VOLUME TWELVE NUMBER TWO

ORIGINAL RESEARCH
Two-Dimensional Video Analysis is Comparable to 3D Motion Capture in Lower Extremity Movement Assessment.
Authors:  Schuur SA, Marshall AN, Resch JE, Saliba SA
Although 3D motion capture is considered the “gold standard” for recording and analyzing kinematics, 2D video analysis may be a more reasonable, inexpensive, and portable option for kinematic assessment during pre-participation screenings. Few studies have compared quantitative measurements of lower extremity functional tasks between 2D and 3D. The purpose of this study was to compare kinematic measurements of the trunk and lower extremity in the frontal and sagittal planes between 2D video camera and 3D motion capture analyses obtained concurrently during a single leg squat (SLS). Twenty-six healthy, recreationally active adults volunteered to participate. Participants performed three trials of the SLS on each limb, which were recorded simultaneously by three 2D video cameras and a 3D motion capture system. Dependent variables analyzed were joint displacement at the trunk, hip, knee, and ankle in the frontal and sagittal planes during the task compared to single leg quiet standing. Dependent variables exhibited moderate to strong correlations between the two measures in the sagittal plane (r=0.51-0.93), and a poor correlation at the knee in the frontal plane (r=0.308) at p ≤0.05. All other dependent variables revealed non-significant results between the two measures. Bland-Altman plots revealed strong agreement in the average mean difference in the amount of joint displacement between 2D and 3D in the sagittal plane (trunk = 1.68º, hip = 2.60º, knee = 0.74º, and ankle = 3.12º). Agreement in the frontal plane was good (trunk = 7.92, hip = -8.72º, knee = -6.62º, and ankle = 3.03). Moderate to strong relationships were observed between 2D video camera and 3D motion capture analyses at all joints in the sagittal plane, and the average mean difference was comparable to the standard error of measure with goniometry. The results suggest that despite the lack of precision and ability to capture rotations, 2D measurements may provide a pragmatic method of evaluating sagittal plane joint displacement for assessing gross movement displacement and therein risk of lower extremity injury.Abstract  |  Full Article (subscribers only)  |  Purchase Article

Prediction of Functional Movement Screen Performance from Lower Extremity Range of Motion and Core Tests.
Authors:  Chimera NJ, Knoeller S, Cooper R, Kothe N, Smith C, Warren M
There are varied reports in the literature regarding the association of the Functional Movement Screen™ (FMS™) with injury. The FMS™ has been correlated with hamstring range of motion and plank hold times; however, limited research is available on the predictability of lower extremity range of motion (ROM) and core function on FMS™ performance. The purpose of this study was to examine whether active lower extremity ROM measurements and core functional tests predict FMS™ performance. The authors hypothesized that lower extremity ROM and core functional tests would predict FMS™ composite score (CS) and performance on individual FMS™ fundamental movement patterns. Forty recreationally active participants had active lower extremity ROM measured, performed two core functional tests, the single leg wall sit hold (SLWS) and the repetitive single leg squat (RSLS), and performed the FMS.™ Independent T tests were used to assess differences between right and left limb ROM measures and outcomes of core functional tests. Linear and ordinal logistic regressions were used to determine the best predictors of FMS™ CS and fundamental movement patterns, respectively. On the left side, reduced DF and SLWS significantly predicted lower FMS™ CS. On the right side only reduced DF significantly predicted lower FMS™ CS.  Ordinal logistic regression models for the fundamental movement patterns demonstrated that reduced DF ROM was significantly associated with lower performance on deep squat. Reduced left knee extension was significantly associated with better performance in left straight leg raise; while reduced right hip flexion was significantly associated with reduced right straight leg raise. Lower SLWS was associated with reduced trunk stability performance. FMS™ movement patterns were affected by lower extremity ROM and core function. Researchers should consider lower FMS™ performance as indicative of underlying issues in ROM and core function. Clinicians may consider ROM interventions and core training strategies to improve FMS™ CS.

