Acute pleurisy mimicking neck pain in a young volleyball player: a case report.

INTRODUCTION: Patients presenting to direct access physiotherapists may present with a serious pathology that mimics a musculoskeletal condition. Recognition of atypical clinical patterns allows for referral to an appropriate provider when a serious pathology is present. This case report details a patient with a pulmonary pathology who presented to a physiotherapist with a complaint of neck and chest pain following medical consultations. CASE PRESENTATION: A 29-year-old amateur volleyball player arrived at the physiotherapist's clinic five days after experiencing the onset of neck pain. She complained of pain on the right side, which extended to the trapezius, as well as occasional discomfort in the lower lateral and anterior chest. The patient noted that the pain worsened when lying supine or on her left side, and during coughing. After developing symptoms resembling a cold, she sought care at two different emergency clinics where physicians diagnosed seasonal flu and an unrelated muscle strain. Despite treatment, the pain persisted, accompanied by fever and general weakness, disrupting her sleep. Following a review of a medical history and a physical examination, musculoskeletal causes of pain appeared unlikely, prompting consideration of a pulmonary pathology. Referral to a specialist was deemed necessary. CONCLUSION: This case report highlights the importance of screening for serious pathology in direct access physiotherapy, irrespective of a prior physician consultation.

Impact of Concussions on Postural Stability Performance Using the Head Shake-Sensory Organization Test.

Background: A concussion is a traumatic brain injury that can result in vestibular and oculomotor dysfunctions. The Head Shake-Sensory Organization Test was developed from the original Sensory Organization Test to measure a subject's ability to maintain balance while moving their head. Purpose: The purpose of this study was to compare the performance of adults with no history of concussion to those with a history of concussion on the Head Shake-Sensory Organization Test to determine if long-standing balance deficits are present after concussion. Study Design: Cross-sectional study. Methods: Subjects with a history of concussion and healthy normal controls completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence Scale, the sensory organization test, the head shake SOT, and the Foam Head Shake-Sensory Organization test in a single testing session. Scores were analyzed for differences between the two groups. Results: Twenty-five participants (nine patients with history of concussion and 16 healthy controls; mean age, 21.08±4.10 years) completed testing. The equilibrium scores in both groups significantly decreased with more complex tasks. Furthermore, the concussion group had significantly worse equilibrium scores than the control group during the Head Shake (p = 0.007) and Foam Head Shake-Sensory Organization Test (p = 0.002) tasks but not during the Sensory Organization Test task. Conclusion: Adding head shake and foam cushion conditions to postural stability tests improves sensitivity in detecting balance deficits in individuals with a concussion. Level of Evidence: 3.

Effectiveness and Consequences of Direct Access in Physiotherapy: A Systematic Review.

Background. Direct access in physiotherapy (DAPT) occurs when a patient has the ability to self-refer to physical therapy without physician referral. This model of care in musculoskeletal diseases (MSDs) has shown better outcomes than the traditional-based medical model of care that requires physician referral to access physiotherapist services. This traditional physician referral often results in a delay in care. Unfortunately, DAPT is still not permitted in many countries. Objectives. The primary objective of this systematic review was to compare the effectiveness, safety, and the accuracy of DAPT compared to the physician-led model of care for the management of patients with musculoskeletal disorders. The secondary objective of the present study is to define the physiotherapists' characteristics or qualifications involved in DAPT. Materials and methods. Databases searched included: Medline, Scopus and Web of Science. Databases were searched from their inception to July 2022. Research strings were developed according to the PICO model of clinical questions (patient, intervention, comparison, and outcome). Free terms or synonyms (e.g., physical therapy; primary health care; direct access; musculoskeletal disease; cost-effectiveness) and when possible MeSH (Medical Subject Headings) terms were used and combined with Boolean operators (AND, OR, NOT). Risk of bias assessment was carried out through Version 2 of the Cochrane risk-of-bias tool (ROB-2) for randomized controlled trials (RCTs) and the Newcastle Ottawa Scale (NOS) for observational studies. Authors conducted a qualitative analysis of the results through narrative analysis and narrative synthesis. The narrative analysis was provided for an extraction of the key concepts and common meanings of the different studies, while the summary narrative provided a textual combination of data. In addition, a quantitative analysis was conducted comparing the analysis of the mean and differences between the means. Results. Twenty-eight articles met the inclusion criteria and were analyzed. Results show that DAPT had a high referral accuracy and a reduction in the rate of return visits. The medical model had a higher use of imaging, drugs, and referral to another specialist. DAPT was found to be more cost-effective than the medical model. DAPT resulted in better work-related outcomes and was superior when considering patient satisfaction. There were no adverse events noted in any of the studies. In regard to health outcomes, there was no difference between models. ROB-2 shows an intermediate risk of bias risk for the RCTs with an average of 6/9 points for the NOS scale for observational studies. Conclusion. DAPT is a safe, less expensive, reliable triage and management model of care that results in higher levels of satisfaction for patients compared to the traditional medical model. Prospero Registration Number: CRD42022349261.

