volume twelve NUMBER three

 
2017Masthead_V12N3-1
Full articles may be found at this link. Full articles are only available to SPTS Members and subscribers.

June 2017

ORIGINAL RESEARCH
Dynamic Oscillatory Stretching Efficacy on Hamstring Extensibility and Stretch Tolerance:  A Randomized Controlled Trial. 
 
Authors: Michaeli A, Tee JC, Stewart A
While static stretch (SS), proprioceptive neuromuscular facilitation (PNF) and oscillatory physiological mobilization techniques are documented to have positive effects on a range of motion, there are no reports on the effect of dynamic oscillatory stretching (DOS), a technique that combines these three techniques, on hamstring extensibility. The purpose of this study was to determine whether DOS improves hamstring extensibility and stretch tolerance to a greater degree than SS in asymptomatic young participants.  Sixty participants (47 females, 13 males, mean age 22 ± 1 years, height 166 ± 6 centimeters, body mass 67.6 ± 9.7 kg) completed a passive straight leg (SLR) to establish hamstring extensibility and stretch tolerance as perceived by participants using a visual analogue scale (VAS).  Participants were randomly assigned to one of two treatment groups (SS or DOS) or a placebo control (20 per group). Tests were repeated immediately following and one hour after each intervention. Data were assessed using a two-way repeated measure analysis of variance (ANOVA) and Tukey’s post hoc test. Immediately post-intervention, there was a significant improvement in the hamstring extensibility as measured by the SLR in both the SS and DOS groups, with the DOS group exhibiting a significantly greater increase than the SS group (Control 73 ± 12°, SS 86 ± 8°, DOS 94 ± 11°, p < 0.001). One hour post-intervention, hamstring extensibility in the DOS group remained elevated, while the SS group no longer differed from the control group (Control 73 ± 12°, SS 80 ± 8°, DOS 89 ± 12°, p = 0.001).  Furthermore, the stretch tolerance remained significantly elevated for the SS group, but there was no difference between the control and DOS groups, (Control 4.6 ± 1.3, SS 5.9 ± 0.8, DOS 4.3 ± 1.0 AU, p < 0.001). The authors concluded that DOS was more effective than SS at achieving an immediate increase in hamstring extensibility, and DOS demonstrated an increased stretch tolerance one-hour post-intervention. 
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Postural Stability and Kinetic Change in Subjects with Patellofemoral Pain after a Nine-Week Hip and Core Strengthening Intervention.
Authors:  Carry PM, Gala R, Worster K, Kanai S, Miller NH, James D, Provance AJ, Carollo JJ
Idiopathic patellofemoral pain (PFP) has been linked to hip weakness and abnormal lower extremity mechanics. The effect of a strengthening intervention on balance has not been well studied among individuals with PFP.   The primary aim of this study was to evaluate changes in center of pressure displacement during the single limb squat following a nine-week physical therapy intervention among adolescent females with PFP. Seven adolescent females with PFP (10 extremities) were included in the study. Center of Pressure (CoP) excursions during a single limb squat task were measured before and after a nine week of physical therapy intervention focused on strengthening of the hip and core. Seven asymptomatic females were matched to the PFP group on the basis of age and activity level, and were tested as a reference group. CoP trajectories were reduced into four variables: mean distance (MDIST), root-mean-square distance (RDIST), range (RANGE), and 95% confidence interval circle area (AREA-CC). Maximum knee flexion angle, peak knee power generation and absorption were also recorded. Linear mixed models were used to test for within and between group differences in CoP metrics. Pre-intervention, CoP range, knee power absorption and generation were significantly decreased in the PFP group relative to the reference group. Post-intervention, the PFP group reported a significant decrease in symptom severity. There was also a significant (p<0.05) increase in MDIST, RDIST, RANGE, AREA-CC, peak knee flexion angle, peak power absorption and power generation. There was no difference (p>0.05) in knee flexion, knee power or CoP displacement between the two groups after the physical therapy intervention. The authors concluded that hip and core-strengthening resulted in a significant decrease in symptom severity as well as significant reductions in CoP displacement.
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Kinematic and Kinetic Variables Differ Between Kettlebell Swing Styles.
