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STUDY DESIGN: Cross-sectional study. OBJECTIVE: To examine differences between arms in humeral torsion in adult and adolescent throwing and nonthrowing athletes, and nonathletic adults. BACKGROUND: It is hypothesized that humeral retrotorsion develops by, and is beneficial for, throwing. Thus throwers should demonstrate greater retrotorsion in their dominant arm relative to their nondominant arm and have more side-to-side retrotorsion difference than nonthrowing groups. In addition, adult throwers should have a greater side-to-side retrotorsion difference than adolescent throwers, and swimmers should not demonstrate a retrotorsion difference. METHODS AND MEASURES: Using ultrasound to standardize the location of the bicipital groove, the amount of humeral torsion was measured in both arms of male baseball players (85 adult, 35 adolescent), female softball players (16 adult, 37 adolescent), 29 elite adolescent swimmers (19 female), and 16 nonathletic adults (8 female). RESULTS: More retrotorsion was found in the dominant arm of almost all throwing athletes, irrespective of their gender or whether they were adults or adolescents (mean +/- SD side-to-side difference, 11.9 degrees +/- 10.5 degrees ). This difference was less for swimmers (6.4 degrees +/- 9.9 degrees ) and nonathletic adults (1.3 degrees +/- 8.9 degrees ). CONCLUSION: Greater dominant armhumeral retrotorsion is observed contingent with participation in throwing sports.J Orthop Sports Phys Ther 2009;39(4):256-263, Epub 24 February 2009. doi:10.2519/jospt.2009.2821. [ABSTRACT FROM AUTHOR]

STUDY DESIGN: This study analyzed the effects of autografted nucleus pulposus on nerve root axon morphology, neurophysiologic function, and sodium channel expression. OBJECTIVES: To investigate the chronic effects of the epidural implantation of nucleus pulposus on nerve root morphology, neural activity, ectopic discharge, mechanosensitivity, and sodium channel expression. SUMMARY OF BACKGROUND DATA: It has been reported that ectopic discharges were recorded antidromically from sural nerve on compressing nucleus pulposus exposed spinal nerves. However, it is not clear what the effects of nucleus pulposus are on ectopic discharges recorded directly from the spinal nerve roots. It is also not clear what the effects of nucleus pulposus are on the threshold pressure to provoke ectopic discharges in the spinal nerves. Sodium channel content increases in remodeling axons after nerve injury, but it is not clear what the effects of nucleus pulposus are on sodium channel expression in spinal nerve. METHODS: Forty-six male Sprague-Dawley rats were used, 20 in a nucleus pulposus-implanted group, 18 in a fat-implanted group, and 8 in a normal group. Fresh autografted nucleus pulposus or fat tissue was implanted into the dorsal epidural space at the L4-L5 disc level. On the 7th, 21st, or 42nd day, neurophysiologic recordings were made to determine nerve root response to compression. Nerve roots were then harvested to determine sodium channel protein concentration and histologic changes in the nerve root. The correlations between sodium channel density and neural activity and mechanosensitivity of dorsal root were analyzed statistically. RESULTS: Ectopic discharge rate was higher in nucleus pulposus 7-day group. Threshold pressure to evoke ectopic discharges was lower in the nucleus pulposus 7-day group, and higher in the nucleus pulposus 42-day group compared to the normal group. Sodium channel protein density increased in the nucleus pulposus 7-day and nucleus pulposus 21-day group compared to normal nerve. Sodium channel density changes were not correlated to threshold pressure. Ectopic discharge rate increased with increase of sodium channel density in the nerve roots. The number of axons with neuropathy increased in the nucleus pulposus 7-day and 21-day groups. CONCLUSIONS: Acute exposure of nerve root to nucleus pulposus resulted in increased number of axons with neuropathy, higher intensity of ectopic discharges on compression, and nerve mechanosensitization. Chronic exposure resulted in mechanical desensitization. Changes of sodium channel density were correlated to ectopic discharge rate. [ABSTRACT FROM AUTHOR]

BACKGROUND: Training manual therapists in the judgment of spinal stiffness traditionally requires the spines of human volunteers. Presenting the range of stiffness values representative of spines requires both time and resources. When investigating the ability of therapists to judge spinal stiffness, several studies have therefore utilized spine analogues, nonbiological devices designed to present either purely elastic stimuli or viscoelastic stimuli with unknown relative contributions of elastic and viscous components. Previous research has suggested that the viscous component of stiffness is more difficult to judge. OBJECTIVE: This study determined for each subject the just-noticeable difference, or discrimination threshold, for manual judgment of viscous stiffness against a constant elastic and friction background. DESIGN: This psychophysical study utilized the Weber fraction as a measure of the ability of subjects to discriminate between viscoelastic stiffness stimuli. METHODS: Twenty-five subjects with both physiotherapy and lay backgrounds volunteered to participate in the study. Stiffness stimuli were generated by a device incorporating a fluid-filled plunger and a spring, with only the amount of viscous stiffness being manipulated by the experimenter. The method of constant stimuli was used to estimate the just-discriminable change in viscous stiffness, and results were expressed as a percentage of the base stiffness or Weber fraction. RESULTS: The mean Weber fraction for manual judgments of viscous stiffness was 14.7%. For 13 of the subjects who had previously participated in elastic stiffness discrimination studies, the Weber fraction for viscous stimuli was significantly greater than that for elastic stimuli. CONCLUSION: The significantly higher Weber fraction for viscous stiffness perception compared with that for pure elastic stiffness suggests that the poor reliability of manual judgments of spinal stiffness may be due to the difficulty in judging the viscous stiffness component. [ABSTRACT FROM AUTHOR]

Purpose: Hypermobile Ehlers-Danlos Syndrome (hEDS) and hypermobility spectrum disorder (HSD) are painful, chronic and multi-systemic conditions. No online pain management programs for hEDS/HSD currently exist. We aimed to develop one by exploring what people with hEDS/HSD want in such programs., Materials and Methods: A Delphi was conducted via online surveys of stakeholders: participants with hEDS/HSD and healthcare professionals (HCP). In survey 1, participants were asked if a hEDS/HSD-specific online pain management program was important, listing up to 20 topics important to know about pain. In survey 2, participants rated the importance of those topics. Consensus was set as ≥75% rating of at least "important". Using topics that reached consensus, the online program was developed. Usability testing was performed using the Systems Usability Scale (SUS)., Results: 396 hEDS/HSD and 29 HCP completed survey 1; 151 hEDS/HSD and 12 HCP completed survey 2. 81% of hEDS/HSD and 69% of HCP rated a hEDS/HSD-specific program as at least "important". Thirty-five topics reached consensus to guide content for the HOPE program (Hypermobile Online Pain managemEnt). SUS score was 82.5, corresponding to "high acceptability"., Conclusions: A hEDS/HSD-specific online pain management program is important to stakeholders. Utilising a Delphi approach to incorporate stakeholder input, an evidence-informed and user appropriate program was developed.

Background: Physical activity is known to improve psychological and cognitive outcomes. Learning dance sequences may challenge cognition, partnered or group dance may benefit social interactions, and the artistic aspect may improve psychological wellbeing. Dance is an equally effective form of physical activity compared with other structured physical activities to improve physical health, but it is unclear how effective dance could be for psychological and cognitive outcome measures., Objective: To systematically review the literature on the effectiveness of structured dance interventions, compared with structured exercise programmes, on psychological and cognitive outcomes across the lifespan., Methods: Eight databases were searched from earliest records to July 2022. Studies investigating a dance intervention lasting ≥ 4 weeks, including psychological and/or cognitive health outcomes, and having a structured exercise comparison group were included. Screening and data extraction were performed by two independent reviewers at all stages. All reviewer disagreements were resolved by the primary author. Where appropriate, meta-analysis was performed, or an effect size estimate generated., Results: Of 21,737 records identified, 27 studies met the inclusion criteria. Total sample size of included studies was 1392 (944 females, 418 males, 30 unreported). Dance was equally as effective as other physical activity interventions in improving quality of life for people with Parkinson's disease [mean difference 3.09; 95% confidence interval (CI) - 2.13 to 8.30; p = 0.25], reducing anxiety (standardised mean difference 2.26; 95% CI - 2.37 to 6.90; p = 0.34), and improving depressive symptoms (standardised mean difference 0.78; 95% CI - 0.92 to 2.48; p = 0.37). Preliminary evidence found dance to be superior to other physical activity interventions to improve motivation, aspects of memory, and social cognition and to reduce distress. Preliminary evidence found dance to be inferior to other physical activity interventions to improve stress, self-efficacy and language fluency., Conclusion: Undertaking structured dance of any genre is generally equally and occasionally more effective than other types of structured exercise for improving a range of psychological and cognitive outcomes., Trial Registration: PROSPERO: CRD42018099637., (© 2024. The Author(s).)

