ABSTRACT Introduction Shoulder stabilization surgery is common among military personnel, causing severe acute postoperative pain that may contribute to the development of chronic pain, thereby reducing military readiness. Battlefield Acupuncture (BFA) has shown promise as a non-pharmaceutical intervention for acute postoperative pain. The purpose of this study was to determine the effectiveness of BFA combined with standard physical therapy on pain, self-reported mood, self-reported improvement, and medication use in patients after shoulder stabilization surgery. Materials and Methods The study design was a single-blind, randomized clinical trial, approved by the Naval Medical Center Portsmouth Institutional Review Board and registered with ClinicalTrials.gov (NCT04094246). Ninety-five participants were recruited after shoulder stabilization surgery. Participants were randomized via concealed allocation into a standard physical therapy (PT) group or a group receiving standard PT and BFA. Both groups received standard postoperative pain medication. The BFA intervention followed a standard protocol with the insertion of gold aiguille d’acupuncture emiermanente needles at 5 specific points in the ear. At 4 time points (baseline [24–48 hours], 72 hours, 1 week, and 4 weeks post-surgery), participants reported worst and average pain using a Visual Analog Scale (VAS), self-reported mood using the Profile of Mood States (POMS), self-recorded medication intake between study visits, and self-reported improvement in symptoms using a Global Rating of Change (GROC) Scale. Outcome assessors were blinded to treatment allocation. An alpha level of 0.05 was set a priori. For pain, a mixed-model analysis of variance was used to analyze the interaction effect between group and time. Differences in baseline data, total opioid usage, and pain change scores between groups were analyzed using independent t-tests. Results Of the 95 participants enrolled, 7 failed to provide complete study visits after the baseline, leaving 88 patients (43 BFA, 45 control, mean age 21.8 (2.1) years, 23% female). There were no significant group-by-time interactions for VAS worst pain (F = 0.70, P = .54), VAS average pain (F = 0.99, P = .39), the POMS (F = 1.04, P = .37), or GROC (F = 0.43, P = 0.63). There was a significant main effect of time for VAS worst pain (F = 159.7, P < .001), VAS average pain (F = 122.4, P < .001), the POMS (F = 11.4, P < .001), and the GROC (F = 78.5, P < .001). While both groups demonstrated statistically significant and clinically meaningful improvements in pain and self-reported mood over time, BFA did not provide any additional benefit compared to standard physical therapy alone. There was no significant difference in opioid usage between groups at 4 weeks (t = 0.49, P = .63). Finally, both groups also demonstrated statistically significant and clinically meaningful self-reported improvements in function, but again, there was no additional benefit when adding BFA to standard physical therapy. Conclusion The results of this study do not support the effectiveness of BFA for postsurgical pain management as there were no significant differences in pain, self-reported mood, self-reported improvement, and medication use between participants who received BFA and those who did not. As this is the only known study of BFA in postsurgical participants, continued research is needed to determine if BFA is effective for pain reduction in that setting. Clinical Trial Registration ClinicalTrials.gov, NCT04094246. Registered September 16, 2019, http://clinicaltrials.gov/NCT04094246.

Noticing is a momentary act. Enriching the possibility of noticing something specific in the future marks the beginning of an action labelled "professional development". Thus, what happens as a result of noticing is what matters for the teacher, but what really matters is what happens for the learner. Whether something noticed enables a passing remark, acts an object of reflection, stimulates a shift of attention, provides an action for pre-flection, or instantiates some theoretical construct, the consequence of noticing is much more complex than simply noticing, involving as it does the power of attention, and implicitly all other aspects of the human psyche. As a discipline, noticing encompasses all of these aspects. As a domain of research, noticing is sometimes divided into component parts, with distinctions between different kinds of things worth noticing and distinctions between different ways of behaving as a consequence of noticing. As a subject of research, the key issues about noticing are how it can be promoted, fostered, provoked and even directed, and what it enables. This paper re-integrates various disparate aspects of noticing appearing in the literature, in order to stress the complexity of sensitising oneself to notice, and informing one’s future practice through noticing opportunities to act freshly. The reports in this issue are used as an indication of the range of things which people are encouraged to notice (be sensitised to notice) as part of their professional development and practice in mathematics education. This occasions reflection on the complexity of researching, not only what people notice and attend to, but how their noticing might be influenced as part of their professional development, and more importantly, what consequences of such noticing might be anticipated, such as how it might influence future practice.

