VOLUME TWELVE NUMBER ONE

 
2017Masthead_V12N1-1
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February 2017

EDITORIAL
What is the Movement System and Why is it Important?  
Authors: Voight ML, Hoogenboom BJ 
Physical therapists are too often identified by what we do rather than by what we know as professionals. In accordance with the APTA Vision statement from 2013, "Transforming society by optimizing movement to improve the human experience," IJSPT has embraced the concept of the movement system and the editorial team is committed to the integration of movement system language, a focus on the movement system, and furthering the educational, research, and practice agendas set forth by the APTA. Please read the entire editorial for details.

Editorial

SYSTEMATIC REVIEW

Exercises That Facilitate Optimal Hamstring and Quadriceps Co-Activation to Help Decrease ACL Injury Risk In Healthy Females: A Systematic Review of the Literature.
Authors:  Dedinsky R, Baker L, Imbus S, Bowman M, Murray L
Anterior cruciate ligament (ACL) injury is common among females due to many anatomic, hormonal, and neuromuscular risk factors. One modifiable risk factor that places females at increased risk of ACL injury is a poor hamstrings: quadriceps (H:Q) co-activation ratio, which should be 0.6 or greater in order to decrease the stress placed on the ACL. Exercises that produce increased quadriceps muscle activation as compared to the hamstrings (“quadriceps dominance”) can add to the tension placed upon the ACL, potentially increasing the risk of ACL injury. The purpose of this systematic review was to compare quadriceps and hamstring muscle activation during common closed kinetic chain therapeutic exercises in healthy females to determine what exercises are able to produce adequate H:Q co-activation ratios.  Multiple online databases were systematically searched and screened for inclusion. Eight articles were identified for inclusion.  Data on mean electromyographic (EMG) activation of both quadriceps and hamstring muscles, percent maximal voluntary isometric contraction (MVIC), and H:Q co-activation ratios were extracted from the studies. Exercises analyzed in the studies included variations of the double leg squat, variations of the single leg squat, the lateral step-up, and the use of the Fitter, Stairmaster® (Core Health and Fitness, Vancouver, WA), and slide board. All exercises, except the squat machine with posterior support at the level of the scapula and feet placed 50 cm in front of the hips, produced higher quadriceps muscle activation compared to hamstring muscle activation. Overall, two leg squats demonstrate poor H:Q co-activation ratios. Single leg exercises, when performed between 30 and 90 degrees of knee flexion, produce adequate H:Q ratios, thereby potentially reducing the risk of tensile stress on the ACL and ACL injury.

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ORIGINAL RESEARCH
Deformation Response of the Iliotibial Band-Tensor Fascia Lata Complex to Clinical-Grade Longitudinal Tension Loading In-Vitro.
Authors:  Wilhelm M, Matthijs O, Browne K, Seeber G, Matthijs A, Sizer P, Brismee JM, James R, Gilbert KK
Iliotibial Band (ITB) syndrome is a troublesome condition with prevalence as high as 12% in runners. Stretching has been utilized as a conservative treatment. However, there is limited evidence supporting ITB elongation in response to a stretching force. The purpose of this study was to describe the iliotibial band tensor fascia lata complex (ITBTFLC) tissue elongation response to a simulated clinical stretch in-vitro. The authors hypothesized that the ITBTFLC would undergo statistically significant elongation when exposed to clinical-grade stretching regimen, with the majority of the elongation occurring within the proximal ITBTFLC region.  The strain response of six un-embalmed ITBTFLCs to a simulated clinical stretch of 2.75% elongation was assessed. Four sets of array marks were placed along the length of the ITBTFLC. Photographic images were taken in resting position (with 1.0% in-situ elongation) and with an additional 2.75% elongation. Tissue elongation was compared between proximal, middle, and distal ITBTFLC regions. A paired samples t-test demonstrated a significantly longer ITBTFLC in the “stretched” versus resting condition (p=0.001). Significant elongation was observed in the proximal (3.96mm (SD=1.35); p=0.001), middle (2.12mm (SD=1.49); p= 0.018) and distal (2.25mm (SD=1.37); p= 0.01) regions during the “stretched” versus the resting condition. A one-way ANOVA demonstrated a significant main effect for region (p=0.002). The proximal region exhibited significantly greater elongation versus the middle (p=0.003) and distal (p=0.007) regions, with no significant difference between the middle and distal regions (p=0.932).  The results of this study demonstrate that the ITBTFLC is capable of elongation in response to a clinically simulated stretch. The proximal ITB region underwent significantly greater elongation than the middle and distal regions and may be more likely to respond to “stretching” in clinical situations. Future investigation should assess the ITBTFLC load/deformation properties to determine whether a short-term clinically available stretch translates into permanent tissue elongation.

