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Journal of Orthopaedic & Sports Physical Therapy®
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Orthopaedic Section Abstracts:
Poster Presentations
OPO1-OPO243
The abstracts below are presented as prepared by the authors.
The accuracy and content of each abstract remain the responsibility
of the authors. In the identification number above each abstract,
OPO designates an Orthopaedic Section poster presentation.
OPO1
EFFECTS OF DESENSITIZATION ON PAIN DISTRIBUTION AND NORMALIZATION
OF SOMATOSENSATION IN A PATIENT WITH QUADRILATERAL COMPLEX
REGIONAL PAIN SYNDROME
Roger J. Allen, Lisa J. Cook, Dullen R. Kristen,
Jacob N. Hoffman, Megan A. Vento
Physical Therapy, University of Puget Sound, Tacoma, Washington
BACKGROUND AND PURPOSE: Complex regional pain syndrome (CRPS) is a
chronic condition affecting 1 or more extremities that can develop after
injury, involving constant limb pain, allodynia, and hyperpathic autonomic and somatic symptoms. Somatosensory desensitization (SD) has long
been considered essential in CRPS treatment, yet efficacy evidence remains limited. This study’s aim was to assess pain intensity and distribution differences between treated and untreated limbs, as well as potential
somatosensory normalization of proximal nonpainful limb regions, following 10 weeks of SD in a patient with quadrilateral CRPS.
CASE DESCRIPTION: The patient was a 54-year-old male with incomplete
C5 SCI. Eighteen months of physical therapy yielded nearly full functional unassisted mobility, yet constant searing pain and tactile allodynia developed in all extremities. Prior to seeking SD therapy, the patient
experienced constant pain for 5 years following type II CRPS diagnosis.
Quadrilateral involvement afforded an opportunity to desensitize 1 upper and 1 lower limb, allowing outcome assessment of treated and untreated limbs. During a 10-week treatment, the patient was exposed to
progressively coarser materials via self-massage BID with weekly stimulus progression. Pain body diagrams (PBD) were completed pre and post
SD and at 7-month follow-up. Changes in limb pain extent were quantified with pain distribution score (PDS) calculations applied to PBDs.
Outcome measures taken weekly and at the 7-month follow-up on each
limb included visual analog pain scale (VAS) and allodynia assessments
via algometry. Semmes Weinstein monofilaments and 2-point discrimination were used to assess somatosensory changes to affected and unaffected limb areas.
OUTCOMES: Overall PDS decreased by 23.5%, with reductions of 9.5% for
treated and 14.0% for untreated limbs. VAS scores for the treated limbs
decreased by 5.5 cm UE and 2.4 cm LE, with reductions of 0.3 cm and 1.2
cm for the untreated UE and LE, respectively. Monofilament and 2-point
discrimination testing revealed pretreatment subnormal somatosensory thresholds and acuity of proximal nonpainful limb areas, that subsequently normalized with corresponding reductions in distal pain. Other
posttreatment changes included reduced allodynia and improvements in
UE grip/pinch strength and axial loading tolerance in all limbs.
DISCUSSION: Prior literature suggests that SD can lead to decreased pain
in treated limbs; however, changes in untreated painful areas have not
been documented. After 10 weeks of SD, this spinal cord injured patient
showed notable reductions in pain intensity, distribution, and allodynia in
both treated and untreated limbs. Somatosensation in proximal, nonpainful areas normalized as pain decreased in more distal areas. These findings suggest central neuroplastic changes may occur from SD treatment,
perhaps involving normalization of representation of affected and unaffected areas in the neuromatrix.
REFERENCES: Freedman M, Greis A, Marino L, Sinha A, Henstenburg J.
Complex regional pain syndrome: diagnosis and treatment. Phys Med
Rehabil Clin N Am. 2014;25:291-303. Barnhoorn KJ, Oostendorp RA,
van Dongen RT, et al. The effectiveness and cost evaluation of pain exposure physical therapy and conventional therapy in patients with complex regional pain syndrome type 1. Rationale and design of a randomized controlled trial. BMC Musculoskelet Disord. 2012;13:58. Allen RJ,
Soterakopoulos C, Fugere KJ, et al. Pain distribution quantification using
enhanced ‘rule-of-nines’: reliability and correlations with intensity, sensory, affective, and functional pain measures. Physiother. 2011;97:309.
Allen R. Multimodal allodynia treated with somatosensory specific desensitization in patients with complex regional pain syndrome. Eur J
Pain. 2009;13:144-145. Allen R. Physical agents used in the management of chronic pain by physical therapists. Phys Med Rehabil Clin N Am.
2006;17:315-345. Taub E, Uswatte G, Mark VW, Morris DM. The learned
nonuse phenomenon: implications for rehabilitation. Eura Medicophys.
2006;42:241-256.
OPO2
MANUAL THERAPY INTERVENTIONS FOR ADOLESCENT TO COLLEGIATE-AGED
INDIVIDUALS WITH POSTCONCUSSION DISORDER: A RAPID REVIEW
Jordan E. Allison, Chris A. Sebelski
Department of Physical Therapy and Athletic Training, Saint
Louis University, St Louis, Missouri; SLU-SSM Physical Therapy
Orthopedic Residency, St Louis, Missouri
PURPOSE/HYPOTHESIS: The purpose of this rapid review was to examine
current literature related to manual therapy interventions for adolescent
to collegiate-aged individuals with postconcussion disorder (PCD) with
persistent headache, neck pain, or dizziness.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: Eligible studies included randomized-controlled
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trials, meta-analyses, prospective and retrospective comparative cohort studies, case series, and case reports examining the use of manual therapy for treatment in adolescent to collegiate-aged individuals with PCD. Standardized search terms were used to search PubMed,
Scopus, CINAHL Plus with full text, SPORTDiscus with full text and
the Cochrane Library. Grey literature included conference, symposium
and website data from the American Academy of Orthopaedic Manual
Physical Therapists, the North American Institute of Orthopedic Manual
Therapy and the Maitland-Australian Physiotherapy Seminars. Inclusion
criteria: literature published from 2006 to present, incorporation of manual therapy as defined by the American Physical Therapy Association
and participants 13 to 26 years old. Exclusion criteria: studies specific
to acute concussion management and those not including manual therapy interventions. Study level of evidence was assessed using criteria from
the Centre for Evidence-Based Medicine, for prospective and therapeutic studies.
RESULTS: Three hundred eighty-three studies were retrieved. After duplicates removed, 260 titles/abstracts were reviewed and 30 full-text articles were assessed for eligibility. Five of the 30 studies were eligible, and
assessed for level of evidence. Four of the studies were case studies/series
(level 4 evidence) and 1 was a randomized controlled trial, (level 1b evidence). One of 5 studies evaluated the effects of manual therapy intervention in isolation, whereas the remaining 4 studies utilized a multimodal approach including manual therapy. Based on this rapid review, these
studies concluded that integration of manual therapy for management of
individuals with PCD improves neck pain, dizziness, and headache, and
facilitates a quicker return to athletic competition.
CONCLUSIONS: This rapid review included 5 studies of individuals with
PCD and the associated symptoms of neck pain, headache and dizziness.
A multimodal approach, including manual therapy interventions, is an effective way to decrease neck pain, headache and/or dizziness associated
with PCD. There is a paucity of literature available at this time specific to
manual therapy interventions for those with PCD.
CLINICAL RELEVANCE: Based on the limited evidence available, manual therapy interventions are a safe and effective mode of treatment for individuals suffering from PCD. Further investigation is required to validate this
conclusion.
OPO3
CROSS-CULTURAL ADAPTATION AND PSYCHOMETRIC PROPERTIES
TESTING OF THE ARABIC ANTERIOR KNEE PAIN SCALE
Abdullah Alshehri
Loma Linda University, Riyadh, Saudi Arabia
PURPOSE/HYPOTHESIS: The purpose of this study was to translate, develop a
cross-cultural adaptation, and examine validity, test-retest reliability and
feasibility of the Arabic version of the Anterior Knee Pain Scale (AKPS)
in patients with Patellofemoral Pain Syndrome (PFPS).
NUMBER OF SUBJECTS: Forty subjects with age ranging from 18 to 50 years.
MATERIALS/METHODS: We followed international recommendations to perform a cross-cultural adaptation of the AKPS. The measurements tested were reliability, validity, and feasibility. The cross-cultural adaptation
was conducted in 2 major stages: translation and cross-cultural adaptation and assessment of psychometric properties. The first stage was performed according to the guidelines published for the translation and
cross-cultural adaptations of health-related questionnaires and adopted
by the American Orthopaedic Surgeons Association (AOSA). The second
stage employed the use of quality criteria for assessing properties of the
questionnaire; this included (1) translation, (2) synthesis, (3) back-translation, (4) expert committee review, (5) pretesting, and (6) validation. The
Arabic AKPS and the Arabic RAND 36-item Health Survey were administered to 40 patients who were diagnosed with PFPS. Participants were
assessed at baseline for both scales and after 2 to 3 days, assessed with the
Arabic AKPS only.
RESULTS: The Arabic AKPS showed high reliability for temporal stabili-
ty, internal consistency (Cronbach’s alpha was .81 for the first assessment
and 0.75 for the second), excellent test-retest reliability (intraclass correlation coefficients [ICC] = 0.96; 95% confidence interval [CI]: 0.93,
0.98) and good agreement (standard error of measurement [SEM],
1.8%). The Arabic AKPS was significantly correlated with physical components of the RAND 36-Item Health Survey (Spearman’s rho = 0.69:
P<.001). No ceiling or floor effects were observed.
CONCLUSIONS: The Arabic AKPS is sufficiently reliable, valid, and appropriate for use as a patient reported outcome measure for Arabic speaking
individuals with patellofemoral pain syndrome.
CLINICAL RELEVANCE: The Arabic version of the AKPS can be used as a subjective and functional assessment tool for Arabic-speaking individuals
with patellofemoral pain syndrome in daily clinical practice and in research studies.
OPO4
DIFFERENTIAL DIAGNOSIS IN A PATIENT REFERRED TO PHYSICAL THERAPY
FOR KNEE PAIN
Rocio Antone, Eric Reyes, Elizabeth Lemos
Quentin Mease Hospital Outpatient Rehabilitation, Harris Health
System, Missouri City, Texas
BACKGROUND AND PURPOSE: Cervical myelopathy is a progressive neurological condition that presents with a wide variety of clinical symptoms.
Evidence supports surgical intervention to halt further neurological decline in function. Given the wide range of signs and symptoms of myelopathy, diagnosis can be challenging and requires a thorough neurological
screening. The ability of a physical therapist to adequately discern the
presence of sinister pathologies masked as a musculoskeletal complaint
has been a source of concern by some physicians in a direct patient access
practice environment. The purpose of this case is to demonstrate a physical therapist’s ability to perform a complete review of systems with emphasis on neurological testing to make appropriate medical referral in a
patient with undiagnosed cervical myelopathy.
CASE DESCRIPTION: A 48-year-old woman presented to a hospital-based
outpatient orthopaedic physical therapy clinic after being referred by an
orthopaedic surgeon for a complaint of chronic right knee pain. Prior to
seeing PT, this patient was evaluated by a neurologist due to elevated creatine kinase level in the presence of imbalance and gait abnormalities. At
that time, deficits were attributed to mechanical knee pain. Upon PT evaluation, she confirmed insidious onset of knee pain ongoing for 7 months
and also endorsed stiffness, difficulty with gait and balance. Physical therapist’s evaluation produced findings inconsistent with mechanical knee
pain. Furthermore, observational gait analysis prompted more in-depth
neurological testing that revealed the presence of pathological reflexes,
hyperreflexia and spasticity on multiple limbs with right side more pronounced. Per physical therapist’s recommendation, the patient was sent
for a follow-up with referring provider as well as neurologist. Orthopedics
ordered an MRI of her painful knee, which the radiologist deemed unremarkable. As recommended by the physical therapist, the patient returned for a second consult with a neurologist. An MRI of her cervical
spine showed the presence of severe central canal stenosis at C4-5 confirming the suspected presence of cervical myelopathy.
OUTCOMES: Following the physical therapist’s recommendation, the patient received advanced imaging and a new physical exam by a neurologist. A diagnosis of cervical myelopathy was made and the patient was
immediately scheduled for decompressive spinal surgery in order to prevent further neurologic compromise and maximize functional outcomes.
DISCUSSION: This case highlights the importance of continual consideration of nonmusculoskeletal problems as the cause of symptoms and the
competence of a physical therapist in making appropriate medical referrals in light of the presence of red flags. By using a thorough review of systems and sound clinical reasoning, a physical therapist is able to request
for additional testing to adequately diagnose the cause of signs and symptoms noted on examination.
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REFERENCES: Edwards C, Riew D, Anderson P, et al. Cervical myelopa-
thy: currect diagnostic and treatment strategies. Spine J. 2003;3:68-81.
Elliott J, Flynn T, Al-Naijar A, et al. The pearls and pitfalls of magnetic
resonance imaging for the spine. J Orthop Sports Phys Ther. 2011;41:848860. Flautt W, Westrick R. Cervical myelopathy in a special operations
soldier. J Orthop Sports Phys Ther. 2015;45:233. Ren H, LeuF, Yu D, et
al. Patterns of neurological recovery after anterior decompression with
fusion and posterior decompression with laminoplasty for the treatment of multilevel cervical spondylotic myelopathy. Clin Spine Surg. In
press. Salvi F, Jones J, Weigert B. The assessment of cervical myelopathy. Spine J. 2006;6:1825-1895. Tetreault L, Goldstein C, Arnold P, et al.
Degenerative cervical myelopathy: a spectrum of related disorders affecting the aging spine. Neurosurgery. 2015:77:S51-S67.
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OPO5
MENISCAL ABNORMALITIES: A COMPARISON OF ULTRASONOGRAPHY
AND MCMURRAY’S TEST
Eryn K. Apanovitch, Bryon A. Smith, Nicole Limpabandh,
Ashalee Cyears, Samantha Perez, Lauren Scheuing,
Clara Stroud
Department of Physical Therapy, University of Miami, Miami,
Florida
PURPOSE/HYPOTHESIS: Ultrasound is emerging as a viable imaging modality in diagnosis and assessment of the musculoskeletal system. It is unknown whether diagnostic ultrasound can accurately and reliably detect
abnormalities of menisci in the knee. In 2014, Sladjan et al investigated
accuracy of detecting acute and chronic lateral meniscal lesions with ultrasound imaging (UI) and determined chronic detection to be 85% sensitivity and 90% specificity while acute detection to be 71% and 87% respectively. These results indicate that UI is clinically useful for meniscal
pathology assessment, but further research must be done concerning clinical diagnosis with UI. The purpose of this study was to determine if there
is a relationship between physical therapy students identifying meniscal
abnormalities using UI and McMurray’s test (MT).
NUMBER OF SUBJECTS: Twenty-seven patients with suspected meniscal injuries were assessed using UI and MT.
MATERIALS/METHODS: Two examiners performed UI on all subjects while 2
additional raters were blinded and performed the MT. UI was performed
at the joint line, on the medial and lateral aspects of the knee while patients were positioned supine with their knee at 90° of flexion. The criterion for consideration of a meniscal abnormality includes imaging with
presentation of inflammation, extrusion of the meniscus, and inconsistent
fiber alignment. MT was performed to compare to the meniscal abnormalities found using UI. A positive test would elicit pain and/or clicking.
RESULTS: In 18 of the subjects, meniscal pathology was suspected based on
UI. After MT, the first rater identified 15 abnormalities while the second
rater detected 16 abnormalities. Further analysis revealed that, for the
first rater, 12 of the subjects who tested positive with the MT were suspected of having the same meniscal pathology based on the UI (80%). For
the second rater 11 of these subjects matched (68.8%).
CONCLUSIONS: Results indicate that student physical therapists can accurate visualize meniscal pathologies, possibly even tears using UI. UI can
be a cost and time efficient tool in the clinical setting for detecting meniscal abnormalities and can be utilized by physical therapists. At this time
specificities in detecting types of meniscal abnormalities is unknown, but
research is ongoing.
CLINICAL RELEVANCE: The ability of physical therapists to confirm meniscal
abnormalities identified through clinical examination (MT) with UI, if reliable, would benefit the overall health care industry via significant cost
reduction and time efficiency. With the expansion of direct access growing nationwide, UI further allows the physical therapist to act as an independent health care professional without the need for MRI confirmation.
OPO6
NORMAL HOLD TIMES OF THE MODIFIED SIDE BRIDGE IN SUBJECTS
30 YEARS AND OLDER
Mark J. Armstrong, Marsha D. Rutland, Janelle K. O’Connell,
Scott Newberry, Kathryn Bromiey, Christopher Adamcik
Physical Therapy, Hardin Simmons University, Abilene, Texas
PURPOSE/HYPOTHESIS: The purpose of this study was to (1) determine average maximum endurance hold times for the modified side-bridge (on elbow and knees) position among healthy subjects 30 to 69 years old, (2)
identify relationships between subjects’ characteristics (body mass index
and sex)and the modified side-bridge hold times.
NUMBER OF SUBJECTS: Thirty subjects per age group participated (30-49
and 50-60 years).
MATERIALS/METHODS: A sample of convenience were recruited from universities and local businesses. Following completion of an informed consent and health status questionnaire, demographic information was obtained. Resting blood pressure, height, weight, body mass index (BMI)
were assessed. Prior to testing, initial side-bridge hold side (left or right)
was randomly determined. An instructional video was viewed to familiarize subjects with the testing procedure. Subjects performed the modified side-bridge on both sides with a 1-minute rest between efforts. One
cue was given when the examiner noted deviation from the initial starting
position. A second deviation within 15 seconds of the first, or hip contact
with the mat terminated the testing procedure. Hold times was limited to
a maximum of 3 minutes per side. Independent-samples t tests were used
to identify differences in average hold times between age groups (30-49,
50-69), left and right hold sides, and sex. A Pearson correlation was used
to identify relationships between BMI, exercise frequency, and hold times.
RESULTS: Subjects: n = 60 (23 male, 37 female; mean ± SD age, 47.2 ±
10.9 years) completed the study. The average hold times of the subjects
were reported in seconds for sex and age groups: F (30-49 years old) =
100.45 ± 49.4 seconds (right) and 91.01 ± 50.1 seconds (left); M (30-49
years old), 129.63 ± 34.4 seconds (right) and 116.05 ± 38.7 seconds (left);
F (50-69 years old) = 109.90 ± 56.7 seconds (right) and 106.49 s ± 42.5
seconds (left); and M (50-69 years old), 127.06 ± 47.7 seconds (right) and
127.02 ± 50.2 seconds (left). Overall, males held the modified side-bridge
longer than females with a mean difference of 23.4 seconds right side (P
= .038) and 24 seconds left side (P = .027). No significant differences in
hold times between age groups (30-49, 50-69) or test sides (right,left)
were found. Fair, inverse correlations were found between BMI and hold
times (right, r = –0.419; left, r = –0.359). Primary reasons for test termination were hip musculature fatigue in males and arm/shoulder muscular fatigue in females.
CONCLUSIONS: Modified side-bridge mean overall hold times in subjects
30 and older is over 1 minute. No significant difference in hold times between left or right sides or age groups were shown. There was a fair, inverse relationship between BMI classification and hold time. Males held
significantly longer than females.
CLINICAL RELEVANCE: A modified side bridge is an adapted form for those
whom may not be able to perform a full side bridge. Findings of the normal values for the modified side-bridge in healthy individuals 30 to 69
years may serve as useful tool when used clinically as a core endurance
outcome measure.
OPO7
AN INITIAL INVESTIGATION INTO A CLINICALLY FEASIBLE MEASURE OF
MEDIAL LONGITUDINAL ARCH FLEXIBILITY
Lindsay Backiev, K. Michael Rowley, Hai-Jung Shih,
Kornelia Kulig
Division of Biokinesiology and Physical Therapy, University of
Southern California, Los Angeles, California
PURPOSE/HYPOTHESIS: Medial longitudinal arch (MLA) flexibility is clinically important due to its purported association with lower extremity in-
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jury [1-4]. Much literature utilizes a variety of evaluation methods when
measuring MLA height [1,5], and while most methods mutually employ
the navicular as a bony landmark, small variances result in difficulty comparing between studies. To assess MLA flexibility independent of absolute height, researchers developed a measurement of the foot’s response
to compressive loads, relative arch deformation (RAD) the RAD equation
described by Nigg and collaborators [6] was later modified by Williams
and McClay [7]. Methods reported in the literature are complex procedures, however, that may be unreasonable to perform with patients clinically such as using scales to load precisely 10% and 90% of body weight
[6,7]. We propose a clinically simple method of obtaining 2 comparable
measurements to determine RAD: the first seated, approximating an unloaded condition, and the second a bilateral stance, approximating 50%
body weight loading. The purpose of this study was to compare results of
this RAD methodology to published methods.
NUMBER OF SUBJECTS: Data were collected on the dominant stance foot, defined as contralateral to the preferred kicking limb, of each healthy adult
participant (n = 45; mean age, 26.5 years; 8 male).
MATERIALS/METHODS: Weight, arch height seated (AHU), arch height
standing (AH), and truncated foot length were measured and recorded.
Arch height was measured at the dorsal aspect of the talonavicular joint.
RAD, and AHU and AH normalized to truncated foot length, were calculated. Results were compared against reported mean values of Williams
and McClay [7].
RESULTS: AHU and AH were significantly greater than the mean heights
reported by Williams and McClay (AHU, P<.0001; AH, P<.0001), and
there was no difference in truncated foot length (P = .42). Average RAD
was calculated as 1.28 ± 0.67 N, significantly larger than the mean value reported by Williams and McClay of 1.05 ± 0.51 N (P = .02, Cohen’s
d = 0.39).
CONCLUSIONS: Greater absolute arch heights measured in this study can be
explained by our procedure of measuring at the dorsal aspect of the talonavicular joint versus previous definitions of 50% of foot length or highest aspect of the dorsum, which may result in more intersubject variability. Greater RAD may also reflect greater motion at this joint line, more
indicative of real arch deformation during loading, or may be influenced
by an 82% female sample [8]. Future studies will further explore validity,
reliability, and functional significance of RAD measures.
CLINICAL RELEVANCE: We determined that a simple procedure of measuring
arch height while seated, then standing with bilateral weight distribution,
is a promising method of measuring RAD and quantifying MLA flexibility.
OPO8
RELIABILITY OF FABER MEASUREMENTS
Jennifer J. Bagwell, Lauren Bauer, Marissa Gradoz,
Terry L. Grindstaff
Creighton University, Lincoln, Nebraska
PURPOSE/HYPOTHESIS: The FABER (Flexion ABduction External Rotation)
test is an indicator of hip pain and range of motion (ROM) with emphasis on side-to-side asymmetry. Normative and reliability data regarding FABER are lacking. Additionally, while thigh length would influence FABER height, no study has examined use of an inclinometer versus
standard ruler or considered normalization to thigh length. Therefore,
the purposes of this study were to determine normative values and inter and intrarater reliability of FABER height, thigh length normalized
FABER, and interlimb FABER differences. We also compared intrarater
reliability of FABER measured via a ruler, thigh length normalized, and
via inclinometry.
NUMBER OF SUBJECTS: Nineteen participants without hip, knee, or lumbar
spine pain (11 female, 8 male; mean ± SD age 23.5 ± 1.2 years).
MATERIALS/METHODS: Three testers performed measurements during 2 sessions (3-7 days between sessions). Passive FABER ROM was measured
with the participant in the figure 4 position using a ruler (perpendicular
distance from the lateral femoral epicondyle to table) and with an incli-
nometer. Next, thigh length was measured between the greater trochanter and the lateral epicondyle of the femur and was used to normalize
FABER values obtained with the ruler (FABER/thigh length). The difference between limbs was calculated as the absolute value of right minus left FABER ruler measurements. Interrater and intrarater reliability were calculated in SPSS using interclass correlation coefficients (ICC).
Minimal detectable change (MDC) was also calculated (standard error of
the measure × 1.96 × √2).
RESULTS: Mean values for right/left FABER height were 12.3 ± 2.9 cm and
12.4 ± 2.7 cm. Mean thigh length normalized FABER for right/left were
0.29 ± 0.07 and 0.30 ± 0.07. Interrater reliability for height and normalized height were good (ICC = 0.62-0.73) and between session intrarater
reliability were good to excellent (ICC = 0.70-0.88). FABER height and
normalized FABER MDC for the 3 testers ranged from 1.2 to 1.9 cm and
0.02 to 0.05, respectively. Mean FABER difference was 2.0 ± 0.9 cm with
poor interrater reliability (ICC = 0.20), poor to good intrarater reliability
(ICC = 0.38-0.66), and an MDC of 1.3 to 2.0 cm. FABER height measured
with a ruler, normalized height, and inclinometry all resulted in excellent
intrarater reliability, with the highest ICC for inclinometry (ICC = 0.840.87, 0.83-0.88, and 0.87-0.95).
CONCLUSIONS: Overall, FABER measurements were reliable, whether normalized to thigh length or not. Furthermore, results indicate that use of
an inclinometer may increase reliability. However, we found poor to good
reliability for assessment of interlimb differences in FABER.
CLINICAL RELEVANCE: This study established normative and MDC values for
FABER and demonstrated that FABER measurements can be used reliability. However, due to poor to good reliability when assessing interlimb
differences, more research is necessary to determine if FABER asymmetries can be reliably used to identify potential hip pathology, as has been
suggested clinically.
OPO9
DIFFERENCES IN KNEE AND HIP ADDUCTION AND HIP MUSCLE ACTIVATION
IN RUNNERS WITH AND WITHOUT ILIOTIBIAL BAND SYNDROME
Robert L. Baker, Richard B. Souza, Christopher Powers,
Mitchell J. Rauh, Mike Fredericson, Michael D. Rosenthal
Physical Therapy, University of California San Francisco, San
Francisco, California; Sports and Orthopedics, Rocky Mountain
University of Health Professions, Provo, Utah; Physical Therapy,
University of Southern California, Los Angeles, California; Physical
Therapy, San Diego State University, San Diego, California; Sports
Medicine, Stanford University, Palo Alto, California
PURPOSE/HYPOTHESIS: Increased hip and knee adduction has been reported in runners with iliotibial band syndrome. Recent reports have focused
on the hip and neuromuscular factors to determine who may be at greater risk. The influence of muscle activation in the hip muscles has not been
reported. We hypothesized that increased hip and knee adduction would
be associated with increased tensor fasciae latae muscle activation, reduced gluteus medius and gluteus maximus muscle activation. The kinematic and activation differences were expected to be greater at 30 minutes than 3 minutes of running.
NUMBER OF SUBJECTS: Thirty.
MATERIALS/METHODS: Motion capture and surface electromyography were
performed on 15 runners with iliotibial band syndrome and 15 matched
controls. The average muscle activation was compared for the gluteus medius, gluteus maximus and tensor fasciae latae muscles. Kinematics were
compared for peak hip adduction and knee adduction. Data were collected at 3 minutes and 30 minutes.
RESULTS: Injured runners demonstrated increased knee adduction compared to control runners at 30 minutes (P = .002; control, –1.48°; injured,
3.74°). The tensor fasciae latae (TFL) muscle activation in injured runners was increased compared to control runners at 3 minutes (P = .017).
CONCLUSIONS: The results of this study suggest that injured runners had
increased knee adduction at 30 minutes and increased TFL muscle acti-
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vation at 3 minutes.
CLINICAL RELEVANCE: These findings were consistent with neuromuscular
OPO11
factors of the hip muscles and increased knee adduction in runners with
iliotibial band syndrome. This study confirms the need to further investigate hip muscle control as an influence on kinematic deviations of the
knee in patients with iliotibial band syndrome. In addition, the increased
deviation in knee adduction needs further investigation as a factor that affects kinematic changes during a prolonged run.
THE RELATIONSHIP BETWEEN THORACIC AND LUMBAR SPINE
REPOSITIONING ERROR IN ASYMPTOMATIC YOUNG ADULTS
Brian Baranyi, Bradley Myers, Aaron Keil, Deborah Davey
University of Illinois at Chicago, Chicago, Illinois
PURPOSE/HYPOTHESIS: Recent literature has highlighted the potential for
motor control deficits as underlying factors in the development of acute
low back pain (LBP) or as factors that contribute to ongoing, chronic LBP.
Spinal motor control may be represented through the measurement of
Repositioning Error (RPE). Altered lumbar RPE has been identified in
patients with LBP and may indicate altered central nervous system processing and reduced proprioceptive awareness. These findings are well established for the lumbar spine, however the relationship between thoracic
and lumbar spine RPE has not been reported. A recent systematic review
revealed that lumbar RPE has not been assessed beyond 10 repetitions,
leaving the effect of higher repetition tasks in asymptomatic individuals
unknown. The purpose of this study is to determine the relationship between thoracic and lumbar RPE during a high repetition trunk flexion
task in asymptomatic young adults.
NUMBER OF SUBJECTS: Twenty-eight asymptomatic individuals between the
ages of 23 and 29 participated in this study (8 male, 20 female; mean ±
SD age, 24.91 ± 2.044 years). Participants had no history of spinal injury
or thoracic/lumbar pain requiring medical care in the last 2 years.
MATERIALS/METHODS: Anatomical markers were placed at the T4 and L2
spinous processes. Participants were placed in a seated position and asked
to perform 50 repetitions of trunk flexion, at a self-selected speed, and
were instructed to return to the starting position after each repetition.
RPE was measured at T4 and L2 as the absolute distance from the starting position with the use of Dartfish video analysis software. Cumulative
Repositioning Error (CRPE) was calculated in increments of 10 repetitions for both T4 and L2 spinal levels, in order to identify potential changes in relationship as the repetitions increased.
RESULTS: Thoracic and lumbar CRPE were strongly and significantly
(P<.05) correlated throughout all 50 repetitions and the strength of correlation was greatest in the largest repetition range. Repetition range and
the associated Pearson’s r are supplied below: 1-10, 0.687; 1-20, 0.680;
1-30, 0.710; 1-40, 0.745; 1-50, 0.773.
CONCLUSIONS: As the repetitions increased past 20, so did the strength of
correlation between thoracic and lumbar spine CRPE. The positive nature of the correlation also indicates that as absolute thoracic spine RPE
increases, so does lumbar spine RPE.
CLINICAL RELEVANCE: The majority of research and intervention related to
spinal RPE has focused on the lumbar spine. Given the greater ability for
thoracic spine motion and the strong relationship between thoracic and
lumbar spine RPE, especially as repetitions increase, perhaps more attention to motor control of the entire spine is needed. Motor control deficits at the thoracic spine may contribute to deficits at the lumbar spine.
Future research is needed to determine whether motor control intervention at the thoracic spine can influence RPE of the lumbar spine, and
whether or not these factors may contribute to the development and persistence of low back pain.
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OPO10
A SURVEY OF PHYSICAL THERAPISTS’ UTILIZATION OF THE PILATES
METHOD IN REHABILITATION
Debra Bangs, Candice Carajohn, Chelsea Aaron
The Department of Physical Therapy, Movement and
Rehabilitation Sciences, Northeastern University, Wrentham,
Massachusetts
PURPOSE/HYPOTHESIS: Physical therapists are incorporating Pilates equipment, and mat exercises into treatments. Patients often seek guidance to
determine readiness for returning to Pilates following injury. This study’s
purpose was to: determine PTs utilization of Pilates in practice, their
opinions regarding Pilates education and determine if associations exist
between utilization of Pilates, years of experience, region of practice and
personal utilization.
NUMBER OF SUBJECTS: One hundred thirty-two.
MATERIALS/METHODS: The survey was sent electronically to 2166 members
of the American Academy of Orthopedic Manual Physical Therapists and
to 17 000 members of the Orthopaedic Section of the APTA through the
Osteoblast newsletter. 150 PTs responded to the survey, 18 were incomplete and 132 responses were analyzed. Descriptive and chi-square statistics were used to describe the data and determine if correlations existed
between variables.
RESULTS: Thirty-six percent of respondents utilize the Pilates Method in
practice, 81% incorporate mat exercises, 50% equipment, 50% refer patients to classes at other facilities and 27% refer to Pilates instructors
at their facilities. 48% of respondents practice Pilates themselves while
68% recommend Pilates to their patients. Of this group, 67% recommend small group classes and 53% recommend private lessons. 73% of
respondents aren’t trained in Pilates and 53% of them were interested in
learning more about Pilates. 48% preferred a weekend course while 42%
would prefer an online course. There was an association between PTs who
practiced Pilates themselves and PTs who utilized Pilates in their practice
with a P<.001. No other significant associations were found. 94% of respondents felt that more research is needed regarding the benefits of the
Pilates Method.
CONCLUSIONS: PTs should have some training in Pilates to be able to appropriately and safely refer their patients to Pilates classes. There is a missed
opportunity by practice owners who would benefit from offering Pilates
classes onsite. PTs who practice Pilates themselves were more likely to
utilize Pilates with their patients. This may indicate that PTs who practice Pilates have a better understanding of the benefits and principles of
Pilates making them more likely to utilize Pilates with their patients. If
there was further research and education regarding Pilates, utilization
rates may increase. Overwhelmingly respondents see the value in further
research into the benefits of Pilates.
CLINICAL RELEVANCE: It’s important to understand the educational needs
of the PT population with respect to Pilates. PTs are referring patients to
Pilates and patients come to PT with a desire to return to Pilates classes.
It is incumbent on PTs to have an understanding of what Pilates is and
how to safely perform Pilates exercises following injury and recovery. This
survey has shown that not only does the PT community wish to see more
evidence regarding Pilates but there is a need for further education regarding the Pilates method.
OPO12
THE RECOGNITION AND TREATMENT OF AMPLIFIED PAIN SYNDROME
FOLLOWING SALTER-HARRIS FRACTURE
Brittney Barrie
Rehab at Magnolia Parke, UF Health, Gainesville, Florida
BACKGROUND AND PURPOSE: Chronic pain in children and adolescents can
be treated effectively with a multidisciplinary approach including physical therapy. Amplified Pain Syndrome can occur following an orthopaedic injury or trauma in adolescents and may contribute to adult chronic
pain syndromes. Treatment of amplified pain syndrome using a multidisciplinary biopsychosocial treatment strategy is effective, however there
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is a lack of practical, specific published treatment protocols available to
guide physical therapists who may encounter this disorder in the outpatient setting. This case report serves to describe the treatment and associated outcomes in an 8-year-old child presenting with Salter Harris
fracture who developed Amplified Pain Syndrome. Treatment strategies
included functional neuromuscular re-education, desensitization techniques, graded exposure, and psychological interventions.
CASE DESCRIPTION: An 8-year-old girl was referred for treatment in an outpatient physical therapy setting for Salter Harris fracture of the right distal fibula following cast removal. She began physical therapy to address
physical impairments related to immobilization. Potential amplified pain
symptoms were noted at initial evaluation presenting as allodynia to light
and rough touch as well as avoidance of all weight bearing on right lower extremity. Over the course of 1 month, she developed pain in the contralateral limb, bilateral wrists and hands, generalized hyperalgesia, abdominal pains, and headache and was diagnosed with Amplified Pain
Syndrome. Treatment strategies expanded to include education to the
patient and family regarding central nervous system sensitization, psychological interventions including mindfulness activities, and pain coping
strategies. The treatment team was also expanded to include Cognitive
Behavioral Therapy and Occupational Therapy based on successful
treatment outcomes in pain rehabilitation programs. The patient was
seen for 57 visits over 10 months. Outcome criteria included pain measures (FACES scale), functional self-report measures (Lower Extremity
Functional Scale [LEFS]), gait and biomechanical task analysis.
OUTCOMES: The patient improved in all quantitative and qualitative outcomes. She met all functional age-appropriate milestones and gross motor
skills without compensatory patterns including running, jumping, skipping, crawling, and stair climbing. The patient resumed all school activities with minimal modifications (compressive garments and seated on a
pillow) and returned to participating in organized swimming and soccer.
Clinically meaningful improvements were observed in pain and the LEFS.
DISCUSSION: The results of this case study describe the management of a
child referred to physical therapy with an orthopaedic injury which developed into Amplified Pain Syndrome. The use of a holistic biopsychosocial
management approach and a multidisciplinary team was associated with
clinically meaningful improvements in pain and function and resumption
of her usual school and recreational activity participation.
REFERENCES: 1. Landry BW, et al. Managing chronic pain in children
and adolescents: a clinical review. PM R. 2015:5295-5315. 2. Sherry, D.
An overview of amplified musculoskeletal pain syndromes. J Rheum.
2000;27:44-48. 3. Hoffart CM, Wallace, DP. Amplified pain syndromes
in children: treatment and new insights into disease pathogenesis. Curr
Opin Rheum. 2014;26:592-601. 4. Walker LS, et al. Functional abdominal pain in childhood and adolescence increases risk for chronic pain in
adulthood. Pain. 2010;150:568-572. 5. Jiao J et al. Physical trauma and
infection as precipitating factors in patients with fibromyalgia. Am J Phys
Med Rehabil. 2016. 6. Stanton-Hicks, M. Plasticity of complex regional pain syndrome (CRPS) in children. Pain Med. 2010;11:1216-1223. 7.
Sherry, DD, et al. The treatment of juvenile fibromyalgia with an intensive
physical and psychological program. J Peds. 2015;167:731-737.
OPO13
COMBINED EFFECTS OF WEIGHT GAIN AND REDUCED WALKING SPEED
ON TIBIOFEMORAL CONTACT FORCES: EXPERIMENTAL SIMULATION
OF CHANGES TYPICAL OF OSTEOARTHRITIS
Joaquin Barrios, Christopher Colatruglio, Matthew Cox,
David Farwick, Louis Fullenkamp, Kevin P. O’Brien,
Justin Seekins, John D. Willson
Physical Therapy, University of Dayton, Dayton, Ohio; Physical
Therapy, East Carolina University, Greenville, North Carolina
PURPOSE/HYPOTHESIS: Weight gain and reduced walking speed typically accompany knee osteoarthritis. However, the combined effect of these
changes on the knee joint loading environment is unclear. Thus, the pri-
mary purpose of this study was to experimentally simulate weight gain
and slowed walking speed to observe the effects on tibiofemoral and medial compartment contact forces during walking. It was hypothesized that
peak contact force and contact force by time (impulse) would increase.
Secondarily, the changes in joint contact forces were compared against
minimum detectable change (MDC) thresholds, testing the hypothesis
that impulse data would be more sensitive to these experimental effects
than peak forces.
NUMBER OF SUBJECTS: Thirty (16 female; mean ± SD age, 23.0 ± 1.4 years;
weight,69.1 ± 13.8 kg; height, 1.70 ± 0.09 m) healthy participants.
MATERIALS/METHODS: Three-dimensional gait analysis was performed for
2 walking conditions: a self-selected speed and an experimental condition involving a 10% reduction in walking speed and a vest loaded with
10% body weight. An inverse dynamics driven knee joint model previously validated against in vivo tibiofemoral compartment loads was used to
estimate tibiofemoral and medial compartment peak force and impulse
data, which were compared between conditions using paired t tests and
effect sizes. The difference between conditions was also assessed relative
to MDC thresholds derived from reliability testing. The proportion of participants who showed changes in peak tibiofemoral and medial compartment force exceeding the MDC was compared with the proportion who
showed impulse changes exceeding the MDC during the experimental
condition using Fisher’s exact test (all tests, α = .05).
RESULTS: Peak contact force for the tibiofemoral joint (P<.001; ES, 0.21)
and medial compartment (P<.001; ES, 0.19) showed small increases in
the experimental condition. Impulse changes were much larger for both
the tibiofemoral joint (P<.001; ES, 1.01) and the medial compartment
(P<.001; ES, 1.05). When assessed against the MDCs for peak tibiofemoral and medial compartment forces, 10% and 13% of participants showed
increases greater than the MDC, respectively. Conversely, 97% (P<.001)
and 100% (P<.001) of participants experienced increased tibiofemoral
and medial compartment impulse greater than the MDC, respectively.
CONCLUSIONS: Increased tibiofemoral and medial compartment peak force
and impulse values were observed when walking 10% slower and with
10% weight gain. Joint impulses were much more sensitive metrics of
these experimental effects than peak forces.
CLINICAL RELEVANCE: Increasing body weight and walking slower conjointly increase knee contact forces, but this effect is more evident using timedependent loading metrics than peak loads. As progression of knee OA
appears more closely associated with knee joint force impulse than peak
values during gait, clinicians may consider both body weight and walking
speed management as therapeutic targets.
OPO14
LOW BACK PAIN IS ASSOCIATED WITH INCREASED RESTING STIFFNESS OF
THE LUMBAR MUSCLES: A SHEAR-WAVE ELASTOGRAPHY IMAGING STUDY
Emily Barth, Shane Koppenhaver, Amber Davis, Laura Eberle,
Laurel Proulx, Brian A. Young, Jeffrey Hebert
US Army-Baylor University, San Antonio, Texas; Murdoch
University, Perth, Australia
PURPOSE/HYPOTHESIS: Dysfunction of lumbar musculature is commonly implicated in low back pain (LBP) [1,3]. Ultrasound shear wave elastography (SWE) uses the propagation of transverse shear waves in conjunction with B-mode ultrasound imaging to estimate the stiffness (shear
modulus) of soft tissues. This emergent technology estimates individual
muscle contraction and quantifies local areas of muscle function in people with LBP [2,4,6]. No previous studies have quantified lumbar muscle
function with SWE. Therefore, the primary purpose of this study was to
compare resting and contracted stiffness of lumbar multifidus (LM) and
paraspinal (PS) musculature in individuals with and without LBP. We hypothesized that individuals with LBP will have higher resting muscle stiffness and lower contracted muscle stiffness than asymptomatic individuals. Additionally we sought to examine the relationship between lumbar
muscle stiffness outcomes and findings from a standardized clinical ex-
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amination in individuals with LBP.
NUMBER OF SUBJECTS: One hundred twenty individuals (60 with current
mechanical LBP and 60 without current LBP) volunteered to participate
(average ± SD age, 31 ± 7 years; 51.7% male, 48.3% female; BMI, 25.4 ±
2.9 kg/m2).
MATERIALS/METHODS: All subjects underwent a standardized clinical examination followed by SWE stiffness measures of the LM and PS muscles at
rest as well as the LM during submaximal contraction [5]. Images of the
LM and PS muscles were captured at the right L4 level in asymptomatic subjects and on the painful side at the most painful level of the L3, L4,
or L5 vertebral levels in patients with LBP. Stiffness (shear modulus) was
compared between individuals with and without LBP using independent
t tests. The bivariate relationship between lumbar muscle stiffness and
various clinical examination findings were analyzed using Pearson’s r and
point biserial correlations in individuals with LBP.
RESULTS: Mean ± SD LM resting stiffness was higher in individuals with
LBP (20.4 ± 9.6 kPa) than without LBP (17.1 ± 5.9 kPa) (P = .03). Mean
± SD PS resting stiffness was higher in individuals with LBP (19.2 ± 10.1
kPa) than without LBP (13.4 ± 5.0 kPa) (P<.001). Mean ± SD LM submaximal contraction stiffness was not different between individuals with LBP
(62.3 ± 32.5 kPa) and without LBP (67.9 ± 29.4 kPa) (P = .32). Correlations
between clinical exam findings and shear modulus were not significant.
CONCLUSIONS: Subjects with LBP had greater resting but not contracted
lumbar muscle stiffness than asymptomatic individuals. These findings
support an association between LBP and with increased lumbar muscle tone.
CLINICAL RELEVANCE: Individuals with LBP have greater resting lumbar
muscle stiffness than individuals without LBP. This is consistent with a
pattern of increased lumbar muscle tone with LBP.
OPO15
PERFORMANCE AND RELIABILITY OF THE CERVICAL JOINT POSITION
ERROR TEST IN HIGH SCHOOL ATHLETES
Ryan Bean, Laura Smith, Becky J. Rodda, Bara Alsalaheen
Physical Therapy, University of Michigan Flint, Davison,
Michigan
PURPOSE/HYPOTHESIS: The cervical joint position error test (CJPET) provides an objective measure of neck reposition sense and has been shown
to document differences between healthy controls and individuals suffering from whiplash associated disorders and chronic neck pain. The majority of these studies assessed middle aged individuals and some have assessed younger adults (18-19 years old). With the number of adolescents
participating in high school sports on the rise along with the number of
sports injuries involving the head and neck, having performance data and
information on the reliability of this test in this population is needed. The
primary purpose of this study is to (1) describe the performance of the
Cervical Joint Position Test Error (CJPET) in a cross-sectional population
of adolescents, (2) examine the associations between sex, age, and body
mass on the performance of the CJPET, and (3) describe the test-retest
reliability of the CJPET in a subsample of adolescents.
NUMBER OF SUBJECTS: One hundred eighteen high school athletes (91 male,
27 female) with an average ± SD age of 15.07 ± 1.15 years.
MATERIALS/METHODS: Subjects performed the cervical joint position error
test that included 6 measurements in each direction (flexion, extension,
right rotation, and left rotation). The head mounted laser method was
used and order of direction of testing was randomized. Seventeen of these
participants performed the test at 2 different times to assess the reliability
of the cervical joint position error test. The distance in error was recorded
in cm and converted to degrees of error.
RESULTS: Average error for all directions combined was 3.59° + 1.31°.
Extension had the highest frequency of error at 33% of the participants.
Ninety-five of the 118 (80.51%) participants were classified as “abnormal”
using the accepted norm as 4.5° as the cutoff point. There was an inverse
correlation (r = –0.218, P = .018) with relation of BMI and total number
of joint positions classified as abnormal. There were no significant correlation between sexes (P = .75) and with age (r = –0.134, P = .152) ICCs
ranged from 0.70 to 0.87, indicating moderate to good reliability in all directions. The majority of MDC was between 2.2° to 4.7°, with extension
being the highest.
CONCLUSIONS: There appears there are larger errors in the healthy adolescent population as compared to healthy adults resulting in the possibility of needing a larger error accepted cut-off point for this younger population compared to the 4.5° currently used in adults. BMI has an impact
on the performance of the CJPET (those with higher BMI had a reduced
amount of errors). The CJPET appears to be a reliable assessment tool in
this population.
CLINICAL RELEVANCE: This study was the first to the author’s knowledge
to analyze the performance characteristics of adolescent population on
the CJPET. Having performance measures of the CJPET in this population could be a reference for clinicians treating an adolescent patient with
neck pain or whiplash as these injuries are occurring at an increased rate
in the high school population.
OPO16
SCREENING FOR LATERAL PROCESS OF TALUS FRACTURE
IN PHYSICAL THERAPY
Jennifer J. Bell, Samuel Cotnoir, Maggie Warren
School of Physical Therapy and Rehabilitation Sciences, University
of Montana, Missoula, Montana
BACKGROUND AND PURPOSE: Fracture of the lateral process of the talus
(LPT) is a rare injury, making up 0.86% of 1500 cases of ankle sprains or
fractures. This fracture often presents with signs and symptoms similar
to a severe ankle sprain, which leads to misdiagnosis and definitive treatment [1-3]. According to a study of 39 cases of LPT fracture, only 59%
were correctly diagnosed initially. This study shows that these fractures
are difficult to see on plain radiographs, increasing the probability of being missed upon initial examination [4]. Long term consequences of misdiagnosed LPT fractures include lateral hindfoot impingement [5], loose
bodies in the subtalar joint [6], malunion, nonunion, posttraumatic arthritis, or avascular necrosis [7,8].
CASE DESCRIPTION: A 24-year-old female student presented to PT 8 days after a fall while ice climbing. The patient landed on her left foot, which became fixed in dorsiflexion due to the nature of her ice climbing boots and
crampons. Immediately after the fall, she was unable to weight bear and
presented to urgent care the next day. Standard AP, lateral, and mortise
radiographs were taken and the PA read them as normal. The PT evaluation found moderate ankle pain, tenderness along both malleoli, anterior talofibular ligament and insertion of the Achilles. Significant edema
and bruising were observed on the medial and lateral aspects of her ankle
and anterior tibia. Passive and active motion was limited in all directions.
Special tests revealed marked laxity in the anterior and posterior talofibular and calcaneal fibular ligaments.
OUTCOMES: Due to the high-energy mechanism of injury (MOI), lack of
improvement in weight bearing, significant pain, and positive ligamentous testing, PT was ceased. She was referred to the student health center for more imaging due to the high level of suspicion of an undiagnosed
fracture or complex ligamentous injury. The patient had an MRI which
revealed a left displaced LPT fracture. Subsequently, the patient was referred to an orthopaedic surgeon for definitive ORIF of the LPT. The surgeon reported no complications. But, he did report finding a small detachment of articular cartilage from the posterior calcaneus. This should
have no long-standing effect on the patient’s prognosis.
DISCUSSION: It is essential for PTs to know the MOI and presentation of
LPT fractures as many are missed at initial evaluation and with plain
radiographs. PTs should suspect an LPT fracture in patients with injuries resulting from high impact loading in dorsiflexion. Upon exam, patients may have significant pain, inability to weight bear, tenderness distal
and anterior to the lateral malleolus, and severe edema and ecchymosis.
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Clinicians should also rule out LPT fracture in patients with nonhealing
ankle sprains due to the potential for misdiagnosis. Using the patient’s
history of the MOI and clinical findings, PTs can screen for this commonly missed fracture to minimize long term repercussions and secure definitive treatment in a timely fashion.
REFERENCES: 1. Perera A, Baker JF, Lui DF, Stephens MM. The management and outcome of lateral process fracture of the talus. Foot Ankle Surg.
2010;16:15-20. 2. Worsham JR, Elliott MR, Harris AM. Open calcaneus fractures and associated injuries. J Foot Ankle Surg. 2016;55:68-71.
3. Mukherjee SK, Pringle RM, Baxter AD. Fracture of the lateral process of the talus. A report of 13 cases. J Bone Joint Surg Br. 1974;56:263273. 4. Mills HJ, Horne G. Fractures of the lateral process of the talus.
Aust N Z J Surg. 1987;57:643-646. 5. Wang PH, Su WR, Jou IM. Lateral
hindfoot impingement after nonunion of fracture of the lateral process
of the talus. J Foot Ankle Surg. 2016;55:387-390. 6. Bali K, Prabhakar S,
Gahlot N, Dhillon MS. Neglected lateral process of talus fracture presenting as a loose body in tarsal canal. Chin J Traumatol. 2011;14:379-382. 7.
Miller S. Fractures of the lateral process of the talus: snowboarder’s fracture. Update 2008. The Proceedings of the Annual Meeting of the Podiatry
Institute: The Podiatry Institute; 2008:119-123. 8. Tucker DJ, Feder JM,
Boylan JP. Fractures of the lateral process of the talus: 2 case reports and
a comprehensive literature review. Foot Ankle Int. 1998;19:641-646.
OPO17
CHANGES IN LUMBAR MULTIFIDUS MUSCLE THICKNESS
DURING COMMON SPINE STABILIZATION EXERCISES
USING REHABILITATIVE ULTRASOUND IMAGING
Barbara Belyea, Lisa Bates, Ellen FitzPatrick, Jonah Larson,
Kyle McKeighan, Jaime Odin
Physical Therapy, Ithaca College, Ithaca, New York
PURPOSE/HYPOTHESIS: Lumbar paraspinal musculature, particularly the
lumbar multifidus muscle (LMM), plays a key role in spinal stability during dynamic activities. Selective exercises targeting the core muscles has
been shown to be effective for improving spinal stability; however, efficacy of these exercises has yet to be determined. Rehabilitative ultrasound
imaging (RUSI) has been utilized to assess changes in muscle thickness
reflective of muscle activation. The purpose of this study was to determine which commonly prescribed core exercises demonstrated the greatest change in LMM thickness using RUSI.
NUMBER OF SUBJECTS: Twenty healthy subjects (10 female, 10 male; mean
age, 23.75 years; height, 67.625 inches; weight, 154.6 lb; body mass index, 23.46 kg/m2).
MATERIALS/METHODS: Prior to data collection, intra and intertester reliability of the 6 testers using RUSI was determined by measuring LMM
thickness on 6 different subjects. Data collection included using RUSI to
measure thickness changes of the right LMM at the level of the fourth
lumbar vertebrae while 4 commonly prescribed trunk stabilization exercises were performed. The exercises included: prone superman, bird dog,
seated row, and Paloff Press. Thickness changes were determined by subtracting the LMM thickness at rest from the thickness at peak contraction, and the change for 3 trials of each exercise was averaged for analysis.
Cronbach’s alpha and Intraclass correlation coefficients (ICC) were used
to determine intratester and intertester reliability of RUSI measurements
of the LMM. A 1-way analysis of variance (ANOVA) was used to determine significant changes in muscle thickness for each exercise.
RESULTS: Four out of the 5 testers demonstrated strong intratester reliability with values that ranged from 0.81 to 0.99, with 1 tester falling outside that range (0.27). Intertester reliability was moderately strong with
a value of 0.753. All 4 exercises showed increases in LMM thickness, but
significant increases were seen in the superman (P<.01) and bird dog exercises (P = .01).
CONCLUSIONS: Increases in LMM thickness varied across 4 commonly prescribed core stabilization exercises among healthy young adults. The results suggest that prone and quadruped positions may isolate LMM more
effectively than exercises in seated and standing positions.
CLINICAL RELEVANCE: Knowledge about muscle activation in lumbar stabilizers during certain exercises may be helpful when prescribing exercises
for patients with low back pain related to trunk instability.
OPO18
PSYCHOLOGICALLY INFORMED PHYSICAL THERAPY:
DESCRIBING TREATMENT MONITORING FOR HIGH-RISK LOW BACK PAIN
Jason Beneciuk, Steven George
Physical Therapy, University of Florida, Gainesville, Florida
PURPOSE/HYPOTHESIS: Psychologically informed physical therapy (PIPT) for
low back pain (LBP) involves targeting psychological factors in conjunction with impairment based physical therapy. Treatment monitoring is an
important part of PIPT and involves identifying changes in key process
measures to better inform clinical decision making. Therefore, the purpose
of this case series was to describe treatment monitoring during a 4-week
period for patients with LBP and high risk for prolonged disability.
NUMBER OF SUBJECTS: Patients (n = 23) identified as high risk using the
STarT Back Tool and enrolled in a preliminary pragmatic implementation study.
MATERIALS/METHODS: Physical therapists (n = 5) were educated on using psychological measures (Fear-Avoidance Beliefs Questionnaire
[FABQ-PA, FABQ-W], Tampa Scale of Kinesiophobia [TSK-11], Pain
Catastrophizing Scale [PCS] and Fear of Daily Activities Questionnaire
[FDAQ]) for treatment monitoring. Outcome measures (numeric pain
rating scale [NPRS], Oswestry Disability Index [ODI] and lumbar flexion range-of-motion [ROM]) were administered at intake and 4 weeks
later. Spearman’s rho correlation coefficients were calculated to identify univariate relationships among psychological and clinical measure
change scores. One-way analysis of covariance (controlling for baseline
outcome measure) was used to identify how change in psychological measure and 4-week clinical outcomes were associated.
RESULTS: Moderate to strong positive associations among all psychological measure change scores were observed (r = 0.51-0.79, P<.01). Changes
in FABQ-PA, PCS and TSK-11 scores were correlated with changes in
ODI scores (r = 0.48-0.78, P<.05) while only FABQ-PA change scores
were correlated with changes in lumbar flexion ROM (r = –0.68, P<.01).
Associations between psychological measure and NPRS change scores
were weak (r = 0.01-0.25, P>.05). After controlling for intake ODI scores,
change in FABQ-PA (P<.01; partial η2 = 0.42) and PCS (P<.05, partial
η2 = 0.28) scores contributed to 4-week ODI scores. Similar associations
were not identified for 4-week NPRS or lumbar flexion ROM (P>.05).
CONCLUSIONS: Several psychological measures have the potential to aid
clinical decision making for self-reported disability, while only FABQ-PA
was correlated to physical impairment. Treatment monitoring for pain intensity was not supported in this sample.
CLINICAL RELEVANCE: Treatment monitoring during PIPT has potential to
enhance clinical decision making by identifying certain aspects of treatment that may require additional attention to obtain optimal clinical
outcomes for patients at higher risk for poor LBP outcomes. Using psychological measures seems to have stronger implications for disability
outcomes, with further research required for identifying measures that
exhibit stronger covariation with pain intensity outcomes.
OPO19
DISCRIMINATIVE AND RELIABILITY ASSESSMENT OF PARASPINAL MUSCLE
CROSS-SECTIONAL AREA MEASUREMENTS FROM MAGNETIC RESONANCE
IMAGES OF PERSONS WITH LOW BACK PAIN IN NOVICE EXAMINERS:
A NEW CLINICAL MEASURE
George J. Beneck, Kristen Andrion, Jared Leeper
Physical Therapy, California State University, Long Beach, Long
Beach, California
PURPOSE/HYPOTHESIS: Lumbar paraspinal muscle (PM) atrophy is common
in persons with low back pain (LBP). Clinical methods to quantify PM
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size are limited. Patients with chronic low back pain and patients awaiting microdiscectomy frequently receive magnetic resonance (MR) images
which can be examined by the treating clinician. The purpose of this study
was to determine the reliability and discriminative validity of PM (erector
spinae (ES), psoas (PS) and quadratus lumborum (QL)) cross-sectional
area (CSA) measurements performed by novice examiners.
NUMBER OF SUBJECTS: MR images from 3 groups: (1) chronic LBP, mild disability, n = 14; (2) matched group without LBP, n = 14; (3) 14 unmatched
patients awaiting microdiscectomy.
MATERIALS/METHODS: Two groups of 4 examiners (2 physical therapy students and 2 orthopaedic physical therapists), performed the measurements. Each received 1 hour of instruction and a manual to perform
measurements using ImageJ software (Free NIH download) prior to performing the measurements. Each examiner, blinded to group, performed
PM and L5 vertebral body (VB) CSA measurements from each image series. CSA values were normalized to vertebral body (VB) CSA to generate
a PM/VB ratio to normalize for body size differences. Intraclass correlation coefficients (ICCs) were calculated to estimate reliability. Area under
the curve (AUC) of the receiver operator characteristic curve was calculated to determine if the measurements could discriminate between persons with and without LBP.
RESULTS: Interexaminer reliability consisted of 18 comparisons across the
3 patient groups. For ES, agreement was moderate to substantial in all
comparisons (ICC range, 0.70-0.95) of muscle CSA. Agreement was substantial in 17 of 18 comparisons (ICC range, 0.79-0.97) of ES/VB ratio.
For PS, agreement was moderate to substantial in 17 of 18 comparisons
(ICC range, 0.70-0.95) of muscle CSA. Agreement was moderate to substantial in 15 of 18 comparisons (ICC range, 0.53-0.99) of PS/VB ratio.
For QL, agreement was moderate to substantial in 15 of 18 comparisons
(ICC range, 0.76-0.97) of muscle CSA. Agreement was moderate to substantial in 16 of 18 comparisons (ICC range, 0.51-0.96) of QL/VB ratio.
Three of 4 examiners showed significant discriminative validity between
healthy and premicrodiscectomy groups with either QL CSA or QL/VB
ratio (AUC range, 0.73-0.80; P<.05). No discriminative validity was demonstrated by any examiner using ES or PM.
CONCLUSIONS: PM measurements from MR images have adequate interexaminer reliability in novice examiners. MR image measurements of QL
may be a valid discriminative tool for novice examiners.
CLINICAL RELEVANCE: Physical therapists should consider using this method
of muscle measurement to quantify muscle loss in persons with low back
pain. Such findings could enhance decisions regarding exercise prescription for the lumbar paraspinal muscles.
OPO20
THE EFFECTS OF LUMBAR ROTATIONAL MANIPULATION ON GLUTEAL
MUSCLE ACTIVATION DURING FUNCTIONAL ACTIVITIES IN PERSONS
WITH CHRONIC LOW BACK PAIN
George J. Beneck, Cassandra Hippensteel, Jessie Byers
Physical Therapy, California State University, Long Beach,
Long Beach, California
PURPOSE/HYPOTHESIS: Evidence supports the effectiveness of spinal manipulative therapy (SMT) for persons with chronic low back pain. However,
little is known regarding the underlying mechanisms for its effectiveness.
Improved muscle activation following mobilization or manipulation has
been reported in the multifidus, abdominal muscles and quadriceps.
Recent evidence supports the premise that impaired gluteal muscle performance may play an important role in low back pain. However, the effects of lumbar manipulation on gluteal muscle activation is lacking. The
purpose of this experiment was to generate pilot data for a future study
which would analyze the immediate effects of lumbar spinal manipulation on gluteal muscle activation during functional activities. It was hypothesized that gluteal muscle activity would increase post0SMT in subjects with CLBP during the performance of functional tasks.
NUMBER OF SUBJECTS: Three persons (2 men, 1 woman; ages 18, 40, and 18
years) with chronic non radicular LBP were recruited. Subjects were excluded if they had spinal surgery, osteoporosis or a positive straight-legraise. Pain duration was 10, 4, and 0.5 years and Oswestry Disability score
were 20%, 26%, and 26% disability.
MATERIALS/METHODS: Prior to instrumentation, subjects practiced the 2
functional tasks: (1) step-up, (2) forward bending. The pace of each task
was set using a metronome for 5 repetitions. The tasks were performed
prior to and immediately following side-lying rotational lumbar thrust
manipulation. To record gluteal activity and avoid crosstalk, intramuscular electrodes were inserted into gluteus medius and maximus on the
side of greatest low back pain. EMG signals were sampled at 2000 Hz
and high-pass filtered at 10 Hz. The signal was smoothed with a rootmean-square using a 75-millisecond moving window. Onset and offset
of the EMG signal for each repetition was visually determined with high
reliability (ICC3,5 = 0.99 for each muscle). The average amplitude for the
5 repetitions was calculated for each task before and after the manipulation. Percent change [(mean RMS (post Rx) – mean RMS (pre Rx)/mean
RMS (pre Rx)] was the dependent variable. Effect sizes were calculated.
RESULTS: During the step-up, the change in EMG amplitude for gluteus
medius in each subject was –50.7%, –0.7%, and –21%, and for the gluteus
maximus –29.8%, –74.1%, and 1.6%, respectively. During forward bending, the change in EMG amplitude for gluteus maximus in each subject
was 13.9%, 30.0%, and 5.7%, respectively. Effect size for gluteus medius
during step-up: –0.96; gluteus maximus: –0.90; forward bending, gluteus maximus: –0.71.
CONCLUSIONS: This preliminary data suggests that SMT reduces gluteal
muscle activation immediately following the manipulation. Further work
in this area is warranted.
CLINICAL RELEVANCE: These findings do not support the hypothesis that
SMT may be effective due to its effect on gluteal muscle activation.
OPO21
WHAT BIOPSYCHOSOCIAL FACTORS ARE DRIVING THE CLINICAL COURSE
OF WHIPLASH: A CASE SERIES
Giovanni Berardi, James M. Elliott, David M. Walton
Department of Physical Therapy, Presence St Joseph Medical
Center, Joliet, Illinois; Department of Physical Therapy and
Human Movement Sciences, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois; School of Physical
Therapy, Western University, London, Ontario, Canada
BACKGROUND AND PURPOSE: Approximately 4 million individuals in the
United States seek acute medical care for injuries following a motor vehicle collision (MVC) with indirect and direct costs ranging $30 to $100
billion per annum [3,4,11]. The majority of recovery is expected to occur
within the first 3 months for nearly 50% of those injured. Recovery rates
slow considerably after 3 months and nearly 25% of this group will have
moderate to severe symptoms impacting their day-to-day life [1,2,5,6,7,8].
A number of biological and psychological factors have shown to influence
recovery rates for whiplash-associated disorders (WAD) [2,13,14,15,16],
but multidisciplinary management of such factors has made little advance
of improving recovery rates for those approximately 25% with poor recovery [9,10]. Despite the challenges in managing whiplash, the landscape of
prognostic-based studies is changing our understanding of recovery trajectories. Accordingly, a recently derived and validated clinical prediction
rule (CPR) could assist the clinician by identifying factors contributing to
each patient’s pain experience and thus potential for recovery [12]. The
purpose of this case series is to (1) describe the application of the whiplash
recovery CPR and (2) introduce a novel visual presentation of a triangulation method of pain assessment on a patient-by-patient basis.
CASE DESCRIPTION: Twenty-three patients diagnosed with acute whiplash
injury were examined and issued outcome measures at 3 time points: initial evaluation, fourth visit, and discharge. Recorded measures included
cervical AROM, P4 Instrument, Neck Disability Index (NDI), Impact of
Event Scale-Revised (IES-R), Pain Catastrophizing Scale (PCS), and Self-
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Administered Leeds Assessment of Neuropathic Symptoms and Signs
(S-LANSS).
OUTCOMES: Marked improvements were observed for total cervical AROM,
P4 Instrument, NDI, IES-R, PCS, and S-LANSS at time of discharge.
Group and individual patient data is presented with use of radar plots
surveying pain from a biopsychosocial model.
DISCUSSION: This case series provides preliminary data to support further
formal investigation utilizing a biopsychosocial model for the assessment
of pain in not only WAD, but other musculoskeletal disorders. The results
provide a visual presentation of a triangulation method capturing the etiological factors of the heterogeneous WAD condition, providing the clinician with a detailed assessment of pain and disability to assist in determining prognosis, implementing a plan of care, and monitoring recovery.
Further research will survey other domains of pain processing; physiological, psychological, and social factors not assessed in this preliminary
proof-of-concept study. Application of this assessment method in a busy
clinical environment is dependent upon the ability to capture all known
prognostic domains of a multifaceted condition. Such practice may allow
the clinician to deliver individualized care that reduces pain and improves
functional outcome on a patient-by-patient basis.
REFERENCES: 1. Carroll LJ. Beliefs and expectations for recovery,
coping, and depression in whiplash-associated disorders. Spine.
2011;36:S250-S256. 2. Carroll LJ, Holm LW, Hogg-Johnson S, et al.
Course and prognostic factors for neck pain in whiplash-associated disorders (WAD): results of the Bone and Joint Decade 2000-2010 Task Force
on Neck Pain and Its Associated Disorders. Spine. 2008;33:S83-S92. 3.
CDC. Vital Signs: Health Burden and Medical Costs of Nonfatal Injuries
to Motor Vehicle Occupants—United States, 2012. Available at http://
www.cdc.gov/VitalSigns/crash-injuries. Accessed May 23, 2016. 4. CDC.
WISQARS (Web-based Injury Statistics Query and Reporting System).
Atlanta, GA: US Department of Health and Human Services; 2010.
Available at http://www.cdc.gov/injury/wisqars. Accessed May 23, 2016.
5. Elliott JM, Kerry R, Flynn T, Parrish TB. Content not quantity is a better measure of muscle degeneration in whiplash. Man Ther. 2013;18:578582. 6. Elliott JM, Noteboom JT, Flynn TW, Sterling M. Characterization
of acute and chronic whiplash-associated disorders. J Orthop Sports Phys
Ther. 2009;39:312-323. 7. Elliott J, Pedler A, Kenardy J, Galloway G, Jull
G, Sterling M. The temporal development of fatty infiltrates in the neck
muscles following whiplash injury: an association with pain and posttraumatic stress. PLoS One. 2011;6:e21194. 8. Elliott J, Sterling M, Noteboom
JT, Treleaven J, Galloway G, Jull G. The clinical presentation of chronic
whiplash and the relationship to findings of MRI fatty infiltrates in the
cervical extensor musculature: a preliminary investigation. Eur Spine J.
2009:18:1371-1378. 9. Jull G, Kenardy J, Hendrikz J, Cohen M, Sterling
M. Management of acute whiplash: a randomized controlled trial of
multidisciplinary stratified treatments. Pain. 2013;154:1798-1806. 10.
Lamb S, Gates S, Williams M, et al. Emergency department treatments
and physiotherapy for acute whiplash: a pragmatic, 2-step, randomized
controlled trial. Lancet Neurology. 2013;381:546-556. 11. Naumann RB,
Dellinger AM, Zaloshnja E, Lawrence BA, Miller TR. Incidence and total
lifetime costs of motor vehicle-related fatal and nonfatal injury by road
user type, United States, 2005. Traf Inj Prev. 2010:11(4):353-360. 12.
Ritchie C, Hendrikz J, Jull G, Elliott J, Sterling M. External validation of a
clinical prediction rule to predict full recovery and ongoing moderate/severe disability following acute whiplash injury. J Orthop Sports Phys Ther.
2015;45:242-250. 13. Sterling M, Jull G, Kenardy J. Physical and psychological factors maintain long-term predictive capacity postwhiplash
injury. Pain. 2006;122:102-108. 14. Sterling M, Kenardy J. Physical and
psychological aspects of whiplash: important considerations for primary care assessment. Man Ther. 2008:13:93-102. 15. Sterling M, McLean
SA, Sullivan MJL, Elliott JM, Buitenhuis J, Kamper SJ. Potential processes involved in the initiation and maintenance of whiplash-associated
disorder. Spine. 2011;36:S322-S329. 16. Walton DM, Carroll LJ, Kasch
H, Sterling M, Verhagen AP, MacDermid JC, Gross A, Santaguida PL,
Carlesso L, ICON. An overview of systematic reviews on prognostic factors in neck pain: results from the International Collaboration on Neck
Pain (ICON) Project. Open Orthop J. 2013;7:494-505.
OPO22
THE EFFECT OF DRY NEEDLING ON PAIN REDUCTION IN SUBJECTS
WITH MYOFASCIAL TRIGGER POINTS IN THE UPPER TRAPEZIUS:
A SYSTEMATIC REVIEW
Anthony Bertrand, Kelsey Mastin, Bennett Rader,
Matthew Standage, Tom Sneed
Southwest Baptist University, Bolivar, Missouri
PURPOSE/HYPOTHESIS: Due to sedentary lifestyles in today’s society, myofascial pain of the neck and shoulder region are commonly seen by physical
therapists. This pain can be due to prolonged muscle activity which creates muscle imbalance resulting in trigger point formation. Interventions
for myofascial trigger points have been developing in recent years. Today,
dry needling has become much more common to the point of potentially becoming part of foundational sciences in physical therapy. Since dry
needling has become more common, physical therapists need to know:
how effective dry needling is on pain reduction in patients with myofascial trigger points in the upper trapezius?
NUMBER OF SUBJECTS: Two hundred thirty-six.
MATERIALS/METHODS: Databases searched for relevant studies were
CINAHL complete, MEDLINE, MEDLINE with Full Text, SPORTDiscus,
Science Reference Center, Cochrane Central Register of Controlled Trials,
and OVID. The searches used the key words “dry needling” and “upper
trapezius.” The initial search resulted in 103 studies with a reduction to
53 studies after duplicates were removed. All 53 studies were screened by
title and abstract resulting in 41 records being excluded due to additional treatments used in conjunction with dry needling or nonrelevant studies associated with the topic. Full text analysis of the 12 remaining studies led to 6 more studies excluded. The 6 included studies were assessed
for level of research and strength of quality using an assessment tool by
the American Academy for Cerebral Palsy and Developmental Medicine.
RESULTS: Of the 6 studies analyzed, 4 were categorized as Level II randomized controlled trials (RCT) while the remaining 2 were Level IV case series. Two RCTs scored strong quality of 7/7 while the other 2 scored a
moderate quality 4/7. The 2 case series scored a strong 6/7 and moderate 5/7. The quality of research was moderate to strong overall. The study
results reveal dry needling decreases pain via Visual Analog Scale and
Numeric Pain Rating Scale. Additionally, dry needling decreases subject
perceived level of disability via Pressure Pain Threshold and Disabilities
of the Arm, Shoulder, and Hand. The study results also reveal overall improvement in mood and quality of life via Short Form Health Survey-36.
CONCLUSIONS: It is clearly evident dry needling is beneficial at reducing
pain in the upper trapezius muscle. Each study used some type of patient
reported pain rating scale. The results of each study showed that pain ratings decreased, proving effectiveness of dry needling treatment for reducing myofascial pain.
CLINICAL RELEVANCE: Dry needling is an effective intervention for upper trapezius myofascial pain but has additional benefits as well. The intervention is less costly than other physical therapy treatments and is much less
time consuming, taking only seconds to administer. Dry needling also has
the potential to reduce the number of visits for a pain reduction benefit
compared to other current interventions.
OPO23
THE EFFECT OF DRY CUPPING AND EXERCISE ON LOW BACK PAIN
AND RANGE OF MOTION: A CASE STUDY
Steven B. Boswell, Alex Siyufy, Brent Harper, Adrian Aron
Doctor of Physical Therapy, Radford University, Roanoke, Virginia
BACKGROUND AND PURPOSE: Dry cupping (DC) is a noninvasive modality
that is gaining popularity in the areas of massage and physical rehabilitation despite the scarce amount of research available. The most common
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indication for DC is musculoskeletal pain. Past studies have found that
DC can decrease musculoskeletal pain in the neck and low back. Fewer
studies have shown DC can decrease pain and increase range of motion
(ROM). The purpose of the present case report is to determine the effects
of DC and simultaneous exercise on low back pain and range of motion.
CASE DESCRIPTION: The subject was a 24-year-old female that had been experiencing chronic recurring low back pain for greater than 2 months.
The subject had limitations in multisegmental flexion and extension and
experienced increases in pain with active ROM of the lumbar spine.
OUTCOMES: For this case 4 cups were applied to the subject’s low back
while prone and remained in place for 10 minutes. The cups were then
removed and 4 cups were applied to the anterior thigh on each leg. Next,
the subject performed knee flexion and extension in the seated position
on each leg for 2 sets of 10. The cups were removed and another 4 cups
were applied to the posterior thigh. The subject then performed 2 sets of
10 active straight leg raises (SLRs). The subject repeated the intervention
every 2 days for a total of 3 treatments. A fourth follow-up session was
scheduled a week later to reassess outcome measures. The following measures were assessed prior to the first treatment and in the fourth followup session: Selective Functional Movement Assessment (SFMA) categorization for multisegmental flexion and extension, SLR passive ROM, Pain
Pressure Threshold (PPT) for areas of the low back and lower extremity,
and the Oswestry Disability Index (ODI). The numeric pain rating scale
(NPRS) was also taken pre and post intervention for each session as well
as the global rating of change (GROC) for the low back. In addition, the
subjects worse NPRS rating for the low back over the past 7 days was taken. Notable changes include a 15° increase in left SLR PROM, a decrease
in ODI score from 20% to 12%, a GROC increase of 3, notable increases in all PPT locations, and decreased NPRS scores. The subjects NPRS
scores decreased after each treatment session and the NPRS at worst over
the past 7 days also decreased from a 5/10 to a 3/10. The subject also reported 0/10 NPRS scores after treatment session 2 and 3 as well as in the
fourth follow-up session. There were no changes in SFMA categories for
multisegmental flexion or extension.
DISCUSSION: In this case report, we examined the effects of DC in addition
to exercise on low back pain and ROM. Overall, there were improvements
any many of the outcome measures including pain, ROM, and PPT. To
our knowledge, there are no studies examining the effects of DC with simultaneous exercise for low back pain. Future studies are needed to test
the protocol against a control on a large sample size.
REFERENCES: 1. Emerich M, Braeunig M, Clement H, Lädtke R, and
Huber R Mode of action of cupping—local metabolism and pain thresholds in neck pain patients and healthy subjects. Complement Ther Med.
2014;22,148-158. 2. Kim J, Lee M, Lee D, Boddy K, and Ernst E. Cupping
for treating pain: a systematic review. Evid Based Complement Alternat
Med. 2011:1-7. 3. Lauche R, Cramer H, Choi K, Rampp T, Saha F, Dobos
G, Musial F. The influence of a series of 5 dry cupping treatments on pain
and mechanical thresholds in patients with chronic nonspecific neck
pain - a randomised controlled pilot study. BMC Complement Alternat
Med. 2011;11:63. 4. Markowski, A., Sanford, S., Pikowski, J., Fauvell, D.,
Cimino, D., and Caplan, S. A pilot study analyzing the effects of Chinese
cupping as an adjunct treatment for patients with subacute low back pain
on relieving pain, improving range of motion, and improving function. J
Alternat Complement Med (New York, NY). 2014;20:113-117. 5. Cao H,
Li X, Yan X, Wang NS, Bensoussan A, and Liu J. Cupping therapy for
acute and chronic pain management: a systematic review of randomized
clinical trials. J Trad Chin Med Sci. 2014;1:49-61. 6. Lauche R, Materdey
S, Cramer H, Haller H, Stange R, Dobos G, Rampp T. Effectiveness of
home-based cupping massage compared to progressive muscle relaxation
in patients with chronic neck pain—a randomized controlled trial. PLoS
One. 2013;8:1-9. 7. Rozenfeld E, Kalichman L. New is the well-forgotten
old: The use of dry cupping in musculoskeletal medicine. J Bodyw Mov
Ther. 2016;20:173-178. 8. Tham L, Lee H, Lu C. Cupping: from a biomechanical perspective. J Biomech. 2006;39:2183-2193.
OPO24
STATIC AND DYNAMIC BALANCE DIFFERS BETWEEN INDIVIDUALS WHO
ARE MIDDLE-AGED WITH AND WITHOUT CHRONIC LOW BACK PAIN
Lucinda Bouillon, Eric Ondrus, Nathan Bylicki,
Anthony Boyle
Rehabilitation Sciences, The University of Toledo, Toledo, Ohio
PURPOSE/HYPOTHESIS: Chronic low back pain (CLBP) has been found to
reduce postural control and impair motor patterns. Balance deficits have
also been associated with aging, as early as middle age. It is unclear if
static or dynamic balance is affected by CLBP among individuals who are
middle-aged. The purpose of this study was to assess static balance using single-limb stance (SLS) and dynamic balance using Star Excursion
Balance Test (SEBT) among individuals who are middle-aged with and
without CLBP. Two hypotheses were tested: (1) static and dynamic balance would be lower among individuals with CLBP compared to individuals without CLBP, and (2) lower balance scores would be found on
both dominant (D) and nondominant (ND) limbs among individuals with
CLBP compared to people without CLBP.
NUMBER OF SUBJECTS: Sixteen individuals with CLBP (age, 52.1 years) and
20 without CLBP served as controls (age, 48.9 years).
MATERIALS/METHODS: Subjects were assigned a random order of tests (SLS
versus SEBT) and limb (D versus ND). Limb dominance was identified
as the preferred kicking limb. The SLS test was recorded in seconds for D
and ND limbs. The SEBT used a composite score (sum of maximal anterior, posterolateral, and posteromedial directions divided by 3 times the
leg length (LL) and multiplied by 100) for D and ND limbs, and recorded as percent LL.
RESULTS: The control group stood longer (53 seconds) compared to CLBP
group (29 seconds) during SLS on only the ND limb (P = .001). The control group obtained 88% LL compared to CLBP group (79% LL) during
SEBT on only the D limb (P = .02).
CONCLUSIONS: The hypotheses were partially accepted as the CLBP group
had lower static and dynamic balance values compared to those without
CLBP; however, the score differences were dependent upon which limb
was tested.
CLINICAL RELEVANCE: Individuals with CLBP perform static and balance tests
with different motor-control strategies between limbs resulting in lower
scores compared to the pain-free group. Thus, both limbs should be tested when using SLS and SEBT outcome measures since limb dominance
appears to influence balance among middle-aged individuals with CLBP.
OPO25
PHYSICAL THERAPY COMBINED WITH PROLOTHERAPY IN A RECREATIONALLY
ACTIVE MIDDLE-AGED MAN WITH KNEE PAIN AND CHONDROMALACIA PATELLA
Kristin Bowne, Michael D. Ross
Department of Physical Therapy, Daemen College, East Amherst,
New York; Physical Therapy, Scotts Valley, California
BACKGROUND AND PURPOSE: Recent evidence suggests that prolotherapy
may be beneficial in patients with knee pain and osteoarthritis/chondromalacia patella for decreasing pain and stiffness, and increasing strength,
range of motion, and functional activity levels. However, the use of physical therapy in combination with prolotherapy for patients with knee
pain and chondromalacia patella has not been adequately described.
Therefore, the purpose of this case report is to describe the use of physical
therapy combined with prolotherapy in a recreationally active, middleaged man with knee pain and chondromalacia patella.
CASE DESCRIPTION: The patient was a 50-year-old male triathlete presenting with a chief complaint of persistent left knee stiffness and anterolateral knee pain. The patient’s symptoms began insidiously 9 months
prior after an increase in his triathlon training activities. His knee pain
progressed to the point that he could not perform any weight-bearing
exercise without significant discomfort. Previous treatments included
management by a physical therapist, as well as corticosteroid and hyal-
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uronic acid injections. Although these previous treatments provided minimal benefit, the patient sought further management by another physical
therapist. Physical examination findings at the time of the most recent
physical therapist evaluation revealed an antalgic gait characterized by
decreased stance phase on the left. Although knee range of motion was
within normal limits, decreased patellofemoral joint mobility and patellofemoral joint crepitus and tenderness to palpation along the lateral aspect
of the patella were noted. Quadriceps and hamstring muscle weakness
was also noted. Ligamentous and meniscal testing was normal. Magnetic
resonance imaging findings revealed moderate to severe chondromalacia
at the lateral patellar facet.
OUTCOMES: In addition to management by a physical therapist, the patient received a series of 3 prolotherapy injections to the knee, each 3 to
4 weeks apart. Physical therapy management consisted of manual therapy for lower quarter soft tissue and joint mobilization, targeted therapeutic exercise to address strength deficits of the quadriceps and hamstring
muscles, and a gradual return to weight-bearing exercise and functional
activity. At 4 months following the physical therapy and prolotherapy injections, the patient reported no pain during daily activities. Additionally,
he had a normal gait, no complaints of stiffness, and full strength of the
quadriceps and hamstrings muscles. Additionally, he had returned to
swimming, cycling, unlimited walking and hiking on various surfaces,
and agility drills.
DISCUSSION: In patients with knee pain and chondromalacia patella, especially those who have not responded to prior interventions, physical therapy combined with prolotherapy may serve as a treatment option.
REFERENCES: Hauser RA, Sprague IS. Outcomes of prolotherapy in chondromalacia patella patients: improvements in pain level and function.
Clin Med Insights Arthritis Musculoskelet Disord. 2014;7:13-20. Rabago
D, Kijowski R, Woods M, Patterson JJ, Mundt M, Zgierska A, Grettie J,
Lyftogt J, Fortney L. Association between disease-specific quality of life
and magnetic resonance imaging outcomes in a clinical trial of prolotherapy for knee osteoarthritis. Arch Phys Med Rehabil. 2013;94:20752082. Rabago D, Patterson JJ, Mundt M, Kijowski R, Grettie J, Segal NA,
Zgierska A. Dextrose prolotherapy for knee osteoarthritis: a randomized controlled trial. Ann Fam Med. 2013;11:229-237. Sit RW, Chung
VC, Reeves KD, Rabago D, Chan KK, Chan DC, Wu X, Ho RS, Wong SY.
Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: a systematic review and meta-analysis. Sci
Rep. 2016;6:25247. Topol GA, Podesta LA, Reeves KD, Giraldo MM,
Johnson LL, Grasso R, Jamà­n A, Clark T, Rabago D. Chondrogenic effect
of intra-articular hypertonic-dextrose (prolotherapy) in severe knee osteoarthritis. PM R. In press.
OPO26
IMPACT OF TOURING, PERFORMANCE SCHEDULE, AND DEFINITIONS
ON 1-YEAR INJURY RATES IN PROFESSIONAL MODERN DANCERS
Shaw Bronner, Lily Wood
ADAM Center, New York, New York
PURPOSE/HYPOTHESIS: This study augments recent analysis of injury rates
over 15 years in a professional modern dance company. Time-loss injuries (TLinj) averaged 0.16 injuries/1000-h exposure. Medical attention injuries without time loss or injury report, defined as complaints,
were not analyzed. Our objective was to examine the relationship between touring, performance, rehearsal schedule and injury in this company over 1 year in greater detail. This granularity may permit insight
into the physical demands upon professional dancers.
NUMBER OF SUBJECTS: Thirty-five dancers; 17 male (mean ± SD age, 29 ±
6 years).
MATERIALS/METHODS: Prospective data for this company were recorded
over 1 year, tracking new work-related musculoskeletal injuries (WMSI)
involving an injury report, TLinj, complaints, diagnoses, and exposure
hours. Injury data were excluded if sustained outside working hours, or
defined as a re-injury occurring within 8 weeks of original diagnosis. The
year was divided up into 6 segments alternating with breaks approximately 6 days. Injuries occurring during each segment were converted
to injuries/1000-h dance exposure to allow comparisons of the effects of
performance, rehearsal and travel. We conducted a quasi-Poisson analysis to determine differences between segments, sex, dance experience, covaried with combined travel-performance days (P<.05).
RESULTS: Twenty WMSI and 10 TLinj were sustained by dancers over 1
year: 0.44 WMSI and 0.22 TLinj/1000-h exposure. There were significant WMSI differences between segments but no differences due to sex or
experience. WMSI were 6 times more likely to occur in Segment 6 (IRR
= 6.033, P = .031), with 1.0 injuries/1000-h exposure. The highest rate of
TLinj and traumatic injuries also occurred in segment 6 (0.57/1000 h).
The greatest number of overuse injuries, 0.57/1000-h, were in segment
2, during an international tour. Although covariance with travel days
was not significant, there was a moderate correlation between WMSI
and travel days (r = 0.53). There was a ratio of 55%:45% trauma:overuse
WMSI and 80%:20% TLinj over the year. Complaints/1000-h were fairly evenly distributed across segments as physical therapy hours were also
consistent. The majority of WMSI and TLinj were muscle-tendon diagnoses, affecting the lower leg-Achilles and cervical areas.
CONCLUSIONS: High rates of WMSI, TLinj and traumatic injuries in segment 6 reflected a concentrated period of learning new choreography, 2
weeks NY season and 1 week travel/performance abroad without break.
We attribute the large number of overuse injuries in segment 2 to raked
stages encountered on tour. While tracking complaints permits understanding of stressors to specific body regions and utilization of resources,
WMSI and TLinj are the most important to track for injury surveillance.
CLINICAL RELEVANCE: Time zones can affect sports performance however we
have no method to quantify performance in dance other than injury. This
may mask the effects of frequent travel on dancer’s well-being. Future
studies will focus on the effect of travel on longer international tours.
OPO27
THE NATURE OF MOVEMENT SYMMETRY: IMPLICATIONS FOR FUNCTION
AND INJURY RISK
Laura E. Broudy, Danny J. McMillian, Aerie Gloweeksa,
Katie Schaner, Michelle Wrigley
Physical Therapy, University of Puget Sound, Tacoma, Washington
PURPOSE: The purpose of this report is to identify movement asymmetries
that negatively impact function or increase the risk for injury, and therefore warrant physical therapy intervention.
DESCRIPTION: Movement asymmetries can present in a variety of ways, including range of motion, force production, morphology and neuromuscular control. Asymmetries might affect functional performance or injury
risk. Quality of life might be negatively impacted for several reasons, such
as loss of playing time in sports, inability to work, and decreased social
participation. Currently there is limited evidence to identify which asymmetries negatively impact function and injury risk, and at what point
physical therapy intervention would be beneficial. To aid in identifying
such asymmetries, a review of the literature was completed. Sixty-nine
peer-reviewed studies met the inclusion criteria and were analyzed for
the effect of force production, mobility, and neuromuscular control asymmetries on functional performance and injury risk. Excluded were studies
of neurological conditions, structural spinal conditions or leg length discrepancies, and studies that included prepubescent children.
SUMMARY OF USE: There is strong evidence that supports the importance
of symmetrical force production for optimal function and low injury risk. However, there is inconsistent evidence on the degree of asymmetrical force that creates functional limitations or increased injury risk.
Asymmetrical mobility is general defined as a side-to-side difference
greater than 10%. However, some activities are inherently asymmetrical,
and having those asymmetries is advantageous to function (eg, overhead
throwing). The evidence suggests that sports such as soccer or basketball might demand more symmetry of the limbs, therefore side-to-side
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mobility differences are more likely to increase injury risk. The available
research demonstrates that asymmetries in balance and neuromuscular control are present in a variety of populations. The preponderance of
evidence suggests that a lack of neuromuscular control and side-to-side
asymmetry places the individual at an increased risk of injury, though targeted training has often proven to decrease such deficits, with subsequent
decreases in the risk of injury. Trauma and several chronic conditions (eg,
chronic ankle instability, anterior cruciate ligament rupture) are associated with movement asymmetries and degeneration of affected joints.
IMPORTANCE TO MEMBERS: A general trend in the literature revealed that
LE asymmetries have a more pronounced negative impact on function
and injury risk than UE asymmetries. Movement symmetry appears to
be most important: (1) following injury to indicate readiness for return
to sport, and (2) for tasks associated with bilateral weight bearing, since
altered movement in 1 limb might transfer excessive stress to the other.
Movement symmetry appears relatively less important when: (1) functional tasks demand asymmetrical patterns (eg, throwing, kicking sports),
and (2) loads involved remain within the tissue tolerance.
OPO28
AN INVESTIGATION OF FUNCTIONAL MOVEMENT IMPAIRMENTS IN YOGA
PRACTITIONERS BEFORE AND AFTER YOGA POSTURE TRAINING AND WITH
TARGETED EXERCISE INTERVENTION
Sean A. Buchner, Brenda Boucher, Mandi Folger
Physical Therapy, Texas State University, Austin, Texas
PURPOSE/HYPOTHESIS: Movement impairments involve faulty movement
patterns including abnormalities in posture and musculature. Spine and/
or extremity deficits cluster to form movement impairments, which may
result in mechanical breakdown over time. The study purpose was 3-fold:
(1) investigate the extent to which common movement impairments were
found in a group of asymptomatic yoga practitioners prior to participation in an 8-week yoga training course, (2) assess the extent to which
movement impairments initially identified changed upon completion of
an 8-week yoga training course, and (3) assess response to a follow-up
6-week home exercise program (HEP) that addressed individual impairments of participants. Our study focused on the following movement impairments as described by Sahrmann: cervical extension rotation, scapular depression and downward rotation, anterior glide and medial rotation
of the shoulder, lumbar extension rotation, anterior glide and medial rotation of the hip and dominant hamstrings.
NUMBER OF SUBJECTS: Twelve.
MATERIALS/METHODS: Twelve subjects (3 male, 9 female; mean ± SD age,
28 ± 8.06 years). Inclusion criteria: greater than 18 years of age, greater than 3 months of participation in yoga, registration and completion of
an 8-week yoga training course, functional AROM and PROM in all extremities, greater than 3 months without major injury, and no current
spine abnormalities. Prior to initiation of an 8-week yoga training course,
each participant was assessed using functional movements, and postural and muscular length/strength measurements. Identified deficits were
placed into appropriate categories, ranked from 0 to 3 (0, absent; 3, severe). Assessment of movement impairments, defined and measured by
Sahrmann, were performed for each participant prior to initiation and at
completion of the training course.
RESULTS: Movement impairments existed in all subjects prior to participation in an 8-week yoga training course. At completion of the training
course, re-assessment revealed significant increase in severity of movement impairments. Post 6-week individualized HEP, a significant decrease in severity of movement impairments was found in all subjects.
CONCLUSIONS: In the sample studied, movement impairments existed at a
high rate among yoga practitioners, and the severity increased after participation in a yoga training course. The severity of movement impairments decreased among all subjects after a targeted exercise program.
CLINICAL RELEVANCE: The study identified the presence of movement impairments in a regularly practicing yoga population and revealed an in-
creased severity of these impairments following an 8-week yoga training
course. This indicates that yoga may enhance faulty movement patterns
present in individuals who practice regularly. The results also support the
clinical use of specific exercises that effectively treated the movement impairments addressed in this study.
OPO29
ELECTROMYOGRAPHY ACTIVATION OF THE SHOULDER GIRDLE MUSCLES
DURING ABDUCTION AT DIFFERENT BODY-ORIENTATION POSITIONS
Traci A. Bush, Samantha Kotz, Oz Wolfensperger,
Jordan Overland, David Stapleton, Vassilios Vardaxis
Physical Therapy, Des Moines University, Des Moines, Iowa
PURPOSE/HYPOTHESIS: Muscle performance deficits are therapeutically addressed via the use of resistance training [1,2]. Core components include
frequency, intensity, time and type of exercise [2]. These components may
be modified in different ways, including shifting the direction and rotational effect of gravity by altering the plane of motion [3]. This study assessed the effect of body position on muscle activation levels during shoulder abduction. We hypothesized that the abduction muscle demands will
be affected by position in terms of peak activation level and the coincidental joint angle.
NUMBER OF SUBJECTS: Twelve.
MATERIALS/METHODS: Subjects performed shoulder abduction to 100° in
4 positions: seated, side-lying, supine, and prone. Arm movement was
monitored using 3-D motion capture. Muscle demand was assessed using peak activation, in terms of percent manual muscle testing activation
(percent MMT), and the coincidental shoulder joint angle. Surface EMG
electrodes were placed on: posterior, middle, and anterior deltoid, upper
trapezius, pectoralis major (sternal and clavicular), biceps brachii (long
and short), triceps brachii (long), and latissimus dorsi muscles. Repeated
measures ANOVA and paired t tests were used to test for significant differences between positions.
RESULTS: The average abduction ROM across subjects and positions was
95.7° (93°-97.5°). The magnitude of activation (pooled across all deltoids
and the trapezius) was modulated significantly (P = .001) by position,
with higher demands in the seated and prone (65% ± 13% MMT) versus the side-lying and supine (24% ± 8% MMT) positions. The abduction
task imposed significantly higher demands on the posterior deltoid (26%
MMT more) in prone and on anterior deltoid in seated and supine (22%
and 21% MMT more, respectively). The upper trapezius showed significant (P = .001) progressive activation across positions (13%, 27%, 66%,
and 82% MMT) for side-lying, supine, prone, and seated, respectively.
There were significant differences in the activation of both pectoralis portions between positions (9.5% MMT, P = .01) as well as between both
heads of the biceps at different positions (P = .05). The triceps and the latissimus dorsi showed higher activation (P = .01) in prone (33% and 23%
MMT, respectively). The peak activation coincidental joint angle was also
different amongst the different positions.
CONCLUSIONS: The change of plane of motion provided a significant modulation on muscle activation demands and offers the ability to focus loading on an identified muscle or group of muscles, aiming at the improvement of muscle performance and/or the reduction of muscle imbalances
[3,4]. Depending on the rehabilitation goals the change in the gravitational direction can progress the therapeutic exercise protocol from assisted to active, and thus facilitate the tissue healing process [2,4,5].
CLINICAL RELEVANCE: During examination, diagnosis and therapeutic exercise protocol development focusing on rehabilitating an injured joint or
strengthening a muscle, it is imperative to modulate the level of activation
and excursion of the muscle.
OPO30
WHAT ARE THE ODDS? A SERIES OF SPINE REFERRALS IN RESIDENCY
TRAINING: A CASE SERIES
Bethany Buzzell
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Department of Physical Therapy and Occupational Therapy, Duke
University Medical Center, Durham, North Carolina
BACKGROUND AND PURPOSE: The decision-making ability of physical therapists in evaluating whether management by a physical therapist or referral to another medical professional is appropriate is well documented.
Jette et al concluded that physical therapists were able to make correct
decisions for patients with musculoskeletal and critical medical conditions, however the results suggested that there is a “need for further emphasis on education in medical screening, identification of red flag symptoms, and differential diagnosis.” The purpose of this case series is to
highlight the identification of 3 spine cases for medical referral and the
value of careful analysis of clinical reasoning strategies during specialty training.
CASE DESCRIPTION: The prevalence of serious spine pathology from a cohort of patient’s seeking primary care treatment for low back pain has
been documented to be .9%. In the first 3 months of orthopaedic residency training, 6% of evaluations performed were diagnosed for medical
referral. The examination of 3 of these noncritical medical referrals were
analyzed due to the discrepancy in odds. All 3 patients were initially referred to a hospital-based outpatient physical therapy clinic from physicians who specialized in the spine.
OUTCOMES: Pretest probabilities were estimated from prevalence statistics.
