VOLUME THIRTEEN NUMBER TWO

 
2018_V13N2-1

April 2018

ORIGINAL RESEARCH
Electromyography of the Hip and Thigh Muscles During Two Variations of the Lunge Exercise: A Cross-Sectional Study.

Authors:  Krause DA, Elliott JJ, Fraboni DF, McWilliams TJ, Rebhan RL, Hollman JH
doi: 10.26603/ijspt20180137
The lunge is a closed kinetic chain exercise that athletes frequently use as part of training and rehabilitative programs. While typically performed on a stable surface, modifications include the use of balance platforms to create an unstable surface and suspension equipment. Suspension training exercises are theorized to be higher demand exercises and may be considered a progression from exercises on stable surfaces. Comparison of muscle recruitment between the suspended lunge and the standard lunge has not been reported. Therefore, the purpose of this study was to compare differences in muscle recruitment between a standard lunge and a suspended lunge. It was hypothesized that hip and thigh muscle recruitment with a suspended lunge would be greater than a standard lunge due to less inherent support during the suspended lunge exercise. Thirty healthy participants (15 male and 15 female) voluntarily participated in this study. Electromyographic (EMG) muscle recruitment was measured in five hip and thigh muscles while performing a standard and suspended lunge. EMG was normalized to a maximal voluntary isometric contraction. The authors found that recruitment was significantly greater in the suspended lunge condition compared to the standard lunge for the hamstrings (p <.001), gluteus medius (p <.001), gluteus maximus (p<.001), and adductor longus (p <.001). There was no significant difference in rectus femoris recruitment between conditions (p=.154). The authors concluded that the suspended lunge recruits hip muscles to a greater extent than a standard lunge.

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Comparison of Clinical Fatigue Protocols to Decrease Single-Leg Forward Hop Performance in Healthy Individuals.
Authors:  White AK, Klemetson CJ, Farmer B, Katsavelis D, Bagwell J, Grindstaff TL
doi: 10.26603/ijspt20180143
Return to activity decisions after anterior cruciate ligament reconstruction (ACL-R) are limited by functional performance tests that often are performed in a non-fatigued state.  Fatigue can improve test sensitivity, but current methods to induce fatigue typically are bilateral tasks or focus on the quadriceps muscle in isolation. The purpose of this study was to determine the effects of a two-minute lateral step-down fatigue test compared to a 30-second side-hop test on single-leg forward hop distance in healthy individuals. It was hypothesized that participants would demonstrate decreased hop distance with both tests, but the two-minute lateral step-down fatigue test would result in greater deficits in single-leg forward hop distance. Twenty healthy participants (16 females, 4 males; age=23.7±3.0 years, height=153.8±36.2 cm; mass=64.4±12.8 kg; Tegner=6.8±1.2) were asked to perform single-leg forward hop for distance pre- and post-fatigue. Participants were randomly assigned to one of the two fatigue tests, 30-second side-hop or 2-minute lateral step-down test, during the first visit. They returned within a week and performed the same sequence of tests but underwent whichever fatigue test was not assigned at the prior visit.   There was a significant decrease (p < 0.001) in single-leg forward hop distance following the 30-second side-hop test (pre=134.1±23.7 cm, post=126.2±24.4 cm) and the two-minute lateral step-down test (pre=135.0±26.1 cm, post=122.7±27.4 cm). The decrease in hop distance was significantly greater (p < 0.001) for the two-minute lateral step-down test compared to the 30-second side-hop test.  The authors concluded that the two-minute lateral step-down test resulted in a greater decrease in hop performance compared to the 30-second side-hop test. The results establish a threshold for expected changes that occur in a healthy population and that can then be compared with an injured athlete population. The two-minute lateral step-down exercise may be an effective method of inducing fatigue to better mimic performance in a sports environment to inform return-to-sport decisions.