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Dance, Balance, and Core Muscle Performance Measures are Improved Following a 9-week Core Stabilization Training Program Among Competitive Collegiate Dancers. 

Authors: Watson T, Graning J, McPherson S, Carter E, Edwards J, Melcher I, Burgess T
Dance performance requires not only lower extremity muscle strength and endurance, but also sufficient core stabilization during dynamic dance movements. While previous studies have identified a link between core muscle performance and lower extremity injury risk, what has not been determined is if an extended core stabilization training program will improve specific measures of dance performance.  This study examined the impact of a nine-week core stabilization program on indices of dance performance, balance measures, and core muscle performance in competitive collegiate dancers.   A convenience sample of 24 female collegiate dance team members (age = 19.7 + 1.1 years, height = 164.3 + 5.3 cm, weight 60.3 + 6.2 kg, BMI = 22.5 + 3.0) participated. The intervention consisted of a supervised and non-supervised core (trunk musculature) exercise training program designed specifically for dance team participants performed three days/week for nine weeks in addition to routine dance practice. Prior to the program implementation and following initial testing, transversus abdominis (TrA) activation training was completed using the abdominal draw-in maneuver (ADIM) including ultrasound imaging (USI) verification and instructor feedback.  Outcomes after the nine-week core stabilization program on dance performance and balance measures (pirouettes, single leg balance in passe’ releve position, and star excursion balance test [SEBT]) and on tests of muscle performance were examined. Differences between four TrA instruction conditions of activation were also explored: resting baseline, self-selected activation, immediately following ADIM training and four days after completion of the core stabilization training program. Alpha was set at 0.05 for all analysis.  Statistically significant improvements were seen on single leg balance in passe’ releve and bilateral anterior reach for the SEBT (both p < 0.01), number of pirouettes (p = 0.011), and all measures of strength (p < 0.05) except single leg heel raise. The RM ANOVA on mean percentage of change in TrA was significant; post hoc paired t tests demonstrated significant improvements in dancers’ TrA activations across the four instruction conditions.  The authors concluded that the core stabilization training program improves pirouette ability, balance (static and dynamic), and measures of muscle performance. Additionally, ADIM training resulted in immediate and short-term (nine-week) improvements in TrA activation in a functional dance position.

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Muscle Activation Patterns during Suspension Training Exercises.
Authors:  Harris SM, Ruffin E, Brewer WA, Ortiz A
Suspension training (ST) has been suggested for utilization over exercises performed on a stable surface in order to train multiple muscle groups simultaneously to increase muscle activation and joint stability.  The purpose of this study was to determine whether ST augments muscle activation compared to similar exercises performed on a stable surface. Twenty-five healthy adults (male: 16; women: 9; BMI: 23.50 ± 2.48 kg/m2) had 16 pre-amplified wireless surface EMG electrodes placed bilaterally on: the pectoralis major (PM), middle deltoid (MD), serratus anterior (SA), obliques (OB), rectus abdominis (RA), gluteus maximus (GM), erector spinae (ES), and middle trapezius/rhomboids (MT). Each participant performed reference isometric exercises (Sorensen test, push-up, sit-up, and inverted row) to establish a baseline muscle contraction. Muscle activation was assessed during the following exercises: ST bridge, ST push-up, ST inverted row, ST plank, floor bridge, floor push-up, floor row, and floor plank. The root mean square (RMS) of each side for every muscle was averaged for data analysis. Multivariate analyses of variance (MANOVA) for each exercise with post-hoc comparisons were performed to compare muscle activation between each ST exercise and its stable surface counterpart.  MANOVAs for all exercise comparisons showed statistically significant greater muscle activation in at least one muscle group during the ST condition. Post-hoc analyses revealed a statistically significant increase in muscle activation for the following muscles during the plank: OB (p=0.021); Push-up: PM (p=0.002), RA (p<0.0001), OB (p=0.019), MT (p<0.0001), and ES (p=0.006); Row: MD (p=0.016), RA (p=0.059), and OB (p=0.027); and Bridge: RA (p=0.013) and ES (p<0.0001).  The authors concluded that performing ST exercises increases muscle activation of selected muscles when compared to exercises performed on a stable surface.

