Predicting Subsequent Injury after Being Cleared to Return to Work from Initial Lumbar or Lower Extremity Injury.

PURPOSE: The purpose of this study is to develop a model to predict re-injury after being cleared to return to full duty from an initial injury. METHODS: This was a prediction model derivation cohort study. Military service members cleared for unrestricted full duty after sustaining a musculoskeletal injury were enrolled from three large military hospitals. Medical history, demographics, psychological profile, physical performance (Y-Balance Test™, Functional Movement Screen™, Selective Functional Movement Assessment, triple hop, closed chain ankle dorsiflexion, 2-mile run, 75% bodyweight carry time), and past injury history were assessed. Monthly text messages, medical records and limited duty databases were used to identify injuries resulting in time lost from work in the following year. RESULTS: Four hundred fifty participants (65 females), ages 18 to 45 yr were analyzed. Fifteen variables were included in the final model. The area under the curve was 0.74 (95% confidence interval, 0.69-0.80), indicating good performance. The calibration score of the model was 1.05 (95% confidence interval, 0.80-1.30) indicating very good performance. With an injury incidence in our cohort of 38.0%, the treat all net benefit was 0.000, and the net benefit of our predictive model was 0.251. This means 25 additional soldiers out of every 100 were correctly identified as high risk for injury compared with not using a prediction model at all. CONCLUSIONS: This multivariable model accurately predicted injury risk after returning for full duty and was better than not using a prediction model at all (an additional 25 of every 100 tactical athletes were correctly identified). This model provides guidance for proper decision making about when these individuals are not ready to return to full duty, with higher risk of a subsequent injury.

Recovery, Rehabilitation, and Return to Full Duty in a Military Population After a Recent Injury: Differences Between Lower-Extremity and Spine Injuries.

PURPOSE: To compare readiness to return to duty in soldiers following recent lower-extremity versus spine injury. The secondary purposes were to provide normative data for the Selective Functional Movement Assessment Top Tier movements (SFMA-TTM) and assess the association between SFMA-TTM scores and future injury occurrence, comparing injuries of the lower extremity and thoracic/lumbar spine. METHODS: SFMA was rated by trained assessors on 480 U.S. Army soldiers within 2 weeks of being cleared to return to duty after recent lower-extremity or lumbar/thoracic injury. Participants were followed for 1 year to determine incidence of subsequent time-loss injury. RESULTS: Only 74.4% of soldiers felt 100% mission capable when returning to full duty (73.6% lower-extremity; 76.5% spine). After 1 year, 37.9% had sustained a time-loss injury, and pain with movement at baseline was associated with higher odds for having an injury (odd ratio 1.53 95% confidence interval 1.04-2.24; P = .032). Almost all (99.8%) had at least 1 dysfunctional pattern, and 44.1% had pain with at least 1 movement (40.3% with previous lower-extremity injury; 54.6% with previous spine injury) after being cleared to return to duty. CONCLUSIONS: One in four patients did not feel 100% mission capable upon being cleared for full duty. Pain with movement was also associated with future injury. Regardless of recent injury type, 99.8% of soldiers returned to full unrestricted duty with at least 1dysfunctional movement pattern and 44.1% had pain with at least 1 of the SFMA-TTM movements. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

Utilization of Neurophysiological Classification Systems in Determining Interventions for Patients with Carpal Tunnel Syndrome.

