# Background Assessing lower extremity strength and performance is common practice in sports medicine. Sport-specific demands could impact the amount of leg strength asymmetry between the dominant and non-dominant leg present in athletes. # Hypothesis/Purpose The purpose of this pilot study was to explore the amount of lower limb strength asymmetry between the dominant and non-dominant of female collegiate athletes across different sports. # Study Design Case control study. # Methods A total of 43 female Division I collegiate athletes from soccer, tennis, and volleyball teams participated in the study. Subjects were separated into groups based on participation in a jumping sport (volleyball) versus a cutting sport (soccer and tennis). Differences in concentric quadriceps peak torque between the dominant and non-dominant legs at 60 deg/sec, measured using the Biodex System 3 isokinetic dynamometer, were compared across groups. Athletes of each sport type were classified as “dominant stronger”, “equal”, or “non-dominant stronger” based on the differences between leg strength using a cut-off value of a difference of 10ft-lbs of torque. Odds ratios were calculated to determine the association between sport exposure and quadriceps strength on the dominant side. # Results Jumping athletes were 30 times (OR=29.96 (CI 95%, 1.56 - 577.25) more likely than cutting athletes to have a stronger dominant quadriceps. In jumping athletes, the participants were distributed almost evenly across the “dominant stronger”, “non-dominant stronger”, and “equal” groups. In cutting athletes, 76.9% fell into the “equal” category, while the remaining 23.1% fell into the “non-dominant stronger” category. # Conclusion Female collegiate jumping athletes were much more likely to have a stronger quadriceps on the dominant vs non-dominant leg than were cutting athletes. This information can be used to help develop specific strength and conditioning and rehabilitative programs for female athletes. # Level of Evidence Level 3

Background Neuropathic pain is common after spinal cord injury (SCI). Despite the availability of various treatments, many report inadequate pain relief, and various side effects. Objective The primary purpose of the current study was to explore participants' perspectives on a brief, four-week virtual pain education program and second to evaluate any effects on pain and psychosocial factors. Methods This study included 36 participants with SCI who experienced moderate to severe neuropathic pain and explored their perspectives on the pain program using qualitative interviews and evaluated a small set of self-reported pain outcomes. Results The analysis and coding of the qualitative interview data resulted in two primary overarching themes: Benefits of pain education and Content and delivery of pain education. The Benefits of pain education theme was further analyzed and divided into 6 subthemes: Learning about pain and treatment options in general, Learning from and interacting with peers, Learning about non-pharmacological approaches and ways to self-manage pain, Learning about pathophysiology of pain, Learning about pain medication, and Improving communication about the lived experience with pain. Under the main theme of Content and delivery of Pain Education, there were three subthemes: Positive, No effect or negative, and Change suggestions. Specifically, participants reported having a better understanding about treatment options, how their peers managed their pain, and the underlying causes and types of pain. Participants also perceived that this knowledge would improve their ability to talk to others about their pain. Participants mentioned the topics discussed and the small group interactive settings as positive aspect of the education, although some did not benefit or felt that focusing on pain made pain more obvious to them. The overall benefit was consistent with small but significant improvements in perceived pain interference with daily activities and difficulty in dealing with pain (p < 0.05). Conclusion Overall, these findings suggest that a brief, virtually administered pain education program in a small group setting may be a positive addition to an interdisciplinary pain program. Future research should continue to develop and individually tailor such programs in this population, as these approaches are low-cost and easily accessible.