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The Intra- and Inter-rater Reliability of the Soccer Injury Movement Screen (SIMS).
Authors:  McCunn R, Funten K, Govus A, Julian R, Schimpchen J, Meyer T
The growing volume of movement screening research reveals a belief among practitioners and researchers alike that movement quality may have an association with injury risk. However, existing movement screening tools have not considered the sport-specific movement and injury patterns relevant to soccer. The present study introduces the Soccer Injury Movement Screen (SIMS), which has been designed specifically for use with soccer athletes. Furthermore, the purpose of the present study was to assess the intra- and inter-rater reliability of the SIMS and determine its suitability for use in further research.  This study utilized a test-retest design to discern reliability. Twenty-five (11 males, 14 females) healthy, recreationally active university students (age 25.5±4.0 years, height 171±9 cm, weight 64.7±12.6 kg) agreed to participate. The SIMS contains five sub-tests: the anterior reach, single-leg deadlift, in-line lunge, single-leg hop for distance and tuck jump. Each movement was scored out of 10 points and summed to produce a composite score out of 50. The anterior reach and single-leg hop for distance were scored in real-time while the remaining tests were filmed and scored retrospectively. Three raters conducted the SIMS with each participant on three occasions separated by an average of three and a half days (minimum day, maximum seven days). Rater 1 re-scored the filmed movements for all participants on all occasions six months later to establish the ‘pure’ intra-rater (intra-occasion) reliability for those movements.  Intra-class correlation coefficient (ICC) values for intra- and inter-rater composite score reliability ranged from 0.66-0.72 and 0.79-0.86 respectively. Weighted kappa values representing the intra- and inter-rater reliability of the individual sub-tests ranged from 0.35-0.91 indicating fair to almost perfect agreement.  Establishing the reliability of the SIMS is a prerequisite for further research seeking to investigate the relationship between test score and subsequent injury.

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Biomechanical Differences in Brazilian Jiu-Jitsu Athletes: The Role of Combat Style.

Authors:  Lima PO, Lima AA, Coelho ACS, Lima YL, Almeida GPL, Bezerra MA, Oliveira RR
Brazilian Jiu-Jitsu (BJJ) athletes can be divided into two combat styles: pass fighters (PFs) and guard fighters (GFs). Flexibility of the posterior chain muscles is highly necessary in these athletes, especially in GFs. On the other hand, isometric strength of the trunk extensors is required in PFs. Handgrip strength is important in holding the kimono of the opponent, and symmetrical lower-limb strength is important for the prevention of injuries due to the overload caused by training. The aim of this study was to compare the biomechanical profiles of BJJ athletes with different combat styles using the following outcome measures: flexibility, trunk extensor isometric endurance, postural balance, handgrip isometric endurance and lower-limb muscle strength. A cross-sectional study was conducted using 19 GFs and 19 PFs. The sit-and-reach test was used to evaluate the flexibility of the posterior chain muscles. The Biodex Balance System® was used to evaluate balance. A handgrip dynamometer and a dorsal dynamometer were used to evaluate handgrip and trunk extensor endurance, respectively. Quadriceps and hamstring strength were evaluated with an isokinetic dynamometer at 60°/s. No differences were observed between groups in terms of flexibility, balance, handgrip isometric endurance or quadriceps and hamstring strength; however, PFs (81.33) showed more isometric trunk extension endurance than GFs (68.85) (p= 0.02). Both groups had low values for hamstring/quadriceps ratio. No significant biomechanical differences were observed between PFs and GFs.