Authors:  Bullock GS, Schmitt AC, Shutt JM, Cook G, Butler RJ
Kettlebell (KB) and Indian club swings (ICS) are used diversely for developing strength and power.  It has been proposed that multiple swing techniques can be used interchangeably to elicit similar adaptations within performance training.  The authors hypothesized that there will be not be a difference in peak joint angles between types of swings. Furthermore, given the nature of the overhead kettlebell swing (OKS), it was hypothesized that the OKS will be associated with a greater cycle time and a greater vertical impulse compared to shoulder height swing (SKS) and ICS. The purpose of this study was to analyze the kinematics and kinetics of the SKS, OKS, and ICS.  Fifteen healthy subjects underwent 3D biomechanical analysis for assessment of kinematic and kinetic data.  Subjects performed two trials of ten repetitions at full effort for each swing in a randomized order using either a standard set of 0.45 kg indian clubs or sex specific KB loads (Female = 12kg, Male = 20kg). Lower extremity sagittal plane kinematics and kinetics were analyzed for peak values during the down and up portions of the swing patterns. Statistical analyses were carried out utilizing one-way ANOVAs (p<.05) and effect size indices.  Cycle time for the OKS was 34% longer than the SKS and ICS (p<.001; ESISKS= 2.09, ESIICS=1.92). In general, ankle (SKS: 0.82±0.16; OKS: 0.90±0.21; ICS: 0.60±0.15 BW*BH) and hip joint moments (SKS: 2.34±0.68; OKS: 2.32±0.53; ICS: 1.84±0.47 BW*BH) and joint powers, along with peak vertical ground reaction forces (vGRF) (SKS: 0.98±0.14; OKS: 0.96±0.10; ICS: 0.86±0.11 BW/s), were higher in the SKS and OKS than the ICS (p<.001; ankle: ESISKS/OKS=0.43, ESISKS/ICS=1.42; hip: ESISKS/OKS=0.03, ESISKS/ICS=0.87; vGRF: ESISKS/OKS=1.80, ESISKS/ICS=0.20). There were no observed differences found in peak joint angles between the movements.  Although these swings are kinematically similar, the differing kinetic demands of these exercises may be important in selecting the right training modality for specific strength and power training.
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A Dynamic Valgus Index That Combines Hip and Knee Angles: Assessment of Utility in Females With Patellofemoral Pain.
Authors:  Scholtes SA, Salsich GB
Two-dimensional motion analysis of lower-extremity movement typically focuses on the knee frontal plane projection angle, which considers the position of the femur and the tibia. A measure that includes the pelvis may provide a more comprehensive and accurate indicator of lower-extremity movement. The purpose of the study was to describe the utility of a two-dimensional dynamic valgus index (DVI) in females with patellofemoral pain. The hypothesis was that the DVI would be more reliable and valid than the knee frontal plane projection angle, be greater in females with patellofemoral pain during a single-limb squat than in females without patellofemoral pain, and decrease in females with patellofemoral pain following instruction. Data were captured while participants performed single limb squats under two conditions: usual and corrected. Two-dimensional hip and knee angles and a DVI that combined the hip and knee angles were calculated. Three-dimensional sagittal, frontal, and transverse plane angles of the hip and knee and a DVI combining the frontal and transverse plane angles were calculated.   The two-dimensional DVI demonstrated moderate reliability (ICC=0.74). The correlation between the two-dimensional and three-dimensional DVI’s was 0.635 (p<0001). Females with patellofemoral pain demonstrated a greater two-dimensional DVI (31.14°±13.36°) than females without patellofemoral pain (18.30°±14.97°; p=0.010).  Females with patellofemoral pain demonstrated a decreased DVI in the corrected (19.04°±13.70°) versus usual (31.14°±13.36°) condition (p=0.001).  The authors concluded that the DVI is a reliable and valid measure that may provide a more comprehensive assessment of lower-extremity movement patterns than the knee frontal plane projection angle in individuals with lower-extremity musculoskeletal pain problems.
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The Associations Between Hip Strength and Hip Kinematics During a Single Leg Hop in Recreational Athletes Post ACL Reconstruction Compared to Healthy Controls.
