IJSPT NEW MASTHEAD

VOLUME ELEVEN, NUMBER ONE

 
2016Masthead_V11N1

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FEBRUARY 2016

SYSTEMATIC REVIEW
Dry Needling in Subjects with Muscular Trigger Points in the Lower Quarter
Authors: Morihisa R, Eskew J, McNamara A, Young J
Abstract
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Trigger points, which have been defined as highly localized, hyperirritable, palpable taut bands located in skeletal muscle fibers, have been identified in patients with a variety of musculoskeletal conditions. The incidence of trigger point pain is high, with studies showing them as the primary source of pain in 30-85% of patients presenting in a primary care setting or pain clinics. Dry needling has emerged as a possible intervention for trigger points, but its effectiveness has not yet fully been determined. The purpose of this systematic review is to assess and provide a summary of the current literature for the use of dry needling as an intervention for lower quarter trigger points in patients with various orthopedic conditions.  A total of six studies met the inclusion criteria and were analyzed using the PEDro scale. Four of the studies assessed by the PEDro scale were deemed ‘high’ quality and two were ‘fair’ quality. Each of the six included studies reported statistically significant improvements with dry needling for the reduction of pain intensity in the short-term. Only one study reported a statistically significant improvement in short-term functional outcomes; however, there was no maintenance of improved function at long-term follow-up. Furthermore, none of the studies reported statistically significant changes regarding the effect of dry needling on quality of life, depression, range of motion, or strength. The authors concluded from their review of the literature that dry needling is effective in reducing pain associated with lower quarter trigger points in the short-term. However, the findings also suggest that dry needling does not have a positive effect on function, quality of life, depression, range of motion, or strength.

ORIGINAL RESEARCH
Validation of Two Clinical Measures of Core Stability
Authors:  Butowicz CM, Ebaugh DD, Noehren B, Silfies S
Abstract
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Emerging evidence suggests poor core stability is a risk factor for low back and lower extremity injuries in athletes. Recently, the trunk stability test (TST) and unilateral hip bridge endurance test (UHBE) were developed to clinically assess core stability. Although these and other clinical tests of core stability exist, how well they assess core stability when compared to biomechanical measures of isolated core stability has not been thoroughly evaluated. The purposes of this study were to 1) determine concurrent validity of two novel clinical core stability assessments (TST and UHBE), and 2) assess relationships between these assessments and the trunk extensor endurance and Y-Balance tests. The authors’ hypothesized that the TST and UHBE would be highly correlated to the lab-based biomechanical measure of isolated core stability. Also, the TST and UHBE would be moderately correlated with each other, but not with the trunk extensor endurance and Y-Balance. Twenty healthy, active individuals completed the TST (recorded number of errors), UHBE (s), trunk extensor endurance (s), Y-Balance (% leg length) test (YBT), and biomechanical tests of core stability.  Correlational analyses revealed a small, non-significant association between TST and biomechanical measures (rs = 0.2 – 0.22), while a moderate, significant relationship existed between UHBE and biomechanical measures (rs = -0.49 to -0.56, p<0.05). There was little to no relationship between TST and UHBE (r = -0.07 to – 0.21), or TST and extensor endurance (r = -0.18 to -0.24). A moderate, significant association existed between TST and two reach directions of the YBT (r = -0.41 to -0.43, p<0.05). Study data support the utility of UHBE as a clinical measure of core stability. The poor relationship between the TST and biomechanical measures, combined with observation of most control faults occurring in the lower extremity (LE) suggest the TST may not be an appropriate clinical test of core stability.