Clinical reasoning strategies were evaluated, and the diagnostic accuracy
of subjective data and clinical findings were applied to calculate the posttest probability of pathology. Patient outcomes and appropriateness of referral for the 3 case examples are described.
DISCUSSION: Successful noncritical medical referral was demonstrated in
these 3 patients. This case series highlights the analysis of red flag screening and the use of a consistent management model in differential diagnosis of the spine. When used in isolation, red flags have little diagnostic
value. It is imperative for physical therapists to implement best-evidence
strategies to appropriately screen for these pathologies so as to avoid unnecessary investigations that are themselves harmful. Despite the odds,
utilizing the diagnostic accuracy of test findings to reflect back on these
cases demonstrated that the clinical decision-making was consistent with
what was diagnosed on imaging. This series highlights the values of reflective clinical practice with red flag screening for residency or fellowship education.
REFERENCES: 1. Ross M, Boissonnault W. Red flags: to screen or not to
screen? J Orthop Sports Phys Ther. 2010;40: 682-684. 2. Henschke N,
Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, York
J, Das A, McAuley JH. Prevalence of and screening for serious spinal pathology in patients presenting to primary care settings with acute low
back pain. Arthritis Rheum. 2009;60:3072-3080. 3. Hegedus E, Stern
B. Beyond SpPIN and SnNOUT: considerations with dichotomous tests
during assessment of diagnostic accuracy. J Man Manip Ther. 2013;17:E1E5. 4. Cook C, Brown C, Isaacs R, Roman M, Davis S, Richardson W.
Clustered clinical findings for diagnosis of cervical spine myelopathy. J
Man Manip Ther. 2010;18:175-180. 5. Guss D, Smith J, Chiodo C. Acute
Achilles tendon rupture: a critical analysis review. BJS Rev. 2015;3:e2.
OPO31
VALIDATION OF SMOOTH-PURSUIT NECK TORSION AND SEATED CERVICAL
TORSION TESTS FOR THE DIAGNOSIS OF CERVICOGENIC DIZZINESS:
A SYSTEMATIC REVIEW OF THE LITERATURE
Janet Callahan, Marianne Beninato, Makinde O. Olufisayo,
Urvashi Mehta
Physical Therapy, MGH Institute of Health Professions, Boston,
Massachusetts
PURPOSE/HYPOTHESIS: Due to the lack of a gold standard diagnostic test,
cervicogenic dizziness (CGD) remains a controversial entity. Nevertheless,
use of certain clinical tests are recommended in the literature for determining a clinical diagnosis of CGD. Two of these tests are the smooth
pursuit neck torsion test (SPNTT) and the seated cervical torsion test
(SCTT). The quality of the evidence for the diagnostic validity of these
clinical tests has not been systematically analyzed. The purpose of this
study was to evaluate the quality of literature on the diagnostic psychometric properties of these tests to diagnose CGD.
NUMBER OF SUBJECTS: Five studies were analyzed.
MATERIALS/METHODS: Search of PubMed, CINAHL and Google Scholar was
conducted. Articles were included if (1) they were clinical or laboratory validation studies on the diagnostic test properties of the SPNTT and
SCTT (2) the primary diagnostic group as patients with dizziness or vertigo of cervical origin with whiplash associated disorders, cervical dysfunction, chronic neck syndromes or cervical degenerative disorder with or
without pain and (3) published in English from June 1992 to April 2015.
Studies were excluded if they were validation studies where the primary
diagnostic group was patients with headaches, vertigo of known origin,
benign paroxysmal positional vertigo, or cerebral vascular disease. The
quality of the identified diagnostic studies was assessed using version 2
of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)
scale. Study design was rated based on the risk of bias and the applicability to a diagnostic patient group or condition across 4 major domains: (1)
patient selection, (2) index test, (3) reference standard and (4) the flow
and timing of the administration of tests. Bias and applicability concerns
were rated as “low,” “high” or “unclear” for each domain.
RESULTS: Five studies examined the validity of the SPNTT and 1 also examined the SCTT. Most studies (3/5) compared people with suspected
CGD to people with other nonCGD confirmed clinical diagnoses, thereby introducing bias that likely inflated the diagnostic accuracy of the index test. All 5 studies used instrumented laboratory measure of smooth
pursuit gain as the index test. Most (3/5) papers were rated as “high” risk
for bias on patient selection and all papers were at “high” risk for choice
of reference standard. The majority of papers had “high” concern that the
findings were not applicable to all people with CGD due to flaws or inconsistencies in patient selection, and index test or reference standard
applications.
CONCLUSIONS: A lack of robust validity of these tests, even as instrumented
in the laboratory setting, renders these tests of questionable value as diagnostic tools for CGD.
CLINICAL RELEVANCE: Results from studies of instrumented versions of
these tests should not be generalized for noninstrumented clinical use.
Noninstrumented versions of these tests have never been validated thus,
their clinical use for the diagnosis of CGD is not recommended.
OPO32
EVIDENCE BASED TREATMENT ALGORITHM FOR PATIENTS
WITH A DIAGNOSED CONCUSSION: CASE STUDY
James Camarinos, George Padin
Physical Therapy, Boston University, Allston, Massachusetts
BACKGROUND AND PURPOSE: The management of concussion injuries remains controversial, in particular decisions on when and how to intervene with targeted therapies and when rest is less beneficial than activity. Furthermore, specific examination and treatment descriptions are not
readily available in many sources. There is growing evidence in utilizing
a system-based classification in treating the somatic symptoms of concussion and postconcussion syndrome. The purpose of this paper is to
highlight the decision making process and subsequent treatment based
on system subgroups of concussion in 2 patients presenting with a similar mechanism of injury with different courses of treatment.
CASE DESCRIPTION: Two patients, both 3 weeks postconcussion were referred to an outpatient private practice. Both individuals presented with
a similar mechanism of concussion injury.
OUTCOMES: Pain was assessed using a numeric pain rating scale (NPRS),
symptom type and severity was measured by the Post Concussion
Symptom Scale (PCSS), activity limitation was assessed using the PatientSpecific Functional Scale (PSFS), vestibular dysfunction was measured
using the Vestibular/Ocular-Motor Screen (VOMS), and cardiovas-
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cular/physiologic response to exercise was assessed using the Buffalo
Concussion Treadmill Test (BCTT). A cervical spine exam was completed on both patients as well. Patient 1 presented with convergence deficits and limited cardiovascular/physiologic response to exercise, while
patient 2 presented with more gaze stability deficits, cervical hypomobility associated with headaches, visual motion sensitivity, and limited cardiovascular response to exercise. Physical therapy was tailored to the specific pathophysiological dysfunctions for each patient. After 4 visits each,
both patients displayed a decrease in NPRS values by at least 4 points,
decrease in PCSS scores by at least 50%, an improvement in PSFS by
at least 5 points, and at least a 15 bpm heart rate improvement on the
BCTT. Vestibular function for patient 1 improved as documented by a
decrease in near point convergence distance by 4 cm and 0/10 score on
the symptomatic VOMS scale for convergence. Vestibular function for patient 2 improved as documented by a 40 bpm increase in VOR X1 viewing and 0/10 score on the symptomatic VOMS scale for Visual Motion
Sensitivity. Cervical mobility for patient 2 normalized and no longer reproduced headache with active motion.
DISCUSSION: Pain, symptom response, vestibular function, and cardiovascular/physiologic response to exercise all improved in both patients after
4 visits of tailored physical therapy using a system-based classification approach. Functional evidence of this improvement was noted on the significant activity improvement made in the PSFS for each patient. The impairment and activity improvement noted across both patients indicates
that a symptom-based classification approach has the potential to produce positive treatment effects and facilitate return to play time in athletes with persistent symptoms after sustaining a concussion.
REFERENCES: 1. Ellis MJ, Leddy JJ, Willer B. Physiological, vestibulo-ocular
and cervicogenic postconcussion disorders: an evidence-based classification system with directions for treatment. Brain Inj. 2015;29:238-248. 2.
Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et al. Craniovestibular
rehabilitation in sport related concussion: a randomised control trial.
Br J Sports Med. 2014;48:1294-1298. 3. Mucha A, Collins MW, Elbin
RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med.
2014;42:2479-2486. 4. Leddy JJ, Sandhu H, Sodhi V, Baker JG, Willer
B. Rehabilitation of concussion and postconcussion syndrome. Sports
Health. 2012;4:147-154. 5. Marshall CM, Vernon H, Leddy JJ, Baldwin
BA. The role of the cervical spine in postconcussion syndrome. Phys
Sportsmed. 2015;43:274-284.
OPO33
THE CLINICAL MANAGEMENT OF SHOULDER PAIN AND THE SICK SCAPULA
IN THE FEMALE OVERHEAD ATHLETE: A CASE SERIES REPORT
Taryn E. Cappadona, Dale Yake, Zachary E. Walston,
Carlos Johnson
PT Solutions, Smyrna, Georgia
BACKGROUND AND PURPOSE: The prevalence of shoulder injuries in the overhead athlete is on the rise, with an estimated 30% of athletes incurring
documented shoulder injuries at some point in their athletic career. There
have been a multitude of studies looking at shoulder pain in athletes, with
the primary focus on baseball players. The purpose of this case series was
to evaluate effective treatment strategies geared toward the female overhead athlete in a variety of settings. Specifically, this study addresses the
female overhead athlete presenting with a resting malposition of the scapula known as SICK scapula, in addition to pain with participation in their
respective sport.
CASE DESCRIPTION: The study looked at 3 young female athletes, participating in track and field, tennis, and softball. Methods include use of a
specialized protocol with 4 main phases. The first phase focuses on improving neuromotor control of the scapula, reducing pain, and muscular
endurance. The second phase, the intermediate phase, addresses muscle
imbalances of the upper quarter as well as capsular mobility. The third
phase is the advanced phase, in which the athlete begins higher level
sport-specific drills. The final phase is return to sport.
OUTCOMES: Patients were treated 2 to 3 times per week for 12 weeks. Using
this protocol, all 3 of the female athletes had a full reduction in symptoms,
demonstrated normalized scapular positioning with overhead activities,
and were able to have a full return to sport.
DISCUSSION: The overall results of this study suggests that further research
is needed in this area of physical therapy in order to draw any definitive
conclusions.
REFERENCES: Wilk K, Obma P, Simpson II C, et al. Shoulder injuries in the
overhead athlete. J Orthop Sports Phys Ther. 2009;39:38-54. Lawrence
R, Braman J, Laprade R, Ludewig P. Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain,
part 1: sternoclavicular, acromioclavicular, and scapulothoracic joints.
J Orthop Sports Phys Ther. 2014;44:636-645. Lawrence R, Braman J,
Staker J, et al. Comparison of 3-dimensional shoulder kinematics in individuals with and without shoulder pain, part 2: glenohumeral joint. J
Orthop Sports Phys Ther. 2014;44:646-655. Postacchini R, Carbone S.
Scapular dyskinesis: diagnosis and treatment. OA Musculoskelet Med.
2013;1:20. Burkhart S, et al. The disabled throwing shoulder: spectrum of
pathology part iii: the sick scapula, scapular dyskinesis, the kinetic chain,
and rehabilitation. Arthroscopy. 2003;19:641-661. Shanley E, Thigpen
C. Throwing injuries in the adolescent athlete. Int J Sports Phys Ther.
2013;8;630-640. Wilk K, Macrina L, Reinold, M. Non-operative rehabilitation for traumatic and atraumatic glenohumeral instability. N Am J
Sports Phys Ther. 2006;1:16-31.
OPO34
EFFECTS OF VIDEO AND VERBAL AUGMENTED FEEDBACK
ON JUMP-LANDING ERROR
Joe G. Carpenter
Physical Therapy, Winston Salem State University, Gibsonville,
North Carolina
PURPOSE/HYPOTHESIS: Augmented external feedback, by visual, video review and oral instruction have been shown to improve jump-landing
technique immediately following jump-landing trials and when retested (without any interventions) 1 week later. This study analyzed whether
augmented feedback provided over an extended period of time improved
jump-landing errors.
NUMBER OF SUBJECTS: Fifteen (mean ± SD age, 23.5 ± 1.2 years).
MATERIALS/METHODS: Subjects were assigned to 1 of 3 groups: A (no feedback), B (verbal feedback), or C (iPad video and verbal feedback) for separate analysis on feedback. On day 1, all subjects completed a baseline
jump-landing test, a jump landing training session, and an initial jumplanding posttest. In all testing sessions (baseline, initial posttest, final
posttest), and training sessions subjects completed 3 practice jumps followed by 5 recorded jumps. For baseline testing, initial post testing, and
final post testing kinetic and kinematic data were collected using Qualisys
3-D motion capture systems and AMTI force plates. During jump training sessions, data were collected on 2 iPads and scored using the Landing
Error Scoring System (LESS), a clinical assessment tool of jump-landing biomechanics. Following day one, each subject participated in a jump
training session once a week for 3 consecutive weeks. During jump training sessions, subjects in groups B were given 2 verbal cues correlating to 2
errors the researcher believed were most prominent upon reviewing LESS
found the video footage prior to feedback. Those in group C were given
verbal feedback similar to group B while viewing the video on the iPads.
Subjects completed a final jump-landing posttest 2 weeks after the last
jump training session. A time (pre, post, final) by group (A, B, C) mixed
ANOVA was performed.
RESULTS: No significant differences were found between groups for any of
the dependent variables using a repeated measures ANOVA. Over training sessions, the control group showed little improvement on the LESS
(average decrease of 0.4 errors), the verbal feedback group improved
slightly (average decrease of 1.6 errors), and video and verbal group im-
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proved the most (average decrease of 3.0 errors). For kinetic and kinematic data, all sagittal plane data (knee and hip flexion) and ground reaction forces relative to body weight improved for the video and verbal
group over testing sessions. Video and verbal group improved more than
both the control and verbal only groups in all sagittal plane and ground
reaction force data.
CONCLUSIONS: Although not significant, subjects showed improvements
in jump-landing error using video and verbal feedback over an extended
period of time. Further studies with larger sample sizes need to be conducted to understand the best means of feedback for decreasing risk of
ACL injury.
CLINICAL RELEVANCE: This study examines different means of feedback for
jump landing analysis that can be used in a clinical setting. With new and
evolving technologies, clinicians should be aware of the efficacy of different mechanisms for feedback.
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OPO35
VALIDATION OF LIMB-LOADING SYMMETRY USING WEARABLE PLANTAR
PRESSURE INSERTS: APPLICATION FOR MONITORING OF DAILY LOADING
Ming-Sheng M. Chan, Emily Hernandez, Susan Sigward
Biokinesiology and Physical Therapy, University of Southern
California, Pasadena, California
PURPOSE/HYPOTHESIS: Persistent loading asymmetry following anterior cruciate ligament reconstruction (ACLR) is a concern as it is thought to contribute to increase risk for re-injury [1-7]. Daily loading behaviors outside
of formal rehabilitation may provide a strong stimulus to reinforce asymmetrical loading patterns during early recovery [8]. However, how individuals load their limbs throughout the day is not known. Recent advances in wearable technology may provide a mechanism for quantifying limb
loading outside of a laboratory setting. The purpose of this study was to determine the level of agreement between force platforms and wearable pressure inserts for measurements of loading symmetry during daily activities.
NUMBER OF SUBJECTS: Seven healthy individuals (3 male) participated.
MATERIALS/METHODS: Participants performed single limb stance, sit-tostand, stand-to-sit, and walking and a combined sit-to-stand, turning,
walking and stooping tasks. Data were collected concurrently from force
platforms (BTS, Milan, Italy; 1000 Hz) and shoe insert equipped with 8
pressure sensors positioned across the heel, midfoot, forefoot and toes
(Orpyx, Calgary, Canada; 100 Hz). Vertical ground reaction force (vGRF)
impulse was calculated from force platforms as the area under vGRF time
curve for each condition. Vertical force (vF) impulse was calculated from
shoe inserts. Total force from pressure sensors (PSI) was multiplied by
sensor area (mm2) for each sensor and summing the forces from 8 sensors. Total force measured during a single limb stance task was used to
normalize forces measured during all other experimental tasks (%BW).
vF impulse was calculated as the area under the total force (% BW) time
curve for each task. Symmetry indices were calculated as a ratio of nondominant/dominant for vGRF and vF impulses. Averages of 5 symmetry
indices per task per person for vGRF and vF were considered for analyses.
To quantify the level of agreement between systems, concurrent validity of
was determined using intraclass correlation coefficients (ICC3,k) analyses
were performed individually on each task.
RESULTS: Symmetry indices of vGRF and vF impulse ranged from vGRF:
0.03-0.19; vF: 0.05-0.17 across tasks. ICCs were 0.88 (P = .011) for sit-tostand, 0.84 (P = .021) for stand-to-sit, 0.93 (P = .003) for walking, and
0.88 (P = .01) for continuous task.
CONCLUSIONS: ICCs greater than or equal to 0.88 indicate a high level of
agreement between measurement systems for calculation of limb loading
symmetry in healthy individuals during tasks that represent daily activities. The level of asymmetry between limbs measured with the gold standard force platforms ranged from 3% to 20%. The strong concurrent validity with relatively small asymmetries suggests these shoe sensors will
be capable of quantifying between limb loading deficits in individuals following ACLR.
CLINICAL RELEVANCE: Wearable pressure inserts may provide valuable information for quantification of loading behaviors in individuals following ACLR in a daily basis.
OPO36
THE EFFICACY OF INSTRUMENTED ASSISTED SOFT TISSUE MOBILIZATION:
A SYSTEMATIC REVIEW
Scott W. Cheatham, Morey J. Kolber, William J. Hanney,
Paul Salamh
California State University Dominguez Hills, Torrance, California;
Nova Southeastern University, Fort Lauderdale, Florida; Physical
Therapy, University of Central Florida, Orlando, Florida; Duke
University, Durham, North Carolina
PURPOSE/HYPOTHESIS: Instrument assisted soft-tissue mobilization (IASTM)
is a popular intervention for musculoskeletal pathology. Several types of instruments and approaches exist. Despite popularity, a consensus on the optimal IASTM approach has not been identified in the literature. Moreover,
a paucity of research exists to establish a consensus for the efficacy of
IASTM. Thus, a systematic review of the current evidence assessing the effects of IASTM as an intervention for musculoskeletal pathology or to enhance joint range of motion (ROM) was conducted.
NUMBER OF SUBJECTS: None.
MATERIALS/METHODS: A systematic search strategy was conducted according to the Preferred Reporting Items for systematic reviews and
meta-analyses (PRISMA) guidelines. The following databases were
searched during the month of December 2015: PubMed, PEDro, Science
Direct, and EBSCOHost collection. The search terms included individual
or a combination of the following: instrument assisted augmented softtissue mobilization Graston and technique. Studies considered for inclusion met the following criteria: (1) peer reviewed, English language publications; (2) controlled clinical trials that compared pretest and posttest
measurements for an intervention program using IASTM; (3) studies that
compared an intervention program using IASTM; (4) studies that compared 2 intervention programs using IASTM. Studies were excluded if
they were non-English publications, clinical trials that did not directly
measure the effects of IASTM, clinical trials that included Gua Sha and
ASTYM, case reports, clinical commentary, dissertations, and conference
proceedings. Two reviewers participated in the review and agreed upon
articles retained and excluded.
RESULTS: A total of 7 randomized controlled trials were appraised. Five
studies measured an IASTM intervention versus a control or alternate
intervention. The results of the studies showed improvement, albeit no
significant difference between the groups (P>.05) for pain, function,
strength, muscle length, and balance. Two studies measured an IASTM
intervention versus a control or alternate intervention group on the effects of joint ROM via the effect of muscle length. The IASTM intervention produced significant (P<.05) short-term gains up to 24 hours.
CONCLUSIONS: The literature measuring the effects of IASTM is still
emerging. The consensus of current research suggests favorable results
of IASTM as a treatment for common musculoskeletal pathology, however, the results are not superior to other interventions such as soft tissue mobilization or stretching. Among asymptomatic individuals there
appears to be supportive evidence for IASTM as an intervention to increase short-term joint ROM with a superior effect compared to a control group (P≤.001).
CLINICAL RELEVANCE: IASTM may be an effective intervention for improving joint ROM among healthy and injured individuals, however, the efficacy of this intervention for treating individuals with musculoskeletal pathology is not superior to alternative interventions.
OPO37
RELIABILITY OF A PRESSURE PAIN THRESHOLD SCALE:
A PRELIMINARY INVESTIGATION
Scott W. Cheatham, Morey J. Kolber, William J. Hanney,
journal of orthopaedic & sports physical therapy | volume 47 | number 1 | january 2017 | a73
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Combined Sections Meeting
Monique Mokha
Kinesiology, California State University Dominguez Hills, Carson,
California; Exercise and Sports Science, Nova Southeastern
University, Davie, Florida; Physical Therapy, Nova Southeastern
University, Davie, Florida; Physical Therapy, University of
Central Florida, Orlando, Florida
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PURPOSE/HYPOTHESIS: Manual palpation for tenderness is an examination
technique used to identify tissue reactivity, quantify severity, and assist
with the diagnosis of musculoskeletal conditions. Chronic conditions such
as fibromyalgia (FM) depend on the palpation examination for diagnosis
since imaging and blood tests are inconclusive. Despite the widespread
use of manual palpation, a consensus for reliably documenting and quantifying pressure pain thresholds (PPT) does not exist. An ordinal scale,
possessing reliability, that quantifies palpable tenderness would serve useful for identifying tissue reactivity, documentation of change, and assist
with the clinical diagnosis. Thus, the purpose of this study was to determine the intrarater reliability of a 5-point ordinal scale (graded 0-4 with
increasing severity) that may be used for identifying and quantifying palpable tenderness.
NUMBER OF SUBJECTS: Twenty participants (mean ± SD age, 43.81 ± 15.0
years) including 10 diagnosed with FM (2 male, 8 female) and 10 controls (4 male, 6 female) with no known orthopaedic pathology were recruited for this study.
MATERIALS/METHODS: Participants underwent a testing session using the
American College of Rheumatology tender point criteria for the diagnosis of FM. The 18 predetermined tender points were selected as they are
established areas of palpable tenderness, thus allowed assessment of the
full range of the 5-point scale. For each tender point, the examiner graded the response using the scale (0, no tenderness; 1, reports tenderness; 2,
reports tenderness and has facial expression; 3, withdraws; 4, does not allow palpation beyond superficial contact). The session was repeated within 3 days. Pressure up to 4 kg/cm2 was applied at each tender point using
the thumb with a digital pressure algometer. Testing stopped once the examiner reached 4 kg/cm2 of pressure or once a maximum level of pressure
was reported by the patient. Algometry is a well-accepted instrument for
quantifying PPT. Intrarater reliability for all 18 tender points was calculated using the intraclass correlation coefficient (ICC) model 3,k.
RESULTS: The ordinal scale had good intrarater reliability with the FM (ICC
= 0.92; CI: 0.89, 0.94) and control group (ICC = 0.91; CI: 0.88, 0.93).
CONCLUSIONS: The results provide preliminary evidence of reliability for
an ordinal scale that may be used for quantifying palpable tenderness.
Future research should determine the diagnostic accuracy of the PPT
scale as well as the minimum threshold cut point to determine tenderness associated with pathology.
CLINICAL RELEVANCE: The development and utilization of a reliable PPT
scale may have clinical applications for identifying tissue reactivity, quantifying tenderness, documenting change, as well as assisting with the clinical diagnosis.
OPO38
EXAMINATION OF BOTH LANDINGS BEFORE AND AFTER 4 WEEKS
OF JUMP-LANDING TRAINING
Susan A. Chinworth, Tyler Cope, Srikant Vallabhajosula,
Joe G. Carpenter
Physical Therapy Education, Elon University, Elon, North
Carolina; Winston-Salem State University, Winston-Salem,
North Carolina
PURPOSE/HYPOTHESIS: Errors in vertical jump landing techniques are associated with increased knee injury. Verbal and visual training techniques
are used to help correct these errors. However, assessment and correction of errors are often recommended for only the first jump not the second jump. Recent evidence suggests that the second landing should be
assessed but the information was only applied to a one-time testing session with no long-term training provided. The purpose of this study was
to examine the biomechanics of both landings before and after 4 weeks of
training with multiple forms of feedback.
NUMBER OF SUBJECTS: Fifteen (mean ± SD age, 23.5 ± 1.2 years).
MATERIALS/METHODS: Subjects were randomly assigned to 1 of 3 groups
(Gpr): A (control-no feedback), B (verbal feedback), or C (iPad video+verbal
feedback). All subjects completed an initial jump-landing rebound pretest followed by a jump training session. Subjects completed weekly jumplanding training sessions for 4 weeks. A week following the final training
session, posttesting was done with the same methods as pretest. Subjects
landed onto 2 force plates from a 30-cm-high box such that 1 foot hit each
plate. Upon landing they immediately rebounded for a maximal vertical
jump and a second landing onto the force plates. After practice, 5 jump trials were recorded. Peak vertical ground reaction forces normalized to body
weight (Fz), hip, knee and ankle joint angles at initial plate contact (IC)
and joint excursions (ROM) were analyzed as first-second landing ratios.
Training sessions consisted of 3 practice jumps and 5 trial jumps with feedback given twice within each session. Verbal feedback provided to the Grp
B and C focused on 2 errors that the researchers believed were most prominent in reviewing the video footage between jumps. Grp C was also provided with video feedback. A time (pre, post)-by-group (A,B,C) mixed ANOVA
was performed.
RESULTS: Fz ratios ranged from 1.03 ± 0.18 (Grp B; pre) to 1.31 ± 0.41 (Grp
B; post). There was a trend towards significant interaction (P = .055) between pre and posttesting and groups (1.22-1.18; 1.04-1.3; 1.12-0.96; prepost and groups A, B and C, respectively). There was a significant main effect (P = .048) for the knee flexion ratio at IC with ratios less than 1 for A
and B but 1.97 for C. There was also a significant main effect of time (prepost) for ankle sagittal joint excursion (P = .017) with ratios 1.16 (pre) and
1.07 (post) regardless of group.
CONCLUSIONS: The differences in ratios for different variables, groups and
testing sessions findings indicate that the second landing should be considered when examining vertical jump and/or rebound landing techniques. As the findings were consistent across training groups, both landings should be examined when training activities are utilized.
CLINICAL RELEVANCE: Jump landings are being used clinically with assessment tools to determine risk of knee injury. Often the second landing is either ignored or not assessed similarly to the first. This study supports that
the second landing be examined when training sessions are performed.
OPO39
EXAMINATION OF FIRST AND SECOND LANDINGS OF DROP JUMPS
WITH A SINGLE SESSION OF JUMP-LANDING TRAINING
Susan A. Chinworth, Srikant Vallabhajosula, Tyler Cope,
Joe G. Carpenter
Physical Therapy Education, Elon University, Elon, North
Carolina; Winston-Salem State University, Winston-Salem,
North Carolina
PURPOSE/HYPOTHESIS: Analyses of vertical jump and rebound landing techniques are used to identify and decrease risk of knee injury. Techniques
are generally examined only for the first landing although 2 landings are
involved in these jumps. Recent evidence suggests that the second landing
should also be assessed but the findings were only applied to a one-time
testing session with no training performed. Therefore, the purpose of this
study was to examine the kinematics and kinetics of both landings before
and after a single training session with augmented feedback.
NUMBER OF SUBJECTS: Fifteen (mean ± SD age, 23.5 ± 1.2 years).
MATERIALS/METHODS: Subjects were randomly assigned to 1 of 3 groups (Grp):
A (control-no feedback), B (verbal feedback), or C (iPad video+verbal feedback). All subjects completed: jump-landing rebound pretest, jump training session, and jump-landing rebound posttest within 1 day. Subjects landed onto 2 force plates from a 30-cm-high box such that 1 foot hit each plate.
Upon landing they immediately rebounded for a maximal vertical jump and
a second landing onto the force plates. After practice, 5 jump trials were recorded. Data were collected using Qualisys Motion Capture System and an-
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alyzed using Visual3D software. Peak vertical ground reaction forces normalized to body weight (Fz), hip, knee and ankle joint angles at initial plate
contact (IC) and joint excursions (ROM) were analyzed as first-second landing ratios. The training session consisted of practice jumps and 5 trial jumps
with verbal feedback given to Grp B and verbal+video feedback to Grp C. A
time (pre, post)-by-group (A,B,C) mixed ANOVA was performed.
RESULTS: There were no significant interaction and main effects for Fz ratios, angles at IC and joint excursions. However, there was a trend towards significance for Time main effect for knee ROM ratio (P = .064).
Subjects had more similar knee ROM during post (1.01 ± 0.05) compared
to pre (1.06 ± 0.04). Fz ratios ranged from 1.04 ± 0.16 (Grp B; pre) to 1.3 ±
0.17 (Grp A; post) and slightly increased from pre-to-post testing (1.2-1.3;
1.04-1.18; 1.12-1.13 for Grp A, B, and C, respectively). Ratios for sagittal
angle joint excursion, were mostly around 1. Ratios for sagittal plane angles at IC ranged from 0.96 (Knee Grp C; pre) to 5.4 (Ankle Grp C; pre).
There was more variability in the hip and knee frontal plane ratios with
range of 0.33 (Knee Grp B; post) to 2.9 (Hip Grp B; pre).
CONCLUSIONS: The near 1:1 ratios for Fz and sagittal plane angles as well
as variability seen in knee and hip frontal plane angles indicate that the
second landing should be considered when examining vertical jump and/
or rebound landing techniques. As the findings were consistent across
training groups, both landings should be examined when training activities are utilized.
CLINICAL RELEVANCE: Jump landings are being used clinically with assessment tools to determine risk of knee injury. Often the second landing is
either ignored or not assessed in the same manner as the first. This study
supports that the second landing be examined regardless if the assessment is one-time or with training sessions.
OPO40
THE ASSOCIATION OF PHYSICAL ACTIVITY WITH OUTPATIENT PHYSICAL
THERAPY UTILIZATION AFTER TOTAL KNEE REPLACEMENT
Meredith B. Christiansen, Louise M. Thoma, Hiral Master,
Robert Cowley, Emily Polakowski, Laura A. A. Schmitt,
Daniel Rhon, Daniel White
Physical Therapy and Biomechanical and Movement Science,
University of Delaware, Newark, Delaware; Physical Therapy,
US Army-Baylor University, Houston, Texas
PURPOSE/HYPOTHESIS: While standard postoperative care includes a 3-day
discharge after surgery for Total Knee Replacement (TKR), utilization of
outpatient physical therapy (PT) remains highly variable [1]. It is unclear
why this occurs. preoperative and postoperative levels of physical activity
(PA) may be an important predictor of utilization, though little is known
about this association. The purpose of this study, therefore, was to explore
the association of presurgical and postsurgical PA levels with subsequent
utilization of PT services in people after TKR.
NUMBER OF SUBJECTS: Forty-five participants receiving standardized PT
care for a unilateral TKR at a University PT clinic between September
2015 and May 2016.
MATERIALS/METHODS: We utilized data from an ongoing pilot study of PA
after TKR. Presurgical (pre-TKR) PA was measured using self-report at
the initial PT evaluation in response to the question, “What was your preinjury physical activity level?” Response choices including predominantly
sedentary or sitting with some standing were classified as Light pre-TKR
PA, while walking, some handling of material or heavy manual work were
classified as Moderate pre-TKR PA. Postsurgical (post-TKR) PA was objectively measured as steps per day using an accelerometer (Actigraph
GT3X) worn by the participant for the first week of PT. We categorized
less than 2500 steps/d as Light post-TKA PA, and greater than 2500
steps/d as Moderate post-TKR. Utilization of PT was defined as the total number of PT visits (frequency) and the number of days of service
from admission to discharge (duration). Participants were classified as
high or low utilizers based on the mean values of frequency and duration
of PT. We explored the association of pre- and post-TKR PA (Light versus
Moderate PA) with high versus low utilizers, with unadjusted odds ratio
(OR) and 95% confidence intervals (CIs).
RESULTS: We used data from 32 participants (mean ± SD age, 65 ± 9 years;
56% female; BMI, 33 ± 7.5 kg/m2) who had 21 ± 6 PT appointments and
68 ± 23 days of PT. Participants with Light Pre-TKR PA were 1.5 times
more likely to be high frequency of PT (95% CI: 0.34, 6.53) and 2.0 times
as likely to have long duration of PT (95% CI: 0.45, 8.77) compared with
those who with Moderate pre-TKR PA. Those with Light-post-TKR PA
were half as likely to have a high frequency of PT OR = 0.5 (95% CI: 0.11,
2.32) and 25% less likely to have a long duration of PT (OR = 0.75; 95%
CI: 0.17, 3.27) compared with those with Moderate post-TKR PA.
CONCLUSIONS: PA before and after surgery may be an important marker of
the frequency and duration of the utilization of PT after TKR. We found
people who reported less active pre-TKR PA tend to be high utilizers of
PT services. Conversely, participants who were less active post-TKR tend
to be low utilizers of PT services. Our study conclusions are preliminary
given our small sample size.
CLINICAL RELEVANCE: Measuring PA after TKR may help to plan for the utilization of PT after TKR.
OPO41
MORPHOLOGY AND CONTRACTILE PROPERTIES OF THE RECTUS FEMORIS
MUSCLE DURING VARIOUS TASKS PERFORMED BY HEALTHY ADULT SUBJECTS
Zachary Christopherson, Ashley Lake, Heather Myers,
Corina Martinez, Robert J. Butler, Chad E. Cook
Physical and Occupational Therapy, Duke University, Durham,
North Carolina; Duke University, Durham, North Carolina
PURPOSE/HYPOTHESIS: Traditionally, strength assessment of the quadriceps
has focused on manual muscle testing and isokinetic testing protocols.
Additionally, the cross-sectional area (CSA) of a muscle can be used to
measure the amount of muscle available to produce strength [1-4]. The
potential for assessment of this cross-sectional area is expanding through
the use of portable ultrasound imaging devices. The aim of this study is
to capture images of the rectus femoris muscle in healthy adults in order
to establish a valid and reliable protocol for using musculoskeletal ultrasound to assess muscle size and contractility of the rectus femoris muscle
in patient populations.
NUMBER OF SUBJECTS: Ten (5 male, 5 female) completed, with a final goal
of 40 total subjects.
MATERIALS/METHODS: All subjects completed the MARX Activity
Questionnaire [5] and a body composition test using bioelectrical impedance. This was followed by ultrasound image capture of the rectus femoris (CSA) at 35% of the femur length in 3 conditions: quadriceps contraction at 0° of flexion (quad set) with the knee resting over a 6-inch foam
roll, and during a straight leg raise. Each condition was measured bilaterally at rest and during contraction. Contractile index (CI) (CSA at rest –
CSA during contraction) was calculated and compared utilizing KruskalWallis analysis.
RESULTS: A significant difference (0.009) existed for the (CI) of the rectus
femoris on the right leg between quad sets (mean ± SD, 0.21 ± 0.41 cm2),
foam roll (0.467 ± 0.33 cm2), and SLR (1.11 ± 0.78 cm2) positions. There
was also a significant difference for the CI of the rectus femoris on the left
leg between quad sets (0.17 ± 0.31 cm2), foam roll, (0.38 ± 0.31 cm2) and
SLR (1.55 ± 0.78 cm2) positions.
CONCLUSIONS: There appears to be a difference in CI of the rectus femoris
between commonly prescribed exercises used for early strengthening during knee rehabilitation when measured in healthy subjects.
CLINICAL RELEVANCE: With the improved feasibility of ultrasound imaging
in the clinical setting, quadriceps contractile behavior may be more accurately and objectively measured. Knowing the contractile behavior of the
knee extensors during various tasks and exercises in healthy subjects will
allow future researchers, who will use imaging as an outcome for patients
recovering from injury such as ACL reconstruction, a means to best study
muscle morphology and force production.
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OPO42
IN PECTORALIS MAJOR RUPTURES, DOES SURGICAL OR NONSURGICAL
INTERVENTION PRODUCE BETTER STRENGTH OUTCOMES?
A SYSTEMATIC REVIEW
Nathan Church, Coby Nattier, Morgan Stemple, Tom Sneed
Southwest Baptist University, Bolivar, Missouri
PURPOSE/HYPOTHESIS: In today’s American culture, physical fitness and
appearance is greatly valued. Weightlifting has been popularized as has
other high level sporting and fitness activities. With this greater population of athletes, more uncommon injuries are being noted as well to
include pectoralis major muscle rupture. Unlike typical musculoskeletal
injuries, a well defined standard of care has not been established for pectoralis major rupture. Nonsurgical treatment has limited studies on incomplete ruptures focused on the geriatric population. Surgical treatment
has been researched with a focus on which technique gives best outcomes.
Cosmesis, pain reduction, and overall satisfaction are good outcomes but
strength leading to return of function is most valuable. With this basic information regarding pectoralis major rupture, physical therapists must be
able to answer the question which leads to better strength outcomes, surgical or nonsurgical intervention?
NUMBER OF SUBJECTS: Ninety-two.
MATERIALS/METHODS: In February 2016 databases CINAHL, Cochrane,
MEDLINE, and SPORTDiscus were searched using the terms, “pectoralis major rupture OR pectoralis major tear AND treatment.” Limiting
time to 2000 to 2016 resulted in 241 articles. Removal of duplicates reduced articles to 137. Title and abstract screening reduced the number
to 8 studies. These were reviewed full text leading to exclusion of 4 studies. The final 4 studies were assessed for their level of research design and
strength of quality using a question tool from the AACPDM. Additionally,
studies were assessed for strength outcome measures.
RESULTS: All 4 studies were identified as level IV research. Three studies
were cases series and 1 was a cohort series. All 4 studies received a quality of study score of 5/7. This score results in studies showing moderate
strength of evidence. From the 4 studies, 48 pectoralis majors had surgical intervention and 44 had nonsurgical intervention. One study reported 6 nonsurgical went on to have surgery. Strength outcome revealed surgical intervention lead to peak torque of 74% to 110% of uninvolved side
while nonsurgical intervention lead to only 56% to 75% of uninvolved side.
CONCLUSIONS: Overwhelmingly surgery was far better for rupture. Strength
outcome alone shows an 18% to 35% greater improvement in surgical intervention. Additional subjective outcome measures studied also demonstrated greater outcomes which include cosmesis, pain, and overall
satisfaction.
CLINICAL RELEVANCE: With surgical intervention obviously superior for
strength outcome in complete ruptures, perhaps what is now more glaring is the gap in knowledge and evidence of how varying degrees of partial tear will best respond to surgical versus nonsurgical intervention.
Additionally, how might the physical therapist accurately identify patients
who require surgery versus those who would best respond to a nonsurgical approach to rehabilitation? Clearly, these are the questions future research needs to answer.
OPO43
EMG ACTIVITY OF THE MEDIAL AND LATERAL GASTROCNEMIUS MUSCLE
IN TOE-IN AND TOE-OUT FOOT POSITIONS WHILE PRONE AND STANDING
Michael T. Cibulka, April Wenthe
Physical Therapy, Maryville University, St Louis, Missouri
PURPOSE/HYPOTHESIS: The purpose is to examine if EMG activity is different between the MG and LG muscles in toe-in versus toe-out test position.
Our hypothesis is the gastrocnemius when toe-in would elicit more LG activity than MG while toe-out would elicit greater activity in MG than LG.
The gastrocnemius muscle comprises the MG and LG; the medial is more
often injured than the lateral. No tests exist that distinguishes them.
NUMBER OF SUBJECTS: Thirty-three subjects.
MATERIALS/METHODS: Thirty-three subjects were recruited. Electrodes were
placed on the MG and LG. The gastrocnemius was tested prone, resisting knee flexion and during a standing heel-rise in toe-in and toe-out positions. Tests were normalized against a MVIC during a heel raise in neutral. A 2-by-2-by-2 (test position by foot position by muscle) ANOVA was
used to determine if differences exist in activity between the MG and LG
for toe-in versus toe-out while standing and prone.
RESULTS: Significant test position main effect (F1,32 = 86.9, P<.01), significant muscle main effect (F1,32 = 5.5, P<.01), and significant foot position
by muscle interaction (F1,32 = 14.58, P<.01) were found. Follow-up test
showed differences between MG and LG in toe-out position (t = 3.10,
P<.01) but not in the toe-in for both test positions (t = 1.27, P = .21).
CONCLUSIONS: With toe-out the MG was more active than LG in standing
and prone; no difference was noted between MG and LG in toe-in for either position.
CLINICAL RELEVANCE: This information may allow us to bias the MG over
the LG when MMT or when strengthening the gastrocnemius muscle.
OPO44
DIFFERENTIAL DIAGNOSIS OF RIGHT FLANK PAIN IN A PATIENT WITH
GILBERT’S SYNDROME AND PERSISTENT COUGH: A CASE STUDY REPORT
Mark A. Ciolek, Craig P. Hensley
Physical Therapy, McCullough-Hyde Memorial Hospital,
Cincinnati, Ohio; Physical Therapy and Human Movement
Sciences, Northwestern University, Chicago, Illinois
BACKGROUND AND PURPOSE: Evaluating the source of a patient’s pain in the
right flank region can be difficult, especially when complicated by mechanical complaints and comorbidities. A clinician must consider ribs,
accessory breathing musculature, abdominals, and visceral referral patterns. Gilbert’s Syndrome is a condition that alters bilirubin metabolism
and effects an estimated 3% to 7% of the population. The purpose of this
poster is to describe the clinical decision-making process for a patient
with right flank pain after upper respiratory infection.
CASE DESCRIPTION: The patient is a 44-year-old man with Gilbert’s syndrome that presented with a 3 week presence of right flank pain that began following an upper respiratory infection and severe coughing. The
referring physician diagnosed the patient with a diaphragm strain. The
patient reports minimal medical management of Gilbert’s syndrome and
describes current symptoms as different than previous liver related pain.
Chief complaints included coughing, lying supine, prone or on ipsilateral side, bed mobility, and sexual activity. Initial examination revealed
signs and symptoms consistent with muscular strain with no abdominal tenderness or pain related to recent eating or drinking habits. Testing
showed pain with end range lumbar spine flexion, tenderness to palpation of anterolateral ribs 8 to 10, and pain with supine curl-up. Flank
pain improved quickly, but continued to persist for 1.5 weeks. The patient returned after 15 days with minimal coughing, but significantly increased right flank pain. The patient reports the preceding days included
increased driving, alcohol consumption, and poor diet habits including
increased fat intake. At this time assessment shows pain with right upper-quarter pain with deep palpation and led to a decision to refer back
to referring provider. To note, original signs of pain with curl up and rib
tenderness persisted.
OUTCOMES: The patient was referred back to his primary care physician
who completed a metabolic panel and ultrasound. Results demonstrated no hepatic abnormality, but show a 3-mm gallstone and high bilirubin levels.
DISCUSSION: This case demonstrates the importance of ongoing reevaluation for individuals with Gilbert’s syndrome and right flank pain, even if
initial physical therapy testing suggests musculoskeletal origin.
REFERENCES: 1. Goodman CC, Boissonnault WG, Fuller KS. Pathology:
Implications for the Physical Therapist. Philadelphia, PA: Saunders;
2009. 2. Strassburg C. Hyperbilirubinemia syndromes (Gilbert-
a76 | january 2017 | volume 47 | number 1 | journal of orthopaedic & sports physical therapy
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Combined Sections Meeting
Meulengracht, Crigler-Najjar, Dubin-Johnson, and Rotor syndrome).
Best Pract Res Clin Gastroenterol. 2010;24:555-571. 3. Fretzayas A,
Moustaki M, Liapi O, Karpathios T. Gilbert syndrome. Eur J Pediatr.
2012;171:11. 4. Naha K, Dasari S, Vivek G, Hande M, Acharya V. Severe
unconjugated hyperbilirubinaemia: 1 and 1 makes 3? BMJ Case Reports.
2013;2013:bcr2013009962. 5. Hillenbrand A, Henne-Bruns D, Wurl P.
Cough induced rib fracture, rupture of the diaphragm and abdominal
herniation. World J Emerg Surg. 2006;1:34. 6. Memon N, Weinberger
BI, Hegyi T, Aleksunes LM. Inherited disorders of bilirubin clearance.
Pediatr Res. 2016;79:378-386.
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OPO45
THE LAST ENCOUNTER: DIAGNOSTIC EXAMINATION AND MANAGEMENT
OF A PATIENT WITH ABDOMINAL PAIN
Lauren Clark, Jason Beneciuk, Robert Rowe
Physical Therapy, Brooks Rehabilitation, Orlando, Florida
BACKGROUND AND PURPOSE: Patients who present to physicians with abdominal quadrant pain are often referred to other medical providers to
rule-out visceral pathologies; however injuries to the abdominal musculature commonly present as symptoms in the abdominal region and may be
appropriate for physical therapy management. These injuries commonly
occur in athletes who perform unbalanced eccentric trunk rotations such
as golfers; therefore it is important for clinicians to consider perpetuating
factors that may have predisposed the athlete to injury and intervention
strategies that will be most useful for resolution of symptoms and return
to function. The purpose of this case report is to describe the use of exercise combined with thoracolumbar region targeted manual therapy to address abdominal pain in a recreational golfer.
CASE DESCRIPTION: A 63-year-old man presented to physical therapy with
an 18-month history of right lower quadrant pain that radiated to the
upper quadrant with difficulty performing lumbar rotational and flexion
movements such as golfing and household tasks. The patient had previously been evaluated by multiple medical providers and underwent
surgical cholecystectomy and kidney stone procedures with no relief of
symptoms. He demonstrated muscular guarding and poor coordination
of muscles of active spinal stabilization. Clinical outcome measures consisted of the Modified Oswestry Low Back Pain Questionnaire (ODI), numeric pain rating scale (NPRS), and the Patient-Specific Functional Scale
(PSFS) administered at intake and 6 weeks. Interventions included coordination training for the thoracacolumbar region and joint mobilizations to restore necessary dynamic movement patterns necessary for golfing and household tasks.
OUTCOMES: Following 7 weeks of physical therapy the patient demonstrated the ability to perform pain free movement patterns necessary for golfing and household activities and was able to participate in a graded return
to golf at his desired frequency of 5 days a week. Improvements in NPRS
(4 to 0), ODI (18% to 6%), and PSFS (5.5 to 7) scores were also observed,
meeting minimal clinically important differences for pain and low back
pain related function.
DISCUSSION: With increased direct access opportunities, it is vitally important for physical therapists to become efficient in medical screening
and clinical decision making to distinguish between orthopaedic and visceral conditions. Upon examination, reproduction of symptoms occurred
with thoracic and lumbar movements in the transverse and sagittal planes
which increased confidence that symptoms were of musculoskeletal origin. Abdominal wall injuries may occur in patients who participate in repetitive movements of the lumbar spine and are appropriate for physical
therapy treatment when considering muscular coordination, movement,
and loading. Screening for movement disorders that present as abdominal pain is an important component to physical therapy management
which has the potential to limit unnecessary health care utilization and
improve patient outcomes.
REFERENCES: Dauty M, Menu P, Dubois C. Uncommon external abdominal oblique muscle strain in a professional soccer player: a case report.
BMC Res Notes. 2014;7:684. George SZ, Beneciuk JM, Bialosky JE, et
al. Development of a review-of-systems screening tool for orthopaedic
physical therapists: results from the Optimal Screening for Prediction
of Referral and Outcome (OSPRO) cohort. J Orthop Sports Phys Ther.
2015;45:512-526. King E, Ward J, Small L, et al. Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes. Br J Sports Med. 2015;49:1447-1451. Rodeghero J,
Denninger T, Ross M. Abdominal pain in physical therapy practice: 3 patient cases. J Orthop Sports Phys Ther. 2013;43:44-53. Van Wyngaarden
J, Ross M, Hando B. Abdominal aortic aneurysm in a patient with low
back pain. J Orthop Sports Phys Ther. 2014;44:500-507.
OPO46
NONINJECTABLE NEEDLING INTERVENTIONS FOR SHOULDER PAIN
CONSISTENT WITH IMPINGEMENT SYNDROME: A SYSTEMATIC REVIEW
Derek Clewley, Elizabeth Lane, Jeff Moore, Timothy W. Flynn
Physical Therapy, Duke University, Durham, North Carolina;
Physical Therapy, University of Utah, Salt Lake City, Utah;
Institute of Clinical Excellence, Windsor, Colorado; Physical
Therapy, South College, Knoxville, Tennessee
PURPOSE/HYPOTHESIS: Subacromial impingement syndrome (SIS) is one
of the more common disorders of the musculoskeletal system. Shoulder
pain accounts for one third of physician office visits for musculoskeletal
pain and the most frequent cause of shoulder pain is SIS. Though SIS is
commonly associated with biomechanical and anatomical impairments,
there have been a few studies published recently that demonstrate an association with soft tissue dysfunction and SIS. An APTA paper indicated
a limited number of studies that included dry needling as a primary intervention for soft tissue dysfunction. The purpose of this systematic review was to synthesize and investigate the use of non injectable needling
intervention strategies for the management of SIS.
NUMBER OF SUBJECTS: Nine randomized controlled trials and 307 subjects
total were included in this review.
MATERIALS/METHODS: A systematic literature review consistent with the
PRISMA guidelines was used to investigate the use of needling intervention strategies for SIS. All studies that investigated patients with shoulder
pain consistent with SIS were included. Included techniques were those
related to needling strategies where a non injectable needle approach was
used targeting the shoulder complex with a specific focus on treatment
of muscle tissue.
RESULTS: Five trials that investigated the use of acupuncture and 4 trials
that investigated the use of dry needling were included in this review. The
PEDro risk of bias assessment tool was used. The average PEDro score for
the acupuncture trials was 5.4. The average PEDro score for dry needling
trials was 7.25. Included trials varied in the treatment intent and the type
of outcome measures used and therefore only qualitative analysis could be
performed. Pain pressure threshold (PPT) was included for all 4 studies
focused on dry needling trials and all 4 trials had significant within group
increased PPT. For the measure of pain, all trials demonstrated significant
within group changes in pain. However, between group differences were
only noted at immediate and 1 week.
CONCLUSIONS: The findings from this systematic review provide insight regarding the emerging effectiveness of dry needling. Both muscle tissue directed acupuncture and dry needling does appear to have immediate and
short term effects on pain and PPT. However, none of the studies reported on long term effectiveness. There was inconsistency in the use of outcome measures to make a conclusion about effect on function. The type of
needling strategy used was also inconsistent and the descriptions of technique were often limited.
CLINICAL RELEVANCE: The use of dry needling intervention strategies is becoming widely used in physical therapy practice. The findings from this
systematic review suggest that there might be an effect on pain and PPT
both immediate and short term for SIS. There were no studies that looked
at long term outcomes; therefore it is recommended if the clinician uses
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dry needling that it is incorporated into a treatment package that includes
evidence supported interventions.
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OPO47
DOES THE PRESENCE OF RADIATING PAIN IN A COHORT OF CARE-SEEKING
PATIENTS WITH BACK PAIN INFLUENCE OUTCOME?
Spencer Cole, Thomas R. Denninger, Chad E. Cook,
Timothy McHenry, Charles A. Thigpen
Research and Analytics, ATI Physical Therapy, Greenville, South
Carolina; Department of Orthopedics, Duke University, Durham,
North Carolina; Department of Orthopedics, Greenville Health
System, Greenville, South Carolina
PURPOSE/HYPOTHESIS: Previous literature has established the presence of
radiating pain in patients with low back pain as a prognostic indicator for
worse outcome. This finding has been included in screening tools for low
back pain such as the START Back Tool. The purpose of this analysis of
a cohort of patients is to establish if difference exists in duration of care
and outcomes in patients presenting to physical therapy with nonradiating and radiating low back pain.
NUMBER OF SUBJECTS: The study involves 368 patients with back pain with
or without radiating lower extremity symptoms who received guideline
oriented care by physical therapists over a 3-year period.
MATERIALS/METHODS: The data included patients who were seen via direct
access or through referral. Baseline measures of pain, disability (Oswestry
disability index [ODI]), depression and quality of life were captured for
each subject. Final outcomes measures captured include pain and the
ODI. Comparative analyses between groups were performed for all baseline measures (using a t test/chi-square) and for discharge percentage
change scores for pain and disability (using an analysis of covariance
[ANCOVA]; α = .05).
RESULTS: Of the 368 patients enrolled, 256 (69.5%) had low back pain
without radiation and 112 (30.5%) had radiating symptoms. No differences existed in baseline age, BMI, or baseline quality of life scores of patients
in each group. Differences existed in number of PT session with those
with radiating symptoms being seen 1.39 more visits (P = .011). Baseline
pain and disability were not significantly different, nor was reductions in
disability between groups.
CONCLUSIONS: Despite the commonly accepted belief that the presence of
radiating lower extremity symptoms in patients with low back pain is indicative of worse outcome, our findings did not support this. This difference may be due to continued visits if the patient demonstrated progression of symptoms where prior research has limited the number of PT
visits. This suggests that a capitated number of visits for all patients is
not an effective strategy to determine if conservative treatment is definitive for all patients.
CLINICAL RELEVANCE: Clinicians should consider that some patients radiating symptoms may have different lengths in episode of care but can be expected to reach similar functional levels at discharge.
OPO48
THE EFFECTS OF CORE STABILIZATION EXERCISE ON DISABILITY IN THE
TREATMENT OF NONSPECIFIC LOW BACK PAIN AS COMPARED TO OTHER
FORMS OF EXERCISE: A SYSTEMATIC REVIEW
Sherry T. Colson, Anna Fulton Barnes, Natalie Berg,
Craig Howard, Courtney Purvis, Adam L. Robin, Haley Sligh
School of Physical Therapy, University of Mississippi Medical
Center, Jackson, Mississippi
PURPOSE/HYPOTHESIS: Studies suggest that between 50% to 70% of
Americans will be diagnosed with some type of low back pain (LBP) during adulthood. Risk factors for LBP include weakness and lack of motor
control of the trunk and abdominal muscles. Core stabilization exercises (CSE) are a more recent approach to treating LBP. These exercises are
based on research indicating that impairments in motor control of the
deep abdominal muscles, including the transverse abdominis and lumbar
multifidus, may be an underlying cause of LBP. The purpose of this systematic review is to measure the effects of CSE in the treatment of nonspecific LBP as compared to other forms of exercise utilizing the Oswestry
Disability Index.
NUMBER OF SUBJECTS: Six studies.
MATERIALS/METHODS: The PubMed database was searched in January 2016
with no date limitations using various terminology for LBP and stabilization treatment protocols. Specific search terms included “lumbago,”
“core stability exercise,” and “Oswestry,” searched alone and in combination. The electronic limit included the use of clinical trial studies. The inclusion criteria specified the use of the ODI as an outcome measure and
the use of studies that compare CSE that activate the TrA and LM with
other forms of exercise. The exclusion criteria specified studies that compare CSE to manual therapy, modalities, or surgical intervention. Study
quality was assessed using the PEDro Scale and CEBM Level of Evidence.
RESULTS: Twenty-five articles were identified through the electronic
screening process. After the title screen, abstract screen, and inclusion/
exclusion screen, 6 articles met the criteria for inclusion in this systematic review. The mean PEDro score was 5.5/10, ranging from 4/10 to 8/10.
The frequency of CEBM levels included 2 level II studies, 2 level III studies, 2 level IV studies.
CONCLUSIONS: Three out of 6 studies with the highest level of evidence
and best internal validity indicated a statistically significant improvement with CSE as compared to strengthening, conventional exercises,
and stretching exercises. Two of the 6 articles resulted in no significant
difference in the ODI compared to the Movement System ImpairmentBased Treatment (MSI) and traditional trunk exercise, and 1 article indicated evidence that “Global Postural Reeducation” (GPR) may be significantly better than CSE. All participants in the studies reviewed showed
significant within-group improvements in ODI scores after participation
in exercise.
CLINICAL RELEVANCE: Based on the findings in this systematic review, CSE
should be considered as a viable exercise option in the treatment of LBP.
Overall, the evidence in these studies was graded as a “B” due to a mixture
of moderate to strong CEBM levels and PEDro scores.
OPO49
EFFECTS OF NOVEL DEVICE-SUPPORTED NEUTRAL SPINAL SITTING IN
INDIVIDUALS WITH LOW BACK PAIN: A RANDOMIZED CONTROLLED TRIAL
Patricia Connors, Melodie Kondratek, Xianggui (Harvey) Qu,
Sara F. Maher
Physical Therapy, Oakland University-School of Health Sciences,
Rochester, Michigan; Physical Therapy Department, Wayne
State University, Detroit, Michigan; Math Department, Oakland
University, Rochester, Michigan
PURPOSE/HYPOTHESIS: Sitting is a predominant work posture. Without
muscle action or external support, sitting leads to a posterior pelvic tilt
and a decreased lumbar lordosis, at times leading to low back pain (LBP).
Sitting in a neutral spinal posture is preferred. There are currently no
studies known that examined neutral sitting posture in adults with LBP
for greater than 48 hours. This study investigated the effects of supporting neutral sitting posture via a novel pelvic support device over 3 weeks
in an adult population with LBP and a seated occupation. It was hypothesized that the subjects who utilized the device would have significant improvements in pain, functional tolerance, ROM and strength.
NUMBER OF SUBJECTS: Fifteen.
MATERIALS/METHODS: Fifteen subjects between ages 20 and 65 with LBP
who sat at a desk 25 or more hours/week were randomized into 2 groups:
8 subjects in the experimental group utilized the pelvic support device
in their chair at their workplace during the trial and 7 subjects in the
control group continued in their current desk set-up with no changes.
Preoutcome and postoutcome measures included: Modified Oswestry
Disability Index (ODI), numeric pain rating scale (NPRS), the fingertip
to floor and Sorensen tests and hamstring extensibility. The device uti-
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lized is a portable unit that takes the shape of a 3-D triangle, is covered by
a nonskid surface and has a cut out in the region of the coccyx for pressure
relief. It is placed on the seat just posterior and caudal to the user’s ischial tuberosities. Through its shape and placement, it helps keep the pelvis
from posteriorly rotating and aids in keeping the lumbar spine in a more
neutral posture. Conflict of Interest (COI): The US patented devices used
in this study are owned by Posture and Purpose, LLC. Patricia Connors,
the Principal Investigator (PI) in this study, is majority owner of Posture
and Purpose and invented the pelvic support device. For control of COI,
the PI did not participate in any subject screening, consenting or clinical
measures and all data were coded concealing group assignment until the
completion of all data analysis.
RESULTS: There were significant improvements in ODI and the averaged
NPRS measures. MCID was also attained for ODI. There were no significant changes in any of the physical measures.
CONCLUSIONS: The findings provide preliminary evidence that external
support of neutral spinal position from the pelvis in sitting has a positive effect on self-reported pain and functional tolerance levels in adults
with LBP over a 3-week period. Changes in ROM and strength do not appear associated with this postural change in the time frame investigated.
CLINICAL RELEVANCE: Identifying effective options to support neutral spinal
sitting posture, while minimizing passive strain on spinal structures and
limiting the muscle activity needed to maintain this posture that can lead
to fatigue, would be of benefit for the sitting health of individuals with
and without LBP. This study demonstrates preliminary evidence that direct support at the pelvis may be an effective strategy.
OPO50
CLINICAL EFFICACY AND SAFETY OF AN EARLY HOME EXERCISE PROGRAM
AFTER ANTERIOR CERVICAL DISCECTOMY AND FUSION: A CASE SERIES
Rogelio A. Coronado, Clinton J. Devin, Erin E. Van Hoy,
Christine M. Haug, Susan Vanston, Oran S. Aaronson,
Kristin Archer
Physical Therapy, University of Texas Medical Branch, Galveston,
Texas; Orthopaedic Surgery, Vanderbilt University Medical Center,
Nashville, Tennessee
PURPOSE/HYPOTHESIS: Anterior cervical discectomy and fusion (ACDF) is
the most common surgery for cervical spine conditions. Poor outcomes
after ACDF have been linked to impaired muscle functioning from postsurgical disuse and deconditioning. Postoperative exercise can counteract the effects of deconditioning and promote an increase in self-efficacy.
To date, no study has determined whether performance of an early home
exercise program (HEP) is safe and efficacious for improving ACDF outcomes. The purpose of this case series is to describe the clinical efficacy
and safety of an early HEP performed within the first 6 weeks after ACDF.
NUMBER OF SUBJECTS: Five consecutive patients (mean ± SD age, 53.0 ±
12.4 years; 4 female) who underwent ACDF were enrolled.
MATERIALS/METHODS: Patients were given a 6-week HEP to be started immediately following hospital discharge after ACDF. The HEP intervention included daily walking, deep breathing, distraction techniques,
cervical (limited to 30°) and upper body range of motion, cervical and
shoulder isometrics, abdominal strengthening, and shoulder theraband
exercises. Compliance (eg days completing exercise) and adverse events
during the 6-week exercise phase were monitored using a diary log and
weekly calls with a physical therapist. Patient-reported outcomes for neck
and arm pain (Numeric Rating Scale), disability (Neck Disability Index),
and physical and mental health (SF-12) were assessed preoperatively,
after completing the HEP (6 weeks after surgery) and at 6-month follow-up. Self-efficacy (Pain Self-Efficacy Questionnaire) was measured at
baseline, 6 weeks, and 6 months after surgery. Minimal clinically important differences were used to determine meaningful change in pain (2.6
points), disability (7.5 points), physical (8.1 points) and mental health (4.7
points), and self-efficacy (11 points). Safety was assessed with radiographic imaging at 6 months.
RESULTS: After surgery and the early HEP, a majority of patients reported meaningful change in disability (4 patients at 6 weeks; 5 patients at 6
months), arm pain (4 patients at 6 weeks and 6 months), neck pain (4 patients at 6 weeks; 3 patients at 6 months), and self-efficacy (3 patients at 6
weeks and 6 months). Two patients reported meaningful change in mental health at 6 weeks and 6 months. Only 1 patient reported meaningful
change in physical health at 6 months. No adverse events were reported
during the 6-week exercise phase. The average number of days performing exercises was 33 days (79% of the 6-week period) with a range of 27
to 37 days (64%-83%). Radiographic imaging did not show any signs of
abnormal healing after fusion.
CONCLUSIONS: The findings of this case series suggest that an early HEP
can be safely implemented immediately after surgery and may positively
affect ACDF outcomes.
CLINICAL RELEVANCE: These data support the early implementation of exercise after cervical spine fusion surgery with potential long-term benefits
and no apparent safety concerns. Future trials will determine the effectiveness of an early HEP after ACDF.
OPO51
EFFICACY OF MECHANICAL DIAGNOSIS AND THERAPY IN PATIENTS
WITH CHRONIC NONSPECIFIC LOW BACK PAIN: A RANDOMIZED
PLACEBO-CONTROLLED TRIAL
Leonardo O. Costa, Alessandra N. Garcia, Luciola M. Costa,
Mark J. Hancock, Fabricio Souza, Georgia Freschi,
Matheus Almeida
Masters and Doctoral Programs in Physical Therapy, Universidade
Cidade de São Paulo, São Paulo, Brazil; Physiotherapy, Macquarie
University, Sydney, Australia
PURPOSE/HYPOTHESIS: The McKenzie Method, also defined as “Mechanical
Diagnosis and Therapy (MDT)” is commonly used in treatment patients
with chronic low back pain (CLBP). This intervention has never been
compared to a placebo treatment. We conducted a randomized placebocontrolled trial with 148 seeking care patients with CLBP to evaluate the
efficacy of MDT.
NUMBER OF SUBJECTS: One hundred forty-eight.
MATERIALS/METHODS: This study was conducted in the outpatient physical
therapy clinic of the Universidade Cidade de São Paulo, Brazil. Patients
were randomly allocated through a computer system to either MDT (n =
74) or placebo (n = 74). The allocation was concealed. Patients from both
groups received 10 treatment sessions, twice a week, for 30 to 40 minutes
of session duration. The patients of MDT group were treated according
to the principles of the MDT method. Patients allocated to the placebo
group were treated with detuned pulsed ultrasound and shortwave diathermy. Patients from both groups also received an educational booklet.
Clinical outcomes were obtained by a blinded assessor after treatment
and at 3, 6 and 12 months after randomization. Primary outcomes were
pain intensity and disability after the treatment. It was not possible to
blind the therapists and patients to the conditions of treatment. The statistical analysis was conducted in 74 patients from MDT group and 73
from placebo group.
RESULTS: The MDT group had greater improvements in pain intensity at
5 weeks; mean effect, –1.0 point (95% CI: –2.09, –0.01) but not for disability (–0.84 point; 95% CI: –2.62, 0.93). Patients did not report any adverse events. We have not detected any between-group statistical significance for all secondary outcomes.
CONCLUSIONS: We concluded that MDT method was slightly more effective than placebo for pain intensity, but not for disability immediately after treatment in patients with CLBP.
CLINICAL RELEVANCE: We considered that the magnitude of the difference of pain found in this study is small and possibly of doubtful clinical importance.
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OPO52
THE EFFECTS OF MANUAL THERAPY ON FUNCTIONAL OUTCOMES AND
PAIN IN PATIENTS WITH HIP OSTEOARTHRITIS: A SYSTEMATIC REVIEW
Terry Cox, Levi J. Hibma, Warren Frevert, Jill Kalinowski
Physical Therapy, Southwest Baptist University, Springfield,
Missouri
PURPOSE/HYPOTHESIS: Hip osteoarthritis (OA) is a degenerative condition
that has been shown to produce pain and affect physical functioning in
patients, becoming more debilitating as the condition progresses. With
these difficulties, patients struggle with quality of life and productivity,
as well as the cost burden of conservative and surgical treatments. While
there is no cure for hip OA, manual physical therapy may be a viable treatment to reduce symptoms and increase patients’ quality of life. The purpose of this systematic review is to determine whether manual therapy
has a positive effect on functional outcomes or pain when treating patients with hip osteoarthritis.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: The following databases were systematically
searched: CINAHL Complete, SPORTDiscus with full text, MEDLINE,
MEDLINE with full text, Cochrane Central Register of Controlled Trials,
Cochrane Database of Systematic Reviews, and Cochrane Methodology
Register. The keywords used were “hip osteoarthritis,” “manual therapy,” “hip mobilization,” “hip mobilization,” “hip joint mobilizations,” “hip
joint mobilization,” “hip joint mobilizations,” and “hip joint mobilization.”
Studies that were identified as appropriate for this review were assessed
for quality using the PEDro scale.
RESULTS: The initial search yielded 126 articles which were then filtered
by the authors and after excluding duplicates, 78 articles were left for title search. After a title and abstract search and reference search through
a systematic review, 5 articles were chosen for this review. All 5 of the articles were deemed high quality using the PEDro scale. Therefore 5 studies looking at manual therapy for patients with hip osteoarthritis were included in this review. Two of the reviewed studies utilized the WOMAC
to measure improvement in function and showed benefits when using
manual therapy. A third reviewed study that utilized the WOMAC did
show improvements in function, but the results were not statistically significant. The final 2 studies reviewed utilized pain as a functional outcome measure, and both showed benefits in patient’s functional pain levels when utilizing manual therapy.
CONCLUSIONS: Manual therapy, especially when combined with other treatments should be considered as interventions for improving functional
outcomes and pain in patients with hip OA.
CLINICAL RELEVANCE: Physical therapists should incorporate manual therapy within their comprehensive treatment program to improve functional
outcomes and reduce pain in patients with hip OA. While manual therapy has been shown to improve outcomes, it should not be used in isolation, but rather as a supplement to other treatments such as exercise and
patient education.
OPO53
EFFECT OF CONTINUUM OF CARE ON PATIENT OUTCOMES
AND COMPLIANCE IN PEDIATRIC PATIENTS WITH ANTERIOR HIP PAIN:
A RETROSPECTIVE REVIEW
Briana Crowe, Mindy Galleher, Mitchell Selhorst
Sports Physical Therapy, Nationwide Children’s Hospital,
Columbus, Ohio
PURPOSE/HYPOTHESIS: A positive relationship between therapist and patient has been shown to influence patient compliance, satisfaction, and
outcomes with therapy [1-4]. As part of this relationship, many physical therapists feel that a good continuum of care is important to effectively treat their patients; however, it can be difficult to maintain this continuity in a busy clinic. While patient satisfaction has been linked to a
good continuum of care [5-6], it is currently unknown if a poor continu-
um of care affects patient outcomes. We hypothesized that the more therapists involved in care would result in worse patient outcomes and reduced compliance. The primary objective of this study was to assess the
effect of the number of treating therapists involved in an episode of care
on patient outcomes. The secondary objective was to assess its effect on
patient compliance.
NUMBER OF SUBJECTS: From a retrospective database of patients with anterior hip pain, 164 patients (mean ± SD age, 14.3 ± 2.2 years) met the inclusion criteria.
MATERIALS/METHODS: This was a retrospective study consisting of the review of each patient’s medical chart. The information was obtained from
a database of patients with anterior hip pain, treated between 2010 and
2015 at a pediatric sports and orthopaedic physical therapy department.
The number of therapists who treated each patient was the independent
variable. Reduction in pain per visit, change in patient self-reported outcome measures, and patient compliance with therapy were the dependent
variables. Compliance was defined as attending approximately 75% of visits outlined in the therapist’s most recent plan of care. The covariates were
duration of symptoms and initial pain levels. Data analysis: an analysis of
covariance assessed the primary outcome and a chi-squared analysis calculated the secondary outcome.
RESULTS: The mean ± SD reduction of pain per visit was 0.64 ± 0.39. Two
or fewer therapists involved in care resulted in significantly greater reductions in pain (mean difference, 0.30; 95% CI: 0.01, 0.59; P = .038 for 2
therapists and 0.3053; 95% CI: –0.0009, 0.6116; P = .051 for 1 therapist).
The number of patients compliant with care was 111 (67.7%). No significant differences were noted between the number of therapists involved in
care and compliance (P = .094). Patient self-reported outcome measures
were evaluated, but no results could be derived due to approximately 75%
of patients lacking outcome measures data.
CONCLUSIONS: Having 2 or less therapists involved in a patient’s care was
associated with significantly greater reductions of pain. The number of
therapists involved had no significant effect on compliance.
CLINICAL RELEVANCE: Maintaining a continuum of care of 2 or less therapists shows superior reduction in pain levels then having 3 or more therapists involved. This study gives support to the potential benefit of maintaining a good continuum of care to achieve optimal improvement in our
patient’s pain levels.
OPO54
DIAGNOSTIC IMAGING IN A DIRECT-ACCESS SPORTS PHYSICAL THERAPY
CLINIC: A 2-YEAR RETROSPECTIVE PRACTICE ANALYSIS
Michael Crowell, Erik Dedekam, Michael Johnson,
Scott Dembowski, Richard Westrick, Donald Goss
US Military-Baylor University Sports Physical Therapy DSc
Program, West Point, New York; Keller Army Community Hospital,
West Point, New York; Columbia University, New York, New
York; Moncreif Army Community Hospital, Fort Jackson, South
Carolina; US Army Research Institute of Environmental Medicine,
Natick, Massachusetts
PURPOSE/HYPOTHESIS: The primary objective of this study is to describe the
appropriateness of magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA) exams ordered by physical therapists in a direct-access sports physical therapy clinic. Secondary objectives are to describe the utilization rates of diagnostic imaging, describe the diagnostic
accuracy of the physical therapist’s clinical examination compared to MRI
findings and, if applicable, surgical findings, and to compare utilization,
appropriateness, and diagnostic accuracy between board certified physical therapists and nonboard certified physical therapists. We hypothesized that: (1) greater than 80% of advanced diagnostic imaging orders
will comply with American College of Radiology (ACR) Appropriateness
Criteria (ACR rating greater than 6); (2) all physical therapists will utilize imaging at rates equal to or lower than previously published data; (3)
agreement between the clinical examination diagnosis and the MRI/sur-
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gical diagnosis will be greater than 75%; (4) board-certified physical therapists will utilize diagnostic imaging at lower rates and with increased appropriateness based on ACR criteria.
NUMBER OF SUBJECTS: One hundred eight patients with MRI/MRA examinations ordered by a physical therapist.
MATERIALS/METHODS: The study design was a 2-year retrospective practice
analysis. A board-certified radiologist determined the appropriateness of
each order based on ACR. The principal investigator and coinvestigator
radiologist assessed agreement between the clinical diagnosis and MRI/
surgical findings.
RESULTS: Knee (31%) and shoulder (25%) injuries were the most common. Overall, 55% of injuries were acute. The mean ACR rating was 7.7
and the percentage of orders complying with ACR appropriateness criteria was 83.2%. Physical therapist’s clinical diagnosis agreed with the
MRI/MRA findings in 64.8% of cases and agreed with surgical findings
in 90% of cases.
CONCLUSIONS: Physical therapists providing musculoskeletal primary care
in a direct-access sports physical therapy clinic appropriately ordered advanced diagnostic imaging in over 80% of cases. Future research should
prospectively compare physical therapist appropriateness and utilization
to other groups of providers and explore the effects of physical therapist
imaging privileging on outcomes.
CLINICAL RELEVANCE: Physical therapists appear to appropriately order advanced diagnostic imaging at rates that do not exceed other published data.
OPO55
CONFIDENCE OF PHYSICAL THERAPISTS’ DIAGNOSTIC CLINICAL DECISION
MAKING USING SPECIAL TESTS DURING A SHOULDER EVALUATION:
A QUALITATIVE STUDY
Ryan Cummings, Deborah Davey, Bradley Myers, Aaron Keil
Physical Therapy, University of Illinois at Chicago, Chicago,
Illinois
PURPOSE/HYPOTHESIS: Recent literature indicates poor diagnostic accuracy for shoulder special tests during an evaluation. There is minimal evidence to determine if a change in diagnostic accuracy is influenced by the
use of special tests. This study attempts to add to the current literature.
Opinions vary on the importance of clinical special tests within a shoulder evaluation. The purpose of this study was to determine whether confidence in diagnostic hypotheses using shoulder special tests is dependent
on the years of experience and expertise.
NUMBER OF SUBJECTS: Ninety-five.
MATERIALS/METHODS: One hundred fifteen physical therapists responded
to an online survey distributed through the Orthopaedic Section of the
American Physical Therapy Association (APTA), in addition it was posted to several social medial platforms followed by orthopaedic physical
therapists. Survey respondents consisted of Doctors of Physical Therapy
(DPT) students on orthopaedic internships, physical therapists of less
than 1 year, 1 to 5 years, 5 to 10 years, and over 10 years of experience.
Survey was completed by 95 out of the 115 respondents, consisting of 46
females and 49 males, with a mean ± SD age of 32 ± 9.2 years. A 13-question survey included demographic questions related to number of years of
experience, and postgraduate clinical experiences or education. Questions
regarding confidence of diagnostic hypothesis during a shoulder evaluation were reported on a Likert scale 0 (not confident at all) to 5 (very confident). Clinicians’ primary influence during an evaluation for diagnostic
hypothesis was explored based upon years of experience and expertise.
Data were analyzed using IBM SPSS Statistics to determine if relationships exist between reported years of experience, postprofessional education and rated confidence levels following special tests.
RESULTS: No significant differences or correlations were found between
years of experience and confidence levels following the performance of
an orthopaedic shoulder evaluation. Significant differences (P<.05) were
found between groups with and without specialty certifications while performing the subjective portion of the evaluation; however, there were no
significant changes in confidence based upon objective and special test
outcomes. Physical therapists with postprofessional education showed no
significant differences between confidence levels following special tests.
CONCLUSIONS: Results indicate that the level of confidence during an orthopaedic shoulder evaluation remain constant and was not dependent
on years of experience or influenced by special tests. Less reliance on special tests was seen with increased years of experience.
CLINICAL RELEVANCE: The lack of significant changes in confidence between
years of experience and expertise, demonstrates less reliance on special
tests based upon responses. This study provides a foundational study for
further investigation on clinicians’ confidence with special tests in the
consideration of physical therapy education.
OPO56
FRONTAL PLANE PROJECTION ANGLE AND ACCELERATIONS DURING THE
SINGLE-LEG SQUAT WITH VISUAL PERTURBATION
Robert B. Dale, Taylor L. Price, Luke Ford, Katie Megahee,
Morgan Duncan, Nick Tolstick
Physical Therapy, University of South Alabama, Mobile, Alabama
PURPOSE/HYPOTHESIS: Faulty movement patterns provide the therapist
with information on the patient’s diagnosis and visual feedback to the
patient during such tasks is improves performance. The single-leg squat
(SLS) is one such functional test and the purpose of this study was to
compare frontal plane projection angles (FPPA) and accelerometer data
in the SLS with normal vision and with visual perturbation in healthy individuals to establish normative data. We hypothesized to see differences between the conditions and that visual perturbation would increase
movement variability but not necessarily FPPA.
NUMBER OF SUBJECTS: Thirty-eight healthy subjects (22 female, 16 male)
that were 24.7 ± 3.3 years old and weighed 74.1 ± 1.6 kg.
MATERIALS/METHODS: In a counter-balanced, repeated-measures design,
subjects performed squats in 2 visual conditions: Normal vision and then
while wearing visual perturbation strobe-glasses set at 30 Hz (OpuS USA,
West Milford, NJ). The squatting technique was performed in 2 conditions, single leg and also double-legged, which served as a control condition. Both squatting conditions required the subject to squat to 60°
of knee flexion using a predetermined seat target for consistency while
moving at an externally-paced metronome recording set to 30°/s. The
SLS required subjects to squat with the dominant leg. A smartphone was
attached to the subjects’ distal thigh, and data were exported using the
Sensor Kinetics Pro accelerometer application that recorded data at 30
Hz. Raw accelerometer data were filtered and a composite index was
computed for all 3 axes, and z-axis (mediolateral) data were also extracted for comparison. For the z-axis data, a coefficient of variation (COV)
was computed. The FPPA was calculated at the knee position of 60° with
the 2-dimensional HUDL technique video analysis application recording
at 30 Hz. Accelerometer data were subsequently compared with a condition by vision repeated measures ANOVA and post hoc paired t tests corrected for alpha inflation with the Bonferroni procedure using SPSS software (Version 22.0; IBM, Armonk, NY).
RESULTS: The FPPA grand mean was 174.5° ± 2°, and was not different between conditions (P>.05). For the composite axes data, we found significant main effects for vision (P = .034), condition (P<.001), and also the interaction of vision and condition. For the interaction, paired t tests showed
a significant difference (P = .04) between the SLS strobe (9.86° ± 0.07°)
compared to the SLS with normal vision (9.85° ± 0.6°). The SLS strobed
condition (0.82° ± 0.3°) also had a higher COV (P<.001) with the z-axis (mediolateral) data compared to SLS with normal vision (0.75° ± 0.3°).
CONCLUSIONS: This data show that despite a small FPPA angle of approximately 5°, accelerometer data revealed that subjects performed differently in
the various conditions, but particularly in the SLS with visual perturbation.
CLINICAL RELEVANCE: The oscillations detected by the smartphone accelerometer provide objective information about movement quality during the
SLS that are not associated with a large FPPA.
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OPO57
THE EFFECT OF GAIT CADENCE MODIFICATIONS ON KNEE JOINT LOAD
DURING WALKING
Christine Davis, Charles Homoky, Daniel Karam, Chieh Lo,
Kristofer Lopardo, Brennan Jackson, Alison H. Chang
Physical Therapy and Human Movement Sciences, Northwestern
University, Chicago, Illinois; Biomedical Engineering,
Northwestern University, Evanston, Illinois
PURPOSE/HYPOTHESIS: Knee osteoarthritis (OA) commonly affects the medial tibiofemoral (TF) and/or the patellofemoral (PF) compartments, and
often leads to disability and functional limitation. Elevated external knee
adduction moment (KAM) and external knee flexion moment (KFM)
during stance phase of gait increases medial TF and PF load respectively.
Greater KAM and KFM have been linked to OA disease progression and
subjective complaints of pain [1,2]. Many interventions aimed to lower
knee load during gait and ultimately slow disease progression [3-6]. A
previous study [7] showed that increasing runners’ cadence by 5% to 10%
reduced KFM and PF joint force. It is unclear whether this observation
translates into walking, a less demanding task. The purpose of this study
was to examine how cadence modifications at a fixed self-selected walking speed influence KAM and KFM during gait.
NUMBER OF SUBJECTS: Twelve persons contributing 24 knees.
MATERIALS/METHODS: Healthy participants ambulated on a split-belt treadmill at a self-selected speed and cadence. Following this control condition, participants underwent 2 randomized conditions: 10% increase in
cadence (+10%) and 10% decrease in cadence (–10%) at the same selfselected speed. KFM and KAM were measured using the instrumented
split-belt treadmill (R-Mill, Force Link, the Netherlands) and 10-camera
motion capture system (Qualisys, Sweden). After baseline control treadmill walking, participants were given 10 minutes to adapt to the altered
cadence for the 2 randomized conditions. Gait kinematics and kinetics
were processed and computed using the Visual3D software (C-Motion,
USA). A repeated-measures analysis of variance (ANOVA) was used to
compare the 3 conditions and Bonferroni post hoc tests for pairwise comparisons, with the peak KAM and KFM as dependent variables and the
varying cadences as independent variables.
RESULTS: Mean ± SD peak KAM was 2.004% ± 0.729% body weight·height
in the control condition, 2.096% ± 0.742% in +10% cadence, and 2.021%
± 0.649% in –10% cadence. Mean ± SD peak KFM was 4.252% ± 0.729%
body weight·height in the control condition, 3.800% ± 1.211% and
4.808% ± 1.486% in +10% and –10% cadence, respectively. KAM did not
differ among 3 conditions (F1.47,33.89 = 1.58, P = .22). KFM differed among
3 conditions (F2,46 = 46.73, P<.0005); +10% cadence resulted in 11% lower KFM and –10% cadence had the opposite effect of 13% greater KFM.
CONCLUSIONS: Walking with a faster cadence significantly reduced peak
KFM. Similar to the observations in runners, these results suggest that
increasing cadence is an effective strategy at reducing KFM, thereby reducing PF compressive forces during gait.
CLINICAL RELEVANCE: The findings of this study support a simple and effective approach to significantly reduce PF knee load, which may in turn relieve pain during walking. This creates a possible adjunct to therapy for
patients with PF pain or knee OA, as it may decrease load and pain during
daily ambulation. Further investigation is needed to examine the longerterm effect of this intervention on KAM, KFM, and subjective reports of
pain in patients with PF pain and/or knee OA.
OPO58
THE EFFECTS OF MYOFASCIAL RELEASE ON THE LATENCY OF DELAYEDONSET MUSCLE SORENESS
Duane S. Davis, Michael Piazza, Caleb Dodd, Kenneth C. Paz,
Joey Potesta, Kayla Weiser, Corrie A. Mancinelli
Human Performance and Exercise Sciences, West Virginia
University, Morgantown, West Virginia
PURPOSE/HYPOTHESIS: The purpose of this study was to determine the ef-
fectiveness of a manual myofascial release technique (MFRT) in reducing
the symptoms of delayed-onset muscle soreness (DOMS) in recreational athletes. Previous research has shown that many proposed treatments
for DOMS are not effective at reducing eccentric-induced muscle soreness. One of the most effective interventions has been shown to be manual massage. It is unclear if manual myofascial release is effective in reducing pressure pain threshold and perceived pain associated with DOMS.
NUMBER OF SUBJECTS: Thirty recreational athletes were recruited to participate in the investigation; however, 10 subjects did not develop sufficient
DOMS (operationally defined as greater than 20% decrease in pressure
pain threshold 48 hours postexercise) and were excluded from the study.
Thus, 20 adult athletes (16 women, 4 men) participated in this investigation. Mean ± SD for age was 24 ± 1.2 years.
MATERIALS/METHODS: Before the initiation of the eccentric protocol to create
DOMS, baseline perceived pain level and pressure pain threshold (PPT)
were assessed using the visual analog scale (VAS) and pressure algometry,
respectively. The PPT measurement sites were standardized according to
anatomic landmarks on the right thigh. Participants completed the DOMS
protocol, consisting of 5 sets of 25 eccentric quadriceps contractions on
a Cybex dynamometer. Forty-eight hours after the protocol completion,
pretreatment measurements were taken to establish the baseline level of
DOMS. Participants were randomly assigned to the treatment or control
group. The treatment group received the manual MFR technique on the
lateral side of the right thigh between the greater trochanter and lateral
epicondyle of the femur. Pressure pain threshold and VAS measurements
were collected at 5 minutes, 20 minutes, and 24 hours posttreatment. Data
were analyzed using a repeated measures ANOVA.
RESULTS: There was not a significant interaction effect between group and
time for PPT (P = .16) or VAS (P = .45). There was not a significant main
effect for group for PPT (P = .59) but there was for VAS (P = .01). There
was a significant main effect for time for both PPT (P< 0.03) and VAS
(P = .002).
CONCLUSIONS: Based on the results of this investigation, there is inconclusive evidence to support the use of myofascial release technique to reduce
pressure pain threshold in subjects with eccentric-induced delayed onset
muscle soreness. This study supports long-standing evidence that time is
perhaps the most effective treatment for reducing the symptoms of delayed onset muscle soreness. Further research with a larger sample size
and a higher dose of the treatment technique is warranted.
CLINICAL RELEVANCE: Healthcare providers, coaches, and athletes have long
sought to identify effective interventions to reduce and speed the recovery of eccentric-induced delayed onset muscle soreness. There is insufficient evidence at this time to support myofascial release techniques as an
effective treatment.
OPO59
EFFECTS OF SENSORIMOTOR TRAINING ON LIMITS OF STABILITY
POSTUROGRAPHY MEASURES IN HEALTHY INDIVIDUALS:
A PROOF-OF-CONCEPT INVESTIGATION
Duane S. Davis, Michael Priestas, Emily Hargreaves,
Shane Piatt, Chelsea Anderson, Stephen Armitage
Armitage, Human Performance and Exercise Sciences, West
Virginia University, Morgantown, West Virginia
PURPOSE/HYPOTHESIS: Nonacute low back pain (NALBP) is a common
condition in western cultures. Recent literature supports that individuals
with NALBP have altered sensorimotor and postural control. Identifying
the effectiveness and optimal dose of a sensorimotor training program
may offer a novel, nonopioid treatment alternative in this population.
Before conducting a randomized controlled trial (RCT) in individuals with NALBP, a proof of concept investigation with healthy subjects
was designed to provide preliminary data and assess the feasibility of the
training program. It is hypothesized that a properly dosed pragmatic sensorimotor training program will improve measures of posturography, re-
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duce pain, and improve function in individuals with NALBP.
NUMBER OF SUBJECTS: Twenty-four healthy adults (7 male, 17 female) participated in this investigation. Mean ± SD for age was 21.0 ± 1.6 years.
MATERIALS/METHODS: Participants were randomized to the treatment or
control group (n = 12 experimental, n = 12 control). The treatment group
participated in a 4-week (30 minutes, 2 times per week) pragmatic sensorimotor training program that included kinesthetic and graphesthesia
training, traditional motor control/strengthening exercises, and novel diaphragm/respiratory training with a SpiroTiger (SpiroTigerMedical) device. The control group received a 5-minute educational session that focused on the anatomy and biomechanics of the lumbar spine. Limits of
stability measures (reaction time, movement velocity, directional control.
and maximal excursion) were assessed using the Balance Master Version
7.0.9 at baseline and at 5 weeks.
RESULTS: Independent pooled t tests revealed no statistical differences between the treatment and the control groups for any of the tested variables; however, several variables approached the alpha level of .05. The
P value for reaction time in the forward direction was .06, and a post hoc
power analysis revealing that n = 27 subjects would be needed to have a
power of 0.80 with a raw effect size of 0.33 seconds.
CONCLUSIONS: This proof of concept investigation did not reveal a statistical difference between groups in healthy subjects over a 4-week training
program. It is hypothesized that the effect sizes will be larger in individuals with NALBP that have altered sensorimotor function. The training
protocol was designed for individuals with NALBP; thus, it is believed
that the treatment dose was insufficient for healthy individuals. When
translated to individuals with NALBP, the treatment duration will be extended to 8 weeks.
CLINICAL RELEVANCE: As movement system specialists, physical therapists
need to better understand how individuals with LBP move and respond to
targeted training programs to help prevent chronification and recurrence
of LBP. While the results of this study cannot be translated into clinical
practice, valuable information was obtained to help design an RCT for individuals with NALBP.
OPO60
SPINAL IMAGING IN PATIENTS WITH SYMPTOMATIC LOW BACK PAIN:
A SYSTEMATIC LITERATURE REVIEW
Jessica Davis, Daniel Rhon, Ben R. Hando, Robert Boyles
Wilford Hall Ambulatory Surgical Center, Lackland Air Force
Base, Texas; Physical Therapy School, University of Puget Sound,
Tacoma, Washington; Graduate Programs in Physical Therapy,
Baylor University, San Antonio, Texas; Manual Therapy
Fellowship, Evidence in Motion, Louisville, Kentucky
PURPOSE/HYPOTHESIS: Rates of advanced imaging in the lumbar spine continue to rise despite a growing body of literature indicating its limited
value for individuals with low back pain (LBP). Some studies have even
shown an increased risk of poor outcomes with overutilization of imaging. Systematic reviews have pooled data on abnormal findings in asymptomatic individuals with low back pain, however, no reviews to date have
included only symptomatic low back pain patients. Therefore, the purpose of this review was to identify the ratio of patients with abnormal
findings to those without in a population specifically with symptomatic
low back pain.
NUMBER OF SUBJECTS: Four thousand three hundred eighty-four total subjects with low back pain.
MATERIALS/METHODS: An online search was conducted on PUBMed for
studies published through May 2016. Search strategy included keywords
such as “low back pain,” “spine pain,” and “imaging,” “radiographs” or
“MRI,” and “asymptomatic,” “irrelevant,” and “incidental.” Studies were
included if authors reported the specific number of unique patients with
or without back pain, and excluded if they included only asymptomatic subjects. Only patients with low back pain were extracted from studies that included both symptomatic and asymptomatic patients for the fi-
nal count.
RESULTS: Out of 1389 potential studies, 11 were included in the final assessment, representing a total of 4384 subjects. Ages ranged from 14 to 86,
with a median age of 46. Of these, 1824 (41.6%) unique patients with low
back pain had an abnormal finding on imaging, while the majority 2560
(58.4%) had normal imaging reports. Large heterogeneity with reporting
methods, such as reporting number of findings versus unique individuals,
limits the studies from which counts of unique individuals can be extracted. In the studies analyzed, the majority of patients that sought medical
care for low back pain had normal findings. Most studies with longitudinal data related to pain and disability, showed no significant association
between changes in imaging abnormalities and changes in symptoms.
The exception was in Modic endplate changes, which showed a greater
association, at specific levels, with symptoms in some subsets of patients
with low back pain.
CONCLUSIONS: While spine abnormalities on imaging are common in asymptomatic individuals, this review found that they are also common in
symptomatic patients with low back pain. However, there were higher
rates of normal findings in symptomatic individuals compared to abnormal findings.
CLINICAL RELEVANCE: It may be more likely that patients seeking medical
care for low back pain have normal imaging findings than abnormal findings. Patients may still have high levels of pain and disability, and clinicians may need to focus on other education strategies that help explain
pain and the cause of symptoms to the majority of patients seeking care
for low back pain.
OPO61
THE RELATIONSHIP BETWEEN ELECTROMYOGRAPHIC ACTIVITY AND
PERCENT CHANGE IN MUSCLE THICKNESS OF THE SERRATUS ANTERIOR
Joseph M. Day, Robert B. Dale, Sean A. Hiller
University of South Alabama, Mobile, Alabama
PURPOSE/HYPOTHESIS: Research consistently demonstrates that individuals with shoulder pathologies are likely to have altered serratus anterior
(SA) muscle performance. Assessment of the SA using ultrasound imaging (UI) allows real-time visualization of the isolated changes in muscle
thickness. A reliable method for measuring SA thickness has been reported, yet the procedure has never been formally validated. The purpose of
this study was to determine the relationship between electromyography
(EMG) and percent change in thickness of the SA as measured by UI.
NUMBER OF SUBJECTS: Thirty subjects (mean ± SD age, 24 ± 2 years; 53%
male; 94% right-handed).
MATERIALS/METHODS: Healthy subjects were positioned in a standardized
sitting posture and anatomical landmarks were marked for ultrasound
probe and EMG surface electrode placement. Tegaderm occlusive dressing was applied over the electrode in order to prevent ultrasound gel from
interfering with the EMG signal. EMG activity of the SA was recorded
during rest, and subsequent isotonic EMG activity was normalized to the
subject’s maximum voluntary isometric contraction (MVIC). Subjects
were asked to raise the upper extremity from a resting position to 120° of
scaption for a total of 3 trials. Upper extremity elevation velocity was externally paced by previously recorded verbal instructions at a rate of 10°/s.
EMG activity was collected through the entire range of motion, while ultrasound images were taken at rest and at 120° of scaption. EMG signals were real-time conditioned with proprietary manufacturer software
(Sierra Wave). SA thickness measures were obtained post hoc with manufacturer software (Mindray MSK Z6). Percent change in thickness was
calculated by subtracting the average rest value from the average contractile value, and dividing the difference by the average rest value. A paired t
test was used to compare absolute resting from contractile values at 120°
of scaption both for EMG and ultrasound data. Pearson’s correlation coefficient was used to determine the relationship between the normalized
EMG activity at 120° of elevation and the ultrasound data.
RESULTS: There were significant increases in both EMG activity and ab-
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solute muscle thickness when comparing resting values to 120° of scaption (P<.001). There was a significant relationship between percent MVIC
EMG activity and the percent change in muscle thickness (P = .01) (r =
0.49, R2 = 0.26).
CONCLUSIONS: There is a moderate positive relationship between SA EMG
activity and percent change in muscle thickness as measured by UI.
However, more research is needed with a pathological population to validate the use of UI in measuring SA muscle performance.
CLINICAL RELEVANCE: UI has the potential to be used on the SA as a means
of assessment or biofeedback in a clinical setting.
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OPO62
PSYCHOSOCIAL FACTORS ASSOCIATED WITH DISABILITY IN PATIENTS
WITH CHRONIC LOW BACK PAIN
Justine Dee, Sharon Henry
Rehabilitation and Movement Science, University of Vermont,
Burlington, Vermont; Physical Therapy, University of Vermont
Medical Center, Burlington, Vermont
PURPOSE/HYPOTHESIS: The combination of physical and psychosocial
factors associated with improved outcomes in the care of chronic low
back pain (LBP) is unclear [1-5]. We assessed which factors were most
strongly associated with treatment success, regardless of physical therapy treatment. We hypothesized that psychosocial variables would correlate with and could predict the initial Oswestry Disability Index (ODI).
Furthermore, we hypothesized that psychosocial variables could predict
treatment success.
NUMBER OF SUBJECTS: Ninety-two subjects with chronic low back pain
(NCT01362049).
MATERIALS/METHODS: In this prospective study, subjects were treated for
6 weeks with a matched or unmatched treatment according to classification based on the Treatment Based Classification or Movement System
Impairment schema [1,6-8]. Primary outcome measures (ODI) were taken at pre and posttreatment, and at 6 and 12 months. Treatment success was defined as an 8% or greater reduction on the ODI from pre to
posttreatment [9]. In this planned secondary analysis, predictive variables included 5 psychosocial variables: the Fear-Avoidance Behavior
Questionnaire, Short Form (SF)-36, Patient Health Questionnaire
9 (PHQ9), Stanford Presenteeism Scale, and the Baecke Leisure
Questionnaire (BLQ). Pearson’s Correlation Coefficient was performed to
assess correlations between ODI scores and all 5 psychosocial variables.
A linear regression model determined the association between the initial
psychosocial variables and the initial ODI. Logistic regression was used
to determine if any psychosocial variables predicted treatment success.
RESULTS: Pearson’s Correlation Coefficient demonstrated significant correlations (0.22-0.46) between the initial ODI and initial psychosocial
measures except the BLQ. Also, there were moderate correlations (0.300.56) between the posttreatment ODI and the posttreatment psychosocial measures, (except the BLQ and the SF-36 mental health component).
