VOLUME FIFTEEN NUMBER THREE

 
2019Masthead_V15N3-1

JUNE 2020

SYSTEMATIC REVIEW/META ANALYSIS
Health-Related Quality of Life (HRQoL) Measures Used in Dance: A Systematic Review
Authors:  Fauntroy V, Nolton EC, Ambegaonkar JP
Dancers are aesthetic athletes who engage in rigorous physical activity. Researchers have noted that 50-85% of dancers are injured annually. Therefore, clinicians have begun providing healthcare for dancers. As part of standard care, clinicians often use health-related quality of life (HRQoL) measures to examine their patient's physical, mental, and social health. While clinicians have previously used several measures to examine athletes' HRQoL, which measures are used to examine dancers' HRQoL remains unclear. This lack of information may make it difficult for clinicians working with dancers to understand their patients' overall wellbeing and impede their ability to devise appropriate treatment plans. The purpose of this systematic review was to look at the existing literature on HRQoL instruments used to measure dancers' health and wellbeing. Three databases were searched (EBSCO Host, Web of Science, and ProQuest Performing Arts) through March 2019 to identify studies that used HRQoL measures to study dancers. Four studies qualified based on the eligibility criteria. Two reviewers independently scored the studies using (1) the modified Downs and Black Quality Index Tool (mDB) yielding a percentage out of 28 possible points scoring methodological rigor; (2) Strength of Recommendation Taxonomy (SORT) tool (i.e. A, B, or C); and (3) Level of Evidence (i.e. Level 1, 2, or 3). Any disagreement was resolved by discussion and a third reviewer (X3) was available when consensus could not be reached.  All four studies ranged from 46.4-60.7% of mDB scores, B or C strength of recommendations, and Level 2 evidence. Eight different HRQoL instruments were used across the four studies. Although no two HRQoL measures were the same across studies, several measures had variations of similar overlapping constructs, and all measured some mental health construct. Overall, eight different measures were used to examine dancers' HRQoL. All measures examine some construct of mental health. This finding is important considering the mental aspect of dance. Clinicians can use this information to track their dancers' overall wellbeing by noting how HRQoL fluctuates over a season, after injury, and over a dancer's career - overall reducing their dancers' injury risk and enhancing performance.

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ORIGINAL RESEARCH
The Effect of a Rhythmic Gymnastics-Based Power-Flexibility Program on the Lower Limb Flexibility and Power of Contemporary Dancers
Authors:   Skopal L, Netto K, Aisbett B, Takla A, Castricum T
There is an increasing cross-fertilization between the movements in contemporary dance and aesthetic sports such as rhythmic gymnastics. In such sports, supplementary training is commonly used to enable athletes to achieve all of their training goals, however dancers typically do not engage in cross training from other disciplines. The aim of this research was to test the effectiveness of a rhythmic gymnastics-based supplementary training program on lower limb flexibility and power of contemporary dancers. Eleven female contemporary dancers were randomly assigned to either a control or intervention group. The intervention group (n=6) participated in an eight-week rhythmic gymnastics-based supplementary training program comprising two one-hour sessions per week in addition to their usual training. The control group (n=5) continued their usual dance training. Pre- and post- measures of range of motion (ROM) and power were taken via a dance-specific kick test using an isokinetic dynamometer and a customized grand jeté test in a 3D-motion laboratory. Significant increases in right and left leg grand jeté ROM, right leg peak kicking torque and left leg grand jeté height were recorded in the intervention compared to the con-trol group. The results of the study suggest that rhythmic gymnastics training could provide a viable means for contemporary dancers to target active ROM and power of explosive dance movements.