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Relationship Between the Lower Quarter Y-Balance Test Scores and Isokinetic Strength Testing in Patients Status Post ACL Reconstruction.
Authors:  Myers H, Christopherson Z, Butler RJ
doi: 10.26603/ijspt20180152
Ankle ACL injuries are common among sports populations and achieving adequate lower extremity strength is important prior to return to play. Access to isokinetic testing equipment that measures lower extremity strength is limited. Screening tools that measure functional criteria are accessible to clinicians, however the tools’ relationship to strength constructs have not been investigated in an ACL reconstructed (ACLR) population. The primary objective of this study was to determine if relationships exist between isokinetic peak knee extension torque (PKET), peak knee flexion torque (PKFT), hamstring to quadriceps (HQ) ratios, and YBT-LQ performance following ACLR. The secondary objective was to observe differences in isokinetic strength ability between high and low performers on the YBT-LQ. Medical records of forty-five ACL-reconstructed subjects, between five-12 months post-surgery were queried for functional assessment data collected during the institution’s standard outcome testing battery. Variables of interest included: demographic and anthropomorphic measures, YBT-LQ performance, and involved limb isokinetic PKET, PKFT, and HQ ratios. Performance on each measure, as well as asymmetry between sides, was analyzed using a correlation matrix. Statistically significant (p<0.01) relationships were identified between YBT-LQ anterior reach asymmetry and the PKET deficit (r=0.264).  PKET and PKFT on the involved limb correlated to performance of anterior reach (r=0.591, p<0.01)(r=0.493, p<0.01), posteromedial reach (r=0.498, p<0.01)(r=0.577, p<0.01), and posterolateral reach (r=0.294, p<0.05)(r=0.445, p<0.01) respectively. Similar relationships existed on the uninvolved side, but to a lesser extent. High and low performers on the YBT-LQ demonstrated lower and higher extension torque deficits, respectively. While each test measures unique constructs, there are associations between components of the tests.  In the ACLR population, both the YBT-LQ and isokinetic strength testing can expose asymmetries and impact return to play decision making.

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Do Males With Patellofemoral Pain Have Posterolateral Hip Muscle Weakness?
Authors:  Hoglund LT, Burns RO, Stepney AL
doi: 10.26603/ijspt20180160
Patellofemoral pain is common in physically active adults. Females with patellofemoral pain have been shown to have posterolateral hip muscle weakness, but there is a paucity of research examining hip muscle strength in males with patellofemoral pain. The purpose of this study was to examine posterolateral hip muscle strength in males with patellofemoral pain compared to asymptomatic males. It was hypothesized that males with patellofemoral pain would have decreased strength of the hip extensor, hip external rotator, and hip abductor muscles compared to healthy, asymptomatic males. Thirty-six adult males with patellofemoral pain and 36 pain-free males participated in the study. The patellofemoral pain group were required to have retropatellar pain reproduced by activities that loaded the patellofemoral joint (squatting, descending stairs, etc.). Peak isometric torque of the hip extensors, hip external rotators, and hip abductors was measured with an instrumented dynamometer. Torque was normalized by body mass and height. Between-group differences were analyzed with parametric or non-parametric tests, as appropriate. The level of significance was adjusted for multiple comparisons.  Hip extensor torque was significantly reduced in the patellofemoral pain group compared to the control group (p = .0165). No differences were found between groups for the hip external rotators or hip abductors (p > .0167). The authors concluded that males with patellofemoral pain appear to have weakness of the hip extensors, but unlike females with patellofemoral pain, they do not appear to have weakness of the hip abductors or hip external rotators. The findings of this study suggest that muscle strength factors associated with patellofemoral pain in males may be different from muscle strength factors in females. Clinicians examining and designing plans of care for male patients with patellofemoral pain should consider that the hip abductors and hip external rotators may not be weak in men with this condition.

