VOLUME ELEVEN NUMBER FIVE

 
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October 2016

SYSTEMATIC REVIEW

Ultrasonography, an Effective Tool in Diagnosing Plantar Fasciitis:  A Systematic Review of Diagnostic Trials
Authors:  Radwan A, Wyland M, Applequist L, Bolowsky E, Klingensmith H, Virag I
Plantar fasciitis (PF) is the most common cause of heel pain that affects 10% of the general population, whether living an athletic or sedentary lifestyle. The most frequent mechanism of injury is an inflammatory response that is caused by repetitive microtrauma. Many techniques are available to diagnose PF, including the use of ultrasonography (US). The purpose of this study was to systematically review and appraise previously published articles published between the years 2000 and 2015 that evaluated the effectiveness of using US in the process of diagnosing PF, as compared to alternative diagnostic methods. A total of eight databases were searched to systematically review scholarly (peer reviewed) diagnostic and intervention articles pertaining to the ability of US to diagnose PF.  Using specific key words the preliminary search yielded 264 articles, 10 of which were deemed relevant for inclusion in the study.  Two raters independently scored each article using the 15 point modified QUADAS scale.  Six studies compared the diagnostic efficacy of US to another diagnostic technique to diagnose PF, and four studies focused on comparing baseline assessment of plantar fascia before subsequent intervention. The most notable US outcomes measured were plantar fascia thickness, enthesopathy, and hypoechogenicity.  Overall, US was found to be accurate and reliable compared to alternative reference standards such as MRI in the diagnosis of PF.  The general advantages of US (cost efficient, ease of administration, non-invasive, limited contraindications) make it a superior diagnostic modality for use in the diagnosis of PF. US should be considered in rehabilitation clinics to effectively diagnose PF and to accurately monitor improvement in the disease process following rehabilitation interventions.  

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ORIGINAL RESEARCH

The Effectiveness of Dry Needling and Stretching vs. Stretching Alone on Hamstring Flexibility in Patients with Knee Pain: A Randomized Controlled Trial.
Authors:  Mason J, Morris J, Terry A, Koppenhaver S, Goss DL, Crowell MS, Dolbeer J
Recently, dry needling (DN) has emerged as a popular treatment for muscular pain and impairments. While there are numerous studies detailing the benefits of DN for pain, few studies exist examining the effects on soft tissue mobility. The purpose of this study was to determine if the addition of hamstring DN to a standard stretching program results in greater improvements in hamstring flexibility compared to sham DN and stretching in subjects with atraumatic knee pain. Additionally, squat range of motion, knee pain, and the Lower Extremity Functional Scale were compared between the two groups.  Thirty-nine subjects were randomized to receive either DN (n=20) or sham (n=19) DN in addition to hamstring stretching, to all detected hamstring trigger points on two visits.  All dependent variables were measured at baseline, immediately post intervention, and 1, 3, and 7 days after the initial treatment.  Each subject also performed hamstring stretching three times daily for one week.  Significant improvements in hamstring range of motion and all other dependent variables were observed across time regardless of treatment group.  However, the lack of significant time by group interactions indicated the improvements were not different between DN and sham dry needling groups.  The results of the current randomized controlled trial suggest that two sessions of DN did not improve hamstring range of motion or other knee pain-related impairments more than sham DN in a young active population with atraumatic knee pain.
 
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A Delphi Study of Risk Factors for Achilles Tendinopathy – Opinions of World Tendon Experts.
Authors:  O’Neill S, Watson P, Barry S
Achilles tendinopathy can be a debilitating chronic condition for both active and inactive individuals. The identification of risk factors is important both in preventing but also treating tendinopathy; many factors have been proposed but there is a lack of primary epidemiological data. The purpose of this study was to develop a statement of expert consensus on risk factors for Achilles tendinopathy in active and sedentary patient populations to inform a primary epidemiological study.  An online Delphi study was completed inviting participation from world tendon experts. The consensus was developed using three rounds of the Delphi technique. The first round developed a complete list of potential risk factors, the second round refined this list but also separated the factors into two population groups – active/athletic and inactive/sedentary. The third round ranked this list in order of perceived importance. Forty-four experts were invited to participate, 16 participated in the first round (response rate 40%) and two dropped out in the second round (resulting in a response rate of 35%). A total of 27 intrinsic and eight extrinsic risk factors were identified during round one. During round two only 12 intrinsic and five extrinsic risk factors were identified as important in active/athletic tendinopathy while 14 intrinsic and three extrinsic factors were identified as important for inactive/sedentary tendinopathy. Plantarflexor strength was identified as the primary modifiable factor in the active/athletic group while systemic factors were identified as important in the inactive/sedentary group, many of the potential factors suggested for either group were non-modifiable. Non-modifiable factors include: previous tendinopathy, previous injury, advancing age, sex, steroid exposure, and antibiotic treatment.

