- Email: [email protected]
The effect of a cricket fielding session on glenohumeral range of motion and active joint position sense
Accepted Manuscript The effect of a cricket fielding session on glenohumeral range of motion and active joint position sense Liam Newton, Steve McCaig PII:
S1466-853X(17)30132-3
DOI:
10.1016/j.ptsp.2018.04.002
Reference:
YPTSP 871
To appear in:
Physical Therapy in Sport
Received Date: 5 April 2017 Revised Date:
8 March 2018
Accepted Date: 3 April 2018
Please cite this article as: Newton, L., McCaig, S., The effect of a cricket fielding session on glenohumeral range of motion and active joint position sense, Physical Therapy in Sports (2018), doi: 10.1016/j.ptsp.2018.04.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE.
Acknowledgements: The authors would like to thank the participants for taking
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ACCEPTED MANUSCRIPT THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE. Authors: Mr Liam Newtona a
School of Sport, Exercise and Rehabilitation Science
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University of Birmingham Edgbaston campus Edgbaston Birmingham
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England B15 2TT
Mr Steve McCaigb b
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[email protected]
National Cricket Performance Centre
Loughborough University
Leicestershire England LE 11 3TU
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Corresponding Author: Liam Newton @newton_liam
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[email protected]
Current address: Romsey Hospital, Physiotherapy Outpatients, Winchester Hill, Romsey SO51 7ZA Phone: 07854544334
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THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL
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RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE.
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ACCEPTED MANUSCRIPT Abstract
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Objective: To assess the effects of a cricket fielding session, at an identified
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throwing injury risk workload, on shoulder joint position sense (JPS) and active
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range of motion (AROM) in cricketers.
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Design: Repeated measures observational study
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Setting: Indoor cricket centre
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Participants: Nineteen, asymptomatic University cricketers.
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Main outcome: AROM was assessed supine at 90o abduction and from this
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10% off end range IR and ER was used as the position matching angle to
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assess JPS. JPS error scores as well as AROM were assessed pre and post a
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cricket fielding session consisting of 40 throws.
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Results: Following the cricket fielding session, no alteration in JPS in ER (p =
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0.91) or IR (p = 0.27) was observed. There was however a significant decrease
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in IR (-3.9o) following the fielding drill (p = 0.007) while no significant change
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was observed in ER or total motion.
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Conclusion: Active IR ROM is significantly decreased immediately following a
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cricket fielding drill, while no alterations in JPS were observed. High levels of
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eccentric stress have been reported in the external rotators after throwing which
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may contribute to the acute musculotendinous adaptations observed. Changes
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in IR may be a contributing factor to workload-acquired shoulder throwing
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injuries.
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Keywords: Throwing; Shoulder; Joint position sense; Workload: Range of
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motion.
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ACCEPTED MANUSCRIPT Introduction
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The sport of cricket is broken down into three broad skills; batting, bowling and
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fielding. The skill of fielding is further divided into catching, stopping the ball and
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throwing. Similarities, can be drawn between the mechanism’s of a cricket and
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baseball throw (Cook and Strike, 2000) with much of our knowledge of throwing
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shoulder pain (TSP) arising from baseball literature (Dick, Sauers, Agel, &
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Keuter, 2007; Fleisig et al., 1995). Findings of altered overhead glenohumeral
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joint (GHJ) characteristics, such as increased external rotation (ER) and
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reduced internal rotation (IR), have been reported in baseballers (Borsa, Dover,
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Wilk, & Reinold, 2006) as well as cricketers (Giles and Musa, 2008).
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The skill of throwing has less of an essential nature in cricket, as pitching does
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in baseball, and this is reflected in low rates of shoulder injuries recorded over
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an eleven season period (Orchard, James, Kountouris, & Portus, 2010).
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However, these low levels of shoulder injury may be explained by the injury
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definition used in this study, included only match time loss injuries. It is
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postulated that the true prevalence of TSP maybe much higher as TSP rarely
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causes missed games with players typically choosing to field in alternative
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positions to avoid throwing (Ranson and Gregory, 2008)
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The mechanics of an overhead throw inflict significant compressive and shear
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stress on the GHJ (Meister, 2000) as well as eccentric stress on the posterior
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rotator cuff
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maintained by passive and active mechanisms (Myers, Laudner, K Pasquale,
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Bradley, & Lephart, 2006), that are mediated by the sensorimotor system
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(Myers and Lephart, 2000). It has been proposed that a failure of the dynamic
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(Yanagisawa, Niitsu, Takahashi,, & Itai, 2003). GHJ stability is
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ACCEPTED MANUSCRIPT muscular constraints or its feedback loop may therefore increase the load and
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stress placed on the passive structures – compromising joint integrity, which
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could in part be due to reduced proprioception (Janwantanakul et al., 2001.,
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Myers and Lephart, 2000).
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Proprioception is often broken down into three categories; joint position sense
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(JPS), a person’s ability to perceive where their limb is in space, perception of
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tension, ability to recognise force generation about a joint and kinesthesia, the
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perception of active and passive motion (Aydin et al., 2001; Riemann and
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Lephart, 2002). Disruptions in JPS, have been reported following fatiguing ER
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and IR exercise of the GHJ (Myers, Guskiewicz, Schneider, & Prentice, 1999)
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as well as after a repetitive pitching protocol (Tripp, Yochem, & Uhl, 2007). This
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disruption in JPS as a muscle fatigues, may be due to alteration in
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mechanoreceptor firing and interaction with the central nervous system
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reducing the neuromuscular control of the GHJ (Lephart, Warner, Borsa, & Fu,
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1994). This is particularly important for injury risk during throwing as the arm
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cocked position, end range external rotation, has been shown to be a critical
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position in the cause of shoulder injuries (Jobe, Kvitne, and Giangarra, 1989). A
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reduction in JPS towards the end range of motion (ROM) may increase the
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mechanical stress on active and passive structures responsibly for joint stability
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(Myers et a., 1999).
