VOLUME ELEVEN NUMBER FOUR

 
2016Cover_V11N4
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August 2016

ORIGINAL RESEARCH
Utilization of ImPact Testing to Measure Injury Risk in Alpine Ski and Snowboard Athletes
Authors: Faultus J, Huntimer B, Kernozek T, Cole J
While studies that have examined the prevalence of musculoskeletal injuries in alpine skiing and snowboarding exist, there has been no discussion of how neurocognitive deficits may influence such injuries. Recent authors have identified a possible link between Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) testing results and the prevalence of musculoskeletal injury in athletic populations. However, no study has specifically examined this in the alpine skiing and snowboard athletes who sustain injury and those that do not.  Therefore, the purpose of paper was to review injury data and ImPACT test results within the local ski/snowboard population to determine if there was a difference in components of ImPACT test scores between injured and non-injured athletes. It was hypothesized that differences would exist in component scores on ImPACT testing between injured and non-injured athletes.   The authors found that there was no difference in reaction time and visual motor speed (VMS) between non-injured and injured females and non-injured and injured males, however there was an interaction between gender and injury status on composite reaction time and visual motor speed, or VMS. The composite reaction time for females was 4.7% faster with injury while males without injury had a composite reaction time that was slower by 5.8%. Females had a 4.1% higher mean VMS score with injury while males had a 14.4% higher VMS score without injury.  Future research may consider prospectively examining neurocognitive testing scores and injury prevalence within the disciplines of snowboarding and both alpine and freestyle skiing.
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The Efficacy of an Eight-week Core Stabilization Program on Core Muscle Function and Endurance: A Randomized Trial
Authors:  Hoppes CW, Sperier AD, Hopkins CF, Griffiths BD, Principe MF, Schnall BL, Bell JC, Koppenhaver SL
Body armor is credited with increased survival rates in soldiers but the additional axial load may negatively impact the biomechanics of the spine resulting in low back pain.   Multiple studies have found that lumbar stabilization programs are superior to generalized programs for patients with chronic low back pain.  It is not known if such programs produce objective changes in trunk muscle function with wear of body armor.  The purpose of this study was to assess the effectiveness of an eight-week core stability exercise program on physical endurance and abdominal muscle thickness with and without body armor.  Participants (n = 33) were randomized into either the core strengthening exercise group or the control group.  Testing included ultrasound imaging of abdominal muscle thickness in hook-lying and standing with and without body armor and timed measures of endurance.  There were statistically significant group by time interactions for transversus abdominis muscle contraction thickness during standing, both with (p = 0.018) and without body armor (p = 0.038). The main effect for hold-time during the horizontal side-support (p = 0.016) indicated improvement over time regardless of group. There was a significant group by time interaction (p = 0.014) for horizontal side-support hold-time when compliance with the exercise protocol was set at 85%, indicating more improvement in the core stabilization group than in the control group.  Therefore, the authors concluded that performing an eight-week core stabilization exercise program significantly improves transversus abdominis muscle activation in standing and standing with body armor. When compliant with the exercises, such a program may increase trunk strength and muscle endurance.
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A New Clinical Muscle Function Test For Assessment of Hip External Rotation Strength: Augustsson Strength Test
Authors:  Augustsson J
Dynamic clinical tests of hip strength applicable on patients, non–athletes and athletes alike, are lacking. The aim of this study was to develop and evaluate the reliability of a dynamic muscle function test of hip external rotation strength, using a novel device. A second aim was to determine if gender differences exist in absolute and relative hip strength values determined using the new test.  Fifty–three healthy sport science students (34 women and 19 men) were tested for hip external rotation strength using a device that consisted of a strap connected in series with an elastic resistance band loop, and a measuring tape connected in parallel with the elastic resistance band. The test was carried out with the subject side lying, positioned in 45° of hip flexion and the knees flexed to 90° with the device firmly fastened proximally across the knees. The subject then exerted maximal concentric hip external rotation force against the device thereby extending the elastic resistance band. The displacement achieved by the subject was documented by the tape measure and the corresponding force production was calculated. Both right and left hip strength was measured. Fifteen of the subjects were tested on repeated occasions to evaluate test–retest reliability.  No significant test–retest differences were observed. Intra–class correlation coefficients ranged 0.93–0.94 and coefficients of variation 2.76–4.60%. In absolute values, men were significantly stronger in hip external rotation than women (right side 13.2 vs 11.0 kg, p = 0.001, left side 13.2 vs 11.5 kg, p = 0.002). There were no significant differences in hip external rotation strength normalized for body weight (BW) between men and women (right side 0.17 kg/BW vs 0.17 kg/BW, p = 0.675, left side 0.17 kg/BW vs 0.18 kg/BW, p = 0.156).  The authors state that the new muscle function test showed high reliability and thus could be useful for measuring dynamic hip external rotation strength in patients, non–athletes and athletes. The test is practical and easy to perform in any setting and could provide additional information to the common clinical hip examination, in the rehabilitation or research setting, as well as when conducting on–the–field testing in sports.
