The reliability and minimal detectable change of common tests and measures for temporomandibular disorders.

BACKGROUND: Temporomandibular disorders are a source of orofacial pain. Understanding clinimetric properties of evaluation procedures is necessary for assessing impairments and determining response to interventions. PURPOSE: Reliability, minimal detectable change (MDC95), and 95% limits of agreement of TMJ examination procedures were investigated. METHODS: Occlusion (central incisor alignment, overjet, overbite), mandibular dynamics (maximal incisor opening, laterotrusion, protrusion active range of motion (AROM)), auscultation, tenderness, and joint play were measured on 50 asymptomatic adults (30 females), mean age 24.8. The inter-rater reliability assessment used an intra-session design. Participants returned 24-48 h later for intra-rater assessments. Intraclass correlation coefficients (ICC) and Kappa values were used to determine reproducibility. RESULTS: Intra-rater reliability for occlusion and AROM was ICC 3,1 ≥ 0.75, whereas interrater reliability was ICC 2,1 ≥ 0.68. Kappa values for inter-rater agreement of joint mobility was K = .18, whereas auscultation and palpation were K ≥ 0.48. Intra-rater Kappa values were ≥ 0.24, with lateral pterygoid region palpation having poor agreement. The MDC95 for occlusion was 1 mm, whereas AROM ranged from 3 to 6 mm. Mean AROM differences between raters were -1.16, -0.42, -0.18, and -0.8 mm for maximal incisor opening, left and right laterotrusion, and protrusion, respectively. CONCLUSION: AROM and occlusion measurements may be used with confidence; however, poor agreement for joint mobility measurements and lateral pterygoid region palpation must be recognized. When re-assessing measurements, a 3-6 and 1-mm change in AROM and occlusion, respectively, is required to be 95% certain change is not due to error. Future symptomatic population research is needed (250/250).

The effect of auto-generated corrective exercise programming on movement literacy among firefighters: a pilot study.

INTRODUCTION: Approximately 50% of firefighter injuries occur in the musculoskeletal system. Poor movement quality increases injury risk, while movement-based interventions may reduce injuries. PURPOSE: Investigate the effectiveness of auto-generated exercise programming on movement literacy scores among firefighters with lower baseline Functional Movement System (FMS™) scores. METHODS: Eleven male firefighters (mean age 44) with FMS™ scores less than 14/21 were included. Detailed explanations of the seven movement screens, five clearing procedures, and scoring were provided prior to baseline FMS™ assessments. Firefighters attempted each test up to three times, with highest scores retained. Scores ranged from 0 to 3 for each of the seven movement screens, with a maximum composite score of 21. Completed test scores were reviewed, and a report was provided to each firefighter through the FMS™PRO App. Additionally, auto-generated programs from the FMS™PRO App with exercise figures, descriptions, and videos to be performed prior to routine conditioning programs were provided. On average, participants were followed up after 262 days for a re-assessment. RESULTS: Mean composite scores significantly improved (p = .003) from 11.2 to 15.6/21, with a large effect size (r = 0.9). Individual item scores significantly improved for the deep overhead squat, hurdle, shoulder mobility, and rotary stability (p ≤ .046), with effect sizes of r = 0.3-0.8. Significant changes were not present for the inline lunge, active straight leg raise, and trunk stability push-up (p ≥ .083). CONCLUSION: An auto-generated corrective exercise program individualized to scores on the FMS™ was effective and exceeded error thresholds based on a minimal detectable change of 2.5/21.

The correlation of trust as part of the therapeutic alliance in physical therapy and their relation to outcomes for patients with chronic low back pain.

BACKGROUND: Previous qualitative research has listed trust as a component of the therapeutic alliance in physical therapy. OBJECTIVE: Quantitatively correlate trust and therapeutic alliance in physical therapy care for patients with chronic low back pain. The secondary aim was to investigate the relation of trust and therapeutic alliance with outcomes over the course of treatment. METHODS: The Primary Care Assessment Survey was used to measure trust and the Working Alliance Inventory-Short Revised tool measured therapeutic alliance. The patient recorded these measures after the initial visit and at discharge. Self-report patient outcome measures for pain, function, and global rating of change were also measured at the same time points. RESULTS: A strong correlation (rs = 0.747 and rs = 0.801) was found between trust scores and therapeutic alliance measures post-initial visit and at discharge, respectively. In addition, there were moderate to strong correlations between trust and therapeutic alliance scores with the various improved outcome measures of pain, function, and global rating of change. CONCLUSION: There appears to be a connection between trust and therapeutic alliance along with improved patient outcomes related to higher trust and therapeutic alliance scores in a cohort with chronic low back pain.

