Edith Holmes Met the Challenges to Lead JOSPT to the Next Level.

SYNOPSIS: After 19 years at the helm, we are privileged to honor Ms. Edith Holmes upon her retirement as Executive Director/Publisher of JOSPT. Ms. Holmes set the standard by integrating and communicating effectively with a diverse group of stakeholders. Ms. Holmes is honored for her superb work, inspiration, and commitment to JOSPT. J Orthop Sports Phys Ther 2022;52(4):169. doi:10.2519/jospt.2022.11258.

Task-Based Functional Connectivity and Blood-Oxygen-Level-Dependent Activation During Within-Scanner Performance of Lumbopelvic Motor Tasks: A Functional Magnetic Resonance Imaging Study.

There are a limited number of neuroimaging investigations into motor control of the lumbopelvic musculature. Most investigation examining motor control of the lumbopelvic musculature utilize transcranial magnetic stimulation (TMS) and focus primarily on the motor cortex. This has resulted in a dearth of knowledge as it relates to how other regions of the brain activate during lumbopelvic movement. Additionally, task-based functional connectivity during lumbopelvic movements has not been well elucidated. Therefore, we used functional magnetic resonance imaging (fMRI) to examine brain activation and ROI-to-ROI task-based functional connectivity in 19 healthy individuals (12 female, age 29.8 ± 4.5 years) during the performance of three lumbopelvic movements: modified bilateral bridge, left unilateral bridge, and right unilateral bridge. The whole brain analysis found robust, bilateral activation within the motor regions of the brain during the bilateral bridge task, and contralateral activation of the motor regions during unilateral bridging tasks. Furthermore, the ROI-to-ROI analysis demonstrated significant connectivity of a motor network that included the supplemental motor area, bilateral precentral gyrus, and bilateral cerebellum regardless of the motor task performed. These data suggest that while whole brain activation reveals unique patterns of activation across the three tasks, functional connectivity is very similar. As motor control of the lumbopelvic area is of high interest to those studying low back pain (LBP), this study can provide a comparison for future research into potential connectivity changes that occur in individuals with LBP.

Normalized Isometric Shoulder Strength as a Predictor of Ball Velocity in Youth Baseball Players.

BACKGROUND: Despite increased awareness of factors related to athletic performance and injury prevention, youth and adolescent baseball players continue to report injuries at alarming rates. Upper extremity muscle strength is an integral part of physical assessment and injury prevention in baseball players, however minimal data exists in youth populations. Changes in anthropometric measures, inherent in physically developing athletes, have been shown to impact strength measures, however normalization methodology is rarely reported. PURPOSE: The purposes of this study were to 1) compare the measurement properties of five potential methods for normalizing isometric shoulder strength in a cohort of 9-12 year old male baseball players and 2) examine the relationship between normalized isometric shoulder strength and ball velocity in a cohort of 9-12 year old male baseball players. STUDY DESIGN: Prospective cohort study (n=159). METHODS: Baseline and follow up height, weight and bilateral ulnar length measurements were assessed followed by isometric strength in both the dominant and non-dominant shoulders. Strength measures included scapular plane abduction (scaption), external rotation (ER) at 0°, ER and internal rotation (IR) at 90°. Ball velocity was assessed as a measure of throwing performance. Intraclass correlation coefficients (ICC2,1), standard errors of measurement (SEM) and minimal detectable change (MDC95) were calculated for all strength measures. Repeated measures ANOVA were conducted comparing changes in normalized strength using five separate anthropometric measures: weight, height, body mass index, ulnar length and % of non-dominant shoulder strength. Linear regression models were used to examine the relationships between normalized isometric shoulder strength and ball velocity. Statistical significance was set a priori at α=0.05. RESULTS: Shoulder strength normalized using ulnar length was the only method that demonstrated excellent reliability (ICC2,1 0.98-0.99) and detected significant changes between strength in each of the four measures tested (SEM 0.39-0.69 Nm). Modest but significant correlations were observed between scaption and ball velocity (r2 = 0.27, p < 0.001) and ER at 0° and ball velocity (r2 = 0.23, p < 0.001). CONCLUSION: Ulnar length was the most stable and reliable normalization method for assessing isometric shoulder strength in youth baseball players. In addition, normalized scaption strength was the most significant predictor of ball velocity, followed by ER at 0° strength in this population. LEVEL OF EVIDENCE: Level 2b (etiology).