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Determination of Clinically Relevant Differences in Frontal Plane Hop Tests in Women’s Collegiate Basketball and Soccer Players.
Authors:  Hardesty K, Hegedus EJ, Ford KR, Nguyen AD, Taylor JB
ACL injury prevention programs are less successful in female basketball players than in soccer players. Previous authors have identified anthropometric and biomechanical differences between the athletes and different sport-specific demands, including a higher frequency of frontal plane activities in basketball. Current injury risk screening and preventive training practices do not place a strong emphasis on frontal plane activities. The medial and lateral triple hop for distance tests may be beneficial for use in the basketball population. The purpose of this study was to 1) establish normative values for the medial and lateral triple hop tests in healthy female collegiate athletes, and 2) analyze differences in test scores between female basketball and soccer players. It was hypothesized that due to the frequent frontal plane demands of their sport, basketball players would exhibit greater performance during these frontal plane performance tests. Thirty-two NCAA Division-1 female athletes (20 soccer, 12 basketball) performed three trials each of a medial and lateral triple hop for distance test. Distances were normalized to height and mass in order to account for anthropometric differences. Repeated measures ANOVAs were performed to identify statistically significant main effects of sport (basketball vs. soccer), and side (right vs. left), and sport x side interactions. After accounting for anthropometric differences, soccer players exhibited significantly better performance than basketball players in the medial and lateral triple hop tests. Significant side differences (p=0.02) were identified in the entire population for the medial triple hop test, such that participants jumped farther on their left (400.3±41.5 cm) than right (387.9±43.4 cm) limbs, but no side differences were identified in the lateral triple hop. No significant side x sport interactions were identified.  The authors concluded that women’s basketball players exhibit decreased performance of frontal plane hop tests when compared to women’s soccer players. Additionally, the medial triple hop for distance test may be effective at identifying side-to-side asymmetries.

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Intra-Rater Reliability of the Multiple Single-Leg Hop-Stabilization Test and Relationships with Age, Leg Dominance and Training.
Authors:  Sawle L, Freeman J, Marsden J
Balance is a complex construct, affected by multiple components such as strength and coordination. However, while assessing an athlete’s dynamic balance is an important part of clinical examination there is no gold standard measure. The multiple single-leg hop-stabilization test (MSLHST) is a functional test which may offer a method of evaluating the dynamic attributes of balance, but it needs to show adequate intra-tester reliability. The purpose of this study was to assess the intra-rater reliability of a dynamic balance test, the multiple single-leg hop-stabilization test (MSLHST) on the dominant and non-dominant legs.  Fifteen active participants were tested twice with a 10-minute break between tests. The outcome measure was the multiple single-leg hop-stabilization test score, based on a clinically assessed numerical scoring system. Results were analyzed using an Intra-class Correlations Coefficient (ICC 2,1) and Bland-Altman plots. Regression analyses explored relationships between test scores, leg dominance, age and training (an alpha level of p = 0.05 was selected). ICCs for intra-rater reliability were 0.85 for the dominant and non-dominant legs (confidence intervals = 0.62-0.95 and 0.61-0.95 respectively). Bland-Altman plots showed scores within two standard deviations. A significant correlation was observed between the dominant and non-dominant leg on balance scores (R²=0.49, p<0.05), and better balance was associated with younger participants in their non-dominant leg (R²=0.28, p<0.05) and their dominant leg (R²=0.39, p<0.05) and a higher number of hours spent training for the non-dominant leg R²=0.37, p<0.05).   The authors concluded that the multiple single-leg hop-stabilization test demonstrated strong intra-tester reliability with active participants. Younger participants who trained more, have better balance scores. This test may be a useful measure for evaluating the dynamic attributes of balance.

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The Effect of Fatigue on Upper Quarter Y-Balance Test Scores in Recreational Weightlifters:  A Randomized Controlled Trial.
Authors:  Salo TD, Chaconas E
A paucity of research currently exists for upper extremity return to sport testing. The Upper Quarter Y-Balance Test (YBT-UQ) is a clinical test of closed kinetic chain performance with demonstrated reliability.  Prior investigations of the YBT-UQ were conducted with individuals in a resting state and no comparison to performance in a fatigued state has been conducted. The purpose of this study was to examine the effect of upper extremity fatigue on the performance of the YBT-UQ in recreational weightlifters. Twenty-four participants who participated in recreational weight training three days per week were randomly allocated to a control or experimental group. Individuals in the control group were tested using the YBT-UQ and re-tested after a 20-minute rest period. Participants in the experimental group were tested with the YBT-UQ, performed an upper extremity exercise fatigue protocol, and immediately re-tested. Examiners were blinded to participant allocation. Differences from pre to post fatigue YBT-UQ testing revealed score reductions between 2.04cm – 12.16cm for both composite scores and individual reach directions. The repeated measures ANOVA revealed significant differences when comparing the pre and post testing results between the fatigue and non-fatigue groups for all individual directions (p≤ .006) and composite scores both limbs (p<.035). The authors concluded that the performance of an upper body fatigue protocol significantly reduces YBT-UQ scores in recreational weightlifters.

