Sunday, May 2, 2021

Lupine Publishers | The Effectiveness of Lunges and Static Stretching Exercises On Pain And Disability In Chronic Patellar Tendinopathy: A Case Report

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)


Eccentric exercises are not effective for all patients with chronic patellar tendinopathy (CPT). The aim of the present case report is to present the effect of eccentric - concentric loading combined with stretching exercises on pain and disability in a patient experiencing CPT. A patient with unilateral CPT for 7 months was included in the present report. The patient followed a supervised exercise program five times per week for 6 weeks consisting of slow progressive eccentric - concentric loading of quadriceps using forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) and static stretching exercises of hamstrings and quadriceps. The program was individualized on the basis of the patient’s description of pain experienced during the procedure. The patient was evaluated using the VISA-P questionnaire at baseline, at the end of treatment (week 6), and 1 month (week 10) after the end of treatment. At the end of the treatment and at the follow-up there was a decline in pain and a rise in function. The results of the present trial suggest that the combination of slow progressive eccentric - concentric loading of quadriceps using forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) and static stretching exercises of hamstrings and quadriceps can produce significant improvements in terms of pain and disability in CPT.

Keywords: Patellar Tendinopathy; Lunges; Stretching; Jumper’s Knee


Chronic Patellar Tendinopathy (CPT) commonly referred to as Jumper’s knee is the most common tendinopathy in the knee area. It is a degenerative condition and not an inflammatory one. Pain and decreased function are the main symptoms of CPT. Diagnosis is simple. The symptoms are reproduced by (1) lower limb activities such as squat or hop; (2) palpation on the site of pain (mainly at the inferior pole of the patella); and (3) clinical tests such as decline test [1]. No ideal treatment has emerged for the management of CPT. Many clinicians advocate a conservative approach [1] and physiotherapy is usually recommended [2]. A wide array of physiotherapy treatments has been recommended for the management of CPT such as electrotherapeutic/physical modalities, exercise program s, soft tissue manipulation, and manual techniques [3]. These treatments have different theoretical mechanisms of action, but all have the same aim, to reduce pain and improve function. Such a variety of treatment options suggests that the optimal treatment strategy is not known, and more research is needed to discover the most effective treatment in patients with CPT. One of the most common physiotherapy treatments for CPT is exercise. Eccentric exercise has shown good clinical results in CPT [4] as well as in conditions similar to CPT in clinical behaviour and histopathological appearance, such as lateral elbow [5], rotator cuff [6] and Achilles tendinopathy [4]. Eccentric training is not enough for all patients with CPT [7]. Malliaras and his colleagues [8] concluded that clinicians should consider eccentricconcentric loading alongside or instead of eccentric loading in lower limb tendinopathy. Tightness of hamstring and quadriceps has been found in patients with CPT as an aetiological factor [9]. Thus, stretching exercises of the above muscles are needed in the rehabilitation program. To our knowledge, there have been no studies to investigate the effectiveness of eccentric-concentric loading and stretching exercises for the management of CPT. It is possible to combine eccentric-concentric loading with stretching exercises to see if the combination of these two therapeutic approaches offers results in the management of CPT. Therefore, the aim of the present case report is to present the effect of eccentricconcentric training combined with stretching exercises on pain and disability in a patient experiencing CPT.

Case Presentation

The subject was a 26-year-old female volleyball player with a seventh- month history of anterior knee pain, in her right knee. She was diagnosed by a specialist (orthopaedic) as having CPT. She has played volleyball for about 12 years. The site of pain was over the inferior pole of the patella without spreading down and she complained of pain during her training walking downstairs. The pain subsided within one or two hours after her training. She did not complain of pain after prolonged sitting. She did not have any problems with the other joints. She did not complain of other symptoms such as stiffness, swelling, locking, crepitus or giving away. She took no drugs at the time of assessment; she had no history of trauma in the knee before, only four ankle sprains in the other leg. She had followed a physiotherapy rehabilitation program following the ankle sprains. She had no prior physiotherapy treatment for the problem in her knee. She did not have a history of diabetes, epilepsy or cancer and none in her family did. She did not have any operation or illness in the past.

Examination Findings
Although the condition was diagnosed by a specialist, the physiotherapist D. S. assessed her knee to rule out other conditions and confirm the diagnosis. No pain was mentioned during gait and posture. Body deformity, colour changes, muscle wasting, or swelling were not noted. In palpation, signs of inflammatory activity like heat, swelling and synovial thickening were not found. On physical examination, the movements of the low back, hip and ankle were pain free, with full range of motion and full power. All ligamentous stress tests were normal, meniscal stress tests were normal, muscle strength tests were normal and no capsular pattern was found. Isotonic resisted extension reproduced mild pain on the inferior pole of the patella; what is more, after ten fast squats (decline test) [8], she experienced a mild pain. The squats were carried out, because the researcher wanted to reproduce the pain. Knee extension by gliding the patella medially was negative, without reproducing the pain; furthermore, the position of the patella was normal [10]. These two latter procedures ruled out the patellofemoral joint dysfunction. Tenderness with palpation over the inferior pole of the patella was found, confirming the diagnosis.