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Further risk factors for TSP, reported in both cricket and baseball populations
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include a reduction in GHJ IR and total ROM (Giles and Musa, 2008, Wiki et al.,
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2011). Tightening of the posterior cuff and capsule, which can result in reduced
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IR has been shown to contribute to internal impingement (Myers et al., 2006) as
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ACCEPTED MANUSCRIPT well as increase shoulder injury risk two fold (Wiki et al., 2011). Another
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common risk factor established for TSP is an increase in throwing workloads
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(Olsen et al., 2006; Saw, Dennis, Bentley, & Farhart, 2009). The first study to
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monitor throwing workloads in elite cricketers found 75 throws, and a reduced
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number of rest days, per week significantly increased shoulder injury risk (Saw
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et al., 2011). The authors also found a trend towards an increased injury risk for
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40 or more throws in a single day.
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Following a pitching session involving a similar number of throws Reinold et al.,
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(2008) found a 9.5o reduction in throwing shoulder passive IR, which was still
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evident 24 hours after pitching. It is postulated that the discussed eccentric
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muscle contractions and restrictions in the posterior rotator cuff and capsule
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may contribute to the acute adaptations and altered ROM, which may increase
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the risk of TSP (Shandley et al., 2012). While the effects on an acute bout of
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throwing on the shoulder have been investigated in baseball, it remains unclear
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what effect, if any, these highlighted workloads may have on acute changes in
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joint ROM and the sensory motor system in cricketers.
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Therefore, the aim of the present study was to examine the effects of a cricket
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throwing training session on JPS and active ROM of the throwing shoulder. It is
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hypothesised that a cricket throwing training session would result in altered JPS
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acuity and a reduction in GHJ IR active ROM.
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Method
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An experimental design approach was selected for the project, utilising a
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convenience sample design. Data collection occurred during indoor training
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ACCEPTED MANUSCRIPT over a 6-week period Participants were included if they had a history of playing
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cricket for greater than 3 years including representing district or county age
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groups squads and an ability to perform an overhead throw. The Kerlan-Jobe
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Orthopedic Clinic Shoulder and Elbow score (KJOCSES) was completed by all
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participants prior to the study. A cut off of 90% was selected as representing a
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optimal level of pain free overhead shoulder function in a throwing population
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(Alberta et al., 2010). Participants were excluded if they were wicket keepers,
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had a history of elbow or shoulder injury/pathology/surgery on their throwing
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arm in the past 2 years or had participated in an overhead throwing session the
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pervious day. Ethical approval was granted by the University of Birmingham
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Ethics/Health and safety committee.
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Study design and setting
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An experimental design approach was selected for the project. Data collection
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occurred during pre-season indoor training for the university cricket team over a
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6-week period. Participants that were selected for testing performed GHJ ROM
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assessments at 90 degrees abduction and 90 degrees elbow flexion in the
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supine position, which has been shown to have high intrarater reliability (Sabari,
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Maltzev, Lubarsky, Liszkay, & Homel, 1998), as well as JPS tasks into internal
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and external rotation pre and post a fielding session.
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Participant preparation
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The olecranon and ulna styloid process were marked using a marker pen for
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joint angle calculation while a mark 4cm below the radioulnar joint line was used
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for placement of the electronic inclinometer (Wixey, USA). Participants lay
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ACCEPTED MANUSCRIPT supine on a portable plinth with the deltoid tuberosity of their throwing arm
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aligned with the edge of the plinth to allow for ROM greater than 90 degrees
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ER. The throwing arm was abducted to 90 degrees and elbow flexed to 90
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degrees a position to be termed neutral. Both knees were flexed to a 90o angle
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to reduce lumbar extension during assessment. Prior to data collection
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participants conducted a five minute warm up, lead by the lead investigator,
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which consisted of active ROM exercises of the GHJ, thoracic rotations, lunges
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as well as partner assisted isometric presses into IR and ER a 0o and 90o of
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shoulder abduction. Participants were familiarised with the JPS task once prior
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to the data collection.
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Range of Motion Assessment
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Prior to active ROM assessment participants were informed of physical
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compensation that may occur at end range in ER (extension of lumbar and/or
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thoracic spine) or IR (anterior translation of the glenohumeral head) and along
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with the judgment of the investigator, were instructed to stop the movement
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when they felt these compensations. From this neutral position participants
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were instructed to move into end range ER. This angle was then calculated
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using the electronic inclinometer, which has been shown to have a high degree
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of intra- and inter-tester reliability (r = 0.98-0.91) (Mullaney et al., 2010) and
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accuracy + 0.2o (Wixey, USA). A photograph using a digital camera (Nikon
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Coolpix E8400, digital camera, 8 mega pixels) was taken for analysis using
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ImageJ computer software (http://rsb.info.nih.gov/ij/download.html). Angles
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were calculated at the intersection of two lines at the olecronon of the elbow.
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The first line comprised of a vertical line perpendicular to the olecranon
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marking. The second line was taken from the olecranon to the ulna styloid at
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the wrist.
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participants shoulder on a tripod (Velbon cx 444, UK), 1.5 meters away. No
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zoom was applied. Participants returned to neutral and were then instructed to
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move to end range IR, with this angle being calculated with the inclinometer as
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well as a photo being taken. Attempts were deemed void if the investigator
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noted a significant compensation and another attempt was attained. With the
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total ranges of motion identified, 10% off end range internal and external
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rotation was calculated and used as the joint replication task target angles. The
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use of 10% off end range, as a target angle, allows each participant to target
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the same relative target angle (Dover et al., 2003).
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Joint Position Sense Task
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The JPS task began with the participant in neutral, with a blindfold on to
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minimise visual input. Participants were passively rotated to the target angle
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(10% off end range) using the electronic inclinometer. The participant was
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instructed to hold this position, actively, for 5 seconds while a photograph was
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taken and was then returned to neutral (Figure 1). The participant was verbally
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instructed to actively replicate that angle and say ‘’OK’’ when they perceived
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they had achieved the angle, and a photo was taken. This procedure took place
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three times for ER and three times in IR in order to calculate joint reposition
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error.
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The camera was positioned at the height of and inline with the
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ACCEPTED MANUSCRIPT Following the JPS task participants then undertook a cricket fielding drill, which
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was followed by the second JPS task using the exact procedure as described
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above.
