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The Use of Imagery to Improve Self-Efficacy of Rehabilitation Capabilities in Athletes Following a Sport-Related Injury: A Critically Appraised Topic

K. Michelle Singleton and Jamie McAllister-Deitrick

Clinical Scenario: Sport-related injuries are a common occurrence within the athletic population and every athlete responds differently. The cognitive, emotional, and behavioral responses associated with injuries ultimately impact the injury rehabilitation process and return to play. Specifically, self-efficacy significantly impacts the rehabilitation process and psychological techniques to improve self-efficacy are crucial in the recovery process. Imagery is one of these beneficial techniques. Clinical Question: Does the use of imagery during injury rehabilitation improve self-efficacy of rehabilitation capabilities compared with rehabilitation alone in athletes with a sport-related injury? Summary of Key Findings: The current literature was searched to identify the effects of imagery use to improve self-efficacy of rehabilitation capabilities, and 2 studies were selected: a mixed methods ecologically valid design and randomized controlled trial. Both studies investigated the relationship between imagery and self-efficacy and found positive results for imagery use in rehabilitation. Additionally, one of the studies specifically assessed rehabilitation satisfaction and found positive results. Clinical Bottom Line: The use of imagery should be considered as a clinical option for increasing self-efficacy during injury rehabilitation. Strength of Recommendation: Based on the Oxford Centre for Evidence-Based Medicine strength of recommendation, there is a grade B of recommendation to support the use of imagery to improve self-efficacy of rehabilitation capabilities during an injury rehabilitation program.

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Early Moderate to Vigorous Physical Activity After Concussion Is Associated With Faster Symptom Resolution Time

Jacob G. Rademacher, Mathew J. Wingerson, Katherine L. Smulligan, Casey C. Little, Julie C. Wilson, and David R. Howell

Context: Early physical activity (PA) after concussion may promote symptom resolution. Prior studies have investigated exercise frequency/duration, yet precise PA intensity or volume required for optimal recovery requires further investigation. moderate to vigorous physical activity (MVPA) is beneficial for physical health. We investigated whether sedentary time, light activity time, MVPA time, or activity frequency in the weeks following concussion are associated with time to symptom resolution among adolescents. Design: Prospective cohort study. Methods: Adolescents 10–18 years of age were tested ≤14 days of concussion and followed until symptom resolution. At the initial visit, participants rated symptom severity and were provided wrist-worn activity trackers to monitor PA for the following week. PA behavior was categorized each day based on heart rate: sedentary (resting), light PA (50%–69% age-predicted max heart rate), and MVPA (70%–100% age-predicted max heart rate). Symptom resolution was defined as the date when participants reported cessation of concussion-like symptoms. Patients were not given specific PA instructions, though some may have received instructions from their physician. Results: Fifty-four participants were included in the study (54% female; mean age = 15.0 [1.8] y; initially assessed 7.5 [3.2] d after concussion). Female athletes recorded more sedentary time (900 [46] vs 738 [185] min/d; P = .01; Cohen d = 0.72), and less time in light PA (194.7 [64.5] vs 224 [55] min/d; P = .08; Cohen d = 0.48) and MVPA (23 [17] vs 38 [31] min/d; P = .04; Cohen d = 0.58) than male athletes. After adjusting for sedentary time, hours per day with >250 steps, sex, and initial symptom severity, more MVPA time was associated with faster symptom resolution time (hazard ratio = 1.016; 95% confidence interval, 1.001–1.032; P = .04). Conclusion: Our findings offer preliminary insight into how varying PA intensities affect concussion recovery, as MVPA may be a higher intensity than what is typically prescribed in concussion care.

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Association of Dynamic Knee Valgus and Bone Stress Injury in US Military Academy Cadets

Jaimie V. Little, Timothy G. Eckard, Lindsay J. DiStefano, Kenneth L. Cameron, Stephen W. Marshall, and Darin A. Padua

Context: Early identification of incoming military personnel at elevated odds for bone stress injury (BSI) is important for the health and readiness of the US military. Design: Prospective cohort study. Methods: Knee kinematic data of the incoming US Military Academy cadets were collected while performing a jump-landing task (The Landing Error Scoring System) using a markerless motion capture system and depth camera. Data on incidence of lower-extremity injury, including BSI, were collected throughout the study period. Results: A total of 1905 participants (452 females, 23.7%) were examined for knee valgus and BSI status. A total of 50 BSI occurred during the study period (incidence proportion = 2.6%). The unadjusted odds ratio for BSI at initial contact was 1.03 (95% confidence interval [CI], 0.94–1.14; P = .49). Adjusted for sex, the odds ratio for BSI at initial contact was 0.97 (95% CI, 0.87–1.06; P = .47). At the instant of maximum knee-flexion angle, the unadjusted odds ratio was 1.06 (95% CI, 1.02–1.10; P = .01), and the odds ratio was 1.02 (95% CI, 0.98–1.07; P = .29) after adjusting for sex. This suggests that there was not a significant enough association for an increase in the odds of BSI based on either degree of knee valgus. Conclusions: Our results did not demonstrate an association between knee valgus angle data during a jump-landing task and future increased odds of BSI in a military training population. Further analysis is warranted, but the results suggests the association between kinematics and BSI cannot be effectively screened by knee valgus angle data in isolation.

