VOLUME TWELVE NUMBER FIVE

 
2017Cover_V12N5

OCTOBER 2017

ORIGINAL RESEARCH
The Effect of Heel Lifts on Patellofemoral Joint Stress During Running.
Authors:  Mestelle Z, Kernozek T, Adkins KS, Miller J, Gheidi N
DOI: 10.16603/ijspt20170711
Patellofemoral pain is a debilitating injury for many recreational runners. Excessive patellofemoral joint stress may be the underlying source of pain and interventions often focus on ways to reduce patellofemoral joint stress.   Heel lifts have been used as an intervention within Achilles tendon rehabilitation programs and to address leg length discrepancies. The purpose of this study was to examine the effect of running with heel lifts on patellofemoral joint stress, patellofemoral stress impulse, quadriceps force, step length, cadence, and other related kinematic and spatiotemporal variables. Sixteen healthy female runners completed five running trials in a controlled laboratory setting with and without 11mm heel lifts inserted in a standard running shoe. Kinetic and kinematic data were used in combination with a static optimization technique to estimate individual muscle forces. These data were inserted into a patellofemoral joint model which was used to estimate patellofemoral joint stress and other variables during running.  When running with heel lifts, peak patellofemoral joint stress and patellofemoral stress impulse were reduced by a 4.2% (p=0.049) and 9.3% (p=0.002). Initial center of pressure was shifted anteriorly 9.1% when running with heel lifts (p<0.001) despite all runners utilizing a heel strike pattern. Dorsiflexion at initial contact was reduced 28% (p=0.016) when heel lifts were donned. No differences in step length and cadence (p>0.05) were shown between conditions.  The authors concluded that heel lift use resulted in decreased patellofemoral joint stress and impulse without associated changes in step length or frequency, or other variables shown to influence patellofemoral joint stress. The center of pressure at initial contact was also more anterior using heel lifts.  The use of heel lifts may have therapeutic benefits for runners with patellofemoral pain if the primary goal is to reduce patellofemoral joint stress.

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Comparison of Hamstring Muscle Activation During High-speed Running and Various Hamstring Strengthening Exercises.
Authors:  van den Tillar R, Solheim JAB, Bencke J
DOI: 10.16603/ijspt20170718
Several studies have examined the effect of hamstring strengthening exercises upon hamstring strains in team sports that involve many sprints. However, there has been no cross comparison among muscle activation occurring during these hamstring training exercises with the activation that occurs during actual sprinting. Therefore, the aim of this study was to examine different hamstring exercises and compare the muscle activity in the hamstring muscle group during various exercises with the muscular activity produced during maximal sprints. Twelve male sports students (age 25 ± 6.2 years, 1.80 ± 7.1 m, body mass 81.1 ± 15.6 kg) participated in this study. Surface EMG electrodes were placed on semimembranosus, semitendinosus and biceps femoris to measure muscle activity during seven hamstrings exercises and sprinting together with 3D motion capture to establish at what hip and knee angles maximal muscle activation (EMG) occurs. Maximal EMG activity during sprints for each muscle was used in order to express each exercise as a percentage of max activation during sprinting.  The main findings were that maximal EMG activity of the different hamstring exercises were on average between 40-65% (Semitendinosus), 18-40% (biceps femoris) and 40-75% (Semimembranosus) compared with the max EMG activity in sprints, which were considered as 100%. The laying kick together with the Nordic hamstring exercises and its variations had the highest muscle activations, while the cranes showed the lowest muscle activation (in all muscles) together with the standing kick for the semimembranosus. In addition, angles at which the peak EMG activity of the hamstring muscle occurs were similar for the Nordic hamstring exercises and different for the two crane exercises (hip angle), standing kick (hip angle) and the laying kick (knee angle) compared with the sprint. The authors concluded that nordic hamstring exercises with its variation together with the laying kick activates the hamstrings at high levels and at angles similar to the joint angles at which peak hamstring activation occurs during sprinting, while cranes did not reach high levels of hamstring activation compared with sprinting.