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Maximum Repetition Performance After Different Antagonist Foam Rolling Volumes in the Inter-Set Rest Period.
Authors:  Monteiro ER, Skarabot J, Vigotsky AD, Brown AF, Gomes TM, Novaes JD
Foam rollers, or other similar devices, are a method for acutely increasing range of motion, but in contrast to static stretching, do not appear to have detrimental effects on neuromuscular performance.  The purpose of this study was to investigate the effects of different volumes (60 and 120 seconds) of foam rolling of the hamstrings during the inter-set rest period on repetition performance of the knee extension exercise.  Twenty-five recreationally active females were recruited for the study (27.8 ± 3.6 years, 168.4 ± 7.2 cm, 69.1 ± 10.2 kg, 27.2 ± 2.1 m2/kg). Initially, subjects underwent a ten-repetition maximum testing and retesting, respectively. Thereafter, the experiment involved three sets of knee extensions with a pre-determined 10 RM load to concentric failure with the goal of completing the maximum number of repetitions. During the inter-set rest period, either passive rest or foam rolling of different durations (60 and 120 seconds) in a randomized order was employed.  Ninety-five percent confidence intervals revealed dose-dependent, detrimental effects, with more time spent foam rolling resulting in fewer performed knee extension repetitions (Cohen’s d of 2.0 and 1.2 for 120 and 60 seconds, respectively, in comparison with passive rest).  The results of the present study suggest that more inter-set foam rolling applied to the antagonist muscle group is detrimental to the ability to continually produce force of the agonist muscle. The finding that inter-set foam rolling of the antagonist muscle group decreases maximum repetition performance has implications for foam rolling prescription and implementation, in both rehabilitation and athletic populations.

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The Effects of Varied Tensions of Kinesiology Taping on Quadriceps Strength and Lower Limb Function.
Authors:  Jesus JF, Franco YR, Nannini SB, Nakaoka GB, Reis AC, Bryk FF

Kinesiology Taping (KT) may promote changes in muscle strength and motor performance.  These characteristics are purported to be associated with the tension generated by the KT on the skin. However, the most suitable tension for the attainment of these strength and performance effects has not yet been confirmed.  The purpose of this study was to analyze the effects of different tensions of KT on the isometric contraction of the quadriceps and lower limb function of healthy individuals over a period of seven days.  One hundred and thirty healthy individuals were distributed into the following five groups: control (without KT); KT0 (KT without tension); KT50; KT75 and KT100 (approximately 50%, 75% and 100% tension applied to the tape, respectively). Assessments of isometric quadriceps strength were conducted using a hand held dynamometer. Lower limb function was assessed through Single Hop Test for Distance, with five measurement periods: baseline; immediately after KT application; three days after KT; five days after KT; and 72h after KT removal (follow-up).  There were no statistically significant differences (p>0.05) at any of the studied periods on participants’ quadriceps strength alterations nor in the function of the lower extremity dominant limb, based on comparisons between the control group and the experimental groups.  The authors concluded that KT applied with different tensions did not produce modulations, in short or long-term, on quadriceps’ strength or lower limb function of healthy individuals. Therefore, this type of KT application, when seeking these objectives, should be reconsidered.

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Acute Effects of Different Self-Massage Volumes on the FMSTM Overhead Deep Squat Performance.
Authors:  Monteiro ER, Skarabot J, Vigotsky AD, Brown AF, Gomes TM, Novaes JD
The Functional Movement Screen (FMS™) consists of a battery of tests designed to assess movement competency.  Within the FMS™, the overhead deep squat test, specifically, has been shown to be an accurate predictor of overall FMS™ scores. Self-massage (SM) is a ubiquitous warm-up utilized to increase joint range of motion and, therefore, may be effective for improving performance of the overhead deep squat test.  The purpose of this study was to examine how different doses (30, 60, 90, and 120 seconds) of SM on different areas of the body (plantar fascia, latissimus dorsi, and lateral thigh) affects the score obtained on an overhead deep squat test. Twenty recreationally active females were recruited to be tested on four occasions: sessions one and two consisted of baseline testing, session three consisted of SM applied to the lateral thigh, and session four consisted of SM applied to the lateral torso and plantar fascia.  In all SM conditions, at least 90 seconds was required for a change in deep squat score from baseline; therefore, it is concluded that SM to the lateral torso, plantar fascia, and lateral thigh for 90 seconds or more are effective interventions for acutely improving overhead deep squat scores.  The authors concluded that self-massage appears to be an effective modality for inducing acute improvements in the performance of the FMS™ overhead deep squat in all conditions tested.