OBJECTIVE:To describe the clinical reasoning and use of the American Diabetes Association (ADA) blood glucose and exercise guidelines in the face of an emerging acute glycemic crisis for a patient with type 2 diabetes mellitus receiving physical therapy for chronic ankle instability and fibromyalgia. CASE DESCRIPTION:Assessment of the patient's baseline blood glucose and ketone urinalysis revealed hyperglycemia and ketonuria, respectively. Shortly after testing, the patient became nauseous and vomited. This prompted assessment of her end-tidal carbon dioxide via nasal capnography to screen for diabetic keto-acidosis. Evidence of Kussmaul breathing, tachypnea, and hypocapnia in conjunction with hyperglycemia and ketonuria, as well as symptoms of nausea and signs of vomiting prompted a referral to the emergency department. OUTCOMES:The patient was admitted to the hospital for five days with a diagnosis of acute kidney injury. It was determined that the acute kidney injury was caused by hyperglycemia in combination with impaired kidney function and an exacerbation of her congestive heart failure, all of which are known risk factors for acute kidney injuries in patients with diabetes mellitus. CONCLUSIONS:Compliance with the ADA blood glucose exercise guidelines allowed for early recognition of metabolic dysfunction prior to the onset of symptoms. Failure to have complied with the ADA blood glucose exercise guidelines may have resulted in the physical therapist administering therapeutic exercise that likely would have contributed to a worse prognosis.

AbstractBackground and AimsThe purpose of this study was to compare the knowledge and practices of specialist and experienced nonspecialist physical therapists in performing patient education about physical activity with patients with heart failure (HF).MethodsResponses on a nationwide anonymous online survey were used to compare specialist and experienced nonspecialist physical therapists on knowledge and frequency of providing physical activity related education to patients hospitalized with acutely decompensated HF. Responses to survey items were scored on 5‐point scales ranging from “Strongly agree” to “Strongly disagree” or “Always” to “Never.” Mann−Whitney U statistics were used to compare specialist and experienced nonspecialist responses and Wilcoxon signed‐ranks tests were used to examine the gap between knowledge and practice.ResultsTwenty‐seven specialists and 43 experienced nonspecialists completed the survey. Both groups were similar in age, and experience treating patients hospitalized with acutely decompensated HF. Both groups “strongly agree” that they had the required knowledge and skills to educate patients with HF on the physical activity topics. However, specialists more often than experienced nonspecialists provided education on topics such as how to monitor vital signs during physical activity (“most of the time” vs. “about half of the time”) that promoted patient confidence and safety during exercise. Specialists demonstrated a smaller gap between knowledge and frequency of providing patient education than experienced nonspecialists on three of the four patient education topics.ConclusionSpecialist physical therapists treating patients with HF in the inpatient hospital setting provided patient education on physical activity at a level more closely matching their skills and the clinical practice guideline than did experienced nonspecialists. Physical therapy clinical specialists practicing in the inpatient hospital setting may improve patient outcomes and lower costs to the health care system by improving physical activity adherence and thereby may reduce avoidable hospital readmissions.

Background: The aim of this study was to analyze the influence of beliefs and attitudes of practicing physical therapists (PTs) about aging on their expectations concerning the behavior and outcomes of patients with orthopedic conditions. We hypothesized that some beliefs and attitudes would be related to expectations of worse outcomes in older patients compared to clinically identical younger patients. Methods: Seventy-one (71) practicing PTs with a mean age of 40 years (±10.44, range 24–67) were recruited via snowball sampling and asked to participate in a three-part online questionnaire. For part 1, participants were randomly assigned a hypothetical case involving either a 42-year-old or an 85-year-old patient s/p surgical repair of a femoral shaft fracture. Thirty-five (35) participants were randomly assigned to the young case group (YCG) and 37 to the old case group (OCG). Participants were asked questions related to their expectations concerning the patient’s clinical and functional potential, response and adherence to physical therapy, and patient responsibility for their own outcomes. For part 2, all participants completed the Kogan Attitude Toward Old People Scale consisting of 34 paired (positive/negative) statements. Part 3 consisted of subject demographics. Results: Participants in the YCG and the OCG were similar in age (41 vs. 40 years), PT experience (16.7 vs. 14.8 years), gender (82.9% vs. 86.5% female), and positive Kogan score (69.5 vs. 68.2). The groups differed in belief the patient would return to their prior level of function. YCG believed it was “extremely likely”, while the OCG believed it was “moderately likely”. In the OCG, greater likelihood that the patient would return to prior level of function was related to stronger belief that “Most ageing adults are really no different from anybody else” (r = 0.35). Conclusion: In general, physical therapist participants in this study agreed with positive attitudes and beliefs about aging adults as measured by total positive Kogan score. The only outcome expectation that appeared to be influenced by the age of hypothetical patient was return to prior level of function. Although some specific age-related beliefs were correlated to expectation of return to prior level of function, the positive Kogan score was not. It is possible that age related differences in expectations of return to prior level of function were influenced by clinical experience rehabilitating older patients rather than negative attitudes and beliefs about aging.

