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Chronic low back pain (cLBP) rates among younger individuals are rising. Although pain and disability are often less severe, underlying changes in trunk behavior may be responsible for recurrence. We examine the biomarker capacity of a simple Trunk Compliance Index (TCI) to distinguish individuals with and without cLBP. A random subset (n = 49) of the RELIEF RCT were matched to healthy controls for sex, age, height and weight. We measured TCI (as displacement/ weight-normalized perturbation force) using anthropometrically-matched, suddenly-applied pulling perturbations to the trunk segment, randomized across three planes of motion (antero-posterior, medio-lateral, and rotational). Mean differences between cLBP, sex and perturbation direction were assessed with repeated-measures analysis of variance. Discriminatory accuracy of TCI was assessed using Receiver Operator Characteristic (ROC) analysis. Baseline characteristics between groups were equivalent (x̅ [range]): sex (57% female / group), age (23.0 [18–45], 22.8 [18–45]), height, cm (173.0 [156.5–205], 171.3 [121.2–197], weight, kg (71.8 [44.5–116.6], 71.7 [46.8–117.5]) with cLBP associated with significantly lower TCI for 5 of 6 directions (range mean difference, − 5.35: − 1.49, range 95% CI [− 6.46: − 2.18 to − 4.35: − 0.30]. Classification via ROC showed that composite TCI had high discriminatory potential (area under curve [95% CI], 0.90 [0.84–0.96]), driven by TCI from antero-posterior perturbations (area under curve [95% CI], 0.99 [0.97–1.00]). Consistent reductions in TCI suggests global changes in trunk mechanics that may go undetected in classic clinical examination. Evaluation of TCI in younger adults with mild pain and disability may serve as a biomarker for chronicity, leading to improved preventative measures in cLBP.Trial Registration and Funding RELIEF is registered with clinicaltrials.gov (NCT01854892) and funded by the NIH National Center for Complementary & Integrative Health (R01AT006978).

Date Presented 03/26/20 Infants who sustain brachial plexus injury are at risk for neuromuscular and sensibility deficits contributing to prehensile dysfunction. OTs practicing in early intervention often have limited resources available to improve muscle activation. Yet our experimental program offers a solution, since infant-initiated muscle activation or arm movement will trigger a toy to move, reinforcing them to move again. If done repeatedly, this program could contribute to their recovery. Primary Author and Speaker: Susan Duff Contributing Authors: Milan Stevanovic, Jamie Berggren, Barbara Sargent, Andrew Kimbel, Cyril Rakovski, Ehsan Yaghmaei, Peter Pidcoe, Benjamin Leiby, Mitchel Seruya, Eric Wade

Context:Chronic ankle instability (CAI) is characterized by repeated ankle sprains, which have been linked to postural instability. Therefore, it is important for clinicians to identify individuals with CAI who can benefit from rehabilitation.Objective:To assess the likelihood that CAI participants will exhibit impaired postural stability and that healthy control participants will exhibit better test performance values.Design:Case-control study.Setting:Laboratory.Patients or Other Participants:People with CAI (n = 17, age = 23 ± 4 years, height = 168 ± 9 cm, weight = 68 ± 12 kg) who reported ankle “giving-way” sensations and healthy volunteers (n = 17, age = 23 ± 3 years, height = 168 ± 8 cm, weight = 66 ± 12 kg).Intervention(s):Participants performed 7 balance tests: Balance Error Scoring System (BESS), time in balance, foot lift, single-legged stance on a force plate, Star Excursion Balance Test, side hop, and figure-of-8 hop.Main Outcome Measure(s):Balance was quantified with errors (score) for the BESS, length of time balancing (seconds) for time-in-balance test, frequency of foot lifts (score) for foot-lift test, velocity (cm/s) for all center-of-pressure velocity measures, excursion (cm) for center-of-pressure excursion measures, area (cm2) for 95% confidence ellipse center-of-pressure area and center-of-pressure rectangular area, time (seconds) for anterior-posterior and medial-lateral time-to-boundary (TTB) measures, distance reached (cm) for Star Excursion Balance Test, and time (seconds) to complete side-hop and figure-of-8 hop tests. We calculated area-under-the-curve values and cutoff scores and used the odds ratio to determine if those with and without CAI could be distinguished using cutoff scores.Results:We found significant area-under-the-curve values for 4 static noninstrumented measures, 3 force-plate measures, and 3 functional measures. Significant cutoff scores were noted for the time-in-balance test (≤25.89 seconds), foot-lift test (≥5), single-legged stance on the firm surface (≥3 errors) and total (≥14 errors) on the BESS, center-of-pressure resultant velocity (≥1.56 cm/s), standard deviations for medial-lateral (≤1.56 seconds) time-to-boundary and anterior-posterior (≤3.78 seconds) time-to-boundary test, posteromedial direction on the Star Excursion Balance Test (≤0.91), side-hop test (≥12.88 seconds), and figure-of-8 hop test (≥17.36 seconds).Conclusions:Clinicians can use any of the 10 significant measures with their associated cutoff scores to identify those who could benefit from rehabilitation that reestablishes postural stability.

