Department of Behavioral Health

CONTEXT: Despite the high prevalence and potentially serious outcomes associated with concussion in athletes, there is little systematic research examining risk factors and short- and long-term outcomes. OBJECTIVES: To assess the relationship between concussion history and learning disability (LD) and the association of these variables with neuropsychological performance and to evaluate postconcussion recovery in a sample of college football players. DESIGN, SETTING, AND PARTICIPANTS: A total of 393 athletes from 4 university football programs across the United States received preseason baseline evaluations between May 1997 and February 1999. Subjects who had subsequent football-related acute concussions (n = 16) underwent neuropsychological comparison with matched control athletes from within the sample (n = 10). MAIN OUTCOME MEASURES: Clinical interview, 8 neuropsychological measures, and concussion symptom scale ratings at baseline and after concussion. RESULTS: Of the 393 players, 129 (34%) had experienced 1 previous concussion and 79 (20%) had experienced 2 or more concussions. Multivariate analysis of variance yielded significant main effects for both LD (P<.001) and concussion history (P=.009), resulting in lowered baseline neuropsychological performance. A significant interaction was found between LD and history of multiple concussions and LD on 2 neuropsychological measures (Trail-Making Test, Form B [P=.007] and Symbol Digit Modalities Test [P=.009]), indicating poorer performance for the group with LD and multiple concussions compared with other groups. A discriminant function analysis using neuropsychological testing of athletes 24 hours after acute in-season concussion compared with controls resulted in an overall 89.5% correct classification rate. CONCLUSIONS: Our study suggests that neuropsychological assessment is a useful indicator of cognitive functioning in athletes and that both history of multiple concussions and LD are associated with reduced cognitive performance. These variables may be detrimentally synergistic and should receive further study.

BACKGROUND: Current clinical practice guidelines (CPGs) for posttraumatic stress disorder (PTSD) offer contradictory recommendations regarding use of medications or psychotherapy as first-line treatment. Direct head-to-head comparisons are lacking. METHODS: Systemic review of Medline, EMBASE, PILOTS, Cochrane Central Register of Controlled Trials, PsycINFO, and Global Health Library was conducted without language restrictions. Randomized clinical trials ≥8 weeks in duration using structured clinical interview-based outcome measures, active-control conditions (e.g. supportive psychotherapy), and intent-to-treat analysis were selected for analyses. Independent review, data abstraction, and bias assessment were performed using standardized processes. Study outcomes were grouped around conventional follow-up time periods (3, 6, and 9 months). Combined effect sizes were computed using meta-analyses for medication versus control, medication pre-/posttreatment, psychotherapy versus control, and psychotherapy pre-/posttreatment. RESULTS: Effect sizes for trauma-focused psychotherapies (TFPs) versus active control conditions were greater than medications versus placebo and other psychotherapies versus active controls. TFPs resulted in greater sustained benefit over time than medications. Sertraline, venlafaxine, and nefazodone outperformed other medications, although potential for methodological biases were high. Improvement following paroxetine and fluoxetine treatment was small. Venlafaxine and stress inoculation training (SIT) demonstrated large initial effects that decreased over time. Bupropion, citalopram, divalproex, mirtazapine, tiagabine, and topiramate failed to differentiate from placebo. Aripiprazole, divalproex, guanfacine, and olanzapine failed to differentiate from placebo when combined with an antidepressant. CONCLUSIONS: Study findings support use of TFPs over nontrauma-focused psychotherapy or medication as first-line interventions. Second-line interventions include SIT, and potentially sertraline or venlafaxine, rather than entire classes of medication, such as SSRIs. Future revisions of CPGs should prioritize studies that utilize active controls over waitlist or treatment-as-usual conditions. Direct head-to-head trials of TFPs versus sertraline or venlafaxine are needed.