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Rapid Knee Extensions to Increase Quadriceps Muscle Activity in Patients with Total Knee Arthroplasty: A Randomized Crossover Study.
Authors: Husted RS, Wilquin L, Jakobsen TL, Holsgaard-Larsen A, Bandholm T
Inhibition of the quadriceps muscle and reduced knee-extension strength is common shortly following total knee arthroplasty (weeks to months), due to reduced voluntary activation of the quadriceps muscle. In healthy subjects, strength training with heavy loads is known to increase agonist muscle activity, especially if the exercise is conducted using rapid muscle contractions. The purpose of this study was to examine if patients with total knee arthroplasty  could perform rapid knee-extensions using a 10 RM load four to eight weeks after surgery, and the degree to which rapid knee-extensions were associated with greater voluntary quadriceps muscle activity during an experimental strength training session, compared to that elicited using slow knee-extensions. Twenty-four patients (age 66.5) 4-8 weeks post total knee arthroplasty randomly performed one set of five rapid, and one set of five slow knee-extensions with the operated leg, using a load of their 10 repetition maximum, while surface electromyography recordings were obtained from the vastus medialis and lateralis of the quadriceps muscle. Data from 23 of the 24 included patients were analyzed. Muscle activity was significantly higher during rapid knee-extensions (120.2% [10th-90th percentile: 98.3-149.1]) compared to slow knee-extensions (106.0% [88.8-140.8]) for the vastus lateralis (p<0.01), but not for the vastus medialis (120.8% [90.4-134.0]) and (121.8% [93.0-133.0]) (p=0.17), respectively. Slow and rapid knee-extensions were performed at a median angular velocity of 19.7 degrees/sec (13.7-24.4) and 51.4 degrees/sec (28.9-63.1), respectively. Four to eight weeks after their total knee arthroplasty, the patients in the present study were able to conduct rapid knee-extensions according to the experimental protocol with an approximately doubled angular velocity compared to slow knee-extensions. This was associated with increased muscle activity in the vastus lateralis when compared to slow knee-extensions, but not in the vastus medialis. Whether this significant, although relatively small, difference in vastus lateralis muscle activity has any clinical relevance needs further study.

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Exploration of Score Agreement on a Modified Upper Quarter Y-Balance Test Kit as Compared to the Upper Quarter Y-Balance Test.
Authors:  Cramer J, Quintero M, Rhinehart A, Rutherford C, Nasypany A, May J, Baker RT
Physical performance measures (PPMs) such as The Star Excursion Balance Test (SEBT) and the Y-Balance Test (YBT) are functional movement tests used to assess participants’ dynamic balance, which can be a vital component in physical exams to identify predisposing factors for risk of injury. The YBT is a functional assessment tool for the upper and lower body. It evolved from the SEBT, which has been previously used in research as a lower body functional assessment. It is comprised of fewer movement directions, which help limit fatigue. The YBT kit is a commercialized tool, which may pose barriers for clinicians with limited budgets and/or strict approval processes for purchasing capital items in their clinics, especially healthcare providers in the secondary school setting. The cost may also pose a barrier for researchers with limited budgets. A less expensive, easy to make kit may provide clinicians an opportunity to integrate functional testing into their evaluation or research. The purpose of this study was to describe a cost efficient method to gather participant’s upper quarter YBT (UQYBT) measurements and examine the inter- and intra-rater score agreement between this method and the commercial YBT measurements.  A convenience sample of 20 physically active participants volunteered to participate in a comparison study of the of Upper Quarter Y-Balance Test (UQYBT) using the commercialized kit and the Modified Upper Quarter Y-Balance Test kit (mUQYBT) made with three cloth tape measures, athletic tape, a goniometer and three 2x4x8 wood blocks. A Pearson Product Moment correlation and Bland-Altman analyses were used to examine the relationship between intra-rater scores comparing the UQYBT and mUQYBT. Inter-rater scores were analyzed using intraclass correlation coefficients (ICC) (2,1) and Bland-Altman analyses.  All Pearson Product Moment r-values for intra-rater scores were greater than .96 and statistically significant at p<0.05. Coefficients of determination suggest that the mUQYBT scores account for approximately 92% of the UQYBT composite score when analyzing intra-rater comparisons. Bland-Altman plots suggest moderate agreement between the two tests with a potential bias towards higher composite scores in the mUQYBT. Inter-rater ICC scores were all greater than .98, while Bland-Altman plot analyses suggest moderate agreement between the raters. The authors concluded that the mUQYBT produced similar results in both inter- and intra-rater measurements when compared to the commercialized YBT kit and offers a cost-effective alternative for assessing upper quarter PPMs for clinicians with limited budgets.