Background: Practice facilitators (PFs) coach practices through quality improvement (QI) initiatives aimed at enhancing patient outcomes and operational efficiencies. Practice facilitation is a dynamic intervention that, by design, is tailored to practices' unique needs and contexts. Little research has explored the amount of time PFs spend with practices on QI activities. This short report expands on previously published work that detailed a 12-month practice facilitation intervention as part of the Southeastern Collaboration to Improve Blood Pressure Control (SEC) trial, which focused on improving hypertension control among people living in rural settings in the southeastern USA. This report analyzes data on the time PFs spent to guide 32 primary care practices in implementing QI activities to support enhanced outcomes in patients with high blood pressure., Methods: The SEC trial employed four certified PFs across all practice sites, who documented time spent: (1) driving to support practices; (2) working on-site with staff and clinicians; and (3) communicating remotely (phone, email, or video conference) with practice members. We analyzed the data using descriptive statistics to help understand time devoted to individual and aggregated tasks. Additionally, we explored correlations between practice characteristics and time spent with PFs., Results: In aggregate, the PFs completed 416 visits to practices and spent an average of 130 (SD 65) min per visit driving to and from practices. The average time spent on-site per visit with practices was 87 (SD 37) min, while an average of 17 (SD 12) min was spent on individual remote communications. During the 12-month intervention, 1131 remote communications were conducted with practices. PFs spent most of their time with clinical staff members (n = 886 instances) or with practice managers alone (n = 670 instances) while relatively few on-site visits were conducted with primary care providers alone (n = 15). In 19 practices, no communications were solely with providers. No significant correlations were found between time spent on PF activities and a practices' percent of Medicaid and uninsured patients, staff-provider ratio, or federally qualified health center (FQHC) status., Conclusions: PFs working with practices serving rural patients with hypertension devote substantial time to driving, highlighting the importance of optimizing a balance between time spent on-site vs. communicating remotely. Most time spent was with clinical staff, not primary care providers. These findings may be useful to researchers and business leaders who design, test, and implement efficient facilitation services., Trial Registration: NIH ClinicalTrials.gov NCT02866669 . Registered on 15 August 2016. NHLBI AWARD number: PCS-1UH3HL130691., (© 2023. The Author(s).)

Face-to-face pain management programs demonstrate positive clinical outcomes in the chronic pain population by improving pain intensity and attitudes, depression, and functional disability scores. The effects of this modality carried out online is less known, particularly in subgroups of chronic pain. This systematic review assessed the effects of online pain management programs in chronic, widespread musculoskeletal conditions on pain measurements (intensity, interference, coping, and catastrophizing), health-related quality of life, depression, and anxiety scores immediately post-intervention. Five electronic databases (Embase, Medline, CINAHL, Scopus, and PEDro) were searched with 3546 studies identified. Eighteen randomized controlled trials fulfilled the inclusion criteria. Included studies had moderate methodological quality (using the Effective Public Health Practice Project (EPHPP) quality assessment tool) but high risk of bias (using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2)). There were significant improvements in pain intensity (11 studies, 1397 participants, SMD -0.30, 95% CI -0.50 to -0.10, p = 0.004), health-related quality of life (eight studies, 1054 participants, SMD 0.41, 95% CI 0.08 to 0.75, p = 0.02), and depression (nine studies, 1283 participants, SMD -0.32, 95% CI -0.55 to -0.08, p = 0.008). However, effect sizes were small and did not meet their respective measure's minimal clinically important change score. Guided interventions (regular interaction with an instructor) appeared to be superior to self-completed interventions. Future research should standardize outcome measures for assessing pain, use active control groups, and analyze other outcome measures such as cost and long-term effects. This study was registered with Prospero on August 15, 2021 (CRD42021267565)., (© 2023 The Authors. Pain Practice published by Wiley Periodicals LLC on behalf of World Institute of Pain.)

Purpose: To establish reference ranges for four most commonly used diagnostic measures of craniocervical instability (CCI) in three cervical sagittal positions. This necessitated development of a reliable measurement protocol using upright, dynamic MRI (udMRI), to determine differences in the extent of motion between positions, and whether age and sex correlate with these measures., Materials and Methods: Deidentified udMRIs of 50 adults, referred for reasons other than CCI, were captured at three positions (maximal flexion, maximal extension and neutral). Images were analyzed, providing measures of basion-axial interval, basion-axial angle, basion-dens interval (BDI) and the Grabb-Oakes line (GOL) for all three positions (12 measures per participant). All measures were independently recorded by a radiologist and neurosurgeon to determine their reliability. Descriptive statistics, correlations, paired and independent t-tests were used. Mean (± 2 SD) identified the reference range for all four measures at each craniocervical position., Results: The revised measurement protocol produced inter-rater reliability indices of 0.69-0.97 (moderate-excellent). Fifty adults' (50% male; mean age 41.2 years (± 9.7)) reference ranges for all twelve measures were reported. Except for the BDI and GOL when moving between neutral and full flexion, significant extents of movement were identified between the three craniocervical positions for all four measures (p ≤ 0.005). Only a minor effect of age was found., Conclusions: This is the first study to provide a rigorous standardized protocol for four diagnostic measures of CCI. Reference ranges are established at mid and ends of sagittal cervical range corresponding to where exacerbations of signs and symptoms are commonly reported., (© 2023. The Author(s).)

Experts in symptomatic generalized joint hypermobility (S-GJH) agree that upper cervical instability (UCI) needs to be better recognized in S-GJH, which commonly presents in the clinic as generalized hypermobility spectrum disorder and hypermobile Ehlers-Danlos syndrome. While mild UCI may be common, it can still be impactful; though considerably less common, severe UCI can potentially be debilitating. UCI includes both atlanto-occipital and atlantoaxial instability. In the absence of research or published literature describing validated tests or prediction rules, it is not clear what signs and symptoms are most important for diagnosis of UCI. Similarly, healthcare providers lack agreed-upon ways to screen and classify different types or severity of UCI and how to manage UCI in this population. Consequently, recognition and management of UCI in this population has likely been inconsistent and not based on the knowledge and skills of the most experienced clinicians. The current work represents efforts of an international team of physical/physiotherapy clinicians and a S-GJH expert rheumatologist to develop expert consensus recommendations for screening, assessing, and managing patients with UCI associated with S-GJH. Hopefully these recommendations can improve overall recognition and care for this population by combining expertise from physical/physiotherapy clinicians and researchers spanning three continents. These recommendations may also stimulate more research into recognition and conservative care for this complex condition., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Russek, Block, Byrne, Chalela, Chan, Comerford, Frost, Hennessy, McCarthy, Nicholson, Parry, Simmonds, Stott, Thomas, Treleaven, Wagner and Hakim.)

Importance: Heritable disorders of connective tissue (HDCTs) affect hand function and participation in daily activities for children and adolescents., Objective: To describe hand impairment and function and determine the extent to which hand impairment and function explain the variation in self-reported functional performance., Design: Cross-sectional observational study., Setting: Specialist tertiary hospital., Participants: Children and adolescents ages 8-18 yr with HDCTs (N = 73)., Intervention: None., Outcomes and Measures: Hand function outcomes included grip strength (digital dynamometer), manipulation and dexterity (Functional Dexterity Test, Nine-Hole Peg Test), and fine motor skills (Bruininks-Oseretsky Test of Motor Proficiency). Upper limb hypermobility was assessed using the Upper Limb Hypermobility Assessment Tool. Hand pain and fatigue were recorded for a timed button test and 3- and 9-min handwriting tasks. Functional performance was measured using the Childhood Health Assessment Questionnaire., Results: Scores on all hand function measures were below expected norms. Pain and fatigue were significantly worse after the writing tasks (p < .001) but not the button test (p > .40). Secondary students had significantly lower handwriting scores than primary students (p = .03) but similar grip strength z scores (p = .95). Variation in self-reported functional performance was explained by grip strength (6%) and upper limb hypermobility and dexterity (16%)., Conclusions and Relevance: Young people with HDCTs have poor hand function attributable to poor grip strength and hand pain and fatigue. Comprehensive upper limb evaluation and ongoing monitoring throughout the school years are warranted to inform timely intervention. What This Article Adds: Children and adolescents with heritable disorders of connective tissue have difficulty with hand function that affect their participation in daily activities. The results of this study can help clinicians identify, assess, and monitor daily activities, performance skills, and symptoms of children and adolescents with HDCTs to promote their participation in all aspects of daily life., (Copyright © 2022 by the American Occupational Therapy Association, Inc.)

