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1.  Neuromuscular Control Training Programs and Noncontact Anterior Cruciate Ligament Injury Rates in Female Athletes: A Numbers-Needed-to-Treat Analysis 
Journal of Athletic Training  2006;41(4):450-456.
Objective: To determine the numbers needed to treat (NNT) and relative risk reduction (RRR) associated with neuromuscular training programs aimed at preventing noncontact anterior cruciate ligament (ACL) injuries in female athletes.
Data Sources: We searched PubMed, MEDLINE, SPORT Discus, CINAHL, and Web of Science from 1966 through 2005 using the terms knee, injury, anterior cruciate ligament, ACL, prevention, plyometric, and neuromuscular training.
Study Selection: Selected articles were from peer-reviewed journals written in English that described original research studies comparing neuromuscular training programs with control programs to determine the number of noncontact ACL injuries per event exposure or hours of playing time. Five studies met the inclusion criteria and were independently rated by 3 reviewers using the Physiotherapy Evidence Database (PEDro) scale. Consensus PEDro scores ranged from 4 to 7 out of 10.
Data Extraction: We used numbers of subjects, ACL injuries, and injury exposure rates to calculate NNT and RRR for each study. The NNT calculations from all studies were based on the number of players across 1 competitive season and were described as NNT benefit or NNT harm.
Data Synthesis: All 5 studies demonstrated a prophylactic effect due to the neuromuscular training programs. The pooled NNT estimates showed that 89 individuals (95% confidence interval: 66 to 136) would need to participate in the prophylactic training program to prevent 1 ACL injury over the course of 1 competitive season. Pooled RRR was 70% (95% confidence interval: 54% to 80%) among individuals who participated in the intervention program. One high-quality randomized control trial and 4 medium-quality prospective cohort studies showed mostly consistent findings. Thus, a Strength of Recommendation Taxonomy level of evidence of 1 with a grade B recommendation supports the use of neuromuscular training programs in the prevention of noncontact ACL injuries in female athletes.
PMCID: PMC1748422  PMID: 17273472
knee injury; balance; plyometrics; injury prevention
Individuals with chronic ankle instability (CAI) often have impairments in ankle range of motion (ROM) and balance. There is limited evidence that these impairments are related in individuals with CAI. The purpose of this study was to determine the relationship between ankle dorsiflexion ROM and dynamic balance in individuals with CAI.
Forty‐five participants (age=23.2±2.8 y, height=172.1±10.8 cm, mass=70.6±13.3 kg, Foot and Ankle Ability Measure Sport= 71.2±11.7, Modified Ankle Instability Instrument= 6.4±1.3) volunteered for this study. Ankle dorsiflexion ROM was measured in a weight‐bearing position while dynamic balance was measured using the Star Excursion Balance Test (SEBT) in the anterior, posteromedial, and posterolateral directions. Linear regression was used to determine the relationship between ankle dorsiflexion ROM and measures of dynamic balance.
There were fair positive correlations between dorsiflexion ROM and the anterior reach direction (r = .55, r2= .31, P < .001), posterolateral reach direction (r = .29, r2 = .09, P = .03), and the composite SEBT scores (r = .30, r2 = .09, P= .02). There was little or no relationship between ankle dorsiflexion and the posteromedial reach direction (r = .01, r2 = .001, P = .47).
Ankle dorsiflexion ROM can influence dynamic balance, specifically the anterior reach portion of the SEBT.
Clinical Relevance:
Individuals with CAI who demonstrate impairments in dorsiflexion ROM may also demonstrate difficulty with portions of the SEBT. Clinicians may use this information to better optimize rehabilitation programs that address ankle dorsiflexion ROM and dynamic balance.
Level of Evidence:
PMCID: PMC3625791  PMID: 23593550
Ankle sprain; functional ankle instability; postural control
3.  Lumbopelvic Joint Manipulation and Quadriceps Activation of People With Patellofemoral Pain Syndrome 
Journal of Athletic Training  2012;47(1):24-31.
Quadriceps weakness and inhibition are impairments associated with patellofemoral pain syndrome (PFPS). Lumbopelvic joint manipulation has been shown to improve quadriceps force output and inhibition, but the duration of the effect is unknown.
To determine whether quadriceps strength and activation are increased and maintained for 1 hour after high-grade or low-grade joint mobilization or manipulation applied at the lumbopelvic region in people with PFPS.
Randomized controlled clinical trial.
