Search

Web-based modified Delphi study.Therapy is widely considered the first choice of treatment for posttraumatic stiffness of the elbow since loss of motion is a common sequela following traumatic elbow injuries. There is high variability in practice patterns for the management of the posttraumtic elbow.The aim of this study is to identify the current therapeutic management of posttraumatic elbow stiffness using expert consensus.This study surveyed experts using a web-based 3 round modified Delphi method. Quantitative data and comments were collected during the first round. Questions with Likert scaling were used to identify consensus (defined as 75% agreement) with each statement and comment boxes enabled open-ended responses to gather expert opinion. Lack of consensus and data from comments guided the second-round of the survey. This process was repeated after Round 2 to develop the Round 3 survey. Consensus was achieved at Round 3 and no further rounds were needed.Round 1 included 34 experts (response rate 20%), not all experts were able to continue through all rounds. Round 2 included 18 experts and Round 3 included 15 experts. Survey items were categorized as follows: examination procedures, therapeutic interventions, orthotic intervention considerations, contributing patient factors, and clinical decisions and rehabilitation challenges. Twenty-five percent of items achieved consensus after Round 1, 30% after Round 2 and 52% after Round 3. Although most participants agreed that orthotic intervention is critical to patient outcomes, there were conflicting thoughts about the orthotic design and wearing schedule.The findings of this web-based modified Delphi study helped to establish a current body of knowledge using expert consensus to guide practice and identify specific questions that can be studied in future clinical studies on posttraumatic elbow stiffness.

Low back pain (LBP) remains a musculoskeletal condition with an adverse societal impact. Globally, LBP is highly prevalent and a leading cause of disability. This is an update to the 2012 Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), clinical practice guideline (CPG) for LBP. The overall objective of this update was to provide recommendations on interventions delivered by physical therapists or studied in care settings that included physical therapy providers. It also focused on synthesizing new evidence, with the purpose of making recommendations for specific nonpharmacologic treatments. J Orthop Sports Phys Ther 2021;51(11):CPG1-CPG60. doi:10.2519/jospt.2021.0304.

To assess the effectiveness of mind-body (MB) exercise interventions provided by physical therapists for reducing pain and disability in people with low back pain (LBP).MEDLINE, Embase, CINAHL, and the Cochrane Library were searched for articles published in English between Dec. 2010 and June 2020.Randomized controlled trials evaluating the effects of Pilates, yoga, and Tai Chi interventions performed by physical therapists on pain or disability outcomes in adults with musculoskeletal LBP were included.Data were extracted by 2 independent reviewers. Quality of evidence and risk of bias were assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework and Cochrane risk of bias tools, respectively.21,230 exercise trials were identified; 161 progressed to full-text review. Eight trials, 7 reporting on Pilates and one reporting on yoga, were included. Short-term outcomes for pain (SMD: -0.93; 95%CI: -1.65 to -0.021) and disability (SMD: -0.74 95%CI: -1.36 to -0.012) indicated MB exercise was more effective than control intervention. Tests for subgroup differences between studies with exercise vs non-exercise control groups revealed a moderating effect on short-term outcomes where larger effects were observed in studies with non-exercise comparators. Long-term outcomes for pain (SMD: -0.60; 95% CI:-1.43 to 0.23) and disability (SMD: -1.05; 95% CI:-3.51 to 1.41) suggested that MB exercise is not more effective than control interventions for pain or disability. Quality of the evidence ranged from very low to low.Physical therapist-delivered MB exercise interventions, which overwhelmingly consisted of Pilates, were more effective than control in the short and long-term for pain and in the short-term for disability, with differences in the short-term effects lessened when compared to an active intervention. Pilates interventions delivered by physical therapists represent a viable tool for the clinical management of chronic LBP.

Context Swimmers are known for experiencing high training loads and a high incidence of overuse injuries, but few researchers have investigated the relationship between the two at the collegiate level. Objective To determine the association between workload and noncontact musculoskeletal injury in collegiate swimmers. Design Prospective cohort study. Setting College natatorium. Patients or Other Participants A total of 37 National Collegiate Athletic Association Division III swimmers, 26 uninjured (age = 19 years [interquartile range = 3 years], height = 175 ± 11 cm, mass = 70.2 ± 10 kg) and 11 injured (age = 19 years [interquartile range = 3 years], height = 173 ± 9 cm, mass = 69.4 ± 13.5 kg) individuals. Main Outcome Measure(s) Logistic regression using generalized estimating equations was conducted to calculate odds ratios (ORs) with 95% CIs for injury relative to high workloads and high acute:chronic workload ratio (ACWRs). Injury rates for several ranges of workloads and ACWRs were also calculated. Results A total of 11 participants (29.7%) sustained 12 injuries, with 7 injuries occurring during the participants' winter training trip. Injury was associated with high acute workloads (OR = 27.1; 95% CI = 8.2, 89.8) and high ACWRs (OR = 25.1; 95% CI = 7.7, 81.4) but not high chronic (OR = 2.6; 95% CI = 0.3, 20.0) or overall (OR = 1.00; 95% CI = 0.99, 1.01) workloads. High acute workloads (>37.2 km/wk) and ACWRs (>1.56) increased the injury rate from ≤1% to 15% and 14%, respectively, compared with all lower acute workloads and ACWRs. Conclusions Collegiate swimmers tolerated high workloads spread out during the season. However, caution should be used when prescribing high acute workloads and high ACWRs (eg, winter training trip) because of the increased odds of injury.