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The Efficacy of Angle-Matched Isokinetic Knee Flexor and Extensor Strength Parameters in Predicting Agility Test Performance.
Authors:  Greig M, Naylor J
DOI: 10.16603/ijspt20170728
Agility is a fundamental performance element in many sports, but poses a high risk of injury.  Hierarchical modelling has shown that eccentric hamstring strength is the primary determinant of agility performance.  
The purpose of this study was to investigate the relationship between knee flexor and extensor strength parameters and a battery of agility tests.  Nineteen recreational intermittent games players completed an agility battery and isokinetic testing of the eccentric knee flexors (eccH) and concentric knee extensors (conQ) at 60, 180 and 300°·s-1.  Peak torque and the angle at which peak torque occurred were calculated for eccH and conQ at each speed. Dynamic control ratios (eccH:conQ) and fast:slow ratios (300:60) were calculated using peak torque values, and again using angle-matched data, for eccH and conQ.  The agility test battery differentiated linear vs directional changes and prescriptive vs reactive tasks. Linear regression showed that eccH parameters were generally a better predictor of agility performance than conQ parameters. Stepwise regression showed that only angle-matched strength ratios contributed to the prediction of each agility test.  Traditionally calculated strength ratios using peak torque values failed to predict performance.  Angle-matched strength parameters were able to account for 80% of the variation in T-test performance, 70% of deceleration distance, 55% of 10m sprint performance, and 44% of reactive change of direction speed.  The authors concluded that traditionally calculated strength ratios failed to predict agility performance, whereas angle-matched strength ratios had better predictive ability and featured in a predictive stepwise model for each agility task.  

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Lower Extremity Kinematics of ACL-Repaired and Non-Injured Females when using Knee Savers®.
Authors:  Stone WJ, Arnett SW, Hoover DL
DOI: 10.16603/ijspt20170737
Knee Savers® (KS) are an ergonomic aid purported to lessen the risk of injuries linked to deep squats. While widely used in sports such as baseball and softball, KS have not been tested to determine their effect upon lower extremity kinematics in any population. The purpose of the study was to determine if KS influenced the lower extremity kinematics when females with previous anterior cruciate ligament (ACL)-reconstruction and healthy participants completed an end-range squat. Twenty female participants (mean (SD) – age: 21.65 (2.06) yrs, height: 175.26 (9.29) cm, weight: 64.66 (7.72) kg) with a history of ACL-repair (n=10) or non-injury (n=10) completed this study. Participants completed a standardized trial of three deep squats with and without KS.  Movement was analyzed using 2D video analysis methods increasingly available in clinical environments. During the ascending phases of a squatting motion, there was significantly greater medial (p = .009) and lateral (p = .005) motion of the patella in the frontal plane for non-injured participants, when compared to the ACL-repaired group. No significant differences were found in sagittal plane lower extremity kinematics when squatting with and without KS. Ascending angular velocity was slower in ACL-repaired than non-injured females (p = .008) and slower with the KS than without KS for non-injured females (p = .007).  The authors found that when squatting with and without KS, the non-injured group experienced more frontal plane motion at the knee, compared to the ACL-repaired group. However, while KS are purported to influence lower extremity joint positions during the bottom phase of a deep squat, the data from the current study did not support this claim. Additionally, KS appear to slow ascending velocity for those without a history of ACL-repair. These findings may have clinically meaningful implications for athletes who use KS during sport activities.

