Use of a Patient-Specific Outcome Measure and a Movement Classification System to Guide Nonsurgical Management of a Circus Performer with Low Back Pain: A Case Report.

Low back pain (LBP) can be detrimental to the career of a circus arts performer, yet there is minimal population-specific literature to guide care. Moreover, reluctance to discontinue training and the need to resume end-range lumbar motion can impede the success of conservative care. The purpose of this case report is to describe the use of a patient-specific outcome measure and a movement classification system to structure a home exercise program (HEP) for an adolescent training to be a circus performer. The patient was a 16-year-old female with a 10-month history of LBP. A Movement System Impairment examination indicated that she had lower abdominal weakness, gluteal weakness, and hip flexors that were short and stiff; hence, extension and rotation were repeated patterns of lumbopelvic movement associated with her LBP symptoms. The patient was seen for 16 visits over 16 weeks. The HEP focused on minimizing lumbopelvic extension and rotation movements while improving abdominal and gluteal strength and hip flexor flexibility. Resumption of acrobatic activities was guided by the Patient-Specific Functional Scale. As measured by this scale, her difficulty with five functional and acrobatic activities decreased from 4/10 at initial evaluation to less than or equal to 1/10 by discharge. It is concluded that using an outcome measure to assess difficulty of activities chosen by the patient and education on how to avoid movement patterns associated with LBP symptoms can help facilitate return to performance.

Presentation and management of arthrofibrosis of the knee: A case report.

STUDY DESIGN: Case report. BACKGROUND: Arthrofibrosis is a debilitating condition that results in pain, decreased range of motion, and decreased function. Although surgical management of arthrofibrosis has been well described in the literature, rehabilitation of the arthrofibrotic knee is less well described. CASE DESCRIPTION: A 28-year-old female presented with swelling, pain, and decreased strength, range of motion, patellar mobility, and function following an exploratory arthroscopy of her left knee. After failed conservative management, the patient underwent two additional surgeries to remove scar tissue. Following each surgery, the emphasis was on decreasing inflammation and maintaining patellar mobility while increasing joint range of motion and strength. Therapy progression was determined by the presence or absence of inflammatory signs. The second scar tissue removal surgery resulted in a femoral neuropathy that further complicated the rehabilitation process. OUTCOMES: At 3-year follow-up, the patient continued to present with decreased range of motion and strength compared to the uninvolved limb, but had returned to a modified running program and reported pain no longer limited her ability to participate in activities of daily living. DISCUSSION: This case report highlights the importance of recognizing that arthrofibrosis may result following a minor knee surgery and with minimal range of motion loss. Additional complications also may result during arthrofibrosis treatment. Progressing rehabilitation based on the inflammatory response may decrease the likelihood of additional scar tissue formation and potentially improve the outcome for the patient.

Examination and treatment of a professional ballet dancer with a suspected acetabular labral tear: A case report.

Dancers are at risk for developing groin pain that is due to acetabular labral tears. Although surgical management of labral tears has been reported extensively, conservative management has been poorly described. This case report describes the examination, diagnosis, and treatment of groin pain in a professional ballet dancer with a suspected acetabular labral tear. Treatment focused on decreasing anterior hip joint stresses and improving the precision of hip motion through correction of alignment and movement impairments noted during functional activities and dance. Successful outcomes included a reduction in pain and return to professional ballet dancing.

Underutilization of worker's compensation insurance among professional orchestral musicians.

UNLABELLED: Orchestral musicians commonly have playing-related symptoms (PRS) but few use worker's compensation (WC) insurance for assessment and treatment. The purpose of this study was to examine the frequency of, and factors related to, filing a WC claim among musicians. METHODS: An online questionnaire was completed by 261 members of the International Conference of Symphony and Opera Musicians (ICSOM). The responses were analyzed to describe the frequency and type of injuries, perceived cause of PRS, and severity of injury in musicians who did and did not file a WC claim. RESULTS: Of the musicians, 93% reported PRS in the 12 months prior to the study. Only 9 musicians filed WC claims during their careers, and all claims were for upper extremity injuries. The most frequent reason for not filing a WC claim was insufficient severity. Yet among musicians describing their PRS as not severe enough for a WC claim, 47% had symptoms for >15 minutes after playing and 16% had symptoms that interfered with daily activities. CONCLUSION: These data suggest there is frequent under-reporting of injuries to WC among professional orchestral musicians. Although most musicians reported PRS that persisted after playing, the most common reason for not filing a WC claim was insufficient severity of symptoms perceived by the musicians. Future research should focus on clearly defining severity for PRS-related injuries and determining when treatment for overuse syndromes should be paid for through the WC system.

Predictors of first position turnout in collegiate dancers: the role of tibiofemoral external rotation and hip external rotation.

