Majority of Studies Show Similar Rates of Return to Play After Arthroscopic Bankart Repair or Latarjet Procedure: A Systematic Review.

PURPOSE: To systematically review the current evidence in the literature to compare return to play following arthroscopic Bankart repair versus open Latarjet procedure for the treatment of anterior shoulder instability. METHODS: A literature search was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparative studies reporting return to play following arthroscopic Bankart repair versus open Latarjet procedure were included. Return to play was compared, with all statistical analysis performed using Review Manager, Version 5.3. RESULTS: Nine studies with 1,242 patients (mean age: 15-30 years) were included. The rate of return to play was 61% to 94.1% among those undergoing arthroscopic Bankart repair and 72% to 96.8% in those undergoing an open Latarjet procedure. Two studies (Bessiere et al. and Zimmerman et al.) found a significant difference in favor of the Latarjet procedure (P < .05 for both, I2 = 37%). The rate of return to play at preinjury level was 9% to 83.8% among those undergoing arthroscopic Bankart repair and 19.4% to 80.6% in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 0%). The mean time of return to play was 5.4 to 7.3 months among those undergoing arthroscopic Bankart repair and 5.5 to 6.2 months in those undergoing an open Latarjet procedure, with no study finding a significant difference (P > .05 for all, I2 = 39%). CONCLUSIONS: Overall, the majority of studies showed no significant difference in rates of return to play or timing following arthroscopic Bankart repair or open Latarjet procedure. Furthermore, no study has found a significant difference in rate of return to play at pre-injury level, or rate of return to play among collision athletes. LEVEL OF EVIDENCE: Level III, systematic review of Level I-III studies.

Effect of a Patient Engagement, Education, and Restructuring of Cognitions (PEERC) approach on conservative care in rotator cuff related shoulder pain treatment: a randomized control trial.

BACKGROUND: Despite similar outcomes for surgery and physical therapy (PT), the number of surgeries to treat rotator cuff related shoulder pain (RCRSP) is increasing. Interventions designed to enhance treatment expectations for PT have been shown to improve patient expectations, but no studies have explored whether such interventions influence patient reports of having had surgery, or being scheduled for surgery. The purpose of this randomized clinical trial was to examine the effect of a cognitive behavioral intervention aimed at changing expectations for PT on patient-report of having had or being scheduled for surgery and on the outcomes of PT. METHODS: The Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention, was designed to change expectations regarding PT. PEERC was evaluated in a randomized, pragmatic "add-on" trial in by randomizing patients with RCRSP to receive either PT intervention alone (PT) or PT + PEERC. Fifty-four (54) individuals, recruited from an outpatient hospital-based orthopedic clinic, were enrolled in the trial (25 randomized to PT, 29 randomized to PT + PEERC). Outcomes assessed at enrollment, 6 weeks, discharge, and six months after discharge included the patient report of having had surgery, or being scheduled for surgery (primary) and satisfaction with PT outcome, pain, and function (secondary outcomes). RESULTS: The average age of the 54 participants was 51.81; SD = 12.54, and 63% were female. Chronicity of shoulder pain averaged 174.61 days; SD = 179.58. Study results showed that at the time of six months follow up, three (12%) of the participants in the PT alone group and one (3.4%) in the PT + PEERC group reported have had surgery or being scheduled for surgery (p = .32). There were no significant differences between groups on measures of satisfaction with the outcome of PT (p = .08), pain (p = .58) or function (p = .82). CONCLUSIONS: In patients with RCRSP, PT plus the cognitive behavioral intervention aimed at changing expectations for PT provided no additional benefit compared to PT alone with regard to patient report of having had surgery, or being scheduled to have surgery, patient reported treatment satisfaction with the outcome of PT, or improvements in pain, or function. TRIAL REGISTRATION: The trial is registered on ClinicalTrials.gov: NCT03353272 (27/11/2017).

The influence of a cognitive behavioural approach on changing patient expectations for conservative care in shoulder pain treatment: a protocol for a pragmatic randomized controlled trial.