BACKGROUND: Median mononeuropathy at or distal to the wrist, or carpal tunnel syndrome (CTS), is the most common peripheral nerve compression disorder in the upper extremity. Neurophysiological classification systems for patients with CTS have been developed and implemented to provide health care providers an enhanced system of electrophysiological evaluation with a grading scale, so that they may evaluate their patients with CTS within a system that confers relative severity. Electrophysiological data collected within these classification systems includes either nerve conduction studies (NCS), or both NCS and electromyography (EMG) test results. The purpose of this study was to assess the utilization of neurophysiological classification systems in determining interventions for patients with carpal tunnel syndrome (CTS). METHODS: To assess the utilization of neurophysiological classification systems in determining interventions for patients with CTS, an on-line survey of referring providers to NCS/EMG (electrophysiological testing) clinics was developed. These clinical sites were asked to submit three referring providers of their NCS/EMG services. The survey was emailed to the referring providers with a letter of introduction that included an overview and purpose of the study and specifically stated their responses were completely anonymous and analyzed data would be in an aggregate form. RESULTS: Of the 35 referring providers of NCS/EMG services for their patients with CTS contacted to participate in this study, 14 providers completed the on-line survey (40%). This included 12 physicians (MD), one osteopathic physician (DO), and one nurse practitioner (NP). Twelve of the referring providers (85.7%) were familiar with clinical electrophysiological classification systems for patients with CTS. Nine referring providers use a neurophysiological classification system (Greathouse Ernst Hall Shaffer (GEHS) and Bland-six; GEHS only-two; alternate system-one). Five respondents did not use a neurophysiological classification system, two of which were not familiar with these classification systems. The nine providers who use a neurophysiological classification system for their patients with CTS found these systems useful in assessing patient prognosis, treatment planning, and communicating back to referral services. The most preferable treatments for the very mild and mild (sensory only; sensory and motor) classifications were splinting followed by oral medication and injection. Splinting and surgery (open and endoscopic) were the interventions of choice for the moderate/severe and severe electrophysiological classifications. CONCLUSION: Referring providers of NCS/EMG services completed an on-line survey to assess the utilization of neurophysiological classification systems in determining interventions for patients with CTS. The most preferable treatments for the very mild and mild (sensory only; sensory and motor) classifications were splinting followed by oral medication and injection. Splinting and surgery (open and endoscopic) were the interventions of choice for the moderate/severe and severe electrophysiological classifications. A method for using a neurophysiological classification system for patients with CTS in a clinical report is provided. Additional research to assess the prognostic validity and utilization of carpal tunnel classification systems as longitudinal outcome measures is needed.

Identification of Risk Factors Prospectively Associated With Musculoskeletal Injury in a Warrior Athlete Population.

BACKGROUND: Musculoskeletal injuries are a primary source of disability. Understanding how risk factors predict injury is necessary to individualize and enhance injury reduction programs. HYPOTHESIS: Because of the multifactorial nature of musculoskeletal injuries, multiple risk factors will provide a useful method of categorizing warrior athletes based on injury risk. STUDY DESIGN: Prospective observational cohort study. LEVEL OF EVIDENCE: Level 2. METHODS: Baseline data were collected on 922 US Army soldiers/warrior athletes (mean age, 24.7 ± 5.2 years; mean body mass index, 26.8 ± 3.4 kg/m2) using surveys and physical measures. Injury occurrence and health care utilization were collected for 1 year. Variables were compared in healthy versus injured participants using independent t tests or chi-square analysis. Significantly different factors between each group were entered into a logistic regression equation. Receiver operating characteristic curve and accuracy statistics were calculated for regression variables. RESULTS: Of the 922 warrior athletes, 38.8% suffered a time-loss injury (TLI). Overall, 35 variables had a significant relationship with TLIs. The logistic regression equation, consisting of 11 variables of interest, was significant (adjusted R2 = 0.21; odds ratio, 5.7 [95% CI, 4.1-7.9]; relative risk, 2.5 [95% CI, 2.1-2.9]; area under the curve, 0.73). Individuals with 2 variables had a sensitivity of 0.89, those with 7 or more variables had a specificity of 0.94. CONCLUSION: The sum of individual risk factors (prior injury, prior work restrictions, lower perceived recovery from injury, asymmetrical ankle dorsiflexion, decreased or asymmetrical performance on the Lower and Upper Quarter Y-Balance test, pain with movement, slower 2-mile run times, age, and sex) produced a highly sensitive and specific multivariate model for TLI in military servicemembers. CLINICAL RELEVANCE: A better understanding of characteristics associated with future injury risk can provide a foundation for prevention programs designed to reduce medical costs and time lost.

Normative parameters and anthropometric variability of lumbar muscle stiffness using ultrasound shear-wave elastography.

