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26.  REHABILITATION STRATEGIES ADDRESSING NEUROCOGNITIVE AND BALANCE DEFICITS FOLLOWING A CONCUSSION IN A FEMALE SNOWBOARD ATHLETE: A CASE REPORT 
Head injuries, including concussions, in athletes can account for an extended period of time lost from sports competition. Neurocognitive and balance deficits which may linger following a concussion affect an athlete's ability to return to sport safely. If these deficits are not specifically addressed in a rehabilitation program then the athlete may be at risk for not only additional concussions but possible musculoskeletal injury. ImPACT testing is a reliable method for identifying neurocognitive deficits and assists in the development of a neurocognitive training program. The information gathered from ImPACT may also indicate risk for musculoskeletal injuries. Research evidence suggesting specific rehabilitation strategies and interventions addressing neurocognitive deficits following a concussion is lacking. Progressions in a neurocognitive training program may include the integration of balance, reaction training, and activities that address memory deficits. The purpose of this case report is to discuss the evaluation and treatment plan for a female snowboard athlete following a concussion.
Level of Evidence:
5
PMCID: PMC4004128  PMID: 24790784
Concussion; neurocognitive rehabilitation; reaction training
27.  PEDIATRIC SPORTS SPECIFIC RETURN TO PLAY GUIDELINES FOLLOWING CONCUSSION 
Purpose/Background:
In 2010, the American Academy of Pediatrics officially adopted the recommended return to play guidelines proposed by the International Conference on Concussion in Sport. The guidelines include a six‐step process that provides structure to guide an athlete who is recovering from a concussion in a gradual return to play (RTP) by allowing participation in increasingly difficult physical activities. Unfortunately, the guidelines fail to take into account the variability that occurs within different sports and the resulting challenges medical professionals face in making sure each athlete is able to withstand the rigors of their specific sport, without return of symptoms. Therefore, the purpose of this clinical commentary is to expand upon the current general consensus guidelines for treatment of concussed pediatric athletes and provide sport specific RTP guidelines.
Description of Topic:
The intention of the sport specific guidelines is to maintain the integrity of the current six‐step model, add a moderate activity phase highlighted by resistance training, and to provide contact and limited contact drills specific to the athlete's sport and/or position. The drills and activities in the proposed seven‐step programs are designed to simulate sport specific movements; the sports include: football, gymnastics, cheerleading, wrestling, soccer, basketball, lacrosse, baseball, softball, and ice hockey. These activities will provide sports specific challenges to each athlete while simultaneously accomplishing the objectives of each stage of the RTP progression. The final RTP determination should occur with documented medical clearance from a licensed healthcare provider who has been trained in the evaluation and management of concussions.
Discussion/Relation to Clinical Practice:
There have been significant strides in the management and care of concussed athletes. However, there continues to be a lot of confusion among, athletes, parents, and coaches regarding the proper management of an athlete with a concussion, particularly in the pediatric population. In an effort to eliminate ambiguity and help further promote adherence to the RTP guidelines, the authors developed several sports‐specific RTP guidelines.
Level of Evidence:
5
PMCID: PMC4004129  PMID: 24790785
Concussion; pediatric; return to play guidelines; sports
28.  RADIOLOGICAL EXAMINATION OF THE HIP ‐ CLINICAL INDICATIONS, METHODS, AND INTERPRETATION: A CLINICAL COMMENTARY 
There is a growing interest in musculoskeletal rehabilitation for young active individuals with non‐arthritic hip pathology. History and physical examination can be useful to classify those with non‐arthritic intra‐articular hip pathology as having impingement or instability. However, the specific type of deformity leading to symptoms may not be apparent from this evaluation, which may compromise the clinical decision‐making. Several radiological indexes have been described in the literature for individuals with non‐arthritic hip pathology. These indexes identify and quantify acetabular and femoral deformities that may contribute to instability and impingement. The aim of this paper is to discuss clinical indications, methods, and the use of hip radiological images or radiology reports as they relate to physical examination findings for those with non‐arthritic hip pathology.
Level of evidence:
5
PMCID: PMC4004130  PMID: 24790786
Examination; Femoroacetabular impingement (FAI); imaging; labrum
29.  ACL RECONSTRUCTION ‐ IT'S ALL ABOUT TIMING 
Injury to the anterior cruciate ligament (ACL) is the most common ligamentous injury, ranging from up to 200,000 injuries per year in the United States. Sports such as soccer, football, and skiing have been reported to be high‐risk sports that can cause injury to the ACL when compared to other sport activities. Due to the high incidence of ACL injuries, approximately 100,000 ACL reconstructions are performed each year. Although conservative treatment can potentially be successful in the appropriate population, patients with goals of returning to high levels of sport activity may not be successful with conservative treatment. Even though reconstruction is the most common treatment for ACL rupture, there remains debate in the literature regarding the optimal timing of surgery. Therefore, the purpose of this clinical commentary is to review the available evidence to provide insight into the optimal timing of ACL reconstruction.
PMCID: PMC4004131  PMID: 24790787
Anterior cruciate ligament; arthrofibrosis; reconstruction; timing
30.  CURRENT CONCEPTS OF ROTATOR CUFF TENDINOPATHY 
Purpose/Background:
Tendinopathies are a broad topic that can be examined from the lab to their impact upon function. Improved understanding will serve to bring this pathology to the forefront of discussion, whether in the clinic or the classroom. The purpose of this current concepts clinical commentary is to explore intrinsic and extrinsic mechanisms of rotator cuff (RC) tendinopathy in order to improve clinical and research understanding.