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Comparison of Dry Needling vs. Sham on the Performance of Vertical Jump.
Authors:  Bandy WD, Nelson R, Beamer L
DOI: 10.16603/ijspt20170747
Dry needling has been reported to decrease pain in subjects having myofascial trigger points, as well as pain in muscle and connective tissue. The purpose of the study was to compare the effects on the ability to perform a two-legged vertical jump between a group who received one bout of dry needling and a group who received one bout of a sham treatment. Thirty-five healthy students (19 males, 16 females) were recruited to participate in this study (mean age 22.7+/- 2.4 years). The subjects were randomly divided into two groups- dry needling (n=18) vs. sham (n=17). The dry needling group received needling to four sites on bilateral gastrocnemius muscles; two at the medial head and two at the lateral head. The sham group had the four areas of the gastrocnemius muscle pressed with the tube housing the needle, but the needle was never inserted into the skin. Two-legged vertical jump was measured with chalk marks on the wall before and after the dry needling and sham treatments.  Analysis indicated that the dry needling group significantly increased vertical jump height 1.2 inches over the sham group. The authors concluded that one bout of dry needling showed an immediate effect at significantly increasing vertical jump height in healthy, young adults. Future research is needed to determine if dry needling has any long-term effects.

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Inter-Rater Reliability of the Selective Functional Movement Assessment (SFMA) by SFMA Certified Physical Therapists with Similar Clinical and Rating Experience.
Authors:  Dolbeer J, Mason J, Morris J, Crowell M, Goss D
DOI: 10.16603/ijspt20170752
The Selective Functional Movement Assessment (SFMA) assesses posture, muscle balance, and movement patterns in order to identify relevant musculoskeletal dysfunction in a clinical population.  
Purpose: The purposes of this study were to: (1) determine if raters with similar clinical experience and rating experience exhibit adequate agreement of the scoring for the SFMA during clinical use; (2) determine the reliability of the categorical scoring of the SFMA in a clinical population; (3) determine the reliability of the criterion checklist scoring of the SFMA in a clinical population; (4) compare the reliability of real-time assessment to recorded assessment.  Forty-nine subjects (20.7 years ± 1.6) were simultaneously assessed in real-time by two physical therapists and were recorded with digital video cameras in the sagittal and frontal view while they performed the fifteen component movement patterns that comprise the top-tier SFMA. The third physical therapist assessed the patterns from the video. Subjects were assessed using the SFMA categorical scoring and criterion checklist scoring tools. The two live clinical raters demonstrated the greatest Cohen’s Kappa scores (10 of 15) with moderate or better inter-rater agreement (Kappa > 0.40) using the categorical scoring tool. The overall ICC score indicated fair to moderate agreement between all raters for the criterion checklist scoring (ICC, SEM, p-value) (0.61, 8.23, p < 0.001).  Real time clinical use was the most reliable method for using the criterion checklist scoring tool (0.72, 1.95, p=0.43). The authors concluded that using the categorical and criterion checklist tools in a clinical population to score the fifteen component fundamental movements of the SFMA demonstrated moderate or better reliability when performed clinically by certified SFMA raters.

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Hip Range of Motion in Recreational Weight Training Participants: A Descriptive Report.
Authors:  Cheatham S, Hanney WJ, Kolber MJ
DOI: 10.16603/ijspt20170764
The surveillance of hip injuries and risk factors have become an emerging focus in sports medicine due to the increased recognition of hip pathologies. Researchers suggest that decreased hip range of motion (ROM) is a risk factor for injury in various athletic activities. One under reported population that has potential for hip injuries is recreational weight training (WT) participants. Currently, no studies have reported hip ROM values in WT participants which creates a knowledge gap in this population. The purpose of this study was to report hip passive ROM values of WT participants to develop reference data for future research on injury patterns and prevention strategies for this population. Two-hundred healthy recreational adult WT participants (age = 27.18 ± 9.3 years, height = 174.84 ± 9.8 cm, mass = 91.0 ± 17.9 kg, body mass index = 29.6 ± 4.5 kg/m2) were recruited. Bilateral hip passive ROM was assessed for flexion, extension, internal rotation, external rotation, and abduction. Statistical analysis included subject demographics (means and SD) and a two-tailed independent t-test to compare mean passive hip ROM values between sexes and hips. Statistical significance was considered p < .05. A total of 400 hundred hips (right + left) were measured for this analysis. When comparing hip ROM values within sexes, men had no significant difference (p≥.28) between the right and left hip for all motions. Women did have a significant difference (p≤.05) between the right and left hip for all motions. The right hip had lower values for all motions than the left hip suggesting a more global decrease in right hip ROM. When comparing hip ROM values between men and women, there was a significant difference (p≤.05) between men and women for all motions. Men had lower ROM values for all hip motions when compared to women. This is the first investigation to provide a descriptive analysis of hip ROM in healthy recreational WT participants. These data provide a starting point for clinicians and researchers to further study this population for injury prevention.