Authors:  Tate J, Suckut T, Wages J, Lyles H, Perrin B
Only minimal evidence exists linking hip abductor weakness to dynamic knee valgus during static and dynamic activities. The associations of hip extensor strength and hip kinematics during the landing of a single leg hop are not known. The purpose of this study was to determine if relationships exist between hip extensor and abductor strength and hip kinematics in both involved and uninvolved limb during the landing phase of a single leg hop in recreational athletes post anterior cruciate ligament (ACL) reconstruction.  The presence of similar associations was also evaluated in healthy recreational athletes. Twenty-four recreational college-aged athletes participated in the study (12 post ACL reconstruction; 12 healthy controls).  Sagittal and frontal plane hip kinematic data were collected for five trials during the landing of a single leg hop. Hip extensor and abductor isometric force production was measured using a hand-held dynamometer and normalized to participants’ height and weight.  Dependent and independent t-tests were used to analyze for any potential differences in hip strength or kinematics within and between groups, respectively.  Pearson’s r was used to demonstrate potential associations between hip strength and hip kinematics for both limbs in the ACL group and the right limb in the healthy control group.  Independent t-tests revealed that participants post ACL reconstruction exhibited less hip strength (0.18 N/Ht*BW vs. 0.25 N/Ht*BW, p=<.01) and landed with greater hip adduction (9.0 º vs. 0.8º, p=<.01) compared with their healthy counterparts.  In the ACL group, Pearson’s r demonstrated a moderate and indirect relationship (r=-.62, p=.03) between hip extensor strength and maximum hip abduction/adduction angle in the involved limb.  A moderate and direct relationship between hip abductor strength and maximum hip flexion angle was demonstrated in the both the involved (r=.62) and uninvolved limb (r=.65, p=.02). No significant associations were demonstrated between hip extensor or abductor strength and hip flexion and/or abduction/adduction angles in the healthy group.  The results suggest that hip extensors may play a role in minimizing hip adduction in the involved limb while the hip abductors seem to play a role in facilitating hip flexion during the landing phase of a single leg hop for both limbs following ACL reconstruction. Researchers and clinicians alike should consider the importance of the hip extensors in playing a more prominent role in contributing to frontal plane motion.
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Injury Incidence, Dance Exposure and the Use of the Movement Competency Screen (MCS) to Identify Variables Associated With Injury in Full-time Pre-professional Dancers.
Authors:  Lee L, Reid D, Caldwell J, Palmar P
Prospective studies utilizing standardized injury and exposure measures are needed to consolidate our knowledge of injury incidence and associated risk factors for musculoskeletal injury amongst pre-professional dancers. The purpose of this study was to investigate the injury incidence amongst pre-professional dancers attending a fulltime training school in New Zealand. The secondary purposes of this study were to investigate the relationship between dance exposure and injury risk, and the relationship between risk factors (specifically the MCS outcome scores) and injury risk.  A prospective cohort study of 66 full-time pre-professional dancers was undertaken over one full academic year (38 weeks), included 40 females (mean age 17.78 yrs, SD 1.18) and 26 males (mean age 18.57yrs, SD 1.72). Injury surveillance included both reported and self reported injury data. Dancers were screened using the MCS in the first week of term one.  Eighty-six per cent of dancers sustained one or more injuries. Fifty-nine per cent of all injuries were time-loss. The injury incidence rate was 2.27 per 1000 hours of dance exposure (DEhr) and 3.35 per 1000 dance exposures (DE). There was a significant association between the total number of injuries and total DE per month (B=0.003, 95% CI 0.001 - 0.006, p=0.016). Dancers who had a MCS score < 23 were more likely to be injured than those who scored ≥23 (B= -0.702, 95% CI = -1.354 – -0.050, p=0.035). The author concluded that injury prevalence and incidence was comparable with other international cohorts. The number of dance exposures was more highly associated with injury risk than the hours of dance exposure. The MCS may be a useful tool to help identify dancers at risk of injury.
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Dynamic Hip Adduction, Abduction and Abdominal Exercises From the Hölmich Groin-Injury Prevention Program Are Intense Enough To Be Considered Strengthening Exercises – A Cross-Sectional Study.
Authors:  Krommes K, Bandholm T, Jakobsen MD, Anderson LL, Serner A, Hölmich P, Thorborg K
Training intensity is an important variable in strength training and above 80% of one repetition maximum is recommended for promoting strength for athletes. Four dynamic and two isometric on-field exercises are included in the Hölmich groin-injury prevention study that initially failed to show a reduction in groin injuries in soccer players. It has been speculated that exercise-intensity in this groin-injury prevention program was too low to induce the strength gains necessary to protect against groin-related injuries. The purpose of this study was to estimate the intensity of the six exercises from the Hölmich program using electromyography (EMG) and possibly categorize them as strength-training exercises. Twenty-one adult male soccer players training >5 hours weekly were included. Surface-EMG was recorded from adductor longus, gluteus medius, rectus abdominis and external obliques during isometric adduction against a football placed between the ankles (IBA), isometric adduction against a football placed between the knees (IBK), folding knife (FK), cross-country skiing on one leg (CCS), adduction partner (ADP) and abduction partner (ABP). The EMG-signals were normalized (nEMG) to an isometric maximal voluntary contraction for each tested muscle.  Adductor longus activity during IBA was 84% nEMG (95% CI: 70-98) and during IBK it was 118% nEMG (95% CI 106-130).  For the dynamic exercises, ADP evoked 87% nEMG (95% CI 69-105) in adductor longus, ABP evoked 88% nEMG (95% CI 76-100) in gluteus medius, FK evoked 82% nEMG (95% CI 68-96) rectus abdominis, and 101% nEMG (95% CI 85-118) in external obliques. During CSS <37% nEMG was evoked from all muscles. These data suggest that exercise-intensity of each of the six investigated exercises in the Hölmich groin injury prevention program, except cross-county skiing, is sufficient to be considered strength-training for specific muscle groups in and around the groin region.
