Patient Outcomes After Treatment by Athletic Therapy Students.

CONTEXT: Patient-reported outcome measures (PROMs) should be used in athletic training and athletic therapy but are rarely incorporated in internships. Student-run clinics are common in other health professions and provide effective treatment and valuable learning environments. To our knowledge, no one has evaluated rehabilitation outcomes in patients treated by athletic therapy students (ATSs). OBJECTIVE: To measure the improvement in function in injured patients seeking treatment at an ATS clinic. DESIGN: Cohort study. SETTING: An ATS clinic. PATIENTS OR OTHER PARTICIPANTS: A total of 59 patients (32 women, age = 33.9 ± 14.7 years; 27 men, age = 38 ± 14.4 years) from the community with a variety of low back, lower extremity, and upper extremity injuries participated. MAIN OUTCOME MEASURE(S): At baseline and 6-week follow-up, all patients completed 1 of 3 scales (depending on their injury location) to assess their injured level of function. Scales were the Oswestry Disability Index for low back injuries; Lower Extremity Functional Scale for lower extremity injuries; and Disabilities of the Arm, Shoulder and Hand for upper extremity injuries. RESULTS: On average, patients received 4.7 ± 1.8 treatments across 48.8 ± 16.1 days. They experienced an increase in function between baseline and follow-up assessments (18.8% ± 20.3%; P < .001, Cohen d = 1.06). Moreover, the amount of functional improvement was clinically meaningful, as it was greater than the minimal clinically important difference for each scale. The efficacy of treatments did not differ according to the internship experiences of the ATSs. CONCLUSIONS: Function improved in patients after treatment delivered by an ATS. Patient-reported outcome measures were useful for the students in monitoring patient improvement, but more research is needed regarding effective treatments for patients with chronic pain. Our results suggested that ATS clinics provide effective treatments for patients, service to the community, and a learning opportunity for students.

Chronic Pain Patients' Kinesiophobia and Catastrophizing are Associated with Activity Intensity at Different Times of the Day.

PURPOSE: To examine the relationship between baseline kinesiophobia and baseline pain catastrophizing with the 4-day average activity intensity at different times of the day while accounting for different wake and sleep-onset times in chronic pain patients. METHODS: Twenty-one participants suffering from idiopathic chronic pain completed baseline questionnaires about kinesiophobia, catastrophizing, disability, depression, and pain. We measured the participants' activity using accelerometers and calculated activity intensity in the morning, afternoon, and evening. We performed a 2-way repeated measures ANOVA to compare activity levels at different times of the day, and multiple linear regressions. RESULTS: Baseline kinesiophobia was significantly associated with 4-day average evening light activity and sedentary activity at all time periods while baseline catastrophizing was significantly associated with increased 4-day average light activity in the evening and more moderate to vigorous activity in the morning. Our participants engaged in more light activity on average than sedentary activity, and very little moderate-vigorous activity. Participants were most active in the afternoon. CONCLUSION: Baseline kinesiophobia and baseline catastrophizing were not associated with the 4-day average total daily activity; however, they were associated with 4-day average activity intensities at different times throughout the day. Segmenting daily activity into morning, afternoon, evening may influence the relationship between daily activity, and kinesiophobia and pain catastrophizing. Individuals with chronic pain are less sedentary than previously thought which may affect future interventions.

Low Back Pain Treatment by Athletic Trainers and Athletic Therapists: Biomedical or Biopsychosocial Orientation?