The patient followed a supervised exercise program consisting of eccentric-concentric loading and static stretching exercises of hamstrings and quadriceps. As eccentric-concentric training, the participant carried out three sets of 15 repetitions of forward step lunge (FSL) with the anterior knee motion going in front of the toes (FT) with 1-min rest interval between each set. The FSLFT was performed at a slow speed at every treatment session. The patient counted to 6 during the FSL-FT. As the subject moved from the standing to the FSL-FT position, the quadriceps muscle and patellar tendon by inference were loaded eccentrically; followed by concentric loading, as the injured leg was used to get back to the start position. At the beginning the load consisted of the body weight and the participant was standing with all her body weight on the injured leg. The subject was told to go ahead with the exercise even if she experienced mild pain. However, she was told to stop the exercise if the pain became disabling. When the FSL-FT was pain-free the load was increased by holding hand weights. Static stretching exercises of quadriceps and hamstrings were performed as described by Dimitrios and his colleagues [9] before and after the eccentric - concentric loading. Each stretch lasted 30 seconds and there was a one minute rest between each stretch.
Supervised exercise program was given five times a week for 6 weeks and was individualized on the basis of the patient’s description of pain experienced during the procedure. The patient was instructed to use her knee during the course of the study but to avoid activities that irritated pain such as jumping, hopping and running [7-11]. She was also told to refrain from taking antiinflammatory drugs throughout the course of the study. Patient compliance was monitored using a treatment diary. Communication and interaction (verbal and non-verbal) between the therapist and patient was kept to a minimum, and behaviors sometimes used by therapists to facilitate positive treatment outcomes were purposefully avoided. For example, patients were given no indication of the potentially beneficial effects of the treatments or any feedback on their performance in the pre-application and postapplication measurements [12]. Pain and function were measured in the present study. The patient was evaluated at the baseline (week 0), at the end of treatment (week 6) and at 1 month (week 10) after the end of treatment. The VISA-P questionnaire was used to monitor the pain and function of patients. The instrument is a simple questionnaire, consisted of eight questions that takes less than five minutes to complete and once patients are familiar with it they will be able to complete most of it themselves. It is a valid and reliable outcome measure for patients with patellar tendinopathy [13].



The present study examined the effect of FSL-FT with static stretching exercises of hamstrings and quadriceps in a patient experiencing CPT and its findings have demonstrated significant improvements in terms of pain and disability. The results obtained from this case report are novel; as to date, similar studies have not been conducted. Alfredson, et al. [14] first proposed the eccentric training of the injured tendon. It is the most commonly used conservative approach in the treatment of tendinopathy. Unilateral squat eccentric training of the patellar tendon was the most commonly used conservative approach in the treatment of CPT [15] when the problem is at the inferior pole of the patella; however, no studies have investigated the effectiveness of training on other sites of patellar tendinopathy. Studies determining the effectiveness of exercises at other sites of patellar tendinopathy are needed. Later, it was found that the unilateral squat eccentric training on a 25o decline board applied more load on the tendon [9]. However, squat eccentric training of the patellar tendon alone, on decline board or not, was not effective for many patients with CPT. Malliaras and his colleagues [4] concluded that clinicians should consider eccentricconcentric loading alongside or instead of eccentric loading in Achilles and patellar tendinopathy. A Heavy Slow Resistance (HSR) program is recommended in the management of lower limb tendinopathy [16,17]. The HSR program was produced equivalent pain and function improvement (VISA) than the Alfredson eccentric program, but significantly better patient satisfaction at six months follow-up. In the Achilles tendon, eccentric and HSR have recently been shown to yield similar clinical outcomes (VISA and patient satisfaction) at 1 year follow up. Based on the above findings, the HSR program can be recommended as an alternative to the Alfredson eccentric program lower limb tendinopathy rehabilitation for young active people. Recently, isometric exercises have been recommended to reduce and manage tendon pain increasing the strength at the angle of contraction without producing inflammatory signs [8-18]. Five repetitions of 45-second isometric mid-range quadriceps exercise at 70% of maximal voluntary contraction have been shown to reduce patellar tendon pain for 45 minutes post exercise and this was also associated with a reduction in motor cortex inhibition of the quadriceps that was associated with patellar tendinopathy [18]. The dosage of isometric contractions is based on clinical experience [8-18] and their effect on pain in patients with CPT requires further study. The ‘Spanish squat is- used as isometric contraction and is useful when there is limited or no access to gym equipment [8]. However, conflicting results have been reported in terms of immediate and short-term pain relief [19]. Definitive conclusions about the effectiveness of isometric exercise in tendinopathy are yet to be made [19]. A component lacking from evidence-based programs is adequate potential to alter load distribution on the lower limb kinetic chain and increase the risk of lower limb tendinopathy [1-20]. It is our belief that the improvement of lumbo-pelvic control can be achieved by performing simple exercises such as single leg bridging in supine and four - point prone bridging exercises. Future research is needed to confirm this suggestion. In addition, hip extensors weakness has been associated with patellar tendinopathy [21]. Exercises to strengthen these muscle groups should be considered in exercise protocols and patellar tendinopathy. However, hip extensors were not strengthened in the present case trial because the strength of hip muscles in the assessment was normal. Functional activities such as jumping, cutting and sprinting should also be included in lower limb tendinopathy rehabilitation programs among athletes, but have so far not been included in popular programs in the literature [21]. These activities were included in the present study. The athlete carried out these activities in the court under the supervision of the gymnast. There are different techniques for lunges, including variations in step length, walking or jumping lunges, or different trunk positions [22]. Keeping the knee behind the toes is a common cue during performing a proper form of lunges [22]. Research is needed to find out 1) which technique of lunges is the most effective and 2) if the lunge is more effective treatment approach than squat for CPT patients and 3) the load applied to the patellar tendon during the lunges. The load of exercises was increased according to the patients’ symptoms otherwise the results are poor [23]. Furthermore, eccentric exercises were performed at a low speed in every treatment session because this allows tissue healing [24]. Ice was not recommended at the end of the treatment because research has shown that ice as a supplement to an eccentric exercise program offers no benefit to patients with tendinopathy [25]. Finally, the avoidance of painful activities is crucial for tendon healing, because training during the treatment period increases patients’ symptoms and delays tendon healing [26].
Eccentric exercises appear to reduce the pain and improve function. The mechanism by which eccentric training achieves these outcomes remains uncertain, as there is a lack of good quality evidence relating to physiological effects. The clinical improvement of the HSR group was accompanied by increased collagen turnover. It is unknown if the isometric contractions can reverse the pathology of the tendinopathy and in this case the pathology of CPT. Although a home exercise program can be performed any time during the day without requiring supervision from a therapist, our clinical experience has shown that patients fail to comply with the regimen of home exercise programs [25]. Although many ways can be recommended to improve the compliance of patients with the home exercise program such as phone calls, exercise monitors and better self-management education, it is believed that this problem can be solved by the supervised exercise programs performed in a clinical setting under the supervision of a therapist. It is believed because our experience has shown that many patients stopped the home exercise program without giving an explanation, whereas patients completed the supervised program. One possible reason why they continue the supervised exercise program could be the cost. In the supervised exercise program, the patients visit the therapist more times than the home exercise program, and this is more expensive. A future study will combine the both types of exercise program s in order to maximize the compliance of the patients. Even though the positive effects of such an exercise program in CPT have been reported in the present report, its study design limits the generalization of these findings. Future welldesigned clinical trials are needed to confirm the positive results of this case study establishing the effectiveness of such an exercise program in the management of CPT. In addition, structural changes in the tendons related to the treatment interventions and the longterm effects (6 months or more after the end of treatment) of these treatments are needed to investigate. Further research is needed to establish the possible mechanism of action of this treatment approach, and the cost effectiveness of such treatment, because reduced cost is an important issue for the recommendation of any given treatment.