BACKGROUND: Despite similar outcomes for surgery and conservative care, the number of surgeries to treat rotator cuff related shoulder pain has increased. Interventions designed to enhance treatment expectations for conservative care have been shown to improve patient expectations, but no studies have yet explored whether such interventions influence patient decisions to pursue surgery. The purpose of this randomized clinical trial is to examine the effect of an intervention designed to improve expectations of conservative care on the decision to have surgery. METHODS: We will test the effectiveness of the Patient Engagement, Education, and Restructuring of Cognitions (PEERC) intervention which is intended to change expectations regarding conservative care. The PEERC intervention will be evaluated in a randomized, pragmatic "add-on" trial, to better understand the effect the intervention has on outcomes. Ninety-four (94) participants with rotator cuff related shoulder pain referred for physical therapy will be randomized to receive either impairment-based care or impairment-based care plus PEERC. Both groups will receive impairment-based conservative treatment created by compiling the evidence associated with established, effective interventions. Participants assigned to the impairment-based care plus PEERC condition will also receive the PEERC intervention. This intervention, informed by principles of cognitive behavioral therapy, involves three components: (1) strategies to enhance engagement, (2) education and (3) cognitive restructuring and behavioral activation. Outcomes will be assessed at multiple points between enrolment and six months after discharge. The primary outcome is patient reported decision to have surgery and the secondary outcomes are pain, function, expectations and satisfaction with conservative care. DISCUSSION: Rotator cuff related shoulder pain is highly prevalent, and because conservative and surgical treatments have similar outcomes, an intervention that changes expectations about conservative care could alter patient reports of their decision to have surgery and ultimately could lead to lower healthcare costs and decreased risk of surgical complications. TRIAL REGISTRATION: This study is registered as NCT03353272 at ClincialTrials.gov.

Factors predictive of poorer outcomes in the surgical repair of multiligament knee injuries.

PURPOSE: To investigate the influence of injury and treatment factors on clinical/functional outcomes in multiligament knee injuries (MLKI). METHODS: Thirty-nine consecutive patients with confirmed and surgically treated MLKI who met inclusion criteria were scheduled for a follow-up visit to obtain: SF-12 and subjective feeling of normalcy between the operated and healthy knee, and IKDC, active range of motion (ROM), and stability exam (Lachman test, posterior drawer, and dial test at 30°). A chart review was used to obtain data on injury and treatment factors. RESULTS: The postoperative mean (SD) outcomes were: IKDC score 62.7 (25.9), flexion-extension ROM 125° (29°), and percentage of normalcy 74% (20%). The postoperative normal/nearly normal stability exam was: Lachman test 36 (95%) patients, posterior drawer at 90° 38 (97%) patients, and dial test of 39 (100%) patients. There were 24 (61.5%) and 23 (59%) patients with complications and reoperations, respectively. The presence of bicruciate injuries was associated with worse Lachman (p = 0.03) and posterior drawer tests (p = 0.03). Presence of injury to meniscal structures was associated with worse Lachman test (p = 0.03), lower percentage of normalcy (p = 0.02) and extension lag (p = 0.04). Injury to cartilage structures was associated with worse IKDC scores (p = 0.04). IKDC was lower in cases of posterolateral corner reconstruction (p = 0.03) and use of allograft tendons for reconstruction (p = 0.02); ROM was lower in allograft reconstruction (p = 0.02) and need for meniscal repair (p = 0.01). Bicruciate reconstruction led to worst posterior drawer test (p = 0.006). CONCLUSIONS: The outcomes of MLKI might be negatively influenced by bicruciate ligament, meniscal, and cartilage injuries; with regards to treatment characteristics, need for posterolateral corner or bicruciate ligament reconstruction, use of allografts, or need for meniscal repair may similarly diminish outcomes. While surgical treatment provides good overall function, ROM and stability, it rarely results in a "normal" knee and the chances of complications and reoperations are high. LEVEL OF EVIDENCE: Cross-sectional comparative study, Level III.

Correction to: Factors associated with poorer outcomes in the surgical treatment of multiligament knee injuries.

The author would like to correct the following errors in the publication of the original article.

Difference in Functional Performance on the Upper-Quarter Y-Balance Test Between High School Baseball Players and Wrestlers.