University laboratory.
Patients or Other Participants:
Forty-eight people with PFPS (age = 24.6±8.9 years, height = 174.3 ± 11.2 cm, mass = 78.4 ± 16.8 kg) participated.
Participants were randomized to 1 of 3 groups: lumbopelvic joint manipulation (grade V), side-lying lumbar midrange flexion and extension passive range of motion (grade II) for 1 minute, or prone extension on the elbows for 3 minutes.
Main Outcome Measure(s):
Quadriceps force and activation were measured using the burst superimposition technique during a seated isometric knee extension task. A 2-way repeated-measures analysis of variance was performed to compare changes in quadriceps force and activation among groups over time (before intervention and at 0, 20, 40, and 60 minutes after intervention).
We found no differences in quadriceps force output (F5,33,101,18 = 0.65, P = .67) or central activation ratio (F4.84,92.03 = 0.38, P= .86) values among groups after intervention. When groups were pooled, we found differences across time for quadriceps force (F2.66,101.18 = 5.03, P = .004) and activation (F2.42,92.03 = 3.85, P = .02). Quadriceps force was not different at 0 minutes after intervention (t40 = 1.68, P = .10), but it decreased at 20 (t40 = 2.16, P = .04), 40 (t40 = 2.87, P = .01) and 60 (t40 = 3.04, P = .004) minutes after intervention. All groups demonstrated decreased quadriceps activation at 0 minutes after intervention (t40 = 4.17, P <.001), but subsequent measures were not different from preintervention levels (t40 range, 1.53–1.83, P >.09).
Interventions directed at the lumbopelvic region did not have immediate effects on quadriceps force output or activation. Muscle fatigue might have contributed to decreased force output and activation over 1 hour of testing.
PMCID: PMC3418111  PMID: 22488227
force output; knee pain; manual therapy; muscle activation
4.  Reliability of Thoracic Spine Rotation Range-of-Motion Measurements in Healthy Adults 
Journal of Athletic Training  2012;47(1):52-60.
The reliability of clinical techniques to quantify thoracic spine rotation range of motion (ROM) has not been evaluated.
To determine the intratester and intertester reliability of 5 thoracic rotation measurement techniques.
Descriptive laboratory study.
University research laboratory.
Patients or Other Participants:
Forty-six healthy volunteers (age = 23.6±4.3 years, height = 171.0±9.6 cm, mass = 71.4 ±16.7 kg).
Main Outcome Measure(s):
We tested 5 thoracic rotation ROM techniques over 2 days: seated rotation (bar in back and front), half-kneeling rotation (bar in back and front), and lumbar-locked rotation. On day 1, 2 examiners obtained 2 sets of measurements (sessions 1, 2) to determine the within-session intertester reliability and within-day intratester reliability. A single examiner obtained measurements on day 2 (session 3) to determine the intratester reliability between days. Each technique was performed 3 times per side, and averages were used for data analysis. Reliability was determined using intraclass correlation coefficients, standard error of measurement (SEM), and minimal detectable change (MDC). Differences between raters during session 1 were determined using paired t tests.
Within-session intertester reliability estimates ranged from 0.85 to 0.94. Ranges for the SEM were 1.0° to 2.3° and for the MDC were 2.8° to 6.3°. No differences were seen between examiners during session 1 for seated rotation (bar in front, both sides), half-kneeling rotation (bar in front, left side), or the lumbar locked position (both sides) (all values of P > .05). Within-day intratester reliability estimates ranged from 0.86 to 0.95. Ranges for the SEM were 0.8° to 2.1° and for the MDC were 2.1 ° to 5. 9°. Between-days intratester reliability estimates ranged from 0.84 to 0.91. Ranges for the SEM were 1.4° to 2.0° and for the MDC were 3.9° to 5.6°.
All techniques had good reliability and low levels of measurement error. The seated rotation, bar in front, and lumbar-locked rotation tests may be used reliably when more than 1 examiner is obtaining measurements.
PMCID: PMC3418115  PMID: 22488230
biomechanics; bubble inclinometer; goniometer; scapulothoracic joint
Writing a scientific manuscript can be a consuming, but rewarding task with a number of intrinsic and extrinsic benefits. The ability to write a scientific manuscript is typically not an emphasized component of most entry‐level professional programs. The purpose of this overview is to provide authors with suggestions to improve manuscript quality and to provide mechanisms to avoid common manuscript mistakes that are often identified by journal reviewers and editors.