Referral Decision-Making and Care Continuity in Physical Therapist Practice.

Efficient referral pathways have held promise in improving clinical outcomes, raising patient satisfaction, and reducing costs. Referral decision-making presents a distinct challenge because it requires the consideration of such variables as technology, health-care systems, and local resources. However, best practices for generating a high-value referral and improving care continuity are rarely discussed in the context of physical therapist practice. With physical therapists in some states obtaining explicit imaging privileges and a renewed focus on the physical therapist's role in primary care and patient management over the lifespan, it is time to focus on this underappreciated area of practice. This perspective discusses referral decision-making and provides recommendations for making a high-value referral and improving care continuity. Improving referral and care continuity has potential to enhance clinical outcomes and patient satisfaction and to reduce costs. This perspective explicitly defines and describes strategies to improve physical therapist decision-making about referral and care continuity to improve overall patient management.

Spontaneous spleen rupture mimicking non-specific thoracic pain: A rare case in physiotherapy practice.

BACKGROUND: The prevalence of Thoracic Pain (TP) is estimated to be low compared to other common musculoskeletal disorders such as nonspecific low back pain (LBP). Notably, compared to LBP, TP or referral pain to the thoracic area potentially may involve serious pathologies. Visceral referral of pain may present to the thoracic spine or anteriorly in the abdomen or chest. Rupture of the spleen in the absence of trauma or previously diagnosed disease is rare and rarely documented in emergency medicine literature. The incidence of red flags are higher in the thoracic area in comparison to the lumbar or cervical regions, but TP can also be of musculoskeletal origin and for this reason it is important to assess the origin of pain. CASE DESCRIPTION: This case report describes the clinical history, evaluation and management of a 60-year-old complaining of upper thoracic, bilateral shoulder, and right upper quadrant abdominal pain. The patient's clinical findings from a physiotherapist's assessment led to a referral to a physician to explore a potential non-musculoskeletal origin. A splenectomy was required due to a non-traumatic rupture of the spleen. After 20 days of hospitalization from the surgery, the patient returned to all normal activities of daily living. DISCUSSION AND CONCLUSION: The purpose of this current case report is to describe the clinical reasoning of a physiotherapist screening a patient who presented with thoracic pain due to a spontaneous rupture of the spleen, that resulted in a referral to another health practitioner.

Recognition of pulmonary pathology in a patient presenting with shoulder pain.