Methods:
Pubmed, Medline, Cinahl, PEDro, and Cochrane databases were searched, limiting results to those published in the English language, between the years of 2005 and 2012. The key search terms utilized were intrinsic mechanisms, tendinopathy, stem cells, biologics, platelet‐rich plasma (PRP), healing, rotator cuff tears, full‐thickness tears, tests, impingement, imaging, ultrasound, Magnetic Resonance Imaging (MRI), radiograph, shoulder advances, treatment, diagnoses, tendon disorders, pathogenesis, matrix metalloproteinase, injections, and RC repair. Over 150 abstracts were reviewed and 43 articles were analyzed for quality and relevance using the University of Alberta Evidence Based Medicine Toolkit.
Results/Conclusions:
Current evidence suggests that tendinopathies arise from a multivariate etiology.It is increasingly evident that intrinsic mechanisms play a greater role than extrinsic mechanisms in this process. Emphasis should be placed on patient information (i.e. background information and personal description of symptoms) and imaging/ injection techniques in order to aid in diagnosis. Future treatment technologies such as cell therapy and biological engineering offer the hope of improving patient outcomes and quality of life.
Level of Evidence:
Level 5 – Clinical Commentary Related to a Review of Literature
PMCID: PMC4004132  PMID: 24790788
Rotator cuff; tendinopathy; tendinitis; tendinosis
31.  ACUTE EFFECTS OF INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION FOR IMPROVING POSTERIOR SHOULDER RANGE OF MOTION IN COLLEGIATE BASEBALL PLAYERS 
Background:
Due to the repetitive rotational and distractive forces exerted onto the posterior shoulder during the deceleration phase of the overhead throwing motion, limited glenohumeral (GH) range of motion (ROM) is a common trait found among baseball players, making them prone to a wide variety of shoulder injuries. Although utilization of instrument‐assisted soft tissue mobilization (IASTM), such as the Graston® Technique, has proven effective for various injuries and disorders, there is currently no empirical data regarding the effectiveness of this treatment on posterior shoulder tightness.
Purpose:
To determine the effectiveness of IASTM in improving acute passive GH horizontal adduction and internal rotation ROM in collegiate baseball players.
Methods:
Thirty‐five asymptomatic collegiate baseball players were randomly assigned to one of two groups. Seventeen participants received one application of IASTM to the posterior shoulder in between pretest and posttest measurements of passive GH horizontal adduction and internal rotation ROM. The remaining 18 participants did not receive a treatment intervention between tests, serving as the controls. Data were analyzed using separate 2× 2 mixed‐model analysis of variance, with treatment group as the between‐subjects variable and time as the within‐subjects variable.
Results:
A significant group‐by‐time interaction was present for GH horizontal adduction ROM with the IASTM group showing greater improvements in ROM (11.1°) compared to the control group (‐0.12°) (p <0.001). A significant group‐by‐time interaction was also present for GH internal rotation ROM with the IASTM group having greater improvements (4.8°) compared to the control group (‐0.14°) (p < 0.001).
Conclusions:
The results of this study indicate that an application of IASTM to the posterior shoulder provides acute improvements in both GH horizontal adduction ROM and internal rotation ROM among baseball players.
Level of Evidence:
2b
PMCID: PMC3924602  PMID: 24567849
Manual therapy; rehabilitation; shoulder; throwing athlete
32.  IS THERE A RELATION BETWEEN SHOULDER DYSFUNCTION AND CORE INSTABILITY? 
Background:
Overhead athletes often suffer injury to the glenohumeral joint secondary to inherent instability. However, little is known about the relationship between core stability and shoulder dysfunction among athletes.
Purpose:
The purpose of this study was to analyze the difference between healthy athletes and those with shoulder dysfunction in regard to core stability measures. Secondary purpose was to explore the relationship between measures of core stability and measures of shoulder dysfunction.
Methods:
Participants consisted of NCAA Division III overhead athletes (28 males, 33 females) with a mean age of 19.3 ± (1.1) years, mean weight of 173.6 ± (36.9) pounds, mean height of 67.8 ± (3.5) inches. Functional questionnaires (the Kerlan‐Jobe Orthopaedic Clinical Scale [KJOC] and the QuickDASH sports module) as well as Single‐Leg Stance Balance Test (SLBT), Double Straight Leg Lowering Test (DLL), Sorensen Test, and Modified Side Plank Test were completed in a randomized order with consistent raters.
Results:
MANOVA was significant at (p = .038) for the comparison between the experimental group and the control group for the values of Right SLBT. The experimental group had significantly less balance than the control group with means of 10.14 ± (5.76) seconds and 18.98 ± (15.22) seconds respectively. Additionally, a positive correlation was found between the DLL and the KJOC at (r = .394, p > .05) and a negative correlation was found between the Right SLBT and the Quick DASH sports module (QD) at (r = –.271, p > .05).
Discussion and Conclusion:
Balance deficiency was found in athletes with shoulder dysfunction. According to this study, greater shoulder dysfunction is correlated with greater balance and stability deficiency. Therapists and trainers should consider incorporating balance training as an integral component of core stability into rehabilitation of athletes with shoulder dysfunction.
Level of Evidence:
3b
PMCID: PMC3924603  PMID: 24567850
Core stability; KJOC; overhead athletes; shoulder dysfunction
33.  THE FUNCTIONAL MOVEMENT SCREENING (FMS)™: AN INTER‐RATER RELIABILITY STUDY BETWEEN RATERS OF VARIED EXPERIENCE 
Background:
Previous researchers have reported on the reliability of the scoring of the FMS™ movement screens. Those authors have reported good to excellent inter‐rater reliability between paired raters of similar experience level (either novice or expert), but no comparisons of inter‐rater reliability exist between a novice and an expert.
Purpose:
The purpose of this investigation was to examine the inter‐rater reliability of the scoring of the FMS™ between trained novices and an expert rater using video records.
