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Driban JB, Vincent HK, Trojian TH, Ambrose KR, Baez S, Beresic N, Berkoff DJ, Callahan LF, Cohen B, Franek M, Golightly YM, Harkey M, Kuenze CM, Minnig MC, Mobasheri A, Naylor A, Newman CB, Padua DA, Pietrosimone B, Pinto D, Root H, Salzler M, Schmitt L, Snyder-Mackler L, Taylor JB, Thoma LM, Vincent KR, Wellsandt E, Williams M. Evidence Review for Preventing Osteoarthritis After an Anterior Cruciate Ligament Injury: An Osteoarthritis Action Alliance Consensus Statement. J Athl Train 2023; 58:198-219. [PMID: 37130279 PMCID: PMC10176847 DOI: 10.4085/1062-6050-0504.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
CONTEXT The Osteoarthritis Action Alliance formed a secondary prevention task group to develop a consensus on secondary prevention recommendations to reduce the risk of osteoarthritis after a knee injury. OBJECTIVE Our goal was to provide clinicians with secondary prevention recommendations that are intended to reduce the risk of osteoarthritis after a person has sustained an anterior cruciate ligament injury. Specifically, this manuscript describes our methods, literature reviews, and dissenting opinions to elaborate on the rationale for our recommendations and to identify critical gaps. DESIGN Consensus process. SETTING Virtual video conference calls and online voting. PATIENTS OR OTHER PARTICIPANTS The Secondary Prevention Task Group consisted of 29 members from various clinical backgrounds. MAIN OUTCOME MEASURE(S) The group initially convened online in August 2020 to discuss the target population, goals, and key topics. After a second call, the task group divided into 9 subgroups to draft the recommendations and supportive text for crucial content areas. Twenty-one members completed 2 rounds of voting and revising the recommendations and supportive text between February and April 2021. A virtual meeting was held to review the wording of the recommendations and obtain final votes. We defined consensus as >80% of voting members supporting a proposed recommendation. RESULTS The group achieved consensus on 15 of 16 recommendations. The recommendations address patient education, exercise and rehabilitation, psychological skills training, graded-exposure therapy, cognitive-behavioral counseling (lacked consensus), outcomes to monitor, secondary injury prevention, system-level social support, leveraging technology, and coordinated care models. CONCLUSIONS This consensus statement reflects information synthesized from an interdisciplinary group of experts based on the best available evidence from the literature or personal experience. We hope this document raises awareness among clinicians and researchers to take steps to mitigate the risk of osteoarthritis after an anterior cruciate ligament injury.
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Affiliation(s)
| | - Jeffrey B. Driban
- Division of Rheumatology, Allergy, and Immunology, Tufts Medical Center, Boston, MA
| | - Heather K. Vincent
- UF Health Sports Performance Center, Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville
| | - Thomas H. Trojian
- UF Health Sports Performance Center, Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville
| | | | - Shelby Baez
- Osteoarthritis Action Alliance, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill
| | | | - David J. Berkoff
- Department of Kinesiology, Michigan State University, East Lansing
| | - Leigh F. Callahan
- Osteoarthritis Action Alliance, Thurston Arthritis Research Center, University of North Carolina at Chapel Hill
| | | | - Madison Franek
- University of North Carolina Therapy Services, UNC Wellness Center at Meadowmont, Chapel Hill
| | - Yvonne M. Golightly
- Department of Epidemiology, Thurston Arthritis Research Center, Injury Prevention Research Center, Osteoarthritis Action Alliance, University of North Carolina at Chapel Hill
| | - Matthew Harkey
- Department of Kinesiology, Michigan State University, East Lansing
| | | | - Mary Catherine Minnig
- Department of Epidemiology, Thurston Arthritis Research Center, Injury Prevention Research Center, Osteoarthritis Action Alliance, University of North Carolina at Chapel Hill
| | - Ali Mobasheri
- Research Unit of Medical Imaging, Physics and Technology, University of Oulu, Finland; Department of Regenerative Medicine, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania; Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; World Health Organization Collaborating Centre for Public Health Aspects of Musculoskeletal Health and Aging, Liege, Belgium
| | | | - Connie B. Newman
- Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, NYU Grossman School of Medicine, New York, NY
| | - Darin A. Padua
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Brian Pietrosimone