Fit to Play? Health-Related Fitness Levels of Youth Athletes: A Pilot Study.

ABSTRACT: Pfeifer, CE, Sacko, RS, Ortaglia, A, Monsma, EV, Beattie, PF, Goins, J, and Stodden, DF. Fit to play? Health-related fitness levels of youth athletes: A pilot study. J Strength Cond Res 36(1): 245-251, 2022-A recent National Strength and Conditioning Association position statement suggests that many youth are not prepared for the physical demands of sport. The purpose of this study was to compare health-related fitness (HRF) of youth athletes with normative findings from the general population. We recruited 136 athletes (63 male and 73 female athletes) aged 11-19 (16.01 ± 1.35) years and collected HRF (body composition, cardiorespiratory endurance, musculoskeletal strength and endurance). Results were categorized based on FITNESSGRAM® standards and compared with Canadian youth general population normative data. Most male athletes were classified as "needs improvement" for cardiorespiratory and muscular endurance, and body mass index (BMI). Conversely, most female athletes were at or above the "healthy fitness zone" for all measures. Male athletes at both age groups (11-14, 15-19; p < 0.001) and female athletes aged 11-14 (p < 0.05) demonstrated lower cardiorespiratory endurance compared with Canadian general population. Female athletes (both age groups) demonstrated greater muscular strength, and male athletes (age, 15-19 years) demonstrated lower BMI than the Canadian general population. The results are concerning as male athletes demonstrated poorer HRF compared with the general population. Although most female athletes were within healthy ranges, a portion of them were still at risk. Considering the demands sport places on the body, evaluating HRF is paramount for performance and injury prevention but more importantly for overall health. Youth sport and strength coaches should evaluate and aim to enhance HRF, as participation in sport does not guarantee adequate HRF. Promoting long-term athletic development and life-long health should be a priority in youth.

An interdisciplinary intensive outpatient pain program is associated with improved patient activation and key outcomes.

Aim: To examine the change in the Patient Activation Measure and physical and psychosocial outcome measures in a military interdisciplinary intensive outpatient program for persistent pain. Materials & methods: Pre- and post-intervention measures, which were also stratified by gender and baseline activation, included patient-reported outcomes and physical function assessment, obtained from 2017 to 2018 program database. Results: The majority of the participants were male (70.9%), with an average age of 29.18 years and pain duration of 4.78 years (n = 103). Patient activation, majority of the patient reported outcomes and functional assessments improved in the overall sample with fewer changes in females on the Defense and Veterans Pain Rating Scale. Conclusion: Improvements were noted on the Patient Activation Measure and majority of the other outcome measures suggesting that service members with persistent pain at any level of patient activation or baseline function, may benefit from an intensive outpatient program.

FUNCTIONAL MOVEMENT SCREEN™ in YOUTH SPORT PARTICIPANTS: EVALUATING the PROFICIENCY BARRIER for INJURY.

