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Background and aim: Fatigue is the inability to generate the maximal force that can be produced by the muscle . Fatigue is a subject that patients and athletes frequently encounter. Fatigue is one factor that limits muscle function and may lead to various pain and injury conditions. It is most commonly caused either by repetitive motion or by sustained muscular
contractions. Massage has been used for rehabilitation and relaxation for thousands of years. Massage is widely believed to have a beneficial effect on treating muscle fatigue and has been used in clinical and sports setting for that purpose. There is limited scientific evidence, however, to support the use of massage for enhancing performance and recovery from injury, or for preventing injury. The comparison of massage and rest on the knee extensor muscles fatigue after maximal isokinetic contractions is the main objective of this research.
Materials and methods: Fifteen healthy female aged between 20-30 volunteered to participate in this research. They did at least once a week some non-professional light sporting activities. Each of volunteers was evaluated in 3 different times. The first session was in order to familiarize the volunteers with the test and Isokinetic. For the main test, each of the volunteers was evaluated twice with one week interval. At the start of each session after warm up, the following parameters were measured: Perceived fatigue by Visual Analog Scale ¸average peak torque and average power maximal concentric of quadriceps at the velocity of 60 degrees per second by Isokinetic apparatus. Then in order to fatigue protocol ¸ the subjects were asked to perform successive and maximal quadriceps contractions until three subsequent quadriceps torque output reaches below 50 percent maximal torque output. Afterwards average peak torque and average power was measured. The extent of perceived fatigue was evaluated as before. Subjects then either received massage on the knee extensors or rested for 15 minute duration. Recovery from fatigue was quantified using average peak torque (APT), average power (AP) and perceived recovery scale (VAS).
Results: After maximal fatigue and decrease in torque output, below 50 percent maximal torque, 15 minutes of massage could change APT after fatigue from mean 56.70 (Nm) to 91.53 (Nm)) , AP from 38.64 to 63.62 (Nm) and VAS from 90.06 to 10.20 (mm). After 15 minute rest could change APT from 55.36 to 68.10 (Nm), AP from 37.69 to 48 (Nm) and VAS from 90.06 to 20.73 (mm).
Conclusion: There was significant difference between rest and massage conditions for recovery of fatigue. Massage was an effective intervention for enhancing muscle performance and recovery from fatigue but rest didn`t have such an effect. In both cases, recovery stage (massage or rest) caused significant change in perceived fatigue but massage is more effective on the decrease of perceived fatigue. Therefore, massage has been more effective than rest as a strategy to return to normal state and has caused more relief in perceived fatigue.

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Background and Aim: Muscular fatigue is common problem that an athlete faces repeatedly during sport competition or therapeutic exercise. Undoubtedly¸ fatigue affects the precision of subjects’ performance and limits the range of physical and sport activities. Muscle fatigue advantages and disadvantages have been reviewed in many previous studies. To challenge this controversy fatigue evaluation requires reliable, stable and precise methods of analysis itself. Researches on muscle strength and subject’s perception of fatigue have been done in many studies. Therefore researchers in this study focus on temporal stability of both subjective perception of fatigue and produced muscle torque after fatigue.
Materials and methods: Fifteen healthy female between 20-30 years of age, who at least had some nonprofessional light sporting activities once a week, volunteered in this research. Each of volunteers was evaluated in 3 different sessions. The first session was to familiarize the volunteers with the Isokinetic tests. For the main test, each of the volunteers was evaluated once and then after one week interval. At each session after warm up, perceived fatigue was measured using Visual Analog Scale. Then Average peak torque and average power maximal concentric Isokinetic of quadriceps were measured at the velocity of 60 degrees per second. To perform the fatigue protocol, subjects were asked to perform successive maximal quadriceps contractions until the three subsequent quadriceps torque output drop below 50 percent of maximal torque output. Afterwards, for re-measurement average peak torque, average power and perceived fatigue were evaluated similarly.
Results: The interaclass correlation coefficient (ICC) of average peak torque¸ average power and visual analog scale before performing fatigue protocol were calculated %81.6, %87.4 and %47.9 respectively. The repeated ICC after fatigue has estimated %59.9 ¸%64.4 and %96.6 respectively.
Conclusion: This research demonstrated that Isokinetic temporal stability parameters were high before fatigue. In other words, both torque and power are reliable in two repetition times in a session, as well after one week interval between. After fatigue the stability rate of torque and power recorded by Isokinetic were repeatable and this repeatability has been moderate to high. However VAS showed a completely opposite results, in which before fatigue the stability of imagined local fatigue perception has been very low and was not significant, although after fatigue the VAS showed high repeatability.