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The Adolescent Measure of Confidence and Musculoskeletal Performance (AMCaMP):  Development and Initial Validation
Authors:  May KH,  Guccione AA, Edwards MC, Goldstein MS
Although the relationship of self-efficacy to sports performance is well established, little attention has been paid to self-efficacy in the movements or actions that are required to perform daily activities and prepare the individual to resume sports participation following an injury and associated period of rehabilitation. There are no instruments to measure self-confidence in movement that have been validated in an adolescent population.  The purpose of this paper is to report on the development of the AMCaMP, a self-report measure of confidence in movement and provide some initial evidence to support its use as a measure of confidence in movement.  The AMCaMP was adapted from OPTIMAL, a self-report instrument that measures confidence in movement, which had been previously designed and validated in an adult population. Data were collected from 1,115 adolescent athletes from 12 outpatient physical therapy clinics in a single healthcare system.  Exploratory factor analysis of the 22 items of the AMCaMP using a test sample revealed a three factor structure (trunk, lower body, upper body).  Confirmatory factor analysis using a validation demonstrated a similar model fit with the data.  Reliability of scores on each of three clusters of items identified by factor analysis was assessed with coefficient alpha (range=0.82 to 0.94), Standard Error of Measurement (1.38 to 2.74), and Minimum Detectable Change (3.83 to 7.6).  The authors concluded that the AMCaMP has acceptable psychometric properties for use in adolescents (ages 11 to 18) as a patient-centric outcome measure of confidence in movement abilities after rehabilitation.

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Diagnostic Imaging in a Direct-Access Sports Physical Therapy Clinic: A 2-Year Retrospective Practice Analysis
Authors: Crowell MS, Johnson MR, Dembowski SC, Westrick RB, Goss DL
While advanced diagnostic imaging is a large contributor to the growth in health care costs, direct-access to physical therapy is associated with decreased rates of diagnostic imaging.  No study has systematically evaluated with evidence-based criteria the appropriateness of advanced diagnostic imaging, including magnetic resonance imaging (MRI), when ordered by physical therapists. The primary purpose of this study was to describe the appropriateness of magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) exams ordered by physical therapists in a direct-access sports physical therapy clinic.  The hypothesis of this study was that greater than 80% of advanced diagnostic imaging orders would have an American College of Radiology (ACR) Appropriateness Criteria rating of greater than 6, indicating an imaging order that is usually appropriate.  A 2-year retrospective analysis identified 108 MRI/MRA examination orders from four physical therapists.  A board-certified radiologist determined the appropriateness of each order based on ACR appropriateness criteria.  The principal investigator and co-investigator radiologist assessed agreement between the clinical diagnosis and MRI/surgical findings.  The authors found that knee (31%) and shoulder (25%) injuries were the most common.  Overall, 55% of injuries were acute.  The mean ACR rating was 7.7; scores from six to nine have been considered appropriate orders and higher ratings are better.  The percentage of orders complying with ACR appropriateness criteria was 83.2%.  Physical therapist’s clinical diagnosis was confirmed by MRI/MRA findings in 64.8% of cases and was confirmed by surgical findings in 90% of cases.  Therefore, the authors concluded that physical therapists providing musculoskeletal primary care in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases.  Future research should prospectively compare physical therapist appropriateness and utilization to other groups of providers and explore the effects of physical therapist imaging privileging on outcomes.