CONTEXT: The Upper Quarter Y-Balance Test (YBT-UQ) is a unique movement test where individuals perform at the limits of their stability, requiring the coordination of balance, proprioception, range of motion, and stabilization. It is not yet clear if performance on the YBT-UQ differs between sports with dissimilar emphasis on upper-extremity performance. OBJECTIVE: To compare performance on the YBT-UQ between wrestlers, whose sport requires some degree of closed-chain activity, and baseball players, whose sport is primarily open kinetic chain in nature. DESIGN: Cross-sectional. SETTING: High school preparticipation physical assessment. PARTICIPANTS: 24 healthy high school male wrestlers (mean age 16.12 ± 1.24 y) and 24 healthy high school male baseball players (mean age 15.79 ± 1.25 y). INTERVENTIONS: All subjects performed the YBT-UQ, which requires reaching in 3 directions while maintaining a push-up position. MAIN OUTCOME MEASURES: The variables of interest include the maximum reach in each direction, as well as the composite score. In addition, asymmetries between limbs for each reach direction were compared. RESULTS: Wrestlers performed significantly better than baseball players in the medial direction, inferolateral direction, and in composite scores. In the medial direction, wrestlers exhibited greater scores (P < .01) on both left and right limbs, 10.5 ± 10.2%LL and 9.95 ± 10.2%LL, respectively. Significant differences (P < .01) were also observed in the inferolateral direction, with a difference of 11.3 ± 12.0%LL on the left and 8.7 ± 11.0%LL on the right. Composite scores were higher (P < .01) for the wrestlers, with a difference of 7.0% on the left and 7.1% on the right. CONCLUSIONS: This study suggests that wrestlers perform better on the YBT-UQ than baseball players. The findings may suggest sport-specific normative data for the YBT-UQ in high school athletes.

Reliability and Validity of a Novel Approach to Measure Hip Rotation.

CONTEXT: Currently, hip-rotation range of motion (ROM) is clinically measured in an open kinetic chain in either seated or prone position using passive or active ROM. However, during activities of daily living and during sports participation the hip must be able to rotate in a loaded position, and there is no standard measurement for this. OBJECTIVE: To determine if a novel method for measuring hip rotation in weight bearing will result in good to very good reliability as demonstrated by an intraclass correlation coefficient (ICC) of >.80 and to investigate if weight-bearing hip measurements will result in significantly reduced hip ROM compared with non-weight-bearing methods. DESIGN: Repeated measures. SETTING: Outpatient sports physical therapy clinic. PARTICIPANTS: 20 healthy participants (10 men, 10 women) recruited for hip-rotation measurements. METHODS: Three trials of both internal and external rotation were measured in sitting, prone, and weight bearing. Two therapists independently measured each participant on the same day. The participants returned the following day to repeat the same measurements with the same 2 therapists. MAIN OUTCOME MEASURES: Degrees of hip internal and external rotation measured in prone, sitting, and loaded positions. RESULTS: In general, the measurement of hip ROM across the different conditions was reliable. The intrarater reliability was .67-.95, while interrater reliability was .59-.96. Interrater reliability was improved when values were averaged across the measures (.75-.97). ICCs for active loaded ROM were .67-.81, while interrater ICCs were .53-.87. In general, prone hip ROM was greater than supine and supine was greater than loaded. CONCLUSIONS: Loaded hip rotation can be measured in a clinical setting with moderate to good reliability. The rotation ROM of a loaded hip can be significantly decreased compared with unloaded motion.

Sink or Swim? Clinical Objective Tests and Measures Associated with Shoulder Pain in Swimmers of Varied Age Levels of Competition: A Systematic Review.