PMCID: PMC3474299  PMID: 23091784
manuscript; scientific writing
A variety of methods exist to measure ankle dorsiflexion range of motion (ROM). Few studies have examined the reliability of a novice rater. The purpose of this study was to determine the reliability of ankle ROM measurements using three different techniques in a novice rater.
Twenty healthy subjects (mean±SD, age=24±3 years, height=173.2±8.1 cm, mass=72.6±15.2 kg) participated in this study. Ankle dorsiflexion ROM measures were obtained in a weight-bearing lunge position using a standard goniometer, digital inclinometer, and a tape measure using the distance-to-wall technique. All measures were obtained three times per side, with 10 minutes of rest between the first and second set of measures. Intrarater reliability was determined using an intraclass correlation coefficient (ICC2,3) and associated 95% confidence intervals (CI). Standard error of measurement (SEM) and the minimal detectable change (MDC) for each measurement technique were also calculated.
The within-session intrarater reliability (ICC2,3) estimates for each measure are as follows: tape measure (right 0.98, left 0.99), digital inclinometer (right 0.96; left 0.97), and goniometer (right 0.85; left 0.96). The SEM for the tape measure method ranged from 0.4–0.6 cm and the MDC was between 1.1–1.5 cm. The SEM for the inclinometer was between 1.3–1.4° and the MDC was 3.7–3.8°. The SEM for the goniometer ranged from 1.8–2.8° with an MDC of 5.0–7.7°.
The results indicate that reliable measures of weight-bearing ankle dorsiflexion ROM can be obtained from a novice rater. All three techniques had good reliability and low measurement error, with the distance-to-wall technique using a tape measure and inclinometer methods resulting in higher reliability coefficients (ICC2,3=0.96 to 0.99) and a lower SEM compared to the goniometer (ICC2,3=0.85 to 0.96).
Level of Evidence:
PMCID: PMC3362988  PMID: 22666642
goniometry; inclinometer; talocrural joint
A number of sporting and daily activities involve rotation of the spine. The ability to quantify motion of the spine in a clinical setting usually relies on the use of a device to measure angles (goniometer or inclinometer) or visual assessment. Standardized measurement criteria exist for measuring rotation at the cervical and lumbar spine. Little has been written regarding established methods for measuring thoracic spine rotation. Thoracic rotation may be measured in a seated position, half-kneeling position, or quadruped position. Steps should be taken to minimize motion of surrounding segments such as the shoulder and hips, which may improve measurement accuracy. Key words: inclinometer, goniometer, range of motion
PMCID: PMC3096146  PMID: 21655383
8.  Community-Associated Methicillin-Resistant Staphylococcus Aureus 
Methicillin resistant Staphylococcus aureus (MRSA), is a problematic infection which is becoming more common in a variety of athletic related environments. Early recognition, diagnosis, and timely management of infection can help minimize the severity of infection and decrease the rate of transmission. Since most sports physical therapists typically lack adequate knowledge and ability to identify cases of MRSA infection, the pur-pose of this review is to provide a background for associated risk factors, recognition, treatment, and prevention of community associated-MRSA in athletic environments.
PMCID: PMC2953299  PMID: 21522209
9.  Immediate effects of anterior to posterior talocrural joint mobilizations following acute lateral ankle sprain 
Restrictions in ankle dorsiflexion range of motion (ROM) have been associated with decreased posterior talar glide in individuals with an acute lateral ankle sprain. Talocrural joint mobilizations may be used to restore joint arthrokinematics. Our purpose was to examine the effects of a single bout of anterior to posterior (AP) talocrural joint mobilization on self-reported function, dorsiflexion ROM, and posterior talar translation in individuals with an acute lateral ankle sprain. This single-blinded, randomized controlled trial utilized 17 volunteers (nine treatment and eight control) with an acute lateral ankle sprain (grade I/II) who were immobilized for a period of 1–7 days. The treatment group received a single 30-second bout of grade III AP talocrural joint mobilization the day their immobilization device was removed, while the control group did not receive any intervention. Active dorsiflexion ROM and posterior talar translation were assessed before, immediately after, and 24 hours after receipt of the treatment or control interventions. Self-reported function and pain were assessed before and 24 hours after the receipt of the treatment or control interventions using the foot and ankle disability index. Collectively all groups demonstrated improved dorsiflexion ROM and self-reported function. There was a significant decrease in pain perception at 24-hour follow-up for the treatment group. A single bout of AP talocrural joint mobilizations may not have an immediate effect on ankle dorsiflexion ROM, posterior talar translation, or self-reported function; however, they may have an immediate effect on pain perception in individuals with an acute lateral ankle sprain.
