Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up.

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

Reliability of isokinetic decay slope is superior to using fatigue indices for shoulder horizontal abduction.

INTRODUCTION: Reliable and valid measurements for shoulder muscular endurance should be available for clinical use. The posterior shoulder endurance test offers a potential clinical assessment, but its construct validity isn't available. Since a criterion measure of muscular endurance is not available, this study's purpose was to determine a reliable method for testing shoulder muscular endurance using an isokinetic dynamometer. METHODS: The test-retest reliability, standard error measurement, and minimal detectable change were calculated on four different paradigms to quantify muscular fatigue using two isokinetic speeds (60°sec-1,180°sec-1). Calculation paradigms included peak torque fatigue index (FI), average torque FI, area-under-the-curve FI, and peak torque decay slope. Testing occurred on two days. Repeated measures analysis of variance compared the two peak torque decay slopes across both testing days. RESULTS: Superior reliability was found within the decay slope measurements at both 60°sec-1 (ICC = 0.941) and 180°sec-1 (ICC = 0.764) speeds, with the 60°sec-1 decay slope being the highest reliability between the two angular velocities. There was a greater amount of fatigue in the 60°sec-1 decay slope compared to the 180°sec-1 decay slope. CONCLUSION: Using the decay slope of isokinetic shoulder horizontal abduction at 60°sec-1 is a reliable method to validate other muscular endurance clinical measures. Rehabilitation specialists should utilize the decay slope of the isokinetic dynamometry to monitor responsiveness.

Examination of Dry Needling Dose and Effect Duration for Individuals With Chronic Ankle Instability.

OBJECTIVE: The purpose of this study was to evaluate the effect of a single treatment vs serial dry needling (DN) treatments of the fibularis longus on individuals with chronic ankle instability and to determine the longevity of any effect found. METHODS: Thirty-five adults with chronic ankle instability (24.17 ± 7.01 years, 167.67 ± 9.15 cm, 74.90 ± 13.23 kg) volunteered for a university laboratory repeated-measures study. All participants completed patient-reported outcomes and were objectively tested using the Star Excursion Balance Test (SEBT), threshold to detect passive motion (TTDPM) measurements, and single limb time-to-boundary measurements. Participants received DN treatment to the fibularis longus once weekly for 4 weeks on the affected lower extremity by a single physical therapist. Data were collected 5 times: baseline 1 week before initial treatment (T0), pre-treatment (T1A), immediately after the first treatment (T1B), after 4 weekly treatments (T2), and 4 weeks after the cessation of treatment (T3). RESULTS: Significant improvements were found for clinician-oriented (SEBT-Composite P < .001; SEBT-Posteromedial P = .024; SEBT-Posterolateral P < .001; TTDPM-Inversion P = .042) and patient-oriented outcome measures (Foot and Ankle Ability Measure-Activities of Daily Living P < .001; Foot and Ankle Ability Measure-Sport P = .001; Fear Avoidance Belief Questionnaire P = .021) following a single DN treatment. Compounding effects from additional treatments exhibited improvement of TTDPM (T1B to T2). No significant losses were noted 4 weeks after cessation of treatment (T2 to T3). CONCLUSION: For the participants in this study, outcomes improved immediately following the first DN treatment. This improvement was sustained but not further improved with subsequent treatments.

Dry needling equilibration theory: A mechanistic explanation for enhancing sensorimotor function in individuals with chronic ankle instability.

Patients with chronic ankle instability (CAI) experience a dynamic interplay between impaired mechanical structures and sensorimotor deficiencies that contribute to recurrent sprains and sensations of instability. Concomitantly, muscular trigger points (MTrPs) are known to occur following trauma, maximal or submaximal concentric contractions, and unaccustomed eccentric loads. Additionally, MTrPs are theorized to be exacerbated in low-load and repetitive strain activities. MTrPs located within a muscle are associated with altered motor control, reaction delay, and decreased strength, deficits also found among those with CAI. Dry needling (DN) is reported to improve muscle range of motion, motor control, and pain in a myriad of neuromusculoskeletal conditions by decreasing spontaneous electrical activity and stiffness of taut muscle bands while improving filament overlap. Building on evidence supporting neuromechanical decoupling in chronic ligamentous injury with what is known about the development of MTrPs, this paper proposes a centrally mediated mechanism for improved sensorimotor function following DN for individuals with CAI. Dry needling equilibration theory (DNET) states that proprioception is improved following DN in the lower extremity by changing the muscle's length-tension relationship and leveraging minor acute discomfort to improve muscle spindle afferent information via the gamma motor system. The application of DNET for individuals with CAI may provide a mechanistic explanation for improved descending cortical output, resulting in enhanced sensorimotor function.