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Background and aim: This study was aimed to examine the reliability of a developed device measuring "arch height ratio" index.

Materials and Methods: 40 feet (the right and left foot of 20 subjects) were measured. Foot length was measured from posterior aspect of calcaneus to the tip of longest toe and dorsum height was measured at the midpoint of total foot length. All measurements were assessed in three weight bearing conditions of 10, 50 and 90 percent of total body weight on three occasions (10 minutes and five days after the first measurement) by a single rater. Finally the arch height ratio index was calculated.

Results: The ICC values in different conditions of 10, 50 and 90 percent of total body weight in 10 minutes after the first measurement were calculated 0.96, 0.97 and 0.92 and in five days after the first measurement were calculated 0.97, 0.97 and 0.91. Minimal detectable change values of arch height ratio index in all conditions of measurement were 0.01.

Conclusion: Simplicity of usage, low cost and high reliability of this device is highly recommended for clinical and research use. 

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Background and Aim: Few studies have assessed the reliability of postural balance measures during dynamic balance performance that introduce additional challenging to postural control system. In addition sometimes in the static conditions some deficiencies of the postural control system may not be revealed obviously therefore the aim of this study was to assess the reliability of postural control parameters during functional performance on force plate in healthy subjects.
Materials and Methods:  Ten healthy male subjects (mean age: 25.4 years, weight: 68.2 kg height:176.9cm) participated  in this study. None of the subjects were involved in sport activities. Every subject performed three 15seconds trials of eyes open single leg stance on a force plate during dynamic balance task. Participants grasped object with hand at their waist level and release it at above shoulder level.  The reproducibility of the center of pressure (COP) deviations (average speed &length of path) was assessed. All participants were tested on 2 sessions with an inter-measurement interval of 7 days. COP data was collected for each trial. The intraclass correlation coefficient (ICC) was used as parameter of intra-session and inter-session (Test-Retest) reliability.
Results: The ICCs for intra-session reliability of average speed and length of COP path were  0.89 and 0.91  respectively. The ICCs for inter-session reliability were 0.95 and 0.96 respectively.
Conclusion: The study showed high and very high reliability for center of pressure measures during dynamic balance task. Therefore this dynamic performance can be used as a balance pattern in postural control assessment. These can be used as reliable parameters in dynamic postural control assessment due to high reliability of average speed and length of COP path

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Background and aim:  For the rehabilitation program of the anterior cruciate ligament reconstructed patients (ACLR) strength and functional assessment and comparing with the uninvolved side is in great importance. Strength plays an important role in performing vertical jump moreover. It is performed in closed kinetic chain. Despite this importance, no information exists regarding the relationship on peak force of linear isokinetic and vertical jump score. The purposes of this study were1- To determine correlation between isokinetic squat and vertical jump in healthy and ACLR patients. 2- Comparing the peak force and vertical jump between the involved and uninvolved side of the ACLR patients.   
Materials and Methods: Twenty two ACLR patients with 6 months post-surgery and 16 healthy men participated in this study. Their isokinetic squat strength at the testing velocity of 25.4 cm/sec and vertical jump was measured.
Results: ACLR patients' peak force and vertical jump were significantly different between the involved and uninvolved side P≤0.05. The findings showed low relationship )r=0.425)  at the involved side between the vertical jump and peak force of squat, however, there was no relationship in the uninvolved side and the control group.
Conclusion: Findings of  this study indicate no relationship between vertical jump and peak force of squat. Both testing methods should be used since strength not always correlate strongly with physical performance.   Closed kinetic chain isokinetic testing should be used for testing lower extremity strength, while vertical jump should be used to determine performance levels.

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Background and aim: Knee joint has a major role in various lower extremity activities. Among different elements of knee joint complex more interest was seen to anterior cruciate ligament because of its alignment, structural complications, more nerve receptors and susceptibility to injury. After injury of this ligament, knee extensor torque decreases but it is believed that this decrease compensated for by muscles of hip and ankle joints. This suggestion has not investigated by isokinetic studies. Therefore, the aim of this research was that if quadriceps muscle torque decreases in spite of rehabilitation process and if this decrease compensated for by hip extensors and ankle plantar flexors?