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A Comprehensive Instrument for Evaluating Mild Traumatic Brain Injury (mTBI)/Concussion in Independent Adults: A Pilot Study.
Authors:  Borges A, Raab S, Lininger M
One common component of concussion rehabilitation is a computerized cognitive test free of concomitant physical demands. Healthcare professionals may be able to provide more patient-centered care after a diagnosed concussion if specific areas of impairment are identified and treated, such as the physical aspect of neurocognitive function. The purpose of this study was to evaluate the test-retest reliability of a unique combination of neurocognitive assessment tools currently utilized in concussion assessments into one single, inclusive instrument that measures both neurocognitive function and physical capability.  Fourteen individuals (nine males, age: 29 + 17.9, five females, age: 46.0 ± 21.5 years) either with normal cognitive function (NBI) without history of a health event (e.g. cerebral vascular accident/stroke, mTBI) that resulted in brain injury within one year of the study, or who had suffered a health event that has resulted in a medically documented brain injury (BI) participated in the study. Participants completed the full hybrid assessment instrument for a baseline test, and then completed a follow-up test using the same instrument within 72-96 hours of baseline. Test-retest reliability was measured using Pearson product-moment correlations of the first and second testing sessions, and a two-way ANOVA (group between factor: NBI and BI and time within factor: session 1 and session 2) was performed on the summative scores to determine differences between each group.  Test-retest reliability was strong and statistical significant for both the NBI (r = .858, p = .014) and the BI (r = .967, p =.033) groups. There was a significant difference between summative scores for the NBI and BI groups (F1,20 = 42.325, p < .0001).  The authors concluded that the newly created Comprehensive Instrument for Evaluating Mild Traumatic Brain Injury (CIEMTBI) demonstrates good test-retest reliability and was able to discriminate the results between individuals in the NBI and BI groups. Further research, specifically with different samples, is needed to better determine the reliability and diagnostic accuracy of the instrument.
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Strength Profiles in Healthy Individuals With and Without Scapular Dyskinesis.
Authors: Hannah DC, Scibek JS, Carcia CR
Muscular weakness of the shoulder complex is commonly found in patients presenting with scapular dyskinesis; however, little is known regarding muscular performance in healthy individuals with scapular dyskinesis. The purpose of this study was to compare isometric strength measures of the shoulder complex between healthy individuals with and without scapular dyskinesis. It was hypothesized that healthy individuals with scapular dyskinesis would demonstrate decreased isometric strength of the scapular stabilizers and rotator cuff when compared to healthy individuals without scapular dyskinesis.  Forty healthy, college-aged participants were recruited. Sixty-eight percent of subjects (27 of 40) presented with scapular dyskinesis. Thus, a matched-pairs analysis was conducted with 26 subjects (age: 22.00 ± 2.06 y; height: 168.77 ± 8.07 cm; mass: 70.98 ± 13.14 kg; BMI: 24.75 ± 3.04 kg/m2; 6 males; 20 females). The presence of scapular dyskinesis was determined visually using the scapular dyskinesis test with a dichotomous outcome (yes/no). Strength of the scapular stabilizers and rotator cuff was assessed via manual muscle testing using a handheld dynamometer. Force measures obtained with the handheld dynamometer were used to quantify strength. For each muscle tested, the mean peak force of three trials were normalized to body weight and used for data analysis. Additionally, strength ratios were calculated and analyzed. Differences in strength and strength ratios between those with and without scapular dyskinesis were compared using separate two-way mixed ANOVAs with repeated measures.  No significant differences for either strength (F1.83,43.92 = 1.10, p = .34) or strength ratios (F1.83,44.02 = 1.93, p = .16) were observed between those with and without scapular dyskinesis. A significant main effect (F1.83,43.92 = 239.32, p < .01) for muscles tested was observed, and post-hoc analysis revealed significant trends resulting in a generalized order: the upper trapezius generated the greatest amount of force, followed by serratus anterior and middle trapezius, lower trapezius, supraspinatus, medial rotators, and lateral rotators.  The results of this study indicate that differences in shoulder muscle strength do not exist between healthy subjects with and without scapular dyskinesis. Additionally, scapular dyskinesis appears to be prevalent in healthy populations.