Objectives: Telehealth platforms have become a crucial part of healthcare since the onset of the COVID-19 pandemic. The primary aim of this cohort study was to investigate pain outcomes, following telehealth group-based pain management programs (GPMPs) with a focus on comparing subjects who were readier to change (RTC) maladaptive pain behaviors prior to intervention versus those subjects who were less ready to change. Methods: Subjects were divided at baseline into one of 2 cohort groups; the exposed group (more RTC) and unexposed group (less RTC). There were 5 separate telehealth GPMP groups each consisting of subjects from both cohort groups. Each group met once a week via zoom software and ran over a course of 6 weeks in which Chronic Pain (CP) self-management techniques were taught. Pain outcome measures were taken at baseline and at after the final telehealth GPMP. Results: The unexposed group scored greater magnitude in change of scores from pre-to-post intervention in which these changes all signified improvements in scores following the telehealth GPMPs. The primary pain constructs examined being pain self-efficacy, pain catastrophizing and pain kinesiophobia all showed moderate to large effect sizes between the groups; Cohen`s d= 0.55, 0.77 and 0.65 respectively. Conclusions: Within and post the COVID-19 pandemic, telehealth GPMPs have a clinically relevant role to play in the self-management treatment of patients with CP. Understanding individuals` levels of RTC prior to running telehealth GPMPs, seems to be an important factor in predicting improvements in various CP outcomes.

Objectives: Telehealth pain management has become instrumental in managing patents with chronic pain (CP) since the onset of the COVID-19 pandemic. Little is known, however, about which patient’s best respond to these telehealth interventions. The primary aim of this study was to investigate patients’ demographic and clinical characteristics that predict the efficacy of telehealth Group-Based Pain Management Programs (GPMPs) based on change in various pain outcome measures from pre-to-post-intervention. Methods: The research included five separate telehealth GPMP groups each consisting of patients from different countries with various musculoskeletal CP conditions. Each group met once a week for 3 hours via zoom software and ran over a course of 6 weeks in which CP self-management techniques were taught. Pain outcome measures were taken at baseline and after the final telehealth GPMP. Regression analyses as well as other statistical procedures were used to determine the predictive nature of the patient’s demographic and clinical variables. Results: Baseline emotional wellbeing demonstrated statistically significant associations (p<0.05) with baseline outcome measures. The primary pain outcome measures including the Pain Self-Efficacy Questionnaire, the Pain Catastrophizing Scale-Total and the Tampa Scale of Kinesiophobia, all showed large effect sizes; d=0.90, d=0.75 and d=0.77 respectively. Changes in the primary pain outcome measures` scores all showed statistically significant relationships (p<0.05) with their individual baseline scores. Conclusion: Telehealth GPMPs have an important clinical role to play in the management of patients with CP. Understanding patients` clinical and demographic characteristics appears to be an important factor in predicting changes in pain manifestations.