Test-retest Reliability of Two Clinical Tests for the Assessment of Hip Abductor Endurance in Healthy Females
Authors: Van Cant J, Dumont G, Pitance L, Demoulin C, Feipel V
Abstract
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Substantial deficits in performance of hip abductors in patients with common lower extremity injuries are reported in literature. Therefore, assessing hip abductor endurance might be of importance for clinicians and researchers. The purpose of this study was to examine the test-retest reliability of two hip abductor endurance tests in healthy females. Learning effect, systematic difference in the rate of perceived exertion, and the relationship between endurance performance and some clinical characteristics of participants were also investigated. Thirty-six healthy females, aged 18-30 years, were recruited for this study. In two identical assessment sessions, the participants performed an isometric hip abductor strength test and two different hip abductor endurance tests.  Isometric and dynamic endurance tests demonstrated good test-retest reliability (ICC’s = 0.73 and 0.78, respectively). The standard errors of measurement (SEM) and the minimal detectable changes (MDC) were 19.8 and 54.9 seconds for isometric endurance test and 21.2 and 58.7 repetitions for dynamic endurance test, respectively. Moderate correlation between both endurance tests (r = 0.60, p = 0.0001) and weak correlation between dynamic endurance test and strength (r = 0.44, p =0.008) were found. Therefore, the results of the present study demonstrate good test-retest reliability of two non-instrumented clinical tests of hip abductor endurance in healthy females.

Lower Limb Asymmetries in Rhythmic Gymnastics Athletes

Authors: Frutuoso AS, Diefenthaeler F, Vaz MA, de la Rocha Freitas C
Abstract
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Different limb training demands and limb preference may determine anthropometric and muscle force inter-limb asymmetries in Rhythmic Gymnastics (RG) athletes. The purpose of this study was to evaluate the influence of lateral preference of the lower limb on anthropometric, range of motion, and isokinetic torque measurements of RG athletes. Lower limb anthropometric measurements (girth, estimated anatomical cross-sectional area), hip, knee and ankle range of motion, flexor and extensor isokinetic torques (angular velocities = 60, 180, e 240°·s-1) and bilateral asymmetry index were evaluated in 11 international level Rhythmic Gymnastics athletes (17.9 ± 4.0 years of age; 9.1 ± 5,1 years of experience; 26.8 ± 6.0 weekly training hours). The preferred limb showed larger thigh girth and anatomical cross-sectional area, higher ankle dorsiflexor range of motion, higher hip flexor torque at 60°·s-1 and higher plantarflexor torque at 180°·s-1 compared to the non-preferred limb. The authors concluded that the observed differences seem to be strictly related to lateral preference and rhythmic gymnastics training.

SportsMetrics™ Training Improves Power and Landing in High School Rowers
Authors:  Chimera NJ, Kremer K
Abstract
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Successful rowing participation requires leg power, back strength, cardiovascular endurance, and balance.  SportsMetrics™ training improves lower limb alignment, hamstring peak torque, and vertical jump height; however, this training has not been used in athletes who row and may have different outcomes based on rowers experience levels. The purpose of this study was to compare the effects of a six-week SportsMetrics™ training program on vertical jump height (VJH), Y Balance Test (YBT), and Drop Jump Screening Test (DJST) between novice and varsity high school rowers. The authors enrolled 52 (31 varsity: 16.4±0.8 years, 62.0±9.0 kg, 1.7±0.1m [mean ± SD], 21 novice: 14.5±0.7years, 58.6±5.4 kg, 1.7±0.1m [mean ± SD]) high school rowers completed the Sportsmetrics™ training and participated in the study.  Differences in age, weight, and height were examined using independent t-tests. Repeated measures ANOVA assessed pre- to post-training differences between groups in VJH, YBT composite score (CS) and reach asymmetry (ASY), and normalized knee joint separation distance (DJST).  The authors found that VJH significantly improved for all athletes from pre- to post-training (mean ± SD: 29.0±7.0 vs. 31.9±5.1cm; p=0.001) and normalized knee separation distance significantly increased for all athletes pre to post training at the pre-landing (mean ± SD: 58.2±12.5 vs. 68.7±7.4%; p<0.001), landing (mean ± SD: 49.4±18.2 vs. 66.3±14.2%; p<0.001), and take off (mean ± SD: 47.8±18.4 vs. 64.8±13.8%; p<0.001) phases of the jump; there was no effect for group. There was no difference in varsity and novice pre to post training in YBT CS (99.3±7.5 vs. 99.7±7.1%; p=0.53) or ANT ASY (mean ± SD: 3.4±4.6 vs. 2.7±2.3; p=0.36).  Therefore, the authors concluded that SportsMetrics™ training improved VJH regardless of experience level; suggesting rowers may have more leg power following training. Normalized knee joint separation distance increased to greater than 60% of hip joint separation distance following training, indicating that training reduced serious knee injury risk.