Materials and methods: 10 healthy men (age: 22-35 years old) and 10 patients with ACL deficiency (age: 23-42 years old) participated in this study. Plantar flexor muscle strength, quadriceps muscle strength and hip extensor muscle strength were tested by Isokinetic Biodex System 3 at 60 and 180 degrees of angular velocities. Also functional vertical jump test was done for each lower extremity.
Results: Will coxson test and Spearman correlation coefficient were used. Results showed that there was no significant difference between mean strength of gastrosoleus, hip extensors and sum of mean strength of gastrosoleus, quadriceps and hip extensors of patient's injured and sound limbs (P>0.05). Results showed that there was significant difference between mean strength of quadriceps of injured and sound limbs (P> 0.01). There was no relationship between gastrosoleus, quadriceps and hip extensor summation and vertical jump functional test in the patients and normal subjects (P>0.05).
Conclusion: The results show that compensation occurs in the ankle plantar flexors and hip extensors of injured lower extremity. Thus in spite of significant decrease in quadriceps strength in the injured limb, sum of mean strength of gastrosoleus, quadriceps and hip extensor muscles between injured and sound limbs was not statistically significant. Also there was no relationship between functional test and isokinetic parameters. Thus functional vertical jump test can not be used instead of isokinetic test.

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 Background and Aim: The common mechanism for lateral ankle sprain is inversion, plantar flexion, or the combination of both, if untreated successfully can lead to chronic ankle instability. It seems that the foot position, while touching the ground, has an effective role to cause ankle sprain. Thus it is possible to prevent ankle sprain through limiting foot position. Therefore the aim of this research is to study the effect of plantar flexion and eversion on mediolateral ground reaction force while landing in individuals who suffering from functional ankle instability.

Materials and Methods: In this case-control research study 32 subjects (17 subjects with unilateral functional ankle instability (FAI) and 15 control subjects), aged from 18 to 35 years, were tested. All subjects in instability group were selected by the orthopedic physician, then the anterior drawer and talar tilt tests were  performed for diagnosis of functional ankle instability and other physical examinations. Control group were matched with instability group by age, weight, height, gender and body mass index. The subjects standing with single leg on a 40 cm high platform in 25 cm front of a force-plate while the test leg relaxed and non-weight bearing. The subject landed on the test leg on the center of the force-plate. The subjects landed according to four types of position: A: neutral position of ankle and lateral foot wedge, B: neutral position of ankle, C: positive heel and lateral foot wedge and D: positive heel. 

Results: Among control group, medial ground reaction force increased in the "C" position relative to "B" position (p=0.007) and "C" position relative to "D" position (p=0.018). In FAI group, lateral ground reaction force increased in "C" position relative to "B" position (p=0.001) and "C" position relative to "A" position (p=0.002). Also in FAI group medial ground reaction force decreased in "D" position relative to "A" position (p=0.014). 

Conclusion: According to the findings, applying lateral foot wedge, while the ankle is in plantar flexion, increases the mediolateral ground reaction forces. Based on the results, position of plantar flexion is more possibly effective than inversion in ankle sprain. According to the study, the lateral foot wedge in ankle plantar flexion position may be more effective than in neutral one to change mediolateral ground reaction forces. 

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Background and Aim: People with schizophrenia have deficits in interpersonal and social skills associated with social dysfunction. Facial processing ability is an effective component of social functioning. The purpose of this study was to examine the relationship between facial identity discrimination and social functioning in 20-55 years old schizophrenic patients and comparison with normal matched group.

 Materials and Methods: The method of this study was analytical- descriptive and comparative. Twenty normal individuals and 20 schizophrenic patients matched in age, sex and educational level, were assessed about facial identity by researcher- made test, and interaction skills by "Assessment of Communication and Interaction Skills"(ACIS) questionnaire. Available sampling was used for census patients (who inhabited Tolou rehabilitation center and supported houses in Tehran) and normal group.

 Results: There were significant difference in scores of "communication and interaction skills" (p<0.01) without any significant difference between facial identity discrimination testing variables (p>0.05) between two groups. The relationships between "facial identity discrimination" and "communication and interaction skills" in schizophrenia were compared with control group and did not show significant difference. (p>0.05).  