Methods:
Twenty healthy college students participated. Each participant performed the series of seven functional movement screens. Four raters (three novices and one expert) independently scored the seven FMS™ tests by watching video recordings of the movements..
Results:
The mean total FMS™ score for all subjects was 14.6 ± 1.9, and was not significantly different between raters (p = 0.136). For the individual tests, half of them had perfect agreement, while the other half ranged from slight to moderate agreement (33‐66%).
Conclusion:
Conclusion: Total FMS™ scores were similar among the raters, and the inter‐rater reliability for a majority of the individual tests had as strong agreement despite the various level of experience of the raters scoring the FMS™ tests.
Clinical Relevance:
Although there was mostly moderate to perfect agreement among raters, the level of experience of the rater scoring the FMS™ should be considered, as it appears that the expert rater was more critical than novice raters in the interpretation of the scoring criteria.
Level of Evidence:
Level 3
PMCID: PMC3924604  PMID: 24567851
Functional movement screen; reliability
34.  RELATIONSHIP BETWEEN FUNCTIONAL MOVEMENT SCREENING SCORE AND HISTORY OF INJURY 
Background and Aim:
The Functional Movement Screen (FMS™) is a screening instrument that evaluates selective fundamental movement patterns. The main aim of this study was to investigate the relationship between the FMS™ score and history of injury, and attempt to determine which active students are prone to injury.
Methods:
One hundred physically active (50 females and 50 males) students, between 18 and 25 years of age, with no recent (<6 weeks) history of musculoskeletal injury were recruited. All participants performed the FMS™ and were scored using the previously established standardized FMS™ criteria. The chi square, independent t‐test, one‐way analysis of variance, and POSTHOC Bonferroni tests were used for data analysis with a preset alpha value of p < 0.05.
Results:
Of the 100 subjects, 35 suffered an acute lower extremity (ankle = 20, knee = 15) injury in practice or competition. An odds ratio was calculated at 4.70, meaning that an athlete had an approximately 4.7 times greater chance of suffering a lower extremity injury during a regular competitive season if they scored less than 17 on the FMS™. There were statistical differences between the pre‐season FMS™ scores of the injured and non‐injured groups, the ankle injury, knee injury, and non‐injured groups, and also between contact injury, non‐contact injury, and non‐injured groups.
Discussion and Conclusion:
This cross‐sectional study provides FMS™ reference values for physically active students, which will assist in the interpretation of individual scores when screening athletes for musculoskeletal injury and performance factors. More research is still necessary before implementing the FMS™ into a pre‐participation physical examination (PPE) for athletics, but due to the low cost and its simplicity to implement, it should be considered by clinicians and researchers in the future.
Level of Evidence:
2B
PMCID: PMC3924605  PMID: 24567852
Athletic performance; Functional Movement Screen™; injury risk; physically active students; pre‐participation screening
35.  BREATHING PATTERN DISORDERS AND FUNCTIONAL MOVEMENT 
Study Design:
Experimental design
Background:
Normal breathing mechanics play a key role in posture and spinal stabilization. Breathing Pattern Disorders (BPD) have been shown to contribute to pain and motor control deficits, which can result in dysfunctional movement patterns. The Functional Movement Screen™ (FMS™) has been shown to accurately predict injury in individuals who demonstrate poor movement patterns. The role BPD play on functional movement is not well established. Furthermore, there is currently no single test to clinically diagnose BPD. A variety of methods are used, but correlations between them are poor.
Purpose:
To examine the relationship between BPD and functional movement and identify correlations between different measures of BPD.
Methods:
Breathing was assessed in 34 healthy individuals using a multi‐dimensional approach that included biomechanical, biochemical, breathing related symptoms, and breathing functionality measures. Movement was assessed using the FMS™. Analysis, involving independent t‐tests and Pearson correlation were performed to identify associations between measures.
Results:
Individuals who exhibited biochemical and biomechanical signs of BPD were significantly more likely to score poorly on the FMS™. These studied measures of BPD correlated highly with each other.
Conclusion:
These results demonstrate the importance of diaphragmatic breathing on functional movement. Inefficient breathing could result in muscular imbalance, motor control alterations, and physiological adaptations that are capable of modifying movement. These findings provide evidence for improved breathing evaluations by clinicians.
Level of Evidence:
2B
PMCID: PMC3924606  PMID: 24567853
Capnography; diaphragm; FMS™; motor control
36.  THE INFLUENCE OF UPPER BODY FATIGUE ON DYNAMIC STANDING BALANCE 
Purpose/Background:
Muscle fatigue is related to a decline in force output and proprioception. These can ultimately have an adverse effect on neuromuscular control and functional performance. Local muscle fatigue has been shown to have adverse consequences on dynamic standing balance; however, much less is known regarding the relationship between distant fatigue and dynamic standing. The purpose of this study was to investigate the effects of upper body fatigue on dynamic standing balance. It was hypothesized that distant fatigue in upper body musculature would show a significant decrease in dynamic standing balance as assessed by the Lower Quarter Y‐Balance Test (YBT‐LQ).
Methods:
Twenty healthy individuals (age: 25.0 ± 3.42 years, height: 172.72 ± 13.11 cm, mass: 71.36 ± 13.50 kg) participated in this study. A kayak ergometer was used to implement a fatigue protocol for the upper body. The protocol consisted of a graded intensity session ranging from 50% to 90% of maximum effort lasting ten minutes in duration (2 minutes each at 50% 60%, 70%, 80%, and 90%). The anterior (ANT), posteromedial (PM), and posterolateral (PL) reach directions were normalized to leg length and measured on the YBT‐LQ before and after the fatigue protocol for each participant. A fourth value termed overall balance was calculated as the sum of the furthest reach distance of the three directions. Blood lactate analysis taken before and immediately after the fatigue protocol was used to quantify fatigue. Multiple paired t‐tests were performed for pre‐fatigue and post‐fatigue balance assessment. A Bonferroni correction was applied to set the significance value ≤0.0125 a priori. Effect size was calculated using the effect size index.