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Comparison of Lumbopelvic Rhythm Among Adolescent Soccer Players With And Without Low Back Pain.
Authors:  Tojima M, Torii S
doi: 10.26603/ijspt20180171
Hip–spine incoordination can cause low back pain (LBP) in adolescents. Hip–spine coordination, including the lumbopelvic rhythm (LPR) and the lumbar–hip ratio (LHR), can be used to assess lower limb and spine function. However, there are no reports of the values of LPR or LHR in adolescent soccer players with and without LBP.  The purpose of this study was to clarify the effect of LBP on LPR and LHR during trunk extension among adolescent soccer players. One hundred and nine adolescent soccer players were recruited and divided into two groups, one with and one without LBP. Using three-dimensional motion analysis, participants range of motion (ROM) of the lumbar spine (LS) and hip during trunk and hip extension was measured to calculate the LPR and LHR. Paired, two-tailed t-tests were used to compare the LS and hip ROM between the non-LBP and LBP groups, two-way repeated measures analysis of variance was used to compare time with the non-LBP and LBP groups for LHR, and linear prediction was used to describe the LPR. The maximum LS ROM in the LBP group was significantly less than that in the non-LBP group by 6.6° (p = .005). There was no difference in the maximum hip ROM between the groups (p = .376). The LHR did not change during trunk extension (F [4, 428] = 1.840, p = .120), the mean LHR was 4.6 in the non-LBP group and 3.7 in the LBP group, and there was no difference between the groups (p = .320). The linear function of the LPR indicated, that when the hip joint was extended by 1°, the LS extended by 3.2° in the non-LBP group (R2 = .997, p < .001) and 2.8° in the LBP group (R2 = .999, p < .001). The authors found that LBP inhibited lumbar motion relative to hip extension as LPR was smaller in the LBP group than in the non-LBP group. However, there was no difference between the groups in LHR because inter-individual variability affected the LHR.

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Radiographic Hip Osteoarthritis is Prevalent, and is Related to Cam Deformity 12-24 Months Post-Hip Arthroscopy.
Authors:  Kemp JL, Crossley KM, Agricola R, Geuskens F, van Middlekoop M
doi: 10.26603/ijspt20180177
The prevalence of radiographic hip osteoarthritis (OA), and its relationship with outcomes after hip arthroscopy is unclear. The aims of this study were to: (i) describe the prevalence of OA and cam deformity 12-24 months post hip arthroscopy; (ii) to determine the association between radiographic OA and cam deformity, surgical and clinical findings and symptoms; and (iii) describe the differences between legs for radiological and clinical findings. Seventy patients, mean age 36.7(range 18-59) years, 12-24 months post-arthroscopy. Outcomes were collected prospectively via clinical and radiographic examination. (i)Prevalence of OA and cam deformity measured on and anteroposterior pelvic radiographs; (ii)Hip disability and Osteoarthritis Outcome Score (HOOS) and International Hip Outcome Tool (iHOT-33) patient-reported outcomes (PROs); (iii)hip internal and external rotation range of motion (ROM). Associations between OA and surgical findings, PROs and clinical findings were determined using generalized estimated equations, between operated and non-operated sides. The prevalence of OA was 37%. The likelihood of OA 12-24 months after surgery was positively associated with alpha angle size 12-24 months post-hip arthroscopy surgery (p=0.010). There were no differences between operated and non-operated legs in radiographic or clinical findings. The authors concluded that radiographic OA is prevalent in a population which has undergone hip arthroscopy. Increased OA severity is associated with a higher alpha angle 12-24 months post-surgery.