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Predictors of Judo-Specific Tasks From Neuromuscular Perfromance in Young Athletes Aged 11-16 Years
Authors:  Kons RL, da Silva Athayde MS, da Silva Junior JN, Katcipis LFG, Detanico D
Physiological capacities are continuously developed throughout childhood and adolescence enhancing physical performance, but the years of formal training also contribute to performance improvements seen in young athletes. Thus, identifying the variables that may predict performance in young athletes is important for monitoring and planning the season.  This study aimed to identify the predictors of judo-specific performance tasks from neuromuscular tests in young judo athletes. Ninety-four young judo athletes: 28 girls and 66 boys (aged 11-16 years) participated in the study. Athletes performed the following neuromuscular assessments: the standing long jump (SLJ), the seated medicine ball throw (MBT) and the measurement of handgrip strength (HGS). They also performed judo-specific tests including the Special Judo Fitness Test (SJFT) and Judogi Grip Strength Test (JGST). Pearson's linear correlation and a multiple linear regression were used with the level of significance at p<0.05. The main results showed correlations between all neuromuscular tests and the number of throws and index obtained in the SJFT for boys (r=0.35-0.54, p<0.05) and girls (r=0.41-0.47, p<0.05). Additionally, the JGST performance was correlated with HGS (r=0.48, p<0.01) and the MBT (r=0.38, p=0.013), but only in boys. The SLJ and HGS predicted close to 30% of the variance in the SJFT performance (p < 0.001). The authors concluded that strength and power in upper and lower limbs are related to judo-specific tasks in young judo athletes and can moderately predict the performance in SJFT performance.

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Intrapersonal Factors Affecting Concussion Reporting Behaviors According to the Theory of Planned Behavior in High School Football Players
Authors:  Carpenter S, Lininger M, Craig D
The diagnosis of a sports-related concussion (SRC) relies heavily on self-report from the athlete; therefore, the true percentage of those sustaining an SRC is not readily known. Concussed athletes are at higher risk for permanent or more catastrophic injury, especially without a diagnosis. Limited research has been done to determine the factors associated with concussion reporting behaviors in high school athletes. The purpose of this study was to determine the intrapersonal factors affecting concussion reporting behavior in high school athletes based on the Theory of Planned Behavior (TPB). A convenience sample of 40 high school football players (age: 15.6 +/- 1.0 years) who played during the fall 2017 season and had not been diagnosed with a sports-related concussion two weeks prior to data collection completed a previously validated questionnaire. Of these, 58% were underclassmen and 65% were skill players. An ordinal regression was used to analyze the association between the intention to report and four variables (attitudes of reporting, reporting self-efficacy, symptoms and behavior, subjective norms, and concussion knowledge). Before data collection, it was hypothesized that these factors could be used to form a model to determine the athletes' intention to report, which can then be related to their reporting behavior. Self-efficacy was the only TPB variable significantly associated with reporting intention. Reporting self-efficacy was significantly associated with intention to report, where participants with a high self-efficacy score were 3.15 times more likely to report an SRC than those with a lower score. Freshmen athletes had higher reporting intentions than juniors, and participants that identified as 'white' had higher intentions than those who identified as 'other'. Concussion knowledge, subjective norms, attitudes of reporting, and symptoms and behavior were not significantly associated with intention to report.

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The Effect of Humeral Retrotorsion on Pitch Velocity in Youth Baseball Players
Authors:  Greenberg EM, Fernandez AF, Lawrence JT, McClure P
Pitching velocity is a critical measure of performance, but it may also play a role in the development of injury.  It has been proposed that increased humeral retrotorsion (HRT) may be an advantageous adaptation among throwers, resulting in increased throwing velocity. However, there is limited published data directly investigating this relationship. The purpose of this study was to examine the effects of HRT on pitching velocity in a group of youth baseball players. The authors hypothesized that there would be a positive association between pitching velocity and increased humeral retrotorsion. Demographic and physical variables that may correlate to pitching velocity (age, height, weight, glenohumeral external rotation (ER) range of motion, dominant arm humeral retrotorsion and shoulder internal rotation (IR) strength) were assessed. Univariate analysis using Pearson correlation coefficients examined the relationship of each variable to pitching velocity. Significant variables were retained and entered into a multivariable regression analysis. All variables significantly correlated with pitching velocity (p<0.05) with the exception of ER (r = -0.169,p=0.145). Multivariable regression model was significant and accounted for 81.7% of pitching velocity (R2=0.817 F(5,70)=62.59,p<0.001). Player age (B=1.7,p < 0.001), height (B=0.225,p=0.001) and shoulder IR strength (B=0.622,p< 0.001) significantly contributed to the model. After accounting for all other variables, HRT had a non-significant (B=0.005,p=0.884) and very small contribution to pitching velocity adding only .005mph per degree of HRT. The authors concluded that pitching velocity in youth baseball players is strongly influenced by age, height and IR strength. In opposition to the hypothesis, the degree of humeral retrotorsion did not have a significant effect on pitching velocity.

