VOLUME FOURTEEN NUMBER FOUR

 
2019Masthead_V14N4

August 2019

SYSTEMATIC REVIEW - META ANALYSIS
The Impact of Lumbopelvic Control on Overhead Performance and Shoulder Injury in Overhead Athletes: A Systematic Review.
Authors:  Cope T, Wechter S, Stucky M, Thomas C, Wilhelm M
The lumbopelvic region is utilized in almost all functional tasks and has been proposed to provide dynamic stability to distal extremities. The purpose of this review was to systematically evaluate the current literature that has examined the effect of lumbopelvic control on overhead performance and shoulder injury in overhead athletes. A comprehensive systematic electronic search revealed 3,312 total articles and 45 full text articles were reviewed. Fifteen full-text articles ultimately met inclusion criteria. Effect sizes ranged from trivial (0.10) to large (0.86), indicating a varying degree of positive effects on performance and shoulder injuries. The majority of included articles concluded that individuals with greater lumbopelvic control demonstrated improved performance and decreased occurrence of injury.  The results of this review suggest that improved lumbopelvic control relates to improved athletic performance and decreased shoulder injury. Additional higher quality research is needed to further support these findings, establish a standard measure for lumbopelvic control, and determine preventative factors for injury, pain, and disability.

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Short-term Outcomes of Conservative Treatment for Femoroacetabular Impingement: A Systematic Review and Meta-Analysis
Authors:  Mallets E, Turner A, Durbin J, Bader A, Murray L
Femoroacetabular Impingement (FAI) is becoming increasingly more common with noted impairments in physical function, increased pain, and decreased quality of life. Typically, a conservative approach is used through physical therapy or intra-articular injections before an invasive surgical approach is utilized. Identifying the proper course of conservative care by the clinician will aid in improving outcomes. The purpose of this systematic review and meta-analysis was to investigate short-term effects of conservative physical therapy and intra-articular injections on pain and physical function measures in patients with FAI. The results of this review  showed that conservative interventions for short-term periods are effective in reducing pain and improving function for femoroacetabular impingement. Overall, physical therapy revealed moderate to large effect sizes and statistically significant differences in both pain (SMD, 0.91, CI: 0.07, 1.76, p=0.030) and function (SMD, 0.80, CI: 0.34, 1.28, p=0.001) for femoroacetabular impingement. Intra-articular injection demonstrated small effect sizes for pain outcomes (SMD, 0.29, CI: -1.25, 1.83, p = 0.710) and small to moderate effect size for improvement in function (SMD, 0.49, CI: 0.03, 0.96, p = 0.040).   Overall, physical therapy demonstrated positive results in self-reported pain and function and may hold more promise than intra-articular injection alone. Common treatments that were associated with improved outcomes were patient education, activity modification, manual therapy, and strengthening.

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ORIGINAL RESEARCH
A Comparative Study of Core Musculature Endurance and Strength Between Soccer Players With and Without Lower Extremity Sprain and Strain Injury.
Authors:  Abdallah AA, Mohamed NA, Hegazy MA
Lower extremity sprain and strain injury constitutes a large percentage of lower extremity injuries experienced by soccer players. Yet, very limited data exists on the association between core strength and endurance and this injury. The purpose of this study was to compare core muscle endurance and hip muscle strength between soccer players who experienced non-contact lower extremity sprain and/or strain injury during their season and those who did not. Additionally, the frequency of injury was correlated with core muscle endurance and hip strength, and endurance was used for predicting the risk for injury.  Fifty-nine male athletes (mean age 20.92±4.08 years, mass 77.34±12.02 kg and height 1.79±0.06m) were tested. Prior to the start of the season, prone-bridge, side-bridge, trunk flexion and horizontal back extension hold times were recorded for endurance assessment and peak hip abductor and external rotator isokinetic torques for strength assessment. Twenty-one (35.59%) athletes experienced non-contact lower extremity sprain and/or strain injury during the season. Prone-bridge and side-bridge hold times were significantly longer in the non-injured players when compared with the times of the injured players (p=0.043 & 0.008 for the prone-bridge and side-bridge, respectively). There were significant negative correlations between the frequency of injury and both prone-bridge (r=-0.324, p=0.007) and side-bridge (r=-0.385, p=0.003) hold times. Logistic regression analysis revealed that side-bridge hold time was a significant predictor of injury (OR=0.956, CI=0.925-0.989). The authors concluded that soccer players with non-contact lower extremity sprain and/or strain have less core endurance than non-injured players. Reduced core endurance is associated with increased incidence of injury. Improving side-bridge hold time, specifically, may reduce the risk for injury.