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Figure 1. Photograph showing participants’ in the ER (left) and IR (right) target angles during the active angle replication task. (colour reproduction)
Fielding task
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The outline of the cricket fielding drill lead by the team coach can be seen in
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Figure 2. Participants were instructed to perform maximal throws at the stumps
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as if they were aiming to run a batsman out, as well as to throw each ball
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overarm. Participants attacked the ball, picked up the ball and threw towards
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the stumps on their side. The drill was progressed to throwing at the stumps at
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the other side, to replicate the dynamic nature of a cricket throw with
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participants moving to the opposite station following the throw. The drill was
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terminated when each participant had completed 40 successful throws,
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previously identified as an injury risk (Saw et al., 2011).
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Figure 2. Diagram showing the cricket fielding drill. Data reduction and statistical analysis
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For each participant the target angle was subtracted from the reproduced angle
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to give a resultant absolute error score (angle) with any negative values made
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positive, an average was taken from the three trials in ER and IR. Once all
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photos were collected, a second investigator coded all photos to unidentifiable
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numbers, blinding the lead investigator during the angle calculation task. The
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identities of the photos were disguised and password protected by the second
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investigator and only revealed after data analysis. The absolute error scores
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were then statistically analysed using SPSS (SPSS, Chicago, IL, USA) version
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21, statistical package. A repeated measures ANOVA with two factors: Rotation
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(ER or IR) and throwing status (PRE and POST), with Greenhouse-Geisser
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adjustment applied, was used to calculate differences in mean error scores.
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Paired t-tests with bonferoni adjustment were used to investigate specific
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differences in ROM, pre and post throwing protocol. Statistical significance was
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set at p < 0.05 with all values presented as mean + SD. A post hoc power
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2007) with non-significant results undergoing a priori analysis to determine what
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sample size would have been needed to reach satisfactory statistical power of
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0.08.
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230 Results
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Participants
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Nineteen university 1st team cricketers, aged between 19 and 23 (mean 20.7 +
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1.4) years, were recruited on for the study on a convenience basis. All subjects
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met inclusion criteria and the average score for KJOCSES was 93.1 + 4.1
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Reliability
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The test re-test reliability of the angle calculation method was tested on a
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separate group of six participants. Angle calculation was identified using six
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photos assessed over the same angle over two separate time points, 30
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minutes apart. A comparison of the two photographs using intra-class
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correlation coefficient, revealed a strong correlation of f = 0.82 (p = 0.03)
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between the two photos and no statistical differences (p = 0.175) on testing with
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repeated measures t-tests. The mean difference between the two photographed
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angles was 0.3o (+ 0.49) with 95% confidence intervals of 0 – 0.95o. Using the
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formula displayed by Donoghue and Stokes (2009) a minimal detectable
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change score of 1.52o was calculated, indicating that any change over 1.52o
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would be due to genuine change rather than measurement error.
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ACCEPTED MANUSCRIPT Range of motion
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Active ROM measurements pre and post fielding session are displayed in
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Figure 3. There was a significant decrease in internal rotation (-3.9o) as a result
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of the fielding drill, t (19) = 3.036, p = 0.007 and represented a medium-size
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effect (d = 0.66) with a power of 0.87. There was no significant difference
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between pre and post fielding on external rotation (+2.2o), t (19) = -1.72, p =
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0.101, which represented a small effect size (d = 0.38). The post hoc analyses
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revealed the statistical power was 0.47 for detecting this effect size. A priori
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post-hoc power analysis revealed that in order for an effect of this size to be
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detected (80% chance) as significant at the 5% level, a sample of 46
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participants would be required.
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There was no significant difference between pre and post fielding on total
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motion (-1.7o)t (19) = 0.791, p = 0.439, and no effect represented with a small
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effects size (d = 0.12), power 0.13. A priori post hoc power revealed that in
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order for an effect of this size to be detected (80% chance) as significant at the
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5% level, a sample of 411 participants would be required.
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Figure 3 . Internal, external and total range of motion measurements, pre and post fielding session. Data is mean + SD. * P <0.05 significant reduction in internal rotation. 12
ACCEPTED MANUSCRIPT Joint Reposition Error
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Joint reposition error scores are displayed pre and post fielding session in
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Figure 4. Prior to the fielding drill, ER error score was 3.28 + 2.23o while IR was
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2.98 + 1.48o. Following the fielding drill, ER error was 2.86 + 1.26o while IR was
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3.46 + 1.6o.
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Figure 4. Mean joint reposition error scores for internal and external rotation, pre and post fielding session. Data mean + SD.
There was no significant main effect for throwing status (F (1,18) = 0.16, p =
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0.90), rotation angle (F (1,18) = 2.77, p = 0.61) or an intervention by rotation
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angle interaction (F (1,18) = 2.3, p = 0.15). Paired sample t-test indicated no
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significant difference in JPS error in ER, t (18) = 0.91, p = 0.36, with a small
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effect size (d = 0.24) and a power of 0.24. A priori post hoc power revealed that
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in order for an effect of this size to be detected (80% chance) as significant at
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the 5% level, a sample of 130 participants would be required. There was no
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significant difference in JPS error in IR t (18) = -1.2 p = 0.27, with a small effect
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size (d = 0.26), and a power of 0.29 following the fielding session. A priori post
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hoc power revealed that in order for an effect of this size to be detected (80%
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chance) as significant at the 5% level, a sample of 94 participants would be
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required.
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This study is the first to investigate the acute effects of throwing on the GHJ in a
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cricket population. Following a fielding session involving a throwing workload
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that has been reported to increase the risk of TSP (Saw et al., 2011), active
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GHJ IR was acutely reduced while there were no significant changes in ER,
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TROM or JPS. These findings are consistent with acute IR reductions following
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baseball pitching (Reinold et al., 2008) but contrast the findings of reduced JPS
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acuity observed following a baseball pitching protocol (Tripp et al., 2007).