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Anodal Transcranial Direct Current Stimulation (tDCS) Increases Isometric Strength of Shoulder Rotator Muscles in Handball Players.
Authors:  Hazime FA, Cunha R, Soliaman RR, Romancini A, Pochini A, Ejnisman B, Baptista AF
Weakness of the rotator cuff muscles can lead to imbalances in the strength of shoulder external and internal rotators, change the biomechanics of the glenohumeral joint and predispose an athlete to injury. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has demonstrated promising results in a variety of health conditions. However few studies addressed its potential approach in the realm of athletics. The purpose of this study was to investigate if transcranial direct current stimulation (tDCS) technique increases the isometric muscle strength of shoulder external and internal rotators in handball athletes. Eight female handball players aged between 17 and 21 years (Mean=19.65; SD=2.55) with 7.1 ± 4.8 years of experience in training, participating in regional and national competitions were recruited. Maximal voluntary isometric contraction (MVIC) of shoulder external and internal rotator muscles was evaluated during and after 30 and 60 minutes post one session of anodal and sham current (2mA; 0.057mA/cm2) with a one-week interval between stimulations. Compared to baseline, MVIC of shoulder external and internal rotators significantly increased after real but not sham tDCS. Between-group differences were observed for external and internal rotator muscles. Maximal voluntary isometric contraction of external rotation increased significantly during tDCS, and 30 and 60 minutes post-tDCS for real tDCS compared to that for sham tDCS. For internal rotation MVIC increased significantly during and 60 minutes post-tDCS. The results indicate that transcranial direct current stimulation temporarily increases maximal isometric contractions of the internal and external rotators of the shoulder in handball players.
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Load-Enhanced Movement Quality Screening and Tactical Athleticism: An Extension of Evidence.
Authors: Glass SM, Schmitz RJ, Rhea CK, Ross SE
Military organizations use movement quality screening for prediction of injury risk and performance potential. Currently, evidence of an association between movement quality and performance is limited.  Recent work has demonstrated that external loading strengthens the relationship between movement screens and performance outcomes. Such loading may therefore steer us toward robust implementations of movement quality screens while maintaining their appeal as cost effective, field-expedient tools. The purpose of the current study was to quantify the effect of external load-bearing on the relationship between clinically rated movement quality and tactical performance outcomes while addressing the noted limitations.  Fifty young adults (25 male, 25 female, 22.98±3.09 years, 171.95±11.46 cm, 71.77±14.03 kg) completed the Functional Movement Screen™ with (FMS™W) and without (FMS™C) a weight vest in randomized order.  Following FMS™ testing, criterion measures of tactical performance were administered, including agility T-Tests, sprints, a 400-meter run, the Mobility for Battle (MOB) course, and a simulated casualty rescue. For each performance outcome, regression models were selected via group lasso with smoothed FMS™ item scores as candidate predictor variables. For all outcomes, proportion of variance accounted for was greater in FMS™W (R2=0.22 [T-Test], 0.29 [Sprint], 0.17 [400 meter], 0.29 [MOB], and 0.11 [casualty rescue]) than in FMS™C (R2=0.00 [T-Test], 0.11 [Sprint], 0.00 [400 meter], 0.19 [MOB], and 0.00 [casualty rescue]).  From the FMS™W condition, beneficial performance effects (p<0.05) were observed for Deep Squat (sprint, casualty rescue), Hurdle Step (T-Agility, 400 meter run), Inline Lunge (sprint, MOB), and Trunk Stability Push Up (all models). Similar effects for FMS™C item scores were limited to Trunk Stability Push Up (p<0.05, all models). The present study extends evidence supporting the validity of load-enhanced movement quality screening as a predictor of tactical performance ability.  Future designs should seek to identify mechanisms explaining this effect.
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EMG of Shoulder Muscles During Reactive Isometric Elastic Resistance Exercises.