Attributed to William James, the phrase acting as if turns out to pervade educational practices and research, including assessment. It lies at the heart of interactions between teachers and learners and, in the presence of artificial intelligence, raises questions about how assessment is conducted. This paper explores the consequences of ‘acting as if’ for mathematics education and educational research.

BACKGROUND:After an anterior cruciate ligament reconstruction (ACLR), only 47% of military members return to full duty, possibly due to persistent neuromuscular asymmetries. Psychological factors may also contribute to reduced return to duty in military members. HYPOTHESIS:Psychological factors and time since surgery would be associated negatively with neuromuscular asymmetries, asymmetries would be greater in cadets postsurgery when compared with healthy controls, and asymmetries would be greater at earlier timepoints after ACLR. STUDY DESIGN:Case control. LEVEL OF EVIDENCE:Level 4. METHODS:This study examined the relationship between psychological factors and time since surgery with neuromuscular asymmetry, compared neuromuscular asymmetries between cadets with and without a history of ACLR, and explored differences in neuromuscular asymmetries at different timepoints in cadets with a history of ACLR. A total of 37 cadets post-ACLR (18.3 ± 9 months) and 28 controls participated. Psychological factors were assessed using the Tampa Scale of Kinesiophobia and Anterior Cruciate Ligament-Return to Sport after Injury scale (ACL-RSI). Participants performed a drop-jump landing, joint positioning sense (JPS), and isometric quadriceps strength testing. Peak vertical ground-reaction forces (vGRF), absolute angle of replication, peak quadriceps torque, rate of torque development (RTD), and RTD time torque interval 200 ms (TTI200) were analyzed. RESULTS:The ACL-RSI score was significantly related to limb symmetry index (LSI) peak quadriceps torque (r = 0.617, P < 0.01), LSI RTD (r = 0.367, P = 0.05), and LSI TTI200 (r = 0.0489, P < 0.01), but not time since surgery, JPS, or LSI peak vGRF. Cadets with a history of ACLR had significantly lesser ACL-RSI scores and greater asymmetries compared with controls. CONCLUSION:Reduced psychological readiness was associated with increased neuromuscular asymmetries after ACLR. CLINICAL RELEVANCE:Clinicians should assess psychological readiness during rehabilitation after ACLR.

Abstract Introduction Extracellular vesicles (EVs) are nanoized vesicles, which deliver bioactive cargoes to target cells. Our lab has shown that metabolic stress leads to changes in the trafficking and also the cargo and functions of EVs secreted from colorectal cancer (CRC) cells: a so-called “EV switch”. Proteomic analysis revealed that switched EVs carry increased levels of the EGFR-ligand Amphiregulin (AREG). The aim of this work was to investigate the pro-tumorigenic properties of switched EVs in vitro and in vivo. Methods Size exclusion chromatography was used to isolate EVs from HCT116 and Caco-2 CRC cells grown under glutamine-replete and -depleted conditions, and their effect on recipient cell growth measured using the IncuCyte Live Cell Imager. Co-incubation assays with an AREG-neutralising antibody were undertaken to test the role of switched EVs. The in vivo role of switched EVs were investigated using a novel chick embryo model. In addition, we tested whether the growth inhibitory effects of cetuximab could be reversed by co-treatment with switched EVs. Results Switched EVs from HCT116 and Caco-2 cells contain increased levels of AREG and promote EGFR-ERK dependent growth in recipient cells in vitro and in vivo. These effects were inhibited by co-treatment with an AREG neutralising antibody. Caco-2 (KRAS-wild type), but not HCT116 (KRAS-mutant), cell growth was inhibited by cetuximab, which was partially reversed by co-treatment with switched EVs. AREG neutralisation reversed this EV-induced cetuximab rescue. Conclusion Switched EVs mediate CRC cell growth and cetuximab resistance, and could serve as novel biomarkers to predict treatment response.