Background. Shoulder pain is a common symptom of musculoskeletal disorder about the shoulder. However, shoulder pain can also be symptomatic of other non- musculoskeletal disease. Careful assessment of the clinical presentation is essential in differential diagnosis and decisions to treat or refer.Case Description. A 56-year-old male preseted with shoulder pain and a previous diagnosis of subacromial impingement of the left shoulder. The shoulder pain increased with effort, was present at night making it difficult to sleep and became disabling for the patient in work and activities of daily living. In addition, the patient reported left thoracic pain and increasing episodes of dry coughing, shortness of breath, fever and unusual generalized fatigue. Physical examination did not reveal a musculoskeletal concern about the patient's shoulder. An increased body temperature was detected and when combined with auscultation and thorax percussion led the physiotherapist to hypothesize pulmonary involvement, later reinforced by the evocation of the patient's symptoms while measuring his peak expiratory flow.Discussion. An underlyng serious pathology can be easily masked by shoulder pain. Physiotherapists need to consider that when a patient presents with a cluster of history and physical examination findings that are negative for mechanical shoulder pain, other systems must be considered as the source of presenting symptoms. Through the identification of risk factors and red flag findings, the physiotherapist can identify the need for referral.

A Comparison of Resting Scapular Posture and the Davies Closed Kinetic Chain Upper Extremity Stability Test.

BACKGROUND: In orthopaedic practice, it is well established that weak scapular stabilizers and an unstable scapula is related to shoulder dysfunction. Faulty scapular position has been linked to decreased scapular stability and is thought to be a result of weak or unbalanced timing in the recruitment of scapulothoracic dynamic stabilizing muscles. Kibler has described a four-type classification of scapulothoracic dysfunction. Functional performance testing is used to objectively measure activities that simulate various desired activities. The reliability of assessing the four static scapular positions may be important in diagnosing shoulder dysfunction. An understanding of the scapular position and its relationship to functional performance testing is needed. PURPOSE: The purpose of this study was to determine if a static scapular test, the Kibler scapula classification, in healthy participants affects the ability to perform a closed chain functional test that involves the use of the scapula and the upper extremity, the Davies Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST). A secondary analysis was performed to evaluate the reliability of a student physical therapist and an experienced physical therapist to identify scapular type by observation. STUDY DESIGN: Multicenter, single session descriptive cohort. METHODS: Sixty-one healthy participants (33 males, 28 females; mean age 24.19±2.61) completed testing across two locations in one testing session. Blood pressure and heart rate as well as height and weight were measured for each participant. Participants were classified by visual observation of Kibler scapular classification. The average number of CKUEST touches, a normalized score, and a power score were calculated for each participant. Three trials were performed and participants were required to take a 45-second rest break between each CKCUEST trial. RESULTS: One way analysis of variance (ANOVA) showed statistically significant differences in Type I and Type IV Kibler scapula classification for the CKCUEST power score, however when an ANCOVA controlled for body mass index, there was no statistically significant difference. A strong correlation r=.94 was observed between student and experienced physical therapist in evaluating all four types of Kibler scapular classification. CONCLUSIONS: Visually observed Kibler scapular position does not affect the ability to perform the Davies CKCUEST in healthy young adults. The ability to identify Kibler scapular position was reliable between student and experienced physical therapists. Additional studies are required to identify the usefulness of the Kibler scapular position classification. LEVEL OF EVIDENCE: 2b: Individual Cohort Study.

A Knowledge Translation Framework for Optimizing Physical Therapy in Patients With Heart Failure.

The American Physical Therapy Association has supported the development of clinical practice guidelines to promote and support evidence-based practice and reduce unwarranted practice variation. Essential to the success of this effort is the generation of knowledge translation, a concept that emphasizes the translation of global knowledge to an application that can be effectively integrated into clinical practice. The Physical Therapy Clinical Practice Guideline for the Management of Individuals with Heart Failure published in the Physical Therapy Journal in January 2020 provides a broad base of knowledge related to evidence-based treatment interventions for patients with heart failure. However, the application and integration of this knowledge in clinical practice need further elucidation. Therefore, this perspective paper aims to serve as a complementary knowledge translation resource to the recently published practice guideline to maximize the utilization of contemporary evidence in clinical practice. This resource provides the physical therapist with practical guidance in the management of patients with heart failure by placing research findings in the context of other knowledge and practice norms that can be applied at the point of care and across the continuum of care. We propose a novel ABCDE (assessment, behavior modification, cardiorespiratory fitness, dosage, and education) practical framework. This clinical paradigm is grounded in ongoing physical therapist assessment throughout the episode of care, along with behavior modification, assessment of cardiorespiratory fitness, appropriate selection and dosing of interventions, and patient education. Examples highlighting the use of this model in patients with heart failure across the continuum of care are provided for application in clinical care.