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Development of a Screening Protocol to Identify Individuals With Dysfunctional Breathing.
Authors:  Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R
DOI: 10.16603/ijspt20170774
Dysfunctional breathing (DB) has been linked to health conditions including low back pain and neck pain and adversely effects the musculoskeletal system. Individuals with DB often have decreased pain thresholds and impaired motor control, balance, and movement. No single test or screen identifies DB, which is multi-dimensional, and includes biochemical, biomechanical, and psychophysiological components. Several tools assess and test for DB, but no screen exists to determine whether additional testing and assessment are indicated. The purpose of this study was to develop a breathing screening procedure that could be utilized by fitness and healthcare providers to screen for the presence of disordered breathing. A diagnostic test study approach was utilized to establish the diagnostic accuracy of the newly developed screen for DB. A convenience sample of 51 subjects (27 females, 27.0 years, BMI 23.3) were included. To test for DB related to the biochemical dimension, end-tidal CO2 (ETCO2) was measured with a capnography unit. To test for DB related to biomechanical dimension, the Hi-Lo test was utilized. To test for DB related to the psychophysiological dimension, the Self Evaluation of Breathing Symptoms Questionnaire (SEBQ) and Nijmegen questionnaires were utilized. Potential screening items that have been shown to be related to DB in previous research and that could be performed by non-health care personnel were utilized to create the index test including activity level, breath hold time (BHT), respiration rate, and the Functional Movement Screen (FMS™). There were no strong correlations between the three measures of DB. Five subjects had normal breathing, 14 failed at least one measure, 20 failed at least two, and 12 failed all three. To develop screening items for each dimension, data were examined for association with failure. BHT and a four-item mini-questionnaire were identified as the most closely associated variables with failure of all three dimensions. A BHT of <25 seconds and four questions were combined and yielded a sensitivity of 0.89 (0.85-0.93) and a specificity of 0.60 (0.18-0.92) for clinical identification of DB.   The authors concluded that easily obtained clinical measures of BHT and four questions can be utilized to screen for the presence of DB. If the screen is passed, there is an 89% chance that DB is not present. If the screen is failed, further assessment is recommended.

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Sports Physical Therapy Curricula in Physical Therapist Professional Degree Programs.
Authors:  Mulligan EP, DeVahl J
DOI: 10.16603/ijspt20170787
The specialty niche of sports physical therapy has grown at a significant rate over the past 40 years. Despite this growth there is little information or direction from the physical therapy education accreditation body or professional association to guide academic programs on the interest or necessity of this type of practice content in physical therapy professional degree programs. The purpose of this survey study is to report on the prevalence, attitudes, barriers, resources, and faculty expertise in providing required or elective sports physical therapy course work.  A 57-item questionnaire with branching logic was distributed via a web-based electronic data capture tool to survey all Commission on Accreditation for Physical Therapy Education (CAPTE) accredited and candidate schools in the United States. Response data was analyzed to describe typical educational program profiles, faculty demographics, and correlational factors consistent with the presence or absence of specific sports physical therapy curricular content. Thirty-one percent of the schools responded to the survey and the program demographics were consistent with all currently accredited schools in regards to their geography, Carnegie classification, and faculty and student size. Forty three percent of programs offered a required or elective course distinct to the practice of sports physical therapy. Descriptive information regarding the sequencing, curricular make-up, resources, and assessment of content competence is reported. The odds of providing this content nearly doubles for programs that have faculty with sports clinical specialist credentials, accredited sports residency curriculums, or state practice acts that allow sports venue coverage. This survey provides an initial overview of sports physical therapy educational efforts in professional physical therapy degree programs. The data can used to spur further discussion on the necessity, structure, and implementation of education content that is inherent to a growing specialty practice in the physical therapy profession.