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Fundamental Movement and Dynamic Balance Disparities Among Varying Skill Levels in Golfers.
Authors:   Krysak S, Harnish CR, Plisky PJ, Knab AM, Bullock GS

Sports medicine professionals have instituted easy to use on field screening tests to determine physical readiness and identify athletes who may have increased injury risk. Currently there is little research on fundamental movement and dynamic balance abilities in golfers. The purpose of this study was to examine differences in fundamental movement patterns and dynamic balance in varying competition levels in golfers. The Functional Movement Screen™ (FMS™), and Y-Balance Test Upper Quarter and Lower Quarter (YBT-LQ/UQ) were performed on middle school (MS), high school (HS), college (COL), and professional (PRO) golfers. The FMS™ was assessed for individual tests and composite score. The YBT-LQ/UQ reaches were averaged normalized to limb length. A total of 53 MS, 129 HS, 207 COL, and 29 PRO golfers were included in this study. Significant differences were observed between COL and HS in two FMS™ tests (push up; p=0.001), active straight leg raise; p=0.0019). PRO golfers YBT-LQ posteromedial reaches were greater than MS (p=0.0127, ESI = 4.3552). PRO YBT-UQ medial reaches were greater than COL (p<0.0001, ESI = 0.8915), HS (p<0.0001, ESI = 1.2640) and MS (p<0.001, ESI = 1.4218). PRO inferolateral (IL) and superoloateral (SL) reaches were greater [IL: COL (p=0.0427, ESI = 0.4413), HS (p=0.0002, ESI = 0.5851)], [SL: COL (p=0.0005, ESI = 0.5990), HS (p=0.0004, ESI= 0.6068)].  YBT-UQ composite scores were greater for PRO compared to COL (p<0.0001, ESI = 0.7657), HS (p<0.0001, ESI =0.8161) and MS (p<0.0001, ESI = 1.085). The authors found differences in golfer’s fundamental movement patterns in relationship to competition level. These data can be utilized to design personalized training programs that focus to improve movement quality.

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Does the Graft Used For ACL Reconstruction Affect the Knee Muscular Strength Ratio at Six Months Postoperatively?
Authors:  Rogowski I, Vigne G, Blache Y, Thaunat M, Fayard JM, Monnot D, Sonnery-Cottet B
Restoring knee muscle strength after an anterior cruciate ligament (ACL) reconstruction remains challenging. Improvement of rehabilitation programs specificity demands additional knowledge on knee muscle strength deficits associated with the graft used for ACL reconstruction. This study aimed to investigate the effects of graft used for ACL reconstruction on the knee muscle strength and balance assessed at six months postoperatively, based on comparisons of the isokinetic strength curves measured throughout knee extension. One-hundred-and-forty-four patients were assigned into three groups according to the graft used for a primary ACL reconstruction: semitendinosus (n=47), semitendinosus+gracilis (n= 75) and patellar (n=22) tendon graft. Normalized hamstring eccentric and quadriceps concentric torques, and hamstrings-to-quadriceps torque ratio (defined as the dynamic functional ratio) were bilaterally assessed during knee extension. Statistical parametric mapping was used to compare the curves of torques and ratio from 90° to 30°of knee flexion between groups. The uninvolved knees presented similar strength and ratio curves in the three groups. When compared involved to uninvolved knees, hamstring strength deficit was found in hamstring tendon groups throughout knee extension (p<0.001), and quadriceps strength deficit in the three groups throughout knee extension (p<0.001). Hamstrings-to-quadriceps torque ratio was unaltered when using hamstring tendon grafts, while increased ratio was observed up to knee mid-extension when using patellar tendon graft (p<0.001). These findings suggest exercises with specific range of motion and contraction type in relation to graft may be considered for implementation into postoperative rehabilitation program in order to eliminate the regional strength deficits observed after ACL reconstruction.