Furthermore, post treatment ODI was highly correlated with all initial
psychosocial measures (0.31-0.55) except the BLQ. The linear regression
model demonstrated significant association between initial ODI and initial SF-36 (physical activity) score (P = .01) and the PHQ9 (P = .004).
Logistic regression modeling found treatment success significantly associated with initial ODI (P = .01) but not with any of the other psychosocial measures.
CONCLUSIONS: Our study demonstrated that initial psychosocial measures
are correlated with initial and posttreatment disability due to LBP and
that initial psychologic (PHQ9) and physical (SF-36 physical activity)
measures are predictive of initial disability. Both initial and 6 week ODI
score are predictive of treatment success.
CLINICAL RELEVANCE: An interdisciplinary approach is warranted in the
treatment of patients with LBP to reduce depression, address fear of
movement, and promote activity and participation. Using tools to assess
physical function and depression at the onset of treatment of LBP can
successfully screen patients to determine who may require additional services to promote reduction of LBP disability.
OPO63
MANUAL THERAPY FOR NONCARDIAC-RELATED CHEST WALL PAIN:
A CASE REPORT
Abby Dill, Michael O’Hearn, Jeffrey D. Clark
Lakeland Orthopedic Physical Therapy, Lakeland Health, Saint
Joseph, Michigan; Imove, Spring Lake, Michigan
BACKGROUND AND PURPOSE: Chest wall pain is one of the most common reasons individuals seek medical attention in the world. Because of the nature of the symptoms and the possible resemblance of signs and symptoms of a heart attack, chest wall pain accounts for 7.16 million visits to
the emergency room annually in the United States. Only about one third
are diagnosed with acute coronary symptoms and the remaining with
noncardiac chest pain. Patients with noncardiac chest pain continue to
experience chest pain for 1 to 11 years after the initial episode and almost half of noncardiac chest pain patients still believe they have a cardiac condition up to 1 year after negative cardiac evaluations. About 30%
of noncardiac chest pain patients are diagnosed with costochondritis. No
systematic reviews or clinical trials regarding optimal treatment for costochondritis have been identified. The purpose of this case report is to describe the successful treatment of a patient diagnosed with costochondritis and the important role physical therapy plays in easing anxiety over
chest wall pain.
CASE DESCRIPTION: A 29-year-old man presented with left sided anterior
chest wall pain that began insidiously about 1 year prior. His pain was described as a strong ache, rated 6/10 on the numeric pain rating scale. He
went to the emergency room on 2 separate occasions due his symptoms
and the fear of a heart attack, with negative findings. Significant past medical history included anxiety. Examination revealed: pain with left shoulder combined flexion, adduction and external rotation with overpressure,
seated AROM thoracic left rotation with overpressure and with palpation
of the left fourth to sixth costosternal joint, pain and hypomobility of the
upper thoracic spine and a positive left upper limb neural provocation test
with median nerve bias. Interventions included anterior to posterior mobilization at the left fourth to sixth costosternal joint, posterior to anterior
mobilization to the upper thoracic spine (T2-T7), pectoral stretching for
home and assurance that his chest wall pain was musculoskeletal.
OUTCOMES: Three physical therapy appointments resulted in improvements in: pain 0/10 at the worst, pain-free AROM thoracic rotation,
pain-free left shoulder combined flexion, adduction and external rotation,
negative neural provocation testing, Neck Disability Index score: 0/100,
and decreased anxiety.
DISCUSSION: Costochondritis is a common cause of noncardiac chest pain.
This case report details the successful treatment of a 29-year-old man
with a diagnosis of costochondritis who reported to the emergency department on 2 separate occasions due to the nature of his chest pain.
Physical therapy assessment clearly reproduced the patient’s pain, which
had not occurred in previous medical visits. Earlier multimodal therapy
intervention could have saved unnecessary visits to the emergency department and improved his quality of life sooner.
REFERENCES: 1. Eken C, Oktay C, Bacanli A, et al. Anxiety and depressive
disorders in patients presenting with chest pain to the emergency department: a comparison between cardiac and noncardiac origin. J Emerg
Med. 2010;39:144-150. 2. Ayloo A, Cvengros T, Marella S. Evaluation and
treatment of musculoskeletal chest pain. Prim Care. 2013;40:863-887. 3.
Jonsbu E, Dammen T, Morken G, Moum T, Martinsen EW. Short-term
cognitive behavioral therapy for noncardiac chest pain and benign palpitations: A randomized controlled trial. J Psychosom Res. 2011;70:117123. 4. Proulx A. Costochondritis: diagnosis and treatment. Am Fam
Physician. 2009;80:617-620 5. Yelland M. Back, chest and abdominal
pain: how good are spinal signs at identifying musculoskeletal causes of
back, chest or abdominal pain? Aust Fam Physician. 2001;30:908-912.
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OPO64
DOES THE DIRECTION OF ELASTIC TAPE APPLICATION INFLUENCE
JUMPING ABILITY IN ASYMPTOMATIC INDIVIDUALS?
Michelle Dolphin, Adam Rufa, Gary Brooks
Physical Therapy Education, Upstate Medical University,
Syracuse, New York
PURPOSE/HYPOTHESIS: Elastic tape is commonly used for athletic performance enhancement. One of the proposed mechanisms for the effects of
elastic tape is changes in local muscle contractions. This study examined
the short term effects of the direction of elastic tape application to the
quadriceps muscle on 2 jumping tasks.
NUMBER OF SUBJECTS: Fifteen.
MATERIALS/METHODS: Fifteen healthy subjects (9 female, 6 male), with a
mean age of 23 years, participated in this pilot study. Using a crossover
design, subjects were tested over 2 sessions with a one-week washout period between sessions. All subjects were naïve to the use of elastic tape.
Each session began with a 5-minute warm-up followed by baseline triple hop and vertical jump testing. Following baseline testing, tape with
a “Y” cut was applied with 25% tension to the quadriceps muscle on the
dominant leg in a distal-to-proximal or proximal-to-distal direction, and
subjects were re-tested. Triple hop distance with the dominant leg and
vertical jump height were measured over 3 trials. The mean and maximum scores of the 3 trials were computed for each participant under each
taping condition. One week later, subjects repeated all testing with tape
applied in the direction opposite to their initial testing. The direction of
tape application was randomized and subjects, testers and the data analyst were blinded to the direction of tape application.
RESULTS: Mean triple hop distance increased by 13.6 cm when taped proximal to distal, and decreased by 0.7 cm when taped distal to proximal (P
= .046). Maximum triple hop distance increased by 9.4 cm when taped
proximal to distal, and decreased by 3.8 cm when taped distal to proximal
(P = .33). There were no significant baseline-taped differences in vertical
jump scores according to taped condition.
CONCLUSIONS: The results of this study suggest that the application of elastic tape may have an impact on hopping distance but not on jumping
height. The direction of tape application was associated with hopping distance. This is a pilot study and may not be powered by enough subjects to
detect a minimal difference. These finds are interesting however and may
be worth exploring in further studies.
CLINICAL RELEVANCE: The effects seen in this study were small and limited
to 1 of the functional tests. As a result, clinicians should remain skeptical
of the claim that the application of elastic tape has an impact on lower extremity functional performance.
OPO65
THE USE OF DROPOUT CASTING IN A PATIENT WITH PERSISTENT
KNEE FLEXION CONTRACTURE POST–ANTERIOR CRUCIATE LIGAMENT
RECONSTRUCTION
Melissa Dreger, Laura A. A. Schmitt, Airelle O. Giordano
Physical Therapy, University of Delaware, Newark, Delaware
BACKGROUND AND PURPOSE: Research has shown that loss of extension following anterior cruciate ligament reconstruction (ACLR) may be related to limited preoperative extension and effusion [2]. Other factors that
may also impact knee extension include concomitant injury and postinjury stiffness [4]. However, treatment of those who have a loss of extension has been limited in the research community, with very little evidence
available on the use of dropout casting [1,3]. The purpose of this case
study is to demonstrate the effectiveness of drop out casting in a patient
with a loss of knee extension following ACLR.
CASE DESCRIPTION: Patient is a 45-year-old woman who was initially seen
preoperatively for L ACL tear, grade 2 MCL tear and medial meniscus
tear. After failure to improve in her range of motion (ROM), she underwent surgical intervention with a knee flexion contracture (although not
recommended), including manipulation under anesthesia, ACLR with allograft, a partial meniscectomy, and synovectomy. At initial postoperative
evaluation, impairments on the involved side included lacking 1° of knee
extension to 55° of knee flexion, 28% quadriceps MVIC, and KOS ADL
score of 20%. Although patient did make gains in knee ROM, quadriceps
strength, and function over the initial postoperative 8 week period, her
knee extension ROM began to regress (up to lacking 9°). After no resolution of flexion contracture for 2 weeks, a dropout cast was utilized for a
total of 6 weeks to provide low-load long duration (LLLD) stretching to
assist with improving knee extension ROM while physical therapy continued to emphasize quadriceps strengthening and improved functional
use of knee extension. Provided treatment included quadriceps strengthening, NMES, gait training, and manual therapy. After she consistently
presented with full knee extension between and during visits for 2 weeks,
the cast was gradually weaned from use.
OUTCOMES: Postoperatively, the patient was seen for a total of 50 visits
over 24 weeks. At the first visit following initiation of the dropout casting, patient demonstrated a 6° improvement in knee extension ROM that
maintained for 8 visits over 2 weeks. The cast was remade after the LLLD
stretching was no longer increasing range due to loosening at that time.
Following a second casting intervention for an additional 8 visits over a
2-week period, patient demonstrated further improvement in ROM (3°4°) that remained until discharge. From baseline to discharge, the patient
made a 7° improvement (lacking 2°) in knee extension ROM overall. KOS
ADL scores also made a clinically significant improvement to 79% following the implementation of the dropout cast while quadriceps strength also
improved to 114% MVIC [5].
DISCUSSION: This case study demonstrates the effectiveness of dropout
casting in a patient with loss of knee extension following ACLR. However,
additional research should be completed to determine the best parameters for usage and number of casts needed per person.
REFERENCES: 1. Logerstedt D, Sennett B. Case series utilizing drop-out
casting for the treatment of knee joint extension motion loss following
anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther.
2007;37:404-411. 2. Mauro CS, Irrgang JJ, et al. Loss of extension following anterior cruciate ligament reconstruction: analysis of incidence
and etiology using IKDC criteria. Arthroscopy. 2008;24:146-153. 3. Pace
JL, Nasreddine AY, et al. Dynamic splinting in children and adolescents
with stiffness after knee surgery. J Pediatr Orthop. 2016. 4. Robertson,
GA, Coleman SG, Keating JF. Knee stiffness following anterior cruciate ligament reconstruction: the incidence and associated factors of
knee stiffness following anterior cruciate ligament reconstruction. Knee.
2009;16:245-247. 5. Williams VJ, Piva SR, et al. Comparison of reliability and responsiveness of patient-reported clinical outcome measures in
knee osteoarthritis rehabilitation. 2012;42:716-723.
OPO66
THE USE OF A MODIFIED TENDON-LOADING PROGRAM IN A PATIENT
WITH COMPLEX UNILATERAL ACHILLES TENDON REPAIR
Melissa Dreger, Jennifer A. Zellers, Airelle O. Giordano,
Karin G. Silbernagel
Physical Therapy Clinic, University of Delaware, Newark,
Delaware; Program in Biomechanics and Movement Science,
University of Delaware, Newark, Delaware; Department of
Physical Therapy, University of Delaware, Newark, Delaware
BACKGROUND AND PURPOSE: Acute Achilles tendon rupture is commonly
treated via surgical repair. However, a serious complication to surgery is
infection, with superficial wound infection occurring in 4% to 20% and
deep wound infection in 1% to 2% of patients [1,4]. The most optimal
treatment following postoperative wound infection is undescribed [4].
This case study describes the use of a comprehensive rehabilitation program including gradual tendon loading on a patient post–Achilles tendon
repair complicated by deep wound infection.
CASE DESCRIPTION: This case is a 63-year-old man 6 months post–Achilles
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tendon repair, followed by multiple debridements and wound vacuum
(VAC) closure. The most recent debridement was 3 months prior to initiation of physical therapy (PT). Diagnostic ultrasound imaging revealed
an in-tact, hypoechoic tendon repair with osteotomy on the ruptured side
and tendinosis on the nonruptured side. Upon initial evaluation, the patient presented with weakness of the ankle musculature with an inability to perform a unilateral heel-rise. Limb symmetry indexes [LSI = (affected/unaffected) × 100%] showed 66% inversion, 78% eversion, and
79% dorsiflexion asymmetries [6]. Functionally, the patient reported
moderate to severe disability evidenced by Victorian Institute of Sports
Assessment-Achilles Questionnaire (VISA-A) score of 50/100 on nonrupture side, Achilles Tendon Total Rupture Score (ATRS) of 31/100 on ruptured side, and Patient Specific Functional Scale (PSFS) average of 4/10
points [2,3,5]. The patient was seen by PT for 24 visits over 4 months.
Rehabilitation emphasized gradual tendon loading, using a slow progression of heel rises following the pain-monitoring model. Balance activities,
gait retraining, and functional/neuromuscular electrical stimulation were
also included in the patient’s plan of care.
OUTCOMES: Midway through the patient’s PT course, ankle, inversion,
eversion, and dorsiflexion LSI improved to 94%, 99%, and 104%, respectively. At discharge, the patient had a VISA-A score of 89/100, ATRS
score of 57/100, and PSFS average score of 7/10. The patient was also
able to complete the heel-rise test, performing 189 J total work, 7 repetitions, and maximum heel-rise height of 4 cm on ruptured and 906 J, 26
repetitions, and 6.7 cm maximum heel-rise height on nonruptured sides.
DISCUSSION: A multimodal PT plan of care, incorporating gradual tendon loading yielded positive functional outcomes, evidenced by improved
clinical and patient self-reported outcomes, in an individual following
Achilles tendon repair with a complex healing course.
REFERENCES: 1. Bhandari M, Guyatt G, Siddiqui, et al. Treatment of acute
Achilles tendon ruptures: a systematic overview and metaanalysis. Clin
Orthop Relat Res. 2002;400:190-200. 2. Horn KK, Jennings S, et al.
The Patient-Specific Functional Scale: psychometrics, clinimetrics, and
application as a clinical outcome measure. J Orthop Sports Phys Ther.
2012;42:30-42. 3. Nilsson-Helander K, Thomee R, et al. The Achilles
tendon Total Rupture Score (ATRS): development and validation. Am J
Sports Med. 2007;35:421-426. 4. Pajala, A, Kangas, J, et al. Rerupture
and Deep infection following treatment of total Achilles tendon rupture.
J Bone Joint Surg Am. 2002;84-A:2016-2021. 5. Robinson JM, Cook JL,
et al. The VISA-A questionnaire: a valid and reliable index of the clinical
severity of Achilles tendinopathy. Br J Sports Med. 2001;35:335-341. 6.
Silbernagel KG, Nilsson-Helander K, et al. A new measurement of heelrise endurance with the ability to detect functional deficits in patients
with Achilles tendon rupture. Knee Surg Sports Traumatol Arthrosc.
2010;18:258-264.
OPO67
TIBIAL PLATEAU FRACTURE IN A PROFESSIONAL MUSICAL ATHLETE
PARTICIPATING IN DRUM CORPS INTERNATIONAL: A CASE REPORT
Carolyn A. Drislane, Cora Ray, Skye Donovan
Physical Therapy, Marymount University, Arlington, Virginia;
Athletic Training, Western Kentucky University, Bowling Green,
Kentucky
BACKGROUND AND PURPOSE: Drum Corps International (DCI), beginning
only 30 years ago, is the most popular activity of professional musical
athletes today. Considered the “Marching Music’s Major League,” DCI
has more than 5000 top musicians participate every year. With performers ranging from 13 to 22 years in age, DCI is considered to be one of
the fastest growing youth activities in America. Membership in DCI requires significant mental and physical strength, increased biomechanical
demands directly related to performing with instruments while marching, and demanding time commitments. Performers may be at risk of sustaining musculoskeletal injuries due to the repetitive nature of the activities performed during practice and performance. The most common
injuries are over-use injuries including stress fractures of the lower extremity (hip, tibia, and metatarsals) and tendinopathy (dependent performer’s instrument). The purpose of this case report is to describe the
diagnosis of a closed transverse tibial plateau fracture in a musical athlete. Additionally, this case will highlight an area of emerging practice for
physical therapists through the importance of screening professional musicians, especially those in DCI, for biomechanical abnormalities to aid in
prevention of injuries.
CASE DESCRIPTION: This case report examines a 20-year-old male mellophone player in Carolina Crown Drum and Bugle Corps. The subject was
a healthy musician who had history of tibialis anterior tendinitis in the
left leg 1 year prior to participation. No other medical issues were reported in the preseason physical performed by his primary care physician. At
Crown, he rehearsed 8 to 10 hours a day, 7 days a week over 12 weeks. He
was treated by a certified athletic trainer who was on site the entire season.
OUTCOMES: Ten days before his final performance, the patient reported a
constant dull pain in his L LE. After evaluation, his ATC gave an initial diagnosis of tendinitis and performed conservative treatment: L tibial taping, ice therapy after every rehearsal and show and ibuprofen as needed
for pain. During his final performance, he fell over and was rushed off the
field by sideline medics. The patient was taken to the emergency room
where X-ray revealed a tibial plateau fracture. He immediately underwent surgery which included placement of intramedullary rod and screws
to oppose the ends of the fracture. The patient recovered unsatisfactorily after initial operation due to mal-union of apposed fracture ends. The
patient underwent a second surgery to correct and realign the injury. The
patient recovered satisfactorily after second surgery and underwent physical therapy to return to performing.
DISCUSSION: This case report describes an extreme injury sustained during a single season of drum corps. Drum corps is a unique activity that
would benefit from the involvement of physical therapists. By specializing
in prevention, assessment, treatment and education of these athletes, better care can be provided and severe injury can be prevented.
REFERENCES: 1. Moffitt DM, Russ AC, Mansell JL. Marching band camp injury rates at the collegiate level. Med Probl Perform Art. 2015;30:96-99.
2. Beckett S, Seidelman L, Hanney WJ, Liu X, Rothschild CE. Prevalence
of musculoskeletal injury among collegiate marching band and color
guard members. Med Probl Perform Art. 2015;30:106-110. 3. Kilanowski
JF. Marching athletes: injuries and illnesses at band camp. MCN Am
J Matern Child Nurs. 2008;33:338-345; quiz 346-347. 4. Hatheway
M, Chesky K. Epidemiology of health concerns among collegiate student musicians participating in marching band. Med Probl Perform Art.
2013;28:242-251. 5. Steinmetz A, Màöller H, Seidel W, Rigotti T. Playingrelated musculoskeletal disorders in music students-associated musculoskeletal signs. Eur J Phys Rehabil Med. 2012;48:625-633. 6. Kok LM,
Vlieland TPV, Fiocco M, Nelissen RG. A comparative study on the prevalence of musculoskeletal complaints among musicians and nonmusicians.
BMC Musculoskelet Disord. 2013;14:9-15. 7. Guptill CA. The lived experience of professional musicians with playing-related injuries: a phenomenological inquiry. Med Probl Perform Art. 2011;26:84-95.
OPO68
EFFECT OF FREE-SWING GAIT TRAINING ON BACK PAIN IN A PATIENT
WITH BILATERAL AMPUTATION: A CASE REPORT
Cassie Duff, Megan Flores
Doctor of Physical Therapy Program, University of St Augustine
for Health Sciences, Austin, Texas
BACKGROUND AND PURPOSE: Back pain is a common occurrence in persons with a lower extremity amputation, and can cause a chronic disability. Early prosthetic gait training can prevent patients with amputations
from becoming disabled by chronic back pain. One technique for patients
learning to walk with a prosthesis is free-swing gait training. This method
of gait training includes unlocking the knee component of the prosthesis
and leaving it unlocked throughout the gait cycle. Ambulation with an un-
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locked prosthesis requires the patient to exhibit confidence in his or her
balance capabilities and ability to control where his or her weight is being placed throughout the gait cycle. Free swing gait training has the potential to reduce the number of gait deviations these patients would normally adopt during ambulation. However, there is a lack of evidence for
the benefits of free-swing gait training on decreasing back pain. The purpose of this case study is to describe the effect of free-swing gait training
on low back pain in a patient with bilateral lower extremity amputation.
CASE DESCRIPTION: The patient was a 57-year-old Caucasian man with a
history of left transtibial amputation and recent right transfemoral amputation. He was referred to physical therapy for education on using his new
transfemoral prosthetic and to improve functional independence. One of
his chief complaints was debilitating low back pain that had increased
since his latest amputation. It was hypothesized that the normalization of
the patient’s gait pattern through free-swing gait training would decrease
his complaint of back pain.
OUTCOMES: Upon initial evaluation, the patient reported pain of 6/10 in
both shoulders and low back, as measured by the Numerical Rating Scale.
The Outpatient Physical Therapy Improvement in Movement Assessment
Log (OPTIMAL) was administered to assess the patient’s self-confidence
when performing different functional activities. He scored a 34/60 on the
initial OPTIMAL, indicating he felt approximately 60% impaired with his
ability to perform daily activities in his home and in the community. After
8 weeks of physical therapy, including 3 weeks of free-swing gait training, the patient’s OPTIMAL score decreased to 20/60, indicating he felt
more confident being able to perform functional activities out in the community. Additionally, he reported a decrease in bilateral shoulder and low
back pain to 0/10. The patient also improved with ambulation from an initial distance of 50 ft with a rolling walker and physical assistance, to 300
ft with a rolling walker independently utilizing a free-swing gait pattern.
DISCUSSION: After an intervention of free-swing gait training, the patient
demonstrated decreased low back pain, increased strength, and improved
gait quality and distance. The results of this case report demonstrate that
the use of free-swing gait training can be beneficial to decrease back pain
in a patient with bilateral amputation.
REFERENCES: Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison
TG, Brookmeyer R. Estimating the prevalence of limb loss in the
United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89:422429. Pasquina PF, Miller M, Carvalho AJ, et al. Special considerations
for multiple limb amputation. Curr Phys Med Rehabil Rep. 2014;2:273289. Prinsen EC, Nederhand MJ, Rietman JS. Adaptation strategies of
the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review. Arch Phys Med Rehabil.
2011;92:1311-1325. Gailey R. Review of secondary physical conditions
associated with lower-limb amputation and long-term prosthesis use.
J Rehabil Res Dev. 2008;45:15-30. Devan H, Hendrick P, Ribeiro DC,
Hale L a, Carman A. Asymmetrical movements of the lumbopelvic region: is this a potential mechanism for low back pain in people with lower limb amputation? Med Hypoth. 2014;82:77-85. Bae TS, Choi K, Hong
D, Mun M. Dynamic analysis of above-knee amputee gait. Clin Biomech
(Bristol, Avon). 2007;22:557-566. Dillingham TR, Pezzin LE, Shore AD.
Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations. Arch Phys Med Rehabil. 2005;86:480486. Ehde DM, Czerniecki JM, Smith DG, et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after
lower limb amputation. Arch Phys Med Rehabil. 2000;81:1039-1044.
Kulkarni, J, Gaine, WJ, Rankine, JJ, Adams J. Chronic low back pain in
traumatic lower limb amputees. Clin Rehabil. 2005;19:81-86. Williamson
A, Hoggart B. Pain: a review of 3 commonly used pain rating scales.
2005;1994 (Spence 2000):798-804. Guccione AA, Mielenz TJ, Robert
F, et al. Research report development and testing of a self-report instrument to measure actions: Outpatient Physical Therapy Improvement in
Movement Assessment Log (OPTIMAL). Phys Ther. 2005;85:515-530.
OPO69
MOVEMENT AND SUSTAINED FUNCTIONAL ACTIVITY NECK PAIN RATINGS:
A USEFUL ADDITION TO MEASURE IMPROVEMENT?
Kim Dunleavy, Charles W. Gay, Mark Bishop
Physical Therapy, University of Florida, Gainesville, Florida
PURPOSE/HYPOTHESIS: Neck pain is common disorder managed by physical
therapists. However, there is a need for additional intermediate measures
of clinical improvement in disability for clinicians to monitor progress.
Range of motion and motor control are weakly associated with disability,
and resting pain is only moderately related to disability. Measures of movement-related pain account for unique variance in self-reported disability,
beyond the variance accounted for by a traditional measure of neck pain
suggesting these additional specific pain-related metrics may be more sensitive to track clinical improvement. Therefore, the purpose of this study
was to investigate whether fluctuations in pain related to movement and
sustained positions account for unique fluctuations in self-reported disability not accounted for by traditional measures of pain intensity.
NUMBER OF SUBJECTS: Eighty-seven people with moderate (approximately
3/10) chronic mechanical neck pain (mean ± SD age, 56 ± 8 years; 85%
female; NDI, 13 ± 6) completed 18 weeks of self-reported disability, intensity of neck pain, pain with movement, and pain with sustained activities.
MATERIALS/METHODS: Secondary analysis of data collected for a therapeutic
exercise intervention study. Disability was assessed with the neck disability index (NDI). Spontaneous pain intensity, pain with movement (personal care, lifting, overhead activities, meal prep, housework) and sustained
activities (driving, reading, computer use, sleeping, work, sitting, standing) were assessed using 11-point numeric rating scales. Multilevel modeling for change was used to address within-person and between-person
questions about changes in NDI simultaneously. NDI was the dependent
variable in all models with neck pain intensity, age, and treatment group
included as baseline model predictors. Subsequent models included the
same predictors and added measures of movement-evoked pain. A final
parsimonious model was constructed with significant (P<.05) pain characteristic predictors.
RESULTS: The baseline model explained 39% of the variance in NDI. The
final parsimonious model (–2LL = 3964, AIC = 3974, BIC = 3998) explained 47% of the variance in NDI and showed a significant improvement in model fit statistics (χ2 = 350, df = 2, P<.01) compared to the baseline model.
CONCLUSIONS: The final model showed that fluctuations in disability covaried with the intensity of spontaneous pain and pain with sustained activities while the intensity of movement-evoked neck pain explained individual differences in the trajectory of disability improvement. These results
suggest that pain related to movement and sustained activities represent
disability-relevant dimensions of neck pain not captured by traditional
measures of spontaneous pain.
CLINICAL RELEVANCE: Movement and sustained activity- related pain ratings are a useful, fast and simple, additional measure for clinicians to assess. Fluctuations in activity-specific pain help explain variations in patient disability over time and distinguish between patients and may be
useful for clinicians to assess intermediate changes.
OPO70
EPIDEMIOLOGY OF HIP FLEXOR AND ADDUCTOR STRAINS IN NATIONAL
COLLEGIATE ATHLETIC ASSOCIATION ATHLETES, 2009/10-2014/15
Timothy Eckard, Zachary Y. Kerr, Darin Padua,
Thomas P. Dompier, Aristarque Djoko
Human Movement Science Curriculum, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina; Datalys
Center for Sports Injury Research and Prevention, Indianapolis,
Indiana
PURPOSE/HYPOTHESIS: The purpose of this study was to describe the epidemiology of hip flexor and adductor strains across 25 NCAA championship
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sports during the 2009-2010 to 2014-2015 academic years.
NUMBER OF SUBJECTS: Six hundred nineteen hip flexor and 464 hip adductor strains.
MATERIALS/METHODS: The NCAA Injury Surveillance Program (NCAAISP), a prospective injury surveillance program, utilized a convenience
sample of NCAA varsity teams from 25 sports with athletic trainers reporting injury data. Rates and patterns of hip flexor and adductor strains
sustained during collegiate sports were examined. Analyses included
strain rates and distributions of injuries by injury mechanism, recurrence,
and participation restriction time. Injury rate ratios (IRRs) were calculated to compare rates within sports by event type and to compare overall rates by sex among sex-comparable sports. Injury proportion ratios
(IPRs) were calculated to examine sex differences in injury mechanism,
recurrence, and participation restriction time in sex-comparable sports.
All 95% confidence intervals (CIs) not including 1.00 were considered
statistically significant.
RESULTS: Six hundred nineteen hip flexor and 464 hip adductor strains occurred in the study period, representing overall injury rates of 1.26/10 000
athlete-exposures (AE) and 0.96/10 000 AE, respectively. The majority
of hip flexor (73.1%) and adductor strains (72.9%), occurred in practices, though both had higher rates in competition (hip flexor 1.38 versus
0.85/10 000 AE; IRR = 1.63; 95% CI: 1.33, 2.00); (hip adductor 1.86 versus 1.13/10 000 AE; IRR = 1.65; 95% CI: 1.38, 1.97). Among sex-comparable sports, the hip flexor strain rate was higher in men than women (1.51
versus 0.97/10 000AE: IRR = 1.56; 95% CI: 1.28, 1.90), with no difference
between the sexes in rate of hip adductor strains (0.89 versus 0.76/10 000
AE; IRR = 1.18; 95% CI: 0.93, 1.49). Noncontact was the mechanism for
most hip flexor (62.4%) and adductor strains (65.7%); 11.1% of hip flexor
strains, and 11.4% of adductor strains, were recurrent. 80.0% of hip flexor strains and 82.3% of adductor strains resulted in less than 1 week of
participation restriction, and over 50% of each were NTL. No differences
were found between sex-comparable sports in mechanism, recurrence, or
participation restriction.
CONCLUSIONS: The majority of hip flexor and adductor strains occurred in
practice, were due to noncontact, and resulted in less than 1 week participation restriction. In sex-comparable sports, men experienced a higher
rate of hip flexor, but not adductor, strains than women, and no differences were found in mechanism, recurrence, or participation restriction.
CLINICAL RELEVANCE: This study provides a baseline from which to develop
improved recommendations for the prevention and rehabilitation of hip
flexor and adductor strains that are both sport- and mechanism-specific.
Evaluating the effectiveness of prevention programs is not possible without accurate baseline data.
OPO71
EPIDEMIOLOGY OF QUADRICEPS STRAINS IN NATIONAL COLLEGIATE
ATHLETIC ASSOCIATION ATHLETES, 2009/10-2014/15
Timothy Eckard, Darin Padua, Aristarque Djoko,
Thomas P. Dompier, Zachary Y. Kerr
Human Movement Science Curriculum, University of North
Carolina at Chapel Hill, Chapel Hill, North Carolina; Datalys
Center for Sports Injury Research and Prevention, Indianapolis,
Indiana
PURPOSE/HYPOTHESIS: This study was designed to describe the epidemiology of quadriceps strains in collegiate athletics during the 2009-2010
to 2014-2015 academic years utilizing a convenience sample of NCAA
programs from 25 sports during the 2009-2010 to 2014-2015 academic years.
NUMBER OF SUBJECTS: Five hundred twelve quadriceps strains.
MATERIALS/METHODS: The NCAA Injury Surveillance Program (NCAAISP), a prospective injury surveillance program, utilized a convenience
sample of NCAA varsity teams from 25 sports with athletic trainers reporting injury data. Data were analyzed to assess rates and patterns of
quadriceps strains sustained during collegiate sports. Analyses included
quadriceps strain rates and distributions of injuries by injury mechanism,
recurrence, and participation restriction time. Injury rate ratios (IRRs)
were calculated comparing rates within sports by event type and time in
season. IRRs were also used to compare overall rates by sex among sexcomparable sports. Injury proportion ratios (IPRs) were calculated to examine sex differences in distributions of injury mechanism, recurrence,
and participation restriction time. All 95% confidence intervals (CIs) not
including 1.00 were considered statistically significant.
RESULTS: The overall rate of quadriceps strains during the study period
was 1.04/10 000 athlete-exposures (AE). The sports with the highest rates
were women’s soccer (5.57/10 000 AE), men’s soccer (2.49/10 000 AE),
and women’s softball (2.12/10 000 AE) Across sex-comparable sports,
women had a higher rate of quadriceps strains than men overall (1.91 versus 0.63/10 000 AE: IRR = 3.03; 95% CI: 2.44, 3.76). The majority of
quadriceps strains (77.9%) were sustained during practice. However, the
rate was higher during competition (1.25 versus 1.00/10 000 AE; IRR =
1.25; 95% CI: 1.02, 1.54). Most quadriceps strains (57.8%) occurred in the
preseason and rates were significantly higher during the preseason than
the regular season (2.23 versus 0.62/10 000 AE; IRR = 3.60; 95% CI:
3.02, 4.31). Common injury mechanisms included noncontact (62.9%)
and overuse (22.1%). Most quadriceps strains (79.9%) resulted in participation restriction time less than 1 week.
CONCLUSIONS: Across 25 sports, higher quadriceps strain rates were found
in females versus males, in competitions versus practices, and in the preseason versus the regular season. The incidence of quadriceps strains in
NCAA athletics was lower than hamstring strains but higher than other
strains in the lower extremities. Most quadriceps strains resulted in participation restriction under 1 week.
CLINICAL RELEVANCE: This study provides a baseline from which to develop improved recommendations for the prevention and rehabilitation of quadriceps strains that are both sport- and mechanism-specific.
Evaluating the effectiveness of prevention programs is not possible without accurate baseline data.
OPO72
DIFFERENCES BETWEEN DYNAMIC FUNCTIONAL TESTING AND PRESSURE
PAIN THRESHOLD VALUES IN FEMALE DISTANCE RUNNERS WITH AND
WITHOUT A PRIOR INJURY HISTORY
Brian J. Eckenrode, Tara Chadwick, Justin Gardner,
Lauren Nederostek
Physical Therapy, Arcadia University, Glenside, Pennsylvania
PURPOSE/HYPOTHESIS: A prior injury history and being female has been
shown to be associated with an increased risk for sustaining a running-related injury (RRI). These overuse injuries can frequently recur or become
chronic. Muscle weakness, temporal parameters, and altered biomechanics have been described as potential contributors to RRIs. Recently theorized, individuals with greater localized hyperalgesia from chronic lower
extremity conditions may also exhibit altered lower extremity mechanics
from increased nociceptive input. The purpose of this pilot study was to
investigate differences between dynamic functional testing and pressure
pain threshold (PPT) values in female distance runners with and without
a prior injury history.
NUMBER OF SUBJECTS: Sixteen female runners (mean ± SD age, 23 ± 3.4
years) were recruited from the local university community. Inclusion criteria consisted of running a minimum of 1.5 hours per week for at least
6 weeks prior to testing. Subjects had a mean ± SD body mass index of
24.02 ± 2.12 kg/m2, and had reported running for a mean 7.11 ± 3.74 years
at an average of 18.89 ± 9.40 mi/wk.
MATERIALS/METHODS: A running activity and injury questionnaire, Pain
Catastrophizing Scale, and Lower Extremity Functional scale was completed by all subjects prior to testing. Functional performance testing was
assessed via the Y Balance Test (YBT), and PPT was quantified at 6 different lower extremity sites bilaterally with a digital pressure algometer.
RESULTS: Of the 16 subjects, 8 had reported a prior history of lower ex-
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tremity injury requiring time off from running and medical treatment. No
significant differences were found between prior injury history and running pace, running volume, or years running. There was a significant difference for runners with an injury history to have a greater than 4 cm side
to side difference on the YBT (P = .009), in addition to a significant difference for YBT absolute difference between extremities (P = .030). For
PPT, no significant difference in pain threshold values between groups
was found. There was a fair to moderate correlation (ICC range, 0.460.62) between YBT composite score and PPT at both the distal tibia and
patella retinaculum in this group of runners.
CONCLUSIONS: Female runners with a prior history of lower extremity injury exhibited greater asymmetry with dynamic functional testing compared to the uninjured group. While no significant differences were found
between groups for PPT values in the lower extremity, there was a fair to
moderate association between YBT scores and PPT of the distal tibia and
patella retinaculum. Further investigations should expand on the relationship between lower extremity functional performance and running
mechanics on PPT.
CLINICAL RELEVANCE: Female distance runners with a prior history of a RRI
may exhibit continued deficits in dynamic functional testing. The relationship between nociceptive changes and functional performance in
should be considered in the management of those runners with a prior
injury history.
OPO73
ANODAL TRANSCRANIAL DIRECT-CURRENT STIMULATION RESULTS
IN INCREASED MAXIMUM ISOMETRIC TRUNK EXTENSOR STRENGTH
IN HEALTHY SUBJECTS
Emily Ellerbrock, Cody Chabola, Megan E. Applegate,
Gabrielle Hausfeld, Jacob Magary, James S. Thomas
Rehabilitation and Communication Sciences, Ohio University,
Athens, Ohio
PURPOSE/HYPOTHESIS: Direct medical costs for low back pain exceed $90
billion per year in the United States, driven primarily by 10% of patients
who develop chronic low back pain (cLBP). Existing treatments for cLBP
pain have proven to be of limited benefit to reduce disability and improve
function. The purpose of this study was to investigate the effects of anodal transcranial direct current stimulation (tDCS) on trunk extensor
strength. Anodal tDCS treatment has been shown to increase strength
in arm muscles, but its effects on isometric trunk extensor strength are
unknown. Accordingly, trunk extensor strength was tested during 20
minutes of tDCS treatment and for 40 minutes after treatment in both
healthy control (HC) and cLBP subjects.
NUMBER OF SUBJECTS: Seventeen subjects (8 HC and 9 cLBP) aged 20 to
44 years.
MATERIALS/METHODS: Subjects attended 2 sessions. Baseline maximum isometric trunk extensor force was tested using a MedX core trunk extension device custom fitted with a single DOF load cell (Load Cell Central).
Subjects were seated with a neutral spine position, 90° of hip flexion, and
60° of knee flexion, and were instructed to push back into the backrest.
Subjects received visual feedback displaying their max force and current force on a computer screen and verbal encouragement was provided using a digital recording to ensure uniformity. Subjects then received
a 20-minute treatment of either sham or anodal tDCS (subjects and researchers were blinded to treatment order) at 2-mA intensity with a 30
second ramp up and ramp down. During sham tDCS, subjects received
only the ramp up and ramp down. The 2 × 2-inch stimulating electrode
was positioned on a saline soaked sponge over the central sulcus of M1;
the cathode was placed on the right side of the forehead. Every 10 minutes
during the session, participants performed a maximum isometric trunk
extension.
RESULTS: The cLBP group generated lower peak isometric extension force
compared to HC (P<.05). There was a main effect of treatment (anodal,
sham) on peak isometric extensor force (P = .014) and a trend for an in-
teraction of group (cLBP, HC) by treatment (P = .062). Follow up analyses revealed a single treatment of anodal tDCS resulted in increased trunk
extensor force compared to sham only for HC (P<.001). Although statistically insignificant, trunk extensor force was larger during anodal tDCS
compared to sham in the cLBP group.
CONCLUSIONS: These preliminary results indicate that anodal tDCS placed
over the central sulcus for 20 minutes can result in increased back extension strength up to 40 minutes posttreatment in HC, which may have potential use as an adjunct to trunk extension exercises in order to maximize force generation.
CLINICAL RELEVANCE: This study has revealed the potential for anodal tDCS
to be used to increase motor function resulting in increased trunk extensor force in healthy individuals. The next step in this research will be to
determine how anodal tDCS can be used to improve motor function and
ultimately reduce disability in a larger population of people with cLBP.
OPO74
MUSCLE QUALITY MATTERS: TRANSLATION OF MUSCLE FAT INFILTRATION
ANALYSIS TO CLINICAL PRACTICE AND BIOMECHANICAL MODELING
James M. Elliott, Anneli Peolsson, Janne West, Rebecca Abbott,
Ulrika Åslund, Anette Karlsson, Olof Dahlqvist Leinhard
Physical Therapy and Human Movement Sciences, Northwestern
University, Chicago, Illinois; Medical and Health Sciences,
Physiotherapy, Linköping University, Linköping, Sweden; Medical
and Health Sciences and Center for Medical Image Science and
Visualization (CMIV), Linköping University, Linköping, Sweden;
Biomechanical Engineering and Center for Medical Image Science and
Visualization (CMIV), Linköping University, Linköping, Sweden
PURPOSE/HYPOTHESIS: Increased muscle fat infiltration (MFI) is related to
poor functional recovery following whiplash. However, the complexity
and time constraints of a quantitative analysis of MRI images may hinder
translation into radiology clinical practice and interdisciplinary research.
We employed a qualitative metric for magnitude and distribution of MFI
in the cervical multifidus muscle using fat/water MRI. We assessed the
ability of this method to predict clinical presentation. Additionally, we
demonstrate the value of the resulting muscle quality data to explore the
functional consequences of muscle degeneration in a biomechanical model of the neck.
NUMBER OF SUBJECTS: Thirty-one subjects (14 male, 17 female; mean ± SD
age, 41.5 ± 10.6 years; range, 22-61 years) and 31 age- and sex-matched
healthy controls were recruited from a randomized controlled trial at
baseline. Inclusion criteria included neck disability index (NDI) of greater than 20% at 3 months to 3 years postcollision. Three study groups
were controls, mild/moderate WAD (NDI greater than 20%, less than
40%), and severe WAD (NDI greater than 40%). The local ethics committee approved the study, and written informed consent was obtained
from all participants.
MATERIALS/METHODS: Phase sensitive reconstruction of the data were performed and the multifidus was identified and segmented by a blinded operator in the fat/water images (C4-C7), using Analyze 11.0 (AnalyzeDirect,
USA). The multifidus muscle was manually divided in 8 equally sized regions. MFI was visually graded according to: 0 for no or marginal MFI, 1
for light MFI, and 2 for distinct MFI. Statistical analysis was performed
in SPSS 19 (IBM, 2010). Data characterizing the spatial distribution of
MFI in the severe, mild/moderate, and control groups was used to specify
muscle parameters in a computational neck model.
RESULTS: Twenty-one (68%) of the patients had mild to moderate disability and 10 (32%) had severe disability. Statistically significant differences
in the overall frequency of a grade 2 were found between healthy controls
and severe WAD (P = .03) and between mild/moderate and severe WAD
(P = .03). The ROC analyses indicated fair (AUC = 0.768) discrimination
between the severe versus mild/moderate WAD groups when considering
frequency of distinct (grade 2) MFI.
CONCLUSIONS: The distribution of MFI agreed with previous work showing
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greater fat along the medial and anterior regions of the multifidus muscle in all groups, with globally elevated MFI in the severe WAD group.
Predictions from the biomechanical model highlight potential differences in muscle activation patterns and joint stresses due to the specific spatial distribution of MFI in severe WAD.
CLINICAL RELEVANCE: The complexity of methods for measuring quantitative MFI has been a barrier to translation into clinical practice and crossdisciplinary research (eg, biomechanics). With translation in mind, this
study proposes a novel qualitative MR method for grading degeneration
in neck muscles and demonstrates an example of its use in a biomechanical modeling application.
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OPO75
HEIGHTENED PAIN SENSITIVITY AND INEFFICIENT ENDOGENOUS PAIN
MODULATION IN PATIENTS WITH OROFACIAL PAIN: A LONGITUDINAL STUDY
Carla S. Enriquez
Rehabilitation and Movement Science, Rutgers, The State
University of New Jersey, Newark, New Jersey
PURPOSE/HYPOTHESIS: We aimed to investigate if heightened pain sensitivity [1] is associated with inefficient endogenous pain modulation [2] using
quantitative sensory testing (QST) [3,4,5] in patients with orofacial pain.
NUMBER OF SUBJECTS: Forty.
MATERIALS/METHODS: A convenience sample of subjects (n = 40) with orofacial pain seen for an initial visit at a specialized orofacial pain clinic were
assessed for individual pain processing mechanisms using QST [3]. Pain
sensitivity was assessed through Temporal Summation (TS) [3,4] while
endogenous pain modulation through Conditioned Pain Modulation
(CPM) [3,5] testing protocols. These procedures were administered prior to the subjects receiving any intervention, where baseline demographics, psychological variables, and self-reported disability scores were also
collected. Psychological variables were measured using physical activity
and work subscales of the Fear-Avoidance Beliefs Questionnaire (FABQ).
The numeric pain-rating scale was used for QST pain ratings and the
Therapeutic Associates Outcomes Scale (TAOS) was used for self-reported disability measure. Pearson correlation analyses were conducted on
TS and CPM scores, as well as self-reported psychological and disability measures.
RESULTS: A strong positive correlation was found between increased pain
sensitivity and inefficient endogenous inhibitory pain modulation activity in patients with orofacial pain (r = 0.69, P<.001). A moderate negative
correlation was also found between FABQ physical activity subscale and
self-reported disability scores (r = –0.43, P = .006); and FABQ work subscale and self-reported disability (r = –0.39, P = .012). Results of our study
suggest that increased pain sensitivity is associated with marked deficiency in endogenous pain modulation system as measured through QST in
patients who seek treatment for orofacial pain. It also appears that self-reported disability scores does not directly correlate with psychological factors on FABQ in these patients.
CONCLUSIONS: Our study was able to demonstrate a strong and direct correlation between heightened pain sensitivity and inefficient endogenous
pain modulation in patients with orofacial pain. Furthermore, psychological factors did not appear to directly correlate with self-reported disability in this patient population.
CLINICAL RELEVANCE: Identification of factors that contribute to the cause
and persistence of orofacial pain is an important research goal, as it is a
preliminary step towards developing effective interventions in these individuals. Quantitative Sensory Testing provides direct and quantitative
measure of individual pain processing mechanisms essential in understanding the etiology and associated impairments and limitations with
orofacial pain. Future studies should support or refute these findings and
investigate the nature of these associations to create effective intervention
strategies in this patient population.
OPO76
SEX-SPECIFIC KINETIC AND KINEMATIC INDICATORS OF MEDIAL
TIBIOFEMORAL FORCE DURING RUNNING
Jean-Francois Esculier, Richard W. Willy, Michael Baggaley,
Stacey A. Meardon, John D. Willson
Laval University, Quebec, Quebec, Canada; East Carolina
University, Greenville, North Carolina
PURPOSE/HYPOTHESIS: Maintaining an active lifestyle while avoiding excessive joint loading is recommended for individuals with medial tibiofemoral joint (TFJ) osteoarthritis (OA) [1]. During walking, lower medial TFJ force can be achieved by decreasing peak knee adduction moment
(pKAM) and knee flexion moment (pKFM) [2,3]. However, the contribution of pKAM and pKFM to medial TFJ force during running is not
known. Additionally, clinically modifiable kinematic variables to decrease peak medial TFJ force during running have yet to be identified.
Differences in running mechanics between males and females raise the
possibility that contributions to medial TFJ force are sex-specific [4].
Thus, the goals of this study were to (1) evaluate the sex-specific contribution of pKFM and pKAM to medial TFJ force during running; (2) identify sex-specific kinematic variables that can be measured in the clinic to
estimate and modify peak medial TFJ loads.
NUMBER OF SUBJECTS: Eighty-seven healthy runners (36 female, 51 male;
mean ± SD age, 23.0 ± 3.8 years).
MATERIALS/METHODS: Three-dimensional kinematic and kinetic data were
collected during treadmill running at preferred speed (3.0 ± 0.4 m/s).
Peak medial TFJ contact force was estimated using a validated musculoskeletal model [5]. Linear regression analyses were used to assess the
contribution of kinetic (pKFM, pKAM) and kinematic variables to estimated peak medial TFJ force. Clinically modifiable kinematic variables
of interest included sagittal and frontal knee, ankle and foot kinematics
as well as step rate, step length, foot progression angle and center of mass
(COM) vertical displacement.
RESULTS: In the whole cohort, the combination of pKAM and pKFM
explained 64.5% of peak medial TFJ force variance during running
(P<.001). Together, both variables accounted for 79.5% of peak medial TFJ force in females, and 73.8% in males (P<.001). However, pKAM
contribution was only 26.8% in females compared to 50.4% in males.
Analyses also revealed sex-specific kinematic predictors of peak medial TFJ force during running. In females, lower ankle dorsiflexion at foot
strike and center of mass (COM) vertical displacement best predicted
lower peak medial TFJ force (R2 = 0.364, P = .012). In males, greater
peak knee abduction angle and shorter step length best predicted lower
medial compartment force (R2 = 0.508, P = .019).
CONCLUSIONS: Our results suggest that pKAM and pKFM make significant but potentially sex-specific contributions to peak medial TFJ forces
during running. Clinicians seeking reductions in peak medial TFJ force
through running retraining interventions should aim for reduced ankle
dorsiflexion at foot strike and COM vertical oscillation in females, and
greater knee abduction and shorter step length in males.
CLINICAL RELEVANCE: These results provide insights on modifiable kinematic variables that can be addressed in the clinic to decrease medial TFJ
force during running. Targeting identified predictors through running
gait modifications may help physical therapists in treating their patient
runners with symptomatic medial TFJ OA.
OPO77
FOR INDIVIDUALS WITH NONCONTACT ACL RUPTURE, IS THERE EVIDENCE
OF HIP ROTATION RANGE-OF-MOTION LIMITATIONS? A LITERATURE REVIEW
Melanie Eskin, Kathleen Esler, Kelly Haspel,
Julie Lezak, Katelyn Miele, Christopher Salaga, Tyler Smith,
Daniel Spinelli, Allison M. Brown
Rutgers, The State University of New Jersey, Newark, New Jersey
PURPOSE/HYPOTHESIS: Anterior cruciate ligament (ACL) ruptures occur
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frequently and with high financial implications. It is estimated that 80%
of ACL ruptures occur through a noncontact mechanism [1]. Studies have
suggested that limited range of motion, specifically hip internal rotation,
is a risk factor for noncontact ACL ruptures [2]. The purpose of this review is to determine whether there is evidence to support an association
between hip rotation range of motion (ROM) limitations and noncontact ACL rupture.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: Web of Science and PubMed were searched using the
following search terms: ACL AND hip range; ACL risk AND hip range;
ACL AND hip rotation; ACL AND hip; ACL risk factor. Studies were included if they examined healthy individuals, aged 13 to 65 years with noncontact ACL rupture. Additionally, studies using goniometric measures of
hip rotation range of motion and those written in the English language
were included. Studies were excluded if they examined participants with
lower extremity pathologies other than ACL rupture, participants with
contact ACL rupture, hip rotation range of motion measured during functional tasks or cadaveric studies.
RESULTS: Six articles met the inclusion criteria [2-7]. All studies were cross
sectional by design, with male and female participants ranging from 13 to
40 years old. Studies included both athletes and nonathletes alike; however, a majority of the participants were male soccer players. Overall, participants with a limited sum of hip rotation range of motion had greater odds of having a history of ACL rupture compared to those without
ACL rupture. Additionally, these studies suggested there was a statistically significant decrease in hip internal rotation range of motion among
participants with ACL rupture compared to control participants. With the
exception of 2 studies [2,3], there was no significant difference in hip external rotation range of motion differences between groups.
CONCLUSIONS: The results suggest that subjects with decreased hip rotation beyond a predetermined threshold, mainly due to internal rotation
limitations, are at greater odds of having a history of ACL rupture. This
is consistent with the theory that insufficient range of motion at the hip
transfers rotational forces to the knee joint, thereby increasing stress on
the ACL. Our review is limited in that the most at-risk population (eg, females and adolescents) are not represented.
CLINICAL RELEVANCE: Patients with a history of noncontact ACL rupture are
at greater odds of presenting with limited hip rotation ROM, specifically in internal rotation. Clinicians should screen and consider hip rotation ROM when designing ACL prevention and rehabilitation programs.
OPO78
CLINICAL PERSPECTIVE ON THE USE OF PAIN CLASSIFICATION
AND CLINICAL OUTCOMES
Memrie D. Ferguson, Janna M. McGaugh
Department of Physical Therapy, The University of Texas Medical
Branch, Galveston, Texas
PURPOSE/HYPOTHESIS: Appropriate identification of pain type should enable the clinician to select interventions hypothesized to target specific
mechanisms involved in pain signal generation and maintenance, influencing clinical outcomes. Current evidence suggests 3 clinically meaningful categories exist for musculoskeletal pain: nociceptive pain (NP),
peripheral neuropathic pain (PNP), and central sensitization (CS). The
purpose of this pilot study was to investigate the utilization of a Pain
Classification Tool (PCT) in determining pain type and associated outcomes in an outpatient clinical practice setting.
NUMBER OF SUBJECTS: Two licensed physical therapists utilized a PCT to
identify pain type and track outcome data in 72 patients who were referred to an orthopaedic physical therapy clinic with complaints of musculoskeletal pain over an 8-month period.
MATERIALS/METHODS: The PCT included 32 criteria defining symptom nature, duration, behavior, and severity in addition to physical signs and
patient beliefs. The criteria were divided into 1 of 3 categories (NP, PNP,
CS) and organized as a checklist based on best evidence and current un-
derstanding of neurophysiology. Criteria includes 8 suggestive of NP, 5 of
PNP, and 9 of CS. Additional outcomes include duration of physical therapy episode of care, number of visits, and therapist-selected standardized
outcome measures assessed at the initial and discharge encounter.
RESULTS: A PCT was utilized in 72 patients to identify the primary pain
type and the impact of pain type on treatment outcomes, including total number of visits, duration of care, and presence of clinically meaningful outcomes. Thirty-nine patients (54.2%) were identified as NP type, 25
(34.7%) were identified as PNP type, and 8 (11%) were identified as CS
pain type. Patients with NP type received an average of 6.8 treatment sessions over a 31.4 day period with 29 of 39 reporting clinically meaningful outcomes (74.4%). Patients with PNP received an average of 9.1 treatment sessions over a 43.1-day period with 17 of 25 reporting clinically
meaningful outcomes (68%). Patients with CS pain type received an average of 12.4 treatment sessions over a 101.4-day period, with 4 of 8 (50%)
reporting clinically meaningful outcomes.
CONCLUSIONS: This pilot study offers insight on the impact of pain classification on treatment outcomes. NP was the most frequently encountered pain type, requiring the least number of visits, the shortest duration of care, and the highest outcome of clinically meaningful change.
PNP ranks second in all measured outcomes. CS was the least encountered pain type requiring most number of visits, longest duration of care,
and lowest outcome of clinically meaningful change. Further research is
necessary to establish validity of the tool and impact of symptom classification on outcomes.
CLINICAL RELEVANCE: Implementation of a pain classification tool may provide valued decision making in clinical care influencing the utilization and
duration of physical therapy services as well as the presence of clinically
meaningful outcomes in patients with musculoskeletal pain presentations.
OPO79
INFLUENCE OF NEUROMUSCULAR CONTROL AND STRENGTH TRAINING
OF CORE MUSCULATURE ON DISTAL FUNCTION: A SYSTEMATIC REVIEW
Richard Ferraro, Alexandria Achille, Andrew Frazzini,
Sarah J. Garman, Seth C. Gentile, Adam C. Huynh
Rutgers University, Stratford, New Jersey
PURPOSE/HYPOTHESIS: The purpose of this review was to identify and differentiate the effects of neuromuscular and strength training of core musculature on distal function.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: A comprehensive search was performed using
PubMed, CINAHL, MEDLINE, and Google Scholar databases. Search
terms included combinations such as: “Transversus Abdominis” AND
“Daily Activities,” “TrA” AND “Activation,” and “TrA” AND “Strength.”
This review targeted randomized control trials and cohort studies. Sackett
(2000) ratings were used for initial inclusion assessing article eligibility. All remaining articles were then scored for internal validity by at least
2 reviewers using the MacDermid (2004) scoring (0-48 point scale).
Discrepancies in scores were reviewed by all authors to achieve consensus for a final score.
RESULTS: Nine articles met our standards for inclusion in this review (level of evidence: 1 article, 1b; 8 articles, 2b). MacDermid scores ranged from
25 to 39, with a mean of 30. Interestingly, results of the review were evenly
split yielding 4 studies that proposed using neuromuscular training techniques, 4 supported strength training and 1 study supported both intervention strategies for augmenting various aspects of distal extremity function.
CONCLUSIONS: Based on the evidence, both neuromuscular and strength
training of the transverse abdominis and surrounding core musculature
have beneficial effects when they are included in treatments aimed at improving gait and upper and lower extremity function. However, the mechanism of application and time required to reach desired effects of each
of these approaches is often very different. Future research in this area
should make efforts to delineate the long term effects of the aforementioned interventions, increase size and diversity of the populations be-
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ing studied and include the use of controls to increase confidence levels in results.
CLINICAL RELEVANCE: It is recommended that physical therapy interventions
include neuromuscular training and re-education of core musculature to
improve distal function, gait and balance. Regardless of the clinical setting, this may be the most efficient method to reach optimal functional
performance. While many current treatment strategies focus on strengthening that requires weeks and months, neuromuscular re-education of the
transverse abdominis and surrounding core musculature yields similar results but requires less physical resources, time and exertion by the patient.
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OPO80
DO ALTERED KINEMATICS AND KINETICS IN GAIT INCREASE PREVALENCE
OF LOW BACK PAIN IN LOWER-LIMB AMPUTEES COMPARED TO ABLE-BODIED
PEOPLE? A SYSTEMATIC REVIEW
Amber Fleer, Andrew Brimhall, Bryson Jarman,
Victoria Stack, Heather Wharton
Physical Therapy, Southwest Baptist University, Bolivar, Missouri
PURPOSE/HYPOTHESIS: Low back pain (LBP) is a common cause of decreased
function, lost workdays, and disability in the general population and one
of the leading reasons patients seek physical therapy services. This systematic review was designed to investigate the cause of the higher prevalence of LBP in lower limb amputees (LLA) compared to able-bodied people. Specifically, we investigated if altered kinematics and kinetics in gait
increases the prevalence of LBP in LLA compared to able-bodied people.
NUMBER OF SUBJECTS: One hundred thirty-one.
MATERIALS/METHODS: In April 2016 we searched Southwest Baptist
University’s library database using keywords: low back pain, amputation or amputee, and able-bodied people and found 15 598 articles.
Limitations were added to bring the number of articles to 237: date from
2006 to 2016, peer reviewed articles, academic journals, and English language. These articles were screened by title and 225 records were excluded due to relevance. The final 12 articles were assessed for inclusion of kinetics or kinematics in gait as the cause of LBP in amputees. This left 4
studies to be included for data extraction and analysis.
RESULTS: The 4 studies reviewed were all cross-sectional studies. All 4
studies were analyzed using the modified Downs and Black quality assessment tool. Using the modified Downs and Black assessment tool, 1 study
was graded as good quality and 3 were graded as fair quality. Between
the 4 studies evaluated, each had different hypotheses as for the cause of
LBP in LLA. A majority of the studies found notable alterations during
gait in LLA with LBP compared to able-bodied individuals or LLA without LBP. Gait alterations included differences in transverse, sagittal, or
frontal plane motion, muscle activation, and forces applied through the
lower extremities.
CONCLUSIONS: Based on the quality and quantity of evidence evaluated in
this review, we could not form a definitive conclusion to the cause of LBP
in LLA. In addition, the studies failed to consider types of prostheses in
their inclusion and exclusion criteria which could cause differences within the LLA group. Transverse plane motion was shown to be significantly different between LLA with LBP and both able-bodied individuals and
LLA without LBP [8]. Another contributor to a higher prevalence in LBP
in LLA includes increased spinal loads leading to coactivation and fatigue
failure [6] of trunk musculature. Future research is needed to assess asymmetries between LLA with LBP and able-bodied individuals with LBP. In
addition, research is needed to examine the differences in the prevalence
and cause of LBP between transtibial and transfemoral amputees.
CLINICAL RELEVANCE: While we cannot identify specific asymmetries as the
cause of LBP in LLA, we can surmise that altered kinematics and kinetics may contribute to the higher prevalence of LBP in LLA based on the
research. Clinicians must be aware of an increased risk of LBP in LLA
and work to eliminate as many asymmetries as possible and increase core
strength to counteract any residual asymmetries and abnormal spinal
loads present.
OPO81
INTEREXAMINER RELIABILITY OF THE MYOMETER TO MEASURE ACHILLES
TENDON BIOMECHANICAL PROPERTIES AND CORRELATION WITH A
FUNCTIONAL CALF-LENGTH TEST
Jacquelyn Fletcher, Spenser Studebaker, Stuart J. Warden,
Amy J. Bayliss
Physical Therapy, Indiana University, Indianapolis, Indiana
PURPOSE/HYPOTHESIS: In vivo Achilles tendon mechanical properties have
traditionally been estimated using a combination of real-time diagnostic imaging and dynamometry. The approach provides measures such as
Achilles tendon stiffness and Young’s modulus, but is labor and resource
intensive reducing its clinical utility. Myometry is a newer technique that
utilizes a simple handheld, portable instrument to provide quick and noninvasive measures of the mechanical properties of soft tissue. The aim of
the current work was to begin exploring the clinical utility of myometry measures of the Achilles tendon by assessing their: (1) short-term between-examiner precision, and (2) correlation with a clinical measure of
Achilles length.
NUMBER OF SUBJECTS: Twenty-seven adults, 54 tendons (mean ± SD age,
24.4 ± 1.1 years; 52% male).
MATERIALS/METHODS: Healthy young subjects between 20 and 30 years old
were recruited. Subjects were excluded if they reported: (1) pain in the
ankle or heel, (2) a history of Achilles tendon rupture or surgery, or, (3)
foot or ankle surgery in the past 12 months. A MyotonPro myometer was
used which delivers a quick-released mechanical impulse exerting 0.40
N of pressure for 15 milliseconds. Two blinded examiners took myometer
measurements on each tendon with the subject positioned in prone and
the foot held in 0° of dorsiflexion. The myometer captured the following
parameters for each tendon: state of tension, decrement, dynamic stiffness, creep and stress relaxation. A third examiner performed a weightbearing lunge test and recorded the distance of the great toe from the wall
for each tendon.
RESULTS: Intraclass correlation coefficients (ICC) revealed short-term between-examiner precision was excellent for tension (ICC2,1 = 0.94; 95%
CI: 0.85, 0.97), good for stiffness (ICC2,1 = 0.88; 95% CI: 0.78, 0.93), and
fair for decrement (ICC2,1 = 0.77; 95% CI: 0.61, 0.87), creep (ICC2,1 = 0.70;
95% CI: 0.46, 0.83) and stress relaxation (ICC2,1 = 0.63; 95% CI: 0.36,
0.78). Tension, stiffness and decrement were all negatively correlated with
toe-to-wall distance during a weight-bearing lunge test (all, P<.05), respectively, explaining 7.0%, 10.9%, and 11.3% of the variance in the lunge
test performance.
CONCLUSIONS: MyotonPro measures of the Achilles tendon had fair-toexcellent short-term between-examiner precision, with the best precision being for measures of tendon tension and stiffness. MyotonPro measures of tension, stiffness and decrement were all negatively associated
with Achilles tendon length on a functional lunge test suggesting that
MyotonPro measures of the Achilles tendon provide indications of tendon functional properties/length.
CLINICAL RELEVANCE: The MyotonPro is a noninvasive device that has the
potential to rapidly quantify soft tissue mechanical properties in a clinical setting.
OPO82
THE IMPACT THAT MANAGERS’ PERSONAL FITNESS LEVELS AND THEIR
PERCEIVED IMPORTANCE OF FITNESS IN THE WORKPLACE HAVE
ON THE OVERALL FITNESS LEVELS OF PUBLIC EMPLOYEES WITH HIGHLY
PHYSICAL JOBS
Douglas Flint, Tyler Sedgwick, Nicole Stephens
Intermountain Healthcare, Ogden, Utah
PURPOSE: The purpose of this study was to explore the correlation of manager’s perception of the importance of fitness and their own individual fitness levels have on the over all fitness levels of the employees they manage.
DESCRIPTION: This study compared the fitness levels and perceived impor-
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tance of fitness of mangers to the overall fitness of the employees in each
mangers department. A combination of job task specific fitness testing
following the NFPA 1582 fitness guidelines and a survey of managers perceived importance of fitness was used to collect data.
SUMMARY OF USE: This study reviewed the fitness testing results of 243 firefighters from 7 different city and county fire departments over a 4-year
period and compared the overall fitness levels of each department’s fire
fighters to the fitness level of the department’s Fire Chiefs and Deputy
Chiefs and their perceived importance of fitness. This study found that
there was a high correlation between the individual fitness level of the department’s Fire Chiefs and Deputy Chiefs to the overall fitness level of the
individual fire fighter in each department but a low correlation between
the Fire Chiefs and Deputy Chiefs perceived importance of fitness and
the overall fitness levels of the individual fire fighter in each department.
IMPORTANCE TO MEMBERS: This study suggests that a key factor on the overall fitness of public employees with highly physical jobs like fire fighters,
is the fitness level of the department’s Fire Chief and Deputy Chief and
not their perceived importance of fitness. This information can be useful
in promoting health and wellness in the workplace by identifying the key
role that department leaders play in promoting health and wellness to the
individual employee by being fit themselves.
OPO83
CERVICAL TRACTION TRAINING PROGRAM: UTILIZING BIOFEEDBACK
AND MOTOR LEARNING PRINCIPLES
Eric Folkins, Thomas J. Buklarewicz, Lisa T. Hoglund,
Yaroslav Sokoloversuskyy, Zachary Theinert, Francis Ryan
Physical Therapy, University of the Sciences, Philadelphia,
Pennsylvania
PURPOSE/HYPOTHESIS: Manual cervical traction (MCT) is a common intervention used by physical therapists to treat persons with neck pain and
the cervical distraction test assists with the diagnosis of radiculopathy
or zygapophyseal joint irritation by reducing the compression on irritated structures. The therapeutic range of cervical traction is reported to be
between 11.34 and 18.14 kg. A previous study demonstrated only 19% of
novice clinicians and 73% of “master clinicians” (P<.01) produce the appropriate amount of force. The purpose of this study was to evaluate the
effectiveness of a MCT training protocol using biofeedback and motor
learning principles to improve students’ ability to apply the appropriate
amount of force during MCT.
NUMBER OF SUBJECTS: Seventeen recruited, 11 in the training portion.
MATERIALS/METHODS: Third year doctor of physical therapy students from
1 university were recruited. Inclusion criteria included completion of
one 8-week outpatient orthopaedic clinical experience and performance
of MCT with patients. Participants completed MCT on a mannequin
head/neck attached to the BTE Primus RS instrumented dynamometer.
Participants who did not perform MCT within the recommended range
of force, 11.34 to 18.14 kg, were enrolled in the training portion of the
study. Training consisted of 3 phases of a faded auditory and visual feedback protocol schedule. Participants were posttested 24 to 72 hours following the training session. Average peak force of three 20-second trials
was recorded.
RESULTS: There was significantly more average force of pull posttest (17.44
kg) compared to pretest (9.68 kg) (P<.01). Five of 17 (29%) subjects pulled
with the correct amount of force during pretesting and post testing results
demonstrated 7/11 (72.7%) students pulled with the correct amount of
force. There was a direct association between the training and the participant’s ability to pull within the appropriate range of force (P = .01).
CONCLUSIONS: The present study demonstrated 29% of students pull with
the correct amount of force during MCT. This is in close agreement from
a previous study that reported 19% of students. One motor learning-biofeedback training session was effective in teaching 72.7% of students MCT.
CLINICAL RELEVANCE: Clinical practice guidelines recommend MCT as an intervention for persons with neck pain and valid results of the cervical dis-
traction test are dependent on practitioners pulling with enough force to
cause vertebral separation. This study demonstrated an effective training
technique for proper performance of MCT. A 1-day training session that
used motor learning principles and knowledge of results allowed physical therapy students to perfect their MCT skills. The training produced
the same percentage of participants that pulled within the correct range as
previously reported for “master clinicians” (73%). Future research should
investigate the effectiveness of utilizing biofeedback and motor learning
principles to efficiently teach other manual therapy techniques.
OPO84
PHYSICAL THERAPY REHABILITATION AFTER LONG-TERM CERVICAL
IMMOBILIZATION FOLLOWING ATLAS (JEFFERSON) FRACTURE:
A CASE REPORT
Carla C. Franck, Judy Jicinsky, Alicia Emerson Kavchak
Physical Therapy, UI Health, Chicago, Illinois; Performance
Therapies, PC, Cedar Rapids, Iowa; Physical Therapy, High Point
University, High Point, North Carolina
BACKGROUND AND PURPOSE: Fractures of the atlas (C1), though estimated to
be as low as 3% of spinal injuries, have a reported mortality rate as high
as 11.7%. Typical mechanism is axial loading at the top of the head with
a resultant burst fracture, or Jefferson fracture, with or without upper
cervical ligamentous rupture. Often there is no neurological involvement
secondary to the width of the spinal canal at the level of C1. Medical management of the dynamic instability requires cervical fusion and/or longterm immobilization. Common patient complaints following medical intervention include pain, stiffness, and limited cervical range of motion
(ROM). Minimal evidence exists for rehabilitation following spinal stabilization after a Jefferson fracture. This case report describes the physical
therapy (PT) interventions and outcomes of a patient after cervical immobilization following a Jefferson fracture.
CASE DESCRIPTION: Patient was a 49-year-old woman who sustained a
Jefferson fracture while in a motor vehicle accident where she rolled her
car landing upside down. She was treated conservatively for 7 months
in a halo vest with bone stimulator and subsequently with a rigid cervical collar. Patient was referred to PT after the immobilization with initial impairments of decreased cervical ROM, lack of cervical muscle flexibility and strength, cervicothoracic and rib joint hypomobility, impaired
posture, reports of “muscular pain,” and functional limitations in driving. Interventions included joint mobilizations targeting the lower cervical spine and ribs and soft tissue mobilizations to the suboccipital region,
scalene and trapezius muscles. Exercise progression included postural correction, deep neck flexor training, and upper extremity resistance
training.
OUTCOMES: The patient was seen for 25 PT sessions with interventions focused on manual therapy and exercise. She demonstrated improvements
in all her cervical active ROM: flexion from 0° to 10° to 0° to 50°, extension 0° to 0° to 46°, right (R) rotation 0° to 25° to 0° to 60°, and left (L)
rotation 0° to 18° to 0° to 55°. Her upper extremity strength improved to
grossly 5/5 with manual muscle testing. Grip strength increased: (R) 40
to 54 lb, (L) 38 to 47 lb. Further, her average “muscular pain” on the numeric pain-rating scale improved from 4/10 to 0/10. She returned to all
work and all daily activities without limitation. Patient returned to driving with the soft collar per the physician’s instruction.
DISCUSSION: Orthopaedic manual physical therapy (OMPT) treatment directed at the lower cervical spine/rib joints and soft tissue interventions,
with follow-up therapeutic exercise, resulted in functional improvements
after long-term cervical immobilization following a Jefferson fracture.
While there is minimal evidence on the best PT treatment approach following Jefferson fractures, clinical reasoning facilitated the direction and
use of OMPT and therapeutic exercise.
REFERENCES: 1. Delcourt T, Begue T, Saintyves G, Mebtouche N, Cottin
P. Management of upper cervical spine fractures in elderly patients:
Current trends and outcomes. Injury. 2015;46:S24-S27. 2. Longo UG,
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Denaro L, Campi S, Maffulli N, Denaro V. Upper cervical spine injuries:
Indications and limits of the conservative management in halo vest. A systematic review of efficacy and safety. Injury. 2010;41:1127-1135. 3. Miller
J, Gross A, D’Sylva J, Burnie SJ, Goldsmith CH, Graham N, Hoving JL.
Manual therapy and exercise for neck pain: a systematic review. Man
Ther. 2010;15:334-354. 4. Mitchell RJ, Stanford R, McVeigh C, Bell D,
Close JC. Incidence, circumstances, treatment and outcome of high-level cervical spinal fracture without associated spinal cord injury in new
south wales, Australia over a 12 year period. Injury. 2014;45:217-222.
5. Babak Kalantar S. Fractures of the C1 and C2 vertebrae. Semin Spine
Surg. 2013;25:23-35.
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OPO85
RELIABILITY OF ULTRASOUND MEASURES OF INTRINSIC FOOT MOTOR FUNCTION
John J. Fraser, Jay Hertel
Kinesiology Department, Sports Medicine PhD Program,
University of Virginia, Charlottesville, Virginia
PURPOSE/HYPOTHESIS: The intrinsic foot muscles (IFM) play an important
role in the shaping of the foot [1,2], force attenuation [1,3], and force
transmission [1,3] during propulsion. Currently, clinically accessible assessment of IFM function and size has been limited to the IFM test [4]
and resting ultrasound (US) imaging measures [5]. Reliability has yet
to be established for innovative measures of IFM function under US imaging during dynamic activity. The purpose of this study was to establish test-retest reliability of US measures of IFM size and motor function.
NUMBER OF SUBJECTS: Data from 24 healthy, recreationally active individuals ages 18 to 50 with no history of ankle or foot sprain or fracture were
included (12 male, 12 female; mean ± SD age, 21.5 ± 4.8 years; BMI, 23.5
± 2.9 kg/m2).
MATERIALS/METHODS: Participants were imaged on 2 separate days by a
physical therapist with 14 years of clinical experience and 2 months of
experience using US imaging. Washout period between test sessions was
3 to 10 days. US cross section area (CSA, cm2) and thickness (cm) of the
right (RT) and left (LT) abductor hallucis (AbdH), flexor digitorum brevis (FDB), quadratus plantae (QP), and flexor hallucis brevis (FHB) were
measured at rest and during active contraction, while resisted, and while
performing toe spread, isolated hallux extension, and lesser toe extension
exercises. Contracted measures were normalized to resting values and reported as activation ratios. Reliability was assessed with intraclass coefficients (ICC model 2,k), with greater than 0.75 interpreted as being excellent, 0.40 to 0.75 as fair to good, and less than 0.40 as poor [6].
RESULTS: Reliability of resting US measures of AbdH CSA (Baseline RT,
2.66 ± 0.64 cm2; LT, 2.63 ± 0.57 cm2; Final RT, 2.66 ± 0.60 cm2; LT, 2.67
± 0.54 cm2; ICC = 0.97-0.98) and thickness (Baseline RT, 1.25 ± 0.20 cm;
LT, 1.26 ± 0.19 cm; Final RT, 1.28 ± 0.21 cm; LT, 1.25 ± 0.21 cm; ICC =
0.88-0.91), FDB CSA (Baseline RT, 1.87 ± 0.52 cm2; LT, 1.81 ± 0.44 cm2;
Final RT, 1.77 ± 0.46 cm2; LT, 1.80 ± 0.42 cm2; ICC = 0.93-0.91) and
thickness (Baseline RT, 0.84 ± 0.19 cm; LT, 0.80 ± 0.15 cm; Final RT, 0.81
± 0.16 cm; LT, 0.76 ± 0.14 cm; ICC = 0.87-0.89), QP CSA (Baseline RT,
1.47 ± 0.59 cm2; LT, 1.40 ± 0.51 cm2; Final RT, 1.47 ± 0.61 cm2; LT, 1.47 ±
0.58 cm2; ICC = 0.97-0.98) and thickness (Baseline RT, 0.91 ± 0.18 cm;
LT, 0.91 ± 0.15 cm; Final RT, 0.90 ± 0.17 cm; LT, 0.94 ± 0.18 cm; ICC =
0.90-0.92), and FHB CSA (Baseline RT, 3.00 ± 0.69 cm2; LT, 2.99 ± 0.85
cm2; Final RT, 2.97 ± 0.68 cm2; LT, 2.97 ± 0.83 cm2; ICC = 0.95-0.98) and
thickness (Baseline RT, 1.42 ± 0.22 cm; LT, 1.38 ± 0.18 cm; Final RT, 1.38
± 0.19 cm; LT, 1.38 ± 0.19 cm; ICC = 0.76-0.83) were excellent. During
function, reliability of active, resisted and toe exercise CSA measures was
excellent (ICC = 0.81-0.99) and good to excellent (ICC = 0.66-0.93) for
thickness measures.
CONCLUSIONS: US measures of IFM function were found to have good to
excellent reliability.
CLINICAL RELEVANCE: These measures may have utility in patient care and
clinical research and should be considered as a potential outcome measure.
OPO86
RELIABILITY OF MEASURES OF ANKLE-FOOT MORPHOLOGY, MOBILITY,
AND STRENGTH
John J. Fraser, Rachel Koldenhoven, Jay Hertel
Kinesiology Department, Sports Medicine PhD Program,
University of Virginia, Charlottesville, Virginia
PURPOSE/HYPOTHESIS: Lateral ankle and midfoot sprains result from high
velocity moments and extremes of plantarflexion, adduction, and inversion [1-3]. Clinical assessment of foot posture, morphology, intersegmental mobility, and strength of the ankle-foot complex following sprain is
recommended for instruction in physical therapy education programs [4]
and in practice [5]. The purpose was to determine test-retest reliability
and interrater reliability of innovative and established clinical measures
of morphology, joint excursion and accessory motion, and strength of the
ankle-foot complex. We hypothesized reliability to be excellent for morphologic measures, fair to good for joint excursion and strength, and poor
for joint accessory measures.
NUMBER OF SUBJECTS: Data from 24 healthy, recreationally active individuals aged 18 to 50 with no history of ankle or foot sprain or fracture were
included (12 male, 12 female; mean ± SD age, 21.5 ± 4.8 years; BMI, 23.5
± 2.9 kg/m2).
MATERIALS/METHODS: Participants were assessed by 2 clinicians (a physical
therapist with 14 years of experience and an athletic trainer with 2 years
of experience) on 2 separate days. Order of clinician assessment was randomized using a Latin-square. Washout period between test sessions was
3 to 10 days. Foot posture and morphology was assessed using the Foot
Posture Index and measures of foot length, width, truncated length and
arch height. Joint mobility was assessed using goniometry (rearfoot and
hallux excursion), inclinometry (forefoot), linear measures of sagittal excursion (first ray and loaded rearfoot), and rating of joint accessory motion. Strength was assessed using handheld dynamometry. Reliability was
assessed with intraclass coefficients (ICC model 2,k), with greater than
0.75 interpreted as being excellent, 0.40 to 0.75 as fair to good, and less
than 0.40 as poor [7].
RESULTS: Test-retest reliability was excellent in all foot posture and morphologic measures (0.80-1.00), talocrural (0.81-0.97) and hallux (0.820.95) joint excursion measures, fair to excellent for first ray sagittal excursion (0.62-0.90) and frontal plane rearfoot (0.58-0.73) and forefoot
(0.72-0.86) excursion, and strength (0.67-0.92) measures. Intertester reliability of joint accessory motion (–0.67 to 0.84) varied on clinical experience, with the more experienced clinician demonstrating greater consistency (67% of measures greater than 0.40) compared the novice clinician
(36% of measures greater than 0.40). Interrater reliability was excellent
in morphologic measures (0.81-1.00) and talocrural (0.76-0.97) and hallux (0.85-0.91) excursion measures, fair to excellent in forefoot (0.660.86) excursion and strength measures (0.53-0.90), fair to good in rearfoot frontal plane excursion (0.53-0.69), poor to good in hallux excursion
(0.32-0.53), and poor (–1.06 to 0.39) in 73% of joint accessory measures.
CONCLUSIONS: Measures of ankle-foot posture, morphology, joint excursion, and strength demonstrated fair to excellent test-retest and interrater
reliability. Joint accessory measures had poor to fair agreement overall.
CLINICAL RELEVANCE: These findings should be considered when selecting
ankle-foot assessment measures.
OPO87
THE INFLUENCE OF TENSION AND SLIDING TECHNIQUES ON
NEURODYNAMIC DYSFUNCTION IN THE CONTRALATERAL EXTREMITY
Robert J. Friberg, Stephanie Thurmond
Department of Physical Therapy, Hardin-Simmons University,
Abilene, Texas; Physical Therapy, University of the Incarnate
Word, San Antonio, Texas
PURPOSE/HYPOTHESIS: To determine if neural tissue management, via sliding or tensioning of the least neurodynamically involved upper extremity
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influences function of the contralateral extremity in individuals with median or ulnar nerve dysfunction
NUMBER OF SUBJECTS: Forty-two college students (15 male, 27 female) who
demonstrated a positive Upper Limb Neural Tension Test (ULNTT) for
either the median or ulnar nerve.
MATERIALS/METHODS: Subjects completed an informed consent, demographic information sheet, Neck Disability Index (NDI), and Disabilities
of the Shoulder and Hand Questionnaire (QuickDASH) prior to screening before being randomly assigned to either a tensioning (n = 11), sliding
(n = 9), combination of tensioning and sliding (n = 11), or control (n = 11)
group for treatment. Outcome measures included cervical range of motion (ROM), grip and pinch strength, and upper limb tension test (ULTT)
of the median (extension range of motion at the elbow) and ulnar (abduction range of motion at the shoulder) nerves. Tensioning, sliding, and
combination groups received a home exercise program (HEP) to perform
2 minutes per day for 2 weeks. Tensioning is defined as a technique to increase tension in neural structures by stabilizing the nerve at 1 point and
elongating at another point. Sliding is defined as an technique to produce
sliding of neural structures relative to their adjacent tissues. Sliding is
produced by elongating the nerve at 1 joint and shortening at another to
create the sliding motion. The control group was advised to continue their
usual activities. ULTT restrictions were assessed goniometrically during
elbow extension (for median nerve) and shoulder abduction (for ulnar
nerve) at the point in the ROM where symptoms were provoked. Grip and
pinch strength were assessed using a handheld dynamometer (setting 2).
The mean of 3 successive trials was used for analysis.
RESULTS: No statistically significant differences were found among treatment groups on any outcome variable prior to the intervention. No statistically significant changes in any outcome measures were found in the
contralateral arm (P>.05), although positive trends were observed in median and ulnar ROM in the tensioning group.
CONCLUSIONS: Neurodynamic treatment of the opposite extremity did not
produce a significant change in the neurodynamic function as measured
by range of motion and strength of the contralateral limb.
CLINICAL RELEVANCE: Neurodynamic treatment through tensioning, sliding,
or a combination of both using the opposite extremity is not effective. The
extremity with median or ulnar neurodynamic dysfunction is where treatment should be directed.
OPO88
DOES PATIENT SELF-EFFICACY AT INTAKE PREDICT THE THERAPEUTIC
OUTCOME?
Molly J. Geiger, Stephanie Juhnke, Ellen Maloney,
Danny J. McMillian
Physical Therapy, University of Puget Sound, Tacoma, Washington
PURPOSE/HYPOTHESIS: While the biopsychosocial model has become increasingly understood and accepted amongst physical therapists, identifying all psychological factors relating to physical therapy seems unrealistic due to limited time and resources. While depression, catastrophizing,
and fear-avoidance have been the main focus of current research looking
at psychosocial risk factors, Foster has shown self-efficacy to be a more
important factor in determining patient outcomes in a primary care setting. Therefore, the purpose of this study was to explore the relationship
between patient self-efficacy (SE) levels at intake and physical therapy
outcomes. We hypothesized that higher SE scores would be associated
with more successful outcomes upon conclusion of the episode of care.
NUMBER OF SUBJECTS: Seventeen.
MATERIALS/METHODS: Subjects from the University of Puget Sound’s outpatient musculoskeletal clinic were included in the study. Prior to their
initial PT evaluation, subjects completed the General Self Efficacy
Questionnaire, a relevant outcome measure given their presenting condition, and the numeric pain-rating scale (NPRS). The relevant outcome
measure and NPRS were repeated at the conclusion of the episode of care.
Changes in outcomes measures and NPRS were compared against the
minimal clinically important difference (MCID), and the association with
the SE score at intake was determined.
RESULTS: The results of this study show no significant effect for SE levels
and any of the physical therapy outcome measures as evident by the statistically high power values. Point biserial correlation revealed that self
efficacy at intake was not associated with meeting the MCID in either
the specified outcome measures, r = 0.175, P = .606 or the pain scale, r =
0.589, P = .296. Relative to other reports, the average SE score was particularly high at 81% ± 0.12%.
CONCLUSIONS: The lack of association between SE at intake and clinical
outcome might indicate a true disassociation of the variables or unique
circumstances in this study. As subjects were treated by student physical
therapists under the supervision of clinical instructors, it is possible that
patients seeking treatment in this setting might represent a unique subset of the population with higher SE levels on average. This could explain
the lack of SE variability in the data collected.
CLINICAL RELEVANCE: The particularly high SE scores obtained in this study
might indicate a need for larger sampling and expansion of the psychosocial parameters measured. Additionally, clinical researchers collecting
data in an educational setting should consider if generalizability is limited by the unique characteristics of patients seeking care in that setting.
OPO89
EXAMINATION OF ACROMIOHUMERAL DISTANCE IN UPRIGHT AND SELFSELECTED SEATED POSTURES USING REAL-TIME ULTRASOUND IMAGING
IN NORMAL HEALTHY SUBJECTS
Cynthia H. Gill, Caitlin Murray, Tamar Sivaslian,
Brian Lloyd, Bo Murphy
Physical Therapy, University of Maryland Eastern Shore, Princess
Anne, Maryland
PURPOSE/HYPOTHESIS: The subacromial space, a common site of shoulder
impingement, pain, and dysfunction can be assessed by measuring the
acromiohumeral distance (AHD). A decrease in the AHD can lead to an
increase in the risk of impingement, which can lead to pain and disability. Postural changes have been theorized to impact AHD. The purpose of
this study was to examine the relationship between AHD and varying degrees of shoulder abduction in self-selected (SSP) and standardized upright seated posture (USP) using Real-Time Ultrasound (RTUS).
NUMBER OF SUBJECTS: Thirty-four normal subjects (mean age, 25 years; 22
male, 12 female).
MATERIALS/METHODS: Anthropometric measurements were obtained and
maximal grip strength was assessed. Subjects were screened for scapular
stability and impingement using standardized clinical tests. Ultrasound
images of AHD were captured with the arm at rest and at 30°, 45°, and
60° abduction with the subject in SSP and in USP. The AHD was determined to be the linear distance between the “last” visible point of the humerus and the highest point of the acromion process. Intraexaminer reliability between sessions using 10 subjects was measured and resulted in
ICC values ranging from 0.85 (CI: 0.41, 0.96) to 0.95 (CI: 0.82, 0.99) for
SSP and 0.92 (CI: 0.68, 0.98) to 0.97 (CI: 0.89, 0.99) for USP. All analyses were performed with SPSS Version 21.
RESULTS: Statistical analysis showed no significant differences in AHD between SSP and USP positions. Within SSP, AHD at rest (1.31 ± 0.20 cm)
was significantly larger than 30° (1.18 ± 0.25 cm), 45° (1.02 ± 0.22 cm),
and 60° (1.03 ± 0.20 cm) abduction and AHD at 30° abduction was significantly larger than 45° and 60°. Within USP, AHD at rest (1.30 ± 0.19
cm) was significantly larger than 30° (1.21 ± 0.24 cm), 45° (0.99 ± 0.23
cm), and 60° (1.01 ± 0.19 cm) abduction and AHD at 30° abduction was
significantly larger than 45° and 60° abduction. No significant differences in AHD were found between 45° and 60°abduction within either SSP
or USP.
CONCLUSIONS: These results provide evidence suggesting that posture may
not have a significant effect on AHD and therefore may not be a primary
cause of subacromial impingement. AHD appears to be largest at rest (0°
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abduction) and smallest at 45° abduction. However, due to the limitation
of measuring abduction past 45° with RTUS, future research is needed to
confirm these results.
CLINICAL RELEVANCE: The practice of RTUS allows PTs to observe neuromuscular structures in real time and during various physiological movements. Through our background and clinical knowledge, posture can
have an effect on impingement syndrome in the GH joint. By observing
this in the clinic, PTs can note the PTs posture in the examination process
and use the RTUS to observe any SAS narrowing that could be contributing to the impingement. Our data suggest that posture may have a small
to minimal effect on subacromial space and shoulder impingement, but
given our limitations, more research is needed to further investigate the
effects of posture on AHD.
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OPO90
TALAR DOME ARTICULAR CARTILAGE THICKNESS IN INDIVIDUALS WITH
AND WITHOUT ANKLE SPRAINS
Megan M. Gill, John Kipp, Gary S. Chleboun
Division of Physical Therapy, Ohio University, Athens, Ohio
PURPOSE/HYPOTHESIS: Continuous joint stresses due to joint instability can
degrade the articular cartilage, decrease articular cartilage thickness, and
potentially lead to osteoarthritis. While much attention has been directed toward the use of ultrasound imaging to determine femoral condyle
articular cartilage thickness in patients with knee instability, relatively
few studies have addressed talar dome articular cartilage thickness in patients with ankle instability. The purpose of this study was to determine
if a single ankle sprain or multiple ankle sprains results in changes in the
thickness of the talar dome articular cartilage as measured by ultrasound
(US) imaging.
NUMBER OF SUBJECTS: Seventeen.
MATERIALS/METHODS: Subjects were assigned to 1 of 3 groups: control (no
ankle sprains, n = 6; 22.0 ± 1.1 years), coper (single ankle sprain, no selfreported episodes of instability, n = 5; 22.8 ± 1.3 years), and chronic instability (multiple ankle sprains with episodes of instability, n = 6; 24.5
± 2.2 years). Subjects with ankle sprains were included only if the most
recent sprain was at least 2 months prior to participation in the study.
Longitudinal US images of the talar dome were recorded on the lateral,
middle, and medial aspects of the talar dome with the subject’s ankle in
full plantarflexion. The articular cartilage thickness was measured perpendicular to the subchondral bone at 3 points (both ends and the middle
of the visible image of the dome of the talus) using ImageJ (a Java-based
version of the public domain NIH Image Software). The average of the 3
measurements was calculated for each location (lateral, middle, and medial) of the talar dome.
RESULTS: The results suggest that there was a difference (P≤.05) in talar
dome articular cartilage thickness between the medial (0.88 ± 0.31 mm)
and middle (0.72 ± 0.22 mm) locations of the talar dome. The main effect
of group was not significant (P = .235); however, there was a trend suggesting that the subjects with multiple ankle sprains had increased talar
dome thickness compared to control subjects. The location by group interaction was also not significant (P = .268).
CONCLUSIONS: Preliminary results show that the thickness of the talar
dome articular cartilage may vary slightly between the medial and middle
aspects of the talar dome. A history of a single or multiple ankle sprains
does not appear to have an effect on the thickness of the talar dome articular cartilage thickness in college age subjects.
CLINICAL RELEVANCE: Joint instability is thought to be a precipitating factor in the development of osteoarthritis. As a consequence of osteoarthritis, the articular cartilage becomes thinner. These results suggest that in
young subjects, single or multiple ankle sprains do not have an effect on
talar dome articular cartilage thickness. Although some changes in articular cartilage collagen fiber integrity have been seen in young subjects
with chronic ankle instability, thickness does not appear to change.
OPO91
DIFFERENTIAL DIAGNOSIS FOR ANTERIOR KNEE PAIN UTILIZING
MECHANICAL DIAGNOSIS AND THERAPY
Gerard Gordon
Center for Musculoskeletal Care, NYU Langone Medical Center,
East Rockaway, New York
BACKGROUND AND PURPOSE: Research shows that determining a pathoanatomical diagnosis for non–red flag musculoskeletal conditions is challenging. The McKenzie Method of Mechanical Diagnosis and Therapy (MDT)
has been found to be a valid and reliable assessment approach for the
spine and is undergoing initial trials in the extremities. MDT attempts to
classify patients into distinct subgroups based on a thorough history and
symptomatic and mechanical response to different loading strategies. The
treatment is tailored to the patient based on the classification. This case
highlights the utility of MDT to differentially diagnose between 2 classifications and provide an effective treatment.
CASE DESCRIPTION: The patient was a 20-year-old man who presented with
a diagnosis of bilateral patellar tendonitis. He reported an onset of bilateral anterior knee pain which began 3 years ago when he landed hard
while playing basketball. He felt as though the condition was worsening because he could no longer play basketball or squat. Additional aggravating factors included prolonged sitting and ascending stairs. At the
completion of the history a provisional MDT classification of contractile
dysfunction and derangement were possible. Contractile dysfunction is
considered to be structurally compromised contractile soft tissue which
is analogous to chronic tendinopathy. The hallmark of dysfunction is consistency of pain which is only produced when the dysfunctional tissue is
sufficiently loaded. Derangement is the clinical presentation associated
with a mechanical obstruction of an affected joint. Directional preference
is an essential feature and variability is the hallmark symptom behavior.
The physical exam that followed was structured to help differentiate between the 2. Primary concordant baselines included end range pain with
passive knee flexion, end range pain and obstruction of passive knee extension, patellar tendon tenderness to palpation, pain and weakness with
knee extension manual muscle testing, pain with ascending stairs, and
painful squat limited to 90°. Screen of the lumbar spine was negative.
Repeated end-range patient-generated knee extension techniques produced clinically significant changes in all concordant baselines. Due to
rapid change of baselines in response to a specific directional preference,
provisional classification of derangement was made. The patient was seen
for 4 sessions over the course of 6 weeks. During this time all baselines
were normalized.
OUTCOMES: Initial LEFS: 35/80. The patient was contacted 2 weeks after his final appointment. He reported having played in basketball tournament without limitations and that he continues to use his specific directional preference exercise to keep the knees feeling good. Final LEFS:
80/80.
DISCUSSION: This case demonstrates the importance of classification to
help guide treatment. Thoughtful mechanical testing allows the clinician
to understand the true nature of a condition. In this case, classification
of derangement led to rapid resolution of a chronic worsening condition.
REFERENCES: Crossley KM, Callaghan MJ, Linschoten R. Patellofemoral
pain. Br J Sports Med. 2016;50:247-250. Hegedus EJ, et al. Physical examination tests for assessing a torn meniscus in the knee: a systematic
review with meta-analysis. J Orthop Sports Phys Ther. 2007;37:541-550.
Lynch G, May S. Directional preference at the knee: a case report using
mechanical diagnosis and therapy. J Man Manip Ther. 2013;21:60-66.
May S, Rosedale R. A survey of the McKenzie classification system in the
extremities: prevalence of mechanical syndromes and preferred loading
strategies. Phys Ther. 2012;92:1175-1186. May S, Ross J. The McKenzie
classification system in the extremities: a reliability study using McKenzie
assessment forms and experienced clinicians. J Manipulative Physiol
Ther. 2009;32:556-563. McKenzie R, May S. The Human Extremities.
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Raumati Beach, New Zealand: Spinal Publications New Zealand Ltd;
2000. Rosedale R, et al. Efficacy of exercise intervention as determined
by the McKenzie system of mechanical diagnosis and therapy for knee
osteoarthritis: a randomized controlled trial. J Orthop Sports Phys Ther.
2014;44:173-181. Smith BE, Hendrick P, Logan P. Patellofemoral pain:
challenging current practice—a case report. Man Ther. 2015. Smith BE,
et al. Patellofemoral pain: is it time for a rethink? McKenzie Institute
Mechanical Diagnosis and Therapy Practitioners (MIMDTP) UK
Newsletter; 2015.
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OPO92
RELIABILITY OF HIP ROTATION RANGE OF MOTION IN SUPINE
AND SEATED POSITIONS
Marissa Gradoz, Lauren Bauer, Terry L. Grindstaff,
Jennifer J. Bagwell
Creighton University, Omaha, Nebraska
PURPOSE/HYPOTHESIS: Hip rotation range of motion (ROM) is a commonly assessed in individuals with hip pathology. While supine and seated
hip rotation range of motion testing positions are both common, it remains unknown which testing position has optimal reliability. Therefore,
the purpose of this study was to compare inter and intrarater reliability
between hip internal and external rotation in the supine and seated positions in experienced and novice practitioners.
NUMBER OF SUBJECTS: Nineteen participants without hip, knee, or lumbar
spine pain (11 female, 8 male; mean ± SD age, 23.5 ± 1.2 years).
MATERIALS/METHODS: Three testers (one with 10 years of orthopaedic physical therapy experience and 2 first year physical therapy students) performed 2 testing sessions (3-7 days between sessions). Passive external
and internal rotation ROM was measured using a standard goniometer.
Measures were obtained on both right and left limbs in 2 positions: supine and seated (hip and knee in 90° of flexion). Interrater and intrarater
reliability were calculated in SPSS using interclass correlation coefficients
(ICC). Minimal detectable change (MDC) was also calculated (standard
error of the measure × 1.96 × √2).