Objectives: Descriptive labels of performance test scores are a critical component of communicating outcomes of neuropsychological and psychological evaluations. Yet, no universally accepted system exists for assigning qualitative descriptors to scores in specific ranges. In addition, the definition and use of the term “impairment” lacks specificity and consensus. Consequently, test score labels and the denotation of impairment are inconsistently applied by clinicians, creating confusion among consumers of neuropsychological services, including referral sources, trainees, colleagues, and the judicial system. To reduce this confusion, experts in clinical and forensic neuropsychological and psychological assessment convened in a consensus conference at the 2018 Annual Meeting of the American Academy of Clinical Neuropsychology (AACN). The goals of the consensus conference were to recommend (1) a system of qualitative labels to describe results from performance-based tests with normal and non-normal distributions and (2) a definition of impairment and its application in individual case determinations. Results: The goals of the consensus conference were met resulting in specific recommendations for the application of uniform labels for performance tests and for the definition of impairment, which are described in this paper. In addition, included in this consensus statement is a description of the conference process and the rationales for these recommendations. Conclusions/Importance: This consensus conference is the first formal attempt by the professional neuropsychological community to make recommendations for uniform performance test score labels and to advance a consistent definition of impairment. Using uniform descriptors and terms will reduce confusion and enhance report comprehensibility by the consumers of our reports as well as our trainees and colleagues.

BACKGROUND: Biomechanical analyses suggest that the loss of neuromuscular control is associated with noncontact anterior cruciate ligament sprains; however, previous research has not explored the link between neurocognitive function and unintentional knee injuries. PURPOSE: To determine if athletes who suffer a noncontact anterior cruciate ligament injury demonstrate decreased baseline neurocognitive performance when compared with matched controls. STUDY DESIGN: Case control study; Level of evidence, 3. METHODS: The baseline scores from a computerized neurocognitive test battery (ImPACT) were analyzed to compare verbal memory, visual memory, processing speed, and reaction time. Eighty intercollegiate athletes who, subsequent to testing, experienced noncontact anterior cruciate ligament injuries, were matched with 80 controls based on height, weight, age, gender, sport, position, and years of experience at the collegiate level. RESULTS: Statistical differences were found between the noncontact anterior cruciate ligament injury group and the matched controls on all 4 neurocognitive subtests. Noncontact anterior cruciate ligament-injured athletes demonstrated significantly slower reaction time (F(1,158) = 9.66, P = .002) and processing speed (F(1,158) = 12.04, P = .001) and performed worse on visual (F(1,158) = 19.16, P = .000) and verbal memory (F(1,158) = 4.08, P = .045) composite scores when compared with controls. CONCLUSION: Neurocognitive differences may be associated with the loss of neuromuscular control and coordination errors, predisposing certain intercollegiate athletes to noncontact anterior cruciate ligament injuries.

This analysis examines the association of death from overdose among individuals released from the Rhode Island correctional system after implementation of a comprehensive program of medications for addiction therapy.

PURPOSE: Recent epidemiological research has revealed that gender differences exist in concussion incidence but no study has investigated why females may be at greater risk of concussion. Our purpose was to determine whether gender differences existed in head-neck segment kinematic and neuromuscular control variables responses to an external force application with and without neck muscle preactivation. METHODS: Forty (20 females and 20 males) physically active volunteers participated in the study. The independent variables were gender, force application (known vs unknown), and force direction (forced flexion vs forced extension). The dependent variables were kinematic and EMG variables, head-neck segment stiffness, and head-neck segment flexor and extensor isometric strength. Statistical analyses consisted of multiple multivariate and univariate analyses of variance, follow-up univariate analyses of variance, and t-tests (P < or = 0.05). RESULTS: Gender differences existed in head-neck segment dynamic stabilization during head angular acceleration. Females exhibited significantly greater head-neck segment peak angular acceleration (50%) and displacement (39%) than males despite initiating muscle activity significantly earlier (SCM only) and using a greater percentage of their maximum head-neck segment muscle activity (79% peak activity and 117% muscle activity area). The head-neck segment angular acceleration differences may be because females exhibited significantly less isometric strength (49%), neck girth (30%), and head mass (43%), resulting in lower levels of head-neck segment stiffness (29%). CONCLUSION: For our subject demographic, the results revealed gender differences in head-neck segment dynamic stabilization during head acceleration in response to an external force application. Females exhibited significantly greater head-neck segment peak angular acceleration and displacement than males despite initiating muscle activity earlier (SCM only) and using a greater percentage of their maximum head-neck segment muscle activity.