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Immediate and Short Term Effect of Dry Needling on Triceps Surae Range of Motion and Functional Movement:  A Randomized Trial.
Authors:  Lake AD, Myers H, Aefsky B, Butler R
doi: 10.26603/ijspt20180185
Impaired Dry needling (DN) has been established as an effective treatment for myofascial pain, however, there are no studies thus far investigating the benefit to movement and motor control. The primary purpose of this study was to compare differences in a series of outcomes between dry needling, dry needling and stretching, and stretching only in a sample of healthy males. A secondary purpose was to compare change over time.  Thirty healthy male subjects were randomly assigned to one of three intervention groups:  DN, stretching, or combination DN +stretching. Subjects in the DN group and DN+stretch group received DN to a palpated trigger point (TrP) in the triceps surae to elicit local twitch response. Subjects in the stretch group and DN+stretch group were instructed in a home stretching program for gastrocnemius and soleus muscles. All groups were tested for dorsiflexion range of motion and performed functional tasks (overhead deep squat, and Y-Balance test, Lower Quarter) prior to intervention, directly after intervention, and four days post intervention. Group comparisons were performed using a repeated measure Analysis of Variance and a partial eta squared calculation for effect size. For all measures a p-value of <0.05 was used to determine significance. Cohen’s criteria were used to categorize strength of effect size. There were no statistically significant differences among groups for range of motion nor functional measures, with the exception of the deep squat. Proportionally, the DN group improved significantly in deep squat performance (p<0.01) compared to the other groups. Time oriented improvements were seen for the YBT posterior-lateral reach (p=0.02) only. Between groups effect sizes ranged from 0.02 (small) to 0.17 (large).  The authors concluded that the inclusion of DN did not markedly influence range of motion nor functional assessment measures, excluding those seen during the overhead deep squat. Effect measures suggest the lack of significant findings may be an issue of statistical power.

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The Degree of Tendinosis is Related to Symptom Severity and Physical Activity Levels in Patients with Midportion Achilles Tendinopathy.
Authors:  Corrigan P, Cortes DH, Pontiggia L, Silbernagel KG
doi: 10.26603/ijspt20180196
Achilles tendinopathy negatively affects a person’s ability to be physically active. However, remaining physically active during the rehabilitation process does not impact clinical outcomes when a pain-monitoring model is followed. There are several factors, such as the progression of pain and structural changes, kinesiophobia, functional impairments, or medical advice, which may explain why some patients become physically inactive while others maintain a physically active lifestyle. The purposes of this study were 1) to compare the clinical presentation of patients with Achilles tendinopathy with high and low activity levels 2) to examine the relationship between tendon thickening and symptom severity in patients with Achilles tendinopathy and 3) to determine the proportion of patients with Achilles tendinopathy who have a high degree of kinesiophobia and if this proportion differs based on activity level.  Fifty-three patients with Achilles tendinopathy were dichotomized into low activity (n=30) and high activity (n=23) groups based on their physical activity level. Patient characteristics, symptom severity, kinesiophobia, tendon thickening, and lower leg function were quantified and analyzed to test the study hypotheses.  Patients with low activity levels had greater tendon thickening and a larger body mass compared to patients with high activity levels. There were no differences in symptom severity, kinesiophobia, or lower leg function between groups. A negative relationship (r=-0.491; p<0.001) was found between tendon thickening and symptom severity. Thirty-eight percent of patients demonstrated a high degree of kinesiophobia, but the proportion did not differ between groups. The authors concluded that patients with Achilles tendinopathy who have low physical activity levels demonstrate greater tendinosis than patients who are highly active. These structural changes are negatively associated with symptom severity. However, symptom severity, kinesiophobia, and functional deficits do not differ between patients with different activity levels.

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A Mechanism for Ligamentum Teres Injuries in Femoroacetabular Impingement: An Anatomical Study.
Authors:  Martin RL, McGovern RP, Martin HD, Kivlan BR
doi: 10.26603/ijspt20180208
Femoroacetabular impingement can produce abnormal biomechanics that lead to compensatory injuries around the hip and pelvis. Ligamentum teres pathologies are commonly associated with these bony deformities but a mechanism for injury has not been described in the literature. The purpose of this study was to describe a potential mechanism behind ligamentum teres injury and impingement between the femoral neck and acetabulum. Twenty-six hips from 15 embalmed cadavers (8 male; 7 female) with lifespans between 55-93 years were skeletonized. The hip was placed in 90° flexion and 0° abduction/adduction and internally rotated until the femoral head neck contacted the acetabulum. This position of impingement with respect to internal rotation was recorded with a goniometer. The hip was then further internally rotated until end range of motion was achieved and again the position of internal rotation recorded with a goniometer. The positions of internal rotation at which impingement occurred (mean 9°; SD 4.2; Range -2° to 15°) when compared to end range (mean 21°; SD 5.7; Range 5° to 27°) were significantly different (p<0.005; t=14.8). In all the hips, after impingement occurred the site of bony contact between the femoral neck and acetabulum acted as a pivot point. The femoral head was levered inferiorly with a loss of the rotational center within the acetabulum, as internal rotation continued. This movement of the femoral head caused the ligamentum teres to tighten and restricted further movement. Movement into internal rotation beyond this end position caused rupture of the ligamentum teres. Therefore, internal rotation range of motion can occur beyond the position of impingement and resulted in abnormal inferior movement of the femoral head and tightening of the ligament teres. This study provides cadaveric evidence for the mechanism of ligamentum teres injury in those with who engage in activities that required motion beyond the point of impingement.