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The Relationship Between Trunk Endurance Plank Tests and Athletic Performance Tests in Adolescent Soccer Players
Authors:  Imai A
Although it is believed that trunk function is important for athletic performance, few researchers have demonstrated a significant relationship between the trunk function and athletic performance. Recently, the prone plank and side plank tests have been used to assess trunk function.  The purpose of this study was to investigate the relationships between trunk endurance plank tests and athletic performance tests, including whether there is a relationship between long distance running and trunk endurance plank tests in adolescent male soccer players.  Fifty-five adolescent male soccer players performed prone and side plank tests and seven performance tests: the Cooper test, the Yo-Yo intermittent recovery test, the step 50 agility test, a 30-m sprint test, a vertical countermovement jump, a standing five-step jump, and a rebound jump. The relationships between each individual plank test, the combined score of both plank tests, and performance tests were analyzed using the Pearson correlation coefficient.   The combined score of plank tests was highly correlated with the Yo-Yo intermittent recovery test (r=0.710, p<0.001), and was moderately correlated with the Cooper test (r=0.567, p<0.001). Poor correlation was observed between the prone plank test and step 50 agility test (r=-0.436, p=0.001) and no significant correlations were observed between plank tests and jump performance tests. The results suggest that trunk endurance plank tests are positively correlated with the Yo-Yo intermittent recovery test, the Cooper test, and the step 50 agility test.

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The Clinical, Functional and Biomechanical Presentation of Patients With Symptomatic Hip Abductor Tendon Tears
Authors:  Ebert JR, Retheesh T, Mutreja R, Janes GC
Hip abductor tendon (HAT) tearing is commonly implicated in greater trochanteric pain syndrome (GTPS), though limited information exists on the disability associated with this condition and specific presentation of these patients. The purpose of this study was to describe the clinical, functional and biomechanical presentation of patients with symptomatic HAT tears. Secondary purposes were to investigate the association between these clinical and functional measures, and to compare the pain and disability reported by HAT tear patients to those with end-stage hip osteoarthritis (OA). One hundred forty-nine consecutive patients with symptomatic HAT tears were evaluated using the Harris (HHS) and Oxford (OHS) Hip Scores, the SF-12, an additional series of 10 questions more pertinent to those with lateral hip pain, active hip range of motion (ROM), maximal isometric hip abduction strength, six-minute walk capacity and a 30-second SLS test. The presence of a Trendelenburg sign and pelvis-on-femur (POF) angle were determined via 2D video analysis. An age matched comparative sample of patients with end-stage hip OA was recruited for comparison of all patient-reported outcome scores. Independent t-tests investigated group and limb differences, while analysis of variance evaluated pain changes during the functional tests. Pearson’s correlation coefficients investigated the correlation between clinical measures in the HAT tear group. No differences existed in patient demographics and patient-reported outcome scores between HAT tear and hip OA cohorts, apart from significantly worse SF-12 mental subscale scores (p=0.032) in the HAT tear group. Patients with HAT tears demonstrated significantly lower (p<0.05) hip abduction strength and active ROM in all planes of motion on their affected limb. Pain significantly increased throughout the 30-second stance test for the HAT tear group, with 57% of HAT tear patients demonstrating a positive Trendelenburg sign. POF angle during the test was not significantly associated with pain.  The authors concluded that patients with symptomatic HAT tears demonstrate poor function, and report pain and disability similar to or worse than those with end-stage hip OA. This information aids in defining and differentiating the presentation of patients with HAT tears from other patients.