BACKGROUND: Partial PTSD, employed initially in relation to Vietnam veterans, has been recently extended to civilian victims of trauma. We examined the extent to which partial PTSD is distinguishable from full DSM-PTSD with respect to level of impairment. METHOD: A representative sample of 2181 persons was interviewed by telephone to record lifetime traumatic events and to assess DSM-IV PTSD criteria. Partial PTSD was defined as > or = 1 symptom in each of three symptom groups (criteria B, C and D) and duration of > or = 1 month. Impairment in persons with PTSD and partial PTSD was measured by number of work-related and personal disability days during the 30-day period when the respondent was most upset by the trauma. RESULTS: Compared to exposed persons with neither PTSD nor partial PTSD, increment in work-loss days associated with PTSD was 11.4 (S.E. =0.6) days and with partial PTSD, 3.3 (S.E. =0.4) days (adjusted for sex, education and employment). Similar disparities were found across other impairment indicators. Persons who fell short of PTSD criteria by one symptom of avoidance and numbing reported an increment of 5.0 (S.E. =0.7) work-loss days, 6.0 fewer than full PTSD. PTSD was associated with excess impairment, controlling for number of symptoms. A significantly lower proportion of persons with partial PTSD than full PTSD experienced symptoms for more than 2 years. A lower proportion of persons with partial PTSD than full PTSD had an etiologic event of high magnitude. CONCLUSIONS: PTSD identifies the most severe trauma victims, who are markedly distinguishable from victims with subthreshold PTSD.

OBJECTIVES: The current study meta-analyzed studies examining changes in alcohol consumption during the COVID-19 pandemic and systematically reviewed contextual and individual difference factors related to these changes. METHOD: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) protocol, studies were gathered via PsycINFO, PubMed/MEDLINE, and preprint databases (published 29 April 2021) that examined individual-level changes in consumption during the initial COVID-19 mitigation measures (before October 2020). Next, sample proportion increases and decreases in consumption, in addition to mean change in consumption variables from pre- to during-COVID, were meta-analyzed, and contextual and individual difference variables related to consumption changes during the pandemic were summarized. RESULTS: One hundred and twenty-eight studies provided data from 58 countries (mean n = 3,876; median n = 1,092; aggregate sample n = 492,235). The average mean change in alcohol consumption was nonsignificant (Cohen’s d = −0.01, p = .68); however, meta-analysis revealed that 23% of participants reported increases in consumption and 23% reported decreases. These changes were moderated by per capita gross domestic product and country. Narrative synthesis revealed multiple predictors of increased drinking, including contextual changes (e.g., children at home, income loss, working remotely, low social support), individual difference variables (being female, a young-to-middle aged adult, or Black), and mental health/alcohol-related risk factors (e.g., depression). CONCLUSIONS: The identified factors associated with increased alcohol consumption should be considered in planning behavioral health services during future crisis events that abruptly alter everyday environments in ways that increase stress and decrease access to naturally occurring rewards.

BACKGROUND: Differences in range of motion and rotational motion between the dominant and nondominant shoulders in throwing athletes are well documented, although the age at which these changes begin to occur is not known. HYPOTHESIS: Changes in glenohumeral rotational motion in the shoulder of the Little League/adolescent baseball player occur during the most formative years of physical development. STUDY DESIGN: Cross-sectional study. METHODS: Elevation, internal rotation at 90 degrees of abduction, and external rotation at 90 degrees of abduction were measured in the dominant and nondominant shoulders of 294 baseball players, aged 8 to 16 years. RESULTS: Analysis of variance revealed 2-way interactions between arm dominance by age for elevation (P = .005) and internal rotation (P = .001). Significant differences were noted between dominant and nondominant arms for internal rotation at 90 degrees (P = .001) and external rotation at 90 degrees (P = .001). Elevation, internal rotation at 90 degrees , external rotation at 90 degrees , and total range of motion varied significantly (P = .001) among age groups. Elevation in the dominant arms of 16-year-olds was on average 5.3 degrees less than in 8-year-olds (179.6 degrees vs 174.3 degrees ). In the nondominant arms, mean elevation for 16-year-olds was 5.6 degrees less than in 8-year-olds (179.7 degrees vs 174.1 degrees ). Internal rotation at 90 degrees for the dominant arms averaged 39.0 degrees at age 8 and only 21.3 degrees at age 16. In the non-dominant arms, internal rotation for 8-year-olds averaged 42.2 degrees and only 33.1 degrees for 16-year-olds. CONCLUSIONS: Elevation and total range of motion decreased as age increased. These changes may be consequences of both bone and soft tissue adaptation. The most dramatic decline in total range of motion was seen between the 13-year-olds and 14-year-olds, in the year before peak incidence of Little Leaguer's shoulder. This decrease in rotational motion may cause increased stress at the physis during throwing.