Background The kinetic chain theory is widely used as a rationale for the inclusion of core stability training in athletes. Core stability (muscle capacity and neuromuscular control) impairments may result in less than optimal performance and abnormal force dissipation to the shoulder complex that could lead to shoulder injuries. However, a paucity of literature exists to support this relationship, and no previous studies have investigated the relationship between isolated core neuromuscular control and shoulder injuries. Additionally, lower extremity postural stability has been associated with athletic function and may also be associated with shoulder injuries. The purpose of this study was to compare biomechanical measures of isolated core neuromuscular control and lower extremity postural stability between athletes with and without non-traumatic shoulder injuries. Methods Eighty athletes (55 males, age: 21.2 ± 3.3 years, 40 with a current shoulder injury) completed biomechanical measures of isolated core neuromuscular control and lower extremity postural stability. Athletes were matched by age, gender, body mass index, and sport type. MANOVAs were used to assess differences between measures of core neuromuscular control and lower extremity postural stability between groups. Findings There were no statistically significant differences between athletes with and without shoulder injuries for the static core neuromuscular control measures, F(4,75) = 0.45, P = 0.78, η2 = 0.02; dynamic core neuromuscular control measures, F(4,75) = 0.81, P = 0.52, η2 = 0.04; or lower extremity postural stability measures, F(8,61) = 0.85, P = 0.56, η2 = 0.10. Interpretation Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, athletes with current non-traumatic shoulder injuries may not present with impairments in core neuromuscular control or lower extremity postural stability.

Context Shoulder pain is pervasive in swimmers of all ages. However, given the limited number of prospective studies, injury risk factors in swimmers remain uncertain. Objective To determine the extent to which the risk factors of previous injury, poor movement competency, erroneous freestyle swimming technique, and low perceived susceptibility to sport injury were associated with noncontact musculoskeletal injury in collegiate swimmers. Design Prospective cohort study. Setting College natatorium. Patients or Other Participants Thirty-seven National College Athletic Association Division III swimmers (21 females, 16 males; median age = 19 years [interquartile range = 3 years], height = 175 ± 10 cm; mass = 70.0 ± 10.9 kg). Main Outcome Measure(s) Participants completed preseason questionnaires on their previous injuries and perceived susceptibility to sport injury. At the beginning of the season, they completed the Movement System Screening Tool and the Freestyle Swimming Technique Assessment. Logistic regression was used to calculate odds ratios (ORs) with 95% CIs for the association between each risk factor and injury. Results Eleven of the 37 participants (29.7%) sustained an injury. Univariate analyses identified 2 risk factors: previous injury (OR = 8.89 [95% CI = 1.78, 44.48]) and crossover hand positions during the freestyle entry phase (OR = 8.50 [95% CI = 1.50, 48.05]). After adjusting for previous injury, we found that a higher perceived percentage chance of injury (1 item from the Perceived Susceptibility to Sport Injury) decreased the injury odds (adjusted OR = 0.11 [95% CI = 0.02, 0.82]). Poor movement competency was not associated with injury (P > .05). Conclusions Previous injury, a crossover hand-entry position in freestyle, and a low perceived percentage chance of injury were associated with increased injury odds. Ascertaining injury histories and assessing for crossover positions may help identify swimmers with an elevated injury risk and inform injury-prevention strategies.

Context: Swimming technique is widely believed to influence performance, but this relationship has rarely been tested objectively using a real-time poolside assessment. Objective: To determine the (1) test–retest reliability, interrater reliability, and criterion validity (live vs video) of real-time poolside assessment of upper limb (UL) errors in front crawl (FC) swimming technique and (2) the relationship between UL errors and FC swimming performance. Design: Cross-sectional reliability, validity, and correlational study. Setting: Swim team practice at a college natatorium. Participants: Thirty-nine Division III college swimmers (21 women and 18 men, age = 19 [1] y, swimming experience = 11 [3] y). Main Outcome Measures: Seven UL errors in FC swimming technique, many of which involved unnecessary vertical and mediolateral motions, were assessed in real time from outside the pool during swim practice. Test–retest reliability, interrater reliability, and criterion validity were calculated using Cohen kappa (κ) and weighted kappa (κw). Swimming performance was determined by the participants’ best FC events relative to the conference records. The correlation between total UL errors and FC swimming performance was assessed with Pearson r. Results: Cohen κ and κw were moderate for the majority of errors, with the following ranges: 0.46 to 0.90 (test–retest), −0.01 to 1.00 (interrater), and 0.36 to 0.66 (criterion validity). There was a significant correlation between total UL errors and FC swimming performance: r(24) = −.59 (P = .001, R2 = .35). Conclusions: Reliability and validity were moderate for the majority of errors. The fewer UL errors swimmers made while practicing FC, the faster their best FC race times tended to be relative to the conference record. UL errors in FC swimming technique explained 35% of the variance in performance.

BACKGROUND: New motor adaptation to pain theory suggests that patients with low back pain (LBP) use the lumbopelvic stiffening strategy by redistribution of within and between muscle activities to protect painful structure. This could result in an altered postural control of the lumbopelvic region during active prone hip rotation (PHR). OBJECTIVE: To investigate coordination and timing of lumbopelvic and hip movements, and smoothness of the lumbopelvic control during PHR between participants with and without LBP. METHODS: Eight participants with LBP and eight participants without LBP were recruited. The electromagnetic tracking system was used to record kinematic data during PHR. Cross-correlation between hip rotation and lumbopelvic movement in the transverse plane was calculated. Correlation at zero time-lag, time-lag, correlation at time-lag, and maximal lumbopelvic motion were derived. Frequency of movement disruption was identified. An independent t-test was used in conjunction with the effect size and 95% minimal detectable difference (MDD95) to determine the difference in kinematic parameters. RESULTS: Participants with LBP demonstrated a significant delay (exceeding MDD95) in lumbopelvic motion while nonsignificant frequency of disrupted motion on the painful side PHR demonstrated a trend with a large effect size that exceeded MDD95. There were trends with moderate to large effect sizes and differences exceeding MDD95 in delay of lumbopelvic motion with greater movement disruption on the nonpainful side in participants with LBP. CONCLUSION: Participants with LBP used a lumbopelvic stiffening strategy for postural control to protect painful structures; however, the stiffening might complicate efforts to smoothly control lumbopelvic movement.