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Hip and Glenohumeral Passive Range of Motion in Collegiate Softball Players.
Authors:  Oliver GD, Plummer H, Brambeck A
Range of motion deficits at the hip and glenohumeral joint (GHJ) may contribute to the incidence of injury in softball players. With injury in softball players on the rise, softball related studies in the literature are important. The purpose of this study was to examine hip and GHJ passive range of motion (PROM) patterns in collegiate softball players. It was hypothesized that position players would exhibit significantly different PROM patterns than pitchers. Additionally, position players would exhibit significantly different side-to-side differences in PROM for both the hip and GHJ compared to pitchers.  Forty-nine collegiate softball players (19.63 + 1.15 years; 170.88 + 8.08 cm; 72.96 + 19.41 kg) participated. Passive hip and GHJ internal (IR) and external rotation (ER) measures were assessed. Glenohumeral PROM was measured with the participant’s supine with the arm abducted to 90?. The measurements were recorded when the scapula began to move or a firm capsular end-feel was achieved. The hip was positioned in 90° of flexion and passively rotated until a capsular end-feel was achieved. Total PROM was calculated by taking the sum of IR and ER for both the hip and GHJ.   No significant PROM rotational side-to-side differences were observed in pitchers, at either the GHJ or hip joint. Position players throwing side hip IR was significantly greater than the non-throwing side hip (p = 0.002). For ER, the non-throwing side hip was significantly greater compared to the throwing side hip (p = 0.002). When examining side-to-side differences at the GHJ, IR was significantly greater in the non-throwing shoulder (p = 0.047). No significant differences in total range of motion of the hip and GHJ were observed.   In the current study, position players displayed side-to-side differences in hip and GHJ IR PROM while no statistically significant differences were observed in the softball pitchers. The findings of the current study add to the body of literature related to PROM in throwing athletes, additionally these are the first hip IR and ER PROM data presented in softball players.

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Ultrasound Measurements and Objective Forces of Glenohumeral Translations during Shoulder Accessory Passive Motion Testing in Healthy Individuals
Authors:  Henderson N, Worst H, Decarreau R, Davies G
Clinical examination of the caspuloligamentous structures of the glenohumeral joint has historically been subjective in nature, as demonstrated by limited intra-rater and inter-rater reproducibility. Therefore, musculoskeletal diagnostic ultrasound was utilized to develop a clinically objective measurement technique for glenohumeral inferior and posterolateral translation.  The purpose of this study was to measure the accessory passive force required to achieve end range glenohumeral posterolateral and inferior accessory translation, as well as to quantify the amount of translation of the glenohumeral joint caused by the applied force.  Twenty-five asymptomatic subjects between the ages of 18 and 30 were recruited via convenience sampling. Posterolateral and inferior shoulder accessory passive translation was assessed and measured using a GE LOGIQe ultrasound, while concurrently using a hand held dynamometer to quantify the passive force applied during assessment. Normative values for force and translation were described as means and standard deviations.   Mean values for posterolateral translation were 6.5 +/- 4.0 mm on the right shoulder and 6.3 +/- 3.5 mm on the left with an associated mean force of 127.1 +/- 55.6 N and 114.4 +/- 50.7 N, respectively. Mean values for inferior translation was 4.8 +/- 1.7 mm on the right shoulder and 5.4 +/- 1.8 mm on the left with an associated mean force of 84.5 +/- 30.5 N and 76.1 +/- 30.1 N, respectively. There was a significant association between inferior translation and inferior force (r=.51). No significant association was found between posterolateral translation and posterolateral force. Significant differences were found between dominant and non-dominant shoulders for posterolateral translation, posterolateral force to produce translation, and inferior translation values.   Force data in the posterolateral and inferior direction is consistent with previously reported data for passive accessory motion testing at the shoulder. The results of this study provide data for glenohumeral translations and actual forces applied. Musculoskeletal diagnostic ultrasound can be a clinically relevant way to objectively measure the translation of the glenohumeral joint for assessing accessory passive motion joint translation while performing mobilizations or passive structure testing.

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Corrected Error Video Versus a Physical Therapist Instructed Home Exercise Program: Accuracy of Performing Therapeutic Shoulder Exercises
Authors:  Berkoff DJ, Krishnamurthy K, Hopp J, Stanley L, Spores K,  Braunreiter D
The accurate performance of physical therapy exercises can be difficult. In this evolving healthcare climate it is important to continually look for better methods to educate patients. The use of handouts, in-person demonstration, and video instruction are all potential avenues to teach proper exercise form. The purpose of this study was to examine if a corrected error video (CEV) would be as effective as a single visit with a physical therapist (PT) to teach healthy subjects how to properly perform four different shoulder rehabilitation exercises.  Fifty-eight subjects with no shoulder complaints were recruited from two institutions and randomized into one of two groups: the CEV group (30 subjects) was given a CEV comprised of four shoulder exercises, while the physical therapy group (28 subjects) had one session with a PT as well as a handout on how to complete the exercises. Each subject practiced the exercises for one week and was then videotaped performing them during a return visit. Videos were scored with the shoulder exam assessment tool (SEAT) created by the authors.  There was no difference between the groups on total SEAT score (13.66 + 0.29 vs 13.46 + 0.30 for CEV vs PT, p = 0.64, 95% CI [-0.06, 0.037]). Average scores for individual exercises also showed no significant differences. These results demonstrate that the inexpensive and accessible CEV is as beneficial as direct instruction in teaching subjects to properly perform shoulder rehabilitation exercises.