Introduction Telehealth pain management has become instrumental in managing patients with chronic pain (CP) since the onset of the COVID-19 pandemic. The primary aim of this study was to investigate whether various covert therapeutic variables aid in the efficacy of telehealth group-based pain management programs (GPMPs). The therapeutic alliance (TA), group dynamics (GDs), attendance and change in pain neuroscience knowledge were evaluated as potential predictor covert variables of change in pain outcome measures and readiness to change (RTC) maladaptive pain behaviors. Methods Telehealth GPMP groups met once a week for 3 hours via zoom software and ran over a course of 6 weeks in which CP self-management techniques were taught. Pain outcome measures were taken at baseline and after the final telehealth GPMP. In addition, the measures around pain neuroscience understanding were examined at baseline and post-intervention. Finally, the TA and GDs were examined at post-treatment using the Therapeutic Group Context Questionnaire (TGCQ). Various statistical procedures were utilized to determine the predictive nature between the specific variables. Results The TA and GDs showed statistically significant ( p < 0.05) predictive relationships with improved changes in maladaptive pain behaviors and pain self-efficacy. There was also a statistically significant ( p < 0.05) predictive relationship between maladaptive pain behavioral changes and improvements in pain self-efficacy, pain catastrophizing and pain kinesiophobia. Discussion This research suggested that covert components in a telehealth GPMP such as changes in readiness to change (RTC) maladaptive pain behaviors, the TA, and GDs are all strong predictors of improvements in pain outcome measures following such an intervention.

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

Background: Elite tennis athletes experience injuries throughout the entire body. Impairments in trunk stability, lower limb flexibility, and hip range of motion (ROM) are modifiable risk factors that can impact injuries and performance. Information on nonmodifiable risk factors such as age and gender is limited. The purpose of this investigation was to provide information on risk factors to direct clinical decision-making and injury prevention and rehab programming in this population. Hypothesis: Prevalence and location of injuries will differ by age group and gender. Trunk stability, lower limb flexibility, and hip ROM will differ by age group and gender. Study Design: Cross-sectional study. Level of Evidence: Level 3. Methods: A de-identified database (n = 237; females = 126) from the United States Tennis Association High Performance Profile (HPP) 2014-2015 was used for the analysis. Subjects were elite junior and professional tennis players (mean age 14.6 [range, 9-27] years). The HPP is a tennis-specific assessment and questionnaire that includes retrospective information on injury history. Subjects were categorized by injury, gender, and age. Injury locations were classified by region. Trunk stability measures included drop vertical jump (DVJ), single-leg squat, and prone and side planks. Lower limb measures included hamstring, quadriceps and hip flexor flexibility, and hip rotation ROM. Results: A total of 46% of athletes reported an injury. Significant differences were found for injury prevalence and location by age group. Adolescent athletes (age 13-17 years) had more trunk injuries, while adult athletes (age ≥18 years) had more lower limb injuries. Adolescent athletes performed worse on DVJ, dominant side plank, and hamstring flexibility compared with young (age ≤12 years) and adult athletes. Significant gender differences in hip ROM included internal rotation on both the dominant and nondominant sides. Conclusion: Impairments in trunk stability, lower limb flexibility, and hip rotation ROM may affect both health and performance outcomes in this population. Elite tennis athletes may benefit from additional off court programming to address trunk and lower limb impairments. Clinical Relevance: Adolescent elite tennis athletes may be at higher risk of trunk injuries. Age, gender, injury history, and impairments should be considered with all assessments and programming.

Background: The Shoulder Pain and Disability Index (SPADI) is the most commonly used self-administered questionnaire which is a valid and reliable instrument to assess the proportion of pain and disability in shoulder disorders. There is no evidence of SPADI questionnaire being translated into regional Indian language (Marathi). Objective: This study aims to translate and culturally adapt and validate the Marathi version of the SPADI questionnaire. This was done as per the AAOS outcomes committee guidelines. Methods: Cross-cultural adaptation and psychometric testing of SPADI was done in the Outpatient Physiotherapy Department of Tertiary Care Hospital, Ahmednagar, India. Results: The internal consistency was assessed by calculating Cronbach alpha value for the pain score (0.908), disability score (0.959), and total SPADI (0.969) which were all high. The Test-retest reliability was assessed using the intraclass correlation coefficient (ICC) values for the pain score (0.993), disability score (0.997), and total SPADI (0.997) which showed excellent reliability. The criterion validity was assessed using Pearson correlation coefficient. In Males, weak to strong negative correlation was observed except for shoulder extension and in females, moderate negative correlation was observed between baseline shoulder range of motion and initial total SPADI scores and individual pain and disability except for shoulder internal rotation. The internal consistency of the Marathi SPADI (Cronbach's alpha >0.99) was higher than the original English version. The reliability of the total Marathi SPADI and its subscale (Intraclass correlation coefficient >0.90) were found to be higher than that of the English SPADI and were consistent with the German, Brazilian, Slovene and Greek versions. Conclusion: The translated and culturally adapted Marathi version of the SPADI questionnaire is a reliable and valid tool for the assessment of pain and disability in Marathi population.