 Conclusion: The facial identity in schizophrenic patients and healthy adults were processed globally (configural). However, its relation with "Communication and Interaction Skills in schizophrenic patients requires further study.

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Background and Aim: Anterior knee pain (AKP or AnKP) is one of the most common disorders of knee. Many studies have been implemented about anterior knee pain and effect of different treatments on this disorder. Todays, this general term has been divided and studied more closely. Knee extension syndrome is one of the common disorders in orthopedic and physical therapy that diagnosed with increased stiffness of quadriceps muscle and causes anterior knee pain. The purpose of this review article is to evaluate this disorder more closely.

Materials and Methods: A literature search was carried out using MEDLINE and SCIENCE DIRECT cite and JOSPT journal database to assess existing literature about anterior knee pain. Furthermore, literatures about the different standpoints of anterior knee pain and effectiveness of different treatments and interventions of anterior knee pain and knee extension syndrome have been identified.

 Results: Fifty articles have been surveyed: forty-two articles evaluated the effect of different treatments on anterior knee pain. Five articles evaluated the various aspects of anterior knee pain more closely and three ones related to knee extension syndrome.

Conclusion: According to these studies results, the causes of anterior knee pain can be classified in two categories: 1) anterior knee pain associated with patellofemoral disorders and 2) anterior knee pain non-associated with patellofemoral disorders. The knee extension syndrome is the cause for anterior knee pain but non-associated with patellofemoral disorders. In this disorder, the tilt angle of patella could be increased and this factor can increase the patients' pain. In contrast to general belief that focuses on tensor fascia lata- ilotiobial band complex (TFL-ITB complex), the rectus femoris muscle stretching should be focused more, because the ilotiobial band has a less effect on patellar tilt. 

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Background and Aim: The aim of present study was to examine effect of attentional focus on balance performance and EMG activity of athletes.

  

Materials and Methods: The semi-dynamic balance task of 10 gymnasts (22.2±2.09 years old) with 3-5 years of experience in two periods, one in internal focus (focus on leg) and one in external focus (focus on stabilometer plate) was assessed. Postural sways were measuredby Biodexstabilometer and muscular activity of tibialis anterior and soleus muscles were recorded using ME6000electromygram device. Data were analyzed using paired t- test.

  

Results : muscular activity for controlling posture was reduced in external focus condition than internal focus. Postural sways is more in internal focus condition than internal focus.

  

Conclusion: Research findings (enhanced performance and reduced EMG) showed that antinational focus conditions (internal or external) have significant effect on athletes balance performance. In conditions that attention is focused on external feedback and information (rather than focus on body itself) balance is enhanced and requirement to muscular activity will reduce.

  

Key words: Attentional focus, Electromyography, Semi-dynamic balance

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Background and Aim: Anterior Cruciate Ligament (ACL) is responsible for physical and somatosensory function. It is expected that additional sensory information improves dynamic balance of ACL reconstruction patients. This study is aimed to determine the effect of sensory information on knee dynamic balance after ACL reconstruction in comparison with normal people.

 

Materials and Methods: The study was designed as a randomized clinical trial. Thirty two men (16 men with unilateral ACL reconstruction and 16 healthy men), assigned in three groups: ACLR, reconstructed knee ACLR, non-reconstructed knee and normal. All participants received tactile information during functional tests. Dynamic postural stability was assessed by two functional tests including: Star Excursion Balance test and Cross over Hop for distance. The functional tests scores were conducted both pre and post applying sensory information in ACLR and normal people.

  

Results: The data showed that tactile information improves functional performance of ACLR patients. There were significant difference in reconstructed knee’s SEBT scores in medial (p=0.005) and posteromedial (p=0.034) directions by adding touch information. Significant difference in dynamic balance by addition of touch sense, in COH scores of ACLR people and normal population was found.

  

Conclusion: The findings of this study showed that additional sensory information improves dynamic balance in ACLR patients. The positive effect of tactile information supports to apply additional sensory information as a new method for increasing dynamic balance.

  

Key words: Anterior cruciate ligament, Sensory information, Dynamic balance.