This study investigated the scaling of upper arm kinematics, joint motion, and muscle activation for three-dimensional (3D) reaches to targets of increasing distance. Fifteen participants completed 108 total reaches to targets placed 7, 14, and 21 cm across midline. Peak velocity, acceleration, and time to peak velocity scaled to both target and movement distance. Shoulder and elbow excursion scaled to target distance and were highly coordinated. Anterior deltoid activation scaled to both target and movement distance in the early and late phases of reach control. Biceps and triceps activation scaled to movement distance primarily in the late phase. Scaling of these outcome variables provides a model for understanding the control of reach distance in a 3D environment.

Objective This study preliminarily characterizes and compares the impact of lower limb loss and development of chronic low back pain (cLBP) on psychosocial factors, as well as the relationship between these factors and low back pain–related functional disability. Design Cross-sectional study. Methods Participants were adults, active duty or retired military, with traumatic lower limb loss with and without chronic low back pain. Psychosocial factors and low back pain–related functional disability were measured using common clinical self-report questionnaires. The presence of psychosocial factors was compared between those with and without cLBP using multivariate analysis of covariance (P Results There were no statistically significant differences among psychosocial factors between those with vs without cLBP (F(4, 13) = 0.81, P = 0.54, η2= 0.19). Employment status (ρ = 0.43, P = 0.02), anxiety (ρ = 0.45, P = 0.04), and kinesiophobia (ρ = 0.47, P = 0.04) were moderately associated with low back pain–related disability. Conclusions Psychological (i.e., anxiety) and social (i.e., employment status) factors may influence how persons with traumatic lower limb loss respond to self-reported measures of low back pain–related disability. The findings suggest that the Modified Oswestry Disability Index identifies cLBP-related functional disability in the context of lower limb loss. These results support the interdependence among biological, psychological, and social factors, which should be collectively considered during the development of rehabilitative strategies to treat secondary musculoskeletal conditions within this population.

Background Persons with unilateral lower-limb loss are at increased risk for developing chronic low back pain. Aberrant trunk and pelvis motor behavior secondary to lower-limb loss potentially alters trunk postural control and increases demands on the trunk musculature for stability. However, it is unclear whether trunk postural control is associated with the presence or chronicity of low back pain within this population. Research question Is there a potential role of impaired trunk postural control among persons with lower limb loss and chronic low back pain? Methods Two groups of males with unilateral lower-limb loss (n = 18 with chronic low back pain; n = 13 without pain) performed an unstable sitting task. Trunk postural control was characterized using traditional and non-linear measures derived from center-of-pressure time series, as well as trunk kinematics and the ratio of lumbar to thoracic erector spinae muscle activations. Results Traditional and non-linear center-of-pressure measures and trunk muscle activation ratios were similar between groups, while participants with chronic low back pain demonstrated greater trunk motion and reduced local dynamic stability. Significance Our results suggest that persons with both lower-limb loss and chronic low back pain exhibit impaired trunk postural control compared to those with limb loss but without pain. Aberrant trunk motor behavior may be a response to altered functional requirements of walking with a prosthesis. An inability to adequately control the trunk could lead to spinal instability and pain in the presence of repetitive exposure to aberrant motor behavior of these proximal structures during everyday activities.

Background Prone hip extension is used to clinically assess movement control in patients with nonspecific low back pain (LBP). Excessive lumbopelvic movements and altered muscle activation patterns are common in patients with nonspecific LBP. However, no evidence exists regarding lumbar multifidus and lumbar erector spinae muscle synergy patterns in patients with nonspecific LBP during this clinical test. Objective To determine the difference in lumbopelvic motion and change in muscle synergy between patients with nonspecific LBP and healthy individuals. Design A cross-sectional study design. Setting University physical therapy clinic and laboratory. Participants Seven patients with nonspecific LBP (age [mean ± SD] 29 ± 5 years, 43% female, body mass index [BMI] of 25 ± 2 kg/m2 , Numeric Pain Rating Scale 6 ± 2; Oswestry Disability Index 20% ± 8%) and seven age-, sex-, and BMI-matched healthy individuals (mean age 28 ± 5 years, 43% female, BMI of 22 ± 2 kg/m2 ) were recruited. Methods Each participant performed six repetitions of prone hip extension on each side; kinematic and electromyographic data were collected simultaneously. Main outcome measurements Kinematic data were used to represent lumbopelvic motion, whereas electromyography (EMG) data were used to represent muscle activity. A paired t-test was used to determine the difference in lumbopelvic motion. Principal component analysis and two-way repeated-measures analysis of variance were used to extract muscle synergies and identify differences in muscle synergy patterns between and within groups. Results Results demonstrated no significant group difference (P > .05) in amount of lumbopelvic motion. However, healthy individuals synergistically activate lumbar multifidus and lumbar erector spinae with 81.0% variance accounted for (VAF). Patients with nonspecific LBP had an altered synergy with independent activation of lumbar multifidus on the painful side with 32.0% VAF and the lumbar multifidus on the nonpainful side, and both lumbar erector spinae with 52.2% VAF synergistically activated. Conclusions These findings suggest that clinicians should focus on muscle activation patterns rather than the amount of lumbopelvic motion during clinical observation of prone hip extension. Level of evidence Level III.

