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Barton E. Anderson and Kellie C. Huxel Bliven

Clinical Scenario:

Research has shown a link between poor core stability and chronic, nonspecific low back pain, with data to suggest that alterations in core muscle activation patterns, breathing patterns, lung function, and diaphragm mechanics may occur. Traditional treatment approaches for chronic, nonspecific low back pain focus on exercise and manual therapy interventions, however it is not clear whether breathing exercises are effective in treating back pain.

Focused Clinical Question:

In adults with chronic, nonspecific low back pain, are breathing exercises effective in reducing pain, improving respiratory function, and/or health related quality of life?

Summary of Key Findings:

Following a literature search, 3 studies were identified for inclusion in the review. All reviewed studies were critically appraised at level 2 evidence and reported improvements in either low back pain or quality of life following breathing program intervention.

Clinical Bottom Line:

Exercise programs were shown to be effective in improving lung function, reducing back pain, and improving quality of life. Breathing program frequencies ranged from daily to 2–3 times per week, with durations ranging from 4 to 8 weeks. Based on these results, athletic trainers and physical therapists caring for patients with chronic, nonspecific low back pain should consider the inclusion of breathing exercises for the treatment of back pain when such treatments align with the clinician’s own judgment and clinical expertise and the patient’s preferences and values.

Strength of Recommendation:

Grade B evidence exists to support the use of breathing exercises in the treatment of chronic, nonspecific low back pain.

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Alison R. Valier, Ryan S. Averett, Barton E. Anderson and Cailee E. Welch Bacon

Clinical Scenario:

Shoulder pain is a common musculoskeletal complaint and is often associated with shoulder impingement. The annual incidence of shoulder pain is estimated to be 7% of all injuries, and is the third-most-common type of musculoskeletal pain. Initial treatment of shoulder impingement follows a conservative plan and emphasizes rehabilitation programs as opposed to surgical interventions. Shoulder rehabilitation programs commonly focus on strengthening the muscles of the shoulder complex and, more specifically, the rotator cuff. The rotator cuff is a primary dynamic stabilizer of the glenohumeral joint, using both eccentric and concentric contractions. The posterior rotator cuff, including teres minor and infraspinatus, works eccentrically to decelerate the arm during overhead throwing. Exercises to strengthen the rotator cuff and the surrounding dynamic stabilizers of the shoulder girdle vary and include activities such as internal and external rotation, full-can lifts, and rhythmic stabilizations. Traditionally, shoulder rehabilitation programs have focused on isotonic concentric contractions. Common strengthening exercises typically involve movements that result in shortening the muscle length while simultaneously loading the muscles. However, recent attention has been given to eccentric exercises, which involve lengthening of the muscle during loading, for the treatment of a variety of different tendinopathies including those of the Achilles and patellar tendons. The eccentric, or lengthening, motion is thought to be beneficial for people who are involved in activities that place eccentric stress on their shoulder, such as overhead throwers. Based on studies related to the Achilles tendon, eccentric exercise may positively influence the tendon structure by increasing collagen production and decreasing neovascularization. The changes that occur as a result of eccentric exercises may improve function, strength, and performance and decrease pain more than concentric programs, producing better patient outcomes. Although eccentric strength training has been shown to provide strength gains, there are no clear guidelines as to the inclusion of this form of exercise training in shoulder rehabilitation programs for the purposes of improving function and decreasing pain.

Focused Clinical Question:

Does adding an eccentric-exercise component to the rehabilitation program of patients with shoulder impingement improve shoulder function and/or decrease pain?

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Lindsay M. Minthorn, Shirleeah D. Fayson, Lisa M. Stobierski, Cailee E. Welch and Barton E. Anderson

Clinical Scenario:

Appropriate movement patterns during sports and physical activities are important for both athletic performance and injury prevention. The assessment of movement dysfunction can assist clinicians in implementing appropriate rehabilitation programs after injury, as well as developing injury-prevention plans. No gold standard test exists for the evaluation of movement capacity; however, the Functional Movement Screen (FMS) has been recommended as a tool to screen for movement-pattern limitations and side-to-side movement asymmetries. Limited research has suggested that movement limitations and asymmetries may be linked to increased risk for injury. While this line of research is continuing to evolve, the use of the FMS to measure movement capacity and the development of intervention programs to improve movement patterns has become popular. Recently, additional research examining changes in movement patterns after standardized intervention programs has emerged.

Clinical Question:

Does an individualized training program improve movement patterns in adults who participate in high-intensity activities?

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Hannah Horris, Barton E. Anderson, R. Curtis Bay and Kellie C. Huxel Bliven

Context: Altered diaphragm function is linked to decreased core stabilization, postural changes, and decreased function. Two clinical tests used to assess breathing are the Hi-lo and lateral rib expansion (LRE) tests. It is currently unknown how breathing classification based on these tests differ and how their results are affected by varying test positions. Objective: To compare the results of breathing tests when conducted in varying test positions. Design: Prospective cross-sectional study. Setting: University laboratory. Participants: A total of 50 healthy adults (females 31 and males 29; age 29.3 [4.1] y; height 170.0 [10.4] cm; weight70.7 [15.1] kg). Intervention(s): Hi-lo and LRE tests in supine, seated, standing, and half-kneeling body positions. All tests were recorded and later scored by a single examiner. A generalized estimating equations approach with breathing test and body position as factors was used for analysis. Pairwise comparison with Bonferroni correction was used to adjust for multiple tests. Statistical significance was set at P = .05, 2 tailed. Main Outcome Measures: Hi-lo and LRE tests were scored based on the presence or absence of abdominal excursion, LRE, and superior rib cage migration. Following scoring, results were classified as functional or dysfunctional based on observation of these criteria. Results: A significant breathing test × test position interaction (P < .01) was noted, as well as main effects for test (P < .01) and test position (P < .01). All Hi-lo test positions identified significantly more dysfunctional breathers in positions of increased stability demand (P < .01), except between standing and half-kneeling positions (P = .52). In the LRE test, all positions were similar (P > .99) except for half-kneeling, which was significantly different from all other positions (P < .01). Conclusions: The Hi-lo test and LRE tests assess different breathing mechanics. Clinicians should use these tests in combination to gain a comprehensive understanding of a person’s breathing pattern. The Hi-lo test should be administered in multiple testing positions.