Results:
Blood lactate values immediately following the fatigue protocol had an average concentration of 6.15 millimoles (pre: 2.3, post: 8.4). The ANT reach direction (ρ = 0.004) and the calculated overall balance (ρ = 0.011) significantly decreased post‐fatigue in the dominant lower extremity. No significant differences were found for the PM (ρ = 0.017) or PL (ρ = 0.021) directions. The ANT reach direction (0.64) and overall balance (0.44) also showed a moderate effect size based on the effect size index.
Conclusions:
ANT and overall dynamic standing balance were negatively affected after completing the upper body fatigue protocol. The findings of this research demonstrate that upper body fatigue has adverse effects on dynamic standing balance, as measured by performance on the YBT‐LQ. Significant and clinically relevant differences were noted in ANT and overall dynamic standing balance.
Clinical Relevance:
Physical therapists should be aware of the adverse influence distant fatigue may exhibit on neuromuscular control in muscles not actively involved in the fatiguing exercise. The balance deficits noted may indicate an increased risk of injury with muscle fatigue in muscles not directly contributing to standing balance.
Level of Evidence:
3b, Case‐control study
PMCID: PMC3924607  PMID: 24567854
Distant fatigue; dynamic standing balance; Lower Quarter Y‐Balance Test
37.  EFFECTS OF TWO TYPES OF TRUNK EXERCISES ON BALANCE AND ATHLETIC PERFORMANCE IN YOUTH SOCCER PLAYERS 
Purpose/Background:
Many athletes perform trunk stabilization exercises (SE) and conventional trunk exercises (CE) to enhance trunk stability and strength. However, evidence regarding the specific training effects of SE and CE is lacking and there have been no studies for youth athletes. Therefore, the purpose of this study was to investigate the training effects of SE and CE on balance and athletic performance in youth soccer players.
Methods:
Twenty‐seven male youth soccer players were assigned randomly to either an SE group (n = 13) or CE group (n = 14). Data from nineteen players who completed all training sessions were used for statistical analyses (SE, n = 10; CE, n = 9). Before and after the 12‐week intervention program, pre‐ and post‐testing comprised of a static balance test, Star Excursion Balance Test (SEBT), Cooper’s test, sprint, the Step 50, vertical jump, and rebound jump were performed. After pre‐testing, players performed the SE or CE program three times per week for 12 weeks. A two‐way repeated‐measures ANOVA was used to assess the changes over time, and differences between the groups. Within‐group changes from pre‐testing to post‐testing were determined using paired t‐tests. Statistical significance was inferred from p < 0.05.
Results:
There were significant group‐by‐time interactions for posterolateral (p = 0.022) and posteromedial (p < 0.001) directions of the SEBT. Paired t‐tests revealed significant improvements of the posterolateral and posteromedial directions in the SE group. Although other measurements did not find group‐by‐time interactions, within‐group changes were detected indicating significant improvements in the static balance test, Cooper’s test, and rebound jump in the only SE group (p < 0.05). Vertical jump and sprint were improved significantly in both groups (p < 0.05), but the Step 50 was not improved in either group (p > 0.05).
Conclusions:
Results suggested that the SE has specific training effects that enhance static and dynamic balance, Cooper’s test, and rebound jump.
Level of Evidence:
3b
PMCID: PMC3924608  PMID: 24567855
core training; stabilization exercise; trunk muscle; trunk stability
38.  THE IMPACT OF SAGITTAL PLANE HIP POSITION ON ISOMETRIC FORCE OF HIP EXTERNAL ROTATOR AND INTERNAL ROTATOR MUSCLES IN HEALTHY YOUNG ADULTS 
Purpose/Background:
Hip external rotator (ER) and internal rotator (IR) muscle weakness is theorized to be associated with lower extremity injury in athletes including knee ligament tears and patellofemoral pain. Previous studies investigating hip musculature strength have utilized various sagittal plane hip positions for testing. The relationship between results at these different positions is unknown.
Methods:
Eighty healthy, pain‐free young adults participated in the study: 40 female, mean age 22.90 (± 2.32) years, and 40 male, mean age 23.50 (± 2.15) years. Peak isometric torque of bilateral hip ER and IR were tested at 90° and 0° of hip flexion with an instrumented dynamometer. Peak muscle forces were calculated. Peak forces were normalized by body mass. Mean normalized force was calculated for dominant and non‐dominant limbs for ER and IR in both positions. Male and female data were analyzed separately with paired t‐tests (2‐tailed). Reference values for average muscle force and torque were calculated for dominant and non‐dominant limbs for both hip positions.
Results:
Hip IR normalized peak force was greater at 90° compared to 0° flexion position bilaterally in both genders (p < .01). Hip ER normalized peak force was greater at 90° compared to 0° flexion in dominant limbs of both genders and in non‐dominant limbs of males (p < .01). Non‐dominant hip ER normalized force in females was greater at 90° versus 0° flexion; however, it was not significant (p = .092). Post hoc analysis of normalized average force (average over 5‐second contraction) yielded similar results.
Conclusion:
Clinicians and researchers should use consistent positioning for testing of hip ER and IR strength. This will improve certainty of determining if a patient’s strength has changed or if differences between groups are present. Reference values reported will be useful in order to determine if weakness is present and to set goals, particularly in cases of bilateral involvement.