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Comparison of Range of Motion, Strength, and Hop Test Performance of Dancers With and Without a Clinical Diagnosis of Femoroacetabular Impingement
Authors:  Kivlan BR, Carcia CR, Christoforetti JJ, Martin RL
Dancers commonly experience anterior hip pain caused by femoroacetabular impingement (FAI) that interrupts their ability to train and perform.  A paucity of literature exists to guide appropriate evaluation and management of FAI among dancers.  The purpose of this study was to determine if dancers with clinical signs of FAI have differences in hip range of motion, strength, and hop test performance compared to healthy dancers.  Fifteen dancers aged between 18- 21 years with clinical signs of FAI (including anterior hip pain and provocative impingement tests) were compared to 13 age-matched dancers for passive hip joint range of motion, isometric hip strength, and performance of the medial triple hop, lateral triple hop, and cross-over hop tests.  No statistically significant differences in range of motion were noted for flexion (Healthy =145º + 7º; FAI = 147º + 10º; p=0.59), internal rotation (Healthy = 63º + 7º; FAI = 61º + 11º; p=0.50), and external rotation (Healthy =37º+ 9º; FAI = 34º + 12º; p=0.68) between the two groups. Hip extension strength was significantly less in the dancers with FAI (224 + 55 Newtons) compared to the healthy group (293 ± 58 Newtons; F(1,26) = 10.2; p=0.004). No statistically significant differences were noted for flexion, internal rotation, external rotation, abduction, or adduction isometric strength.  The medial triple hop test was significantly less in the FAI group (354 ± 43 cm) compared to the healthy group (410 ± 50 cm; F(1,26) = 10.3; p = 0.004). Similar results were observed for the lateral hop test, as the FAI group (294 ± 38 cm) performed worse than the healthy controls (344 ± 54cm; F(1,26) = 7.8; p = 0.01). There was no statistically significant difference between the FAI group (2.7 ± 0.92 seconds) and the healthy group (2.5 ± 0.75 seconds) on the crossover hop test.  The authors concluded that dancers with FAI have less strength of the hip extensors and perform worse during medial and lateral hop triple tests as compared to healthy dancers. Clinicians may use this information to assist in screening of dancers with complaints of hip pain and to measure their progress for return to dance.
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The Effect of Conservatively Treated ACL Injury on Knee Joint Position Sense.
Authors: Relph N, Herrington L
Proprioception is critical for effective movement patterns. However, methods for proprioceptive measurement in previous research have been inconsistent and lacking in reliability statistics making application to clinical practice difficult. Researchers have suggested that damage to the anterior cruciate ligament (ACL) can alter proprioceptive ability due to a loss of functioning mechanoreceptors. The majority of patients opt for reconstructive surgery following this injury. However, some patients choose conservative rehabilitation options rather than surgical intervention. The purpose of this study was to determine the effect of ACL deficiency on knee joint position sense following conservative, non-operative treatment and return to physical activity.  A secondary purpose was to report the reliability and measurement error of the technique used to measure joint position sense (JPS) and comment on the clinical utility of this measurement. Twenty active conservatively treated ACL deficient patients who had returned to physical activity and twenty active matched controls were included in the study. Knee joint position sense was measured using a seated passive-active reproductive angle technique. The average absolute angle of error score, between 10°-30° of knee flexion was determined. This error score was derived from the difference between the target and repositioning angle. The authors found that ACL deficient patients had a greater error score (7.9°±3.6) and hence poorer static proprioception ability that both the contra-lateral leg (2.0°±1.6; p=0.0001) and the control group (2.6°±0.9; p=0.0001). The standard error of the mean (SEM) of this JPS technique was 0.5° and 0.2° and the minimum detectable change (MDC) was 1.3° and 0.4° on asymptomatic and symptomatic subjects, respectively. Therefore, this study confirms a static proprioceptive deficiency exists in the knee joint following ACL injury and rehabilitation, potentially due to a reduction in functioning mechanoreceptors in the ligament over time. The differences between the ACL deficient knee and the control group were above the SEMs and MDCs of the measurement which suggests clinical relevance.