BACKGROUND: Swimming is enjoyed by athletes of all ages, and shoulder pain is a common problem. Clinicians identify impairments which impact shoulder pain and these impairments may differ depending on the swimmer's age competition level. PURPOSE: The purpose of this study was to investigate objective measures utilized to assess swimmers and assess the relationship of test values to shoulder pain in distinct age groups/competition levels. A secondary aim was to report normative/expected values for these tests. DESIGN: Systematic review. METHODS: PRISMA methodology was employed to assess studies evaluating clinical tests and measures associated with shoulder pain for swimmers in varied age competition levels. The Methodological Index for Non-Randomized Studies instrument was used to evaluate the quality of the included studies, and a qualitative synthesis of findings was conducted to determine the strength of the evidence in four age competition levels for nine objective measures. Distinct cut points for proposed measures were identified. RESULTS: Twenty-seven studies were included in the analysis and the majority were of moderate quality in adolescent/adult swimmers. Youth swimmers had limited evidence for the development of shoulder pain associated with scapular position/dyskinesia, weakness of periscapular muscles, low endurance of core muscles, and moderate evidence for shoulder pain associated with laxity and altered range of motion (ROM). Adolescent/adult swimmers demonstrated limited evidence for a positive association between developing shoulder pain if there is a low eccentric ER:concentric IR ratio, and moderate evidence for pectoralis minor tightness and glenohumeral laxity. There were limited studies regarding masters swimmers to derive conclusive evidence. Cut points were identified from the included studies but these have not been validated in other studies. CONCLUSION: Swimmers of various ages may have different objective clinical tests and measures associated with the risk for developing shoulder pain. More studies are needed to fully understand risk factors for shoulder pain in the masters swim competition level, and to validate recommended cut points for various tests and measures. Key level of evidence: 3, Systematic review of mostly Level 3 studies.

Do Climate and Environmental Characteristics Influence Concussion Incidence in Outdoor Contact Sports? A Systematic Review.

OBJECTIVE: To obtain a comprehensive understanding of the implications of environmental and climate factors on sport-related concussion incidence in outdoor contact sports. DATA SOURCES: MEDLINE (via Ovid), Embase (via Elsevier), CINAHL Complete (via EBSCOhost), SPORTDiscus (via EBSCOhost), and Scopus (via Elsevier). STUDY SELECTION: Studies that report incidence of sport-related concussion, assess data from athletes participating in outdoor contact sports, report on 1 or more climate or environmental factors, and report a diagnosis of concussion performed by a licensed medical professional were included. Reasons for exclusion included no report on extrinsic or environmental factors, no data on sport-related concussion incidence, and self-report of concussion diagnosis. DATA EXTRACTION: This systematic review was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using 2 reviewers at each phase and a third reviewer for conflict resolution. DATA SYNTHESIS: A total of 7558 articles were reviewed, and 20 met the inclusion criteria. There was moderate to strong strength of evidence concluding no difference between surface type (grass versus artificial) on sport-related concussion risk. Moderate to strong strength of evidence was found supporting no difference in sport-related concussion incidence based on game location (home versus away). There was no consensus on the effects of altitude or temperature on sport-related concussion incidence. One high-quality study found a decreased risk of sport-related concussion when playing in wet versus dry conditions. Heterogenous populations and data collection methods prevented extraction and meta-analysis. CONCLUSIONS: Although a consensus on specific environmental and climate factors that influence sport-related concussion incidence was limited, the majority of studies were of high quality and gave insight into opportunities for future investigation. Administrators of large injury surveillance databases should consider including specific environmental and climate factors to provide investigators with robust data sets to better understand potential associations with sport-related concussion.

Return to Sport After Shoulder Stabilization Procedures: A Criteria-Based Testing Continuum to Guide Rehabilitation and Inform Return-to-Play Decision Making.

The athlete with shoulder instability poses a unique challenge to the sports medicine team. Clinical studies support surgical intervention followed by a phased approach to rehabilitation. In the latter phases, it is important to tailor this program to the individual's specific athletic needs, which requires ongoing qualitative assessment and objective measurement. Passing a return-to-sport testing battery has been shown to decrease the risk of recurrent instability. What is lacking in the literature is a consensus for how to best measure shoulder performance when the required athletic demands are widely varied by hand dominance, sport played, and playing position. Multiple upper-extremity tests have been described in the literature, but there is no consensus on which tests should be used to direct rehabilitation and to safely return the athlete to unrestricted athletic exposure. Using available evidence, we suggest a framework for return-to-play testing that integrates traditional rehabilitation phases with performance testing and graduated sports exposure. LEVEL OF EVIDENCE: Level V, expert opinion.