Development of a pain neuroscience education program for post-traumatic stress disorder and pain.

Introduction: Individuals with co-morbid post-traumatic stress disorder (PTSD) and pain have higher disability, pain, and pain catastrophizing beliefs than patients without PTSD. Pain neuroscience education (PNE) may be an effective tool to help those with PTSD and pain reduce maladaptive beliefs about pain. The purpose of this paper is to report the development and evaluation of a PNE curriculum for participants with PTSD and pain. Methods: After writing an initial draft of PNE for PTSD and pain, a panel of medical experts in PNE, PTSD, and rehabilitation reviewed the booklet. After addressing recommendations from the medical panel (n = 29), individuals with (n = 13) and without (n = 20) PTSD reviewed the booklet. Results: Overall, 89% of participants recommended the PNE booklet and 90% thought it would help patients with PTSD and pain. Although patients with PTSD rated the PNE booklet more critically than other participants, a particular support group (n = 4) rated the PNE booklet significantly different (p < .05) than remaining participants with PTSD (n = 9). Individuals with PTSD and pain were able to comprehend the PNE booklet at a comparable rate to an expert medical panel and participants without PTSD after adjusting for education levels (p = .12). Conclusions: Many patients with PTSD and pain avoid painful activities because they believe they are harmful. This research demonstrates that individuals with PTSD and pain can comprehend PNE that challenges these beliefs. The PNE curriculum developed by this research may provide a logical explanation for the link between PTSD symptoms and pain and should be tested for clinical effectiveness.

Effect of Dry Needling on Spinal Reflex Excitability and Postural Control in Individuals With Chronic Ankle Instability.

OBJECTIVE: The purpose of this study was to compare postural control and neurophysiologic components of balance after dry needling of the fibularis longus between individuals with chronic ankle instability (CAI) and a healthy control group. METHODS: This quasi-experimental university-laboratory study included 50 adult volunteers-25 with CAI (16 female, 9 male; age: 26 ± 9.42 years; height: 173.12 ± 9.85 cm; weight: 79.27 ± 18 kg) and 25 healthy controls (15 female, 10 male; age: 25.8 ± 5.45 years; height: 169.47 ± 9.43 cm; weight: 68.47 ± 13 kg). Participants completed the Star Excursion Balance Test (SEBT), single-leg balance, and assessment of spinal reflex excitability before and after a single treatment of dry needling to the fibularis longus. The anterior, posterolateral, and posteromedial directions of the SEBT were randomized, and reach distances were normalized to a percentage of leg length. A composite SEBT score was calculated by averaging the normalized scores. Postural control was assessed in single-limb stance on a force plate through time-to-boundary measurements in eyes-open and eyes-closed conditions. Fibularis longus and soleus spinal reflexes were obtained by providing electrical stimulation to the common fibular and tibial nerves with participants lying prone. A Group × Time analysis examined changes in performance, and effect sizes were calculated to assess significance. RESULTS: Significant group × time interactions were identified for composite (P = .006) and posteromedial (P = .017) SEBT scores. Significant time effects for all directions of the SEBT, time to boundary with eyes open, and the mediolateral direction with eyes closed indicate improved postural control following treatment (P < .008). Within-group effect sizes for significant time effects ranged from small to large, indicating potential clinical utility. CONCLUSION: Dry needling demonstrated immediate short-term improvement in measures of static and postural control in individuals with CAI as well as healthy controls.

Novel application of dry needling for neuropathic myofascial ankle pain and dysfunction following insidious integumentary infection: A case report.

BACKGROUND: Dry needling (DN) was effectively applied to a patient whose primary complaint was hyperalgesia and decreased ankle function meeting criteria for neuropathic myofascial pain following an integumentary infection, skin grafting and immobilization. CASE DESCRIPTION: A 33-year-old male serving on active duty in the United States Air Force was referred to physical therapy for decreased ankle range of motion and pain, eight weeks after an integumentary infection on his ankle. The infection was complicated by tissue loss requiring skin grafting for closure. Two months of traditional rehabilitation was unsuccessful and this patient was referred for DN treatment. OUTCOMES: Clinically relevant improvements were achieved after one treatment. After 48 hours, the patient's reported Pain Quality Assessment Scale (PQAS) dropped from a baseline 67 to 34 and Lower Extremity Functional Scale (LEFS) increased from 44 to 56. Plantarflexion and dorsiflexion improved by 15° and inversion and eversion by five degrees. After one year and 11 DN treatments, function continued to improve as demonstrated by single leg stance time improvement from 4 s to more than 60 seconds, without pain, a final LEFS of 72 and a return to unrestricted full duty. CONCLUSION: DN is an increasingly utilized treatment option for myofascial pain. This case report represents a unique application of DN to an atypical patient presenting with neuropathic myofascial pain syndrome that demonstrated improvement with DN as the sole intervention. Further research regarding the application of DN as a treatment option for neuropathic myofascial pain syndromes is needed.