Level of Evidence:
2b
PMCID: PMC3924609  PMID: 24567856
Hip; muscle; strength; reference values
39.  NORMATIVE VALUES OF ECCENTRIC HIP ABDUCTION STRENGTH IN NOVICE RUNNERS: AN EQUATION ADJUSTING FOR AGE AND GENDER 
Purpose:
Low eccentric strength of the hip abductors, might increase the risk of patellofemoral pain syndrome and iliotibial band syndrome in runners. No normative values for maximal eccentric hip abduction strength have been established. Therefore the purpose of this study was to establish normative values of maximal eccentric hip abduction strength in novice runners.
Methods:
Novice healthy runners (n = 831) were recruited through advertisements at a hospital and a university. Maximal eccentric hip abduction strength was measured with a hand–held dynamometer. The demographic variables associated with maximal eccentric hip abduction strength from a univariate analysis were included in a multivariate linear regression model. Based on the results from the regression model, a regression equation for normative hip abduction strength is presented.
Results:
A significant difference in maximal eccentric hip abduction strength was found between males and females: 1.62 ± 0.38 Nm/kg (SD) for males versus 1.41 ± 0.33 Nm/kg (SD) for females (p < 0.001). Age was associated with maximal eccentric hip abduction strength: per one year increase in age a ‐0.0045 ± 0.0013 Nm/kg (SD) decrease in strength was found, p < 0.001. Normative values were identified using a regression equation adjusting for age and gender. Based on this, the equation to calculate normative values for relative eccentric hip abduction strength became: (1.600 + (age * ‐0.005) + (gender (1 = male / 0 = female) * 0.215) ± 1 or 2 * 0.354) Nm/kg.
Conclusion:
Normative values for maximal eccentric hip abduction strength in novice runners can be calculated by taking into account the differences in strength across genders and the decline in strength that occurs with increasing age. Age and gender were associated with maximal eccentric hip abduction strength in novice runners, and these variables should be taken into account when evaluating eccentric hip abduction strength in this group of athletes.
Level of Evidence:
2A
PMCID: PMC3924610  PMID: 24567857
Eccentric hip abduction strength; novice runners
40.  ELECTROMYOGRAPHY DURING PEDALING ON UPRIGHT AND RECUMBENT ERGOMETER 
Background:
Ergometers are used during rehabilitation and fitness to restore range of motion, muscular strength, and cardiovascular fitness. The primary difference between upright and recumbent ergometers is that the seat and crank spindle are aligned nearly vertically on upright bicycles and nearly horizontally on recumbent ergometers. In addition, recumbent ergometers are characterized by large seats with backrests to provide support for the upper body and are low to the ground, permitting easier access for wheelchair users and individuals with mobility impairments. Despite the great utility of the recumbent bike, it has not been studied with regard to energy costs or muscular output. This is the first study to investigate the differences between two commercial ergometers by analyzing of lower limb EMG in participants who are not habitual cyclers.
Methods:
Ten non‐cyclist males with no history of musculoskeletal lower limb injury pedaled on standard recumbent and upright ergometers. EMG data were recorded from the volunteers’ lower limb muscles (rectus femoris, semitendinosus, tibialis anterior, and medial gastrocnemius muscles). EMG signals were normalized to the highest EMG signals recorded for the maximum voluntary isometric contractions (MVIC). The peak normalized EMG value of the studied muscles over the average of the 10 pedal cycles was analyzed.
Results:
The differences in average peak muscle activity were not statistically significant for any of the four muscles tested. Pedaling a recumbent ergometer resulted in greater activity in two (semitendinosus and tibialis anterior) of the four muscles studied. Only the rectus femoris muscle demonstrated greater activity during upright pedaling.
Conclusion:
There were no differences in the EMG activity of the muscles studied during pedaling on a standard recumbent and an upright stationary exercise ergometer at moderate workload. This increased understanding of muscle activity during pedaling may be useful in the development of new exercise protocols and therapeutic approaches.
Level of Evidence:
2c
PMCID: PMC3924611  PMID: 24567858
Bicycling; electromyography; ergometry; lower extremity; pedaling
41.  SPECIFIC AND CROSS OVER EFFECTS OF MASSAGE FOR MUSCLE SORENESS: RANDOMIZED CONTROLLED TRIAL 
Purpose/Background:
Muscle soreness can negatively interfere with the activities of daily living as well as sports performance. In the working environment, a common problem is muscle tenderness, soreness and pain, especially for workers frequently exposed to unilateral high repetitive movements tasks. The aim of the study is therefore to investigate the acute effect of massage applied using a simple device Thera‐band roller Massager on laboratory induced hamstring muscle soreness, and the potential cross over effect to the non‐massaged limb.
Methods:
22 healthy untrained men (Mean age 34 +/− 7 years; mean height 181.7 +/− 6.9 cm; mean weight 80.6 +/− 6.4 kg; BMI: 24.5 +/− 1.3) with no prior history of knee, low back or neck injury or other adverse health issues were recruited. Participants visited the researchers on two separate occasions, separated by 48 hours, each time providing a soreness rating (modified visual analog scale 0‐10), and being tested for pressure pain threshold (PPT) and active range of motion (ROM) of the hamstring muscles. During the first visit, delayed onset muscular soreness of the hamstring muscles was induced by 10 x 10 repetitions of the stiff‐legged dead‐lift. On the second visit participants received either 1) 10 minutes of roller massage on one leg, while the contralateral leg served as a cross over control, or 2) Resting for 10 minutes with no massage at all. Measurement of soreness, PPT and ROM were taken immediately before and at 0, 10, 30 and 60 min. after treatment.
Results:
There was a significant group by time interaction for soreness (p < 0.0001) and PPT (p = 0.0007), with the massage group experiencing reduced soreness and increasing PPT compared with the control group. There was no group by time interaction for ROM (p = 0.18). At 10 min. post massage there was a significant reduction in soreness of the non‐massaged limb in the cross over control group compared to controls but this effect was lost 30 minutes post massage.