PMCID: PMC3172942  PMID: 22547917
Arthrokinematics; Ankle sprain; Talocrural joint mobilization; Dorsiflexion; Self-reported function
10.  Memoriam: James R Beazell, DPT, FAAOMPT, OCS, ATC 
PMCID: PMC3172948
Limitations in thoracic spine motion may be due to restrictions in contractile or non-contractile tissues. Joint mobilizations are indicated when hypomobility of a joint (non-contractile tissue) is identified. The ability for a patient to perform self-mobilizations of the thoracic spine and ribs may help maximize intervention outcomes. The purpose of this article is to describe a low cost, portable device which can be used for thoracic spine self-mobilization techniques.
PMCID: PMC3325630  PMID: 22530198
12.  Treatment of a female collegiate rower with costochondritis: a case report 
Rib injuries are common in collegiate rowing. The purpose of this case report is to provide insight into examination, evaluation, and treatment of persistent costochondritis in an elite athlete as well as propose an explanation for chronic dysfunction. The case involved a 21 year old female collegiate rower with multiple episodes of costochondritis over a 1-year period of time. Symptoms were localized to the left third costosternal junction and bilaterally at the fourth costosternal junction with moderate swelling. Initial interventions were directed at the costosternal joint, but only mild, temporary relief of symptoms was attained. Reexamination findings included hypomobility of the upper thoracic spine, costovertebral joints, and lateral ribs. Interventions included postural exercises and manual therapies directed at the lateral and posterior rib structures to improve rib and thoracic spine mobility. Over a 3-week time period pain experienced throughout the day had subsided (visual analog scale – VAS 0/10). She was able to resume running and elliptical aerobic training with minimal discomfort (VAS 2/10) and began to reintegrate into collegiate rowing. Examination of the lateral ribs, cervical and thoracic spine should be part of the comprehensive evaluation of costochondritis. Addressing posterior hypomobility may have allowed for a more thorough recovery in this case study.
PMCID: PMC3101071  PMID: 21655387
Costochondritis; Joint mobilization; Rib; Thoracic spine
13.  Lumbar instability: an evolving and challenging concept 
Identification and management of chronic lumbar spine instability is a clinical challenge for manual physical therapists. Chronic lumbar instability is presented as a term that can encompass two types of lumbar instability: mechanical (radiographic) and functional (clinical) instability (FLI). The components of mechanical and FLI are presented relative to the development of a physical therapy diagnosis and management. The purpose of this paper is to review the historical framework of chronic lumbar spine instability from a physical therapy perspective and to summarize current research relative to clinical diagnosis in physical therapy.
PMCID: PMC3103111  PMID: 21655418
Diagnosis; Hypermobility; Low back pain; Physical examination; Segmental instability
14.  Differences in Transverse Abdominis Activation with Stable and Unstable Bridging Exercises in Individuals with Low Back Pain 
The transversus abdominis (TrA) is a spine stabilizer frequently targeted during rehabilitation exercises for individuals with low back pain (LBP). Performance of exercises on unstable surfaces is thought to increase muscle activation, however no research has investigated differences in TrA activation when stable or unstable surfaces are used.
The purpose of this study was to investigate whether TrA activation in individuals with LBP is greater when performing bridging exercises on an unstable surface versus a stable surface.
Fifty one adults (mean ± SD, age 23.1 ± 6.0 years, height 173.60 ± 10.5 cm, mass 74.7 ± 14.5 kg) with stabilization classification of LBP were randomly assigned to either exercise progression utilizing a sling bridge device or a traditional bridging exercise progression, each with 4 levels of increasing difficulty. TrA activation ratio (TrA contracted thickness/TrA resting thickness) was measured during each exercise using ultrasound imaging. The dependent variable was the TrA activation ratio.
The first 3 levels of the sling-based and traditional bridging exercise progression were not significantly different. There was a significant increase in the TrA activation ratio in the sling-based exercise group when bridging was performed with abduction of the hip (1.48 ± .38) compared to the traditional bridge with abduction of the hip (1.22 ± .38; p<.05).