Context: Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited. Objective: To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings. Design: Cross-sectional study. Setting: Sports medicine research laboratory. Patients or Other Participants: Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78). Intervention(s): Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded. Main Outcome Measure(s): Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM. Results: Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05). Conclusions: Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.

Randomized controlled trial.To determine if thoracic spinal manipulative therapy (SMT) alters thoracic kinematics, thoracic excursion, and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome, and also to compare changes in patient-reported outcomes between treatment groups.Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome. However, the mechanisms underlying these benefits are not well understood.Participants with shoulder impingement symptoms (n = 52) were randomly assigned to receive a single session of thoracic SMT or sham SMT. Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention. Patient-reported outcomes measured were pain (numeric pain-rating scale), function (Penn Shoulder Score), and global rating of change.Following the intervention, there were no significant differences in changes between groups for thoracic kinematics or excursion, scapular kinematics, and patient-reported outcomes (P.05). Both groups showed an increase in scapular internal rotation during arm raising (mean, 0.9°; 95% confidence interval [CI]: 0.3°, 1.6°; P = .003) and lowering (0.8°; 95% CI: 0.0°, 1.5°; P = .041), as well as improved pain reported on the numeric pain-rating scale (1.2 points; 95% CI: 0.3, 1.8; P.001) and function on the Penn Shoulder Score (9.1 points; 95% CI: 6.5, 11.7; P.001).Thoracic spine extension and excursion did not change significantly following thoracic SMT. There were small but likely not clinically meaningful changes in scapular internal rotation in both groups. Patient-reported pain and function improved in both groups; however, there were no significant differences in the changes between the SMT and the sham SMT groups. Overall, patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion.Therapy, level 1b-.

Background and Purpose. Scapular muscle performance evaluated with a handheld dynamometer (HHD) has been investigated only in people without shoulder dysfunction for test-retest reliability of data obtained with a single scapular muscle test. The purpose of this study was to assess the reliability, error, and validity of data obtained with an HHD for 4 scapular muscle tests in subjects with shoulder pain and functional loss. Subjects and Methods. Subjects (N=40) with shoulder pain and functional loss were tested bymeasuring the kilograms applied with an HHD during 3 trials for muscle tests for the lower trapezius, upper trapezius, middle trapezius, and serratus anterior muscles. Concurrently, surface electromyography (sEMG) data were collected for the 4 muscles. The same procedures were performed 24 to 72 hours after the initial testing by the same tester. Muscle tests were performed 3 times, and the results were averaged for data analysis. Results. Intraclass correlation coefficients for intratester reliability of measurements of isometricforce obtained using an HHD ranged from .89 to .96. The standard error of the measure (90% confidenceinterval [CI]) ranged from 1.3 to 2.7 kg; the minimal detectable change (90% CI) ranged from 1.8 to 3.6 kg. Construct validity assessment, done by comparing the amounts of isometric muscle activity (sEMG) for each muscle across the 4 muscle tests, revealed that the muscle activity of the upper trapezius and lower trapezius muscles washighest during their respective tests. Conversely, the isometric muscle activity of the middle trapezius and serratus anterior muscles was not highest during their respective tests. Discussion and Conclusion. In people with shoulder pain and functional loss, the intrarater reliability and error over 1 to 3 days were established using an HHD for measurement of isometric force for the assessment of scapular muscle performance. Error values can be used to make decisions regarding individual patients. Construct validity was established for the lower and upper trapezius muscle tests; therefore, these tests are advocated for use. However, construct validity was not demonstrated for the serratus anterior and middle trapezius muscle tests as performed in this study. Further investigation of these muscle tests is warranted.