Authors:  Mullaney MJ, Perinson C, Kremenic I, Tyler TT, Orishimo K, Johnson C
Traditionally, shoulder isometrics are introduced in the early stages of shoulder rehabilitation. A patient’s isometric torque output is based on a subjective perception of force generation. By utilizing elastic resistance elongation (strain) to standardize force output, clinicians could prescribe shoulder therapeutic isometrics based on % maximum voluntary contraction (%MVC). The purpose of this study was to measure electromyographic (EMG) activity and determine the %MVC during shoulder flexion, external rotation and abduction isometrics at varying lengths of TheraBand® elastic resistance. It was hypothesized that increased elongation of progressive resistance bands would proportionately increase the %MVC of the shoulder musculature. Eight healthy subjects (16 shoulders) (5 females, 3 males; avg. age 29.2) were tested. Surface EMG electrodes were placed over the anterior deltoid, middle deltoid, and infraspinatus muscles. A force transducer was anchored to a stable surface with its corresponding end in series with an extremity strap securely holding the elastic band.  Subjects were asked to maintain shoulder position for the proper isometric contraction (flexion, abduction and external rotation) while taking incremental steps away from the anchored elastic resistance, to the beat of a metronome to clearly marked distances on the floor (50, 100, 150, 200 and 250% of band elongation). This was repeated with yellow, red, green, and blue TheraBand® resistance levels. Maximum voluntary contractions for both force and EMG were collected for each subject in all three test positions. EMG data were normalized and expressed as a %MVC.  For external rotation and flexion, the infraspinatus and anterior deltoid activity increased with band elongation (p<0.01) and progressive colors (p<0.01). The increases in EMG activity with elongation plateaued with the yellow and red bands but continued to increase with the green and blue bands (p<0.01). The increase in infraspinatus and anterior deltoid EMG activity with progressive band color was more apparent for green and blue bands compared with yellow and red band (p<0.01). For the abduction exercise, middle deltoid activity increased with band elongation (p<0.01) and progressive color (p<0.01). In all three exercises, there was an increase in force exerted by the band with increasing length and band color (p < 0.001). However, while there were clear increases in force from red to green to blue, there was no difference in force between yellow and red regardless of elongation (p<0.01). The authors concluded that isometric flexion, external rotation and abduction muscle activity can be accurately prescribed clinically by adjusting the elongation and resistance associated with progressive colors of resistance bands.
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The Effect of Electrical Stimulation Versus Sham Cueing on Scapular Position during Exercise in Patients with Scapular Dyskinesis.
Authors: Walker D, Hickey C, Mason T
Conventional therapeutic exercise programs are commonly used to treat patients with scapular dyskinesis. There are no studies that have examined traditional therapeutic exercise programs with the addition of remote triggered electrical stimulation (ES) to affect the position of the scapula (using spine to scapular border distance as a reference point) during the performance of exercises that have lower upper trapezius (UT) to lower trapezius (LT) ratio exercises. The purpose of this pilot study was to compare scapular position after performance of three low UT/LT ratio therapeutic exercises in two conditions, electrical stimulation (ESTherex) and sham electrical stimulation (ShamTherex) in asymptomatic persons who were positive for scapular dyskinesis. Eleven asymptomatic university students representing 15 scapulae with a positive Scapular Dyskinesis Test were recruited as subjects. Participants were randomized into exercise and electrical stimulation (ESTherex) or exercise and sham electrical stimulation (ShamTherex). Subjects performed side-lying shoulder external rotation and flexion, and prone horizontal abduction with external rotation in both conditions. Scapular position was assessed during active abduction at four angles before and after performance of these exercises. There were no significant differences in scapula to spine distance between ESTherex and ShamTherex groups at 0, 45, 90 and 120 degrees of shoulder abduction.  A between group difference (ESTherex and ShamTherex) approached significance at 45 degrees (p= 0.089, CI=-.152 to 1.88cm) with the post mean measurement of the ShamTherex group (6.44 cm) greater than the post mean measurement of the ESTherex group (5.57cm). The ESTherex showed a significant pre-to-post mean within group improvement in spine to scapula distance at 120 degrees (mean 2.76 cm, t=4.89, p=.003). The authors concluded that electrical stimulation with exercises for scapular dyskinesis showed improvements in spine to scapula distance at 120 degrees of shoulder abduction.
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Reliability and Validity of a Biomechanically Based Analysis Method for the Tennis Serve.