CONTEXT: Low back pain (LBP) remains a societal burden due to consistently high rates of recurrence and chronicity. Recent evidence suggested that a provider's treatment orientation influences patient beliefs, the clinical approach, and subsequently, rehabilitation outcomes. OBJECTIVE: To characterize American athletic trainer (AT) and Canadian athletic therapist (C-AT) treatment orientations toward LBP. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 273 ATs (response rate = 13.3%) and 382 C-ATs (response rate = 15.3%). MAIN OUTCOME MEASURE(S): Participants completed demographic questions and the Pain Attitudes and Beliefs Scale (PABS) for ATs/C-ATs. The PABS measures the biomedical and biopsychosocial treatment orientation of health care providers and is scored on a 6-point Likert scale. Descriptive statistics characterized the participants; t tests and 1-way analyses of variance identified differences between group means; and Spearman correlations assessed relationships between the biomedical and biopsychosocial scores and age, number of LBP patients per year, and years of experience. RESULTS: Athletic trainers treating 9 to 15 LBP patients per year had higher biomedical scores (35.0 ± 5.7) than ATs treating 16 to 34 (31.9 ± 5.5, P = .039) or >34 (31.7 ± 8.6, P = .018) LBP patients per year. The C-ATs treating 16 to 34 (31.8 ± 6.3, P = .038) and >34 (31.0 ± 6.7, P < .001) LBP patients per year had lower biomedical scores than those treating ≤8 LBP patients per year (34.8 ± 5.9). The C-ATs with ≤5 years of experience had higher biomedical scores than those with 10 to 15 (31.0 ± 6.7, P = .011) and 16 to 24 (29.8 ± 7.5, P < .001) years of experience. Canadian athletic therapists treating the general public had higher (31.7 ± 4.0) biopsychosocial scores than ATs treating athletes (31.3 ± 3.5, P = .006). The C-ATs ≤35.6 years of age had higher biomedical scores (33.1 ± 5.9) than those >35.6 years of age (30.5 ± 7.0, P < .001). CONCLUSIONS: Athletic trainers and C-ATs who treated more LBP patients per year were more likely to score low on a biomedical treatment orientation subscale. Because this orientation has predicted poor outcomes in other health care providers, further research is needed to determine the effects of ATs' and C-ATs' biomedical orientations on rehabilitation outcomes.

Prolonged Reduction in Shoulder Strength after Transcutaneous Electrical Nerve Stimulation Treatment of Exercise-Induced Acute Muscle Pain.

OBJECTIVES: Transcutaneous electrical nerve stimulation (TENS) is commonly used for reducing musculoskeletal pain to improve function. However, peripheral nerve stimulation using TENS can alter muscle motor output. Few studies examine motor outcomes following TENS in a human pain model. Therefore, this study investigated the influence of TENS sensory stimulation primarily on motor output (strength) and secondarily on pain and disability following exercise-induced delayed-onset muscle soreness (DOMS). METHODS: Thirty-six participants were randomized to a TENS treatment, TENS placebo, or control group after completing a standardized DOMS protocol. Measures included shoulder strength, pain, mechanical pain sensitivity, and disability. TENS treatment and TENS placebo groups received 90 minutes of active or sham treatment 24, 48, and 72 hours post-DOMS. All participants were assessed daily. RESULTS: A repeated measures analysis of variance and post-hoc analysis indicated that, compared to the control group, strength remained reduced in the TENS treatment group (48 hours post-DOMS, P < 0.05) and TENS placebo group (48 hours post-DOMS, P < 0.05; 72 hours post-DOMS, P < 0.05). A mixed-linear modeling analysis was conducted to examine the strength (motor) change. Randomization group explained 5.6% of between-subject strength variance (P < 0.05). Independent of randomization group, pain explained 8.9% of within-subject strength variance and disability explained 3.3% of between-subject strength variance (both P < 0.05). DISCUSSION: While active and placebo TENS resulted in prolonged strength inhibition, the results were nonsignificant for pain. Results indicated that higher pain and higher disability were independently related to decreased strength. Regardless of the impact on pain, TENS, or even the perception of TENS, may act as a nocebo for motor output.

Expectancy Reduces Symptoms but not Functional Impairment Following Exercise-induced Musculoskeletal Injury.