Post-Traumatic Stress Disorder Symptoms Contribute to Worse Pain and Health Outcomes in Veterans With PTSD Compared to Those Without: A Systematic Review With Meta-Analysis.

INTRODUCTION: Post-traumatic stress disorder (PTSD) and chronic pain are frequently co-morbid conditions in the U.S. veteran population. Although several theories about the cause of increased pain prevalence in individuals with PTSD have been presented, no synthesis of primary data informing the impact of co-morbid PTSD and pain has been completed. The purpose of this study was to systematically review the literature and quantify disability, function, and pain-related beliefs and outcomes in veterans with PTSD compared to veterans without PTSD. MATERIALS AND METHODS: A systematic search of three electronic databases was conducted. Inclusion criteria required pain-related comparison of veterans with PTSD to those without PTSD. Primary outcome measures and standardized mean differences (SMDs) were assessed for pain, function, disability, pain beliefs, and healthcare utilization using a random effects model. RESULTS: 20 original research studies met inclusion criteria and were assessed for quality and outcomes of interest. The majority of studies were cross-sectional. Veterans with PTSD and pain demonstrated higher pain (SMD = 0.58, 95% CI 0.28-0.89), disability (SMD = 0.52, 95%CI 0.33-0.71), depression (SMD = 1.40, 95%CI 1.2-1.6), catastrophizing beliefs (SMD = 0.95, 95% CI 0.69-1.2), sleep disturbance (SMD = 0.80, 95% CI 0.57-1.02), and healthcare utilization; they had lower function (SMD = 0.41, 95% CI 0.25-0.56) and pain self-efficacy (SMD = 0.77, 95% CI 0.55-0.99) compared to veterans without PTSD. CONCLUSION: In veterans with chronic pain, PTSD symptomology has a large effect for many negative health-related outcomes. This review supports the need for clinicians to screen and understand the effects of PTSD symptoms on patients with pain. Clinicians should recognize that veterans with PTSD and pain likely have elevated pain catastrophizing beliefs and decreased self-efficacy that should be targeted for intervention.

Effect of Chronic Low Back Pain and Post-Traumatic Stress Disorder on the Risk for Separation from the US Army.

INTRODUCTION: Co-morbid post-traumatic stress disorder (PTSD) and low back pain (LBP) are common reasons for increased disability in the Veteran communities. Medical discharge from the military represents a considerable financial cost to society. Little is currently known about the impact of LBP and PTSD as longitudinal risk factors for medical discharge from Active Duty military service. MATERIALS AND METHODS: A retrospective analysis of US Army Active Duty Soldiers from 2002 to 2012 was performed to determine the risk for medical discharge. Four levels of exposure for were identified as independent variables: no chronic LBP or PTSD, chronic LBP only, PTSD only, and co-morbid PTSD present with chronic LBP. Statistical analysis utilized modified Poisson regression controlling for sex, age, rank, time in service, deployment, mental health, sleep disorders, alcohol use, tobacco use, obesity, and military occupation. This study was approved by a Department of Defense Institutional Review Board. RESULTS: After controlling for potential confounding variables, the RR for chronic LBP and PTSD independently was 3.65 (95% CI: 3.59-3.72) and 3.64 (95% CI: 3.53-3.75), respectively, and 5.17 (95% CI: 5.01-5.33) when both were present. CONCLUSIONS: This is the first study to identify a history of both chronic LBP and PTSD as substantial risk factors for medical discharge from the US Army. PTSD and chronic LBP may mutually reinforce one another and deplete active coping strategies, making Soldiers less likely to be able to continue military service. Future research should target therapies for co-morbid PTSD and chronic LBP as these conditions contribute a substantial increase in risk of medical discharge from the US Army.

Musculoskeletal Ultrasonography to Detect a Displaced Fracture of the Fifth Metatarsal.