Background Olympic class sailors commonly report Knee pain. Our previous research associates hiking with increased knee pain in competition. Objective Examine the protective nature of training participation on sailors’ knee pain in terms of risk reduction. Design A cohort completed a 61-item anonymous questionnaire concerning sailing-related activities, demographics, and knee pain status. Risk factor exposures were in place at the beginning of racing. Setting Sailing World Cup regatta. Patients (or Participants) 97 subjects (37 female), age 23.62 years (SD 4.74, range 8–43), Body Mass Index 23.95 kg/m2 (SD 5.8, range 19.2–28.6), 11.49 (SD 5.9, range 3–45), years competitive sailing experience, and 4.72 (SD 3.19, range 0–16) years current class sailing experience. Interventions (or assessment of risk factors) Risk Ratios (RR) and 95% confidence intervals(CI95%) via Cochran-Mantel-Haenzel statistic. Previous research describes increased risk of knee pain exposures of hiking, younger age (<23 yrs) and high unloading (>2hr) times pre-regatta. Female gender, obesity, and previous injury have increased knee pain associations in other populations. These factors were examined for confounding training’s effect on knee pain risk. Main outcome measurements Eighteen new cases of knee pain were reported. 91(94%) subjects reported training habits (13 non-training). RR(CI95%) calculated risk of knee pain in training/non-training sailors. Results Training participation reduced knee pain risk 83%, RR=0.17(CI95%.08, 0.34). Subjects with previous history of injury were 4.5 times more likely to develop knee pain during the regatta. RR=4.5(CI95%2, 10). Confounding analysis found training and previous injury history the only variables significantly different in both exposure/disease groups. Stratified analysis found training associated with 82% decreased incident knee pain risk in sailors with no injury history RR=0.18(CI95%.06, 0.61) and 74% in sailors with previous injury RR=0.26(CI95%.12, 0.62). Adjusted for previous injury, training reduced knee pain risk 76%, RR=0.24(CI95%.11, 0.93). Conclusions The protective effect of training, adjusted for previous injury, decreased incident knee pain risk throughout a week-long regatta. The protective effect of training associated with incident knee pain is greater for sailors without previous injury.

Background Despite the prevalence of lower limb amputation (LLA), only a small percentage of people with LLA actually receive physical therapy post amputation and are rehabilitated to their full potential level of function. There is a need for the development of a rehabilitation program that targets impairments and limitations specific to people with LLA. Objective The objective of this study was to determine whether the Evidence-Based Amputee Rehabilitation program would improve functional mobility of people with unilateral transtibial amputation (TTA) who have already completed physical therapy and prosthetic training. Design This study was a randomized, wait-list control, single-blinded pilot clinical trial. Setting This study researched participants who had received postamputation rehabilitation to varying degrees, either in an inpatient and/or outpatient settings. Participants The participants in this study included veterans and nonveterans with unilateral TTA due to dysvascular disease and trauma. Intervention This study included a prescription-based rehabilitation program for people with amputations. Measurements Results were measured with The Amputee Mobility Predictor with (AMPPro) and without a prosthesis (AMPnoPro) and 6-Minute Walk Test (6MWT) at baseline and at the end of the 8-week intervention. Results The intervention group improved on the AMPPro scores (36.4 to 41.7), AMPnoro scores (23.2 to 27.1), and 6MWT distance (313.6 to 387.7 m). The effect size for the intervention was very large (1.32). In contrast, the wait-list control group demonstrated no change in AMPPro scores (35.3 to 35.6), AMPnoPro scores (24.7 to 25.0), and 6MWT distance (262.6 m to 268.8 m). Limitations The sample size was small. A total 326 potential candidates were screened with 306 unable to meet inclusion criteria or unwilling to participate. Conclusion People with unilateral TTA who received Evidence-Based Amputee Rehabilitation program demonstrated significant improvement in functional mobility, with most participants (66.7%) improved at least 1 K-level (58.3%) and greater than the minimal detectable change (66.7%).