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Inter-Rater and Test-Retest Reliability of Two New Single Leg Sit-to-Stand Tests
Authors:  Waldhelm A, Gubler C, Sullivan K, Witte C, Buchheister D, Bartz-Brouussard J  
The single leg sit-to-stand test (SLSTST) is a functional test that assesses quadriceps strength. The original SLSTST was used to diagnose lumbar nerve root impingement/radiculopathy -- specifically at the L3 and L4 level. The original SLSTST used one repetition as the requirement for a successful test, therefore it may not identify quadriceps weakness in highly functional individuals with or recovering from an athletic injury. The purpose of this study was to determine the interrater and test-retest reliability of two new SLSTSTs, one for maximum number of repetitions over 30 seconds and one for time to complete five repetitions. Twenty healthy college-aged individuals (12 males, age: 22.5 years ± 1.37, height: 1.72 m ± 0.09; weight: 70.2 kg ± 11.0) participated in the study. Two testing sessions were held three to seven days apart, and two second-year physical therapy students served as examiners. The objective of the 30-second SLSTST was for the participant to perform as many single leg sit-to-stand repetitions they could in thirty seconds, while the five repetitions SLSTST measured how quickly the subjects could perform five single leg sit to stand repetitions. Both lower extremities were tested and Intraclass Correlation Coefficients (ICC) were calculated to determine reliability. Both SLSTSTs were found to have excellent interrater and good to excellent test-retest reliability. The 30-second SLSTSTs had inter-rater ICC = 0.99 on the right and 0.98 on the left while the test-retest ICCs ranged from 0.92 to 0.94. The five repetition SLSTSTs had an inter-rater ICC = .99 on both legs while the test-retest ICC ranged from 0.87 to 0.94. The results of the current study indicate that the two new SLSTSTs had good to excellent test-retest and excellent inter-rater reliability.

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Tuck Jump Score is Not Related to Hopping Performance or Patient-Reported Outcome Measures in Female Soccer Players
Authors:   Arundale AJH, Kvist J, Hagglund M, Falstrom A
The tuck jump assessment was developed to identify players at risk for anterior cruciate ligament (ACL) injuries or gauge a player's progress through rehabilitation after ACL reconstruction. A tuck jump score of ≥ 6 out of 10 has been labeled poor and thought to identify players with high risk landing patterns. The purpose of this exploratory study was to examine if there was a relationship between tuck jump score, particularly tuck jump scores ≥ 6, hopping performance, and patient-reported outcome measures in female soccer players with ACL reconstruction (ACLR) and knee-healthy controls. Female soccer players (117 after ACLR, 117 knee-healthy) performed the single hop for distance, tuck jump assessment, and drop vertical jump (DVJ). All players were categorized based on as having a total tuck jump score ≥ 6 or < 6. Analyzing all players together, Spearman's rank correlations assessed if there were relationships between total tuck jump score or tuck jump scores ≥ 6 and single-legged hop limb symmetry or DVJ measures. Players with an ACLR also filled out the International Knee Documentation Committee 2000 Subjective Knee Form and the Knee injury Osteoarthritis Outcome Score. Spearman's rank correlations assessed if there were relationships between total tuck jump score or tuck jump scores > 6 and patient-reported outcome measures. The mean tuck jump scores was 4.8 +/- 1.8 (tuck jump score 6, 6.7 +/-0.9, tuck jump score < 6, 3.7  +/- 1.1) with 87 (37%) athletes having tuck jump score ≥6. There were no significant relationships between tuck jump score or tuck jump score > 6 and hopping performance or patient-reported outcome measures. The results of this current study indicate that tuck jump scores, including tuck jump scores ≥6, may not be related to functional or patient-reported outcome measures.