Application of the Staged Approach for Rehabilitation Classification System and Associated Improvements in Patient-Reported Outcomes Following Rehabilitation for Shoulder Pain.

OBJECTIVE: The Staged Approach for Rehabilitation Classification for the Shoulder (STAR-Shoulder) has been proposed as a model to guide management and improve outcomes for patients with shoulder pain; however, the effect of its utilization on patient outcomes has not been established. Therefore, the primary purpose of this study was to determine whether patient outcomes were improved if care was matched to the STAR-Shoulder system compared with unmatched care. METHODS: Collected and reviewed demographic, examination, and intervention data for all patients receiving physical therapist treatment for shoulder pain during a 1-year period within a single health care system. Outcome variables included the numeric pain rating scale, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the number of visits. Clinical records from patients receiving care at the discretion of the therapist were systematically audited to determine whether care provided was considered matched or unmatched. RESULTS: A total of 692 patient records were examined. The interrater reliability of classifying care as matched or unmatched was substantial (κ = 0.6; 95% CI = 0.4 to 0.9), with 82% agreement. Changes in patient outcome scores were significantly better for those patients whose care matched the STAR-Shoulder system for pain changes (mean difference = -1.2; 95% CI = 0.8 to 1.6; effect size [d] = 0.5) and QuickDASH score (mean difference = 12.7; 95% CI = 9.9 to 15.5; d = 0.7). No difference was noted for number of visits. CONCLUSION: The STAR-Shoulder system appears to be a meaningful way to classify patients and guide intervention to improve patient outcomes. IMPACT: Application of the STAR-Shoulder system to help align physical therapist interventions more closely with tissue irritability and physical impairments appears to improve patient outcomes. These findings support this model as a promising approach to advance evidence-based practice for shoulder pain.

Effect of a Standardized Training Program to Enhance the Therapeutic Alliance in Patients with Low Back Pain: A Mixed-Methods Analytical Approach.

BACKGROUND: Therapeutic alliance improves pain, disability, and quality of life outcomes. The purpose of this study was to investigate the effectiveness of a training protocol aimed at enhancing the therapeutic alliance in patients with chronic low back pain. METHODS: 19 physical therapists (DPT) and 16 student physical therapists (SPT) completed a therapeutic alliance training course with a quantitative questionnaire completed before and after the training along with a follow-up qualitative interview. Quantitative results were analyzed for differences resulting from participation in the training, while qualitative results were analyzed via interview transcription analysis by independent researchers blinded to the participants. RESULTS: All three groups (SPT/DPT combined, SPT, DPT) demonstrated a significant improvement in feeling comfortable in building a strong therapeutic alliance (p<0.01). The themes of Training Enhances Consciousness, Communication is Key, and Personalized Approach emerged from qualitative interviews indicating that the course was valuable in improving their approach to therapeutic alliance, communication, and individualized interventions contribute to a successful therapeutic alliance. CONCLUSION: The results of this study demonstrate the efficacy of therapeutic alliance training and suggest potential to enhance therapeutic alliance through a training protocol.

Is it Time to Normalize Scapular Dyskinesis? The Incidence of Scapular Dyskinesis in Those With and Without Symptoms: a Systematic Review of the Literature.