Abstract: There is exponential clinical and research interest in joint hypermobility due to recognition of the complexity of identification, assessment, and its appropriate referral pathways, ultimately impacting management. This state-of-the-science review provides an international, multidisciplinary perspective on the presentation, etiology, and assessment of joint hypermobility, as it presents in those with and without a systemic condition. We synthesize the literature, propose standardizing the use of terminology and outcome measures, and suggest potential management directions. The major topics covered are (i) historical perspectives; (ii) current definitions of hypermobility, laxity, and instability; (iii) inheritance and acquisition of hypermobility; (iv) traditional and novel assessments; (v) strengths and limitations of current assessment tools; (vi) age, sex, and racial considerations; (vii) phenotypic presentations; (viii) generalized hypermobility spectrum disorder and hypermobility Ehlers-Danlos syndrome; and (ix) clinical implications and research directions. A thorough understanding of these topics will equip the reader seeking to manage individuals presenting with joint hypermobility, while mindful of its etiology. Management of generalized joint hypermobility in the context of a complex, multisystem condition will differ from that of acquired hypermobility commonly seen in performing artists, specific athletic populations, posttrauma, and so on. In addition, people with symptomatic hypermobility present predominantly with musculoskeletal symptoms and sometimes systemic symptoms including fatigue, orthostatic intolerance, and gastrointestinal or genitourinary issues. Some also display skeletal deformities, tissue and skin fragility, and structural vascular or cardiac differences, and these warrant further medical follow-up. This comprehensive review on the full spectrum of joint hypermobility will assist clinicians, coaches/sports trainers, educators, and/or researchers in this area., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Managing children and adolescents with syndromic hypermobility and their parents is challenging in the context of a standard consultation. The multi-organ involvement of the syndromes, the evolving classification criteria and their highly heterogeneous presentation complicate both diagnosis and management., Objective: The purpose of this article is to provide an overview of the diagnosis, management and support of children with hypermobility syndromes, including the role of the multidisciplinary team and common associated features., Discussion: Optimising the quality of life of people with syndromic hypermobility begins with the early identification of their signs and symptoms. Diagnosis, ideally by adolescence, provides affected children and their parents with validation and directs their focus to management aimed at mitigating the socioeconomic, educational and health-related quality of life impact of these conditions.

Background: Practice facilitation (PF) is a promising but relatively new intervention supporting data-driven practice change. There is a need to better detail research-based facilitation methods, which must balance intervention fidelity and time restrictions with the flexibility required for the intervention. As part of a multi-level 4-armed cluster randomized clinical trial (RCT), 32 rural primary care practices received PF for 1 year. We evaluated the feasibility of having facilitators guide practices to perform 4 key driver domain activities, implemented as Plan-Do-Study-Act (PDSA) cycles, to better understand facilitation "exposure." We describe the intervention and activity length such that our experiences may be useful to other PF research efforts., Methods: Thirty-two practices serving rural patients involved in the Southeastern Collaboration to Improvement Blood Pressure Control engaged with a facilitator to develop and implement PDSAs nested within key drivers of change domains. Numbers of months practices worked on activities deemed most likely to be sustained were captured along with practice satisfaction data., Results: All practices engaged in at least 4 domain-level activities, and 59% of the PDSAs were active for at least 3 months. There was variation by domain in the average length of the PDSA activities. Ninety-seven percent (31 of 32) of practices recommended similarly structured facilitation services to other primary care practices, and 84% (27 of 32) noted substantive changes in their care processes., Conclusion: In this trial, it was feasible for PFs to engage practices in at least 4 Key Driver quality improvement activities within 1 year, which will inform PF methods and protocol development in future trials., Competing Interests: Conflict of interest: The authors have no conflicts of interest to disclose., (© Copyright 2021 by the American Board of Family Medicine.)

Objectives: The primary aim was to determine the association between sagittal cervical mobility and the presence and extent of GJH across the lifespan. Secondary aims were to determine which features explain variability in cervical range of motion (CROM) and to establish the sagittal cervical hypermobile range in both genders across the lifespan., Design: Cross-sectional observational study. Spearman's rho determined the relationship between presence and extent of GJH and CROM, age, gender and ethnicity. Multiple regression identified the factors explaining variability in CROM. The hypermobile CROM was identified as the upper 5% of flexion, extension and combined ranges for age and gender., Setting: University laboratory in Sydney Australia., Participants: One thousand healthy individuals, aged 3-101 years., Outcome Measures: Cervical active range of motion was assessed using an inclinometer, extent of and presence of generalised joint hypermobility were assessed using the Beighton scoring system and age- and gender-specific criteria respectively., Results: CROM correlated positively with GJH (Beighton score as a continuous or dichotomous age and gender specific variable) (rho=0.12-0.50; p < 0.001) and negatively with age (rho=0.54; p < 0.001). Age, gender and extent of GJH (Beighton as a continuous score) accounted for 19 to 51% of variability in CROM. Cut-offs for cervical hypermobility were calculated across the lifespan., Conclusions: Increased sagittal CROM was observed in individuals identified with GJH. Extension CROM decreased with age more than flexion; the greatest loss in the second and third decades. CROM screening is warranted for patients identified with GJH and for rehabilitation goal-setting., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

Aim: The primary aim of this study was to determine the association between generalized joint hypermobility (GJH), knee-specific hypermobility (KSH) and self-reported knee health in an Australian population. Secondary aims included elucidating ethnic/gender differences in GJH/KSH prevalence and knee health, and identifying KSH using a novel knee extension range of motion cut-off method., Method: Knee extension range, Beighton score, and 5 domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS) were collected from adults aged 18-101 years self-identifying as healthy, and were grouped by ethnicity and gender. Two established Beighton score criteria and 1 novel knee extension range cut-off method were used to determine GJH and KSH respectively. Point-biserial correlation tested the associations between GJH/KSH and KOOS. Differences in GJH/KSH prevalence and knee health between ethnic/gender groups were determined with the Chi-squared test., Results: Of 732 participants (50% male), 80.3% were Caucasian. No correlations were found between GJH and KOOS while a very weak correlation was found between KSH and 1 KOOS domain (r > -.30; P = .04). Prevalence of GJH was higher in non-Caucasians (17.4% vs 5.6%, P < .001) and females (4.4% vs 1.1%, P = .007). Prevalence of KSH between ethnic and gender groups was not significantly different (P = .50 and P = .69 respectively). Non-Caucasians scored higher (better) in all KOOS domains than Caucasians (all P < .05)., Conclusion: Those who met the age- and gender-specific criteria for GJH/KSH did not report worse knee health than their non-hypermobile counterparts. Clinicians can assure individuals who exhibit GJH/KSH that these are not associated with lower knee health and function., (© 2021 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Objectives: Determine the prevalence of lower limb hypermobility in elite dancers and secondarily to describe the patterns of mobility., Design: Cross sectional., Setting: Self-report questionnaires and physical assessments were undertaken at a tertiary dance institution and a professional ballet company., Participants: Fifty-seven pre-professional and 29 professional ballet dancers (21±4years, 64% female, mean 13.7years training) were recruited., Main Outcome Measures: Lower Limb Assessment Score (LLAS) was used to assess hypermobility. Prevalence was determined by descriptive statistics, between-leg and -group comparisons were analysed using the chi-square statistic and the pattern of mobility by cluster analyses., Results: The right leg was significantly more hypermobile than the left for the whole cohort (44% vs 40% meeting ≥7/12 for the LLAS; LLAS mean/12(SD): right:5.0(2.4) and 7.6(1.9); left:4.8(2.1) and 6.7(2.0) in pre-professionals and professionals respectively (p = 0.02)). Subtalar pronation (p < 0.001) and hip abduction/external rotation (left:p = 0.01; right:p < 0.001) were significantly more hypermobile bilaterally in professionals. Three hypermobility profiles on the left and four on the right lower limb were identified., Conclusions: This paper presents unique lower limb hypermobility profiles identified in elite dancers., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Some commonly reported systemic features of joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome hypermobility type (EDS-HT) are absent from nosologies due to insufficient validity. The primary aim was to examine the hypothesised high prevalence and frequency of orthostatic intolerance, easy bruising, and urinary incontinence in adults with JHS/EDS-HT and secondarily to determine the association between extent of generalised joint hypermobility (GJH) and these systemic features. A cross-sectional cohort study was conducted via online recruitment of medically diagnosed JHS/EDS-HT patients. A survey collected demographic data and clinical history. A subgroup of participants underwent physical testing of GJH using the Beighton score and Lower Limb Assessment Score (LLAS). Descriptive analysis was performed on demographic data and self-reported non-musculoskeletal systemic features. Correlation of GJH scores and systemic features were performed using Spearman's rank correlation. The survey was completed by 116 individuals (95% female; 16-68 years) with 57 (93% female) also participating in the physical assessment. The most prevalent systemic feature was orthostatic intolerance (98%), followed by easy bruising and urinary incontinence (97% and 84% respectively). Of those reporting symptoms of orthostatic intolerance, easy bruising, and urinary incontinence, 58%, 40%, and 18% described them as very highly frequent respectively (frequency > 75%). No significant correlations were found between the extent of systemic features and GJH scores as measured by either the Beighton score or the LLAS. The high prevalence and frequency of the systemic features found in this study, which are omitted in diagnostic classification criteria, suggest that further research on their diagnostic accuracy is warranted.