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Background and Aim: Anterior cruciate ligament (ACL) injury is common in sports competition and training. Following ACL rupture, neuromuscular system performance is disrupted. Perturbation training can improve the function of patients with ACL reconstruction. The aim of the present study was to assess the effects of perturbation training on ground reaction force and functional status of these patients .

  

Materials and Methods: Twenty patients with ACL reconstruction were randomly assigned into intervention (mean age: 24/2 ±3/4 years) and control (mean age: 27/1 ± 2/5 years) groups. The intervention group performed ten sessions perturbation training with rocker board, wobble board and Bosu. Peak vertical ground reaction force (GRF) and time to peak vertical GRF were recorded by KISTLER force plate during single leg landing from a 30cm height step. In addition, cross hop test also was evaluated as a functional test.

  

Results: Before perturbation training, both GRF and time to peak vertical GRF in reconstructed knee had not significant difference between two groups (P>0/05). In addition, functional test score had not significant difference between the groups (P=0/62). Following perturbation training, peak vertical GRF in reconstructed knee was greater than that in control groups (P<0/003).Although time to peak vertical GRF in reconstructed knee increased, there was not statistically significant difference between two groups (P=0/50). Furthermore, functional test score was statistically greater in intervention group (P=0/03).

  

Conclusion: This s tudy showed that perturbation training can improve functional status in patients with ACL reconstruction. In addition, force plate findings indicated that the patients tolerated more forces at longer time in single leg landing.

  

Key words: Perturbation training, Ground reaction force, ACL reconstruction, Function

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Background and Aim: Researches had shown that the high levels of shear and compression stresses that appear in the articular cartilage after meniscectomy are partly responsible for cartilage pathologies, such as osteoarthrosis . In this study, we probe to determine the stress distribution of the medial and lateral meniscus and to choose the appropriate region of meniscectomy.

 

Materials and Methods: Biomechanical 3D finite element model of the knee joint was generated from CT-scan images. Mimics modeled the bony structure of knee and Solidworks developed the medial and lateral meniscus.

  

Results: Under an axial femoral compressive load, the maximal contact stress in the articular cartilage after meniscectomy was about twice that of a healthy joint. The maximal contact pressures took place in the posterior region of the medial meniscus, with average values of 1.622 MPa and in the anterior horn of the lateral menisci with 1.159 MPa.

  

Results: Critical regions determine the allowed region of menisectomy for surgeon. Not only stress distribution doesn`t change by increasing of body weight or meniscectomy, but also the rate of stress increase after meniscectomy.

 

 

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Background and Aim: Patellofemoral pain syndrome (PFPS) is the most common overuse injury occurring at the knee. Reduction of proprioception, pain, changes in muscle activity patterns are seen in PFPS. Therefore these patients may demonstrate less balance. Thus the main objective of this study was to determine the postural control in patients with patellofemoral syndrome and compare it with healthy subjects.

Materials and Methods: Ten subjects (age 31.1 ± 5.31, weight 59.6 ± 8.95, height 1.62 ± 0.05) presenting with PFPS were compared with 10 matched control subjects (age 27.2 ± 1.81, weight 60.6 ± 2.36, height 1.67 ± 0.01).

Pain was measured with VAS scale and patella position was assessed using the method first described by McConnell. Force Plate was used to measures COP paths in sagittal and frontal plane with open and close eyes.

Results: The data showed that COP paths were different between PFPS and healthy subjects with open eyes in sagittal and frontal plane (P< 0.05). Means of COP paths increase in patients with PFPS. No differences were detected between PFPS and healthy subjects with closed eyes in sagittal and frontal plane.

Conclusion: Body sways increase in patients with PFPS with open eyes due to pain, lateral tracking patella and reduction of proprioception in knee.

Keyword:  Postural control, Patellofemoral syndrome, Open & close eye

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Background and Aim: Reliability or unreliability of the results achieved from recording of surface electromyography of muscles has always been questioned. The aim of present study was to  measure the reliability of the delayed reaction time of muscle electromyography of the knee joints on the exposure of unexpected rotary turbulence in the transverse plane from the area of supporting surface.

Materials and Methods: Twenty healthy women from 19 to 30 years old and free from any clear deformities in the lower extremities were participated in the present study. Surface electromyography of the six knee musculature was carried out for every subject separately in 4 situations including: External Rotation (Ext Rot) from plantar area on the transverse plane with bent and straight knee, Internal Rotation (Int. Rot) with the same conditions, Single Leg Stance situation in 4 stages, and repeatability of Intra Session through intra-class correlation coefficients when the muscles are in action on the exposure of turbulence in four applied forms were analyzed.