Healthy Pediatric Athletes Have Significant Baseline Limb Asymmetries on Common Return-to-Sport Physical Performance Tests.

BACKGROUND: Return to sport (RTS) after anterior cruciate ligament (ACL) reconstruction in children is associated with a much higher risk (∼30%) of subsequent ACL injury than in adults. Most RTS testing protocols use a limb symmetry index (LSI) ≥90% on physical performance tests (PPTs) to assess an athlete's readiness for sport. This assumes that, in a healthy state, the physical performances across both lower extremities are and should be equal. PURPOSE: To determine the prevalence of limb asymmetries >10% in the uninjured pediatric population on common PPTs as well as to explore the relationship between athlete variables, limb preference, and LSI values. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: This study included healthy volunteers (N = 100) evenly distributed between the ages of 6 and 18 years (mean age, 11.7 ± 3.6 years; 52% female). Participants performed 9 common PPTs. For analysis, we developed a composite score for each limb by averaging trials. We then calculated the LSI for each test. Univariable and multivariable linear regression analyses were performed to assess the relationship between athlete variables (age, sex, height, and weight) and LSI for each PPT. RESULTS: Instances of poor baseline limb symmetry (<90% LSI) were common across all PPTs. The single-leg timed hop had the highest percentage of participants, with LSI ≥90% at 73%, while the stork on a Bosu ball had the lowest percentage at 23%. After adjusting for age, female sex showed a significant association with LSI for the stork test (P = .010) and the quadrant hop-counterclockwise (P = .021). Additionally, after adjusting for sex, increasing age showed a significant association with LSI for the stork test (P < .001), single-leg squat on a Bosu ball (P = .010), quadrant hop-clockwise (P = .016), and quadrant hop-counterclockwise (P = .009). CONCLUSION: The majority of healthy athletes 18 years and younger demonstrated significant (<90%) limb asymmetries. Limb symmetry was not consistently affected by participant age or sex, and the effect sizes of these relationships were small. These findings should encourage clinicians and coaches to exercise caution in using the LSI as an isolated measure of RTS readiness after injury in pediatric athletes.

Establishing Age- and Sex-Specific Norms for Pediatric Return-to-Sports Physical Performance Testing.

BACKGROUND: Graft tears and contralateral anterior cruciate ligament (ACL) tears are common in pediatric athletes after ACL reconstruction. Use of objective return-to-sports (RTS) criteria, in particular physical performance tests (PPTs), is believed to reduce the incidence of secondary injury; however, pediatric norms for these tests are unknown. PURPOSE: To establish a proof of concept for the creation of age- and sex-based norms for commonly used RTS PPTs in healthy pediatric athletes, allowing the creation of growth curves for clinical referencing. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: A total of 100 healthy people who were between the ages of 6 and 18 years and involved in organized sports were enrolled, with even distributions of age and sex. All participants underwent 9 common RTS PPTs: stork test, stork test on Bosu, single-leg squat, single-leg squat on Bosu, clockwise and counterclockwise quadrant hops, single-leg hop for distance, 6-m timed hop, and triple crossover hop for distance. Mean performance across limbs was calculated for each individual. Chronological age, height, weight, sex, and self-reported Pubertal Maturational Observational Scale (PMOS) score were recorded. Univariable and multivariable models were created for each PPT, assessing the importance of the recorded descriptive variables. Quantile regression was used to create growth curves for each PPT. RESULTS: The cohort was 52% female, and the mean ± standard deviation age was 11.7 ± 3.6 years. PMOS was highly correlated with age (r = 0.86) and was excluded from the regressions. In univariable regression, age, height, and weight were strong predictors of performance for all PPTs, whereas sex was a predictor of performance on the single-leg and triple crossover hops for distance (with males outperforming females). Height and weight were excluded from multivariable regression because of multicollinearity with age. Multivariable regression showed predictive patterns for age and sex that were identical to those shown in the univariable analysis. Given ceiling effects, quantile regression for the stork tests was not possible, but quantile regression growth curves were successfully created for the 7 remaining PPTs. CONCLUSION: Chronological age and sex accurately predicted performance on common RTS PPTs in pediatric patients. The growth curves presented herein could assist clinicians with benchmarking pediatric patients postoperatively against a healthy athletic cohort.