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Shoulder Pain in Competitive Teenage Swimmers and its Prevention:  A Retrospective Epidemiological Cross Sectional Study of Prevalence.
Authors:  Tessaro M, Granzotto G, Poser A, Plebani G, Rossi A
DOI: 10.16603/ijspt20170798
The term “swimmer’s shoulder” was first introduced in 1974 by Kennedy and Hawkins to describe a common condition among competitive swimmers characterized by pain and dysfunction of the shoulder complex. Currently, the term does not define a specific clinical diagnosis and its etiology is considered to be multifactorial. In the literature shoulder pain prevalence varies according to the adopted definitions (from 3% to 91%); however, in the Italian environment there is no prevalence study regarding swimmer shoulder. Prevention by means of dry land activities may assist in delimiting shoulder pain in swimmers. The purpose of this study was to investigate the prevalence of swimmer’s shoulder over the prior 12 months among teenage athletes and the preventive activities carried out across different sport’s teams. A second purpose was to determine whether the extent of the condition is affected by dry land preventive activity. And finally, to compare different preventive activities related to the prevalence of swimmer’s shoulder.  Athletes from four levels of training belonging to eight Italian swimming teams and their respective coaches were involved in this study. Shoulder pain prevalence over the previous 12 months from the completion of the survey was 51%. In six out of eight of the societies a specific shoulder dry land warm-up was carried out before water training, whereas among seven out of eight societies also utilized weekly sessions of performance (physical) training. Statistically significant differences were noticed between shoulder pain and gender, weekly frequency and duration of dry land warm-up and duration of physical training.   The results of the current study indicate that shoulder pain is prevalent in youth swimmers (51%) and appears to be affected by dry land preventive activities. A weekly frequency of dry land warm-up more than five times appeared to protect swimmers from pain (p=0.044); whereas, a dry land warm-up duration greater than 10 minutes seems to cause shoulder pain (p=0.043). A single weekly physical training session of duration lower than 45 minutes seems to be associated with pain (p=0.035).

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Age Differences in Measures of Functional Movement and Performance in Highly Trained Youth Basketball Players.
Authors:  Gonzalo-Skok O, Serna J, Rhea MR, Marin PJ
DOI: 10.16603/ijspt20170812
There is a lack of information about influence of age on functional movement tests (FMT) and performance tests as well as in their relationships in young basketball players.  The purpose of the present study was to determine the variations in FMT and jump and/or sprint performance scores between age groups (U-14 vs. U-16) in highly trained young basketball players. The second purpose was to investigate the relationship between FMT for lower body and jump and/or sprint performance in highly-trained young (U-14 and U-16) male basketball players. Thirty elite young (U-14 to U-16) male basketball players performed several FMT (weight-bearing dorsiflexion test [WB-DF] and a modified Star Excursion Balance test [SEBT]) and performance including unilateral and bilateral countermovement jumps, unilateral horizontal jumping, linear sprinting and change of direction tests. All anthropometric and performance tests showed a statistically significant advantage (p<0.05) in the U-16 group, excluding the unilateral jump with left leg (p=0.127). Five out of the eight FMT performed showed a statistically significant advantage (p<0.05) in the U-16 group. The U-14 group did not differ statistically from the U-16 group in WB-DF with left leg and the SEBT anterior right leg and posteromedial left leg reaches. Effect size calculations did show small to moderate effects in favor of U-16. Only two significant correlations (p<0.05) between functional movement and performance measures were identified in the U-16 group for either limb (10-m sprint and SEBT-PLL, SEBT-Composite), while a total of 13 significant correlations (p<0.05) in the U-14 group were found. The results of this study demonstrated differences in FMT and jump and/or sprint performance test between age groups (U-16 vs U-14). The findings of this study support the idea that the age of the player should be considered when interpreting FMT scores, which could have implications when implementing the FMT for injury risk prediction.