Result: The results from 24 analyzed forms showed that 18 forms of muscles at the time of action had moderate to high repeatability (Monroe Classification)

Conclusion: Regarding reliability, the muscles indicated different amounts in onset latency time, on the exposure of rotary turbulence, according to joint angle and the direction of applying rotation on the transverse plane. In respect to direction of rotation, most of the muscles indicated more reliability on the exposure of external rotation turbulence (clockwise) in relation to internal rotation (anti-clockwise) and also regarding the joint angle in turbulences with straight knee in relation to turbulences with bent knee. 

Keyword: Knee muscles, Surface electromyography, Reliability, Rotational turbulence

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Background and Aim: One of the impaired senses in patients with chronic hemiparesis is the sole cutaneous sense. The role of this sense in maintaining the functional balance and mobility is still controversial in these patients. The aim of this study was to investigate the relationship between the threshold of sole cutaneous sense and functional balance and mobility tests in patient with chronic hemiparesis.

 

Material and Methods: In this correlational study, seventeen chronic stroke patients by mean age of 59.10 (13.31) years and mean time after injury of 31.70 (23.61) months were selected by simple non– probability method. Functional Reach with ankle and hip strategy (FR), Step Test (ST) in affected and non- affected foot, Bend– Reach test (BR), Timed Up and Go test (TUG) and Berg Balance Scale (BBS) were used for assessment of functional balance and mobility and Semmes- Weinstein monofilaments test was used to measure the cutaneous sense of seven different points of sole in affected and non– affected foot.

 

Results: The main effect of foot (affected and non– affected foot) and points (seven different points of sole) of cutaneous sense threshold was significant (P˂0.0001) and interaction effect of foot ˣ points not significant (P=0.2).

The cutaneous sense threshold in all seven points of affected sole showed significant (p˂0.05) low to high correlation (r= 0.24-0.81) with all of functional balance and mobility tests. There was not significant correlation between cutaneous sense threshold in seven points of non- affected foot and any of functional balance and mobility tests, with the exception of cutaneous sense threshold of the little toe floor with total, dynamic and static score of BBS, FR with ankle and hip strategy and TUG; cutaneous sense threshold of big toe with static score of BBS and FR with hip strategy; and medial border of sole with static score of BBS and FR with ankle strategy.

 

Conclusion: The cutaneous sense threshold of affected sole has a more correlation with functional balance and mobility tests. The cutaneous sense threshold of sole in big toe and medial border points has a significant role in functional balance and mobility tests in patients with hemiparesis.

 

Keywords: Functional balance and mobility, Cutaneous sense threshold, Hemiparesis

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Background and Aim: ACL injury is one of the most common sport injuries which undergo reconstructive surgery. Electromyography or recording of muscles’ electrical activity is a suitable means to assess changes in motor control system output. The goal of this study is to compare the lower limb muscles EMG activity during drop landing in individuals after ACL reconstruction and healthy subjects.

Materials and Methods: Eleven men who had undergone ACL reconstruction 6 to 24 months ago (Age 29±6 years old) and 11 healthy men (Age 28±2 years old) participated in the study. Amount of electrical activity for tibialis anterior, vastus medialis, vastus lateralis, semitendinosus and biceps femoris muscles was recorded using surface electrodes during drop landing and calculated for two time intervals. The amount of activity was measured in -150 to +50 and +50 to +180 intervals in relation to the landing moment. Subjective IKDC questionnaire and cross-over hop functional test were used to determine the subjective and objective functional level.  Independent t test was used to determine between-group statistical differences.

Results: Feed forward activity of semitendinosus (P=.041) and biceps femoris (P=.008) muscles were significantly higher in ACLR group and feedback activity of vastus medialis (P=.03) muscles was significantly lower in ACLR group. Healthy individuals showed higher score on both the functional test and IKDC questionnaire. (P<.0005)

Conclusion: Individuals who had undergone reconstructive surgery of ACL showed different muscular activity compared to healthy subjects and closer to ACL deficient individuals 6 months after surgery and routine rehabilitation.

Keywords: Anterior cruciate ligament reconstruction, Electromyography, Neuromuscular control