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Specific and Cross-Over Effects of Foam Rolling on Ankle Dorsiflexion Range of Motion.
Authors:  Kelly S, Beardsley C
Flexibility is an important physical quality. Self-myofascial release (SMFR) methods such as foam rolling (FR) increase flexibility acutely but how long such increases in range of motion (ROM) last is unclear. Static stretching (SS) also increases flexibility acutely and produces a cross-over effect to contralateral limbs. FR may also produce a cross-over effect to contralateral limbs but this has not yet been fully investigated.  The purpose of this study was to explore the potential cross-over effect of SMFR by investigating the effects of a FR treatment on the ipsilateral limb of 3 bouts of 30 seconds on changes in ipsilateral and contralateral ankle DF ROM and to assess the time-course of those effects up to 20 minutes post-treatment.  A within- and between-subject design was carried out in a convenience sample of 26 subjects, allocated into FR (n=13) and control (CON, n=13) groups. Ankle DF ROM was recorded at baseline with the in-line weight-bearing lunge test for both ipsilateral and contralateral legs and at 0, 5, 10, 15, 20 minutes following either a two-minute seated rest (CON) or 3 x 30 seconds of FR of the plantar flexors of the dominant leg (FR). Repeated measures ANOVA was used to examine differences in ankle DF ROM.  The authors found no significant between-group effect following the intervention. However, a significant within-group effect (p<0.05) in the FR group was seen between baseline and all post-treatment time-points (0, 5, 10, 15 and 20 minutes). Significant within-group effects (p<0.05) were also seen in the ipsilateral leg between baseline and at all post-treatment time-points, and in the contralateral leg up to 10 minutes post-treatment, indicating the presence of a cross-over effect.  Therefore, the authors concluded that FR improves ankle DF ROM for at least 20 minutes in the ipsilateral limb and up to 10 minutes in the contralateral limb, indicating that FR produces a cross-over effect into the contralateral limb. The mechanism producing these cross-over effects is unclear but may involve increased stretch tolerance, as observed following SS.
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CASE REPORT / SERIES

Rehabilitation of Subacromial Pain Syndrome Emphasizing Scapular Dyskinesis in Amateur Athletes:  A Case Series
Authors:  Moura KF, Monteiro RL, Lucareli PRG, Fukuda TY
Scapular dyskinesis has been associated with several shoulder injuries. Recent literature has suggested that greater activation of the scapular muscles can play an important role in reducing subacromial impingement in patients with shoulder pain. Thus, the purpose of this case series was to describe a rehabilitation program that emphasizes scapular dyskinesis correction for those with clinical evidence of subacromial pain syndrome.   The results of this case series suggest that subjects with clinical tests positive for subacromial pain syndrome can show significant improvement with an intervention focused on scapular dyskinesis correction. Serratus anterior activation can play an important role in this process given that all subjects presented with better recruitment after rehabilitation, as measured by electromyography.
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An Alternative Approach to the Treatment of Meniscal Pathologies: A Case Series Analysis of the Mulligan Concept “Squeeze” Technique.
Authors:  Hudson R, Richmond A, Sanchez B, Stevenson V, Baker RT, May J, Nasypany A, Reordan D
Partial meniscectomy does not consistently produce the desired positive outcomes intended for meniscal tears lesions; therefore, a need exists for research into alternatives for treating symptoms of meniscal tears. The purpose of this case series was to examine the effect of the Mulligan Concept (MC) “Squeeze” technique in physically active participants who presented with clinical symptoms of meniscal tears. The MC “Squeeze” technique was applied in five cases of clinically diagnosed meniscal tears in a physically active population. The Numeric Pain Rating Scale (NRS), the Patient Specific Functional Scale (PSFS), the Disability in the Physically Active (DPA) Scale, and the Knee injury and Osteoarthritis Outcomes Score (KOOS) were administered to assess participant pain level and function.  Statistically significant improvements were found on cumulative NRS (p ≤ .001), current NRS (p ≤ .002), PSFS (p ≤ .003), DPA (p ≤ 0.019), and KOOS (p ≤ 0.002) scores across all five participants. All participants exceeded the minimal clinically important difference (MCID) on the first treatment and reported an NRS score and current pain score of one point or less at discharge. The MC “Squeeze” technique produced statistically and clinically significant changes across all outcome measures in all five participants. The use of the MC “Squeeze” technique in this case series indicated positive outcomes in five participants who presented with meniscal tear symptoms. Of importance to the athletic population, each of the participants continued to engage in sport activity as tolerated unless otherwise required during the treatment period. The outcomes reported in this case series exceed those reported when using traditional conservative therapy and the return to play timelines for meniscal tears treated with partial meniscectomies.