BACKGROUND & PURPOSE: The number of youth participating in sport increases yearly; however, the evaluation of youths' movement ability and preparedness for sport remains inadequate or neglected. The Functional Movement Screen (FMS™) is an assessment of an individual's movement quality that has been utilized to evaluate risk of injury in collegiate and professional sport; however, there is minimal support regarding the predictive value of the screen in youth sport. The purpose of this study was to evaluate the mean and distribution of FMS™ performance in sport participants age 11-18, and to evaluate the existence of a composite FMS™ score proficiency barrier to predict injury risk. STUDY DESIGN: Prospective cohort study. METHODS: One hundred, thirty-six participants (63 male, 73 female) age 11 to 18 years (16.01 + 1.35) were recruited from local schools and sport organizations. The FMS™ was administered prior to each participant's competitive season and scored by researchers who demonstrated reliability in assessments derived from the screen (κw = 0.70 to 1). Injury data were collected by the participants' Athletic Trainer over one season. An injury was defined as any physical insult or harm resulting from sports participation that required an evaluation from a health professional with time modified or time lost from sport participation. RESULTS: Females scored significantly higher than males for mean FMS™ composite score (t = 14.40; m = 12.62; p < 0.001), and on individual measures including: the hurdle step (t = 1.91; m = 1.65; p < 0.001), shoulder mobility (t = 2.68; m = 2.02; p < 0.001), active straight leg raise (t = 2.32; m = 1.87; p < 0.001), and the rotary stability components (t = 1.91; m = 1.65; p < 0.05). Two FMS™ composite scores (score < 14 and <15) significantly increased the odds of injury (OR = 2.955). When adjusting for sport, there was no score relating to increased odds of injury. CONCLUSION: Dysfunctional movement as identified by the FMS™ may be related to increased odds of injury during the competitive season in youth athletes. Consideration of an individual's movement within the context of their sport is necessary, as each sport and individual have unique characteristics. Addressing movement dysfunction may aid in injury reduction and potentially improve sport performance. LEVEL OF EVIDENCE: 1b.

Sport Specialization and Increased Injury Frequency in Youth Baseball Players: A Prospective Study.

CONTEXT: Sport specialization is thought to be a primary contributor to the throwing-related injury risk in youth baseball players. OBJECTIVE: To (1) establish arm-injury incidence in a cohort of male youth (9-12 years old) baseball players and (2) examine sport specialization and the frequency of arm injuries in the same cohort. DESIGN: Cohort study. SETTING: Greenville, South Carolina, youth baseball programs and tournaments. PATIENTS OR OTHER PARTICIPANTS: A total of 159 asymptomatic youth baseball players (age = 11.1 ± 1.1 years) were physically assessed and then were prospectively followed for 6.7 ± 1.5 months. MAIN OUTCOME MEASURE(S): Athlete demographics and playing and injury histories were initially recorded. Athlete-exposures and presence of arm injury were prospectively tracked. All injuries were physically confirmed by a licensed physical therapist. RESULTS: Youth players demonstrated an arm-injury incidence rate of 2.22 per 1000 athlete-exposures. Parents and players underestimated sport-specialization status based on the standard research definition (self versus research based: 31% versus 83%, respectively; P = .001). The frequency of arm injuries was higher in specialized players (100%) than in nonspecialized players (80%, P = .03) but did not differ between pitchers and position players (13.2% each, P = 1.00). CONCLUSIONS: Sport specialization was associated with throwing-related arm injuries in a small cohort of youth baseball players. It is concerning that 57.9% of parents and specialized players were unaware of the athletes' status. Larger studies with longer follow-up periods are needed to further evaluate injury-risk profiles in physically developing youth populations.

The effectiveness of interdisciplinary intensive outpatient programs in a population with diverse chronic pain conditions: a systematic review and meta-analysis.

Aim: To explore the overall effectiveness of interdisciplinary intensive outpatient treatment programs in adults with chronic pain. The secondary aim was to examine the effect of the intervention on individual outcome measures including pain intensity, pain catastrophizing, depressive symptoms, quality of life and describe its effect on medication use. Methods: The preferred reporting items for systematic review and meta-analysis protocols reporting guidelines were followed in this systematic review and meta-analysis. Results: A total of 13 peer-reviewed studies were included in analysis: one randomized controlled trial and 12 observational studies. Conclusion: Although interdisciplinary intensive outpatient programs for chronic pain have only been examined in a limited number of studies, trends suggest that participation in these programs may improve physical, emotional, social and mental health as measured by quality of life measures, while decreasing pain intensity, pain catastrophizing and depressive symptoms in a population with diverse diagnoses.