Swimmers are known for high training loads and overuse injuries, but few studies have investigated the relationship between the two at the college level.To determine the association between workload and non-contact musculoskeletal injury in college swimmers. We hypothesized (1) higher overall workload (kilometers swum throughout the season) would be associated with increased odds of injury and (2) the ratio of the current week's (acute) workload divided by the current month's (chronic) workload (i.e., the acute:chronic workload ratio (ACWR)) would be more strongly associated with odds of injury than acute or chronic workloads alone.Prospective cohort study.College natatorium.Thirty-seven Division III college swimmers.Logistic regression using generalized estimating equations was used to calculate odds ratios (OR) with 95% confidence intervals (CI) for injury relative to high workloads and high ACWRs. Injury rates for several ranges of workloads and ACWRs were also calculated.Eleven participants (29.7%) sustained 12 injuries, with seven injuries occurring during the participants' winter training trip. Injury was associated with high acute workloads (OR = 27.1 [95% CI = 8.2, 89.8]) and high ACWRs (OR = 25.1 [95% CI = 7.7, 81.4]) but not high chronic workloads (OR = 2.6 [95% CI = 0.3, 20.0]) or overall workloads (OR = 1.00 [95% CI = 0.99, 1.01]). High acute workloads (37.2 km/week) and high ACWRs (1.56) increased injury rate from ≤1% to 15% and 14%, respectively, compared to all lower acute workloads and ACWRs.College swimmers can tolerate high workloads spread out over the season. However, caution should be used when prescribing high acute workloads and high ACWRs (e.g., winter training trip) due to increased odds of injury.

Recent brain imaging studies have suggested that cortical remodeling within sensorimotor regions are associated with persistent low back pain and may be a driving mechanism for the impaired neuromuscular control associated with this condition. This paper outlines a new approach for investigating cortical sensorimotor integration during the performance of small-amplitude lumbopelvic movements with functional MRI. Fourteen healthy right-handed participants were instructed in the lumbopelvic movement tasks performed during fMRI acquisition. Surface electromyography (EMG) collected on 8 lumbopelvic and thigh muscles captured organized patterns of muscle activation during the movement tasks. fMRI data were collected on 10 of 14 participants. Sensorimotor cortical activation across the tasks was identified using a whole brain analysis and further explored with regional analyses of key components of the cortical sensorimotor network. Head motion had low correlation to the tasks (

Background Relationships between core stability and lower extremity injuries have been described in the literature; however, evidence of the relationship between upper extremity injuries and core stability and balance is limited. Hypothesis/purpose The purpose of this study was to compare clinical measures of core stability and balance between athletes with and without non-traumatic shoulder injuries. Study design Cross sectional. Methods Eighty athletes (54 males, age: 21.2 + 3.3 years) participated in this study. Forty athletes with a current shoulder injury were matched to healthy athletes by age, gender, BMI, and sport. Athletes completed clinical core stability tests including flexor and extensor endurance tests, double leg lower test (°) and balance tests including single leg stance under eyes open and eyes closed conditions, and the Y-balance test. MANOVAs were used to assess group differences. Results No statistically significant differences existed between athletes with and without shoulder injuries for clinical tests of core stability, F(1,78)=0.97, p=0.41; η2 = 0.04. No statistically significant differences existed between injured athletes with and without shoulder injuries for static and dynamic balance measures, F(1,78)=0.86, p=0.53; η2 = 0.07. Conclusions Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, performance on these clinical tests did not differ in the group of athletes assessed in this study. Level of evidence 3.

Background: Individuals with multiple sclerosis (MS) have balance deficits that result in falls. Balance tests developed for older adults do not discriminate between fallers and nonfallers with MS. The Balance Evaluation Systems Test (BESTest) identifies body systems contributing to imbalance/fall risk. This study evaluated the test-retest reliability and construct validity of the BESTest to assess balance in individuals with MS, compared the diagnostic accuracy of the BESTest and Berg Balance Scale (BBS), and investigated the minimal detectable change of the BESTest in this population. Methods: Twenty individuals with MS were recruited. Age, onset of disease, and fall history were obtained. The following measures were used: Expanded Disability Status Scale, University of Illinois at Chicago Fear of Falling Measure, BESTest, and BBS. Twelve participants were retested to determine test-retest reliability of the BESTest. Results: The BESTest demonstrated strong test-retest reliability (intraclass correlation coefficient [3,1] = 0.98 [95% CI, 0.91–0.99], P = .01) and was highly correlated with the BBS (r = 0.94, P = .01). The BBS had poor accuracy to identify fallers. Using a score of 81%, the BESTest had moderate sensitivity (0.89) to identify fallers. The standard error of the measurement for the BESTest was 4.16 points, which translates into a minimal detectable change of 9.7% [90% CI] to 11.5% [95% CI]. Conclusions: The BESTest demonstrates excellent test-retest reliability and diagnostic utility as a measure of functional balance in persons with moderate MS. A change in BESTest score of at least 10% may indicate a true change in balance performance in this population.

Research supports the use of interprofessional care to manage chronic pain. Despite ample programs for patients and continuing education for clinicians, we see a gap in provider mentorship for skill building and implementation. Atlas PainCare is a program we are developing to provide mentorship to enhance care delivery by helping clinicians and organizations build the tools, pain science knowledge base, administrative support, and interprofessional teamwork required to implement best practice. Atlas PainCare's Mentoring Group helps interprofessional teams develop care structures for patients with chronic pain using multimodal, evidence-based, and patient-centered approaches that focus on minimizing opioid use and promoting self-management. The purpose of this study was to collect feedback from potential mentee teams about the Atlas PainCare program. Feedback is being used to refine the program before implementation. Clinical chronic pain teams of at least two distinct professions were invited to participate. Participants attended an information session to review the proposed program and ask questions. Participants unable to attend, viewed a recording of the session. We then conducted virtual semi-structured focus groups to elicit feedback about Atlas PainCare's utility, perceived benefits, and perceived barriers. Focus groups were recorded, transcribed, and analyzed for themes using NVivo. We collected feedback from 4 teams (12 participants) representing PT, MD, CRNP, SW, PsyD, OT, and dental and spanning multiple settings. The feedback fell into four themes: overall feedback, perceived barriers, perceived strengths, and suggestions for improvement. Our conclusions coalesce around: Affirmations: feedback supporting planned program design a. mentor team make up b. inter-team sharing c. well-designed technology platform for clear communication d. mentoring for team functioning and financial support Improvements: feedback prompting us to consider design alterations a. reducing time demand b. clarifying role definitions c. incorporating patient voices d. enhancing interprofessional resources