BACKGROUND: Quantifying stiffness of the lumbar spine musculature using shear-wave elastography (SWE) maybe beneficial in the diagnosis and treatment of non-specific low back pain (LBP). The primary purpose of this study was to establish normative parameter and variance estimates of lumbar spine muscle stiffness at rest and during submaximal contraction levels using SWE in healthy individuals. A second aim was to determine the relationship between lumbar spine muscle stiffness and a variety of demographic, anthropometric, and medical history variables. METHODS: This cross-sectional study included stiffness measurements of the lumbar musculature in 120 asymptomatic individuals using ultrasound SWE. The lumbar erector spinae muscle was measured during rest only and lumbar multifidus muscle was measured during rest and during submaximal contraction using a prone contralateral arm lift. Statistical comparisons of shear modulus were made between sex (male vs. female) and muscle condition (erector spinae rest, lumbar multifidus rest, lumbar multifidus contracted) using 2 × 3 repeated measures analysis of variance (ANOVA). Univariate associations between shear modulus and age, sex, BMI, activity level, and history of back pain were assessed using correlation analysis. FINDINGS: Shear modulus at rest was approximately 4 kPa for the erector spinae muscles and approximately 6 kPa for the lumbar multifidus muscles. Shear modulus substantially increased during contraction, and varied by sex, BMI, and self-reported activity level, with men and more active individuals generally having stiffer muscles. INTERPRETATION: Variability in shear modulus of the lumbar musculature may be mediated through a combination of muscle size and contractile state, which is consistent with our findings of higher stiffness in the more postural lumbar multifidi muscles, during contraction, and in larger and more active individuals. These findings should inform and be accounted for in future comparative clinical studies.

Incidence of Musculoskeletal Injury in US Army Unit Types: A Prospective Cohort Study.

BACKGROUND: Musculoskeletal injuries during military service are a primary source of disability, resulting in 2.4 million annual health care visits and 25 million limited-duty days. While the injury incidence during basic training is well documented, there is little understanding of injury distribution by organization type in the US Army following initial training. OBJECTIVE: To compare injury incidence, distribution, and impact across various military units. METHODS: In this prospective observational cohort study, comprehensive injury data from subject questionnaires and medical chart reviews were collected over 12 months for 1430 initially healthy Army personnel, representing combat, combat support, combat service support, and ranger units. Health care utilization and time loss due to injury were also collected. RESULTS: Of 1430 soldiers, 481 (33.6%) had time-loss injury, 222 (15.5%) were injured without limited work, 60 (4.2%) reported an injury but did not seek medical care, and 667 (46.6%) were uninjured. Across the whole sample, injuries were responsible for 5.9 ±14.4 medical visits per soldier, 21 902 days of limited work, and $1 337 000 ($1901 ± $6535 per soldier) in medical costs. Considering only those reporting injury, each person averaged 36.3 ± 59.7 limited-work days. The injury incidence was highest in combat service support units (65.6%), with a risk ratio 1.60 times that of the reference group (combat, 41.1%). CONCLUSION: Combat support and combat service support personnel were more likely to have 1 or more injuries compared to rangers and combat personnel. The higher relative risk of injury in support units should be explored further. J Orthop Sports Phys Ther 2018;48(10):749-757. Epub 22 May 2018. doi:10.2519/jospt.2018.7979.

Physical Performance Limitations After Severe Lower Extremity Trauma in Military Service Members.

OBJECTIVES: To characterize the type and magnitude of lower extremity physical performance deficits in military service members who have undergone rehabilitation after limb salvage or transtibial amputation. DESIGN: Cross-sectional prospective. SETTING: Level I trauma military medical and rehabilitation center. PATIENTS/PARTICIPANTS: Service members with lower extremity trauma resulting in limb salvage (n = 20) or unilateral transtibial amputation (n = 14) compared with uninjured actively training service members (n = 123). INTERVENTION: Control participants and individuals with amputation were tested during a single session. Participants with limb salvage were tested with and without the use of a custom carbon fiber orthosis. MAIN OUTCOME MEASUREMENTS: Physical performance as measured using four-square step, sit-to-stand 5 times, and timed stair ascent tests. Secondary outcomes included the associations between these lower extremity activity measures to determine the interrelationship of activity limitations. RESULTS: The ability of service members to rapidly ascend stairs, a demanding lower limb mobility task, is limited after amputation and limb salvage. However, performance on an agility test similar to the four-square step test approximated normative levels. Differences between individuals with amputation or limb salvage were less than 1 second for all tests and were not statistically significant. Correlations were observed among the physical performance measures in the tested patient populations, particularly between the sit-to-stand and timed stair ascent tests. CONCLUSIONS: Severe limb trauma significantly affects performance, particularly during tasks requiring lower extremity strength and power. Individuals with amputation or limb salvage who were provided a custom carbon fiber orthosis and intensive rehabilitation had similar performance. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Developing predictive models for return to work using the Military Power, Performance and Prevention (MP3) musculoskeletal injury risk algorithm: a study protocol for an injury risk assessment programme.