Background: Up to 67% of adults experience shoulder pain in their lifetime. Numerous factors are related to the etiology of shoulder pain, one of which is thought to be scapular dyskinesis (SD). Given the prevalence of SD among the asymptomatic population a concern is that the condition is being medicalized (clinical findings suggested to require treatment but is ultimately a normal finding). Therefore, the purpose of this systematic review was to investigate the prevalence of SD among both symptomatic and asymptomatic populations. Methods: A systematic review of the literature up to July of 2021. Relevant studies identified from PubMed, EMBASE, Cochrane and CINAHL were screened utilizing the following inclusion and exclusion criteria; inclusion: (a) individuals being assessed as having SD, including reliability and validity studies (b) subjects aged 18 or older; (c) sport and non-sport participants; (d) no date restriction; (e) symptomatic, asymptomatic, or both populations; (f) all study designs except case reports. Studies were excluded if: (a) they were not published in the English language; (b) they were a case report design; (c) the presence of SD was part of the studies inclusion criteria; (d) data were not present distinguishing the number of subjects with or without SD; (e) they did not define participants as having or not having SD. Methodological quality of the studies was assessed utilizing the Joanna Briggs Institute checklist. Results: The search resulted in 11,619 after duplicates were removed with 34 studies ultimately retained for analysis after three were removed due to low quality. A total of 2,365 individuals were studied. Within the studies for the symptomatic athletic and general orthopedic population there were 81% and 57% individuals with SD, respectively, and a total of 60% among both symptomatic groups (sport and general orthopedic population). Within the studies for the asymptomatic athletic and general population there were 42% and 59% individuals with SD, respectively, and a total of 48% among both asymptomatic groups (sport and general orthopedic population). Limitation: A strict inclusion and exclusion criteria was used to identify studies that provided the appropriate data for the purpose of this study. There was a lack of consistency for measuring SD across studies. Conclusion: A considerable number of individuals with shoulder symptoms do not present with SD. More revealing is the number of asymptomatic individuals who do present with SD, suggesting that SD may be a normal finding among nearly half of the asymptomatic population. Level of Evidence: 2a.

Exploring sex as a moderator of other prognostic variables in whiplash associated disorder: An observational study.

BACKGROUND: Prognostic variables for assessing people with whiplash associated disorder (WAD) following a motor vehicle collision (MVC) have been evaluated in numerous studies. However, there is minimal evidence assessing how these variables may differ between males and females. QUESTION/PURPOSE: 1) To assess if the sex of a person interacts with known prognostic variables within the development of chronic WAD. 2) To determine if commonly used outcome measures used in the assessment of chronic WAD differ between sexes. METHODS: The study was a secondary analysis of an observational study with an inception cohort immediately following an MVC in an emergency department in Chicago, IL, USA. Ninety-seven adults aged 18 to 60 (mean 34.7 years old; 74% female) participated in the study. The primary outcome was long-term disability as determined by Neck Disability Index (NDI) scores at 52-weeks post-MVC. Data was collected at baseline (less than 1-week), 2, 12, 52-weeks post MVC. Hierarchal linear regression was used to determine significance (ΔF-score, p < 0.05) and R2 for each of the variables. The primary variables of interest were sex of the participant, age, baseline scores on the numeric pain rating scale (NPRS) and NDI and created interaction terms for sex x z-baseline NPRS and sex x z-NDI. RESULTS: From analysis 1, both NDI (R2 = 8.7%, p < 0.01) and NPRS (R2 = 5.7%, p = 0.02) collected at baseline predicted significant variance in NDI score at 52-weeks. The interaction term of sex x z-NPRS was also significant (R2 = 3.8%, p = 0.04). In analysis 2 the regression models when disaggregated by sex showed that baseline NDI was the significant predictor of 52-week outcome in males (R2 = 22.4%, p = 0.02) while it was the NPRS as the significant predictor in females (R2 = 10.5%, p < 0.01).

The relationship between trust and outcomes during physical therapy care for chronic low back pain.

INTRODUCTION: Enhancing the therapeutic alliance has been associated with improved outcomes for patients with chronic low back pain (CLBP). Qualitatively trust has been described to be part of the therapeutic alliance, but it has not been measured quantitatively within the physical therapy literature. OBJECTIVE: Examine the relationship between trust and outcomes during physical therapy for CLBP. METHODS: Observational study of patients with CLBP being seen for physical therapy were assessed through self-report measures. The Primary Care Assessment Survey (PCAS) trust measurement scale was completed by patients at initial, post-initial, and discharge visit. These measurements were compared for correlations with patient reported outcome measures for pain and function recorded at initial visit and discharge. RESULTS: A convenience sample of 29 patients (49.3 ± 15 years old) with CLBP were measured. The PCAS showed correlations for changes in trust throughout treatment for improvements in pain and discharge pain rating. Average discharge pain rating correlated to changes in the PCAS (rs = -0.692, p < .001), with lower pain ratings relating to higher changes in trust over time. Average change in pain (rs = 0.745, p < .001) throughout treatment also correlated with higher changes in trust. Higher trust scores at discharge also correlated with improved Global Rating of Change and Oswestry Disability Index scores at discharge. The linear regression model showed adjusted R2 values for the trust scores and outcomes varied between 0.247 and 0.642. CONCLUSION: Both increases in trust throughout the treatment and end trust scores during physical therapy were related to improved outcomes for patients with CLBP.