Trunk muscle timing impairment has been associated with nonspecific low back pain (NSLBP), but this finding has not been consistent. This study investigated trunk muscle timing in a subgroup of patients with NSLBP attributed to movement coordination impairment (MCI) and matched asymptomatic controls in response to a rapid arm-raising task. Twenty-one NSLBP subjects and 21 matched controls had arm motion and surface EMG data collected from seven bilateral trunk muscles. Muscle onset and offset relative to deltoid muscle activation and arm motion, duration of muscle burst and abdominal-extensor co-contraction time were derived. Trunk muscle onset and offset latencies, and burst and co-contraction durations were not different (p > .05) between groups. Patterns of trunk muscle activation and deactivation relative to arm motion were not different. Task performance was similar between groups. Trunk muscle timing does not appear to be an underlying impairment in the subgroup of NSLBP with MCI.

The prone instability test is used to identify individuals with low back pain (LBP) who would benefit from trunk stabilization exercises. Although activity from muscles during the leg-raising portion of the prone instability test theoretically enhances spinal stiffness and reduces pain, evidence for this is lacking.To compare and contrast (1) pain and stiffness changes between prone instability testing positions, and (2) muscle activation patterns during the prone instability test leg raise in individuals with and without LBP.Participants with (n = 10) and without (n = 10) LBP participated in this laboratory case-control study. Spinal stiffness was measured using a beam-bending model and 3-D kinematic data. Stiffness changes were compared across the test positions and between groups. Surface electromyographic data were collected on trunk and limb musculature. Principal-component analysis was used to extract muscle synergies.Spinal stiffness increased across testing positions in all participants (Spinal stiffness increased in all participants; however, participants without LBP demonstrated a muscle synergy pattern where each synergy was associated with a distinct function of the prone instability test. Participants with LBP used a more global stabilization pattern, which may reflect a maladaptive method of enhancing spinal stability.

Objectives Non-traumatic extremity injuries are particularly common in sports, representing a significant economic, academic, and psychosocial burden on athletes. Proposed musculoskeletal risk factors for increased injury and decreased performance in athletes include movement pattern inefficiency, decreased regional stability, decreased mobility, and asymmetrical movement. The Movement System Screening Tool (MSST) is a comprehensive screening tool designed to assess these factors. Thus, the purpose of this study was to describe the development and determine the content and construct validity and inter-rater reliability of the MSST. Methods A modified Delphi panel of experts determined content validity. 80 athletes (40 with and 40 without a current non-traumatic shoulder injury) completed 21 clinical tests, with exploratory factor analysis and known group analysis performed to determine construct validity. Two independent raters were used to establish individual item and composite score inter-rater reliability. Results Exploratory factor analysis identified three of the four apriori constructs over 7 factors (14 tests), representing 63% of the variance. Known group analysis revealed a significantly lower composite score in athletes with vs. without a current non-traumatic shoulder injury (56.9 ± 5.8 vs. 62.7 ± 4.5, respectively). A preliminary cut score of 62 was chosen with sensitivity of 85% and specificity of 44%. Composite score inter-rater reliability was excellent ICC (2,1) = 0.94, 95% CI (0.91, 0.96) and item reliability ranged from κ = .57 to 1.00. Conclusions The MSST possesses constructs representative of injury risk and measurement properties acceptable for use in clinical settings. Comprehensive screens with construct validity and known measurement error are needed not only to identify athletes at risk of injury, but also provide an instrument that can be used in studies that seek to validate training approaches proposed to change movement impairment and injury risk in athletes.

BACKGROUND: Programs designed to prevent or rehabilitate athletic injuries or improve athletic performance frequently focus on core stability. This approach is based upon the theory that poor core stability increases the risk of poor performance and/or injury. Despite the widespread use of core stability training amongst athletes, the question of whether or not sufficient evidence exists to support this practice remains to be answered. OBJECTIVES: 1) Open a dialogue on the definition and components of core stability. 2) Provide an overview of current science linking core stability to musculoskeletal injuries of the upper extremity. 3) Provide an overview of evidence for the association between core stability and athletic performance. DISCUSSION: Core stability is the ability to control the position and movement of the trunk for optimal production, transfer, and control of forces to and from the upper and lower extremities during functional activities. Muscle capacity and neuromuscular control are critical components of core stability. A limited body of evidence provides some support for a link between core stability and upper extremity injuries amongst athletes who participate in baseball, football, or swimming. Likewise, few studies exist to support a relationship between core stability and athletic performance. CONCLUSIONS: A limited body of evidence exists to support the use of core stability training in injury prevention or performance enhancement programs for athletes. Clearly more research is needed to inform decision making when it comes to inclusion or emphasis of core training when designing injury prevention and rehabilitation programs for athletes.

These are exciting times for physical therapists who treat people with chronic low back pain (CLBP). Many of the mysteries of this condition are starting to be revealed, and it appears that major breakthroughs are on the way. Advances in neuroimaging, coupled with increased understanding of the molecular and submolecular events associated with the symptoms of back pain, are helping us reconceptualize the etiologies and mechanisms of this condition. The result of these advances is that physical therapists now have a wide range of potential “treatment packages” that can include patient education, manual therapy, and a wide variety of exercise options for people with CLBP. The question is, “How can long-term, self-management programs become more effective?” J Orthop Sports Phys Ther 2015;45(4):236–239. doi:10.2519/jospt.2015.0105