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Management of a Special Warfare Trainee With Repeat Exertional Heat Stroke: A Case Study

J. Joseph Caraway, Julius Shepard, Courtney Hintz, and Cody R. Butler

Context: Exertional heat stroke (EHS) is the most deadly form the exertional heat illness with a higher incidence among active duty US military members than in the general population. Current guidelines on EHS recovery timelines and return to duty vary among the military branches. In some cases, individuals experience prolonged heat and exercise intolerance with repeat exertional heat illness events, which can complicate the recovery process. Management and rehabilitation of such individuals is unclear. Case Presentation: This manuscript addresses the case and management of a US Air Force Special Warfare trainee who experienced 2 episodes of EHS, despite early recognition, gold standard treatment, and undergoing 4 weeks of a stepwise recovery after an initial EHS. Management and Outcomes: After the second episode, a 3-step process was utilized, consisting of a prolonged and personalized recovery period, heat tolerance testing using Israeli Defense Force advanced modeling, and stepwise reacclimatization. This process allowed the trainee to successfully recover from repeat EHS and return to duty, and set a framework for future repeat EHS treatment guidelines. Conclusions: In individuals with repeat EHS, a prolonged recovery period followed by heat tolerance testing can be used to demonstrate appropriate thermotolerance and safely clear an individual to begin stepwise reacclimatization. Overall, patient care and military readiness may be improved by unified Department of Defense guidelines for return to duty after EHS.

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Validity and Reliability of the Kinvent Handheld Dynamometer in the Athletic Shoulder Test

Margie Olds, Sally McLaine, and Nico Magni

Context: Long-lever shoulder strength tests may aid clinical decision-making regarding return to sport after a shoulder injury. The Athletic Shoulder Test (AST) was developed to measure force production in 3 positions of shoulder abduction (90°, 135°, and 180°) using force plates. However, handheld dynamometers (HHDs) are more portable, affordable, and may provide valid and reliable results which would increase the clinical utility of long-lever tests. HHDs vary in shape, design, and their capacity to report parameters such as rate of force production and require further investigation. The aim of this study was to examine the intrarater reliability of the Kinvent HHD and assess its validity against Kinvent force plates in the AST. Peak force (in kilograms), torque (in Newton meters), and normalized torque (in Newton meters per kilogram) were reported. Design: Validity and reliability study. Methods: Twenty-seven participants with no history of upper limb injury performed the test in a randomized order using the Kinvent HHD and force plates. Each condition was assessed 3 times, and peak force was recorded. Arm length was measured to calculate peak torque. Normalized peak torque was calculated by dividing torque by bodyweight (in kilograms). Results: The Kinvent HHD is reliable when measuring force (intraclass correlation coefficient [ICC] ≥ .80), torque (ICC ≥ .84), and normalized torque (ICC ≥ .64) during the AST. The Kinvent HHD is also valid when compared with the Kinvent force plates for force (ICC ≥ .79; r ≥ .82), torque (ICC ≥ .82; r ≥ .76), and normalized torque (ICC ≥ .71; r ≥ .61). There were no statistically significant differences across the 3 trials on analyses of variance (P > .05). Conclusions: The Kinvent HHD is a reliable tool when used to measure force, torque, and normalized torque in the AST. Furthermore, given the lack of significant difference between trials, clinicians can use one test to accurately report relative peak force/torque/normalized torque rather than average 3 separate trials. Finally, the Kinvent HHD is valid when compared with Kinvent force plates.

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The Influence of Athletic Identity, Passion, and Perceptions of Severity of Concussions on Athletes’ Willingness to Report Concussion Symptoms

Eric M. Martin, Megan Byrd, Adriana Amador, Emma Ridenhour, and Carolena Charalambous

Context: The influence of several psychological characteristics on the willingness of athletes to report concussion behaviors has not been well explored. Therefore, the purpose of this study was to understand how athletic identity and sport passion predicted participants’ willingness to report symptoms above what was explained by athlete demographics, concussion knowledge, and perceived seriousness of concussions. Design: The study was cross-sectional. Methods: Three-hundred and twenty-two male and female high school and club sport athletes completed survey measures of concussion knowledge, athletic identity, harmonious and obsessive passion, and degree to which athletes indicated they would report concussions and concussion symptoms. Results: Athletes scored moderately high on their knowledge of symptoms and other concussion information (mean = 16.21; ± = 2.88) and above the midpoint on their attitudes and behaviors toward reporting concussion symptoms (mean = 3.64; ± = 0.70). There were no differences between gender, t(299) = −.78, P = .44, and previous concussion education, t(296) = 1.93, P = .06, related to concussion knowledge. Results of a hierarchical regression indicated that after entering athlete demographics, concussion knowledge, and perceived seriousness of concussions, of the 3 psychological variables in the final stage of the model, only obsessive passion was a significant predictor of athlete’s attitudes to report a concussion. Conclusions: Perceived seriousness of concussion, perceived threat to long-term health, and obsessive passion were the strongest predictors of athlete’s willingness to report concussions. Athletes who did not believe concussions posed a threat to their current or future health, and those that held an obsessive passion for sport were most at risk for not reporting concussions. Future research should continue to investigate the relationship between reporting behaviors and psychological factors.