The exercise program, consisting of FSL-FT and static stretching exercises of hamstrings and quadriceps had reduced the pain and improved the function in a patient with CPT at the end of the treatment and at one month follow-up. Further well-designed trials are needed to confirm the results of the present case report.

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Monday, February 8, 2021

Lupine Publishers | The Effect of Aerobic Exercise on The Cardiorespiratory Endurance and Skeletal Muscle of Metabolic Syndrome

 Lupine Publishers | Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)


This study examined the influence of aerobic exercise on the cardiorespiratory endurance and skeletal muscle of metabolic syndrome. An experimental research method was adopted, sampling community health service center people participating in health examination, 15 middle-aged men with waist circumference greater than 90cm (age 49.11±3.32) as subjects. Participants received 60-min aerobic exercise sessions two times a week for 10 weeks (20 sessions in total). The research tool uses a body composition analyzer (In Body) to detect skeletal muscle and basal metabolic rate; a three-minute cardiorespiratory endurance test (Harvard Step Test) is used to understand the subject’s cardiorespiratory endurance index after aerobic training. The results of the study found that weight loss, skeletal muscle rate t = -6.58*, and basal metabolic rate t = -5.77* all improved, and the cardiopulmonary endurance index increased from 52.64 to 58.31, from “poor” to “average” “within. The study concluded that aerobic exercise can consume more deep fat, reduce the risk of suffering from metabolic syndrome, help improve cardiorespiratory endurance and skeletal muscles, and achieve the results of rehabilitation and health improvement.

Keywords: Metabolic Syndrome; Cardiorespiratory Endurance; Aerobic Exercise; Skeletal Muscle Rate; Basal Metabolic Rate


Metabolic syndrome (MS) is a group of metabolic diseases that appear in the same person. Its main metabolic abnormalities include obesity, dyslipidemia, hyperglycemia, hypertension, insulin resistance or glucose intolerance and other risk factors [1-4], one person At the same time, as long as there are more than three risk factors, it can be presumed to be metabolic syndrome [5], that is, MS is not a disease but a warning sign of the body [6,7], it is also a “predisease state” in which the body begins to experience metabolic abnormalities. MS is an aggregation of risk factors that increase the incidence of cardiovascular events and diabetes mellitus (DM). Population aging is accompanied by higher prevalence of MS [8,9]. The prevalence of MS increases with age, with about 40% of people older than 60 years meeting the criteria [10]. Now days MS can no longer be considered a disease of only adult populations. Alarmingly, MS and DM are increasingly prevalent in the pediatric population, again in parallel with a rise in obesity [11]. Most middleaged people have abdominal obesity, and thus constitute a high-risk group for MS. Statistics have indicated that people with visceral obesity have a 50% chance of developing MS [12]. Middle-aged people who belong to the high-risk group of MS can easily lead to chronic diseases such as diabetes, heart disease, and hypertension if they do not control their diet and exercise [13-15]. General body composition is composed of body fat mass, body fat percentage, skeletal muscle rate (SMR) and basal metabolic rate (BMR) [16]. Among them, the MS is closely related to its own BMR [17], and because the BMR is positively correlated with SMR growth and exercise [18]. One of the most critical elements of physical fitness is cardiorespiratory endurance. Relying on the kinetic functions of the heart and lungs, cardiorespiratory endurance refers to the body’s ability to continue supplying energy to the human circulatory system and muscles over extended periods [17]. There had been positive reports [19,21] about how advanced cardiorespiratory endurance not only enables one to engage in aerobic exercises, such as walking and jogging for a longer time. From the above literature, we could see the feasibility of this study. After a long period of aerobic exercise, people with metabolic syndrome and generally healthy people should be able to improve the growth rate of skeletal muscle and improve cardiorespiratory endurance [22,25]. This was also the focus of this research. In addition to dietary control, frequent exercise is the best method for staving off MS, where daily exercise invigorates the body [26]. Evidence has indicated that aerobic exercise is an effective method of improving cardiorespiratory endurance, aerobic exercise can significantly improve health [27,30]. Relevant studies have indicated that starting from 30 years old, lack of exercise is the primary driver of aging-related loss of muscle mass [31,32]. Some other studies have indicated that exercise can enhance bone density, reduce body fat, enhance metabolism, and prevent chronic diseases [33,34]. Aerobic exercise can strengthen the muscles surrounding and supporting the joints can help maintain a good body shape and enhance the integrity of the joints, thereby helping to prevent injuries [35,36]. Aerobic exercise will strengthen the skeletal muscles and help the bones to stay strong. Just like your brain, skeletal muscles need to be exercised to maintain muscle strength [37]. Some MS become obese, muscle strength deteriorates, physical vitality decreases, and even chronic diseases are caused by lack of exercise [38]. MS is a symptom produced by modern society and civilization, and because aerobic exercise has a positive effect on the physical composition of individuals, this study uses middle-aged people with MS as the research object, and uses aerobic exercise to understand the cardiorespiratory endurance and skeletal muscles of MS.