OBJECTIVES: To quantify the extent to which the participant-provider interaction influences the response to sham treatment following exercised-induced acute musculoskeletal pain. MATERIALS AND METHODS: In total, 40 participants between the ages of 18 and 35 volunteered for the study. Participants came to the laboratory for 3 test sessions 48-hour apart (day 1, 3, and 5). During the initial session, baseline measures were assessed and participants underwent a fatigue protocol for the biceps brachii. Participants were then assigned to a positive expectation or a no-expectation condition before receiving a sham laser therapy treatment. The positive expectation group received symptom improvement priming before their sham treatment. Participants allocated to the no-expectation condition received no feedback before the sham treatment. Maximum voluntary isometric contraction; relaxed elbow angle; visual analog scale; and the QuickDash questionnaire were used as outcome measures. RESULTS: The positive expectation group had a significant reduction in perceived pain compared with the no-expectation group at day 3 follow-up, with the mean scores being 34.65 mm (SE=4.44) compared with 49.4 mm (SE=5.79), respectively. There were no between-group differences with respect to maximum voluntary isometric contraction, QuickDash, or relaxed elbow angle outcomes. In addition, there were no significant between-group differences observed with expected pain on follow-up visits, the effect sizes were d=0.26 on day 1 for day 3 and d=0.51 on day for day 5. DISCUSSION: Positive expectations before a sham treatment enhanced reduction in pain intensity but did not improve functional impairments following exercise-induced acute musculoskeletal injury.

Unilateral eccentric exercise of the knee flexors affects muscle activation during gait.

Uni-lateral muscle soreness is common yet the effects on gait or electromyographic (EMG) activity are unknown. The purpose of our study was to induce delayed onset muscle soreness (DOMS) in the knee flexor group and measure the resultant change in EMG activity and knee motion during gait. Nine healthy subjects participated in the study. Measures of function, evoked tenderness of the biceps femoris, as well as knee angle, and EMG activity during gait were assessed prior and 48 h after an eccentric exercise protocol. DOMS was induced unilaterally in the knee flexors using an isokinetic dynamometer and subjects exercised until they could not generate 50% of their maximal voluntary isometric contraction (MVIC). There was a significant decrease in biceps femoris activity after DOMS during the last phase of gait. Moreover, there was a day × phase interaction for gastrocnemius activity with the last two phases displaying an increase in activity. There was no significant change in knee angle during gait. The decrease in biceps femoris activity as well as the increase in gastrocnemius activity could be evidence of a protective mechanism designed to decrease activity of the sore muscle while increasing the activity of a synergistic muscle.

Biopsychosocial influence on exercise-induced delayed onset muscle soreness at the shoulder: pain catastrophizing and catechol-o-methyltransferase (COMT) diplotype predict pain ratings.

OBJECTIVE: The experience of pain is believed to be influenced by psychologic and genetic factors. A previous study suggested pain catastrophizing and catechol-O-methyltransferase (COMT) genotype influenced clinical pain ratings for patients seeking operative treatment of shoulder pain. This study investigated whether these same psychologic and genetic factors predicted responses to induced shoulder pain. METHODS: Participants (n=63) completed self-report questionnaires and had COMT genotype determined before performing a standardized fatigue protocol to induce delayed onset muscle soreness. Then, shoulder pain ratings, self-report of upper-extremity disability ratings, and muscle torque production were reassessed 24, 48, and 72 hours later. RESULTS: This cohort consisted of 35 women and 28 men, with a mean age of 20.9 years (SD=1.7). The frequency of COMT diplotypes was 42 with "high COMT enzyme activity" (low pain sensitivity group) and 21 with "low COMT enzyme activity" (average pain sensitivity/high pain sensitivity group). A hierarchical regression model indicated that an interaction between pain catastrophizing and COMT diplotype was the strongest unique predictor of 72-hour pain ratings. The same interaction was not predictive of self-report of disability or muscle torque production at 72 hours. The pain catastrophizingxCOMT diplotype interaction indicated that participants with high pain catastrophizing and low COMT enzyme activity (average pain sensitivity/high pain sensitivity group) were more likely (relative risk=3.5, P=0.025) to have elevated pain intensity ratings (40/100 or higher). DISCUSSION: These findings from an experimental model converge with those from a surgical cohort and provide additional evidence that the presence of elevated pain catastrophizing and COMT diplotype indicative of low COMT enzyme activity have the potential to increase the risk of developing chronic pain syndromes.

