeted at all these audiences to improve awareness of the importance of exercise in cancer prevention and healthy aging, and exercise as oncological treatment. Finally, the authors acknowledge the need for healthcare policy change to ensure optimal care for all oncological patients.

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/33090477/

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This week's article is "Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial" by Breda et al. published in 2021 in the British Journal of Sports Medicine. It compares a progressive tendon loading program using a 3/10 pain threshold to an eccentric exercise program with >5/10 pain threshold for management of patellar tendinopathy. After 24 weeks, they found 43% of those in the progressive loading group returned to their prior level of sport, while 27% of those in the eccentric exercise group returned to their prior level. They found similar levels of satisfaction with the program (~80%) and adherence (~45%), and length of symptoms prior to participation did not impact timeline to return to sport. One of our key critiques of this study is clinically it is rare to perform an exercise program at greater than 5/10 pain levels, with typical pain thresholds being 3-4/10 pain. Would there have been a difference if they utilized a similar pain threshold? In addition, the eccentric program could have been progressive, like their other tendon loading program. Those in the eccentric group essentially did the same exercise for the same amount of time that the other group progressed through 3 phases of exercise (isometric, isotonic, plyometric). We would also would have liked to have seen an analysis that grouped participants based on high adherence vs low adherence to see if exercise adherence moderated the effect on return to prior level. It would not be surprising if those who were more adherent to the exercise program, whether it was progressive loading vs eccentric exercise, saw faster return to prior level of function than those who were not adherent. Physical therapists could use this result to justify their services since this was an unsupervised program, so this result would show a benefit to supervised PT. What are your thoughts on patellar tendinopathy? What does your programming typically look like for those with patellar tendinopathy?

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Reference: (Breda et al., 2021) Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial

The abstract can be found here: https://pubmed.ncbi.nlm.nih.gov/33219115/

As always, if you enjoy what you hear, be sure to follow us on your favorite podcast platform and on Instagram @readingrehabpod. If you have any article recommendations be sure to send them our way!

This week's article, "Judgment and decision making in clinical and return-to-sports decision making: a narrative review," dives deep into decision making frameworks and theories for how we make decisions. While this is written to the specific context of sports rehab and return to sport decision making, the decision making process is a critical aspect of all areas of rehab whether we are deciding if an athlete is ready to return to their sport or if a stroke victim is safe to return home. This article discusses bounded rationality, heuristics, and the dual process model of decision making. Bounded rationality is a theory that explains how humans make decisions, while heuristics and the dual process model describe how humans reduce cognitive load when making decisions. The authors note "the complexity and variability of real-world situations often necessitate the consideration and adaptation of multiple decision-making models or approaches." We can become better decision makers with experience, decreasing cognitive load via minimizing distractions and fatigue, use external decision aids, group decision making, and minimizing time pressure, among other things. For students and new grads, it is particularly important to spend time thinking through decisions, considering alternative options/theories (i.e. playing Devil's Advocate), and finding supportive environments for your growth as a thinker and clinician.

The abstract can be found here: https://link.springer.com/article/10.1007/s40279-024-02054-9

As always, if you enjoy what you hear, be sure to follow us on your favorite podcast platform and on Instagram @readingrehabpod. If you have any article recommendations be sure to send them our way!