Materials and Methods

Experimental Approach to the Participants

An experimental research method was adopted, in cooperation with the community health service center, and implemented in the school gym. The subjects were people who participated in the health checkup at the community health service center. Middleaged men with a waist circumference greater than 90cm were the sample objects, a total of 15 people were sampled (age = 47.89 ± 6.24 years). Participants received 60-min aerobic exercise training sessions two times a week for 10 weeks (20 sessions in total). All training and testing are performed by the research team. This study did not involve personal privacy and strictly adhered to research ethics. As for the subjects’ psychological symptoms, disease history, family factors and other potential variables, they were listed as control variables. Aerobic training courses are shown in Table 1[39].

Experimental Detection Tools

A body composition analyzer (InBody 230) was used to measure SMR, and BMR. The mechanism underlying the InBody analyzer is the method of bioelectrical impedance analysis, which utilizes the impedance of current flow; specifically, the lower the conductivity of the muscles, blood, body fat, and skin, the higher the impedance is [40]. Take a 3-minute test of cardiorespiratory endurance (Harvard step test) to learn about the subjects’ cardiorespiratory endurance index after aerobic training. Use a 35cm high step, 96 beats per minute metronome, a total of three minutes of operation, after completing the test, measure 1 minute to 1.5 minutes, 2 minutes to 2.5 minutes, 3 minutes to 3.5 minutes, three 30-second wrist pulse rates. The cardiorespiratory endurance index score is then determined by the following equations. Cardiorespiratory Endurance Index = (100 x test duration in seconds) divided by (2 x sum of heart beats in the recovery periods). And consider the male cardiorespiratory endurance index norm [41], as shown in Table 2.

Statistical Analysis

Pre-test and post-test data were obtained and analyzed in SPSS (version 23.0). Descriptive statistics (specifically, the mean and standard deviation) were used to summarize the participants’ characteristics, and t tests were used to analyze after aerobic training changes in cardiorespiratory endurance (CRE), SMR and BMR.


The results of this study are divided into two parts: First, Descriptive statistics of SMR, BMR, CRE before and after aerobic exercise; Second, Difference analysis of SMR, BMR, CRE before and after aerobic exercise for subjects.

Descriptive Statistics of SMR BMR CRE Before and After Aerobic Exercise

In this study, 15 men (age 49.11±3.32) were the subjects. These subjects were middle-aged men with waist circumference greater than 90 cm. According to the data in Table 3, the weight of the subjects was overweight or obese, and the cardiorespiratory endurance did not reach the standard average value. The data in Table 4 shows that the average weight of the subjects decreased significantly after aerobic exercise training, while the skeletal muscle, basal metabolism, and cardiopulmonary endurance were significantly improved.

Pre-test results: The average weight of the subjects was 84.47 kg, the SMR was 29.30%, which was slightly too low, the BMR was 1585 kcal/day, and the cardiorespiratory endurance index was 52.64, which was a poor state.

Post-test results: The average weight of the subjects was 78.67 kg, the SMR was 34.98% above the normal range (32~34% of the normal range), and the BMR was 1623 kcal/day, which was in the normal range (the male is 1400~1700) Card) [42], cardiorespiratory endurance index (cardiorespiratory endurance index) of 58.31 belongs to average state. According to the above data, aerobic exercise can increase the body’s BMR [43,44], and improve the effect of cardiopulmonary endurance [45,46], and the BMR is positively correlated with skeletal muscle [47]. Increasing skeletal muscle can increase the BMR, which not only helps burn calories and avoid weight gain, so the metabolic rate is low, and the risk of weight gain is low higher. For more Orthopedics and Sports Medicine Open Access Journal (OSMOAJ) Please Click Here: 

Wednesday, January 20, 2021

Lupine Publishers | Recurrent Ischemic Stroke as a First Manifestation of Poorly Differentiated Carcinoma (PDC) of Unknown Etiology

  Lupine Publishers | Open Access Journal of Oncology and Medicine (OAJOM)


The association between cancer and thrombosis has been known for a long time, and the majority of the thromboembolic events associated with cancer are usually diagnosed after the cancer being identified [1]. However, a thromboembolic event may precede the identification of a cancer and maybe the first manifestation of the underlying malignancy [2]. Malignant cancers promote hypercoagulable state and increases the risk of thromboembolism. Carcinoma is the most common cause of ischemic stroke associated with malignancy [3] with lung cancers being the most common [1,4] while adenocarcinoma confers a higher risk of recurrent venous thromboembolism (VTE) [5]. We report a case of recurrent embolic strokes resistant to anticoagulation as the first manifestation of poorly differentiated carcinoma (PDC) of unknown etiology. It is the first case reported in the literature.