Heterogeneity in head and neck cancer incidence among black populations from Africa, the Caribbean and the USA: Analysis of cancer registry data by the AC3.

BACKGROUND: Africa and the Caribbean are projected to have greater increases in Head and neck cancer (HNC) burden in comparison to North America and Europe. The knowledge needed to reinforce prevention in these populations is limited. We compared for the first time, incidence rates of HNC in black populations from African, the Caribbean and USA. METHODS: Annual age-standardized incidence rates (IR) and 95% confidence intervals (95%CI) per 100,000 were calculated for 2013-2015 using population-based cancer registry data for 14,911 HNC cases from the Caribbean (Barbados, Guadeloupe, Trinidad & Tobago, N = 443), Africa (Kenya, Nigeria, N = 772) and the United States (SEER, Florida, N = 13,696). We compared rates by sub-sites and sex among countries using data from registries with high quality and completeness. RESULTS: In 2013-2015, compared to other countries, HNC incidence was highest among SEER states (IR: 18.2, 95%CI = 17.6-18.8) among men, and highest in Kenya (IR: 7.5, 95%CI = 6.3-8.7) among women. Nasopharyngeal cancer IR was higher in Kenya for men (IR: 3.1, 95%CI = 2.5-3.7) and women (IR: 1.5, 95%CI = 1.0-1.9). Female oral cavity cancer was also notably higher in Kenya (IR = 3.9, 95%CI = 3.0-4.9). Blacks from SEER states had higher incidence of laryngeal cancer (IR: 5.5, 95%CI = 5.2-5.8) compared to other countries and even Florida blacks (IR: 4.4, 95%CI = 3.9-5.0). CONCLUSION: We found heterogeneity in IRs for HNC among these diverse black populations; notably, Kenya which had distinctively higher incidence of nasopharyngeal and female oral cavity cancer. Targeted etiological investigations are warranted considering the low consumption of tobacco and alcohol among Kenyan women. Overall, our findings suggest that behavioral and environmental factors are more important determinants of HNC than race.

Do older adults with shoulder disorders who meet the minimal clinically important difference also present low disability at discharge? An observational study.

BACKGROUND: The choice of outcome success thresholds may influence clinical management, pay-for-performance, and assessment of value-based care. OBJECTIVE: To evaluate outcomes success thresholds in older adults using two different methods: 1) Minimal clinically important differences (MCIDs) of the Quick-DASH and 2) Dichotomization of the Quick-DASH based on low disability rating at discharge DESIGN: An observational design (retrospective database study). SETTING: Dataset of 1109 patients with shoulder disorders. PARTICIPANTS: 297 older adults patients who were diagnosed with rotator cuff related shoulder disorders and were managed through physical therapy treatment. MAIN OUTCOME MEASURES: We categorized and calculated how many patients met 8.0 and 16.0 point changes on the Quick-DASH. To evaluate outcomes success thresholds using dichotomization, patients who discharge score of ≤20 on the Quick-DASH were considered positive responders with successful outcomes. RESULTS: The percentage of positive responders who met the MCID thresholds for the Quick-DASH were 63.3% using MCID of 8.0 points, 39.7% using the MCID of 16.0 points, and 46.12% who met discharge score of ≤ 20 on the Quick-DASH. 39.0% met both MCID of 8.0 points and discharge score of ≤ 20 on the Quick-DASH. Only 28% met both MCID of 16.0 points and discharge score of = 20 on the Quick-DASH. CONCLUSION: Three different success threshold derivations classified patients into three very different assessments of success. Quick-DASH scores of ≤ 20 represent low levels of self-report disability at discharge and can be a stable clinical option for a measure of success to capture whether a treatment results in meaningful improvement.

Development of Concise Physical Performance Test Batteries in Young Athletes.