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Sixty Seconds of Foam Rolling Does Not Affect Functional Flexibility or Change Muscle Temperature in Adolescent Athletes.
Authors:  Murray AM, Jones TW, Horobeanu C, Turner AP, Sproule J
Physiotherapists and other practitioners commonly prescribe foam rolling as an intervention, but the mechanistic effects of this intervention are not known. The aim of this investigation was to establish if a single bout of foam rolling affects flexibility, skeletal muscle contractility, and reflected temperature.  Twelve adolescent male squash players were evaluated on two separate occasions (treatment and control visits) and were tested on both legs for flexibility of the hip flexors and quadriceps, muscle contractility as measured by tensiomyography and temperature of the quadriceps (assessed via thermography) at repeated time points pre- and post a 60s rolling intervention (pre-, immediately post, 5, 10, 15, and 30 minutes post). They rolled one leg on the treatment visit and did not perform rolling on the control visit.  The main outcome measure was the flexibility of hip flexor and quadriceps at repeated time points up to 30 minutes post intervention. The average foam rolling force was 68% of subject’s body weight. This force affected the combination of hip and quadriceps flexibility (p=0.03; 2.4 degrees total increase with foam rolling) but not each muscle independently (p = 0.05 – 0.98) following a single 60s bout. Muscle contractility was not affected (p = 0.09 – 0.93) and temperature was not increased by foam rolling across time points (p=0.19).  A single sixty-second bout of rolling applied to the quadriceps induces a small significant change in flexibility that is of little practical relevance, while muscle contractility and temperature remain unchanged. Investigation of larger doses of rolling is merited in athletic populations to justify current practice.

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CASE REPORT / SERIES

Bipartite Patella in 35-year-old Fitness Instructor: A Case Report.
Authors:  Zabierek S,  Zabierek J,  Kwapisz A,  Domzalski ME
The patella plays an important role in knee biomechanics and provides anterior coverage of the knee joint. One to two percent of population has an anatomical variant of patella called a bipartite patella that usually does not case pain. However, occasionally after injury or overuse during sport it can be a source of anterior knee pain. The purpose of this case report was to present a rare variant of bipartite patella and highlight conservative treatment of this condition. A 35-year-old female patient presented with persistent bilateral non-traumatic anterior knee pain of a six-year duration that was enhanced by strenuous kinds of sport activity. Standard radiographs and MRI revealed the presence of bipartite patella with medial pole cartilage edema bilaterally. Conservative care including physical therapy, extracorporeal shock wave therapy (ESWT), and viscosupplementation was utilized. After treatment VAS decreased to 0/10 from 5/10 in the left knee and 1/10 from 5/10 in the right knee. The Kujala Scores improved after treatment 100 and 95 for the left and right knees respectively. The subject returned to full sport activity and work as a fitness instructor without pain and limitations.  This case describes a rare finding of medial bipartite patella and the successful use of physical therapy with viscosupplementation in patellar pain caused by bipartite patella. It also supports the use of ESWT in bipartite patella pain as a supplemental therapy.

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CLINICAL COMMENTARY / LITERATURE REVIEWS