BACKGROUND: Musculoskeletal injuries are a primary source of disability in the US Military, and low back pain and lower extremity injuries account for over 44% of limited work days annually. History of prior musculoskeletal injury increases the risk for future injury. This study aims to determine the risk of injury after returning to work from a previous injury. The objective is to identify criteria that can help predict likelihood for future injury or re-injury. METHODS: There will be 480 active duty soldiers recruited from across four medical centres. These will be patients who have sustained a musculoskeletal injury in the lower extremity or lumbar/thoracic spine, and have now been cleared to return back to work without any limitations. Subjects will undergo a battery of physical performance tests and fill out sociodemographic surveys. They will be followed for a year to identify any musculoskeletal injuries that occur. Prediction algorithms will be derived using regression analysis from performance and sociodemographic variables found to be significantly different between injured and non-injured subjects. DISCUSSION: Due to the high rates of injuries, injury prevention and prediction initiatives are growing. This is the first study looking at predicting re-injury rates after an initial musculoskeletal injury. In addition, multivariate prediction models appear to have move value than models based on only one variable. This approach aims to validate a multivariate model used in healthy non-injured individuals to help improve variables that best predict the ability to return to work with lower risk of injury, after a recent musculoskeletal injury. TRIAL REGISTRATION NUMBER: NCT02776930.

GEHS neurophysiological classification system for patients with neuropathy of the ulnar nerve at the elbow.

BACKGROUND: Neuropathy of the ulnar nerve at the elbow is one of a number of muscle-related and nerve-related disorders that affect people performing intensive work with their hands and upper extremities, and is the second most prevalent peripheral nerve mononeuropathy. There are several classification systems currently being used by the medical community for patients with neuropathy of the ulnar nerve at the elbow. However, few of these classification systems include the clinical electrophysiologic parameters nerve conduction (NCS) and electromyographic (EMG) studies. PURPOSE: This article describes the GEHS (Greathouse, Ernst, Halle, and Shaffer) neurophysiological classification system for patients with neuropathy of the ulnar nerve at the elbow and includes 2 case studies of patients with electrophysiological evidence of neuropathy of the ulnar nerve at the elbow. CASE STUDIES: Two case studies of patients with electrophysiological evidence of neuropathy of the ulnar nerve at the elbow are presented. The GEHS neurophysiological classification system is incorporated into the discussion of these case studies. SUMMARY AND CLINICAL RELEVANCE: This article describes the GEHS neurophysiological classification system for patients with neuropathy of the ulnar nerve at the elbow which incorporates findings for both the NCS and EMG components of the electrophysiological examination. Availability of expanded electrophysiological data that includes both NCS and EMG testing provides the healthcare team and the patient with more detailed information that may be useful in determining next treatment steps as well as long-term prognosis. Future research comparing the psychometric properties and prognostic utility of the GEHS neurophysiologic classifications is warranted.

Effects of technique-focused training in conjunction with physical readiness training on Army physical fitness test performance.

The Army Physical Fitness Test (APFT) is a semiannual requirement. While conducting physical readiness training (PRT) is a requirement for all Soldiers, there is no requirement to train Soldiers on techniques that may help to optimize their performance on the APFT. A cohort of 34 officers that attended the Army Medical Department Basic Officer Leadership Course completed a technique-focused training program in conjunction with their required PRT program subsequent to failing one or more events on their initial APFT. The training consisted of a 30-minute video lesson and an individualized performance assessment completed by an Army physical therapist. Upon retest 10 days after the initial test, 27 (79.4%) participants passed the APFT with a mean improvement of 22.3 points on their overall APFT score. When evaluating change in performance by event based on failing the event initially, the observed improvement was an increase of over 9 push-ups, over 11 sit-ups, and nearly 2 minutes on the run event. The addition of a technique-focused training program to an existing PRT program can result in significant short-term improvement for those with substandard APFT performance.

Adaptation of postural recovery responses to a vestibular sensory illusion in individuals with Parkinson disease and healthy controls.