Aim: To assess the prevalence, severity and impact of fatigue on individuals with joint hypermobility syndrome (JHS)/Ehlers-Danlos syndrome - hypermobility type (EDS-HT) and establish potential determinants of fatigue severity in this population., Methods: Questionnaires on symptoms and signs related to fatigue, quality of life, mental health, physical activity participation and sleep quality were completed by people with JHS/EDS-HT recruited through two social media sites. Multiple regression analysis was performed to identify predictors of fatigue in this population., Results: Significant fatigue was reported by 79.5% of the 117 participants. Multiple regression analysis identified five predictors of fatigue severity, four being potentially modifiable, accounting for 52.3% of the variance in reported fatigue scores. Predictors of fatigue severity were: the self-perceived extent of joint hypermobility, orthostatic dizziness related to heat and exercise, levels of participation in personal relationships and community, current levels of physical activity and dissatisfaction with the diagnostic process and management options provided for their condition., Conclusion: Fatigue is a significant symptom associated with JHS/EDS-HT. Assessment of individuals with this condition should include measures of fatigue severity to enable targeted management of potentially modifiable factors associated with fatigue severity. Implications for rehabilitation Fatigue is a significant symptom reported by individuals affected by joint hypermobility syndrome/Ehlers-Danlos syndrome - hypermobility type. Potentially modifiable features that contribute to fatigue severity in this population have been identified. Targeted management of these features may decrease the severity and impact of fatigue in joint hypermobility syndrome/Ehlers-Danlos syndrome - hypermobility type.

Objectives: To determine the prevalence of Generalized Joint Hypermobility (GJH) and Joint Hypermobility Syndrome/Ehlers-Danlos Syndrome-Hypermobility Type (JHS/EDS-HT) among dancers using established validated measures., Design: Observational Cohort Study., Setting: Laboratory., Participants: 85 dancers from two dance institutions., Main Outcome Measures: GJH was determined using the Beighton score (cut-point ≥5/9) and the Lower Limb Assessment Scale (LLAS) (cut-point ≥7/12). Presence of JHS/EDS-HT was assessed using the Brighton and Villefranche criteria. Paired sample t-test was performed to compare LLAS side-to-side scores, and percentage disagreements calculated to determine differences between the two GJH and the two JHS/EDS-HT measures., Results: 72% of dancers met the Beighton cut-point for GJH, while 38% and 42% met the LLAS cut-point on the left and right respectively. The proportion of dancers identified with GJH was different when assessed using the Beighton compared to the left and right LLAS (both p < 0.001), a disagreement of 48% and 46% respectively, with Beighton classifying more participants as having GJH. The Villefranche identified more dancers with JHS/EDS-HT than the Brighton (84% vs 31%, p < 0.001), with 54% disagreement., Conclusions: High prevalence of generalized and syndromic hypermobility was found regardless of the criteria used. A higher Beighton cut-point, e.g. ≥6/9, to identify true GJH amongst dancers maybe warranted., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Existing measures of generalized joint hypermobility do not include commonly affected upper limb joints., Objective: To evaluate the reliability of a novel clinically-applicable measure of upper limb joint mobility, its ability to discriminate between varying extents of hypermobility, identify generalized joint hypermobility, and to establish a cut-point for hypermobility classification., Design: Validation of a diagnostic tool., Method: Participants were sought from three groups - healthy controls, likely and known hypermobiles, and assessed using the Upper Limb Hypermobility Assessment Tool (ULHAT), Beighton score and clinical opinion. Pearson's correlation coefficient examined individual group and whole cohort relationships between upper limb hypermobility, age, gender and ethnicity. MANOVA investigated between-group differences in ULHAT scores. Median interquartile ranges and ROC Curve analysis identified the cut-off score for identification of upper limb hypermobility. Percent agreement with clinical opinion assessed the ability of the ULHAT to identify generalized joint hypermobility., Results: 112 adult participants (mean age 24.3 ± 5.5years) across the three groups were assessed. Inter-rater reliability of the tool was high (ICC2,1 = 0.92). The cut-point was established at ≥7/12 (sensitivity 0.84, specificity 0.77, +LR 3.7, -LR 0.2). Upper limb hypermobility did not vary with age or ethnicity (both p > 0.12), but was greater in females (p < 0.001). The ULHAT discriminated between the three groups and identified generalized hypermobility., Conclusions: The 12-item ULHAT measures mobility of multiple upper limb joints in all movement planes. Using a cut-off of ≥7/12 in adults, the ULHAT is a reliable and valid tool for identifying upper limb hypermobility and generalized joint hypermobility., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Physical inactivity is one of the key global health challenges as it is associated with adverse effects related to ageing, weight control, physical function, longevity, and quality of life. Dancing is a form of physical activity associated with health benefits across the lifespan, even at amateur levels of participation. However, it is unclear whether dance interventions are equally as effective as other forms of physical activity., Objective: The aim was to systematically review the literature on the effectiveness of structured dance interventions, in comparison to structured exercise programmes, on physical health outcome measures., Methods: Seven databases were searched from earliest records to 4 August 2017. Studies investigating dance interventions lasting > 4 weeks that included physical health outcomes and had a structured exercise comparison group were included in the study. Screening and data extraction were performed by two reviewers, with all disagreements resolved by the primary author. Where appropriate, meta-analysis was performed or an effect size estimate generated., Results: Of 11,434 studies identified, 28 (total sample size 1276 participants) met the inclusion criteria. A variety of dance genres and structured exercise interventions were compared. Meta-analyses showed dance interventions significantly improved body composition, blood biomarkers, and musculoskeletal function. The effect of either intervention on cardiovascular function and self-perceived mobility was equivalent., Conclusion: Undertaking structured dance of any genre is equally and occasionally more effective than other types of structured exercise for improving a range of health outcome measures. Health practitioners can recommend structured dance as a safe and effective exercise alternative.

Background: The Lower Limb Assessment Score (LLAS) has only been validated in a paediatric population. The aim of this study was to validate the use of the LLAS in an adult population by: i) evaluating its ability to discriminate between different extents of lower limb hypermobility, ii) establishing a cut-off score to identify lower limb hypermobility, and iii) determining if the LLAS is able to identify Generalised Joint Hypermobility (GJH)., Methods: Participants were recruited across three groups representing varying degrees of hypermobility. They were assessed using the LLAS, Beighton score and clinical opinion. Pearson's correlation coefficient and MANOVA were used to assess between-group differences in the LLAS. The cut-off score was determined using median and inter-quartile ranges and the Receiver Operator Characteristic Curve. The ability of the LLAS to identify GJH was assessed using percent agreement with clinical opinion., Results: One hundred twelve participants aged 18-40 years were recruited. The LLAS distinguished the control from the likely hypermobile and known hypermobile cohorts (both p < 0.001), as well as the likely hypermobile from the known hypermobile cohort (p = 0.003). The LLAS cut-off score for identifying lower limb hypermobility was ≥7/12 with a specificity of 86% and sensitivity of 68%. The LLAS accurately identified those with GJH with high percentage agreement compared to clinical opinion across all cohorts (69-98%)., Conclusions: The LLAS is a valid tool for identifying lower limb specific hypermobility and GJH in adults at a cut-off score of ≥7/12. It demonstrates excellent specificity and moderate sensitivity, and discriminates well between extents of hypermobility.