Learning is here considered to have taken place when someone has developed the habit, propensity, and disposition to attend productively to things not previously noticed, and in ways not previously experienced, to do with some specific and particular content. ‘Active learning’ sounds like a tautology, but was introduced as a contrast to the more passive activity of students sitting in lectures listening and transcribing mathematics written on a board or screen onto their own paper. The stance taken here is that effective and efficient learning involves active engagement in activity, but includes enculturation through being in the presence of a relative expert1 who themselves is manifesting mathematical thinking, not simply passing on the records of the results of previous mathematical thought. Such ‘passivity’ does not necessarily require intention. Following Bennett2 actions are here taken to involve three agents or impulses: initiating, responding, and reconciling or mediating. All three agents are thus active, but in different ways. Interactions intended to contribute to learning are considered to be actions, and so involve three agents: learner, teacher (in some manifestation), and mathematical content, all within a culture or ethos. Since there are six different ways in which the triple of agents can be assigned to the triple of impulses, six different modes are possible. Analysing these modes sheds light on different ways in which learning could be said to be ‘active’. Activity takes place within a mode of interaction. Again following Bennett, effective activity is here taken to require appropriate relationships among the gap between current state and intended goal, the resources available, and the tasks set. 1Vygotsky (1978) pointed out that ‘higher psychological processes’ are first encountered in others. 2Bennett (1993); see also Shantock Systematics Group (1975)

# Background Limitations exist with current ACLR functional testing assessments that may be mitigated by including single-leg multi-directional testing. # Hypothesis/Purpose To compare Anterior Cruciate Ligament-Return to Sport after Injury Scale (ACL-RSI) scores, limb symmetry index (LSI) of the single-leg vertical jump (SLVJ), single-leg medial rotation hop (SLMRH), single-leg lateral hop (SLLH), and isokinetic quadriceps strength between participants with an ACLR and healthy controls and assess predictors of quadriceps strength asymmetry. It was hypothesized that ACL-RSI scores and LSIs for all tests would differ between ACLR and healthy control groups and within the ACLR group a strong correlation would exist between all outcome measures and quadriceps strength. # Study Design Cross-Sectional Study # Methods Twenty-six participants with an ACLR (median 13 months after surgery) and twenty-six matched healthy controls were recruited to participate in this study. Performance was assessed via SLVJ, SLMRH, SLLH, and isokinetic quadriceps strength. Between-group comparisons were made with independent t-tests and Mann-Whitney U test. Within the ACLR group, bivariate correlation and multivariate regression analysis were performed to assess the relationship between the outcome measures and quadriceps strength asymmetry. # Results Significant between-limb differences were only identified in the ACLR group (p< 0.05): SLVJ LSI: 88.5%, SLMRH LSI: 93.6%, SLLH LSI: 92.7%, quadriceps strength LSI 80.9% - 83.9%, which were significantly lower (p <0.05) than the healthy control group. Within the ACLR group, a moderate-strong significant (p < 0.05) correlations existed with quadriceps strength and SLVJ (r=0.44-0.65), SLMRH (r =0.43-0.83), and SLLH (r=0.54-0.63); while ACL-RSI had a weak non-significant (p > 0.05) correlation with quadriceps strength (r= 0.12-0.30). # Conclusion Single-leg multidirectional test LSIs were less in ACLR participants than matched healthy controls and all were directly related to quadriceps strength. Psychological readiness to return to sport was not related to quadriceps strength.