Determining Near Point of Convergence: Exploring a Component of the Vestibular/Ocular Motor Screen Comparing Varied Target Sizes.

BACKGROUND: Near point of convergence (NPC), a component of the Vestibular Ocular Motor Screening (VOMS) assessment, may be helpful in diagnosing concussion. The VOMS uses a standardized approach to measure NPC; however, methods of screening for NPC are not standardized. PURPOSE: The purpose of this study was to determine whether four different methods of measuring NPC yielded different estimates. STUDY DESIGN: Descriptive within-subjects laboratory study. LEVEL OF EVIDENCE: Level 3. METHODS: Healthy recreational athletes participated in a comparison of 4 commonly used methods of measuring NPC: a 12-point font target, the VOMS (14-point font target), the tip of a black pen, and the Bernell VergelTM device (9-point font target). The order of the presentation of the 4 targets was randomized. RESULTS: Seventy-five participants (59 females, 16 males; mean [SD] age=21.0 [6.12] years) completed 3 trials. The mean (SD) of the 900 NPC measurements was 7.11 (3.67) cm. Measurements for all targets had excellent reliability (r=0.94 to 0.98). In a comparative analysis, participant age was associated with NPC (p<0.01) and was covaried. The NPCs derived from both the 12-point and 14-point font targets were smaller than NPCs from the tip of the black pen and the 9-point font device (p<0.01). Measurements between the tip of the black pen and the 9-point font device (p=0.25) and between the 12-point and 14-point font targets (p=0.84) did not differ. CONCLUSIONS: The method used to measure NPC as a screening test for concussion should be standardized because the estimate differs depending on the technique chosen. The current study supports previous findings that the type of target used to measure NPC should be standardized for concussion assessment. CLINICAL RELEVANCE: Screening of NPC should be standardized for concussion assessment to improve the reliability of NPC testing.

Low back pain and calf pain in a recreational runner masking peripheral artery disease: A case report.

Background: Running is one of the most popular sports worldwide due to its low costs and its beneficial impact on health. Recent evidence suggests 11% to 85% of recreational runners experience at least one running-related injury each year and most of these are related to musculoskeletal conditions. The aim of this case report is to describe the clinical decision-making process that guided a physiotherapist to suspect a non-musculoskeletal cause in a recreational runner presenting with low back pain and calf pain secondary to Peripheral Artery Disease.Case Presentation: This case report describes the clinical history, clinical exam, laboratory and imaging tests, and surgical procedure of a 65 y.o. amateur runner suffering low back pain and left calf pain for 3 months. The patient's clinical findings suggested that referral to another health-care provider was required to explore potential non-musculoskeletal sources of pain. An angioplasty was necessary to solve the patient's clinical situation.Discussion and Conclusion: In this patient case, clinical findings along with a comprehensive family and personal history, ruled out a musculoskeletal condition and implicated a vascular condition.

ELECTROMYOGRAPHIC ANALYSIS OF GLUTEAL RECRUITMENT: AN EXPLORATION OF ACTIVATION DURING JUMPING TASKS.

