Journal Club December 2016: The Impact of Trunk Impairment on Performance-Determining Activities in Wheelchair Rugby

Article Title: The Impact of Trunk Impairment on Performance-Determining Activities in Wheelchair Rugby

Author: V. C. Altmann, B. E. Groen, A. L. Hart, Y. C. Vanlandewijck, J. van Limbeek, N. L.W. Keijsers

Journal: Scandinavian Journal of Medicine & Science in Sports


Imagine the game of rugby, one of the rougher contact sports played worldwide. Now imagine that each of those rugby athletes are tetraplegic and are in a wheelchair, but don’t tone down the contact. Wheels screeching, chairs crashing, crowds roaring! This is the adaptive sport known as wheelchair rugby.

The following study by Altmann et al. 2016 observed the impact of the severity of an individual’s trunk impairment on their performance in wheelchair rugby. They assessed the relationship between the Trunk Impairment Classifications (TIC) system with wheelchair activities that determine the performance in the sport of wheelchair rugby. Typically the lower the TIC score, the more physically impaired an individual is.

The study took 55 athletes with a variety of TIC scores and put them through a series of tests. Specifically, they looked at four activities that they thought would be really affected by trunk impairment, including: a 10-m sprint test, a turn test, a tilt test and a maximal initial acceleration test. Each athlete performed three trials per test. Two athletes participated simultaneously during each test, to ensure some competitiveness.

Ultimately the performance of a wheelchair rugby athlete is determined by three separate items: (1) how they avoid a hit (maneuverability and acceleration), (2) how well they hit (acceleration, peak speed and impulse of hit) and (3) how well they free themselves from being held by the opposing player’s chair (impulse and tilting). They better they performed on the four assigned activities, the better they would perform in a real-life athletic setting of a wheelchair rugby match.

As a result, the study showed that the players with higher TIC scores were better athletes in wheelchair rugby than those with lower TIC scores.

Discussion by James Meiling, OMS-II, Texas College of Osteopathic Medicine

Discussion Points:

  1. Why is it important to rank paraolympic athletes by severity of disability?
  2. Describe the terms hitting and tilting when related to wheelchair rugby.
  3. How would a larger sample size aid the committees that designed the Trunk Impairment Classification (TIC) guidelines?
  4. Athletes with which health conditions participated in this study? Additionally, how would each health condition affect the performance of each athlete?
  5. Why was it important to test two athletes at the same time? How would the results of the study have differed if they ran each test individually, one at a time?
  6. Can these results be used to determine effectiveness of an athlete in other adaptive sports?
  7. Why do guidelines differ from one adaptive sport to another?
  8. How could future studies improve upon the Trunk Impairment Classification system?
  9. With the results of this study, what implications does this have for the future athletes you see within your practice?

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Journal Discussion Questions December 2016

Journal Article December 2016

Journal Club November 2016: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy

Article Title: Older Age as a Prognostic Factor of Attenuated Pain Recovery After Shoulder Arthroscopy


Author: Simon CB, Riley III JL, Coronado RA, Valencia C, Wright T, Moser M, Farmer K, George SZ


Journal: PM R. 2016 Apr;8(4):297-304. doi: 10.1016/j.pmrj.2015.09.004. Epub 2015 Sep 12.




Shoulder injuries, pain, and subsequent shoulder surgeries are common among the older adults.   It is estimated that up to 30% of adults older than 50 years of age have been affected by shoulder pain, a major indicator for shoulder surgery and in particular, arthroscopic rotator cuff repair.  Due to the widespread prevalence of shoulder pain and surgery in the community, Simon conducted a prospective cohort study looking at the variance between postoperative outcomes in younger, middle-aged, and older adults.  The article was originally published in the American Journal of Physical Medicine and Rehabilitation in April 2016 and obtained via the online journal for review.


Inclusion criteria included age (between 20 to 79 years of age), pain in the anterior, lateral, or posterior shoulder, a diagnosis of musculoskeletal dysfunction based on imaging and clinical assessment, and having been scheduled for an arthroscopic shoulder procedure.  Exclusion criteria included pain for more than 3 months in other regions, prior shoulder surgery in the past year, shoulder-related fractures, tumor, or infections, and current or previous chronic pain disorders, psychiatric management or gastrointestinal or renal diseases.  A total of 139 participants were recruited with 30 older adults, 57 younger adults, and 52 middle aged adults.


The study observed both subjective and objective measures of dysfunction and pain utilizing self-reported pain duration and intensity, disability levels, and current medications together with movement-evoked pain and experimental pain response physical testing.  Each utility was assessed pre-operatively, and three and six months post-operatively.  Univariate analysis was used to examine the difference between preoperative physical testing with 3 and 6 month measures postoperatively.  Influence of age group on pain outcomes were performed using a multivariate regression analyses, accounting for prognostic factors preoperative (movement-evoked pain, pain duration, and pain catastrophizing), intraoperatively (arthroscopic procedure), and postoperatively (analgesic use).


Results revealed that older adults had significantly higher movement-evoked pain intensity and experimental pain response at 3 months postoperatively compared to young and middle-aged adults.  Older age is a positive predictor for movement-evoked pain at 3 and 6 months and experimental pain at 3 months.  However, there were no age-group related differences in outcomes.  These results provide data for older age contributing to poorer pain outcomes after shoulder arthroscopy and further age-related studies on managing pain among older adults were recommended.


Discussion Points:


  1. What is the study’s objective?
  2. What is the main rationale behind investigating the objective?
  3. What methodological approach (statistical analysis, design) was used and why was it used?
  4. Was the sample size adequate?
  5. Are there any other factors that can be considered for inclusion or exclusion criteria in the study?
  6. What were the main results of the study?
  7. What were the strengths and weakness of the study?
  8. What biologic factors do you think accounts for the variance in movement-evoked pain intensity between older adults and middle age/young adults?
  9. What recommendations can you make to future older age patients who present with shoulder pain?  Would you change your conversation based on the results found in this article?
  10. What OMM techniques could be utilized in the management of shoulder pain and at what stage of the treatment do you think these techniques will benefit the patients, regardless of age?