RESULTS: Interrater reliability for supine hip external and internal rotation ROM were good to excellent (ICC = 0.62-0.87 [right and left] and
0.70-0.88, respectively). Between session intrarater reliability for supine
hip external and internal rotation ROM was excellent for all raters (ICC =
0.77-0.96). Interrater reliability was fair to excellent for seated hip external rotation ROM (ICC = 0.52-0.79) and was good for seated hip internal
rotation ROM (ICC = 0.60-0.68). In the seated position, intrarater reliability for hip external rotation ROM was excellent for the experienced
clinician (ICC = 0.81-0.83) and fair to excellent for the novice clinicians
(ICC = 0.52-0.94). Seated hip internal rotation ROM intrarater reliability was good to excellent for the experienced clinician (ICC = 0.61-0.77)
and was fair to excellent for the novice clinicians (ICC = 0.59-0.82). MDC
values among the 3 testers were as follows: supine hip external rotation
ROM, 4.5°-10.5°; supine hip internal rotation ROM, 4.5°-11.3°; seated
hip external rotation ROM, 4.2°-8.0°; and seated hip internal rotation
ROM, 5.6°-11.5°.
CONCLUSIONS: Overall, both seated and supine hip rotation ROM measures
had fair to excellent reliability between and within testers. However, hip
rotation measured in supine had slightly higher inter and intrarater values, particularly for the novice clinicians. The MDC values did not vary
substantially between seated and supine hip rotation ROM.
CLINICAL RELEVANCE: This study demonstrated reliability and MDC values of supine and seated hip rotation ROM testing for experienced and
novice clinicians. This is important clinically because hip rotation ROM
is a common measurement used to evaluate persons with hip pathology. Furthermore, this study suggests that the supine testing position may
be more reliable than the seated position and may be the optimal choice,
particularly for novice clinicians.
OPO93
NORMAL SENSORY RESPONSE AND DISTRIBUTION OF THE STRAIGHT LEG
RAISE TEST ON ASYMPTOMATIC INDIVIDUALS
Mark Gugliotti, Peter C. Douris, Yiyu Lin, Anika Paul,
Alessandro L. Asaro, Jillian Epifania, Robert Garrick,
Brian Mathew, Gleb Kartsev
New York Institute of Technology, Wading River, New York
PURPOSE/HYPOTHESIS: The straight leg raise (SLR) is a passive test commonly used to assess neurodynamic response to movement. To date, there
is a lack of research describing the quality, quantity, and distribution of
normal sensory response associated with the SLR test. The purpose of
our study was to examine the normal sensory response and distribution
of the SLR test on asymptomatic individuals. We hypothesized that: (1)
the sensory response would be along the sciatic nerve distribution and its
distal tributaries, (2) no significant difference in sensory response would
exist between limbs.
NUMBER OF SUBJECTS: Forty-seven.
MATERIALS/METHODS: This was a cross-sectional study. The range of motion, quality, quantity, and distribution of sensory responses were measured in 47 asymptomatic individuals during the SLR test. Passive ankle dorsiflexion and passive neck flexion were used as neural sensitizing
maneuvers.
RESULTS: The total means ± SD of sensory responses for the left and right
lower extremities were respectively as follows: stretching was 6.25 ± 1.75
and 6.63 ± 2.09 cm; burning was 4.28 ± 3.07 and 6.70 ± 5.39 cm; tingling was 2.65 ± 3.06 and 2.63 ± 3.05 cm; and numbness was 2.80 ± 0.14
and 0.60 ± 0.14 cm. The sensation of stretch was the most prominent
response (96%) of those experienced. The distribution and frequency of
sensory response for the left and right lower extremities were respectively as follows: posterior thigh was 74% and 74%; posterior knee was 26%
and 32%; posterior calf was 21% and 34%; and plantar foot surface 2%
and 4%. The frequency at which passive ankle dorsiflexion increased the
local sensory response intensity was 98% for the left lower extremity and
89% for the right lower extremity. Finally, the frequency at which passive
neck flexion increased the local sensory response intensity was 11% for
both lower extremities.
CONCLUSIONS: The results of this study provide evidence that there are no
significant differences in sensory response between limbs during the SLR
test in asymptomatic individuals. Sensory responses were along the sciatic nerve distribution and its distal tributaries. The results also suggest
passive ankle dorsiflexion acts as an effective neural sensitizing maneuver
when performing the SLR test.
CLINICAL RELEVANCE: The clinical implications of these findings suggest that
therapists should expect sensory responses during SLR testing to follow
along the sciatic nerve distribution and to confirm the suspicion of nerve
tissue involvement with passive ankle dorsiflexion.
OPO94
CLINICAL DECISION MAKING WITH AN UNDIAGNOSED POSTTRAUMATIC
TYPE I FRACTURE OF THE RADIAL NECK
Desarae N. Gutierrez, Anthony Cheung, Daniel Cricchio,
Trisha Perry
Nova Medical Centers, Houston, Texas
BACKGROUND AND PURPOSE: Posttraumatic type I fractures of the radial neck
should be considered as potential acute injuries of the arm with an aging
and labor intensive workforce. A physical therapist’s (PT) knowledge of
an abnormal patient presentation in addition to the use of evidence-based
tools is beneficial towards the clinical decision making of musculoskeletal-related injuries.
CASE DESCRIPTION: A 60-year-old female housekeeper experienced heightened pain in her right elbow after catching her left foot in a bed skirt and
suffering a fall onto her right elbow. Initial X-rays (3 views) that were
taken the day after her injury were found negative for fracture and/or
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dislocation. A small bone spur off the olecranon was found leading the
physician to order an X-ray overread. X-ray overread was also found to
be negative for fracture and/or dislocation. Upon initial physical therapy
evaluation, the patient reported a pulling type pain at the right elbow during elbow extension. Patient presented with moderate swelling and was
without visible bruising. Tenderness to palpation was present over the
olecranon, posterior fat pad, the cubital fossa with minimal depth palpation, and throughout the forearm and wrist. Right elbow range of motion, both active and passive, was decreased in flexion and greatly limited into extension. Extension was met with an abrupt stop passively with
a hard end feel and heightened pain. Grip strength findings were reduced
50% compared to the uninvolved side, although manual muscle testing of
the involved elbow was minimally decreased with flexion and extension.
OUTCOMES: Upon initial evaluation, positive objective findings and symptoms suggested a radial neck fracture. PT proceeded to review X-ray images with the physician for a possible fat pad sign/sail sign and abnormal
joint spacing to further support objective findings. X-rays appeared to be
negative for a fat pad sign/sail sign but showed decreased joint spacing of
the humeroradial joint. Due to increased patient complaints of wrist pain,
repeat X-rays were completed in addition to advanced imaging being ordered to rule out a radial neck fracture. Both repeat X-rays and CT scan
results returned negative findings. Patient continued to present with decreased elbow extension with a hard end feel and pain. PT, secondary to
ongoing patient complaints and objective findings of positive elbow extension test 1, tuning fork [3,4] and ultrasound [2,5], indicating a possible fracture, recommended further imaging to the referring physician.
MRI results revealed a type I fracture of the radial neck.
DISCUSSION: Patient presentation along with strong clinical reasoning
skills based on current evidence-based literature can assist PTs in the
differential diagnosis of adverse events that have yet to be substantiated with advanced imaging. PTs can contribute to the efficiency of diagnostic imaging pathways by collaborating with physicians in the differential diagnosis of potentially undiagnosed fractures and avoid unnecessary
interventions.
REFERENCES: 1. Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation
and observational study of diagnostic accuracy in adults and children.
BMJ. 2008;337:a2428. 2. Beck B. Can therapeutic ultrasound accurately detect bone stress injuries in athletes? Clin J Sport Med. 2013;23:241242. 3. Moore, MB. The use of a tuning fork and stethoscope to identify fractures. J Athl Train. 2009;44:272-274. 4. Mugunthan K, Doust J,
Kurz B, Glasziou P. Is there sufficient evidence for tuning fork tests in diagnosing fractures? A systematic review. BMJ Open. 2014;4:e005238. 5.
Papalada A, Malliaropoulos N, Tsitas K, Kiritsi O, Padhiar N, Del Buono
A, et al. Ultrasound as a primary evaluation tool of bone stress injuries in
elite track and field athletes. Am J Sports Med. 2012;40:915-919.
OPO95
THE RELIABILITY OF MEASUREMENTS USED TO QUANTIFY FRONTAL
PLANE KNEE KINEMATICS DURING A SINGLE-LEG HOP TEST:
A VIDEO ANALYSIS
William J. Hanney, Morey J. Kolber, Michelle M. Ramirez,
Rodney Negrete, Kathleen Palmer, Scott W. Cheatham,
Patrick Pabian, Xinliang Liu
Health Professions, University of Central Florida, Orlando,
Florida; Sports Medicine and Rehabilitation, Florida Hospital,
Orlando, Florida; Physical Therapy, Nova Southeastern
University, Fort Lauderdale, Florida; California State University
Dominguez Hills, Carson, California
PURPOSE/HYPOTHESIS: It has been reported that functional landing valgus
during the single-leg hop may be associated with lower extremity dysfunction and risk based assessments are often inclusive of this test. Video
analysis may be a tool used by clinicians to identify abnormal movement patterns that might be elusive to standard observation. Thus, the
purpose of this study was to evaluate the interrater reliability of frontal
plane knee valgus motion during the landing phase of a single limb hop
in asymptomatic participants using the iPad application SparkMotion
(SparkMotion, LLC).
NUMBER OF SUBJECTS: Thirty asymptomatic adult participants, 14 male and
16 female.
MATERIALS/METHODS: Participants meeting inclusion criteria completed a
demographic questionnaire reporting their age, height, body mass, and
dominant leg. Two investigators independently observed a video of a subject performing the single-leg hop test with a standardized landing point
in real time and estimated the degree of knee valgus at the terminal point
where eccentric momentum ended. Then, investigators watched the video again using the software to pause the video at the terminal point and
measured the amount of knee valgus with a virtual goniometer tool. Each
of the 30 subjects performed the test 3 times on each leg for a total of 6
jumps. The reliability was evaluated by the intraclass correlation coefficient (ICC) model 3,k for the intrarater component of analysis and model 2,k for the interrater analysis. Model 2,k was used to determine if the
SparkMotion can be used with confidence and reliability among equally
trained clinicians.
RESULTS: ICCs for visual estimate of dominant leg were 0.90; ICC for visual estimate of nondominant leg was 0.87; ICC SparkMotion dominant
leg was 0.95; ICC SparkMotion non dominant leg = 0.91. The concurrent
validity between visual and SparkMotion had an ICC value of 0.91 for rater A and 0.86 for rater B.
CONCLUSIONS: The results show higher interrater reliability with the use of
the SparkMotion application compared to visual estimate alone; however,
the visual estimates still showed moderate to high reliability with ICC values. To our knowledge, this is the only study to evaluate the single-leg hop
test utilizing a 2-D application. Results may not be generalized to symptomatic cohorts; however, the utility of these findings support reliability
for potential screenings purposes.
CLINICAL RELEVANCE: The results of our study support the use of real-time
video observation as a reliable measurement of frontal plane knee kinematics; however, video-based measurements utilizing an app that can
slow movement and measure angels via a virtual goniometer offer greater
reliability. Moreover, real-time visual estimation of video may offer comparable correlation and agreement to analysis utilizing specific movement
analysis applications (eg, video goniometric).
OPO96
ARTHROSCOPIC PARTIAL MENISCECTOMY VERSUS CONSERVATIVE
TREATMENT FOR THE DEGENERATIVE MENISCUS: A SYSTEMATIC REVIEW
Richard Haydt, Kyle D. Freeman, Zach Bottone,
Jomar Farrales, Jared E. Hunt
Physical Therapy, Misericordia University, Dallas, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to examine available evidence regarding arthroscopic partial meniscectomy
(APM) and conservative therapy for the treatment of the degenerative
meniscus. Practitioners may be uncertain of the best intervention upon
which to treat patients with this musculoskeletal disorder. Current literature provides research on conservative therapies and surgical intervention, but a review of this research is needed to establish which intervention is cost effective and has the best patient outcomes.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: Data sources, including MEDLINE, CINAHL,
PubMed, EBSCO, and PEDro, were used to conduct the literature review.
Inclusion criteria was comprised of degenerative meniscal tears, chronic knee pain affecting function, 35- to 80-year-old subjects, and MRIverified meniscal tears. Exclusion criteria was comprised of traumatic
meniscal tears, additional ACL rupture with the meniscal tear, prior knee
surgery, and OA graded 3, 4 on the Kellgren-Lawrence classification scale.
The average level of evidence was found to be a level II and the average
PEDro score was a 6.6/10. Keywords included physical therapy, degener-
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ative meniscus, meniscectomy, conservative treatment, arthroscopy, surgery, exercise therapy, rehabilitation, and meniscal tear.
RESULTS: This systematic review utilized a total of ten peer-reviewed articles. These ten articles were examined and grouped by their intended purpose. Four articles directly compared conservative therapy and APM. One
article described a sham surgery compared to APM. Two articles examined the clinical effectiveness of conservative therapy alone in treating the
degenerative meniscus. One article observed the effects of APM alone on
the treatment of the degenerative meniscus. The last 2 articles examined
the effects of conservative therapy after APM was performed.
CONCLUSIONS: In this study, the authors found no difference between APM
and conservative therapy in the categories of pain, muscle strength, function, and overall patient satisfaction after healing. Previous outcomes
show that conservative treatment would incur less risk to the patient and
be a more cost-effective and less traumatic option for patients with degenerative meniscus. Therefore, it may be beneficial for the patient to undergo conservative therapy as an alternative to arthroscopic partial meniscectomy, for symptom reduction and better functional outcomes.
CLINICAL RELEVANCE: APM disrupts the innate tissues that protect the knee
from further degenerative processes such as the progression of osteoarthritis. If conservative therapy is ineffective in reducing patient symptoms,
it can still serve to provide the patient with presurgical strengthening.
Patient education is crucial in the patient’s choice of treatment for degenerative meniscal tears. Future research on this topic is recommended.
OPO97
TRIGGER POINT DRY NEEDLING FOR A PATIENT PRESENTING WITH
PLANTAR FASCIITIS FOLLOWING SURGICAL REMOVAL OF A STIEDA
PROCESS AND STABILIZATION OF A TALAR FRACTURE: A CASE STUDY
Margaret L. Hazlett, Joel E. Bialosky
Physical Therapy, University of Florida, Gainesville, Florida
BACKGROUND AND PURPOSE: Plantar fasciitis is a common musculoskeletal
disorder of the foot with a lifetime incidence of 10% afflicting both sedentary and highly active individuals. Trigger point dry needling (TDN) is
a treatment for individuals experiencing musculoskeletal pain with limited evidence for its effectiveness in individuals with plantar fasciitis. The
purpose of this case study is to describe outcomes associated with the use
of TDN as a supplemental intervention for a patient presenting for postsurgical rehabilitation in whom rehabilitation was limited by the development of plantar fasciitis associated with prolonged use of a walker boot.
CASE DESCRIPTION: The patient was a 36-year-old man who presented to
physical therapy for postoperative rehabilitation following surgical removal of a Stieda process and stabilization of a talus fracture. The patient
was seen for 8 weeks of physical therapy directed by a standard post operative protocol and was progressing as expected. At this time, the patient
developed signs and symptoms consistent with plantar fasciitis pain preventing progression and necessitating continued use of the post operative
boot. Pain was rated as an 8/10 using a numeric pain rating scale and his
Lower Extremity Functional Scale was 58/80. Trigger points were identified in the adductor hallucis and flexor hallucis muscles and TDN was initiated to these areas for 2 sessions over a 2-week period.
OUTCOMES: Following 2 TDN treatments, patient reported 0/10 on pain
and scored 80/80 of the LEFS which translated to 100% of maximal
function, and was able ambulate without the post operative boot with full
weight-bearing on his affected extremity.
DISCUSSION: The addition of TDN to a standard physical therapy program was associated with complete functional recovery and absence of
pain upon discharge in a patient in whom postoperative rehabilitation
was limited by the onset of plantar fasciitis. This case is novel in describing the supplemental use of TDN in a patient in whom the development
of plantar fasciitis limited return to full function following an unrelated
surgical procedure.
REFERENCES: 1. Martin RL, Davenport TE, Reischl SF, McPoil TG,
Matheson JW, Wukich DK, McDonough CM. Heel pain. Plantar fasci-
itis: revision 2014 clinical practice guidelines. J Orthop Sports Phys Ther.
2014;44;1-23. 2. Cotchett MP, Landorf KB, Munteanu SE, Raspovic
A. Effectiveness of trigger point dry needling for plantar heel pain: a
randomized controlled trial. Am J Phys Ther. 2014:94;1083-1095. 3.
Dommerholt J, Hooks T, Finnegan M, Grieve R. A critical overview of
the current myofascial pain literature-March 2016. J Bodyw Mov Ther.
2016;20:397-408. 4. Rodríguez-Mansilla J, Gonzàlez-Sànchez B, De Toro
García À, Valera-Donoso E, Garrido-Ardila EM, Jiménez-Palomares M,
Gonzàlez López-Arza MV. Effectiveness of dry needling on reducing pain
intensity in patients with myofascial pain syndrome: a meta-analysis. J
Tradit Chin Med. 2016;36:1-13. 5. Tough EA, White AR, Cummings M,
Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and metaanalysis of randomized controlled trial. Eur J Pain. 2009;13:3-10.
OPO98
DIAGNOSIS OF NON–SMALL CELL CARCINOMA IN A PATIENT
WITH UPPER-QUARTER PAIN
Craig P. Hensley
Physical Therapy and Human Movement Sciences, Northwestern
University, Chicago, Illinois
BACKGROUND AND PURPOSE: While emphasis has been placed on screening
for serious medical pathology during the initial evaluation, it is also important for physical therapists (PT)s to screen for “red flags” throughout
the episode of care. Further, patients with a presentation complicated by
multiple issues, including central sensitization and/or biopsychosocial influences, can challenge the clinician’s screening accuracy [1]. The purpose
of this case report is to describe the differential diagnosis process and
clinical reasoning of a patient with upper-quarter pain.
CASE DESCRIPTION: A 59-year-old woman presented with a 5-month history of left thorax, cervical, and shoulder pain. She received multiple interventions, including chest wall injections of Tordol and anti-inflammatory medications, which did not completely resolve her pain. Chest, cervical
spine, and shoulder X-rays were negative. The patient reported multiple
recent psychosocial stressors, including her husband recently being diagnosed with cancer, mother with stroke, and the recent death of a close
friend. She answered yes to the Whooley questions [2]. She reported an
increase in dyspnea and sweating in the recent past, but stated both were
improving. She endorsed smoking for 20 years, but quit 12 years prior.
She denied any other red flags. Past medical history was significant for hypertension, diabetes mellitus type II, and asthma. Multiple activities were
reportedly aggravating, including sleeping on the involved side, reaching
overhead, rotating her neck, sitting, eating, coughing, and deep breathing.
Shoulder, cervical, and thoracic active/passive range of motion (ROM)
and joint mobility examination increased her pain. Allodynia was present throughout the left upper quarter. She tolerated the bike for 20 minutes with no increase in symptoms and reported a decrease in pain with
relatively stable vitals. Thus, manual therapy, therapeutic exercise, stress
management, and pain education were initiated.
OUTCOMES: The patient was seen for 5 visits over 35 days. Her shoulder
flexion active ROM improved (85°-140°), pain improved (9-6 on numeric pain-rating scale) and QuickDASH score decreased (43%-34%).
However, on her fifth visit, she reported an increase in pain, fatigue,
sweating, dyspnea, and loss of appetite over the past week. The patient
was sweating on her face. The primary care physician was notified and a
CT scan of the chest was ordered. The patient was diagnosed with a nonsmall cell lung carcinoma.
DISCUSSION: This case report highlights the importance of PTs evaluating
for red flags throughout the course of care as pathological conditions can
be masked in a presentation complicated by central sensitization and/or
biopyschosocial stressors.
REFERENCES: Mitchell ED, Rubin G, Macleod U. Understanding diagnosis
of lung cancer in primary care: qualitative synthesis of significant event
audit reports. Br J Gen Pract. 2013;606:e37-e46. Bosanquet K, Bailey D,
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Gilbody S, Harden M, Manea L, Nutbrown S, McMillan D. Diagnostic accuracy of the Whooley questions for the identification of depression: a diagnostic meta-analysis. BMJ Open. 2015:e008913.
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OPO99
KINEMATIC ANALYSES OF THE TEMPOROMANDIBULAR JOINT DURING
FUNCTIONAL MOVEMENTS AND JOINT MOBILIZATION:
A CADAVERIC STUDY
Jing-Ching Sally Ho, Mei-ling Chiu, Shiubong Larry Ho,
Ar-Tyan Hsu
Department of Biokinesiology and Physical Therapy, University
of Southern California, Los Angeles, California; Department of
Physical Therapy, National Cheng Kung University, Tainan,
Republic of China
PURPOSE/HYPOTHESIS: Temporomandibular disorder (TMD) is characterized by pain and dysfunction of the temporomandibular joint (TMJ) and
muscles of mastication. It affects 6% to 12% of the adult population [1].
Joint mobilization has been employed for managing TMD [2]. Recent reviews in the management of TMD failed to identify high-quality evidence
and certainty of effectiveness for manual therapy [3,4,5]. No existing literature has analyzed the biomechanical characteristics of TMJ mobilizations,. therefore, purposes of this study were to investigate the kinematics
of TMJ during jaw functional movements and during TMJ mobilization.
NUMBER OF SUBJECTS: Nine fresh cadaveric head specimens were used.
MATERIALS/METHODS: The specimen was mounted on a test frame with a
6-axis load cell. A Vicon Motion Analysis System was used to track movements of TMJ. Functional movements (jaw opening, protrusion, retrusion, and lateral deviations) were performed passively by a TMD specialist (SH). Unilateral inferior glide with anteromedial translation (UIGAT),
bilateral inferior glide with anterior translation (BIGAT), inferior glide
with anterior rotation (IGAR), inferior glide with posterior rotation
(IGPR), and lateral glide were performed. Jaw movements were tested
again at the end of the experiment. The condylar rotation and translation
of both left (LC) and right condyle (RC) were analyzed.
RESULTS: During passive jaw opening the condyle rotated 16.1° ± 3.0° and
moved anteriorly (LC, 1.88 ± 1.89 mm; RC, 2.24 ± 1.42 mm) and inferiorly (LC, 3.87 ± 1.77 mm; RC, 3.53 ± 2.18 mm). During passive jaw deviation
to the left, the left condyle moved posteriorly (1.04 ± 0.82 mm), laterally
(1.34 ± 0.44 mm), and superiorly (0.71 ± 0.59 mm) and the right condyle
moved anteriorly (1.32 ± 0.87 mm), medially (1.35 ± 0.48 mm), and inferiorly (0.91 ± 0.54 mm). Similar patterns of condylar movements were
observed during passive jaw deviation to the right. UIGAT and BIGAT
produced anterior translation (2.59 ± 1.75 mm and 2.08 ± 0.97 mm) and
inferior translation (1.72 ± 0.64 mm and 1.58 ± 0.52 mm) of the condyle.
UIGAT and lateral glide produced lateral translation (1.61 ± 0.66 mm
and 0.83 ± 0.44 mm). There were significant increase of condylar rotation (P = .008) and translation in the anterior (P = .011 in LC) and inferior directions (P = .021 in both LC and RC) between pre and posttest of
jaw opening.
CONCLUSIONS: During functional movements and TMJ mobilizations directions of condylar rotation and translation were consistent with intended applications [2]. Results of the present study also suggest that UIGAT
and BIGAT can be applied if anterior or inferior movement of the condyle or if jaw opening is limited and UIGAT and lateral glide, if the lateral
movement of the condyle is limited.
CLINICAL RELEVANCE: This study presented the kinematics of TMJ during
functional jaw movements and during TMJ mobilization and therefore
provided quantitative data for research references and clinical evidence
to verify the effectiveness of the TMJ mobilization techniques.
OPO100
RELIABILITY OF MEASURING ANTERIOR TRANSLATION OF THE MANDIBULAR
CONDYLE DURING MOUTH OPENING USING ULTRASONOGRAPHY
Kai-Yu Ho, Brooke Basar, Danielle Hahn, Christensen J. Hardy
Physical Therapy, University of Nevada, Las Vegas, Las Vegas,
Nevada
PURPOSE/HYPOTHESIS: Temporomandibular dysfunction (TMD) is a com-
mon orofacial condition, which often leads to restricted mandibular
opening. In order for physical therapy intervention to be optimal, it is
important to identify arthrokinematic limitations in individuals with
TMD. Specifically, anterior translation of the mandibular condyle is a required arthrokinematical component to achieve maximal mouth opening. To date, quantifying TMJ arthroknematics relies on advanced imaging techniques (eg, computerized tomography [CT]) or motion analysis
systems, which are expensive and impractical for on-site clinical use.
Ultrasonography could provide an inexpensive, more practical means of
obtaining measurements of anterior translation of the mandibular condyle. The purpose of this study was to investigate the reliability of using
ultrasound (US) imaging for measuring TMJ arthrokinematics (ie, anterior translation of the mandibular condyle) during mouth opening.
NUMBER OF SUBJECTS: Twenty-eight subjects (mean ± SD age, 25.9 ± 4.1
years; 14 male, 14 female) with no current diagnosis of TMD.
MATERIALS/METHODS: During day 1 of data collection, all 28 subjects were
asked to repeatedly perform maximal mouth opening while a single examiner placed a linear US transducer overlying the TMJ and the zygomatic arch to record dynamic images of bilateral TMJs. On day 2 of data
collection, the same US imaging acquisition procedure was performed on
6 of the subjects that participated in day 1 of data collection. Data analysis was performed to determine (1) imaging processing reliability, and
(2) imaging acquisition reliability. Reliability of imaging processing was
determined by 3 examiners. Each examiner measured condylar translational distance during mouth opening of 28 subjects on 2 separate days
with at least 7 days apart. Averages on each side from both data processing days were analyzed to determine inter and intrarater reliability using
intraclass correlation coefficients (ICCs). Standard errors of measurement
(SEMs) of each examiner were also calculated. To determine intrarater
reliability of US imaging acquisition (ie, transducer placement accuracy), data obtain from day 1 and day 2 of data collection was analyzed using ICCs and SEMs.
RESULTS: Data analyses revealed excellent interrater reliability among
the 3 examiners for measurements of both TMJs (ICC = 0.989-0.999).
Excellent intrarater reliability for imaging processing was also achieved
(ICC = 0.960-0.977; SEM, 0.704- 0.871 mm). Data also revealed excellent intrarater reliability for US imaging acquisition (ICC = 0.929-0.939;
SEM, 1.214-1.268 mm).
CONCLUSIONS: This is the first study assessing the reliability of using US
imaging to measure anterior condylar translation in healthy adults. Our
data demonstrated that anterior condylar displacement during mouth
opening can be measured reliably using our US imaging approach.
CLINICAL RELEVANCE: Our research provides an inexpensive, reliable mean
of obtaining anterior translation of the mandibular condyle during mouth
opening.
OPO101
ACUTE EFFECTS OF WALKING ON THE DEFORMATION OF FEMORAL
ARTICULAR CARTILAGE
Kai-Yu Ho, Jayson McClaren, Skyler Sudweeks,
William R. McGee
Physical Therapy, University of Nevada Las Vegas, Las Vegas,
Nevada; Total Sports Medicine and Orthopedics, Las Vegas, Nevada
PURPOSE/HYPOTHESIS: Knee osteoarthritis (OA) is characterized by a progressive loss of the articular cartilage, increasing the amount of friction
in the joint, resulting in pain and decreases in mobility and function.
Additionally, it has been hypothesized that frontal plane knee malalignment (eg, varus, valgus) is associated with initiation/progression of OA.
Previous studies show that static loading of the knee results in more cartilage deformation in those with knee OA compared to healthy controls.
Static loading of the knee is only proportional to their body weight, where-
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as walking produces forces in the knee that are 2 to 3 times body weight.
This may result in greater cartilage deformation. The purpose of our study
was to compare the acute effects of walking on the femoral cartilage deformation between individuals with and without knee OA and determine
whether knee alignment is associated with cartilage deformation.
NUMBER OF SUBJECTS: Ten subjects without OA (5 female, 5 male; mean ±
SD age, 55.0 ± 1.8 years; weight, 78.8 ± 14.0 kg; height, 1.8 ± 0.2 m) and 7
subjects with OA (4 female, 3 male; age, 55.4 ± 5.2 years; weight, 94.0 ±
13.1 kg; height, 1.7 ± 0.1 m) were recruited.
MATERIALS/METHODS: Each subject underwent X-ray and magnetic resonance imaging (MRI) assessment. For X-ray assessment, participants
with Kellgren-Lawrence grades 2 to 3 were assigned to the OA group
whereas subjects with grades 0 to 1 were assigned to the control group.
During MRI assessment, 3 T, frontal-plane MRI was obtained before and
immediately after 30 minutes of treadmill walking at 3 to 4 mph. Knee
alignment was obtained by measuring the angle between the long axes of
femur and tibia using a goniometer. To obtain cartilage deformation postwalking, the medial and lateral femoral cartilage of the weight-bearing areas was segmented on subjects’ MRI. Cartilage thickness was quantified
by computing the average perpendicular distance between opposing voxels defining the edges of the femoral cartilage. Independent t tests were
used to compare cartilage deformation (ie, percent changes in medial and
lateral cartilage thickness) postwalking between the 2 groups. Pearson
correlation coefficients were used to assess the association between cartilage deformation and knee alignment of all subjects.
RESULTS: Independent t tests revealed no significant difference in cartilage
deformation between OA group and control group in medial (P = .843) or
lateral (P = .660) femur. Pearson correlation coefficient analyses revealed
a significant correlation between lateral femoral cartilage deformation
and increased knee valgus alignment (r = 0.505, P = .039).
CONCLUSIONS: This is the first study assessing the acute effects of walking
on femoral cartilage deformation in persons with and without knee OA.
Although there was not a difference in cartilage deformation between the
2 groups, we found that knee valgus was related to lateral femoral cartilage deformation postwalking.
CLINICAL RELEVANCE: Our findings provide further understanding of the
contribution of LE alignment and development of OA. This research can
impact the interventions for individuals with knee OA.
OPO102
PERSONS WITH PATELLOFEMORAL OSTEOARTHRITIS HAVE REDUCED
HIP AND KNEE JOINT VELOCITIES DURING FUNCTIONAL TASKS AND
DECREASED PROXIMAL LOWER EXTREMITY STRENGTH
Lisa T. Hoglund, Neil B. Sheth, Joshua R. Orlow, Niraj A. Patel,
Michael Polejaev, Laura Pontiggia, John D. Kelly, James Carey
Physical Therapy, University of the Sciences, Philadelphia,
Pennsylvania; Physical Therapy, Thomas Jefferson University,
Philadelphia, Pennsylvania; Mathematics, Physics, and Statistics,
University of the Sciences, Philadelphia, Pennsylvania; Orthopedic
Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
PURPOSE/HYPOTHESIS: Patellofemoral osteoarthritis (PFOA) was reported
present in 69% of adults approximately 40 years with chronic knee pain
[1]. PFOA causes significant pain and disability [2,3]. Altered lower extremity (LE) biomechanics may contribute to PFOA development or progression. But there are conflicting reports of the presence of aberrant LE
biomechanics in persons with PFOA [4-8]. Altered hip or knee joint angular velocity may be an indication of poor LE control, such as valgus LE
collapse in persons with patellofemoral pain. The purpose of this study
was to examine hip and knee joint peak angular velocities during stepdown (StDn) and sit-to-stand (STS) tasks in persons with PFOA versus
pain-free controls.
NUMBER OF SUBJECTS: Twenty.
MATERIALS/METHODS: A cross-sectional study compared 10 persons with
painful PFOA to 10 age- and sex-matched pain-free adults. The most
painful LE of the PFOA group and the same side LE of matched control participants was examined. A motion capture system was used to
track LE motion during StDn and STS. Peak hip and knee joint velocities during stance phase were determined. Peak isometric torque of the
hip abductors, hip external rotators (ER), hip extensors, and knee extensors were measured with an instrumented dynamometer and normalized
by mass and height. Data were analyzed with nonparametric statistics.
RESULTS: Participant median age was 50 years (PFOA group) and 52 years
(control group); all were female. Peak hip adduction velocity during StDn
and peak knee extension velocity during STS were slower in the PFOA
group than the control group (P<.05). All normalized muscle torques
were lower in the PFOA group versus the control group (P<.01). Moderate
positive relationships existed between hip ER torque and (1) hip flexion
velocity during St Dn (r = 0.51, P = .02) and (2) knee abduction velocity
during StDn (r = 0.63, P = .003). A moderate inverse relationship existed
between hip ER torque and hip internal rotation velocity during StDn (r
= –0.52, P = .02). A moderate inverse relationship existed between peak
hip abductor torque and (1) minimal knee flexion velocity during STS (r
= –0.64, P = .003) and (2) minimal hip flexion velocity during STS (r =
–0.47, P = .04).
CONCLUSIONS: Persons with PFOA had reduced hip and knee joint angular
velocities during StDn and STS as well as lower peak isometric LE muscle
torque. Significant associations between hip ER and hip abductor torques
with hip and knee joint velocities indicate that weakness of these muscles
may contribute to aberrant LE biomechanics during StDn and STS. The
negative association between hip ER torque and hip internal rotation velocity during StDn indicates that hip ER weakness may contribute to poor
LE control during stair descent in persons with PFOA.
CLINICAL RELEVANCE: Persons with PFOA have proximal LE muscle weakness and reduced LE joint angular velocities during tasks of stair descent
and STS. Future research should study the effect of a strengthening program for persons with PFOA on joint velocities and pain during functional tasks.
OPO103
DOES THE PRESENCE OF RADIATING PAIN IN A COHORT OF CARE-SEEKING
PATIENTS WITH NECK PAIN INFLUENCE OUTCOME?
Joshua Holskey, Charles A. Thigpen, Chad E. Cook,
Thomas R. Denninger, Timothy McHenry
Research and Analytics, ATI Physical Therapy, Greenville, South
Carolina; Department of Orthopedics, Duke University, Durham,
North Carolina; Department of Orthopedics, Greenville Health
System, Greenville, South Carolina
PURPOSE/HYPOTHESIS: Previous literature has established the presence of
radiating pain in patients with neck pain as a prognostic indicator for
worse outcome. The purpose of this analysis of a cohort of patients is to
establish if difference exists in duration of care and outcomes in patients
presenting to physical therapy with nonradiating and radiating neck pain.
NUMBER OF SUBJECTS: The nonrandomized comparative study involved a
cohort of 200 patients with neck pain with or without radiating upper extremity symptoms who received guideline oriented care by physical therapists over a 3-year period.
MATERIALS/METHODS: The data included patients who were seen via direct
access or through referral. Baseline measures of pain, disability (Neck
Disability Index), depression and quality of life were captured for each
subject. Final outcomes measures captured include pain and the NDI.
Comparative analyses between groups were performed for all baseline
measures (using a t test/chi-square) and for discharge percentage change
scores for pain and disability (using an analysis of covariance [ANCOVA];
α = .05).
RESULTS: Of the 200 patients enrolled, 135 (67.5%) had neck back pain
without radiation and 65 (32.5%) had radiating symptoms. No differences existed age of patients in each group. Differences existed in number of
PT session with those with radiating symptoms being seen 1.8 more visits
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(P = .015). Baseline pain and disability were not significantly difference,
nor was reductions in disability. Both groups experienced reductions in
pain and disability that exceeded statistical significance and minimally
clinically important difference.
CONCLUSIONS: Despite the commonly accepted belief that the presence of
radiating upper extremity symptoms in patients with neck pain is indicative of worse outcome, our findings did not support this. This difference
may be due to continued visits if the patient demonstrated progression
of symptoms where prior research has limited the number of PT visits.
This suggest a capitated number of visits for all patients is not an effective strategy to determine if conservative treatment is definitive for all
patients.
CLINICAL RELEVANCE: Clinicians should consider that some patients radiating symptoms may have different lengths in episode of care but can be expected to reach similar functional levels at discharge.
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OPO104
THE CLINICAL USE OF MUSCULOSKELETAL ULTRASOUND IN THE
MANAGEMENT OF ANTEROLATERAL ANKLE IMPINGEMENT:
A CASE REPORT
Amanda J. Humphrey, Ross Schumer, Theodore Croy
US Army-Baylor University Doctor of Physical Therapy Program,
San Antonio, Texas; F. Edward Hebert School of Medicine,
Uniformed Services University of Health Science, Joint Base San
Antonio, Fort Sam Houston, Texas
BACKGROUND AND PURPOSE: Sports-related ankle injuries are problematic
and result in persistent pain and disability. Musculoskeletal ultrasound
(MSK US) imaging can augment the clinical examination and help guide
patient education and management. The purpose of this case study is to
describe the clinical presentation, diagnosis and management of a female
Soldier who underwent MSK US, physical therapy (PT) and arthroscopic ankle surgery.
CASE DESCRIPTION: The patient is a 24-year-old woman with a past history
of recurrent ankle sprains who injured her ankle playing soccer where she
was slide tackled and forced into end range plantar flexion. Immediately
postinjury she reported to the ER where radiographs were obtained and
she was placed on crutches for 2 weeks. She underwent Physical Therapy
for 3 months. After completing a bout of conservative care she still had
persistent and unresolved complaints of sharp anterolateral ankle pain
with dorsiflexion, running, and stair descent, which did not improve despite PT intervention. MSK US demonstrated an intact anterior talofibular ligament and a bony fragment on the dorsal neck of the talus, which
engaged the talocrural joint during dorsiflexion. This lesion was confirmed on MRI. Ankle arthroscopy confirmed an 8-mm bony loose body
with soft tissue attachment to the dorsal-lateral talar neck with surrounding synovitis. The articular cartilage was intact without any evidence of
a donor site. Dorsiflexion under arthroscopic visualization demonstrated bony impingement on the anterior distal tibia. The loose body was removed, and a limited synovectomy with osteoplasty of the talar neck was
performed to allow full, unrestricted dorsiflexion without impingement.
The patient was placed in a cam walker weight bearing as tolerated for 3
weeks and allowed to perform early full range of motion.
OUTCOMES: MSK US augmented the PT clinical exam with this patient.
This provided the PT and the patient with a visualization of the loose
body and capsular synovitis that contributed to her symptoms. This aided the PT in educating her and helped to adjust her return to sport and
functional expectations. The patient demonstrated full passive dorsiflexion under anesthesia after the synovitis and loose body were removed.
She is currently following an uncomplicated postoperative clinical course.
DISCUSSION: MSK US in conjunction with clinical examination can aid in
patient education and prognosis management with clinical conditions
that may require referral and subsequent ankle surgery. The patient demonstrated MSK US findings consistent with an impinging lesion in the
anterior ankle, corroborated by MRI and arthroscopy. These findings
helped the PT educate the patient on the nature of the symptoms, the inability to progress with rehabilitation, the need for further orthopaedic
referral, and to better understand the prognosis for clinical management,
which included both PT and orthopaedic care.
REFERENCES: 1. Croy T, Cosby N, Hertel J. Active ankle motion may result in an anterior talar positional fault in individuals with chronic ankle
instability and ankle sprain copers: a preliminary study. J Man Manip
Ther. 2013;21:127-133. 2. Croy T, Saliba S, Saliba E, Anderson M, Hertel
J. Talofibular length increases following ankle sprain: a stress ultrasonography study of ankle laxity. J Sport Rehabil. 2013;22:257-263. 3. Croy T,
Saliba S, Saliba E, Anderson M, Hertel J. Differences in lateral ankle laxity measured via stress ultrasonography in individuals with chronic ankle
instability, ankle sprain copers, and healthy individuals. J Orthop Sports
Phys Ther. 2012;42:593-601. 4. Pesquer L, Guillo S, Meyer P, Hauger
O. US in ankle impingement syndrome. J Ultrasound. 2014;17:89-97.
5. Radwan A, Bakowski J, Dew S, Greenwald B, Hyde E, Webber N.
Effectiveness of ultrasonography in diagnosing chronic lateral ankle instability: a systematic review. Int J Sports Phys Ther. 2016;11:164-174.
OPO105
THE EFFECTS OF BALANCE VERSUS STRENGTH TRAINING
ON ACTIVE AND PASSIVE ANKLE POSITION SENSE IN INDIVIDUALS
WITH ANKLE INSTABILITY
You-jou Hung, Jacob Miller
Physical Therapy, Angelo State University, San Angelo, Texas
PURPOSE/HYPOTHESIS: Ankle instability is a common problem for individuals with a history of ankle sprains. It was suggested that altered motor
control due to less accurate ankle position sense can contribute to recurrent injuries. The purpose of this study was to compare the training outcome of 2 ankle rehabilitation protocols on active and passive ankle position sense.
NUMBER OF SUBJECTS: Seventeen subjects (19-30 years old) with a history of ankle sprains volunteered for the study. Their Cumberland Ankle
Instability Tool (CAIT) score ranges from 10 to 27 for the participants at
the baseline testing session.
MATERIALS/METHODS: Subjects were randomly assigned to 1 of the 2
groups: (1) balance training, and (2) strength training. The supervised
training lasted for 30 minutes each time, 2 times a week for 4 weeks. For
balance training, exercise progressed from standing on both legs to single leg, from standing on stable surfaces to unstable surfaces, and from
standing with visual feedback to standing with eyes closed. For strength
training, subjects engaged resistance training for their ankle joint muscles, emphasizing ankle dorsiflexors and everters. Ankle position sense
was examined with the Active Reproduction of Active Positioning and
Passive Reproduction of Passive Positioning protocols. A dual-axis ankle
electronic goniometer was used to examine ankle angles. Two-way analysis of variance with 1 between-group factor and 1 repeated-measures factor was used to analyze the data.
RESULTS: Baseline examination indicated that there is no ankle stability
difference between the 2 treatment groups using their CAIT scores (F =
0.366, P>.55). For active ankle position sense, there is no difference between balance and strength training protocols (F = 0.086, P>.77), no difference among pre, post and follow-up testing (for ankle stability index (F
= 1.558, P>.23), and no training-testing interaction (F = 1.026, P>.35). For
passive ankle position sense, there is no difference between balance and
strength training protocols (F = 0.304, P>.59), no difference among pre,
post and follow-up testing (for ankle stability index (F = 3.350, P>.06),
and no training-testing interaction (F = 1.172, P>.31).
CONCLUSIONS: Balance training is a common intervention for individuals with
ankle instability. Results of the present investigation indicate that there is
no treatment effect difference between a 4-week-long balance and strength
training programs on active or passive ankle position sense. In addition, active ankle position sense has a better functional significance over passive
position sense. However, neither active nor passive ankle position sense im-
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proved at the completion and 1 month after the 4-week intervention.
CLINICAL RELEVANCE: It was reported that ankle balance training may enhance ankle proprioception and stability. However, the current study suggests that the improvement of ankle stability after training may be the
result of other factors (eg, enhanced muscle/ligament strength and supraspinal control) instead of improved ankle position sense.
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OPO106
DOES HIP STRENGTHENING DECREASE PAIN AND INCREASE FUNCTIONAL
OUTCOMES IN WOMEN WITH PATELLOFEMORAL JOINT DYSFUNCTION?
A SYSTEMATIC REVIEW
Ellen Jackson, Drew Lollar, Josh Lopez, Morgan Ogale,
Tom Sneed
Southwest Baptist University, Bolivar, Missouri
PURPOSE/HYPOTHESIS: Since Title IX was signed into law in 1972, the
amount of females participating in high school athletics has increased
902% and in collegiate sports 456%. With this increased activity level, there has been an increase in injury, patellafemoral joint dysfunction, seen at the knee joint more prevalent in women. The common approach to intervention for this has been to focus on the knee joint itself
with strengthening and taping to help with the strengthening. Recently a
more global approach has been introduced incorporating proximal muscle strengthening at the hip. As this approach develops, the question arises: does hip strengthening decrease pain while increasing functional outcome measures in women with patellofemoral joint dysfunction?
NUMBER OF SUBJECTS: Three hundred fifty-four.
MATERIALS/METHODS: Five collections of search terms were used to search
databases resulting in 206 studies identified. The number of studies after duplicates were removed resulted in 49 studies. The 49 studies were
screened via title and abstract for relevance and inclusion criteria of female subjects diagnosed with patellofemoral joint dysfunction and a hipstrengthening component of rehab. After this screening, 10 studies remained. The 10 studies were reviewed in full text leading to an additional
3 studies excluded. The 7 selected studies were evaluated to determine
level of research and quality of study.
RESULTS: All studies were considered high level design being level II randomized controlled trials. Out of the 7 studies, 3 indicated strong quality of study, 3 moderate quality of study, and only 1 showed weak quality.
Subjects placed in groups with a hip strengthening component in their
treatment had a decrease in pain on the VAS and an increase in function
via LEFS and isometric strength measures. Out of the 7 studies, 5 used
the VAS, 5 used the LEFS, and 4 used isokinetic strength testing as outcome measures. The studies using VAS reduced scores from average 6.4
to 1.4, a 77.7% improvement. The studies using LEFS increased scores
from 53.8 to 70.3, an average of 30.6% improvement. The studies using isometric strength all showed improvement with an average increased
strength of 25.9% compared to controls which decreased 4.3%.
CONCLUSIONS: Hip strengthening exercises should be included in the treatment of patellofemoral joint dysfunction. Closed chain exercises that include the hip and the knee should also be used during treatment.
CLINICAL RELEVANCE: Based upon the results of the studies reviewed, looking at the number of subjects who achieved positive outcomes with a hip
strengthening component added to their treatment, it can be inferred that
this approach should be added to the physical therapy protocol. Through
adding a hip strengthening component to the rehab process as well as
working at the knee joint itself, the patient is receiving a global treatment
approach. With the patient participating in a global treatment approach
to their rehab process, better outcomes can be attained by focusing interventions at more than 1 joint.
OPO107
THE IMPACT OF SCAPULOTHORACIC EXERCISE TRAINING ON INDIVIDUALS
WITH SHOULDER PAIN: AN EMG AND KINEMATIC INVESTIGATION
Laura E. Jacobs, Tom P. Ebert, Noah Fessler, Amy Evans,
Justin L. Staker, Paula M. Ludewig
Physical Medicine and Rehabilitation, University of Minnesota,
Minneapolis, Minnesota; Program in Physical Therapy, University
of Minnesota, Minneapolis, Minnesota
PURPOSE/HYPOTHESIS: Shoulder pain is a prevalent musculoskeletal com-
plaint, with estimates of up to 26% of people experiencing shoulder pain
during their lifetime. Scapulothoracic exercise interventions are commonly employed clinically for these patients. The purpose of this study
was to determine any differences in EMG and kinematics between shoulder exercises completed with and without incorporation of scapulothoracic training in subjects with shoulder pain.
NUMBER OF SUBJECTS: Eleven subjects (5 female; average age, 28 years; 8
right shoulders) with shoulder pain meeting clinical inclusion/exclusion
criteria.
MATERIALS/METHODS: Five exercises: I’s, T’s, Y’s, external rotation with
theraband (ERT), and external rotation with weight (ERW) were completed under 3 conditions: (1) without specific scapulothoracic instructions, (2) with scapular manual and verbal guidance, and (3) with scapular verbal guidance alone. Electromagnetic surface sensors tracked the
trunk, clavicle, scapula, and humeral kinematics, while electromyographic (EMG) sensors captured muscle activity of the upper trapezius (UT),
lower trapezius (LT), middle and posterior deltoid, and serratus anterior
muscles (SA). EMG data were normalized as a percentage of maximum
contraction. A one-way repeated measures ANOVA compared the conditions within subjects. Tukey follow-up tests were used in the presence of
significant condition effects.
RESULTS: Significant (P<.05) changes in position, displacement, and EMG
were recorded across conditions for several exercises with scapulothoracic training. Clavicular elevation position was reduced 1° during ERT, I
and Y exercises. Clavicular retraction displacement increased during ERT,
ERW, I and T exercises (4°-5°). Scapular internal rotation position significantly decreased (4°-8°) during ERT between the control and both
guidance conditions, and during I exercises between control and manual
guidance. Electromyography showed significant changes during ERT and
ERW exercises for LT magnitude (16%-38% increase) as well as UT to
LT ratio (10%-11% reduction). The SA magnitude significantly increased
3%-12% during ERT and T exercises, in addition to a significant reduction (17%) in the UT to SA ratio during ERT exercises.
CONCLUSIONS: Results support that manual and verbal guidance can positively influence muscle activity and motion during scapular-focused
shoulder exercises. Changes seen with the 2 guidance conditions were
consistent with those targeted. This data suggests that manual and verbal guidance during scapulothoracic exercises can positively affect scapulothoracic kinematics and EMG activation of scapulothoracic musculature. Future studies should work to expand the generalizability through
larger sample sizes and a range of clinician expertise providing manual
and verbal guidance.
CLINICAL RELEVANCE: Clinicians should consider using manual and verbal
scapular guidance to improve scapular exercise performance in individuals with shoulder pain.
OPO108
DRY NEEDLING IN THE UPPER THORAX: HAND DOMINANCE DOES NOT
AFFECT THE DISTANCE TO THE LUNGS
Aaron W. Johnson, Ulrike H. Mitchell
Brigham Young University, Provo, Utah
PURPOSE/HYPOTHESIS: Dry Needling (DN) has gained popularity and its
use in physical therapy is increasing. One concern associated with DN is
the risk of an inadvertent piercing of the thorax pleura leading to lung collapse. It is important to understand the typical distance to the pleura and
factors that will alter this distance, especially as the use of DN increases.
For example, the dominant limb may have larger muscles. The aim of this
study was to present data on the distance from the skin to the lungs in 3
locations in the upper thorax, using ultrasound imaging (US) and to de-
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termine if there was a significant difference in this distance based on the
side of hand dominance.
NUMBER OF SUBJECTS: Thirty individuals (9 women, 21 men; mean ± SD
age, 25.5 ± 4.6 years; BMI, 28 ± 3 kg/m2) participated in the study.
MATERIALS/METHODS: Subjects laid prone on a plinth with the arms positioned at their sides. The spinous processes of thoracic vertebrae were
marked for referencing during the imaging. On both the right and left
side of the thorax, the thorax pleura, adjacent ribs, and over-lying tissue
were visualized with US and a brief video was recorded noting the movement of the lungs. From the recorded video, a still image was selected and
the distance to the pleura was measured using the US unit’s internal software. Images were captured at the location of the levator scapulae (LS),
rhomboid minor (Rmin) and lower rhomboid major (Rmaj) in 2 conditions, with and without a supportive towel placed under the shoulder.
ANOVA was run to determine differences between the side of dominant
and nondominant hands.
RESULTS: There was no significant difference, based on hand dominance,
in distance to the pleura at any of the locations assessed with or without
the supportive towel under the shoulder (P values between .2 and .9) The
average distance to the pleura, no towel, was LS 4.05 ± 0.8 cm, Rmin 3.5
± 0.8 cm, Rmaj 2.6 ± 0.5 cm. The average distance to the pleura with supportive towel was LS 4.6 ± 0.9 cm, Rmin 4.1 ± 0.8 cm, Rmaj 3.1 ± 0.6 cm.
CONCLUSIONS: There is not a significant difference in the distance to the
lung pleura at the locations of the LS, Rmin, or Rmaj based on the side of
hand dominance. Depth to the pleura appears to be fairly consistent between right or left sides of the body in young health adults.
CLINICAL RELEVANCE: Physical therapist practicing DN need to have detailed
knowledge of the anatomy in the body regions they treat in order to minimize risk associated with DN, such as pneumothorax. It is important to
understand the effect of various factors that may alter the distance to the
lung pleura. Hand dominance does not appear to make a significant difference in this depth. Other factors, such as body composition, sex, age,
should be examined, on their influence of this distance. Caution and reservation need to be exercised when DN muscles that have close approximation to the lungs.
OPO109
THE EFFECTS OF ISOLATED JOINT VERSUS MULTIPLE JOINT TRAINING
ON THE SHOULDER
Charles E. Jones, Evan McGuire, Tim Mettenburg,
Brittney Hill, Nancy Henderson, Haley S. Worst, Keri Mans,
George J. Davies
Physical Therapy, Armstrong State University, Savannah, Georgia
PURPOSE/HYPOTHESIS: Multi-joint (MJ) and isolated-joint (IJ) training are
2 strengthening techniques used in upper extremity (UE) rehabilitation
and performance enhancement. The literature comparing IJ and MJ exercises for the UE is mixed and focused more on the lower extremity (LE).
The purpose of this study was to determine if significant differences existed between these MJ and IJ training in the UE. We hypothesized that
MJ training will have greater effects on the outcome measures compared
to the IJ training.
NUMBER OF SUBJECTS: Fifty Armstrong State University students, between
18 and 40 years old, completed the study. Subjects were excluded if they
had any current shoulder pain or pathology, previous history of UE or cervical surgery/injury.
MATERIALS/METHODS: The study was a prospective experimental, pretestposttest controlled study comparing the effectiveness between 2 multijoint and isolated training programs in the UE. Seventy-nine volunteers
were recruited via convenience sampling. Following pretesting which consisted of 6 outcome measures (push up (PU) test, seated shot put, Closed
Kinetic Chain Upper Extremity Stability Test, handheld dynamometry:
triceps, serratus anterior, horizontal abduction). Sixty-three subjects were
randomized into 3 groups: MJ training, IJ training, or control. Subjects
in the training groups performed 6 weeks of training sessions twice per
week. The MJ group performed bench press. The IJ group performed
serratus punch, triceps extension, and shoulder flys. Following the training period, all groups were posttested using the same outcome measures.
Between group differences were determined using 1-way ANOVAs for
each outcome measure.
RESULTS: A statistically significant difference of 4.5 repetitions (P<.05)
were found between the MJ group and the control group in the PU test
with the MJ group performing more, though there was no significant difference between MJ and IJ. No other differences between training groups
were found from pre to posttesting in the other 5 outcome measures.
There was significant within group improvement in all outcome measures
in both training groups.
CONCLUSIONS: All groups improved in all outcome measures, though MJ
training resulted in significant improvement in PU performance when
compared with the control group. Neither MJ or IJ training resulted in
improvements in power as demonstrated by the seated shot-put. Studies
comparing MJ versus IJ training in the LE found MJ training to be superior. This study found no significant difference between the training
methods in the UE. MJ training was shown to be an effective method of
improving shoulder strength and endurance in healthy 18- to 40-year-old
individuals via the PU test outcome measure. Further research on training for pathological individuals and on the best methods for improving
shoulder power is needed.
CLINICAL RELEVANCE: Improvement in PU max repetitions is best achieved
with MJ exercises, rather than multiple IJ exercises. Further research
should be done on subjects with pathological shoulders to determine the
clinical significance of these treatment programs.
OPO110
COMPARATIVE EFFECTS OF MIRROR SQUAT EXERCISE AND HIP-STRENGTHENING
EXERCISE ON PATELLOFEMORAL PAIN SYNDROME
Park Joo-Hee, Sungyong Kang, Hye-Seon Jeon
Department of Physical Therapy, Yonsei University, Wonju,
Republic of Korea
PURPOSE/HYPOTHESIS: Patellofemoral pain syndrome (PFPS) is a common
knee-related complaint in the sporting and general populations. Although
many researchers have suggested a variety of clinical intervention methods, optimal treatments for the PFPS remain unclear. The main purpose
of this study was to compare recently recommended exercise methods; a
mirror squat exercise (MSE) and a hip-strengthening exercise (HSE), in
pain, function, kinematics, and activation onset of gluteus medius in females with PFPS.
NUMBER OF SUBJECTS: Thirty-two females with PFPS participated in this
study (16 per group) and conducted 3 times per week for 12 exercise sessions over the course of 4 weeks.
MATERIALS/METHODS: This study assessed pain using the visual analogue
scale (VAS), and self-reported function using lower extremity functional scale (LEFS). Kinematics of lower extremity (using 3-D motion analysis) assessed hip adduction (HADD), hip internal rotation (HIR), knee
adduction (KADD), and contralateral pelvic drop (CPD). Activation onset of gluteus medius was assessed using a surface EMG. The kinematics
and activation onset were measured as participants performed a singleleg squat (SLS) test and a step descent test. All assessments were repeatedly measured at pretest, posttest, and 1-month and 3-month follow-ups.
RESULTS: In results of the SLS test, all kinematic variables (HADD, HIR,
KADD and CPD) after 4 weeks of exercise showed significant improvement in both groups. Especially, patients assigned to the MSE group
showed greater improvement and maintained it longer (up to 3 months)
than those in the HSE group. In activation onset of the gluteus medius,
both the MSE and HSE groups showed significantly earlier activation onset at posttest and maintained to 1 month.
CONCLUSIONS: After 4 weeks of exercises, both groups showed significant
improvement in pain, function, kinematics, and activation onset. More
specifically, in the SLS test, patients assigned to the MSE group showed
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greater improvement that were maintained longer (up to 3 months) than
those of the HSE group. Likewise, kinematic findings in stair descent test
also showed that MSE promoted greater improvement with longer maintenance (up to 1 month) than HSE. In the activation onset of the gluteus medius, both groups showed earlier activation onset at posttest and
that effects maintained to 1 month. Regarding pain and function, MSE
showed superior improvement and longer maintenance (up to 1 month)
than HSE.
CLINICAL RELEVANCE: The present study suggests that when MSE and HSE
are performed for 4 weeks, MSE is more effective than HSE on pain,
function, and kinematics in females with PFPS.
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OPO111
SPINAL MANIPULATION INCREASES MOTOR CORTEX ACTIVITY IN HEALTHY
ADULTS: PRELIMINARY RESULTS FROM AN FMRI STUDY
Max Jordon, Sheri P. Silfies, Paul F. Beattie,
Jennifer M. Vendemia, Scott A. Vendemia
University of South Carolina, Cayce, South Carolina; Physical
Therapy, Drexel University, Philadelphia, Pennsylvania
PURPOSE/HYPOTHESIS: Proposed mechanisms underlying the affects of spinal manipulation (SM) include biomechanical and neurophysiological
changes to sensory and motor systems [1]. To date, much of the work
associated with motor system change has been focused on peripheral changes or has indirectly assessed central changes. While it has been
shown that SM can alter cerebral response to pain [2] and therapeutic
neuroscience education can increase motor cortex activation [3], there is
a paucity of data on the effects of SM on motor cortex activation. No study
to date has used functional magnetic resonance imaging (fMRI) to assess changes in the motor cortex after SM. Therefore, the purpose of this
study was to measure the hemodynamic changes in the motor cortex immediately after SM associated with trunk muscle activation during performance of trunk movements in the scanner. Previous work has shown
that SM can increase trunk extensor muscle activation [4], therefore, we
hypothesize that some of this increase was cortically driven by an increase
in motor cortex activation.
NUMBER OF SUBJECTS: Eight.
MATERIALS/METHODS: Eight participants, 2 with a history of low back pain
(5 female; mean ± SD age, 28.6 ± 7.2 years) performed 4 trunk movement tasks while undergoing brain functional imaging: supine bilateral
and unilateral modified bridging and abdominal tightening. These tasks
were chosen specifically to engage the musculature of the lumbopelvic
region. A block design was utilized in which each task was performed 6
times in random order. Participants were then removed from the scanner
and received bilateral side lying, rotatory manipulations directed at L45. Trunk movements were repeated in the scanner post manipulation. T1weighted structural scans were also completed. All scans were performed
on Siemens Trio 3-T MRI. FMRI data processing was carried out using
FEAT (FMRI Expert Analysis Tool) with higher-level analysis in FLAME
(FMRIB’s Local Analysis of Mixed Effects) [5]. A region of Interest (ROI)
analysis was used to determine specific changes that occurred in the motor cortex. The ROI was generated in FSLView (FMRIB Software Library
View) using the Juelich Atlas and the analysis run in FEATQuery.
RESULTS: The fMRI data revealed a significant increase in the blood-oxygen-level dependent (BOLD) activation in the motor cortex after SM.
This increase in the BOLD activation was seen for all 4 tasks. Further exploration of specific regions within the motor cortex demonstrated that
the abdominal task response was spatially different from the other tasks.
CONCLUSIONS: The data from this preliminary study suggests that SM may
result in increased activation of the motor cortex in healthy adults with
no current pain. This study lends to the evidence that SM exhibits not
just a biomechanical effect to local structures but can also effects supraspinal structures.
CLINICAL RELEVANCE: Further understanding of the mechanisms behind spinal manipulation can assist the clinician with the integration of this tech-
nique into a comprehensive treatment plan for the patient.
OPO112
A CASE STUDY REVIEWING THE PRESENTATION OF SPINAL ACCESSORY
NERVE PALSY IN A WORKMAN’S COMPENSATION CASE
Jennifer Junkin, Margaret Wicinski
Benchmark Physical Therapy, Conyers, Georgia; University of
St Augustine, St Augustine, Florida
BACKGROUND AND PURPOSE: Spinal Accessory Nerve Palsy can occur after a
cervical surgery, blunt injury to the neck, or trauma resulting in a cervical stretch or traction injury. The spinal accessory nerve is also known as
the 11th cranial nerve and innervates the trapezius and sternocleidomastoid. Damage to the nerve can cause motor dysfunction to the trapezius
or sternocleidomastoid muscles with marked muscle wasting, poor shoulder girdle strength, scapular dyskinesis, marked scapular depression and
protraction of the affected shoulder. The purpose of this case study was to
examine the steps necessary for differential diagnosis necessary for spinal
accessory nerve palsy as well as the rehab program utilized for full functional return to work.
CASE DESCRIPTION: The patient was a 30-year-old male electrical engineer
referred to physical therapy with a physician referral of an upper trap
strain. The patient was injured on the job while swinging 1000-lb electrical boxes on a pulley system. The patient’s arm got caught on the box and
the head was pushed the opposite way resulting in a neck traction mechanism of injury. The patient had a difficult time with work over the following 2 days and was sent to an urgent care by his safety director. A workman’s comp claim was filed. The physician at the urgent care referred the
patient to physical therapy for 6 visits with a diagnosis of an upper trap
strain. The patient presented to PT at his initial visit with his arm in a
sling, a marked depression of his right shoulder compared to his left, atrophy in right scapulothoracic region, significant scapular winging, inability
to elevate or retract scapula, and inability to elevate his shoulder past 90°.
The patient also had general UE weakness, poor grip strength and significant pain in right upper trap region.
OUTCOMES: Significant changes were seen during treatment over a 3
month period. Changes were made with the QuickDASH subjective questionnaire, grip strength, shoulder AROM, and postural changes which
were documented with photographic evidence throughout care (pictures
taken at initial evaluation, mid-treatment, and at discharge). Patient returned to work at full-time, full-duty.
DISCUSSION: Spinal Accessory Nerve Palsy is a rare condition to see in the
outpatient physical therapy realm and a difficult case to treat. This case
was interesting due to differential diagnosis of possible shoulder pathologies, as well as the patient being a workman’s comp case with 6 initial authorized visits. A thorough examination is necessary for correct diagnosis
as well as effective communication with workman’s comp regarding diagnosis. An effective rehab program is essential for successful treatment
with a return to work emphasis.
REFERENCES: 1. Kelley MJ, Kane TE, Leggin BG. Spinal accessory nerve
palsy: associated signs and symptoms. J Orthop Sports Phys Ther.
2008;38:78-86. 2. Chan PK, Hems TE. Clinical signs of accessory nerve
palsy. J Trauma. 2006;60:1142-1144. 3. Koybasioglu A, Bora Tokcaer A,
Inal E, Uslu S, Kocak T, Ural A. Accessory nerve function in lateral selective neck dissection with undissected level IIb.ORL J Otorhinolaryngol
Relat Spec. 2006;68:88-92. 4. Kozin F. Injuries of the brachial plexus. In:
Iannotti J, Williams GR, eds. Disorders of the Shoulder: Diagnosis and
Management. Philadelphia, PA: Lippincott Williaims and Wilkins; 2007.
5. Orhan KS, Demirel T, Baslo B, et al. Spinal accessory nerve function after neck dissections. J Laryngol Otol. 2007;121:44-48.
OPO113
A COMPARISON OF COMMON TAPING TECHNIQUES IN THE MANAGEMENT
OF PATELLOFEMORAL PAIN SYNDROME IN COLLEGE-AGED INDIVIDUALS
Rumit S. Kakar, Linda K. Annan, Andrew Claypool,
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Joseph P. Coviello, Jeannina DeStefano, Jenna Marchinetti,
Karli Spencer, Hilary B. Greenberger
Physical Therapy, Ithaca College, Ithaca, New York
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PURPOSE/HYPOTHESIS: Patellofemoral Pain Syndrome (PFPS) is a frequent-
ly encountered musculoskeletal disorder characterized by retropatellar
knee pain that worsens with activity. The multifactorial etiology of PFPS
alters lower extremity mechanics, increasing PF joint stresses during
weight-bearing tasks. Kinesio (KT) and McConnell (MC) tapings are often incorporated into PFPS treatment, but their efficacy is still unclear.
Purpose: To test the efficacy of KT, MC and sham taping (ST) in improving knee mechanics and reducing pain during activity. Hypothesis: KT
will show better results than MC and ST, given the corrective and facilitative properties of KT.
NUMBER OF SUBJECTS: Ten participants (mean ± SD age, 20.3 ± 1.5 years;
height, 169.9 ± 10.4 cm; weight, 70.17 ± 13.1 kg) with anterior knee pain
and no history of trauma.
MATERIALS/METHODS: Three trials each of squat, drop jump, and step-down
tasks with no tape (baseline) and under 3 taping conditions in a randomized order were performed. Two-dimensional motion analysis of lower extremities in frontal and sagittal planes was performed using 3 iPads and
Sparkmotion app. RM univariate ANOVA (P<.05) compared baseline and
taping conditions during exercises for pain VAS and knee flexion in all exercises, hip abduction in step-down and drop jump, frontal plane projection in step-downs and anterior knee translation in squat.
RESULTS: Significant reductions in VAS were recorded during squats between tapes (F2.505,12.867 = 3.407, P = .042). Pairwise comparison showed a
mean decrease in VAS for ST (1.14, P = .008) and KT (1.54, P = .018) compared to baseline during squats. Anterior knee translation reduced with
KT when compared to baseline during squats (1.92 cm, P = .048). A tendency for significance (P = .05-.10) was observed for MC with 1.7° greater
reduction in hip abduction in step-down compared to KT (SE, 0.83; P =
.075). ST also showed tendency to achieve 6.1° greater knee flexion compared to baseline during drop jump (SE, 2.98; P = .073). No other differences were observed (P = .11-.949).
CONCLUSIONS: Findings demonstrate mixed results between various tapings, including detectable changes with ST similar to previous reports.
The effect of tape on pathomechanics is unclear. Sensory effects associated with short term taping may have been sufficient enough to modify knee
pain by afferent input blocking nociceptive pain, before the participants
could adapt. The role of KT in decreasing anterior knee translation and
increasing knee flexion more than other tapings during squats and drop
jumps, respectively, may be due to more effective proprioceptive input or
neuromuscular facilitation. Minimal changes observed in MC may be due
to inferiorly shifted patella leading to increased patellofemoral contact
area, allowing for improved knee mechanics.
CLINICAL RELEVANCE: A variety of taping methods can potentially reduce
perceived pain in individuals with PFPS, allowing clinicians to better target underlying pathomechanics with greater patient satisfaction. Further
research is needed to examine the efficacy of patellar taping in correcting
pathomechanics and serving as a placebo on perceived pain.
OPO114
LONG-TERM CLINICAL OUTCOMES OF 3 DIFFERENT TREATMENT
PROGRAMS IN THE MANAGEMENT OF KNEE OSTEOARTHRITIS:
A RANDOMIZED CLINICAL TRIAL
Ebru Kaya Mutlu, Ersin Ersin, Arzu Razak Ozdincler,
Nadir Ones
Division of Physiotherapy and Rehabilitation, Istanbul University,
Faculty of Health Sciences, Istanbul, Turkey; Department of
Orthopedics and Traumatology, Bakirkoy; Training and Research
Hospital, Istanbul, Turkey
PURPOSE/HYPOTHESIS: Manual therapy is beneficial in the management of
knee osteoarthritis (OA), but whether this technique or electrotherapy is
superior in knee OA is unclear from the current evidence. The aim of the
study was to compare long-term results between 3 treatment groups (mobilization with movements [MwMs], passive joint mobilization [PJM]
and electrotherapy) to determine which treatment is most effective in patients with knee OA.
NUMBER OF SUBJECTS: Seventy-two consecutive patients (mean ± SD age,
56.11 ± 6.80 years) with bilateral knee OA were randomly assigned to 1 of
3 treatment groups: MwMs, PJM and electrotherapy.
MATERIALS/METHODS: A double-blinded randomized clinical trial with
parallel design was conducted in patients with knee OA. The primary outcome measures of the functional assessment were the Western
Ontario and McMaster Universities Osteoarthritis index (WOMAC) and
Aggregated Locomotor Function (ALF) test scores. The secondary outcome measures were pain level, measured using a pressure algometer and
a visual analogue scale (VAS), range of motion (ROM), measured using a
digital goniometer, and muscle strength, evaluated with a handheld dynamometer. Patients were assessed before treatment, after treatment and
after 1 year of follow-up. Comparisons of score changes measuring improvements in level of function, ROM values and muscle strength and
decrease in pain levels were carried out using 2-by-2 repeated-measures
ANOVA with time (baseline and end of treatment). To test the effects on
functional outcomes, pain, ROM values and muscle strength at each time
point (end of treatment to 1-year follow-up) as the within-subject variable and group (MwMs, PJM and electrotherapy) as the between-subject variable, we used a mixed-model repeated-measures analysis of covariance (ANCOVA) with baseline values, sex and duration of symptoms
as covariates.
RESULTS: Participants receiving the MwMs or PJM demonstrated a greater decrease in VAS scores at rest, activity and night compared to those in
the electrotherapy group from baseline to after the treatment (P<.05).
This improvement continued at the 1-year follow-up (P<.05). The MwMs
and PJM groups also showed significantly improved knee ROM, quadriceps muscle strength, and WOMAC and ALF scores from baseline to
1-year follow-up (P<.05).
CONCLUSIONS: In the treatment of patients with knee OA, either MwMs
or PJM in addition to exercise therapy is better than electrotherapy and
exercise in terms of pain level, knee ROM, quadriceps muscle strength
and functional level. Future longitudinal studies with larger sample sizes are required to confirm which treatment is most effective in managing knee OA.
CLINICAL RELEVANCE: In patients with knee OA, adding either MwMs or
PJM to a program of treatment carried out over 12 sessions may lead to a
short-term improvement in pain. The beneficial effects on level of function, pain, ROM and muscle strength remain evident 1 year later.
OPO115
CAN THE AMOUNT OF EXERCISE IMPACT OUTCOMES IN THE PRESENCE OF
SHOULDER PAIN?
Michael Kayajanian, Lee N. Marinko
Boston University, Boston, Massachusetts
PURPOSE/HYPOTHESIS: Shoulder pain is the third most common musculoskeletal condition requiring medical attention. Current evidence supports the use of exercise for painful shoulder conditions; however, there
is limited research related to the impact of dosing exercise and outcomes.
This study was designed to investigate whether higher volumes of exercise
prescribed for patients with shoulder injuries results in greater improvements in functional and pain-based outcome measures.
NUMBER OF SUBJECTS: Three hundred forty-nine.
MATERIALS/METHODS: Retrospective analysis of patient data using diagnostic codes for nonsurgical shoulder pathology was accessed through
an electronic medical record. Records that included 2 separate measurements for the outcomes on QuickDASH and numeric pain-rating scale
(NPRS) were identified. Records were then accessed to calculate volume
of exercises performed. Patients were categorized into 1 of 3 groups, high,
moderate, and low with each group further divided into success or fail-
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ure based upon the minimal clinically important difference (MCID) outcomes. Effect of exercise volume on outcomes was determined using a
multivariate analysis of variance with a least significant difference (LSD)
used in post hoc analyses.
RESULTS: A total of 194 records were included for QuickDASH and 202
for the NPRS scores. The between group analysis of variance for exercise
group to QuickDASH change was significant (P<.001) as well as for meeting the MCID (P = .001). Post hoc analysis demonstrated QuickDASH
change between the high volume group and the moderate and low volume
groups were both significant (P<.001). Between group analysis of variance
for group difference in NPRS change was significant (P = .013), but not
for meeting the MCID (P = .469).
CONCLUSIONS: These results suggest that dosing exercise with a high volume may positively influence outcomes reported on the QuickDASH but
not on the NPRS.
CLINICAL RELEVANCE: Higher volume exercise prescriptions for shoulderbased injuries may maximize functional improvements.
OPO116
INNOVATIVE EDUCATIONAL PRACTICES FOR PHYSICAL THERAPISTS
IN THE DEVELOPMENT OF A COMPREHENSIVE SPORTS CONCUSSION
CLINIC IN THE UNIVERSITY OF MICHIGAN HEALTH SYSTEM
Pamela S. Knickerbocker
Physical Therapy Division of Physical Medicine and
Rehabilitation, University of Michigan Health System, South
Lyon, Michigan
PURPOSE: Describe an educational strategy to bring a wider cohort of physical therapists in the University of Michigan Health System to a minimum
level of competence for delivering physical therapy care in the NeuroSport
Clinic and additional outpatient clinics throughout the system to the postconcussion population.
DESCRIPTION: Sport concussions are a growing health concern. The CDC
estimates more than 170 000 children and teens are treated in the
Emergency Department annually for sports related concussion. It is unknown how many additional athletes self-manage or seek care from a
nonconcussion specialist. The primary symptoms after concussion are
headache, neck pain, dizziness and balance difficulties. These are all diagnoses routinely seen by Physical Therapists for treatment. Neurologists
from the UMHS NeuroSport Clinic expressed the need for increased
access to physical therapy services for their postconcussion patients. It
was decided to provide a continuing education course for UMHS physical therapists to gain both didactic and clinical skills for improved comprehensive treatment of the postconcussion patient. Content areas were
identified and content experts were surveyed to determine the minimum
competencies for these clinical problems in the context of sport concussion. Content areas identified were: manual therapy for cervical spine,
vestibular/balance issues, cranial mobility, TMJ and exertional testing.
Content experts identified minimum clinical competencies for lab instruction and check off. A total of 49 individuals participated. Thirtyeight physical therapists (including 9 presenters and lab assistants), 5
physicians, 1 Occupational Therapist presenter, 4 ATCs and 1 academic PT faculty/researcher participated. As part of the development of the
course new home exercises were developed and existing home exercises
were revised and updated. A post course survey was conducted. Nineteen
participants responded (excluding presenters and lab assistants). Among
the results of the survey, 14 responded “definitely yes” and 4 responded
“probably yes” to the question “Would you recommend this course to others?” Survey results also illuminated areas of improvement on the course
for future offerings.
SUMMARY OF USE: For this platform, topics and competencies performed
from the course “PT Management of the Post-Concussion Patient” will be
presented as well as samples of home exercises developed for this population. Postcourse survey results will be presented as well as suggestions for
modifications for future course presentations.
IMPORTANCE TO MEMBERS: This platform is designed to demonstrate devel-
opment of continuing education efforts for PT treatment of postconcussion patients to a minimum level of competency for this growing patient
population in our health system, as well as ongoing team development
and innovation.
OPO117
SUBCHONDRAL INSUFFICIENCY FRACTURE OF THE FEMORAL HEAD
IN A 59-YEAR-OLD WOMAN: A CASE STUDY
Joshua R. Kniss, Brian A. Young, Elizabeth Painter,
Teddy E. Ortiz
Physical Therapy, US Army-Baylor University, Converse, Texas
BACKGROUND AND PURPOSE: Subchondral insufficiency fracture (SIF) occurs
when normal, physiological stress is applied to weakened or nutritionally deficient bone. SIF is most often observed in the hips of osteoporotic women or renal transplant recipients. Painful hip flexion and internal
rotation are the most common clinical signs, but diagnosis is made from
positive MRI findings. This case study highlights the use of diagnostic imaging and clinical reasoning in the diagnosis and medical management of
a patient with SIF of the hip.
CASE DESCRIPTION: A 59-year-old woman presented to physical therapy with
constant right anterior hip and thigh pain of insidious onset. Initial objective exam findings included: markedly antalgic gait with reluctance to bear
weight through the right lower extremity, need for assistance with transfers and activities of daily living, pain limited hip flexion to 45°, pain limited internal rotation to 0°, right leg 1 cm shorter than left, and positive pain
provocation tests (scour, FABER, log roll). The patient had a past history of
thyroid cancer. Following evaluation, the leading differential diagnosis was
primary hip osteoarthritis (OA) and physical therapy treatment was initiated, consisting of gait normalization, hip range of motion, hip strengthening, and functional movement training. The physical therapist also ordered
conventional radiographs to evaluate for more sinister pathology, such as
fracture or metastatic cancer, due to symptom severity beyond that expected for hip OA. The patient completed the radiographs 2 weeks after the initial evaluation, which revealed severe joint space narrowing with potential
for SIF, avascular necrosis of the femoral head, or blastic metastatic disease. Subsequent MRI revealed SIF of the femoral head and acetabulum,
severe OA, and a degenerative tear of the acetabular labrum. The patient
was placed on axillary crutches, instructed on toe touch weight bearing, and
referred to orthopaedics for further management.
OUTCOMES: Prior to orthopaedics referral, the patient received 3 weeks of
physical therapy treatment. The patient’s gait was normalized with the
use of an assistive device, right hip flexion improved to 90°, and her LEFS
score improved from 20/80 to 32/80 over the course of treatment. Due to
persistent pain and functional limitations, the patient elected to undergo
total hip arthroplasty (THA). Two weeks post THA, the patient reported 0/10 resting pain, demonstrated 120° of active hip flexion and 20° active internal rotation, had returned to work, and re-initiated outpatient
physical therapy.
DISCUSSION: This case study supports that physical therapists are competent and effective in identifying and managing musculoskeletal conditions that require diagnostic imaging. The choice of diagnostic imaging
was supported by patient history and clinical exam, and resulted in rapid
definitive management. Furthermore, physical therapy treatment helped
restore the patient’s quality of life through improved gait and hip mobility while the patient underwent imaging.
REFERENCES: Iwasaki K, Yamamoto T, Motomura G, et al. Prognostic factors associated with a subchondral insufficiency fracture of the femoral
head. Br J Radiol. 2012;85:214-218. Yamamoto T. Subchondral insufficiency fractures of the femoral head. Clin Orthop Surg. 2012;4:173-180.
Yamamoto T, Iwamoto Y, Schneider R, Bullough PG. Histopathological
prevalence of subchondral insufficiency fracture of the femoral head. Ann
Rheum Dis. 2008;67:150-153. Zalavras CG, Lieberman JR. Osteonecrosis
of the femoral head: evaluation and treatment. J Am Acad Orthop
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Surg. 2014;22:455-464. Altman R, Alarcón G, Appelrouth D, Bloch
D, Borenstein D, Brandt K, Brown C, Cooke TD, Daniel W, Feldman
D, Greenwald R, Hochberg M, Howell D, Ike R, Kapila P, Kaplan D,
Koopman W, Marino C, McDonald E, McShane DJ, Medsger T, Michel
B, Murphy WA, Osial T, Ramsey-Goldman R, Rothschild B, Wolfe F.
The American College of Rheumatology criteria for the classification
and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991;34:5055514. Childs JD, Whitman JM, Sizer PS, et al. A description of physical therapist’s knowledge in managing musculoskeletal conditions. BMC
Musculoskelet Disord. 2005;6:32.
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OPO118
USE OF THORACIC MANUAL THERAPY IN THE SUCCESSFUL MANAGEMENT
OF A PROFESSIONAL CYCLIST WITH NEURAL MECHANOSENSITIVITY
IMPAIRING POWER OUTPUT: A CASE REPORT
Stacey Knowles, Christine Schauerte, Darren Earnshaw
Rush University Medical Center, Chicago, Illinois
BACKGROUND AND PURPOSE: Thoracolumbar pain is the most common complaint that leads professional cyclists to seek medical attention, and may
lead to an inability to maintain efficient postures and generate power.
Sustained thoracolumbar flexion during cycling loads the posterior spinal, neural and musculoskeletal structures potentially increasing neural
mechanosensitivity (NMS). Utilization of the Thoracic Slump Test (TST),
which closely mimics the cyclist’s posture, has not been studied in this
population. The purpose of this case report is to describe the utilization of
TST and manual therapy, specifically thoracic and hip joint mobilization
and neural mobilization, in the successful management of an elite cyclist
with pain, reduced power output and NMS.
CASE DESCRIPTION: A 49-year-old female professional cyclist with no significant past medical history presented to physical therapy (PT) with left anterior hip pain, left lower thoracic pain and complaint of decreased power
output for 2 months during her transition from indoor to outdoor track
and criterion cycling. Stretching, rest and bike component modification
previously alleviated pain however symptoms had worsened with cycling
greater than 20 minutes, sprints and uphill climbing. Significant evaluation findings included pain, decreased thoracic extension and left hip flexion AROM, thoracic spine hypomobility with passive accessory mobility
testing and limited left TKE during TST. She was treated with hip mobilizations, thoracic thrust/nonthrust mobilizations, therapeutic exercise and
neural mobilization in TST position.
OUTCOMES: She was seen in PT for 6 sessions over 8 weeks. The numeric pain-rating scale scores improved from 8/10 to 2/10, global rating of
change +2 to +7, Patient Specific Functional Scale from 6 to 8, TKE in
TST position improved from –75° TKE to 0°, and her L hip flexion AROM
improved from 120° to 140°. Power output improved from 250 W/kg to
287 W/kg.
DISCUSSION: Utilization of the TST, which mimics the cyclist’s posture and
reproduced the concordant pain, guided the decision to use neural mobilization and thoracic manual therapy in the treatment. NMS may lessen
force generation if the cyclist is not able to assume efficient cycling postures and achieve full TKE during the power phase of the pedal stroke.
This case study suggests the potential importance of the TST in the evaluation of cyclists and the role of manual therapy in efficiently resolving
thoracolumbar pain and impaired power output.
REFERENCES: 1. Andrade RJ, Freitas SR, Vaz JR, Bruno PM, PezaratCorreia P. Provocative mechanical tests of the peripheral nervous system
affect the joint torque-angle during passive knee motion. Scand J Med
Sci Sports. 2015;25:338-345 2. Clarsen B, Krosshaug T, Bahr R. Overuse
injuries in professional road cyclists. Am J Sports Med. 2010;38:24942501]. 3. Joshi KC, Eapen C, Kumar SP. Normal sensory and range of
motion (ROM) responses during thoracic slump test (ST) in asymptomatic subjects. J Man Manip Ther. 2013;21:24-32 4. Lalanne K, Lafond
D, Descarreaux M. Modulation of the flexion-relaxation response by
spinal manipulative therapy: a control group study. J Manipulative
Physiol Ther. 2009;32:203-209 5. Van Hoof W, Volkaerts K, O’Sullivan
K, Verschueren S, Dankaerts W. Comparing lower lumbar kinematics in
cyclists with low back pain (flexion pattern) versus asymptomatic controls--field study using a wireless posture monitoring system. Man Ther.
2012;17:312-317.
OPO119
ABNORMAL IMAGING FINDINGS IN ASYMPTOMATIC SHOULDERS:
A SYSTEMATIC LITERATURE REVIEW
Eric L. Koehler, Robert Boyles, Daniel Rhon, Ben R. Hando
Physical Therapy, University of Puget Sound, Tacoma,
Washington; Evidence in Motion, Louisville, Kentucky; Graduate
Program in Physical Therapy, Baylor University, San Antonio,
Texas; Physical Therapy, US Air Force, San Antonio, Texas
PURPOSE/HYPOTHESIS: Diagnostic imaging is frequently utilized as part of
a comprehensive exam for patients with shoulder complaints. However,
previous studies have found high rates of pathological findings in asymptomatic individuals [1]. This phenomenon has been reported extensively in the lumbar spine [2], but to a lesser degree in the shoulder [3].
The purpose of this study is to systematically review the literature and report the pooled prevalence of abnormal imaging findings in asymptomatic shoulders.
NUMBER OF SUBJECTS: Four thousand three hundred three asymptomatic shoulders.
MATERIALS/METHODS: An online search was performed using PubMed and
Google Scholar for studies through December 2015. Search terms included keywords such as, “shoulder” or “rotator cuff ” or “glenohumeral” or
“glenoid labrum” or “AC joint” or “sternoclavicular joint” or “biceps tendon”, AND “X-ray” or “imaging” or “MRI” or “ultrasound” AND “incidental” or “asymptomatic.” Studies where included if authors reported the
specific number of unique shoulders with abnormal findings in symptomatic versus asymptomatic patients, or only in asymptomatic patients. In
either case, only asymptomatic subjects were extracted and used in our
analysis. This search yielded 261 abstracts that where reviewed for relevance, of which 29 studies met the criteria for inclusion.
RESULTS: The search yielded 4303 asymptomatic shoulders from 3768 human subjects. Both athletic and nonathletic populations were represented with ages ranging from 13 to 90 years. In studies that reported age
and sex, the weighted mean age was 54 years, and 45.5% were males. The
prevalence of abnormal findings in shoulders ranged widely. On the lower end, 7% of asymptomatic subjects had evidence of full thickness rotator cuff tear on ultrasound [4]. On the higher end, 100% of asymptomatic subjects had minor abnormalities in both the supraspinatus and
infraspinatus tendons with MRI [5]. In most studies (19/29), abnormal
findings equaled, or exceeded 50% of subjects. Common abnormal findings were found in the articular, peri-articular and musculotendinous tissues. Common articular abnormalities in asymptomatic shoulders included subchondral cysts, osteophytes, joint erosion, labrum tears, capsular
distention, irregular margins, and joint hypertrophy. Abnormal peri-articular joint findings ranged from bursal thickening to impingement.
Abnormal musculotendinous findings included partial-thickness tears,
full-thickness tears, and tendinopathy.
CONCLUSIONS: Asymptomatic shoulders have a high prevalence of pathological findings.
CLINICAL RELEVANCE: With a high rate of abnormal findings in asymptomatic shoulders, clinicians should interpret findings in symptomatic patients with caution. This underscores the importance of interpreting
results from imaging studies in the context of a detailed clinical examination. Clinicians can also incorporate this information into their patient education.
OPO120
MCKENZIE APPROACH IN MANAGEMENT OF A WOMAN WITH CHRONIC
SHOULDER PAIN: A CASE STUDY
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McKenzie M. Kraus, A. Russell Smith, Scott Bossman
Lynchburg College, Lynchburg, Virginia
BACKGROUND AND PURPOSE: Diagnosing shoulder disorders is challenging
given the moderate reliability/validity of shoulder special tests. Incidental
imaging findings of rotator cuff pathology in 65% of asymptomatic individuals complicates the identification of a specific pathoanatomical structure. Mechanical Diagnosis and Therapy (MDT) focuses primarily on patient response to movement. McKenzie proposed the method could also
be applied to the peripheral joints. The approach to the extremities also
utilizes the patient’s response to repeated movements and loading strategies, as opposed to the identification of a pathoanatomical structure with
classification of a patient into 1 of 3 categories: derangement, dysfunction, or postural syndrome. The purpose of this case report is to describe
the application of the Mechanical Diagnosis and Treatment approach to
the assessment and management of a patient with nonspecific, chronic
shoulder pain.
CASE DESCRIPTION: A 66-year-old woman presented reporting generalized
left shoulder pain. MRI findings included a partial supraspinatus tear,
acromioclavicular arthritis, and biceps tendinitis. Applying elements of
the International Classification of Functioning (WHO), functional losses related to inability to play with her grandchildren and perform activities of daily living (ADLs) were noted. The Shoulder Pain and Disability
Index (SPADI) initially indicated an 81% perceived disability. Physical examination focused on the left shoulder with standard movement screen
followed by repeated movement testing (RMT), a key component of the
MDT physical examination. Behind-the-back movements were particularly limited and painful. During RMT, the patient’s range improved with
decreased pain. Repeated external rotation provoked symptoms and reduced ROM. Education for self-management included instructed on enforcing repeated movement in the direction of preference with over pressure and avoidance of provocative. Further treatments continued to
emphasize repeated movements with addition of functional strengthening exercises related to her functional losses.
OUTCOMES: Abolishment of pain with ADLs and functional tasks were noted at the fifth and final visit with an improved SPADI score (5% perceived
disability). Via telephone 3 weeks following discharge, the patient reported continued pain abolishment with full pain free movement. Additional
follow-up was conducted 3 months after discharge with a SPADI score
of 0.01%.
DISCUSSION: Despite chronicity and high pain intensity, she demonstrated significantly decreased pain and simultaneous improvement in motion, strength, and function within 5 visits. Improved SPADI scores were
significantly greater than the minimal clinically important difference [8].
Actively involved in self-managing her own symptoms, this treatment approach was effective and economical. The patient’s improvement continued to be evident 3 months after discharge.
REFERENCES: 1. Hegedus EJ, Goode A, Campbell S, et al. Physical examination tests of the shoulder: a systematic review with meta-analysis of individual tests. Br J Sports Med. 2008;42:80-92; discussion 92. 2. Tennent
TD, Beach WR, Meyers JF. A review of the special tests associated with
shoulder examination. Part I: the rotator cuff tests. Am J Sports Med.
2003;31:154-160. 3. May S, Chance-Larsen K, Littlewood C, Lomas D,
Saad M. Reliability of physical examination tests used in the assessment
of patient with shoulder problems: a systematic review. Physiotherapy..
2010;96:179-190. 4. Yamamoto A, Takagishi K, Osawa T, Yanagawa T,
Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff
tear in the general population. J Shoulder Elbow Surg. 2010;19:116-120.
5. McKenzie R, May S. The Human Extremities Mechanical Diagnosis
and Therapy. Waikanae, New Zealand: Spinal Publications; 2000. 6.
May S. Classification by McKenzie’s mechanical syndromes; report on
directional preference and extremity patients. Int J Mech Diag Ther.
2006;1:3,7-11. 7. May S, Ross J. The McKenzie classification system in the
extremities: a reliability study using McKenzie assessment forms and experienced clinicians. J Manipulative Physiol Ther. 2009;32:556-563. 8.
MacDermid JC, Solomon P, Prkachin K. The shoulder pain and disability index demonstrates factor, construct and longitudinal validity. BMC
Musculoskelet Disord. 2006 7:12. 9. Luime JJ, Koes BW, Hendriksen IJ,
Burdorf A, Verhagen AP, Miedema HS, et al. Prevalence and incidence
of shoulder pain in the general population: a systematic review. Scand J
Rheumatol. 2004;33:73-81. 10. McKenzie RA, May S. The Lumbar Spine:
Mechanical Diagnosis and Therapy. 2nd ed. Waikanae, New Zealand:
Spinal Publications; 2003. 11. Aina A, May S: Case report - a shoulder derangement. Man Ther. 2005.
OPO121
EFFECTS OF MULTIDIRECTIONAL GASTROCNEMIUS-SOLEUS STRETCHING
VERSUS STATIC GASTROCNEMIUS-SOLEUS STRETCHING ON CLOSED-CHAIN
DORSIFLEXION
Kimberly Kruchowsky, Thomas Land, Blake K. McDonald,
Christopher Melcher, Derrick Talley
Physical Therapy, Franklin Pierce University, Rindge, New Hampshire
PURPOSE/HYPOTHESIS: Limited ankle dorsiflexion (DF) ROM has been
linked to risk factors related to lower extremity injuries. The purpose of
this study was to determine if ankle DF improved when the gastrocnemius-soleus (GS) complex was stretched via a dynamic multidirectional
maneuver involving hip and knee drivers when compared to a static GS
stretch alone.
NUMBER OF SUBJECTS: Twenty-eight physical therapy students (12 male, 16
female) with mean ± SD age of 26.04 ± 5.07 years voluntarily consented
for participation in this convenience sample study.
MATERIALS/METHODS: Performance of static and multidirectional GS
stretches was accomplished with subjects standing barefoot on a slant
board. A standardized script was used to describe the desired stretching maneuvers. Verbal cuing was employed as needed to facilitate proper
foot positioning and performance of both the static and multidirectional
stretches. Subjects were first randomly allocated to either static or multidirectional stretch via random card selection. Pre– and post–weightbearing ankle DF measurements were then obtained using the distanceto-wall technique with attained values acquired in cm. Two replicated
measurement stations were used with an ICC calculated to ensure interrater consistency. ANOVA was used to assess within and between group
differences; significance was set at α = .05. Repeated-measures ANOVA
was employed to assess pairwise differences. Bonferroni adjustment was
provided for all repeated measure comparisons. Version 23 SPSS software
was utilized for data analyses.
RESULTS: No significant difference was found between dynamic and static
stretching (P = .86). There was, however, significant improvement from
the baseline measurement for both static and dynamic stretches (P≤.05).
Mean ± SD measures for baseline, static, and dynamic maneuvers were:
10.0 ± 3.7, 11.1 ± 3.5, 11.2 ± 3.5, respectively.
CONCLUSIONS: Multidirectional dynamic stretching produced no significant increase in knee-to-wall distance compared to static stretching.
However, a significant difference was noted between baseline and both
static and dynamic stretching.
CLINICAL RELEVANCE: When improved ankle DF is a treatment goal, patients
can benefit from performing either a dynamic multiplanar stretch or a
static stretch. However, the movements associated with a dynamic stretch
can benefit the body as a whole. Future considerations for improving performance of ankle DF ROM point to the value of incorporating a structured dynamic warm-up prior to obtaining ROM measurements.
OPO122
EFFECTS OF A VARIABLE VIBRATION BRACE ON PROPRIOCEPTION
IN ACUTE ANKLE SPRAINS POSTIMMOBILIZATION: A PILOT STUDY
Jeff Kunze, Adam Moore, Collin McDonell, Mark Huntsinger,
Rebecca Araki, Jana Sadler, Ryan Yoshida, Courtney Peterson,
Aimie Kachingwe
CORE Physical Therapy, Huntington Beach, California; Torrey
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Pines Orthopedic Medical Group, San Diego, California; George
Erb Physical Therapy, Camarillo, California; Daily Thera-Stretch
Physical Therapy, Los Angeles, California; Doctorate of Physical
Therapy Program, California State University Northridge,
Northridge, California
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PURPOSE/HYPOTHESIS: Lateral ankle sprains account for 25% of all muscu-
loskeletal injuries, are the single most prevalent sports-related injury, and
have a 70% recurrence rate [1-3]. Ankle sprains are typically treated with
immobilization, leading to significant proprioceptive deficits [1]. Ankle
sprains often result in chronic ankle instability due to ligamentous laxity, proprioceptive deficits, and/or functional ankle instability (FAI) “the
subject’s perception that the ankle is unstable, weaker, more painful, or
less functional following injury [3]. The purpose of this study was to investigate the effects of applying variable vibrations via an external vibration-inducing device to an immobilized ankle joint after sustaining an
acute ankle sprain. Vibrations are theorized to improve FAI by preventing the loss of proprioceptive input from the joint via activation of muscle
spindles and mechanoreceptors typically impaired during immobilization
[4]. We hypothesized that applying variable frequency and amplitude vibrations with a vibration AFO would produce significant improvements
in outcome measures evaluating postimmobilization kinesthesia (Joint
Position Sense [JPS]), proprioceptive input (Sensory Organization Test
[SOT]), and ankle function (Motor Control Test [MCT]), Unilateral
Stance (US), STAR Excursion Balance Test (SEBT), Foot and Ankle
Disability Index [FAD]]) as compared to standard immobilization without vibration.
NUMBER OF SUBJECTS: Ten.
MATERIALS/METHODS: Ten subjects presenting to a university student health
center with a grade II-III lateral ankle sprain were randomly allocated
into 2 groups. Control subjects were immobilized with a standard ankle
foot orthosis (AFO). Experimental subjects were immobilized with a specially designed vibration AFO. Motors were placed at 5 tendons surrounding the ankle to create illusory movement [5] and controlled by a circuit
board set to perform vibrations at 50 to 100 Hz for a cumulative time of
45 minutes per day. Subjects were evaluated after 7 days of immobilization by testers blinded to group assignment.