Fear of pain influences outcomes after exercise-induced delayed onset muscle soreness at the shoulder.

OBJECTIVES: This study investigated whether anxiety, fear of pain, or pain catastrophizing were predictive of pain-related outcomes after induced delayed onset muscle soreness (DOMS) at the shoulder. METHODS: Healthy participants (19 males and 23 females) were eligible for participation if they had (a) no history of neck or shoulder pain, (b) no sensory or motor impairments of the upper-extremity, (c) not regularly participating in upper-extremity weight training, (d) not currently or regularly taking pain medication, and (e) no history of upper-extremity surgery. Participants completed self-report measures for fear of pain, pain catastrophizing, and anxiety. Then, participants underwent a standard fatigue protocol to induce DOMS in the shoulder external rotator muscles. Participants were reassessed 24 hours after DOMS induction on clinical and evoked pressure pain reports, muscle force production, self-report of upper-extremity disability, and kinesiophobia. Stepwise regression models considered sex, anxiety, pain intensity, fear of pain, and pain catastrophizing as outcome predictors. RESULTS: Fear of pain alone explained 16% (P=0.008) of the variance in clinical pain and 10% (P=0.047) evoked pressure pain intensity. Clinical pain intensity alone explained 11% (P<0.031) of the variance in muscle force production. Clinical pain intensity and fear of pain explained 50% (P<0.001) of the variance in upper-extremity disability, whereas fear of pain and sex accounted for 26% (P=0.005) of the variance in kinesiophobia. CONCLUSIONS: With the exception of muscle force production, fear of pain had a consistent influence on shoulder DOMS outcomes, even after controlling for pain intensity. This study suggests fear of pain may be a relevant psychologic factor to consider in clinical studies investigating the development and treatment of chronic shoulder pain.

Glenohumeral range of motion and stiffness in professional baseball pitchers.

PURPOSE: This study was conducted to perform kinematic measures in a group of asymptomatic professional baseball pitchers to determine side-to-side differences in passive glenohumeral range of motion (ROM) and stiffness. We hypothesized that the throwing shoulder in asymptomatic pitchers would display greater passive glenohumeral stiffness than the contralateral nonthrowing shoulder. METHODS: Thirty-four professional baseball pitchers had bilateral assessments for passive glenohumeral ROM and stiffness during a single test session. ROM and stiffness measures were obtained objectively using standard goniometry and instrumented stress arthrometry, respectively. RESULTS: The throwing shoulder had significantly less (-8.5 degrees) internal rotation and significantly more external rotation (5.1 degrees) than the nonthrowing shoulder (P < 0.01). Passive joint stiffness was not significantly different between the throwing and nonthrowing shoulder, and anterior joint stiffness was significantly greater than posterior joint stiffness for both shoulders (P < 0.05). CONCLUSIONS: The repetitive stress of long-term throwing creates altered glenohumeral rotational patterns in the throwing shoulder of the professional baseball pitcher without compromising the joint's passive restraining quality.

Correlation of range of motion and glenohumeral translation in professional baseball pitchers.