BACKGROUND: The ability to adapt postural responses to sensory illusions diminishes with age and is further impaired by Parkinson disease. However, limited information exists regarding training-related adaptions of sensory reweighting in these populations. METHODS: This study sought to determine whether Parkinson disease or age would differentially affect acute postural recovery or adaptive postural responses to novel or repeated exposure to sensory illusions using galvanic vestibular stimulation during quiet stance. FINDINGS: Acutely, individuals with Parkinson disease demonstrated larger center of pressure coefficient of variation compared to controls. Unlike individuals with Parkinson disease and asymptomatic older adults, healthy young adults acutely demonstrated a reduction in Sample Entropy to the sensory illusion. Following a period of consolidation Sample Entropy increased in the healthy young group, which coincided with a decreased center of pressure coefficient of variation. Similar changes were not observed in the Parkinson disease or older adult groups. INTERPRETATION: Taken together, these results suggest that young adults learn to adapt to vestibular illusion in a more robust manner than older adults or those with Parkinson disease. Further investigation into the nature of this adaptive difference is warranted.

Association of Physical Inactivity, Weight, Smoking, and Prior Injury on Physical Performance in a Military Setting.

CONTEXT: Although inactivity, being overweight, smoking, and a history of injury are identified as risk factors for poor health and injury, few authors have examined their association on physical performance. Young adults may be more likely to adopt healthier lifestyles if they understand the effect of health behaviors on performance. OBJECTIVE: To determine the association of being overweight, smoking, inactivity, and a history of injury with physical performance. DESIGN: Cross-sectional study. SETTING: Military population. PATIENTS OR OTHER PARTICIPANTS: Active-duty service members (N = 1466; 1380 men, 86 women; age = 24.7 ± 5.0 years; body mass index = 26.7 ± 3.4 kg/m2). MAIN OUTCOME MEASURE(S): Participants performed 8 measures (the triple-crossover hop for distance, the 6-m timed-hop test, the Functional Movement Screen, the Lower Quarter Y-Balance Test, the Upper Quarter Y-Balance Test, and the 3-event Army Physical Fitness Test) for evaluation of endurance, strength, muscular endurance, power, agility, balance, and motor control. Participants were categorized based on the number of health risk factors present. Using an analysis of covariance, we assessed the relationship between risk factors and physical performance with age and sex as covariates. RESULTS: Compared with those who had no risk factors (27.9% of men, 34.9% of women), physical performance was worse in those who had 1, 2, or 3 to 4 risk factors present by 4.3%, 6.7%, and 10.3%, respectively. Decrements in performance for those with 3 to 4 risk factors ranged from 3.3% to 14.4%. CONCLUSIONS: An unhealthy lifestyle habit or a history of injury was negatively associated with physical performance. Physical performance decrements were associated with the number of risk factors present. Understanding how risk factors contribute to decreased physical performance may enable clinicians to improve compliance with injury-prevention programs in occupational settings in which a young and relatively healthy workforce may be more concerned about performance than health.

Application of Athletic Movement Tests that Predict Injury Risk in a Military Population: Development of Normative Data.

Performance on movement tests helps to predict injury risk in a variety of physically active populations. Understanding baseline measures for normal is an important first step. OBJECTIVES: Determine differences in physical performance assessments and describe normative values for these tests based on military unit type. METHODS: Assessment of power, balance, mobility, motor control, and performance on the Army Physical Fitness Test were assessed in a cohort of 1,466 soldiers. Analysis of variance was performed to compare the results based on military unit type (Rangers, Combat, Combat Service, and Combat Service Support) and analysis of covariance was performed to determine the influence of age and gender. RESULTS: Rangers performed the best on all performance and fitness measures (p < 0.05). Combat soldiers performed better than Combat Service and Service Support soldiers on several physical performance tests and the Army Physical Fitness Test (p < 0.05). Performance in Combat Service and Service Support soldiers was equivalent on most measures (p < 0.05). CONCLUSIONS: Functional performance and level of fitness varied significantly by military unit type. Understanding these differences will provide a foundation for future injury prediction and prevention strategies.

US Army Physical Therapist Roles and Contributions in Operations Enduring Freedom and Iraqi Freedom.