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The lack of change in JPS in the current study, compared to that of Tripp et al.,
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(2007) may be accounted for by a number of factors. The cricket throw differs
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from a baseball pitch, due to the fluctuating throw distance, throw force,
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dynamic base of support and increased urgency to release the ball reducing the
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ER ROM. Additionally, the fatiguing protocol was based on subjective reporting
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of upper limb fatigue which varied considerably from person to person resulting
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in some individual throwing workloads up to 140 throws. This maximal pitch
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over a higher volume of throws may have been sufficient to elicit enough
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disruption to musculotendinous and articular mechanoreceptors. The use of 40
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throws in the present study may not have been enough of an acute workload to
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disrupt the JPS acuity but it does reflect a workload previous identified as
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increasing cricketers injury risk (Saw, 2011).
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ACCEPTED MANUSCRIPT The assessment of JPS in the current study was performed supine using a 2D
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assessment, while in contrast, Tripp et al., (2007) used a 3D assessment which
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has been suggested as a more valid and accurate tool of assessing
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proprioception (Ashton-miller, 2000). The method in the present study, whilst
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acknowledging its limitations, does provide a time efficient and easy to method
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for front line clinicians. Participants in the present study were set at 10% off end
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range ROM to mitigate for higher reductions in JPS reported at a mid-range
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position (Janwantanakul et al., 2001) and may provide an explanation for the
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accuracy of JPS in the present study as no fixed ROM assessment was used by
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Trip et al., (2007). Similar findings of enhanced JPS towards end of range have
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been reported by Olivier, Stewart, & Mckinon, (2014). Assessment of end of
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range JPS may provide clinically useful information as accurate identification of
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extremes of motion could stop unnecessary mechanical stress of structures
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responsible to joint stability (Myers et al., 1999).
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The findings of a greater IR deficit found by Reinold et al., (2008) than the
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present study maybe again be explained by a greater throwing intensity and
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volume. No significant change in TROM was observed within this study, which
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maybe explain by the loss of IR is canceled out by the non-significant increase
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in ER. In a larger sample size a greater increase may be observed. Although
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statically significant and greater than the MDC, the 3.9o reduction in IR, has
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questionable clinical relevance. However, it does provide an insight into the
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acute effect of a single training session on the GHJ and further research should
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examine if this change increases over the course of a season.
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ACCEPTED MANUSCRIPT The cause for this acute adaptation is proposed to be due to changes in
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posterior rotator cuff stiffness, rather than bone morphology or capsular scaring
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(Bailey et al., 2015) as these would not be seen so soon after throwing. It is the
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exposure to the high levels of eccentric stress experienced during the throwing
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action that are proposed to increase the posterior rotator cuff tightness (Fleisig
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et al., 1995). Furthermore, following baseball pitching, increased long lasting
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signal changes on T2-weighted MRIs of the posterior rotator cuff muscles, have
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been attributed to the eccentric induced muscle damage required to decelerate
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the throwing arm (Yanagisawa et al., 2003). Eccentric induced muscle damage
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has also been correlated with an increase in muscular tension and a loss of
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joint motion (Proske and Morgan, 2001) and could be a key factor in TSP.
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It has been proposed that baseball pitchers maybe more susceptible to
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shoulder injury if they continue to pitch with decreased IR and TROM. While no
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research has investigated this prospectively within cricket, it is possibly, a
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contributing factor to the development of workload related TSP. It is
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recommended that clinicians working with cricketer’s monitor GHJ ROM,
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particularly at times of high throwing workloads and individuals with a history of
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TAP, such as during limited overs cricket.
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There are a number of limitations to the current study that should be considered
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when extrapolating the findings. All participants experienced the same absolute
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workload, but with ranges in throwing history and techniques, it could be argued
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that some participants may not have been fatigued from the protocol and
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individual reports of perceived fatigue were not measured. The cricket fielding
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drill was conducted from a single distance and did not accommodate throws
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ACCEPTED MANUSCRIPT from greater distances that typically require greater force and as a result,
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replicated exclusively inner circle throws. The controlled distance did however,
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ensure all participants did the same volume and intensity of throws and is
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replicable of indoor conditions that British cricketers have to train in during the
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winter months. A final limitation of the current study was the use of a small
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convenience sample, that may not have been large enough to gain satisfactory
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statistical power, as displayed in post hoc analysis. However, the significant
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reduction in IR ROM had a promising effect size and future research is required
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to validate these findings.
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Future directions of this study could include the prospective monitoring of ROM
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and JPS over the course of a season and their relationship with the reporting of
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TAP. Within this, identification of the acute effects of throwing on the shoulder
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at differing workloads would provide more insight the onset of TAP.
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Conclusion
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In conclusion, the present study showed the acute effect of a cricket fielding
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session, at an injury risk workload, resulted in no alteration in GHJ JPS but did
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however significantly reduce active GHJ IR immediately following throwing. It
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therefore seems possible to suggest that reductions in IR may have a significant
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role in the onset of workload related TSP.
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needed to investigate the acute and chronic effects of throwing and how these
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may relate to injury risk.
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Further prospective research is
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(2006). Glenohumeral range of motion deficits and posterior shoulder tightness
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Harker, P.,
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rotation deficit and total rotational motion to shoulder injuries in professional
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Highlights Although throwing injuries do not result in large amounts of match loss, the prevalence of TSP is high in first class cricket. Technique and workloads have been reported as risk factors for the development of TSP The acute effects of 40 throws in a fielding drill reduced IR ROM but did not alter ER, TROM or JPS. Reductions in GHJ IR may have a significant role in the onset of TSP, particularly during periods of high throwing workloads.
ACCEPTED MANUSCRIPT Conflict of interest No financial support was received in undertaking this study nor did the authors have any conflicts of interest when undertaking this study.
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Ethical approval The study was given ethical approval by the University of Birmingham, School of Sport and Rehabilitation Science ethics committee. All participants gave full informed consent to participate in the study as well as have their photos
Funding None declared.
Acknowledgements
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The authors would like to thank the participants for taking part in the study as
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well as Mr Callum Brown for blinding the data prior to analysis.
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To:
Jill Ramsay
From:
Raymond Reynolds
Date:
27th Jan 2015
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School of Sport and Exercise Sciences MEMORANDUM
The effect of a Cricket fielding session on glenohumeral joint position sense and range of motion in university level cricketers.