Both types of exercise result in activation of the TrA, however, the sling based exercise when combined with dynamic movement resulted in a significantly higher activation of the local stabilizers of the spine compared to traditional bridging exercise. This may have implications for rehabilitation of individuals with LBP.
PMCID: PMC2953390  PMID: 21589663
Core stability; rehabilitation; Rehabilitative Ultrasound Imaging
15.  Treatment of Lateral Knee Pain by Addressing Tibiofibular Hypomobility in a Recreational Runner 
Altered joint arthrokinematics can affect structures distal and proximal to the site of dysfunction. Hypomobility of the proximal tibiofibular joint may limit ankle dorsiflexion and indirectly alter stresses about the knee.
To examine the effect of addressing hypomobility of the proximal tibiofibular joint in an individual with lateral knee pain.
Case Description
A 24 year old female recreational runner presented with a three month history of right lateral knee pain. Limited right ankle dorsiflexion was noted and determined to be related to decreased mobility of the proximal tibiofibular joint, as well as, the talocrural and distal tibiofibular joints. Functional movement deficits were noted during the squat test and step down test. Treatment was performed three times over the course of two weeks which included proximal tibiofibular joint manipulation and an exercise program consisting of hip strengthening, balance, and gastrocnemius/soleus muscle complex stretching.
Immediately following intervention, improvements were noted for ankle dorsiflexion, squat test, and step down test. One week following the initial intervention the patient reported she was able to run pain free.
Addressing impairments distant to the site of dysfunction, such as the proximal tibiofibular joint, may be indicated in individuals with lateral knee pain.
PMCID: PMC2953316  PMID: 21509117
ankle sprain; arthrokinematics; manipulation
16.  Short-Term Effect of Muscle Energy Technique on Pain in Individuals with Non-Specific Lumbopelvic Pain: A Pilot Study 
Muscle energy technique (MET) is a form of manual therapy frequently used to correct lumbopelvic pain (LPP), herein the patient voluntarily contracts specific muscles against the resistance of the clinician. Studies on MET regarding magnitude and duration of effectiveness are limited. This study was a randomized controlled trial in which 20 subjects with self-reported LPP were randomized into two groups (MET or control) after magnitude of pain was determined. MET of the hamstrings and iliopsoas consisted of four 5-second hold/relax periods, while the control group received a sham treatment. Tests for current and worst pain, and pain with provocation were administered at baseline, immediately following intervention and 24 hours after intervention. Separate 2×3 ANOVAs were used to assess results as change scores. Visual analog score (VAS) for worst pain reported in the past 24 hours decreased for the MET group (4.3mm±19.9, p=.03) and increased for the sham (control) group (17.1mm±21.2, p=.03). Subjects receiving MET demonstrated a decrease in VAS worst pain over the past 24 hours, thereby suggesting that MET may be useful to decrease LPP over 24 hours.
PMCID: PMC2704351  PMID: 20046557
Inclinometer; Lumbopelvic Pain; Manual Therapy; Pain Provocation Tests
17.  A Systematic Review of Prophylactic Braces in the Prevention of Knee Ligament Injuries in Collegiate Football Players 
Journal of Athletic Training  2008;43(4):409-415.
To determine the relative risk reduction associated with prophylactic knee braces in the prevention of knee injuries in collegiate football players.
Data Sources:
An exhaustive search for original research was performed using the PubMed, SportDiscus, and CINAHL databases from 1970 through November 2006, with the search terms knee brace, knee braces, knee bracing and football, prophylactic brace, and prophylactic knee braces.
Study Selection:
Seven studies comparing knee injuries among braced and nonbraced collegiate football players were included. Study methods were assessed using the Physiotherapy Evidence Database (PEDro) scale. PEDro scores ranged from 2 to 5.
Data Extraction:
The number of participants and frequency of knee injuries were used to calculate the relative risk reduction or increase.
Data Synthesis:
We found a relative risk reduction for 3 studies with point estimates of 10% (36% to −26%), 58% (25% to 76%), and 56% (13% to 77%). Four studies demonstrated an increased risk of injury, with point estimates of 17% (19% to −71%), 49% (−31% to −69%), 114% (23% to −492%), and 42% (−18% to −70%).
Data from existing research are inconsistent. Based on a Strength of Recommendation Taxonomy level of evidence of 2 with a grade B recommendation, we cannot conclusively advocate or discourage the use of prophylactic knee braces in the prevention of knee injuries in collegiate football players.
PMCID: PMC2474821  PMID: 18668174
protective equipment; injury prevention

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