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Incorporating a Dual-Task Assessment Protocol with Functional Hop Testing
Authors:  Ness BM, Zimney K, Kernozek T, Schweinle WE, Schweinle A  
Hop tests are commonly used within a testing battery to assess readiness for return to sport after anterior cruciate ligament (ACL) injury, yet athletes still experience a high rate of re-injury.  Simultaneous performance of a secondary task requiring cognitive processing or decision-making may test the athlete under more realistic contexts. The purpose of this study was to examine a clinically feasible, dual-task assessment paradigm applied during functional hop tests in healthy individuals.  Participants performed the crossover triple hop for distance (XHOP) and medial triple hop for distance test (MHOP) under three separate conditions: standard procedures and two dual-task protocols including the backward digit span memory task and a visuospatial recognition task. The visuospatial task involved briefly displaying an image consisting of 18 randomly placed red and blue circles on a screen, where the participant was asked to identify the number of red circles in each image. The backward digit span task was applied by introducing a sequence of random numbers to the participants, who were required to repeat the sequence in reverse order. Each motor and cognitive task was performed independently and simultaneously, in accordance with the dual-task paradigm. Thirty-four healthy participants (age: 24.0 ± 3.9 years) completed testing procedures.  No differences in hop distance were observed with the simultaneous application of a cognitive task, with the exception of the backward digit span memory task resulting in decreased hop distance (p = 0.04, d = 0.14). There were no differences in cognitive accuracy according to hop test type, although the effect size was greater for the XHOP (p = 0.08, d = 0.49) compared to the MHOP (p = 1.0, d = 0.07).  The dual-task protocol revealed good-excellent within- (ICC3,1 = 0.85 - 0.99) and between-session (ICC3,k = 0.94 - 0.99) intrarater reliability for hop distance across all dual-task conditions. The addition of a cognitive task to the XHOP and MHOP resulted in a lower standard error of measurement and decreased minimal detectable change, as compared to standard testing procedures. The simultaneous application of a cognitive task did not alter hop distance, with the exception of the backward digit span memory task resulting in decreased hop distance with a trivial effect size. There were no differences in cognitive accuracy according to task type (sitting, XHOP, MHOP). All combinations of dual-task assessment demonstrated good-excellent within- and between-session intrarater reliability among healthy individuals, but measurement precision was deficient.  

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Mapping Tenderness to Palpation Predicts Return To Play Following Acute Hamstring Strain
Authors:  Schmitt BM, Tyler TF, Kwicien SK, Fox MB, McHugh MP
Currently there is little evidence supporting the use of objective tests, measures, or imaging to help predict time to return to sport (RTS) following a hamstring strain. The purpose of this study was to investigate the predictive value of tenderness to palpation (TTP) as measured by area and location following hamstring strain. Nineteen male athletes (age 28±9 yr) who sustained an acute hamstring strain underwent hamstring tenderness mapping on initial evaluation. The length and width of tenderness of the hamstring was identified with manual palpation, outlined in pen, and was then calculated as a percentage of the length and width of the posterior thigh. All patients underwent the same hamstring rehabilitation protocol with remapping performed at specific stages in rehabilitation. The association between mapping tenderness indices and RTS was assessed by linear regression. The average length of the area of tenderness was 22±12% with an average RTS of 43±36 days. The length of the area of tenderness measured on initial evaluation was a strong predictor of RTS (R2=0.58, p<0.001; y=2.3x - 6.2). Area of injury (R2=0.36, p=0.006) and age (R2=0.27, p=0.024) were also related to RTS, while width of injury (R2=0.006, p=0.75) and location of injury were not (proximal-distal p=0.62, medial-lateral p=0.64). Adding age with length of injury into a multiple regression analysis improved the prediction of RTS (R2=0.73). The relationship between RTS and length of tenderness was relatively unchanged when the additional mapping indices taken during the course of rehabilitation were added to the analysis (R2=0.61, p<0.001; y=2.3x - 4.4). This indicates that the regression equation can be used to estimate RTS regardless of when in the post injury/rehabilitation process the mapping is performed. The length of the area of tenderness to palpation of the injured hamstring muscle was highly predictive of RTS time. Based on the regression equation a patient with a length of tenderness of 10% would have an estimated RTS time of 17 days, while a tenderness length of 30% would be estimated to return in 63 days. This hamstring mapping technique described was predictive of the RTS and may be a useful clinical tool.