Objectives: The objective of the manuscript was to describe the natural history of complaints and disability in children diagnosed with joint hypermobility syndrome (JHS)/Ehlers-Danlos-hypermobility type (EDS-HT) and to identify the constructs that underlie functional decline., Methods: One hundred and one JHS/EDS-HT children were observed over 3 years and assessed at three time points on the following: functional impairments, quality of life, connective tissue laxity, muscle function, postural control and musculoskeletal and multi-systemic complaints. Cluster analysis was performed to identify subgroups in severity. Clinical profiles were determined for these subgroups, and differences were assessed by multivariate analysis of covariance. Mixed linear regression models were used to determine the subsequent trajectories. Finally, an exploratory factor analysis was used to uncover the underlying constructs of functional impairment., Results: Three clusters of children were identified in terms of functional impairment: mild, moderately and severely affected. Functional impairment at baseline was predictive of worsening trajectories in terms of reduced walking distance and decreased quality of life (P ⩽ 0.05) over 3 years. Multiple interactions between the secondary outcomes were observed, with four underlying constructs identified. All four constructs (multi-systemic effects, pain, fatigue and loss of postural control) contributed significantly to disability (P ⩽ 0.046)., Conclusion: Children diagnosed with JHS/EDS-HT who have a high incidence of multi-systemic complaints (particularly, orthostatic intolerance, urinary incontinence and diarrhoea) and poor postural control in addition to high levels of pain and fatigue at baseline are most likely to have a deteriorating trajectory of functional impairment and, accordingly, warrant clinical prioritization., (© The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Study Design Cross-sectional study. Background The effect of current participation in dance training on joint pain and instability, fatigue, and quality of life is unknown. Objectives To examine differences in joint pain, instability, gross motor skills, nonmusculoskeletal systemic manifestations, health-related quality of life (HRQoL), and fatigue between children with joint hypermobility syndrome/Ehlers-Danlos syndrome-hypermobility type (JHS/EDS-HT) who currently undertake formal dance training and those who do not. Methods Children with JHS/EDS-HT and 1 parent completed reports providing data on demographic variables, symptoms, organized activity participation, HRQoL, and fatigue. Physical and functional measures included extent of hypermobility, aerobic fitness, balance, and muscle endurance. Results Of the 102 participating children, 22 currently undertook dance classes, averaging 3.3 h/wk. While the dancers reported a number of painful joints similar to that reported by nondancers (mean ± SD, 5.5 ± 3.7 versus 6.4 ± 3.9 joints, respectively; P = .36), they reported significantly lower pain levels on a 0-to-10 scale (3.8 ± 3.3 versus 5.6 ± 3.4, P = .04) and found pain to be less problematic, affecting less of their body. They reported fewer unstable joints (1.0 ± 1.0 versus 2.0 ± 1.8 joints, P = .001), despite being more hypermobile (Beighton score, 7.3 ± 1.4 versus 6.6 ± 1.6 on a 9-point scale, P = .047; Lower Limb Assessment Score, 9.2 ± 2.0 versus 8.1 ± 1.9 on a 12-point scale, P = .02). The dancers had significantly better HRQoL in the subdomain of school functioning (P = .004) and reported less fatigue (P = .024). Conclusion Children with JHS/EDS-HT who are currently undertaking formal dance training have fewer joint pain and instability symptoms, less fatigue, and better HRQoL; however, the cross-sectional nature of the study means that causation cannot be determined. Level of Evidence Therapy, level 2b. J Orthop Sports Phys Ther 2017;47(10):782-791. Epub 4 Sep 2017. doi:10.2519/jospt.2017.7331.

Objective: Lowered pressure-pain thresholds have been demonstrated in adults with Ehlers-Danlos syndrome hypermobility type (EDS-HT), but whether these findings are also present in children is unclear. Therefore, the objectives of the study were to determine whether generalized hyperalgesia is present in children with hypermobility syndrome (HMS)/EDS-HT, explore potential differences in pressure-pain thresholds between children and adults with HMS/EDS-HT, and determine the discriminative value of generalized hyperalgesia., Methods: Patients were classified in 1 of 3 groups: HMS/EDS-HT, hypermobile (Beighton score ≥4 of 9), and healthy controls. Descriptive data of age, sex, body mass index, Beighton score, skin laxity, and medication usage were collected. Generalized hyperalgesia was quantified by the average pressure-pain thresholds collected from 12 locations. Confounders collected were pain locations/intensity, fatigue, and psychological distress. Comparisons between children with HMS/EDS-HT and normative values, between children and adults with HMS/EDS-HT, and corrected confounders were analyzed with multivariate analysis of covariance. The discriminative value of generalized hyperalgesia employed to differentiate between HMS/EDS-HT, hypermobility, and controls was quantified with logistic regression., Results: Significantly lower pressure-pain thresholds were found in children with HMS/EDS-HT compared to normative values (range -22.0% to -59.0%; P ≤ 0.05). When applying a threshold of 30.8 N/cm 2 for males and 29.0 N/cm 2 for females, the presence of generalized hyperalgesia discriminated between individuals with HMS/EDS-HT, hypermobility, and healthy controls (odds ratio 6.0)., Conclusion: Children and adults with HMS/EDS-HT are characterized by hypermobility, chronic pain, and generalized hyperalgesia. The presence of generalized hyperalgesia may indicate involvement of the central nervous system in the development of chronic pain., (© 2016, American College of Rheumatology.)

Low range femoral torsion, termed "lateral shaft torsion," has been associated with greater range of hip external rotation and turnout in dancers. It is also hypothesized that achieving greater turnout at the hip minimizes torsion at the knee, shank, ankle, and foot, and consequently reduces incidence of lower limb injuries. The primary aims of this study were to investigate: 1. differences in range of femoral shaft torsion between dancers with and without lower limb injuries; and 2. the relationship between femoral shaft torsion, hip external rotation range, and turnout. A secondary aim was to examine the relationship between femoral shaft torsion and other hip measures: hip strength, lower limb joint hypermobility, hip stability, and foot progression angle, as explanatory variables. Demographic, dance, and injury data were collected, along with physical measures of femoral shaft torsion, hip rotation range of motion, and turnout. Hip strength, control, lower limb hypermobility, and foot progression angle were also measured. Eighty female dancers, 50 with lower limb injury (20.7 ± 4.8 years of age) and 30 without lower limb injury (17.8 ± 4.1 years of age), participated in the study. There was no difference in range of femoral shaft torsion between the groups (p = 0.941). Femoral shaft torsion was weakly correlated with range of hip external rotation (r = -0.034, p = 0.384) and turnout (r = -0.066, p = 0.558). Injured dancers had a significantly longer training history than non-injured dancers (p = 0.001). It was concluded that femoral shaft torsion does not appear to be associated with the overall incidence of lower limb injury in dancers or to be a primary factor influencing extent of turnout in this population.

Background: Clinical decision-making regarding diagnosis and management largely depends on comparison with healthy or 'normal' values. Physiotherapists and researchers therefore need access to robust patient-centred outcome measures and appropriate reference values. However there is a lack of high-quality reference data for many clinical measures. The aim of the 1000 Norms Project is to generate a freely accessible database of musculoskeletal and neurological reference values representative of the healthy population across the lifespan., Methods/design: In 2012 the 1000 Norms Project Consortium defined the concept of 'normal', established a sampling strategy and selected measures based on clinical significance, psychometric properties and the need for reference data. Musculoskeletal and neurological items tapping the constructs of dexterity, balance, ambulation, joint range of motion, strength and power, endurance and motor planning will be collected in this cross-sectional study. Standardised questionnaires will evaluate quality of life, physical activity, and musculoskeletal health. Saliva DNA will be analysed for the ACTN3 genotype ('gene for speed'). A volunteer cohort of 1000 participants aged 3 to 100 years will be recruited according to a set of self-reported health criteria. Descriptive statistics will be generated, creating tables of mean values and standard deviations stratified for age and gender. Quantile regression equations will be used to generate age charts and age-specific centile values., Discussion: This project will be a powerful resource to assist physiotherapists and clinicians across all areas of healthcare to diagnose pathology, track disease progression and evaluate treatment response. This reference dataset will also contribute to the development of robust patient-centred clinical trial outcome measures., (Copyright © 2015 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.)

Background: Students often strategically adopt surface approaches to learning anatomy in order to pass this necessarily content-heavy subject. The consequence of this approach, without understanding and contextualisation, limits transfer of anatomical knowledge to clinical applications. Encouraging deep approaches to learning is challenging in the current environment of lectures and laboratory-based practica. A novel interactive anatomy workshop was proposed in an attempt to address this issue., Methods: This workshop comprised of body painting, clay modelling, white-boarding and quizzes, and was undertaken by 66 health science students utilising their preferred learning styles. Performance was measured prior to the workshop at the mid-semester examination and after the workshop at the end-semester examination. Differences between mid- and end-semester performances were calculated and compared between workshop attendees and non-attendees. Baseline, post-workshop and follow-up surveys were administered to identify learning styles, goals for attendance, useful aspects of the workshop and self-confidence ratings., Results: Workshop attendees significantly improved their performance compared to non-attendees (p = 0.001) despite a difference at baseline (p = 0.05). Increased self-confidence was reported by the attendees (p < 0.001). To optimise their learning, 97% of attendees reported utilising multi-modal learning styles. Five main goals for participating in the workshop included: understanding, strategic engagement, examination preparation, memorisation and increasing self-confidence. All attendees reported achieving these goals. The most useful components of the workshop were body painting and clay modelling., Conclusions: This interactive workshop improved attendees' examination performance and promoted engaged-enquiry and deeper learning. This tool accommodates varied learning styles and improves self-confidence, which may be a valuable supplement to traditional anatomy teaching.