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Prospective Functional Performance Testing and Relationship to Lower Extremity Injury Incidence in Adolescent Sports Participants.
Authors:  Smith J, DePhillipo N, Kimura I, Kocher M, Hetzler R
Due to the high number of adolescent athletes who sustain lower extremity injuries, improvements of injury prevention strategies with emphasis on clinic-based and practical assessments are warranted. The purpose of this study was to prospectively investigate if a battery of functional performance tests (FPT) could be used as a preseason-screening tool to identify adolescent athletes at risk for sports-related acute lower extremity injury via comparison of injured and uninjured subjects. One hundred adolescent volleyball, basketball and soccer athletes (female, n=62; male, n=38; mean age = 14.4±1.6) participated. The FPT assessment included: triple hop for distance, star excursion balance test, double leg lowering maneuver, drop jump video test, and multi-stage fitness test. Composite scores were calculated using a derived equation. Subjects were monitored throughout their designated sport season(s), which consisted of a six-month surveillance period. The schools certified athletic trainer (ATC) recorded all injuries. Subjects were categorized into groups according to sex and injury incidence (acute lower extremity injury vs. uninjured) for analysis. Mean FPT composite scores were significantly lower for the injured compared to the uninjured groups in both sexes (males: 19.06±3.59 vs. 21.90±2.44; females: 19.48±3.35 vs. 22.10±3.06 injured and uninjured, respectively)(p < .05). The receiver-operator characteristic analysis determined the cut-off score at ≤20 for both genders (sensitivity=.71, specificity=.81, for males; sensitivity=.67, specificity=.69, for females)(p<.05) for acute noncontact lower extremity injuries. Significant positive correlations were found between the FPT composite score and the multi-stage fitness test in male subjects (r=.474, p=.003), suggesting a relationship between functional performance, aerobic capacity, and potential injury risk.   The authors concluded that a comprehensive assessment of functional performance tests may be beneficial to identify high-injury risk adolescents prior to athletic participation.

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The Acute Effects of Concentric Versus Eccentric Muscle Fatigue on Shoulder Active Repositioning Sense.
Authors:  Spargoli G
Shoulder proprioception is essential in the activities of daily living as well as in sports. Acute muscle fatigue is believed to cause a deterioration of proprioception, increasing the risk of injury. The purpose of this study was to evaluate if fatigue of the shoulder external rotators during eccentric versus concentric activity affects shoulder joint proprioception as determined by active reproduction of position.  Twenty-two healthy subjects with no recent history of shoulder pathology were randomly allocated to either a concentric or an eccentric exercise group for fatiguing the shoulder external rotators. Proprioception was assessed before and after the fatiguing protocol using an isokinetic dynamometer, by measuring active reproduction of position at 30° of shoulder external rotation, reported as absolute angular error. The fatiguing protocol consisted of sets of fifteen consecutive external rotator muscle contractions in either the concentric or eccentric action. The subjects were exercised until there was a 30% decline from the peak torque of the subjects’ maximal voluntary contraction over three consecutive muscle contractions.  A one-way analysis of variance test revealed no statistical difference in absolute angular error (p> 0.05) between concentric and eccentric groups. Moreover, no statistical difference (p> 0.05) was found in absolute angular error between pre- and post-fatigue in either group.  The author concluded that eccentric exercise does not seem to acutely affect shoulder proprioception to a larger extent than concentric exercise.

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Establishing Normative Change Values in Visual Acuity Loss during the Dynamic Visual Acuity Test.
Authors:  Marquez C, Lininger M, Raab S
Visual acuity (VA) declines from static to dynamic head conditions assessed using the Dynamic Visual Acuity Testing (DVAT) have not been established in NCAA football players. DVAT assesses the Vestibulo-Ocular Reflex (VOR) which is measured in Logarithm of the Minimum Angle of Resolution (logMAR).  Decreased VA beyond baseline measures may detect VOR impairment and impact treatment protocols and assist in return to play decisions post-concussion. The purpose of this study was to establish normative VA mean scores during a static head posture as well as dynamically during the DVAT with a head speed of 150 deg/sec in the pitch (vertical) and yaw (horizontal) planes rotating 20 degrees in each direction. Sixty-seven, NCAA Division I College football players (age= 19.68 ± 1.53) completed static VA and DVAT assessment in the pitch and yaw planes during baseline concussion testing at the beginning of the 2014 regular football season. Comparison of VA was evaluated by calculating the difference in players’ static and dynamic VA values using the DVAT. Static VA for all participants (n=67) was -0.232 ± 0.109 logMAR. Dynamic VA for participants (n=67) was 0.0845 ± 0.159 in pitch and -0.007 ± 0.141 in yaw at 150 deg/sec. Mean losses in VA during pitch and yaw at 150 deg/sec were 0.317 ± 0.140 and 0.227 ± 0.133, respectively. The authors concluded that VA diminishes during head movement at 150 degrees/sec. Loss of acuity beyond established normative values from baseline may be indicative of VOR dysfunction, especially secondary to head trauma. The assessment of visual acuity function with head movements of 150 deg/sec can potentially identify concussion and subsequent sequelae.