 Case Report

 A 57 years old male patient presented to our hospital with nonfluent aphasia. There was no significant past medical history and he denied smoking, alcohol or illicit drug use. Clinical examination revealed a right inferior quadrantanopsia, a right upper extremity weakness with strength 4/5 according to Medical Research Council Scale. There were difficulties in word-finding, naming and reading with intact repetition. His admission National Institute of Health Stroke Scale (NIHSS) was 6. He was deemed ineligible for thrombolysis due to unclear onset time and was started on aspirin and high intensity statin. The CT angiography of the head and neck showed no evidence of aneurysm, dissection, significant flow stenosis, or arteriovenous malformations. A Transesophageal Echocardiography (TEE) showed normal left ventricular function with no evidence of a thrombus or a Patent Foramen Ovale (PFO). A Magnetic Resonance Imaging (MRI) of the brain showed acute infarcts within multiple vascular territories, involving the bilateral cerebellum, left frontal, temporal, parietal and occipital lobes, consistent with embolic infarcts (Figure1). A four-vessel digital subtraction cerebral angiogram did not show evidence of vasculitis or vessel malformation. A hypercoagulable panel did not reveal evidence of hematologic hypercoagulability. The patient was treated with warfarin with low molecular weight heparin bridging due to the highly embolic nature of the MRI findings, and was discharged to the acute inpatient rehabilitation facility. While at the rehab, the patient started complaining of back and abdominal pain. A CT abdomen and pelvis identified heterogeneously enhancing lesion within the lower pole of kidney with extensive lymphadenopathy (Figure 2). While waiting for biopsy to be done, the patient had worsening of aphasia and dysarthria prompting readmission. Repeat MRI brain showed new scattered areas of acite infarcts in different vascular territories (Figure 3). Anticoagulation was continued. Two days later, he had worsening mental status and repeat imaging showed more acute infarction. Biopsy of the abdominal lymph node was facilitated, and result showed poorly differentiated carcinoma of unknown origin. The family opted for comfort measures only and the patient expired shortly


Hypercoagulable state is a common finding in patients with malignancy due to the production of substances with procoagulant activity. Different mechanisms have been implicated in the cerebrovascular complications of cancer patients and includes the following: [6]

I. Cerebral infarction from nonbacterial thrombotic endocarditis (NBTE).

II. Thrombosis due to compression or infiltration of cerebral vessels by tumor or coagulopathy induced by chemotherapy.

III. Cerebral venous sinus thrombosis due to hypercoagulable state or chemotherapy.

IV. Cerebral infarction due to tumor emboli or septic thrombi.

V. Intracranial hemorrhage which is more common in patients with hematological malignancies.

Our patient presented with ischemic stokes involving multiple vascular territories. A complete workup for ischemic stroke was performed, including Brain MRI, TEE and cerebral angiogram that ruled out the presence of brain tumors, atherosclerosis, vasculitis, cardiac embolic source as well as sinus thrombosis. The results were in favor of embolic strokes. The physical examination did not reveal any signs of sepsis or infection. The conventional etiologies of stroke could not be identified. Despite appropriate therapeutic anticoagulation the patient had recurrent ischemic strokes. The commonest cause of stroke in cancer patients is embolic due to hypercoagulation [1,4]. Recent study showed that infarction in multiple vascular territories in stroke patients associated with cancer is significantly elevated (34%), compared to 15% of stroke patients not associated with cancer [5], so it is important to consider the existence of a concealed cancer in stroke patients with multiple vascular territories involvement and conventional mechanisms for stroke etiology not identified. A retrospective study showed that in patients with ischemic stroke associated with cancer, the cumulative rates of recurrent ischemic stroke were 7 % at 1 month, 15 % at 3 and 6 months [3]. In our case the patient experienced recurrent events within a two-week period and continued despite adequate anticoagulation. It is unclear whether initiation of aggressive cancer treatment may have improved patient outcome as the family opted for withdrawal of care. Further study on the early initiation of cancer therapy in malignancy-associated ischemic strokes even during the acute phase may be warranted.

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Monday, January 11, 2021

Lupine Publishers : A Systematic Review of Anterior Cruciate Ligament Reconstructions with Hamstring Autograft in Patients Over 50 Years of Age

  Lupine Publishers |  Orthopedics and Sports Medicine


Background: While ACL injuries in older patients have historically been treated non-surgically, several recent studies have demonstrated excellent clinical outcomes with ACL reconstruction in patients over 50 years of age. Despite these outcomes, the ideal graft choice in this age group has yet to be defined.

Objective: The purpose of this study was to systematically review the literature and analyze the clinical outcomes, failure rates and complication rates in patients over the age of 50 who have undergone ACL reconstruction using a hamstring autograft.

Methods: A systematic review of the literature was performed according to the PRISMA guidelines and included English studies from January 2000 to 2020. Studies that reported on outcomes of patients over 50 years of age undergoing ACL reconstruction with a hamstring autograft were included. Studies with other graft types, patients under 50 and expert opinions were excluded. Data consisted of patient demographics, physical exam findings, functional outcome scores, failure rates and complications.

Results: 6 studies met the inclusion criteria and included 167 patients with a mean age of 54.8 (50-71). Mean follow up was 41.4 (12-72) months. All studies demonstrated a significant improvement in functional outcomes at final follow up, including IKDC, Lysholm, and Tegner scores. Very few complications and no clinical failures or revisions were reported in this cohort.

Conclusions: The results of this systematic review support hamstring autograft as a viable graft option for ACLR in patients over 50 with excellent functional outcomes, high patient satisfaction, low failure rates and minimal donor site morbidity.