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The Effects of an Aquatic Manual Therapy Technique, AquaStretch™ on Recreational Athletes with Lower Extremity Injuries.
Authors:  Alejo T, Shihanek C, McGrath M, Heick JD
doi: 10.26603/ijspt20180214
When paired together, manual therapy and exercise have been effective for regaining range of motion (ROM) in multiple conditions across varied populations. Although exercise in an aquatic environment is common, research investigating manual therapy in this environment is limited. There is little evidence on AquaStretch™ an aquatic manual therapy technique, but anecdotal clinical evidence suggests its effectiveness.  The purpose of this study was to investigate the effects of AquaStretch™ on ROM and function in recreational athletes with self-reported lower extremity injury and pain.  Injured recreational athletes participated in a 30-minute intervention session of AquaStretch.™ Injuries ranged from ankle (sprains and overuse), knee (contusions, sprains, and overuse), and hip conditions (contusions, overuse, and pain). Before a single intervention (preintervention) and within 24 hours after the intervention (postintervention), participants completed the following patient-reported outcome instruments: the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Ability Measure (FAAM) Sports subscale. AROM measurements of the ankle, knee, and hip and the following muscle length tests were measured: Ober’s test, measurement of the popliteal angle, and he modified Thomas test. Finally, the overhead deep squat test was performed as a test of function. Twenty-six recreational athletes with lower extremity injuries of the ankle, knee, and hip, aged 18-60 years (18 males, 8 females, mean age 27.4 years) completed the study. The overall group by time interaction for the mixed-model Generalized Estimating Equations analysis was statistically significant for the LEFS (all p<.002) and for the FAAM Sports subscale (p<.01).  There were no statistically significant time (pre vs post) by group interactions for range of motion and other measures, including the Ober’s test, the overhead deep squat test, popliteal angle, and the modified Thomas test for injured athletes. The authors cocluded that one session of AquaStretch™ in recreational athletes improved the patient-rated outcome measures of function specifically the LEFS and FAAM Sports subscale. These results suggest that AquaStretch™ may be an effective form of manual therapy to improve lower extremity function in injured athletes.  

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The Effect of Tackling Training on Head Accelerations in Youth American Football.
Authors:  Schussler E,  Jagacinski RJ, White SE, Chaudhari AM, Buford JA, Onate JA
doi: 10.26603/ijspt20180229
Many organizations have introduced frameworks to reduce the incidence of football related concussions through proper equipment fitting, coach education, and alteration of tackling technique. The purpose of this study was to examine the effects of training in a vertical, head up tackling style on the number of head accelerations experienced while tackling in a controlled laboratory situation. The authors hypothesized that training in a head up tackling technique would reduce the severity of head acceleration experienced by participants. Twenty-four participants (11.5±0.6 years old, 60.5±2.2 in, 110±18.4 lbs.) with previous playing experience completed a one-day training session on tackling technique utilizing a tackling dummy. A subgroup of these participants completed an additional two days of training with a 48 hour retention test.  Head accelerations were analyzed at baseline and end of training. Feedback consisted of verbal feedback utilizing the Qualitative Youth Tackling Scale (QYTS) and video tackling playback. A significant reduction in the number of peak linear head accelerations over 10 g and peak rotational head accelerations over 1885 deg/s2 were found in dummy tackling after training in both the one day and three day training regimens. A significant change in QYTS tackling form score was found between pretest and post-test (p=0.004). Participants with larger steps had a 2.28, 4.42 and 4.14 increased odds ratio of sustaining head accelerations over 10, 15 and 20 g respectively.  Training in a vertical, head up tackling style decreased the number of head accelerations over threshold values sustained while tackling; decreased step length may be the driving factor in the effectiveness of this tackling form.  