A 27-year-old man presented to an outpatient physical therapy clinic with left lateral foot pain after playing lacrosse 1 day prior. Ultrasound imaging was performed immediately by the physical therapist, focusing on the fifth metatarsal distal shaft. Images obtained with a 13- to 6-MHz linear transducer demonstrated cortical bone disruption. The patient's primary care physician subsequently ordered radiographs, which demonstrated an obliquely oriented fracture through the shaft of the fifth metatarsal. J Orthop Sports Phys Ther 2018;48(11):903. doi:10.2519/jospt.2018.7884.

Factors influencing final outcomes in patients with shoulder pain: A retrospective review.

STUDY DESIGN: Retrospective cohort. INTRODUCTION: Rehabilitation interventions are commonly prescribed for patients with shoulder pain, but it is unclear what factors may help clinicians' prognosis for final outcomes. PURPOSE OF THE STUDY: The purpose of this study is to determine what factors are the best predictors of improved patient-reported outcomes at discharge in patients with shoulder pain. METHODS: Retrospective chart review of 128 patients presenting with shoulder pain to an outpatient physical therapy clinic. Chart review captured data regarding patient demographics, treatment interventions, patient history, and patient-reported outcome scores. The primary dependent variable was the overall change score of the QuickDASH (initial to discharge). Thirty-eight predictor variables were entered into a forward stepwise multivariate linear regression model to determine which variables and to what degree contributed to the dependent variable. RESULTS: The linear regression model identified 5 predictor variables that yielded an R = 0.74 and adjusted R2 = 0.538 (P < .001). The 5 predictor variables identified in order of explained variance are QuickDASH change at the fifth visit, a total number of visits, initial QuickDASH score, scapular retraction exercise, and age. DISCUSSION: Early change scores, equal to minimal detectable change scores on patient-reported outcomes appear to be strong indicators that patients with shoulder pain are on a positive trajectory to benefit from rehabilitation. CONCLUSION: Using patient-reported outcomes throughout care, not just at the start and end of care, will provide therapist feedback regarding patient's progress and indicate treatment effectiveness. LEVELS OF EVIDENCE: 4.

Scapular muscle performance in individuals with lateral epicondylalgia.

STUDY DESIGN: Descriptive, laboratory-based, cross-sectional study. OBJECTIVES: To describe scapular musculature strength, endurance, and change in thickness in individuals with unilateral lateral epicondylalgia (LE) compared to the uninvolved limb and the corresponding limb of a matched comparison group. BACKGROUND: Reported poor long-term outcomes for the nonsurgical management of individuals with LE suggest a less-than-optimal rehabilitation process. Knowledge of scapular muscle function in a working population of individuals with LE may help to further refine conservative management of this condition. METHODS: Twenty-eight patients with symptomatic LE and 28 controls matched by age and sex were recruited to participate in the study. Strength of the middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) was measured with a handheld dynamometer. A scapular isometric muscle endurance task was performed in prone. Changes in muscle thickness of the SA and LT were measured with ultrasound imaging. Analysis-of-variance models were used to determine within- and between-group differences. RESULTS: The involved side of the group with LE had significantly lower values for MT strength (P = .031), SA strength (P<.001), LT strength (P = .006), endurance (P = .003), and change in SA thickness (P = .028) when compared to the corresponding limb of the control group. The involved side of the group with LE had significantly lower strength of the LT (P = .023) and SA (P = .016) when compared to the uninvolved limb; however, these differences were small and of potentially limited clinical significance. CONCLUSION: When compared to a matched comparison group, there were impairments of scapular musculature strength and endurance in patients with LE, suggesting that the scapular musculature should be assessed and potentially treated in this population. Cause and effect cannot be established, as the weakness of the scapular musculature could be a result of LE.

Effects of Lumbosacral Manipulation on Isokinetic Strength of the Knee Extensors and Flexors in Healthy Subjects: A Randomized, Controlled, Single-Blind Crossover Trial.