The objective of this technical paper is to demonstrate how graphing kinematic data to represent body segment coordination and control can assist clinicians and researchers in understanding typical and aberrant human movement patterns. Aberrant movements are believed to be associated with musculoskeletal pain and dysfunction. A dynamical systems approach to analysing movement provides a useful way to study movement control and coordination. Continuous motion angle-angle and coupling angle-movement cycle graphs provide information about coordinated movement between body segments, whereas phase-plane graphs provide information about neuromuscular control of a body segment. Examples demonstrate how a dynamical systems approach can be used to represent (1) typical movement patterns of the lumbopelvic and shoulder regions; (2) aberrant coordination in an individual with low back pain who presented with altered lumbopelvic rhythm; and (3) aberrant control of shoulder movement in an individual with observed scapular dysrhythmia. Angle-angle and coupling angle-movement cycle graphs were consistent with clinical operational definitions of typical and altered lumbopelvic rhythm. Phase-plane graphs illustrated differences in scapular control between individuals having typical scapular motion and an individual with scapular dysrhythmia. Angle-angle, coupling angle-movement cycle, and phase-plane graphs provide information about the amount and timing of segmental motion, which clinicians assess when they observe movements. These approaches have the potential to (1) enhance understanding of typical and aberrant movement patterns; (2) assist with identifying underlying movement impairments that contribute to aberrant movements: and (3) improve clinicians' ability to visually assess and categorize functional movements.

Background Clinical observation of aberrant movement patterns during active forward bending is one criterion used to identify patients with non-specific low back pain suspected to have movement coordination impairment. The purpose of this study was to describe and quantify kinematic patterns of the pelvis and trunk using a dynamics systems approach, and determine agreement between clinical observation and kinematic classification. Method Ninety-eight subjects performed repeated forward bending with clinical observation and kinematic data simultaneously collected. Kinematic data were plotted using angle-angle, coupling-angle, and phase-plane diagrams. Accuracy statistics in conjunction with receiver operating characteristic curves were used to determine agreement between clinical observation and kinematic patterns. Results Kinematic patterns were consistent with clinical observation and definitions of typical and aberrant movement patterns with moderate agreement (kappa = 0.46–0.50; PABAK = 0.49–0.73). Early pelvic motion dominance in lumbopelvic coupling-angle diagram ≥59° within the first 38% of the movement represent observed altered lumbopelvic rhythm. Frequent disruptions in lumbar spine velocity represented by phase-plane diagrams with local minimum occurrences ≥6 and sudden decoupling in lumbopelvic coupling-angle diagrams with sum of local minimum and maximum occurrences ≥15 represent observed judder. Conclusion These findings further define observations of movement coordination between the pelvis and lumbar spine for the presence of altered lumbopelvic rhythm and judder. Movement quality of the lumbar spine segment is key to identifying judder. This information will help clinicians better understand and identify aberrant movement patterns in patients with non-specific low back pain.

The instantaneous center of rotation (ICR) can be used to investigate movement coordination and control in patients with low back pain (LBP). Tracking of the ICR in LBP patients has not been systematically investigated. This study aimed to (1) determine the within-session measurement error of ICR parameters, and (2) characterize the change in ICR among three groups of participants (no history of LBP = HC; history of LBP = HLBP; and current LBP = LBP). Ninety-three participants (HC = 31; HLBP = 33; and LBP = 29) were recruited. Participants performed two sets of three repetitions of an active forward bend, while their lumbar and pelvic movements were recorded with an electromagnetic tracking system. Total ICR displacement and the radius of the bounding sphere containing the ICR were derived during the forward bending and the return to upright phases. Intra-class correlation coefficients (ICC3,3) and minimal detectable difference (MDD) were used to determine measurement error and interpret findings of the group analysis. One-way ANOVAs and post hoc Bonferroni comparisons were used to determine differences among groups. ICC3,3 demonstrated excellent within-session test–retest reliability of the ICR parameters (ICC3,3 = 0.86–0.97). The MDD values were 0.20–3.40 mm. Comparisons between the HC and LBP groups and between the HLBP and LBP groups showed significant differences (p

Background Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited “windows” of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a “unique biosignature of pain” that may explain much of the variation in a person’s clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT. Objectives The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction. Conclusion Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.

Emerging evidence suggests poor core stability is a risk factor for low back and lower extremity injuries in athletes. Recently the trunk stability test (TST) and unilateral hip bridge endurance test (UHBE) were developed to clinically assess core stability. Although these and other clinical tests of core stability exist, how well they assess core stability when compared to biomechanical measures of isolated core stability has not been thoroughly evaluated.The purposes of this study were to 1) determine concurrent validity of two novel clinical core stability assessments (TST and UHBE), and 2) assess relationships between these assessments and the trunk endurance and Y-Balance tests. The authors' hypothesized that the TST and UHBE would be highly correlated to the lab-based biomechanical measure of isolated core stability. Also, the TST and UHBE would be moderately correlated with each other, but not with the trunk extensor endurance and Y-Balance.Cross-Sectional design.Twenty healthy active individuals completed the TST (recorded number of errors), UHBE (s), trunk extensor endurance (s), Y-Balance (% leg length) test (YBT), and biomechanical test of core stability.Correlational analyses revealed a small, non-significant association between TST and biomechanical measures (rs = 0.2 - 0.22), while a moderate, significant relationship existed between UHBE and biomechanical measures (rs = -0.49 to -0.56, p 0.05). There was little to no relationship between TST and UHBE (r = -0.07 to - 0.21), or TST and extensor endurance (r = -0.18 to -0.24). A moderate, significant association existed between TST and two reach directions of the YBT (r = -0.41 to -0.43, p 0.05).Study data support the utility of UHBE as a clinical measure of core stability. The poor relationship between the TST and biomechanical measures, combined with observation of most control faults occurring in the lower extremity (LE) suggest the TST may not be an appropriate clinical test of core stability.Level 3.

The authors investigated differences in trunk muscle activation timing between patients with chronic nonspecific low back pain (NSLBP) and asymptomatic controls during a self-initiated postural challenge. The authors compared 30 participants with NSLBP to 30 controls. Surface electromyographic data were collected from bilateral trunk muscles. Dependent variables were trunk muscle onset and offset relative to extremity muscle activation and duration of the trunk muscle burst and abdominal–extensor cocontraction. Patients with NSLBP demonstrated significantly delayed trunk muscle onset latency (p < .01), and shorter burst (p = .02) and cocontraction durations (p < .01). Results suggest that patients with NSLBP may be inefficient in regulating trunk posture during voluntary extremity movements. These alterations could also represent a compensatory control pattern imposed by the CNS to avoid pain.