Background:Physical therapist clinical residency programs vary widely in administrative structure, instructional characteristics, and program design. The impact of program-level factors on resident outcomes such as graduation and board certification is unknown. Objective:The objective of this study was to examine the influence of program-level factors on participant outcomes of physical therapist residency programs. Design:This was a retrospective cohort study using data from accredited programs from 2010 to 2013. Methods:Data were collected on program characteristics such as administrative structure, size, salary, tuition, full- or part-time options, didactic format, and clinical-site structure. The odds ratios were calculated to examine the impact of program characteristics on graduation, board certification, and passing the exam. A logistic regression analysis to determine the combined contribution of these characteristics on the 3 outcomes was performed. Results:Data from 183 residency programs and 1589 residents were analyzed. Participants attending programs that were single site or multifacility, provided live didactic instruction, did not charge tuition, and paid residents ≥ 70% full-time equivalent salary were 9.8 times more likely to graduate, 5.1 times more likely to become board certified, and 3.2 times more likely to pass the specialty board examination. Limitations:This study did not examine the impact of program location, resident attributes, or resident exposure to patient diagnostic volume and variety. Conclusions:This study has identified some program-level factors that appear to influence the odds of graduating, becoming board-certified, and passing the specialty board examination. This information could inform existing and developing residency programs, as well as applicants, on program-level factors that might influence participant outcomes.

shown in Figure 1.Sixteen PCs were retained in total across the three GRFs (Table 2).Across the stance phase, FKPþROA limbs had flatter V-GRF (PC1) than controls.They also had flatter ML-GRF (PC5) and a smaller difference between early and late stance AP-GRF (PC1) than limbs without ROA (control or FKPonly).In late stance, FKPþROA had lower V-GRF (PC3) and propulsive force (AP-GRF PC3) compared to all other groups.ROAonly limbs had a lower overall magnitude of ML-GRF (PC1) and flatter ML-GRF (PC5) compared to those without ROA (control or FKPonly).There were no significant differences between FKPonly and control limbs.Conclusions: We observed that limbs with FKPþROA exhibited less dynamic V-GRF, ML-GRF, and AP-GRF across stance compared to the other groups.It is possible that some of the differences observed for ML-GRF between limbs with and without ROA could be affected by lower limb alignment.However, the GRF patterns overall suggest that in the presence of both pain and ROA, walking patterns result in less dynamic GRF.Cyclic loading and unloading during dynamic weight-bearing activities is critical for maintaining articular tissue health.A constant loading pattern, even if lower in magnitude, could potentially overload articular tissues and cause further damage.These results suggest that differences in late-stance GRF can discriminate between asymptomatic and symptomatic ROA.These are novel findings that future work should investigate.Kinematic patterns may be responsible for these GRF adaptations.We did not see significant differences between control limbs and those with knee pain but no ROA once we accounted for multiple factors that could affect walking patterns including gait speed.With data from a large cohort, and using principal component analysis, we observed differences in GRF waveforms with FKP and/or ROA, after accounting for other factors that could affect walking patterns.Future longitudinal studies can clarify the role of these observed GRF patterns in OA onset and progression.

