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Clinical Scenario: Patellofemoral pain (PFP) is characterized by general anterior knee pain around the patella and is one of the most prevalent knee conditions. PFP is challenging to treat due to a wide range of contributing factors and often has chronic, reoccurring symptoms. Traditional treatment focuses on quadriceps and gluteal strengthening with minimal emphasis on deep trunk musculature. Recently, there has been a growing body of literature supporting the beneficial effects of core stability exercises as a treatment option for PFP. Clinical Question: Are core stability exercises coupled with traditional rehabilitation more effective than only traditional rehabilitation techniques for decreasing pain in patients with PFP? Summary of Key Findings: Three articles met the inclusion criteria and investigated core strengthening exercises as a treatment for PFP. Two studies investigated a 4-week exercise protocol and demonstrated a greater decrease in pain when compared to the control group. The third study examined the effects of a 6-week program where both the intervention and control groups resulted in similar reduction of pain. All articles included received a minimum of 6 on the PEDro scale. Clinical Bottom Line: There is evidence that supports core stability exercise protocols coupled with traditional rehabilitation as being more effective in reducing pain in patients with PFP when compared to traditional rehabilitation alone. Strength of Recommendation: The grade of A is recommended based on the Strength of Recommendation Taxonomy.

Clinical Scenerio: Neck pain is a costly symptom in both civilian and military worlds. While traditional treatments include deep neck flexor stabilizing exercises, manual therapy, electrical therapy, and other nonsurgical interventions, scapular orientation and stability training has emerged as a possible tool to reduce neck pain severity. Methods that can be coached at a distance could be of value in virtual appointments or circumstances where access to a qualified manual therapist is limited. Focused Clinical Question: What is the effectiveness of including exercise programs targeting scapular kinematics and stability to decrease neck pain? Summary of Key Findings: Exercise programs targeting scapular kinematics and stability, with coaching and individualized progressions, appear to reduce neck pain severity. Clinical Bottom Line: Evidence supports the inclusion of exercises for scapular kinematics and stability at a prescription of 3 sessions per week, with a duration of 4 or 6 weeks. Exercise programs should include a “learning” or coaching phase to ensure exercises are performed as intended, and exercise progressions should be based on participant ability rather than predetermined timelines. Further research is needed to better understand the benefits of this potential strategy and the statistical impact of scapular-focused exercise interventions on neck pain in specific populations like military and athletes. Strength of Recommendation: There is ‘Fair’ to ‘Good’ evidence from 2 level 1b single-blind randomized control studies and 1 level 2b pre-post test control design study supporting the inclusion of exercise programs targeting scapular kinematics and stability to decrease chronic neck pain severity.

Context: Monitoring training loads and consequent fatigue responses are usually a result of personal trainers’ experiences and an adaptation of methods used in sports for people without disabilities. Currently, there is little scientific evidence on the relationship between training load and fatigue resulting from training sessions in wheelchair sports. Analogous to the vertical jump, which has been associated with competitive performance and used to assess fatigue in Olympic sports, the medicine ball throw (MBT) is a fast, feasible, and accessible test that might be used to measure performance outcomes in Paralympic athletes. Objective: To test the MBT responsiveness to detect meaningful changes after training sessions in beginner wheelchair basketball players (WBP). Design: Cross-sectional study. Setting: Rehabilitation Hospital Network, Paralympic Program. Participants: Twelve male WBP. Main Outcomes Measures: The participants performed 3 consecutive days of training sessions involving exercises of wheelchair basketball skills, strength, and power. The MBT test was performed pre and post training sessions. Results: The smallest worthwhile change for MBT was 0.10 cm, and the lower and upper limits were 3.54 and 3.75 m, respectively. On the first day, the MBT started below the smallest worthwhile change lower limit and increased above the upper limit (3.53 and 3.78 m, respectively). On the second day, the MBT pretraining and posttraining session results were near the sample mean (3.62 and 3.59 m, respectively). On the third day, the WBP started the MBT test training higher than the upper limit (3.78 m) and decreased to near the mean (3.58 m). Conclusions: During 3 consecutive days of training sessions, the magnitude-based inference model presented meaningful changes in MBT test performance. The accurate association of the magnitude-based inference model with the MBT allows coaches and sports team staff to interpret the correct magnitude of change in WBP performance.