PURPOSE: This study aimed 1) to define the principal components of physical function assessed by 10 common lower extremity physical performance tests and 2) to derive a reduced-item set of physical performance tests that efficiently and accurately measures raw performance and limb symmetry on each underlying component in pediatric and adolescent athletes. METHODS: This study included healthy, uninjured volunteers (n = 100) between the ages 6 and 18 yr (mean age = 11.7 ± 3.6 yr; 52 females). Subjects performed the stork balance, stork balance on BOSU® Balance Trainer, single leg squat (SLS), SLS on BOSU, clockwise and counterclockwise quadrant single leg hop (SLH), forward SLH, timed SLH, triple crossover SLH, and lower quarter Y-Balance Test™. Item reduction was performed using principal components analysis (PCA). We developed separate principal components analysis for average raw performance and side-to-side limb symmetry, with secondary analyses to evaluate consistency of results by age and sex. RESULTS: We identified two components for average raw performance (accounting for 65.2% of the variance in total test battery) with a reduced-item set composed of five tests, and four components for limb symmetry (accounting for 62.9% of the variance in total test battery) with a reduced-item set of seven tests. The most parsimonious test suitable for screening both average raw performance and limb symmetry would consist of five tests (stork balance on BOSU, SLS on BOSU, forward SLH, timed SLH, and lower quarter Y-Balance Test™). Age- and sex-specific test batteries may be warranted. CONCLUSION: Comprehensive screening for lower extremity average raw performance and limb symmetry is possible with short physical performance test batteries.

Clinical examination factors that predict delayed recovery in individuals with concussion.

BACKGROUND: Risk factors for prolonged recovery after concussion have been well researched, but specific objective clinical examination findings have not. This study examined whether clinical examination results could predict delayed recovery (DR) in individuals with concussion diagnosis. A secondary aim explored the influence of early examination on individual prognosis. METHODS: The study was a retrospective, observational cohort design that included 163 individuals seen at a concussion clinic who were followed longitudinally until cleared for sports activity. Cognitive, visual, balance, vestibular, and cervical clinical testing and symptom assessment were performed at initial evaluation. DR was calculated by taking the median value associated with time to clearance for activity. Bivariate logistic regression analysis was calculated to determine odds ratios (and 95% confidence intervals) for the odds of DR with presence or absence of each clinical finding. Multivariate analyses were used to define the best predictors of DR. RESULTS: 80 of 163 individuals were considered delayed in their clearance to activity. Cognitive impairments (OR = 2.72; 95%CI = 1.40, 5.28), visual exam findings (OR = 2.98; 95%CI = 1.31, 6.80), and vestibular exam findings (OR = 4.28; 95%CI = 2.18, 8.43) all increased the odds of a DR. Multivariate modeling retained cognitive symptoms and clinical examination-vestibular testing as predictors of delayed recovery. Time to examination after injury was a mediator for DR. CONCLUSIONS: The clinical examination provides value in identifying individuals who are likely to exhibit a delayed clearance. In particular, vestibular impairments identified clinically at initial evaluation and cognitive symptoms were associated with increased odds of a DR to return to activity. Our data support that early implementation of a standardized clinical examination can help to identify individuals who may be more at risk of prolonged recovery from concussion.

RELATIONSHIP BETWEEN THE LOWER QUARTER Y-BALANCE TEST SCORES AND ISOKINETIC STRENGTH TESTING IN PATIENTS STATUS POST ACL RECONSTRUCTION.

BACKGROUND: ACL injuries are common among sports populations and achieving adequate lower extremity strength is important prior to return to play. Access to isokinetic testing equipment that measures lower extremity strength is limited. Screening tools that measure functional criteria are accessible to clinicians, however the tools' relationship to strength constructs have not been investigated in an ACL reconstructed (ACLR) population. PURPOSE: The primary objective was to determine if relationships exist between isokinetic peak knee extension torque (PKET), peak knee flexion torque (PKFT), hamstring to quadriceps (HQ) ratios, and YBT-LQ performance following ACLR. The secondary objective was to observe differences in isokinetic strength ability between high and low performers on the YBT-LQ. STUDY DESIGN: Retrospective Chart Review. METHODS: Medical records of forty-five ACL-reconstructed subjects, between five-12 months post-surgery were queried for functional assessment data collected during the institution's standard outcome testing battery. Variables of interest included: demographic and anthropomorphic measures, YBT-LQ performance, and involved limb isokinetic PKET, PKFT, and HQ ratios. Performance on each measure, as well as asymmetry between sides, was analyzed using a correlation matrix. RESULTS: Statistically significant (p<0.01) relationships were identified between YBT-LQ anterior reach asymmetry and the PKET deficit (r=0.264). PKET and PKFT on the involved limb correlated to performance of anterior reach (r=0.591, p<0.01)(r=0.493, p<0.01), posteromedial reach (r=0.498, p<0.01)(r=0.577, p<0.01), and posterolateral reach (r=0.294, p<0.05)(r=0.445, p<0.01) respectively. Similar relationships existed on the uninvolved side, but to a lesser extent. High and low performers on the YBT-LQ demonstrated lower and higher extension torque deficits, respectively. CONCLUSION: While each test measures unique constructs, there are associations between components of the tests. In the ACLR population, both the YBT-LQ and isokinetic strength testing can expose asymmetries and impact return to play decision making. LEVEL OF EVIDENCE: 2b.