The objective of this study was to investigate the effects of LE fatigue on ground impact force, LE kinematics, and LE kinetics during landing. Ground reaction force (GRF), kinematic, and electromyogram (EMG) data were collected from 12 male subjects during a fatiguing landing activity (FLA). This activity allowed not only the biomechanical differences between unfatigued and fatigued landings to be determined, but also the time history of multiple biomechanical variables as fatigue progressed. EMG mean frequency analysis using data collected immediately before and after the FLA indicated that subjects experienced fatigue of the quadriceps muscles. Results indicated a decrease in ground impact force and an increase in maximum joint flexion during landing with fatigue. Joint impulse values were consistent with a distal to proximal redistribution of extensor moment production. Potential reasons for this redistribution are discussed. A trend reversal in hip and ankle impulse during the activity suggest a change in landing strategy as fatigue progressed. The data also suggest that the measured changes in landing biomechanics may have been influenced by other factors, in addition to fatigue, such as a neuromuscular protective mechanism to decrease impact force magnitude.

PURPOSE The use of electromyogram-based fatigue measurements during high-intensity, dynamic activities is confounded by the accompanying increase in muscle temperature. The purpose of this communication was to demonstrate the use of a muscle temperature compensation technique for electromyogram (EMG) fatigue measurements. METHODS Subjects were six healthy men (mean age 30.8 +/- 5.6 yr) with no recent history of lower extremity injury. In part 1 of this study, the relationship between muscle temperature and EMG mean power frequency was determined for the vastus lateralis muscle (VL). The VL was heated with diathermy to a temperature of approximately 39 degrees C. Isometric EMG data were collected during the performance of a nonfatiguing protocol as the muscle cooled (39-34 degrees C). In part 2 of this study, the subjects rode a lower-extremity ergometer at workloads of 25%, 50%, and 75% of their VO2max. Isometric EMG and intramuscular temperature data were collected from the VL during intermittent interruptions of the activity. The relationship between muscle temperature and EMG mean power frequency established in part 1 was used with the measured change in muscle temperature to correct for the effect of temperature on the EMG mean power frequency. RESULTS The results from part 1 revealed a linear relationship between EMG mean power frequency and muscle temperature (N = 5, mean slope = 2.82 +/- 0.27 Hz. degrees C-1, R2 = 0.88 +/- 0.02). The mean slope was used as a muscle temperature compensation factor that quantified the influence of muscle temperature on EMG mean power frequency. For part 2, representative data from a single subject are presented to demonstrate the use of the muscle temperature compensation technique. CONCLUSION A muscle temperature compensation technique for EMG mean power frequency analysis has been demonstrated. This technique corrects for the detrimental influence of muscle temperature changes on EMG fatigue measurements, thereby improving the efficacy of EMG fatigue measurements during high-intensity, dynamic activities that result in muscle temperature increases.

A training system intended for myoelectric prosthetic hands for upper limb amputees was developed to assist in learning myoelectric control schemes and training muscle isolation. The trainer allowed a user to operate a remote controlled car by use of a control scheme commonly used in myoelectric prosthetic hands. The trainer was designed to be easy for therapists to use and more engaging for the user than current methods of signal training. Preliminary testing of the trainer was conducted with eight nonamputee adult volunteers. The results indicated that the trainer could be a useful tool for myoelectric training in upper limb amputees. All subjects' skill with the myoelectric control scheme improved over the course of testing, with the improvements being greater at the beginning of the training period than at the end. Whereas the individual subjects' performance varied greatly at the beginning of the training, the subjects had achieved a more uniform level of performance by the end of the training, approaching the minimum possible values for the assessments.

Setting: Outpatient rehabilitation clinic. Patient: A 37-year-old physically active male. Case Description: The patient presented with anterior left knee pain, exacerbated when climbing stairs, sitting, and running. Exam showed lateral tracking patellae and palpable crepitus. One hundred fifty units of botulinum toxin A was injected into his left vastus lateralis. He underwent a 12-week home exercise program targeting the vastus medialis (VM). Assessment/Results: Visual analog scale decreased from 70 to 0 on a 150-mm scale, from initial until 8 weeks postinjection. Functional Index Questionnaire increased from 5 to 16 over the same period. Knee torque and surface electromyography findings showed increased activity of the VM during knee extension. Conclusion: Botulinum injection into the vastus lateralis in conjunction with VM strengthening may provide more effective treatment of patellofemoral pain syndrome. Further study is needed to explore this novel treatment of patellofemoral pain syndrome.