Keywords: ACL: Anterior Cruciate Ligament; Reconstruction; Hamstring Autograft; Advanced Age


Anterior cruciate ligament (ACL) rupture is one of the most common injuries seen in orthopedic sports medicine with over 129,000 occurring every year [1]. Until relatively recently, operative treatment has focused mostly on younger active athletes while older individuals were treated conservatively. Ciccotti et al. have reported an 83% satisfaction rate at final follow-up for older patients with an ACL tear treated conservatively [2]. Despite the high patient satisfaction rate, the authors noted persistent instability on exam in 97% of the patients and a reinjury rate of close to 40%, calling into question the benefit of conservative treatment in this age group. With an ever-increasing number of active individuals and increasing life expectancy, more and more patients are participating in high risk activities for ACL injury well into the later years of life. As a result, there has been an increasing number of studies evaluating the clinical outcomes of ACL reconstruction in older patients [3-16]. While 40 years of age has traditionally been the cut off for older patients, several published case reports have documented satisfactory clinical outcomes in patients in their 70s and 80s [11-15]. Because of this growing evidence, many have advocated for ACL reconstruction (ACLR) regardless of the age of the patient in the absence of advanced degenerative changes in the knee. Despite the positive outcomes of ACL reconstruction in older patients, the ideal graft choice in patients over the age of 50 remains controversial. While allograft is commonly utilized, several studies have advocated for the use of hamstring autograft in this population demonstrating excellent clinical outcomes and minimal donor site morbidity. The purpose of this study was to systematically review the literature and analyze the clinical outcomes in patients over the age of 50 who have undergone ACL reconstruction using a hamstring autograft. The secondary purpose was to characterize the overall failure and complication rate.


A systematic review of the literature was performed per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

Search Strategy and Criteria
A literature search was conducted in the PubMed, Ovid, EMBASE, and Medline databases for studies in the English language between January 2000 and March 2020. Keywords used to identify relevant articles included “anterior cruciate ligament” OR “ACL” AND “50” OR “aged” OR “aging” OR “older patient”. Filters activated included: clinical trial, comparative study, controlled clinical trial, meta-analysis, multicenter study, observational study, randomized controlled trial, review, systematic reviews, validation studies, humans, and English. The focus was to study the various outcomes reported after ACLR among patients who are 50 years or older and had a hamstring autograft. Studies included prospective cohort studies, retrospective studies, and case series. A cohort of patients over the age of 50 years undergoing ACL reconstruction with a hamstring autograft was the primary inclusion criteria. Studies that did not have all patients treated with hamstring autograft, expert opinions, nonclinical studies, clinical studies that did not include a cohort over 50 years of age, clinical studies that were primarily centered on arthroplasty and studies in which the primary pathology did not involve the ACL were excluded from the analysis.

Extraction of Data and Synthesis
The primary outcomes were clinical and functional results such as Lysholm score and International Knee Documentation Committee (IKDC) score. These scores were extracted independently (M.M and G.Y) and presented as the mean with range of values listed in parentheses. Both pre-operative and post-operative scores were evaluated when available. To evaluate patient’s activity level, the Tegner activity score was used where 0 represented disability because of knee problems, and 10 represented the highest score corresponding to national and international elite competitive sports. Failure rate was also extracted which corresponded to a need for surgical revision due to recurrent ACL tear. The Lachman test and pivot-shift test were also assessed. An exam of 0-1 was listed as negative and 2-3 were listed as positive for both tests. Patient satisfaction information was also evaluated when listed.


Statistical Analysis

The meta-analyses were carried out using STATA software version 14 (Stata Corp, College Station, TX) and R software version 3.6.3. Heterogeneity was quantified by I2 statistic. A random-effect model was used when significant heterogeneity was detected among studies (p < 0.10, I2 ≥ 50%). The Egger’s linear regression test and funnel plots were used to examine the possibility of publication bias due to small-study effects (Figure 1 and 2). Differences in change of mean and standard deviation were calculated using:


The results of this systematic review support hamstring autograft as a viable graft option for ACLR in patients over 50 with excellent functional outcomes, high patient satisfaction, low failure rates and minimal donor site morbidity. 

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Thursday, January 7, 2021

 Orthopedics and Sports Medicine Open Access Journal (OSMOAJ)


This study aimed to analyze the effect of a training circuit, applied for 3 weeks, during the warm-up phase of practical physical education classes, and to verify the resulting effects on the analyzed variables. Twenty-five students participated in the study (mean ± age = 15.67 ± 1.02), weight (67.31 ± 9.29 kg), height (1.72 ± 0.08 m). The training program in circuit was applied twice a week, for 3 weeks, and it was containing burpees, jumping together, squats, sit-ups, push-ups, countermovement jumps, sprints with change direction. The students were analyzed in two different moments (i.e., pre/post application of the training program). The results indicated that the application of the training program induced positive effects in the optimization of aerobics fitness, specifically in the shuttle test. The study also concluded that the circuit training program, in addition to inducing positive changes in the shuttle test, is also a viable alternative for warming up in the physical education class.


Physical education plays a fundamental role in the integral development of the student, enabling cognitive, psychomotor, and affective development while also encouraging healthy lifestyles, socialization, team spirit, and sports practice. The benefits of regular physical activity are diverse; namely, improvements in cardiovascular and respiratory function, decreased levels of anxiety and depression, and increased sense of well-being, and the development of cognitive and social valences [1-43]. In contrast, a sedentary lifestyle in adults is associated with a decrease in functional capacity, an increase in morbidity and mortality, and chronic diseases [19-32]. Therefore, it is essential to promote healthy living habits and physical activity during childhood, which, when prolonged during adolescence until adulthood, can be useful in combating physical inactivity and also have a beneficial influence on health in general [22-24]. Currently, and in the face of an increasingly challenging and stimulating world, it would be expected that there would be concerns regarding the development of motor, social, and cognitive abilities from an early age [5-35]. However, the reality is that an increase in sedentary lifestyle, interaction problems, and less contact with nature is exponential and endangering the development of children’s motor skills [40]. The daily recommendation for physical activity for young people is 60 minutes of moderate to vigorous activity, 5 times a week [42]. However, in most cases, this is not the case, as most adolescents practice exercise only in a school context, particularly during physical education classes, hence its exponential importance in children’s development [28]. Therefore, the school can be characterized as the perfect location to implement health promotion strategies and promote healthy lifestyle habits [18]. In particular, with regard to physical education classes, one of the strategies that can increase their efficiency, and which has been increasingly implemented in the school context, is circuit training, which, when properly adapted, enables the inclusion of various content and the development of several individual skills [10] as well as the enhancement of physical exercise practices [17]. In fact, the need for training and increased strength in children and young people has gained greater significance, as well as the knowledge that there are significant improvements associated with the application of these programs, provided that they be run in sufficient quantities-with functional loads that exceed the usual muscular activity-and are adequate, in that they strictly follow the methodological recommendations for the development of strength in children and young people [21].