Musculoskeletal injuries are a leading cause of health care utilization, medical evacuation, and disability. US Army physical therapists (PTs) have served as physician extenders for the management of nonsurgical neuromusculoskeletal injuries since the Vietnam conflict. The roles and evidence supporting US Army physical therapy continue to evolve. This article discusses the different levels of care and roles of US Army PTs, the contributions and evidence regarding US Army physical therapy, and physical therapy lessons learned during Operations Enduring Freedom and Iraqi Freedom. Since 2001, US Army PTs and enlisted physical therapy technicians have provided care from Levels 1 to 5 and assignments have expanded to special operations and brigade combat teams. Evidence suggests US Army PTs serving both in referral and direct access roles provided safe and definitive care that maximized readiness while reducing evacuation. Key physical therapy lessons learned include: (1) a continued focus on a Soldier sports medicine forward care model, (2) a need for injury risk assessment, physical performance screenings, and reconditioning programs that optimize readiness, and (3) continued support for physical therapy structure, training, and research that maximizes Soldier readiness and health.

GEHS Neurophysiological Classification System for Patients with Carpal Tunnel Syndrome.

BACKGROUND: Median neuropathy at or distal to the wrist or carpal tunnel syndrome (CTS) is one of a number of muscle, tendon, and nerve-related disorders that affect people performing intensive work with their hands. Following a thorough history and physical examination, electrophysiological examination including both nerve conduction studies (NCS) and electromyography (EMG) testing may be performed and currently serve as the reference standard for the diagnosis of CTS. The EMG and NCS exams should identify the peripheral nerve, specific location in the nerve pathway, involvement of sensory and/or motor axons, and the presence of myelinopathy and/or axonopathy neuropathic process. NEUROPHYSIOLOGICAL CLASSIFICATION SYSTEMS: Clinical electrophysiologists now have 2 neurophysiological classification systems for patients with CTS from which to choose when preparing their electrophysiological testing reports. The Bland (2000) and GEHS (2012) neurophysiological classification systems for patients with CTS are discussed. CASE STUDIES: Two case studies of patients with electrophysiological evidence of CTS are presented. Application and comparison of categorizations by the Bland and GEHS neurophysiological classification systems are incorporated into the presentation and discussion of these case studies. SUMMARY AND CLINICAL RELEVANCE: This article describes 2 neurophysiological classification systems for patients with CTS. The Bland system documents the distribution of patients with CTS on a scale based upon nerve conduction study findings, but it does not include any EMG findings in its grading scale. The GEHS neurophysiological classification system includes findings for both the NCS and EMG components of the electrophysiological examination. The GEHS classification system provides electrophysiological evidence of myelinopathy and/or axonopathy for patients with CTS. Additional research comparing the psychometric properties and prognostic utility of the Bland and GEHS neurophysiologic classifications is warranted.

Thoracic Spine Manipulation in Individuals With Subacromial Impingement Syndrome Does Not Immediately Alter Thoracic Spine Kinematics, Thoracic Excursion, or Scapular Kinematics: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVES: To determine if thoracic spinal manipulative therapy (SMT) alters thoracic kinematics, thoracic excursion, and scapular kinematics compared to a sham SMT in individuals with subacromial impingement syndrome, and also to compare changes in patient-reported outcomes between treatment groups. BACKGROUND: Prior studies indicate that thoracic SMT can improve pain and disability in individuals with subacromial impingment syndrome. However, the mechanisms underlying these benefits are not well understood. METHODS: Participants with shoulder impingement symptoms (n = 52) were randomly assigned to receive a single session of thoracic SMT or sham SMT. Thoracic and scapular kinematics during active arm elevation and overall thoracic excursion were measured before and after the intervention. Patient-reported outcomes measured were pain (numeric pain-rating scale), function (Penn Shoulder Score), and global rating of change. RESULTS: Following the intervention, there were no significant differences in changes between groups for thoracic kinematics or excursion, scapular kinematics, and patient-reported outcomes (P>.05). Both groups showed an increase in scapular internal rotation during arm raising (mean, 0.9°; 95% confidence interval [CI]: 0.3°, 1.6°; P = .003) and lowering (0.8°; 95% CI: 0.0°, 1.5°; P = .041), as well as improved pain reported on the numeric pain-rating scale (1.2 points; 95% CI: 0.3, 1.8; P<.001) and function on the Penn Shoulder Score (9.1 points; 95% CI: 6.5, 11.7; P<.001). CONCLUSION: Thoracic spine extension and excursion did not change significantly following thoracic SMT. There were small but likely not clinically meaningful changes in scapular internal rotation in both groups. Patient-reported pain and function improved in both groups; however, there were no significant differences in the changes between the SMT and the sham SMT groups. Overall, patient-reported outcomes improved in both groups without meaningful changes to thoracic or scapular motion. LEVEL OF EVIDENCE: Therapy, level 1b-.