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Using the Selective Functional Movement Assessment and Regional Interdependence Theory to Guide Treatment of an Athlete with Back Pain: A Case Report.
Authors:  Goshtigian GR, Swanson BT
Despite the multidirectional quality of human movement, common measurement procedures used in physical therapy examination are often uni-planar and lack the ability to assess functional complexities involved in daily activities. Currently, there is no widely accepted, validated standard to assess movement quality. The Selective Functional Movement Assessment (SFMA) is one possible system to objectively assess complex functional movements. The purpose of this case report is to illustrate the application of the SFMA as a guide to the examination, evaluation, and management of a patient with non-specific low back pain (LBP).  An adolescent male athlete with LBP was evaluated using the SFMA. It was determined that the patient had mobility limitations remote to the site of pain (thoracic spine and hips) which therapists hypothesized were leading to compensatory hypermobility at the lumbar spine. Guided by the SFMA, initial interventions focused on local (lumbar) symptom management, progressing to remote mobility deficits, and then addressing the local stability deficit.  Following treatment, all movement patterns became functional/non-painful except the right upper extremity medial rotation-extension pattern. At discharge, the patient demonstrated increased soft tissue extensibility of hip musculature and joint mobility of the thoracic spine along with normalization of lumbopelvic motor control.  Improvements in pain exceeded minimal clinically important differences, from 2-7/10 on a verbal analog scale at initial exam to 0-2/10 at discharge.   Developing and progressing a plan of care for an otherwise healthy and active adolescent with non-specific LBP can be challenging. Human movement is a collaborative effort of muscle groups that are interdependent; the use of a movement-based assessment model can help identify weak links affecting overall function. The SFMA helped guide therapists to dysfunctional movements not seen with more conventional examination procedures.
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Conservative Management of an Isolated Grade III Lateral Collateral Ligament Injury in an Adolescent Multi-sport Athlete: A Case Report.
Authors:  Haddad MA, Budich JM, Eckenrode BL
Isolated, Grade III lateral collateral ligament knee injuries are an uncommon traumatic injury with little guidance available in the literature for conservative management and prognosis for return to sport. The purpose of this case report is to describe the clinical decision-making in both differential diagnosis and physical therapy management of an isolated Grade III lateral collateral ligament sprain in an adolescent multi-sport high school athlete.  A 16 year-old male, high school, multi-sport athlete (cross country, wrestling, and track and field) sustained a traumatic knee injury during a wrestling match when his involved lower extremity was forcefully externally rotated by his opponent. Initial clinical presentation revealed pain and increased laxity with varus stress testing of the left knee, which was subsequently identified via MRI as a complete lateral collateral ligament rupture (Grade III). A conservative physical therapy program was developed targeting the active and neuromuscular subsystems, theorized to compensate for the lack of an intact lateral collateral ligament.  The patient attended 18 visits of physical therapy over a period of 12 weeks. His rehabilitation program focused on functional strengthening of the posterolateral corner, enhancement of neuromuscular control, and graded progression to sports specific drills. Return to play decisions were based on a combination of lower extremity functional performance measures, condition specific outcome measures and subjective performance on sports specific tasks. At discharge from physical therapy, he reported 0/10 pain, scored a 76/80 on the Lower Extremity Functional Scale, and was able to return to competitive track and field events.
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Screening For Referral By a Sports Physical Therapist Reveals an Effort Thrombosis in a Collegiate Pitcher: A Case Report.