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Variation in Medial and Lateral Gastrocnemius Muscle Activity with Foot Position.
Authors:  Cibulka M, Wenthe A, Boyle Z, Callier D, Schwerdt A, Jarman D, Strube MJ
The gastrocnemius has two heads, the medial gastrocnemius (MG) and the lateral gastrocnemius (LG); little is known how they contract with different foot positions. The MG is more frequently strained than the LG; and altered gastrocnemius activation pattern due to foot position may play a role in injury. Leg exercises often use a toe-in versus toe-out foot position to isolate one gastrocnemius head over another.  The purpose of this study was to determine the electromyographic gastrocnemius muscle activity in the toe-out and toe-in foot positions during weight bearing and non-weight bearing activities. The hypothesis was that a toe-out foot position would elicit greater MG than LG activity; while the toe-in position would elicit greater activity in LG than MG in both weight bearing and non-weight bearing (NWB) positions. Thirty-three healthy young adult participants were recruited. Surface electrodes were placed on the bellies of the MG and LG. The gastrocnemius muscle was tested in toe-in and toe-out foot positions using two different tests: a standing heel-rise and resisted knee flexion while prone. Electromyographic activity was normalized against a MVIC during a heel raise with a neutral foot position. A 2x2x2 (Foot Position x Test Position x Muscle) ANOVA was used to determine if differences exist in activity between the MG and LG for toe-in versus toe-out standing and prone test positions. Significant test position main effect (F [1,32] = 86.9; p < .01), significant muscle main effect (F [1,32]=5.5; p < .01), and significant foot position x muscle interaction (F [1,32] = 14.58; p < .01) were found. Post hoc tests showed differences between MG and LG in toe-out position (t = 3.10; p < .01) but not in the toe-in for both test positions (t = 1.27; p= 0.21).  The authors concluded that with toe-out, the MG was more active than LG in standing and prone; no difference was noted between MG and LG in toe-in for either position.

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Comparison of Video-Guided, Live Instructed, and Self-Guided Foam Roll Interventions on Knee Joint Range of Motion and Pressure Pain Threshold: A Randomized Controlled Trial.
Authors:  Cheatham SW,  Kolber MJ, Cain M
The use of foam rollers to provide tissue massage is a commonly used intervention by rehabilitation professionals for their patients and clients. Currently, there is no consensus on the optimal foam rolling treatment approach. Of particular interest are the effects of different instructional methods of foam rolling, as individuals ultimately perform these interventions independently outside of formal care. Finding the optimal instructional method may help improve the individual’s understanding of the technique allowing for a safe and effective intervention. The purpose of this study was to compare the effects of video-guided, live instructed, and self-guided foam roll interventions on knee flexion ROM and pressure pain thresholds.  Forty-five healthy adults were recruited and randomly allocated to one of three intervention groups: video-guided, live-instructed, and self-guided. Each foam roll intervention lasted a total of 2 minutes. Dependent variables included knee flexion ROM and pressure pain threshold of the left quadriceps. Statistical analysis included subject demographic calculations and appropriate parametric and non-parametric tests to measure changes within and between intervention groups. Each intervention group showed significant gains in knee flexion ROM (p≤ 0.003) and pressure pain thresholds (p< 0.001). An approximate 5 degree increase of knee flexion and a 150 kPa increase in pressure pain threshold was observed at the posttest measure for all groups. There was no significant difference (p=0.25) found between intervention groups.   All three foam roll interventions showed short-term increases in knee flexion ROM and pressure pain thresholds. The two instructional methods (video and live instruction) and the self-guided method produced similar outcomes and can be used interchangeably. The authors concluded that individuals can benefit from various types of instruction and in cases of limited resources video may offer an alternative or adjunct to live instruction or an existing self-guided program.