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Inter-rater Agreement and Validity of a Tackling Performance Assessment Scale in Youth American Football.
Authors:  Schussler E, Jagacinski RJ, White SE, Chaudhari AM, Buford JA, Onate JA
doi: 10.26603/ijspt20180238
Long term neurologic injury and concussion have been identified as risks from participation in American football. Altering tackling form has been recommended to reduce the risk of neurologic injury caused by head accelerations when tackling. The purpose of this research is to determine the inter-rater agreement and validity of the Qualitative Youth Tackling System (QYTS), a six- item feedback scale to correct tackling form, when utilized by novice and expert raters. The authors hypothesized that experienced raters will have higher levels of agreement with each other and with motion capture when compared to novice raters. Both novice and experienced raters viewed video of youth athletes (ages 9-13) tackling a dummy in a laboratory setting along.  The raters identified successful performance according to a binary rating scale for each component. Analysis of both the raters’ agreement with each other and with an objective motion capture measure were completed. Fliess’ Kappa measures between all raters were found to be moderate for head placement (k=.48), fair for cervical extension (k=.38), trunk inclination (k=.37), shoulder extension (k=.27) and step length (k=.29), and there was no agreement for pelvic height (k=.-16). When compared to the dichotomized validation measures of each of the six components provided by the motion capture system the average Cohen’s Kappa agreement was substantial for pelvic height (k=.63), fair for step length (k=.34), and cervical extension (k=.40),  and trunk inclination (k=.35), and slight for shoulder extension (k=.16). The experienced raters outperformed the novice raters in all categories. The results of this study indicates skilled raters are better able to identify the movement patterns included in the QYTS when compared to a validation measure as well have higher rates of inter-rater agreement than novice raters.  

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CASE SERIES / STUDIES
The Effects of Blood Flow Restriction Training on Functional Improvements in an Active Single Subject with Parkinson Disease.

Authors:  Douris PC, Cogen ZS, Fields HT, Greco LC, Hasley MR, Machado CM, Romagnuolo PM, Stamboulis G, DiFrancisco-Donoghue J
doi: 10.26603/ijspt20180247
Blood flow restriction (BFR) applied during low intensity exercise produces hypertrophy and strength gains equivalent to traditional training. Previous research has shown the positive effects of BFR on younger and older adults. However, the effectiveness of BFR on subjects with Parkinson Disease (PD) has not been investigated. The purpose of this case study was to determine the effects of BFR on a recreationally active person with PD in regards to functional improvements and safety. The hypothesis was that BFR training will demonstrate improvements in motor function, gait and endurance, while decreasing symptoms associated with Restless Leg Syndrome (RLS) in a subject with PD. The subject was an active 65-year-old male recreational boxer diagnosed with PD. Baseline data were measured on day one. The intervention (Phase B) consisted of five, two-minute bouts of walking on treadmill with lower extremity BFR cuffs interspersed with 1 minute rest, three times a week for six weeks, at 0 grade incline, and speed of 50 meters/min. The pressure increased from the initial 120 to 160 mmHg at the end of the phase B as per the subject’s tolerance. A four-week baseline phase (A) without the BFR intervention followed phase B. The outcome measures which were measured every two weeks over the 10 weeks included: Timed Up and Go Test, 6-Minute Walk Test, 30-Second Chair Stand Test, and the RLS Questionnaire. All outcome measures steadily improved every two weeks during the six week intervention phase and steadily declined when the intervention was removed during the second four week baseline phase according to visual inspection of the graphed data points. The subject enjoyed and tolerated the intervention well without any adverse effects.  The results suggest that BFR training can produce functional improvements, reduce restless leg syndrome symptoms and can be safely utilized with a subject with PD who wished to maintain his ability to remain recreationally active.