Purpose:The Test of Incremental Respiratory Endurance (TIRE) provides a comprehensive assessment of inspiratory muscle performance by measuring maximal inspiratory pressure (MIP) over time. The integration of MIP over inspiratory duration (ID) provides the sustained maximal inspiratory pressure (SMIP). Evidence on the reliability and validity of these measurements in COPD is not currently available. Therefore, we assessed the reliability, responsiveness and construct validity of the TIRE measures of inspiratory muscle performance in subjects with COPD.Patients and methods:Test-retest reliability, known-groups and convergent validity assessments were implemented simultaneously in 81 male subjects with mild to very severe COPD. TIRE measures were obtained using the portable PrO2 device, following standard guidelines.Results:All TIRE measures were found to be highly reliable, with SMIP demonstrating the strongest test-retest reliability with a nearly perfect intraclass correlation coefficient (ICC) of 0.99, while MIP and ID clustered closely together behind SMIP with ICC values of about 0.97. Our findings also demonstrated known-groups validity of all TIRE measures, with SMIP and ID yielding larger effect sizes when compared to MIP in distinguishing between subjects of different COPD status. Finally, our analyses confirmed convergent validity for both SMIP and ID, but not MIP.Conclusion:The TIRE measures of MIP, SMIP and ID have excellent test-retest reliability and demonstrated known-groups validity in subjects with COPD. SMIP and ID also demonstrated evidence of moderate convergent validity and appear to be more stable measures in this patient population than the traditional MIP.

Background and Purpose: Clonus arising from plantar flexor hyperreflexia is a phenomenon that is commonly observed in persons with spastic hypertonia. We assessed the temporal components of a biomechanical measure to quantify ankle clonus, and validated these in persons with spasticity due to spinal cord injury. Methods: In 40 individuals with chronic (>1 year) spinal cord injury, we elicited ankle clonus using a standardized mechanical perturbation (drop test). We examined reliability and construct validity of 2 components of the drop test: clonus duration (timed with a stopwatch) and number of oscillations in the first 10-second interval (measured via optical motion capture). We compared these measures to the Spinal Cord Assessment Tool for Spastic reflexes (SCATS) clonus score and H-reflex/M-wave (H/M) ratio, a clinical and electrophysiologic measure, respectively. Results: Intra- and interrater reliability of clonus duration measurement was good [intraclass correlation coefficient, ICC (2, 1) = 1.00]; test-retest reliability was good both at 1 hour [ICC (2, 2) = 0.99] and at 1 week [ICC (2, 2) = 0.99]. Clonus duration was moderately correlated with SCATS clonus score ( r = 0.58). Number of oscillations had good within-session test-retest reliability [ICC (2, 1) > 0.90] and strong correlations with SCATS clonus score ( r = 0.86) and soleus H/M ratio ( r = 0.77). Discussion and Conclusions: Clonus duration and number of oscillations as measured with a standardized test are reliable and valid measures of plantar flexor hyperreflexia that are accessible for clinical use. Tools for objective measurement of ankle clonus are valuable for assessing effectiveness of interventions directed at normalizing reflex activity associated with spasticity. Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A179).

Outcomes of training are thought to be related to the amount of training (training dose). Although various approaches to locomotor training have been used to improve walking function in persons with spinal cord injury (SCI), little is known about the relationship between dose of locomotor training and walking outcomes. This secondary analysis aimed to identify the relationship between training dose and improvement in walking distance and speed associated with locomotor training in participants with chronic motor-incomplete spinal cord injury (MISCI). We compared the dose-response relationships associated with each of four different locomotor training approaches. Participants were randomized to either: treadmill-based training with manual assistance (TM = 17), treadmill-based training with stimulation (TS = 18), overground training with stimulation (OG = 15), and treadmill-based training with locomotor robotic device assistance (LR = 14). Subjects trained 5 days/week for 12 weeks, with a target of 60 training sessions. The distance-dose and time-dose were calculated based on the total distance and total time, respectively, participants engaged in walking over all sessions combined. Primary outcome measures included walking distance (traversed in 2 min) and walking speed (over 10 m). Only OG training showed a good correlation between distance-dose and change in walking distance and speed walked over ground (r = 0.61, p = 0.02; r = 0.62, p = 0.01). None of the treadmill-based training approaches were associated with significant correlations between training dose and improvement of functional walking outcome. The findings suggest that greater distance achieved over the course of OG training is associated with better walking outcomes in the studied population. Further investigation to identify the essential elements that determine outcomes would be valuable for guiding rehabilitation.