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Investigating the Effectiveness of Kinesio® Taping Space Correction Method in Healthy Adults on Patellofemoral Joint and Subcutaneous Space.
Authors:  Lyman KJ, Keister K, Gange K, Mellinger CD, Hanson TD
Limited quantitative, physiological evidence exists regarding the effectiveness of Kinesio® Taping methods, particularly with respect to the potential ability to impact underlying physiological joint space and structures. To better understand the impact of these techniques, the underlying physiological processes must be investigated in addition to the examination of more subjective measures related to pain.  The purpose of this study was to determine whether the Kinesio® Taping Space Correction Method created a significant difference in patellofemoral joint space, as quantified by diagnostic ultrasound.  Thirty-two participants with bilaterally healthy knees and no past history of surgery took part in the study. For each participant, diagnostic ultrasound was utilized to collect three measurements: the patellofemoral joint space, the distance from the skin to the superficial patella, and distance from the skin to the patellar tendon. The Kinesio® Taping Space Correction Method was then applied. After a ten-minute waiting period in a non-weight bearing position, all three measurements were repeated. Each participant served as his or her own control.  Paired t tests showed a statistically significant difference (mean difference = 1.1 mm, t[31] = 2.823, p = 0.008, g = .465) between baseline and taped conditions in the space between the posterior surface of the patella to the medial femoral condyle. Neither the distance from the skin to the superficial patella nor the distance from the skin to the patellar tendon increased to a statistically significant degree.  The authors concluded that the application of the Kinesio® Taping Space Correction Method increases the patellofemoral joint space in healthy adults by increasing the distance between the patella and the medial femoral condyle, though it does not increase the distance from the skin to the superficial patella nor to the patellar tendon.

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CASE STUDIES
A Six-Week Supervised Exercise and Educational Intervention After Total Hip Arthroplasty: A Case Series.
Authors:  Pozzi F, Madara K, Zeni JA
Most rehabilitation interventions after total hip arthroplasty (THA) are not designed to return patients to high-levels of physical activity and, thus, low levels of physical activity and residual weakness are common. The purpose of this case series was to describe the feasibility and preliminary efficacy of an exercise and education intervention for patients after THA who had already completed formal outpatient physical therapy.

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CLINICAL COMMENTARY
Current Concepts on the Genetic Factors in Rotator Cuff Pathology and Future Implications for Sports Physical Therapists.
Authors:  Orth T, Pare J, Froehlich JE
Recent advances within the field of genetics are currently changing many of the methodologies in which medicine is practiced. These advances are also beginning to influence the manner in which physical therapy services are rendered. Rotator cuff pathology is one of the most common diagnoses treated by the sports physical therapist. Recent advances regarding the understanding of rotator cuff pathology have further elucidated the cellular and molecular mechanism associated with rotator cuff tears. There appears to be a hypoxic-induced apoptotic cellular pathway that contributes to rotator cuff tears. Activation of specific proteins termed matrix metalloproteinases appear to be involved in not only primary rotator cuff tears, but also may influence the re-tear rate after surgical intervention. Further advancements in the understanding of the cellular mechanisms contributing to rotator cuff tears and postoperative techniques to help prevent re-tears, may soon influence the methodology in which physical therapy services are provided to patients sustaining a rotator cuff injury. The purpose of this commentary is to educate sports physical therapists on the recent advances regarding how genetics influences rotator cuff pathology, including rotator cuff tears, and provide a perspective on how this information will likely influence post-operative shoulder rehabilitation in the near future.

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A Conceptual Model for Physical Therapists Treating Athletes with Protracted Recovery following a Concussion.
Authors:  Lundblad M
Sports-related concussions are receiving growing attention in healthcare.  Most concussions resolve spontaneously with little or no treatment, but twenty percent of concussions take longer than three weeks to resolve.  In some cases, symptoms can last for five years following a traumatic brain injury. Physical Therapists have unique skills that can assist patients experiencing protracted recovery. The purpose of this clinical commentary is to describe a new conceptual model that provides a framework for Physical Therapy management of patients with protracted recovery following a sports-related concussion. The end product is a visual diagram that represents the full scope of clinical practice that Physical Therapy can provide to an athlete following a concussion.

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Improving the Reporting of Therapeutic Exercise Interventions in Rehabilitation Research.
Authors:  Page P, Hoogenboom B, Voight ML
The foundation of evidence-based practice lies in clinical research, which is based on the utilization of the scientific method. The scientific method requires that all details of the experiment be provided in publications to support replication of the study in order to evaluate and validate the results. More importantly, clinical research can only be translated into practice when researchers provide explicit details of the study.  Too often, rehabilitation exercise intervention studies lack the appropriate detail to allow clinicians to replicate the exercise protocol in their patient populations. Therefore, the purpose of this clinical commentary is to provide guidelines for optimal reporting of therapeutic exercise interventions in rehabilitation research.

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