This type of training program is carried out through interval training and consists of several stations that involve work on strength, balance, resistance, and coordination, depending on the objectives [37]. This type of training program has several advantages: it is easy to adapt to the target audience and existing resources; it enables the stimulation of several muscle groups in each season and the application of different loads, and allows results to be obtained in a short period of time [12]. In this regard, recent studies indicate that children and adolescents could benefit from this type of training program in a school context [2-30]. A recent study [7] showed significant improvements in all investigated physical capacities after the application of this type of program. Efficiency was demonstrated even in a short period, and these conclusions have been corroborated by a previous investigation [29]. Another study [2] also found improvements in the physical fitness of the students, although the program application time was different. Emphasizing these results [11] considered that physical fitness is an important health marker that should be monitored from a young age and be assessed through aptitude tests, which are easy to apply, do not require many resources, and enable an evaluation in little time, therefore offering an excellent alternative for schools in symbiosis with the training programs mentioned above [36] mentioned the importance of physical education teachers using this type of test, given that, in addition to being a vehicle for promoting physical activity, it also detects certain health problems. Based on the evidence that indicates that physical fitness has a fundamental role in our society and health, at any age [34] as well as the indicators pointed out by some studies regarding the relevance of the application of programs of training in the school context, it is important to consolidate this idea and continue to investigate the effects of the application of training programs in the school context, in order to analyze the potential of application to the alternative development of students’ physical condition in physical education classes. Despite the variability of studies on this subject, which emphasize the improvements resulting from the application of various training programs, there is still no consensus regarding the characteristics they should have, namely with regard to their duration, intensity, type of training, exercise, and ideal application time. Thus, the objective of this study was to analyze the effect of a training circuit, applied for 3 weeks, at the beginning of each physical education class, and to verify the resulting effects on the analyzed variables. As a study hypothesis, it was considered that the varied program may have positive effects on the physical condition of the participants across determined variables, including the horizontal thrust, reciprocating, abdominals, and push-ups.



A group of 25 students belonging to a Portuguese school-mean age (15.67 ± 1.02), weight (67.31 ± 9.29 kg), height (1.72 ± 0.08 m) and index of body mass (BMI) (22.50 ± 2.65%)-participated in the study. None of the participants had regular strength training habits. Before the study began, students underwent a physical examination by a doctor, and each was considered free from any disorder that would prevent full participation in the investigation. All participants and the teacher were fully informed verbally and in writing about the nature of the study. As for the nature and requirements of the study, as well as the known health risks, the participants filled out a questionnaire about their health history and were informed that they could withdraw from the study at any time. All guardians provided their consent through informed consent, attesting to their children’s voluntary participation in the study. The study was approved by the school’s Ethical Advisory Committee and conducted in accordance with the Declaration of Helsinki.

Experimental Design This study aimed to verify the effects of applying a circuit training program during the warm-up phase of practical physical education classes on specific physical fitness variables (i.e., the shuttle test, sit-up test, push-up test, and horizontal impulse test). A varied circuit training program was applied, with the aim of stimulating increments in four indicators of physical fitness (i.e., shuttle, horizontal thrust, extension of arms, and abdominals). These were evaluated at two different points: before the start of the training program (pre-test) (T1) and after applying the training program (post-test) (T2). The training program lasted for 3 weeks and was run during the academic year, between February and March, during the warm-up period of physical education classes. In addition, on a weekly timetable of 3 hours per week, divided into 2 classes of 1h 30m, the students took part in a training program that included exercises lasting 15 minutes. All experimental procedures were performed in coordination with the teachers and, therefore, did not cause any change in the individuals’ routine. Pre and posttests were carried out in the internal space to eliminate the effect of climatic conditions on the results. These tests were chosen because they could be applied quickly and because they did not influence the normal course of activities in the classroom.Procedures

Four specific variables were analyzed with adaptations to previously used protocols: the shuttle test [14], sit-up test [9], pushup test [4], and horizontal impulse test [31]. These were evaluated in 2 distinct phases: before the application of the training program (i.e. pre-test) and after the application of the training program (i.e. post-test). The values for each test were recorded for subsequent analysis. The anthropometric variables of height and body mass were measured for each subject, on a levelled platform scale (Año Sayol, Barcelona, Spain), with an accuracy of 0.001 m and 0.01 kg, respectively.

Training Program

The training program was applied twice a week for a total of 3 weeks. The program had a weekly increment of one repetition. The exercises applied contained strength exercises: burpees, jumping together, squats, sit-ups, push-ups, and countermovement jumps. The program was also composed of sprints, with changes in direction (5 m) and speed (20 m), as shown in Table 1, and were performed according to the protocol described in Figure 1 [15].