This article describes challenges and successes seen in the first four years of efforts the state of Connecticut has made to reorient its behavioral health system to promoting recovery. Beginning in 2000, the Connecticut initiative was conceptualized as a multi-year, systemic process that involved the following interrelated steps: a) developing core values and principles based on the input of people in recovery; b) establishing a conceptual and policy framework based on this vision; c) building workforce competencies and skills; d) changing programs and service structures; e) aligning fiscal and administrative policies; and, finally, f) monitoring, evaluating, and adjusting these efforts. Following descriptions of the first four steps, the authors offer a few lessons that might benefit other states engaged in similar processes of transformation.

BACKGROUND: Clinicians often modify evidence-based psychotherapies (EBPs) when delivering them in routine care settings. There has been little study of factors associated with or implications of modifications to EBP protocols. This paper differentiates between fidelity-consistent and fidelity-inconsistent modifications and it examines the potential influence of two clinician characteristics, training outcomes, and attitudes toward EBPs on fidelity-consistent and fidelity-inconsistent modifications of cognitive behavioral therapy in a sample of clinicians who had been trained to deliver these treatments for children or adults. METHODS: Survey and coded interview data collected 2 years after completion of training programs in cognitive behavioral therapy were used to examine associations between successful or unsuccessful completion of training, clinician attitudes, and modifications. Modifications endorsed by clinicians were categorized as fidelity-consistent or fidelity-inconsistent and entered as outcomes into separate regression models, with training success and attitudes entered as independent variables. RESULTS: Successful completion of a training program was associated with subsequent fidelity-inconsistent modifications but not fidelity-consistent modifications. Therapists who reported greater openness to using EBPs prior to training reported more fidelity-consistent modifications at follow-up, and those who reported greater willingness to adopt EBPs if they found them appealing were more likely to make fidelity-inconsistent modifications. CONCLUSIONS: Implications of these findings for training, implementation, EBP sustainment, and future studies are discussed. Research on contextual and protocol-related factors that may impact decisions to modify EBPs will be an important future direction of study to complement to this research.

Increasing demand for global health education in medical training has driven the growth of educational programs predicated on a model of short-term medical service abroad. Almost two-thirds of matriculating medical students expect to participate in a global health experience during medical school, continuing into residency and early careers. Despite positive intent, such short-term experiences in global health (STEGHs) may exacerbate global health inequities and even cause harm. Growing out of the "medical missions" tradition, contemporary participation continues to evolve. Ethical concerns and other disciplinary approaches, such as public health and anthropology, can be incorpo rated to increase effectiveness and sustainability, and to shift the culture of STEGHs from focusing on trainees and their home institutions to also considering benefits in host communities and nurtur ing partnerships. The authors propose four core principles to guide ethical development of educational STEGHs: (1) skills building in cross-cultural effective ness and cultural humility, (2) bidirectional participatory relationships, (3) local capacity building, and (4) long-term sustainability. Application of these principles highlights the need for assessment of STEGHs: data collection that allows transparent compar isons, standards of quality, bidirectionality of agreements, defined curricula, and ethics that meet both host and sending countries' standards and needs. To capture the enormous potential of STEGHs, a paradigm shift in the culture of STEGHs is needed to ensure that these experiences balance training level, personal competencies, medical and cross-cultural ethics, and educational objectives to minimize harm and maximize benefits for all involved.