RESULTS: Within-subject statistically significant differences were found
for MCT amplitude scaling with backward translation (P = .038) and for
SEBT in the posteromedial direction (P = .038). Between-subject differences were found for SOT condition 1 (P = .019) and FADI (P = .010).
Statistical significance (P<.05) was not detected for the other outcome
measures, although they trended in support of vibration for reduced proprioceptive loss.
CONCLUSIONS: Applying variable vibrations via an external vibration-inducing device to an immobilized ankle joint following an acute lateral
ankle sprain showed limited support for preventing proprioceptive loss.
CLINICAL RELEVANCE: There is some evidence suggesting that individuals
receiving vibration during immobilization post ankle sprain had less proprioceptive loss. This may result in returning to previous level of function more quickly and fewer recurring ankle sprains compared to standard immobilization.
OPO123
THE EFFECTS OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION
COMPARED TO OTHER INTERVENTIONS ON PAIN AND FUNCTION:
A SYSTEMATIC REVIEW
Matthew D. Lambert, Rebecca Hitchcock, Kelly Lavallee,
Eric Hayford, Russ V. Morazzini, Amber L. Wallace,
Dakota Conroy, Joshua Cleland
Franklin Pierce University, Manchester, New Hampshire
PURPOSE/HYPOTHESIS: To systematically examine evidence on the effectiveness of instrument assisted soft tissue mobilization (IASTM), compared
to other manual therapy interventions on patients with pain and disability resulting from musculoskeletal impairments.
NUMBER OF SUBJECTS: Seven included randomized clinical trials that satis-
fied eligibility requirements.
MATERIALS/METHODS: The following databases were searched using the
terms Instrument Assisted Soft Tissue, Pain, Function, Graston, and soft
tissue mobilization: CINAHL, PubMed, and Academic Search Complete.
Criteria for inclusion in this review were: studies on patients with musculoskeletal impairments, studies needed to include soft tissue mobilization as a treatment intervention, studies had to be a randomized clinical
trial, studies were performed on human subjects, and studies had to capture a measure of pain or function. Criteria for exclusion in this review
were: studies not published in English or if the subjects in the study were
of the pediatric or geriatric populations. Included articles were appraised
using the PEDro scale.
RESULTS: Seven studies met the inclusion criteria. All 7 articles scored between a 4/10 and 7/10 on the PEDro scale. The articles that met the inclusion criteria involved treatment of numerous anatomical locations and
the majority of the studies demonstrated significant improvements in either pain and/or range of motion, or exceeded the minimal clinically important difference of a standardized functional outcome measure when
using IASTM compared to control or conservative treatment groups.
CONCLUSIONS: These outcomes suggest that IASTM can have an impact on
physiological changes by providing an increase in blood flow, reduction in
tissue viscosity, myofascial release, interruption of pain receptors, and improvement of flexibility of underlying tissue compared to other commonly utilized interventions.
CLINICAL RELEVANCE: The results of the studies included in this review
suggest that IASTM is an effective treatment intervention for reducing
pain and improving range of motion and/or function within a 3-month
follow-up.
OPO124
USING MEASURES OF CENTER OF MASS ESTIMATED AND CENTER
OF PRESSURE DURING GAIT IN THE DESIGN OF A ROCKER-SOLE
MODIFICATION FOR AN INDIVIDUAL WITH FUNCTIONAL ANKLE MOBILITY
LIMITATION
Steve Laslovich, Anna M. Edwards
Physical Therapy, University of St Augustine, San Marcos,
California
BACKGROUND AND PURPOSE: Instrumented walkway assessment can be used
to allow dynamic simultaneous quantification of center of mass estimated
(COMe) and center of pressure (COP) relationships during normal, slow,
and fast gait. The purpose of this case report is to demonstrate the successful utilization of dynamic measures of COMe with simultaneous measurement of COP during gait in the design of shoe modification to promote ankle and forefoot rocker function in an individual with severe loss
of functional sagittal plane ankle mobility.
CASE DESCRIPTION: The patient was a 32-year-old man who suffered a TBI
in a MVA with multiple lower extremity injuries including severe bilateral
distal tibia and fibula fractures. At 18 months postinjury, ankle doriflexion
remained severely limited with significant ankle joint pain. Joint mobility
assessment suggested limited potential to regain functional dorsiflexion
ROM. Self-selected gait velocity measured over repeated trials 0.67 m/s.
Instrumented walkway analysis showed both a delay and abnormal relationship between COMe and COP forward progression during early mid
through terminal stance. Based on the COMe and COP measures, shoe
modifications were fabricated consisting of a right sole based rocker located 1 cm forwards of the anterior lateral malleolus with an approximate
5 cm radius. Additionally, moderately aggressive rigid toe spring modifications were done bilaterally.
OUTCOMES: Following the shoe modification and gait training, velocity of
the forward progression of the COP, initially slowed during early stance,
phase improved to 1.18 m/s. Forward progression velocity of the COMe,
significantly delayed initially also improved in concert with the COP progression. Simultaneously, subjective complaints of ankle pain decreased
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progressively over the proceeding weeks leading to self-measured daily
ambulation bouts of up to 3 mi.
DISCUSSION: Clinical decision-making skills of a physical therapist in cases of chronic dysfunction leading to significant impairments in gait can
be aided by the use of emerging technologies such as instrumented walkways. This case demonstrates the ability to utilize quantitative measures
of COMe and COP during gait as a potential tool to guide external shoe
modification designs in an individual with chronic painful loss of ankle
dorsiflexion motion limiting gait. Shoe modifications such as rocker soles,
while not new to physical therapy, can be effective when designed targeting a specific gait impairment. The relationships in biomechanical measures such as COP and COM dynamics during gait do not lend themselves
easily to visual observation even in the experienced therapist. This case
report demonstrates the potential of using measures such as the relationship between COM and COP gathered through an instrumented walkway
and hopes to stimulate future studies in individuals with gait dysfunction.
REFERENCES: 1. Arazpour M, Hutchins SW, Ghomshe FT, Shaky F, Karami
MV, Aksenov AY. Effects of the heel-to-toe rocker sole on walking in ablebodied persons. Prosthet Orthot Int. 2013;37:429-435. 2. Bachasson D,
Moraux A, Ollivier G, et al. Relationship between muscle impairments,
postural stability, and gait parameters assessed with lower-trunk accelerometry in myotonic dystrophy type 1. Neuromusc Disord. 2016. 3. Chien
HL, Lu TW, Liu MW. Control of the motion of the body’s center of mass
in relation to the center of pressure during high-heeled gait. Gait Posture.
2013;38:391-396. 4. Demura T, Demura S, Uchiyama M, Kitabayashi
T, Takahashi K. Effect of shoes with rounded soft soles in the anteriorposterior direction on the center of pressure during static standing. Foot
(Edinb). 2015;25:97-100. 5. Demura T, Demura S, Yamaji S, Yamada T,
Kitabayashi T. Gait characteristics when walking with rounded soft sole
shoes. Foot (Edinb). 2012;22:18-23. 6. Fukaya T, Mutsuzaki H, Okubo
T, Mori K, Wadano Y. Relationships between the center of pressure and
the movements of the ankle and knee joints during the stance phase in
patients with severe medial knee osteoarthritis. Knee. 2016. 7. Gard SA,
Miff SC, Kuo AD. Comparison of kinematic and kinetic methods for computing the vertical motion of the body center of mass during walking.
Hum Mov Sci. 2004;22:597-610. 8. Gutierrez-Farewik EM, Bartonek A,
Saraste H. Comparison and evaluation of 2 common methods to measure
center of mass displacement in 3 dimensions during gait. Hum Mov Sci.
2006;25:238-256. 9. Hong SW, Leu TH, Wang TM, Li JD, Ho WP, Lu
TW. Control of body’s center of mass motion relative to center of pressure
during uphill walking in the elderly. Gait Posture. 2015;42:523-528. 10.
Howcroft J, Lemaire ED, Kofman J, Kendell C. Understanding responses
to gait instability from plantar pressure measurement and the relationship to balance and mobility in lower-limb amputees. Clinical Biomech
(Bristol, Avon). 2016;32:241-248. 11. Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008;16:152-158. 12. Long JT, Sirota
N, Klein JP, Wertsch JJ, Janisse D, Harris GF. Biomechanics of the double rocker sole shoe: gait kinematics and kinetics. Proceedings of the
Annual International Conference of the IEEE Engineering in Medicine
and Biology Society. 2004;7:5107-5110. 13. Luximon Y, Cong Y, Luximon
A, Zhang M. Effects of heel base size, walking speed, and slope angle on
center of pressure trajectory and plantar pressure when wearing highheeled shoes. Hum Mov Sci. 2015;41:307-319. 14. Myers KA, Long JT,
Klein JP, Wertsch JJ, Janisse D, Harris GF. Biomechanical implications
of the negative heel rocker sole shoe: gait kinematics and kinetics. Gait
Posture. 2006;24:323-330. 15. Simonsen EB. Contributions to the understanding of gait control. Dan Med J. 2014;61:B4823. 16. Van Bogart
JJ, Long JT, Klein JP, Wertsch JJ, Janisse DJ, Harris GF. Effects of the
toe-only rocker on gait kinematics and kinetics in able-bodied persons.
IEEE Trans Neural Syst Rehabil Eng. 2005;13:542-550. 17. Wang CC,
Hansen AH. Response of able-bodied persons to changes in shoe rocker radius during walking: changes in ankle kinematics to maintain a consistent roll-over shape. J Biomech. 2010;43:2288-2293. 18. Winiarski S,
Rutkowska-Kucharska A. Estimated ground reaction force in normal and
pathological gait. Acta Bioeng Biomech. 2009;11:53-60.
OPO125
TELEREHABILITATION IMPROVES QUALITY OF LIFE, REDUCES DISABILITY,
AND IS ASSOCIATED WITH PATIENT SATISFACTION AFTER TOTAL KNEE
ARTHROPLASTY: A SYSTEMATIC REVIEW OF THE LITERATURE
Danika LeBlanc, Courtney Summers, Paula Smith,
Nancy A. Bianchi, Reuben S. Escorpizo
Department of Rehabilitation and Movement Science, Doctor of
Physical Therapy Program, University of Vermont, Burlington,
Vermont; Dana Medical Library, University of Vermont,
Burlington, Vermont
PURPOSE/HYPOTHESIS: Total knee arthroplasty (TKA) is a common surgery
requiring postsurgical rehabilitation to improve outcomes in function.
Telerehabilitation is a feasible alternative approach to face-to-face outpatient and home care in delivering health care services in rural settings
where demand is high and access is limited. The benefits of telerehabilitation in TKA have been less thoroughly analyzed. The purpose of this
review is to compare conventional face-to-face therapy and telerehabilitation in terms of therapeutic outcomes, patient satisfaction, and cost effectiveness for post-TKA patients.
NUMBER OF SUBJECTS: Six studies were included in this systematic literature review.
MATERIALS/METHODS: Four electronic databases were searched: Cochrane
Library, Ovid MEDLINE, CINAHL, and PEDro. Studies were considered for inclusion if physical therapy was implemented via telerehabilitation for postoperative TKA patients. Outcomes had to address therapeutic outcomes, patient satisfaction, or cost effectiveness. Two reviewers
extracted study and participant characteristics. Quality and level of evidence were assessed using the PEDro scale and OCEBM levels of evidence. Action statements were generated and assigned an OCEBM grade
of recommendation.
RESULTS: The review included 6 RCTs providing 731 participants. There
was Grade B evidence for action statements related to improving quality of life, reducing disability, and maintaining patient satisfaction.
Improving functional activity was also supported by grade B evidence,
however, based on a preponderance rather than consistent evidence. Due
to insufficient evidence pertaining to cost-effectiveness we were unable to
form an action statement.
CONCLUSIONS: This review identified moderate evidence to support that
telerehabilitation can be as effective as conventional face-to-face therapy
in improving quality of life, reducing disability, and maintaining patient
satisfaction post TKA. There is conflicting evidence that telerehabilitation is as effective in improving functional activity, though supporting evidence outweighs refuting evidence. Despite a lack of supporting studies,
cost analyses demonstrated telerehabilitation might be a cost-effective alternative to conventional therapy, although further research on economic costing is required.
CLINICAL RELEVANCE: Although face-to-face care may be necessary on some
occasions for particular patients, the results of this review strongly suggest that in-home telerehabilitation could be used to improve accessibility of health care services in rural, remote communities and dense urban
locations where high volume, waiting times, and cost of services are major
barriers to people who have undergone a TKA procedure.
OPO126
DOES SLEEP QUALITY MODERATE THE RELATIONSHIP BETWEEN PAIN
INTENSITY AND HEALTH CARE UTILIZATION? LONGITUDINAL ANALYSIS
FROM A COHORT OF PATIENTS WITH LOW BACK PAIN
Hopin Lee, Daniel Rhon, Vincent Mysliwiec, Edel O’Hagan
Body in Mind Research Group, Neuroscience Research Australia,
Sydney, Australia; Sleep Medicine Fellowship, Brooke Army
Medical Center, Joint Base San Antonio, Fort Sam Houston, Texas;
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Graduate Programs in Physical Therapy, Baylor University, San
Antonio, Texas
NUMBER OF SUBJECTS: Forty-eight (130 limbs).
MATERIALS/METHODS: Forty-eight adults were randomized into 2 groups,
PURPOSE/HYPOTHESIS: Pain intensity in patients with back pain is associat-
TSM or a sham intervention (TSM procedure without a thrust), and tested for the presence of neurodynamic limitations via the ULPT and SST.
Those who met previously published range of motion limitations (n = 43)
for at least 1 of the 4 limbs measured received their preassigned intervention (TSM, n = 22; sham, n = 21). Neurodynamic mobility was reassessed
after intervention. Subjects were questioned preintervention and postintervention regarding perceived effect and to determine believability of the
proposed sham manipulation.
RESULTS: Forty-three subjects (60 UE and 70 LE) demonstrated positive neurodynamic testing. Separate 2-by-2 repeated-measures analyses of variance were used to examine the effects of intervention (TSM,
sham) and time (preintervention, postintervention) on ULPT and SST
measurements. Both the ULPT (F1,49 = 42.56, P<.001) and SST (F1,59 =
20.50, P<.001) demonstrated improvements at posttest regardless of intervention received. ULPT effect size for both TSM (d = 0.75) and sham
(d = 0.79) groups were medium. However, for the SST, the effect size for
the TSM group (d = 0.60) was medium, while the sham group (d = 0.22)
was small. No significant differences were noted for believability of the
intervention received (η2 = 3.74, P = .44) or for perception of effect between groups pretreatment (η2 = 2.83, P = .24) and posttreatment (η2 =
2.71, P = .61).
CONCLUSIONS: These findings indicate that peripheral neurodynamic mobility improved in both the upper and lower quarter regardless of intervention. The magnitude of change in lower quarter neurodynamic mobility following TSM further supports a neurophysiologic mechanism of
manipulation. In addition to proposed neurophysiologic effects supported
by previous research, the remaining findings highlight nonspecific effects
such as therapeutic alliance and patient expectation that may impact the
clinical benefit of manipulation. The sham utilized in this study demonstrated adequacy as a sham comparator to a supine TSM.
CLINICAL RELEVANCE: While thoracic spine manipulation has been correlated with improvements in local and peripheral impairments, assessment
of patient expectations and beliefs may assist therapists in technique selection if improvement in peripheral neurodynamic mobility is sought.
ed with pain related disability and health care utilization. It is also known
that these patients have comorbidities that can influence factors like disability and the back pain related health care utilization. One of these comorbidities is sleep quality. The purpose of this study was to evaluate the
relationship between perceptions of daytime sleepiness and patients seeking continued care for back pain. Specifically, we wanted to determine
whether sleepiness was able to moderate the relationship between pain
and health care utilization, and disability and health care utilization.
NUMBER OF SUBJECTS: Seven hundred fifty-eight patients referred to selfmanagement education class for low back pain in the physical therapy
clinic at Madigan Army Medical Center, Tacoma, WA, between March 1,
2010 and December 4, 2012.
MATERIALS/METHODS: Participants completed self-reported measures of
pain intensity, disability (Oswestry Disability Index), and sleepiness
(Epworth Sleepiness Scale). Healthcare utilization was extracted from
the Military Health System Data Repository (MDR) for a 24-month period (12 months before and after the self-management class). Total number of lumbar spine-related medical visits was abstracted for the 1-year
period after the class based on relevant International Classification of
Diseases, Ninth Edition (ICD-9) codes. Total number of comorbidities
over the 24-month period was also collected for each subject. The association between pain intensity and health care utilization (medical visits)
was investigated using multivariate Poisson regression analyses, adjusted
for previous history of back pain, and the total number of comorbidities.
To examine the moderating effect of sleepiness, we tested its interaction
with pain intensity. These analyses were repeated with disability as the
outcome, using multivariate linear regression.
RESULTS: Pain intensity levels were associated with the total number of
medical visits (IRR = 1.11; 95% CI: 1.09, 1.13; P<.01) and disability ratings
(IRR = 1.03; 95% CI: 1.02, 1.03; P<.01). Sleepiness significantly moderated the relationship between disability rating and the number medical
visits (IRR = 0.99; 95% CI: 0.99, 0.10; P<.01), but did not moderate the
relationship between pain intensity and medical visits (IRR = 0.99; 95%
CI: –0.99, 1.00; P = .40).
CONCLUSIONS: Higher pain intensity and disability were associated with
greater 1-year LBP-related health care utilization. The presence of sleepiness increased the amount of LBP-related health care utilization in patients with higher disability, but not in patients with higher pain intensity.
CLINICAL RELEVANCE: Assessing and addressing sleepiness in patients with
low back pain has the potential to assist clinicians in their interpretation
of how disability will impact long-term health care utilization.
OPO127
THE IMMEDIATE EFFECTS OF THORACIC SPINE MANIPULATION VERSUS
A SHAM COMPARATOR ON THE UPPER-LIMB PROVOCATION TEST
AND SEATED SLUMP TEST
AJ Lievre, Aaron Hartstein, Kristina Clinton, Julia L. Falken­
klous, Erika Finn, Reihle Kash, Heather E. Lauth, Robert Nester,
Sheri A. Hale
Division of Physical Therapy, Shenandoah University, Winchester,
Virginia
PURPOSE/HYPOTHESIS: Previous research suggests that mechanical and
neurophysiologic mechanisms may be responsible for the clinical benefits of manipulation. While studies indicate remote and peripheral improvements in pain, range of motion, and motor function following manipulation, no studies have investigated the effects of a supine thoracic
spine manipulation (TSM) on neurodynamic mobility, as compared to a
sham intervention. This study aimed to determine the immediate effects
of TSM on the Upper Limb Provocation Test (ULPT) and Seated Slump
Test (SST) compared to a sham intervention in asymptomatic subjects
with neurodynamic limitations.
OPO128
INTERRATER AND INTRARATER RELIABILITY OF A CORE STABILITY
PERFORMANCE TEST
Kari M. Lindegren, Kristin Bastian, Robyn McHugh,
Christopher J. Kovacs, Mark V. Paterno
Orthopedic and Sports Physical Therapy, Cincinnati Children’s
Hospital Medical Center, Cincinnati, Ohio
PURPOSE/HYPOTHESIS: The supine double leg lowering test (SDLLT) as initially described by Kendall has been previously reported in the literature
as a reliable measure of core activation and stability during lower extremity movement [1]. However, there is wide variability in the execution and
measurement of the SDLLT. The purpose of this study was to define a
standard method of implementing the SDLLT and to investigate the inter
and intrarater reliability of this method. It was hypothesized that examiners would demonstrate moderate to good inter and intrarater reliability in
their measurement of the SDLLT.
NUMBER OF SUBJECTS: Ten healthy subjects (mean ± SD age, 22.5 ± 1.6
years; 6 female, 4 male).
MATERIALS/METHODS: Two licensed physical therapists measured and recorded data for ten subjects who performed 4 trials of the SDLLT with
a 1-minute break between each. The physical therapists were trained in
performing and measuring the SDLLT using a protocol developed using
previous research published in the literature [2,3]. A stabilizer, which
was placed under the subject’s lumbar spine, was used to monitor the end
of the test. At this end point, 1 examiner used a single inclinometer to record performance in degrees from horizontal. Specific methodology was
utilized to eliminate the potential for intrarater bias while measuring the
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test. Intrarater agreement was calculated using intraclass correlation coefficients and Pearson correlation was used to assess interrater reliability.
RESULTS: Intraclass correlation coefficients assessing the intrarater reliability of the SDLLT in a population of young, healthy subjects suggests this is a highly reliable method to assess core activation and stability (0.885, P<.001). Interrater reliability using this methodology was also
highly reliable (0.832, P<.001).
CONCLUSIONS: These findings are consistent with the hypothesis that the
SDLLT method described has high inter and intrarater reliability when
assessing core stability and activation.
CLINICAL RELEVANCE: It is necessary to utilize a reliable test to assess core
stability and activation during physical therapy evaluation and treatment. Previously, researchers have described a subgroup of patients who
would benefit from core stabilization in the treatment of low back pain
and a clinical prediction rule has been developed for this subset of patients [4,5,6]. Currently no gold standard for measuring this impairment
has been described in the literature and there is inconsistency in how
the SDLLT is performed [2,7]. This study demonstrates that the defined
standardized method of measuring the SDLLT has good inter and intrarater reliability and can be used to assess core stability. This study prepares the foundation for future planned studies to establish normative
values for the SDLLT in the pediatric population.
OPO129
TREATMENT OF THORACIC SPINE AND RIB IMPAIRMENTS IN A PATIENT
COMPLAINING OF SHOULDER AND NECK PAIN: A CASE REPORT
Alex Linko, Scott Getsoian
University of St Augustine for Health Sciences, St Augustine,
Florida
BACKGROUND AND PURPOSE: To demonstrate the role of upper thoracic and
rib joint hypomobility in shoulder pain and dysfunction. The upper ribs
are commonly overlooked in the evaluation of shoulder and neck pain,
but play an integral role concerning interregional interdependence.
CASE DESCRIPTION: The patient was a 23-year-old female OT. She was hurt
during a patient transfer. MRI was negative for a rotator cuff tear. Use of
her right upper extremity increased pain. Isolated AROM of the shoulder
and cervical spine were WNL. A limitation was noted with combined cervical right rotation and right shoulder external rotation. Joint mobility of
the glenohumeral joint was WNL. P/A and rotational hypomobility was
noted at C7/T1-T3/4 facet joints and costotransverse/vertebral joints [14]. During first rib assessment with the patient, I heard and felt a clunk
with nearly all symptoms alleviated.
OUTCOMES: After 9 treatment sessions, the patient was able to return to
a full case load on an inpatient rehab unit. Joint and myofascial mobility were WNL. The patient no longer had any pain complaints or difficulty transferring patients. Outcomes and function were assessed using the
NDI and QuickDASH. Both were 0% at discharge.
DISCUSSION: This case demonstrated the role of interregional dependence
in a patient with shoulder pain. Initial thoracic spine and costotransverse/
vertebral manipulation alleviated nearly all of the patient’s symptoms.
Range of motion exercises and stretching were used as supportive treatments to manual therapy. Lower trapezius and middle trapezius were used
to maintain improvements in joint and myofascial mobility. Combining
upper thoracic and upper rib manipulation lead to a significant decrease
in pain and increase in function. It is important to consider the thoracic
spine and rib joints contribution to full shoulder and cervical range of motion and function. Significant and rapid changes can be made in patient’s
complaining of shoulder pain, when utilizing these techniques.
REFERENCES: 1. Kendall FP, McCreary EK, Provance PG, Rodgers MM,
Romani WA. Muscles Testing and Function With Pain and Posture.
Baltimore, MD: Lippincott Williams and Wilkins; 2005. 2. MacDermid
JC, Walton DM, Avery S, Blanchard AA, Etrum E, McAlpine C, Goldsmith
CH. Measurement properties of the Neck Disability Index: a systematic review. J Orthop Sports Phys Ther. 2009;39:400-417. 3. Mintken
PE, Glynn P, Cleland JA. Psychometric properties of the Shortened
Disabilities of the Arm, Shoulder, and Hand Questionnaire and numeric
pain rating scale in patients with shoulder Pain. J Shoulder Elbow Surg.
2009;18:920-926. 4. Strunce JB, Walker MJ, Boyles RE, Young BA. The
immediate effects of thoracic spine and rib manipulation on subjects with
primary complaints of shoulder pain. J Man Manip Ther. 2009;17:230236. 5. Walser RF, Meserve BB, Boucher TR. The effectiveness of thoracic spine manipulation for the management of musculoskeletal conditions: a systematic review and meta-analysis of randomized clinical trials.
J Man Manip Ther. 2009;17:237-246. 6. Cleland J, Selleck B, Stowell T,
Browne L, Alberini S, St. Cyears H, Caron T. Short-term effects of thoracic manipulation on lower trapezius muscle strength. J Man Manip
Ther. 2004;12:82-90. 7. Feuerherd R, Saliba S. Manual therapy for firstrib dysfunction. Athl Train Sports Health Care. 2013;5:5-6. 8. Ekstrom
RA, Donatelli RA, Soderberg GL. Surface electromyographic analysis of
exercises for the trapezius and serratus anterior muscles. J Orthop Sports
Phys Ther. 2003;33:247-259. 9. Patla CE. E2: Extremity Integration. St
Augustine, FL: Institute Press; 2002.
OPO130
A NOVEL SOFT TISSUE MANIPULATION MOTION AND FORCE
QUANTIFICATION SYSTEM FOR RESEARCH AND CLINICAL USE
Terry Loghmani, Bruce Neff, Sohel Anwar, Samantha Bane,
Stanley Chien, Keith L. March, Allison Longgood, Colleen Quigley,
Carolyn Tobin
Physical Therapy, Indiana University, Indianapolis, Indiana;
Mechanical Engineering, IUPUI-Purdue, Indianapolis, Indiana;
Electrical Engineering, IUPUI-Purdue, Indianapolis, Indiana;
Medicine, Indiana University, Indianapolis, Indiana
PURPOSE: Soft tissue mobilization/manipulation (STM) is a type of manual therapy commonly used by therapists; the forces delivered during STM
have not been adequately quantified in humans. This, however, echnological gap has markedly limited the ability to establish and compare realistic
STM protocols and outcomes. Instrument-assisted soft tissue mobilization (IASTM), a type of massage that uses rigid devices, has demonstrated therapeutic benefit. The purpose of this project was to fabricate and
compare design concepts for an accurate and reliable mechano-therapeutic instrument that provides real-time quantification of motion and force
delivered during IASTM for research and clinical use.
DESCRIPTION: Two STM motion and force quantification (MFQ) system
prototypes were designed, fabricated and compared. A system was selected for further development based on established criteria: precision,
cost, maneuverability, and the ability to apply force to the soft tissue in a
clinically replicable, user-friendly and feasible manner. The STM MFQ
system consists of a 3-D compression load cell and a microcontroller.
The 3-D compression load cell quantifies the force components in 3-D
space, while the microcontroller measures the stroke angle and frequency. Other parameters include total resultant force in 3-D, average peak
force and treatment time. The accuracy of stroke angle measurements,
frequency and maximal force measures during compression of the device
at 90° and 45° angles were determined against external, calibrated scales.
Preliminary intrarater and interrater reliability testing of force measurements between 2 trained, novice clinicians instructed to press the device
at a 90° angle against an inanimate, flat surface for 15 trials at a perceived
maximal clinical pressure was also performed.
SUMMARY OF USE: The average ± SD force generated with the STM MFQ
device held at a 90° angle device to the scale was 21.88 (4.9 lb) ± 4.18 N
(0.94 lb), with a range of 15.38 (3.46 lb) to 30.11 N (6.77 lb). The accuracy
of the device was excellent, within 1 N, for determining compressive force
as compared to the external scale (n = 30 trials; at 90°, χ2 = 0.92; at 45°,
χ2 = 0.97). Stroke angle and frequency were also accurate. Test-retest intrarater reliability for examiner 1 was good (ICC = 0.619; 95% CI: –0.136,
0.872; P = .041). Interrater reliability between examiners 1 and 2 was also
good (ICC = 0.653; 95% CI: 0.271, 0.835; P = .003).
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IMPORTANCE TO MEMBERS: A novel STM MFQ system was developed, demonstrating excellent accuracy and good reliability during preliminary testing. Future studies will further evaluate the system in animals and humans. Ultimately, the ability to objectively characterize motion and force
during manipulation of the soft tissue is important since it will permit
protocols to be standardized and compared. Quantification of the forces
delivered during soft tissue assessment and intervention is essential for
this form of manual therapy to be validated and established as a viable
mechanotherapy option for a variety of conditions.
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OPO131
TREATMENT OF CERVICOGENIC HEADACHE IN AN ADULT PATIENT
USING THERAPEUTIC EXERCISES FOR CORRECTION OF MOVEMENT
IMPAIRMENTS: A CASE REPORT
McKenzie D. Long
Physical Therapy, Orthosports Physical Therapy, Glendale,
Arizona
BACKGROUND AND PURPOSE: Tension HA, cervicogenic HA, and migraine
are the most prevalent types of HA among adults [1]. The prevalence of
cervicogenic HA is estimated at 0.5% to 4% of the general population,
but may be as high as 20% of points presenting with severe chronic HA
[2,3,4]. A common postural impairment noted in this population is a forward head position with increased upper cervical extension [5]. This position, when sustained or habitually repeated, produces increased stress
on the cervical facet joints and is likely a contributing factor in cervicogenic HA or cervicalgia [5,6,7]. The purpose of this case report is to describe evaluation and treatment of neck pain with tension HA and migraines. It will describe how education in proper postural alignment and
therapeutic exercise can address impairments of the cervical and scapular
regions to abolish cervicogenic HA symptoms.
CASE DESCRIPTION: The patient was a 42-year-old woman with a medical
diagnosis of “cervicalgia.” She worked from home 5 days a week and spent
most of her time on a computer. She reported her migraines began at
14 years old. She also reported experiencing tension-HA, that would last
for multiple days. She reported 4 d/mo symptom-free. At evaluation, she
reported a tension-HA intensity of 3 to 4/10 that had been present for
48 hours. Location of pain was retro-orbital, suboccipital and radiated
into her shoulders. Severity of tension-HA and migraine pain increased
to 10/10, at worst. Her initial NDI score was 38, indicating complete disability. Static alignment revealed extension of the upper cervical spine
and decreased kyphosis in the thoracic spine, B scapular depression, abduction of the scapula, slight downward rotation of R scapula, and slight
upward rotation of L scapula. She displayed cervical extension during B
shoulder flexion, and cervical extension with vertebral rotation during
unilateral shoulder flexion. Scapular elevation with capitol flexion corrected the movement faults. Strength deficits were identified in the lower abdominals and deep neck flexors. These findings implicate poor motor control and decreased strength as contributing factor to the cervical
movement faults. Therapeutic exercises, postural education, and modalities were implemented. Exercises focused on correcting the alignment of
the cervical and scapulothoracic regions by strengthening the deep cervical neck flexors, middle and lower trapezius muscles, and lower abdominals. She was seen over a period of 3.5 weeks for a total of 8 treatment sessions, each lasting approximately 60 minutes.
OUTCOMES: The patient had decreased HA intensity to 0/10 by the sixth
visit and neck pain to 0/10 by the seventh visit. Additionally, her postural
control and awareness had improved at the conclusion of treatment and
she reported decreased reliance on medication.
DISCUSSION: The result of this case report suggest that therapeutic exercises focused on correcting posture and movement faults during ADLs can
be helpful in reducing the symptoms associated with cervicogenic HA.
REFERENCES: 1. Fernandez-de-las-Penas C, Alonso-Blanco C, San-Roman
J, Miangolarra-Page JC. Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type
headache, migraine, and cervicogenic headache. J Orthop Sports Phys
Ther. 2006;36:160-169. 2. Evers S. Comparison of cervicogenic headache
with migraine. Cephalalgia. 2008;28:16-17. 3. Sjaatstad O. Cervicogenic
Headache: comparison with migraine without aura: Vaga study.
Cephalalgia. 2008;28:18-20. 4. Haldeman S, Dagenais S. Cervicogenic
headaches: a critical review. Spine J. 2001;1:31-46. 5. Sahrmann S.
Movement System Impairment Syndromes of the Extremities, Cervical
and Thoracic Spines. St Louis, MO: Elsevier Health Sciences; 2010. 6.
McDonnell MK, Sahrmann SA, Van Dillen L. A specific exercise program and modification of postural alignment for treatment of cervicogenic headache: a case report. J Orthop Sports Phys Ther. 2005;35:315. 7. Porterfield JA, DeRosa C. Mechanical Neck Pain: Perspectives in
Functional Anatomy. Philadelphia, PA: W.B. Saunders; 1995.
OPO132
RELATIONSHIP BETWEEN THE FUNCTIONAL MOVEMENT SCREEN,
HOP TEST, AND OTHER PERFORMANCE-RELATED PARAMETERS
IN HIGH SCHOOL BASKETBALL PLAYERS
Paul B. Lonnemann, Clinton W. Morris, Michael Fauser,
Cody Mumaw, Gina L. Pariser
Physical Therapy, Bellarmine University, Louisville, Kentucky
PURPOSE/HYPOTHESIS: The Functional Movement Screen (FMS) has been
shown to reliably assess an athlete’s risk of injury. Recent research has
suggested that the Hop Test may also be able to assess asymmetry and
risk of injury. However, there is little evidence correlating FMS scores
to the Hop Test. Additionally, there is very little research relating scores
from either assessment to athletic performance, specifically in basketball.
This study aims to determine if there is a correlation between the FMS,
Hop Test, and the NBA Draft Combine testing battery.
NUMBER OF SUBJECTS: Twenty-five.
MATERIALS/METHODS: Twenty-five participants selected from a high school
basketball program were evaluated using the FMS, Hop Test, and selected tests adapted from the NBA Draft Combine. Data collected from these
test batteries was then analyzed for significant correlations using either a
Pearson or Spearman correlation statistic as appropriate.
RESULTS: Pearson correlations for the data demonstrate statistically significant relationships between the FMS and certain NBA Combine tests including the box drill and on the move shooting drill (r = –0.45 and 0.42,
respectively). Right sided FMS scores were correlated with right sided
single-leg timed hop and triple hops (r = –0.49 and 0.41, respectively).
Left sided FMS scores were correlated with the single-leg timed hop,
triple hop, and crossover hop (r = –0.63, 0.63, and 0.59, respectively).
Individual components of the hop test were also correlated in some extent to nearly all individual tests from the NBA Combine. Notable correlations were found between triple hop to standing vertical, max vertical, box
drill, three-quarter-court sprint, and reactive shuttle drill (for right side: r
= 0.60, 0.75, –0.74, –0.77, –0.62; for left side: r = 0.56, 0.70, –0.61, –0.78,
–0.53, respectively) and between the single-leg timed hop and standing
vertical, max vertical, box drill, three-quarter-court sprint, and reactive
shuttle drill (for right side: r = –0.42, –0.63, 0.55, 0.66, 0.54; for left side:
r = –0.45, –0.62, 0.58, 0.66, 0.48, respectively).
CONCLUSIONS: These findings appear to support the hypothesis that components of the FMS, Hop Test, and NBA Combine Hop Test are correlated with performance ability. Additionally, these correlations may indicate
that the Hop Test is a tool that may potentially be utilized to determine
an athlete’s risk of injury. More studies are needed to further examine the
Hop Test as a reliable assessment of an athlete’s risk of injury and also to
address the link between the FMS and Hop Test as predictors of athletic performance.
CLINICAL RELEVANCE: Correlating the FMS to athletic ability would allow
clinicians in the field of sports performance to quickly and efficiently target deficits to improve skill. The Hop Test may also be a reliable addition,
or substitution, for the FMS in preseason physical screenings.
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PURPOSE/HYPOTHESIS: The effectiveness of treatment for chronic, degener-
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OPO133
BODY FUNCTIONS, ACTIVITY LIMITATIONS, AND PARTICIPATION
RESTRICTIONS IN PATIENTS WITH CHRONIC LOW BACK PAIN WHO CHOOSE
TO UNDERGO LUMBAR SPINE SURGERY
Anat V. Lubetzky, Youssef Masharawi, Daphna Harel,
Justin Burr, Thomas Errico, John Bendo, Marilyn Moffat
Physical Therapy, New York University, New York, New
York; Physical Therapy, Tel Aviv University, Tel Aviv, Israel;
Humanities and Social Sciences, New York University, New York,
New York; Spine Surgery, New York University Langone Medical
Center, New York, New York
PURPOSE/HYPOTHESIS: Despite large variation in recommendations and
quality of surgery-related clinical guidelines, approximately 3.2 million
patients underwent low back surgery in the US in 2010 [1]. A shift toward a patient-centric “personalized’ approach to management encourages clinicians to account for individual characteristics of each patient [2].
No classification system currently directs the choice of surgical treatment
[3,4]. Using the International Classification of Functioning, Disability
and Health (ICF) Framework [5], the purpose of this study was to comprehensively describe the body function, activities, and participation levels of patients who choose to go through lumbar decompression or fusion surgery.
NUMBER OF SUBJECTS: Twenty-five adults (8 female, 17 male) with chronic low back pain who were recommended for lumbar spine surgery and
chose to go through one, were tested prior to their surgery.
MATERIALS/METHODS: Each patient went through a quick but comprehensive battery of self-reported and functional tests. Questionnaires included the Oswestry Disability Index (ODI), Roland-Morris Disability
Questionnaire (RMQ), Physical Activity Subscale of the Fear-Avoidance
Beliefs Questionnaire (PA-FABQ), International Physical Activity
Questionnaire (IPAQ), and numeric pain-rating scale (NPRS). Clinical
measures included the 400-m walk test (400MWT), 8-ft timed up-andgo (TUG), Four Square Step Test (FSST), 30-second sit-to-stand test,
Single-Leg Balance Test, Chair Sit and Reach Test, passive straight leg
raise (PSLR), and single-leg heel rise (SLHR) test. Descriptive statistics
for presurgical questionnaires and clinical measures were performed.
RESULTS: Patients self-reported a minimum of 20 (minimal disability) to
a maximum of 76 (crippling back pain) on the ODI; a minimum of 1 to a
maximum of 21 on the RMQ; 0 to 10 for back or leg pain on the NPRS;
and “not active” to “ highly active” on the IPAQ with 0 to 150 minutes of
walking per week. The minimum to maximum on the PA-FABQ was 6
to 24. Eight patients completed the 400MWT in less than 5 minutes, 8
patients could not complete the test. The minimum to maximum on the
TUG was 3.66 to 17.81 seconds and on the FSST was 4.56 to 23.2 seconds.
The number of sit-to-stands performed in 30 seconds ranged between 2
to 29. Balance on a single leg was held between 0 to 30 seconds. Chair sit
and reach ranged between –30 and +30 cm. PSLR ranged between 35° to
115° with 0 to 10 pain reported in either the back or the leg. The number
of SLHR completed out of 20 ranged between 0 and 20.
CONCLUSIONS: Results of body function, activity, and participation-level
measures for these patients were from one end of the spectrum to the
other. No single test demonstrated the ability to indicate the surgical need
for all individuals tested. These patients will be followed up after surgery
to see if any of the measures correlate with surgical outcomes.
CLINICAL RELEVANCE: A comprehensive battery of measures at all ICF levels
presurgery, may shed light on patients’ postsurgical outcomes.
OPO134
INDIVIDUALS WITH LUMBAR SPINAL STENOSIS DESIRE EMPATHETIC CARE
FOCUSED ON SELF-MANAGEMENT: RESULTS OF FOCUS GROUPS
WITH RCT PARTICIPANTS
Andrew D. Lynch, Allyn M. Bove, Michael J. Schneider
Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania
ative conditions of the lumbar spine are largely influenced by patient perceptions in addition to the scientific rationale behind the intervention.
Therefore, the primary purpose of this study was to understand the factors that are important to individuals with lumbar spinal stenosis (LSS)
regarding treatment for their condition. These factors were considered
within the context of each treatment arm of the parent RCT.
NUMBER OF SUBJECTS: Fifty individuals (28 female; average ± SD age, 73
± 7.7 years) who had completed participation in a RCT for nonsurgical
LSS treatment were invited to participate in focus groups to discuss perceptions about their study treatment, and their experiences with LSS
in general. Treatment arms included usual medical care, communitybased group exercise, and clinic-based manual therapy and individualized exercise.
MATERIALS/METHODS: Six focus groups were conducted, 2 focus groups for
each of the 3 treatment groups. Focus group topics included treatment effectiveness, suggestions for treatment improvement, barriers and facilitators to treatment, and opinions of research outcome measures. A mixed
approach was used to analyze focus group transcriptions; primary coding
was focused on the research questions. Secondary coding sought to identify themes concerning living with LSS and seeking treatment that were
emergent from the focus groups.
RESULTS: Five themes related to medical treatment and symptom management arose from the focus group analyses: (1) a desire for individualized care based on self-management techniques; (2) a desire for education about LSS and motivation to pursue education from any available
source; (3) positive and negative emotional responses to LSS symptoms
and care; (4) the importance of social support in managing symptoms;
and (5) seeking dietary changes and supplement use to improve symptoms. These themes were consistent across all 3 treatment groups, with
no substantial differences observed between the groups.
CONCLUSIONS: Individuals with LSS are interested in reducing pain by any
reasonable methods, which can lead to believing misinformation and considering information from nonmedical sources, especially when medical
providers do not take the time to explain the disease process and the theory behind treatment. Receiving individualized care focused on self-management from an empathetic provider led to fewer negative emotions towards care and the disease process. Social support from family and others
with LSS is also an important part of care.
CLINICAL RELEVANCE: Clinicians should provide information about the disease process and techniques for self-management in an empathetic manner. This will improve the likelihood that individuals with LSS have a positive response to treatment. Individuals with LSS will seek empathetic
care from nontraditional sources if they feel that traditional medical providers are not providing appropriate or compassionate care.
OPO135
TEST-RETEST RELIABILITY AND MINIMAL DETECTABLE CHANGE OF THE
PATIENT-REPORTED OUTCOME MEASUREMENT INFORMATION SYSTEM
PHYSICAL FUNCTION AND PAIN INTERFERENCE COMPUTER ADAPTIVE
TESTS IN INDIVIDUALS WITH KNEE OA
Andrew D. Lynch, Allyn M. Bove, Lan Yu, Paul A. Pilkonis,
G. Kelley Fitzgerald, James J. Irrgang
Physical Therapy, University of Pittsburgh, Pittsburgh,
Pennsylvania; School of Medicine, University of Pittsburgh,
Pittsburgh, Pennsylvania
PURPOSE/HYPOTHESIS: To determine the test-retest reliability and estimate
the minimal detectable change (MDC) score of the NIH’s PROMIS Pain
Interference (PI) and Physical Function (PF) CATs in individuals with
knee osteoarthritis (OA). We hypothesized that the CATs would demonstrate good test-retest reliability over clinically relevant time frames in individuals who report no change in status.
NUMBER OF SUBJECTS: Thirty-two individuals with knee OA (mean ± SD
age, 62.0 ± 11 years old; 66% female) participated in up to 4 data collec-
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tion sessions.
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MATERIALS/METHODS: Participants were asked to complete the PROMIS
PF and PI CATs at a baseline session, and at follow-ups of 1, 3, and 6
months. Participants answered a 15 point global rating of change (GRC)
question at each follow-up. We operationally defined a participant to be
stable if they responded they were “hardly any worse at all” (–1), “about
the same” (0), or “hardly any better at all” (1) on the GRC. Scores outside
of this range were categorized as not stable. We compared the follow-up
CAT scores to the baseline CAT scores for each cohort of stable participants and summarized change scores. Test-retest reliability was assessed
with a 2-way Random Effects Intraclass Correlation Coefficient for absolute agreement of single measures (ICC model 2,1). We operationally defined an ICC2,1 of 0.75 to indicate good test-retest reliability. Based on the
ICC2,1, an MDC was calculated.
RESULTS: Follow-up was obtained from 27 participants at 1 m (84%), 30
participants at 3 m (94%) and 28 participants at 6 m (88%). On average,
participants completed the PF CATs in 4.1 items (range, 4-6 items) and
PI CATs in 5.5 items (range, 4-13 items). For the PROMIS PF CAT, average change scores were all less than 1.5 points and all ICC2,1 values were
greater than 0.8, but tended to decrease over time. MDC values were 8
points at 1 m, 7.4 points at 3 m, and 5.7 points at 6 m, with upper limits
of the 95% of confidence intervals less than 12.3 points. PROMIS PI CAT
scores were not reliable over time (ICCs ranged from 0.56 to 0.69), and
point estimates of the ICC were not precise as indicated by the wide confidence intervals (eg, 1 m; ICC2,1 95% CI: 0.04, 0.84 points). Poor reliability led to large MDC values (13.8-17.9 points).
CONCLUSIONS: The PROMIS PF CAT is a reliable and efficient measure in
individuals with knee OA over periods of 1, 3, and 6 months. Depending
on the time frame, changes less than 8 points may be attributed to measurement error, and changes greater than 12 points would be considered
a true change in physical function. The PROMIS PI CAT is not a reliable
measure in individuals with knee OA, potentially due to the variable nature of pain with OA.
CLINICAL RELEVANCE: The PROMIS PF CAT can be used with individuals
with knee OA over time, with changes greater than 8 points likely indicating a change beyond measurement error. Future work to establish PF CAT
responsiveness and minimal clinically important differences is needed.
OPO136
THE RATIO OF MUSCLE STRENGTH BETWEEN EXTERNAL/INTERNAL
ROTATION AND FLEXION/EXTENSION OF THE SHOULDER MEASURED WITH
A CYBEX ISOKINETIC UNIT COMPARED TO A 10-REPETITION MAXIMUM
USING A PULLEY SYSTEM
Angela MacCabe, Richard A. Ekstrom, Steven Bloom,
Kelsey R. Tobin, Kory Zimney
Physical Therapy, University of South Dakota, Vermillion, South
Dakota
PURPOSE/HYPOTHESIS: The objectives of our study were (1) to determine shoulder external rotation (ER):internal rotation (IR) and flexion
(FX):extension (EX) muscle strength ratios for the shoulder using both a
Cybex isokinetic unit and a 10 repetition max (RM) on a weighted pulley
system and (2) to determine if ER/IR and FX/EX strength ratios measured by 10 RM predict strength ratios measured by a Cybex isokinetic unit.
NUMBER OF SUBJECTS: Twenty subjects without shoulder dysfunction were
recruited to participate in the research protocol.
MATERIALS/METHODS: Prospective, single-group, repeated measures design. Shoulder muscle strength ratios were measured utilizing a Cybex
isokinetic machine set at 90°/s and by finding a 10 RM on a weighted pulley system. On the first day of testing, subjects were tested on the isokinetic machine and also found an approximate 10 RM on the weighted pulley
machine. Two days following, the subjects found their true 10 RM on the
weighted pulley machine. A metronome was used in calculating the 10
RM to mimic the speed of the isokinetic machine. All subjects were test-
ed in supine and with the shoulder in the 90°/90° position for measuring
ER and IR and supine with elbow extended for measuring shoulder FX
and EX dynamic muscular strength.
RESULTS: The mean dynamic strength ratios measured by 10 RM and
Cybex did not approximate the values found in the literature. There is
good to excellent internal consistency between 10 RM and Cybex for
strength values. Cronbach’s alpha equal to .855 for ER, .898 for IR, .870
for FX, and .854 for EX. Strength ratios for ER:IR and FX:EX were not
consistent between the 10 RM and Cybex, Cronbach’s alpha at .144 and
.492 respectively. The 10 RM predicted Cybex dynamic strength measures
for ER, IR, FX, and EX, but not for strength ratios. Comparison of instruments resulted in large effect sizes for independent strength values, but
not for strength ratios.
CONCLUSIONS: Finding a 10 RM on a weighted pulley system is a practical
method that can be utilized in a clinical setting for finding shoulder muscle strength measurement that is comparable to Cybex testing. The ratio
of ER/IR and FX/EX of the 10 RM weighted pulley system should not
be compared to published results of ratio testing utilizing Cybex testing.
CLINICAL RELEVANCE: Strength measurements of shoulder ER, IR, FX, and
EX can be determined with the lower cost device of a pulley system that
are comparable to a Cybex machine. The ratios of ER/IR and FX/EX
strength found in the literature based on Cybex testing, however, do not
equate with the ratios utilizing the pulley system.
OPO137
EFFECTIVENESS OF A NOVEL KNEE UNLOADER BRACE FOR
OSTEOARTHRITIS ON GAIT AND FUNCTIONAL PERFORMANCE
Kathleen C. Madara, Joseph Zeni, Federico Pozzi
Physical Therapy, University of Delaware, Newark, Delaware;
Biokinesiology and Physical Therapy, University of Southern
California, Los Angeles, California
PURPOSE/HYPOTHESIS: There are few noninvasive treatment options to
stop the progression of osteoarthritis; however, unloader bracing reduces abnormal joint forces in the frontal plane and reduces pain. Recently,
a novel knee unloader brace that reduces frontal plane forces and promotes more normal knee extension has become commercially available
(Ongoing Care Solutions, Inc). The purpose of this study was to evaluate
the effectiveness of a novel unloader brace with knee extension assist on
functional measures and gait biomechanics after 6 weeks of use.
NUMBER OF SUBJECTS: Thirty-two subjects completed this study; 18 (8 male,
10 female; age range, 50-78 years) in the control group and 16 in the brace
group (8 male, 8 female; age range, 48-77 years).
MATERIALS/METHODS: Patients were randomized into a Brace or No Brace
group after baseline testing. Follow-up testing occurred 6 weeks after
baseline assessment. Three dimensional gait data at a self-selected speed
was captured using 8 infrared cameras (Vicon, Oxford, UK). Knee kinetics and kinematics were analyzed using Visual3D software. Functional
tests (Timed Up and Go, Stair Climbing Test and Six Minute Walk) and
isometric knee extension strength were assessed. Pain was assessed as
worst pain, best pain, and average pain in the previous week on a scale
of 0 to 10. Repeated measure ANOVAs were used to identify differences in group and time. Both groups received a basic set of lower extremity
stretches to be performed 3 times a week for 20 minutes. Subjects in the
Brace group also were instructed to wear the brace for up to 8 hours a day.
Subjects in the Brace group were seen after 3 weeks to ensure appropriate brace fitting and readjustments as needed. All testing was performed
without the subject wearing the brace.
RESULTS: There were no significant differences in gait biomechanics between time or between groups. There was a significant interaction effect
for “worst pain” (P = .003) and post hoc testing revealed the brace improved from a 7/10 at baseline to 4/10 at follow-up (P = .006). There
was no change for the control group (6/10 at baseline and follow-up, P =
.849). There was an effect of time for the stair climb test (P = .02) and best
reported affected knee pain (P = .050).
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CONCLUSIONS: There were no biomechanical benefits of wearing the brace
for 6 weeks, but individuals in the Brace group did demonstrate a significant and important reduction in the worst pain outcome. This may indicate that wearing the brace was able to reduce painful flares in the experimental group. Both groups improved over time for the stair climbing
test and the “best knee pain.” These improvements may be attributed to
the stretching protocol that was identical in each group. The duration of
wear was only 6 weeks and most previous research has evaluated biomechanical and functional outcomes over a longer period of wear time. The
shorter time between testing sessions may contribute to the lack of difference between groups.
CLINICAL RELEVANCE: This unloader brace is a promising noninvasive treatment option for patients with osteoarthritis who experience high levels
of knee pain.
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OPO138
NOVEL REHABILITATION PROTOCOL TO RETURN PATIENTS TO HIGH-LEVEL
ACTIVITIES, SPORTS, AND OCCUPATIONS AFTER TOTAL HIP ARTHROPLASTY
Kathleen C. Madara, Joseph Zeni, Leo W. Raisis
Physical Therapy, University of Delaware, Newark, Delaware;
First State Orthopaedics, Newark, Delaware
PURPOSE/HYPOTHESIS: Individuals undergoing total hip arthroplasties
(THA) are getting progressively younger. Although the surgical techniques and biomaterials have improved, rehabilitation has not kept pace
with the goals and expectations of this younger patient demographic. The
purpose of this study was to evaluate the feasibility and effectiveness of a
treatment intervention protocol that included progressive strengthening
and high-level activity retraining.
NUMBER OF SUBJECTS: Seven subjects completed this ongoing clinical study;
3 subjects in the control group (age range, 58-70 years; 2 female, 1 male)
and 4 in the experimental group (age range, 53-70 years; 1 female, 3 male).
MATERIALS/METHODS: The experimental intervention was novel with respect to timing and content. The experimental group received 16 sessions over 16 weeks. Subjects were seen once every 2 weeks for the first
12 weeks, followed by 3 times a week for 4 weeks. Training was tailored
to individual patient goals, but included a comprehensive and progressive home exercise program, biofeedback to promote movement symmetry, progressive strengthening and high level activities in the later
stage. The control group received usual care and the timing and content
of rehabilitation was not constrained. Testing included 3-D gait analysis (Vicon Motion Systems Ltd, Oxford, UK) and functional and clinical measures (Timed Up and Go, Stair Climbing Test, and 10-point pain
scores). Change scores for each group were calculated and compared using independent t tests. Biomechanical variables included peak vertical
ground reaction force (vGRF), peak hip adduction angle, and external
peak hip adduction moment.
RESULTS: The experimental group had a 9.35% increase in peak vGRF
compared to a 0.37% increase in the control group (P = .04). Hip adduction increased 4.58° in the control group, whereas the experimental group increased 1.99° (P = .122). There was a 10.26% increase in the
hip adduction moment in the experimental group, while the control increased 2.26% (P = .720). Hip pain decreased 3.5 points in the experimental group, but there was no reduction in pain in the control group (P
= .009). Both groups improved in the Timed Up and Go. The experimental group had substantial improvement in stair climbing time (8.4 seconds) compared to the control group (1.15 seconds) (P = .472). Similarly,
the experimental group increased Six-Minute Walk Distance by 147.1 m,
while the control increased 39.6 m (P = .138).
CONCLUSIONS: This novel treatment protocol is feasible in a clinical setting
and had a positive impact on function and hip biomechanics. The experimental group had improved joint kinetics and dramatic improvements
in performance by 16 weeks. Differences between groups were fairly large
and the lack of significance is likely attributed to the low sample size of
this preliminary analysis.
CLINICAL RELEVANCE: This novel therapy protocol may be more appropriate
and provide better clinical outcomes than traditional rehabilitation given
the changing patient demographics.
OPO139
TREATMENT OF UNILATERAL SCAPULAR DYSKINESIS AND PAIN IN A HEALTHY,
ACTIVE ADULT: A CASE STUDY
Evan J. Madsen
CPRS Physical Therapy, Mifflintown, Pennsylvania
BACKGROUND AND PURPOSE: The purpose of this study was to discuss treatment of a healthy, high functioning adult with scapular pain. It was hypothesized that in the absence of strength, muscular endurance, ROM,
and glenohumeral joint mobility deficits, improving scapular control
through neuromuscular re-education alone would effectively restore scapular positioning and normal scapular rhythm, thereby reducing pain and
functional limitations.
CASE DESCRIPTION: The subject was evaluated with complaints of fluctuating scapular pain that hindered his ability to sleep, exercise, and perform
his usual work duties. Upon examination, he was found to have no muscle
endurance, ROM, or glenohumeral joint mobility deficits, and minimal
strength deficits. Upon visual inspection of his scapulae, the patient was
found to have an obvious scapular dyskinesis of his involved scapula when
weight bearing through the upper extremities. An attempt was made to
objectify this asymmetry using the lateral scapular slide test (LSST). This
scapular dyskinesis was used as the basis for treatment, which included
verbal and tactile cuing for scapular movement quality as well as neuromuscular re-education for scapular stability and control.
OUTCOMES: The patient was seen in the clinic for a total of 14 visits. The
QuickDash and NDI outcome measures improved from 13.6% and 12%,
respectively, to 0% at discharge. Objective measures were taken once
weekly, except for the LSST, which was performed pretreatment and posttreatment at each therapy visit; however, there are visits where the LSST
was not performed due to clinical constraints. The patient’s initial pain of
1 to 4/10 at initial visit was resolved by discharge. At the initial visit, manual muscle testing of the middle scapula, lower scapula, and shoulder external rotation revealed minimal strength deficits, which improved slightly by discharge. The differences in the right and left scapular positions
varied by as much as 2.5 cm with the LSST, but trended toward improvement and were symmetrical at discharge. The patient reported full return
to his prior level of function without restriction at discharge.
DISCUSSION: The results of the LSST showed a consistent trend toward improvement in scapular symmetry, both within therapy sessions and between therapy sessions. However, the LSST has poor reliability, specificity, and sensitivity, and obvious scapular dyskinesis in weight bearing was
visualized throughout treatment to discharge. This not only reinforces the
need for further research into development of a valid and reliable objective measure for scapular dyskinesia, but also raises the question of how
one can improve pain and function without changing the position of the
scapula in functional positions. In this case scenario, it is hypothesized
that the patient’s resolution of pain and full return to prior level of function was due to neuromuscular re-education of the scapulothoracic musculature resulting in improved control throughout the movement pattern
rather than improved positioning of the scapula.
REFERENCES: Kibler BW, McMullen J, Uhl T. Shoulder rehabilitation strategies, guidelines, and practice. Oper Tech Sports Med. 2012;20:103-112.
Kibler BW, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia
AD. Clinical implications of scapular dyskinesis in shoulder injury: the
2013 consensus statement from the “scapular summit’. Br J Sports Med.
2013:1-12. McClure P, Tate AR, Kareha S, Irwin D, Zlupko E. A clinical method for identifying scapular dyskinesis, part 1: reliability. J Athl
Train. 2009;44:160-164. Shadmehr A, Bagheri H, Ansari NN, Sarafraz
H. The reliability measures of lateral scapular slide test at 3 different degrees of shoulder joint abduction. Br J Sports Med. 2010;44:289-293. Uhl
TL, Kibler BW, Gecewich B, Tripp BL. Evaluation of clinical assessment
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methods for scapular dyskinesis. Arthroscopy. 25:1240-1248.
OPO141
creased energy expenditure (EE), and risk for falling. The timed up and
Go (TUG) and 6 minute walk test (6MWT) are frequently used to determine fall risk by means of a single score. Additionally, sharp turns, as involved in TUG and 6MWT, suggest quality of turns, and not only distance
walked, can increase EE. This report compared temporospatial components of gait and EE in an individual using assistive devices over 3 different time points during the TUG and 6MWT.
CASE DESCRIPTION: The subject was a 44-year-old woman who developed
a dropped foot following a fall shortly after a L4-S1 fusion. Prior to surgery she was an active individual and a former gymnast. She presented
with diminished patellar and Achilles reflexes of 1/4 and 2/4 respectively,
and diminished sensation of the left lower extremity (LE). MMT for her
LLE was: hip flexion 4/5; knee extension 4/5; tibialis anterior 1/5; extensor hallucis longus 1/5 and heel raises 3/5. She ambulated with a straight
cane and a customized ankle-foot orthosis (AFO). Data were collected at
3 time points separated by at least 1 week. However, on return for the second session she related that she had a fall at home several days previously.
OUTCOMES: The subject used her AFO for session 1, while she used her
cane and AFO for sessions 2 to 3. A Kinesis QTUG wireless system was
used to acquire temporospatial parameters. Energy expenditure (EE) was
assessed using the energy expenditure index (EEI) and the Borg scale of
perceived exertion. Times to complete the TUG were 7.7, 9.1, and 7.3 seconds and velocity was 0.78, 0.66 and 0.82 m/sec for sessions 1 to 3, respectively. Velocity decreased approximately 18% while cadence (24%)
and stance time (20%) decreased from session 1 to session 2. 6MWT EEI
for sessions 1 to 3 was 0.64, 0.28 and 0.34 beats/min, while velocity was
1.78, 1.4 and 1.75 m/secs and distance (6MWD) covered was 653, 520 and
632 m, respectively. 6MWT velocity was approximately 50% faster than
the TUG, while cadence for the 6MWT versus TUG differed (mean, 127
versus 115.9 steps/min) across all sessions with average stride length remaining consistent. Surprisingly, turning efficiency was not affected by
the fall. EEI correlated with 6MWD (r = 0.72), Borg score (r = 1), and
gait velocity (r = 0.54). By session 3 most parameters had returned to at
least prefall levels.
DISCUSSION: The availability of portable wireless technology provides a
plethora of real-time data that is not readily apparent from the TUG and
6MWT. This case report showed the impact of a fall was apparent from
TUG and 6MWT scores. However, the value in being able to quantify key
biomechanical inefficiencies contributing to such scores using the QTUG
could lead to targeted interventions to specific components which are
readily identifiable. Moreover, such a device can provide objective information on patient response to treatment and could result in considerable
time cost savings with regard to productivity and outcomes assessment..
REFERENCES: Smith E, Walsh L, Doyle J, Greene B, Blake C. The reliability
of the quantitative timed up and go test (QTUG) measured over 5 consecutive days under single and dual-task conditions in community dwelling
older adults. Gait Posture. 2016;43:239-244. Horak F, King L, Mancini
M. Role of body-worn movement monitor technology for balance and
gait rehabilitation. Phys Ther. 2015 ;95:461-470. Justine M, Manaf H,
Sulaiman A, Razi S, Alias HA. Sharp turning and corner turning: comparison of energy expenditure, gait parameters, and level of fatigue
among community-dwelling elderly. Biomed Res Int. 2014:1-6. Schrack
JA, Simonsick EM, Chaves PHM, Ferrucci L. The role of energetic cost
in the age-related slowing of gait speed. J Am Geriatr Soc. 2012; 60:18111816. Bregman DJJ, Harlaar J, Meskers CGM, de Groot V. Spring-like ankle foot orthoses reduce the energy cost of walking by taking over ankle
work. Gait Posture. 2012; 35:148-153.
DETERMINING CONTRIBUTING FACTORS TO OUTCOME MEASURE SCORES
USING TRIAXIAL WEARABLE SENSOR TECHNOLOGY IN AN INDIVIDUAL
USING A STRAIGHT CANE AND ANKLE-FOOT ORTHOSIS
Ruth M. Maher, Devon G. Cota, Sonal Sheth
Physical Therapy, Shenandoah University, Leesburg, Virginia;
Physical Therapy, UAMS-Northwest, Fayetteville, Arkansas
BACKGROUND AND PURPOSE: There is a strong association between gait, in-
EFFECTIVE ELECTRONIC BEHAVIOR MODIFICATION TOOL
FOR SEATED POSTURE
Adam J. Malek, Julie B. Barnett, Zachary R. Johnson,
Jennifer Croft, Margaret W. Norton
Physical Therapy, University of Texas Health Science Center San
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OPO140
IN VIVO ULTRASOUND OF RADIAL-HEAD MOTION AND EFFECT
OF MOBILIZATION DIRECTION ON FOREARM RANGE OF MOTION
Ruth M. Maher, Megan R. Bureau, Melissa A. Conway,
Paul Ellington, Amber Harrison, Chelsey Thornsberry
Thornsberry, Physical Therapy, Shenandoah University, Leesburg,
Virginia; Physical Therapy, UAMS-Northwest, Fayetteville,
Arkansas
PURPOSE/HYPOTHESIS: Describe the motion of the radial head during forearm pronation and supination using real-time ultrasound (US) imaging
and determine the immediate effects of joint mobilization.
NUMBER OF SUBJECTS: Forty-three subjects (32 female, 11 male; mean age,
29 years) with normal upper extremity (UE) range of motion.
MATERIALS/METHODS: The experimental UE was randomly selected and assessed in full elbow extension and 90° of elbow flexion. An adjustable
height table was used to standardize positioning while the glenohumeral joint was stabilized. Subjects performed pronation and supination
from neutral synchronized to a metronome at 60 bpm. Ultrasound (US)
cineloops were recorded using a linear transducer oriented in the transverse plane over the radial head. Subjects were then randomized to receive an anterior or posterior radial head mobilization the rate of which
was standardized at 2 Hz (120 bpm) with a metronome. Range of motion
(ROM) measurements were taken premobilization and postmobilization.
RESULTS: US showed the radial head rolled in an anteromedial direction during pronation and a posterolateral direction during supination. No translation was evident on US imaging in the transverse plane.
Multivariate analysis revealed significant interaction effects (P = .02;
power, 0.66) between direction of mobilization and ROM and elbow position and ROM (P = .03; power, 0.60). Post hoc ROM analysis revealed
anterior mobilization significantly increased passive pronation (P = .040)
while significantly decreasing active supination (P = .045) when assessed
in full extension but significantly increased active supination (P = .037)
when assessed in 90° of flexion. Posterior mobilization significantly increased ROM for active supination (P = .028) while significantly decreasing passive pronation (P = .044) in 90° of flexion.
CONCLUSIONS: Studies have reported translatory motion of the radius that
contrasts with that opined by the convex-concave rule which therapists
frequently use to determine the direction of joint mobilization. Our findings appear to support previous findings which question the application
of the convex-concave rule, albeit we did not note any translation which
may be a consequence of imaging in 1 plane and the magnitude of translation. Neumann has postulated that the rule is not flawed but misinterpreted as it was not intended for use to enhance joint motion but merely
to describe physiological joint motion. The motion in pathological joints
by definition may be different. Should we now reconsider application of
the convex-concave rule as a means of improving joint motion or just mobilize based on where the restrictions are?
CLINICAL RELEVANCE: Elbow trauma often leads to deficits in PRUJ motion
which can be difficult to treat given the complexity of the joints involved.
This study is in agreement with others which have reported inconsistencies which are paradoxical to the convex-concave rule. Further study is
required to determine if current mobilizations are efficacious and if the
technique should be changed given recent findings.
OPO142
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Antonio, San Antonio, Texas
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PURPOSE/HYPOTHESIS: Prior studies have shown new digital technologies
are effective in significantly measuring and improving spinal posture
when individuals have worn accelerometer/gyroscope sensors with realtime biofeedback that measure changes in lumbopelvic angle [1-3]. The
purpose of this study was to determine if a lumbar sensor-based accelerometer and gyroscope technology (LUMOback), when combined with
posture education could effectively modify seated lumbar postural behavior during prolonged sitting.
NUMBER OF SUBJECTS: Seventeen health science students were randomly assigned into 4 test groups.
MATERIALS/METHODS: Test groups consisted of: (1) Control Group
(2) LUMOback Visual Feedback Group with posture education (3)
LUMOback Vibration Biofeedback Group with posture education (4)
LUMOback Visual and Vibration Biofeedback Group with posture education. All subjects attended a pre and post photographic postural evaluation, answered a postural/device questionnaire, and wore the LUMOback
sensor in a seated posture for 8 (±18 minutes) hours a week for 4 weeks.
Postural score (PS) data representing the percent of time maintained in
neutral lumbopelvic was collected. Data analysis: nonparametric tests
were utilized to determine if there were differences between mean PSs
and if experimental groups demonstrated better mean PSs than the control group.
RESULTS: All 3 experimental groups had different average daily PSs when
compared to controls. The Visual/Vibration group demonstrated the
highest postural scores on a daily basis when compared to the Control,
Visual, and Vibration groups. Intragroup comparisons of PSs from the
first and last day of testing for all 4 groups showed a significant improvement in mean PSs. On the first and last day of testing, all 3 test groups
had significantly higher mean posture scores than controls. The Visual/
Vibration had the highest final mean PSs (99.2). Additionally, Visual/
Vibration PSs were found to be significantly greater than the PSs of both
Visual and Vibration groups, while Vibration PSs were also significantly
higher than Visual group PSs.
CONCLUSIONS: The results of the study indicate the LUMOback sensor was an
effective electronic behavior modification tool for changing seated posture
in health science students while they were donning the device. The posture
survey indicated that all experimental and control subjects perceived the
quality of their posture had improved over the course of the study.
CLINICAL RELEVANCE: An accelerometer/gyroscope with real-time biofeedback and postural education could be utilized by individuals who are required to maintain a seated posture for prolonged periods of time to improve seated posture. Theoretically, this can improve recall and learning
[4]. This type of technology could also assist clinicians to maintain an optimal seated posture while performing clinical duties, thereby improving
patient perceptions [5]. Finally, the LUMOback could be an effective tool
used to monitor patient performance of therapeutic activities and exercises in a neutral lumbopelvic posture.
OPO143
THE ASSOCIATION OF THE FUNCTIONAL MOVEMENT SCREEN
AND SINGLE-LEG HOP TESTS WITH MUSCULOSKELETAL INJURY
IN FIREFIGHTER RECRUITS
Cory Manton, Benjamin Erbe, Jennifer S. Iyo,
Katherine Randau, Levi Street
Physical Therapy, A.T. Still University, Scottsdale, Arizona
PURPOSE/HYPOTHESIS: The purpose of this study was to determine if the
Functional Movement Screen (FMS) total score of 14 or less and/or single-leg hop tests were associated with musculoskeletal injury in firefighter recruits. It was hypothesized that both an FMS total score of 14 or less
and lower single-leg hop test scores would be associated with musculoskeletal injury in firefighter recruits.
NUMBER OF SUBJECTS: Data from 60 firefighter recruits (59 male) were analyzed for this study.
MATERIALS/METHODS: A retrospective chart review was performed to determine the relationship between the FMS total score and musculoskeletal injury, and single-leg hop tests and musculoskeletal injury. All recruits
were scored on the FMS at the beginning of a fire academy. All recruits
completed 4 single-leg hop tests at the beginning of the fire academy:
single-leg hop test, triple hop test, crossover hop test, and 6-m hop test.
The criterion used to define musculoskeletal injury was that the recruit
was referred to occupational health during the fire academy. Descriptive
statistics were calculated for the sample and for the FMS and single-leg
hop tests data. To determine if there was a significant difference between
the FMS total score of injured recruits and uninjured recruits a MannWhitney U test was performed. A crosstabulation table was used to calculate the relative risk of injury with a FMS total score of 14 or less. The
Mann-Whitney U test was used to identify significant differences between
injured and uninjured recruit single-leg hop test scores.
RESULTS: Fifteen percent of the recruits (n = 60) had a musculoskeletal injury during the fire academy. There was not a significant difference between injured recruit and uninjured recruits for the FMS total score or
the single-leg hop tests. The incidence of injury among recruits with a
FMS total score of 14 or less. The incidence of injury among recruits with
a FMS total score greater than 14 was 15%. The relative risk for musculoskeletal injury with an FMS score of 14 or less was 0.81. The P value
(.83) associated with the relative risk indicates that the 2 groups were
not different.
CONCLUSIONS: There was not a significant difference between the FMS total scores of injured and uninjured recruits. The mean FMS total score
for all recruits indicates that most recruits were able to complete the FMS
with minimal or no compensations. There was not a significant difference between the single-leg hop test scores of injured and uninjured recruits. The crossover hop for distance test displayed the largest difference
in scores between the injured and uninjured results.
CLINICAL RELEVANCE: The FMS total score and single-leg hop tests were not
associated with musculoskeletal injury during a fire academy.
OPO144
RELATION BETWEEN RANGE OF MOTION AND PHYSICAL ACTIVITY WHILE
RECOVERING AFTER TOTAL KNEE REPLACEMENT
Hiral Master, Louise M. Thoma, Oliver Yost,
Meredith B. Christiansen, Ryan Green, Laura A. A. Schmitt,
Daniel White
Physical Therapy and BIOMS, University of Delaware, Newark,
Delaware
PURPOSE/HYPOTHESIS: Standard postoperative physical therapy (PT) for
total knee replacement (TKR) aims to increase knee range of motion
(ROM), which is important for walking and adopting an active lifestyle,
eg, taking more steps/day, after TKR [1-3]. However, it is unclear to what
extent limited ROM may be a barrier to physical activity after TKR. This
is important to study since ROM is a modifiable impairment that can be
prioritized in PT after TKR. The purpose of this study was to evaluate the
association of ROM with physical activity over the first 6 weeks of PT after TKR.
NUMBER OF SUBJECTS: We recruited 26 patients with a first time unilateral
TKR from a local PT clinic. We excluded people with comorbidity that affected physical function other than arthritis.
MATERIALS/METHODS: We quantified physical activity as steps/day using
an accelerometer enabled monitor (Actigraph GT3X) worn for at least 3
days during waking hours. Knee ROM was measured by a physical therapist using a standardized approach. We classified lacking greater than
5° of full knee extension as limited extension and knee flexion less than
95° as limited flexion [4]. We examined the difference in steps/day between those with and without limited knee ROM with physical activity
each week of PT (weeks 1 to 6) using difference tests and 95% confidence
intervals (CIs).
RESULTS: We included 26 people after TKR (mean ± SD age, 64.9 ± 9.1
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years; BMI, 34.5 ± 7.5 kg/m2; 56% female) at baseline. Participants
walked 1889 ± 1467 steps/d at week 1, and 3474 ± 2277 step/d at week 6.
In general, there was little difference in steps/day between those with and
without limited ROM. For instance, there was a nonstatistically significant difference in steps per day between those with limited extension (n
= 20) compared with those without (n = 6) (776 steps/d; 95% CI: –2185,
633.26). In a similar fashion, there was little difference among those with
limited flexion (n = 7) compared with those without (538 steps/d; 95% CI:
–818, 1894). A small difference was observed at week 6 for extension. No
participants had limited flexion after week 3.
CONCLUSIONS: Our preliminary findings show little difference in physical
activity among people with and without ROM limitations after TKR.
CLINICAL RELEVANCE: Clinically significant limited ROM may not be a major barrier to physical activity after TKR. Directing PT interventions to
areas other than ROM are important to consider after TKR to increase
physical activity.
OPO145
PHYSICAL THERAPY UTILIZATION FOLLOWING AN EMERGENCY
DEPARTMENT CONSULTATION FOR LOW BACK PAIN
Lloyd Mayer, Dave Larson, Tasha Olsen, Andrew Bernstetter,
Lee Skinner, John S. Magel
University Orthopaedic Hospital, Department of Physical Therapy,
University of Utah, Salt Lake City, Utah
PURPOSE/HYPOTHESIS: The health care pathways through which patients
with LBP access and receive care are variable [1,2]. The timing of physical
therapy (PT) after accessing health care may influence health care utilization and costs [3,4]. The emergency department is a health care access
point for many patients with LBP [5]. Little is known, however, regarding subsequent health care utilization. The purpose of this study was to
evaluate the utilization and timing PT services following a new consultation to the ED for LBP and to describe the efforts to improve PT access.
NUMBER OF SUBJECTS: One thousand four hundred fifty-three.
MATERIALS/METHODS: This was a retrospective cohort study of patients who
accessed the University of Utah Emergency Department for LBP between
January 1, 2013 through December 31, 2014. Subjects were included if
they had a new consultation to the ED with an associated LBP-related
ICD-9 code and had no claims with a LBP-related ICD-9 and ICD-10
code for any service or provider in the preceding 90 days. We defined the
date of the ED visit as the index visit. Participants were excluded if they
had any red flag (fracture, cauda equine syndrome, infection, etc), neurologic condition (stroke, Parkinson’s disease) or spinal cord injury at the
time of the index visit. Health care utilization was recorded during the
1-to-14- and 15-to-90-day period following the index visit.
RESULTS: The average ± SD age of our cohort was 59.4 ± 18.3 years) and
was 50.3% female. Two hundred thirty-eight patients had LBP-related
health care services in the 1-to-14-day period following the index visit and
0 (0%) accessed PT. Seven hundred fifty-one patients (51.6%) had a LBPrelated consultation to a provider for the first time in the 15-to-90-day period following the index visit, 11 (0.01%) of which were for PT. An effort to
improve PT access has been initiated. ED and PT providers have teamed
to implement a physical therapy pathway. Technicians have modified the
electronic medical record to assist ED providers in initiating an immediate referral to PT. Physical therapy access is currently being tracked.
CONCLUSIONS: Physical therapy services following a new consultation to
the ED for LBP are underutilized. Quality improvement efforts may to
improve future physical therapy access to these patients.
CLINICAL RELEVANCE: Delaying physical therapy services to patients following a consultation to the ED for LBP may be suboptimal care.
OPO146
MUSCULOSKELETAL INJURIES IN PROFESSIONAL MODERN DANCERS:
A 15-YEAR PROSPECTIVE COHORT STUDY
Caroline D. McBride, Shaw Bronner, Allison Gill
ADAM Center, New York, New York; Callan-Harris Physical
Therapy, PC, Rochester, New York; Exchange Place Physical
Therapy Group, Jersey City, New Jersey
PURPOSE/HYPOTHESIS: In-house physical therapy management of work-re-
lated musculoskeletal injuries (WMSI) in a professional dance organization demonstrated decreased new time-loss injuries (TLinj) in dancers
over a 6-year period. The objectives of this study were to identify injury
patterns and determine changes in injury rates over 15 years.
NUMBER OF SUBJECTS: Forty-two professional modern dancers: 30 senior
(Sr) and 12 junior (Jr) company dancers (male-female ratio = 1:1; mean
± SD age, 26 ± 5 years).
MATERIALS/METHODS: Due to annual turnover in both companies, 158 dancers participated in this study. Prospective cohort data were obtained over
a 15-year time period, tracking new WMSI, TLinj, diagnoses, and exposure hours. Injury data were excluded from analysis if sustained outside of working hours, or defined as re-injury if occurring within 8 weeks
of original diagnosis. The 15 years were divided into 5 3-year blocks for
comparison. Injuries occurring during each Block were converted to
injuries/1000-h dance exposure to allow comparisons. Quasi-Poisson
analysis was used to correct for over-dispersion of the data, P<.05.
Exposure hours were converted to the natural log and used as the offset
variable. Block (B), company (Sr versus Jr), sex, and years of professional
dance experience were categorical predictors for the dependent variables:
WMSI, TLinj, traumatic and overuse injury.
RESULTS: One hundred eight of 158 dancers (68%) reported WMSI. Of
these, 74 (47%) sustained at least 1 TLinj. Average annual dance exposure was greater in Sr dancers (157 performances and 40 weeks/years)
compared to the Jr company (76 performances and 33 wk/y; P<.01). Sr
dancers were 1.5 times more likely to sustain TLinj (Incident rate ratio [IRR] = 1.548, P = .030); and twice as likely to sustain overuse injuries (IRR = 2.154, P = .001) compared to Jr dancers. TLinj averaged 0.16
injuries/1000-h exposure over the 15 years. The overall ratio of trauma to
overuse injuries was 64:36 for TLinj. Blocks B2, B3 and B5 demonstrated decreased TLinj/1000-h compared to B1 when the program was initiated, P≤.008. There were no differences due to sex or experience. Lower
extremity injuries occurred most frequently (greater than 62% of total).
CONCLUSIONS: Injury rates in Sr dancers exceeded those of Jr dancers, reflecting differences in hours of exposure between companies. Block 4, despite an increase in TLinj (0.23/1000-h), remained lower than those reported in ballet companies with in-house management programs. Lower
extremity injury patterns were consistent with prior reports. Reports of
professional dance injuries/1000-h exposure are lower than those reported for sports such as gymnastics, soccer, and running. This is the longest study to date supporting the effectiveness of in-house comprehensive management.
CLINICAL RELEVANCE: Periodic re-examination of an in-house physical therapy program is important to determine whether it continues to be effective in preventing and minimizing injury.
OPO147
UTILIZATION OF A PAIN MECHANISM CLASSIFICATION TOOL
IN CLINICAL PRACTICE
Janna M. McGaugh, Memrie D. Ferguson
Department of Physical Therapy, University of Texas Medical
Branch, Galveston, Texas
PURPOSE/HYPOTHESIS: The success of a classification system is based on
its ability to guide assessment and facilitate the selection of appropriate
treatment interventions. The accurate classification of pain type should
enable the clinician to select interventions hypothesized to target the specific mechanisms involved in pain signal generation and maintenance.
Current evidence suggests there are 3 clinically meaningful categories for
musculoskeletal pain: nociceptive pain (NP), peripheral neuropathic pain
(PNP), and central sensitization (CS). The purpose of this pilot study was
to investigate the utilization of a Pain Classification Tool (PCT) in deter-
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mining pain type in an outpatient clinical practice setting.
NUMBER OF SUBJECTS: Two licensed physical therapists utilized the PCT to
assist in the identification of pain type in 228 patients who were referred
to an outpatient orthopaedic physical therapy clinic with complaints of
musculoskeletal pain.
MATERIALS/METHODS: The PCT included 32 criteria that defined symptom
nature, duration, behavior, and severity in addition to physical signs and
patient beliefs. The criteria were divided into 1 of 3 categories (NP, PNP,
CS) based on best evidence and the current understanding of neurophysiology. The criteria were designed as a checklist. There were 8 criteria suggestive of NP, 5 criteria suggestive of PNP, and 9 criteria suggestive of CS.
After completing the patient examination, the therapist would utilize the
PCT to determine the patient’s primary pain classification indicating the
corresponding criteria present.
RESULTS: Utilizing the PCT, 157 patients were identified as NP (69%). An
average of 4.5 criteria were identified as present with the most common
being positive pain provocation testing, aggravation of pain symptoms
with movement or loading, localized pain presentation pattern, and the
absence of neurogenic descriptors. A total of 57 patients were identified
as PNP (25%). An average of 3.3 criteria were identified as present with
the most common being positive neural tension testing and the presence
of neurogenic pain descriptors. A total of 14 patients were identified as
CS (6%). An average of 7.7 criteria were identified as present with the
most common being greater than 3 months in duration of symptoms, report of decreased quality of life, and qualifying scores on selected pain
questionnaires.
CONCLUSIONS: This pilot study provides support for the use of the PCT in
clinical practice to guide classification of pain mechanisms. There was not
a case in which all criteria were present nor was there a specific criterion
present in all cases for the NP or PNP classifications. These findings suggest variability in pain reports and patient presentation indicating a classification tool could be helpful to guide decision making. Further research
is needed to determine the construct and criterion validity of the PCT.
CLINICAL RELEVANCE: Utilization of a PCT may assist in the diagnosis of
musculoskeletal pain syndromes, improve intervention selection, facilitate patient centered plan of care development, and ultimately improve
patient outcomes.
OPO148
LENGTH CHANGE OF THE HIP EXTERNAL ROTATORS IN COMMON
STRETCH POSITIONS
Ryan P. McGovern, RobRoy L. Martin, Benjamin R. Kivlan
Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania
PURPOSE/HYPOTHESIS: The objective of this study was to evaluate length
change of the piriformis, superior gemellus, obturator internus, and inferior gemellus during several commonly used stretch positions.
NUMBER OF SUBJECTS: Nine cadavers.
MATERIALS/METHODS: Seventeen hip joints from 9 embalmed cadavers (5
male, 4 female) aged between 49 and 96 years were skeletonized, leaving
only the short external rotators and joint capsule intact. Polypropylene
strings were attached from the origin to insertion sites of the superior
(SP) and inferior fibers (IP) of the Piriformis, Superior Gemellus (SG),
Obturator Internus (OI), and Inferior Gemellus (IG) to represent the
musculotendinous fibers of the short external rotators of the hip. The
change of length (mm) noted by excursion of the strings when moved
from the anatomical position to 4 specific stretch positions: (1) 45° internal rotation from neutral flexion/extension, (2) 45° external rotation with
90° hip and knee flexion, (3) 30° adduction from 90° of hip and knee flexion, and (4) 30°of adduction with the limb positioned in hip and flexion
with the lateral malleolus in contact with lateral femoral epicondyle of
the contralateral limb (aka, supine piriformis stretch) were recorded. A
MANOVA with post hoc analysis determined the effect of the stretch position on the change of length of each muscle.
RESULTS: There was a significant effect on length change based on the
stretch position, F15,166 = 14.67, P<.0005, Wilk’s λ = 0.097, partial η2 =
0.540. The greatest length change for the SP (30.7 ± 10.2 mm) and IP
(23.7 ± 7.8 mm) as well as the SG (20.8 ± 5.4 mm) occurred when positioned in 30° adduction from 90° of hip and knee flexion followed by 45°
internal rotation from neutral flexion/extension (SP: 22.2 ± 5.9 mm; IP:
20.6 ± 5.3 mm; SG: 17.4 ± 3.0 mm) and 45° external rotation with 90°
hip and knee flexion (SP: 19.4 ± 10.2 mm; IP: 10.4 ± 7.8 mm; SG: 9.4 ±
7.0 mm). The OI (18.2 ± 7.7 mm) and IG (15.5 ± 3.3 mm) had the greatest
length change with 45° internal rotation from neutral flexion/extension
followed closely by 30° adduction from 90° of hip and knee flexion (OI:
17.1 ± 6.0 mm; IG: 14.7 ± 7.2 mm). The supine piriformis stretch caused
the least amount of length change for any of the muscles, (P<.05).
CONCLUSIONS: While all stretch positions caused a length change for the
deep rotators of the hip, the 3 stretch positions that caused the greatest
change were: (1) 30° adduction from 90° of hip and knee flexion, (2) 45°
internal rotation from neutral flexion/extension, and (3) 45° external rotation with 90° hip and knee flexion.
CLINICAL RELEVANCE: Clinicians may apply the results of this study to select
positions to effectively stretch the deep rotators of the hip. The piriformis
and superior gemellus had a larger change in length when adducting the
hip from 90° of hip and knee flexion. The obturator internus and inferior gemellus had a greater length change when internally rotating the hip
from neutral flexion/extension.
OPO149
THE ACCURACY OF 3 CLINICAL TESTS IN DIAGNOSING PROXIMAL
HAMSTRING PATHOLOGY
Ryan P. McGovern, RobRoy L. Martin, Ricardo G. Schroder,
Hal D. Martin
Hip Preservation Center, Baylor University Medical Center, Dallas,
Texas; RSHS Graduate Program, Duquesne University, Pittsburgh,
Pennsylvania; Physical Therapy, Duquesne University, Pittsburgh,
Pennsylvania
PURPOSE/HYPOTHESIS: Studies are needed to investigate the clinical usefulness of tests for individuals with nonarthritic hip pain. The purpose of
this study was to define the diagnostic accuracy of 3 tests in identifying
individuals with proximal hamstring pathology.
NUMBER OF SUBJECTS: Forty subjects (30 female, 10 male).
MATERIALS/METHODS: Clinical records of individuals who underwent a
physical examination, magnetic resonance imaging (MRI) and injection
testing of the hip region due to posterior hip pain were retrospectively reviewed. A routine clinical examination was performed on each subject
that included the active hamstring tests at 30° and 90°as well as noting
pain at heel strike during gait. Sensitivity, specificity, positive likelihood
ratio, negative likelihood ratio, and diagnostic odds ratio were calculated for each test.
RESULTS: Subjects had a mean ± SD age of 48 ± 16.7 years (range, 15-71
years) and reported a mean ± SD symptom duration of 39 ± 39.3 days
(range, 3-120 days). Using MRI imaging and injection testing as the gold
standard, 26 out 40 (65%) were diagnosed and treated for proximal hamstring pathology. The sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio for the active hamstring
test at 30° knee flexion were 0.72, 0.97, 21.7, 0.29, and 75.4, respectively. For the active hamstring test at 90° flexion, sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values were 0.61, 0.97, 18.3, 0.40, and 45.6, respectively. For walking
heel strike pain, sensitivity, specificity, positive likelihood ratio, negative
likelihood ratio, and diagnostic odds ratio values were 0.54, 0.71, 1.88,
0.65, and 2.92, respectively. The most accurate findings were obtained
when the results of the active hamstring tests at 30° and 90° were combined with sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio values of 0.83, 0.97, 25, 0.17, and
145, respectively.
CONCLUSIONS: The active hamstring tests at 30° and 90° of knee flexion
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were valuable in diagnosing hamstring pathologies, while heel strike pain
during gait was not useful.
CLINICAL RELEVANCE: The active hamstring test should be performed at
both 30° and 90° of knee flexion to be most accurate in identifying those
with and without proximal hip pathology.
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OPO150
THE RELATIONSHIP BETWEEN CLINICALLY OBSERVED ABERRANT MOTION
AND GLUTEAL STRENGTH IN YOUNG PATIENTS PRESENTING TO PHYSICAL
THERAPY WITH LOW BACK PAIN
Claire McKeone, Mark V. Paterno
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
PURPOSE/HYPOTHESIS: The pathomechanical behavior of spinal instability
is ambiguous and poorly defined. In order to fully understand the change
in movement patterns physical therapists need to be able to define the
mechanism driving the altered movement. Gluteal muscle inhibition is
often present in people with low back pain, most obviously in the return
from flexion. This study was designed to determine if there is a clinically significant relationship between gluteal strength and aberrant motion
in patients with low back pain. The tested hypothesis was the presence of
impaired gluteus maximus strength would be positively correlated to the
presence of aberrant motion. This hypothesis was investigated using retrospective data from the initial evaluations of patient with the diagnosis of low back pain from hospital based outpatient orthopaedic physical
therapy clinic from April 2015 through March 2016.
NUMBER OF SUBJECTS: One hundred twelve patients.
MATERIALS/METHODS: Using the OT/PT/TR Divisional Patient Registry,
evaluation data were pulled for patients seen between April 2015 and
March 2016 for a spine evaluation. The data were sorted to determine
which patients had values entered for both presence of aberrant motion
and a MMT grade for gluteus maximus strength. There were 112 patients
(mean ± SD age, 16.1 ± 5.0 years) who met this criteria. For the purpose
of this study patients’ who had “Within Functional Limits” or “Within
Normal Limits” recorded for their strength values were not included. In
addition for this study painful arc of movement was not considered aberrant motion. Chi-square analysis was used to determine the association
between gluteal muscle strength and the presence of aberrant motion.
RESULTS: Twenty of 112 patients presented with 5/5 strength of which,
80% (16/20) had aberrant motion. 72/112 patients had 4/5 strength,
82% (59/72) presented with aberrant motion. 20/112 patients had 3/5
strength, 85% (17/20) had aberrant motion. Chi-square analysis suggested no significant difference in the proportion of patients who present with
aberrant motion within each with gluteal muscle strength classification
(3, 4 or 5). Approximately 80% to 85% of all patients with LBP presented
with aberrant motion, regardless of glut max strength.
CONCLUSIONS: These finding support the null hypothesis that there is no
evident correlation between gluteus maximus strength and aberrant motion. Further investigation is needed to determine if there is an objective
measure that correlates with the presence of aberrant motion.
CLINICAL RELEVANCE: There is lack of valid assessments for instability and
the clinical prediction rule for lumbar instability has questionable validity in this population. Further research needs to be done to determine
the underlying factors that influence aberrant motion. Though gluteal
strength is impaired in the low back pain population it does not appear to
have a clinically significant relationship to aberrant motion.
OPO151
MORE THAN KNEE PAIN: FEMALES WITH CHRONIC PATELLOFEMORAL PAIN
DEMONSTRATE ALTERED PSYCHOSOCIAL RESPONSES
Rachelle McKinley, Kaley Robertson, Paul Kline,
Brian Noehren
Department of Rehabilitation Sciences, University of Kentucky,
Lexington, Kentucky; Division of Physical Therapy, University of
Kentucky, Lexington, Kentucky
PURPOSE/HYPOTHESIS: Patellofemoral pain (PFP) is a common orthopae-
dic condition that frequently becomes chronic in females. In other chronic pain conditions, reports of depression and feelings of hopelessness are
reported which may reduce the efficacy of standard therapeutic exercise
programs. Despite the chronic nature of PFP, treatment does not account
for potential alterations in psychosocial factors, potentially limiting the
effectiveness of treatment. In order to better understand the condition
and begin improving treatment we sought to define the differences in reports of depression, kinesiophobia, pain catastrophizing, sleep quality,
and level of fatigue between females with chronic PFP and control subjects. We hypothesized that females with chronic PFP would report significantly higher incidences of depression, kinesiophobia, pain catastrophizing, poor sleep, and fatigue on self-reported outcome measures when
compared to a control group.
NUMBER OF SUBJECTS: Twenty-seven females with PFP (mean ± SD age,
25.8 ± 6.9 years; height, 1.67 ± 0.07 m; mass, 67.64 ± 10.26 kg) and 17
controls (age, 25.8 ± 6.8 years; height, 1.62 ± 0.07 m; mass, 58.25 ± 8.25
kg) were collected. For inclusion in the study, all subjects in the PFP
group were required to have symptoms for at least 3 months.
MATERIALS/METHODS: Participants completed the following self-reported outcome scales: the Tampa Scale of Kinesiophobia (TSK), the Pain
Catastrophizing Scale (PCS), the Fatigue Severity Scale (FSS), the Pain
Self Efficacy Scale (PSEQ), and the Pittsburgh Sleep Quality Index
(PSQI). Additionally, the participants completed a questionnaire about
their PFP history, including the primary location of pain, frequency, and
duration of symptoms, and a questionnaire about their history of depression/hopelessness. Independent 2-sample t tests were used to compare
between groups.
RESULTS: We found significant differences in the following scales: PSQI
(PFP, 8.3 ± 3.7; CON, 5.5 ± 2.3; P = .003), TSK (PFP, 38.3 ± 7.3; CON,
27.1 ± 6.1; P = .00003), PCS (PFP, 9.2 ± 9.8; CON, 0.3 ± 1.4; P = .0008),
FSS (PFP, 31.5 ± 11.7; CON, 18.8 ± 9.1; P = .0004), and PSEQ (PFP, 51.4 ±
8.6; CON, 59 ± 2.7; P = .001). Within the PFP group, 37% reported experiencing depression compared to 11% of the control group.
CONCLUSIONS: Females with chronic PFP reported experiencing poorer
sleep, increased fatigue, higher kinesiophobia, increased pain catastrophization, and increased incidence of depression and feelings of hopelessness compared to the control group. The presence of chronic PFP appears to impact multiple psychosocial constructs, which may impair the
efficacy of current treatment for PFP which is predominantly driven by
therapeutic exercises.
CLINICAL RELEVANCE: The results suggest that females with chronic PFP are
more likely to be depressed, sleep poorly, and have a greater fear of moving than controls. Physical therapists should consider the impact of this
psychological profile on the patient’s presentation and adjust their treatment plans to include patient education and interventions to reduce fear
of movement, depression, and pain catastrophization.
OPO152
WHAT IS THE BEST TIME TO USE THE START BACK TO PREDICT CLINICAL
OUTCOMES IN PATIENTS WITH CHRONIC LOW BACK PAIN WHO RECEIVE
PHYSICAL THERAPY?
Flavia Medeiros, Leonardo O. Costa, Marco Aurélio N. Added,
Evelyn Salomao, Luciola M. Costa
Masters and Doctoral Programs in Physical Therapy, Universidade
Cidade de São Paulo, São Paulo, Brazil
PURPOSE/HYPOTHESIS: The STarT (Subgroups Target Treatment) Back
Screening Tool (SBST) is used to classify patients with low back pain
into 3 risk categories of having a poor prognosis. However, this classification may change over time. In addition, baseline classification does
not take into account variables that can influence the prognosis during
treatment or over time. This study was designed to investigate what is
the best time to using the SBST to predict clinical outcomes. Specifically,
we investigated (1) the changes in the risk classification measured by the
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SBST over a period of 6 months and (2) the long-term predictive ability
of the SBST when applied at different time points in Brazilian patients
with chronic low back pain who have received a standardized physical
therapy treatment.
NUMBER OF SUBJECTS: One hundred forty-eight.
MATERIALS/METHODS: This is a 6-month prospective cohort study nested
into an existing randomised controlled trial. Were included patients with
chronic nonspecific low back pain, of both sexes, aged between 18 and
80 years and who were seeking physical therapy treatment. Clinical outcomes of pain intensity, disability and global perceived effect as well as
SBST were collected at baseline, after 5 weeks, 3 and 6 months. All patients received 10 sessions of physiotherapy based on general and specific exercises for low back pain and manual therapy. Three categories
were created to evaluate the changes in the SBST subgroups, following
the same categorization proposed by Beneciuk (improved, worsened, stable). Changes in SBST subgroups were calculated using descriptive statistics. Linear regression models were built to analyze the predictive ability
of SBST when applied at different points of time.