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Test/Re-test Reliability of the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) in Adolescents.
Authors:  Oliveira VM, Pitangui ACR, Nascimento VYS, Silva HA, Passos MHP, Araujo RC
The Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) has been proposed as an option to assess upper limb function and stability; however, there are few studies that support the use of this test in adolescents. The purpose of the present study was to investigate the intersession reliability and agreement of three CKCUEST scores in adolescents and establish clinical values for this test. Twenty-five healthy adolescents of both sexes were evaluated. The subjects performed two CKCUEST with an interval of one week between the tests. The difference between the evaluation and reevaluation was observed using a paired-sample t test. The level of significance was set at 0.05. Standard error of measurements and minimum detectable changes were calculated. The intersession reliability of the average touches score, normalized score, and power score were 0.68, 0.68 and 0.87, the standard error of measurement were 2.17, 1.35 and 6.49, and the minimal detectable change was 6.01, 3.74 and 17.98, respectively. The presence of systematic error (p < 0.014), the significant difference between the measurements (p < 0.05), and the analysis of the Bland-Altman graph infer that CKCUEST is a discordant test with moderate to excellent reliability when used with adolescents. The authors concluded that the CKCUEST is a measurement with moderate to excellent reliability for adolescents.

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CASE REPORTS
Joint Mobilization in the Management of Persistent Insertional Achilles Tendinopathy: A Case Report.
Authors:  Jayaseelan DJ, Post AA, Mischke JJ, Sault JD
Insertional Achilles tendinopathy (IAT) can be a challenging condition to manage conservatively. Eccentric exercise is commonly used in the management of chronic tendinopathy; however, it may not be as helpful for insertional tendon problems as compared to mid-portion dysfunction. While current evidence describing the physical therapy management of IAT is developing, gaps still exist in descriptions of best practice. The purpose of this case report is to describe the management of a patient with persistent IAT utilizing impairment-based joint mobilization, self-mobilization, and exercise.

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Short-Term Effects of Instrument-Assisted Soft Tissue Mobilization on Pain Free Range of Motion in a Weightlifter with Subacromial Pain Syndrome.
Authors: Coviello JP, Kakar RS, Reynolds TJ
While there is limited evidence supporting the use of soft tissue mobilization techniques for Subacromial Pain Syndrome (SAPS), synonymous with subacromial impingement syndrome, previous studies have reported successful outcomes using soft tissue mobilization as a treatment technique. The purpose of this case report is to document the results of Instrument-Assisted Soft Tissue Mobilization (IASTM) for the treatment of SAPS. IASTM may have a beneficial acute effect on painfree shoulder flexion.  In conjunction with scapulothoracic mobilizations and stretching, IASTM may improve function, decrease pain, and improve patient satisfaction. While this technique will not ameliorate the underlying pathomechanics contributing to SAPS, it may serve as a valuable tool to restore ROM and decrease pain allowing the patient to reap the full benefits of a multi-modal treatment approach.

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Treatment of Anterior Shoulder Subluxation Using the Mulligan Concept and Reflex Neuromuscular Stabilization: A Case Report.
Authors: Hudson RA, Baker R, Nasypany A, Reordan D
Shoulder instability, a common issue among athletes who engage in contact sports, may lead to recurrent subluxations, or partial dislocations of the shoulder. Young athletic patients generally respond poorly to the nonsurgical treatments for shoulder instability that are commonly utilized. The purpose of this case report is to describe the effects of the treatment guided by the Mulligan Concept (MC) coupled with reflex neuromuscular stabilization (RNS) also known as reactive neuromuscular training (RNT), on an adolescent football player with glenohumeral joint (GHJ) instability who sustained a traumatic anterior subluxation.   In this case report, the MC shoulder mobilization with movement, coupled with RNS, was an effective treatment and provided a short time to resolution (6 treatments; 19 days) compared to other descriptions of recovery in the literature. Clinicians treating patients who display anterior shoulder instability can consider this as a viable treatment option.

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