Application of a nonlinear periodization program among firefighters returning to full duty from an injury: A case series.

OBJECTIVE: The purpose of this case series was to observe physical performance changes following an 8-week nonlinear periodization training program on firefighters currently on light duty who were cleared to participate in full physical activities. METHODS: Two firefighters underwent an 8-week nonlinear periodization program. Participant 1 was returning from anterior cruciate ligament reconstruction and participant 2 from a non-surgical low back injury. The Incumbent Physical Ability Test (IPAT), 2-minute push-up test, 300-yard shuttle, and Gerkin protocol testing were assessed at baseline, week 4, and week 8. OUTCOMES: Both participants demonstrated improvement in assessments of physical performance and fitness across each assessment point, with exception of the Gerkin protocol, and were able to return to full duty at the conclusion of their rehabilitation training program. CONCLUSION: The physical demands of tactical professionals such as firefighters exceed those of the general population. As such, these individuals require both job-specific programming and assessments when transitioning from an injury to full duty. An 8-week nonlinear periodization program yielded improvements in performance of firefighting tasks and physical fitness in two firefighters returning to full duty after injury and highlighted effective interprofessional collaboration between the physical therapy and fitness team.

Immediate decrease of muscle biomechanical stiffness following dry needling in asymptomatic participants.

BACKGROUND: Biomechanical muscle stiffness has been linked to musculoskeletal disorders. Assessing changes in muscle stiffness following DN may help elucidate a physiologic mechanism of DN. This study characterizes the effects of dry needling (DN) to the infraspinatus, erector spinae, and gastrocnemius muscles on biomechanical muscle stiffness. METHOD: 60 healthy participants were randomized into infraspinatus, erector spinae, or gastrocnemius groups. One session of DN was applied to the muscle in standardized location. Stiffness was assessed using a MyotonPRO at baseline, immediately post DN, and 24 h later. The presence of a localized twitch response (LTR) during DN was used to subgroup participants. RESULTS: A statistically significant decrease in stiffness was observed in the gastrocnemius, the LTR gastrocnemius, and the LTR erector spinae group immediately following DN treatment. However, stiffness increased after 24 h. No significant change was found in the infraspinatus group. CONCLUSIONS: DN may cause an immediate, yet transitory change in local muscle stiffness. It is unknown whether these effects are present in a symptomatic population or related to improvements in clinical outcomes. Future studies are necessary to determine if a decrease in biomechanical stiffness is related to improvement in symptomatic individuals.

The impact of physical therapist attitudes and beliefs on the outcomes of patients with low back pain.

BACKGROUND: Low back pain (LBP) is a common problem that places a major burden on individuals and society. It has been proposed that patients treated by biomedically oriented clinicians will have worse outcomes than those treated by biopsychosocially oriented clinicians. OBJECTIVE: To investigate the impact of physical therapist LBP related attitudes and beliefs on the outcomes of patients with LBP. DESIGN: Retrospective cohort design. METHOD: United States based physical therapists utilizing the Focus on Therapeutic Outcomes, Inc. (FOTO) database were surveyed using the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) and the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT). Outcomes were measured using average Computerized Lumbar Functional Scale change scores (CLFS) and CLFS residual scores. RESULTS: Analysis was performed on outcome data from 78 physical therapist and included 2345 patients. HC-PAIRS was a univariate predictor of average CLFS change scores and average CLFS residual scores. PABS-PT Biomedical subscale was a univariate predictor of average CLFS change scores. After adjusting for confounding variables, higher HC-PAIRS scores and PABS-BM scores were associated with a greater change in average CLFS score, and higher PABS-BM scores were associated with higher CLFS residual scores. CONCLUSION: Physical therapists who believed in a stronger relationship between pain and disability had improved patient outcomes.