The Effect of Step Rate Manipulation on Foot Strike Pattern of Long Distance Runners
Authors:  Allen DJ, Heisler H, Mooney J, Kring R
IJSPT-11_1-06-Allen_abs
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Running gait retraining to change foot strike pattern in runners from a heel strike pattern to a non heel- strike pattern has been shown to reduce impact forces and may help to reduce running related injuries. Step rate manipulation above preferred is known to help decrease step length, foot inclination angle, and vertical mass excursion, but has not yet been evaluated as a method to change foot strike pattern. The purpose of this study was to investigate the effect of step rate manipulation on foot strike pattern in shod recreational runners who run with a heel strike pattern. A secondary purpose was to describe the effect of step rate manipulation at specific percentages above preferred on foot inclination angle at initial contact. In this study, forty volunteer runners, who were self-reported heel strikers and had a weekly running mileage of at least 10 miles, were recruited. Runners were confirmed to be heel strikers during the warm up period on the treadmill. The subject’s step rate was determined at their preferred running pace. A metronome was used to increase step rate above the preferred step rate by 5%, 10% and 15%. 2D video motion analysis was utilized to determine foot strike pattern and to measure foot inclination angle at initial contact for each step rate condition. The authors found that there was a statistically significant change in foot strike pattern from a heel strike pattern to a mid-foot or forefoot strike pattern at both 10% and 15% step rates above preferred. Seven of the 40 subjects (17.5%) changed from a heel- strike pattern to a non- heel strike pattern at +10% and 12 of the 40 subjects (30%) changed to a non-heel strike pattern at +15%. Mean foot inclination angle at initial contact showed a statistically significant change (reduction) as step rate increased. Therefore, the authors concluded that step rate manipulation of 10% or greater may be enough to change foot strike pattern from a heel strike to a mid-foot or forefoot strike pattern in a small percentage of recreational runners who run in traditional running shoes. If changing the foot strike pattern is the main goal, other gait re-training methods may be needed to make a change from a heel strike to a non-heel strike pattern. Step rate manipulation shows a progressive reduction of foot inclination angle at 5%, 10%, and 15% above preferred step rate which reduces the severity of the heel strike at initial contact.  Step rate manipulation of at least +10% above preferred may be an effective running gait retraining method for clinicians to decrease the severity of heel strike and possibly assist a runner to change to a non-heel strike pattern.

The Use of a Static Measure to Predict Foot Posture at Mid-Support During Running
Authors: Bade MB, Chi TL, Farrell KC, Gresl AJ, Hammel LJ, Koster BN, Leatzow AB, Thomas EC, McPoil TG
Abstract
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The posture of the foot has been implicated as a factor in the development of running-related injuries.  A static measure of foot posture, such as the longitudinal arch angle (LAA) that can be easily performed and is predictive of the posture of the foot at mid-support while running could provide valuable information to enhance the clinician’s overall evaluation of the runner. The purpose of this study was to determine if the LAA, assessed in relaxed standing, could predict the posture of the foot at mid-support while running on a treadmill. The authors recruited forty experienced runners (mean age 26.6 years) to participate in this study. Inclusion criteria included running at least 18 miles per week, previous experience running on a treadmill, no history of lower extremity congenital or traumatic deformity, or acute injury three months prior to the start of the study. Each runner had markers placed on the medial malleolus, navicular tuberosity, and medial aspect 1st metatarsal head of both feet. A high speed camera (240 Hz) was used to film both feet of each runner in standing and while running on a treadmill at their preferred speed. The LAA in standing and at mid-support while running was determined by angle formed by two lines drawn between the three markers with the navicular tuberosity serving as the apex. The LAA in midsupport was determined using the mean of the middle five running trials. The authors found that the levels of intra-rater and inter-rater reliability for the dynamic LAA were excellent.  The results indicated that mean values between the left and right foot were not significantly different for the standing or running LAA.  Additionally, the results of the t-tests between male and female runners were also not significantly different for standing or running LAA.  The Pearson correlation between standing and running LAA for all 80 feet was r = 0.95 (r2 = 0.90). Therefore the authors concluded that the standing LAA was highly predictive of the running LAA at mid-support while running. Approximately 90% of the variance associated with foot posture at mid-support in running could be explained by the standing LAA.