IMMEDIATE AND SHORT TERM EFFECT OF DRY NEEDLING ON TRICEPS SURAE RANGE OF MOTION AND FUNCTIONAL MOVEMENT: A RANDOMIZED TRIAL.

BACKGROUND: Dry needling (DN) has been established as an effective treatment for myofascial pain, however, there are no studies thus far investigating the benefit to movement and motor control. PURPOSE: The primary purpose of this study was to compare differences in a series of outcomes between dry needling, dry needling and stretching, and stretching only in a sample of healthy males. A secondary purpose was to compare change over time. DESIGN: Blinded, randomized controlled trial. METHODS: Thirty healthy male subjects were randomly assigned to one of three intervention groups: DN, stretching, or combination DN +stretching. Subjects in the DN group and DN+stretch group received DN to a palpated trigger point (TrP) in the triceps surae to elicit local twitch response. Subjects in the stretch group and DN+stretch group were instructed in a home stretching program for gastrocnemius and soleus muscles. All groups were tested for dorsiflexion range of motion and performed functional tasks (overhead deep squat, and Y-Balance test, Lower Quarter) prior to intervention, directly after intervention, and four days post intervention. Group comparisons were performed using a repeated measure Analysis of Variance and a partial eta squared calculation for effect size. For all measures a p-value of < 0.05 was used to determine significance. Cohen's criteria were used to categorize strength of effect size. RESULTS: There were no statistically significant differences among groups for range of motion nor functional measures, with the exception of the deep squat. Proportionally, the DN group improved significantly in deep squat performance (p<0.01) compared to the other groups. Time oriented improvements were seen for the YBT posterior-lateral reach (p = 0.02) only. Between groups effect sizes ranged from 0.02 (small) to 0.17 (large). CONCLUSIONS: Including DN did not markedly influence range of motion nor functional assessment measures, excluding those seen during the overhead deep squat. Effect measures suggest the lack of significant findings may be an issue of statistical power. LEVEL OF EVIDENCE: 1b.

Obesity resistance and enhanced glucose metabolism in mice transplanted with white adipose tissue lacking acyl CoA:diacylglycerol acyltransferase 1.

Recent studies have identified the white adipose tissue (WAT) as an important endocrine organ that regulates energy and glucose metabolism via a number of secreted factors. Mice lacking acyl CoA:diacylglycerol acyltransferase 1 (DGAT1), a key enzyme in mammalian triglyceride synthesis, are protected against diet-induced obesity and glucose intolerance because of increased energy expenditure and enhanced insulin sensitivity. Because DGAT1 is highly expressed in WAT, we hypothesized that DGAT1 deficiency affects the expression of adipocyte-derived factors that regulate energy and glucose metabolism. Here we show that the transplantation of DGAT1-deficient WAT decreases adiposity and enhances glucose disposal in wild-type mice. Analysis of DGAT1-deficient WAT revealed a twofold increase in the expression of adiponectin, a molecule that enhances fatty acid oxidation and insulin sensitivity, and this increase may account in part for the transplantation-induced metabolic changes. Our results highlight the importance of the endocrine function of WAT and suggest that an alteration in this function contributes to the increased energy expenditure and insulin sensitivity in DGAT1-deficient mice.