BACKGROUND: Inability to maintain proper alignment of the pelvis and femur due to gluteal muscle weakness has been associated with numerous lower extremity pathologies. Therefore, many lower extremity rehabilitation and injury prevention programs employ exercises that target gluteal muscle strength and activation. While information regarding muscle activation during exercises that are typically done in the beginning stages of rehabilitation is available, evidence regarding the gluteal muscle activity during more functional and advanced exercises used during later stages of rehabilitation is sparse. PURPOSE: To explore the recruitment of the gluteal muscles during jumping tasks in healthy participants to determine which jumping exercise best elicits gluteal muscle activation. STUDY DESIGN: Prospective cohort design. METHODS: Eighteen healthy recreational athletes (23.5 ± 3.8 years, 8M/10F, 67.56 ± 3.2 inches, 66.73 ± 9.5 kg) completed three trials of four jumping tasks: hurdle jump, split jump, V2 lateral jump, and cross-over jump in random order. Surface EMG electrodes were placed on each participant's bilateral gluteus medius (GMed) and maximus (GMax) to measure muscle activity during the jumping tasks. Maximal voluntary isometric muscle contraction (MVIC) was established for each muscle group in order to express each jumping task as a percentage of MVIC and allow standardized comparison across participants. EMG data were analyzed for all jumps using a root-mean-square algorithm and smoothed with a 62.5 millisecond time reference. Rank ordering of muscle activation during jumping tasks was performed utilizing the peak percent MVIC recorded during each jumping task. RESULTS: Three of the jumping tasks produced greater than 70% MVIC of the GMed muscle. In rank order from highest EMG value to lowest, these jumping tasks were: crossover jump (103% MVIC), hurdle jump (93.2% MVIC), and V2 lateral jump (84.7% MVIC). Two of the exercises recruited GMax with values greater than 70% MVIC. In rank order from highest EMG value to lowest, these jumping tasks were: hurdle jump (76.8% MVIC) and split jump (73.1% MVIC). Only the hurdle jump produced greater than 70% MVIC for both GMed and GMax muscles. CONCLUSIONS: The jumping task that resulted in greatest activation of the GMed was the crossover jump, while hurdle jump led to the greatest activation of the GMax. The high %MVIC for the GMed during the crossover jump may be attributed to lack of maximal effort or lack of motivation during performance of maximal contractions during the manual muscle testing. Alternatively, substantial co-contraction of core muscles during the crossover jumping task may have led to higher values. LEVEL OF EVIDENCE: 2b Individual Cohort Study.

A COMPARISON OF THE PAPER AND COMPUTERIZED TABLET VERSION OF THE KING-DEVICK TEST IN COLLEGIATE ATHLETES AND THE INFLUENCE OF AGE ON PERFORMANCE.

BACKGROUND: Sport-related concussion is a public concern with between 1.6 and 3.8 million sport- and recreation-related injuries occurring annually. An estimated 65% to 90% of concussed athletes show oculomotor disruption such as difficulty with saccades, accommodation, smooth pursuit, and fixation. A rapid number-naming saccade test, the King-Devick (K-D) test, has shown promising results as part of a multifaceted concussion assessment tool. PURPOSE: The purpose of the current study was to evaluate the two versions of the K-D in collegiate aged (18-24) athletes to determine the agreement between versions. A secondary purpose was to investigate the association of K-D scores with sport, sex, use of glasses or contacts, and age of the athlete. STUDY DESIGN: Descriptive laboratory study. METHODS: Division 1 NCAA collegiate athletes across ten sports were recruited to participate in baseline concussion assessments at the beginning of their respective athletic season. Correlations and multivariable logistic regression analyses were used to investigate the association of K-D scores with sex and age. RESULTS: One-hundred and nine athletes (69 males, 40 females; mean age = 20.40 ± 1.38 years) were baseline tested. There was excellent agreement (ICC=0.93, 95% CI: 0.90, 0.95) between the paper and computer version. Preseason K-D scores were statistically different (r2=0.873, p<0.05) with athletes scoring a mean of 37.58 seconds on the paper version (95% CI, 36.21, 38.96) and athletes scoring a mean of 41.48 seconds for the computerized tablet version (95% CI, 40.17, 42.91). There were no significant differences in sex, sport, or use of glasses noted for both versions. Age differences were identified; eighteen-year-old athletes took statistically longer than their peers for both K-D versions. Pairwise comparisons showed statistically significant differences between 18-year olds up to the age of 21-year-olds (p<0.05) for the computer version and statistically significant differences between 18-year olds up to 22-year-olds (p<0.05) for the paper version. CONCLUSION: This study supports the use of either version of the K-D test as a potential part of a multifaceted concussion assessment. The age of the athlete influences scores and therefore a K-D baseline should be repeated annually for collegiate athletes. Clinicians should not substitute K-D versions (computer vs. paper) in comparing baseline to a post-concussion K-D score as the scores are quite different. LEVEL OF EVIDENCE: Level 3.