Aims: To assess the child- and parent-reported health-related quality of life (HRQOL) of children with joint hypermobility syndrome (JHS), to compare these with other chronic paediatric conditions and to determine whether symptoms experienced by children with JHS can predict their HRQOL., Methods: Eighty-nine children with JHS and one of their parents completed the Pediatric Quality of Life Inventory 4.0 Generic Core Scale, the Multidimensional Fatigue Scale and the Pediatric Pain Questionnaire. Anthropometric measures and reported symptoms were recorded. Child-reported HRQOL scores were compared with parent report, and both child- and parent-reported HRQOL scores of children with JHS were compared with those of children with other chronic conditions. Stepwise multiple regression was undertaken to determine whether any combination of measures could predict HRQOL., Results: Parent- and child-reported HRQOL scores were strongly correlated (r = 0.6-0.84, all P < 0.001); however, parents of children with JHS perceived lower overall HRQOL (mean difference = 4.44, P = 0.001), physical (mean difference = 7.11, P < 0.0001) and emotional functioning (mean difference = 5.24, P = 0.011) than their children. When considered together with previously reported HRQOL scores for children with other chronic conditions, parent and child scores were similarly strongly correlated (r = 0.93, P = 0.001). Multiple regression revealed that 75% of the variance in child-reported HRQOL scores was accounted for by a child's level of pain and fatigue, and presence of stress incontinence symptoms (P < 0.0001)., Conclusion: Children with JHS experience poor HRQOL and disabling fatigue, with parent scores providing a good proxy. Pain, fatigue and the presence of stress incontinence symptoms have the greatest impact on their HRQOL., (© 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Objective: Our aim was to investigate the diagnostic accuracy of the clinical presentation of ankle syndesmosis injury and four common clinical diagnostic tests., Design: Cross-sectional diagnostic accuracy study., Setting: 9 clinics in two Australian cities., Participants: 87 participants (78% male) with an ankle sprain injury presenting to participating clinics within 2 weeks of injury were enrolled., Methods: Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with MRI results (read by a blinded radiologist) as a reference standard. Tests were evaluated using diagnostic accuracy, sensitivity, specificity and likelihood ratios (LRs). A backwards stepwise Cox regression model determined the combined value of the clinical tests., Results: The clinical presentation of an inability to perform a single leg hop had the highest sensitivity (89%) with a negative LR of 0.37 (95% CI 0.13 to 1.03). Specificity was highest for pain out of proportion to the apparent injury (79%) with a positive LR of 3.05(95% CI 1.68 to 5.55). Of the clinical tests, the squeeze test had the highest specificity (88%) with a positive LR of 2.15 (95% CI 0.86 to 5.39). Syndesmosis ligament tenderness (92%) and the dorsiflexion-external rotation stress test (71%) had the highest sensitivity values and negative LR of 0.28 (95% CI 0.09 to 0.89) and 0.46 (95% CI 0.27 to 0.79), respectively. Syndesmosis injury was four times more likely to be present with positive syndesmosis ligament tenderness (OR 4.04, p=0.048) or a positive dorsiflexion/external rotation stress test (OR 3.9, p=0.004)., Conclusions: Although no single test is sufficiently accurate for diagnosis, we recommend a combination of sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness and the dorsiflexion-external rotation stress test (sensitive) may be combined with pain out of proportion to injury and the squeeze test (specific)., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To determine if exploratory factor analysis can identify subtypes comprising recognisable clinical patterns of the presenting signs and symptoms of children with joint hypermobility syndrome (JHS)., Patients: Eighty-nine children with JHS aged 6-16 years., Methods: Twelve tests comprising anthropometric, musculoskeletal and functional assessments were conducted. Signs, symptoms and family history were recorded. Exploratory factor analysis was performed, factor scores generated, and correlations calculated to identify associations., Results: Sixty-six percent of the variance in the score set could be accounted for by five JHS subtypes (Eigenvalues >1). Factor 1, 'joint affected' JHS, had loadings on multiple joint pain, recurrent joint instability and postural orthostatic hypotension symptoms, and factor scores were associated with worse pain (r=0.48, p<0.01), fatigue (r=-0.54, p<0.01) and reduced health-related quality of life (HRQOL) (r=-0.5, p<0.01). Factor 2, 'athletic' JHS, loaded on muscle endurance, balance and motor skill proficiency, and scores were associated with less fatigue (r=0.3, p<0.01) and better HRQOL (r=0.44, p<0.01). Factor 3, 'systemic' JHS, loaded on skin involvement, incontinence symptoms, bowel involvement and recurrent joint instability, and was associated with reduced HRQOL (r=-0.24, p=0.03). Factor 4, 'soft tissue affected' JHS, loaded on recurrent soft tissue injuries and reduced muscle length, and was associated with greater fatigue (r=-0.43, p<0.01) and reduced HRQOL (r=-0.44, p<0.0001). Factor 5, 'high BMI' JHS, had high loadings on body mass index (BMI) for age, muscle endurance and no gastrointestinal involvement, and was associated with higher pain (r=0.33, p<0.01)., Conclusions: The presenting signs and symptoms of children with JHS can be summarised in five clinically recognisable subtypes., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objectives: Up to 25% of all ankle injuries involve the ankle syndesmosis and factors that increase risk have yet to be investigated prospectively. This study aimed to identify predictors of ankle syndesmosis injury in football players., Design: A prospective study., Methods: Rugby Union and Australian Football League players were recruited during 2010. Rugby League and different Rugby Union players were recruited during 2011. Baseline data collection included: age, body size, flexibility, strength and balance. Bivariate correlations were performed between all predictors. Variables with r ≥ 0.7 had only one variable entered in further analysis. Remaining predictor variables were analysed for association with the presence/absence of ankle syndesmosis injury. Variables with non-significant association with injury (p>0.2) were included in a backward step-wise Cox regression model., Results: 202 male participants aged 21 ± 3.3 years (mean ± SD) were recruited of whom 12 (5.9%) sustained an ankle syndesmosis injury. The overall incidence rate was 0.59/1000 h sport participation for Rugby Union and Rugby League. Australian Football League training data was not available. No significant predictors were identified; however, participants who sustained an injury during the season performed a higher vertical jump (63.6 ± 8.2 cm) and greater Star Excursion Balance Test reach (80.5 ± 5.3 cm), than participants who did not sustain an injury: 59.1 ± 7.8 cm for Vertical Jump and 77.9 ± 6.1 cm for Star Excursion Balance Test. This was normalised for height., Conclusions: Variables such as age, body size, foot posture, flexibility and muscle strength did not increase risk of ankle syndesmosis injury. Jump height and balance performance may play a role in predicting ankle syndesmosis sprains., (Copyright © 2014 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Background: Children with Joint Hypermobility Syndrome (JHS) have reduced knee joint proprioceptive acuity compared to peers. Altered proprioception at end of range in individuals with JHS is hypothesised to contribute to recurrent joint injuries and instability. This study aims to provide the first objective comparison of functional knee joint proprioceptive acuity in hyperextension range compared to early flexion range in children with JHS., Methods: Active, weight-bearing knee joint proprioceptive acuity in both hyperextension and early flexion range was tested with a purpose-built device. Proprioceptive acuity was measured using the psychophysical method of constant stimuli to determine ability to discriminate between the extents of paired active movements made to physical stops. The smallest difference in knee range of motion that the child is able to correctly judge on at least 75% of occasions, the Just Noticeable Difference (JND), was calculated using Probit analysis. Knee pain, muscle strength, amount of physical activity and patient demographic data were collected., Results: Twenty children aged 8-16 years with JHS and hypermobile knees participated. Eleven children demonstrated better proprioceptive acuity in flexion, and 9 in hyperextension (z = 0.45, p = 0.63). Matched pairs t-test found no significant difference in children's ability to discriminate between the same extents of movement in the hyperextension or flexion directions (mean JND difference 0.11°, 95% CI -0.26° - 0.47°, p = 0.545). However, 3 children could not discriminate movements in hyperextension better than chance. Proprioceptive acuity scores were positively correlated between the two directions of movement (r = 0.55, p = 0.02), with no significant correlations found between proprioceptive acuity and age, degree of hypermobility, muscle strength, pain level, amount of physical activity or body mass index centile (r = -0.35 to -0.03, all p ≥ 0.13)., Conclusion: For a group of children with JHS involving hypermobile knees, there was no significant difference between knee joint proprioceptive acuity in early flexion and in hypermobile range when measured by a functional, active, weight-bearing test. Therefore, when implementing a proprioceptive training programme, clinicians should focus training throughout knee range, including into hyperextension. Further research is needed to determine factors contributing to pain and instability in hypermobile range.

Excessive femoral torsion has been associated with various musculoskeletal and neurological problems. To explore this relationship, it is essential to be able to measure femoral torsion in the clinic accurately. Computerized tomography (CT) and magnetic resonance imaging (MRI) are thought to provide the most accurate measurements but CT involves significant radiation exposure and MRI is expensive. The aim of this study was to design a method for measuring femoral torsion in the clinic, and to determine the reliability of this method. Details of design process, including construction of a jig, the protocol developed and the reliability of the method are presented. The protocol developed used ultrasound to image a ridge on the greater trochanter, and a customized jig placed on the femoral condyles as reference points. An inclinometer attached to the customized jig allowed quantification of the degree of femoral torsion. Measurements taken with this protocol had excellent intra- and inter-rater reliability (ICC2,1 = 0.98 and 0.97, respectively). This method of measuring femoral torsion also permitted measurement of femoral torsion with a high degree of accuracy. This method is applicable to the research setting and, with minor adjustments, will be applicable to the clinical setting.