Authors:  Myers NL, Kibler WB, Lamborn L, Smith BJ, English T, Jacobs C, Uhl TL
An observational tennis serve analysis (OTSA) tool was developed using previously established body positions from three-dimensional kinematic motion analysis studies. These positions, defined as nodes, have been associated with efficient force production and minimal joint loading. However, the tool has yet to be examined scientifically. The primary purpose of this investigation was to determine the inter-observer reliability for each node between two health care professionals (HCPs) that developed the OTSA, and secondarily to investigate the validity of the OTSA. Two separate studies were performed to meet these objectives. An inter-observer reliability study preceded the validity study by examining 28 videos of players serving. Two HCPs graded each video and scored the presence or absence of obtaining each node.  Discriminant validity was determined in 33 tennis players using video taped records of three first serves.  Serve mechanics were graded using the OSTA and categorized players into those with good (≥ 5) and poor (≤ 4) mechanics. Participants performed a series of field tests to evaluate trunk flexibility, lower extremity and trunk power, and dynamic balance. The group with good mechanics demonstrated greater backward trunk flexibility (p=0.02), greater rotational power (p=0.02), and higher single leg countermovement jump  (p=0.05). Reliability of the OTSA ranged from K=0.36-1.0, with the majority of all the nodes displaying substantial reliability (K>0.61). This study provides HCPs with a valid and reliable field tool used to assess serve mechanics. Physical characteristics of trunk mobility and power appear to discriminate serve mechanics between players. Future intervention studies are needed to determine if improvement in physical function contribute to improved serve mechanics.
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Do General Medical Practitioners Examine Injured Runners?
Authors:  Videbaek S, Jensen AV, Rasmussen S, Nielsen RO
General Medical Practitioners (GMP) in Denmark perform clinical examinations of patients with musculoskeletal pain. However, the prevalence proportion of examinations caused by running-related injuries remains unknown. The primary purpose of the present study was to estimate the prevalence proportion of consultations in general medical practice caused by running-related injuries. The secondary purpose was to estimate the prevalence proportion of injured runners who consult their GMP that are referred to additional examinations or treatments. An online survey was distributed in October and November 2015 to more than 370 general practitioners and completed by 27. The median prevalence proportion of consultations caused by running-related injuries in the prior two weeks was 0.80% [25th percentile = 0.00%; 75th percentile = 1.43%]. Ten (37%) GMPs reported to refer between 0-24% of the injured runners to additional examination or treatment, whereas 13 (48%) of GMPs referred between 25-49% and 4 (15%) referred 50-74% of injured runners. Although a very small part (<1%) of the GMPs consultations were related to running injuries, this result suggests that injured runners seek advice in the primary health-care system in Denmark. As a consequence, physiotherapists willing to treat runners with running-related injuries may inform the GMPs in their local community about the treatment possibilities they offer. The low response-proportion highlights the challenges recruiting GMPs willing to respond to questionnaires on running-related injuries. It is plausible to assume that the estimates reported in the present study are overestimated owing to selection bias.
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CASE STUDIES
Impairment Based Examination and Treatment of Osteochondritis: A Case Series.

Authors:  Zaruba RA, Wilson E
Costochondritis is commonly encountered in primary care, but is not routinely referred to physical therapy. Costochondritis can last from several weeks to several months, limiting the patient's ability to perform tasks at work and home. The purpose of this case series was to identify common impairments and examine the effects of treatment in subjects with costochondritis. Eight subjects were referred to physical therapy for costochondritis (mean duration of condition 6.3±1.3 months) and reported that their condition restricted their ability to participate in occupational and fitness activities. The numerical pain rating scale (NPRS) and patient-specific functional scale (PSFS) were administered at the initial evaluation and at discharge. The Global Rating of Change (GROC) scale was only administered at discharge. All subjects received treatment directed at the cervicothoracic spine and ribcage and consisting of manual therapy and exercise.  Subjects were seen 4.8±0.9 (mean±standard deviation) times. All subjects showed clinically meaningful changes at discharge. The mean NPRS decreased by 5.1±1.7 points; the mean PSFS increased by 5.3±1.4 points; and the mean GROC was 5.9±1.1 points. All subjects were able to return to participation in previous activities without restrictions at discharge. The results of this case series suggests that PT utilizing an impairment based examination and treatment approach including manual therapy and therapeutic exercise may facilitate the resolution of costochondritis.
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Dry Needling Increases Muscle Thickness in a Subject with Persistent Muscle Dysfunction: A Case Report.