Conclusion:
Massage with a roller device reduces muscle soreness and is accompanied by a higher PPT of the affected muscle.
Level of Evidence:
2c; outcomes research
PMCID: PMC3924612  PMID: 24567859
Cross over effect; delayed onset muscle soreness hyperalgesia; pain
42.  ROLLER MASSAGER IMPROVES RANGE OF MOTION OF PLANTAR FLEXOR MUSCLES WITHOUT SUBSEQUENT DECREASES IN FORCE PARAMETERS 
Background:
Limited dorsiflexion range of motion (ROM) has been linked to lower limb injuries. Improving limited ankle ROM may decrease injury rates. Static stretching (SS) is ubiquitously used to improve ROM but can lead to decreases in force and power if performed prior to the activity. Thus, alternatives to improve ROM without performance decrements are needed.
Objectives/Purpose:
To compare the effects of SS and self massage (SM) with a roller massage of the calf muscles on ankle ROM, maximal voluntary contraction (MVC) force F100 (force produced in the first 100 ms of the MVC), electromyography (EMG of soleus and tibialis anterior) characteristics of the plantar flexors, and a single limb balance test.
Methods:
Fourteen recreationally trained subjects were tested on two separate occasions in a randomized cross‐over design. After a warm up, subjects were assessed for passive dorsiflexion ROM, MVC, and a single‐limb balance test with eyes closed. The same three measurements were repeated after 10 minutes (min) of rest and prior to the interventions. Following the pre‐test, participants randomly performed either SS or SM for 3 sets of 30 seconds (s) with 10s of rest between each set. At one and 10 min post‐interventions the participants repeated the three measurements, for a third and fourth cycle of testing.
Results:
Roller massage increased and SS decreased maximal force output during the post‐test measurements, with a significant difference occurring between the two interventions at 10 min post‐test (p < 0.05, ES = 1.23, 8.2% difference). Both roller massage (p < 0.05, ES = 0.26, ~4%) and SS (p < 0.05, ES = 0.27, ~5.2%) increased ROM immediately and 10 min after the interventions. No significant effects were found for balance or EMG measures.
Conclusions:
Both interventions improved ankle ROM, but only the self‐massage with a roller massager led to small improvements in MVC force relative to SS at 10 min post‐intervention. These results highlight the effectiveness of a roller massager relative to SS. These results could affect the type of warm‐up prior to activities that depend on high force and sufficient ankle ROM.
Level of Evidence:
2c
PMCID: PMC3924613  PMID: 24567860
Dorsiflexion; electromyography; flexibility; self‐massage; strength
43.  THE PREPARTICIPATION EVALUATION FOR ATHLETES WITH DISABILITY 
Background:
Athletes are routinely assessed medically prior to competition. Although standardized preparticipation examinations (PPEs) are available for able‐bodied athletes, the literature lacks any validated equivalent for the athlete with disability (AWD). Since participation and level of competition is increasing in this population, evidence‐based tools such as a standardized PPE form should be available for health professionals to assess AWD health and safety.
Aim of the study:
To develop an AWD‐targeted standardized preparticipation history evaluation (PPE history) using consensus‐based expert recommendations.
Methods:
Researchers developed a PPE history for critical evaluation of its content validity. Structured Delphi method for collecting and interpreting contributions from an expert panel using a series of questionnaires with controlled feedback was performed. Opinions based on the experience of related experts ‐ physiotherapists, sports medicine physicians and physiatrists ‐ were studied during each of the three survey rounds. The process was terminated once adequate consensus relating to the proposed PPE history document was reached.
Results:
Majority consensus was reached for forty‐nine of fifty‐four items to create a refined ten section AWD‐specific document to supplement the current standardized PPE. Modifications were made by researchers to accommodate the five items that did not reach statistical consensus.
Conclusion:
Consensus was reached on a variety of AWD‐specific PPE items, including the disability‐related history and functional review. Equipment issues represent a complex area of evaluation, worthy of future research and discussion. The current proposed PPE history tool is considered comprehensive and ready for application in a clinical setting as an adjunct to existing PPE tools. Injury research in the AWD population will provide guidance for refinement and further validation of this PPE history document.
Level of evidence:
5
PMCID: PMC3924614  PMID: 24567861
Delphi; disabled athlete; paralympic; preparticipation evaluation; sledge
44.  TREATMENT OF SUBACUTE POSTERIOR KNEE PAIN IN AN ADOLESCENT BALLET DANCER UTILIZING TRIGGER POINT DRY NEEDLING: A CASE REPORT 
Study Design:
Case Report.
Background and Purpose:
Dry needling (DN) is an increasingly popular intervention used by clinicians as a treatment of regional neuromusculoskeletal pain. DN is an invasive procedure that involves insertion of a thin monofilament needle directly into a muscle trigger point (MTP) with the intent of stimulating a local twitch response. Current evidence is somewhat limited, but recent literature supports the use of this intervention in specific neuromusculoskeletal conditions. The purpose of this case report is to present the outcomes of DN as a primary treatment intervention in an adolescent subject with subacute posterior knee pain.
Case Description:
The subject was a 16‐year‐old female competitive ballet dancer referred to physical therapy with a two month history of right posterior knee pain. Palpation identified MTPs which reproduced the patient’s primary symptoms. In addition to an exercise program promoting lower extremity flexibility and hip stability, the subject was treated with DN to the right gastrocnemius, soleus, and popliteus muscles.
Outcomes:
The subject reported being pain free on the Numerical Pain Scale and a +7 improvement in perceived change in recovery on the Global Rating of Change at final follow‐up. Physical examination demonstrated no observed impairments or functional limitations, including normal mobility, full strength, and unrestricted execution of dance maneuvers.