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Clinical Decision Making and Differential Diagnosis in a Cyclist with Upper Quarter Pain, Numbness, and Weakness: A Case Report.
Authors:  Briggs MS, Rethman KK, Lopez MT
doi: 10.26603/ijspt20180255
Differentiating between cervical nerve root and peripheral nerve injuries can be challenging. A phenomenon known as double crush syndrome may increase the susceptibility to injury and symptoms at other locations along the course of a nerve. The purpose of this case report was to describe the physical therapy differential diagnosis and management of a cyclist with upper extremity pain, weakness, and paresthesia. The subject was referred to physical therapy with a diagnosis of cervical disc disease. His chief complaints were chronic neck and right shoulder pain as well as a recent onset of right hand numbness and weakness following 100-mile bike ride one month prior. Diagnostic imaging revealed multi-level degenerative changes of the cervical spine. Initial electromyography and nerve conduction studies (EMG/NCS) indicated right ulnar neuropathy at the elbow. The ultimate incorporation of ulnar nerve mobilizations in various positions immediately decreased symptoms. In light of the subject’s improvement after ulnar nerve mobilizations, imaging findings, and EMG/NCS findings, the subject’s presentation was consistent with a double crush syndrome with C8 nerve root compression and distal ulnar nerve compression at the elbow.  The subject demonstrated full resolution of all symptoms, 0% disability on the Neck Disability Index, 8.3% disability of the Disabilities of the Arm, Shoulder, and Hand questionnaire, normal EMG/NCV findings, and unrestricted return to work and endurance cycling at three months and maintained at one year. He did not require hand surgery.   This case report highlights the importance of continual clinical re-examination and re-assessment with ancillary diagnostic testing, especially if chosen interventions are not eliciting desired responses. The identification of key risk factors, such as occupation and recreational activities is imperative in achieving the most efficacious clinical treatment. In this case, the recognition of a double crush syndrome assisted in optimizing the physical therapy plan of care and the subject ultimately achieving full recovery.

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Clinical Decision Making and Treatment in a Runner with Hip Pain and Neuromuscular Control Dysfunction: A Case Report.
Authors:  Vannatta CN, Haberl M
doi: 10.26603/ijspt20180269
The incidence of running related injuries remains high despite numerous efforts to understand the mechanical contributors to the etiology of these injuries. In light of continued running injury, theories of neuromuscular control, or movement patterns, have been suggested as possible contributors to running related injuries. However, the clinical decision making determining when altered neuromuscular control strategies may be affecting a runner’s symptoms has not been completely described. Therefore, the purpose of this case report is to describe the clinical reasoning within the ICF framework for a runner with hip pain and neuromuscular control dysfunction. A 47-year-old, experienced, female runner presented with posterior hip pain and radiating posterior thigh pain limiting her ability to participate in running and threatened her goal to run in an upcoming marathon. Several features of her examination indicated soft tissue muscular irritation of the posterior hip complex related to impaired balance and control of the lower quarter during functional movement and running activities consistent with a neuromuscular control dysfunction. Her initial Focus on Therapeutic Outcomes (FOTO) score was 69 with predicted change score of +7. The subject was able to achieve her goals including a return to participation in her weekly running routine and competing in a marathon race. Objective examination features of range of motion, strength, and control of movement were all improved. Her reported function was greatly improved with a final FOTO score 98. The diagnosis and treatment of running related injuries remains a clinical challenge. This case report describes the examination and clinical reasoning processes used for diagnosing neuromuscular control dysfunction and proposes a treatment progression to address this functional limitation. The decision making scheme is also structured to follow the International Classification of Functioning, Disability, and Health.