Background Hiking activity during sailing involves the hips, trunk, head, and upper extremities held in sustained, unsupported positions over the side of a boat to stabilize it at an optimal angle to the water, preventing velocity loss and overturn. Hiking requires high forces generated by lower extremities and trunk, potentially producing high lumbar spine compression and shear loads linked to acute Low Back Pain. Objective This study examined if competitive sailors performing hiking were at increased risk of developing low back pain (LBP) compared to non-hikers over the course of an Olympic class regatta. Design Prospective Cohort . Setting World Cup Regatta. Patients (or Participants) 172 Olympic class sailors completed a questionnaire concerning sailing activities, previous history of, and new LBP following a 6-day regatta. 152 subjects without LBP at the beginning of the regatta were classified as exposed (hikers) and unexposed (non-hikers) and new LBP cases were recorded for both groups. Interventions (or Assessment of Risk Factors) Relative risk ratios (RR) and CI 95% were calculated compared risk of new LBP in hikers and non-hikers. A priori hypothesis tested: hiking sailors are at increased risk for incident LBP versus non-hikers. Main Outcome Measurements Self-report LBP limiting sailing. Results Twenty-two subjects reported new LBP, 18 from hiking exposure group. Exposed (n=84) and unexposed (n=68) were no different in demographic/anthropometric variables across exposure and disease groups. Boat/equipment unloading time differences persisted across groups (P=0.0016, P=0.0022 respectively). Hikers' raw RR was 3.64 (CI 95% 1.29,10.26) times greater than non-hikers' for developing new LBP. Hikers' risk controlled for unloading time levels yielded an adjusted RR of 2.73 (CI 95% 1.05, 7.08). Hikers exposed to high unloading levels (>2 hours) RR was 8.3 (CI 95% 1.05, 65.76) versus non-hikers. Conclusions Hiking and unloading forces may be risk factors for LBP prior to and during Olympic class regattas. Further study recommended.

BACKGROUND:The Shoulder Pain and Disability Index (SPADI) is a tool designed to evaluate the impact of shoulder pathology. The aim of this study was to cross culturally adapt a Spanish version of the SPADI for Spanish population with a musculoskeletal shoulder pain, and to determine the psychometric properties of this instrument using confirmatory factor analysis (CFA).METHODS:Cross-cultural adaptation was performed according to the international guidelines. To assess factor structure, a confirmatory factor analysis was done. Internal consistency was measured using Cronbach's alpha. Item-total and inter-item correlations were assessed. Pearson and Spearman correlations were calculated to assess the convergent validity between SPADI and quick-DASH.RESULTS:A new Spanish version of SPADI was achieved. The original SPADI factor structure was tested by CFA, obtaining a poor fit: relative chi-square (χ2/df) 3.16, CFI 0.89, NFI 0.92, and RMSEA 0.10 (90 % CI 0.08 to 0.12). An additional model was tested, after deleting items which have had a poor adjustment in the model (1, 11, and 12), obtaining the best fit: relative chi-square (χ2/df) of 1.94, CFI 0.98, NFI 0.95, GFI 0,95, and RMSEA 0.06 (90 % CI 0.04 to 0.09). The analysis confirmed the bidimensional structure (pain and disability subscales). A correlation Spearman's Rho coefficient of 0.752 (p < 0.0001) and a Cronbach's alpha of 0.90 were obtained.CONCLUSIONS:This study validated a new 10-items version of SPADI for Spanish population with musculoskeletal shoulder pain providing a patient reported outcome measure that could be used in both clinical practice and research.