Context: The high rates of adductor injuries and reinjuries in soccer have suggested that the current rehabilitation programs may be insufficient; therefore, there is a need to create prevention and reconditioning programs to prepare athletes for the specific demands of the sport. Objective: The aim of this study is to validate a rehab and reconditioning program (RRP) for adductor injuries through a panel of experts and determine the effectiveness of this program through its application in professional soccer. Design: A 20-item RRP was developed, which was validated by a panel of experts anonymously and then applied to 12 injured male professional soccer players. Setting: Soccer pitch and indoor gym. Participants: Eight rehabilitation fitness coaches (age = 33.25 [2.49] y) and 8 academic researchers (age = 38.50 [3.74] y) with PhDs in sports science and/or physiotherapy. The RRP was applied to 12 male professional players (age = 23.75 [4.97] y; height = 180.56 [8.41] cm; mass = 76.89 [3.43] kg) of the Spanish First and Second Division (La Liga). Interventions: The experts validated an indoor and on-field reconditioning program, which was based on strengthening the injured muscle and retraining conditional capacities with the aim of reducing the risk of reinjury. Main Outcome Measures: Aiken V for each item of the program and number of days taken by the players to return to full team training. Results: The experts evaluated all items of the program very highly as seen from Aiken V values between 0.77 and 0.94 (range: 0.61–0.98) for all drills, and the return to training was in 13.08 (±1.42) days. Conclusion: This RRP following an injury to the adductor longus was validated by injury experts, and initial results suggested that it could permit a faster return to team training.

Clinical Scenario: Traditional loading (TL) is a common technique to employ when engaging in countermovement jumps (CMJ). Accentuated eccentric loading (AEL) is a newer modality that is being explored for acute CMJ performance. Focused Clinical Question: In adult, resistance-trained males, will AEL have a superior impact on acute CMJ performance compared to TL? Summary of Key Findings: The literature was searched for studies that examined the influence of AEL on acute CMJ performance compared to a TL protocol. TL was defined as any loading condition that utilized an equivalent resistance during both the eccentric and concentric contractions. Three studies met the inclusion and exclusion criteria, and were identified and included in the critically appraised topic. Each of the 3 studies found that various AEL conditions were either equal to or better than TL when examining subsequent CMJ performance. In no specific CMJ outcome measure was TL deemed to have a greater impact than AEL. Clinical Bottom Line: AEL provides more favorable acute CMJ performance than TL in adult, resistance-trained males. Strength of Recommendation: Consistent findings from 2 randomized crossover studies and one repeated-measured design investigation suggest level 2b evidence to support AEL as an ideal protocol for acute CMJ performance.

Context: The trunk/pelvis is an important link between the upper- and lower-extremities. Therefore, assessing strength of the trunk and hip muscles that control the segments is clinically meaningful. While an isokinetic dynamometer can be used to measure trunk strength, the equipment is expensive and not portable. Objective: To test the reliability of simple trunk and hip strength measures that utilize a bar, straps, and a portable tension dynamometer. Design: Test–retest reliability study. Setting: Biomechanics research laboratory. Patients (or Other Participants): Twenty college-age individuals (10 males/10 females, age = 20.9 [3.7] y) participated. Intervention(s): The participants attended 2 testing sessions, 1 week apart. The participants’ trunk-flexion, rotation, and hip abduction strength were measured at each session. Main Outcome Measures: Peak trunk flexion, rotation, and hip abduction forces were normalized to the participant’s body weight (BW). In addition, hip-abduction torque was calculated by multiplying the force times the leg length and normalized to BW. The trial data from both sessions were used to calculate the intrasession reliability, and the averages from the 2 sessions were used to calculate the intersession reliability. Intraclass correlation coefficients, SEM, and minimal detectable change were calculated to evaluate reliability of measures. Results: The intrasession intraclass correlation coefficients (SEM) for trunk flexion, rotation, hip abduction, and hip abduction torque were .837 (5.2% BW), .978 (1.3% BW), .955 (1.0% BW), and .969 (5.8 N·m/BW), respectively. The intersession reliability for trunk flexion, rotation, hip abduction, and hip abduction torque were .871 (4.3% BW), .801 (3.8% BW), .894 (1.5% BW), and .968 (5.9 N·m/BW), respectively. Conclusions: The measures of trunk and hip abduction strength are highly repeatable within a session. The reliability of the measures between sessions was also good/excellent with relatively small SEM and minimal detectable change. The tests described in this study can be used to assess changes in trunk/hip strength over time.