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LITERATURE REVIEW
Evaluating the Progress of Mid-Portion Achilles Tendinopathy During Rehabilitation: A Review of Outcome Measures for Self- Reported Pain and Function – A Literature Review.
Authors:  Murphy M, Debenham J, Docking S, Travers M, Gibson W
doi: 10.26603/ijspt20180283
Management of mid-portion Achilles tendinopathy is a challenge for both clinicians and researchers. Alteration in tendon structure, muscle performance and pain processing mechanisms have been suggested as mechanisms driving improvement in pain and function. However, few trials have used consistent outcome measures to track changes in pain and function. The objective of this literature review was: 1) To identify all outcomes measures used in trials utilizing exercise-based interventions for mid-portion Achilles tendinopathy (AT) that assess self-reported pain and function and to report on the reliability and validity of the identified measures, and 2) Propose measures to optimally assess self-reported pain and function in patients with AT. Three major electronic databases were searched from inception until May 2016 for studies using isometric, eccentric or isotonic loading protocols for mid-portion AT. Forty-six studies were included and all outcome measures assessing self-reported pain and function were extracted. While a variety of outcome measures have been used, few have provided reliability data and most are inaccessible to clinicians. There is evidence to suggest that the Victorian Institute of Sports Assessment- Achilles (VISA-A) is the only valid and reliable measure of self-reported pain and function for people with mid-portion AT. No other outcome measures have been validated in mid-portion AT. The VISA-A remains the gold standard for assessing pain and function in mid-portion AT. However, while the validity or reliability of the Numerical Rating Scale (NRS) of pain during a functional task has not been established it may be a better measure of immediate treatment effect.

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CLINICAL COMMENTARY
Post-Operative Criterion Based Rehabilitation of ACL Repairs: A Clinical Commentary.
Authors:  Bousquet BA, O’Brien L, Singleton S, Beggs M
doi: 10.26603/ijspt20180293
The anterior cruciate ligament (ACL) is the most commonly reconstructed ligament of the knee. Most often, the goal of surgical reconstruction is to recreate stability within the knee and prevent joint degeneration. To date, clinical studies have not demonstrated the ability of various reconstruction techniques in establishing complete knee stability when comparing rates of osteoarthritis. Rates of osteoarthritis commonly resemble those of knees which have not be reconstructed and in this light, may not demonstrate a successful outcome. As modern medicine continues to develop and in the understanding of underlying biological processes grows, some surgeons have turned their attention back to an ACL repair technique. The purpose of this clinical commentary is to discuss the parameters associated with a phase progression for an isolated ACL repair. Physiological healing time frames, along with objective clinical assessment, following a criterion-based progression is described in accordance with post-operative healing parameters to serve as a reference for a rehabilitation specialist.

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Non-operative Treatment for Injuries to the In-Season Throwing Shoulder: A Current Concepts Review with Clinical Commentary.
Authors:  Stone MA, Jalali O, Alluri RK, Diaz PR, Omid R, Gamradt SC, Tobone JE, Weber A
doi: 10.26603/ijspt20180306 
Repetitive overhead throwing generates tremendous demands on the shoulder joint of the overhead athlete. Clinicians, therapists, and medical staff are charged with optimizing a throwing athlete’s shoulder mobility and stability to maximize performance and prevent injury. Modifiable risk factors such as strength asymmetry, glenohumeral range of motion deficits, and scapulothoracic joint abnormalities contribute to the overhead athlete’s predisposition to shoulder injury. Most shoulder injuries in the overhead thrower can be successfully treated non-operatively to allow in-season return to sport. The optimal rehabilitation program must be based on an accurate evaluation of historical and physical information as well as diagnostic imaging. Return to play decisions should be individualized and should weigh subjective assessments along with objective measurements of range of motion, strength, and function. The purpose of this clinical commentary is to summarize the current literature regarding the nonoperative treatment options for these common injuries, and to present a treatment plan to safely return these athletes to the field of play.

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