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The Effect of Training on a Compliant Surface on Muscle Activation and Co-contraction After Anterior Cruciate Ligament Injury.
Authors:  Nawasreh ZH, Marmon AR, Logerstedt D, Snyder-Mackler L
Performing physical activities on compliant surfaces alters joints kinematics by decreasing joint motions. However, the effect of administering a training program on a compliant surface on muscle activities after anterior cruciate ligament (ACL) injury is unknown. The purpose of this study was to compare the effects of training on a compliant surface and manual perturbation training on individual muscle activation and muscle co-contraction indexes after an ACL injury. It was hypothesized that patients who received training on the compliant surface would demonstrate higher individual and combined muscle activities compared to the manual group. Sixteen patients who participated in level I/II sport activities who sustained an ACL injury and had not undergone reconstructive surgery participated in this preliminary study. Eight patients received training on a compliant surface (Compliant group) and data of eight patients matched by age and sex from a previous study who received manual perturbation training were used as a control group (Manual group). Patients completed standard three-dimensional gait motion analysis with surface electromyography (EMG) of several lower extremity muscles during gait. Muscle co-contraction index and individual muscle activations were computed during weight acceptance (WA) and mid-stance (MS) intervals. A 2x2 analysis of variance (ANOVA) was used with an alpha level of p<0.10 to account for the high EMG variability. The compliant group had significantly increased muscle co-contraction of vastus lateralis-lateral hamstring (VL-LH), vastus medialis-gastrocnemius medialis (VM-MG), and vastus lateralis (VL) muscle activity during WA (p<0.035) and manual group significantly decreased VM-MG muscle co-contraction during WA (p=0.099) after training. The authors concluded that administering training on a compliant surface provides different effects on muscle activation compared to manual perturbation training after an ACL injury. Training on a compliant surface caused increased muscle co-contraction indexes and individual muscle activation, while manual perturbation training decreased the VM-MG muscle co-contraction index.

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Progressive Rehabilitation After Total Hip Arthroplasty: A Pilot and Feasibility Study.
Authors:  Madara KC, Marmon A, Aljehani M, Hunter-Giordano A, Zeni J, Raisis L
The incidence of total hip arthroplasty (THA) has increased, due in part to younger individuals undergoing the procedure. Surgical techniques and biomaterials have improved, but rehabilitation has not kept pace with the needs of a changing demographic. The purpose of this study was to evaluate the feasibility and preliminary effectiveness of a progressive strengthening and functional retraining intervention after THA. Twenty patients participated in the control group (n=10) or experimental group (n=10). The experimental intervention had few supervised sessions in the early phase after THA (weeks 0-12), followed by supervised, progressive, and high-level activity retraining in the later phase (weeks 12-16). Training in the experimental group was tailored to individual patient goals, which included a variety of vocational and recreational activities. The control group participated in usual rehabilitation care as prescribed by their surgeon. Therefore, the duration and content of rehabilitation of the control group therapy was not constrained. Testing included three-dimensional motion analysis of gait and a clinical evaluation prior to surgery and 16 weeks post-surgery. Change scores were calculated for pain, the Timed Up and Go (TUG), the Stair Climb Test (SCT), the Six-minute Walk Test (6MWT), the Thirty Second Chair Rise Test (30-CRT), strength, the Hip Outcome Scale (HOS), the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS Jr), ground reaction force during stance, hip abduction moment, sit to stand ground reaction force, and symmetry between limbs during stance and sit to stand and compared between groups. Patient satisfaction and number of rehabilitation visits were also compared. Safety and feasibility were assessed using descriptive analysis of the number adverse events.  The intervention group had a significantly greater improvement for the 6MWT than the control group (p=0.011), functional questionnaires (p=0.034), hip abduction strength on the non-surgical side (p=0.01) and greater satisfaction (96 vs. 84 out of 100; p=0.03) at the conclusion of the intervention. The intervention group demonstrated a significantly greater improvement in force symmetry during sit-to-stand (p=0.041) as compared to the control group. There were no other significant differences in change scores for functional measures or discrete biomechanical metrics. This physical therapy protocol, which focused on reducing supervised visits early after THA and retraining higher level activities later in the course of recovery, had a positive effect on biomechanics and functional outcomes without compromising safety. The effect of the experimental intervention was most appreciable for the 6MWT, non-surgical hip strength, satisfaction, and movement symmetry.