INTRODUCTION: Transcranial magnetic stimulation (TMS) is a US Food and Drug Administration-approved treatment for major depressive disorder (MDD) in patients who have not responded to 1 adequate antidepressant trial in the current episode. In a retrospective cohort study, we examined the effectiveness and safety of TMS in the first 100 consecutive patients treated for depression (full DSM-IV criteria for major depressive episode in either major depressive disorder or bipolar disorder) at an academic medical center between July 21, 2008, and March 25, 2011. METHOD: TMS was flexibly dosed in a course of up to 30 sessions, adjunctive to current medications, for 85 patients treated for acute depression. The primary outcomes were response and remission rates at treatment end point as measured by the Clinical Global Impressions-Improvement scale (CGI-I) at 6 weeks. Secondary outcomes included change in the Hamilton Depression Rating Scale (HDRS); Quick Inventory of Depressive Symptomatology, self-report (QIDS-SR); Beck Depression Inventory (BDI); Beck Anxiety Inventory (BAI); and the Sheehan Disability Scale (SDS). Enduring benefit was assessed over 6 months in patients receiving maintenance TMS treatment. Data from 12 patients who received TMS as maintenance or continuation treatment after prior electroconvulsive therapy (ECT) or TMS given in a clinical trial setting were also reviewed. RESULTS: The clinical cohort was treatment resistant, with a mean of 3.4 failed adequate trials in the current episode. Thirty-one individuals had received prior lifetime ECT, and 60% had a history of psychiatric hospitalization. The CGI-I response rate was 50.6% and the remission rate was 24.7% at 6 weeks. The mean change was -7.8 points in HDRS score, -5.4 in QIDS-SR, -11.4 in BDI, -5.8 in BAI, and -6.9 in SDS. The HDRS response and remission rates were 41.2% and 35.3%, respectively. Forty-two patients (49%) entered 6 months of maintenance TMS treatment. Sixty-two percent (26/42 patients) maintained their responder status at the last assessment during the maintenance treatment. TMS treatment was well tolerated, with a discontinuation rate of 3% in the acute treatment phase. No serious adverse events related to TMS were observed during acute or maintenance treatment. CONCLUSIONS: Adjunctive TMS was found to be safe and effective in both acute and maintenance treatment of patients with treatment-resistant depression.

To achieve maximal force output, clinicians and coaches have been experimenting with upper extremity plyometric exercises for years, without sufficient scientific validation of this training method. The goal of this study was to examine the effects of an 8-week course of high volume upper extremity plyometric training on the isokinetic strength and throwing velocity of a group of intercollegiate baseball players. Twenty-four Division I collegiate baseball players (age: 19.7 +/- 1.3 years; height: 183.9 +/- 5.9 cm; mass: 90.7 +/- 10.5 kg) were recruited to participate in this study. Throwing velocity, isokinetic peak torque, isokinetic functional strength ratios, and time to peak torque were measured pre- and posttraining. Subjects were rank-ordered according to concentric internal rotation (IR) strength and were assigned randomly to either the plyometric training group (PLY) or the control group (CON). Training consisted of 6 upper extremity plyometric exercises ("Ballistic Six") performed twice per week for 8 weeks. Subjects assigned to CON performed regular off-season strength and conditioning activities, but did not perform plyometric activities. PLY demonstrated significant increases (p < 0.05) in throwing velocity following 8 weeks of training when compared with CON (83.15 mph [pre] vs. 85.15 mph [post]). There were no statistically significant differences in any of the isokinetic strength measurements between PLY and CON groups pre- to posttraining. Statistically significant differences were seen within PLY for concentric IR and eccentric external rotation (ER) isokinetic strength at 180 degrees x s(-1) and 300 degrees x s(-1); and within CON for eccentric ER isokinetic strength at 300 degrees x s(-1) and concentric IR isokinetic strength at 180 degrees x s(-1). The Ballistic Six training protocol can be a beneficial supplement to a baseball athlete's off-season conditioning by improving functional performance and strengthening the rotator cuff musculature.