Background: Knee pain in children with Joint Hypermobility Syndrome (JHS) is traditionally managed with exercise, however the supporting evidence for this is scarce. No trial has previously examined whether exercising to neutral or into the hypermobile range affects outcomes. This study aimed to (i) determine if a physiotherapist-prescribed exercise programme focused on knee joint strength and control is effective in reducing knee pain in children with JHS compared to no treatment, and (ii) whether the range in which these exercises are performed affects outcomes., Methods: A prospective, parallel-group, randomised controlled trial conducted in a tertiary hospital in Sydney, Australia compared an 8 week exercise programme performed into either the full hypermobile range or only to neutral knee extension, following a minimum 2 week baseline period without treatment. Randomisation was computer-generated, with allocation concealed by sequentially numbered opaque sealed envelopes. Knee pain was the primary outcome. Quality of life, thigh muscle strength, and function were also measured at (i) initial assessment, (ii) following the baseline period and (iii) post treatment. Assessors were blinded to the participants' treatment allocation and participants blinded to the difference in the treatments., Results: Children with JHS and knee pain (n=26) aged 7-16 years were randomly assigned to the hypermobile (n=12) or neutral (n=14) treatment group. Significant improvements in child-reported maximal knee pain were found following treatment, regardless of group allocation with a mean 14.5 mm reduction on the visual analogue scale (95% CI 5.2 - 23.8 mm, p=0.003). Significant differences between treatment groups were noted for parent-reported overall psychosocial health (p=0.009), specifically self-esteem (p=0.034), mental health (p=0.001) and behaviour (p=0.019), in favour of exercising into the hypermobile range (n=11) compared to neutral only (n=14). Conversely, parent-reported overall physical health significantly favoured exercising only to neutral (p=0.037). No other differences were found between groups and no adverse events occurred., Conclusions: Parents perceive improved child psychosocial health when children exercise into the hypermobile range, while exercising to neutral only is perceived to favour the child's physical health. A physiotherapist prescribed, supervised, individualised and progressed exercise programme effectively reduces knee pain in children with JHS., Trial Registration: Australia & New Zealand Clinical Trials Registry; ACTRN12606000109505.

Objectives: To determine if wearing an ankle brace or taping the ankle, compared to no brace or tape, improves proprioceptive acuity in people with a history of ankle sprain or functional ankle instability., Design: Systematic review and meta-analysis., Methods: Studies using controlled, cross-over designs whereby participants who had sprained their ankle at least once or had functional ankle instability, underwent some form of proprioceptive sensation testing with and without ankle brace or tape, were included. Proprioceptive acuity was reported for the ankle tape/brace condition and the condition where no tape or brace was worn. Meta-analysis was employed to compare proprioceptive acuity with and without ankle tape/brace., Results: Eight studies were included in the review. Studies measured either sense of movement or sense of joint position. The mean differences in 19 of 32 comparisons were not significant. Of the remaining mean differences, 10 were positive, indicating better proprioceptive acuity in the taped/braced condition and 3 were negative, indicating poorer proprioceptive acuity. Overall, there was no significant effect with ankle tape/brace compared to the no tape/brace condition (mean difference: 0.08°, 95% CI: -0.39 to 0.55). This finding was consistent when the two aspects of proprioception (sense of movement or joint position) were considered separately., Conclusions: The pooled evidence suggests that using an ankle brace or ankle tape has no effect on proprioceptive acuity in participants with recurrent ankle sprain or who have functional ankle instability., (Copyright © 2012 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

Unlabelled: Wrist pain is common. People with persistent pain commonly undergo arthroscopic investigation. Little is known about the prognosis or prognostic factors for these patients. The purpose of the study was to evaluate prognosis and prognostic factors for pain and functional disability in patients with persistent wrist pain who proceed to arthroscopic investigation. The study design used was a prospective cohort study. One hundred and five consecutive participants who underwent arthroscopic investigation for undiagnosed wrist pain for at least four-week duration were recruited. Patient-rated wrist and hand evaluation (PRWHE) scores were determined at baseline (before arthroscopy) and one year after arthroscopy. One-year follow-up data were obtained for 97 (92%) of 105 participants. Mean PRWHE total score declined from 49 of 100 (standard deviation [SD] 18.5) at baseline to 26 of 100 (SD 20.4) at one year. Two prognostic factors were identified: baseline PRWHE and duration of symptoms. These factors explained 19% and 5% of the variability in the final PRWHE score, respectively. Results of provocative wrist tests and arthroscopic findings did not significantly contribute to prognosis in this cohort. This study provides the first robust evidence of the prognosis of persistent wrist pain. Participants who underwent arthroscopic investigation for persistent wrist pain improved on average by approximately 50% at one year; however, most continued to have some pain and disability. Duration of pain and PRWHE at baseline explained 24% of the one-year PRWHE score., Level of Evidence: Level 2., (Copyright © 2012 Hanley & Belfus. All rights reserved.)

The amount of torsion in the humerus is determined by both genetic and activity-related factors, and affects the external rotation range of motion available at the shoulder. Previous research has shown athletes participating in throwing sports to have a greater amount of humeral retrotorsion in their dominant arm. The purpose of this study was to investigate the predictive ability of both the genetic and activity-related aspects of humeral torsion regarding throwing-related injury. The amount of humeral torsion in both arms of 35 high level adolescent male baseballers (mean age 16.6 years+/-0.6 years) was measured at study commencement. Significantly increased humeral retrotorsion in the dominant arm compared to the non-dominant arm was found (p=0.04). These athletes were followed for a period of 30 months, and any injury to their throwing arm which resulted in missing either a game or practice was recorded. ROC curve analysis was used to determine the predictive ability of humeral torsion with respect to the occurrence of injury to the throwing arm. Of the 35 athletes, 19 suffered a throwing arm injury. AUC values derived from ROC analysis showed humeral torsion in the non-dominant arm (AUC: 0.679, 95% CI: 0.502-0.857), as well as the average of the humeral torsion in both arms (0.692, 0.512-0.873), to be predictive of injury. Torsion in the dominant arm was not a significant throwing arm injury predictor. Thus non-dominant arm humeral torsion (the genetic contribution) was found to be the predictor of throwing arm injury., (Copyright 2009 Sports Medicine Australia. All rights reserved.)

Background: Shoulder movement impairment is a commonly reported consequence of surgery for breast cancer., Objective: The aim of this study was to determine whether shoulder girdle kinematics, including those of the scapula, spine, and upper limb, in women who have undergone a unilateral mastectomy for breast cancer are different from those demonstrated by an age-matched control group., Design: An observational study using 3-dimensional kinematic analysis was performed., Methods: Women who had a unilateral mastectomy on their dominant-arm side (n=29, mean [+/-SD] age=62.4+/-8.9 years) or nondominant-arm side (n=24, mean [+/-SD] age=59.8+/-9.9 years), as well as a control group of age-matched women without upper-limb, shoulder, or spinal problems (n=22, mean [+/-SD] age=58.1+/-11.5 years), were measured while performing bilateral arm movements in the sagittal, scapular, and coronal planes. All of the women were free of shoulder pain at the time of testing. Data were collected from the glenohumeral joint, the scapulothoracic articulation, and the spine (upper and lower thoracic and lumbar regions) using an electromagnetic tracking system., Results: Women following mastectomy displayed altered patterns of scapular rotation compared with controls in all planes of movement. In particular, the scapula on the mastectomy side rotated upward to a markedly greater extent than that on the nonmastectomy side, and women following mastectomy displayed greater scapular excursion than controls., Conclusions: The findings suggest that altered motor patterns of the scapula are associated with mastectomy on the same side. Whether these changes are harmful or not is unclear. Investigation of interventions designed to restore normal scapulohumeral relationships on the affected side following unilateral mastectomy for breast cancer is warranted.