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Development of an Upper Extremity ‘Swing Count’ and Performance Measures in NCAA Division I Volleyball Players Over a Competitive Season.
Authors:  Ness BM, Tao H, Javers D, Thielsen A, Tvedt H, Whitcher J, Zimney K
Monitoring the volume of activity (i.e. pitch counts) and tracking upper extremity (UE) performance changes is common in overhead athletes; however, a lack of evidence exists for volleyball players. The purpose of this study was to investigate changes in shoulder mobility, strength, and pain, along with UE swing count volume in Division I collegiate female volleyball athletes over a competitive season. Swing count data was collected during two separate days of practice during weeks 1, 7, and 14 of the competitive season. Perceived swing counts were collected after each practice from athletes and two coaches. Actual swing counts were tallied by retrospective viewing of video footage. Dominant shoulder passive internal (IR) and external rotation (ER) range of motion (ROM) and isometric strength, along with UE pain, were assessed on five occasions: baseline, in-season (weeks 1, 7, 14) and post-season (week 22).     Perceived UE swing counts among coaching staff were significantly correlated with actual swing count (r = 0.93 - 0.98, p<.05), while athlete perceived swing count was moderately correlated and was not statistically significant (r = 0.64, p =.25).  Shoulder IR ROM decreased from baseline to week 14 (-5.6 ± 10.6, 95% CI: -18.76, 7.6; p = .03), with a large effect size (d = 1.0).  Large effect sizes were observed for increases in UE pain, shoulder ER ROM, and IR strength (d = 0.8 - 2.3). An increase in shoulder IR strength occurred from baseline to week 14 (p = .001), but decreased during the eight weeks of post-season relative rest (p =.02).   UE swing count estimates by coaching staff demonstrated higher correlation with actual swing counts obtained through video recording, as compared to volleyball athlete self-report.  This cohort experienced increased shoulder IR strength and ER ROM over a competitive season.  Shoulder IR ROM decreased during the first 14 weeks with a large effect size.  Monitoring UE performance changes and swing count volume may have implications for injury prevention and program development for volleyball athletes.   

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Effects of a Lighter Discus on Shoulder Muscle Activity in Elite Throwers, Implications for Injury Prevention.
Authors:  Dinu D, Houel N, Louis J
Performance in the discus throw requires high forces and torques generated from the shoulder of the throwing arm, making shoulder muscles at risk of overuse injury. Little is known on muscle activation patterns in elite discus throw. The purpose of this study was to compare the body kinematics and muscle activation patterns of arm and shoulder muscles involved in discus throwing when using discs of different mass (1.7 kg vs 2.0 kg). It was hypothesized that the use of a lighter discus would modify the activation of the shoulder musculature compared to a standard discus. Seven male elite discus throwers performed five throws using a standard discus (STD, 2.0 kg) and five throws using a lighter weight discus (LGT, 1.7 kg). Surface EMG was recorded for the biceps brachii (BB), deltoideus anterior (DA), deltoideus medialis (DM), clavicular head of the pectoralis major (PM), latissimus dorsi (LD), and trapezius medialis (TM). Three-dimensional high-speed video analysis was utilized to record discus speed and identify the different temporal phases of each throw from the preparation phase (P1) to the delivery phase (P5).  The EMG activation of LD lasted longer (p < 0.01) in P1 and was initiated later in P5 with the LGT discus compared to STD. In P5, the EMG intensity of BB decreased (p = 0.02) with LGT (%EMGmax = 50.4 ± 49.6%) compared to STD (64.8 ± 77.9%) and the activation of PM increased (p < 0.01) with LGT (86.2 ± 40.3%) compared to STD (66.2 ± 26.9%). The discus speed at release was increased (p = 0.04) by using the LGT discus (20.62 ± 0.75m.s-1) compared to STD (19.61 ± 0.57m.s-1). The throwing distance was also increased (P < 0.01) with the LGT (43.1 ± 4.3m) discus compared to STD (39.4 ± 3.4m). A lighter discus could be used by elite athletes in training to add variability in muscle solicitation and thus limit the overload on certain muscles of the shoulder region. These results may have implications regarding lowering the risk of injury in discus throw.