Background context A subgroup of patients with acute to subacute low back pain (LBP) presenting with trunk movement control deficits, pain provocation with segmental testing, and segmental hypermobility have been clinically identified as having movement coordination impairments (MCIs) of the trunk. It is hypothesized that these patients have proprioceptive, postural, and movement control impairments of the trunk associated with LBP. Although trunk control impairments have been identified in patients with chronic LBP, they have not been investigated in this subgroup or closer to symptom onset. Purpose The purpose of the study was to identify trunk motor control (postural control and movement precision) impairments in a subgroup of patients with acute to subacute LBP who have been clinically identified to have MCIs and determine association of these impairments with pain and fear of movement. Study design/setting The study design includes observational design, university biomechanics laboratory, and clinical practice. Patient sample Thirty-three patients with acute to subacute LBP presenting with trunk MCIs and 33 healthy controls matched with gender, age, and body mass index were identified. Outcome measures Self-report measures included Numeric Pain Rating Scale, Oswestry Disability Index Questionnaire, and Fear-Avoidance Beliefs Questionnaire and physiologic measures included postural control and movement precision. Methods Center-of-pressure movement was measured while subjects attempted to volitionally control trunk posture and movement while sitting on a platform with a hemisphere mounted underneath. This created an unstable surface that required coordinated trunk control to maintain an upright seated posture. Postural control was tested using eyes-open and -closed balance protocols. Movement precision was tested with a dynamic control test requiring movement of the center of pressure along a discrete path. Group trunk motor control performance was compared with analysis of variance and t test. Performance association with pain and fear of movement were assessed with Pearson correlations. Results Patients’ postural control in the eyes-closed condition (p=.02) and movement precision (p=.04) were significantly impaired compared with healthy controls, with moderate-to-large group difference effect sizes. These trunk motor control impairments were not significantly associated with the patients self-reported pain characteristics and fear of movement. Conclusions Patients with clinical identification of trunk MCIs demonstrated decreased trunk motor control, suggesting that impairments in proprioception, motor output, or central processing occur early in the back pain episode. This information may help to guide interventions to address these specific limitations, improving delivery of care.

Clinical measurement, cross-sectional study.To investigate the reliability of observation of aberrant movement patterns (altered lumbopelvic rhythm, deviation from sagittal plane, instability catch or judder, and painful arc of motion) and to determine whether each pattern is associated with current low back pain (LBP).Identification of aberrant movement patterns during trunk motion is an important component of subclassifying patients with LBP and prescribing evidence-based interventions. However, reported reliability for observation of specific aberrant patterns is low, and observation of any aberrant pattern (clinical definition of positive test) has ranged from poor to moderate. In addition, the validity of the association of clinical observations of aberrant movements during forward bending with LBP or dysfunction has yet to be determined.Experienced physical therapists simultaneously observed trunk movements of 102 subjects with no LBP, current LBP, or history of LBP. Kappa statistics were used to evaluate interrater agreement in identifying different types of aberrant patterns. Associations were used to determine the validity of the hypothesized relationship between aberrant patterns and LBP.Interrater reliability of identifying the different types of aberrant patterns in subjects with LBP ranged from fair (κ = 0.35; 95% confidence interval: 0.00, 0.71) to excellent (κ = 0.89; 95% confidence interval: 0.69, 1.00). Using the clinical definition of 1 observation of any aberrant motion, interrater agreement was substantial (κ = 0.65; 95% confidence interval: 0.00, 1.00). Significant association was found between judder, deviation, and LBP. The frequency of observed aberrant patterns was significantly associated with LBP.Simultaneous observation for specific aberrant movement patterns suggests that identification can be performed with at least fair interrater agreement, and observation of any pattern with substantial agreement. Aberrant patterns are more frequently observed in patients with current complaints of LBP; however, they also appear in individuals with a history of LBP and no LBP.

The words of Hughlings Jackson in 1884 were inspired by a consideration of what was then the recent work of Darwin on evolution. In the quoted article he applied this perspective to CNS evolution, development and subsequent neurological damage. His overall framework likely remains relevant today. Our paper’s goal is to review current perspectives on motor modularity and its mechanisms, especially at the spinal level (for Jackson ‘well-organized’, ‘simpler’ and ‘more automatic’), but also beyond. Modularity can be defined as the use of designs employing standardized components or units, allowing easy assembly, repair and flexible arrangements of the components. The simplest modules in a system, from which other larger modules might be made, can be termed primitives. This term derives from a combination of the biological definition of primitive as ‘occurring in or characteristic of an early stage of development or evolution’, the definition of primitive as an element assumed as a basis, and the computer science definition of ‘a basic or fundamental unit of machine instruction’. Like Jackson, we will argue that these modules and primitives are in significant part already organized at birth. At the end of this review, we discuss how these issues in spinal modularity and protective reflex structure may relate to trunk control and low back pain mechanisms in humans.