BACKGROUND: Altered mobility patterns in the throwing shoulders of professional baseball pitchers have been reported. Most published reports examining glenohumeral laxity have not used an objective testing device. OBJECTIVE: Quantify and compare glenohumeral translation and rotational range of motion between the throwing and non-throwing shoulders in professional baseball pitchers. STUDY DESIGN: Descriptive laboratory study. METHODS: Force-displacement and range of motion measures were performed bilaterally on 43 asymptomatic professional baseball pitchers. Ultrasound imaging was used to measure glenohumeral translations under stressed and unstressed conditions. RESULTS: No significant difference in translation was found between the throwing and nonthrowing shoulders. For both shoulders, posterior translation (5.38 +/- 2.7 mm) was significantly greater (P < .001) than was anterior translation (2.81 +/- 1.6 mm). External rotation in the throwing shoulder was significantly greater than that in the nonthrowing shoulder (P < .001), whereas internal rotation in the throwing shoulder was significantly less than that in the nonthrowing shoulder (P < .001). The total arc of rotation for the throwing shoulder was not significantly different than that for the nonthrowing shoulder, and correlation coefficients were poor between rotational and translational range of motion in the throwing shoulder, ranging from r = 0.232 to 0.209 between variables. CONCLUSION: No significant difference in glenohumeral translation exists between the throwing and nonthrowing shoulders in asymptomatic professional baseball pitchers, posterior translation is significantly greater than anterior translation in the throwing shoulders of professional baseball pitchers, and glenohumeral translation is not related to rotational range of motion in the throwing shoulders of professional baseball pitchers. CLINICAL RELEVANCE: Altered mobility patterns in asymptomatic professional baseball pitchers may be due to factors other than capsular adaptive changes.

Comparison of dynamic sonography to stress radiography for assessing glenohumeral laxity in asymptomatic shoulders.

BACKGROUND: Stress radiography has been the established imaging method for quantifying glenohumeral joint laxity. Dynamic ultrasound is an alternative imaging method that may be used to measure glenohumeral laxity; however, validity and repeatability have not been examined. OBJECTIVE: To determine criterion-related validity and repeatability of a sonographic imaging method for measuring glenohumeral laxity in asymptomatic shoulders. STUDY DESIGN: Controlled laboratory study. METHODS: In experiment 1, 20 subjects were assessed for glenohumeral laxity using stress radiography and dynamic ultrasound. In the second experiment, 13 subjects were assessed for laxity in 2 separate test sessions using the dynamic ultrasound technique. RESULTS: Correlational analysis between the sonographic and radiographic measures revealed an r = 0.79 (r(2) = 0.62), indicating excellent criterion-related validity for the sonographic imaging method. Test-retest repeatability was 0.72 and 0.85 for anterior and posterior translation, respectively, and interrater repeatability was 0.96 and 0.99 for anterior and posterior translation, respectively. CONCLUSIONS: Dynamic ultrasound appears to be a valid and repeatable method for assessing glenohumeral laxity in a clinical setting. CLINICAL RELEVANCE: Based on the results of this study, dynamic ultrasound is a repeatable and valid method for measuring glenohumeral laxity and therefore may be used as a viable replacement for stress radiography during assessments of glenohumeral laxity.

Assessment of shoulder proprioception in the female softball athlete.

BACKGROUND: There have been reports of overhand throwing athletes having decreased joint position sense in their dominant shoulder as compared with the nondominant shoulder. Very little research, however, exists concerning joint position sense in the female athlete. HYPOTHESIS: Female softball athletes have decreased joint position sense in their dominant shoulder as compared with their nondominant shoulder. STUDY DESIGN: Factorial design with investigation of multiple independent variables. METHODS: Joint position sense was assessed in 50 female softball players and 50 nonthrowing female athletes by using an inclinometer during four glenohumeral joint motions. Both the dominant and nondominant shoulders were assessed and error scores were calculated to describe joint position sense. Data were collected during the course of a fall semester and analyzed by using a mixed model analysis of variance with repeated measures on the dependent variable (error scores). RESULTS: A significant group by movement interaction was observed, with the softball athletes demonstrating significantly greater external rotation error scores than the nonthrowing athletes. CONCLUSION: We failed to reject the null hypothesis. Increased error scores (less joint position sense) were observed in both arms of subjects in the softball group. CLINICAL RELEVANCE: This study suggests that there is decreased shoulder proprioception in asymptomatic female athletes involved in overyhand throwing sports, which may predispose them to injury.