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Acute Effects of Neural Gliding on Athletic Performance.
Authors:  Waldhelm A, Gacek M, Davis H, Saia C, Kirby B
Neural mobilization has been used to treat individuals with musculoskeletal and neuromuscular pathologies, but research on neural mobilization in sports rehabilitation is scarce. Furthermore, there have been no studies investigating the effects of neural gliding on sport performance. The purpose of this study was to examine the differences between the acute effects of sciatic nerve gliding and lower extremity dynamic stretching exercises on hamstring flexibility and athletic performance. Twenty-seven (16 males, 11 females, age: 23.6 ± 2.65, height (m): 1.74 ± 0.12, weight (kg): 73.73 ± 16.09) healthy college students volunteered for the study. The neural gliding group had 14 subjects and the dynamic stretching group had 13 subjects. Participants performed a jogging or walking up stairs warm up at a self-selected pace prior to testing. Baseline data were obtained for each of the following measurements: bilateral hamstring flexibility using the active straight leg raise test measured by a digital inclinometer, vertical jump height, 20-yard shuttle run and 10 and 20-yard dash sprint. The participants then performed one of the assigned five-minute stretching protocol, bilateral sciatic neural gliding or dynamic stretching of the lower extremities, followed by the post-test data collection of the same measures. There were no significant group by time interaction for any of the six measurements (2 x 2 repeated measures ANOVA). However, significant time differences, pre-test vs post-test for all participants as one group, for right hamstring length (p = .001), left hamstring length (p = .002) and vertical jump (p = .028) were observed. Post hoc paired t-tests found a significant increase between the pre- and post-tests in right hamstring flexibility, (p = .011) in the dynamic stretching group and left hamstring flexibility of participants in the neural gliding condition, (p = .004). When analyzing the groups individually, pre-test vs. post-test, a significant difference in vertical jump was not observed in either group.   Similar improvement in hamstring flexibility with both dynamic stretching and neural gliding exercises without a negative effect on three sports performance tests was demonstrated. Therefore, athletic performance does not appear to be negatively affected by a pre-participation warm-up which includes neural gliding, but more research is needed.

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Length Change of the Iliofemoral Ligament During Tests for Anterior Microinstability of the Hip Joint:  A Cadaveric Validity Study.
Authors:  Kivlan BR, Carroll L, Burfield A, Enseki K, Martin RL
There is little information to support the use of clinical tests to assess for microinstability of the hip joint. The purpose of this study was to use a string model to describe and compare length changes of the iliofemoral ligament in the test positions commonly used to assess hip ligament laxity. Twelve hip joints from nine cadavers (4 male; 5 female) with lifespans of 57-84 years of age were studied. A string model representing the medial and lateral arms of the iliofemoral ligament was secured to the proximal and distal attachment points. The amount of length change of the string model was compared four test positions: 1) external rotation, 2) hyperextension-external rotation 3) abduction-extension-external rotation, and 4) adduction-extension-external rotation.  For the medial arm, the greatest change occurred in the adduction-extension-external rotation position (12.7mm) of length change. This was significantly greater than the external rotation (5.1mm; p=0.002) and abduction-extension-external rotation position (1.9mm; p<0.001).  The lateral arm also had the greatest excursion in the adduction-extension-external rotation position (16.6mm). This length change was significantly greater than the external rotation position (8.6mm; p=0.002), the hyperextension-external rotation (11.1mm; p=0.047), and the abduction-extension-external rotation position (5.6mm; p<0.001). Tests used for hip instability cause various levels of tension through the iliofemoral ligament. The combination of hip extension and external rotation increased the length change of string model and was maximized with hip adduction.  The least amount of change occurred with the addition of hip abduction to extension and external rotation.  