Subacromial impingement syndrome: a survey of Italian physiotherapists and orthopaedics on diagnostic strategies and management modalities.

BACKGROUND AND AIM: The subacromial impingement syndrome (SIS) represents a common cause of disability in approximately 74% of patients with Shoulder Pain (SP). Even if contemporary research suggests that this mechanism is not (always) the dominant driver in SP, SIS is still a source of debate among scholars and clinicians. From a clinical point of view, evidence has suggested that clinicians can use both medical and physiotherapy approaches as effective methods to treat SIS.This survey aims to investigate models of management of patients with SIS in a sample of Italian physiotherapist specialists (Orthopaedic Manipulative Physical Therapists, -OMPTs-) and orthopaedic surgeons. MATERIALS AND METHODS: An online survey with 29-item questionnaire was administered to assess the knowledge of OMPTs and orthopaedic surgeons about: a) strategies of clinical examination; b) the role of imaging in the diagnostic process; c) the physiotherapy management; and d) the pharmacological and surgical management in patients with SIS. RESULTS: Six-hundred and twenty-nine respondents completed the survey (511 OMPTs (79.97%) and 128 orthopaedic surgeons (20.03%)). Ninety-two percent (n = 470) of the OMPTs and 80.5% (n = 103) of orthopaedic surgeons stated that in patients with SIS, a combination of diagnostic tests produced better accuracy (p = < 0.001). Twenty point seven % of OMPTs (n = 106) and 4.7% of orthopaedic surgeon (n = 6) stated that the Lift off was the most specific test (p = < 0.001). Four-hundred-and-twenty-four OMPTs (83%) and 40 orthopaedic surgeons (31.3%) answered that the gold standard for diagnosis of a patient with SIS are history and clinical examination (p < 0.001). CONCLUSION: OMPTs and orthopaedic surgeons approach patients with SIS differently during both the assessment and the treatment. OMPTs appear to be appropriate in planning and managing clinical examination and therapeutic strategies to use with patients with SIS.

Exploration of Medical Screening and Differential Diagnosis Instructional Methods and Faculty Perceptions in Physical Therapist Educational Programs.

BACKGROUND: Little is known about medical screening and differential diagnosis (MSDD) preparation of physical therapist students. METHODS: Professional degree physical therapist programs in the U.S. were surveyed regarding MSDD content and faculty perception of graduate competence. RESULTS: Fifty-five of 226 programs responded for a 24.3% response rate. Sixty-six percent strongly agreed that students were adequately prepared to perform MSDD with patients who are referred, whereas 47.3% strongly agreed for patients who are direct access. Faculty board specialty certification status affected perception of student competence (p=0.04). Increased emphasis during clinical affiliations was the most beneficial way to increase student knowledge of MSDD skills. Non-response bias assessment was non-significant. CONCLUSION: Increasing clinical exposure was the top recommendation for expanding both faculty and student knowledge and skills. Factors potentially impacting student preparation in MSDD content have been identified and require further study.

Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure.

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular and Pulmonary Section of APTA, have commissioned the development of this clinical practice guideline to assist physical therapists in their clinical decision making when managing patients with heart failure. Physical therapists treat patients with varying degrees of impairments and limitations in activity and participation associated with heart failure pathology across the continuum of care. This document will guide physical therapist practice in the examination and treatment of patients with a known diagnosis of heart failure. The development of this clinical practice guideline followed a structured process and resulted in 9 key action statements to guide physical therapist practice. The level and quality of available evidence were graded based on specific criteria to determine the strength of each action statement. Clinical algorithms were developed to guide the physical therapist in appropriate clinical decision making. Physical therapists are encouraged to work collaboratively with other members of the health care team in implementing these action statements to improve the activity, participation, and quality of life in individuals with heart failure and reduce the incidence of heart failure-related re-admissions.