OBJECTIVE: Turnout is a dance position with known contributions from the hip, knee, and foot. A standardized method measuring total turnout has not been established. This study assessed the relationships between first position turnout (FPT) and measures of hip and tibiofemoral external rotation. DESIGN: This is a retrospective chart review of screening physical examination data of the knee and hip in collegiate female dancers. Measurements included FPT, active hip external rotation in sitting (HERS), active hip external rotation in prone, and passive tibiofemoral external rotation (TFR). Measurement comparisons were made using paired-samples t tests, Pearson product moment correlation coefficients, and hierarchical multiple regression analyses. RESULTS: Twenty-three female dancers (aged 18-21 yrs) participated. Correlations ranged from 0.01 (left HERS and left TFR) to 0.54 (left TFR to left FPT). Hip rotation in sitting explained a significant amount of variance in FPT (17% explained variance on the right and 19% variance on the left). Left TFR explained an additional 30% of the variance in left FPT beyond the variance explained by HERS. Right TFR did not explain a significant amount of the variance in right FPT beyond the variance explained by HERS. CONCLUSIONS: These findings suggest that active HERS and TFR are important contributors to FPT and that the relative contribution of these motions differ between sides.

Comprehensive surgical management of the competitive athlete with effort thrombosis of the subclavian vein (Paget-Schroetter syndrome).

OBJECTIVES: The results of treatment for subclavian vein effort thrombosis were assessed in a series of competitive athletes. METHODS: A retrospective review was conducted of high-performance athletes who underwent multidisciplinary management for venous thoracic outlet syndrome in a specialized referral center. The overall time required to return to athletic activity was assessed with respect to the timing and methods of diagnosis, initial treatment, operative management, and postoperative care. RESULTS: Between January 1997 and January 2007, 32 competitive athletes (29 male and 3 female) were treated for venous thoracic outlet syndrome, of which 31% were in high school, 47% were in college, and 22% were professional. The median age was 20.3 years (range, 16-26 years). Venous duplex ultrasound examination in 21 patients had a diagnostic sensitivity of 71%, and the mean interval between symptoms and definitive venographic diagnosis was 20.2 +/- 5.6 days (range, 1-120 days). Catheter-directed subclavian vein thrombolysis was performed in 26 (81%), with balloon angioplasty in 12 and stent placement in one. Paraclavicular thoracic outlet decompression was performed with circumferential external venolysis alone (56%) or direct axillary-subclavian vein reconstruction (44%), using saphenous vein panel graft bypass (n = 8), reversed saphenous vein graft bypass (n = 3), and saphenous vein patch angioplasty (n = 3). In 19 patients (59%), simultaneous creation of a temporary (12 weeks) adjunctive radiocephalic arteriovenous fistula was done. The mean hospital stay was 5.2 +/- 0.4 days (range, 2-11 days). Seven patients required secondary procedures. Anticoagulation was maintained for 12 weeks. All 32 patients resumed unrestricted use of the upper extremity, with a median interval of 3.5 months between operation and the return to participation in competitive athletics (range, 2-10 months). The overall duration of management from symptoms to full athletic activity was significantly correlated with the time interval from venographic diagnosis to operation (r = 0.820, P < .001) and was longer in patients with persistent symptoms (P < .05) or rethrombosis before referral (P < .01). CONCLUSIONS: Successful outcomes were achieved for the management of effort thrombosis in a series of 32 competitive athletes using a multidisciplinary approach based on (1) early diagnostic venography, thrombolysis, and tertiary referral; (2) paraclavicular thoracic outlet decompression with external venolysis and frequent use of subclavian vein reconstruction; and (3) temporary postoperative anticoagulation, with or without an adjunctive arteriovenous fistula. Optimal outcomes for venous thoracic outlet syndrome depend on early recognition by treating physicians and prompt referral for comprehensive surgical management.

A review of spinal injuries in the invasive cardiologist: part 1. Biomechanics and pain generation.

This review provides a perspective of spinal injuries related to invasive cardiology, an understanding of the anatomy and physiology of the spine, the etiology and pathophysiology of spinal injuries, and options for prevention and treatment. Because of the breadth of this review, it has been divided into two parts with the first describing the biomechanics and generation of back pain and the second discussing treatment options and prevention of back injury. A comprehensive overview of the biomechanics of the spine from the individual vertebral unit to the complex motions involved in everyday life is reviewed. The significant intrinsic and extrinsic factors playing a role in the mechanism of disc damage, including occupational hazards encountered by the invasive cardiologist, are discussed. We also address the mechanisms of pain generation in the spine and the role that inflammation plays, which explains the presence of symptoms with little or no detectable pathology on imaging studies.

A review of spinal injuries in the invasive cardiologist II: prevention and treatment.

This review provides a perspective of spinal injuries related to invasive cardiology, an understanding of the anatomy and physiology of the spine, the etiology and pathophysiology of spinal injuries, and options for prevention and treatment. In this part of our review, conventional surgical and minimally invasive options are discussed as well as emerging techniques for the treatment of back pain. We also discuss methods of preventing back injuries by modifications to the work environment as well as preventive measures that may be practiced by the invasive cardiologist. Our final objective is to describe and illustrate proven techniques for strengthening the supportive musculature to avoid spinal injury as well as to reduce painful exacerbations.