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Foam Rolling and Indices of Autonomic Recovery Following Exercise-Induced Muscle Damage
Authors:  D'Amico A, Gillis J, McCarthy K, Leftin J, Molloy M, Heim H, Burke C  
With the increased popularity of foam rolling as a recovery tool, it is important to explore possible mechanisms of action toward mitigating soreness and restoring athletic performance. The purpose of this study was to assess the influence of foam rolling on gross measures of physical performance and indices of autonomic function following exercise-induced muscle damage.   In a between-group design, 40 participants performed a session of 40x15 meter sprints, inducing muscle damage. Immediately following sprinting and in the four days following, heart rate variability and pulse wave velocity were recorded, in addition to perceived muscle soreness, vertical jump, and agility. Nineteen subjects (mean±sd; age 23.1±5.0 yrs; BMI 25.6±3.3 kg.m-2) foam rolled their quadricep, gluteal, and gastrocnemius areas prior to testing each day, while 21 (mean±sd; age 24.2±3.4 yrs; BMI 26.3±4.0 kg.m-2) served as a control. Mean values from three days of baseline testing were compared to the area under the curve during five days of recovery after the performance of the repeated sprint protocol. The area under the curve was calculated by summing all five values recorded the recovery days, then these data were compared by condition using a two-tailed Mann-Whitney U test (alpha level = 0.05). Following EIMD, neither heart rate variability, pulse wave velocity, agility, nor vertical jumping performance versus previously measured baseline differed significantly between groups (p>0.05). Perceived muscle soreness was significantly diminished in the foam rolling condition (p<0.05). Mean Day 1 to Day 5 values for perceived muscle soreness in control were 16.52, 30.24, 24.48, 17.19, and 11.10. Mean Day 1 to Day 5 values in foam rolling were 12.63, 24.63, 21.79, 15.05, and 10.16. The authors concluded that foam rolling may be useful for reducing soreness following damaging exercise, but according to the outcomes measured in the present experiment, the effect does not appear to be mediated by the autonomic nervous system.  

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Patients Focus on Performance of Physical Activity, Knee Stability and Advice From Clinicians When Making Decisions Concerning the Treatment of Their Anterior Cruciate Ligament Injury
Authors:  Grevnerts HT, Kvist J, Faltstrom A, Sonesson S  
When deciding medical treatment, patients' perspectives are important. There is limited knowledge about patients' views when choosing non-operative treatment or anterior cruciate ligament (ACL) reconstruction (ACLR) after ACL injury. The purpose of this study was to describe reasons that influenced patients' decisions for non-operative treatment or ACLR after ACL injury. This study recruited a total of 223 patients (50% men), aged 28 ± 8 years who had sustained ACL injury, either unilateral or bilateral. Subjects were, at different time points after injury, asked to fill out a questionnaire about their choice of treatment, where an ACLR treatment decision was made, some responded before and some after the ACLR treatment. A rating of the strength of 10 predetermined reasons in their choice of treatment graded as 0 (no reason) to 3 (very strong reason), was done. Patients with unilateral ACL injury treated with ACLR (110 patients) rated "inability to perform physical activity at the same level as before the injury due to impaired knee function" (96%), "fear of increased symptoms during activity" (87%) and "giving way episodes" (83%) as strong or very strong reasons in their treatment decision. Patients with bilateral ACL injury treated with ACLR (109 knees) rated similar reasons as patients with unilateral ACLR and also "low confidence in the ability to perform at the preinjury activity level without ACLR" (80%) as strong or very strong reasons. Patients with unilateral ACL injury treated non-operatively (46 patients) rated "advice from clinician" (69%) as a strong or very strong reason. Patients with bilateral ACL injury treated non-operatively (25 knees) rated "absence of giving way episodes" (62%), and "no feeling of instability" (62%) as strong or very strong reasons.  Inability to perform physical activity, fear of increased symptoms, and giving way episodes were reasons that patients with ACL injury considered when making decisions about ACLR.  When choosing non-operative treatment, patients considered the absence of instability or giving way symptoms, being able to perform physical activity, and advice from clinicians.