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Journal Discussion Questions November 2016

Journal Article November 2016

Journal Club October 2016: Impact of Needle Diameter on Long-Term Dry Needling Treatment of Chronic Lumbar Myofascial Pain Syndrome

Whether it is in the inpatient or outpatient setting, myofascial pain is a common problem that all physiatrists will eventually see in their medical career. The following study conducted by Wang et al. 2016 examined the impact of needle diameter on lumbar myofascial pain. Specifically, the researchers were looking to identify whether the diameter of a dry-needle had an effect on myofascial pain. The article was originally published in the American Journal of Physical Medicine and Rehabilitation. Through a web search, on the database PUBMED, the article was obtained to read.

This was a double-blinded study. Wang et al. 2016 separated 48 patients with a history of lumbar myofascial pain into one of three groups. Each group corresponded to a specific dry-needle diameter. The three groups examined were: 0.25 mm, 0.5mm, and 0.9mm.

The primary outcomes used were the visual analog score (VAS) and the short form health survey (SF-36). Patients rated their pain before treatment and three months after treatment. Secondary outcomes examined included: pain intensity after treatment and whether the patient would consider undergoing the same treatment again if needed.

The researchers determined that dry-needling as a practice improved patient’s pain scores over a three month period regardless of needle diameter. They also determined that the efficacy of the larger diameter needle (0.9mm) improved over the course of three months in comparison to the other two diameter sizes. Patient’s willingness to return for another treatment improved as time went on with the larger diameter needle.

In conclusion, dry-needling and the diameter of the needle both play an important role in the treatment of myofascial pain.  

Discussion Points:

1) What is myofascial pain syndrome? How is it diagnosed?

2) What is dry needling therapy? Can you think of any other forms of alternative medicine that have been used to treat myofascial pain?

3) What is the difference between a tender point and a trigger point? Could dry needling also be used as a treatment modality for tender points?

4) Do you think the diameter of the needle could play a role in other treatment modalities (trigger points, nerve blocks, etc.) for chronic pain?

5) Do you think the VAS score is an accurate way to measure pain? Do you think another scale could be used or designed to better measure a patient’s pain level?

6) How can this study be used to further improve treatment for myofascial pain?

7) What type of future research could be designed based on this new study?

8) With this new information, how will you incorporate this information into your own medical practice?

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Journal Article October 2016

Journal Discussion Questions October 2016


Journal Club September 2016: Effects of Ramelteon on Sleep Disturbance After TBI

Article title: Pilot Study on the Effect of Ramelteon on Sleep Disturbance After Traumatic Brain Injury: Preliminary Evidence From a Clinical Trial.

Author: Lequerica A, Jasey N, Portelli Tremont JN, Chiaravalloti ND

Journal: Arch Phys Med Rehabil. 2015 Oct;96(10):1802-9. doi: 10.1016/j.apmr.2015.05.011. Epub 2015 May 28.


Many people with Traumatic Brain Injury (TBI) report sleep disorders, leading to anxiety, depression, and fatigue. These issues are associated with deficits in neurobehavioral, cognitive, and occupational issues. Currently used medications used to treat sleep disorders further complicate cognitive functioning. Benzodiazepines, Tricyclic antidepressant, Trazodone, and anti-histamines carry their own cognitive, sedating, or poor memory effects.

The suprachiasmatic nucleus of the hypothalamus regulates circadian rhythm, and Ramelteon (TAK-375) is a neurohormone that targets melatonin receptors in this nucleus. While Ramelteon is indicated for long-term management of insomnia, and it has minimal chance for addiction, few trials have studied its role in treating insomnia. Clinical trials showed promising results, but Ramelteon’s use in treating sleep disorder in TBI had not yet been studied.

This study tested Ramelteon’s use in treating sleep disorders after TBI. There were 18 participants, each with TBI for at least a month before enrollment. In addition to meeting inclusion criteria, they were screened for other confounding conditions and medications, and discontinued use of other sleep medications for 2 weeks before the study.

The study used a double-blind, placebo controlled crossover design. Participants were grouped into Ramelteon or placebo groups for the first of the study, at which point they were switched into the opposite group for the second half. Electronic accelerometers (actigraphs) were worn to track “sleep onset latency (SOL), number of awakenings, wake time after sleep onset, and total sleep time (TST)”. Participants kept a sleep log, had CNS vital signs recorded, and were measured with the Pittsburgh Sleep Quality Index and Brunel Mood Scale.

Ramelteon was found to significantly increase total sleep time. It was also found to increase time needed to fall asleep, yet this time was not clinically significant. Likely due to the mechanism of action regulating circadian rhythm, those on Ramelteon also  went to bed earlier. The study found promising benefit for the use of Ramelteon in treating sleep disorders in TBI. Use of polysomnography instead of actinography would provide more detailed data. Additionally, further research would benefit from a larger sample size.


Discussion Points:

1: What is the role of the physiatrist in treating TBI?

2: Who else plays a role in treating TBI?

3: Why are sleep disorders particularly troubling for TBI patients?

4: What are some of the side effects with medications currently used to treat sleep disorders?

5: Why was it important to use a double-blind, placebo-controlled crossover design?

6: In addition to use of the actinography, what are some other ideas for how sleep variables can be measured?

7: What benefit would there be if a study recruited participants with more recent injuries?

8: What other methods could be used to manage sleep disorders in TBI?

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Article - Link to Full Article