Silfies SP, Mehta R, Smith SS, Karduna AR. Differences in feedforward trunk muscle activity in subgroups of patients with mechanical low back pain. Objective To investigate alterations in trunk muscle timing patterns in subgroups of patients with mechanical low back pain (MLBP). Our hypothesis was that subjects with MLBP would demonstrate delayed muscle onset and have fewer muscles functioning in a feedforward manner than the control group. We further hypothesized that we would find differences between subgroups of our patients with MLBP, grouped according to diagnosis (segmental instability and noninstability). Design Case-control. Setting Laboratory. Participants Forty-three patients with chronic MLBP (25 instability, 18 noninstability) and 39 asymptomatic controls. Interventions Not applicable. Main Outcome Measures Surface electromyography was used to measure onset time of 10 trunk muscles during a self-perturbation task. Trunk muscle onset latency relative to the anterior deltoid was calculated and the number of muscles functioning in feedforward determined. Results Activation timing patterns ( P P =.02; η=.30; 1-β=.83) were statistically different between patients with MLBP and controls. The control group activated the external oblique, lumbar multifidus, and erector spinae muscles in a feedforward manner. The heterogeneous MLBP group did not activate the trunk musculature in feedforward, but responded with significantly delayed activations. MLBP subgroups demonstrated significantly different timing patterns. The noninstability MLBP subgroup activated trunk extensors in a feedforward manner, similar to the control group, but significantly earlier than the instability subgroup. Conclusions Lack of feedforward activation of selected trunk musculature in patients with MLBP may result in a period of inefficient muscular stabilization. Activation timing was more impaired in the instability than the noninstability MLBP subgroup. Training specifically for recruitment timing may be an important component of the rehabilitation program.

The purpose of this study was to quantify lumbo-pelvic control differences between patients with mechanical low back pain (MLBP) and asymptomatic controls using a dynamical systems approach to data reduction and interpretation. Subjects were 30 patients with chronic MLBP (age: 41.1+/-8.9 years, body mass index: 26.2+/-5.2 kg/m(2)) and 35 asymptomatic controls (age: 38.8+/-9.2 years, body mass index: 25.3+/-4.8 kg/m(2)). Kinematic data were collected from the femur, pelvis and lumbar spine during repeated trials of bilateral forward reaching under two loading conditions. Sagittal plane angular motion was filtered and time normalized. Continuous relative phases were then calculated for each data point. Mean absolute relative phase (MARP) and deviation phase (DP) parameters were derived to quantify intersegmental coordination and pattern variability. Mixed-model ANOVAs revealed that lumbo-pelvic coordination was more separated in time and more variable in the chronic MLBP group during this task. Trunk neuromuscular control was thus altered in our MLBP group. Unresolved extensor muscle dysfunction is suggested by (a) preliminary analysis of phase plane trajectories, (b) subjects' greater difficulty controlling aspects of the task that required the extensors to contribute to trunk stability and primary movement control.

Background Impaired proprioception in the lumbar spine has often been reported in people with low back pain. However, no prospective studies exist to assert the cause and effect of this association. We hypothesized that athletes with a history of low back injury (LBI) would demonstrate poorer lumbar position sense (PS) than athletes without a history of LBI, and that this deficit would be a risk factor for future LBI. Methods This was a prospective cohort study with 2–3 year follow-up. Lumbar spine PS in the transverse plane was evaluated in 292 athletes using three tests: 1) passive and 2) active trunk repositioning, and 3) motion perception threshold. Mean absolute (accuracy) and variable (precision) errors were computed. Results There were no significant differences in the repositioning errors or motion perception threshold between athletes with and without a history of LBI or between those who did and did not get injured during the follow-up. Active trunk repositioning resulted in smaller errors than passive repositioning (1.6°± 0.8°) versus 2.1°± 1.0°) and 1.7°± 0.8°) versus 2.3°± 1.1°) for the absolute and relative errors, respectively). Conclusion Poor trunk PS in transverse plane is not associated with LBI in athletes, nor does it appear that poor trunk PS predisposes athletes to LBI.

Study design Prospective observational study with a 2- to 3-year follow-up. Objectives To determine whether delayed muscle reflex response to sudden trunk loading is a result of or a risk factor for sustaining a low back injury (LBI). Summary of background data Differences in motor control have been identified in individuals with chronic low back pain and in athletes with a history of LBI when compared with controls. However, it is not known whether these changes are a risk for or a result of LBI. Methods Muscle reflex latencies in response to a quick force release in trunk flexion, extension, and lateral bending were measured in 303 college athletes. Information was also obtained regarding their personal data, athletic experience, and history of LBI. The data were entered into a binary logistic regression model to identify the predictors of future LBI. RESULTS.: A total of 292 athletes were used for the final analysis (148 females and 144 males). During the follow-up period, 31 (11%) athletes sustained an LBI. The regression model, consisting of history of LBI, body weight, and the latency of muscles shutting off during flexion and lateral bending load releases, predicted correctly 74% of LBI outcomes. The odds of sustaining LBI increased 2.8-fold when a history of LBI was present and increased by 3% with each millisecond of abdominal muscle shut-off latency. On average, this latency was 14 milliseconds longer for athletes who sustained LBI in comparison to athletes who did not sustain LBI (77 [36] vs. 63 [31]). There were no significant changes in any of the muscle response latencies on retest following the injury. Conclusions The delayed muscle reflex response significantly increases the odds of sustaining an LBI. These delayed latencies appear to be a preexisting risk factor and not the effect of an LBI.

There are conflicting findings in the literature regarding erector spinae activation imbalance in people with low-back pain (LBP). Some studies have found asymmetric recruitment between muscle pairs in people with LBP, whilst other studies have not; some reported people with LBP recruit more lumbar muscles whilst other have reported greater thoracic activity. Using 242 varsity athletes, EMG activity of thoracic and lumbar erector spinae pairs was recorded during an isometric trunk extension. Activation imbalance among muscle pairs and levels was compared between athletes with and without a history of low-back injury (HxLBI). There were no group differences in the imbalance between sides, but the HxLBI group had greater activation imbalance between lumbar and thoracic levels than the No HxLBI group. Activation imbalance between levels was similar for individuals with No HxLBI and those who sustained first time injury suggesting that imbalance does not cause LBI. There was no difference between the athletes with single and multiple episode LBI, nor between short and long symptom duration suggesting that the presence of imbalance is not an impairment. Interestingly, activation imbalance occurred in both directions, meaning more thoracic activity for some, and more lumbar activity for others, which might be a functional adaptation related to pathology.