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The School Ethics/Health and Safety Committee have reviewed your application and hereby grant full ethical approval for your study.
S1466-853X(17)30132-3
DOI:
10.1016/j.ptsp.2018.04.002
Reference:
YPTSP 871
To appear in:
Physical Therapy in Sport
Received Date: 5 April 2017 Revised Date:
8 March 2018
Accepted Date: 3 April 2018
Please cite this article as: Newton, L., McCaig, S., The effect of a cricket fielding session on glenohumeral range of motion and active joint position sense, Physical Therapy in Sports (2018), doi: 10.1016/j.ptsp.2018.04.002. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE.
Acknowledgements: The authors would like to thank the participants for taking
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part in the study as well as Mr Callum Brown for blinding the data prior to
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ACCEPTED MANUSCRIPT THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE. Authors: Mr Liam Newtona a
School of Sport, Exercise and Rehabilitation Science
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University of Birmingham Edgbaston campus Edgbaston Birmingham
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England B15 2TT
Mr Steve McCaigb b
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National Cricket Performance Centre
Loughborough University
Leicestershire England LE 11 3TU
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Corresponding Author: Liam Newton @newton_liam
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[email protected]
Current address: Romsey Hospital, Physiotherapy Outpatients, Winchester Hill, Romsey SO51 7ZA Phone: 07854544334
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THE EFFECT OF A CRICKET FIELDING SESSION ON GLENOHUMERAL
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RANGE OF MOTION AND ACTIVE JOINT POSITION SENSE.
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ACCEPTED MANUSCRIPT Abstract
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Objective: To assess the effects of a cricket fielding session, at an identified
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throwing injury risk workload, on shoulder joint position sense (JPS) and active
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range of motion (AROM) in cricketers.
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Design: Repeated measures observational study
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Setting: Indoor cricket centre
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Participants: Nineteen, asymptomatic University cricketers.
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Main outcome: AROM was assessed supine at 90o abduction and from this
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10% off end range IR and ER was used as the position matching angle to
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assess JPS. JPS error scores as well as AROM were assessed pre and post a
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cricket fielding session consisting of 40 throws.
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Results: Following the cricket fielding session, no alteration in JPS in ER (p =
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0.91) or IR (p = 0.27) was observed. There was however a significant decrease
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in IR (-3.9o) following the fielding drill (p = 0.007) while no significant change
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was observed in ER or total motion.
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Conclusion: Active IR ROM is significantly decreased immediately following a
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cricket fielding drill, while no alterations in JPS were observed. High levels of
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eccentric stress have been reported in the external rotators after throwing which
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may contribute to the acute musculotendinous adaptations observed. Changes
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in IR may be a contributing factor to workload-acquired shoulder throwing
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injuries.
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Keywords: Throwing; Shoulder; Joint position sense; Workload: Range of
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motion.
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The sport of cricket is broken down into three broad skills; batting, bowling and
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fielding. The skill of fielding is further divided into catching, stopping the ball and
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throwing. Similarities, can be drawn between the mechanism’s of a cricket and
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baseball throw (Cook and Strike, 2000) with much of our knowledge of throwing
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shoulder pain (TSP) arising from baseball literature (Dick, Sauers, Agel, &
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Keuter, 2007; Fleisig et al., 1995). Findings of altered overhead glenohumeral
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joint (GHJ) characteristics, such as increased external rotation (ER) and
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reduced internal rotation (IR), have been reported in baseballers (Borsa, Dover,
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Wilk, & Reinold, 2006) as well as cricketers (Giles and Musa, 2008).
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The skill of throwing has less of an essential nature in cricket, as pitching does
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in baseball, and this is reflected in low rates of shoulder injuries recorded over
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an eleven season period (Orchard, James, Kountouris, & Portus, 2010).
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However, these low levels of shoulder injury may be explained by the injury
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definition used in this study, included only match time loss injuries. It is
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postulated that the true prevalence of TSP maybe much higher as TSP rarely
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causes missed games with players typically choosing to field in alternative
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positions to avoid throwing (Ranson and Gregory, 2008)
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The mechanics of an overhead throw inflict significant compressive and shear
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stress on the GHJ (Meister, 2000) as well as eccentric stress on the posterior
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rotator cuff
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maintained by passive and active mechanisms (Myers, Laudner, K Pasquale,
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Bradley, & Lephart, 2006), that are mediated by the sensorimotor system
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(Myers and Lephart, 2000). It has been proposed that a failure of the dynamic
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(Yanagisawa, Niitsu, Takahashi,, & Itai, 2003). GHJ stability is
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ACCEPTED MANUSCRIPT muscular constraints or its feedback loop may therefore increase the load and
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stress placed on the passive structures – compromising joint integrity, which
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could in part be due to reduced proprioception (Janwantanakul et al., 2001.,
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Myers and Lephart, 2000).
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Proprioception is often broken down into three categories; joint position sense
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(JPS), a person’s ability to perceive where their limb is in space, perception of
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tension, ability to recognise force generation about a joint and kinesthesia, the
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perception of active and passive motion (Aydin et al., 2001; Riemann and
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Lephart, 2002). Disruptions in JPS, have been reported following fatiguing ER
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and IR exercise of the GHJ (Myers, Guskiewicz, Schneider, & Prentice, 1999)
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as well as after a repetitive pitching protocol (Tripp, Yochem, & Uhl, 2007). This
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disruption in JPS as a muscle fatigues, may be due to alteration in
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mechanoreceptor firing and interaction with the central nervous system
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reducing the neuromuscular control of the GHJ (Lephart, Warner, Borsa, & Fu,
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1994). This is particularly important for injury risk during throwing as the arm
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cocked position, end range external rotation, has been shown to be a critical
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position in the cause of shoulder injuries (Jobe, Kvitne, and Giangarra, 1989). A
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reduction in JPS towards the end range of motion (ROM) may increase the
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mechanical stress on active and passive structures responsibly for joint stability
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(Myers et a., 1999).