BACKGROUND: Sleep duration has been implicated in the etiology of obesity but less is known about the association between sleep and other behavioral risk factors for cardiovascular disease. PURPOSE: The aim of this study was to examine the associations among sleep duration, chronotype, and physical activity, screen-based sedentary behavior, tobacco use, and dietary intake. METHODS: Regression models were used to examine sleep duration and chronotype as the predictors and cardiovascular risk factors as outcomes of interest in a cross-sectional sample of 439,933 adults enrolled in the UK Biobank project. RESULTS: Short sleepers were 45 % more likely to smoke tobacco than adequate sleepers (9.8 vs. 6.9 %, respectively). Late chronotypes were more than twice as likely to smoke tobacco than intermediate types (14.9 vs. 7.4 %, respectively). Long sleepers reported 0.61 more hours of television per day than adequate sleepers. Early chronotypes reported 0.20 fewer daily hours of computer use per day than intermediate chronotypes. Early chronotypes had 0.25 more servings of fruit and 0.13 more servings of vegetables per day than late chronotypes. CONCLUSIONS: Short and long sleep duration and late chronotype are associated with greater likelihood of cardiovascular risk behaviors. Further work is needed to determine whether these findings are maintained in the context of objective sleep and circadian estimates, and in more diverse samples. The extent to which promoting adequate sleep duration and earlier sleep timing improves heart health should also be examined prospectively.

PURPOSE: To determine whether exercise training would increase lymphocyte activation in patients with breast cancer following chemotherapy. Activation was determined by the presence of CD4(+)CD69(+) T-helper lymphocytes, mitogen-induced proliferation, and levels of cytokines produced by mitogen-stimulated lymphocytes and in the patients' plasma. METHODS: Patients with breast cancer (N = 28) who participated in a 6-month exercise program were compared with patients (N = 21) who did not exercise. Following chemotherapy, and 3 and 6 months later, patients underwent fitness evaluations and had blood drawn. The exercise program consisted of resistance training and aerobic activity at 60-75% functional capacity three times a week with a personal trainer. Immunochemistry and flow cytometry were used to measure the number of CD4(+)CD69(+) blood lymphocytes. Whole blood was stimulated with concanavalin A (ConA), phytohemagglutin (PHA), or pokeweed mitogen (PWM) to determine proliferation potential. Enzyme-linked immunosorbent assays (ELISA) were used to determine the concentration of interferon-gamma (IFN-gamma) and interleukin-6 (IL-6) in the culture medium of mitogen-stimulated lymphocytes as well as the plasma concentrations of IL-6, soluble IL-6 receptor, soluble gp130, and IFN-gamma. Analysis of groups across time was done using the Wilcoxon signed rank test, and comparisons of groups were done using the Mann-Whitney U test. RESULTS: The exercising patients showed increases in maximal oxygen uptake and upper body strength. This group also showed a greater percentage of CD4(+)CD69(+) cells and a greater level of tritiated thymidine incorporation (DNA synthesis) when stimulated with ConA, PHA, and PWM at the end of the intervention. Plasma and mitogen-stimulated IL-6 and IFN-gamma production were similar in both groups. CONCLUSION: Exercise may improve immune function by increasing lymphocyte activation in patients with breast cancer following treatment.

Patients with multiple sclerosis (MS) present with varying symptoms that can differ between and within individuals. As new interventions and drug treatments become available to MS patients, it is essential to understand the relationship between fatigue and the variability of functional mobility measures in order to define a meaningful change due to treatment within the MS population. The purpose of this study was to examine the within-day and between-day changes in gait variability for subjects with MS in fresh and fatigued conditions. Walking gait parameters were measured from 20 subjects diagnosed with MS and eight healthy control subjects. Standard deviations of hip, knee and ankle kinematic and kinetic variables were quantified as the measure of variability and analysed with a two-way (group by condition) ANOVA. Results indicated MS subjects had significantly greater hip (P <0.020), knee (P <0.011) and ankle (P <0.034) joint angle variability than control subjects, but variability was not different between conditions. Kinetic variability was not different between groups or conditions. MS subjects in this study walked more slowly than the healthy controls and they also reported more fatigue. Research examining treatment effects within the MS population should account for increased levels of kinematic gait variability.