Reliability, Comparability, and Validity of Foot Inversion and Eversion Strength Measurements Using a Hand-held Dynamometer
Authors:  Alfuth M, Hahm MM
Abstract
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There are conflicting results with respect to the validity and reliability of lower extremity strength measurements using a hand-held dynamometer (HHD) in the healthy population. Previous studies exploring foot inversion and eversion strength using a HHD were carried out with predominantly clinically affected participants in different positions. The question arises whether HHD measurements of isometric foot inversion and eversion strength performed with participants in different positions are valid, reliable and comparable and can be used alternatively. The aims of this study were to investigate: a) the intra- and inter-tester reliability of measurements of foot inversion and eversion strength in different participant positions using a belt-stabilized HHD; b) the comparability of results obtained in different positions; and c) the concurrent validity of the aforementioned measurements using an isokinetic dynamometer. Thirty adults (12 females and 18 males; mean age 22.5 ± 3.9 years) volunteered to participate in this study. Maximal isometric foot inversion and eversion torques (Nm) were measured with participants lying supine, sitting with knees extended and lying on their side using a belt-stabilized HHD. Measurements were performed independently by two physiotherapists over two days and were repeated using an isokinetic dynamometer. The authors found that the intra-tester reliability for inversion and eversion torques was fair to excellent in all positions (ICC=0.598–0.828). Excellent inter-tester reliability was found for eversion torques in all positions (ICC=0.773–0.860). For inversion torques, inter-tester reliability was fair to excellent (ICC=0.519–0.879). ICC values of 0.205 to 0.562 indicated a low to fair concurrent validity. A significant difference was observed between the torques of the supine and side-lying positions as well as sitting and side-lying positions (p<0.05). Bland-Altman plots showed that the mean of the differences for inversion and eversion torques deviates considerably from zero, indicating that measurements with the HHD in the three positions produce lower values compared to using the isokinetic dynamometer. Therefore, the authors concluded that inversion and eversion strength measurements with subjects in different positions using HHD seem to be reliable, but consistently underestimated force output when compared with measurements using isokinetic dynamometry. While the HHD outcomes measured in supine and sitting positions seem to be comparable, those measured in supine/sitting and side-lying positions differed.

Intersession Reliability of Upper Extremity Isokinetic Push-pull Testing

Authors:  Riemann BL, Davis SE, Huet K, Davies GJ
Abstract
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Pushing and pulling patterns are frequently used in functional activities, therefore, there is a need to establish an objective method of quantifying the muscle performance characteristics associated with these motions, particularly during the later stages of rehabilitation as criteria for discharge. While isokinetic assessment offers an approach to quantifying muscle performance, little is known about closed kinetic chain (CKC) isokinetic testing of the upper extremity (UE). The purpose of this study was to determine the intersession reliability of isokinetic upper extremity measurement of pushing and pulling peak force and average power at slow (0.24 m/s), medium (0.43 m/s) and fast (0.61 m/s) velocities in healthy young adults. The secondary purpose was to compare pushing and pulling peak force (PF) and average power (AP) between the upper extremity limbs (dominant, non-dominant) across the three velocities.  Twenty-four physically active men and women completed a test-retest (>96 hours) protocol in order to establish isokinetic UE CKC reliability of PF and AP during five maximal push and pull repetitions at three velocities.  Both limb and speed orders were randomized between subjects. The authors found high test-retest relative reliability for PF (ICC= .91-.97) and AP (ICC= .85-.95) across velocities, limbs and directions. PF typical error (% coefficient of variation) ranged from 6.1% to 11.3% while AP ranged from 9.9% to 26.7%. PF decreased significantly (p<.05) as velocity increased whereas AP increased as velocity increased. PF and AP during pushing were significantly greater than pulling at all velocities, however the push-pull differences in PF became less as velocity increased. There were no significant differences identified between the dominant and non-dominant limbs. The authors concluded that isokinetically derived UE CKC push-pull PF and AP are reliable measures.   The lack of limb differences in healthy normals suggests that clinicians can consider bilateral comparisons when interpreting test performance.  The increase in pushing PF and AP compared to pulling can be attributed to the muscles involved and the frequency that pushing patterns are used during functional activities.