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, NC
| | - Daniel Pinto
- Department of Physical Therapy, Marquette University, Milwaukee, WI
| | - Hayley Root
- Department of Physical Therapy, Marquette University, Milwaukee, WI
| | - Matthew Salzler
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Flagstaff
| | - Laura Schmitt
- Division of Physical Therapy, School of Health and Rehabilitation Sciences, Ohio State University, Columbus
| | | | - Jeffrey B. Taylor
- Department of Physical Therapy, Congdon School of Health Sciences, High Point University, NC
| | - Louise M. Thoma
- Division of Physical Therapy, Department of Allied Health Sciences, University of North Carolina at Chapel Hill
| | - Kevin R. Vincent
- UF Health Sports Performance Center, Department of Physical Medicine and Rehabilitation, University of Florida, Gainesville
| | - Elizabeth Wellsandt
- Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha
| | - Monette Williams
- Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha
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Holmes RD, Yan YY, Mallinson PI, Andrews GT, Munk PL, Ouellette HA. Imaging Review of Hockey-related Lower Extremity Injuries. Semin Musculoskelet Radiol 2022; 26:13-27. [PMID: 35139556 DOI: 10.1055/s-0041-1731795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hockey is a fast-paced contact sport with a high incidence of injuries. Although injuries are more frequent among elite players, recreational hockey injuries are a common issue faced by primary care and emergency physicians. Lower extremity injuries in hockey are particularly important because they account for approximately a third of all injuries and > 60% of all overuse injuries. This pictorial review provides the general and specialty trained radiologist with a knowledge of the patterns of lower extremity injury that occur in ice hockey.
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Affiliation(s)
- R Davis Holmes
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Yet Yen Yan
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada.,Department of Radiology, Changi General Hospital, Singapore
| | - Paul I Mallinson
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Gordon T Andrews
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Peter L Munk
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Hugue A Ouellette
- Musculoskeletal Section, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada
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FUNCTIONAL MEASURES DO NOT DIFFER IN LATE STAGE REHABILITATION AFTER ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION ACCORDING TO MECHANISM OF INJURY. Int J Sports Phys Ther 2020; 15:744-754. [PMID: 33110693 DOI: 10.26603/ijspt20200744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Anterior cruciate ligament injuries are among the most common knee injuries. Mechanism of injury is classified as contact or non-contact. The majority of anterior cruciate ligament ruptures occur through a non-contact mechanism of injury. Non-contact anterior cruciate ligament ruptures are associated with biomechanical and neuromuscular risk factors that can predispose athletes to injuries and may impact future function. Non-contact mechanism of injury may be preceded by poor dynamic knee stability and therefore those with a non-contact mechanism of injury may be prone to poor dynamic knee stability post-operatively. Understanding how mechanism of injury affects post-operative functional recovery may have clinical implications on rehabilitation. Purpose The purpose of this study was to determine if mechanism of injury influenced strength, functional performance, patient-reported outcome measures, and psychological outlook in athletes at four time points in the first two years following anterior cruciate ligament reconstruction. Study Design Secondary analysis of a clinical trial. Methods Seventy-nine athletes underwent functional testing at enrollment after impairment resolution. Quadriceps strength, hop testing, and patient-reported outcome measures were evaluated post-operatively at enrollment, following return-to-sport training and one year and two years after anterior cruciate ligament reconstruction. Participants were dichotomized by mechanism of injury (29 contact, 50 noncontact). Independent t-tests were used to compare differences between groups. Results There were no meaningful differences between contact and non-contact mechanism of injury in any variables at enrollment, post-training, one year, or two years after anterior cruciate ligament reconstruction. Conclusion Function did not differ according to mechanism of injury during late stage rehabilitation or one or two years after anterior cruciate ligament reconstruction. Level of Evidence III.