When It Comes to Editor-in-Chief Dr Guy G. Simoneau, Thanks Isn't Enough-It's More About Inspiration.

After 15.5 years of guiding the Journal of Orthopaedic and Sports Physical Therapy (JOSPT) through its amazing progress, Guy G. Simoneau is stepping down as Editor-in-Chief, handing editorial leadership of the Journal to the very talented and able Clare L. Ardern, beginning with the July 2019 issue. In this editorial, we, the JOSPT/Movement Science Media Board of Directors, summarize some of Dr Simoneau's many achievements and humbly express our gratitude and that of the Editorial Board and publishing team for his overwhelming devotion to the JOSPT for nearly 2 decades. Orthop Sports Phys Ther 2019;49(6):363-365. doi:10.2519/jospt.2019.0102.

Cardiorespiratory Fitness and Risk of All-Cause, Cardiovascular Disease, and Cancer Mortality in Men With Musculoskeletal Conditions.

BACKGROUND: To investigate the association between cardiorespiratory fitness and risk of cardiovascular disease, cancer, and all-cause mortality in men with musculoskeletal conditions. METHODS: Participants were 12,728 men (mean age 47.0 [9.3] y) with a history of musculoskeletal conditions (including joint pain, low back pain, stiff joints, arthritis, osteoporosis, or gout) and were followed for all-cause mortality to December 31, 2003. Fitness was quantified by maximal treadmill exercise test and was categorized for analysis as low, moderate, and high performance. Cox proportional hazards regression was used to calculate hazard ratios and 95% confidence intervals. RESULTS: Overall, the multivariable-adjusted hazard ratios and 95% confidence intervals for mortality across incremental fitness categories were 1.00 (reference), 0.45 (0.30-0.68) and 0.35 (0.22-0.53), linear trend P < .01 for all-cause, 0.50 (0.23-1.10) and 0.29 (0.12-0.71), linear trend P = .02 for cardiovascular disease, and 0.38 (0.20-0.74) and 0.40 (0.20-0.80), linear trend P = .01 for cancer mortality. CONCLUSION: Among men with musculoskeletal conditions, higher fitness is associated with lower risk of death by cardiovascular disease, cancer, or any cause, independent of other risk factors.

RISK FACTORS ASSOCIATED WITH NON-CONTACT ANTERIOR CRUCIATE LIGAMENT INJURY: A SYSTEMATIC REVIEW.

BACKGROUND: With the increasing number of individuals participating in sports every year, injury - specifically anterior cruciate ligament (ACL) injury - remains an inherent risk factor for participants. The majority of ACL injuries occur from a non-contact mechanism, and there is a high physical and financial burden associated with injury. Understanding the risk factors for ACL injury may aid in the development of prevention efforts. PURPOSE: The purpose of this review was to synthesize and appraise existing literature for risk factors associated with non-contact anterior cruciate ligament (ACL) injury in both sexes. STUDY DESIGN: Systematic review. METHODS: An electronic literature search was conducted utilizing the MEDLINE database and The Cochrane library for articles available through February 2016. All titles and abstracts were reviewed and full text articles meeting eligibility criteria were assessed in detail to determine inclusion or exclusion. Articles reviewed in full text were reviewed for scientific evidence of risk factors for ACL injury. Results from studies were extracted and initially classified as either intrinsic or extrinsic risk factors, and then further categorized based upon the evidence presented in the studies meeting inclusion criteria. Data extracted from eligible studies included general study characteristics (study design, sample characteristics), methodology, and results for risk factors included. RESULTS: Principal findings of this systematic review identified the following risk factors for ACL injury in both sexes: degrading weather conditions, decreased intercondylar notch index or width, increased lateral or posterior tibial plateau slope, decreased core and hip strength, and potential genetic influence. CONCLUSIONS: Neuromuscular and biomechanical risk factors may be addressed through neuromuscular preventative training programs. Though some extrinsic and other inherent physiological factors tend to be non-modifiable, attempts to improve upon those modifiable factors may lead to a decreased incidence of ACL injury. LEVEL OF EVIDENCE: 2a.