RESULTS: After receiving good quality physiotherapy care, 60.8% changed
their risk classification (54.7% improved the risk). The subgroup with the
highest percentage of change (75%) was the medium risk. The SBST improved the prediction of disability, pain intensity and global perceived effect at 5 weeks, 3 months and changes from 5 weeks to baseline, after controlling for potential confounders (sex, age, duration of symptoms and the
total score of the outcome at baseline). The SBST at baseline did not improve the predictive ability of the models after adjusting for confounding.
CONCLUSIONS: This study confirms partially the findings from Beneciuk et
al 2014 showing that many patients change their risk subgroup after received physiotherapy care. The predictive ability of the SBST in patients
with chronic low back pain increases when applied in different time
points, especially after treatment and after 3 months.
CLINICAL RELEVANCE: Our results show the utility of the SBST for predicting
the prognosis of patients who seek physical therapy treatment. Although
the SBST at baseline does not add predictive information when controlled
for confounding, the SBST is useful when applied after treatment.
OPO153
MEASURING LUMBAR MOBILIZATION WITH INERTIAL MEASUREMENT UNIT
Fahed Mehyar, Sara Wilson, Vincent S. Staggs, Kosaku Aoyagi,
Neena K. Sharma
Physical Therapy and Rehabilitation Science, University of Kansas
Medical Center, Kansas City, Kansas; Mechanical Engineering,
University of Kansas, Lawrence, Kansas; Health Services and
Outcomes Research, Children’s Mercy Hospitals and Clinics, and
School of Medicine, University of Missouri, Kansas City, Missouri
PURPOSE/HYPOTHESIS: Lumbar mobilization is a standard assessment and
treatment method. However, there is inconsistency in the amount of forces applied by clinicians during the mobilization. Optical motion capture
systems and force measuring devices (eg, force plates) have been used in
research laboratories to measure the movements and forces of mobilization. However, these devices are not available in clinical practice. A practical and indirect method of measuring mobilization in clinical practice
is to measure the therapist’s hand motion during mobilization. Inertial
Measurement Unit (IMU) is a small and inexpensive device that can be
used to measure the oscillatory movements (amplitude) of the therapist’s
hand during mobilization. IMU consists of an accelerometer and gyroscope that allows for measurement of acceleration and angular velocity. The amplitude of the therapist’s hand displacement can be calculated from the acceleration and angular velocity using integration methods
and geometric equations. This study investigates the validity and reliability of IMU in measuring the amplitude (oscillation) of the therapist’s hand
movement during lumbar mobilization.
NUMBER OF SUBJECTS: Sixteen healthy subjects with no low back pain for
the last 6 months.
MATERIALS/METHODS: The subjects attended 2 sessions that were 2 to 3
days apart. In each session, 2 therapists (1 experienced and 1 novice) used
pisiform grip to apply central lumbar mobilization to the fourth lumber
vertebrae (L4) of the subject’s spine. The therapists fixed the IMU and 1
Optoptrak marker on their bottom hand, and stood on a force plate to apply the mobilization at a constant maximum force of 200 N with 4 different amplitudes (30, 60, 90, and 120 N). The LabVIEW program was used
to provide live visual feedback to the therapists about the amount of mobilization forces. The validity of IMU was tested by comparing the measurements of IMU to the standard measures of mobilization (force plate
and Optotrak motion capture system). The reliability of IMU was tested in term of agreement of the IMU measurements between the 2 therapists (interrater reliability) and between 2 sessions (intrarater reliability).
RESULTS: Results show that the measurements of IMU had high correlation with force plate (Spearman rho >0.90) and high agreement with
the Optotrak (percent measurement error, percentage less than 15%).
Furthermore, there was high agreement between the IMU measurements
between sessions and therapists (both percents less than or equal to 5%).
CONCLUSIONS: We show that IMU is a valid and a reliable device to measure the amplitude of the therapist’s hand movement during lumbar
mobilization.
CLINICAL RELEVANCE: IMU is portable and inexpensive device that can be used
in the clinic. The use of IMU may increase consistency in applying mobilization and ultimately improve patient outcomes. Furthermore, the mobilization measures from IMU can be used in future to give feedback to physical therapy students while they are learning and practicing mobilization.
OPO154
IS ANKLE TAPING AN APPROPRIATE INTERVENTION FOR PREVENTING
LATERAL ANKLE SPRAINS? A SYSTEMATIC REVIEW
Alicia B. Messer, Tarang K. Jain
Physical Therapy and Athletic Training, Northern Arizona
University, Flagstaff, Arizona
PURPOSE/HYPOTHESIS: The ankle joint is one of the most injured joints in
people participating in sports, representing up to 45% of all sports injuries and accounting for the most musculoskeletal injuries seen in the
emergency department [1,2,3]. Approximately 85% of these ankle injuries are due to an inversion injury involving lateral ligament damage [4].
It is estimated that half of the general population sustains at least 1 ankle sprain during their life and as many as 55% of them do not seek injury treatment from a health care professional [5,6]. Furthermore, an initial ankle sprain leads to high rate of injury recurrence and can lead to
chronic ankle instability, causing long term disability and degeneration
[7,8]. For many years, providers have relied on ankle taping to reduce the
risk of re-injury following an initial lateral acute sprain; however, the current evidence to support the use and effectiveness of prophylactic taping
is unclear. The purpose of this systematic review was to evaluate the current evidence on the use of prophylactic taping use for reducing the risk
of acute and recurrent lateral ankle sprains.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: To conduct this systematic review, we used the basic search index using the combination of keywords “Taping” and “Ankle
sprain” and restricted MeSH terminology to MeSH major topics, including functional ankle instability, chronic ankle instability, biomechanics, kinematics, and injury as subheadings. PubMed, MEDLINE and
Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched for studies that were randomized-controlled trial
(RCT), published in English language, utilized human subjects, and used
at least 1 ankle taping intervention.
RESULTS: Our initial review yielded 64 RCTs. After applying the screening criteria, 8 studies were analyzed using Sackett’s levels of evidence and
were examined for scientific rigor.
CONCLUSIONS: The results suggested that ankle taping has no significant
effect on preventing acute and recurrent ankle sprains in people with or
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without the history of ankle sprains. Ankle taping may affect the available range of motion at the ankle joint, and its effect on proprioception
is debatable. A qualitative analysis suggested all included studies met at
least 4 of 7 applied criteria with only 1 study meeting 6 of 7 criteria. Our
review found ankle bracing to be more cost-effective and beneficial than
ankle taping in reducing long-term risk of reinjury. There is a need for
more well-designed and well-controlled RCTs to evaluate the effect of ankle taping on the incidence of acute and recurrent lateral ankle sprains.
There is limited evidence to support the use of prophylactic ankle taping
for reducing the risk of lateral ankle sprains in people with or without the
history of ankle sprains.
CLINICAL RELEVANCE: Based on available evidence, health care professionals should consider using prophylactic bracing over prophylactic taping to
prevent lateral ankle sprains.
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OPO155
IMPACT OF A 24-HOUR EDUCATIONAL PROGRAM FOR CONSERVATIVE
PRIMARY CARE PRACTITIONERS ON ATTITUDES AND BELIEFS ABOUT
SPINE PAIN MANAGEMENT
Marcia A. Miller Spoto
Health Science and Physical Therapy, Nazareth College, Rochester,
New York
PURPOSE/HYPOTHESIS: There is increased recognition that health conditions represent complex interactions of biological, psychological and sociological factors. The biopsychosocial (BPS) model represents a paradigm shift in health care, superseding the biomedical framework in the
diagnosis and treatment of health conditions. Nowhere is this more important than in the management of spine pain. Many health care providers, however, including conservative providers such as physical therapists
(PTs) and chiropractors (DCs), are acculturated in the biomedical model through formal education. As conservative providers move toward assuming primary care roles for spine related problems, their orientation to
the BPS model of care is essential. The purpose of this study is to investigate the impact of a 24-hour spine pain management program on the relative orientation of conservative care providers to biomedical versus BPS
approaches to care.
NUMBER OF SUBJECTS: Participants included a total of 70 PTs and DCs attending the Excellus BC/BS spine care pathway (SCP) education program
in upstate NY.
MATERIALS/METHODS: The SCP program is evidence-based, spine management education designed to prepare PTs and DCs as primary spine practitioners. The Patient Attitudes and Beliefs Scale (PABS) was utilized to
measure the relative orientation of participants toward the biomedical
and BPS models of care. The tool was administered at the beginning of
the 4-day program, and immediately following the program. There were
2 cohorts: 50 participants completed the program in the fall of 2015, 20
participants completed the program in the spring of 2016. Simple t tests
were used to compare pre and postprogram scores on both the biomedical and BPS subscales of the PABS.
RESULTS: Combined scores for both cohorts are reported. Pre and posttest biomedical subscales were 54% and 45.2%, respectively. Pretest and
posttest BPS subscales were 57.6% and 59.9% respectively. The decrease
in biomedical scores and increase in BPS scores were statistically significant (P<.05).
CONCLUSIONS: A 4-day spine management program based upon the BPS
model of care impacts the relative orientation of health care providers toward the biomedical and BPS models of care; providers demonstrate a
shift in their orientation in favor of the BPS model of care.
CLINICAL RELEVANCE: Clinical guidelines for neck and back pain consistently support a BPS approach to patient management. Healthcare provider
attitudes and beliefs toward spine pain influence clinical decision-making, and therefore adherence to evidence-based practice. As physical therapists and other conservative providers evolve in their roles as primary
spine practitioners, it is important that their clinical behaviors are aligned
with current best practice.
OPO156
RELIABILITY OF ICD-10 CODING OF LOW BACK CONDITIONS BY PHYSICAL
THERAPISTS
Marcia A. Miller Spoto, Andrew J. Opett, John Bulawa,
Abbie Carey, Ryan Downey, Martin Hoogendijk,
Marsden E. Jamie
Health Science and Physical Therapy, Nazareth College, Rochester,
New York
PURPOSE/HYPOTHESIS: Physical therapists in contemporary practice are responsible for assigning International Classification of Disease (ICD)-10
codes to musculoskeletal conditions that fall within their scope of practice. The reliability of assigning ICD codes is important in health care for
reasons that include: appropriate categorization of health conditions for
statistical purposes, communication with third party payers, to inform
prognosis, and to direct treatment. Yet, little is known about the reliability
among physical therapists in assigning ICD-10 codes to these health conditions. As the role of the physical therapist as a primary health care provider for musculoskeletal conditions evolves, it will become increasingly
important for clinicians to assign ICD-10 codes in a consistent manner.
The purpose of the present research is to determine the interrater reliability among physical therapists in assigning ICD-10 codes to musculoskeletal conditions of the low back.
NUMBER OF SUBJECTS: Participants consisted of 12 orthopaedic certified
specialists (OCS) practitioners, with representation of all major geographic regions in the United States.
MATERIALS/METHODS: Using electronic medical records of patients treated
in Rochester, NY outpatient orthopaedic clinics, 10 Low Back Pain paper cases were created. The paper cases described both historical data,
and physical examination findings. Participants were provided a list of
relevant ICD-10 codes for lumbar spine conditions and asked to assign
the most appropriate code to each of 10 cases based on their clinical
judgment. Pairwise comparisons were determined. Interrater reliability
among participants was determined by analyzing overall percent agreement and Cohen’s kappa using SPSS with 95% confidence intervals.
RESULTS: There were a total of 660 classification judgments utilized in the
analysis of reliability. Percent agreement among raters was 28.64%; kappa
was 0.1768, which makes overall intertester reliability slight. Greater interrater agreement was found when using 4-digit codes as compared to 5-digit codes. The most frequently assigned code was M54.5 (low back pain).
CONCLUSIONS: These findings are consistent with other studies that have
demonstrated poor reliability in assigning ICD-10 codes in primary care.
Overall agreement was not much better than what may have occurred
strictly due to chance.
CLINICAL RELEVANCE: The ICD is a universal disease classification system.
There is currently limited evidence on reliability of physical therapists assigning ICD-10 codes. This study raises questions about how physical therapists and other health care providers are engaging in clinical decision
making in diagnostic classification. Future studies should explore code assignment by health care practitioners across all musculoskeletal conditions.
OPO157
THE USE OF MIRROR THERAPY AND CROSS-EDUCATION TO TREAT
CHRONIC PAIN AND WEAKNESS 9 MONTHS POSTOPERATIVE ANTERIOR
CRUCIATE LIGAMENT RECONSTRUCTION: A CASE REPORT
Chelsea A. Miller, Deanna Perchiano, Erin Podracky,
Lacey Scrima, Yvan Trinh, Marlon L. Wong
Physical Therapy, University of Miami, Miami, Florida
BACKGROUND AND PURPOSE: Traditional post-ACLR rehabilitation protocols advocate for a criterion-based progression program, which uses
milestones pertaining to strength, ROM, and functional capabilities to
determine advancement [1,2]. However, a percentage of patients experience complications following ACL surgery, such as arthrofibrosis, and do
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not respond well to these traditional rehab approaches [1,3-6]. This case
study describes the rationale and outcomes of an alternate treatment approach, using the concepts of cross-education and the mirror neuron system, for a patient with chronic pain and weakness 9 months post-ACLR.
CASE DESCRIPTION: The patient was an active 24-year-old who received
ACLR with patellar autograft 8 months after initial injury, but required
a second arthroscopic procedure to address arthrofibrosis. She received 5
months of standard rehabilitation, with continued limitations noted with
range of motion, quadriceps strength, gait mechanics, and functional mobility. Due to the poor response to a traditional protocol, the patient was
then enrolled in a mirror therapy program at 3 times a week for 8 weeks.
Five exercises were performed each session using the uninvolved limb
only. A mirror was placed between the 2 limbs, reflecting the uninvolved
limb to the space overlying the involved limb.
OUTCOMES: Biodex testing on the involved lower extremity demonstrated
improved peak isometric knee extension torque from 38.5 ft-lb to 68.2
ft-lb Isokinetic peak extension torque improved from 27.9 ft-lb to 39.9
ft-lb and total work produced from 402.1 ft-lb to 669.4 ft-lb at 300°/s.
Single-leg anterior reach increased from 48 cm to 57.2 cm and single-leg
sit to stand increasing from 20 to 30 repetitions. Limb symmetry index
of the above measures trended towards improved symmetry throughout
the study. Girth measurements remained relatively unchanged on the involved limb. The patient’s Knee injury and Osteoarthritis Outcome Score
(KOOS) gradually declined throughout the study, with changes from initial to final measurement as follows: Symptoms 46.5 to 36, Pain 72.3 to
59, ADL 96 to 88.3, Sport/recreation 60 to 45, and Quality of Life 69 to
44. Self-reported pain scores peaked during the midpoint of the study,
correlating with an increase in the patient’s activity levels at that time.
DISCUSSION: A top-down treatment approach was incorporated in this case
study, through cross-education and activation of the mirror neuron system, with goals of effecting motor control through cortical activation [710]. It is likely that this patient’s self-reported disability trended more
closely to her pain levels than her performance on strength and functional measures, explaining the decline in KOOS scores. The gains in strength
were likely due to cortical and neuromuscular adaptations since quadriceps girth was relatively unchanged. This case demonstrates the potential
utility of mirror therapy to improve strength and performance in patients
with chronic pain and weakness post-ACLR.
REFERENCES: 1. Adams D, Logerstedt DS, Hunter-Giordano A, Axe MJ,
Snyder-Mackler L. Current concepts for anterior cruciate ligament reconstruction: a criterion-based rehabilitation progression. J Orthop
Sports Phys Ther. 2012;42:601-614. 2. Myer GD, Paterno MV, Ford KR,
Quatman CE, Hewett TE. Rehabilitation after anterior cruciate ligament reconstruction: criteria-based progression through the return-tosport phase. J Orthop Sports Phys Ther. 2006;36:385-402. 3. Skutek
M, Elsner HA, Slateva K, et al. Screening for arthrofibrosis after anterior cruciate ligament reconstruction: analysis of association with human leukocyte antigen. Arthroscopy. 2004;20:469-473. 4. Lyman S,
Koulouvaris P, Sherman S, Do H, Mandl LA, Marx RG. Epidemiology
of anterior cruciate ligament reconstruction: trends, readmissions, and
subsequent knee surgery. J Bone Joint Surg Am. 2009;91:2321-2328. 5.
Mayears HO, Weig TG, Plitz W. Arthrofibrosis following ACL reconstruction--reasons and outcome. Arch Orthop Trauma Surg. 2004;124:518522. 6. Said S, Christainsen SE, Faunoe P, Lund B, Lind M. Outcome
of surgical treatment of arthrofibrosis following ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011;19:1704-1708. 7. Foell
J, Bekrater-Bodmann R, Diers M, Flor H. Mirror therapy for phantom
limb pain: brain changes and the role of body representation. Eur J Pain.
2014;18:729-739. 8. Schabrun SM, Elgueta-Cancino EL, Hodges PW.
Smudging of the motor cortex is related to the severity of low back pain.
Spine (Phila Pa 1976). 2015. 9. Schabrun SM, Jones E, Elgueta Cancino
EL, Hodges PW. Targeting chronic recurrent low back pain from the topdown and the bottom-up: a combined transcranial direct current stimulation and peripheral electrical stimulation intervention. Brain Stim.
2014;7:451-459. 10. Tsao H, Danneels LA, Hodges PW. ISSLS prize winner: smudging the motor brain in young adults with recurrent low back
pain. Spine (Phila Pa 1976). 2011;36:1721-1727.
OPO158
THE ASSOCIATION BETWEEN DEEP NECK FLEXOR ENDURANCE AND
DESKTOP COMPUTING POSTURES IN COLLEGE STUDENTS
Andi Beth Mincer, Taylor Benton, Hawley Emanuele,
Stefanie Ortiz, Molly Rush, David Bringman, Haley S. Worst
Rehabilitation Sciences, Armstrong State University, Savannah,
Georgia
PURPOSE/HYPOTHESIS: Neck pain is common during prolonged computer use, and has been associated with impaired endurance of the deep
neck flexors (DNF). This study attempted to: describe patterns of desktop computing postures; assess the relationship between DNF endurance
and these postures; compile reports of computer use from college students; and assess for a ceiling effect in the Craniocervical Flexion Test
(CCFT). Our main hypothesis was that there would be a relationship between DNF endurance and desktop computing postures.
NUMBER OF SUBJECTS: Survey data were collected and combined from 2
separate trials with 118 undergraduate and graduate student participants
with or without neck pain. In the most current of these trials, CCFT testing and video analysis of a prolonged desktop computing task was also
conducted in 53 of these (18 male, 35 female) participants.
MATERIALS/METHODS: The final phase of the CCFT (30 mmHg) was extended from 3 to 10 repetitions for each subject to allow assessment for a ceiling effect in traditional CCFT testing. Video recordings of subjects engaging in 30-minute desktop computer tasks were qualitatively assessed to
identify patterns of postures and these were analyzed with CCFT results.
During computing, subjects completed a survey of neck symptoms and
computer use. Subjects repeated a similar computer task within 1 week to
analyze for consistency. Subjects were blind to the video recording, and
researchers were blind to results of CCFT and video analysis.
RESULTS: Descriptive statistics compiled on computing habits revealed
that students use laptops far more frequently than desktops, and they use
a computer more than 7 hours daily for school, work and personal tasks.
Qualitative analysis revealed several ranked patterns of trunk and neck
postures during desktop computing. These sitting behaviors differed for
the mouse and keyboard phases of computing, but behavior during each
of these phases was very consistent across sessions. The standard CCFT
is sensitive and does not exhibit a significant ceiling effect, even in young
adults. There was no significant statistical relationship between DNF endurance and either computer use patterns or computing postures.
CONCLUSIONS: This mixed methods study is the first to categorize and rank
postures during computing. This is the first step in establishing relationships between these postures and other musculoskeletal factors, such as
DNF endurance. The results of this study demonstrate that college students exhibit certain patterns of desktop computing postures, but these
do not appear to relate to neck muscle endurance. Future analysis of laptop computing postures is warranted since students use laptop computers almost exclusively.
CLINICAL RELEVANCE: The relationship between neck pain, computer postures, and deep neck flexor endurance is still unclear but warrants further
exploration since neck pain has been correlated to both poor computer ergonomics and poor DNF endurance.
OPO159
CONSIDERATIONS FOR DRY NEEDLING THE LEVATOR
SCAPULAE/UPPER TRAPEZIUS
Ulrike H. Mitchell, Aaron W. Johnson
Exercise Sciences, Brigham Young University, Provo, Utah
PURPOSE/HYPOTHESIS: One complication associated with dry needling
(DN) is the inadvertent piercing of the pleura that holds the lungs to the
inside of the chest wall, which can lead to lung collapse. While it is com-
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monly known that the lung tissue is hidden beneath the ribs, it is less well
appreciated how far superiorly it reaches. Being able to estimate the distance from skin to the pleura and not inserting the needle any further
than that estimate might lower the chances of harming the lung tissue.
Therefore, the purpose of this study was to measure, with diagnostic ultrasound, the distance from skin to pleura at the level of levator scapulae,
with the subject in 2 different prone positions. We assessed for differences
by stratifying the subjects by body composition and sex.
NUMBER OF SUBJECTS: Thirty.
MATERIALS/METHODS: Thirty college-aged subjects were measured for
weight and height. For all ultrasound measurements the subject lay prone
on a treatment table with the arms positioned along the trunk, head nonrotated and slightly lowered. The spinous processes of T1 and T2 were
marked as were the vertebral borders and superior angles of both scapulae. With diagnostic ultrasound we visualized the levator scapulae/upper
trapezius, ribs 1 and 2 and the underlying pleura, just medial to the superior scapular angle. Two 4-second videos were taken and stored for later
analysis. This procedure was repeated on the contralateral side and in 2
different positions, with and without towel under the shoulder.
RESULTS: The average ± SD distance (right and left) from skin to the pleura at the level of levator scapulae/upper trapezius was 4.1 ± 0.8 cm without towel and 4.6 ± 0.9 cm with towel, from skin to first rib (3.3 ± 0.7 cm
and 3.7 ± 0.8 cm) and skin to second rib (2.9 ± 0.7 cm and 3.4 ± 0.7 cm),
respectively; the difference between the 2 positions was highly significant
(P< .0001). Body composition: distances from skin to pleura, skin to rib
1 and skin to rib 2 were all significantly different between subjects with
BMI less than 25 compared to subjects with BMI greater than 25 kg/
m2, regardless of position (P values between .02 and .004). Sex: distances from skin to pleura and skin to ribs 1 and 2 were all significantly different between women and men regardless of position (P values between
.001 and .02).
CONCLUSIONS: (1) When performing DN to the levator scapulae/upper trapezius it is safer to put a towel underneath the shoulder, because it increases the distance between skin and pleura by about 0.5 cm; (2) the
higher the subject’s BMI, the greater the distance from skin to pleura and
chest wall; and (3) women have on average significantly smaller distances from skin to the pleura at the level of levator scapulae/upper trapezius.
CLINICAL RELEVANCE: Physical therapists who undergo DN training have to
demonstrate in-depth knowledge of the anatomy. They are being taught
needle technique-related skills that are crucial to minimize the danger of
inflicting harm. The results of this study underscore the importance of
proper positioning of each patient as well as the need to consider their
body constitution and sex.
OPO160
USE OF MUSCULOSKELETAL ULTRASOUND IMAGING TO AID IN THE
DIAGNOSIS OF SUPRASCAPULAR NEUROPATHY: A CASE REPORT
Tracy Morel, Theodore Croy, Brad Tragord, Scott W. Shaffer
Physical Therapy, Moncrief Army Community Hospital, Columbia,
South Carolina; US Army-Baylor University Doctoral Program in
Physical Therapy, San Antonio, Texas
BACKGROUND AND PURPOSE: Shoulder dysfunction is a common reason for
people to seek care from a physical therapist. The purpose of this case report is to examine infraspinatus muscle atrophy and the use of musculoskeletal ultrasound (MSK US) imaging by a physical therapist to determine if the appearance was similar to denervation injury, rotator cuff tear,
or disuse atrophy.
CASE DESCRIPTION: A 28-year-old Caucasian woman (height, 1.6 m; weight,
54.1 kg; body mass index, 21.1 kg/m2) reported directly to an outpatient
physical therapy clinic complaining of right shoulder weakness with
pushups and repeated overhead activities. The past surgical history was
remarkable for a distal clavicle excision with a coracoclavicular ligament
reconstruction 3 years prior to this encounter [1].
OUTCOMES: Clinical observation revealed marked atrophy of the right in-
fraspinatus muscle and a 75% external rotation strength deficit. A musculoskeletal ultrasound imaging exam was performed by an experienced
orthopaedic physical therapist using a Supersonic Imagine with a HFL
15-MHz probe. With the subject prone, the infraspinatus muscle belly
and tendon, posterior glenohumeral joint, spinoglenoid notch were imaged in long axis directly along the fibers of the infraspinatus muscle with
the probe oriented inferior and parallel to the spine of the scapula. Poor
definition and heterogeneity of the internal architecture of the infraspinatus muscle compared to normal appearing deltoid muscle overlying it
as well as the supraspinatus suggested atrophy associated with denervation or rotator cuff tear. Dynamic MSK US further revealed an absence
of muscle thickness changes during active abduction and external rotation resistance testing as compared to the contralateral shoulder. Reduced
muscle bulk in addition to the echogenic changes to the internal architecture of the infraspinatus muscle suggested atrophy associated with
denervation.
DISCUSSION: MSK US revealed information not present in the clinical examination. Architectural changes in the infraspinatus muscle were consistent with denervation atrophy, not rotator cuff tear nor disuse, and was
subsequently confirmed with EMG testing. The normal appearance of
the supraspinatus muscle suggested that a suprascapular nerve lesion occurred distal to the innervation of the supraspinatus muscle. These MSK
US findings helped guide the prognosis for the patient’s recovery and
helped better define the nature of the patient’s symptoms of weakness
and fatigue with upper extremity exercises.
REFERENCES: Tragord BS, Bui-Mansfield LT, Croy T, Shaffer SW.
Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: a resident’s case problem. J Orthop
Sports Phys Ther.. 2015;45:299-305. Sofka C, et al. Detection of muscle
atrophy on routine sonography of the shoulder. J US Med. 23:1031-1034.
Lesniak BP, et al. Use of ultrasound as a diagnostic and therapeutic tool
in sports medicine. Arthroscopy. 2014;30:260-270. Koppenhaver S, et al.
The reliability of rehabilitative ultrasound imaging in the measurement
of infraspinatus muscle function in the symptomatic and asymptomatic
shoulders of patients with unilateral shoulder impingement syndrome.
Int J Sports Phys Ther. 2015;10:128-135. Khoury V, Cardinal E, Brassard
P. Atrophy and fatty infiltration of the supraspinatus muscle: sonography versus MRI. Am J Roentgenol. 2008;190:1105-1111. Henderson REA,
Walker BF, Young KJ. The accuracy of diagnostic ultrasound imaging for
musculoskeletal soft tissue pathology of the extremities: a comprehensive review of the literature. Chiropr Man Ther. 2015;23:31. de Jesus JO,
Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography,
and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. Am
J Roentgenol. 2009;192:1701-1707.
OPO161
DIAGNOSTIC ACCURACY OF THE SCAPULAR RETRACTION MANEUVER
IN ASSESSING THE STATUS OF THE ROTATOR CUFF
Edward P. Mulligan, Tara Dickson, Michael Khazzam
Department of Physical Therapy, UT Southwestern Medical Center
School of Health Professions, Euless, Texas; Orthopaedic Surgery,
UT Southwestern, Dallas, Texas
PURPOSE/HYPOTHESIS: Currently there are no dependable physical examination maneuvers that can clinically diagnosis the status of the rotator
cuff. The purpose of this study is to evaluate the diagnostic accuracy of
the scapular retraction maneuver (SRT) to predict the status of the rotator cuff (RC).
NUMBER OF SUBJECTS: Three hundred ninety-one subjects were prospectively assessed by clinical examination during initial presentation for a
painful shoulder complaint.
MATERIALS/METHODS: As part of the physical examination the SRT was performed to gauge the status of the RC. Magnetic resonance imaging (MRI)
examination was used as the reference standard to confirm the status of
the RC (intact or torn). The examiner was blinded to the results until after
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the physical exam was completed. Subjects with a diagnosis of calcific tendinitis, adhesive capsulitis, those with prior shoulder surgery, and glenohumeral osteoarthritis were excluded from the study. A positive SRT was
defined as restoration of strength with the scapular retracted and arm elevated 90° in the plane of the scapula. A negative SRT was defined as continued weakness (or the arm dropping). Statistical analysis was conducted to assess the clinical utility of the test maneuver.
RESULTS: The prevalence of full thickness RC tears in the study population was 54% (180/331). The average age of the RC tear group was 54.3
with 80 males and 100 females. There were 180 patients that had a full
thickness tear confirmed on MRI. Of these 180, the scapular retraction
test was negative in 147 patients and positive for the remaining 33. One
hundred and fifty one subjects were diagnosed with an intact RC by MRI,
122 of which had positive SRT and 29 were negative. The average age of
these subjects was 54.6 with 74 males and 77 females. The sensitivity was
81.7 (95% CI: 77.2, 85.4), specificity 80.8 (95% CI: 75.5, 85.33), accuracy
of 81.2 for the SRT to diagnosis a full thickness RC tear. The positive predictive value was 83.5 (95% CI: 78.9, 87.4), negative predictive value 78.7
(95% CI: 73.5, 83.1), positive likelihood ratio 4.3 (95% CI: 3.1, 5.8), negative likelihood ratio 0.23 (95% CI: 0.17, 0.30), diagnostic odds ratio of
18.7 (95% CI: 10.4, 34.0), and number need to diagnose and misdiagnose
of 1.8 (95% CI: 1.5, 2.2) and 4.6 (95% CI: 3.7, 5.8), respectively.
CONCLUSIONS: The results of this diagnostic study indicate that the SRT is
influential in identifying the status of the RC based on its likelihood ratios. We found that the SRT renders a moderate shift in probability for the
presence or absence of an intact RC tendon(s). Continued study is underway to determine if alternate scapular positioning has similar or different
diagnostic capability in differentiating intact from full-thickness RC tears.
CLINICAL RELEVANCE: Clinicians may use the SRT to provide additional clinical insight on the status of the RC and avoid or delay unnecessary imaging studies after a trial of nonoperative physical therapy rehabilitation.
OPO162
CAN 5 MINUTES OF REPETITIVE PRONE PRESS-UPS AND SUSTAINED
PRONE PRESS-UPS FOLLOWING A PERIOD OF SPINAL LOADING REVERSE
SPINAL SHRINKAGE?
Michelle M. Munster, Jean-Michel Brismee, Phillip S. Sizer,
Birendra M. Madi Dewan, Kevin Browne, Stéphane Sobczak
Texas Tech University Health Sciences Center, Lubbock, Texas;
Physical Therapy, Département d’Anatomie, Université du Québec
à Trois-Rivières, Trois-Rivières, Quebec, Canada
PURPOSE/HYPOTHESIS: PURPOSE: To investigate if (1) Sustained and repetitive prone press-ups could reverse spinal shrinkage following a period
of spinal loading; (2) There was a correlation between the degree of end
range of motion (ROM) spinal extension and spine height gains; and (3)
Provide a baseline on how asymptomatic participants responded to sustained and repetitive prone press-ups as a reference for further study with
participants with low back pain. Hypotheses: It was hypothesized that:
(1) Spinal height would increase following both repetitive and sustained
prone press-ups after a period of spinal loading. (2) Sustained prone
press-ups would show a greater increase in spinal height compared to repetitive prone press-ups after a period of spinal loading. (3) There would
be a positive correlation between spinal height changes and the degree
of end ROM lumbar spinal extension measured during prone press-ups.
NUMBER OF SUBJECTS: Thirty-two.
MATERIALS/METHODS: Forty-one healthy men and women were recruited
to participate. Subjects were seated in the stadiometer for 5 minutes with
a 4.5-kg weight placed on each shoulder followed by 5 minutes unloaded
sitting. Spinal height was measured using a stadiometer before and after
5 minutes of the following strategies: (1) repetitive prone press-ups; or (2)
sustained prone press-ups.
RESULTS: Following spinal loading, subjects grew using both repetitive
(mean ± SD, 4.85 ± 3.01 mm) and sustained press-ups (4.46 ± 2.57 mm).
There was no significant interaction (F1,30 = 0.722, P = .402, partial η2 =
0.023) between the repetitive versus sustained press-ups and the time
before and after each prone press-ups strategy. There was no main effect for Strategy (sustained versus repetitive press ups) (F1,30 = 1.359, P =
.253; partial η2 = 0.042). There was a significant main effect for Time (before versus after press-ups) (F1,30 = 140.771, P<.0001, partial η2 = 0.82).
Additionally, no correlation was found between the degree of end ROM
spinal extension and spinal height changes following press-ups strategies.
CONCLUSIONS: Following periods of spinal loading, both repetitive and sustained press-ups increased spinal height. Such strategies could be used to
help recover spinal height and limit the effects of spinal shrinkage as a result of activities of daily living.
CLINICAL RELEVANCE: Preserving spinal health is important for preventing
disability associated with low back pain and nerve root compression resulting from spinal shrinkage. Our study supports that prone press-ups
strategies could be used to assist in rehydration of the intervertebral discs
and in spinal height recovery.
OPO163
TEST-RETEST RELIABILITY OF THE SPORTS AND PERFORMING ARTS
MODULE OF THE DISABILITIES OF THE ARM, SHOULDER AND HAND
QUESTIONNAIRE
Stephanie Muth, Daniel Bresticker, Elizabeth Dalrymple,
David Snyder
Thomas Jefferson University, Philadelphia, Pennsylvania; Arcadia
University, Glenside, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose of this study was to assess the test-retest reliability and validity of a module of a commonly used shoulder pain
questionnaire- The Sports and Performing Arts Module of the Disabilities
of the Arm, Shoulder, and Hand Questionnaire (SPAM-DASH).
NUMBER OF SUBJECTS: Fifteen participants between the ages of 18 to 65 who
engage in sport or play an instrument 2+ times per week participated in
this study. In addition, retrospective analysis of previously collected data
from 30 additional similar participants were used to assess validity. All
participants had shoulder pain that impacted their participation in work,
school or recreation.
MATERIALS/METHODS: During visit 1, participants completed the SPAMDASH and the Penn Shoulder Score (PSS), which was used as the gold
standard to assess validity of the SPAM-DASH. After being distracted
by a cognitive task, participants completed the SPAM-DASH again. The
next day participants returned to re-take the SPAM-DASH. An Intraclass
Correlation Coefficient (ICC) was used to determine test-retest reliability and a Pearson product-moment correlation was used to assess test
validity.
RESULTS: The within day reliability was excellent with an ICC of 0.935
(95% CI: 0.631, 0.982). The between day reliability was very good with
an ICC of 0.890 (95% CI: 0.463, 0.968). The Pearson Correlation between the PSS and SPAM-DASH was –0.428 (P = .004), indicating a fair
correlation that is directionally appropriate given that the PSS measures
function and the SPAM-DASH assesses disability. The minimal detectable change (MDC) for the SPAM-DASH was calculated at both the 90%
and 95% confidence intervals: MDC90, 7.02; MDC95: 1.96 × 3.01 × 1.414
= 8.34.
CONCLUSIONS: The SPAM-DASH is a 4-item subset of the QuickDASH.
It is a reliable tool to assess disability related to patient-specified activities. Correlation to the PSS was fair but directionally appropriate, suggesting the SPAM-DASH may be quick and efficient alternative to the
lengthy PSS.
CLINICAL RELEVANCE: The SPAM-DASH provides patient-specific information, unlike the rest of the Quick-DASH or PSS. The SPAM DASH may
capture information missed due to the ceiling effect of the PSS or Quick
DASH for the higher functioning and more active patient. More research
is needed to assess the minimal clinically important difference for the
SPAM-DASH in order to better support its use in a clinical setting.
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OPO164
EFFECTS OF HIGH-INTENSITY EXERCISE ON CENTRAL NEURAL DRIVE
IN HEALTHY POPULATIONS
Stephanie Muth, Nicholas LeGrand, Kyearsa Robb,
Emily Slobodian, Nicole Weaknecht, Megan Wood
Thomas Jefferson University, Philadelphia, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to examine the effects of high intensity strength training (HIST) on central neural drive. For this review of literature, HIST was defined as greater than
75% of maximal volitional contraction (MVC).
NUMBER OF SUBJECTS: Five RCTs (n = 94 healthy subjects) were evaluated.
These studies investigated high intensity strength training and changes
in central neural drive. All studies compared a training group and control
group. Sample sizes ranged from 14 to 23 participants. The age of participants ranged from 18 to 35 years old.
MATERIALS/METHODS: Five databases were used in primary searches: Ovid,
PubMed, CINAHL, Cochrane, Scopus. Searches were performed using
the following terms: “motor drive and exercise,” “motor evoked potential
and exercise,” “voluntary activation and exercise,” “motor drive and high
intensity,” “voluntary activation and high intensity,” “ motor evoked potential and high intensity.” Additional information was solicited from 1 primary source via email. The initial search yielded 1692 articles. Multiple
levels of review yielded 10 articles which were critically appraised. Five
articles were included in the final review. These 5 articles were rated for
study design quality using the MacDermid Score.
RESULTS: Methodological quality MacDermid quality scores ranged from
28 to 34 out of 48. Effects of HIST All studies demonstrated significant
increases in strength with short-term HIST. Participants demonstrated
increased voluntary activation and/or increased cortical excitability with
minimal or no hypertrophy, indicating neural mechanisms rather than
morphological changes (ie hypertrophy, hyperplagia, etc) were, at least in
part, responsible for increases in strength.
CONCLUSIONS: This review of the literature found evidence for increases in
central neural drive due to HIST. Neural adaptations to HIST occurred
rapidly and strength gains were seen across a range of muscles groups
with both eccentric and concentric muscle training.
CLINICAL RELEVANCE: There are a variety of potential clinical applications
supported by the findings of this review. Patients with an inability to effectively train both sides of the body due to immobilization, may benefit
from neurologic overflow into the immobilized side when the unaffected
side is trained. It may also be possible to capitalize on the rapid cortical
adaptations in patients that need strength gains in a limited time frame,
for instance preoperatively.
OPO165
CHRONIC LEFT ARM PAIN POST–C5-7 ANTERIOR CERVICAL DISC FUSION
MANAGED WITH A BIOPSYCHOSOCIAL MULTIDISCIPLINARY TEAM
APPROACH AND PAIN NEUROSCIENCE EDUCATION
Darren Neeley, Kate Minick
Intermountain Healthcare, Murray, Utah
BACKGROUND AND PURPOSE: The biomedical (BM) approach to chronic pain
is widely acknowledged as inadequate and results in subpar outcomes
compared to a comprehensive biopsychosocial (BPS) approach. However,
there is a significant gap between this knowledge and its clinical application. The purpose of this case report is to outline an episode of care (EOC)
for a patient status post C5-7 anterior cervical disc fusion (ACDF) with
left arm pain for greater than 1 year who was managed in a collaborative
setting by specialists from physical medicine and rehabilitation (PMR),
physical therapy (PT), and neuropsychology (NPsy).
CASE DESCRIPTION: The patient was a 37-year-old female middle school
teacher and triathlete with insidious 12-month onset of diffuse left upper extremity, right upper trap, bilateral periscapular, and neck pain.
Previous treatment included PT at a different clinic for 2 months prior
and 3 months postsurgery with an emphasis on BM limitations as per the
patient report. Her initial exam in PT was consistent with central sensitization with yellow flags of social withdrawal, short term work disability, and severe anxiety. A coordinated plan of care was designed during a
meeting with specialists from PMR, PT, and NPsy. The purpose of this
meeting was to review the patient’s electronic medical record (EMR) and
gather input from all 3 disciplines, which resulted in a comprehensive
BSP plan of care for the patient. All 3 specialists agreed that all interventions and education should be directed away from a typical BM model
and encompass all aspects unique to this particular patient’s pain experience. Ongoing discussion throughout the EOC continued via the EMR
messaging system. PT included manual therapy, exercise, and PNSE regarding neurophysiology of pain, central sensitization, spinal inhibition
and facilitation, plasticity of the nervous system, and no reference to anatomical or pathoanatomical models. Homework after each session included review of concepts presented during the visit, viewing of YouTube videos to reinforce education, self-massage for desensitization, and regular
cardiovascular exercise at moderate intensity.
OUTCOMES: The patient was seen in PT for a total of 6 visits over 9 weeks.
Initial Neck Disability Index (NDI) score, numeric pain rating (NPR),
and Fear Avoidance Components Scale (FACS) were 62%, 7/10, and 77%,
respectively. After 2 months of PT the NDI, NPS and FACS scores were
14%, 6/10, 11%, respectively. At the time of her last PT appointment the
patient had returned to training for a triathlon, full time work, and felt
comfortable interacting again in social situations.
DISCUSSION: As the evidence builds to support the BPS approach to chronic pain there is a need to further define what that approach looks like in a
typical outpatient PT clinic. In this case report the use of specialists from
3 disciplines working together to reinforce the same message to the patient was effective in managing the pain experience unique to this particular patient.
REFERENCES: Louw A, Puentedura EJ. Therapeutic Neuroscience Education,
Volume 1. Minneapolis, MN: OPTP; 2013. Foster NE, Delitto A. (2011).
Embedding psychosocial perspectives within clinical management of low
back pain: integration of psychosocially informed management principles into physical therapist practice: challenges and opportunities. Phys
Ther. 2011;91:790-803. Jull G, Sterling M. Bring back the biopsychosocial model for neck pain disorders Man Ther. 2009;14:117-118. Linton SJ,
Shaw WS. Impact of Psychological Factors in the Experience of Pain. Phys
Ther. 2011;5:700-711. Nijs J, Roussel N, van Wilgen CP, Koke A, Smeets
R. Thinking beyond muscles and joints: therapists’ and patients’ attitudes
and beliefs regarding chronic musculoskeletal pain are key to applying effective treatment. Man Ther. 2012. Gatchel RJ, Neblett R, Kishino N, Ray
CT. Fear-avoidance beliefs and chronic pain. J Orthop Sports Phys Ther.
2016;46:38-43.
OPO166
DOES MEETING THE CLINICAL PREDICTION RULE FOR STABILIZATION
PREDICT SUCCESS IN PATIENTS TREATED WITH LUMBAR STABILIZATION?
A RETROSPECTIVE REVIEW
Darren Neeley, Kate Minick, Gerard P. Brennan
Intermountain Healthcare, Murray, Utah
PURPOSE/HYPOTHESIS: Hicks et al outlined a clinical prediction rule (CPR)
for patients who should respond favorably to stabilization exercises. The
CPR included 4 criteria (1) age less than 41 years; (2) positive aberrant
movements; (3) straight leg raise greater than 90°; and (4) positive prone
instability test (PIT). This CPR has been included as a subgroup in the
treatment based classification (TBC) for low back pain (LBP). The purpose of this retrospective review was to determine the extent of improvement in patients who met varying levels of the stabilization CPR.
NUMBER OF SUBJECTS: Four hundred sixty-two.
MATERIALS/METHODS: Charts were reviewed for 462 patients seen in 12 separate hospital based outpatient clinics by 39 different therapists throughout the Salt Lake City area. Data were collected regarding which stabili-
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zation CPR criteria were met, change score in Oswestry Disability Index
(ODI) and Numeric pain rating (NPR), chronicity of symptoms (days
since initial onset), number of visits, and previous episodes of LBP. In order to identify if any individual component of the CPR was more predictive of success, a hierarchical regression was performed with ODI change
as the dependent variable and the 4 components of the CPR as the independent variables in the second step of the model, after controlling for
chronicity of symptoms.
RESULTS: Of the 462 patients classified as stabilization, 45 met 0/4 criteria
(9.7%), 160 met 1 criterion (34.6%), 150 met 2 criteria (32.5%), 84 met
3 criteria (18.2%), and 23 met all 4 criteria (5.0%). There were no significant associations between the number of criteria met and ODI change
(F4,457 = 0.542, P = .705), pain change (F4,455 = 0.425, P =.790), or number
of visits (F4,457 = 0.655, P =.623). In the hierarchical regression, each step
of the model was significant. After step 1, with chronicity in the equation)
(R2 = 0.035, F1,460 = 16.70, P<.001). After step 2, with all 4 of the criteria
in the model (R2 = 0.016, F5,456 = 4.90, P<.001). A positive prone instability test had a significant impact on ODI change (R2 = 1.58, P = .033) in
acute and subacute patients.
CONCLUSIONS: In this retrospective review the total number of CPR criteria met did not have a statistically or clinically significant impact on ODI
change score in patients who were treated with lumbar stabilization exercises. Having a positive PIT test in a patient seen less than 6 months
from onset of LBP did have a statistically significant impact on outcomes.
CLINICAL RELEVANCE: This retrospective review did not show any greater
improvement in ODI change scores for patients who were treated with
primary intervention of stabilization exercises and who met the stabilization CPR versus those who did not. This calls into question the clinical
usefulness of the stabilization CPR and its utility as a subgroup within the
TBC to direct clinicians towards most effective care. This conclusion is in
alignment with other clinical commentaries recently published. More research is necessary to determine the need for the stabilization subgroup
within the TBC.
OPO167
THE IMPACT OF AN ACCELERATED REHABILITATION PROTOCOL
IN PATIENTS FOLLOWING MINIMALLY INVASIVE TKA WITH IOVERA
Timothy K. Nelson, Kenneth Milton, Aaron Rhodes,
Chris Wilcox, Jeffrey A. Thompson, Vinod Dasa
Physical Therapy, LSUHSC New Orleans, New Orleans, Louisiana;
Orthopedics, LSUHealth New Orleans, New Orleans, Louisiana
PURPOSE/HYPOTHESIS: Total knee arthroplasty (TKA) is one of the most frequently performed surgeries in the US, and the incidence is expected to
grow in the next 15 years. This high volume continues to contribute to the
escalating cost of health care. Iovera, a process of percutaneously freezing sensory nerves prior to surgery has been developed to decrease hospitalization and recovery time following TKA. With Iovera, patients have
decreased postsurgical pain and are able to tolerate increased frequency of outpatient PT. This study investigated the impact of an accelerated rehab protocol on patient outcomes when compared to a more traditional frequency of outpatient PT visits following TKA surgery with the
Iovera procedure.
NUMBER OF SUBJECTS: This study was a retrospective chart review of medical records of all patients who had a TKA from a single surgeon over a
2-year period. Patients were grouped into a high frequency (accelerated)
or low frequency group (traditional) based on the number of PT visits attended in the first 3 weeks of outpatient PT. Individuals who attended
at least 9 times in the first 3 weeks were considered high frequency and
those who attended 8 times or less were grouped into low frequency. A total of 54 patient records were accessed, 25 in the low frequency group and
29 in the high frequency group.
MATERIALS/METHODS: The researchers accessed the PT charts for all 54
patients and gleaned data collected by the PTs. The outcome measure
used was the Knee injury and Osteoarthritis Outcome Score (KOOS).
The KOOS was administered at initial evaluation and every 2 weeks that
the patients attended PT. The KOOS scores on the individual subsections
were compared statistically between the 2 groups using a mixed procedure linear model with SAS statistical package. Descriptive statistics were
run as well as correlative statistics to determine statistically significant
differences between the groups on the KOOS.
RESULTS: There were no statistically significant differences between the 2
groups on any of the KOOS scores at baseline, nor any demographics such
as age, sex, BMI, etc. All individuals showed a statistically significant improvement in KOOS scores over time (P<.0001). When the 2 groups were
compared using those patients who had completed at least 6 weeks of PT,
there was a statistically significant difference seen in the KOOS subscales
of symptoms (P = .045) and quality of life (P = .027), and approached a
statistically significant difference in the KOOS subscale of pain (P = .077).
CONCLUSIONS: Patients who finished 6 weeks of physical therapy with an
accelerated rehab protocol reported significantly less pain and symptoms
and increased quality of life than those who attended PT less frequently.
CLINICAL RELEVANCE: The findings of this research suggests that there may
be a benefit to an accelerated rehabilitation protocol with increased frequency of outpatient PT visits following TKA surgery.
OPO168
USE OF ORTHOPAEDIC MANUAL THERAPY AND THERAPEUTIC EXERCISE
FOR TREATMENT OF DIZZINESS WITH CERVICOGENIC HEADACHE
Antonio Nogueras, Trent Harrison, Jason Beneciuk
Brooks Rehabilitation/University of North Florida Orthopaedic
Residency Program, Jacksonville, Florida
BACKGROUND AND PURPOSE: Physical therapists need to evaluate and when
appropriate, treat the vestibular system and cervical spine to reduce dizziness associated with headaches. The purpose of this case report is to
demonstrate the need to evaluate, and when appropriate, treat the cervical and thoracic spine to reduce dizziness associated with headaches.
CASE DESCRIPTION: The patient was a 27-year-old woman who was referred to outpatient physical therapy with a diagnosis of vertigo. At initial examination, primary symptoms consisted of dizziness, imbalance,
headaches that originated to the left side of the occiput, and cervical
pain. Initial examination findings were negative for peripheral vestibular dysfunctions. Positive examination findings included limited cervical
range of motion, decreased passive joint mobility of the subcranial and
thoracic spine, and decreased strength of the scapulothoracic musculature. Outcome measures consisted of the numeric pain rating scale, the
Neck Disability Index, the Dizziness Handicap Inventory, and the Patient
Specific Functional Scale. Treatment consisted of manual therapy techniques to the cervical and thoracic spine, therapeutic exercises to the upper quarter, and patient education over an 8-week episode of care.
OUTCOMES: Interventions decreased cervical spine pain and headache intensity. Complaints of dizziness decreased as headache intensity decreased. At discharge, the patient reported 0/10 cervical pain, Neck
Disability Index score improved from 40% to 18%, Dizziness Handicap
Inventory score improved from 46 to 19, patient specific functional scale
average scores improved from 4.3 to 9.0.
DISCUSSION: This case report identifies an undiagnosed cervical dysfunction, cervicogenic headache, in association with dizziness. In similar cases, clinicians may only attempt to treat the dizziness because it was the diagnosis listed on the referral from the physician. Physical therapists need
to combine a thorough subjective and objective assessment to determine
the cause of cervical pain, headache, and dizziness. Specific questioning
and assessment of positions that contribute to the onset, duration, and fatigability of symptoms can aide in differential diagnosis.
REFERENCES: 1. Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of
Functioning, Disability, and Health from the Orthopaedic Section of
the American Physical Therapy Association. J Orthop Sports Phys Ther.
2008;38:A1-A34 2. Cleland JA, Glynn P, Whitman JM, Eberhart SL,
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Macdonald C, Childs JD. Short-term effects of thrust versus nonthrust
mobilization/manipulation directed at the thoracic spine in patients
with neck pain: a randomized clinical trial. 2007:431-440. 3. Domenech
MA, Sizer PS, Dedrick GS, McGalliard MK, Brismee JM. The deep neck
flexor endurance test: Normative data scores in healthy adults. PM R.
2011;3:105-110. 4. Grimsby O, Rivard J. Science Theory and Clinical
Application in Orthopaedic Manual Physical Therapy, Volume 1: Applied
Science and Theory. Taylorsville, UT: Academy of Graduate Physical
Therapy; 2008. 5. Page P. Cervicogenic headaches: an evidence-led approach to clinical management. Int J Sports Phys Ther. 2011;6:254-266.
6. Reid et al: Efficacy of manual therapy treatments for people with cervicogenic dizziness and pain protocol of a randomised controlled trial. BMC
Musculiskelet Disord. 2012;13:201. 7. The International Classification of
Headache Disorders. 3rd ed (beta version). 2013;629-808. 8. Thiele A,
Barraclough A. The framework for physical therapist and physician assistant partnership: interprofessional education and collaborative patient-centered care. [serial online]. 2007;21:47-52. 9. Young, IA, Cleland,
JA, Michener, LA, Brown, C. Reliability, construct validity, and responsiveness of the Neck Disability Index, Patient Specific Functional Scale,
and Numeric Pain Rating Scale in patients with cervical radiculopathy.
831-839.
OPO169
THE SLACK OF THE SLUMP: FALSE-NEGATIVE NEURAL PROVOCATION
TESTING WITH A CHRONIC PROXIMAL HAMSTRING TEAR: A CASE REPORT
Timothy J. Nolan, Adam M. Andersen
University of Illinois at Chicago, Chicago, Illinois
BACKGROUND AND PURPOSE: Proximal hamstring tears are commonly seen
in the young, athletic population with an injury involving quick movements. While clinical recommendations have been published on the
treatment of hamstring injuries, there is little literature on the physical
therapy management of individuals with chronic hamstring tears. With
a hamstring tear, neural provocation testing including straight leg raise
(SLR) and slump is utilized to identify any sensitivity of the peripheral or
central nervous system. The slump test is traditionally performed as seated spinal flexion, knee extension, and ankle dorsiflexion with cervical motions creating a change to distal symptoms. The purpose of this case is to
describe the differential diagnosis and clinical reasoning process of an individual presenting with persistent buttock pain.
CASE DESCRIPTION: A 60-year-old woman presented with a 12-month history of right ischial tuberosity pain. MRI confirmed a tear of the proximal
hamstring tendons with 10 mm of retraction. Her buttock pain worsened
to 8/10 pain with walking up hills, stair ascent, and sitting. At initial evaluation, standard slump testing and passive SLR testing with hip IR, adduction, and ankle dorsiflexion were negative. The tear was identified as
the primary pain generator shown with pain upon palpation and reduced
hamstring strength and flexibility. Nonthrust hip joint mobilizations, eccentric hamstring strengthening, soft tissue mobilization and hamstring
stretching were utilized for 7 visits with a home exercise program. Due
to minimal change on the Lower Extremity Functional Scale (LEFS),
continued pain with aggravating activities, and the anatomical proximity of neural tissue to the hamstring origin, neural provocation testing of
passive SLR with a combination of all sensitizing maneuvers including
cervical flexion and slump testing with a neutral pelvis was performed
resulting in positive findings. Seated, supine, and long sitting neural mobilizations using cervical flexion while positioned in hip flexion, IR, adduction and a neutral pelvis were utilized for 6 additional sessions.
OUTCOMES: From the Visit 1 to Visit 8, her pain reduced from 8/10 to 4/10
at worst. Her global rating of change (GRoC) was +2. A little bit better,
and her LEFS went from 51/80 to 53/80. With the addition of neural mobilizations, her pain was 1/10 at worst, GRoC was +6 A great deal better,
and LEFS was 67/80.
DISCUSSION: Lack of improvement with hip mobilizations, stretching, soft
tissue mobilization, and eccentric hamstring strengthening led to the re-
consideration of a neurogenic component to the pain. Slump with a neutral pelvis and the addition of cervical flexion to an already sensitized
SLR identified positive neurodynamic findings in this case. This nonirritable, chronic condition required clinical reasoning to identify positive
neural provocation outside the standard SLR and slump testing positions
and resulted in positive outcomes with the addition of neuromobilization interventions.
REFERENCES: Mason DL, Dickens V, Vail A. Rehabilitation for hamstring
injuries. Cochrane Database Syst Rev. 2007. Heiderscheit BC, Sherry
MA, Silder A, Chumanov ES, Thelen DG. Hamstring strain injuries:
Recommendations for diagnosis, rehabilitation, and injury prevention. J
Orthop Sports Phys Ther. 2010;40:67-81. DeWitt J, Vidale T. Recurrent
hamstring injury: consideration following operative and nonoperative
management. Int J Sports Phys Ther. 2014;9:798-812. Schmitt B, Tim
T, McHugh M. Hamstring injury rehabilitation and prevention of reinjury using lengthened state eccentric training: a new concept. Int J Sports
Phys Ther. 2012;7:333-341. Goom TS, Malliaras P, Reiman MP, Purdam
CR. Proximal hamstring tendinopathy: clinical aspects of assessment
and management. J Orthop Sports Phys Ther. 2016;46:483-493. Martin
HD, Kivlan BR, Palmer IJ, Martin RL. Diagnostic accuracy of clinical
tests for sciatic nerve entrapment in the gluteal region. Knee Surg Sports
Traumatol Arthrosc. 2014;22:882-888. Majlesi J Togay H Ãœnalan H
Toprak S. The sensitivity and specificity of the slump and the straight leg
raising tests in patients with lumbar disc herniation. JCR: J Clin Rheum.
2008;14:87-89.
OPO170
THE VALIDITY OF THE SIT-TO-STAND TEST IN CLASSIFYING
GLOBAL FOOT MOBILITY
Jennifer Norwood, Carissa Lane, Mark W. Cornwall
Physical Therapy and Athletic Training, Northern Arizona
University, Flagstaff, Arizona
PURPOSE/HYPOTHESIS: The Sit-to-Stand (STS) test is a simple way to classify the overall mobility of a patient’s foot. The test involves comparing
the change in a person’s nonweightbearing and weightbearing foot posture and then classifying their mobility as “Hypomobile,” “Hypermobile”
or “Normal.” Unfortunately, the validity of this simple test has not been
investigated. The purpose, therefore, of this study was to determine if the
STS test has sufficient validity to be used clinically.
NUMBER OF SUBJECTS: Sixty-four.
MATERIALS/METHODS: Sixteen male and 48 female subjects with a mean ±
SD age of 25 ± 4.1 years participated in the study. Each subject’s dorsal
arch height (DAH) and midfoot width (MFW) was first measured at 50%
of their overall foot length in nonweightbearing and weightbearing using a digital caliper or linear gauge. The change between the nonweightbearing and weightbearing measurements was then calculated for each
foot. A global foot mobility measure, called the mobility magnitude (MM)
was also calculated for each subject using the change in DAH and MFW.
Using normative data for these measurements, the subject’s foot mobility was classified as “Hypomobile” (first quartile), “Normal” (second and
third quartile), or “Hypermobile” (fourth quartile). Each subject’s foot
mobility was then visually assessed and classified by 2 different raters as
“Hypomobile” (less than 25% change), “Normal” (25%-75% change), or
“Hypermobile” (greater than 75% change) without knowledge of the prior linear measurements. Rater 1 was inexperienced while Rater 2 was experienced in the evaluation and management of foot and ankle disorders.
A series of Cohen’s kappa coefficients, adjusted for bias and prevalence,
were used to assess the amount of agreement between the visual classifications of foot mobility and the objective linear measurements.
RESULTS: The kappa coefficients for the 2 raters ranged from 0.051 to 0.133
for DAH, from 0.109 to 0.309 for MFW and from 0.121 to 0.273 for MM.
These kappa coefficients would be categorized as between “slight to fair”
agreement. The kappa coefficients did not appear to be significantly influenced by the level of education or experience of the raters.
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CONCLUSIONS: Both raters demonstrated between slight and fair agree-
ment between the subjective visual assessment and the objective linear
measurement of foot mobility. As such, it cannot be recommended as a
clinical tool to classify overall foot mobility. Further research is warranted
to find a better screening tool that can be used to easily and quickly classify overall foot mobility.
CLINICAL RELEVANCE: The STS test did not demonstrate sufficient agreement with the objective linear measurements of foot mobility to warrant
clinical use to classifying a patient’s overall foot mobility. Clinicians should
rely on other methods of measuring or classifying global foot mobility.
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OPO171
USING ABBREVIATED THERAPEUTIC NEUROSCIENCE EDUCATION AS AN
ADJUNCT TO EXISTING MANUAL THERAPY AND THERAPEUTIC EXERCISE
INTERVENTIONS IN THE TREATMENT OF CHRONIC KNEE PAIN IN A 59-YEAROLD MALE PATIENT WITH KNEE OSTEOARTHRITIS: A CASE REPORT
Maria Anjanette Nunez
BenchMark Rehab Partners Orthopedic Residency, Atlanta,
Georgia
BACKGROUND AND PURPOSE: Traditionally, physical therapy treatment of
chronic knee pain associated with knee OA has been based on a biomedical model, focusing on anatomical pathology. However, patients with
chronic knee pain receiving an integrated physical therapy treatment program may still report pain and difficulty with performance of ADLs, leading to seek further treatment including surgery, steroid injections and reliance on pain medication. Research on pain neurophysiology has shown
that individuals with moderate to severe symptomatic knee OA demonstrate central sensitization due to an altered central processing of pain.
Therapeutic neuroscience education (TNE) is an effective intervention
for patients with chronic pain conditions. The aim of this case report is
to demonstrate how the addition of TNE to an existing physical therapy regimen of manual therapy, therapeutic activity and therapeutic exercise affects pain and function in a patient with chronic knee pain associated with knee OA.
CASE DESCRIPTION: The patient was a 59-year-old man presenting to physical therapy with a chief complaint of a 2-year history of chronic right
knee pain. At baseline and at a 4-week re-evaluation, pain and function
were measured by the numeric pain-rating scale (NPRS) and the Lower
Extremity Function Scale (LEFS). Fear-avoidance and pain catastrophizing were assessed using the Fear-Avoidance Belief Questionnaire physical
activity (FABQ-PA) and work (FABQ-W) subscales modified to the knee
and the Pain Catastrophizing Scale (PCS). Walking tolerance and functional active movements of squatting and kneeling were also assessed.
Treatment consisted of 5 to 10 minutes of TNE at the beginning of each
session, 3 times a week for 4 weeks in addition to an existing treatment
plan of therapeutic exercise and manual therapy.
OUTCOMES: After 4 weeks of TNE education integrated into therapeutic
exercise and manual therapy interventions, the patient’s LEFS increased
by 110% (11 points). The patient had decreased fear-avoidance behavior (FABQ-PA score change from 24/24 at baseline to 7/24; PCS score
change from 44/52 to 20/52). Pain at worst also decreased from 8/10
to 4/10.
DISCUSSION: decrease in pain, fear avoidance for physical activity, pain catastrophizing, and improvement in functional outcome measure tools for
function, and active functional movement over a 4 week span. The addition of TNE did not affect fear avoidance for work subscale. The results
of this case report suggest that TNE can easily be integrated into a multimodal intervention model for the treatment of chronic knee pain associated with knee OA.
REFERENCES: 1. Nguyen U. et al. Increasing prevalence of knee pain and
symptomatic knee osteoarthritis: survey and cohort data. Ann Intern
Med. 2011;155:725-732. 2. Kittelson AJ, George SZ, et al. Future directions in painful knee osteoarthritis: harnessing complexity in a heterogeneous population. Phys Ther. 2014;94:422-432. 3. Beswick A, Wylde
V, Gooberman-Hill R, et al. What proportion of patients report longterm pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open.
2012;2:e000435. 4. Committee on Advancing Pain Research, Care,
and Education, Institute of Medicine. Relieving Pain in America: A
Blueprint for Transforming Prevention, Care, Education, and Research.
Washington, DC: The National Academies Press; 2011. 5. Courtney CA, et
al. Joint mobilization enhances mechanisms of conditioned pain modulation in individuals with osteoarthritis of the knee. J Orthop Sports Phys
Ther. 2016. 6. Abbott JH, et al. The incremental effects of manual therapy
or booster sessions in addition to exercise therapy for knee osteoarthritis:
a randomized clinical trial. J Orthop Sports Phys Ther. 2015;45:975-983.
7. Deyle G, Gill N. Well-tolerated strategies for managing knee osteoarthritis: a manual physical therapist approach to activity, exercise, and
advice. Physician Sports Med. 2012;40:12-25. 8. Riddle DL, Wade JB,
Jiranek WA, et al. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468:798-806.
9. King C, Sibille K, Fillingim R, et al. Experimental pain sensitivity differs as a function of clinical pain severity in symptomatic knee osteoarthritis. Osteoarthritis Cartilage. 2013;21:1243-1252. 10. Nijs J, Van
Houdenhove AB, Oostendorp R. Recognition of central sensitization in
patients with musculoskeletal pain: Application of pain neurophysiology in manual therapy practice. Man Ther. 2010;15:135-141. 11. Louw A, et
al. Use of an abbreviated neuroscience education approach in the treatment of chronic low back pain: a case report. Physiother Theory Pract.
2012;28:50-62. 12. Louw A, Diener I, Butler D, Puentedura E. The effect
of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Phys Med Rehabil. 2011;92:2041-2056 13.
Nijs J, Meeus M, et al. A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Phys Ther. 2014; 94:730-738. 14. Dowsey
MM, Nikpour M, Dieppe P, et al. Associations between preoperative radiographic changes and outcomes after total knee joint replacement for
osteoarthritis. Osteoarthritis Cartilage. 2012;20:1095-1102. 15. Linton SJ,
Shaw WS. Impact of psychological factors in the experience of pain. Phys
Ther. 2011;91:700-711.
OPO172
HAND DOMINANCE AND POSTURE: A STUDY OF HANDEDNESS PATTERNS
IN POSTURE ANALYSIS
Elizabeth Oakley, Natalie Appelhans, Alyson Jamel,
Meredith Griffin, Lauryl Murphree-James
Physical Therapy, Andrews University, Berrien Springs, Michigan
PURPOSE/HYPOTHESIS: The purpose of this study was to identify if hand
dominance postural patterns, as described by Florence Kendall, can be
identified in a standing posture assessment and if sex influences posture.
Our hypothesis was that hand dominance and sex would have an effect
on posture as demonstrated by measured postural deviations unique for
each subset of participants.
NUMBER OF SUBJECTS: Thirty-eight participants were recruited for our
study, 12 males (32%) and 26 females (68%) with a mean age of 26 years.
Thirty-two were right-handed (84%) and 6 were left-handed (16%).
Inclusion criteria for our study included healthy male and female participants between the ages of 18 and 65 without any postural abnormalities.
MATERIALS/METHODS: Standing posture of each subject was analyzed
against a plumb line and posture grid in the lateral and posterior view
in addition to photographic assessment. Measurements were taken for
the craniocervical angle, shoulder levels, spinal alignment, pelvis and hip
levels, knee alignment, and rearfoot pronation. Statistical analysis: frequencies were used to determine the presence of postural pattern associated with hand dominance and sex. A mixed-design, repeated-measures
ANOVA was used to determine if there was a difference in the frequencies
of each postural deviation observed for hand dominance and sex.
RESULTS: No one demonstrated all 5 postural deviations descriptive of a
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handedness pattern. Of the possible 5 postural deviations, 3% (n = 1) of
right-handed participants and 33% (n = 2) of left-handed participants
demonstrated 3 characteristics associated with their hand dominance
pattern, 34% (n = 11) of right-handed and 50% (n = 3) of left-handed
participants presented with 2, 38% (n = 12) of right-handed and 0% of
left-handed participants presented with only one, and 25% (n = 8) of
right-handed participants and 16% (n = 1) of left-handed participants
presented with none of the characteristics. There was no consistent posture pattern among the sexes. A repeated-measures ANOVA found that
neither hand dominance or sex was statistically significant for any of the
postural variables.
CONCLUSIONS: This study found that hand dominance and sex do not have
an effect on a person’s posture. Thus, we rejected our hypothesis that hand
dominance and sex would have an effect on posture as demonstrated by
measured postural deviations unique for each subset of participants.
CLINICAL RELEVANCE: Participants exhibited multiple variations of Kendall’s
proposed handedness posture patterns suggesting that there are other
factors of greater influence on posture that should be given more important consideration than hand dominance and sex. Thus, clinicians should
not assume that an observed postural pattern is due to hand dominance
or sex.
OPO173
GLOBAL REHABILITATION IMPROVES UPPER-LIMB PROPRIOCEPTION
IN INDIVIDUALS WITH ROTATOR CUFF TENDINOPATHY
Benoit Pairot de Fontenay, Jean-Sebastien Roy,
Catherine Mercier, Laurent J. Bouyer
CIRRIS, Quebec, Quebec, Canada
PURPOSE/HYPOTHESIS: Shoulder disorders affects approximately 20% of
the population, and rotator cuff (RC) tendinopathy is the most prevalent
shoulder diagnosis [1]. Proprioception deficits have been highlighted in
patients with RC tendinopathy during shoulder-specific active repositioning tasks as well as during multijoint upper limb repositioning task [2,3].
As proprioception is fundamental for joint control, a deficit could contribute to changes in shoulder muscle activations and kinematics, and ultimately to pain and disabilities [4]. A global rehabilitation intervention
has already demonstrated benefits for pain and function in patients with
RC tendinopathy [5]. However, it is unknown how it affects proprioception. The aim of this study was to evaluate the effects of a 6-week rehabilitation program on upper limb proprioception in individuals with RC
tendinopathy.
NUMBER OF SUBJECTS: Twenty-three individuals with RC tendinopathy.
MATERIALS/METHODS: Upper-limb joint position sense was evaluated before and after a 6-week rehabilitation program by an active-repositioning
(AR) task in participants with RC tendinopathy. The task was executed
in a seated position and the subjects were blindfolded. The movement assessed was a multijoint joint reaching movement of the upper limb. The
difference between the determined position and the reaching position
was measured. The mean error in lateral (LR), neutral (NR), and medial
rotation (MR), and the global mean error were reported. Symptoms and
functional limitations were assessed using the DASH questionnaire before and after the intervention.
RESULTS: Paired t tests showed a significant decrease only for the error
in LR (P = .044). As more than 50% of the patients did not present any
deficits of proprioception at baseline based on normative data (20 subjects without shoulder deficit), we decided to separate the patients into 2
subgroups (patients with and without proprioception deficit at baseline).
Subgroup ANOVA showed significant interaction for the global error and
the error in LR (P = .045 and P = .017, respectively). Post hoc tests showed
a decrease in global error and in error in LR after the intervention in patients with deficit at baseline (P = .022 and P = .002, respectively), and
proprioception ability was not different between both subgroups at the
end of the intervention (P = .204 and P = .342, respectively). A significant
time effect was reported for the DASH questionnaire (P<.001, meaning a
decrease in symptoms and functional limitations after the rehabilitation
program for both subgroups).
CONCLUSIONS: A 6-week rehabilitation program improves function in patients with RC tendinopathy and restores to normal proprioception ability in those with deficits at baseline.
CLINICAL RELEVANCE: Our result supports the idea that RC tendinopathy is
multifactorial and that functional limitation is not directly link to proprioception ability. A rehabilitation program is effective for patients with
RC tendinopathy and improves proprioception if impaired.
OPO174
THE EFFECT OF LOWER EXTREMITY STRENGTHENING AND FLEXIBILITY
ON PITCHING BIOMECHANICS IN PITCHERS WITH UPPER EXTREMITY
INJURIES: A CASE SERIES
Alexandra Perry
College of Public Health and Health Professions, University of
Florida, Gainesville, Florida
BACKGROUND AND PURPOSE: Rehabilitation for overhead athletes typically
focuses on upper extremity interventions, despite the fact that the pitching motion is a complex sequence of movements requiring the coordination of the lower extremities, pelvis, trunk and the upper extremities to
achieve ball velocity. The purpose of this study was to compare the effectiveness on pitching performance of traditional upper extremity biased
rehabilitation to traditional rehabilitation augmented with lower extremity focused interventions in pitchers with upper extremity injuries due to
overhead throwing.
CASE DESCRIPTION: Five pitchers (mean ± SD age, 18.6 ± 4.7 years; weight,
181.0 ± 19.6 lb;, height, 73.6 ± 1.9 inches) with upper extremity pathology due to overhead throwing were recruited. Subjects were randomly assigned to receive standard care (SC group): traditional, upper extremity
(UE) focused interventions or SC plus lower extremity (LE) interventions
(hybrid group). Both stride LE (lead leg) and stance LE (push-off leg) was
assessed. Subjects’ passive hip internal rotation (IR) and external rotation (ER) range of motion (ROM), knee flexion angle at lead foot contact,
and shoulder ER ROM in late cocking was assessed while pitching with
a 2-motion video capture system pre and post physical therapy intervention (12.6 ± 5.8 visits).
OUTCOMES: There was a significant decrease of the stride LE hip IR ROM
for the SC group, compared to the hybrid group, (mean ± SD change,
–6.5° ± 3.0°; P = .024). There was a significant increase in hip IR ROM
of the stride LE (mean ± SD difference, 6.3° ± 3.3°; P = .014) and hip ER
ROM of the stance LE (mean difference, 5.5° ± 3.4°; P = .050) postintervention between groups. There were significant changes, with an increase in knee flexion (mean ± SD change, +9.4° ± 8.4°; P = .022) and decrease in shoulder ER (mean ± SD change, –2.0° ± 3.1°; P = .037) seen in
the hybrid group.
DISCUSSION: Implementation of traditional rehabilitation augmented
with LE interventions could potentially assist with reducing stress on the
throwing arm. Inhibiting the loss of stride hip IR and increasing knee
flexion will decrease shoulder ER angle that will allow the efficient transfer of energy up the kinetic chain. Addressing stride length and direction with traditional upper extremity focused rehabilitation augmented
by lower extremity intervention may improve the timing of the throwing
shoulder during stride foot contact, decreasing the strain on the shoulder and elbow.
REFERENCES: Calabrese G. Pitching mechanics, revisited. Int J Sports Phys
Ther. 2013:652-660. Laudner K, Wong R, Onuki T, Lynall R, Meister K.
The relationship between clinically measured hip rotational motion and
shoulder biomechanics during the pitching motion. J Sci Med Sport. 2014.
Ramsey D, Crotin R, White S. Effect of stride length of overarm throwing delivery: a linear momentum response. Hum Mov Sci. 2014:185-196.
Robb A, Fleisig G, Wilk K, Macrina L, Bolt B, Pajaczkowski J. Passive
ranges of motion of the hips and their relationship with pitching biomechanics and ball velocity in professional baseball pitchers. Am J Sports
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Med. 2010:1-7. Seroyer S, Nho S, Bach B, Bush-Joseph C, Nicholson
G, Romeo A. The kinetic chain in overhand pitching: its potential role
for performance enhancement and injury prevention. Sports Health.
2010:135-146.
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OPO175
SURGICAL INDICATIONS FOR FEMOROACETABULAR IMPINGEMENT
WITH/WITHOUT ACETABULAR LABRAL TEAR: A SCOPING REVIEW
Scott Peters, Alisha Laing, Courtney Emerson, Kelsey Mutchler,
Thomas Joyce, Michael Reiman
Duke University Physical Therapy, Durham, North Carolina
PURPOSE/HYPOTHESIS: The prevalence of cam femoroacetabular impingement (FAI) is estimated to range from 5% to 75%, while pincer FAI prevalence is more consistently reported at 61% to 76% of patients presenting
with hip and/or groin pain. The consistency of specific criteria reporting
for diagnosis and surgical treatment of FAI appears unclear, despite recent suggestions for comprehensive and concise inclusion/exclusion criteria for FAI surgery. Therefore, the purpose of this review was to analyze and report the indications utilized for open and arthroscopic surgical
treatment of FAI. We hypothesized that radiographic evidence of FAI
would be the primary indication for surgery.
NUMBER OF SUBJECTS: Within the scoping review there were 10 078 patients
(56.2% male; mean age, 33 years) and 10 698 hips included from 110 articles matching the inclusion criteria.
MATERIALS/METHODS: A librarian assisted computer search of MEDLINE,
CINAHL, and Embase for articles related to surgical indications for FAI
was employed for study inclusion. The Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines were also
used for the search and reporting phases of this study. Inclusion criteria
for this review included: studies of subjects with surgical treatment of
FAI, studies with the primary purpose of surgery or surgical outcomes for
treatment of FAI, and studies with defined indications for FAI surgery.
RESULTS: Radiographic imaging (eg alpha angle, central edge, crossover
sign) was a surgical indication in 78% of the included studies. Subjective
history was a reported surgical indication in 74% of the studies, and special tests were reported in 69% of studies. Various range-of-motion limitations were described in only 28%, while 44% of included studies listed
previous treatment (eg, NSAIDs, activity modification, PT) as indications
for FAI surgery. Failed nonsurgical physical therapy treatment was only
reported in 18% of studies as a surgical indication.
CONCLUSIONS: As hypothesized, radiographic evidence of FAI was the most
commonly reported indication for FAI surgery. Unfortunately, specific indications, as well as their specific parameters and values, demonstrated
major inconsistencies across the studies.
CLINICAL RELEVANCE: The rate of surgical intervention for FAI is continuing
to escalate despite poorly described and inconsistently reported surgical
indications. The primary surgical indication for FAI surgery is currently
radiographic imaging, despite a lack of consensus on the specific modalities and cut-off values necessary for this intervention. It remains unclear
which indications determine best surgical outcomes for FAI.
OPO176
DORSIFLEXION MOBILITY IMPAIRMENTS AND THE REGIONAL
INTERDEPENDENCE IMPLICATIONS ON FUNDAMENTAL MOVEMENT PATTERNS
Steven J. Pettineo, Michael E. Lehr
Biomechanics, Temple University School of Podiatric Medicine,
Philadelphia, Pennsylvania; Physical Therapy, Lebanon Valley
College, Lebanon, Pennsylvania
PURPOSE/HYPOTHESIS: The APTA recently issued a vision statement,
grounded by the principle of optimizing movement. Physical therapists
typically assess isolated movements at the joint level, as well as open and
closed kinetic chain functional patterns. Correlation between the 2 are
often implied, but research is limited in terms of demonstrating a correlation between specific impairments and movement dysfunction. The
purpose of this poster is to demonstrate how dorsiflexion mobility impairments impact fundamental movement patterns.
NUMBER OF SUBJECTS: One hundred forty-six subjects.
MATERIALS/METHODS: An observational analytical cohort study was conducted. A sample of convenience of 146 collegiate athletes was obtained.
The study was approved by the IRB of Lebanon Valley College. Inclusion
criteria included: (1) self-reported lack of musculoskeletal injury within 6 months prior to data collection, (2) no musculoskeletal pain at time
of testing, (3) medically cleared for sport participation by a physician.
Informed consent was obtained from each subject. Closed chain dorsiflexion range of motion was assessed utilizing the lunge test as described
by Chisolm. The squat movement pattern was assessed utilizing the
Functional Movement Screen criteria. Statistical analysis was performed
to explore the correlation between closed chain dorsiflexion limitations
and a dysfunctional squat.
RESULTS: A cut score for limited dorsiflexion of less than 10 cm was set and
a score of “1” on the deep squat test of the Functional Movement Screen
were investigated. 67 (46.2%) Subjects scored either a “2” or “3” on their
deep squat. Six of these subjects (9%) had both ankles dorsiflex less than
10 cm. 11 subjects (16.4%) had at least 1 ankle dorsiflex less than 10 cm.
78 subjects (53.8%) scored a “1” on their deep Squat test. Of this group,
23 subjects (29.5%) had a bilateral dorsiflexion restriction and 33 subjects (42.3%) had a unilateral restriction. Subjects who scored a “1” on
their deep squat test were 3.73 times as likely to have at least 1 ankle dorsiflex less than 10 cm compared to subjects who scored a “2” or a “3” on
their deep squat test based on an odds ratio analysis (OR = 3.73; 95% confidence interval: 1.60, 8.88; P = .002.).
CONCLUSIONS: A dysfunctional squat pattern can be correlated with a unilateral or bilateral lack of closed chain dorsiflexion mobility. Clinicians
who identify a dysfunctional squat utilizing the Functional Movement
Screen or assessing a functional task may benefit from looking at closed
chain dorsiflexion mobility. Ankle equinus may limit the ability to squat
for functional tasks placing excessive stress on more proximal body
structures.
CLINICAL RELEVANCE: Physical Therapists have an obligation to effectively
manage the complex neuromusculoskeletal system with the goal of reducing the activity limitations in our patients. Considering regional interdependence implications, movement dysfunction can be a product of
clinically meaningful impairments within the kinetic chain. To this end,
a key component to our management model should center on fundamental movement restoration.
OPO177
THE EFFECT OF VARIOUS SITTING POSTURES ON SHOULDER LATERAL
ROTATOR STRENGTH
Steven Pheasant, Richard Haydt, Thomas Gottstein,
Anthony J. Grasso, Nicholas M. Lombard, Brandon L. Stone
Physical Therapy, Misericordia University, Dallas, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose was to assess the relationship between
3 sitting postures and shoulder lateral rotator strength. The null hypothesis was that maintaining various sitting postures for 5 minutes would have
no effect on force production using the lateral rotators of the shoulder.
NUMBER OF SUBJECTS: One hundred healthy volunteers (39 male, 61 female) ages 20 to 26 years.
MATERIALS/METHODS: Each subject was placed in a neutral (NCS) cervical sitting posture which was maintained for 5 minutes after which the
strength of the dominant shoulder lateral rotators was immediately tested
using a microFET3 HandHeld Muscle Testing Dynamometer (HHMTD).
Strength testing consisted of (3) 5-second “make tests” for shoulder lateral rotation. Subjects were instructed to provide a maximal effort for 5
seconds while the tester maintained the static position of the HHMTD.
A 10-second rest period separated each of the 3 trials. The position for
strength testing was 0° of glenohumeral abduction, 0° of glenohumeral
external rotation and 90° of elbow flexion. The HHMTD was held on the
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dorsum of the distal forearm 2 cm proximal to subjects’ radial styloid process. Each subject was returned to the NCS posture for subsequent lateral
rotator strength testing after 5 minutes in a protruded (PCS) cervical sitting posture, 5 additional minutes in the NCS posture and 5 minutes in a
retracted (RCS) cervical sitting posture. Subjects were randomized for order between the PCS and RCS postures.
RESULTS: Mean strength values for each condition were normalized for
each subject to the initial NCS posture mean strength values. ANOVA
demonstrated significance for shoulder lateral rotator strength decline
following the PCS posture (0.92 ± 0.11) compared to each of the strength
values following first NCS (1.0), RCS (0.99 ± 0.09) and second NCS (0.97
± 0.09) postures (P<.05). A frequency analysis revealed 36% of the subjects demonstrated greater than 10% decline in lateral rotator strength
following 5 minutes in the PCS posture. The average percentage strength
deficit of those with greater than 10% decline was 19%.
CONCLUSIONS: The PCS posture can have a direct effect on shoulder lateral rotator strength. Shoulder lateral rotator strength declined 8% following 5 minutes in the PCS posture. A subpopulation of 36% demonstrated
an average decline of 19% in shoulder lateral rotator strength following 5
minutes in the PCS posture. The strength decline appears to resolve over
the short term by returning to the NCS posture.
CLINICAL RELEVANCE: Five minutes in the PCS posture can have a significant, adverse impact on shoulder lateral rotator force production. The
strength decline returns to near normal after 5 minutes in the NCS posture; however, the cumulative effects are unknown. This strength phenomenon can likely effect predisposition to injury, occupational tolerance,
athletic performance and rehabilitation outcomes.
OPO178
INFLUENCE OF TEAR SIZE AND BICEPS PROCEDURE ON PHYSICAL
THERAPY UTILIZATION FOLLOWING ROTATOR CUFF REPAIR
Abigail R. Pinkerton, Sarah P. Pate, Ellen Shanley,
Paul F. Beattie, Michael Kissenberth, Richard J. Hawkins,
Charles A. Thigpen
Research and Analytics, ATI Physical Therapy, Greenville, South
Carolina; Physical Therapy, University of South Carolina,
Columbia, South Carolina; Steadman Hawkins Clinics of the
Carolinas, Greenville Health System, Greenville, South Carolina
PURPOSE/HYPOTHESIS: There are between 250 000 and 400 000 rotator
cuff repairs (RCR) per year in the United States. Evidence suggests that
associated long head of the biceps (LHB) tendon pathology should be addressed in these patients often impacting the physical therapy (PT) plan
after RCR. While standard practice following RCR involves regular, supervised PT visits, there is no clinical evidence describing dosage of PT
following RCR as it relates to tear size and concomitant biceps procedure. Therefore, the purpose of this study was to examine the effects of
RCR tear size and concomitant biceps procedure on PT utilization following RCR.
NUMBER OF SUBJECTS: Patients with RCR (n = 114; tenodesis, 51; tenotomy,
63) by 1 of 3 board certified, fellowship trained surgeons who received
therapy at 1 physical therapy (PT) clinic following a previously published
rotator cuff protocol.
MATERIALS/METHODS: Patients were included if they had an index RCR with
available pre surgical MRI, operative report, and pre- and 2-year postoperative ASES scores. Baseline factors including age, sex, BMI, comorbidities, work type, activity level, pain were recorded. PT utilization was defined as the total length of stay (LOS) in therapy (from initial evaluation
until time of discharge) and number of visits at 6 weeks, 12 weeks, and 3
to 6 months. Tear size was categorized as less than 3 cm (n = 50) or greater than 3 cm (n = 64). A 2-way ANOVA (tear size by biceps procedure)
was used to compare the LOS and dosage of visits over the course of care
and a mixed model ANOVA (tear size by biceps group) over phase of rehabilitation on visits (α = .05).
RESULTS: ASES scores (pre, 36.5 ± 11.6) increased on average 45.1% ±
18.4% with 24.2 ± 13 visits across all patients. There were significant interaction effects of for visits (P = .04) and LOS (P = .02). Post hoc analysis showed that patients with a tenodesis were seen 2.4 visits fewer if
they were greater than 3 cm compared to RCR less than 3 cm and tenodesis during 0 to 6 weeks. Overall, patients with RCR less than 3 cm and
tenotomy (4.6 ± 6.8) were seen less than those with tenodesis (7.8 ± 7.7).
When considering LOS, patients with tenotomy had shorter LOS (LOS,
94.6 ± 117.6) compared to patients with tenodesis (LOS, 129.6 ± 70.0) furthermore, patients with tenotomy and RCR less than 3 cm had shorter
LOS (LOS, 66.2 ± 161.1) compared to all other groups. Patients with RCR
greater than 3 cm had longer LOS (123.0 ± 71.4) compared to patients
with RCR less than 3 cm (93.9 ± 127.1).
CONCLUSIONS: The results of this study indicate that tear size and biceps
procedure influence PT utilization. In this sample, patients with a biceps
tenotomy tended to have less utilization overall as measured by LOS and
PT visits. Tear size was likely influenced by early post operative restrictions based on tear size.
CLINICAL RELEVANCE: Clinicians should consider tear size and concurrent
biceps procedure when developing postoperative expectations following
RCR repair. Understanding the factors that influence will help guide development of improvement PT utilization in emerging value-based payment models.
OPO179
NORMATIVE VALUES FOR THE Y BALANCE TEST IN HEALTHY, ACTIVE
YOUNG ADULTS
Mattie Pontiff, Jane M. Eason, Thuha Hoang
Physical Therapy, LSU Health Science Center, New Orleans,
Louisiana
PURPOSE/HYPOTHESIS: Single-limb balance and dynamic neuromuscular
control are important for daily and sport-related activities. The Y Balance
test is a valid and reliable measure for assessing single limb balance and
neuromuscular control. Scores on the Y Balance test have been related to
lower extremity musculoskeletal impairments and predictive of lower extremity injury in select populations. Despite its widespread clinical utility,
appropriate reference values have yet to be established for healthy, active,
young adults. Normative values based on age, sex, and activity would allow clinicians to correctly interpret test results to determine patient performance and to establish values to be used for screening a young adult
population. The purpose of this study was to establish normative values
for the Y Balance test in healthy, active, young adults (age range, 20-29
years). Secondary aims included assessment of sex differences in normalized reach direction and composite scores.
NUMBER OF SUBJECTS: Seventy-four.
MATERIALS/METHODS: Healthy young adults between the ages of 20 and 29
years who exercised 1 to 2 d/wk were recruited to participate in this study.
Successful reach distances were recorded for each direction and the average for each direction was utilized in calculations. Distances for each direction were normalized to limb length. Composite scores were also calculated for each LE. Sex differences were assessed between groups for each
reach direction and composite scores using an independent t test (P≤.05).
Reference values were calculated for posterior-medial, posterior-lateral,
anterior and composite scores for each lower extremity (mean ± SD, 95%
confidence interval).
RESULTS: Seventy-four subjects (43 female, 31 male) met inclusion criteria
and completed the Y Balance test. There were no statistically significant
differences between males and females in right and left anterior reach (P
= .077, P = .419), right and left posterior medial reach (P = .702, P = .179),
right and left posterior lateral reach (P = .175, P = .404) and right and left
composite reach (P = .615, P = .756). Mean reach distances for each direction were as follows: right and left anterior (67.72 ± 9.13, 67.21 ± 10.23),
right and left posterior medial (107.86 ± 15.21, 110.12 ± 13.77) and right
and left posterior lateral (102.49 ± 15.96, 103.26 ± 15.45). Mean reach distances for composite scores were (96.78 ± 11.58 cm) for RLE, and (97.34
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± 11.398 cm) for the LLE.
CONCLUSIONS: Normative values for the Y Balance test were established for
healthy, active adults aged 20 to 29 years. No difference exists between
males and females in any reach direction (anterior, posterior medial and
posterior lateral) or composite scores when data were normalized for limb
length.
CLINICAL RELEVANCE: Normative data for The Y Balance test can be used for
screening and treatment purposes by physical therapists in clinical practice. Additionally, sex-specific norms are not necessary for the Y Balance
test in healthy adults aged 20 to 29 years.
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OPO180
DETERMINING THE ROLE OF LUMBAR EXTENSOR MOMENT DURING TIME
TO TASK FAILURE
Rachael Puthoff, Ryan Kaya, Megan E. Applegate,
Samuel T. Leitkam, James S. Thomas, David W. Russ
Rehabilitation and Comunication Sciences, Ohio University,
Athens, Ohio
PURPOSE/HYPOTHESIS: Time to task failure (TTF) on the Sörensen test,
which requires individuals to maintain the unsupported trunk in a horizontal position, predicts first-time episodes of low back pain (LBP)
as well as the development of chronic LBP (cLBP). However, TTF on
the Sörensen test may be influenced by trunk mass, trunk length, and
strength of the trunk extensor muscles. Thus, we examined TTF in both
healthy controls (HC) and subjects with cLBP performing (1) a standard
Sörensen test, and (2) a modified test that accounted for anthropometrics
and trunk extensor strength.
NUMBER OF SUBJECTS: Fifteen subjects (8 cLBP, 7 HC) aged 18 to 45 years.
MATERIALS/METHODS: Sessions were separated by at least 72 hours. Subjects
were positioned prone with iliac crests aligned with the edge of the table,
pelvis secured to the table, and ankles secured using a T-bar with an embedded 1-DOF load cell. The trunk rested on a platform connected to a
counterbalancing weight stack through a pulley system. A 6-DOF load
cell fixed between the floor and the platform was used to assess trunk
forces and moments. The eSTIM amplitude of peak twitch force was determined. Subjects performed 4 maximal voluntary contractions (MVC)
of the trunk extensors during the first session; visual feedback of the extensor moment was provided to encourage maximal effort. For the standard Sörensen test session, only the weight of the platform was counterbalanced. For the modified test session, the counterweight load was set
to 30% of the subjects’ maximal trunk extensor moment to maintain the
horizontal position. During both sessions, the subjects viewed digitally
displayed feedback on trunk position from a potentiometer mounted on
the platform. Task failure occurred when the subjects could not maintain
the horizontal position (±1°) for greater than 3 seconds. Following each of
the tests, an MVC was performed and a 200-microsecond wide doublet
pulse was delivered at the subjects’ peak twitch amplitude. The data were
analyzed with a mixed model ANOVA.
RESULTS: TTF was 139 (SE, 13.9) seconds for the HC group and 93 (SE,
13.0) seconds for the cLBP group (P<.05). Collapsed across groups, TTF
was 166 (SE, 16.9) seconds in the modified test compared to 66 (SE, 6.6)
seconds in the standard Sörensen test (P<.05). Baseline vertical forces at
the trunk (441 N for HC versus 460 N for cLBP) and hip (491 N for HC
versus 437 N for cLBP) did not differ between groups. However, baseline trunk extensor moments were significantly lower in subjects with
cLBP than in HC (20.5 Nm; SE, 5.8 versus 40.7; SE, 6.3 Nm, respectively; P<.05). Peak extensor moment during the posttest MVC doublet was
higher in HC compared to cLBP (12.4; SE, 1.5 versus 7.9; SE, 1.4 Nm, respectively; P = .051).
CONCLUSIONS: Differences in performance on the Sörensen test could be accounted for by an inability to generate and sustain trunk extensor moment.
CLINICAL RELEVANCE: These findings suggest that individuals with cLBP
have specific deficits in motor control that impair generation of lumbar
extensor torque that may be missed in classic strength measures by com-
pensation with the hip extensors.
OPO181
SIT-TO-STAND WORKSTATIONS AND HOW THEY INFLUENCE PHYSICAL
AND PSYCHOLOGICAL WELL-BEING OF SEATED WORKERS: A SYSTEMATIC
REVIEW OF RCTS
Ahmed Radwan, Savannah Bernardin, Nicholas Ball,
Spencer Simmons, Julia C. Primps
Utica College, New Hartford, New York
PURPOSE/HYPOTHESIS: Increases in sitting behavior within the workplace
have led to multiple negative health conditions. Installation of sit to stand
workstations can allow users to alternate between the sitting and the
standing position. Currently, there is limited evidence on the benefit of
such workstations. The aim of this systematic review was to determine the
benefits of sit to stand workstations, both physically and psychologically,
on seated workers. This review provides useful knowledge to health care
professionals regarding ergonomics, health and wellness of employees.
NUMBER OF SUBJECTS: Systematic review of 5 randomized controlled trials.
MATERIALS/METHODS: Randomized control trials that studied the effects of
sit to stand workstations were searched and screened based on the following inclusion criteria; being peer-reviewed articles published between
January 1, 2011 till January 1, 2016, published in English language, and
having participants with an age range of 18 to 65 years. Articles were
searched over multiple databases by 2 independent reviewers, followed
by assessment of the methodological quality using the PEDro and The
Cochrane Collaboration’s tool for assessing risk of bias.
RESULTS: The literature search identified 275 potential articles, of these,
5 were included containing a total of 182 participants. The articles had
an average PEDro score of 6/10. Three articles were categorized as having an unclear risk of bias, while the remaining 2 articles were having
high risk of bias.
CONCLUSIONS: Alternating between sitting and standing during an average
workday with the use of a sit-to-stand workstation reduces musculoskeletal discomfort while maintaining or improving productivity standards.
CLINICAL RELEVANCE: Employers are encouraged to consider sit-to-stand workstations because of their affordability and potential benefits to employees.
OPO182
STRENGTH AND RANGE-OF-MOTION DEFICITS RELATED TO FUNCTIONAL
MOBILITY POST–MINIMALLY INVASIVE TOTAL HIP ARTHROPLASTY
Kelsi Rempe, Laura Covill, Vassilios Vardaxis
Physical Therapy, Des Moines University, Des Moines, Iowa
PURPOSE/HYPOTHESIS: Total hip arthroplasty (THA) is an effective surgical technique for individuals in end stage osteoarthritis (OA) for relief
of pain and improvement in functional mobility. Gait speed has been reported to predict independence in mobility, hospitalizations and fall-risk
in older adults [1]. In individuals with OA walking speed is reduced pre
surgery and continues to be limited 1 year post-THA [2]. Hasio [3] has
demonstrated a strong relationship between walking speed and peak anterior ground reaction force (aGRF). The primary contributors of peak
aGRF in increasing gait speed are trailing limb angle (TLA) and ankle
plantarflexion moment (Ma) [4]. TLA represents the line between the
center of pressure to the greater trochanter within the sagittal plane [3].
Additional gait abnormalities post THA include limited hip range of motion (ROM) and strength [5]. The purpose of this study was to assess how
ROM and strength deficits are related to TLA after THA between 2 minimally invasive surgeries (MIS), the posterolateral (PL) and direct anterior (DA).
NUMBER OF SUBJECTS: Forty end stage hip OA patients were recruited to
participate in the study. All patients received MIS THA; 20 patients received PL and 20 the DA approach.