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Capin JJ, Khandha A, Buchanan TS, Snyder-Mackler L. Partial medial meniscectomy leads to altered walking mechanics two years after anterior cruciate ligament reconstruction: Meniscal repair does not. Gait Posture 2019; 74:87-93. [PMID: 31491565 PMCID: PMC6790293 DOI: 10.1016/j.gaitpost.2019.08.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 07/29/2019] [Accepted: 08/25/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Partial meniscectomy dramatically increases the risk for post-traumatic, tibiofemoral osteoarthritis after anterior cruciate ligament reconstruction (ACLR). Concomitant medial meniscus surgery influences walking biomechanics (e.g., medial tibiofemoral joint loading) early after ACLR; whether medial meniscus surgery continues to influence walking biomechanics two years after ACLR is unknown. RESEARCH QUESTION Does medial meniscus treatment at the time of ACLR influence walking biomechanics two years after surgery? METHODS This is a secondary analysis of prospectively collected data from a clinical trial (NCT01773317). Fifty-six athletes (age 24 ± 8 years) with operative reports, two-year biomechanical analyses, and no second injury prior to two-year testing participated after primary ACLR. Participants were classified by concomitant medial meniscal status: no medial meniscus involvement (n = 36), partial medial meniscectomy (n = 9), and medial meniscus repair (n = 11). Participants underwent biomechanical analyses during over-ground walking including surface electromyography; a validated musculoskeletal model estimated medial compartment tibiofemoral contact forces. Gait variables were analyzed using 3 × 2 ANOVAs with group (medial meniscus treatment) and limb (involved versus uninvolved) comparisons. RESULTS There was a main effect of group (p = .039) for peak knee flexion angle (PKFA). Participants after partial medial meniscectomy walked with clinically meaningfully smaller PKFAs in both the involved and uninvolved limbs compared to the no medial meniscus involvement group (group mean difference [95%CI]; involved: -4.9°[-8.7°, -1.0°], p = .015; uninvolved: -3.9°[-7.6°, -0.3°], p = .035) and medial meniscus repair group (involved: -5.2°[-9.9°, -0.6°], p = .029; uninvolved: -4.7°[-9.0°, -0.3°], p = .038). The partial medial meniscectomy group walked with higher involved versus uninvolved limb medial tibiofemoral contact forces (0.45 body weights, 95% CI: -0.01, 0.91 BW, p = 0.053) and truncated sagittal plane knee excursions, which were not present in the other two groups. SIGNIFICANCE Aberrant gait biomechanics may concentrate high forces in the antero-medial tibiofemoral cartilage among patients two years after ACLR plus partial medial meniscectomy, perhaps explaining the higher osteoarthritis rates and offering an opportunity for targeted interventions. LEVEL OF EVIDENCE Level III.
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Capin JJ, Failla M, Zarzycki R, Dix C, Johnson JL, Smith AH, Risberg MA, Huston LJ, Spindler KP, Snyder-Mackler L. Superior 2-Year Functional Outcomes Among Young Female Athletes After ACL Reconstruction in 10 Return-to-Sport Training Sessions: Comparison of ACL-SPORTS Randomized Controlled Trial With Delaware-Oslo and MOON Cohorts. Orthop J Sports Med 2019; 7:2325967119861311. [PMID: 31413963 PMCID: PMC6676263 DOI: 10.1177/2325967119861311] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Outcomes after anterior cruciate ligament reconstruction (ACLR) are not uniformly good and are worse among young female athletes. Developing better rehabilitation and return-to-sport training programs and evaluating their outcomes are essential. PURPOSE (1) Test the effect of strength, agility, plyometric, and secondary prevention (SAPP) exercises with and without perturbation training (SAPP + PERT) on strength, hops, function, activity levels, and return-to-sport rates in young female athletes 1 and 2 years after ACLR and (2) compare 2-year functional outcomes and activity levels among young female athletes in the Anterior Cruciate Ligament Specialized Post-Operative Return-to-Sports (ACL-SPORTS) trial to homogeneous cohorts who completed criterion-based postoperative rehabilitation alone (Multicenter Orthopaedic Outcomes Network [MOON]) and in combination with extended preoperative rehabilitation (Delaware-Oslo). STUDY DESIGN Randomized controlled trial, Level of evidence, 1; and cohort study, Level of evidence, 3. METHODS A total of 40 level 1 and level 2 female athletes were enrolled after postoperative