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Injury Patterns in Adolescent Elite Endurance Athletes Participating in Running, Orienteering, and Cross-Country Skiing.
Authors:  von Rosen P, Flostrom F, Frohm A, Heijne A
DOI: 10.16603/ijspt20170822
Prospective injury registration studies, monitoring adolescent elite athletes, are sparse in running, orienteering and cross-country skiing, yet essential for developing prevention programs. The aims of this study were to describe the injury prevalence/incidence, severity grade, injury location, risk factors and the prevalence of illness in running (RU), orienteering (OR) and cross-country skiing athletes (CR). One hundred fifty adolescent elite athletes (age range 16-19), participating in orienteering (25 females, 20 males), running (13 females, 18 males), cross-country skiing (38 females, 36 males), from 12 National Sports High Schools in Sweden, were prospectively followed over one calendar year using a reliable and validated web-based questionnaire. The main finding was that the average weekly injury prevalence was higher during the pre-season compared to the competitive season in all three sports. RU reported the significantly (p<0.05) highest average weekly injury prevalence (32.4%) and substantial injury prevalence (17.0%), compared to OR (26.0, 8.2%) and CR (21.1%, 8.9%). Most injuries occurred in the lower extremity (RU 94.4%; OR 91.9%; CR 49.9%) and foot and knee injuries had the highest severity grade in all three sports. History of serious injury (p=0.002, OR 4.0, 95% CI 1.6-9.7) and current injury at study start (p=0.004, OR 4.0, 95% CI 1.5-11.2) were identified as the strongest risk factors for substantial injury. Younger athletes aged 16 (p=0.019, OR 2.6, 95% CI 1.2-5.8) and 17 (p=0.045, OR 2.4, 95% CI 1.0-5.9), had a significantly higher injury risk for substantial injury compared to older athletes aged 18-19.   Practitioners should be aware of the increased injury risk during pre-season and in younger athletes. By focus on prevention of foot and knee injuries, the injuries with the highest severity grade will be targeted in adolescent elite athletes participating in running, orienteering and cross-country skiing.

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Injuries in Quidditch: A Descriptive Epidemiological Study.
Authors:  Pennington R, Cooper A, Edmond E, Faulkner A, Reidy MJ
DOI: 10.16603/ijspt20170833
Quidditch is a fast growing, physically intense, mixed-gender full-contact sport. Originally adapted from Harry Potter novels, quidditch was first played in 2005 in the USA but is now played worldwide. It is essential to elucidate patterns of injury for the safety and growth of the sport of quidditch. It also provides a unique opportunity to study injury patterns in mixed-gender full-contact sport, an area of increasing importance with the developing culture of transition from single-gender to mixed-gender sports.  The purpose of this investigation was to examine the types of injuries sustained while playing quidditch in terms of their incidence, anatomical distribution and severity, and gender distribution. An anonymous self-reporting questionnaire was distributed to all active quidditch players in the UK. Data collection included player demographics, type of injury, mechanism of injury, player position, experience and treatment required, relating to the previous 12 months. A total of 348 participants of 684 eligible athletes responded to the questionnaire representing a 50.87% response rate. There were 315 injuries reported by 180 athletes in total, with an overall incidence of 4.06 injuries per 1,000 hours.  A statistically significantly different rate of concussion was observed with female athletes sustaining more concussion than males (p=0.006).  The overall rate of concussion was 0.651/1000hrs in males and 1.163/1000hrs in females (0.877/1000 hours overall). This study provides the first quantitative description of injury rates in quidditch. The overall injury rates are no higher than those reported in other recreational contact sports. Female athletes were found to have a higher rate of concussion, which needs further investigation. These findings are relevant to players concerned about safety in quidditch and to governing bodies regarding governance of the sport.
    