MATERIALS/METHODS: Participants were tested at a self-selected walking
speed in the gait lab at presurgery, 3, and 12 months post-THA. Kinetic
and kinematic data were collected using Cortex 1.1.4. Gait parameters of
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walking speed, TLA, peak aGRF, Ma, and ankle moment arm were produced in Visual3D Version 5. ROM with standard goniometer and manual muscle testing of bilateral lower extremities was performed by an experienced physical therapist. Pearson coefficient of correlation were done
between TLA and hip extension ROM, hip abduction ROM, hip extension strength and hip abduction strength at Pre, 3, and 12 months on the
surgical leg with pooled, PL, and DA group data, in SPSS 22 (IBM), alpha at .05.
RESULTS: No significant correlation existed between TLA and hip extension and abduction ROM. TLA and hip extension strength showed correlation at pre (r = 0.60, P = .01) and 3 months (r = 0.36, P = .05) in pooled
data but only in pre between the PL (0.54, P = .05) and DA (0.63,P = .01)
group. In pooled data, hip abduction strength showed correlation at all
measurement time frames (pre: r = 0.40, P = .05; 3: r = 0.44, P = .01; 12: r
= 0.46, P = .01). The PL group had correlation in hip abductions strength
only at pre surgery (r = 0.41, P = .05) while the DA group at 3 (r = 0.50, P
= .05) and 12 months (r = 0.55, P = .05).
CONCLUSIONS: Hip extension strength appears to affect TLA before surgery and in early rehabilitation but its effect is nonsignificant as healing
continues. Hip abduction strength, usually considered controlling pelvic
alignment in the frontal plane, also has an effect on movement in the
sagittal plane by contributing to TLA throughout the healing continuum.
CLINICAL RELEVANCE: Focusing on hip extension and hip abduction strength
in early rehabilitation may improve gait speed and improve functional
mobility in individuals post-THA.
OPO183
CLINICAL MANAGEMENT OF CHRONIC UPPER QUADRANT PAIN:
“TOP DOWN” VERSUS “BOTTOM UP” APPROACH: CASE STUDY
Colleen Robinson, Michael Costello
Outpatient Physical Therapy, Cayuga Medical Center, Ithaca, New York
BACKGROUND AND PURPOSE: A strict biomedical model is giving way to a
deeper understanding of pain mechanisms including central sensitization and its management. This paradigm shift advocates clinicians address neuroplastic changes that may contribute to the condition via a “top
down approach” in addition to focusing on biomedical pathology alone,
“bottom up approach” (Priganc et al 2011). The purpose of this case report
is to describe how a top down approach was incorporated in the management of chronic neck and shoulder pain.
CASE DESCRIPTION: A 43-year-old man with 5-year history of neck and
shoulder pain, self-referred to physical therapy after being medically
cleared via lab tests and imaging. Physical therapy initially took a bottom
up approach, focusing on biomechanical impairments of ROM, strength
and pain via manual therapy, neurodynamics, and therapeutic exercise.
Since no significant functional or objective progression was seen after 4
weeks, the therapist hypothesized that impaired central processing of sensory information was relevant. The treatment focus was transitioned to
a top down approach. During phase II the therapist utilized a Graded
Motor Imagery program and Neuroscience Education for 8 weeks, resulting in meaningful improvements. In phase III, manual therapy and therapeutic exercise were reintroduced to address remaining physical impairments in a combined treatment approach. Patient was seen for 18 visits
over 4 months.
OUTCOMES: Initially the Patient-Specific Functional Scale (PSFS) was rated as follows: working on a computer, 5/10 and reaching overhead, 0/10.
The numeric pain-rating scale (NPRS) was constant 5/10. Range of motion (ROM) for shoulder abduction and flexion was 90° each. Following
phase I, PSFS remained unchanged, NPRS was 3/10 and constant.
Beginning with phase II, laterality recognition was tested with Recognise
Online. Accuracy for the left was 60%; response time was 3.5 seconds. In
phase II objective and functional measures began to improve. Laterality
accuracy improved to 67%; response time was 3.1 seconds, at discharge
90% accurate, 2.7-second response time. Abduction ROM progressed
from 105° in phase I, to 156° in phase II and 180° at discharge. In phase
II PSFS for computer work was rated 6/10, reaching overhead 8/10. At
discharge NPRS improved to 0 to 3/10. PSFS was 8/10 for working on
computer, 10/10 for reaching overhead.
DISCUSSION: For individuals with persistent pain, it is important to consider relevant pain mechanisms in terms of peripheral nociceptive input and
central processing mechanisms. When treating this patient with a strictly
physical impairment based, or bottom up approach, there was no significant improvement in pain or function. Over the course of treatment with
a change from a bottom up to a top down approach, significant improvement was seen in pain and function. The transition to consider both the
biopsychosocial and central mechanisms as contributors to pain proved
to be beneficial in treatment.
REFERENCES: Bowering KJ, O’Connell NE, Tabor A, Catley MJ, Leake
HB, Moseley GL, Stanton TR. The effects of graded motor imagery and
its components on chronic pain: a systematic review and meta-analysis. J Pain. 2013;14:3-13. Johannes C. Le K. Xiaolei Z. Johnston J.
Dworkin R. The prevalence of chronic pain in United States adults: results of an internet-based survey. J Pain. 2010;11:1230-1239. Louw A.
Diener I. Butler D. Puentedura E. The effect of neuroscience education
on pain, disability, anxiety, and stress in chronic musculoskeletal pain.
Arch Phys Med Rahabil. 2011;92:2041-2056. Moseley GL. Graded motor
imagery for pathologic pain: a randomized controlled trial. Neurology.
200626;67:2129-2134. Nielsen L. Henriksson K. Pathophysiological
mechanisms in chronic musculoskeletal pain (fibromyalgia): the role of
central and peripheral sensitization and pain disinhibition. Best Pract Res
Clin Rheumatol. 2007;21:465-480. Prignac V. Stralka S. Graded motor
imagery. J Hand Ther. 2011;24:164-168. Smart KM, Blake C, Staines A,
Doody C. Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and
‘central’ mechanisms of musculoskeletal pain. A Delphi survey of expert
clinicians. Man Ther. 2010;15:80-87. Walz A. Usichenko T. Moseley L.
Lotz M. Graded motor imagery and the impact on pain processing in a
case of CRPS. Clin J Pain. 2013;29:276-279.
OPO184
A RETROSPECTIVE ANALYSIS OF THE PRESEASON SCREEN USED IN
A PROFESSIONAL BALLET COMPANY, WITH RECOMMENDATIONS FOR
IMPROVEMENTS IN THE SCREEN
Thomas K. Robinson, Ashley Gowen, Amy Krichau,
Ciara Garcia, Ashley Henley
School of Physical Therapy, Belmont University, Nashville,
Tennessee
PURPOSE/HYPOTHESIS: The objectives were to determine if the current preseason screen used by the Nashville Ballet was identifying dancers at risk
for injury, to determine the injury rates and patterns of injury within the
company and to propose measurement tools to enhance the preseason
screen.
NUMBER OF SUBJECTS: Past screen history from the 2007-2014 seasons was
obtained from 285 medical records. Additionally, 17 professional dancers from the Nashville Ballet (11 female, 6 male) were assessed prior to
the 2015 season.
MATERIALS/METHODS: Past screen history from the 2007-2014 seasons
was obtained from 285 medical records. The ability of the established
preseason screen to predict injury among the injured dancers was determined by noting side-to-side differences specifically in the manual muscle test and functional movement analysis portions of the screen.
Additionally, 17 Nashville Ballet dancers from the 2015 season (11 female,
6 male) were included in the study. Strength was assessed by hand dynamometry on the gluteus maximus and gluteus medius muscles of each
subject. Three-dimensional motion analysis of the dancers performing
demi-plies on the right and left sides in parallel and in turnout were assessed. Paired-samples t tests were run with a Bonferroni correction and
significance was set at P≤.05.
RESULTS: All injuries reported during the 2007-2014 seasons were in the
lower extremity. Previous preseason screen data showed the manual mus-
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cle testing identified side-to-side gluteus medius differences in 26.92%
(n = 26). Visual assessment of alignment while performing a plie in parallel and in turnout identified side-to-side differences in 23.08% and
26.92% respectively of the injured dancers. When assessing strength
with the hand dynamometer, a significant difference was found between
right and left gluteus maximus strength in percent body weight (P<.001)
and right and left gluteus medius strength in percent body weight (P =
.025). For the 2015 season, gluteus maximus side-to-side differences were
found in 80% (n = 5) of injured dancers. When assessing alignment using MyoMotion Kinematic Analysis, right and left hip external rotation in
turnout was found to be significant (P = .004).
CONCLUSIONS: Professional ballet dancers are at an increased risk for lower
extremity injuries because the current preseason screen used by professional ballet companies only identifies 25.64% of side-to-side differences.
Adding more objective screening equipment such as the hand dynamometer and 3-D motion analysis is recommended to improve the preseason
screen and to better identify dancers at risk for injury.
CLINICAL RELEVANCE: The current preseason screen that is used for professional ballet does not appear to be adequately identifying dancers who
are at risk for injury. However, by adding more objective tests such as dynametric strength measurements of the gluteal muscles and 3-D analysis
of common dance moves should improve the preseason screens to identify at risk performers.
OPO185
THREE-DIMENSIONAL METATARSAL PROTRUSION DISTANCE: A POTENTIAL
RISK FACTOR FOR BUNION
Michael Rodriguez, Kara Pioske, Ward M. Glasoe
University of Minnesota, Minneapolis, Minnesota
PURPOSE/HYPOTHESIS: First metatarsal protrusion distance (MPD) has
been studied as contributing to bunion formation. A bunion (hallux valgus) is a deformity that presents as a lateral deviation of the hallux with
a corresponding medial deviation of the first metatarsal. To date, the majority of investigations have used radiographic (2-D) methods, with most
reporting a long first metatarsal as a characteristic of hallux valgus. This
study measured MPD using a 3-D computer image reconstruction modeling process, testing the null hypothesis of no group difference in women
with hallux valgus compared to controls.
NUMBER OF SUBJECTS: Twenty-nine women (mean ± SD age, 59 ± 17 years)
were divided into groups (controls, n = 10; hallux valgus, n = 19) based on
the hallux valgus angle. An angle larger than 15° indicated hallux valgus.
MATERIALS/METHODS: Magnetic resonance images of the foot were acquired
in weightbearing on all women. The images were reconstructed into virtual bone model data sets. Two examiners, using a computer tool, measured the distance (length) of the first and second metatarsals in relation to the navicular. Relative difference between length measures was
recorded as MPD. In addition to a reliability analysis, an independent t
test assessed for group differences in demographics (age and BMI) and
foot posture (hallux valgus and intermetatarsal angles), and for the measurement of MPD.
RESULTS: Demographics were not different (P value was approximately
.46), while the hallux valgus and intermetatarsal angles were different
(P<.01) between groups. The interexaminer measurements of MPD were
reliable (ICC = 0.99; SEM, 0.78 mm), and averaged approximately –2.0
mm regardless of group assignment. The negative value indicates that
length of the first metatarsal was short compared to the second metatarsal. There was no group difference (P = .89) in MPD.
CONCLUSIONS: This study used a novel 3-D method to calculate MPD in
subjects with and without hallux valgus. Finding no group difference, and
that the mean relative length of the first metatarsal was short with hallux
valgus runs counter to the existing literature. While unexpected, the result may prompt research to continue to investigate MPD as a characteristic of hallux valgus with 3-D methods, instead of relying solely on single
plane radiograph reports.
CLINICAL RELEVANCE: Our 3-D measurement results demonstrate that MPD
may not be a significant etiological factor of hallux valgus.
OPO186
COMPARISON OF 2 INTERVENTIONS FOR POSTERIOR CAPSULE TIGHTNESS
AND SHOULDER PAIN: A RANDOMIZED CONTROLLED TRIAL
Dayana Rosa, John Borstad, Julia K. Ferreira, Vander Gava,
Paula Camargo
Physical Therapy, The Ohio State University, Columbus, Ohio;
Physical Therapy, Federal University of São Carlos, São Carlos, Brazil
PURPOSE/HYPOTHESIS: Glenohumeral joint posterior capsule tightness
(PCT) is related to altered internal (IR) and external (ER) rotation of the
shoulder, decreased external rotation strength in overhead athletes [1,2],
and shoulder pain [3-6]. Considering that PCT and shoulder pain can result in significant functional limitations, studies evaluating the effectiveness of targeted treatment for PCT are needed. This study compared the
effects of 2 interventions on PCT, IR and ER ROM, ER strength, pressure
pain threshold (PPT), and subjective outcomes in individuals with shoulder pain and PCT.
NUMBER OF SUBJECTS: Fifty-two individuals with PCT and shoulder pain.
MATERIALS/METHODS: Subjects were randomized to 2 groups: experimental (mean ± SD age, 41.2 ± 12.8 years; weight, 78.8 ± 13.4 kg; height, 1.72
± 0.09 m; 41.4 ± 55.3 months of pain) and sham (age, 40.1 ± 12.1 years;
weight, 76.1 ± 15.8 kg; height, 1.69 ± 0.08 m; 42.4 ± 35.9 months of pain).
Self-reported shoulder pain was confirmed with a clinical examination
[7,8]. PCT was determined by a difference between shoulders of at least
7° in the low flexion (LF) test [9]. IR and ER ROM was measured with
a digital inclinometer at 90° of shoulder abduction with 90° elbow flexion. ER strength was measured with a handheld dynamometer. A blinded evaluator took each measurement twice. PPTs for the upper trapezius,
infraspinatus, supraspinatus, deltoid, levator scapulae and tibialis anterior were assessed 3 times each with a digital algometer. Subjective outcomes were recorded using the SPADI. All variables were evaluated at
pre- and posttreatment. The experimental protocol included GHJ posterior glide mobilization (5 minutes), sleeper stretching (3 × 30 seconds)
and ER strengthening (3 × 10 repetitions). The sham group protocol included placebo ultrasound (5 minutes), upper trapezius stretching (3 × 30
seconds) and scapular retraction (3 × 10 repetitions). Both protocols were
performed 3 times per week for 4 weeks. A mixed-model ANOVA compared groups over time with significance set at P<.05.
RESULTS: There was a significant interaction (P = .002) for PCT. The experimental group had increased LF test posttreatment (22.8° ± 1.6°) compared to the sham group (17.5° ± 1.6°). There was a significant main effect
of time for IR ROM, with increased IR ROM (4.56° ± 1.4°) at posttreatment. No significant effects were found for ER ROM or ER strength.
PPTs increased significantly for upper trapezius, supraspinatus and deltoid at posttreatment for both groups. Both groups had significantly decreased pain and improved function posttreatment.
CONCLUSIONS: The experimental protocol was effective at improving PCT,
while both protocols were effective in reducing pain and improving function, IR ROM and local pain sensitivity in individuals with shoulder pain
and PCT.
CLINICAL RELEVANCE: Matching a treatment (GHJ mobilization) to a specific impairment (PCT) was more effective at improving motion than
a nonspecific sham treatment, but not more effective for altering other
outcomes. Possible reasons for this finding includes (1) natural recovery,
(2) placebo effect from therapist interaction, (3) a real effect of shoulder movement in the sham protocol, and (4) the chronicity of symptoms.
OPO187
THE INTERNAL CONSISTENCY OF A MODIFIED VERSION OF THE LOWER
EXTREMITY FUNCTIONAL SCALE FOR PATIENTS RECEIVING A TOTAL JOINT
ARTHROPLASTY
James R. Roush, Thomas J. Curtis, Curt Bay, Randall J. Case,
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Blair J. Packard, Robert L. Whipple, Paul James
East Valley Physical Therapy and Aquatic Rehabilitation, Mesa,
Arizona; Physical Therapy, A. T. Still University of Health
Sciences, Gilbert, Arizona
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PURPOSE/HYPOTHESIS: To examine the internal consistency of a modified
version of the Lower Extremity Functional Scale (mLEFS) for patients
following total knee arthroplasty at the initial examination and at discharge for physical therapy services. The differences between the original
LEFS (oLEFS) and the mLEFS were several items on the oLEFS such as
running on even and uneven ground, making sharp turns while running
fast, hopping, and walking a mile were eliminated in the mLEFS; as these
items may not be appropriate physical therapy goals for older adults at an
outpatient facility. Wording changes were also made to the instructions
to make it easier for patients to answer the questions without assistance.
The total number of questions for the mLEFS was reduced from 20 in the
original instrument to 15, with a maximum score of 60.
NUMBER OF SUBJECTS: This was a retrospective study of 66 patients through
a systematic chart review.
MATERIALS/METHODS: Patients were included if the participant had undergone a total knee arthroplasty or a revision surgery. Patients also had to
have completed the mLEFS a minimum of twice to be included in the
study: once at initial examination and once at discharge. Cronbach’s alphas were calculated for both pretest and posttest of the mLEFS to estimate internal consistency of the scale. A dependent-samples t test was
calculated to assess the significance of the difference between the pretest
and posttest scores. An exploratory factor analysis was also conducted to
assess the dimensionality of the revised scale.
RESULTS: The sample consisted of 40 females and 26 males. Average ± SD
age of the patients was 69.77 ± 9.29 years. The average ± SD number of
visits was 12.03 ± 4.54. The mean score for the pretest was while the mean
score for the posttest was. The mLEFS posttest score was significantly
higher (46.94 ± 8.66) than the pretest score (33.97 ± 12.46; P<.001), At
the initial examination, Cronbach’s alpha was .93, which is considered
high. For the posttest examination, Cronbach’s alpha was .89. Results of
the exploratory factor analysis suggested the presence of at least 2 dimensions, 1 associated with activities of daily living, and the other with walking-related tasks.
CONCLUSIONS: The mLEFS exhibited high internal consistency and revealed a significant change in pretest to posttest administration; however it appears that this scale may be optimally interpreted using more
than 1 scale score. Preliminary analysis of the mLEFS in patients with total joint arthroplasty suggests that this truncated scale may be more efficient and useful in this population than the oLEFS. Further investigation is ongoing.
CLINICAL RELEVANCE: We believe the mLEFS is an improvement on the
oLEFS because items such as running on even and uneven ground, making sharp turns while running fast, hopping, and walking a mile, which
are inappropriate for older adults recovering from total knee arthroplasty.
We believe the instructions were improved to make it easier for patients
to answer the questions without assistance.
OPO188
EFFICACY OF INSTRUMENT-ASSISTED SOFT TISSUE MOBILIZATION
IN COMPARISON TO GASTROCNEMIUS-SOLEUS STRETCHING FOR
DORSIFLEXION RANGE OF MOTION
Carrie Rowlett, William J. Hanney, Jordon Holland,
Morey J. Kolber, Xinliang Liu, Michael Masaracchio
Physical Therapy, University of Central Florida, Orlando, Florida
PURPOSE/HYPOTHESIS: Limited dorsiflexion range of motion (DF ROM) is
associated with numerous injuries that can alter or limit function [1].
Evidence supports stretching interventions to increase DF ROM [2];
however, limited research is available on the efficacy of InstrumentAssisted Soft Tissue Mobilization (IASTM). This study investigates
IASTM and its impact on DF ROM in comparison to traditional stretch-
ing interventions.
NUMBER OF SUBJECTS: Sixty.
MATERIALS/METHODS: Utilizing a randomized controlled trial, partici-
pants were allocated to 1 of 3 groups: IASTM, stretching and control.
The IASTM group received treatment for 2 minutes in a direction parallel to the muscle fibers [3]. The stretching group was instructed in a wall
stretch with the knee extended and then flexed for 3 bouts of 30 seconds
each. DF measurements were assessed before and after interventions to
analyze immediate effects of interventions in weight bearing (WB) versus
nonweight bearing (NWB) conditions. The outcome measures included
the Weight Bearing Lunge Test (WBLT) using a digital inclinometer [4]
as well as the Modified Root Position 1 (MRP1) with the knee extended at
0° and the Modified Root Position 2 (MRP2) with the knee flexed to 90°
using a goniometer [5]. Paired t tests were conducted to evaluate within-group significance. Between-group comparisons were analyzed using
2-way analyses of variance (ANOVAs). Post hoc Tukey’s analyses were utilized to compare mean changes between the groups.
RESULTS: No significant differences in ROM were identified between
groups at baseline. A group-by-time interaction revealed statistically significant changes in ankle DF in the WBLT (P = .011) and MRP2 (P =
.031) favoring the stretching and IASTM groups. No significant changes were observed with the knee extended to 0° for all groups (P = .943).
Specifically, a significant difference was identified with the IASTM intervention for both the WBLT (P = .018) and the MRP2 (P = .045) measures
when compared to controls. Significant improvements were also found
for the stretching group, however, only in the WBLT position (P = .034).
No significant difference existed between the intervention groups. No
within-group significant differences were identified in the control group.
CONCLUSIONS: IASTM produced a statistically significant increase in DF
ROM in WB and NWB conditions compared to control as demonstrated with the WBLT and MRP2. Stretching revealed a statistically significant improvement in WB with the WBLT. It is possible to suggest that
the soleus was attributed to the greatest influence on the increase in ROM
based on significant results with the knee in flexed positions. The results
also suggest that IASTM was more effective than stretching at improving ankle DF ROM in NWB conditions based on MRP2 measurements.
CLINICAL RELEVANCE: Foot and ankle pathologies are inherently associated with WB stresses and limited DF. Since IASTM and stretching both
revealed significant increases in ROM with the WBLT, these interventions can be considered viable treatment options for increasing DF ROM.
OPO189
THE USE OF PAIN NEUROSCIENCE EDUCATION IN OLDER ADULTS WITH
CHRONIC BACK AND/OR LOWER EXTREMITY PAIN
Adam Rufa, Katherine Beissner, Michelle Dolphin
Physical Therapy Education Department, SUNY Upstate Medical
University, Syracuse, New York
PURPOSE/HYPOTHESIS: Chronic pain is highly prevalent among older adults
and contributes to disability [1,2] and increased health service utilization
[3]. Analgesic options are limited due to high levels of comorbidity and
the potential for adverse drug reactions [4]. Pain Neuroscience Education
(PNE) has demonstrated effectiveness in reducing pain and improving
pain self-efficacy in individuals under 60 years of age [5,6], but there is a
paucity of research examining its use with older adults. If PNE has similar
effects in older adults, it has the potential to be a useful nonpharmacological intervention for the older adult population. The purpose of this pilot
project is to determine whether older adults with chronic pain conditions
are receptive to PNE and to determine potential efficacy of this treatment
in terms of pain intensity, kinesiophobia, and mobility.
NUMBER OF SUBJECTS: Twenty.
MATERIALS/METHODS: Twenty subjects, 9 female, aged 65 to 88 (mean age,
73 years) years, reporting low back and/or lower extremity pain on most
days for at least 3 months attended 2 study sessions. The first session
started with data collection including demographic information, Tampa
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Scale of Kinesiophobia (TSK), Pain Disability Index (PDI), Resilience
Scale (RS-14) and Gait Speed. Subjects then received an approximately 60-minute, semi-standardized PNE session. Between sessions they
were asked to read a booklet reinforcing the information from the education session. The second session occurred 2 weeks later and began
with a review of the PNE and provided an opportunity for subjects to ask
questions and express their experience. Immediate posttesting included
the TSK, PDI, Gait Speed and the PNE Acceptability Scale (PAS). Data
were analyzed descriptively and paired t tests were used for prepost test
comparisons.
RESULTS: All subjects reported a positive perception of the educational sessions and universally indicated that, the information was easy to understand, interesting and clear. All but 2 subjects felt that they learned something new and 2 subjects felt that the sessions were too short. Eighteen
subjects believed most of the information and 2 believed some of it.
Subjects universally felt that the education would be helpful to people
in pain and all 20 would recommend PNE to a friend in pain. There was
a statically significant reduction in PDI (P = .001) and TSK (P = .002)
scores after PNE. There were no changes in gait speed.
CONCLUSIONS: Adults over the age of 65 are able to understand PNE and
find it useful. The educational sessions also show potential efficacy for reducing disability and kinesiophobia.
CLINICAL RELEVANCE: There is a high prevalence of chronic pain in adults
over the age of 65. These results suggest that PNE may be an effective intervention for treating chronic pain in this population.
OPO190
TREATMENT MODIFICATIONS IN THE PHYSICAL THERAPY MANAGEMENT
OF A PATIENT WITH CHRONIC LOW BACK PAIN AND SIGNS AND SYMPTOMS
OF CENTRALIZED PAIN: A CASE REPORT
Estey Ruppal, Stephanie Wickham, Joel E. Bialosky
Physical Therapy, University of Florida, Gainesville, Florida; VA
Medical Center, Gainesville, Florida
BACKGROUND AND PURPOSE: Central sensitization is believed to play a role
in the transition from acute to chronic pain, as well as contribute to the
sustainment of chronic pain. Signs and symptoms of centralized pain are
hallmark characteristics of some chronic pain conditions including a subgroup of individuals with chronic low back pain necessitating treatment
modifications. The purpose of this case report is to describe modifications
to clinical practice guidelines in the physical therapy management of a
patient with low back pain and signs and symptoms of centralized pain.
CASE DESCRIPTION: The patient was a 52-year-old woman who presented to physical therapy with a 5-month history of low back and left lower extremity pain. Her past medical history was significant for fibromyalgia, migraines, and irritable bowel syndrome. The patient completed
the Central Sensitization Inventory during her initial visit and scored
a 71/100. Her score on the Central Sensitization Inventory along with
her past medical history of fibromyalgia, migraines, and irritable bowel syndrome suggested a centralized pain component to her clinical
presentation. Furthermore, she scored a 20/24 on the Fear-Avoidance
Beliefs physical activity subscale indicating a potentially poor prognosis for recovery. The patient was classified using the Orthopaedic Section
of American Physical Therapy Association’s clinical practice guidelines
into the categories of chronic LBP with movement coordination impairments and chronic LBP with generalized pain. Treatment was provided
as directed by the guidelines. Important modifications included the use
of pain neuroscience education, graded activity, graded exposure, and activity pacing. Additionally, a Transcutaneous Electrical Nerve Stimulation
(TENS) unit was provided for use at home during functional activities as
this has been shown to positively alter centralized pain.
OUTCOMES: Key outcomes included fear avoidance beliefs and activity as
measured by a pedometer. The patient was seen for 3 physical therapy
sessions over 6 weeks. Clinically meaningful improvements were observed
in both physical activity and fear-avoidance beliefs.
DISCUSSION: This case describes clinically meaningful improvements in
outcomes in a patient with chronic low back pain and signs of a centralized pain condition in whom modifications were made to a treatment approach guided by clinical practice guidelines.
REFERENCES: 1. Delitto A, George SZ, Dillen LV, Whitman JM, Sowa
G, Shekelle P, Denninger TR, Godges JJ. Low back pain clinical practice guidelines linked to the International Classification of Functioning,
Disability, and Health from the Orthopaedic Section of the American
Physical Therapy Association. J Orthop Sports Phys Ther. 2012;42: A1A57. 2. Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy
for individuals with chronic pain: efficacy, innovations, and directions for
research. Am Psychol. 2014;69:153-166. 3. Mayer TG, Neblett R, Cohen
H, Howard KJ, Choi YH, Williams MJ, Gatchel RJ. The development and
psychometric validation of the central sensitization inventory. Pain Pract.
2012;12:276-285. 4. Nijs J, Meeus M, Van Oosterwijck J, Roussel N, De
Kooning M, Ickmans K, Matic M. Treatment of central sensitization in
patients with “unexplained: chronic pain: what options do we have? Exp
Opin Pharmacother. 2011;12:1087-1098. 5. Noehren B, Dailey DL, Rakel
BA, Vance CG, Zimmerman MB, Crofford LJ, Sluka KA. Effect of transcutaneous electrical nerve stimulation on pain, function, and quality of
life in fibromyalgia: A double-blind randomized clinical trial. Phys Ther.
2015;95:129-140.
OPO191
THE EFFICACY OF STRETCHING EXERCISES TO REDUCE POSTERIOR
SHOULDER TIGHTNESS ACUTELY IN THE POSTOPERATIVE POPULATION:
A SINGLE-BLINDED RANDOMIZED CONTROLLED TRIAL
Paul Salamh, Morey J. Kolber, Eric J. Hegedus, Chad E. Cook
Orthopedics, Duke University, Durham, North Carolina; Nova
Southeastern University, Fort Lauderdale, Florida; High Point
University, High Point, North Carolina
PURPOSE/HYPOTHESIS: Shoulder stiffness is a common postoperative complication among individuals having undergone shoulder surgery, with an
incidence of persistent postoperative shoulder stiffness ranging from 1.5%
to 11.1% [1-3]. Of those with postoperative shoulder stiffness requiring a
secondary capsular release, 95.5% exhibited impaired glenohumeral internal rotation; implying a contribution of the posterior shoulder structures [2]. A number of studies have investigated the effectiveness of
stretching exercises for improving overall shoulder range of motion in individuals with posterior shoulder tightness (PST) [4-7] and findings support improvements in both range of motion and complaints of impingement (with symptomatic populations) using exercises such as the sleeper
stretch [4], the cross-body stretch [5], and horizontal adduction stretching with and without joint mobilization [8]. However, none of the reported studies investigated the effectiveness of these stretching methods on
shoulder stiffness in a postsurgical cohort. The purpose of this study was
to determine the short term efficacy of 2 separate stretches designed to reduce PST in the postoperative population.
NUMBER OF SUBJECTS: Sixty-three.
MATERIALS/METHODS: The study was a randomized control trial in which
patients who had arthroscopic shoulder surgery were assigned to 1 of 3
groups (horizontal adduction, modified sleeper, or control). Dependent
variables included measurements of internal rotation (IR) mobility, sidelying PST, pain, and the QuickDASH. Following the physical therapy initial evaluation, subjects were instructed to perform the allocated intervention until their first follow-up appointment 48 to 72 hours following
the initial PT visit.
RESULTS: The study enrolled 63 patients (mean age, 51 years). Between
group analyses of dependent variables revealed significant differences
within PST measurements (P = .005) taken at baseline and follow-up (4872 hours) favoring horizontal adduction stretching. Post hoc testing demonstrated superiority of horizontal adduction stretching over both the
modified sleeper group (P = .01) and control (P = .002). There was no significant differences seen between groups with regards to IR, pain scores,
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or QuickDASH scores measured at baseline and follow-up (P>.05).
CONCLUSIONS: The horizontal adduction stretch is more effective at reducing acute PST in the postoperative shoulder population when compared
to the modified sleeper stretch and no stretch at all. Knowledge of efficacious stretching methods may serve to reduce the potential morbidity associated with postoperative stiffness.
CLINICAL RELEVANCE: Postoperative shoulder stiffness, particularly PST,
has been linked to complications following procedures. This study demonstrates that addressing PST early utilizing the horizontal adduction
stretch among this population can help to reduce postoperative shoulder
stiffness without increasing pain or decreasing overall function.
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OPO192
TASK-SPECIFIC MOVEMENT TRAINING: EFFECT ON LOWER EXTREMITY
KINEMATICS, PAIN, AND ACTIVITY PARTICIPATION IN FEMALES
WITH PATELLOFEMORAL PAIN
Gretchen B. Salsich, Barb Yemm, Angela Reitenbach,
Catherine E. Lang, Linda R. Van Dillen
Physical Therapy, Saint Louis University, St Louis, Missouri;
Program in Physical Therapy, Washington University School of
Medicine, St Louis, Missouri
PURPOSE/HYPOTHESIS: Dynamic knee valgus (DKV), a movement pattern
characterized by increased hip adduction, hip internal rotation and knee
external rotation, has been linked to pain in females with chronic patellofemoral pain (PFP). Optimizing movement during daily activities may be
an effective rehabilitation strategy. This pilot study investigated whether a novel, task-specific movement pattern training intervention would
improve hip and knee kinematics, pain, and activity participation in females with PFP.
NUMBER OF SUBJECTS: Twenty-three females with PFP of approximately 2
months’ duration who demonstrated observable DKV during single limb
squat (mean ± SD age, 21.8 ± 3.7 years; BMI, 22.2 ± 2.0 kg/m2; pain duration, 4.1 ± 3.4 years). Average pain (past week) was 3.7 ± 1.0 (numeric
pain rating, 0-10).
MATERIALS/METHODS: The intervention was delivered 2 times per week
for 6 weeks and consisted of practice of daily activities with a focus on
minimizing DKV. Activities were selected and progressed based on subjects’ interest and ability to minimize DKV without an increase in pain.
Minimal feedback was given, once subjects demonstrated knowledge of
key movement concepts. Primary outcomes were kinematics (hip adduction, hip internal rotation, knee external rotation) at peak knee flexion
during a single limb squat, pain (visual analog scale [0-100]: maximum
during past week), and activity participation (Patient-Specific Functional
Scale, 0-10, 10 is no limitation). Outcomes were assessed (1) before treatment (2 baselines, separated by 6 weeks), (2) posttreatment, and (3) 4
weeks posttreatment. Comparisons were made using mixed model, repeated measures analysis of variance tests (P<.05).
RESULTS: For all outcomes, differences during the treatment phase (baseline 2 to posttreatment) were greater than differences during the control
phase (baseline 1 to baseline 2) (P<.0001). Following treatment, improvements were detected in hip adduction (8.4° ± 6.7° versus 17.9° ± 5.8°),
hip internal rotation (–7.5° ± 6.1° versus –0.7° ± 5.6°), knee external rotation (9.1° ± 4.9° versus 4.2° ± 5.3° of internal rotation), pain (17.1 ± 14.4
versus 42.7 ± 20.8) and activity participation (8.5 ± 0.9 versus 5.9 ± 1.3).
Improvements in all outcomes remained at 4 weeks posttreatment compared to baseline 2.
CONCLUSIONS: Lower extremity movement (hip and knee kinematics),
pain, and activity participation improved in females with PFP following
a 6-week task-specific, movement pattern training intervention. A larger
clinical trial to substantiate these findings is warranted.
CLINICAL RELEVANCE: A physical therapy intervention comprised solely of
movement pattern training during patient-selected tasks may yield positive outcomes in young women with PFP.
OPO193
THE CORRELATION BETWEEN PECTORALIS MINOR MUSCLE LENGTH AND
ROTATOR CUFF STRENGTH USING A COMBINATION SQUARE AND BASELINE
PUSH-PULL DYNAMOMETER
Stephanie Saltarelli, Margaret Vieria, Alexia Kwiatkowski,
Ayse Ozcan Edeer, Valerie Olson
Doctor of Physical Therapy Program, Dominican College,
Orangeburg, New York
PURPOSE/HYPOTHESIS: The chronically tight pectoralis minor muscle pulls
the scapula into elevation and protraction by its attachment to the coracoid processes. This contributes to grossly altered shoulder girdle kinematics by directly interfering with scapular displacement and glenohumeral
joint positioning which further interferes with the resting length-tension
relationship of the rotator cuff musculature. The aim of this research is to
determine whether a relationship between pectoralis minor length and rotator cuff strength exists. Our hypothesis is that a shortened pectoralis minor muscle is associated with decreased rotator cuff strength.
NUMBER OF SUBJECTS: Forty-six young heathy college students (25 male, 21
female) aged 26.4 + 5.0 years.
MATERIALS/METHODS: Three researchers collected the data, and each was
assigned to 1 specific component to measure consistently (researcher 1
measured pectoralis minor length, researcher 2 measured rotator cuff
strength, and researcher 3 measured scapular displacement). The informed consent and demographic information were collected at the initial administration. A combination square was used to measure pectoralis
minor length in standing with subject against the wall, from the anterior
tip of the acromion to the wall. A Baseline handheld push-pull dynamometer was used to quantify strength of shoulder external rotators, internal
rotators, and abductors. A standard tape measure was used to measure
scapular displacement from midline to inferior angle at rest, 90° and 180°
of scaption. Pearson product-moment correlation coefficient was used for
data analysis.
RESULTS: The Pearson correlation coefficient at 95% confidence level between pectoralis minor length and shoulder internal and external rotator, and abductor strength showed a statistical significant moderate to
strong positive correlations (r = 0.552, P<.01; r = 0.619, P<.01; r = 0.542,
P<.01, respectively). Pectoralis minor length and scapular displacement
at rest, 90°, and 180°, also showed statistically significant weak to moderate positive correlations (r = 0.298, P<.01; r = 0.259, P<.01; r = 0.301,
P<.01, respectively).
CONCLUSIONS: Results of this study show correlation of pectoralis minor
length and the strength of the rotator cuff and scapular displacement.
Assessing the pectoralis minor length as a component of shoulder evaluation may enhance clinical outcomes. We thus recommend that physical
therapists consider a pectoralis minor assessment in the plan of care that
intends to rehabilitate and strengthen rotator cuff musculature.
CLINICAL RELEVANCE: It is important to consider the dynamic role of pectoralis minor length in patients who demonstrate postural mal-alignment
and shoulder rotator cuff problem. Restoring optimal pectoralis minor
length will restore optimal kinematics of the shoulder girdle which will
create better positioning for length-tension relationships of the rotator
cuff musculature.
OPO194
SOFT TISSUE MOBILIZATION VERSUS ECCENTRIC EXERCISE FOR THE
TREATMENT OF TENDINOSIS
John P. Sanko, Nicholas Laurente, Jesse Myers,
Robby Ondevilla, Justin J. Ramalho
Physical Therapy, University of Scranton, Scranton, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose of this systematic review was to determine the effectiveness of soft tissue mobilization compared to eccentric
exercise in the treatment of tendinosis in terms of pain reduction and
functional outcomes.
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NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: A literature search (2006-2016) of CINAHL,
MEDLINE, Web of Science, Science Direct, and PubMed using the search
terms: (tendinosis OR tendinopathy) AND (ASTYM OR eccentric exercise). Selection criteria: RCTs, human subjects, and English language.
Two reviewers independently assessed each article for methodological
quality and came to consensus based on PEDro scoring guidelines.
RESULTS: A total of 508 articles were screened for eligibility. Following detailed appraisals, 7 RCTs fulfilled criteria. PEDro scores ranged from 6
to 9/10 (average, 7.3). Samples ranged from 16 to 120 subjects (430 total) with chronic tendinopathy pathology in the shoulder, elbow, knee,
and heel cord across all studies. Ecc was performed for 3 sets of 15 repetitions for 1.67 times per day, 2 to 7 days per week, averaging 9.67 weeks
duration (4-12 weeks). ST was performed for 2.33 times per week averaging 9.33 weeks duration (4-12 weeks). Primary outcomes included the
DASH, VISA-A, and VAS. No adverse events were reported. There were
statistically significant between-group improvements noted in functional outcome measures (VISA-A and DASH) following Ecc and ST versus
Ecc alone in 2 studies. There were statistically significant between-group
improvements noted in pain (VAS) following Ecc versus concentric exercise in 1 study. There were statistically significant improvements noted in functional outcome measures (VISA-A) following Ecc in 1 study.
There were no statistically significant between-group improvements noted in functional outcome measures (VISA) following Ecc versus surgery
in 1 study. There were no statistically significant between-group improvements noted in functional outcome measures (VISA-A) following Ecc versus heavy slow resistance in 1 study. There were no statistically significant
between-group improvements noted in pain (VAS) following ST versus
Therapeutic Exercise in 1 study.
CONCLUSIONS: There is moderate to strong evidence in support of an intervention that includes Ecc versus ST alone for improving pain and functional outcome scores in persons with chronic tendinopathy. Ecc and ST
together have an advantage over Ecc or ST alone. Limitations included
small samples and a lack of blinding participants. Future RCTs should
focus on an optimal dose of Ecc as well as well-defined ST technique for
treating chronic tendinopathy.
CLINICAL RELEVANCE: The outcomes for Ecc and ST together appear superior compared to other forms of treatment for improving functional outcomes in adults with chronic tendinopathy. Effective treatment protocols
use Ecc, for 3 sets of 15 repetitions, and ST 4 to 5 days per week for 9
weeks. Implementing interventions consisting of Ecc and ST are safe and
feasible methods for treating chronic tendinopathy.
OPO195
CLINICAL UTILITY AND RELIABILITY OF CORE ENDURANCE ASSESSMENT
IN A HEALTHY, NORMATIVE POPULATION
Lauren K. Sara, Michael O’Hara, Lucia DeLisa,
Steven M. Jackson
Midwest Orthopaedics at Rush, Chicago, Illinois; Good Shepherd
Penn Partners, Philadelphia, Pennsylvania; University of Chicago
Hospital, Chicago, Illinois; Orange Park Medical Center, Orange
Park, Florida
PURPOSE/HYPOTHESIS: The potential benefits of core endurance for the conservative management of spine and lower extremity conditions has been
well established in the literature. These studies often limit their ability
to describe a general population by selecting young, athletic individuals.
Further, proposed techniques often lack in reproducibility, clinical utility, and robust statistical findings. The purpose of this study was to collect
normative core endurance data for healthy individuals of varied age, sex
and activity levels. A secondary aim was to establish preliminary reliability data for quantification of core endurance.
NUMBER OF SUBJECTS: One hundred sixteen.
MATERIALS/METHODS: All subjects completed a health intake form and SF12 questionnaire prior to the study. Subjects then completed a practice
trial in a variety of positions, including prone, right, and left side planks.
After proper form was briefly demonstrated, subjects completed each
plank position to task failure. For each plank variation, 2 authors blinded
to one another began a timer once the intended testing position was assumed. Time was stopped as soon as any body part other than the feet or
forearm(s) touched the mat.
RESULTS: Mean core endurance was found to be 93 seconds in prone
plank, 40.58 seconds in left side, and 41.41 seconds in right side plank.
Independent t tests revealed significant differences between sex, those
with and without plank experience, and BMI of male versus female
participants. No significant difference was observed for age, functional
health, and exercise characteristics. Interrater reliability was found to be
strong among prone plank, left side plank, and right side plank positions.
CONCLUSIONS: Assessment of core endurance via prone and side planks
was found to have high interrater reliability. Additionally, there were
found to be statistically significant differences in plank hold times across
sexes, in those with prior plank exposure, and according to BMI. As identified in this study, plank hold times were lower in this population than
in many published research studies: specifically when compared to those
measuring plank hold time in higher-level athletes. Clinicians should recognize this when assessing core endurance in a general population. Data
collected for a more heterogeneous population may better represent those
persons most often seen in clinic, thereby optimizing clinical reasoning
and decision making for clinicians.
CLINICAL RELEVANCE: To the knowledge of the authors, this is the first study
of normative data for prone and side planks in a population more representative of the typical adult population seeking outpatient therapy services. When aggregated with existing core endurance data, the findings
from this study may assist in better describing normative core endurance in healthy individuals of varied activity levels. Minimal detectable
change as reported in this study may assist in appreciating the magnitude of change required to declare a true improvement in core endurance. Future research to establish involved musculature in prone and side
planks is indicated.
OPO196
THERAPEUTIC MANAGEMENT AND COMPLICATIONS IN PEDIATRIC
CONGENITAL FEMORAL DEFICIENCY: A CASE REPORT
Joel Sattgast, Lisa Nau, Heather Stremler
Physical Therapy, Davenport University, Grand Rapids,
Michigan; Lynden Family Physical Therapy, Lynden, Washington
BACKGROUND AND PURPOSE: Congenital abnormalities involving limb length
discrepancy of the femur affect pediatric gross motor, neuromuscular, and
social development. Currently, multidisciplinary management is used
to optimize function postnatally and into adolescence. However, therapeutic management is poorly reported and minimal research exists to
guide best-practice therapeutic intervention. This case report identifies
and describes the application of, and outcomes associated with, therapeutic management of pediatric congenital femoral deficiency in order
to contribute to and promote further discourse to develop best-practice
strategies toward managing this diagnosis from a physical, psychosocial,
cognitive dimension as well as patient-family-empowerment related to
self-care management.
CASE DESCRIPTION: A 4-year-old girl presented for rehabilitation following limb lengthening with external fixator secondary to congenital femoral deficiency (CFD) with greater than 40° loss of knee extension limiting
weight bearing, mobility, and ambulation. Evaluation included neuromuscular (strength, range of motion, circumference, balance, gait, movement control) and integumentary (wound care) assessment, as well as
communication with interdisciplinary care providers, pediatric surgeon,
and family. Intervention consisted of 6 weeks of soft tissue stretching and
mobilization, joint mobilization, dyna-splint use, self-care management
education, and creation and implementation of a “Brave Chart” for behavior modification and reinforcement.
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OUTCOMES: Improved soft tissue and joint mobility, increased weight bear-
ing functional use, and decreased emotional distress, combined with improved self-care management and brace compliancy, were observed
throughout the 6-week period. In particular, range of motion improved
from greater than 40° loss of flexion to lacking only 6° from full extension.
Functionally, ambulation was independent of wheeled walker at home
and community distances.
DISCUSSION: Biopsychosocial consideration should occur within the rehabilitation environment to consider the multidimensional approach to
managing CFD. Clear objective goals and outcome assessment should be
provided to the patient, family, surgeon, and other interdisciplinary medical professionals. Additionally, patients in the pediatric population may
require innovative encouragement and reinforcement for intervention
compliancy.
REFERENCES: Paley D Standard SC. Lengthening reconstruction surgery for congenital femoral deficiency. In: Rozbruch SR, Ilizarov S, eds.
Limb Lengthening and Reconstruction Surgery. New York, NY: Informa
Healthcare; 2007:393-428. Monsell FP, Bintcliffe FAC, Evans C, Hughes
R. Management of congenital femoral deficiency. Early Hum Develop.
2013;89:915-918. Oppenheim W, Setoguchi Y, Fowler E. Overview
and comparison of Syme’s amputation and knee fusion with the van
Ness rotationplasty procedure in proximal femoral focal deficiency. In:
Herring J, Birch JG, eds. The Child With a Limb Deficiency. Rosemont,
IL: American Academy of Orthopaedic Surgeons; 1998. Abdelgawad A,
Jauregui J, Standard S, Paley D, Herzenberg J. Prophylactic intramedullary rodding following femoral lengthening in congenital deficiency of the
femur. J Pediatr Orthop. 2015. Prince DE, Herzenberg JE, Standard SC,
and Paley D. Lengthening with external fixation is effective in congenital
femoral deficiency. Clin Orthop Relat Res. 2015:3261-3271.
OPO197
ALTERED JOINT KINETICS IN PATELLOFEMORAL JOINT OSTEOARTHRITIS
PROGRESSION DURING SIT-TO-STAND
Katherine Sawyer, Michael A. Samaan, Hsiang-Ling Teng,
Sharmila Majumdar, Richard B. Souza
University of California, San Francisco, San Francisco, California
PURPOSE/HYPOTHESIS: Patellofemoral joint osteoarthritis (PFJ OA) occurs
in 64% of adults over the age of 50 years and is known to cause pain and
dysfunction in the knee joint. The sit-to-stand (STS) task is a demanding
activity of daily living that is performed by healthy adults on average 60
times per day. Studies have shown altered lower extremity mechanics during the STS task in patients with hip OA and knee OA. Biomechanical assessment of the STS task in PFJ OA patients may prove beneficial in understanding the pathomechanics involved in the progression of PFJ OA.
We hypothesized that patients that exhibit PFJ OA progression over 1 year
would demonstrate altered sagittal plane biomechanical loading at baseline, during the STS task, when compared to nonprogressors.
NUMBER OF SUBJECTS: Thirty-three total patients with PFJ OA (Progressors:
n = 8; mean ± SD age, 52.5 ± 10.1 years; 1 male; BMI, 24.0 ± 2.3 kg/m2;
Nonprogressors: n = 25; age, 54.2 ± 9.5 years; 5 males; BMI, 23.5 ± 3.7
kg/m2).
MATERIALS/METHODS: All patients underwent 3-D motion analysis during
the STS task at baseline as well as a unilateral knee joint magnetic resonance (MR) scan at baseline and one-year follow-up. Lower extremity kinematics (250 Hz, VICON) and ground reaction forces (1000 Hz, AMTI)
were recorded while patients performed the STS task at a self-selected
speed. Sagittal plane hip, knee and ankle joint moments were computed using inverse dynamics (Visual3D) and were normalized to body mass
(Nm/kg). The total support moment (TSM) and the 3 individual joint
contributions of the hip, knee, and ankle (percent TSM) were calculated. Knee MR images were acquired using a high-resolution 3-D fast spinecho CUBE sequence. We used the Whole-Organ Magnetic Resonance
Imaging Score (WORMS), a semi-quantitative MR based scoring method, to grade patella and trochlear cartilage abnormalities. PFJ OA pro-
gression was defined as an increase of at least 1 in the WORMS score
for patella and/or trochlear cartilage lesions over the one-year time period. Group differences were assessed using an independent t test (P≤.05).
RESULTS: There were no group differences in demographics. Mean baseline ankle contribution to TSM during STS task was significantly lower
in PFJ OA progressors (14%) than nonprogressors (20.9%) (P = .048).
Although not significant, mean baseline hip and knee contributions were
4.3% and 4.5% higher, respectively, in progressors when compared to
nonprogressors.
CONCLUSIONS: PFJ OA progressors exhibited altered ankle joint compensation strategies at baseline when compared to nonprogressors.
CLINICAL RELEVANCE: Our findings suggest that altered ankle joint compensations may play a role in PFJ OA progression.
OPO198
SUCCESSFUL OUTCOME AFTER MONTHS OF DEBILITATING POSTCONCUSSION
SYNDROME USING CERVICOGENIC AND VESTIBULO-OCULAR TREATMENT
Gregory Schiller, Airelle O. Giordano
Physical Therapy, University of Delaware, Newark, Delaware
BACKGROUND AND PURPOSE: To explain a comprehensive plan of care for
the management of a patient with postconcussion syndrome (PCS).
Symptoms were cervicogenic and vestibulo-ocular, restricting tolerance
to driving and working as a manager of a restaurant, following a motor
vehicle collision (MVC); the second leading cause of TBI.
CASE DESCRIPTION: A 62-year-old man presented 4 months post-MVC with
postconcussion symptoms including cervical pain, headaches (HA), dizziness and episodes of disorientation/vomiting. Disorientation/vomiting
was concerning and occurred more than 40 times post-MVC. Physician
workup suggested episodes were likely migrainous or seizures. Treatment
of cervical/occipital nerve injections and PT, concentrating on balance
were unsuccessful. PMH included stroke following cardiac valve surgery,
Graves’ Disease, migraines and motion sickness. Evaluation included assessment of the cervical spine and vestibulo-ocular systems to determine
subtypes present. Activity-Specific Balance Confidence Scale (ABCS) 41
(low-level of physical functioning), Dizziness Handicap Inventory Scale
(DHIS) 56 (severe), Headache Disability Index (HDI): 16 (mild). Neuro/
vascular screen: (negative) except for diminished L C7 myotome. Cervical
testing: (negative) ligamentous testing, (positive) TTP of B UT and suboccipitals, with palpation decreasing dizziness and HA. AROM WNL except slight limitation in B rotation and SBing, joint mobility correlated
with AROM. Cervical Joint Position Error (JPE): R 1 error greater than
7 cm, L 3 errors greater than 7 cm. Cervical flexion endurance test: 19
seconds. Oculomotor testing: (positive) VOR, VOR cancellation, vertical saccades, left diagonal and horizontal smooth pursuits, all with dizziness. Motion Sensitivity Quotient: 31 (severe). Balance: SLS less than
3 seconds, unable to complete BESS test. Vestibular Testing: (negative)
testing for BPPV. Treatment: Cervical spine: STM, stretching/joint mobs,
JPE training and neck flexor endurance training. Oculomotor training:
VOR, VOR cancellation, saccades, smooth pursuit and optokinetic drills,
working from sitting in a quiet room to standing with narrow base of support (NBOS) and busy backgrounds like a disco ball. Motion Sensitivity:
Educated on a HEP utilizing oculomotor exercises and online videos at
home. Balance: NBOS, tandem stance and SLS progressing to compliant
surfaces and eyes closed.
OUTCOMES: Over 41 visits; 7 months, vomiting ceased, occasional disorientation lasting less than 10 seconds, reduction in dizziness to 1 to 2/10,
minimal neck pain and HA frequency less than 2 times per weeks that
he was able to modulate with self-STM. BESS: 34. Neck flexor endurance: 32 seconds, JPE L improved. Vestibulo-ocular testing: all (negative). ABCS: 91 (MDC, 13), DHIS: 28 (MCID, 18), HDI: 4 (MCID, 29).
Tolerance to bending/lifting, driving, and multitasking at work returned
to pre-MVC levels.
DISCUSSION: In order to manage PCS effectively, recognition of clinical subtypes and matching them with targeted treatment approaches is pivot-
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al. This approach allowed a patient, who was severely restricted at work
and driving, to return to all functional activities with minimal limitations.
REFERENCES: VA/DoD. Clinical practice guideline for management of concussion-mild traumatic brain injury. J Rehabil Res Dev. 2009;46:CP1CP68. Leddy JJ, Baker JG, Merchant A, et al. Brain or strain? Symptoms
alone do not distinguish physiologic concussion from cervical/vestibular
injury. Clin J Sport Med. 2015;25:237-242. Alsalaheen BA, Whitney SL,
Marchetti GF, et al. Relationship between cognitive assessment and balance measures in adolescents referred for vestibular physical therapy after concussion. Clin J Sport Med. 2016;26:46-52. O’leary S, Jull G, Van
Wyk L, Pedler A, Elliott J. Morphological changes in the cervical muscles
of women with chronic whiplash can be modified with exercise-a pilot
study. Muscle Nerve. 2015;52:772-779. Broglio SP, Collins MW, Williams
RM, Mucha A, Kontos A. Current and emerging rehabilitation for concussion: a review of the evidence. Clinics Sports Med. 2015;34:213-231.
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OPO199
THE EFFECT OF FOAM ROLLING COMPARED TO STATIC STRETCHING ON HIP
ADDUCTION RANGE OF MOTION
Ian Scott, Nina Kelly, Shawn Hunt
Physical Therapy, University of Miami, Coral Gables, Florida
BACKGROUND AND PURPOSE: The effectiveness of foam rolling (FR) to the
lateral thigh as an intervention to improve adduction range of motion
(ROM) is poorly understood despite its popularity as a treatment approach to address Iliotibial band (ITB) pathology. FR is also commonly
used in fitness as a warm-up, cool-down, or mobility exercise.
CASE DESCRIPTION: A 23-year-old female physical therapy student with bilateral positive Ober Test and bilateral lateral thigh pain, left greater than
right, performed static stretching (SS) on 1 lower extremity and FR on
the opposite lower extremity. Both interventions were self-administered
by the subject for 3 repetitions of 30 seconds, once per day during a 7-day
intervention period. ROM was assessed twice each day, first after a 5-minute warm-up on a stationary cycle, and again postintervention on each
lower extremity. Measurements were also taken on days 12 and 20 to determine the duration of each treatment effect. Measurements were recorded using a modified Ober test described by Reese and Bandy (2003).
The test position was marked on a paper template to ensure consistency
in position of subsequent measurements. Measurements were recorded
in degrees below horizontal via a fluid inclinometer on the lateral femoral
epicondyle. The Lower Extremity Functional Score (LEFS) was administered pre and postintervention to assess functional changes in lateral
thigh pain characteristics.
OUTCOMES: ROM increased from 5° to 25° on the SS yielding a negative
Ober test at intervention day 4. The FR extremity ROM improved from
6° to 19°, but failed to achieve a negative Ober test. At days 12 and 20 postintervention, the SS extremity remained at 23° both days, while the FR
extremity remained at 13° and 12° of ROM respectively. LEFS scores improved from 50/80 to 69/80 postintervention; however, the subject reported persistent pain in the proximal thigh of the FR lower extremity.
DISCUSSION: FR and SS both improved ROM, however SS appears to be
more effective providing clinical changes in special tests, ROM, and function, and with longer subject retention. ROM gains via SS versus FR are
consistent with previous research findings for hip flexion ROM, shoulder
external rotation ROM, and plantarflexion ROM. The force applied to the
ITB during FR may not provide the biomechanical stress/strain necessary
to elicit plastic deformation of the ITB longitudinally as effectively as SS.
LEFS scores did not describe unilateral changes, however the subject reported a substantial reduction pain on the SS extremity during prolonged
sitting after day 2, and pain-free sleeping in sidelying after day 3, which
persisted through day 20. Similar improvements were noted on the FR
extremity, however symptoms returned by day 10. Further investigation
is warranted to confirm the results obtained in this case study, and to examine the contribution of length changes of the Tensor Fascia Latae compared to the ITB to improvements in ROM.
REFERENCES: 1. Fairclough J, Hayashi K, Toumi H, et al. The function-
al anatomy of the iliotibial band during flexion and extension of the
knee: implications for understanding iliotibial band syndrome. J Anat.
2006;208:309-316. 2. Ferber R, Kendall KD, McElroy L. Normative and
critical criteria for iliotibial band and iliopsoas muscle flexibility. J Athl
Train. 2010;45:344-348. 3. Melchione WE, Sullivan MS. Reliability of
measurements obtained by use of an instrument designed to indirectly
measure iliotibial band length. J Orthop Sports Phys Ther. 1993;18:511515. 4. Mohr AR, Long BC, Goad CL. Effect of foam rolling and static stretching on passive hip flexion range of motion. J Sport Rehabil.
2014;23:296-299. 5. Noehren B, Schmitz A, Hempel R, Westlake C, Black
W. Assessment of strength, flexibility, and running mechanics in men
with iliotibial band syndrome. J Orthop Sports Phys Ther. 2014;44:217222. 6. Sullivan KM, Silvey DBJ, Button DC, Behm DG. Roller massager application to the hamstrings increases sit-and-reach range of motion
within 5 to ten seconds without performance impairments. Int J Sports
Phys Ther. 2013;8:228-236. 7. Allen DJ. Treatment of distal iliotibial
band syndrome in a long distance runner with gait retraining emphasizing step rate manipulation. Int J Sports Phys Ther. 2014;9:222-231.
8. Cheatham SW, Kolber MJ, Cain M, Lee M. The effects of selfmyofascial release using a foam roll or roller massager on joint range of motion,
muscle recovery, and performance: a systematic review. Int J Sports Phys
Ther. 2015;10:827-838.
OPO200
POSTOPERATIVE REHABILITATION FOR AN UNCOMMON INJURY OF THE
KNEE: A CASE STUDY
Mitchell Selhorst, William Rice, Erin Baumann
Sports and Orthopedic Physical Therapy, Nationwide Children’s
Hospital, Columbus, Ohio
BACKGROUND AND PURPOSE: Chronic instability of the proximal tibiofibular joint (PTFJ) is an uncommon condition and frequently misdiagnosed,
accounting for less than 1% of knee injuries [4]. The mechanism of this
injury is usually a sports related high-velocity twisting motion of a flexed
knee [1,2,4]. Surgical management is controversial with many approaches causing complications [3,6]. To avoid these complications, surgeons
are now utilizing ligament reconstruction to restore stability [3,5]. In current literature there is no report of aftercare for this procedure. The purpose of this case study is to describe postsurgical rehabilitation for an adolescent athlete following PTFJ reconstruction.
CASE DESCRIPTION: The patient was a 15-year-old female soccer player
with reporting left ankle and lateral knee pain over the course of 1 year.
The surgeon determined a diagnosis of chronic PTFJ instability and performed reconstruction of the PTFJ. Patient presented to physical therapy evaluation 3 weeks postsurgery with complete resolution of left ankle
pain and only mild lateral knee pain. The patient’s parents reported anxiety symptoms but no medical diagnosis had been made; patient had no
other significant past medical history. The patient’s goal was to return to
golf as patient reports apprehension with return to soccer. After consulting with the surgeon the treating therapists progressed the patient using
a modified ACL protocol.
OUTCOMES: The outcome measures for this case study were the patient specific functional scale (PSFS), numeric pain rating scale and ability to participate in golf. The initial PSFS score was 3/30 with the 3 activities being walking, jogging and golf. The initial pain level was 3/10 at left lateral
knee. Patient was restricted from sport at that time. Three months after
surgery the patient had significant improvement to 27/30 on the PSFS,
0/10 pain and had progressed to chipping, putting in golf and jogging.
Patient was slower than expected on meeting functional milestones due
to excessive fear avoidance and decreased activity tolerance.
DISCUSSION: The modified ACL protocol was effective in safe treatment
for postoperative rehabilitation following PTFJ reconstruction in an adolescent athlete. This patient demonstrated some yellow flags which may
have slowed progression of rehabilitation. Use of a modified ACL recon-
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struction protocol is a promising guideline for this rare condition and surgery. More research is necessary to establish evidence based guidelines
for treatment.
REFERENCES: 1. Goldstein Y, Gold A, Chechik O, Drexler M. Dislocation
of the proximal tibiofibular joint: a rare sports-related injury. Isr Med
Assoc J, 2011;13:62-63. 2. Hsieh CH, Chen JC. Acute dislocation of the
proximal tibiofibular joint. J Orthop Sports Phys Ther, 2009;39:826. 3.
Kobbe P, Flohe S, Wellmann M, et al. Stabilization of chronic proximal
tibiofibular joint instability with a semitendinosus graft. Acta Orthop
Belg. 2010;76:830-833. 4. Nieuwe Weme RA, Somford MP, Schepers T.
Proximal tibiofibular dislocation: a case report and review of literature.
Strat Trauma Limb Reconstr. 2014;9:185-189. 5. Camarda Abruzzese,
A, D’Arienzo A. Proximal tibiofibular joint reconstruction with autogenous semitendinosus tendon graft. Tech Orthop. 2014:28. 6. Weinert CR,
Jr., Raczka R. Recurrent dislocation of the superior tibiofibular joint.
Surgical stabilization by ligament reconstruction. J Bone Joint Surg Am.
1984;68:126-128.
OPO201
THE NUMBER OF VISITS NECESSARY TO OPTIMALLY TREAT
PATELLOFEMORAL PAIN SYNDROME: A PILOT STUDY
Mitchell Selhorst, William Rice, Michael J. Jackowski,
Todd Degenhart, David Wessells
Sports and Orthopedic Physical Therapy, Nationwide Children’s
Hospital, Columbus, Ohio
PURPOSE/HYPOTHESIS: As health care costs continue to escalate, payers are
examining ways to reduce expenditures. As payment systems evolve under the Affordable Care Act, the ability to deliver value to the consumer
and payers at the lowest cost is increasingly important [1]. Ascertaining
an expected number of treatment sessions to optimally treat patients in
physical therapy is important information for all stakeholders including
the patient, therapist, and payer. Additionally, severity of symptoms and
psychological factors have been found to predict clinical outcomes, and
the relevance of these factors for optimal duration of care should be assessed [2-5]. Conventionally patellofemoral pain syndrome is treated
with 8 to 12 visits; however, to the authors’ knowledge no evidence supports this number of treatments. The aim of this pilot study is to determine the optimal number of sessions necessary to effectively treat patients with patellofemoral pain syndrome.
NUMBER OF SUBJECTS: Fifty-six patients (mean ± SD age,14.38 ± 1.59 years;
40 [71.4%] female) with patellofemoral pain were included in this pilot trial.
MATERIALS/METHODS: The pilot data were pulled from completed cases in 2
research studies assessing physical therapy and patellofemoral pain syndrome. To establish the appropriate number of visits, we determined the
number of sessions necessary to achieve maximal clinically significant
functional improvement on the Anterior Knee Pain Scale. The minimal
clinically important difference was considered 10 points [6]. To determine if severity of the condition was a factor, we assessed the effect of duration of symptoms, initial functional level, and fear avoidance beliefs.
The mean number of sessions was calculated for the number of visits necessary to achieve maximal functional improvement to determine the appropriate number.
RESULTS: Of the 56 patients, 41 (73.2%) experienced a clinically significant
improvement in function. In the patients who achieved significant functional improvement, the mean number of sessions necessary to achieve a
maximal clinically significant improvement was 6.3 visits (95% CI: 5.5,
7.2). Severity of condition did not have a significant effect on the number
of sessions necessary to achieve maximal functional improvement (duration of symptoms, P = .60; initial functional level, P = .07; and fear-avoidance beliefs, P = .29).
CONCLUSIONS: Most patients achieved maximal functional improvement
sooner than the 8 to 12 visits traditionally prescribed to treat patellofemoral pain syndrome. The results of this pilot data suggest that regardless
of the severity of the condition, 6 visits may provide the greatest value for
the least cost when treating patellofemoral pain syndrome. Additional research is necessary to substantiate the findings of this pilot work.
CLINICAL RELEVANCE: Fewer visits may result in the greater value for the
physical therapy care of patients with PFPS.
OPO202
A PORTABLE BRAKE SIMULATOR PROVIDES FEEDBACK ON REACTION TIME
FOR A PATIENT WITH A BRAIN INJURY AND TOTAL HIP ARTHROPLASTY
William G. Seymour, Kurt Manal, Tara J. Manal
Physical Therapy, University of Delaware, Newark, Delaware;
Mechanical Engineering, University of Delaware, Newark,
Delaware
PURPOSE: Describe the use of a newly developed portable brake simulator
(DriveSim; not yet in production) that provided information on visual reaction time and directed the focus of patient care after total hip arthroplasty (THA) complicated by brain injury.
DESCRIPTION: Case study of a 67-year-old man was seen 9 weeks after a
motor vehicle accident (MVA) causing: subarachnoid diverticula (SAD),
subdural hematomas in the frontal and temporal lobes, L clavicular fracture, L distal radial/ulnar fracture, nondisplaced C2 fracture, and R acetabular/femoral fracture with posterior hip dislocation. As a result of
the trauma to his R lower extremity, he required a THA. After 30 visits to outpatient PT (13 weeks post-R THA), the patient was returning to
his surgeon to discuss being medically cleared to drive. He reported having diminished confidence in his ability to return to driving if cleared by
his physician.
SUMMARY OF USE: The patient completed DriveSim testing which replicates an accelerator-to-brake pedal transfer with the R lower extremity. Protocol for DriveSim: patient is seated with R lower extremity starting on the accelerator pedal of the portable device. A green light provides
the patient with visual feedback to stay on the accelerator. When the light
turns red (variable times) the patient must react to lift the foot off the gas
(visual reaction time), transfer the limb to the brake and generate approximately 200 N of force (National Highway Safety Bureau standard force
to stop a vehicle). Previous articles have described similar devices however most do not provide the clinician with information on visual reaction time. Average of 5 trials: visual reaction time (0.416 seconds; greater
than 2 SD above healthy norm [0.276 seconds]), total time (0.772 seconds). Force was met but activities to improve visual reaction time were
included in his care to assist with his confidence and return to driving.
Random and variable practice over 5 treatments: ball toss and kicking,
obstacle courses altered every treatment with visual cues for changes in
gait speed and direction, balance tasks with vertical/lateral head movements visual cues; no direct practice of break simulation. At his 36th visit
(17 weeks post-THA) the DriveSim was repeated (5 trials): visual reaction
time (0.378 ± 0.038 seconds), total time (0.728 ± 0.044 seconds). Patient
was medically cleared to return to driving by his physician and resumed
all driving activities.
IMPORTANCE TO MEMBERS: This newly developed portable brake simulator
can provide therapists with objective data on: visual reaction to visual
stimuli, accelerator-to-brake limb transfer times, and time to generate
200 N of force. Such information could assist with altering a clinician’s
plan of care to improve a patient’s confidence and ability to drive.
OPO203
SHOULDER TREATMENT IMPROVES NECK FUNCTION AND SYMPTOMS
AFTER MULTIPLE FAILED CERVICAL SURGERIES
William G. Seymour, Tara J. Manal
Physical Therapy, University of Delaware, Newark, Delaware
BACKGROUND AND PURPOSE: Describe a case of chronic neck pain and diminished function unresolved after multiple surgical procedures. Both
pain and function improved with treatment directed at shoulder range of
motion and strength.
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CASE DESCRIPTION: A 65-year-old man 5 weeks after a cervical extensor
resection and realignment for chronic neck pain. Past surgical history:
greater than 30 orthopaedic surgeries of multiple body regions, multiple
cervical fusions and revisions due to infection (most recent: 2 years prior to evaluation, posterior cervical fusion C2-T2), multilevel lumbar fusions with multiple revisions, and 2 rotator cuff repairs on each shoulder
(none within the last 10 years). Postoperative restrictions from his most
recent procedure included no lifting greater than 10 lb. Chief complaint
cervical and upper trapezius pain (best, current, worst: 5/10, 3/10, 8/10)
(same as before surgery), as well as difficulty with any form of reaching or
lifting overhead which increases symptoms. Data: Limited cervical ROM,
diminished function (Neck Disability Index [NDI], 65%; DASH, 61.6%;
FABQ-PA, 17/24; Patient-Specific Functional Scale [PSFS], average, 4.66
[driving, sitting, standing]; 6-minute walk test, 1605 ft; UE weakness
[glenohumeral HHD], flexion R, 21.2 lb; L, 15.4 lb; abduction R, 19.0
lb; L, 11.9 lb; ER R, 28.7°; L, 19.0°; IR R, 27.9°; L, 16.5°; scapular MMT
rhomboids: 3/5 B, middle trapezius 3/5 B, lower trapezius 3/5 B); restrictions in shoulder ROM (AROM flexion R, 135° pain L, 130°; pain abduction R, 120°; pain L, 125° pain PROM ER R, 70°; L, 63° pain); restrictions in shoulder mobility (bilateral hypo inferior/posterior). MD referred
the patient to physical therapy for scar mobilization, ultrasound and modalities only received clearance after 7 visits and added: shoulder mobilizations, AAROM, Thera-Band and dumbbell strengthening for 6 visits (10 weeks). Patient educated on a walking program to address deficits
noted in 6-minute walk test.
OUTCOMES: At discharge (13 visits, 14 weeks total) pain free reaching overhead and diminished pain at baseline (best, current, worst, 0/10, 0/10,
3/10). Improved function (NDI, 46% ± 15.6%), DASH, 30.8% ± 30.8%,
PSFS (8.33 ± 3.67), FABQ-PA (8 ± 9/24), 6-minute walk test (1850 ± 245
ft); improved UE strength (shoulder HHD flexion R, 35.3%; L, 81.8%)
abduction (R, 27.8%; L, 100.8%); ER (R ,no improvement; L, 53.1%);
IR (20.7%; L, 102.4%); scapular MMT rhomboids (4/5); middle trapezius (4/5 B); lower trapezius (3+/5 B); improved shoulder ROM (AROM)
from baseline (flexion R/L, 35°-40°); abduction (R, 20°; L, 43°); PROM
(from baseline) (ER R, 6°; L,32°).
DISCUSSION: An impairment based approach identified potential contributors to symptoms previously nonresponsive to surgical interventions.
Comprehensive examination and treatment of impairments should be
considered even in long standing conditions. Improvements in functional mobility, shoulder ROM and strength resulted in resolution of cervical
pain and increased function.
REFERENCES: Abbott JH, Schmitt J. Minimum important differences for
the patient-specific functional scale, 4 region-specific outcome measures, and the numeric pain rating scale. J Orthop Sports Phys Ther.
2014;44:560-564. Horn K, Jennings S, Richardson G, Vliet D, Hefford C,
Abbott J. The Patient-Specific Functional Scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys
Ther. 2012; 42:30-42. Miller J, Gross A, D’Sylva J, Burnie S, Goldsmith
C, Graham N, Haines T, Brönfort G, Hoving J. Manual therapy and exercise for neck pain: a systematic review. Man Ther. 2010;15:334-354.
Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman
JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90:26-42. Petersen S, Domino N, Cook C,
Domino N, Cook C. Scapulothoracic muscle strength in individuals with
neck pain. J Back Musculoskelet Rehabil. In press. Sueki D, Cleland J,
Wainner R. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip
Ther. 2013;21:90-102.
OPO204
RELIABILITY OF ULTRASOUND MEASUREMENTS OF ROTATOR CUFF
MUSCLE CROSS-SECTIONAL AREA IN HEALTHY ADULTS
Kshamata M. Shah, Matthew Brennan, Joseph Bucantis,
Erik J. Kust, Jonathan Washatka, Philip W. McClure
Physical Therapy, Arcadia University, Glenside, Pennsylvania
PURPOSE/HYPOTHESIS: Muscle atrophy has been reported in patients with
rotator cuff pathology [1]. Presumably, exercise yields positive changes in
muscle structure which may be associated with improved strength and
function, though this has not been well-studied. Ultrasound (US) imaging has been used extensively for examining shoulder pathology [2].
However, reliability of shoulder muscle size measurement with US is not
well established. A few studies have reported variable reliability, 0.45 to
0.88, of rotator cuff muscle size using US [3,4,5]. Further, the relationship between muscle cross-sectional area (CSA) and torque measures is
not known. The aim of this study was to establish the reliability of shoulder muscle CSA using US, examine side-to-side differences and to determine the relationship between size and torque.
NUMBER OF SUBJECTS: Nineteen asymptomatic, healthy adults (mean ± SD
age, 30.8 ± 11.8 years; 12 male, 7 female; dominant arm: 19 right, 0 left).
MATERIALS/METHODS: Supraspinatus and infraspinatus muscle CSA of both
shoulders was obtained using US. Multiple scans were performed a mean
of 1.9 days apart to establish the intersession reliability. Supraspinatus
images were captured in the transverse view at the suprascapular notch
identified with the US with subject in a seated position and arm resting
on a pillow. The infraspinatus muscle CSA was determined with subject
in prone position. Using bony landmarks and a custom made template to
standardize the measurement location, serial images of the muscle were
obtained and spliced to calculate the CSA. Three scans were performed
at each session and averaged. Size measurements (cm2) were then performed using ImageJ analysis. Abduction and external rotation torque
(normalized to body weight) was calculated using force measures from a
handheld dynamometer and moment arm length.
RESULTS: The ICC, SEM, and MDC values for the between-session reliability for muscle size measurements were as follows: supraspinatus ICC
= 0.97; 95% CI: 0.93, 0.99; SEM, 0.3; MDC95, 0.8; and infraspinatus
ICC = 0.95; 95% CI: 0.86, 0.98; SEM, 1.3; MDC95, 3.1. The supraspinatus and infraspinatus mean CSA were not different between the arms (supraspinatus: right, 7.3 ± 1.7; left, 6.9 ± 1.5; infraspinatus: right, 16.5 ± 5.7;
left, 14.3 ± 5.5). The abduction torque and external rotation torque were
not strongly related to the muscle size measurements (range of r values
= 0.18-0.37).
CONCLUSIONS: The results of this study show excellent reliability for supraspinatus and infraspinatus muscle CSA measurements. There was no difference in the muscle CSA between arms. Correlation between muscle size
and torque was not strong. These results need to be further validated in a
larger sample size. Future steps include examining the change in muscle
size in response to an exercise program.
CLINICAL RELEVANCE: Understanding mechanisms associated with pathology and response to exercise is important to guide practice. Muscle size
represents a key variable and US offers a feasible and reliable measurement method. Further examination of the relationship between muscle
size changes, and functional changes is warranted.
OPO205
TRUNK AND PELVIC KINEMATICS OF RUNNERS WITH AND WITHOUT LOW
BACK PAIN
Neena K. Sharma, Janice K. Loudon, Jordan Umscheid,
Caleb Laird, Nathan Vogel, Anne Schwartz, Jessie Huisinga
Physical Therapy and Rehab Sciences, University of Kansas
Medical Center, Kansas City, Kansas; Physical Therapy
Department, Rockhurst University, Kansas City, Missouri
PURPOSE/HYPOTHESIS: Low back pain (LBP) can be a potentially devastating injury preventing runners from continuously training. There is a
need for a greater understanding of trunk and pelvic kinematics during
running in healthy people and those with LBP. The purpose of this pilot study was to analyze and compare the pelvic and spinal kinematics in
healthy runners and runners with a history of LBP. We hypothesized that
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(1) healthy long-distance runners will display a consistent kinematic pattern of the trunk during running and (2) long-distance runners with a
history of LBP will display varied pelvic and spinal kinematics compared
to healthy controls.
NUMBER OF SUBJECTS: Ten long-distance runners (8 healthy and 2 with a
history of LBP).
MATERIALS/METHODS: Runners between the ages of 20 and 40 years and
who run at least 20 km (approximately 12 mi) a week were eligible.
Subjects were excluded if they had current LBP, a neurological impairment, a severe structural back deformity, history of back or lower extremity surgery, were pregnant, or answered “yes” on the PAR-Q questionnaire.
Motion capture biomarkers were placed on standard bony landmarks of
trunk and pelvic to record 3-D joint range of motion during standing and
during a 5-minute run on a treadmill. A Matlab software program was
used to analyze joint angles.
RESULTS: Based on observation, healthy runners have a consistent pattern of
trunk and hip kinematics during the running trial. Initial data analysis of
trunk and pelvic ROM shows no clinical differences between healthy subjects and those with a history of LBP, although subjects with history of LBP
have greater anterior pelvic tilt motion (healthy, 13.3 ± 1.6; LBP, 17.2 ± 7.6).
More data collection on participants with a history of LBP is underway.
CONCLUSIONS: This pilot project has identified trunk and pelvic motion
during running between a cohort of healthy runners and 2 runners with a
history of LBP. Observational data revealed that the healthy runners display a consistent kinematic pattern in their trunk and pelvis compared to
an inconsistent pattern displayed by the runners with a history of LBP.
CLINICAL RELEVANCE: Our findings may contribute to the understanding of
the causes of LBP in runners and to the development of rehabilitation
programs for runners with a history of LBP.
OPO206
SCAPULAR MUSCLE ONSET ACTIVATION DURING ARM ELEVATION
IN INDIVIDUALS WITH SUBACROMIAL PAIN SYNDROME
Sapna Sharma, Mark Timmons, Lori A. Michener
Division of Biokinesiology, University of Southern California, Los
Angeles, California; School of Kinesiology, Marshall University,
Huntington, West Virginia
PURPOSE/HYPOTHESIS: Subacromial pain syndrome (SPS) is associated with
alterations in the scapular muscle amplitude of activity of the trapezius
and serratus anterior muscles. However, little is known about the timing
of the activation of the scapular muscles. Characterizing scapular muscle
onset during functional tasks can provide important information about
deficits in motor control strategies in individuals with SPS. The purpose
of this study is to characterize the scapular muscle onset activation during a functional arm task of scaption.
NUMBER OF SUBJECTS: Patients with SPS (n = 28; mean age, 38.4 years; 11
female) and age, sex, and dominant arm matched control group (n = 28;
mean age, 37.9 years; 11 female).
MATERIALS/METHODS: Participants in the SPS and control groups performed 5 repetitions of active arm elevation in the scapular plane. Threedimensional electromagnetic tracking sensors affixed to the humerus,
scapula, and thoracic spine were used to record the humeral motion relative to the thoracic spine. Surface electromyography (EMG) was used to
record the activation onsets for the deltoid, upper trapezius (UT), middle
trapezius (MT), lower trapezius (LT), and serratus anterior (SA) muscles.
Onset was defined as the time value at which the EMG signal exceeded
the mean baseline activity by 2 or more standard deviations. Relative activation muscle onsets of scapular muscles relative to the deltoid, and the
humeral angle of onset were compared between groups.
RESULTS: Mann-Whitney U tests indicated significant differences in the
relative activation onsets for MT, LT, and SA muscles between groups.
Specifically, as compared to the control group, the SPS group showed
significantly delayed relative activation onsets for MT (mean difference,
101.8 milliseconds; P = .03), LT (mean difference, 102.6 milliseconds; P
= .04), and SA (mean difference, 86.1 milliseconds; P = .01). The humeral angle of scapular muscle onset was higher for the SA in the SPS group
as compared to the control group (15.9° for SPS group, 9.2° for control
group; P = .03). Higher humeral angle of muscle onset were observed
for MT and LT in the SPS group: MT (14° for SPS group, 6° for control
group); LT (18.7° for SPS group, 10.9° for control group), but these differences were not significantly different between groups. There were no significant differences for the UT.
CONCLUSIONS: Onset activation of MT, LT and SA relative to the deltoid
were delayed in individuals with SPS, but only a higher humeral angle of
muscle onset was found for the SA. These findings support the theory that
altered MT, LT and SA activation onsets may account for altered scapular
motor control in individuals with SPS. Future research is needed to determine if therapeutic exercises can restore relative onset imbalances in
scapular muscles, and thus improve pain and disability in those with SPS.
CLINICAL RELEVANCE: The MT, LT and SA scapular muscles are slower to
activate during arm elevation in individuals with SPS. Exercises aimed at
correcting the activation onset of the MT, LT and SA muscles relative to
the deltoid muscle may prove beneficial to reduce shoulder pain and disability in individuals with SPS.
OPO207
FLEXOR HALLUCIS LONGUS ACTIVATION IN A DANCER’S MODIFIED HEEL
RAISE: PRELIMINARY RESULTS
Hai-Jung Shih, K. Michael Rowley, Kornelia Kulig
Division of Biokinesiology and Physical Therapy, University of
Southern California, Los Angeles, California
PURPOSE/HYPOTHESIS: Flexor hallucis longus (FHL) tendinopathy is highly prevalent in female ballet dancers and is related to overuse. A “modified heel raise,” where the foot is placed on the edge of a block so that
the toes are unsupported, was introduced as a potential intervention to
reduce demand on the FHL. It was reported in our previous study that
healthy dancers were able to perform fewer repetitions than nondancers during the modified heel raise fatigue task. However, no electromyographic comparisons have been made between traditional and modified
heel raises. Therefore, the aim of this study was to compare muscle activation of the FHL along with the other larger, superficial plantarflexors
during traditional and modified heel raises in a healthy dancer. Our hypothesis was that muscle activation of the FHL will be lower in the modified heel raise condition.
NUMBER OF SUBJECTS: One.
MATERIALS/METHODS: One healthy female dancer was instrumented with
fine-wire electromyography (EMG) of the FHL, soleus, and lateral gastrocnemius and performed traditional and modified heel raises at a rate
of 30 bpm. The peak FHL activation was identified in the rectified EMG
signals, and the activation ratio between FHL and lateral gastrocnemius
and soleus was computed using integrated EMG data. Between-repetition
variability of the EMG signals was visually analyzed.
RESULTS: Analysis revealed higher peak FHL activation, greater FHL/
lateral gastrocnemius activation ratio, and greater FHL/soleus activation ratio in the modified heel raise condition. The FHL had greater between-repetition variability during modified heel raise, while the lateral
gastrocnemius and soleus had greater variability during traditional heel
raise. Kinematic data showed greater toe extension during heel contact
in the modified heel raise, which suggested toe extensor cocontraction.
CONCLUSIONS: These findings are contrary to our hypothesis, suggesting
that the modified heel raise leads to greater FHL activation compared
to traditional heel raise in 1 healthy dancer, but visual inspection of between-repetition EMG variability may tell a contradicting story. Future
research will include toe extensors activation and EMG variability as outcome measures, and include healthy nondancers as well as dancers with
FHL tendinopathy as target populations.
CLINICAL RELEVANCE: This research is a part of an ongoing funded study
that aims to investigate a novel intervention for FHL tendinopathy. The
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modified heel raise is currently being reviewed as 1 potential prevention
or nonsurgical intervention strategy that could benefit populations at risk
of, or suffering from, FHL tendinopathy.
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OPO208
SCAPULAR AND CERVICAL NEUROMUSCULAR CONTROL DEFICITS
IN MUSICIANS WITH PROLONGED UPPER-QUARTER PAIN:
A CASE-CONTROL STUDY
Flavio Silva, Jean-Michel Brismee, Phillip S. Sizer,
Troy Hooper, Gary E. Robinson, Alex B. Diamond
Orthopedics and Rehabilitation, Vanderbilt University Medical
Center, Nashville, Tennessee; Center for Rehabilitation Research,
Texas Tech University Health Sciences Center, Lubbock, Texas
PURPOSE/HYPOTHESIS: More than 50% of musicians will develop upper extremity injuries and pain related to instrument use, which can negatively
affect or even interrupt their careers. Efficient cervical spine and shoulder girdle neuromuscular control is essential for upper-quarter musculoskeletal injury prevention and deficits are linked to a higher prevalence of
upper extremity occupational injuries. The purposes of this research were
to investigate if there were differences between musicians with and without upper quarter prolonged playing related musculoskeletal disorders
(PRMSDs) in the presence of: (1) scapular dyskinesis; (2) cervical neuromuscular control and endurance deficits; and (3) prior injury, playing
patterns, and physical fitness habits.
NUMBER OF SUBJECTS: Eighty-one subjects consecutively recruited including student and professional musicians in Tennessee.
MATERIALS/METHODS: Seventy-two musicians (24 male, 48 female) were
matched based on sex, type of instrument played (string or other) and
average hours played per week and assigned to 1 of 2 groups: (1) a symptomatic group (mean ± SD age, 23.3 ± 8.2 years) with history of prolonged
PRMSDs (symptoms lasting more than 1 week) during the past year; and
(2) a control group (mean ± SD age, 25 ± 10.5 years) with no history of
PRMSDs lasting more than 1 week. Both groups completed a comprehensive demographic questionnaire that included playing patterns, as well as
general health related questions and fitness activities exposures. Subjects
underwent clinical testing for the presence of scapular dyskinesis and cervical neuromuscular control and endurance deficits using the following
tests: (1) deep neck flexor endurance test; (2) scapular dyskinesis test;
and (3) craniocervical flexion test. Blinding of the assessor as to group assignment was ensured.
RESULTS: Symptomatic subjects presented with statistically significant
higher prevalence of positive scapular dyskinesis (26/36 or 72.2% versus
9/36 or 25%; P<.0001) and lower scores for the craniocervical flexion test
(mean ± SD, 26.2 ± 2.3 versus 28.4 ± 1.7 seconds; P<.0001). Deep neck
flexor endurance, physical activity habits, prior history of PRMSDs and
frequency/length of breaks while playing their instrument did not differ
significantly between groups.
CONCLUSIONS: Musicians with prolonged upper-quarter PRMSDs presented with higher prevalence of scapular and cervical neuromuscular control deficits when compared to musicians with no history of prolonged
PRMSDs. Addressing these deficits may help in the recovery and prevention of PRMSDs.
CLINICAL RELEVANCE: Musicians have a very high rate of occupational injuries frequently affecting their ability to play their instrument. Our study
shows that musicians with prolonged PRMSDs in the upper quarter have
higher prevalence of scapular and cervical neuromuscular control deficits possibly contributing to their symptoms than musicians without
PRMSDs. These findings provide insight and may assist with future studies evaluating programs geared at preventing and managing prolonged
PRMSDs in musicians.
OPO209
IMPORTANCE OF EVALUATING SCAPULAR MECHANICS IN PATIENTS
FOLLOWING STERNAL PRECAUTIONS
Elizabeth Sinish
OrthoSports Physical Therapy, Phoenix, Arizona
BACKGROUND AND PURPOSE: The purpose of this case report is to describe
the importance of evaluating scapular mechanics in a patient following
sternal precautions prior to instructing him in upper extremity strengthening exercises.
CASE DESCRIPTION: The patient was a right hand dominant 72-year-old
man who presented with right shoulder pain. He underwent open heart
surgery 5 months prior to the evaluation. Pain began approximately 3
months prior to the evaluation while doing UE resisted exercises at cardiac rehab. He went to a gym regularly after he finished rehab and reported
that he continued the exercises he was taught at rehab. Due to continued
shoulder pain, he decided to seek outpatient treatment. Pain was intermittent, rated 8/10 at highest and he described it as sharp. Pain location
was lateral shoulder and upper arm as well as anterior shoulder. He denied numbness and tingling in his right upper extremity. The patient reported pain with reaching overhead, lifting 10 lb and reaching back to
put on a jacket. During evaluation of this patient’s shoulder motion, the
movement faults of excessive scapular internal rotation and insufficient
scapular elevation and upward rotation were identified with active shoulder flexion and abduction, contributing to impingement. When manual assistance was given to elevate and upwardly rotate his scapula, pain
decreased and ROM improved [1]. However, full passive correction was
limited by stiffness in the scapulothoracic muscles. He also demonstrated excessive anterior tilting of the scapula due to shortness and stiffness
in the pectorals after limiting his shoulder ROM due to precautions following surgery. The patient was given the Diagnosis of Scapular Internal
Rotation with Anterior Tilt and Insufficient Upward Rotation Syndrome.
Treatment included manual therapy to decrease stiffness in the pectorals
[2] and scapulothoracic muscles and then exercises focused of correction
of the scapular movement faults. He was educated in the importance of
proper scapular alignment and mechanics with all exercises and activities
[3] in order to correct his fault movement patterns and decrease stress on
the painful tissues [4].
OUTCOMES: The patient came in for 6 appointments over 4 weeks. DASH
improved from 30 at the initial evaluation to 0 at time of discharge.
Scapular elevation and upward rotation improved, enabling him to reach
back to don jackets, reach overhead, return to a gym routine and perform
all of his activities without pain.
DISCUSSION: Many patients have sternal precautions for up to 12 weeks
following heart surgery, leading to muscle stiffness and impaired scapular mechanics. In this case, the stiffness contributed to insufficient scapular upward rotation of the scapula, which is found in many patients with
impingement [5] and also contributed to excessive anterior tilting of the
scapula. If the patient’s scapular mechanics had been evaluated to identify movement faults prior to giving him an upper extremity strengthening
program, his shoulder pain may have been prevented.
REFERENCES: 1. Seitz AL, McClure PW, Finucane S, Ketchum JM,
Walsworth MK, Boardman ND, 3rd, Michener LA. The scapular assistance test results in changes in scapular position and subacromial space
but not rotator cuff strength in subacromial impingement. J Orthop
Sports Phys Ther. 2012;42:400-412. 2. Muraki T, Aoki M, Izumi T, Fujii
M, Hidaka E, Miyamoto S. Lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study. Phys Ther. 2009;89:333-341. 3. De Mey K,
Danneels LA, Cagnie B, Huyghe L, Seyns E, Cools AM.2013. Conscious
correction of scapular orientation in overhead athletes performing selected shoulder rehabilitation exercises: the effect on trapezius muscle activation measured by surface electromyography.” J Orthop Sports Phys
Ther. 2013;43:3-10. 4. Sahrmann S, et al. Movement System Impairment
Syndromes of the Extremities, Cervical and Thoracic Spines. St Louis,
MO: Mosby; 2011. 5. Lawrence RL, Braman JP, LaPrade RF, Ludewig
PM. Comparison of 3-dimensional shoulder complex kinematics in individuals with and without shoulder pain, part 1: sternoclavicular, ac-
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romioclavicular, and scapulothoracic Joints. J Orthop Sports Phys Ther.
2014;44:636-645.
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OPO210
TIMED UP AND GO IS MOST PREDICTIVE OF PATIENT-REPORTED
OUTCOMES MEASUREMENT INFORMATION SYSTEM SCORE
IN INDIVIDUALS AWAITING TOTAL KNEE ARTHROPLASTY
Kaitlyn Sly, Scott Eskildsen, Richard A. Faldowski,
Christopher W. Olcott, Daniel J. Del Gaizo, Deborah L. Givens
Division of Physical Therapy, University of North Carolina at
Chapel Hill, Chapel Hill, North Carolina; Orthopaedics, University
of North Carolina at Chapel Hill, Chapel Hill, North Carolina;
Allied Health Sciences, University of North Carolina at Chapel Hill,
Chapel Hill, North Carolina
PURPOSE/HYPOTHESIS: The Patient-Reported Outcomes Measurement
Information System (PROMIS) computerized adaptive testing (CAT)
physical function domain has the potential to quickly assess self-reported function before and after total knee arthroplasty (TKA). The timed
up and go (TUG) test is commonly used in clinical practice but administration may be hindered due to space and patient limitations. PROMIS
CAT has the potential to address these limitations but we lack evidence
if TUG as well as other health indicators are predictors of PROMIS CAT.
The purpose was to assess whether TUG, body mass index (BMI), numeric pain-rating scale (NPRS), and smoking status are predictors of physical function, as measured by the PROMIS CAT, in candidates for TKA
surgery.
NUMBER OF SUBJECTS: Sixty-five (40 female; mean ± SD age, 62.6 ± 8.9
years; height, 167.7 ± 9.4 cm; weight, 91.7 ± 17.0 kg).
MATERIALS/METHODS: Participants presenting to the University
Orthopaedic Clinic with a diagnosis of severe knee osteoarthritis (OA)
were offered the option of TKA by an orthopaedic surgeon. The PROMIS
CAT physical function domain score, TUG, NPRS, BMI, and smoking status were collected on enrollment in the clinical trial. Multiple linear regression analyses were performed to determine the strongest predictors
of PROMIS CAT (P<.05).
RESULTS: Smoking status did not affect the relationship between any of
the variables and PROMIS CAT. The multiple regression analyses indicated that the TUG test was the best predictor of PROMIS score. BMI
and NPRS did not incrementally help predict the PROMIS score beyond
the TUG test. PROMIS CAT physical function domain scores had a moderate, negative correlation with the TUG test (r = –0.43; 95% CI: –0.61,
–0.19; P≤.0001) and a weak, negative correlation with NPRS (r = –0.30;
95% CI: –0.51, –0.05; P≤.0102).
CONCLUSIONS: The relationship between PROMIS CAT physical function
and the TUG test suggests that the PROMIS is not a surrogate for this
functional performance measure in candidates for TKA. However, the
TUG test was the best predictor of PROMIS physical function score compared to BMI, NPRS, and smoking status.
CLINICAL RELEVANCE: Clinicians should consider utilizing a variety of selfreport and functional outcome measures to adequately assess patients
with severe knee OA who are candidates for TKA surgery.
OPO211
RELIABILITY AND VALIDITY OF A SMARTPHONE WITH COMPASS APP FOR
MEASURING TRANSVERSE PLANE MOTION
Bryon A. Smith, Shawn Hunt, Philip Grattan,
Kathryn E. Roach, Nina Kelly, Kevin Cochran, Robert B. Smith,
Koren Lavi
Physical Therapy, University of Miami, Coral Gables, Florida
PURPOSE/HYPOTHESIS: A therapist’s ability to accurately assess a patient’s
range of motion (ROM) is a key component of the physical examination.
In order for this information to be useful, it is necessary that it is accurate,
reliable and valid. There are several tools on the market that can assess
joint ROM, including the universal goniometer, electronic goniometers
and digital inclinometers, among others. The iPhone is a commonly used
smartphone with many applications (apps) available for potential use in
measuring joint angles and ROM. If found to be reliable and valid, the
iPhone could be an alternate and possibly more assessable tool to use for
goniometry. Several apps have been found reliable in measuring motion
in the sagittal and coronal planes, but none to date have been found reliable in the transverse plane. The purpose of this study was to test the reliability and validity of the iPhone 6s IOS compass application compared to
the gold standard goniometer for measurements in the transverse plane.
We hypothesize that the iPhone 6s IOS compass application will not be as
valid as the goniometer for transverse plane measurements.
NUMBER OF SUBJECTS: Thirty.
MATERIALS/METHODS: Four Doctorate of Physical Therapy students acted
as raters to measure the 30 randomly selected angles generated by using
a protractor widget in whiteboard software which were then verified via
“gold standard” steel protractor. The raters measured the 30 angles using an iPhone 6s IOS compass software application. Measurements were
taken by each rater 3 times for each angle using different rooms and positions. We calculated the absolute value (AV) of the difference between the
actual and measured angles and across repetitions.
RESULTS: Across all raters, the mean AV of the difference between the first
and second measures ranged from 22.1 to 45.6 (all, P<.05). The difference between the actual angle and both first and second measures varied widely across all raters. Example: rater 1, measure 1 = 0.7 (P = .001);
measure 2 = 38.2 (P<.0001). The mean AV of the difference between actual angle and measured angle varied from 0.7 to 44.1. The difference was
greater for the first measure for some raters and greater for the second
measure for others.
CONCLUSIONS: The “Compass” software application for this smartphone
was found to be unreliable and subsequently invalid in measuring fixed
angles in the transverse plane due to the instruments inability to maintain a stable true north.
CLINICAL RELEVANCE: The results of this study indicate that the specific software and device tested should not be used for clinical goniometry.