Spinal manipulation does not affect pressure pain thresholds in the absence of neuromodulators: a randomized controlled trial.

BACKGROUND: Measurement of pressure pain threshold (PPT) is a way to determine one of the many potential treatment effects of spinal manipulative therapy. OBJECTIVE: To determine how multiple spinal manipulations administered in a single-session affected PPTs at local and distal sites in asymptomatic individuals. METHODS: Participants were randomly assigned into one of three groups: Group one (n = 18) received a lumbar manipulation followed by a cervical manipulation. Group two (n = 17) received a cervical manipulation followed by a lumbar manipulation. The control group (n = 19) received two bouts of five minutes of rest. At baseline and after each intervention or rest period, each participant's PPTs were obtained using a handheld algometer. The PPTs were tested bilaterally over the lateral epicondyles of the humerus and over the mid-bellies of the upper trapezius, lumbar paraspinal, and the tibialis anterior muscles. This study was registered with ClinicalTrials.gov, and its Identifier is NCT02828501. RESULTS: Repeated-measures ANOVAs and Kruskal-Wallis tests showed no significant within- or between-group differences in PPT. Within-group effect sizes in the changes of PPT ranged from -.48 at the left paraspinal muscles to .24 at the left lateral humeral epicondyle. Statistical power to detect significant differences at α of 0.05 was calculated to be 0.94. CONCLUSIONS: This study suggests that in young adults who do not have current or recent symptoms of spinal pain, multiple within-session treatments of cervical and lumbar spinal manipulation fail to influence PPTs. Changes in PPT that are observed in symptomatic individuals are likely to be primarily influenced by pain-related neuromodulators rather than by an isolated, mechanical effect of spinal manipulation.

Age-related differences in the response of the L5-S1 intervertebral disc to spinal traction.

BACKGROUND: Lumbar traction is a common treatment for low back pain; however its mechanisms of action are poorly understood. It has been hypothesized that a key effect of lumbar traction is its capacity to influence fluid movement within the intervertebral disc (IVD). OBJECTIVES: To determine differences in the apparent diffusion coefficient (ADC) obtained with lumbar diffusion-weighted imaging (DWI) of the L5-S1 IVD before, and during, the application of lumbar traction. DESIGN: Case series, repeated measures. METHODS: A static traction load of ∼50% of body-weight was applied to the low back using a novel "MRI-safe" apparatus. DWI of the lumbar spine was performed prior to, and during the application of the traction load. RESULTS: Participants were currently asymptomatic and included a young adult group (n = 18) and a middle-aged group (n = 15). The young adult group had a non-significant 2.2% increase in ADC (mean change = 0.03 × 10-3 mm2/s, SD = 0.24, 95% CI = -0.09, 0.15). The ADC for the middle-aged group significantly increased by 20% (mean change of 0.18 × 10-3 mm2/s, SD = 0.19; 95% CI = 0.07, 0.28; p = 0.003; effect size = 0.95). There was an inverse relationship between the ADC obtained before traction and the percent increase in ADC that was measured during traction. CONCLUSION: Static traction was associated with an increase in diffusion of water within the L5-S1 IVDs of middle-age individuals, but not in young adults, suggesting age-related differences in the diffusion response. Further study is needed to assess the relationship between these findings and the symptoms of back pain. LEVEL OF EVIDENCE: 4.

Effectiveness of Manual Therapy and Stretching for Baseball Players With Shoulder Range of Motion Deficits.