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The Effects of Postural and Anatomical Alignment On Speed, Power, and Athletic Performance In Male Collegiate Athletes: A Randomized Controlled Trial.
Authors:  Jackson LR, Purvis J
Many human beings are strongly influenced by right-sided dominance. This may cause potentially pathologic or dysfunctional asymmetries within the innominates of the pelvis, which in turn influences movement throughout the body including the glenohumeral (GH), vertebral, femoral acetabular (FA), sacroiliac, and costovertebral joints. Techniques based upon the science of Postural Restoration® may help correct these asymmetries and improve multiple physiological and mechanical aspects of sports performance. The purpose of this study was to examine the difference between non-manual, Postural Restoration® exercises and traditional postural interventions on anatomical alignment, available range of motion and symmetry, and speed and power in active college-aged males. Twenty-five male collegiate students (age = 21± 3 years) who met the ACSM guidelines to be considered physically active were chosen to participate. Participants completed a vertical jump test using a power analyzer (Tendo Sport, Lexington, SC, USA) and the pro agility test. Anatomical alignment was assessed through an adduction drop test, extension drop test, and standard goniometric measurements including femoral acetabular external rotation (ER), internal rotation (IR), flexion, and abduction, and glenohumeral internal rotation. Participants were randomly assigned to either non-manual, Postural Restoration® techniques or traditional posture improvement exercises. Following a four-week intervention period, participants were reassessed using the same aforementioned outcomes completed pre-intervention.  Participants who completed the non-manual, Postural Restoration® techniques demonstrated significant improvements in pro-agility scores (-0.03 + 0.10 seconds; p=0.0005). Neither set of interventions improved vertical jump scores (Treatment: +35.7 + 288.02 W, p=0.1000; Control: -10.08 + 301.04 W, p=0.381). Areas of anatomical alignment that demonstrated significant change included the treatment group for FA IR (p=0.010) and FA abduction (p=0.035) symmetry and the left adduction drop test (p=0.039).  Non-manual exercise techniques based upon the science of Postural Restoration® may equalize asymmetries present in FA internal rotation and hip abduction. Improvements in symmetry of joint motion may indicate a restoration of neutrality of the pelvis and femoroacetabular joints. By improving anatomical alignment, athletes may demonstrate improved neuromechanical efficiency, and kinesthetic control of multi-directional motions required for enhanced sports performance markers.

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CASE REVIEW / SERIES
Dry Needling in the Management of Patients Meeting Clinical Diagnostic Criteria for Subacromial Pain Syndrome: A Case Series.
Authors:  Morgan BC, Deyle GD, Petersen EJ, Allen CS, Koppenhaver, SL

Physical therapy interventions of exercise and manual therapy provide benefit in treatment of subacromial pain syndrome (SAPS). Dry needling is an emerging technique for treating musculoskeletal conditions; however, conflicting investigative evidence exists regarding the use of dry needling for SAPS.  The purpose of this case series was to describe the use of dry needling, in conjunction with exercise, as a management strategy for patients meeting clinical diagnostic criteria of SAPS and to observe the short and intermediate term effects of dry needling with therapeutic exercise in this population. A secondary purpose was to describe a framework of clinical reasoning to guide the pragmatic application of dry needling and exercise in clinical practice.  Overall, this case series provides insight to the observed short and intermediate-term effects of dry needling combined with exercise for SAPS.  The results are encouraging for dry needling as an adjunct to exercise for treating patients with SAPS.  

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CLINICAL COMMENTARY
Assessing and Treating Gluteus Maximus Weakness - A Clinical Commentary.
Authors:  Buckthorpe M, Stride M, Della Villa F
The gluteus maximus (GM) muscle is the largest and most powerful in the human body. It plays an important role in optimal functioning of the human movement system as well as athletic performance. It is however, prone to inhibition and weakness which contributes to chronic pain, injury and athletic under-performance. As such, understanding how to assess and treat GM dysfunction is an important aspect of sports science and medicine, as it has relevance for injury prevention, rehabilitation and performance enhancement. Despite GMs considerable importance there is little research attempting to translate evidence into practice to support practitioners when faced with ‘sleepy glutes’. This clinical commentary discusses the importance of GM for athletic performance and injury risk; factors which contribute to GM dysfunction and then provides evidenced informed approaches to assess and treat GM dysfunction. This can be used as part of rehabilitation or injury prevention practices as well as athletic performance training.

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Instrument Assisted Soft-Tissue Mobilization: A Commentary on Clinical Practice Guidelines For Rehabilitation Professionals.
Authors:  Cheatham SW, Baker R, Kreiswirth E 
Instrument assisted soft-tissue mobilization (IASTM) has become a popular myofascial intervention for sports medicine professionals. Despite the widespread use and emerging research, a consensus on clinical standards, such as a describing the intervention, indications, precautions, contraindications, tool hygiene, safe treatment, and assessment, does not exist. There is a need to develop best practice standards for IASTM through a universal consensus on these variables. The purpose of this commentary is to discuss proposed clinical standards and to encourage other sports medicine professionals and researchers to contribute their expertise to the development of such guidelines.

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