Clinical Scenario: Kinesiophobia is a common psychological phenomenon that occurs following injury involving fear of movement. These psychological factors contribute to the variability among patients’ perceived disability scores following injury. In addition, the psychophysiological, behavioral, and cognitive factors of kinesiophobia have been shown to be predictive of a patient’s self-reported disability and pain. Previous kinesiophobia research has mostly focused on lower-extremity injuries. There are fewer studies that investigate upper-extremity injuries despite the influence that upper-extremity injuries can have on an individual’s activities of daily living and, therefore, disability scores. The lack of research calls for a critical evaluation and appraisal of available evidence regarding kinesiophobia and its contribution to perceived disability for the upper-extremity. Focused Clinical Question: How does kinesiophobia in patients with upper-extremity injuries influence perceptions of disability and quality of life measurements? Summary of Key Findings: Two cross-sectional studies and one cohort study were included. The first study found a positive relationship between kinesiophobia and a high degree of perceived disability. Another study found that kinesiophobia and catastrophic thinking scores were the most important predictors of perceived upper-extremity disability. The third study found that kinesiophobia contributes to self-reported disability in the shoulder. Clinical Bottom Line: There is moderate evidence that supports the relationship between kinesiophobia and perceived disability, and the relationship between elevated perceptions of disability and increased kinesiophobia scores in patients with an upper-extremity injury. Clinicians should evaluate and monitor kinesiophobia in patients following injury, a condition that can enhance perceptions of disability. An elevated perception of disability can create a cycle of fear that leads to hypervigilance and fear-avoidance behavior. Strength of Recommendation: Consistent findings from reviewed studies suggest there is grade B evidence to support that kinesiophobia is related to an increased perceived disability following upper-extremity injuries.

Context: Total Motion Release^® (TMR^®) is a novel treatment paradigm used to restore asymmetries in the body (eg, pain, tightness, limited range of motion). Six primary movements, known as the Fab 6, are performed by the patient and scored using a 0 to 100 scale. Clinicians currently utilize the TMR^® scale to modify treatment, assess patient progress, and measure treatment effectiveness; however, the reliability of the TMR^® scale has not been determined. It is imperative to assess scale reliability and establish minimal detectable change (MDC) values to guide clinical practice. Objective: To assess the reliability of the TMR^® scale and establish MDC values for each motion in healthy individuals in a group setting. Design: Retrospective analysis of group TMR^® assessments. Setting: University classroom. Participants: A convenience sample of 61 students (23 males and 38 females; 25.48 [5.73] y), with (n = 31) and without (n = 30) previous exposure to TMR^®. Intervention: The TMR^® Fab 6 movements were tested at 2 time points, 2 hours apart. A clinician with previous training in TMR^® led participant groups through both sessions while participants recorded individual motion scores using the 0 to 100 TMR^® scale. Test–retest reliability was calculated using an intraclass correlation coefficient (2,1) for inexperienced, experienced, and combined student groups. Standard error of measurement and MDC values were also assessed for each intraclass correlation coefficient. Outcome Measure: Self-reported scores on the TMR^® scale. Results: Test–retest reliability ranged from 0.57 to 0.95 across the Fab 6 movements, standard error of measurement values ranged from 4.85 to 11.77, and MDC values ranged from 13.45 to 32.62. Conclusion: The results indicate moderate to excellent reliability across the Fab 6 movements and a range of MDC values. Although this study is the first step in assessing the reliability of the TMR^® scale for clinical practice, caution is warranted until further research is completed to establish reliability and MDC values of the TMR^® scale in various settings to better guide patient care.

Clinical Scenario : Low back pain is a common condition for the general population with 29% of adults having low back pain within the last 3 months. A deadlift is described as a free weight exercise in which a barbell is lifted from the floor in a continuous motion by extending the knees and hips. For those without low back pain, the deadlift was found to have the highest muscle activation of paraspinal musculature compared with other exercises. There are a limited number of studies that investigate the usefulness of incorporating deadlifts as part of a rehabilitation program for low back pain. Clinical Question: For those who live with low back pain, is an exercise routine that includes a deadlift a viable treatment option to improve pain and/or function? Summary of Key Findings: The literature search yielded 3 total studies meeting the inclusion and exclusion criteria: 1 randomized control trial, 1 secondary analysis of a randomized control trial, and 1 cohort study. Exercise programs that include deadlifts can yield improvements in both pain and function for those living with low back pain but were not found to be more beneficial than low load motor control exercises. Those with lower pain levels and higher baseline lumbar extension strength may be most appropriate to participate in an exercise program that includes deadlifts. Further research is needed to compare exercise programs that include deadlifts to other interventions for those living with low back pain. Clinical Bottom Line: There is minimal evidence that exercise programs that included deadlifts are a clinically effective option for the treatment of low back pain for both pain scores and functional outcome measures. Strength of Recommendation: Level B evidence exists that exercise programs that include deadlifts are a clinically effective option for the treatment of low back pain for both pain scores and functional outcome measures.