Authors:  Cross KM, McMurray M
Muscle dysfunction is very common following musculoskeletal injury. There is very little evidence to suggest that muscle function may be positively impacted by soft tissue interventions, such as dry needling.  The purpose of this case report is to describe the immediate effect of dry needling on muscle thickness in a subject after shoulder surgery. A 22 year-old competitive gymnast presented seven months post shoulder surgery with significant impairments and functional limitations. Previous physical therapy focused on restoration of range of motion and strength using general exercise interventions, but the subject had persistent tightness and weakness of musculature of the shoulder complex. A subject-specific physical therapy program including manual physical therapy resulted in significant initial improvement, but lack of flexibility and weakness of the rotator cuff limited progress. Dry needling was used to address persistent myofascial trigger points. Immediately after dry needling the infraspinatus, the muscle’s thickness was significantly improved as measured by rehabilitative ultrasound imaging. There was a corresponding increase in force production of external rotation at 90 degrees of abduction. The results of this case report suggest that dry needling contributed to improvement in muscle thickness and strength in a subject with muscle dysfunction following an injury.
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Aortic Injury due to Paragliding: A Case Report.
Authors:  Omori K, Jitsuiki K, Majima T, Takeuchi I, Yoshizawa T, Ishikawa K, Ohsaka H, Tambara K, Yanagawa Y
A 64-year-old male fell from an altitude of 10 m while paragliding after stalling due to the wind. The purpose of this case report is to describe the outcomes after multiple injuries sustained during a paragliding accident, including a potentially life-threating injury to the thoracic aorta. The subject sustained a bite wound on his tongue, injuries to his chest (left side) and back, and a right forearm deformity. Enhanced whole body computed tomography (CT) revealed fractures of the bilateral laminae of the second and third cervical bones, right first rib, the tenth thoracic vertebral body (compression type), second lumbar vertebral body (burst type) and the right radius, Other injuries included an injury to the thoracic aortic arch and the presence of intraabdominal fluid collection without perforation of the digestive tract.  Endovascular treatment was selected for the aortic injury because of multiple injuries.  Immediate management included hypotensive rate control therapy using calcium and a beta blocker. On the fourth hospital day, the subject underwent deployment of a stent-graft to the aorta and subsequent surgical immobilization for the lumbar burst fracture. He also underwent surgical immobilization of the radial fracture and was discharged on the 28th hospital day. First responders or physicians should consider the possibility of aortic injury when treating patients who suffer falls while paragliding and provide appropriate management. Failure to provide appropriate management of an aortic injury could result in death. 
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CLINICAL COMMENTARY
Superior Capsule Reconstruction for Massive Rotator Cuff Tears – Key Considerations for Rehabilitation.
Authors:  Pogorzelski J, DelVecchio BM, Hussain ZB, Fritz EM, Godin JA, Millett PJ
Superior capsule reconstruction is a recently-developed surgical technique for the treatment of massive, irreparable rotator cuff tears. So far, biomechanical cadaveric studies and clinical outcomes results have been promising concerning integrity, stability, and ROM after superior capsule reconstruction. As this technique has only been recently developed, an evidence-based rehabilitation protocol has not been previously designed. Thus, the purpose of this clinical commentary is to provide an overview of superior capsule reconstruction and to propose a rehabilitation program based on the available scientific evidence. The existing evidence is supplemented by the experience of the senior author who has performed more than forty superior capsule reconstruction procedures to date. This proposed rehabilitation protocol consists of four distinct phases, focusing on maximal protection, range of motion and muscular endurance, muscular strength and return to activity.
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Rehabilitation following Medial Patellofemoral Ligament Reconstruction for Patellar Instability.
Authors:  Manske R, Prohaska D
Patellar instability is a common problem seen by physical therapists, athletic trainers and orthopedic surgeons. Although following an acute dislocation, conservative rehabilitation is usually the first line of defense; refractory cases exist that may require surgical intervention. Substantial progress has been made in the understanding of the medial patellofemoral ligament (MPFL) and its role as the primary stabilizer to lateral patellar displacement. Medial patellofemoral ligament disruption is now considered to be the essential lesion following acute patellar dislocation due to significantly high numbers of ruptures following this injury. Evidence is now mounting that demonstrates the benefits of early reconstruction with a variety of techniques. Recently rehabilitation has become more robust and progressive due to our better understanding of soft tissue reconstruction and repair techniques. This manuscript describes rehabilitation following this unique surgery that has allowed many to return to recreational and competitive activities following incidences of patellar instability.
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