A Rare Consequence after Shoulder Dislocation in a Professional Cyclist: A Case Report.

Background: Cycling is a popular source of recreation and physical activity for children and adults. With regard to the total number of sports injuries, cycling has the highest absolute number of injuries per year in the United States population. Cycling injuries can be classified into bicycle contact, traumatic, or overuse injuries. Aim of this study: The aims of this case report are to report a rare clinical complication of glenohumeral joint anterior dislocation that resulted in a patient experiencing continuous GHJ dislocations secondary to involuntary violent muscular spasms and emphasize the role of the physical therapist's differential diagnosis and clinical decision-making process in a patient following direct access referral. Case presentation: A professional 23-year-old cyclist presented to a physical therapist with spontaneous multidirectional dislocations to the right shoulder after the recurrence of trauma occurred during a recent cycling race. The dislocations do not occur at night, but occur during the day, randomly, and mostly associated with changes in the patient's psychological conditions. Directly from the clinical history, the physical therapist identified a neuro-physiological orange flag as well as an orthopedic red flag and, therefore, decided it was appropriate to refer the patient to a neurologist. It was determined by the physical therapist to be a priority to focus on the patient's neurologic status and then to evaluate the orthopedic problem. The neurological examination revealed a condition of spontaneous multidirectional dislocation associated with recurrent antero-posterior pain spasms of the shoulder joint. The neurologist prescribed medication. Following the second cycle of medication assumption, the patient was able to continue physiotherapy treatment and was referred to the orthopedic specialist to proceed with shoulder stabilization surgery. Discussion and conclusion: Currently, the diagnosis of this unusual clinical condition is still unclear. It is a shared opinion of the authors that the trauma during the past bicycle race awakened an underlying psychological problem of the patient that resulted in a clinical condition of weakness of all the structures of the shoulder, such that these spasms could result in multiple multidirectional dislocations.

EVALUATION OF VERTICAL AND HORIZONTAL SACCADES USING THE DEVELOPMENTAL EYE MOVEMENT TEST COMPARED TO THE KING-DEVICK TEST.

BACKGROUND: Oculomotor function is impaired when an individual has a concussion and as such, it is important to identify tests that are able to assess oculomotor impairment. The King-Devick (K-D) test assesses horizontal saccadic eye movement and attention. The Developmental Eye Movement (DEM) test is designed to identify oculomotor dysfunction in children. It measures both horizontal and vertical saccades. The K-D test shows promise as a concussion-screening tool and part of a multifactorial assessment. The DEM has not been tested as a concussion assessment tool, but the neuroanatomical control of horizontal and vertical saccades originates from different areas of the brain, so one might expect to see differences in performance on the K-D and DEM tests when administered to concussed patients. First, it is important to determine if performance on the DEM and K-D tests, particularly with respect to the measurement of vertical and horizontal saccades, is similar in a healthy population.Hypothesis/Purpose: The primary purpose was to evaluate the relationship between horizontal and vertical saccade tests over repeated trials in normal, healthy subjects. A secondary purpose of this study was to determine the number of trials needed to reach a performance plateau for both the DEM and K-D tests.Study Design: This study used a prospective cohort research design. METHODS: Forty-two healthy non-concussed participants (22 males, 20 females; mean age, 24.2 ± 2.92 years) completed six repeated trials of both the DEM, and then six trials of the K-D test in a single testing session. Trials within each test were performed in random order and participants were offered short rest breaks as needed between test administrations. RESULTS: Results indicated strong correlations, r=.67, or greater, between measurements of horizontal and vertical saccades. Performance plateaued on the K-D at trial three and on the DEM at trial two for both horizontal and vertical saccades. CONCLUSION: It appears that the DEM and K-D tests measure similar constructs in healthy individuals and that no additional information is provided by assessment of vertical saccades. Additional studies are required to investigate the usefulness of the DEM in concussed individuals. LEVEL OF EVIDENCE: 3: Laboratory study with repeated measures.