Authors:  VanWye WR, Pinerole J, Ogle KC, Wallmann H
Screening for possible referral is the responsibility of all physical therapists, regardless of setting.  A serious condition that sports physical therapists may encounter is upper extremity (UE) deep venous thrombosis (DVT), which can result in the important and sometimes fatal complication of pulmonary embolism. This case report highlights the importance of subjective and physical examination findings and use of diagnostic testing for timely identification of an UE DVT.  Ultimately, the physical therapist in this case was able to screen for referral, which led to the correct diagnosis and allowed the athlete to safely and successfully return to sport.  Physical therapists should include effort thrombosis in their upper quarter differential diagnosis list for athletes who perform strenuous UE activity.
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Chronic UCL Injury: A Multimodal Approach to Correcting Altered Mechanics and Improving Healing in a College Athlete – A Case Report.

Authors:  Patrick R, McGinty J, Lucado A, Collier B
Ulnar collateral ligament (UCL) tears and associated Tommy Johns surgical intervention from excessive and poor quality pitching has increased dramatically—with more college and professional pitchers undergoing the surgery in 2014 alone than in the 1990s as a whole.  Faulty mechanics developed at young ages are often well-engrained by the late adolescent years and the minimal healing ability of the largely avascular UCL often leads to delayed safe return to sport. The purpose of this case report was to describe an innovative, multimodal approach to conservative management of a chronic UCL injury in a college-aged baseball pitcher. This innovative approach utilizes both contractile and non-contractile dry needling to enhance soft tissue healing combined with standard conservative treatment to decrease pain and improve sport performance as measured by the Disabilities of Arm, Shoulder and Hand (DASH), Numeric Pain Report Scale (NPRS), and return to sport.
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Evaluation and Treatment of a Patient Diagnosed with Adhesive Capsulitis Classified as a Derangement Using the McKenzie Method: A Case Report
Authors:  Bowser A, Swanson BT
The McKenzie Method of mechanical diagnosis and therapy (MDT) is supported in the literature as a valid and reliable approach to the management of spine injuries.  It can also be applied to the peripheral joints, but has not been explored through research to the same extent.  This method sub-classifies an injury based on tissue response to mechanical loading and repeated motion testing, with directional preferences identified in the exam used to guide treatment.  The purpose of this case report is to demonstrate the assessment, intervention, and clinical outcomes of a subject classified as having a shoulder derangement syndrome using MDT methodology.
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CLINICAL COMMENTARY / LITERATURE REVIEWS
Intervention at the Foot-Shoe-Pedal Interface in Competitive Cyclists.
Authors:  FitzGibbon S, Vicenzino B, Sisto SA
Competitive cyclists are susceptible to injury from the highly repetitive nature of pedaling during training and racing.  Deviation from an optimal movement pattern is often cited as a factor contributing to tissue stress with specific concern for excessive frontal plane knee motion. Wedges and orthoses are increasingly used at the foot-shoe-pedal-interface (FSPI) in cycling shoes to alter the kinematics of the lower limb while cycling. Determination of the effect of FSPI alteration on cycling kinematics may offer a simple, inexpensive tool to reduce anterior knee pain in recreational and competitive cyclists. There have been a limited number of experimental studies examining the effect of this intervention in cyclists, and there is little agreement upon which FSPI interventions can prevent or treat knee injury.  The purpose of this review is to provide a broader review of the literature than has been performed to date, and to critically examine the literature examining the evidence for FSPI intervention in competitive cyclists.
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Pertinent Dry Needling Considerations for Minimizing Adverse Effects: Part One
Authors:  Halle JS, Halle R
Dry needling is an evidence-based treatment technique that is accepted and used by physical therapists in the United States. This treatment approach focuses on releasing or inactivating muscular trigger points to decrease pain, reduce muscle tension, and assist patients with an accelerated return to active rehabilitation. While commonly used, the technique has some patient risk and the value of the treatment should be based on benefit compared to the potential risk. Adverse effects (AEs) with dry needling can be mild or severe, with overall incidence rates varying from zero to rates of approximately 20 percent. While mild AEs are the rule, any procedure that involves a needle insertion has the potential for an AE, with select regions and the underlying anatomy increasing the risk. Known significant AEs from small diameter needle insertion include pneumothorax, cardiac tamponade, hematoma, infection, central nervous system injury, and other complications. Underlying anatomy across individuals has variability, requiring an in-depth knowledge of anatomy prior to any needle placement. This commentary is the first in a two part series, providing an overview of pertinent anatomy in the region of the thorax.  The purpose of the commentary is to minimize the risk of a dry needling AE. Part two will be published in the subsequent issue.
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