Objective: To determine sacroiliac joint compliance characteristics and pelvic floor movements in older women relative to gynecological surgery history and back pain complaints. Design: Single-visit laboratory measurement. Setting: University clinical research center. Participants: Twenty-five women aged 65 years or older. Outcome Measures: Sacroiliac joint compliance measured by Doppler imaging of vibrations and ultrasound measures of pelvic floor motion during the active straight leg raise test. Results: Doppler imaging of vibrations demonstrated test reliability ranging from 0.701 to 0.898 for detecting vibration on the ilium and sacrum sides of the sacroiliac joint. The presence of low-back pain or prior gynecological surgery was not significantly associated with a difference in the compliance or laxity symmetry of the sacroiliac joints. No significant difference in pelvic floor movement was found during the active straight leg raise test between subject groups. All P values were ≥.4159. Conclusions: Prior gynecological surgery and low-back pain were not significantly associated with side-to-side differences in the compliance of the sacroiliac joints or in significant changes in pelvic floor movement during a loading maneuver in a group of older women.

PURPOSE: To investigate the relationship between gluteus medius muscle (GM) activity, pelvic motion, and changes in metabolic energy demands while running. METHODS: Five healthy, female subjects (mean age 22.8±2.2) were obtained from a sample of convenience. Subjects were recreational runners who ran ≥ 5 miles per week (mean 28.0 miles±15.2). Subjects were asked to run on a treadmill for 30 minutes at a self-selected speed (6.52 mph±0.2). Muscle Activity — Surface electromyography (sEMG) data was collected on the GM at a rate of 1000 Hz (MyoSystem 1200™, Noraxon). Kinematics — Three-dimensional data on pelvic position was sampled at a rate of 60 Hz using an electromagnetic kinematic tracking system (MotionMonitor™, Innovative Sports Training) with sensors (Polhemus Fastrak) secured over the posterior superior iliac spines. Metabolic Energy — Oxygen consumption (VO2) was obtained through ventilatory expired gas analysis (SensorMedics, Inc., Yorba Linda, CA) during rest, exercise and five minutes into recovery. The change in VO2 between 25–30 minutes (average value) was determined (δVO2) as was the time constant of VO2 recovery kinetics. MatLab v 7.1 was used for kinematics analyses. A Pearson’s Correlation was calculated using SPSS v 14.0; statistical significance was defined as p

Background This report illustrates the use of pressure for scar management to aid in foot re-shaping following a surgical intervention to repair an arterio-venous (AV) malformation. Methods This report describes the rehabilitation of a 13-year-old girl after surgical reconstruction of a defect in her left foot following the removal of an AV malformation. Early surgical attempts to repair the problem resulted in complications that required the amputation of toes 2, 3, and 4, and the use of a split thickness skin graft to cover the plantar surface of the medial longitudinal arch on the left foot. Following surgery, the patient had an antalgic gait pattern with decreased weight bearing on the left. The graft obliterated the left medial longitudinal arch and the patient would only weight bear on the heel. The patient had decreased metatarsal joint mobility on the affected side and no movement in the remaining toes. Left talocrural joint active range-of-motion (AROM) was within normal limits and gross ankle muscle force production was assessed to have a grade of 3/5. Results Treatment included reshaping the left foot using a pressure garment and orthotic, followed by interventions to address range-of-motion and muscle force production deficiencies. All treatment objectives were achieved and all patient goals were achieved. Conclusions Pressure was effective in re-shaping the foot to promote normal gait mechanics.

Purpose To present the management of a patient with a cervical disc herniation and illustrate the efficacy of cervical traction as a main form of treatment for cervical disc herniation in conjunction with a home exercise program. Background A 71-year-old white female diagnosed with cervical disc herniation at the levels of C5-6 and C6-7 presented to physical therapy with neck pain radiating into the left upper extremity down to the 5th digit of the left hand. Treatment The patient reported to outpatient physical therapy for cervical disc herniation and radiculopathy. After initial evaluation she received intermittent cervical traction and was given a home exercise program consisting of cervical lateral flexion stretch, unilateral wall stretch for pectoralis muscles and to continue with her over the door cervical traction. Conclusion Cervical traction and a good home exercise program have been shown to reduce cervical disc herniation and its subsequent symptoms.