BACKGROUND: Baseball players displaying deficits in shoulder range of motion (ROM) are at increased risk of arm injury. Currently, there is a lack of consensus regarding the best available treatment options to restore shoulder ROM. HYPOTHESIS: Instrumented manual therapy with self-stretching will result in clinically significant deficit reductions when compared with self-stretching alone. STUDY DESIGN: Controlled laboratory study. METHODS: Shoulder ROM and humeral torsion were assessed in 60 active baseball players (mean age, 19 ± 2 years) with ROM deficits (nondominant - dominant, ≥15°). Athletes were randomly assigned to receive a single treatment of instrumented manual therapy plus self-stretching (n = 30) or self-stretching only (n = 30). Deficits in internal rotation, horizontal adduction, and total arc of motion were compared between groups immediately before and after a single treatment session. Treatment effectiveness was determined by mean comparison data, and a number-needed-to-treat (NNT) analysis was used for assessing the presence of ROM risk factors. RESULTS: Prior to intervention, players displayed significant ( P < 0.001) dominant-sided deficits in internal rotation (-26°), total arc of motion (-18°), and horizontal adduction (-17°). After the intervention, both groups displayed significant improvements in ROM, with the instrumented manual therapy plus self-stretching group displaying greater increases in internal rotation (+5°, P = 0.010), total arc of motion (+6°, P = 0.010), and horizontal adduction (+7°, P = 0.004) compared with self-stretching alone. For horizontal adduction deficits, the added use of instrumented manual therapy with self-stretching decreased the NNT to 2.2 (95% CI, 2.1-2.4; P = 0.010). CONCLUSION: Instrumented manual therapy with self-stretching significantly reduces ROM risk factors in baseball players with motion deficits when compared with stretching alone. CLINICAL RELEVANCE: The added benefits of manual therapy may help to reduce ROM deficits in clinical scenarios where stretching alone is ineffective.

Overuse Physeal Injuries in Youth Athletes.

CONTEXT: Despite rising awareness of the risks associated with sports participation, overuse injuries continue to increase in youth athlete populations. Physeal injuries are one type of overuse injury exclusive to pediatric populations that are often sustained during athletic practice or competition. Overuse physeal injuries are, in theory, preventable; however, little consensus has been reached surrounding the risk factors, prevention, and treatment strategies. OBJECTIVE: This systematic review summarizes the best available evidence concerning overuse physeal injuries in youth and adolescent athletes. It can be used to develop prevention and treatment programs specific to this population. DATA SOURCES: PubMed and Academic Search Complete (EBSCOhost) were explored using the keyword physeal injuries from January 1950 through May 2015 to identify 24 studies. STUDY SELECTION: Original research studies of athletic populations with mechanisms of injury related to sport were chosen. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 3. DATA EXTRACTION: Data were extracted as available from 24 eligible studies. Study quality was rated using the Oxford Centre for Evidence-based Medicine (OCEBM) guidelines. RESULTS: Risk factors for injury include periods of accelerated growth, chronological age, body size, training volume, and previous injury. Injury prevention strategies currently emphasize participation limitations and sport-specific training programs in skeletally immature athletes. The most effective treatment after an overuse physeal injury was an extended period of active rest and joint immobilization when necessary. CONCLUSION: Overuse physeal injuries are multifactorial in nature. Muscular imbalances after accelerated growth periods predispose young athletes to overuse injuries. Modifiable risk factors such as flexibility, strength, and training volume should be regularly monitored to prevent these injuries.

The evolving role of physical therapists in the long-term management of chronic low back pain: longitudinal care using assisted self-management strategies.

BACKGROUND: Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited "windows" of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a "unique biosignature of pain" that may explain much of the variation in a person's clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT. OBJECTIVES: The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction. CONCLUSION: Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.

The evolving role of physical therapists in the long-term management of chronic low back pain: longitudinal care using assisted self-management strategies