Shoulder-Specific Patient-Reported Outcome Measures for Use in Patients With Head and Neck Cancer: An Assessment of Reliability, Construct Validity, and Overall Appropriateness of Test Score Interpretation Using Rasch Analysis.

OBJECTIVES: The purpose of this study was to investigate the construct validity and overall appropriateness of test score interpretation of 4 shoulder-related patient-reported outcome (PRO) measures for use in a population of patients with head and neck cancer using Rasch analysis. METHODS: One hundred eighty-two individuals who had received a neck dissection procedure within the past 2 weeks to 18 months were recruited for this cross-sectional psychometric study. Rasch methodologies were used to investigate scale dimensionality, scale hierarchy, response scale structure, and reliability of Disabilities of the Arm, Shoulder and Hand (DASH), QuickDASH, Shoulder Pain and Disability Index (SPADI), and Neck Dissection Impairment Index (NDII). RESULTS: DASH did not meet criteria for unidimensionality and was deemed inappropriate for use in this sample. The QuickDASH, SPADI, and NDII were all determined to be unidimensional. All scales had varying issues with person and item misfit, differential item functioning, coverage of ability levels, and optimal rating scale requirements. The NDII met most requirements. All measures were found to meet thresholds for person and item separation as well as reliability statistics. CONCLUSIONS: Rasch analysis indicates the NDII is the most appropriate measure studied for this population. The QuickDASH and SPADI are recommended with reservation, whereas the DASH is not recommended. IMPACT: This study demonstrates the use of objective methodologies, using Rasch analysis, to validate PRO recommendations provided by clinical experts in forums such as the Evaluation Database to Guide Effectiveness (EDGE) TaskForce, which are based upon a comprehensive literature review, consideration of published psychometric properties, and expert consensus. Use of Rasch methodologies demonstrates weaknesses in this model and provides opportunities to strengthen recommendations for clinicians.

The Efficacy and Treatment Fidelity of Kinesiology Taping in Conjunction With Conservative Treatment Interventions Among Individuals With Shoulder Pain: A Systematic Review with Meta-Analysis.

PURPOSE: Kinesiology taping is a common intervention used to treat individuals with shoulder pain. While there have been several studies published to date evaluating the effectiveness of this intervention, a systematic review with meta-analysis synthesizing the collective effectiveness of kinesiology taping is not available. Therefore, the purpose of this study was to perform a systematic review with meta-analysis investigating the efficacy and treatment fidelity of kinesiology taping (KT) in combination with conservative interventions for shoulder pain. METHODS: Databases (PubMed, EMBASE, SportDiscus, CINAHL) of studies published in English meeting criteria were searched to October 2019. Methodologic quality was assessed utilizing the Modified Downs and Black checklist. Treatment fidelity was evaluated using a modified fidelity tool. Random effects meta-analyses were performed when an outcome (disability, pain, range of motion (ROM)) was reported by two or more studies. Overall effect size (pooled random effects) was estimated for studies with acceptable clinical homogeneity. RESULTS: When KT was used with conservative treatments, meta-analysis revealed large effect sizes for improvements in disability (standard mean difference (SMD) = -1.35; 95% CI, -2.09 to -0.60) and ROM (SMD = 0.96; 95% CI, 0.60-1.33) with no significant effects for pain. The average Modified Downs & Black score for bias was 11.5 ± 3.9. Of 10 retained studies, only two had good treatment fidelity. CONCLUSIONS: Adding KT to interventions performed in clinical settings appears to demonstrate efficacy regarding disability and ROM when compared to conservative interventions alone. However, despite reasonably good methodologic quality, fidelity was lacking in a majority of studies. Because of its impact on the implementation of evidence-based practice, lower fidelity should be considered when interpreting results.

The Reliability and Validity of a Clinical Measurement Proposed to Quantify Humeral Torsion.