impairment resolution 3 to 9 months after primary ACLR. Participants were randomized to 10 SAPP or SAPP + PERT sessions and were tested 1 and 2 years after ACLR on quadriceps strength, hop tests, functional outcomes, and return-to-sport rates. Participants were then compared with homogeneous cohorts of young (<25 years) female athletes who completed criterion-based postoperative rehabilitation alone (MOON) and in combination with extended preoperative rehabilitation (Delaware-Oslo) on 2-year functional outcomes. RESULTS No significant or meaningful differences were found between SAPP and SAPP + PERT, so groups were collapsed for comparison with the other cohorts. At 2-year follow-up, ACL-SPORTS had the highest scores (P < .01) on the Marx activity rating scale (ACL-SPORTS, 13.5 ± 3.3; Delaware-Oslo, 12.5 ± 2.7; MOON, 10.6 ± 5.1); International Knee Documentation Committee Subjective Knee Evaluation Form (96 ± 7, 92 ± 9, and 84 ± 14, respectively); and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales for Pain (98 ± 4, 94 ± 9, and 90 ± 10, respectively), Symptoms (94 ± 6, 90 ± 9, and 83 ± 14, respectively), Activities of Daily Living (100 ± 1, 99 ± 4, and 96 ± 7, respectively), Sports and Recreation (94 ± 8, 86 ± 15, and 82 ± 17, respectively), and Quality of Life (89 ± 14, 78 ± 18, and 76 ± 19, respectively). The Patient Acceptable Symptom State threshold on the KOOS-Sports and Recreation was achieved by 100% of the ACL-SPORTS cohort compared with 90% of Delaware-Oslo and 78% of MOON (P = .011). CONCLUSION Although perturbation training provided no added benefit, 10 sessions of return-to-sport training, compared with criterion-based postoperative rehabilitation alone, yielded statistically significant and clinically meaningfully higher 2-year functional outcomes among young, high-level female athletes after ACLR. REGISTRATION NCT01773317 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Jacob J. Capin
- Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - Mathew Failla
- Department of Rehabilitation and Movement Science, University of Vermont, Burlington, Vermont, USA
| | - Ryan Zarzycki
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
| | - Celeste Dix
- Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
| | - Jessica L. Johnson
- Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
| | - Angela H. Smith
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
| | - May Arna Risberg
- Department of Sport Medicine, Norwegian School of Sports Sciences, Oslo, Norway
- Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway
| | - Laura J. Huston
- Department of Orthopaedics and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kurt P. Spindler
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science Program, University of Delaware, Newark, Delaware, USA
- Department of Physical Therapy, University of Delaware, Newark, Delaware, USA
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Capin JJ, Khandha A, Zarzycki R, Manal K, Buchanan TS, Snyder-Mackler L. Gait Mechanics After ACL Reconstruction Differ According to Medial Meniscal Treatment. J Bone Joint Surg Am 2018; 100:1209-1216. [PMID: 30020126 PMCID: PMC6636792 DOI: 10.2106/jbjs.17.01014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Knee osteoarthritis risk is high after anterior cruciate ligament reconstruction (ACLR) and arthroscopic meniscal surgery, and higher among individuals who undergo both. Although osteoarthritis development is multifactorial, altered walking mechanics may influence osteoarthritis progression. The purpose of this study was to compare gait mechanics after ACLR among participants who had undergone no medial meniscal surgery, partial medial meniscectomy, or medial meniscal repair. METHODS This was a secondary analysis of data collected prospectively as part of a clinical trial. Sixty-one athletes (mean age of 21.4 ± 8.2 years) who had undergone primary ACLR participated in the study when they achieved impairment resolution (5.3 ± 1.7 months postoperatively), including minimal to no effusion, full knee range of motion, and ≥80% quadriceps-strength symmetry. Participants were classified by concomitant medial meniscal treatment: no involvement or nonsurgical management of a small, stable tear; partial meniscectomy; or meniscal repair. Participants underwent comprehensive walking analyses. Joint contact forces were estimated using a previously validated, electromyography-driven musculoskeletal model. Variables were analyzed using a mixed-model analysis of variance with group and limb comparisons (α = 0.05); group