OPO212
ACHILLES TENDINOPATHY OCCURS ACROSS THE AGE SPAN AND AFFECTS
QUALITY OF LIFE
Andrew L. Sprague, Laura Pontiggia, Daniel H. Cortes,
Karin G. Silbernagel
Department of Physical Therapy, University of Delaware, Newark,
Delaware; Statistics, University of the Sciences, Philadelphia,
Pennsylvania; Mechanical and Nuclear Engineering, Pennsylvania
State University, University Park, Pennsylvania
PURPOSE/HYPOTHESIS: Achilles tendinopathy is often described as a sports
injury occurring mainly in runners; however, 1 recent Dutch study reported that only 35% of the patients with Achilles tendinopathy seeking help
from a general practitioner were sports related [1]. Given the large number of nonathletes with Achilles tendinopathy, there is a need to better
understand the condition’s health impacts in a general population. The
purpose of this study was to examine individual and injury-specific factors, along with health-related outcomes in patients with Achilles tendinopathy [2].
NUMBER OF SUBJECTS: All subjects (n = 53, 29 male) included in a larger
prospective study on Achilles tendinopathy between November 13, 2014
and April 6, 2016 were included.
MATERIALS/METHODS: Subjects completed questionnaires regarding their
past medical history, current Achilles tendon injury and physical activity level. Outcome measures used were the Victorian Institute of Sport
Assessment-Achilles (VISA-A), the Foot and Ankle Outcome ScoreQuality of Life subscale (FAOS-QOL), the Pain Catastrophizing Scale
(PCS), and the Tampa Scale of Kinesiophobia (TSK) [3-7]. Lower extremity function was assessed using the single-leg heel rise test.
RESULTS: The mean ± SD (range) age was 48 ± 16 years (19-79 years). Age
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ranges were uniformly distributed (P>.25) and there was no evidence
of age dependency. The median (IQR) symptom duration was 10 (4-17)
months. Past medical history of interest was that 23 (20 on same side as
current injury) out of 52 participants reported a prior ankle injury. The
mean ± SD score for the VISA-A was 57 ± 21 and for the FAOS-QOL was
49 ± 20. Thirty-three out of 51 patients (65%) reported decreased physical activity level due to their Achilles tendon symptoms. There were significant differences in heel rise performance for height (P<.0001), repetitions (P = .0008), and total work (P = .0002) between injured and
uninjured side. There were significant correlations (r = 0.576, P<.0001)
between VISA-A score and participants change in activity level following
their Achilles tendon injury. VISA-A scores did not correlate significantly with FAOS-QOL, TSK, or PCS scores (P = .09-.99). There were significant correlations between FAOS-QOL and PCS (r = –0.436, P = .0039)
and TSK (r = –0.578, P = .0002). Heel rise test performance did not correlate with TSK or PCS scores (P = .12-.92).
CONCLUSIONS: Achilles tendinopathy affects patients across the life-span
and a history of ankle injuries is common. These patients have significant
symptoms, impaired foot and ankle related quality of life and reduced
physical activity. The FAOS-QOL did not correlate with VISA-A but did
correlate with PCS and TSK. This indicates that patient’s beliefs about
pain and movement may have a larger impact on their foot and ankle related quality of life than symptom severity.
CLINICAL RELEVANCE: Clinicians should be aware that Achilles tendinopathy may occur in any age group and that prior ankle injuries are common.
Additionally, clinicians may need to address kinesiophobia or pain catastrophizing beliefs to achieve optimal patient outcomes.
OPO213
THE EFFECTS OF ECCENTRIC, CONCENTRIC, AND ISOMETRIC
CONTRACTIONS ON PAIN SENSITIVITY OVER THE ACHILLES TENDON
Scott K. Stackhouse, Brian J. Eckenrode, Kaitlyn Colagreco,
Elizabeth Michel, Josh Tizzard
Department of Physical Therapy, Arcadia University, Glenside,
Pennsylvania
PURPOSE/HYPOTHESIS: There is mixed evidence on the superiority of eccentric-only exercise in reducing pain in chronic tendinopathies. The purpose of this study was to investigate the effects of plantarflexion exercise
(eccentric, concentric, or isometric) on pain sensitivity measures over the
Achilles tendon. We hypothesized that there will be no between-group
differences in the effects on pain sensitivity when contraction duration is
equivalent across groups.
NUMBER OF SUBJECTS: Sixty-nine adults were screened and 42 were found
eligible (mean ± SD age, 24.6 ± 2.8 years) and block-randomized by sex
into eccentric (ECC), concentric (CON), or isometric (ISOM) groups.
MATERIALS/METHODS: After eligibility screening and consent, subjects completed a series of questionnaires on pain and anxiety. Participants had
their dominant side Achilles tendon assessed for pressure pain threshold
(PPT) with a digital algometer, and heat pain threshold (HPT) and heat
temporal summation (HTS) assessed with a computer-controlled thermode at 2 cm proximal to calcaneal insertion. The study timeline was
as follows: Baseline 1, 48-hour washout, Baseline 2, 1-week intervention,
and next day Postintervention assessment. After the Baseline 2 assessment, participants were instructed in specific exercise according to group
assignment: CON, ECC, or ISOM plantarflexion contractions. One investigator observed and gave feedback during their first 3 sets of 15 repetitions of exercise. All contraction durations were to last 5 seconds and
subjects were asked to complete 3 sets of 15 repetitions 2 times a day for
7 days.
RESULTS: There were no differences between groups on pain and anxiety
questionnaires and for exercise compliance (P>.05). Excluded participants were mostly male due to not meeting a HPT of less than or equal
to 46.5°C. Sex breakdown per group was: CON, 8 female, 6 male; ECC,
8 female, 5 male; ISOM, 8 female, 6 male. Preliminary analysis was per-
formed by calculating absolute and standardized effect sizes of the change
scores (postintervention minus the average baseline) for PPT, HPT, and
HTS. HPT increased in CON by 2.04°C (95% CI: 1.21°C, 2.86°C; η2 =
1.09), ECC by 1.39°C (95% CI: 0.60°C, 2.19°C; η2 = 0.79), and ISOM by
2.45°C (95% CI: 1.39°C, 3.51°C; η2 = 1.17). HTS decreased in CON by 5.09
mm (95% CI: 6.10, –16.27 mm; η2 = –0.28), ECC by 12.50 mm (95% CI:
–3.65, –21.35 mm; η2 = –0.9), and ISOM by 7.39 mm (95% CI: –2.22,
–12.56 mm; η2 = –0.33). There was no consistent change in PPT across
groups. Data collection will continue to include 10 females and males in
each treatment group as per prior sample-size estimate.
CONCLUSIONS: Preliminary analysis showed that after 1 week of exercise, all
treatment groups similarly reduced pain sensitivity for HPT, and ISOM
and ECC groups also reduced HTS consistently. The changes observed in
pain sensitivity support the use of long (5 seconds) duration contractions
to create hypoalgesia and de-emphasize contraction type.
CLINICAL RELEVANCE: Contraction duration, not contraction type, may be an
important variable that imparts hypoalgesic effects of exercise.
OPO214
TRIGGER POINT DRY NEEDLING QUALITY CONTROL MEASURES
AT BAYLOR REHABILITATION
Michelle R. Steinhagen, Laurel DuPont
Doctor of Physical Therapy Program, Baylor Institute for
Rehabilitation-Outpatient Services, Dallas, Texas
PURPOSE: To provide standardized quality control methods to ensure excellent and safe outcomes for clinicians and patients in Trigger Point Dry
Needling (TPDN) procedures in a outpatient rehab setting.
DESCRIPTION: An experienced core group of clinicians (n = 3) regularly
meet to ensure current clinical treatment parameters and outcomes by
developing and performing competency standards and check-offs prior
to initiation of TPDN during patient care. Yearly competency checks are
required to ensure compliance to company policies, procedures and safety
as well as clinical reasoning for the use of TPDN. Baseline requirements
for TPDN clinicians included completion of a certified continuing education course approved by the Texas State Board, received competency
checks by 1 of 3 core clinicians for standardized methodology, and yearly
competency checks through practical and written exam. In 2013, due to
the growth to 20 clinicians performing TPDN from 5 in 2010, an internally developed mandatory refresher class, with CEU approval, was held
to review technique, clinical reasoning, safety and adherence to policies.
As the number of clinicians exponentially increased from 5 to 88 by the
year 2015, we expanded the quality measures by standardizing competencies through baseline written testing to maintain the integrity of the
policies as well as clinical reasoning. In late 2015, an email-based blog
platform for all needlers was initiated to stimulate discussion, answer
questions and provide current concepts in dry needling.
SUMMARY OF USE: Patients expect safety and quality from each interaction with a health care professional. As our Trigger Point Dry Needling
(TPDN) program expanded at Baylor Rehab from 5 clinicians to 88 over
a 6-year span, we were able to demonstrate the ability to maintain the
quality control measures and ensure safety, adherence to policy and standardization. In 2015 alone, we estimate that out of 354 295 patient visits,
approximately 11% of patients seen in the clinic were needled with TPDN
techniques. Of the approximate 38 972 needling encounters in 2015, there
were zero reported adverse patient incidents. In summary, over 6 years
and countless encounters, we were able to maintain zero adverse patient
incidents.
IMPORTANCE TO MEMBERS: Due to the expansion of dry needling in the physical therapy profession in the past 4 to 5 years, there are some increasing
concerns among other health care providers of the safety and qualifications for a licensed physical therapist to perform this invasive procedure.
In order to maintain a level of quality control, our organization has adopted a proactive approach of quality measures and controls to maintain
consistency and safety.
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OPO215
RETURN TO OVERHEAD SPORT FOLLOWING ULNAR COLLATERAL
LIGAMENT INJURY: A SYSTEMATIC REVIEW
Taylor Stern, Jeremy McCullough, Avi Bagley, Derek Poulson,
Aaron Rygiel, Evan M. Vasilauskas, Michael Reiman
Duke University, Durham, North Carolina
PURPOSE/HYPOTHESIS: Ulnar Collateral Ligament (UCL) injuries are common amongst overhead athletes of all ages. Twenty-five percent of major league pitchers report a history of UCL reconstruction. Surgical treatments for UCL injuries have increased over the past 2 decades. The goal
of this systematic review was to examine the RTP rate as well as the return
to same level of play or higher (RTSLP) rate of athletes after UCL injuries.
NUMBER OF SUBJECTS: Twenty-five studies, subjects followed up/enrolled
(2288/3030) (2289 elbows).
MATERIALS/METHODS: A computer-assisted search of PubMed, CINAHL,
Embase and SportDiscus databases was utilized, searching for articles
from 1999 until December 2015. Studies prior to 1999 were not included due to consensus reporting of significant changes in surgical technique. The search utilized key terminology associated with ulnar collateral ligament reconstruction, revision, or repair in overhead athletes.
This systematic review was designed based on the guidelines of the
Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Methodological quality of the individual studies was assessed using a
modified Downs and Black checklist.
RESULTS: The search resulted in 421 abstracts, which was narrowed down
to 25 research articles. Downs and Black scores of the articles revealed 2
high quality and 4 moderate quality. The remaining 19 articles rated in
the low quality category. Overall RTP rate after UCL injury was 89.7%
(range, 42%-100%). The average overall RTSLP rate was 81%. Only 28%
of the articles included pitching performance, 86% of these showed significant decrease in innings pitched, 71% showed an increased trend in
ERA, and 57% showed an increase trend in WHIP.
CONCLUSIONS: Low quality studies demonstrate a high RTP and RTSLP
post UCL injury. Unfortunately, significant variability in reporting of data
and a lack of a standardized definition for returning to play after UCL injury exists in these studies. Therefore, the actual benefit of UCL surgery
is unknown. There also needs to be more high quality studies done to analyze the return to sport outcomes in athletes that undergo UCL surgery.
The decline in pitching statistics throughout the majority of studies included in this review highlights the disparity between public perception
of UCL surgery and the true potential outcomes for an athlete who damages his or her UCL. There is much variability in reporting of data and a
lack of a standardized definition for returning to play after UCL injury.
It is clear that future high quality studies are necessary to clearly elucidate the return to sport outcomes in athletes that undergo UCL surgery.
CLINICAL RELEVANCE: This review will serve to inform health care providers,
coaches and athletes of the limited quality of studies describing the expected prognosis for RTP among athletes that sustain a UCL injury and
undergo subsequent surgery. It will also serve as a stimulus for improved
quality of studies and increased emphasis on prevention of these injuries.
OPO216
THE EFFECT OF A WEIGHT-BEARING WINDLASS TEST ON DORSAL ARCH
HEIGHT IN HEALTHY AND PATHOLOGICAL FEET
Karen Stevens, Jessica Nilles, Amber Lisowe, Shelby Heilman,
Quinn de la Concepcion, Sean Seiler, Kailee Springer
Rosalind Franklin University, Libertyville, Illinois
PURPOSE/HYPOTHESIS: The mobility and support of the medial longitudinal arch is important in managing patients with foot and ankle pathology.
The windlass function of the plantar fascia provides a mechanism of medial arch support and power generation. The Windlass Test has been used
in diagnosing plantar fasciitis, but its sensitivity is low. Clinical measures
assessing the effect of the plantar fascia on midfoot mobility are lacking.
The purpose of this pilot study was to examine the effects of a weight
bearing Windlass Test (WBWT) on midfoot mobility using the dorsal arch
height (DAH) measure in pathological and healthy feet.
NUMBER OF SUBJECTS: Sixteen subjects (mean age, 32.2 years; BMI, 24.3
kg/m2; 81% female) with a history of unilateral foot/ankle pathology consented to participate in the study. Foot and ankle pathology included a
range of pathologies and chronicity, including foot fractures, heel pain,
ankle sprain, and plantar fasciitis.
MATERIALS/METHODS: Subjects were placed in a standardized bilateral
stance position. A digital gauge (Mitutoyo Corporation, Japan) placed at
50% of the total foot length was used by a blinded examiner to measure
DAH (mm) in resting stance position and during the WBWT. Three measures were recorded for each foot. Intertrial reliability across 3 trials was
assessed with intraclass correlation coefficients (ICC model 3,1). Paired t
tests, applied to the mean of 3 trials, were used to examine group differences in DAH change between healthy and pathological feet.
RESULTS: Intertrial reliability was good (ICC = 0.79). DAH change was not
significantly different between healthy feet and pathologic feet (mean ±
SD healthy, 4.4 ± 1.2 mm versus pathologic, 4.3 ± 2.3 mm; P = .89). The
range of DAH change scores across both feet was 1.6 to 9.6 mm.
CONCLUSIONS: The DAH during the WBWT demonstrated excellent intertrial reliability. The range of midfoot motion during the WBWT was
smaller than ranges reported in the literature for the Navicular Drop Test.
No difference in DAH during the WBWT between groups was found, but
may be explained by study limitations.
CLINICAL RELEVANCE: Midfoot mobility during the WBWT is small and may
not reflect overall midfoot motion, but may reflect the specific function of
the plantar fascia. Future research is needed to determine the utility of the
WBWT in examining plantar fascia function.
OPO217
A COMPARISON OF INTRINSIC FOOT STRENGTH IN PATHOLOGICAL
AND HEALTHY FEET: A PILOT STUDY
Karen Stevens, Jessica Nilles, Nicholas Martin,
Troy McGilligan, Erin Rucinski, Ryan Breen, Kahlin Shandley
Rosalind Franklin University, Libertyville, Illinois
PURPOSE/HYPOTHESIS: Intrinsic foot muscle weakness has been implicated
in a range of foot deformities and disorders. However, an objective measure of the relationship between muscle weakness and foot pathology has
not been established. The purpose of the present study was to compare intrinsic foot strength between pathological and healthy feet using a FootStrength Test Device (US Patent Application number 15/689,550).
NUMBER OF SUBJECTS: Sixteen subjects (mean age, 32.2 years; 81% female)
with a history of unilateral foot/ankle pathology consented to participate
in the study. Reported pathology included: fracture (3), ankle sprain (5),
tendinopathy/tendonitis (3), plantar fasciitis (3), and other (2).
MATERIALS/METHODS: Subjects were randomly assigned to side and position (seated or standing) testing order. Foot strength was measured with
a Foot-Strength Test Device (US Patent Application number 15/689,550).
After completing 3 practice trials, subjects pulled on a towel attached to
a dynamometer by curling their toes. Peak force (lb) was recorded. Three
trials were performed on each foot in both standing and seated positions,
and the mean of the 3 trials used for data analysis. Paired t tests were
used to examine group differences in foot intrinsic muscle strength, and
for differences in position (sitting versus standing) with a priori alpha
level of .05.
RESULTS: Mean ± SD strength values were: pathological sitting, 2.03 ±
0.96 lb and standing, 3.28 ± 1.02 lb; healthy sitting, 2.19 ± 1.28 lb and
standing, 3.55 ± 1.32 lb. No differences in strength between pathological and healthy feet in sitting or standing were found. However, a trend of
greater strength of the healthy foot was observed. Differences in strength
between standing and seated positions were found (P<.05).
CONCLUSIONS: No difference in intrinsic foot strength between pathological and healthy feet was found, but may be explained by study limitations
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of sample size and varied pathology. A trend of greater strength on the
healthy side was observed and warrants further research. Position was
found to affect foot strength, with greater force production found in a
standing versus seated position. Future research examining how position
and specific pathology affect foot muscle strength may improve intervention planning.
CLINICAL RELEVANCE: Understanding how foot and/or ankle pathology affects foot muscle strength may lead to improved intervention planning
in managing patients. The trend of greater strength of the healthy foot
in this pilot study should be further investigated to determine if specific
types of pathology are associated with foot weakness. Differences in force
production between the seated and standing positions should be considered in exercise prescription for foot intrinsic strengthening.
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OPO218
ATTITUDES AND PERSPECTIVES ON ANKLE FUNCTION IN PEOPLE
WITH HEMOPHILIA: A QUALITATIVE STUDY
Kate Stribling, Nancy Durben, David Oleson, Michael Recht
Oregon Health and Science University, Portland, Oregon
PURPOSE/HYPOTHESIS: For people with hemophilia, mild trauma can cause
internal joint bleeding. Over time, repeated bleeding episodes can result
in joint stiffness and pain, limited range of motion, and ultimately irreversible bony changes. Ankles are a frequently affected joint and ankle
pain occurs relatively early in life. Impaired ankle function can affect the
ability of people with hemophilia to participate in activities of daily living,
work and leisure. The purpose of this study was to explore the experiences
and priorities of people with hemophilia A or B regarding their foot and
ankle function, activity and participation.
NUMBER OF SUBJECTS: Eleven.
MATERIALS/METHODS: Eleven participants with hemophilia A or B, 21
years and older with a history of ankle pain, were recruited from a sample of convenience from the Pacific Northwestern, USA. Individual and
group interviews were conducted using a semi-structured format. The interviews were recorded, transcribed and then analyzed using thematic
analysis with NVivo 10 Software.
RESULTS: Four themes emerged: (1) “Pain impacts my daily life, but I still
have to get things done.” Participants reported an expectation of joint
pain but were more concerned with how pain affects their ability to participate in activities they want to do. (2) “Management of ankle function
is highly individualized.” Participants reported a wide variety of personal strategies and techniques including but not limited to orthotics, footwear, adaptive equipment, medications and exercise. (3) “Self-advocacy
is crucial.” Participants reported self-advocacy skills as necessary in order to receive quality care but often expressed frustration that achievement of desired outcomes required this skill. (4) “I want health care providers who listen to me and respect my knowledge.” Participants stated a
desire for health care providers to acknowledge and value the patient’s input in his plan of care.
CONCLUSIONS: For our participants, joint paint and ankle dysfunction affect daily life. Expressed themes highlighted priorities for participation,
health management and for desired health care. The sample was limited
to participants in the Pacific Northwest in the United States and therefore
may only be generalized to this demographic.
CLINICAL RELEVANCE: As health care moves from volume-based to valuebased care delivery, the patient’s voice is increasingly important in prioritizing the most impactful interventions. The participant-identified priorities and experiences from our study can begin to inform health care
providers, allowing them to deliver more impactful care, improved rapport, and more valuable services for their patients with hemophilia.
OPO219
A NOVEL INDEX BASED ON KINEMATIC AND KINETIC MEASURES
FOR SPINAL STABILITY IN SUBJECTS WITH RECURRENT LOW BACK PAIN
Paul S. Sung
Central Michigan University, Mt Pleasant, Michigan
PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the rela-
tionship between normalized kinematic and kinetic stability indices for
spinal regions during nondominant leg standing with eyes-open and eyesclosed conditions between subjects with recurrent low back pain (LBP)
and control subjects.
NUMBER OF SUBJECTS: Forty-two subjects participated in the study, including 22 subjects with LBP (12 male, 10 female) and 20 control subjects (12
male, 8 female).
MATERIALS/METHODS: The kinematic stability index for the spinal regions
(core spine model, lumbar spine, lower thorax, and upper thorax) and the
kinetic stability index (utilizing force plate) were measured. All participants were asked to maintain nondominant leg standing for 25 seconds,
with the dominant hip and knee flexed approximately 90°.
RESULTS: For the kinematic index for stability, the visual condition (F =
30.06, P = .0001) and spinal region (F = 10.82, P = .002) were statistically significant. The post hoc test results indicated a significant difference in
the lumbar spine compared with the upper and lower thorax and the core
spine model. The kinetic stability index during the eyes-closed condition
significantly decreased in the LBP group (t = –3.24, P = .002).
CONCLUSIONS: The subjects with recurrent LBP demonstrated higher lumbar spine stability in the eyes-open condition. This higher stability of the
lumbar spine might be due to a possible pain avoiding strategy from the
standing limb. The LBP group also demonstrated significantly decreased
kinetic stability during the eyes-closed condition.
CLINICAL RELEVANCE: The subjects with recurrent LBP rely on visual input
due to decreased proprioception from lumbar spine injuries while minimizing normalized kinetic changes from the ground. Clinicians need to
consider both kinetic and kinematic indices while considering visual condition for lumbar spine stability in subjects with recurrent LBP. Funding
source: Central Michigan University.
OPO220
LUMBAR SPINE STIFFNESS CHANGES AND MUSCLE ACTIVATION
DURING THE PRONE INSTABILITY TEST
Won Sung, David Ebaugh, Gregory E. Hicks,
Scott K. Stackhouse, Sue Smith, Peemongkon Wattananon,
Sheri P. Silfies
Drexel University, Philadelphia, Pennsylvania; University of
Delaware, Newark, Delaware; Arcadia University, Glenside,
Pennsylvania; Mahidol University, Bangkok, Thailand
PURPOSE/HYPOTHESIS: Prone instability testing (PIT) is used to identify individuals with low back pain (LBP) that would benefit from trunk stabilization exercises. Theoretically, activity from muscles such as the lumbar
multifidus (LM) enhances spinal stiffness during leg raising of the PIT, resulting in pain reduction. However, this theory lacks evidence. Our purposes were: (1) compare and contrast lumbar spine stiffness changes and
muscle activation patterns in individuals with and without LPB and (2)
determine if preferential contraction of the LM during the PIT via neuromuscular electrical stimulation (LMES) results in similar pain reduction
and stiffness increases as active leg raising.
NUMBER OF SUBJECTS: Twenty.
MATERIALS/METHODS: Individuals (n = 10) with LBP (5 female; mean ± SD
age, 29 ± 6 years) and individuals (n = 10) without LBP (NLBP) (2 female;
mean ± SD age, 29 ± 3 years) performed the PIT. Three-dimensional kinematics measured lumbar spine stiffness (LSS) via a bending beam model. Stiffness changes were compared across PIT positions (prone, start
position, leg raise) with a repeated ANOVA, and between groups with a
mixed ANOVA, α = .05. Surface EMG electrodes recorded muscle activity of LM, lumbar and thoracic erector spinae (LES, TES), latissimus dorsi
(LD), gluteus maximus (GMX) and hamstrings (HS) bilaterally. Muscle
activations were normalized to maximal volitional contractions. Principal
component analysis (PCA) was used to extract muscle synergies used by
individuals with and without LBP during leg raising. Mixed ANOVA com-
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pared percent activation of individual muscles between groups.
RESULTS: All participants with LBP had a positive PIT with increases in
LSS compared to prone position (P<.001). A significant increase in LSS
was also found compared to prone (P = .042) in the NLBP group. LMES
resulted in greater LSS compared to prone for both LBP (P = .029) and
NLBP (P = .014) groups. PCA revealed 3 muscle synergies that explained
93% of the variance in individuals with NLBP, with 42% of the variance accounted for (VAF) by synergy containing the LM, LES, and LD.
Individuals with LBP had only 2 synergies that yielded 77% of the variance, with 57% of the VAF by the synergy containing the TES, LD, and
HS. NLBP had significantly greater activation of LM, LES, and GMX
compared to those with LBP (P = .03).
CONCLUSIONS: LSS increased during the active leg raising portion of the
PIT and was reproduced with LMES, supporting the role of LM muscle
activity in increasing lumbar stiffness. Despite achieving a positive PIT,
individuals with LBP had differences in their muscle activation patterns
and reduced LM and LES activation that required different muscle synergies to achieve lumbar spine stiffening and a positive test.
CLINICAL RELEVANCE: Individuals with LBP demonstrate lumbar spine stiffening during the PIT, but may accomplish this using a different strategy
compared to NLBP group. This may suggest altered neuromuscular control that responds to a stabilization exercises. The ability to obtain lumbar spine stiffening with LMES, may suggest its potential adjunctive role
in rehabilitation.
OPO221
TRADITIONAL CRATE VERSUS XRTS LEVER ARM LIFT
Marcie C. Swift, Janice K. Loudon, Brian M. Becker,
Garrett Greaves, Megan Reardon, Justin Reinhard
Physical Therapy, Rockhurst University, Kansas City, Missouri
PURPOSE/HYPOTHESIS: Within a functional capacity evaluation (FCE), an
individual’s sincere maximal effort must be determined. Objective tools
or methods such as the traditional crate lift are used to assess sincerity of
effort. The XRTS Lever Arm replicates the biomechanics of the crate lift.
The purpose of this research study is to (1) compare the maximum lifting
capacities on the XRTS Lever Arm with the traditional crate lift and (2)
determine the relationship of perceived exertion between the XRTS Lever
Arm and the traditional crate lift.
NUMBER OF SUBJECTS: A total of 41 subjects between ages 20 and 40 with
no upper or lower extremity injuries within the past 12 months were recruited to participate in this study. Subjects who were able to lift more
than 110 lb in the crate lift were excluded.
MATERIALS/METHODS: On the first day of testing, investigators established
1RM for each subject performing a lift from 20 inches off the ground to
their navel using a traditional crate. Subjects were then randomly assigned 5 weights ranging from 10% to 100% of their determined 1RM
and asked to give a rating of their perceived exertion (RPEs) after each
lift. The subjects repeated the same procedure used for the crate lift 2
to 5 days later using the XRTS Lever Arm. For Purpose 1, paired t tests
were used to compare maximal lifts between subjects. For Purpose 2,
Spearman’s correlation coefficient was used to determine the relationship
of perceived exertion between the XRTS Lever Arm and the traditional
crate lift. For all statistical testing, alpha was set at less than .05.
RESULTS: There was a statistically significant difference (P<.04) between
maximal lift values for the 2 lifting modes. The percent difference between the traditional crate lift and the XRTS Lever Arm was 10.5% ±
6.4% with values ranging between 0.82% and 23.78%. Of the 41 subjects,
38 of the subjects were below a 20% difference and 31 subjects were below a 15% difference. Additionally, there was a positive correlation between the RPE on the traditional crate lift and the XRTS Lever Arm (P
= .92).
CONCLUSIONS: This validation study demonstrates that lift effort and perceived exertion are not different between lifting modes. Although the actual maximal lift values for the modes of lifting were statistically differ-
ent the 2 modes of lifting are equivalent within the standard 20% percent
difference.
CLINICAL RELEVANCE: It is challenging to determine an individual’s sincerity of effort based on visual observation alone during an FCE. Patients
whose efforts are not sincere during physical evaluation may overuse
treatment, have prolonged recovery, or increased cost of care. Ongoing
research using distraction based lifting with the XRTS Lever Arm for determining patient effort during testing is needed in which data collection
simulates the clinical environment by testing subjects for both modes of
lifting on the same day rather than on 2 separate days. Further, increased
scientific evidence to support objective measurement of effort will assist
in eliminating clinician bias in determining functional capacity evaluation results.
OPO222
THE EFFECTS OF DIFFERENT VERBAL INSTRUCTIONS ON HOP HEIGHT
AND CONTACT TIME DURING THE VERTICAL HOP TEST IN RECREATIONAL
ATHLETES POST–ACL RECONSTRUCTION
Jeremiah J. Tate, Betsy A. Myers
Physical Therapy, University of Tennessee at Chattanooga,
Chattanooga, Tennessee
PURPOSE/HYPOTHESIS: The purpose of this study was to assess the effect
of 2 verbal instructions on contact time and jump height during performance of a vertical hop test in recreational athletes post ACL reconstruction. We hypothesized that participants’ contact times would decrease
when asked to perform the test as fast as possible and hop height would
remain similar. We also hypothesized that no differences would exist between limbs for both contact time and hop height.
NUMBER OF SUBJECTS: Twelve college-aged recreational athletes (9 female,
3 male) who had undergone ACL reconstruction surgery were included in
this study. Participants were currently active 2 times per week for a minimum of 30 minutes and participated in jumping/cutting activities at least
1 time per month.
MATERIALS/METHODS: Participants performed a vertical hop test which consisted of 5 consecutive hops on the same lower extremity. An optical measurement system (Optojump, Micrograte, USA) was used to determine
contact time and hop height. Participants were instructed to hop as high
as possible on 1 leg. During the landing, participants were instructed to
try to land in the same spot. The vertical hop test was then repeated in
the same manner, but participants were instructed to perform the test
as quickly as possible. Mixed model ANOVAs (instruction by limb) were
performed to analyze for potential differences and Tukey’s post hoc test
was used for multiple pairwise comparisons.
RESULTS: A significant interaction (P = .04) was demonstrated for contact time. Contact times were faster when participants were asked to perform the hops as quickly as possible (1.88 seconds versus 0.57 seconds, P
= .005). Additionally, contact time on the involved limb was greater than
the uninvolved limb (2.03 seconds versus 1.73 seconds, P = .005). This
difference between limbs was not demonstrated when participants were
asked to hop as quickly as possible (0.59 seconds versus 0.55 seconds, P =
.91). A significant limb effect (P = .009) was demonstrated for hop height
indicating that hop height on the involved limb was less than the uninvolved limb for both instructions (13.7 cm versus 14.7 cm and 12.4 cm versus 13.8 cm).
CONCLUSIONS: Results indicate that vertical hop test verbal instructions
have an effect on contact time and hop height. Participants tended to increase contact time on their involved lower extremity in efforts to maximize hop height when instructions focused primarily on hop height.
There were no differences in contact time between limbs when participants were asked to perform the test as quickly as possible. Hop height
differences were similar between limbs for both instructions.
CLINICAL RELEVANCE: The vertical hop test has the potential to demonstrate
asymmetries in hop height regardless of how fast a person performs the
test. Instructions that are linked to how quickly a person performs the test
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may result in more symmetrical contact times, thus hiding potential limb
differences that maybe related to power development.
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OPO223
3-YEAR OUTCOMES FOR PATIENTS WITH NECK AND BACK PAIN PARTICIPATING
IN AN OPTIMIZED PHYSICAL THERAPY MANAGEMENT PROGRAM
Charles A. Thigpen, Thomas R. Denninger, Allison Bell,
Chad E. Cook, Timothy McHenry
Research and Analytics, ATI Physical Therapy, Greenville, South
Carolina; Department of Orthopedics, Duke University, Durham,
North Carolina; Department of Orthopedics, Greenville Health
System, Greenville, South Carolina
PURPOSE/HYPOTHESIS: Previous research has demonstrated that early PT
consultation for patients with low back pain improve outcomes and decrease cost utilization. Additionally, physical therapy continues to be an
underutilized part of care for patients with back and neck pain. The purpose of this study is to describe the 3-year outcomes of patients participating in a novel Back and Neck program where Physical Therapy was
optimally utilized.
NUMBER OF SUBJECTS: The study involves 604 patients with neck and/or
back pain who received guideline oriented care by physical therapists over
a 3-year period.
MATERIALS/METHODS: The data included patients who were seen via direct
access or through referral. For all patients, patient report outcomes for
pain, disability, depression, and quality of life were captured. Descriptive
statistics examined average number of visits and change scores for measured outcomes.
RESULTS: Of the enrolled participants 440 were female (73%) and the sample had an average age of 48.84 years. Of those enrolled, 197 (33%) had
cervical complaints, 370 (61%) had lumbar complaints, and 33 (6%) had
both. Twenty-nine percent of patients in cohort reported radiating symptoms, 30% of the lumbar patients, and 32% of cervical patients. One hundred forty-eight (25%) of the patients were categorized as acute (symptoms less than 90 days). Patients were seen on average for 6.8 visits.
Patients demonstrated a 3.7 (95% CI: 3.411, 3.942; P<.0001) point reduction on a numeric pain-rating scale, representing a 64% reduction from
baseline. Patients demonstrated a 8.4 (95% CI: 7.216, 9.454; P<.001) and
7.0 (95% CI: 5.776, 8.286; P<.0001) point reductions on the Modified
Oswestry Disability Index and Neck Disability Index, respectively. No significant changes in quality of life and depression were noted (P>.05).
CONCLUSIONS: Our study demonstrates that patients entering a program
where physical therapy is optimally utilized demonstrate significant reductions in pain and disability. Changes in pain and disability exceeded statistical significance, minimally clinically important difference, and
50% reduction threshold.
CLINICAL RELEVANCE: This finding further supports the idea that PT should
be utilized early in the care seeking episode of patients with back and
neck pain and potentially at greater rates than is contemporary practice.
Columbus, Ohio
PURPOSE/HYPOTHESIS: Knee impairments are common in individuals with
articular cartilage defects (ACD) in the patellofemoral (PF) or tibiofemoral (TF) compartment of the knee and may induce a protective response
to unload the ACD. Yet, it is unknown if individuals with ACDs modify
activity to provide compartment-specific unloading. The purpose of this
study was to elucidate the compartment-specific loading patterns during
gait, quantified as joint reaction forces (JRF), of individuals with knee
ACDs compared to healthy controls. We hypothesized that individuals
with ACDs would unload the affected compartment during gait.
NUMBER OF SUBJECTS: Twenty-seven individuals with ACDs, 19 healthy
controls (HC).
MATERIALS/METHODS: Individuals with ACDs were divided into groups according to ACD location: PF (only PF ACD), TF (only TF ACD), and MIX
(both PF and TF ACDs). The involved limb was randomly assigned in
the HC group. Participants underwent 3-D gait analysis at self-selected
speed. TF-JRF was calculated using inverse dynamics. PF-JRF was derived from an estimate of quadriceps force and knee flexion angle. The
primary variables of interest were first and second peaks for the PFand TF-JRF (units body weight [BW]), corresponding with each half
of stance. Secondary variables included gait speed, quadriceps strength,
knee function (Knee Injury and Osteoarthritis Outcomes Score) and activity level (Tegner Activity Scale). We tested for group differences in peak
PF-JRF and TF-JRF with a multivariate analysis of variance. Related secondary variables (correlation analyses, P<.05) were added as covariates in
a multivariate analysis of covariance.
RESULTS: The first peak PF-JRF and TF-JRF were similar in the TF and
MIX groups (0.75-1.0 BW, P = .6-.9). Both peaks were also similar in the
PF and HC groups (1.1-1.3 BW, P = .7-.8), and higher than the TF and
MIX groups (P = .004-.02). For the second peak PF-JRF, only the HC
group was higher than the TF group (P = .02). In the full sample, gait
speed was related to all JRF peaks (r = 0.53-0.78, P<.01), while quadriceps strength was related to TF-JRF peaks (r = 0.33-0.34, P<.05). When
gait speed and quadriceps strength were included as covariates, there
were no differences for any JRF peak. In individuals with ACDs, JRF
peaks were generally not related to knee function and activity level, and
group differences persisted when accounting for these variables.
CONCLUSIONS: Individuals with TF ACDs (TF and MIX groups) walked
slower, which was associated with lower joint loads. Walking slower may
be a protective gait modification to reduce load for individuals with TF
ACDs, but was not observed in those with PF ACDS. Walking is likely
a more provocative activity for TF ACDs compared to PF ACDs, as the
TF joint is weight bearing throughout stance. Future work should examine joint loading in tasks that engage the PF joint, such as stair climbing or squatting.
CLINICAL RELEVANCE: Physical therapists should consider ACD location in
selecting exercises and recommending activity modifications in individuals with ACDs in the knee.
OPO224
OPO225
DIFFERENTIAL KNEE JOINT LOADING PATTERNS DURING GAIT FOR
INDIVIDUALS WITH TIBIOFEMORAL AND PATELLOFEMORAL ARTICULAR
CARTILAGE DEFECTS IN THE KNEE
Louise M. Thoma, Michael P. McNally, Ajit M. Chaudhari,
Thomas Best, David C. Flanigan, Robert A. Siston,
Laura C. Schmitt
School of Health and Rehabilitation Sciences, The Ohio State
University, Columbus, Ohio; Physical Therapy, University of
Delaware, Newark, Delaware; Division of Physical Therapy, The
Ohio State University, Columbus, Ohio; Department of Family
Medicine, OSU Sports Medicine, The Ohio State University,
Columbus, Ohio; Department of Orthopedics, OSU Sports Medicine,
The Ohio State University, Columbus, Ohio; Department of
Mechanical and Aerospace Engineering, The Ohio State University,
MESENCHYMAL STEM CELL FATE IS INFLUENCED BY RECRUITMENT
OF MTORC2 TO THE CELL MEMBRANE BY MYOSIN MOTORS
William R. Thompson, Yong Li, Gunes Uzer, Janet Rubin
Endocrinology, Indiana University, Indianapolis, Indiana;
Physical Therapy, Indiana University, Indianapolis, Indiana
PURPOSE/HYPOTHESIS: Bone quality and quantity is inversely proportional to adipogenic commitment of marrow derived mesenchymal stem cells
(MSCs), where increased adipogenesis depletes the progenitor pool for
osteogenesis. Mechanical strain suppresses adipogenesis by activating a
cascade involving Fyn, mTORC2, and Akt, culminating in both enhanced
Beta catenin nuclear entry and cytoskeletal reinforcement. Previous work
has demonstrated that this signaling cascade initiates at focal adhesion
(FA) platforms, where strain recruits both Fyn and mTORC2 to amplify
downstream responses; however, the mechanisms responsible for recruit-
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ing these signals to FAs is unclear. A mechanical strain induces actin cytoskeletal stress fibers, while disruption of this structure prevents activation of the Fyn/mTORC2/Akt cascade. Furthermore, visualization of Akt,
using immunostaining, after mechanical strain, reveals Akt aligned in a
pattern similar to actin cytoskeletal struts. These observations led us to
hypothesize that recruitment of these upstream kinases to FA platforms
requires movement along the actin cytoskeleton in response to strain.
NUMBER OF SUBJECTS: Not applicable.
MATERIALS/METHODS: Murine MSCs were isolated from marrow aspirates
and cultured using alpha MEM with FBS and antibiotics. MSCs were
plated on silicone bottomed 6-well dishes and subjected to biaxial mechanical strain (2%, 100 cycles). Antibodies were used for immunoprecipitation, followed by mass spec analysis or Western blotting. For Western
blotting, 20.25 g of total cell lysate was loaded per well. Following polyacrylamide gel electrophoresis, proteins were transferred to PVDF membranes, blocked with milk and probed overnight with primary antibodies.
After a 2 hours of incubation with secondary antibodies, blots were exposed using ECL reagent.
RESULTS: Myosins are molecular motors that carry “cargo” to intracellular locations. Myosins also regulate cytoskeletal reorganization in adipocytes, suggesting a role in adipogenic commitment. Mass spec analysis,
revealed a strong association of Rictor with both myosin 1C and myosin
9. Co-immunoprecipitation studies confirmed that both myosin 1C and
myosin 9 bind Rictor. Importantly, mechanical strain enhanced the binding of myosin 1C with Rictor, while the affinity of myosin 9 with Rictor
was not affected.
CONCLUSIONS: These data suggest that myosin 1C is a critical component
of strain-induced recruitment of signaling effectors to the plasma membrane, where signal amplification restricts adipogenesis. As activation of
signaling cascades that direct MSC lineage are temporally and spatially regulated, force is necessary for spatial partitioning of Fyn/mTORC2/
Akt. Myosin motors are necessary for carrying this “signaling cargo” to
FAs, where force is transmitted, and subsequent signal activation occurs.
CLINICAL RELEVANCE: This work seeks to identify the mechanisms by which
MSCs sense mechanical force, and direct signaling molecules to focal contact points in the cell, where force is translated into biochemical signals
that direct stem cell lineage fate to promote bone formation.
OPO226
VALUE OF WITHIN-SESSION AND BETWEEN-SESSION FINDINGS
FOR LONG-TERM OUTCOMES FOR PATIENTS RECEIVING MANUAL THERAPY
Caroline L. Ubben, Ashlee Kim, Adam Dalbo,
Mackenzie Eldridge, Chad E. Cook
Orthopedics, Duke University, Durham, North Carolina
PURPOSE/HYPOTHESIS: The purpose was to determine if early change leads
to improved outcomes in patients who receive a manual therapy-oriented intervention. We hypothesized that early change carried over to a subsequent visit (between-session effects) will be more predictive of longer-term improved outcomes than immediate effects (changes within a
session).
NUMBER OF SUBJECTS: Subjects involved individuals who received manual
therapy treatment beyond 2 scheduled visits.
MATERIALS/METHODS: Relevant databases were searched up to November
of 2015. Studies were included if they were a cohort study or RCT with
covariate control and longitudinal design. Outcomes measured included pain, range of motion (ROM), global rating of change (GRoC) and select physical performance measures with variables assessed 96 hours after initial visit. Risk of bias influencing internal and external validity and
fidelity (quality and strength of the intervention provided) were separately assessed.
RESULTS: Seven studies met the inclusion criteria and were in included
in the review. Early change in pain and GRoC were predictive of longterm improvements. Changes in disability were predictive of changes in
pain, but not predictive of changes in function. Within-session changes in
ROM were predictive of between-session changes.
CONCLUSIONS: The hypothesis that between-session findings are an important form of early change, and can predict treatment success was supported. This review disputes the idea that within-session changes are as
strong of a clinical predictor for patient progress as patient’s betweensession changes. Therefore, between-session changes are a more effective
tool for determining patient plan of care.
CLINICAL RELEVANCE: There is a need for an adequate tool or predictor that
can effectively identify patients who will be strong responders to manual therapy focused interventions. Between-session changes offer more
value than immediate or within session changes in predicting improvements. This review supports that a more effective tool for prediction
should include between-session changes in treatment rather than immediate changes or anything specific to the patient at baseline. Future research should focus on the prediction value of between-session changes
over CPR and immediate effect studies.
OPO227
THE “HEMOPHILIA VERTICAL” PROJECT: FEASIBILITY OF THERAPEUTIC
ROCK CLIMBING FOR PATIENTS WITH HEMOPHILIA AND PRE-EXISTING
ARTHROPATHY
Lena M. Volland, Courtney Schroeder, Colleen Moran,
Richard F. Barnes, Annette von Drygalski
Hemophilia and Thrombosis Treatment Center, UC San Diego
Health, San Diego, California; University of California San Diego,
San Diego, California
PURPOSE/HYPOTHESIS: Hemophilia is a X-chromosome linked genetic disease, which, despite advances in prophylactic clotting factor replacements, causes spontaneous joint and muscle bleeds and leads to
debilitating arthropathy. Therefore, physical therapy and graded exercise programs have become critical interventions for this patient population to further improve upon joint health and enhance overall quality of life (QoL). Generally, only low impact sports, such as swimming,
walking, and yoga, have been deemed safe and thus, were recommended by the National Hemophilia Foundation (NHF) and World Federation
of Hemophilia (WFH). However, these activities were found to be boring by many patients, which often lead to involvements in riskier sports,
such as soccer, skiing, or football, potentially causing detrimental injuries.
Consequently, there is a need for the development of more exciting yet
safe treatment programs in a controlled environment. Therapeutic rock
climbing has been widely used in Europe for various patient populations
with muscular skeletal and neurological diseases and has shown significant physical and psychological health benefits. Thus, it may be a suitable
alternative for patients with hemophilia. The aim of this study was to investigate the feasibility of therapeutic rock climbing for patients with hemophilia and preexisting arthropathy.
NUMBER OF SUBJECTS: Six.
MATERIALS/METHODS: Six male subjects with moderate to severe hemophilia A and preexisting arthropathy (mean ± SD age, 32.67 ± 7.15 years) participated in 12 sessions of therapeutic indoor top rope rock climbing. Each
session was 2 hours long and followed a goal directed structure depending upon participant’s abilities. The participants were instructed by a professional rock climbing instructor and supervised by a licensed physical
therapist. Hemophilia Joint Health Score (HJHS), QoL (Haem-A-QoL
and Hep-Test-Q), range of motion (ROM), and climbing skills (Yosemite
Decimal Scale) were assessed pre and post rock climbing program.
Bleeding episodes, factor usage, and pain reproduction (Borg Scale) were
evaluated during the rock climbing program and compared to values obtain prior to the start of the project.
RESULTS: All participants significantly improved upon their climbing skills
without an increase in bleeding episodes, factor usage or pain reproduction. Small improvements were noted in daily (Haem-A-QoL) and sport
specific (Hep-Test-Q) QoL, HJHS, and ROM, with significant improvements in ankle mobility.
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CONCLUSIONS: Therapeutic rock climbing is feasible, safe and may constitute a valuable activity to be integrated into the physical therapy treatment regime. Additional investigations of its beneficial effects in a larger
cohort are desirable.
CLINICAL RELEVANCE: Due to improved medical treatment regimens patients with hemophilia are aging, but will present with arthropathies and
other comorbidities. Providing this population group with treatment programs challenging their abilities, while contributing to their overall wellbeing in a safe environment is essential.
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OPO228
THE EFFECT OF DRY NEEDLING ON SPINAL MUSCLE FUNCTION, PAIN,
AND DISABILITY IN INDIVIDUALS WITH MECHANICAL LOW BACK PAIN:
A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL USING SHEAR-WAVE
ELASTOGRAPHY
Amelia Weaver, Shane Koppenhaver, Tyler Randall,
Ryan Hollins, Laurel Proulx, Brian A. Young, Jeffrey Hebert,
Cesar Fernàndez de las Peñas
US Army-Baylor University Doctoral Program in Physical
Therapy, San Antonio, Texas; Murdoch University, Murdoch,
Australia; Universidad Rey Juan Carlos, Madrid, Spain
PURPOSE/HYPOTHESIS: Lumbar muscle dysfunction is commonly implicated in low back pain (LBP) [1-4]. Dry needling (DN) is an intervention
aimed at treating painful musculoskeletal conditions and muscular dysfunction [5-8]. However, no randomized controlled trials have assessed
the effects of DN on lumbar muscle function, pain, and disability in patients with LBP. The primary purpose of this study was to investigate the
effects of DN on lumbar muscle stiffness at rest and during submaximal
contractions in individuals with LBP and healthy people. Additionally we
examined the short-term effects of DN on pain and related disability in
those with LBP.
NUMBER OF SUBJECTS: Ninety-one individuals (60 with mechanical LBP
and 31 without current LBP) volunteered to participate (44 male; mean
± SD age, 31 ± 7 years).
MATERIALS/METHODS: Subjects with LBP were randomly allocated to receive true DN (n = 30) or sham DN (n = 30). Asymptomatic participants
received true DN. Study outcomes included muscle stiffness, pressure algometry of the lumbar multifidus (LM) and paraspinal (PS) muscles, and
the Oswestry Disability Index (ODI). Ultrasound shear wave elastography
(SWE) was used to measure LM and PS stiffness at rest and during a submaximal contralateral arm lift while holding a small weight [9]. Images
of the LM and PS muscles were captured at the right L4 level in asymptomatic subjects and on the painful side at the most painful level of the
L3, L4, or L5 vertebral levels in patients with LBP. A single session of dry
needling of the LM and PS muscles was performed at the right L4 level
in asymptomatic individuals. True or sham DN was applied to the painful
side at the most painful level of the L3, L4, or L5 levels in patients with
LBP. All measures were obtained before and immediately after the DN intervention. Study outcomes were obtained immediately after and 1 week
after treatment, except the ODI which was measured only at the 1-week
follow-up. Between-group comparisons were analyzed using ANCOVAs
with baseline scores as covariates.
RESULTS: No significant differences were found in LM or PS stiffness between any groups at either time point. However, a consistent trend indicated larger decreases (3%-11%) in stiffness in the true DN group compared to sham DN across both muscles and at both time points in patients
with LBP. There were no consistent between-groups differences in study
outcomes of pain or related disability.
CONCLUSIONS: There were no clear differences in the efficacy of a single
session of true DN versus sham DN on muscle stiffness, pain, and related-disability in patients with LBP. However, a consistent trend indicated
larger decreases in stiffness in the true DN group compared to sham DN.
CLINICAL RELEVANCE: A single session of DN does not appear to cause predictable changes in muscle function or clinical improvement in patients
with LBP. However, as clinically relevant changes were found in some individuals with LBP, future studies should aim to identify populations that
respond to DN.
OPO229
THE ASSOCIATION BETWEEN STATIC FOOT POSTURE AND HIP AND KNEE
KINEMATICS DURING WALKING
David Werner, Joaquin Barrios
University of Dayton, Cincinnati, Ohio
PURPOSE/HYPOTHESIS: Abnormal foot kinematics may affect more proximal mechanics of the lower extremity during weight-bearing tasks. While
static foot postures have been related to foot and ankle mechanics, little is known regarding the relationships to the hip and knee. The Foot
Posture Index (FPI) is a valid and reliable assessment of static foot posture. Therefore, this study aimed to correlate FPI scores with 3-D hip and
knee kinematics during walking.
NUMBER OF SUBJECTS: Thirteen (8 female; mean ± SD age, 23.2 ± 1.09
years; weight, 70.0 ± 12.5 kg; height, 1.7 ± 0.09 m) healthy individuals
provided bilateral data on 26 limbs.
MATERIALS/METHODS: Each limb was assessed using the FPI by a boardcertified orthopaedic physical therapist. The FPI is a 6-item observational and palpation-based assessment of static foot alignment, with higher
positive values indicating a more pronated foot and lower negative values
indicating a more supinated foot. Subjects were then fitted with an established retroreflective marker set bilaterally and performed 4 trials of level walking at a speed of 1.5 m/s. Kinematic data were collected at 100 Hz
using an 8-camera motion capture system, and reduced in Visual3D using an x-y-z Euler rotation sequence. Pearson-product moment correlation coefficients were then calculated between FPI scores and 3-D hip and
knee initial contact, excursion and peak angle data. An alpha level of .05
was applied for all significance testing.
RESULTS: There were moderate positive correlations between FPI score
and knee frontal plane angle at initial contact (r = 0.408, P = .04) as well
as knee frontal plane excursion (r = 0.467, P = .016), such that increased
pronation was related to increased knee abduction at initial contact and
increased knee movement towards adduction during stance. There was
also a moderate correlation between FPI score and maximum hip extension during stance (r = 0.545, P = .004), such that increased pronation
was related to increased hip extension.
CONCLUSIONS: Increased pronation may contribute to increased dynamic valgus during weight bearing, accounting for some portion of the knee
adduction movement during stance. Whereas, increased pronation may
contribute to increased hip extension by allowing more time in late stance
prior to push-off.
CLINICAL RELEVANCE: Static foot posture related moderately to hip sagittal
plane and knee frontal plane kinematics during ambulation. Clinicians
identifying abnormal motions at the hip and knee may consider evaluation of static foot posture. As this study is cross-sectional, prospective
studies are needed to evaluate if these relationships are causative.
OPO230
THE RELATIONSHIPS OF TRUNK MUSCLE PERFORMANCE AND FOOT TYPE
TO Y BALANCE PERFORMANCE
David Werner, Joaquin Barrios
University of Dayton, Dayton, Ohio
PURPOSE/HYPOTHESIS: Lower extremity injuries can be both debilitating
and costly. Efforts have been made to develop injury risk assessments, often focusing on functional mobility. As an established mobility test, the Y
Balance test has been shown to be prospectively related to injury risk in
athletic and military populations. However, it is likely that underlying factors such as strength and anthropometrics can influence Y Balance performance. Two such factors include trunk muscle performance and foot
type. This study aimed to examine the relationship of trunk muscle performance and foot type to Y Balance performance.
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NUMBER OF SUBJECTS: Twenty healthy subjects provided bilateral data on
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40 limbs.
MATERIALS/METHODS: Each subject performed the McGill Core Battery, the
Y Balance test, and were assessed with the Foot Posture Index (FPI) by a
board-certified orthopaedic physical therapist. The McGill Core Battery
consists of 4 timed static holds to assess overall trunk muscle performance. The positions include a modified sit-up hold, a right and left lateral plank hold, and a prone extension hold with legs and pelvis supported on a plinth with straps and with the upper body off the plinth. Subjects
held each positional hold to failure. The FPI is 6-item observational and
palpation-based assessment of static foot alignment, with positive values
indicating a more pronated foot and negative values indicating a more supinated foot. The Y Balance test is a series of 3 lower extremity reaching
tasks (anterior, posterolateral, posteromedial) that are normalized to limb
length and also combined to derive a composite score based on 3 successful reach trials in each direction. Pearson product-moment correlation coefficients were calculated between the variables assessed, using a conservatively adjusted alpha level of .01.
RESULTS: A moderate negative correlation was seen between FPI score and
anterior reach of the Y Balance (r = –0.492, P = .001), suggesting that a
more pronated foot is associated with reduced anterior reach. There were
moderate correlations between lateral trunk endurance and Y Balance
composite score when the stance leg of the Y Balance was ipsilateral (r =
0.516, P<.001) or contralateral (r = 0.510, P<.001) to the side tested in the
lateral plank hold. Regardless of stance limb, lateral trunk muscle performance was related to performance of the Y Balance test.
CONCLUSIONS: Greater foot pronation may compromise dynamic stability
on the stance leg due to a medialized center of pressure. Greater levels of
lateral trunk muscle performance may assist individuals in maintaining
body positions needed for dynamic lower extremity reach tasks required
for Y Balance.
CLINICAL RELEVANCE: The results of this study suggest that trunk muscle performance and pronation-supination foot type are related to lower extremity functional mobility. Clinicians may consider assessing trunk musculature and foot type when patients demonstrate reduced lower extremity
functional mobility. However, as the correlations were moderate, other factors that contribute to Y Balance performance should also be considered.
OPO231
CURRENT DECISION MAKING OF PHYSICAL THERAPISTS IN THE
MANAGEMENT OF PATIENTS WITH FOOT DROP SECONDARY TO NERVE
ROOT COMPROMISE DUE TO ACUTE LUMBAR DISC HERNIATION:
A SURVEY STUDY
Adam Wielechowski, Aaron Keil, Karrie Hamstra-Wright,
Yi-Fan Chen
Physical Therapy, University of Illinois at Chicago, Chicago,
Illinois; University of Illinois at Chicago, Chicago, Illinois
PURPOSE/HYPOTHESIS: The primary purpose was to examine the association of professional experience level of PTs with referral decisions regarding magnetic resonance imaging (MRI), neurosurgical consult, and
initiation of formal physical therapy for suspected acute lumbar disc
herniation (LDH) with myotomal involvement. A secondary purpose of
this study was to examine if there was an association between severity of
myotomal deficit (presumed to be due to LDH) and likelihood of referral for each of the 3 respective categories. Lastly, identical clinical scenarios were compared both with and without presence of MRI findings
to confirm clinical diagnosis of LDH to examine if there was an association between availability of MRI results and physical therapists’ referral
for neurosurgical consult.
NUMBER OF SUBJECTS: Sixteen thousand six hundred twenty-six members of
the orthopaedic section of the APTA were surveyed. The survey response
rate was 13.2% (n = 2172).
MATERIALS/METHODS: The association between demographic characteristics and clinical questions was assessed using multivariable logistic re-
gression (primary study purpose). Professional characteristics examined (in regards to clinical decisions) were years of clinical experience
(15+ years versus 0-15 years), highest physical therapy degree held (ie,
BSPT/MPT versus DPT), yes versus no regarding Fellow of the American
Academy of Orthopaedic Manual Physical Therapists (FAAOMPT), and
yes versus no regarding specialist certification from the American Board
of Physical Therapy Specialties (ABPTS). McNemar test was utilized to
examine secondary and tertiary purposes of the study (as listed in purpose/hypothesis section).
RESULTS: Years of clinical experience and type of PT degree influenced the
likelihood of several referral decisions. ABPTS certification was not associated with referral decisions. FAAOMPT certification was associated
with decreased likelihood of referral for MRI and neurosurgical consult.
Greater myotomal deficit was correlated with greater likelihood of referral
for MRI and neurosurgical consult and lower likelihood of initiating PT.
The presence of imaging to confirm LDH was associated with increased
likelihood of referral for neurosurgical consult.
CONCLUSIONS: This survey suggests that demographic characteristics,
greater myotomal deficit, and availability of MRI may influence clinical
decisions regarding foot drop due to LDH.
CLINICAL RELEVANCE: Professional characteristics may influence the likelihood of referral decisions. Severity of myotomal deficits may influence
likelihood of referral decisions for additional imaging or neurosurgical
consult amongst physical therapists. More quality evidence describing an
optimal timeline or preferred plan of care for patients with this diagnosis is needed. The association between MRI results and increased likelihood of neurosurgical consult supports current evidence that early imaging may be associated with greater future health care utilization.
OPO232
THE INTRARATER RELIABILITY OF REHABILITATION ULTRASOUND IMAGING
MEASUREMENTS OF THE SACRAL MULTIFIDUS IN HEALTHY SUBJECTS:
A PILOT STUDY
Christopher H. Wise
Doctor of Physical Therapy Program, Alvernia University,
Reading, Pennsylvania
PURPOSE/HYPOTHESIS: The purpose of this study was to explore the intrarater reliability of obtaining Rehabilitation Ultrasound Images (RUSI) of
the sacral multifidi muscles at rest and during a maximum voluntary contraction (MVC) in healthy individuals with no report of low back pain.
NUMBER OF SUBJECTS: Fifteen healthy, normal subjects between the ages of
18 and 65 years old.
MATERIALS/METHODS: After signing an informed consent and obtaining anthropometric data, each subject was placed in a prone position with a pillow beneath the abdomen. Palpation of the inferior-most aspect of the
right PSIS was performed and used as the initial starting point for obtaining images of the multifidus at the level of S2. With the transducer
placed horizontally, gel was applied and the image was obtained using
the PSIS and median sacral crest as landmarks for identification of the
multifidus at rest. The same process was utilized to obtain an image of
the left multifidus. After obtaining images of both multifidi at rest, an image of right then left multifidus was obtained during the performance of
an MVC against a manually-resisted isometric force into lumbar extension. Two images were obtained both at rest and during a contraction for
each subject, alternating between subjects. All measures were obtained
in the same session by a single examiner who had minimal training in
RUSI. Muscle thickness was determined by measuring the perpendicular
distance between the superficial fascia and the deepest aspect of the muscle. Both intraimage, intrarater reliability (error associated with 1 examiner measuring sacral multifidus thickness on 1 ultrasound image) as well
as interimage, intrarater reliability (error associated with the procedures
used to obtain standardized image location and measurements from 2
separate ultrasound images) were determined.
RESULTS: Good to excellent intrarater reliability (ICC3,3) with low SEM
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scores were established for intraimage and interimage RUSI measurements of bilateral sacral multifidi.
CONCLUSIONS: Intrarater reliability was demonstrated for obtaining measures of the sacral multifidus at rest and during an MVC using RUSI.
CLINICAL RELEVANCE: Rehabilitation Ultrasound Imaging is gaining acceptance and may be used by Physical Therapists to measure deep muscle
function in real-time during functional tasks. Good reliability for RUSI
measurements of the transverse abdominis and lumbar multifidus has
been determined by several authors. The results of the present study provide additional reliability data for the use of RUSI in the measurement
of the sacral multifidus muscle at rest and during an MVC. These results support the use of RUSI for assessing the morphology of this muscle, which may be used to quantify the response of the sacral multifidus
to injury and to evaluate the impact of therapeutic interventions on muscle function.
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OPO233
A PRAGMATIC REGIONAL INTERDEPENDENCE APPROACH TO FROZEN
SHOULDER: A CASE SERIES
Christopher K. Wong, Elizabeth Mercer, Galen Schram,
Rebecca Kesting, Bryanna Strang, Karambir Deo
Program in Physical Therapy, Columbia University, New York,
New York
PURPOSE/HYPOTHESIS: Frozen shoulder is known for slow improvement
with motion deficits that last for years. No physical therapy treatments
listed in a recent clinical practice guideline—all directed at the glenohumeral joint—received a Grade A recommendation, including patient
education or stretching (Grade B), and modalities or joint mobilization
(Grade C). The purpose of this case series was to describe the pragmatic application of a regional interdependence approach for frozen shoulder and synthesize outcomes. Secondary purposes were to assess whether (1) final shoulder range of motion (ROM) approached normal values,
(2) ROM changes followed a time-related pattern, and (3) functional outcomes were maintained at follow-up.
NUMBER OF SUBJECTS: Five.
MATERIALS/METHODS: This retrospective case series analyzed existing data
from consecutive patients referred with frozen shoulder diagnoses within 1 year. After confirming the diagnosis with clinical findings, 1 physical therapist used a pragmatic regional interdependence approach that
included treatment to the shoulder girdle (sternoclavicular and acromioclavicular joints, first rib), shoulder (glenohumeral joint, rotator
cuff muscles), scapula-thoracic/humeral-thoracic (pectoralis major/minor, latissimus dorsi, serratus anterior muscles); and cervical-thoracic/
costovertebral joints. A pragmatic treatment approach allows select interventions chosen based on clinical impairments identified by the clinician. Interventions included joint mobilizations (grades III-V, mobilization with movement, strain-counterstrain, muscle energy techniques),
soft tissue mobilization, muscle stretching and strengthening, patient
education, and modalities and aerobic warm-ups. Outcomes included
shoulder ROM upon discharge and the Disability of Arm, Shoulder, and
Hand (DASH) functional outcome measure at approximately 4 weeks
follow-up.
RESULTS: Subjects came for 11 to 21 sessions (mean, 15) over 4 months. All
subjects improved on all outcomes, thus group means were reported. ROM
increased for flexion (117° ± 10° to 179° ± 12°, d = 5.9), abduction (74° ± 8°
to 175° ± 9°, d = 9.3), and external rotation (23° ± 7° to 89° ± 2°, d = 12.0)
with large effect sizes at discharge. DASH scores at mean 11 months postdischarge improved from 40.0 ± 19.4 at evaluation to 6.2 ± 3.7 at follow-up
(d = 1.5), exceeding the minimal clinically important difference.
CONCLUSIONS: A pragmatic regional interdependence approach yielded
large effect size ROM and shoulder function improvements for 5 patients
with frozen shoulder. Final ROM approached normal values-with most
gains achieved early and large effect size functional outcomes were evident months after discharge. The conception that ROM deficits in frozen
shoulder last years was not supported in these cases.
CLINICAL RELEVANCE: A pragmatic approach that directs treatment to related regions beyond the shoulder joint may provide benefits in cases of
frozen shoulder. Controlled study of the effects of a pragmatic regional
interdependence treatment approach on ROM and function in frozen
shoulder patients is warranted.
OPO234
THE EFFECT OF SPINAL MANIPULATION ON BREATHING PATTERN AT REST
Marlon L. Wong, Teresa K. Glynn, David A. Mcapline,
Yusuf Masri, Meira Weiss, Nicholas White, Marlon Pereira,
Ryan Martinson, Lawrence P. Cahalin
Physical Therapy, University of Miami, Palmetto Bay, Florida
PURPOSE/HYPOTHESIS: The effects of spinal manipulation (SM) are known
to have neurophysiologic effects. Breathing pattern (BP), is thought to
have a bidirectional relationship with autonomic nervous system (ANS).
Moreover, abnormal BP and hypocapnia have been associated with low
back pain. BP was defined in this study as respiration rate (RR), tidal volume (VT), and minute ventilation (VE). The purpose of this study was to
assess the effect of SM on BP in healthy subjects.
NUMBER OF SUBJECTS: Eighteen.
MATERIALS/METHODS: Subjects underwent breath-by-breath respiratory
gas analyses (RGA) for 15 minutes in supine before and after receiving
SM targeting the thoracic spine. Maximal inspiratory pressure (MIP) and
maximal expiratory pressure (MEP) were also measured. Statistical analyses included Wilcoxon signed-rank tests to compare RGA before and after SMT, and independent samples Mann-Whitney U tests to compare
subjects with MIP and MEP values less than or greater than 120 cmH2O.
RESULTS: Analysis of the entire sample revealed a statistically significant
decrease in VE after SMT (5% decrease, P = .01), but no significant difference in any other variables. However, BP after SM was significantly
(P<.05) different in subjects with MIP and MEP values greater than 120
cmH2O compared to those with values less than 120 cmH2O. Subjects
with MIP less than 120 cmH2O demonstrated an 8% decrease in VE,
whereas those with MIP greater than 120 cmH2O demonstrated a 2%
increase in VE after SMT (P = .006). Significant (P<.05) differences in
RGA of subjects with MEP less than 120 cmH2O compared to subjects
with MEP greater than 120 cmH2O after SMT were found for RR (2% increase versus a 6% decrease, respectively; P = .04), VT (12% decrease versus 5% increase, respectively; P = .005), and VE (8% decrease versus 1%
decrease, respectively; P = .04). Dichotomized MIP and MEP groups did
not differ in regards to sex, expectations, or baseline BP measures.
CONCLUSIONS: SM appears to decrease VE, but MIP and MEP performance
appear to have a potential modifying effect on BP after SM. The results of
this study suggest that subjects with more robust ventilatory systems (ie,
MIP and MEP values greater than 120 cmH2O) tend to respond to SM by
slowing RR and increasing VT, which is often a desired BP response and
commonly associated with diaphragmatic breathing or breathing exercises for stress reduction. However, subjects with maximal pressure less
than 120 cmH2O had an opposite response, with slight elevations in RR
and decreased VT. The cutoff point of 120 cmH2O is approximately the
age predicted normal value for this cohort (confidence interval: 116, 140),
and may be a useful biomarker for predicting BP response to SM.
CLINICAL RELEVANCE: Better understanding of the underlying mechanisms,
as well as mediating and modifying factors, may allow practitioners to
better predict BP response to SM. Due to the known neurophysiologic effects of SM, bidirectional relationship with breathing and the ANS, and
known association of altered BP and spinal pain conditions, understanding BP response to SM may provide additional insight into the often disparate responses to SM between patients, and help improve patient selection and outcomes with SM.
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OPO235
RESTING HEART RATE AND HEART RATE RECOVERY DIFFER BASED ON
PAIN MECHANISM CLASSIFICATION
Marlon L. Wong, Juan P. Gonzalez, Nelson Treto,
Chelsea A. Miller, Katherine Espinosa, Lawrence P. Cahalin
Physical Therapy, University of Miami, Palmetto Bay, Florida
PURPOSE/HYPOTHESIS: There is conflicting evidence in regards to the association of cardiovascular risk factors and low back pain (LBP). Previous
studies on this relationship have either looked at LBP as a homogenous
group, or distinguished between localized versus radiating symptoms. It
has been advocated that viewing LBP patients as a heterogeneous group,
and categorizing them based on neurophysiological pain mechanisms
[nociceptive (NO), neuropathic (PN), and central sensitization (CS)]
may improve both clinical and research outcomes. The purpose of this
study was to assess if patients with constant LBP, of at least 1 month duration, differed in resting vital signs and heart rate recovery (HRR) based
on their pain mechanism classification. It was hypothesized that subjects categorized as NO would have lower resting heart rate (RHR), lower
blood pressure (BP), higher peak heart rate (PHR) and a higher heart rate
recovery (HRR) than those in the PN and CS pain mechanism groups.
Furthermore, subjects with PN pain would have lower HR, BP, and higher PHR and HRR than subjects with CS.
NUMBER OF SUBJECTS: Fifteen subjects with constant LBP were consecutively recruited from an outpatient physical therapy clinic.
MATERIALS/METHODS: Subjects first received a brief interview and physical examination to determine pain mechanism category. The Pain
Catastrophizing Scale (PCS), Oswestry Disability Index (ODI), and numeric pain-rating scale (NPRS) were then administered. Resting BP and
HR data were collected. One minute HRR was assessed after 15 minutes of
walking at a self-determined pace on a treadmill. Subjects were instructed
to walk at a brisk pace that they could maintain for the entire 15 minutes.
RESULTS: Independent-samples Krustal-Wallis tests (P<.05) were used to
assess distribution across groups. Groups did not differ for age, sex, BMI,
number of comorbidities, or chronicity. Groups also did not differ for resting systolic or diastolic BP, PCS, ODI, or NPRS for current, best, or worst
pain level. However, significant differences between groups were noted
for RHR (averages of 79 for NO, 78 for PN, and 65 bpm for CS), PHR (averages of 105 for NO, 95 for PN, and 88 bpm for CS), and HRR (averages
of 20 for NO, 12 for PN, and 11 for CS). No statistical difference was found
for heart rate reserve (PHR-HR) between groups.
CONCLUSIONS: As expected, PHR and HRR were highest in the NO group
and lowest in the CS group. Contrary to expectations, resting HR was
highest in the NO group and lowest in the CS group, and groups did not
differ in regards to BP.
CLINICAL RELEVANCE: Attenuated HRR after exercise is thought to be a
marker of reduced parasympathetic activity and is an independent predictor of all-cause mortality. PHR and HRR after a simple self-selected
walking test may also provide important information for pain mechanism
classification and prognostication in patients with constant LBP.
OPO236
INCLUSION OF PHYSICAL THERAPY IN AN INTERPROFESSIONAL HEALTH
PROGRAM SERVING THE HOMELESS POPULATION IN LOS ANGELES:
A NEEDS AND FEASIBILITY STUDY
Noriko Yamaguchi, Kenneth Kim, Alyssa Uemura, Eric Tam,
Walter Coppenrath
Biokinesiology and Physical Therapy, University of Southern
California, Los Angeles, California; David Geffen School of
Medicine, University of Southern California, Los Angeles, Los
Angeles, California; Family Medicine, Kaiser Permanente, Los
Angeles, California
PURPOSE/HYPOTHESIS: Competition with basic needs such as food and shelter is a barrier to the homeless accessing health care, and perceptions of
discrimination due to being homeless have been shown to cause negative
experiences that decrease the likelihood of the homeless seeking services. The Mobile Clinic Project (MCP) is an interprofessional collaboration
among medical students, public health graduate students, and undergraduate students which has been providing weekly street-side medical
and social support services to the homeless in West Hollywood, CA for
16 years. In 2014, approximately one third of cases were musculoskeletal (MSK) complaints. Therefore, we hypothesized that physical therapy
(PT) would contribute to the medical care and health promotion goals of
the MCP. The purpose of this study was to determine the need for and feasibility of providing street-side PT services to the homeless community.
NUMBER OF SUBJECTS: One hundred eighty-seven clients were served at the
MCP during the study period.
MATERIALS/METHODS: First- and second-year student physical therapists
(SPTs) (n = 13) from a Doctor of Physical Therapy program participated
in 10 MCP clinics from November 2015 to June 2016. One to 2 clinical
faculty members supervised and mentored the SPTs, who worked alongside the medical students and undergraduates to provide care and determine need for additional services or referrals. If PT services were recommended, the SPT performed a PT evaluation and treatment under the
direct supervision of the attending PT and documented care in the clients’ clinic chart.
RESULTS: The client demographics were as follows: average ± SD age,
49.8 ± 12.0 years; 68.9% male, 31.2% female; 52.5% Caucasian, 21.3%
Hispanic, 21.3% African American, 3.3% Asian/Pacific Islander; 31.6%
of clients reported an MSK condition as their chief complaint; 78.7% of
the PT-appropriate cases were MSK (17.3% upper quarter, 30.7% spine,
30.7% lower quarter). The nonMSK, PT-appropriate cases were neurologic, such as multiple sclerosis, spinal cord injury, peripheral neuropathy, and lumbar myelopathy. Follow-ups accounted for 23.7% of PT visits.
CONCLUSIONS: The high prevalence of homeless clients seeking medical
care at the MCP for MSK conditions suggests a strong need for inclusion
of PT in medical clinics that serve this population. As 23.7% of the PT
visits were follow-ups, the potential exists for developing a consistent PT
practice at the MCP. While further research is needed on the short and
long-term impact of PT on MCP clients’ health and functional outcomes,
existing studies suggest enhancing homeless patients’ functional mobility and decreasing activity limitations may lead to improved community
participation and reduce high risk behaviors.
CLINICAL RELEVANCE: The Los Angeles Homeless Services Authority (LAHSA)
reported the total homeless population in Los Angeles County in 2015 was
44 359 and homeless with physical disability was 8148. This study shows
the need for and feasibility of providing street-side PT to improve function
and mobility in this vulnerable population.
OPO237
RELATIONSHIP BETWEEN HIP ISOMETRIC MUSCLE STRENGTH
AND DYNAMIC POSTURAL CONTROL IN HEALTHY PARTICIPANTS
Adam W. Yoder, Lindsey Doan, Cameron Freund,
Chelsea Morey
Physical Therapy, University of Saint Mary, Leavenworth, Kansas
PURPOSE/HYPOTHESIS: Lower extremity injuries are common in physically
active individuals. Hip strength influences lower extremity injury in the
physically active. Dynamic balance impairments, which may be identified
using the Star Excursion Balance Test (SEBT) or the modified SEBT, have
also been associated with lower extremity injury. However, little is known
about whether hip muscle strength impacts an individual’s dynamic-balance capabilities. Thus, the purpose of this study was to investigate the relationship between hip muscle strength and dynamic balance in healthy
individuals with the SEBT.
NUMBER OF SUBJECTS: Nineteen.
MATERIALS/METHODS: Hip muscle force was tested in 19 young healthy individuals (10 male, 9 female; height, 174 ± 9.9 cm; weight, 88 ± 31.33
kg) with a handheld electronic dynamometer (Newtons) for hip flexion,
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external rotation, abduction, and extension. Individuals then performed
the SEBT in the anterior, posterolateral, and posteromedial direction (recorded as a percent of the individual’s leg length in centimeters). Pearson
product correlations examined the relationship between hip muscle
strength and performance of the SEBT.
RESULTS: No correlation was found between individual muscle strength
and performance of the SEBT in the anterior, posteromedial, and posterolateral directions, or the total composite scores of the SEBT (P>.05).
CONCLUSIONS: Hip isometric strength is not correlated with dynamic balance, as measured by the SEBT. Other factors, such as lumbopelvic endurance and hip, knee, and ankle range of motion, or an individual’s proprioception, may have a greater effect on dynamic balance than isometric
strength of isolated hip muscles. Further research should be done with a
larger sample size, as well as different age groups, to determine if there is
a link between hip strength and dynamic balance.
CLINICAL RELEVANCE: Physical therapists are responsible for identifying risk
factors for lower extremity injuries, managing lower extremity injuries,
and determining if an athlete is safe to return to their sport. According
to this study, hip strength alone is not correlated to performance on the
SEBT. Clinicians should consider other factors, such as balance and lower extremity range of motion, when developing rehabilitation programs
for athletic populations.
OPO238
PATIENTS WITH A FALL HISTORY HAVE WORSE FUNCTION AND STRENGTH
BEFORE AND AFTER KNEE ARTHROPLASTY
Yuri Yoshida, Adam R. Marmon, Joseph Zeni
Department of Physical Therapy, University of Delaware, Newark,
Delaware
PURPOSE/HYPOTHESIS: Falls are a primary concern among older adults with
orthopaedic impairments. Approximately 45% of individuals after total
knee arthroplasty (TKA) experienced a fall prior to surgery will fall again
within 1 year of TKA. Although the prevalence of falls is high, it is not
known whether falling prior to TKA predisposes individuals to a worse
outcome after surgery. We hypothesized that individuals who experienced
a fall prior to their TKA will have persistently lower physical function
compared to those who did not fall prior to TKA.
NUMBER OF SUBJECTS: One hundred twenty-three participants who underwent TKA (mean ± SD age, 66.3 ± 8.3 years; BMI, 33.2 ± 15.5 kg/m2).
MATERIALS/METHODS: Functional outcomes were assessed 2 to 4 weeks prior to TKA and 6 months after TKA. These included the Knee Outcome
Score (KOS), knee range of motion (ROM), Timed Up and Go (TUG),
Stair Climbing Test (SCT), 30-second Chair Rise Test (30SCRT), and 6
Minute Walk Test (6MWT). Maximum Isometric quadriceps strength was
also measured. All participants were categorized as a faller or nonfaller
based on the response to “Have you experienced a fall in the previous 6
months?” which was asked at preoperative testing. Repeated-measures
ANOVAs were used to determine differences between groups and between time points. In the presence of an interaction effect, follow-up t
tests were performed.
RESULTS: Twenty participants experienced a fall prior to their TKA. There
were no significant interaction effects for age, BMI, 30SCRT, 6MWT,
and strength (all approximately .05). There were no main effects for age,
BMI, pain and ROM. There were main effects for time for the KOS (t =
33.3, P≤.01), 30SCRT (t = 3.0, P≤.01), 6MWT (t = 70.9 m, P≤.01), and
strength (t = 14.7%, P = .02), which indicated all participants significantly
improved after TKA regardless of group assignment. There were main effects of group for KOS (difference, 7.0; P = .02), 30SCRT (difference, 1.7;
P = .03), 6MWT (difference, 62.0 m; P = .02), and strength (difference,
23.3%; P≤.01), which indicated that the fallers had lower functional outcomes and weaker quadriceps compared to the nonfallers regardless of
the testing session. There was a significant interaction effect for TUG (P
= .04). Post hoc analysis revealed that the nonfallers improved 0.9 s after
TKA (P≤.01), while the fallers improved 2.1 seconds (P≤.01), but the fall-
ers remained 1.9 s slower than the nonfallers 6 months after TKA.
CONCLUSIONS: Despite the consistent reduction in pain and improvements
in self-reported function, physical function and strength remains lower
in fallers before and after TKA. Although we did see that the fallers had a
significantly better improvement in the TUG, it is likely that this improvement is related to the low ceiling effect for this measure. The fallers simply had more room to improve, given their poor preoperative TUG scores.
CLINICAL RELEVANCE: Despite significant functional improvements after
TKA, individuals who experienced a fall prior to TKA have persistently
lower physical function. These individuals may require additional training to restore normal levels of physical performance and strength.
OPO239
MAGNITUDES OF MUSCLE ACTIVATION OF SPINE STABILIZERS IN HEALTHY
ADULTS DURING PRONE ON ELBOW PLANKING EXERCISES USING A
FITNESS BALL
James W. Youdas, Kendra C. Coleman, Erin E. Holstad,
Stephanie D. Long, Nicole L. Veldkamp, John H. Hollman
Program in Physical Therapy, Mayo Clinic, Rochester, Minnesota
PURPOSE/HYPOTHESIS: This study quantified muscle activation [percent
maximum voluntary isometric contraction (MVIC)] of the right iliocostalis lumborum (IL), longissimus thoracis (LT), lumbar multifidi (LM),
latissimus dorsi (LD), gluteus maximus (GM), hamstrings (HS), rectus
abdominis (RA), external oblique (EO), internal oblique (IO), and serratus anterior (SA) during 4 planking procedures: (1) prone plank on floor
(PPOF), (2) prone plank on ball (PPOB), (3) stir-the-pot on ball (STP),
and (4) prone plank on ball with hip extension (PPHE). Previous investigators have not studied STP and PPHE. We hypothesized STP and PPHE
would generate the highest levels of electromyographic (EMG) activity
because of the concomitant demand for trunk stability and distal mobility of the extremities.
NUMBER OF SUBJECTS: Twenty-six healthy subjects volunteered to participate: 13 males (mean ± SD age, 25.4 ± 5.7 years) and 13 females (age, 25.0
± 3.8 years).
MATERIALS/METHODS: This study used a repeated measures within-subjects
design for each muscle. Subjects performed each of 4 exercises using a
randomized testing sequence. Muscle recruitment levels (percent MVIC)
were obtained concurrently from muscles of the right side. Stability balls
were used and inflated for each subject according to the manufacturer’s
recommendation. During the testing session each subject performed a
10-second hold for exercises 1 (PPOF) and 2 (PPOB) because they involved a static hold. Exercises 3 (STP) and 4 (PPHE) also lasted 10 seconds with 3 repetitions of circular clockwise rotations (STP) or right leg
lifts (PPHE). Data were sampled at a frequency of 1000 Hz. Raw EMG
signals were band-pass filtered and subsequently processed with a rootmean-square algorithm using moving windows with 125 milliseconds
time constants. EMG data collected during the planking tests were normalized to the muscles’ respective MVIC trials, and expressed as a percentage of the MVIC. Peak activation for each muscle was calculated from
the normalized data using a 200-millisecond window about the peak.
RESULTS: Data from each muscle were examined with a repeated measures
analysis of variance (ANOVA) at α = .05. Post hoc comparisons of EMG
recruitment across exercises for statistically significant ANOVAs were
conducted with Bonferroni corrections for multiple comparisons. During
STP, 3 muscles (RA, EO, IO) demonstrated very high (greater than 61%
MVIC) EMG activation and 1 muscle (SA) demonstrated high (41%-60%
MVIC) EMG activation. During PPHE, 5 muscles (GM, HS, EO, IO, LM)
demonstrated very high EMG activation and 2 muscles (RA, SA) demonstrated high EMG activation.
CONCLUSIONS: STP and PPHE are effective at strengthening multiple core
muscles and are reasonable to include in a strengthening program.
CLINICAL RELEVANCE: STP and PPHE pose a unique challenge to the core
muscles by introducing both unstable and stable components during a
dynamic activity, resulting in a greater number of muscles activated (per-
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cent MVIC) at strengthening levels not observed with static planking exercises (PPOF and PPOB).
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OPO240
CRITERION VALIDITY OF SHEAR-WAVE ELASTOGRAPHY COMPARED TO
ELECTROMYOGRAPHY TO ASSESS LUMBAR MULTIFIDUS ACTIVATION
Brian A. Young, Christine M. Kasprisin, Madeline Merriam,
Robert McNeal, Cameron Harms, Elizabeth Painter,
Mark E. Lester, Shane Koppenhaver
Physical Therapy, US Army-Baylor University, Schertz, Texas
PURPOSE/HYPOTHESIS: Low back pain is the most common cause of musculoskeletal health care visits among military personnel. Dysfunction in
lumbar multifidus activation has been associated as a factor contributing to low back pain. The gold standard for muscle activation assessment
has been electromyography (EMG); however, the invasive nature of EMG
can be challenging for patients and providers [2]. Ultrasonic ShearWave
Elastography (SWE) has emerged as a noninvasive technique to quantify
tissue stiffness, and has been shown to be related to superficial muscle activity [3-5]. The purpose of this study was to evaluate the validity of SWE
muscle activation in comparison to EMG during various lumbar multifidus contraction intensities.
NUMBER OF SUBJECTS: Fourteen asymptomatic individuals were enrolled.
MATERIALS/METHODS: The right L4 lumbar multifidus was located with
B-mode ultrasound with the transducer oriented in parallel with the muscle fibers [1]. Muscle stiffness (shear modulus in kilopascals) was assessed
via the Aixplorer ShearWave (Supersonic Imagine, Aix-en-Provence,
France) during rest, low, moderate, high and maximal isometric contractions [2]. Concurrently, lumbar multifidus activation was measured
with fine wire electromyography using the Noraxon MR 3.8.6 software
(Noraxon, USA Inc. Scottsdale, AZ). The EMG wire and insertion site
were separated from the SWE transducer with 3MTM Tegaderm dressing. Three trials were captured for each condition. EMG contraction was
converted to percent maximal voluntary isometric contraction.
RESULTS: Five subjects were excluded, 1 due to EMG instrumentation error, and 4 due to the inability of SWE to adequately capture lumbar multifidus stiffness. The remaining 9 subjects (6 female) had an average ±
SD age of 26 ± 3.71 years and BMI of 22.7 ± 1.38 kg/m2). A 1-by-5 repeated-measures ANOVA revealed a statistically significant main effect for
muscle contraction for both EMG and SWE. Bonferroni post hoc analysis for SWE yielded a statistically significant difference between rest and
low, moderate and max levels (P≤.035). Bonferroni post hoc analysis for
EMG yielded a statistically significant difference between rest and all contraction levels (P≤.004), and between max and all levels (P<.001). Visual
analysis of SWE data suggested a curvilinear relationship across contraction levels. Muscle stiffness as measured by SWE showed fair correlation
with EMG at the L4 multifidus level (r = 0.350, P = .020). When analyzing rest, low and moderate contractions only, the correlation was moderate (r = 0.593, P = .001).
CONCLUSIONS: Use of SWE to assess lumbar multifidus activation appears
to be a potentially valid, noninvasive measure of muscle activation at lower levels of muscle contraction. Further work assessing SWE response
across the entire range of muscle contraction is warranted.
CLINICAL RELEVANCE: SWE is a potential alternative for noninvasive, realtime assessment of deep spinal musculature. With clarifying work, SWE
may eventually substitute when EMG or magnetic resonance imaging is
considered to assess muscle response to exercise or treatment.
OPO241
SYMPATHOINHIBITION CAN IMPROVE FUNCTIONAL AND CLINICAL
OUTCOMES IN ACUTE NECK PAIN: PRELIMINARY FINDINGS OF A
RANDOMIZED CLINICAL TRIAL
Emmanuel Yung, Michael Wong, Muhammad I. Ali,
Allison Breakey, Erica Barton, Kelly Peterson, Karen Ching
Doctor of Physical Therapy and Orthopedic Physical Therapy
Residency Programs, Sacred Heart University, Fairfield,
Connecticut; Doctor of Physical Therapy Program, Azusa Pacific
University, Azusa, California; Doctor of Physical Therapy
Program, Sacred Heart University, Fairfield, Connecticut;
Orthopedic Physical Therapy Residency Program, Kaiser
Permanente, Panorama City, California
PURPOSE/HYPOTHESIS: The study aims to explore whether: (1) identical low
dose lateral glides (LAT) or posterior pressures (AP) is more effective in
altering neck disability, pain, range of motion (ROM) and (2) if the procedures cause sympathoexcitation or inhibition in patients with acute neck
pain (NP). LAT and AP appear efficacious for NP. In individuals without NP, AP and LAT were shown to have divergent cardiovascular responses (CR). The neurophysiologic system that modulates pain overlaps
with blood pressure (BP) and sympathoexcitation seems to mediate pain.
However, it is not known whether AP and LAT results in analogous or
dissimilar functional and clinical (includes CR) outcomes.
NUMBER OF SUBJECTS: Twenty-two patients (10 female; mean ± SD age,
27.09 ± 9.43 years) with NP participated.
MATERIALS/METHODS: Each individual is randomly allocated to 1 of 2
groups. Group 1 and Group 2 obtained AP and LAT respectively to the
most tender and restricted segment. First, baseline neck and shoulder
ROM with numeric pain rating scale (NPRS), and Neck Disability Index
(NDI) were collected. Then, a monitor measured the systolic (SBP), diastolic (DBP) blood pressure and heart rate (HR) recording the following time points: (1) 5 minutes, and (2) 7 minutes after lying supine; (3)
during the first set, and (4) fifth set of 1 of the glides; (5) 2 minutes after
time point 4, and (6) 4 minutes after time point 4. Bonferroni corrections
were applied for repeated analyses. Following time point 6, global rating of change was obtained based on the neck and shoulder ROM retest.
Finally, follow-up NPRS and NDI were obtained within 1 week.
RESULTS: ANOVA indicates that AP and LAT have the following respective
significant findings: cervical spine (CS) rotation to the left ROM is altered
by a mean ± SD of –0.80 ± 4.50 compared to 6.90 ± 9.70 (η2 = 0.22; medium-large effect size); NPRS “at best” increased by a mean of 0.4 ± 1.0 versus a decrease by a mean of –0.6 ± 1.2 (out of 10). CS extension ROM also
altered by an average of +3.40 ± 6.80 for AP compared to –1.60 ± 5.70 for
LAT (η2 = 0.15, P = .07), trending statistical significance favoring AP. As
for the within-group comparisons, follow-up NDI improved (P<.05) 24%
for AP and 37% for LAT. The improved mean NPRS “at worst” for AP is
–1.8 ± 2.9; for LAT is –1.4 ± 2.2 (out of 10). In addition, some statistical
clinically noteworthy CR were found: (1) in the AP group, the HR diminished by an average of 3.6 ± 2.8 bpm from time point 1 to 3; and (2) in the
LAT group, the mean DBP reduction is 2.2 ± 1.5 mmHg from time point
2 to 4. Finally, within the LAT group, shoulder elevation ROM average increase was 11.60° ± 9.60° (P<.05).
CONCLUSIONS: Both low-dose LAT and AP improved neck disability with
analogous sympathoinhibitory CR within 1 week. Furthermore, LAT improved CS rotation ROM more than AP.
CLINICAL RELEVANCE: Therefore, a subset of patients with NP and high BP
may potentially benefit from low dose LAT (or AP) to improve function
without further increasing BP but this requires further research.
OPO242
CLINICAL MEASURES RELATE TO TENDON MECHANICAL PROPERTIES
FOLLOWING ACHILLES TENDON RUPTURE
Jennifer A. Zellers, Laura Pontiggia, Daniel H. Cortes,
Karin G. Silbernagel
Program in Biomechanics and Movement Science, University
of Delaware, Newark, Delaware; Department of Mathematics,
Physics, and Statistics, University of the Sciences, Philadelphia,
Pennsylvania; Department of Mechanical and Nuclear
Engineering, Penn State University, State College, Pennsylvania;
Department of Physical Therapy, University of Delaware, Newark,
Delaware
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PURPOSE/HYPOTHESIS: Tendon mechanical properties have been previous-
ly reported to predict [4] and relate to [7] function in individuals post
Achilles tendon rupture. While these properties can be useful in developing a prognosis and guiding treatment, expensive and invasive techniques limit translation into the clinic. Identifying clinical measures
that could serve as surrogate measures of tendon mechanical properties would provide valuable information to the physical therapist treating these individuals.
NUMBER OF SUBJECTS: Fourteen individuals within 1 year post–Achilles tendon rupture.
MATERIALS/METHODS: Fourteen individuals (mean ± SD age, 43.5 ± 15.2
years) after acute, unilateral Achilles tendon rupture were included in the
study. The median (IQR) time since rupture was 3 (2-6) months with 10
subjects treated via surgical repair and 4 subjects treated nonsurgically. Achilles tendon length to the gastrocnemius myotendinous junction
was measured using B mode ultrasound imaging [5]. Tendon mechanical properties including shear modulus and viscosity were quantified using continuous shear wave elastography (cSWE) [2,6]. Clinical outcomes
included the Achilles tendon resting angle (ATRA) [1] and performance
on the heel-rise test [3]. Participant self-reported activity level, function
and symptoms were measured using the Physical Activity Scale (PAS) and
Achilles tendon total rupture score (ATRS), respectively.
RESULTS: Participants demonstrated elongation of the tendon on the ruptured side, with a median (IQR) length of 22.2 (21.3-23.1) cm on ruptured
and 21.2 (19.7-22.7) cm on nonruptured sides (P<.01). Viscosity was significantly less on the ruptured side, with a median (IQR) of 33.6 (29.342.5) Pa·s on rupture and 52.5 (46.4-62.4) Pa·s on nonrupture sides (P =
.001). Shear modulus was not significantly different between sides, with
a median (IQR) of 95.9 (72.5-106.7) kPa on rupture and 94.9 (91.0-101.1)
kPa on nonrupture sides (P = .64). Participants performed less total work
(P<.01), with less heel-rise height (P<.01) on the heel-rise test on the ruptured side (n = 10). ATRA related both to shear modulus (η2 = 0.692,
P<.01) and viscosity (η2 = 0.637, P<.05) on the ruptured side. Total work
on the heel-rise test related to shear modulus (η2 = 0.642, P<.05) on the
ruptured side (n = 10). Maximum heel-rise height was not related to shear
modulus or viscosity (n = 10). Viscosity related to PAS score (η2 = 0.559,
P<.05). Shear modulus related to both PAS (η2 = 0.581, P<.05) and ATRS
scores (η2 = 0.609, P<.05).
CONCLUSIONS: The results of this study indicate that mechanical properties
are related to patient-reported activity level and self-reported function.
Clinically, our results also support the use of ATRA and heel-rise test performance as surrogate measures for tendon mechanical properties in individuals less than 1 year post–Achilles tendon rupture.
CLINICAL RELEVANCE: Clinical tests, such as questionnaires, ATRA and the
heel-rise test, can be used to indicate recovery of mechanical properties
in a physical therapy setting.
OPO243
Giorgio Zeppieri, Katie M. Davis, Michael W. Moser,
Kevin W. Farmer, Steven George
UF Health, Gainesville, Florida; University of Florida, Gainesville,
Florida
PURPOSE/HYPOTHESIS: There is growing evidence linking psychosocial risk
factors to poor outcomes following musculoskeletal injury. As a result
there is growing interest in determining whether psychosocial screening
can identify athletes at risk for prolonged sport disability. The purpose of
this study was to examine the predictive relationship between 3 established psychosocial risk factors and time lost from sport after musculoskeletal injury.
NUMBER OF SUBJECTS: A prospective study of 30 Division I softball players
over 2 competitive seasons.
MATERIALS/METHODS: At the beginning of each season subjects completed
the Tampa Scale for Kinesiophobia (TSK-11), Pain Catastrophizing Scale
(PCS), and the Fear Avoidance Belief Questionnaire (FABQ), which was
modified to address the subject’s global musculoskeletal pain condition
rather than a specific condition. Subjects were then followed over the season and time (number of days [practice and game]) missed due to musculoskeletal injury was recorded. Independent samples t test were performed to assess the difference in psychosocial scores for athletes who
missed time due to musculoskeletal injury. Chi-square tests for the analysis of whether the psychosocial factors were predictive of future time lost
due to musculoskeletal injury were then assessed. Mann-Whitney U tests
were implemented to analyze the difference in duration of time lost between athletes that demonstrated psychosocial risk factors compared to
those that did not.
RESULTS: There were 49 musculoskeletal injuries, 14 traumatic (coded as
fracture or sprain), 36 nontraumatic (coded as sprain or stress), with 2 repeat injuries. There was not a significant difference between psychosocial
scores (FABQ: P = .588; mean ± SD difference, 3.6 ± 3.96) (TSK: P = .366;
mean difference, 2.18 ± 4.0; PCS: P = .18; mean difference, 5.25 ± 3.86)
for college softball subjects who missed any time due to musculoskeletal
injury. There was no association between psychosocial risk factors and
days lost due to injury ((FABQ: r = 0.907, P = .341), (TSK: r = 0.337, P =
.561), (PCS: r = 0.414, P = .520); however, subjects with higher scores on
psychosocial questionnaires had longer duration of missed playing time
(19.05 playing days) compared to athletes with lower scores (16.11 playing
days), but this difference was not statistically significant (P>.05).
CONCLUSIONS: Established psychosocial risk factors did not predict future
playing time loss or duration of playing time lost due to musculoskeletal
injury in Division I softball athletes.
CLINICAL RELEVANCE: Prescreening athletes to identify psychosocial risk factors may not add to prediction of missing playing time or amount of time
lost following musculoskeletal injury. Furthermore, our results may not
be applicable to other populations or conditions due to our narrow sample and additional methods may be needed in this population aside from
screening alone in predicting return to sport.
THE RELATIONSHIP BETWEEN PSYCHOSOCIAL RISK FACTORS
AND PLAYING TIME LOST DUE TO MUSCULOSKELETAL DYSFUNCTION
IN DIVISION I COLLEGE SOFTBALL ATHLETES: A PILOT STUDY
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