What Risk Factors Are Associated With Musculoskeletal Injury in US Army Rangers? A Prospective Prognostic Study.

BACKGROUND: Musculoskeletal injury is the most common reason that soldiers are medically not ready to deploy. Understanding intrinsic risk factors that may place an elite soldier at risk of musculoskeletal injury may be beneficial in preventing musculoskeletal injury and maintaining operational military readiness. Findings from this population may also be useful as hypothesis-generating work for particular civilian settings such as law enforcement officers (SWAT teams), firefighters (smoke jumpers), or others in physically demanding professions. QUESTIONS/PURPOSES: The purposes of this study were (1) to examine whether using baseline measures of self-report and physical performance can identify musculoskeletal injury risk; and (2) to determine whether a combination of predictors would enhance the accuracy for determining future musculoskeletal injury risk in US Army Rangers. METHODS: Our study was a planned secondary analysis from a prospective cohort examining how baseline factors predict musculoskeletal injury. Baseline predictors associated with musculoskeletal injury were collected using surveys and physical performance measures. Survey data included demographic variables, injury history, and biopsychosocial questions. Physical performance measures included ankle dorsiflexion, Functional Movement Screen, lower and upper quarter Y-balance test, hop testing, pain provocation, and the Army Physical Fitness Test (consisting of a 2-mile run and 2 minutes of sit-ups and push-ups). A total of 320 Rangers were invited to enroll and 211 participated (66%). Occurrence of musculoskeletal injury was tracked for 1 year using monthly injury surveillance surveys, medical record reviews, and a query of the Department of Defense healthcare utilization database. Injury surveillance data were available on 100% of the subjects. Receiver operator characteristic curves and accuracy statistics were calculated to identify predictors of interest. A logistic regression equation was then calculated to find the most pertinent set of predictors. Of the 188 Rangers (age, 23.3 ± 3.7 years; body mass index, 26.0 ± 2.4 kg/m(2)) remaining in the cohort, 85 (45.2%) sustained a musculoskeletal injury of interest. RESULTS: Smoking, prior surgery, recurrent prior musculoskeletal injury, limited-duty days in the prior year for musculoskeletal injury, asymmetrical ankle dorsiflexion, pain with Functional Movement Screen clearing tests, and decreased performance on the 2-mile run and 2-minute sit-up test were associated with increased injury risk. Presenting with one or fewer predictors resulted in a sensitivity of 0.90 (95% confidence interval [CI], 0.83-0.95), and having three or more predictors resulted in a specificity of 0.98 (95% CI, 0.93-0.99). The combined factors that contribute to the final multivariable logistic regression equation yielded an odds ratio of 4.3 (95% CI, 2.0-9.2), relative risk of 1.9 (95% CI, 1.4-2.6), and an area under the curve of 0.64. CONCLUSIONS: Multiple factors (musculoskeletal injury history, smoking, pain provocation, movement tests, and lower scores on physical performance measures) were associated with individuals at risk for musculoskeletal injury. The summation of the number of risk factors produced a highly sensitive (one or less factor) and specific (three or more factors) model that could potentially be used to effectively identify and intervene in those persons with elevated risk for musculoskeletal injury. Future research should establish if screening and intervening can improve musculoskeletal health and if our findings among US Army Rangers translate to other occupations or athletes. LEVEL OF EVIDENCE: Level II, prognostic study.

Suprascapular neuropathy after distal clavicle resection and coracoclavicular ligament reconstruction: a resident's case problem.