Background: Studies assessing proprioceptive acuity in anterior cruciate ligament (ACL)-deficient knees have only considered proprioception for knee movements in the sagittal plane rather than in the transverse plane (ie, rotation), despite the fact that the ACL plays a critical role in knee rotational stability and that the ACL is injured almost exclusively with a rotation mechanism. Therefore a test of proprioception is needed that involves movements similar to the mechanism of injury, in this case, rotation., Purpose: To determine whether proprioceptive acuity in rotation changes after ACL injury and reconstruction, and to examine differences in proprioceptive acuity, range, laxity, and activity level among injured knees, contralateral knees, and healthy controls., Design: Cohort study; Level of evidence, 2., Methods: Proprioceptive acuity for active knee rotation movements, passive rotation range of motion, anterior knee laxity, and knee function were measured in 20 consecutive participants with unilateral ACL rupture and 20 matched controls. Reconstruction was performed using a single-incision technique with a 4-strand hamstring tendon autograft. Thirty participants (15 control and 15 ACL reconstructed) were retested at 3 months, and 14 with ACL reconstruction were tested at 6 months., Results: A deficit was found in preoperative knee rotation proprioception compared with healthy controls (P = .031). Three months after reconstruction, there was a significant improvement (P = .049) in proprioceptive acuity, single-plane anterior laxity (P = .01), and self-reported knee function (P = .001). At 3 months after reconstruction, proprioceptive acuity of the ACL-reconstructed knee was correlated with reported activity level (r = .63; P = .021)., Conclusion: Knee rotation proprioception is reduced in ACL-deficient participants compared with healthy controls. Three to 6 months after reconstruction, rotation proprioceptive acuity, laxity, and function were improved. While these findings are consistent with a return to previous activity level 6 months after reconstruction, the extent of graft maturation and restoration of kinematics should also inform the decision about return to sport.

The aims of this study were to compare proprioception in knee rotation in Olympic-level soccer players (N=18) with non-athletes (N=18), to explore between-limb differences in soccer players, and examine correlations between proprioception and years of playing, function, physical measures and skill level. The knee rotatory kinaesthetic device was used to present stimuli of different magnitudes to determine proprioceptive acuity for internal and external active rotation, and to measure active and passive rotation range of motion (ROM). Knee rotation strength was measured using a dynamometer. Proprioceptive acuity of the athletes was significantly (P=0.004) better than that of the non-athletes. Athletes displayed significantly less passive ROM (P=0.001), higher isometric muscle strength (P=0.006) and greater hop for distance (P=0.001) than non-athletes. No significant between-limb differences were found in the athletes in any objective outcome measure. Internal rotation proprioceptive acuity was negatively correlated with coach-rated ball skill (r=-0.52) and positively correlated with internal rotation ROM (r=0.59). Our findings suggest that highly trained athletes possess enhanced proprioceptive acuity and muscle strength that may be inherent, or may develop as a result of long-term athletic training.

Objectives: To determine the relationship between the amount of humeral torsion and a measure of active proprioception in adolescent male throwing athletes., Design: Cross-sectional laboratory study with uninjured subjects., Setting: University of Sydney and NSW Institute of Sport., Participants: Participants were 16 adolescent male baseball players (15.0-18.1 years old, SD=16.3) holding baseball scholarships at the NSW Institute of Sport., Main Outcome Measures: The main outcome measures, active proprioception (shoulder rotation, in 90 degrees of arm abduction moving towards external rotation, using the Active Movement Extent Discriminating Apparatus) and humeral torsion (using an ultrasound-assisted method), were measured bilaterally., Results: A strong (r=0.88) and significant (p=0.001) correlation was found between increasing humeral retrotorsion and better active proprioceptive acuity in the non-dominant arm, while the relation was weaker (r=0.41) and did not reach statistical significance (p=0.120) for the dominant arm., Conclusions: A cognitive processing capacity model, which suggests that greater humeral retrotorsion reduces neural processing requirements, has been proposed to explain the direct relationship between proprioceptive acuity and humeral retrotorsion.

Objectives: To investigate the ability of asymptomatic participants to discriminate between active knee rotation movements of different magnitude and to determine whether proprioceptive acuity of active knee rotation differs between limbs (dominant and nondominant and right and left)., Design: Cross-sectional study., Setting: Laboratory in an Australian university., Participants: Healthy volunteers (N=30) without previous cruciate ligament injury or surgery, previous fracture of the lower limbs, or other lower-limb disorders in the last 3 months., Interventions: Not applicable., Main Outcome Measures: Knee rotation proprioceptive acuity was determined by using our custom-designed device. The measure of proprioceptive acuity used in this study was the just-noticeable difference (JND). Participants actively rotated the knee (internal or external rotation) to 1 of 4 movement blocks and judged the magnitude of the permitted motion. Proprioceptive acuity scores, representing a participant's ability to detect small differences in magnitude of active knee rotation movements, were then calculated., Results: The means of the JND for proprioceptive acuity of internal rotation (1.37 degrees +/-.11 degrees ) were significantly (P=.04) lower than for external rotation (1.6 degrees +/-.14 degrees ) regardless of side (right, left) or dominance. No significant difference was found between the mean JND for left and right knee rotations (P=.84) or between the mean JND for dominant and nondominant knee rotation (P=.69)., Conclusions: Participants perceived smaller differences between active internal rotation movements than external rotation. No significant difference was found between the dominant and nondominant leg or between the left and right leg; therefore, clinicians can establish whether a proprioceptive deficit exists after unilateral injury and can use acuity of the uninjured knee as a normal status for rehabilitation.

The anterior cruciate ligament (ACL) constrains rotatory motion at the knee and is commonly injured during rotational movements in athletic activity. This densely innervated ligament is assumed to play a role in knee proprioception, however, no study has measured proprioception in a manner relevant to either the kinematics of the ligament or the mechanism of injury, partly because of a lack of suitable equipment. The aims of this technical note are to document the development of a novel knee rotatory kinaesthetic device, and to present details of its construction, reproducibility, accuracy and application. The purpose-built device allows rotational movements at the knee to occur with minimal frictional resistance and provides accurate limits to the magnitude of these movements. This allows analysis of subjects' ability to discriminate between movements of differing magnitudes and thus allows calculation of subjects' sensitivity to small differences in magnitude of active knee rotation. Measurements taken with the device had a high level of agreement with those of a calibrated digital inclinometer (ICC=0.99; 95% CI 0.88 to 0.99) with a mean error of 0.24 degrees . The device also demonstrated excellent reproducibility (Pearson's r=1.0). A single case study is presented to detail the clinical application of the device. This novel device allows subjects to perform active knee rotational movements in a closed kinetic chain with discrete, self-paced movement, enabling calculation of movement discrimination. The device is compact and portable enabling testing to be undertaken in remote settings enhancing its clinical applicability.

While the pronated foot is implicated as a risk factor for sports injury in some studies, others suggest that a supinated foot posture increases the risk of overuse lower limb injuries. Athletes in a given sports discipline may tend to have a similar foot morphology, which varies from that observed elsewhere. Further, the foot morphology that is beneficial for performance in a sport may be detrimental with regard to injury. Intra- and inter-rater reliability of the Foot Posture Index (FPI-6) as a measure of foot morphology was determined (ICC (2,1) 0.88 and 0.69 respectively). Thereafter, in a prospective cohort study using the FPI-6, 76 adolescent male indoor football (Futsal) players were measured and followed monthly over one competition season. Coach-rated ability and reports of any overuse injuries at the ankle and/or foot over this period were obtained. A significant negative linear relationship was found between the mean FPI-6 scores and coach-rated ability (p=0.008), with supinated and under-pronated postures related to higher ability level. Overall, 33% of injuries at the ankle and/or foot were classified as overuse. Foot Posture Index scores of less than 2, indicating the supinated and under-pronated feet, were found to be associated with a significant increase in the risk of overuse injury (p=0.008). The greater rigidity of these foot types may assist adolescent, male, indoor football players to perform at a higher level in their sport. Unfortunately, these players are also more likely to sustain ankle and/or foot overuse injuries.

Anterior cruciate ligament (ACL) rupture is a common sporting injury, often managed surgically with patella-tendon or hamstrings-gracilis autograft. Some people who sustain the injury, request information about their prognosis if they choose to forgo surgery and opt for conservative management. Numerous studies provide data on the prognosis of conservatively managed ACL injuries. These studies have not been systematically reviewed. Thus, the aims of this systematic review are to describe the natural history and clinical course of function and proprioception in the conservatively managed ACL-deficient knee, and to identify prognostic factors. We searched MEDLINE, CINAHL, EMBASE, SportDiscus, PEDro and the Cochrane Central Register of Clinical Trials without language restrictions from the earliest record available up to July 2006. We also searched the Science Citation Index, and iteratively searched bibliographies for prospective studies of outcomes (>6 months follow-up) of conservatively managed complete ACL tears. Six criteria were used to assess the methodological quality of included studies. The main outcome measures were self-reported measures of knee function, activity level, performance in functional tasks and knee proprioception. Fifteen studies of variable methodological quality were included in the review. On average, patients with mixed or isolated ACL-deficient knees reported good knee function (87/100 Lysholm knee scale) at follow-up duration of 12-66 months. On average, functional performance assessed with the hop-for-distance test, was in the normal range. From pre-injury to follow-up there was a reduction in Tegner activity level of 21.3%. According to the methods used in the assessed studies, conservatively managed ACL-deficient knees have a good short- to mid-term prognosis in terms of self-reported knee function and functional performance. However, subjects reduced their activity levels on average by 21% following injury.