ABSTRACT Background Longitudinal studies have shown that the symptoms of chronic low back pain (CLBP) will follow an episodic trajectory characterized by periods of high and low pain intensity that can persist for many years. There is a growing belief that the contemporary approach of limiting physical therapy to short, but intense courses of treatment for (CLBP) may be sub-optimal because these limited “windows” of clinical care are not congruent with the natural history of this condition. Recent research has suggested that people with CLBP undergo substantial, and individualized long-term variations in the neural processing of nociception over time. This has led to the concept of a “unique biosignature of pain” that may explain much of the variation in a person’s clinical picture. These and other findings have led to the reconceptualization of CLBP as an individualized, and continually evolving condition that may be more suitably managed by empowering the patient toward self-management strategies that can be modified as needed over time by the PT. Objectives The purpose of this Master Class Paper is to describe an emerging approach for the treatment of CLBP that emphasizes the formation of a long-term therapeutic alliance between the patient and the PT with an emphasis on individualized, patient-preferred approaches for activity-based self-management as an alternative to the contemporary approach of short, intense episodes of care directed toward pain reduction. Conclusion Longitudinal care using assisted self-management strategies is more congruent with the natural history of CLBP than are traditional approaches for PT intervention. This approach may empower patients to undergo lifestyle changes that will favorably influence long-term outcomes; however additional research is needed.

Mechanisms of Shoulder Range of Motion Deficits in Asymptomatic Baseball Players.

BACKGROUND: Shoulder range of motion (ROM) deficits have been identified as injury risk factors among baseball athletes. Despite the knowledge surrounding these risk factors, there is a lack of consensus regarding the specific tissues responsible for these deficits in ROM. PURPOSE/HYPOTHESIS: The purpose of this study was to elucidate the primary mechanisms of posterior shoulder tightness (capsular, musculotendinous, bony) by examining the tissue responses that occur with the application of an acute intervention in baseball players with ROM deficits. The hypothesis was that posterior rotator cuff stiffness, not glenohumeral joint mobility, would be primarily responsible for ROM gains observed within an acute treatment setting. STUDY DESIGN: Controlled laboratory study. METHODS: Through use of ultrasound elastography, electromagnetic motion analysis, and ultrasound imaging, posterior rotator cuff stiffness, glenohumeral joint translation, and humeral torsion were examined in 60 asymptomatic baseball players (age, mean ± SD, 19 ± 2 years) with shoulder ROM deficits. Tissue mechanisms were examined concurrently, with the ROM gains elicited by an acute application of instrument-assisted soft tissue mobilization plus self-stretching (n = 30) versus self-stretching only (n = 30). Separate 3-way analyses of variance (group × arm × time) and linear regression analyses were used to determine the treatment effects and relationships between tissue mechanisms and ROM gains. RESULTS: ROM gains were associated with decreases in rotator cuff stiffness (internal rotation: r = 0.35, P = .034; horizontal adduction: r = 0.44, P = .008) and increased humeral retrotorsion (internal rotation: r = -0.35, P = .034), not joint translation (P > .05). Players receiving instrument-assisted soft tissue mobilization plus stretching displayed greater shoulder ROM gains (internal rotation, +5° ± 2° [P = .010]; total arc of motion, +8° ± 6° [P = .010]; horizontal adduction, +7° ± 2° [P = .004]; and decreased posterior rotator cuff stiffness, -0.2 ± 0.3 kPa [P = .050]) compared with players receiving self-stretching alone. CONCLUSION: Decreases in rotator cuff stiffness were associated with acute ROM gains in baseball players. The study results show that changes in rotator cuff stiffness, not glenohumeral joint mobility or humeral torsion, are most likely associated with the ROM deficits observed in adolescent baseball players. CLINICAL RELEVANCE: Reducing rotator cuff stiffness may be beneficial in improving the ROM deficits associated with injury risk in overhead athletes.

Improving long-term outcomes for chronic low back pain: time for a new paradigm?

These are exciting times for physical therapists who treat people with chronic low back pain (CLBP). Many of the mysteries of this condition are starting to be revealed, and it appears that major breakthroughs are on the way. Advances in neuroimaging, coupled with increased understanding of the molecular and submolecular events associated with the symptoms of back pain, are helping us reconceptualize the etiologies and mechanisms of this condition. The result of these advances is that physical therapists now have a wide range of potential "treatment packages" that can include patient education, manual therapy, and a wide variety of exercise options for people with CLBP. The question is, "How can long-term, self-management programs become more effective?"