OBJECTIVE: The purpose of this study was to investigate the effect of manual manipulations targeting the lumbar spine and/or sacroiliac joint on concentric knee extension and flexion forces. Torque production was measured during isometric and isokinetic contractions. METHODS: This was a randomized, controlled, single-blind crossover design with 21 asymptomatic, college-aged subjects who had never received spinal manipulation. During 2 separate sessions, subjects' peak torques were recorded while performing maximal voluntary contractions on an isokinetic dynamometer. Isometric knee extension and flexion were recorded at 60° of knee flexion, in addition to isokinetic measurements obtained at 60°/s and 180°/s. Baseline measurements were acquired before either treatment form of lumbosacral manipulation or sham manipulation, followed by identical peak torque measurements within 5 and 20 minutes posttreatment. Data were analyzed with a repeated measures analysis of variance. RESULTS: A statistically significant difference did not occur between the effects of lumbosacral manipulation or the sham manipulation in the percentage changes of knee extension and flexion peak torques at 5 and 20 minutes posttreatment. Similar, nonsignificant results were observed in the overall percentage changes of isometric contractions (spinal manipulation 4.0 ± 9.5 vs sham 1.2 ± 6.3, P = .067), isokinetic contractions at 60°/s (spinal manipulation - 4.0 ± 14.2 vs sham - 0.3 ± 8.2, P = .34), and isokinetic contractions at 180°/s (spinal manipulation - 1.4 ± 13.9 vs sham - 5.5 ± 20.0, P = .18). CONCLUSION: The results of the current study suggest that spinal manipulation does not yield an immediate strength-enhancing effect about the knee in healthy, college-aged subjects when measured with isokinetic dynamometry.

Practice patterns when treating patients with low back pain: a survey of physical therapists.

Low back pain (LBP), is a common musculoskeletal problem, affecting 75-85% of adults in their lifetime. Direct costs of LBP in the USA were estimated over 85 billion dollars in 2005 resulting in a significant economic burden for the healthcare system. LBP classification systems and outcome measures are available to guide physical therapy assessments and intervention. However, little is known about which, if any, physical therapists use in clinical practice. The purpose of this study was to identify the use of and barriers to LBP classification systems and outcome measures among physical therapists in one state. A mixed methods study using a cross-sectional cohort design with descriptive qualitative methods was performed. A survey collected both quantitative and qualitative data relevant to classification systems and outcome measures used by physical therapists working with patients with LBP. Physical therapists responded using classification systems designed to direct treatment predominantly. The McKenzie method was the most frequent approach to classify LBP. Barriers to use of classification systems and outcome measures were lack of knowledge, too limiting and time. Classification systems are being used for decision-making in physical therapy practice for patients with LBP. Lack of knowledge and training seems to be the main barrier to the use of classification systems in practice. The Oswestry Disability Index and Numerical Pain Scale were the most commonly used outcome measures. The main barrier to their use was lack of time. Continuing education and reading the literature were identified as important tools to teach evidence-based practice to physical therapists in practice.

Vascular thoracic outlet in a competitive swimmer: a case report.

Thoracic outlet syndrome (TOS) is a well-described condition resulting from compression of the brachial plexus, subclavian artery and/or vein. Though symptoms of pain, numbness, tingling and signs of muscular weakness associated with this condition usually begin insidiously, on rare occasions the presentation is of acute onset and may represent an acute vascular compression. An unusual form of "effort" thrombosis of the subclavian vein may require emergency care in order to ensure controlled clot lysis and thrombus dissolution. Confirmation of subclavian thrombus is obtained by venography and makes use of real time videography to assess for venous flow impairment. Definitive treatment for the underlying cause of this form of TOS is first rib resection and scalenectomy. This case report presents a competitive swimmer who developed an acute onset of limb cyanosis and turgidity during swim training. Awareness of the possibility of acute thrombosis obstructing venous return and producing such signs and symptoms should lead the astute clinician to consider recommending contrast venography to assess the lesion and lead to appropriate medical intervention.

Electromyographical comparison of four common shoulder exercises in unstable and stable shoulders.

This study examines if electromyographic (EMG) amplitude differences exist between patients with shoulder instability and healthy controls performing scaption, prone horizontal abduction, prone external rotation, and push-up plus shoulder rehabilitation exercises. Thirty nine subjects were categorized by a single orthopedic surgeon as having multidirectional instability (n = 10), anterior instability (n = 9), generalized laxity (n = 10), or a healthy shoulder (n = 10). Indwelling and surface electrodes were utilized to measure EMG activity (reported as a % of maximum voluntary isometric contraction (MVIC)) in various shoulder muscles during 4 common shoulder exercises. The exercises studied effectively activated the primary musculature targeted in each exercise equally among all groups. The serratus anterior generated high activity (50-80% MVIC) during a push-up plus, while the infraspinatus and teres major generated moderate-to-high activity (30-80% MVIC) during both the prone horizontal and prone external rotation exercises. Scaption exercise generated moderate activity (20-50% MVIC) in both rotator cuff and scapular musculature. Clinicians should feel confident in prescribing these shoulder-strengthening exercises in patients with shoulder instability as the activation levels are comparable to previous findings regarding EMG amplitudes and should improve the dynamic stabilization capability of both rotator cuff and scapular muscles using exercises designed to address glenohumeral joint instability.