Discussion:
The patient was able to return to high level dance training and competition without physical limitations and resumed pre‐injury dynamic movement activities including dancing, running, jumping, and pivoting without pain. DN can be an effective and efficient intervention to assist patients in decreasing pain and returning to high intensity physical activity. Additional research is needed to determine if DN is effective for other body regions and has long‐term positive outcomes.
Level of Evidence:
Level 4
PMCID: PMC3924615  PMID: 24567862
Dry needling; knee pain; trigger point; dancing
45.  CHRONIC LEG PAIN IN A DIVISION II FIELD HOCKEY PLAYER: A CASE REPORT 
Exertional compartment syndromes in athletes represent a diagnostic and management challenge for clinicians. The clinical presentation of exertional compartment syndrome is similar to other more common musculoskeletal disorders. A lack of special tests or unique diagnostic identifiers for use in decision making by out‐patient clinicians complicates early recognition of this disorder and may delay optimal management. The purpose of this case report is to retrospectively explore the clinical presentation and the decision‐making during the course of care of a field hockey athlete eventually determined to have exertional compartment syndrome. Suggestions to assist in recognition and guidance in patient management are included as well as the procedures required for differential diagnosis. Procedures utilized during conservative care are also described in detail.
Level of Evidence:
5 (Single Case Report)
PMCID: PMC3924616  PMID: 24567863
Compartment syndrome; diagnosis of leg pain; fasciotomy
46.  TEST‐RETEST CONSISTENCY OF A POSTURAL SWAY ASSESSMENT PROTOCOL FOR ADOLESCENT ATHLETES MEASURED WITH A FORCE PLATE 
Purpose/Background:
Postural control assessments can provide a powerful means of detecting concussion‐related neurophysiological abnormalities and are considered an important part of the concussion management processes. Studies with college athletes indicate that postural sway analyzed using complexity metrics may provide a sensitive and novel way to detect post‐concussion postural control impairments. The purpose of this study was to determine if a postural sway assessment protocol (PSAP) measured using a force plate system can serve as a reliable assessment tool for adolescent athletes.
Methods:
The short‐term and long‐term test‐retest reliability of the PSAP was examined in a group of adolescent female athletes under eyes open and eyes closed conditions. Detrended fluctuation analysis was used to evaluate the complexity of the times series data (i.e., degree of self‐similarity across time scales). Conventional measures of standard deviation and total path length (distance traveled by the center‐of‐pressure) were also assessed.
Results:
The complexity and conventional measures generally demonstrated good reliability coefficients for short‐term and long‐term test‐retest reliability with both eyes open and eyes closed conditions. Intra‐class Correlation Coefficient (ICC) values ranged from .38‐.90 The highest ICC values corresponded with the short‐term reliability for the eyes open condition, while the lower ICC values corresponded with the long‐term reliability for the eyes closed condition.
Conclusions:
The results of this study indicate that the PSAP demonstrated good short‐term and long‐term test‐retest reliability. In addition, no evidence of learning effects was elicited through this study. Future studies should further explore the validity and feasibility of the use of this protocol for different age groups, different types of athletes, and longitudinal evaluations of post‐concussion impairments.
Clinical Relevance:
This study provides preliminary support for the utility of a postural sway assessment protocol measured using a force plate for use with adolescent athletes.
Level of Evidence:
Level III
PMCID: PMC3867067  PMID: 24377060
concussion; force plate; reliability; postural control
47.  COMPARISON OF DYNAMIC BALANCE IN ADOLESCENT MALE SOCCER PLAYERS FROM RWANDA AND THE UNITED STATES 
Purpose/Background:
Dynamic balance is an important component of motor skill development. Poor dynamic balance has previously been associated with sport related injury. However, the vast majority of dynamic balance studies as they relate to sport injury have occurred in developed North American or European countries. Thus, the purpose of this study was to compare dynamic balance in adolescent male soccer players from Rwanda to a matched group from the United States.
Methods:
Twenty‐six adolescent male soccer players from Rwanda and 26 age‐ and gender‐matched control subjects from the United States were screened using the Lower Quarter Y Balance Test during their pre‐participation physical. Reach asymmetry (cm) between limbs was examined for all reach directions. In addition, reach distance in each direction (normalized to limb length, %LL) and the composite reach score (also normalized to %LL) were examined. Dependent samples t‐tests were performed with significant differences identified at p<0.05.
Results:
Twenty‐six male soccer players from Rwanda (R) were matched to twenty‐six male soccer players from the United States (US). The Rwandan soccer players performed better in the anterior (R: 83.9 ± 3.2 %LL; US: 76.5 ± 6.6 %LL, p<0.01), posterolateral (R: 114.4 ± 8.3 %LL ; US: 106.5 ± 8.2 %LL, p<0.01) and composite (R: 105.6 ± 1.3 %LL; US: 97.8 ± 6.2 %LL, p<0.01) reach scores. No significant differences between groups were observed for reach asymmetry.
Conclusions:
Adolescent soccer players from Rwanda exhibit superior performance on a standardized dynamic balance test as comparison to similar athletes from the United States. The examination of movement abilities of athletes from countries of various origins may allow for a greater understanding of the range of true normative values for dynamic balance.