The Effect of Axioscapular and Rotator Cuff Exercise Training Sequence in Patients with Subacromial Impingement Syndrome: A Randomized Crossover Trial

Authors: Mulligan EP, Huang M, Dickson T, Khazzam M
Abstract
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While physical therapy is an effective element in the rehabilitation of rotator cuff (RC) disease, the most effective sequence of exercise training interventions has not been defined. The purpose of this study was to determine if there is a difference in pain or function in patients who are prescribed RC strengthening prior to or after initiating scapular stabilization exercises. This was a prospective study of 26 men and 14 women (mean age of 51) who were diagnosed with subacromial impingement syndrome (SAIS). They were randomly assigned to one of two groups for a comprehensive and standardized rehabilitation program over six visits at an orthopedic outpatient clinic. One group was prescribed a 4-week program beginning with scapular stabilization exercises while the other group began with RC strengthening exercises. The crossover design had each group add the previously excluded four exercises to their second month of rehabilitation. The results showed significant improvements in pain (p < 0.001), function (p < 0.001), and patient satisfaction (p < 0.001) at all follow-up times for both groups. There was not a statistically significant difference in pain or function at any follow-up period for initiating one group of exercise before the other (p > 0.05). There was a statistically significant interaction between the patient's global rating of change at the 4-week follow-up as compared to 8 (p = 0.04) or 16 week (p < 0.001) time frames. Therefore, the authors concluded that patients with SAIS demonstrate improvement in pain and function with a standardized program of physical therapy regardless of group exercise sequencing.

Comparison of Scapular Muscle Activation During Three Overhead Throwing Exercises

Authors: Henning L, Plummer H, Oliver GD
Abstract
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With shoulder pain and injury on the rise in overhead athletes, clinicians are often examining preventative exercises to address functional abnormalities. Because shoulder impingement is prevalent in overhead athletes, focus is typically on scapular stability and the function of the stabilizing force couple of the upper and lower trapezius and serratus anterior. The purpose of this study was to examine scapular muscle activation during a series of throws and holds (throwing without releasing) with two different ball weights (7oz and 12oz). It was hypothesized that the holds exercises would elicit greater activation of the scapular musculature than the throw, irrespective of ball weight. Twenty-two NCAA Division I, right hand dominant, softball players (19.91+1.04 years; 169.24+7.36 cm; 72.09+10.61 kg) volunteered to participate. Surface EMG was utilized to measure muscle activity in the upper, middle and lower trapezius and serratus anterior muscles during three different throwing activities. The 7oz throw was the control variable and the two different holds (7oz and 12oz) were the experimental variables for the four muscles. MANOVA results revealed no significant differences in muscle activity between throwing conditions, F(16,82) = 1.02, p = 0.446, Wilks’ ? = 0.696, Cohen’s d = 0.44 (7oz holds), 0.24 (12oz holds), power = 0.625.  Therefore, the results may provide some clinical insight in advocating the use of holds with different ball weights. The holds throw may be an effective step in shoulder strengthening that can more closely mimic the functional movement of throwing without the element of ball release.

A Comparison Between Civilian and Military Physical Therapists’ Knowledge in Managing Musculoskeletal Conditions: A Descriptive Study

Authors: Rundle R, Roberts J, Whitney G, Mankins S, Dille C, Donaldson M, Hassen A
Abstract
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Military physical therapists have been shown to have the necessary knowledge in musculoskeletal medicine in order to practice as a direct access provider. However, research about musculoskeletal knowledge in the civilian physical therapist (non-military) population is lacking. The purpose of the current study was to compare the knowledge in managing musculoskeletal conditions between civilian and military physical therapists using a validated and standardized musculoskeletal competency examination. Furthermore, this study aims to investigate the potential factors that may lead to increased musculoskeletal competency. This study involved a cross-sectional, electronic survey completed in August and September of 2014 in order to assess licensed physical therapists’ knowledge in identifying and managing musculoskeletal conditions. Only physical therapists practicing in orthopedics were permitted to be involved in the study. Descriptive statistics of the participants, and logistic regressions analyzing variables correlated with passing the musculoskeletal exam were calculated using SPSS 22.0. Frequencies were produced for multiple variables. Binary logistic regressions were used to correlate the frequency variables with performing at competency level on the musculoskeletal exam. A total of 22,750 surveys were sent to physical therapists in Arizona, Ohio, Texas, Maine and Wyoming. Two thousand sixty-five surveys were returned for a response rate of 10.6%. Of the 2,065 surveys completed, 408 responses were included for analysis. The average score for the respondents on the exam was 65.08% and only 28.2% of all respondents met the competency cutoff score (previously established to be 73.1%). Respondents who were orthopedic certified specialists (OCS) or sports certified specialists (SCS) were 3.091 times more likely to perform at the competency level on the examination with a p-value of <0.001 and a confidence interval >95%. The current study utilized the results from a previous study for a comparison between the civilian and military physical therapist populations. The results indicate that civilian physical therapists in the current study (65.08%) scored lower than their military counterparts in the previous study (75.9%) on the musculoskeletal exam. Potential reasons for this include less autonomous practice responsibilities and a disparity in educational experiences. Board certifications may enhance civilian physical therapists ability to practice with greater autonomy as primary care clinicians when managing musculoskeletal conditions.