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The Tensile Behaviors of the Iliotibial Band – A Cadaveric Investigation
Authors:  Seeber GH, Wilhelm MP, Sizer PS, Guthikonda A, Matthijs A, Matthijs OC, Lazovic D, Brismee JM, Gilbert KK
Clinical stretching is frequently recommended for iliotibial band syndrome management. Current literature lacks conclusive findings regarding isolated human iliotibial band tissue elongation and stiffness behaviors. Applying clinical-grade stretching force results to iliotibial band tissue behavior is thus challenging. This study's objectives were to determine isolated iliotibial band tissue tensile behaviors during tension-to-failure testing and to relate the results to previously reported iliotibial band stretch findings. Ten isolated un-embalmed iliotibial band specimens were exposed to tension-to-failure testing using a 10kN material testing system. Peak load, load at yield point, and ultimate failure load were measured in Newtons. Corresponding absolute (mm) and relative (%) tissue deformation was recorded. Load-deformation curves were established to calculate iliotibial band stiffness (N/mm). A mean peak load of 872.8±285.9N and resulting 9.0±3.9% tissue deformation from initial length was recorded. An 805.5±249.7N mean load at yield point and resulting 7.0±1.9% tissue deformation was observed. A 727.6±258.4N mean load was recorded directly prior to ultimate tissue failure. Mean tissue deformation at ultimate failure was 11.3±4.2%. Mean iliotibial band system stiffness was 27.2±4.5N/mm. The authors found that the iliotibial band can withstand substantial tensile forces. Clinical stretching forces likely fall within the load-deformation curve elastic region and may not result in permanent iliotibial band tissue deformation. Sustained elongation resulting from stretching the ITB may require substantial patient compliance. Future studies should investigate potential underlying factors related to positive symptom relief from iliotibial band stretching that include immunological responses, fluid accumulation, altered proprioception, and pain perception.

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LITERATURE REVIEW
A Literature Review and Clinical Commentary on the Development of Iliotibial Band Syndrome in Runners
Authors:  Charles D
Iliotibial Band Syndrome (ITBS) is the second leading cause of pain in runners. Multiple theories exist for the etiology of ITBS related symptoms including anterior-posterior friction of the IT band on the lateral femoral condyle during knee flexion and extension activities, compression of a layer of fat near the IT band distal attachment, and inflammation of the IT band bursa. The purpose of this literature review and clinical commentary was to explore the potential factors that contribute to ITBS development in runners. Overall, the literature was either contradictory or inconclusive to support a link between ITBS and decreased muscle strength or endurance. A weak correlation existed between strain rate of the hip abductor muscles with hip adduction and knee internal rotation, increased knee internal rotation during the stance phase of gait, and a diminished rearfoot eversion angle at heel strike. Additionally, decreased hip adduction angles during stance phase were observed in individuals without active symptoms but who had a previous history of ITBS. Finally, the female gender may be a predisposing factor.  

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CASE REPORT
Electromyographic Analysis of the Scapular Dyskinesis Test in a Baseball Pitcher with a SLAP Lesion: A Case Report
Authors:  Tsuruike M, Ellenbecker TS, Nishime RS
The return to play percentage of baseball pitchers who have undergone isolated superior labrum anterior-posterior (SLAP) repair has been reported to be less than 60%. Scapular dyskinesis (SD), characterized by scapular prominence during dynamic scapulohumeral movements, may be used to assist in diagnosing a baseball pitcher with shoulder pathology including a SLAP lesion. The purpose of this case report was to describe the use of the SD test to assess the scapular muscles and report EMG findings in a college baseball pitcher diagnosed with a Type 2 posterior SLAP lesion.

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CLINICAL COMMENTARY
Framework for Optimizing ACL Rehabilitation Utilizing a Global Systems Approach
Authors:  Dischiavi SL, Wright AA, Bleakley CM, Hegedus EJ, Thornton EP
Knee injuries such as ACL tears commonly occur and there is a high re-injury rate after primary ACL reconstruction with figures estimated at 25% - 33%. Clinicians often use hip strengthening as a key component of knee rehabilitation. Evidence suggests that adopting a "regional" or "proximal" approach to rehabilitation can increase hip strength, but motor control often remains unchanged, particularly during more complex tasks such as running and jumping. It has been previously suggested that the current approach to "regional / proximal" rehabilitation is too basic and is constrained by a reductionist philosophy. This clinical commentary provides the clinician a framework for optimizing knee rehabilitation, underpinned by a more global approach. Although this approach remains hip-focused, it can be easily adapted to modify exercise complexity and key loading variables (speed, direction, flight), which will help the clinician to better replicate the sport specific demands on the knee.

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CORRIGENDUM