Background and Purpose This case report describes the rehabilitation of an elite, 15-year-old gymnast after a nonreduced type II manubriosternal dislocation. The rehabilitation took place in a gymnastics venue but was guided by a physician and a licensed physical therapist. Case Description The gymnast participated in a 13-week rehabilitation program for range of motion and strengthening that was based on a biomechanical hierarchy. Rehabilitation began at week 2 after injury for the lower extremities and at week 4 for the upper extremities. Outcomes By week 4, the patient began upper-extremity strengthening, and by week 6, the patient had no pain with palpation and tolerated light sternal loading. At week 9, a plain-film radiograph revealed a stable manubriosternal joint, and by week 13, the patient returned to gymnastics pain-free. Discussion This case report shows that, after a 13-week regimen of progressive and repetitive, cyclical tensile and compressive loading, the manubriosternal joint was stable, and the elite gymnast was able to return to the sport, successfully competing in a regional competition.

Background: Plantar fasciitis is one of the more common soft-tissue disorders of the foot, yet little is known about its etiology. The purpose of the present study was to use an epidemiological design to determine whether risk factors for plantar fasciitis could be identified. Specifically, we examined the risk factors of limited ankle dorsiflexion with the knee extended, obesity, and time spent weight-bearing. Methods: We used a matched case-control design, with two controls for each patient. The matching criteria were age and gender. We identified fifty consecutive patients with unilateral plantar fasciitis who met the inclusion criteria. The data that were collected included height, weight, whether the subject spent the majority of the workday weight-bearing, and whether the subject was a jogger or runner. We used a reliable goniometric method to measure passive ankle dorsiflexion bilaterally. The main outcome measure was the adjusted odds ratio of plantar fasciitis associated with varying degrees of limitation of ankle dorsiflexion, different levels of body mass, and the subjects' reports on weight-bearing. Results: Individuals with ≤0° of dorsiflexion had an odds ratio of 23.3 (95% confidence interval, 4.3 to 124.4) when compared with the referent group of individuals who had >10° of ankle dorsiflexion. Individuals who had a body-mass index of >30 kg/m 2 had an odds ratio of 5.6 (95% confidence interval, 1.9 to 16.6) when compared with the referent group of individuals who had a body-mass index of ≤25 kg/m 2. Individuals who reported that they spent the majority of their workday on their feet had an odds ratio of 3.6 (95% confidence interval, 1.3 to 10.1) when compared with the referent group of those who did not. Conclusions: The risk of plantar fasciitis increases as the range of ankle dorsiflexion decreases. Individuals who spend the majority of their workday on their feet and those whose body-mass index is >30 kg/m 2 are also at increased risk for the development of plantar fasciitis. Reduced ankle dorsiflexion, obesity, and work-related weight-bearing appear to be independent risk factors for plantar fasciitis. Reduced ankle dorsiflexion appears to be the most important risk factor. Level of Evidence: Prognostic study, Level II-1 (retrospective study). See Instructions to Authors for a complete description of levels of evidence.

Purpose Experiments were conducted on five subjects with no visual impairment to assess tracking strategy differences in subjects with and without a simulated central scotoma. Methods Subjects were asked to visually track horizontally moving periodic and nonperiodic sinusoidal stimuli through a +/-5 degrees range. Scotoma simulation was achieved electronically with a closed-loop feedback system using horizontal eye movement measurements from a monocular limbus eye tracker updated at a rate of 500 Hz. The scotoma was centrally located and had defined horizontal half widths of 1, 2, and 3 degrees . Vertical eye position measurements from a video-based dark-pupil tracker were used to identify and remove trials in which extreme vertical eye position deviations reduced the effectiveness of the simulation. Results All subjects developed a preferred retinal locus (PRL) in the left visual field and demonstrated a tendency for saccadic redirection to this area. Saccadic endpoints into the PRL outnumbered foveally directed saccades by a factor of 2:1. The PRL was located outside the compromised central vision region, typically near the edge of the scotoma boundary, for all subjects except one. This subject had a PRL within the simulated scotoma under two conditions, but the percentage of total time spent at the "compromised" PRL was less than for other subjects. Conclusions Subjects with no visual impairment confronted with a central scotoma develop a preferred retinal locus to replace the nonfunctional fovea and appear to suppress normal refoveating saccadic behavior in favor of this location.