Prevalence of Musculoskeletal Pain in Marathon Runners Who Compete at the Elite Level

Authors: Teixeira RN, Lunardi A, da Silva RA, Lopes A, Carvalho CRF
Abstract
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Musculoskeletal pain can be an important sign of overuse injury in elite athletes. However, its prevalence and whether it is associated with aspects of training in marathon runners who compete at the elite level is still not clear. The purpose of this study was to assess the prevalence, location and intensity of running-related musculoskeletal pain over the previous 12 months in marathon runners who compete at the elite level and to verify whether certain training characteristics are associated with musculoskeletal pain. One hundred and ninety-nine elite marathon runners were verbally interviewed regarding their personal demographics, training routines, and the presence, location and intensity of musculoskeletal pain. The prevalence of any running-related musculoskeletal pain in elite distance runners was 75%, and the most frequently reported location was the lower leg (19.1%). The presence of pain was independent of age, experience, and volume of training. Therefore, the authors concluded that running-related musculoskeletal pain is highly prevalent in marathon runners who compete at the elite level.   

Injuries in Disc Golf – A Descriptive Cross-sectional Study
Authors: Rahbek MA, Nielsen RO
IJSPT-11_1-14-Rahbek_abs
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Disc golf is rapidly increasing in popularity and more than two million people are estimated to regularly participate in disc golf activities. Despite this popularity, the epidemiology of injuries in disc golf remains under reported. The purpose of this study was to investigate the prevalence and anatomic distribution of injuries acquired through disc-golf participation in Danish disc golf players. The study was a cross-sectional study conducted on Danish disc-golf players. In May 2015, invitations to complete a web-based questionnaire were spread online via social media, and around disc-golf courses in Denmark. The questionnaire included questions regarding disc-golf participation and the characteristics of injuries acquired through disc golf participation. The data was analyzed descriptively.  An injury prevalence of 13.3% (95% CI: 6.7% to 19.9%) was reported amongst the 105 disc-golf players who completed the questionnaire. The anatomical locations most commonly affected by injury were the shoulder (31%) and the elbow (20%). Injuries affecting the players at the time of completion of the questionnaire had a median duration of 240 days (IQR 1410 days), and the majority (93%) had a gradual onset. Overall, an 13.3% point prevalence of injury was reported. Most injuries occurred in the shoulder and elbow regions, and were gradual in onset. Injuries affecting the players at the time of data collection had median symptomatic duration of 240 days.

Clinical Applications of Cryotherapy Among Sports Physical Therapists

Authors: Hawkins SW, Hawkins JR
Abstract
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Therapeutic modalities (TM) are used by sports physical therapists (SPT) but how they are used is unknown. The purpose of this study was to identify the current clinical use patterns for cryotherapy among SPT.  All members (n= 7283) of the Sports Physical Therapy Section of the APTA were recruited. A scenario-based survey using pre-participation management of an acute or sub-acute ankle sprain was developed.  Survey results indicated great variability in respondents’ approaches to the treatment of an acute and sub-acute ankle sprain. The authors found that SPT applied cryotherapy with great variability and not always in accordance to the limited research on the TM. Continuing education, application of current research, and additional outcomes based research needs to remain a focus for clinicians.