THE EFFECTS OF AN AQUATIC MANUAL THERAPY TECHNIQUE, AQUASTRETCH™ ON RECREATIONAL ATHLETES WITH LOWER EXTREMITY INJURIES.

BACKGROUND: When paired together, manual therapy and exercise have been effective for regaining range of motion (ROM) in multiple conditions across varied populations. Although exercise in an aquatic environment is common, research investigating manual therapy in this environment is limited. There is little evidence on AquaStretchTM an aquatic manual therapy technique, but anecdotal clinical evidence suggests its effectiveness. PURPOSE: To investigate the effects of AquaStretch™ on ROM and function in recreational athletes with self-reported lower extremity injury and pain. STUDY DESIGN: Quasi-experimental design. METHODS: Injured recreational athletes participated in a 30-minute intervention session of AquaStretch.™ Injuries ranged from ankle (sprains and overuse), knee (contusions, sprains, and overuse), and hip conditions (contusions, overuse, and pain). Before a single intervention (preintervention) and within 24 hours after the intervention (postintervention), participants completed the following patient-reported outcome instruments: the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Ability Measure (FAAM) Sports subscale. AROM measurements of the ankle, knee, and hip and the following muscle length tests were measured: Ober's test, measurement of the popliteal angle, and the modified Thomas test. Finally, the overhead deep squat test was performed as a test of function. RESULTS: Twenty-six recreational athletes with lower extremity injuries of the ankle, knee, and hip, aged 18-60 years (18 males, 8 females, mean age 27.4 years) completed the study. The overall group by time interaction for the mixed-model Generalized Estimating Equations analysis was statistically significant for the LEFS (all p<.002) and for the FAAM Sports subscale (p<.01). There were no statistically significant time (pre vs post) by group interactions for range of motion and other measures, including the Ober's test, the overhead deep squat test, popliteal angle, and the modified Thomas test for injured athletes. CONCLUSION: One session of AquaStretch™ in recreational athletes improved the patient-rated outcome measures of function specifically the LEFS and FAAM Sports subscale. These results suggest that AquaStretch™ may be an effective form of manual therapy to improve lower extremity function in injured athletes. LEVELS OF EVIDENCE: 2b, Individual Cohort Study.

RELATIONSHIPS AMONG COMMON VISION AND VESTIBULAR TESTS IN HEALTHY RECREATIONAL ATHLETES.

BACKGROUND: Disruption of the visual and vestibular systems is commonly observed following concussion. Researchers have explored the utility of screening tools to identify deficits in these systems in concussed patients, but it is unclear if these tests are measuring similar or distinct phenomena. PURPOSE: To determine the relationships between common vestibular tests including the King-Devick (K-D) test, Sensory Organization Test (SOT), Head Shake-Sensory Organization Test (HS-SOT), and Dynamic Visual Acuity (DVA) test, when administered contiguously, to healthy recreational athletes aged 14 to 24 years. STUDY DESIGN: This study used a prospective design to evaluate relationships between the K-D, SOT, HS-SOT, and DVA tests in 60 healthy individuals. METHODS: Sixty participants (30 males, 30 females; mean age, 19.9 ± 3.74 years) completed the four tests in a single testing session. RESULTS: Results did not support a relationship between any pair of the K-D, SOT, HS-SOT, and DVA tests. Pearson correlations between tests were poor, ranging from 0.14 to 0.20. As expected the relationship between condition 2 of the SOT and HS-SOT fixed was strong (ICC=0.81) as well as condition 5 of the SOT with HS-SOT sway (ICC=0.78). The test-retest reliability of all 4 tests was evaluated to ensure the relationships of the 4 tests were consistent between test trials and reliability was excellent with intraclass correlations ranging from 0.79 to 0.97. CONCLUSIONS: The lack of relationships in these tests is clinically important because it suggests that the tests evaluate different aspects of visual and vestibular function. Further, these results suggest that a comprehensive assessment of visual and vestibular deficits following concussion may require a multifaceted approach. LEVEL OF EVIDENCE: 2b: Individual Cohort Study.