BACKGROUND: Range of motion (ROM) impairments of the overhead athletes' shoulder are commonly addressed through mobility-based treatments, however, adaptations from humeral torsion (HT) are not amenable to such interventions. A clinical measurement to quantify HT has been proposed, however, the validity is not conclusive. PURPOSE: The primary aim of this study is to determine the intrarater reliability and standard error of measurement (SEM) of the biceps forearm angle (BFA) measurement. The secondary aim of this study is to investigate the convergent validity of the BFA compared to diagnostic ultrasound. STUDY DESIGN: Cross Sectional Reliability and Validity Study. METHODS: HT measurements, utilizing diagnostic ultrasound, were compared to BFA in 74 shoulders (37 subjects) over two sessions. Each measurement was performed three times and a third investigator recorded measures to ensure blinding. Reliability was investigated using utilizing an intraclass correlation coefficient (ICC 3,k). RESULTS: Intrarater reliability values were 0.923 and 0.849 for diagnostic ultrasound and BFA methods respectively. Convergent validity was r = 0.566. The standard error of measurement for diagnostic ultrasound and BFA was 3° and 5°, respectively. The 95% limits of agreement between the two measurement methods were -24.80° and 19.80° with a mean difference of -2.50° indicating that on average the diagnostic ultrasound measurement was lower than that of the BFA method. CONCLUSION: The BFA is a reliable clinical method for quantifying HT, however, demonstrates moderate to poor convergent validity when compared to diagnostic ultrasound. LEVEL OF EVIDENCE: 2b.

Mechanical Percussion Devices: A Survey of Practice Patterns Among Healthcare Professionals.

Background: Mechanical percussion devices have become popular among sports medicine professionals. These devices provide a similar effect as manual percussion or tapotement used in therapeutic massage. To date, there are few published studies or evidence-based guidelines for these devices. There is a need to understand what professionals believe about this technology and how they use these devices in clinical practice. Purpose: To survey and document the knowledge, clinical application methods, and use of mechanical percussion devices among healthcare professionals in the United States. Design: Cross-sectional survey study. Methods: A 25 question online survey was emailed to members of the National Athletic Trainers Association, Academy of Orthopedic Physical Therapy, and American Academy of Sports Physical Therapy. Results: Four hundred twenty-five professionals completed the survey. Most professionals (92%, n=391) used devices from two manufacturers: Hyperice® and Theragun®. Seventy-seven percent directed clients to manufacturer and generic websites (n=329) to purchase devices. Most respondents used a medium and low device speed setting for pre- and post-exercise (62%, n=185), pain modulation (59%, n=253), and myofascial mobility (52%, n=222). A large proportion of respondents preferred a total treatment time between 30 seconds and three minutes (36-48%, n=153-204) or three to five minutes (18-22%, n=76-93). Most respondents (54-69%, n=229-293) believed that mechanical percussion increases local blood flow, modulates pain, enhances myofascial mobility, and reduces myofascial restrictions. Most respondents (72%, n=305) were influenced by other colleagues to use these devices. Sixty-six percent used patient reported outcomes (n=280) to document treatment efficacy. Live instruction was the most common mode of education (79%, n=334). Conclusion: These results are a starting point for future research and provide insight into how professionals use mechanical percussion devices. This survey also highlights the existing gap between research and practice. Future research should examine the efficacy of this technology and determine consensus-based guidelines. Level of Evidence: 3.

ANALYSIS OF RANGE OF MOTION IN FEMALE RECREATIONAL TENNIS PLAYERS WITH AND WITHOUT LATERAL ELBOW TENDINOPATHY.

BACKGROUND: Intrinsic factors including altered joint motion in the upper extremity may lead to altered biomechanics in tennis players and could result in symptoms of lateral elbow tendinopathy. PURPOSE: To compare upper extremity passive motion and elbow carrying angle between three groups of women: recreational tennis players with LET, non-symptomatic recreational tennis players, and a control group of non-tennis players. STUDY DESIGN: Cross-sectional. METHODS: A convenience sample of 63 women was recruited and placed into one of the three groups: non-symptomatic tennis players (NSTP), symptomatic tennis players (STP), and a control group. Elbow carrying angle, passive range of motion of the shoulder, elbow, forearm, and wrist were measured during a single session. RESULTS: A significant difference was found between the groups for wrist flexion (p < 0.00), forearm pronation (p = 0.002), elbow flexion (p = 0.020) and extension (p = 0.460), as well as shoulder internal rotation (p < 0.00). No significant differences were found in other motions or carrying angle between the three groups (p =0.059). Post-hoc comparisons indicated that shoulder internal rotation and wrist flexion was less in both STP and NSTP groups compared with the control group. Elbow flexion and forearm pronation were greater in STP than the other two groups. CONCLUSION: Impairments including loss of shoulder internal rotation and wrist flexion and greater motion at the elbow and forearm were found in the UE of symptomatic tennis players. Evaluation of passive motion and muscle length should be performed prior to establishing a rehabilitation plan for symptomatic tennis players. LEVELS OF EVIDENCE: 3.