Levels of Evidence:
3b
PMCID: PMC3867068  PMID: 24377061
Global; Injury risk factor; Star Excursion Balance Test
48.  DEVELOPMENT OF A PRELIMINARY CLINICAL PREDICTION RULE TO IDENTIFY PATIENTS WITH NECK PAIN THAT MAY BENEFIT FROM A STANDARDIZED PROGRAM OF STRETCHING AND MUSCLE PERFORMANCE EXERCISE: A PROSPECTIVE COHORT STUDY 
Background and Purpose:
Neck pain is a significant problem and many treatment options exist. While some studies suggest exercise is beneficial for individuals with non‐specific neck pain clinicians have few tools to assist in the decision making process. Therefore, the purpose of this study was to derive a preliminary clinical prediction rule (CPR) for identifying patients with neck pain (NP) who may respond to an exercise‐based treatment program. Exercise‐based interventions have demonstrated positive outcomes in patients with NP, however it is unclear which patients are more likely to respond to this treatment approach.
Methods:
Consecutive patients with a primary report of nonspecific NP with or without arm pain were recruited. All patients participated in a standardized exercise program and then were classified as having a successful or non‐successful outcome at 6 weeks. Potential predictor variables were entered into a stepwise regression analysis. Variables retained in the regression model were used to develop a multivariate CPR that can be used to classify patients with NP that may benefit from exercise‐based treatment. A 6‐month follow up of the patients was used to evaluate the long‐term effects.
Results:
Ninety‐one patients were enrolled in the study of which 50 had a successful outcome. A CPR with 5 variables was identified (Neck Disability Index score < 18/50, presence of shoulder protraction during static postural assessment, patient does not bicycle for exercise, cervical side bending < 32°, and Fear Avoidance Belief Questionnaire–Physical Activity Score < 15). If 4 of the 5 variables were present, the probability of a successful outcome shifted from 56% to 78% (+LR 2.97). At 6 months no significant difference existed in self‐reported outcomes between those considered positive on the rule for a successful outcome and those negative on the rule for a successful outcome.
Conclusions:
The proposed CPR may identify patients with NP likely to benefit from exercise‐based treatment in the short term. However, long‐term follow up did not demonstrate a significant difference between groups.
Level of Evidence:
2b
PMCID: PMC3867069  PMID: 24377062
Clinical prediction rule; exercise; neck pain
49.  THORACOLUMBAR RANGE OF MOTION IN BASEBALL PITCHERS AND POSITION PLAYERS 
Introduction/Background:
Optimal baseball throwing mechanics require a significant contribution of thoracolumbar motion, particularly in the sagittal and transverse planes. This motion is key for proper transmission of forces from the lower to upper extremity, thereby minimizing a throwing athlete's risk of injury and maximizing athletic performance.
Purpose:
To define the active‐assisted thoracolumbar ROM of both baseball pitchers and position players and to compare these motions both within and between groups.
Methods:
Fifty‐six asymptomatic, collegiate and minor league baseball pitchers and 42 position players volunteered to participate. Active‐assisted thoracolumbar flexion, extension, and bilateral rotation ROM, were measured in a standing position, using two bubble inclinometers. Two‐tailed t tests were used to determine differences in ROM between and within the pitchers and position players.
Results:
The pitchers had significantly more rotation to the non‐throwing arm side as compared to the position players (p = .007, effect size = .61). The pitchers also had more rotation to the non‐throwing arm side as compared to their throwing side (p = .006, effect size = .47). There were no other significant differences between the pitchers and the position players (p > .53). Furthermore, the position players did not have a side‐to‐side rotation difference (p = .99).
Conclusions:
Pitchers have a greater amount of rotation ROM towards the non‐throwing arm side as compared to position players. Pitchers also have a greater amount of rotation ROM to the non‐throwing arm side as compared to their throwing side rotation. Because pitchers often present with posterior shoulder tightness and subsequent altered shoulder horizontal adduction and internal rotation ROM, the increase in non‐throwing side rotation ROM may occur in response to these adaptations. More specifically, this increase in non‐throwing side trunk rotation ROM may allow such athletes to bring the arm across the body during the follow‐through phase of the throwing motion despite posterior shoulder tightness. However, future research is necessary to investigate this relationship. Based on these results, clinicians should consider these thoracolumbar ROM adaptations in the prevention, evaluation, and treatment of baseball players.
Level of Evidence:
2b
PMCID: PMC3867070  PMID: 24377063
Flexibility; spine; throwing athlete; trunk
50.  CRITERION VALIDATION OF THE RATE OF RECOVERY, A SINGLE ALPHANUMERIC MEASURE, IN PATIENTS WITH SHOULDER PAIN 
Background and Purpose:
The aim of this study was to identify the minimal clinically important threshold score for rate of recovery (RoR) using the Patient Acceptable Symptom State (PASS) as an anchor measure, and to measure the association of the RoR with the raw and percentage change scores of the QuickDASH and the Numeric Pain Rating Scale (NPRS).
Methods:
Threshold measures for RoR and the PASS were examined using a Receiver Operating Characteristic (ROC) Curve. Participants were dichotomized to those who stated “yes” and those who stated “no” on the PASS. Pearson correlation coefficients were performed to determine the relationship between the NPRS and QuickDASH raw and percentage change scores and the RoR at discharge.
Results:
ROC curve statistics suggest that a cut‐point of greater than 87% on the self‐report RoR (SN=0.62, SP=0.73; +LR=2.26: ‐LR=0.56) corresponded to the patient considering their state acceptable. No significant associations existed between either the raw NPRS or the raw QuickDASH, and the RoR scores although percentage change scores were associated with the RoR (QuickDASH r=0.29; p=0.02; NPRS = r=0.30; p=0.02).
Discussion:
Patients reporting greater than or equal to 87% on RoR are likely to have met the Patient Acceptable Symptom State. Although statistically significant, the lack of strong association between RoR and change scores for the NPRS and QuickDASH suggests that the measures capture different constructs.
Level of Evidence:
Level 2C
PMCID: PMC3867071  PMID: 24377064
Numeric pain rating scale; QuickDASH; Rate of recovery; shoulder pain

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