Statistical Analysis

The calculation of means, standard deviations, and 95% confidence intervals (95% CI) was performed using standardized statistical methods. The normality of the distribution was examined using the Shapiro-Wilk test (n <30) and, depending on the existence of normality, parametric or nonparametric tests were adopted for data analysis. To compare the physiological variables at rest in the two assessment sessions and to compare the responses to the exercises, the paired T-test and the non-parametric correspondent, the Wilcoxin test, were used. The level of statistical significance was found to be p≤0.05. The effect size (TDE), with a 90% CI, was calculated using the Hedge’s g formula, as it produces more reliable results when n <20 [20]. To classify the TDE, a modified classification system was used (trivial: 0.0–0.2; small: 0.2–0.6; moderate: 0.6–1.2; large: 1.2–2 , 0; very large:> 2.0; extremely large:> 4.0) (Hopkins et al., 2009). Percentage variations between the initial evaluation (pre) and the evaluation after the academic period (post) [(posttraining - pre-training) / pre-training) x100] were also calculated and considered statistically significant when 95% of the difference confidence did not include the zero value.


The two moments of evaluation were analyzed and paired, as shown in Table 2 (pre- vs post-training test). The results showed that there were no statistically significant differences (p> 0.05) for the push-up test, sit-up test, and horizontal impulse test (p = 0.085; p = 1.0; p = 0.052) respectively. Regarding the effect size, the results showed a small effect for the push-up test (d = 0.18) a moderate effect for the sit-up test (d = 0.9), and a trivial effect for the horizontal push test (d = 0). With regard to the shuttle test, there were statistically significant differences between the 2 evaluation moments (p <0.05) with a small effect size (d = 0.25). The difference between the pre and post-workout for the push-up test was 6.60%, whereas for the sit-up test it was 4.27%; the shuttle test, however, had a variation of 7.26%, whereas for the horizontal impulse it was 0%.

Table 2: Comparison between Pre- and Post-test Training.


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This study aimed to analyze the effects of applying a training circuit on the physical condition of a school community. This circuit consisted of exercises such as burpees, sit-ups, squats, sprints, pushups, and changes in direction. The findings indicate that it induced positive effects in the optimization of aerobic fitness. The results of this study demonstrate that the training program has a positive effect for the shuttle test only. The shuttle test variable was the only one that showed significant differences after the application of a training circuit in the school context, manifesting changes between the pre-and the post-test, which contradicts previous studies [27- 29]. In this regard, another study [2] also found improvements in the performance of the shuttle test, concluding that circuit training could be an effective way to develop resilience in school. In fact, these results contradict a previous investigation [23], where benefits resulting from the application of training circuits were evidenced, such as an increase in muscular strength and muscular endurance capacity as well as a reduction in the risk of occurrences of injuries during the practice of physical and recreational activities. The analysis of the push-up variable showed that there were no significant changes, probably due to the limited time of application of the circuit, although there was a slight variation between the pretraining and post-training moments. In addition, previous studies have shown that push-up tests are those with the highest failure rates [6-41]. Regarding the horizontal impulse test, it was found that the present study contradicts the data found in previous investigations [8], as there were no significant changes. However, it was expected that there would be an improvement in the results based on the regular use of the muscles of the lower limbs during the daily activities [2]. Other investigations that evaluated the horizontal impulse [38,39] found average values of 177.89 cm after application of the training program, whereas the results of this study show average values of 196.6 cm, a much higher value that may be related to the height of the participants, based on the strong correlation between height and the force of the impulse [38]. The lack of evolution in this variable may also be related to the fact that the students have not assimilated the correct mechanics of the exercises and, therefore, there may be a deficiency in the technique that will not translate into exercise efficiency [44]. Likewise, there were also no significant differences between the moments of analysis (i.e., pre-workout and post-workout) in the sit-up test. In this regard, other investigations that have investigated this variable [13-33] obtained mean values of 35.6 cm, but the current investigation obtained a considerably higher value (i.e., 46.8 cm); in fact, this result may be related to the practice of physical activity outside the school context, which was previously considered decisive for the test result [26]. A study of characteristics similar to ours [25] found significant differences in the variables considered after the application of the training program, which consisted of a training circuit applied weekly, where the degree of difficulty of the exercises increased each week. The fact that the training program had a significant effect only on the variable of aerobic fitness may also be due to the fact that the students do not yet have an established action plan. In other words, the action scheme is enhanced and developed using repeated action, which occurs in all sports movements. This same scheme is kept in memory and can be evoked later. In this specific case, students had little time to assimilate the circuit diagram, which helps to justify the results found. It is also important to note that comparison with other investigations becomes a little reductive due to the methodological differences verified between the studies, such as circuit duration, distinct and adapted circuits, and the sample size, as well as their characteristics.


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This investigation aimed to investigate the effects of the application of a training program in circuit format in the initial part of physical education classes, and to verify its impact on physical fitness variables in students aged between 15 and 18. After 3 weeks of application of the training circuit, the results indicate that despite the short time of exercise applied, significant improvements were obtained in the variable of aerobic fitness (the shuttle test). However, and most likely due to the short period of application of the training program, the remaining analyzed variables did not show statistically significant differences, which also allows for the possibility that if the training program was applied over a longer period, the results of the analyzed variables could show a significant increase. Nevertheless, it appears that the development of similar programs in the school context and during the teaching of teaching units may be beneficial for students in terms of improving their physical fitness and implementing training habits, as well as regular and healthy lifestyles. This investigation also presents a different proposal for the initial part of the physical education class that may be more motivating for the student, in addition to guaranteeing a different practical utility in relation to the time traditionally dedicated to warming up. With regard to study limitations, the fact that only one female member participated in the investigation prevented the results from being compared between genders, which would have been an interesting and enriching route for the study and is therefore recommended for further research. Finally, food and sleep hours were not controlled during pre-training and post-training and are variables that can affect students’ performance.

Disclosure Statement

The authors declare that there are no conflicts of interest.

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