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Further risk factors for TSP, reported in both cricket and baseball populations
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include a reduction in GHJ IR and total ROM (Giles and Musa, 2008, Wiki et al.,
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2011). Tightening of the posterior cuff and capsule, which can result in reduced
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IR has been shown to contribute to internal impingement (Myers et al., 2006) as
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ACCEPTED MANUSCRIPT well as increase shoulder injury risk two fold (Wiki et al., 2011). Another
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common risk factor established for TSP is an increase in throwing workloads
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(Olsen et al., 2006; Saw, Dennis, Bentley, & Farhart, 2009). The first study to
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monitor throwing workloads in elite cricketers found 75 throws, and a reduced
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number of rest days, per week significantly increased shoulder injury risk (Saw
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et al., 2011). The authors also found a trend towards an increased injury risk for
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40 or more throws in a single day.
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Following a pitching session involving a similar number of throws Reinold et al.,
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(2008) found a 9.5o reduction in throwing shoulder passive IR, which was still
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evident 24 hours after pitching. It is postulated that the discussed eccentric
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muscle contractions and restrictions in the posterior rotator cuff and capsule
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may contribute to the acute adaptations and altered ROM, which may increase
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the risk of TSP (Shandley et al., 2012). While the effects on an acute bout of
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throwing on the shoulder have been investigated in baseball, it remains unclear
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what effect, if any, these highlighted workloads may have on acute changes in
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joint ROM and the sensory motor system in cricketers.
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Therefore, the aim of the present study was to examine the effects of a cricket
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throwing training session on JPS and active ROM of the throwing shoulder. It is
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hypothesised that a cricket throwing training session would result in altered JPS
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acuity and a reduction in GHJ IR active ROM.
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Method
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An experimental design approach was selected for the project, utilising a
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convenience sample design. Data collection occurred during indoor training
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ACCEPTED MANUSCRIPT over a 6-week period Participants were included if they had a history of playing
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cricket for greater than 3 years including representing district or county age
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groups squads and an ability to perform an overhead throw. The Kerlan-Jobe
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Orthopedic Clinic Shoulder and Elbow score (KJOCSES) was completed by all
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participants prior to the study. A cut off of 90% was selected as representing a
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optimal level of pain free overhead shoulder function in a throwing population
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(Alberta et al., 2010). Participants were excluded if they were wicket keepers,
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had a history of elbow or shoulder injury/pathology/surgery on their throwing
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arm in the past 2 years or had participated in an overhead throwing session the
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pervious day. Ethical approval was granted by the University of Birmingham
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Ethics/Health and safety committee.
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Study design and setting
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An experimental design approach was selected for the project. Data collection
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occurred during pre-season indoor training for the university cricket team over a
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6-week period. Participants that were selected for testing performed GHJ ROM
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assessments at 90 degrees abduction and 90 degrees elbow flexion in the
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supine position, which has been shown to have high intrarater reliability (Sabari,
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Maltzev, Lubarsky, Liszkay, & Homel, 1998), as well as JPS tasks into internal
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and external rotation pre and post a fielding session.
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Participant preparation
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The olecranon and ulna styloid process were marked using a marker pen for
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joint angle calculation while a mark 4cm below the radioulnar joint line was used
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for placement of the electronic inclinometer (Wixey, USA). Participants lay
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ACCEPTED MANUSCRIPT supine on a portable plinth with the deltoid tuberosity of their throwing arm
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aligned with the edge of the plinth to allow for ROM greater than 90 degrees
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ER. The throwing arm was abducted to 90 degrees and elbow flexed to 90
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degrees a position to be termed neutral. Both knees were flexed to a 90o angle
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to reduce lumbar extension during assessment. Prior to data collection
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participants conducted a five minute warm up, lead by the lead investigator,
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which consisted of active ROM exercises of the GHJ, thoracic rotations, lunges
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as well as partner assisted isometric presses into IR and ER a 0o and 90o of
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shoulder abduction. Participants were familiarised with the JPS task once prior
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to the data collection.
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Range of Motion Assessment
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Prior to active ROM assessment participants were informed of physical
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compensation that may occur at end range in ER (extension of lumbar and/or
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thoracic spine) or IR (anterior translation of the glenohumeral head) and along
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with the judgment of the investigator, were instructed to stop the movement
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when they felt these compensations. From this neutral position participants
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were instructed to move into end range ER. This angle was then calculated
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using the electronic inclinometer, which has been shown to have a high degree
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of intra- and inter-tester reliability (r = 0.98-0.91) (Mullaney et al., 2010) and
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accuracy + 0.2o (Wixey, USA). A photograph using a digital camera (Nikon
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Coolpix E8400, digital camera, 8 mega pixels) was taken for analysis using
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ImageJ computer software (http://rsb.info.nih.gov/ij/download.html). Angles
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were calculated at the intersection of two lines at the olecronon of the elbow.
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The first line comprised of a vertical line perpendicular to the olecranon
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marking. The second line was taken from the olecranon to the ulna styloid at
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the wrist.
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participants shoulder on a tripod (Velbon cx 444, UK), 1.5 meters away. No
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zoom was applied. Participants returned to neutral and were then instructed to
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move to end range IR, with this angle being calculated with the inclinometer as
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well as a photo being taken. Attempts were deemed void if the investigator
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noted a significant compensation and another attempt was attained. With the
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total ranges of motion identified, 10% off end range internal and external
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rotation was calculated and used as the joint replication task target angles. The
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use of 10% off end range, as a target angle, allows each participant to target
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the same relative target angle (Dover et al., 2003).
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Joint Position Sense Task
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The JPS task began with the participant in neutral, with a blindfold on to
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minimise visual input. Participants were passively rotated to the target angle
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(10% off end range) using the electronic inclinometer. The participant was
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instructed to hold this position, actively, for 5 seconds while a photograph was
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taken and was then returned to neutral (Figure 1). The participant was verbally
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instructed to actively replicate that angle and say ‘’OK’’ when they perceived
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they had achieved the angle, and a photo was taken. This procedure took place
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three times for ER and three times in IR in order to calculate joint reposition
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error.