comparisons of interlimb differences in measurements (surgical minus contralateral limb) were performed to determine significant interactions. RESULTS The participants in the partial meniscectomy group walked with a higher peak knee adduction moment (pKAM) in the surgical versus the contralateral limb as compared with those in the meniscal repair group and those with no medial meniscal surgery (group difference for partial versus repair: 0.10 N-m/kg-m, p = 0.020; and for partial versus none: 0.06 N-m/kg-m, p = 0.037). Participants in the repair group walked with a smaller percentage of medial to total tibiofemoral loading in the surgical limb compared with both of the other groups (group difference for repair versus partial: -12%, p = 0.001; and for repair versus none: -7%, p = 0.011). The participants in the repair group loaded the medial compartment of the surgical versus the contralateral limb 0.5 times body weight less than did the participants in the partial meniscectomy group. CONCLUSIONS Participants in the partial meniscectomy group walked with higher pKAM and shifted loading toward the medial compartment of the surgical limb, while participants in the repair group did the opposite, walking with lower pKAM and unloading the surgical limb relative to the contralateral limb. These findings may partially explain the conflicting evidence regarding pKAM after ACLR and the elevated risk for osteoarthritis (whether from overloading or underloading) after ACLR with concomitant medial meniscectomy or repair. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jacob J. Capin
- University of Delaware, Newark, Delaware,E-mail address for J.J. Capin:
| | | | | | - Kurt Manal
- University of Delaware, Newark, Delaware
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Capin JJ, Snyder-Mackler L. The current management of patients with patellofemoral pain from the physical therapist's perspective. ANNALS OF JOINT 2018; 3. [PMID: 31414069 DOI: 10.21037/aoj.2018.04.11] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Patellofemoral pain (PFP) is a common diagnosis that includes an amalgam of conditions that are typically non-traumatic in origin and result in peripatellar and/or retropatellar knee pain. The purpose of this review is to provide an overview of the physical therapist's management, including the evaluation and treatment, of the patient with PFP. A thorough history is critical for appropriately diagnosing and optimally managing PFP; the history should include the date of symptom onset, mechanism of injury and/or antecedent events, location and quality of pain, exacerbating and alleviating symptoms, relevant past medical history, occupational demands, recreational activities, footwear, and patient goals. Physical examination should identify the patient's specific impairments, assessing range of motion (ROM), muscle length, effusion, resisted isometrics, strength, balance and postural control, special tests, movement quality, palpation, function, and patient reported outcome measures. Objective assessments should guide treatment, progression, and clinical decision-making. The rehabilitation program should be individually tailored, addressing the patient's specific impairments and functional limitations and achieving the patient's goals. Exercise therapy, including hip, knee, and core strengthening as well as stretching and aerobic exercise, are central to the successful management of PFP. Other complimentary treatments may include patellofemoral and tibiofemoral joint mobilizations, patellofemoral taping, neuromuscular training, and gait retraining. Appropriate progression of interventions should consider objective evaluations (e.g., effusion, soreness rules), systematic increases in loading, and the chronicity of symptoms. Although short-term changes or reductions in movement often are necessary in a protective capacity, the persistence of altered movement is a key characteristic of chronic pain, which may be managed in part through emphasis on function over symptoms, graded exposure, patient education, and perhaps referral. PFP etiology is largely movement related and a comprehensive conservative treatment using movement can be successful.
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Affiliation(s)
- Jacob John Capin
- Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA
| | - Lynn Snyder-Mackler
- Biomechanics and Movement Science, University of Delaware, Newark, Delaware, USA.,Physical Therapy, University of Delaware, Newark, Delaware, USA
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