STUDY DESIGN: Resident's case problem. BACKGROUND: Acromioclavicular joint pathology is reported to be present in up to 30% of all patients complaining of shoulder dysfunction. The operative approach to treating acromioclavicular joint disease often includes a distal clavicle excision and, in circumstances of acromioclavicular joint instability, reconstruction of the coracoclavicular and/or the acromioclavicular ligament. Surgical complications for these procedures are rare, but potentially include suprascapular neuropathy secondary to the course of the suprascapular nerve posterior to the clavicle prior to entering the supraspinatus fossa. DIAGNOSIS: A 28-year-old Caucasian woman reported directly to an outpatient physical therapy clinic with a complaint of right shoulder weakness. Three years prior, the patient underwent a distal clavicle excision and coracoclavicular ligament reconstruction. A detailed examination, including diagnostic imaging, identified infraspinatus atrophy and weakness, increasing the suspicion for suprascapular nerve injury. Electromyography was ordered to confirm the clinical and imaging diagnosis of suprascapular neuropathy and to rule out other nerve lesions, especially considering the selective atrophy of the infraspinatus muscle without mechanical explanation. DISCUSSION: The clinical decision making and systematic use of diagnostic testing resulted in identifying a rare case of suprascapular neuropathy, selective to the infraspinatus, in a patient who previously underwent a distal clavicle excision and coracoclavicular ligament reconstruction. Without a spinoglenoid cyst or other suprascapular nerve lesion identified on advanced imaging, it is likely that the suprascapular neuropathy identified in this case was related to the surgical procedure. LEVEL OF EVIDENCE: Differential diagnosis, level 4.

Immediate changes in pressure pain sensitivity after thoracic spinal manipulative therapy in patients with subacromial impingement syndrome: A randomized controlled study.

BACKGROUND: Thoracic SMT can improve symptoms in patients with subacromial impingement syndrome. However, at this time the mechanisms of SMT are not well established. It is possible that changes in pain sensitivity may occur following SMT. OBJECTIVES: To assess the immediate pain response in patients with shoulder pain following thoracic spinal manipulative therapy (SMT) using pressure pain threshold (PPT), and to assess the relationship of change in pain sensitivity to patient-rated outcomes of pain and function following treatment. DESIGN: Randomized Controlled Study. METHODS: Subjects with unilateral subacromial impingement syndrome (n = 45) were randomly assigned to receive treatment with thoracic SMT or sham thoracic SMT. PPT was measured at the painful shoulder (deltoid) and unaffected regions (contralateral deltoid and bilateral lower trapezius areas) immediately pre- and post-treatment. Patient-rated outcomes were pain (numeric pain rating scale - NPRS), function (Pennsylvania Shoulder Score - Penn), and global rating of change (GROC). RESULTS: There were no significant differences between groups in pre-to post-treatment changes in PPT (p ≥ 0.583) nor were there significant changes in PPT within either group (p ≥ 0.372) following treatment. NPRS, Penn and GROC improved across both groups (p < 0.001), but there were no differences between the groups (p ≥ 0.574). CONCLUSION: There were no differences in pressure pain sensitivity between participants receiving thoracic SMT versus sham thoracic SMT. Both groups had improved patient-rated pain and function within 24-48 h of treatment, but there was no difference in outcomes between the groups.

Clinical measures associated with dynamic balance and functional movement.

Decreased balance and impaired functional movement have been linked with increased injury risk. The purpose of our study was to determine the association between specific measures of power, strength, flexibility, balance, and endurance compared with more global measures of dynamic balance, using the Y-Balance Test (YBT), and functional movement, using the functional movement screen (FMS), in healthy soldiers. Our participants (n = 64; 53 men, 11 women) were healthy active duty service members (25.2 ± 3.8 years, 25.1 ± 3.1 kg·m(-2)). Seventeen tests with 38 associated measures of strength, power, flexibility, endurance, balance, and functional measures were assessed. A significant Pearson product moment correlation (r > 0.2 and p < 0.01) was used to narrow the number of variables of interest. Two hierarchical stepwise regression analyses were performed to determine the most parsimonious set of variables associated with the YBT and FMS performance scores. Our results included a 4 variable model (F = 13.4, p < 0.001) that was associated with YBT scores (R = 0.72, R2 = 0.51). Superior performance on the YBT was associated with better performance on the FMS lunge and upper trunk mobility tests, decreased number of hops during a 6-m hop test, and greater gastrocnemius flexibility. A second 4 variable model (F = 11.813, p < 0.001) was associated with FMS scores (R = 0.70, R2 = 0.50). Superior performance on the FMS was associated with greater anterior reach on the YBT, greater distance on the crossover hop test, increased hamstring flexibility, and higher levels of self-reported function through the lower-extremity functional scale. Physical fitness leaders and clinicians could use these models to inform decision making when developing and assessing the outcomes of a personalized intervention program for those with low FMS and YBT scores.