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CASE STUDIES
Functional Outcomes of Hip Arthroscopy in an Active Duty Military Population Utilizing a Criterion-Based Early Weight Bearing Progression – A Case Series.
Authors:  Shaw KA, Jacobs JM, Evanson JR, Pniewski J, Mueller T, Bojescul JA
DOI: 10.16603/ijspt20170840
Hip arthroscopy allows surgeons to address intra-articular pathology of the hip while avoiding more invasive open surgical dislocation. However the post-operative rehabilitation protocols have varied greatly in the literature, with many having prolonged periods of limited motion and weight bearing. The purpose of this case series study was to describe a criterion-based early weight bearing protocol following hip arthroscopy and investigate functional outcomes in the subjects who were active duty military. Active duty personnel undergoing hip arthroscopy for symptomatic femoroacetabular impingement were prospectively assessed in a controlled environment for the ability to incorporate early postoperative weight-bearing with the following criteria: no increased pain complaint with weight bearing and normalized gait pattern. Modified Harris Hip (HHS) and Hip Outcome score (HOS) were performed preoperatively and at six months post-op. Participants were progressed with a standard hip arthroscopy protocol.  Hip flexion was limited to not exceed 90 degrees for the first three weeks post-op, with progression back to running beginning at three months. Final discharge was dependent upon the ability to run two miles at military specified pace and do a single leg broad jump within six inches of the contralateral leg without an increase in pain. Eleven participants met inclusion criteria over the study period. Crutch use was discontinued at an average of five days following surgery based on established weight bearing criteria. Only one participant required continued crutch use at 15 days. Participants’ functional outcome was improved postoperatively, as demonstrated by significant increases in HOS and HHS. At the six month follow up, eight of 11 participants were able to take and complete a full Army Physical Fitness Test. Following completion of the early weight bearing rehabilitation protocol, 81% of participants were able to progress to full weight bearing by four days post-operative, with normalized pain-free gait patterns. Active duty personnel utilizing an early weight bearing protocol following hip arthroscopy demonstrated significant functional improvement at six months.

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Exercise, Manual Therapy and Postural Re-education for Uncontrolled Ear Twitching and Related Impairments after Whiplash Injury: A Case Report.
Authors:  Flanders K, Feldner H
DOI: 10.16603/ijspt20170848
Whiplash Associated Disorders and the interventions used to remediate them are well documented in physical therapy literature. However, specific interventions for spasms of the neck musculature that also involve constant ear twitching have yet to be addressed. The purpose of this case report is twofold. First, to describe comprehensive physical therapy management and outcomes for a subject with uncontrolled ear twitching and related musculoskeletal impairments, and second, to discuss the physical therapist’s approach to evidence-based care when faced with a paucity of literature addressing physical therapy interventions for subjects with uncontrolled ear twitching. The subject was a 14-year-old female who sustained a right anterolateral whiplash injury when struck in the head by a volleyball seven months prior to physical therapy. Beginning five months after that injury, she experienced uncontrolled and constant superior/inferior movement of her right ear (hereafter described in this report as a twitch) in addition to facial and cervical pain from her initial injury. She was unable to participate in high school athletics due to her pain. A multimodal treatment approach including exercise, manual therapy, and postural reeducation was utilized during the subject’s episode of care. After eight treatment sessions, the subjects’s cervical range of motion and upper extremity strength improved. The reported frequency of ear twitching decreased, as did reports of neck and shoulder pain. In addition, her Neck Disability Index improved from a score of 22, indicating moderate disability, to 9, indicating mild disability and she was able to return to sport activity. With limited research to direct intervention, clinical reasoning was utilized to formulate an effective therapeutic intervention. A combination of manual therapy, exercise, and postural reeducation intervention was effective for this subject and could assist in guiding interventions for similarly unique clinical presentations in the future. Further research is needed to examine the etiology of ear twitching caused by muscle spasm and to develop additional evidence-based interventions for Whiplash Associated Disorders.

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