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The camera was positioned at the height of and inline with the
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ACCEPTED MANUSCRIPT Following the JPS task participants then undertook a cricket fielding drill, which
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was followed by the second JPS task using the exact procedure as described
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above.
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Figure 1. Photograph showing participants’ in the ER (left) and IR (right) target angles during the active angle replication task. (colour reproduction)
Fielding task
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The outline of the cricket fielding drill lead by the team coach can be seen in
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Figure 2. Participants were instructed to perform maximal throws at the stumps
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as if they were aiming to run a batsman out, as well as to throw each ball
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overarm. Participants attacked the ball, picked up the ball and threw towards
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the stumps on their side. The drill was progressed to throwing at the stumps at
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the other side, to replicate the dynamic nature of a cricket throw with
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participants moving to the opposite station following the throw. The drill was
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terminated when each participant had completed 40 successful throws,
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previously identified as an injury risk (Saw et al., 2011).
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Figure 2. Diagram showing the cricket fielding drill. Data reduction and statistical analysis
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For each participant the target angle was subtracted from the reproduced angle
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to give a resultant absolute error score (angle) with any negative values made
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positive, an average was taken from the three trials in ER and IR. Once all
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photos were collected, a second investigator coded all photos to unidentifiable
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numbers, blinding the lead investigator during the angle calculation task. The
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identities of the photos were disguised and password protected by the second
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investigator and only revealed after data analysis. The absolute error scores
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were then statistically analysed using SPSS (SPSS, Chicago, IL, USA) version
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21, statistical package. A repeated measures ANOVA with two factors: Rotation
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(ER or IR) and throwing status (PRE and POST), with Greenhouse-Geisser
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adjustment applied, was used to calculate differences in mean error scores.
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Paired t-tests with bonferoni adjustment were used to investigate specific
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differences in ROM, pre and post throwing protocol. Statistical significance was
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set at p < 0.05 with all values presented as mean + SD. A post hoc power
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2007) with non-significant results undergoing a priori analysis to determine what
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sample size would have been needed to reach satisfactory statistical power of
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0.08.
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230 Results
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Participants
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Nineteen university 1st team cricketers, aged between 19 and 23 (mean 20.7 +
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1.4) years, were recruited on for the study on a convenience basis. All subjects
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met inclusion criteria and the average score for KJOCSES was 93.1 + 4.1
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Reliability
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The test re-test reliability of the angle calculation method was tested on a
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separate group of six participants. Angle calculation was identified using six
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photos assessed over the same angle over two separate time points, 30
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minutes apart. A comparison of the two photographs using intra-class
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correlation coefficient, revealed a strong correlation of f = 0.82 (p = 0.03)
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between the two photos and no statistical differences (p = 0.175) on testing with
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repeated measures t-tests. The mean difference between the two photographed
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angles was 0.3o (+ 0.49) with 95% confidence intervals of 0 – 0.95o. Using the
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formula displayed by Donoghue and Stokes (2009) a minimal detectable
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change score of 1.52o was calculated, indicating that any change over 1.52o
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would be due to genuine change rather than measurement error.
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Active ROM measurements pre and post fielding session are displayed in
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Figure 3. There was a significant decrease in internal rotation (-3.9o) as a result
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of the fielding drill, t (19) = 3.036, p = 0.007 and represented a medium-size
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effect (d = 0.66) with a power of 0.87. There was no significant difference
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between pre and post fielding on external rotation (+2.2o), t (19) = -1.72, p =
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0.101, which represented a small effect size (d = 0.38). The post hoc analyses
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revealed the statistical power was 0.47 for detecting this effect size. A priori
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post-hoc power analysis revealed that in order for an effect of this size to be
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detected (80% chance) as significant at the 5% level, a sample of 46
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participants would be required.
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There was no significant difference between pre and post fielding on total
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motion (-1.7o)t (19) = 0.791, p = 0.439, and no effect represented with a small
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effects size (d = 0.12), power 0.13. A priori post hoc power revealed that in
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order for an effect of this size to be detected (80% chance) as significant at the
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5% level, a sample of 411 participants would be required.
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125.2 123.5
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90
Pre
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Figure 3 . Internal, external and total range of motion measurements, pre and post fielding session. Data is mean + SD. * P <0.05 significant reduction in internal rotation. 12
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Joint reposition error scores are displayed pre and post fielding session in
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Figure 4. Prior to the fielding drill, ER error score was 3.28 + 2.23o while IR was
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2.98 + 1.48o. Following the fielding drill, ER error was 2.86 + 1.26o while IR was
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3.46 + 1.6o.
2.98 3.49
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Figure 4. Mean joint reposition error scores for internal and external rotation, pre and post fielding session. Data mean + SD.
There was no significant main effect for throwing status (F (1,18) = 0.16, p =
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0.90), rotation angle (F (1,18) = 2.77, p = 0.61) or an intervention by rotation
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angle interaction (F (1,18) = 2.3, p = 0.15). Paired sample t-test indicated no
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significant difference in JPS error in ER, t (18) = 0.91, p = 0.36, with a small
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effect size (d = 0.24) and a power of 0.24. A priori post hoc power revealed that
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in order for an effect of this size to be detected (80% chance) as significant at
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the 5% level, a sample of 130 participants would be required. There was no
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significant difference in JPS error in IR t (18) = -1.2 p = 0.27, with a small effect
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size (d = 0.26), and a power of 0.29 following the fielding session. A priori post
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hoc power revealed that in order for an effect of this size to be detected (80%
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chance) as significant at the 5% level, a sample of 94 participants would be
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required.
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This study is the first to investigate the acute effects of throwing on the GHJ in a
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cricket population. Following a fielding session involving a throwing workload
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that has been reported to increase the risk of TSP (Saw et al., 2011), active
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GHJ IR was acutely reduced while there were no significant changes in ER,
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TROM or JPS. These findings are consistent with acute IR reductions following
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baseball pitching (Reinold et al., 2008) but contrast the findings of reduced JPS
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acuity observed following a baseball pitching protocol (Tripp et al., 2007).