The effect of muscle energy techniques on disability and pain scores in individuals with low back pain.

CLINICAL SCENARIO: Low back pain is the most common type of pain reported by adults in the United States. A variety of manual therapy techniques are used in the management of low back pain to reduce pain, improve function, and reduce disability. In recent years, muscle energy techniques have been increasingly used in clinics to treat low back pain. By definition, a muscle energy technique involves the patient performing a voluntary muscle contraction "in a precisely controlled direction, against a distinctly executed counter force applied by the operator." Muscle energy techniques provide a conservative alternative for clinicians treating patients with precautions or contraindications to joint manipulation.

A simulated passive intervertebral motion task: observations of performance in a cross-sectional study.

INTRODUCTION: Passive motion palpation is an integral component in examination, diagnosis or classification, and treatment of persons with mechanical disorders of the cervical spine. If the magnitude of force application during passive movement assessment is associated with greater palpatory accuracy has not been established. METHODS: This investigation used a novel mechanical model as a basis for assessing the palpatory force of students and clinicians. The model included multiple palpable resistance and displacement levels similar to that observed in humans. The ability of the subjects to discriminate the various levels of resistance and displacement offered by the model was concurrently measured. RESULTS: Large variability occurred in the amount of force applied by the subjects in completing the palpatory examination. The data indicated no major differences in palpatory accuracy across the student and clinician groups with different training and experience levels beyond basic competency. Those subjects applying less force in the palpatory exam demonstrated greater accuracy of palpatory assessment with one measure. DISCUSSION: The data indicate training and experience had minimal relationship to palpatory interpretation precision beyond the basic level and individual natural discriminatory ability may be a factor in accuracy of palpatory skill. The results demonstrate remarkable inconsistency in palpatory force among examiners and suggest that palpatory accuracy may be related to less force application.

Electromyographic analysis of hip abductor exercises performed by a sample of total hip arthroplasty patients.

Weakness of the hip abductors after total hip arthroplasty may result in pain and/or functional limitation. Non-weight-bearing (NWB) exercises are often performed to target the hip abductors; however, muscle activation of NWB exercises has not been compared to weight-bearing (WB) exercises. Our purpose was to evaluate gluteus medius activation during 2 WB and 2 NWB hip abductor strengthening exercises. Fifteen patients at least 6 weeks post unilateral total hip arthroplasty volunteered for the study. Electromyographic amplitude for each exercise was normalized to each patient's maximal voluntary isometric contraction. There were no significant differences in gluteus medius electromyographic amplitudes between the 4 exercises (P = .15). Based on our results, NWB exercises provided no clear benefit in terms of gluteus medius activation when compared to potentially more functional WB exercises in the early postoperative period.

Effect of foot orthotics on single- and double-limb dynamic balance tasks in patients with chronic ankle instability.

Deficits have been observed in patients with chronic ankle instability while performing dynamic balance tasks. Foot orthotic intervention has demonstrated improvements in static balance following lateral ankle sprain, but the effect is unknown in patients with chronic ankle instability during dynamic balance tasks. Twenty patients with self-reported unilateral chronic ankle instability volunteered for participation. They completed a familiarization session and 2 test sessions separated by 4 weeks. The familiarization session consisted of practice trials of the Star Excursion Balance Test (SEBT) and Limits of Stability (LOS) test, orthotic fitting, and the Cumberland Ankle Instability Tool (CAIT) questionnaire. Patients were instructed to wear the custom-fitted orthotics for at least 4 hours a day to a preferred 8 hours a day for the 4 weeks between sessions. There was an increase in distance reached in the posterolateral direction over the 4-week period in the orthotic condition. There was an increase in distance reached in the medial direction, demonstrating an improvement on the injured side in the orthotic condition after 4 weeks of orthotic intervention. No consistent, meaningful results were observed in the LOS. The involved leg had a significantly lower CAIT score than the uninvolved leg during both sessions, but the involved leg CAIT scores significantly improved over 4 weeks compared with the baseline measure. Orthotic intervention may prove beneficial for improving dynamic balance as measured by the SEBT in individuals with chronic ankle instability and may be a useful adjunct to clinical and sport interventions.