PURPOSE: To investigate effects that independent alterations in limb mass and moment of inertia about a transverse axis through the hip have on metabolic and mechanical power of walking and peak electromyography (EMG) amplitude. It was hypothesized that increases in metabolic cost would parallel increases in mechanical power, and that EMG amplitude would increase with greater limb mass or limb moment of inertia. METHODS: Metabolic and mechanical power and lower-extremity EMG were measured on 14 healthy adults walking at 1.5 m.s. Four leg-loading conditions were employed: 1) no load (NL) on the legs; 2) a baseline load (BSLN) condition, with a mean of 2.0 kg per leg distributed on the proximal and distal shank; 3) a load condition with a mean of 2.0 kg per leg distributed on the proximal and distal shank, such that lower-extremity moment of inertia was increased 5% about the hip (MOI5) from the BSLN, but having the same lower-extremity mass as BSLN; and 4) a load condition with a mean of 2.8 kg per leg, concentrated proximally on the shank to increase total lower-extremity mass by 5% (Mass5) from BSLN, but having the same moment of inertia as BSLN. Total subject mass was constant between conditions, as unused leg loads were carried in a waist belt. RESULTS: Changes in mechanical power paralleled changes in metabolic cost as hypothesized. Energy cost increased significantly (4.2%) from NL to BSLN, and from BSLN to MOI5 and Mass5 (3.4 and 4.0%, respectively). EMG did not effectively explain changes in metabolic cost. CONCLUSION: Independent alterations in limb mass and moment of inertia about the hip joint influence energy cost similarly.

Study Design Cross-sectional study. Objective To determine whether there are differences in trunk muscle characteristics between older adults with and without chronic low back pain (LBP), while controlling for age, sex, and body mass index. Background Muscle support for the trunk is provided by the multifidi, erector spinae, psoas, and quadratus lumborum. Trunk muscle characteristics may be altered with aging and/or chronic LBP. To date, most trunk muscle research has been conducted among younger adults. Given age-related muscle changes, such as reduced size and increased intramuscular fat, studies are needed in older adults, including those comparing older adults with and without LBP. Methods One hundred two older adults with (n = 53) and without (n = 49) chronic LBP were included. Cross-sectional area (CSA) measurements were taken by tracing inside the fascial borders on magnetic resonance images. Pixel intensity summaries were obtained to compute muscle-to-fat indices and relative muscle CSA, that is, CSA void of fat. Right/left averages for levels L2 through L5 were determined. Mixed-design analyses of covariance were used to test for differences between groups, based on LBP presence and sex, across levels (P≤.05). Results Older adults with LBP had a greater average multifidus muscle-to-fat index (0.51 versus 0.49) and smaller average erector spinae relative muscle CSA (8.56 cm 2 versus 9.26 cm 2 ) when compared to control participants without LBP. No interactions between LBP status and average muscle characteristics were found for the psoas or quadratus lumborum (P&gt;.05). Conclusion Up to 54% of older adult trunk muscle CSA may be fat. Women have smaller muscles and greater intramuscular fat (at lower spinal levels) than men. J Orthop Sports Phys Ther 2017;47(3):173–179. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7002

Among diabetic patients, experience with hypoglycemia ranges from the unpleasant to the life threatening. The aversiveness of these episodes often results in fear. To examine the impact of hypoglycemia on fear, 69 patients with insulin-dependent diabetes mellitus completed the Behavior and Worry subscales of the Hypoglycemia Fear Survey along with measures of psychological symptoms, perceived stress, risk of future hypoglycemic episodes, and glycosylated hemoglobin. Behavior and Worry scores were positively related to psychological symptoms, perceived stress, and previous experiences with hypoglycemia. Fear was unrelated to glycosylated hemoglobin but was significantly higher for patients who had greater variability and lower mean daily blood glucose.