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The lack of change in JPS in the current study, compared to that of Tripp et al.,
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(2007) may be accounted for by a number of factors. The cricket throw differs
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from a baseball pitch, due to the fluctuating throw distance, throw force,
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dynamic base of support and increased urgency to release the ball reducing the
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ER ROM. Additionally, the fatiguing protocol was based on subjective reporting
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of upper limb fatigue which varied considerably from person to person resulting
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in some individual throwing workloads up to 140 throws. This maximal pitch
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over a higher volume of throws may have been sufficient to elicit enough
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disruption to musculotendinous and articular mechanoreceptors. The use of 40
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throws in the present study may not have been enough of an acute workload to
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disrupt the JPS acuity but it does reflect a workload previous identified as
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increasing cricketers injury risk (Saw, 2011).
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ACCEPTED MANUSCRIPT The assessment of JPS in the current study was performed supine using a 2D
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assessment, while in contrast, Tripp et al., (2007) used a 3D assessment which
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has been suggested as a more valid and accurate tool of assessing
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proprioception (Ashton-miller, 2000). The method in the present study, whilst
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acknowledging its limitations, does provide a time efficient and easy to method
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for front line clinicians. Participants in the present study were set at 10% off end
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range ROM to mitigate for higher reductions in JPS reported at a mid-range
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position (Janwantanakul et al., 2001) and may provide an explanation for the
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accuracy of JPS in the present study as no fixed ROM assessment was used by
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Trip et al., (2007). Similar findings of enhanced JPS towards end of range have
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been reported by Olivier, Stewart, & Mckinon, (2014). Assessment of end of
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range JPS may provide clinically useful information as accurate identification of
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extremes of motion could stop unnecessary mechanical stress of structures
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responsible to joint stability (Myers et al., 1999).
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The findings of a greater IR deficit found by Reinold et al., (2008) than the
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present study maybe again be explained by a greater throwing intensity and
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volume. No significant change in TROM was observed within this study, which
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maybe explain by the loss of IR is canceled out by the non-significant increase
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in ER. In a larger sample size a greater increase may be observed. Although
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statically significant and greater than the MDC, the 3.9o reduction in IR, has
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questionable clinical relevance. However, it does provide an insight into the
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acute effect of a single training session on the GHJ and further research should
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examine if this change increases over the course of a season.
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posterior rotator cuff stiffness, rather than bone morphology or capsular scaring
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(Bailey et al., 2015) as these would not be seen so soon after throwing. It is the
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exposure to the high levels of eccentric stress experienced during the throwing
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action that are proposed to increase the posterior rotator cuff tightness (Fleisig
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et al., 1995). Furthermore, following baseball pitching, increased long lasting
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signal changes on T2-weighted MRIs of the posterior rotator cuff muscles, have
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been attributed to the eccentric induced muscle damage required to decelerate
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the throwing arm (Yanagisawa et al., 2003). Eccentric induced muscle damage
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has also been correlated with an increase in muscular tension and a loss of
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joint motion (Proske and Morgan, 2001) and could be a key factor in TSP.
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It has been proposed that baseball pitchers maybe more susceptible to
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shoulder injury if they continue to pitch with decreased IR and TROM. While no
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research has investigated this prospectively within cricket, it is possibly, a
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contributing factor to the development of workload related TSP. It is
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recommended that clinicians working with cricketer’s monitor GHJ ROM,
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particularly at times of high throwing workloads and individuals with a history of
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TAP, such as during limited overs cricket.
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There are a number of limitations to the current study that should be considered
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when extrapolating the findings. All participants experienced the same absolute
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workload, but with ranges in throwing history and techniques, it could be argued
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that some participants may not have been fatigued from the protocol and
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individual reports of perceived fatigue were not measured. The cricket fielding
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drill was conducted from a single distance and did not accommodate throws
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ACCEPTED MANUSCRIPT from greater distances that typically require greater force and as a result,
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replicated exclusively inner circle throws. The controlled distance did however,
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ensure all participants did the same volume and intensity of throws and is
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replicable of indoor conditions that British cricketers have to train in during the
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winter months. A final limitation of the current study was the use of a small
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convenience sample, that may not have been large enough to gain satisfactory
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statistical power, as displayed in post hoc analysis. However, the significant
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reduction in IR ROM had a promising effect size and future research is required
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to validate these findings.
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Future directions of this study could include the prospective monitoring of ROM
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and JPS over the course of a season and their relationship with the reporting of
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TAP. Within this, identification of the acute effects of throwing on the shoulder
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at differing workloads would provide more insight the onset of TAP.
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Conclusion
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In conclusion, the present study showed the acute effect of a cricket fielding
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session, at an injury risk workload, resulted in no alteration in GHJ JPS but did
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however significantly reduce active GHJ IR immediately following throwing. It
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therefore seems possible to suggest that reductions in IR may have a significant
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role in the onset of workload related TSP.
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needed to investigate the acute and chronic effects of throwing and how these
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may relate to injury risk.
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Further prospective research is
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Highlights Although throwing injuries do not result in large amounts of match loss, the prevalence of TSP is high in first class cricket. Technique and workloads have been reported as risk factors for the development of TSP The acute effects of 40 throws in a fielding drill reduced IR ROM but did not alter ER, TROM or JPS. Reductions in GHJ IR may have a significant role in the onset of TSP, particularly during periods of high throwing workloads.
ACCEPTED MANUSCRIPT Conflict of interest No financial support was received in undertaking this study nor did the authors have any conflicts of interest when undertaking this study.
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Ethical approval The study was given ethical approval by the University of Birmingham, School of Sport and Rehabilitation Science ethics committee. All participants gave full informed consent to participate in the study as well as have their photos
Funding None declared.
Acknowledgements
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The authors would like to thank the participants for taking part in the study as
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well as Mr Callum Brown for blinding the data prior to analysis.
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To:
Jill Ramsay
From:
Raymond Reynolds
Date:
27th Jan 2015
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School of Sport and Exercise Sciences MEMORANDUM
The effect of a Cricket fielding session on glenohumeral joint position sense and range of motion in university level cricketers.
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The School Ethics/Health and Safety Committee have reviewed your application and hereby grant full ethical approval for your study.