Musculoskeletal Screening and Functional Testing:  Considerations for Basketball Players:  A Clinical Commentary.
Authors:  Bird SP, Markwick WJ
Youth participation in basketball in on the rise, with basketball one of the top five participation sports in Australia. With increased participation there is a need for greater awareness of the importance of the pre-participation examination, including musculoskeletal screening and functional performance testing as part of a multidisciplinary approach to reducing the risk for future injuries. As majority of all basketball injuries affect the lower extremities, pre-participation musculoskeletal screening and functional performance testing should assess fundamental movement qualities throughout the kinetic chain with an emphasis on lower extremity force characteristics, specifically eccentric loading tasks.  Thus, the purpose of this clinical commentary is to review the existing literature elucidating pre-participation musculoskeletal screening and functional performance tests that can be used as a framework for rehabilitation professionals in assessing basketball athletes’ readiness to safely perform the movement demands of their sport. Relevant articles published between 2000 and 2016 using the search terms ‘musculoskeletal screening’, ‘functional testing’, ‘youth athletes’, and ‘basketball’ were identified using MEDLINE.  From a basketball-specific perspective, several relevant musculoskeletal assessments were identified, including: the Functional Hop Test Combination, the Landing Error Scoring System, the Tuck Jump Assessment, the Weight-Bearing Lunge Test, and the Star Excursion Balance Test.  Each of these assessments creates movement demands that allow for easy identification of inefficient and/or compensatory movement tendencies. A basic understanding of musculoskeletal deficits including bilateral strength and flexibility imbalances, lower crossed syndrome, and dominance-related factors are key components in determination of injury risk. Assessment of sport-specific movement demands through musculoskeletal screening and functional performance testing is essential for rehabilitation professionals to determine movement competency during performance of fundamental movements related to basketball performance. Youth athletes represent a unique population due to their developing musculoskeletal and neuromuscular systems and should undergo pre-participation musculoskeletal screening for identification of movement limitations. Such an approach to musculoskeletal screening and functional performance may assist in identifying injury risk and also be useful at the end of rehabilitation in determining readiness to return to sport models.

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A Clinical Guide to the Assessment and Treatment of Breathing Pattern Disorders in the Physically Active: Part 1
Authors:  Chapman EB, Honeycutt JH, Nasypany A, Baker RT, May J
Appropriate assessment of and interventions for breathing patterns prior to assessment of a patient’s musculoskeletal complaint may be beneficial. Breathing pattern disorders (BPDs) are remediable and influenced by biochemical, biomechanical, psychological, and/or unknown factors. The purpose of this clinical commentary is to demonstrate the integration of a BPD assessment into a standard clinical musculoskeletal orthopedic examination.   The observation of a patient’s breathing pattern begins when they enter the clinic, and is followed by palpation and orthopedic tests, which allows for proper classification of BPDs.  Disease-oriented measures guide the assessment and classification of BPD, while patient-oriented measures describe clinically important differences among patients.  There are many possible variations of classifications of BPD, however, six primary dysfunctions found in the literature have become the foundation of the BPD assessment. Restoring proper breathing mechanics and neuromuscular motor control during breathing may result in a decrease in pain, improved patient outcomes, and overall sense of patient well being associated with their primary musculoskeletal complaint. A comprehensive evaluation of breathing patterns, as a part of an orthopedic examination, may guide a clinician in providing effective and appropriate treatments to decrease pain and improve function.

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Pertinent Dry Needling Considerations for Minimizing Adverse Effects – Part Two.

Authors:  Halle JS, Halle R
Dry needling (DN) is an evidence based treatment technique that is accepted and used by physical therapists in the United States. This clinical commentary is the second in a two-part series outlining some of the pertinent anatomy and other issues that are needed for optimal utilization of this intervention. As is the case with any intervention, the technique of dry needling has some inherent patient risk.  The incidence of AEs with this procedure is typically low, ranging from zero to approximately 10 percent.  Knowledge of the underlying anatomy can be a key factor associated with decreasing the likelihood of an AE. Part 2 of this clinical commentary goes beyond the thorax (covered in Part 1), to explore the anatomy associated with dry needling in the abdomen, pelvis, and back. In the abdomen, pelvis and back, dry needling can penetrate the peritoneal cavity or adjacent organs, resulting in AEs. A physiological reaction that is an AE secondary to a needle insertion, pain or fear is an autonomic vasovagal response.  Suggestions for dealing with the fearful patient, the obese patient, the use of universal precautions, and other clinical considerations, are discussed. The purpose of parts one and part two of this clinical commentary is to minimize the risk of a dry needling AE. Dry needling is an effective adjunctive treatment procedure that is within the recognized scope of practice of the physical therapist.  An evidence-based implementation of the procedure must be based on a thorough understanding of the underlying anatomy and the potential risks, with risks coordinated with patients via informed consent.  

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