AbstractExosomes are secreted nanovesicles with potent signalling activity that are initially formed as intraluminal vesicles (ILVs) in late Rab7‐positive multivesicular endosomes, and also in recycling Rab11a‐positive endosomes, particularly under some forms of nutrient stress. The core proteins of the Endosomal Sorting Complex Required for Transport (ESCRT) participate in exosome biogenesis and ILV‐mediated destruction of ubiquitinylated cargos. Accessory ESCRT‐III components have reported roles in ESCRT‐III‐mediated vesicle scission, but their precise functions are poorly defined. They frequently only appear essential under stress. Comparative proteomics analysis of human small extracellular vesicles revealed that accessory ESCRT‐III proteins, CHMP1A, CHMP1B, CHMP5 and IST1, are increased in Rab11a‐enriched exosome preparations. We show that these proteins are required to form ILVs in Drosophila secondary cell recycling endosomes, but unlike core ESCRTs, they are not involved in degradation of ubiquitinylated proteins in late endosomes. Furthermore, CHMP5 knockdown in human HCT116 colorectal cancer cells selectively inhibits Rab11a‐exosome production. Accessory ESCRT‐III knockdown suppresses seminal fluid‐mediated reproductive signalling by secondary cells and the growth‐promoting activity of Rab11a‐exosome‐containing EVs from HCT116 cells. We conclude that accessory ESCRT‐III components have a specific, ubiquitin‐independent role in Rab11a‐exosome generation, a mechanism that might be targeted to selectively block pro‐tumorigenic activities of these vesicles in cancer.

# Background Military physical therapists practicing direct-access routinely utilize diagnostic imaging and numerous published case reports demonstrate the ability of physical therapists to diagnose and appropriately disposition patients with foot/ankle and wrist/hand fractures. However, no larger cohort studies have explored the utilization of diagnostic imaging by physical therapists to detect fractures. # Hypothesis/Purpose To describe the utilization of diagnostic imaging in foot/ankle and wrist/hand injuries by physical therapists in a direct-access sports physical therapy clinic. # Study Design Retrospective cohort study. # Methods The Agfa Impax Client 6 image viewing software (IMPAX) was searched from 2014 to 2018 for patients with diagnostic imaging ordered for foot/ankle and wrist/hand injuries. The Armed Forces Health Longitudinal Technology Application (AHLTA) electronic medical record was independently reviewed by the principal and co-investigator physical therapists. Data extracted were demographics and elements from the patient history and physical examination. # Results In foot/ankle injuries, physical therapists diagnosed a fracture in 16% of the 177 cases and waited for an average of 3.9 days and 1.3 visits before ordering imaging. In wrist/hand injuries, physical therapists diagnosed a fracture in 24% of the 178 cases and waited for an average of 3.7 days and 1.2 visits before ordering imaging. The time to definitive care from the initial physical therapy evaluation was significantly different (p = 0.04) for foot/ankle fractures (0.6 days) compared to wrist/hand fractures (5.0 days). The Ottawa Ankle Rules demonstrated a negative likelihood ratio (-LR) of 0.11 (0.02, 0.72) and a positive likelihood ratio (+LR) of 1.99 (1.62, 2.44) for the diagnosis of foot/ankle fracture. # Conclusions Physical therapists utilizing diagnostic imaging in a direct-access sports physical therapy clinic diagnosed fractures in similar proportions for foot/ankle and wrist/hand injuries and quickly dispositioned patients to definitive care for those fractures. The diagnostic accuracy of the Ottawa Ankle Rules was similar to previously reported values. # Level of Evidence Level 3.