BALANCE TRAINING: DOES ANTICIPATED BALANCE CONFIDENCE CORRELATE WITH ACTUAL BALANCE CONFIDENCE FOR DIFFERENT UNSTABLE OBJECTS?

BACKGROUND: Sports rehabilitation professionals often prescribe unstable objects for balance training. Unfortunately, there is a lack of measurement of balance confidence when incorporating these objects. Currently, there is no consensus on the optimal balance confidence measure or proposed progression of unstable objects. Understanding the influence of balance confidence on task performance using unstable objects may help professionals better prescribe a balance training program. PURPOSE: The primary purpose of this investigation was to explore the correlation between anticipated and actual balance confidence on different unstable objects during static double leg and single leg stance. The secondary purpose was to explore the correlation between anticipated and actual unstable object difficulty rankings. STUDY DESIGN: Repeated measure observational, controlled trial. METHODS: Sixty-five active, healthy adults (M = 35, F = 30) (mean age = 24.38 ± 3.56) underwent two testing sessions. During session one, participants took an online survey, rating their anticipated balance confidence after observing images of different unstable objects. During session two, participants stood on each unstable object under two conditions (static double leg stance and single leg stance) and rated their actual balance confidence. The main outcome measure was an ordinal balance confidence score adapted from the activities-specific balance confidence scale. Statistical analysis included subject demographic calculations and appropriate non-parametric tests. RESULTS: For the double leg stance and single leg stance conditions, there was a very strong correlation between anticipated and actual balance confidence scores on the stable surface (ρ = 1.0, p = <.001). There was a weak correlation between scores for foam pad, air-filled discs, Bosu® (dome up), Bosu® (dome down), and wobble board for both conditions. For unstable object rankings, there was a very strong correlation between scores (ρ=1.0, p = <.001). The objects were ranked by perceived difficulty as follows: Level 1 (easy)- ground, Level 2- foam pad, Level 3- air-filled discs, Level 4- Bosu®, and Level 5 (difficult)- wobble board. CONCLUSION: Study findings suggest that actual measures of balance confidence may provide insight into a patient's confidence level and may help with prescribing and progressing their program. The suggested unstable object difficulty rankings may help professionals better match the objects to their patients to produce optimal outcomes. LEVEL OF EVIDENCE: 2c.

THE RELIABILITY AND MINIMAL DETECTABLE CHANGE OF THE ELY AND ACTIVE KNEE EXTENSION TESTS.

BACKGROUND: Muscle length is a common component of the physical therapy examination, which may include the prone knee flexion (Ely) and active knee extension (AKE) tests. Clinicians using these tests should understand the clinimetric properties. PURPOSE: To investigate the reliability and minimal detectable change (MDC95) of the Ely and AKE tests. STUDY DESIGN: Reliability analysis. METHODS: Seventy-one asymptomatic adults (mean age 24.6 + /- 2.8 years) were recruited based on a convenience sample. Two examiners each performed the Ely and AKE test one time each in an intrasession design for the interrater reliability component, with one examiner repeating the tests one time 48 hours later to determine the intra-rater reliability. Results were recorded based on one trial per test and utilized a pelvic strap for the Ely test and an adjustable bolster for the AKE test. A separate researcher recorded measurements and results were blinded from the examiners. RESULTS: The Ely test had excellent intra-rater and inter-rater reliability with an intraclass correlation coefficient (ICC) (3,1) of 0.900 and ICC (2,1) of 0.914 respectively. The intra-rater and inter-rater reliability of the AKE test was good with ICC (3,1) of 0.882 and ICC (2,1) 0.886 respectively. The MDC95 indicated that a change greater than or equal to 8° and 12° is required to exceed the threshold of error for the Ely and AKE test respectively. CONCLUSION: The Ely and AKE tests have good to excellent inter-rater and intra-rater reliability for measuring rectus femoris and hamstring muscle length when stabilization of the pelvis and hip is accounted for. The MDC should be considered as a threshold for true change in the asymptomatic adult population. LEVELS OF EVIDENCE: 2b.