INTRODUCTION:The U.S. Army is updating the physical fitness assessment for soldiers to the six-event Army Combat Fitness Test (ACFT). A paucity of data regarding the ACFT maximum deadlift (MDL) event, especially in military populations, has increased concern over the objectivity of the test. The reliability of scoring the MDL has not been established. It is unknown if grader professional experience impacts the reliability of scoring, and if so, what level of experience is required for reliable assessment. Performance and assessment of the MDL could impact military occupational selection, promotion, and retention within the Army. The purposes of this study were to determine the inter- and intra-rater reliabilities of raters with varying degrees of professional experience on scoring the MDL and to determine the relationships between load lifted, overall lift success, sex, and body mass index (BMI).METHODS:The design is a reliability study. Approval was granted by the Naval Medical Center-Portsmouth Institutional Review Board. Fifty-five healthy soldiers and cadets from the U.S. Military Academy were recruited. Participants completed one data collection session, performing one MDL attempt. The attempt was video recorded using three devices: two handheld tablets placed perpendicular to the sagittal and frontal planes recording at 240 Hz and one digital camera positioned at a 45° angle recording at 30 Hz. A reference standard was established through slow-motion analysis of the sagittal and frontal plane recordings. Six raters with varying degrees of professional experience viewed the 45° camera recordings at real-time speed independently, in a random order, on two separate occasions. Lift success was dichotomously assessed as successful or unsuccessful according to the MDL standards. Cohen's kappa was computed to determine inter- and intra-rater reliabilities among raters. Bivariate correlation was used to assess associations among load lifted, BMI, and sex. A chi-squared test of independence assessed the relationship between sex and overall lift success.RESULTS:Inter-rater reliability between the six raters ranged from 0.29 to 0.69. Inter-rater reliability between the raters to the reference standard ranged from 0.28 to 0.61. Intra-rater reliability ranged from 0.51 to 0.84. Inter-rater reliability of raters who had attended a Training and Doctrine Command-approved ACFT certification course ranged from 0.51 to 0.66, while those who had not ranged from 0.34 to 0.46. BMI and sex were associated with load lifted (r = 0.405, P = .002; r = -0.727, P < .001, respectively). Overall lift success was not associated with load lifted (r = -0.047, P = .731). Overall lift success was not related to sex (χ2 = 0.271, P = .602).CONCLUSION:Inter-rater reliability of the six raters ranged from poor to substantial, while intra-rater reliability ranged from moderate to excellent. Compared to a reference standard, inter-rater reliability ranged from poor to substantial. The wide range in consistency demonstrated in this study, both between and within raters, brings into question the current subjective methods used to grade the MDL. More research is needed to understand the most feasible, valid, and reliable way to assess performance standards like the MDL that may affect a soldier's career progression.

Reflecting on some 60 years of mathematical thinking and teaching leads me to suggest that, in order to be freshly aware of opportunities to support and stimulate the mathematical thinking of others, it has proved greatly valuable to me to continue to explore mathematics for myself. Conversely, maintaining contact with pedagogical issues in my teaching has served to refresh, stimulate and inform my personal awareness of the conduct of mathematical thinking in my mathematical explorations, as well as suggest questions worthy of further exploration. This chapter offers a few examples of mathematical explorations arising from teaching of particular topics and how they bring pedagogical issues to the surface. Similar ideas from other authors have emerged in recent years as interest in both mathematically based pedagogical actions and topic-specific didactical actions has grown.

Se propone que no solo a lo que las personas prestan atención cuando hablan o piensan, sino también a cómo lo prestan, son de importancia clave cuando las personas piensan matemáticamen- te, aprenden matemáticas, leen literatura acerca de educación matemática o realizan investigaciones en educación matemática. Basándose en la disciplina de notar (Mason 2002) y un marco de formas de prestar atención a las cosas (Mason 1986, 2008), se ofrecen al lector experiencias en tratar de atrapar cómo cambia su atención tanto en el enfoque como en la forma.

Background Overutilization of diagnostic imaging is associated with poor outcomes and increased costs. Physical therapists demonstrate the ability to order diagnostic imaging safely and appropriately, and early access to physical therapy reduces unnecessary imaging, lowers healthcare costs, and improves outcomes. Hypothesis/Purpose The primary purpose of this study was to compare rates of compliance with the National Committee for Quality Assurance – Healthcare Effectiveness Data and Information Set (HEDIS) recommendations for diagnostic imaging in low back pain between physical therapists and primary care providers in young, athletic patients. Study Design Retrospective cohort study. Methods Military Health System Data Repository (MDR) data from January 2019 to May 2020 was reviewed for compliance with the low back pain HEDIS recommendation. The low back pain imaging HEDIS measure identifies the percentage of patients who did not have an imaging study (plain X-ray, MRI, CT Scan) ordered on the first encounter with a diagnosis of low back pain or in the 28 days following that first diagnosis. Chi-square tests compared HEDIS compliance rates, with α = 0.05 set a priori. Results From January 2019 to May 2020, in patients age 18-24, the MDR database identified 1,845 total visits for LBP identified in the Physical Therapy Clinic and 467 total visits for LBP in the Primary Care Clinic. In the Physical Therapy Clinic, 96.7% of encounters did not have imaging ordered within the first 28 days of onset of symptoms, compared with 82.0% in the Primary Care Clinic (p < .001). Conclusions Utilizing data from a national standardized healthcare performance measure, physical therapists practicing in a direct-access setting were significantly more likely than primary care providers to adhere to guidelines for low back pain imaging in young, athletic patients. Level of Evidence Level 3.

In this paper we consider implications of the current world-wide inclusion of computational thinking in relation to children’s development of algebraic thinking. Little is known about how newly developed visual programming environments such as Scratch could enhance early algebra learning. The study is based on examples of programming activities used by mathematics teachers in Sweden, teaching students aged 10–12 years during the first two years of implementing programming in the mathematics curriculum. Informed by Chevallard’s praxeology in terms of praxis and logos, we describe, unpack, discuss and expand these activities. Core issues related to algebra found in the three activities are as follows: making implicit variables explicit; using a counter variable; and identifying parameters as a specific type of variable. Our findings show that, in addition to already identified uses of variables in early algebra, programming activities in the early years bring in new aspects and new ways of treating variables that could, potentially, enhance students’ understanding of variables and generalization, provided that programming praxis is embedded in an appropriate algebra logos.

The consequences of a virtual encounter with George Pólya as a teacher are recorded. An instance of his influence on my mathematical thinking is recounted through work on one of the problems in one of his books. Subject Classification: 01A99, 11A05, 97-03, 97D50

Background:Traumatic shoulder instability is a common injury in athletes and military personnel. Surgical stabilization reduces recurrence, but athletes often return to sport before recovering upper extremity rotational strength and sport-specific abilities. Blood flow restriction (BFR) may stimulate muscle growth without the need for heavy resistance training post-surgically. Hypothesis/Purpose:To observe changes in shoulder strength, self-reported function, upper extremity performance, and range of motion (ROM) in military cadets recovering from shoulder stabilization surgery who completed a standard rehabilitation program with six weeks of BFR training. Study Design:Prospective case series. Methods:Military cadets who underwent shoulder stabilization surgery completed six weeks of upper extremity BFR training, beginning post-op week six. Primary outcomes were shoulder isometric strength and patient-reported function assessed at 6-weeks, 12-weeks, and 6-months postoperatively. Secondary outcomes included shoulder ROM assessed at each timepoint and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST), the Upper Extremity Y-Balance Test (UQYBT), and the Unilateral Seated Shotput Test (USPT) assessed at the six-month follow-up. Results:Twenty cadets performed an average 10.9 BFR training sessions over six weeks. Statistically significant and clinically meaningful increases in surgical extremity external rotation strength (p < 0.001; mean difference, .049; 95% CI: .021, .077), abduction strength (p < 0.001; mean difference, .079; 95% CI: .050, .108), and internal rotation strength (p < 0.001; mean difference, .060; CI: .028, .093) occurred from six to 12 weeks postoperatively. Statistically significant and clinically meaningful improvements were reported on the Single Assessment Numeric Evaluation (p < 0.001; mean difference, 17.7; CI: 9.4, 25.9) and Shoulder Pain and Disability Index (p < 0.001; mean difference, -31.1; CI: -44.2, -18.0) from six to 12 weeks postoperatively. Additionally, over 70 percent of participants met reference values on two to three performance tests at 6-months. Conclusion:While the degree of improvement attributable to the addition of BFR is unknown, the clinically meaningful improvements in shoulder strength, self-reported function, and upper extremity performance warrant further exploration of BFR during upper extremity rehabilitation. Level of Evidence:4, Case Series.

Injuries to the meniscus, particularly tears, can have significant negative impacts on pain, function, and quality of life. Preservation of the meniscus is favorable, especially in the athletic and active populations. While first line treatment is often nonoperative in nature, recalcitrant, and more complex tears, typically require surgery. Meniscus repair rates have increased significantly during the last 2 decades as surgical techniques and postoperative outcomes have improved. Longer postoperative timeframes are to be expected when compared with menisectomy, however, accelerated programs have demonstrated favorable outcomes. Rehabilitation and return to play guidelines should reflect the intricacies of the tear type and repair procedure. Close communication with the surgeon is a vital component to optimize patient outcomes. Further, the patient’s goals and expected level of return to function, or sport, must be taken into account for a rehabilitation program to be fully successful.