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Effect of Bridge Exercise Duration on Lateral Abdominal Muscle Thickness and Gluteus Maximus Activation

Eleftherios Kellis, Athanasios Konstantopoulos, and Athanasios Ellinoudis

Context: Bridge exercises are extensively used in trunk-strengthening programs. The aim of this study was to investigate the effect of bridging duration on lateral abdominal muscle thickness and gluteus maximus activation. Design: Cross-sectional. Methods: Twenty-five young males participated in this study. Transversus abdominal (TrA), external and internal oblique ultrasound thickness, gluteus maximus electromyographic activation, and sacral tilt angle were simultaneously measured for every second during 30-second bridging exercise. The contraction thickness ratio and root mean squared signal (normalized to maximum isometric contraction signal) during 6 exercise durations (from 0 to 5, 10, 15, 20, 25, and 30 s) were also calculated and compared using analysis of variance designs. Results: TrA and internal oblique contraction thickness ratio and gluteus maximus root mean squared increased during the first 8 to 10 seconds and remained elevated until the end of the 30-second exercise (P < .05). External oblique contraction thickness ratio declined during exercise (P < .05). Five-second bridging showed less TrA thickness and anteroposterior and mediolateral sacral tilt angle and a lower anteroposterior tilt variability compared with bridges, which lasted more than 10 seconds (P < .05). Conclusions: Bridge exercises longer than 10 seconds may be better for promoting TrA recruitment than bridges of shorter duration. Clinicians and exercise specialists could adjust the duration of bridge exercise based on the aims of the exercise program.

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Single-Leg Squat Test in the Clinical Setting Does Not Discriminate Patients With Femoroacetabular Impingement Syndrome From Asymptomatic Individuals

Letícia Almeida de Oliveira, Viviane Bortoluzzi Frasson, Anna Torresan, Marco Aurélio Vaz, and Bruno Manfredini Baroni

Context: Laboratorial 3-dimensional kinematic analyses have shown changes in the single-leg squat’s (SLS) pattern of patients with femoroacetabular impingement syndrome (FAIS). However, it is unknown whether clinicians are able to detect these changes using 2-dimensional kinematics. Objective: To compare the frontal plane 2-dimensional kinematics of patients with FAIS and asymptomatic individuals in the SLS test performed in a clinical setting. Design: Case-control study. Setting: Physical therapy clinic. Participants: Twenty men with bilateral FAIS and 20 asymptomatic men. Main Outcome Measures: Two-dimensional kinematic analysis was collected in the frontal plane during the execution of the SLS test. The outcomes were squat depth, pelvic drop (pelvis angle relative to the horizontal plane), hip adduction (femur angle relative to the pelvis), and knee valgus (femur angle relative to the tibia). Results: Most and least painful limbs of patients with FAIS had squat depth (9.8% [2.9%] and 9.5% [3.1%] of height), pelvic drop (4.2° [3.9°] and 3.7° [4.2°]), hip adduction (74.9° [5.8°] and 75.9° [5.7°]), and knee valgus (4.0° [11.0°] and 5.0° [9.9°]) similar to asymptomatic individuals (9.0% [2.3%], 4.8° [2.6°], 73.7° [4.9°], and −1.7° [8.5°]; P > .05 for all). Conclusion: The frontal plane 2-dimensional kinematic analysis of the SLS test in the clinical setting is not able to distinguish patients with FAIS from asymptomatic individuals.

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Effectiveness of 448-kHz Capacitive Resistive Monopolar Radiofrequency Therapy After Eccentric Exercise-Induced Muscle Damage to Restore Muscle Strength and Contractile Parameters

Boštjan Šimunič, Monika Doles, Robi Kelc, and Andrej Švent

Context: Exercise-induced muscle damage (EIMD) is prevalent especially in sports and rehabilitation. It causes loss in skeletal muscle function and soreness. As there are no firm preventive strategies, we aimed to evaluate the preventive efficacy of nonthermal 448-kHz capacitive resistive monopolar radiofrequency (CRMRF) therapy after eccentric bouts of EIMD response in knee flexors. Design: Twenty-nine healthy males (age: 25.2 [4.6] y) were randomized in control group (CG; n = 15) and experimental group (EG; n = 14) where EG followed 5 daily 448-kHz CRMRF therapies. All assessments were performed at baseline and post EIMD (EIMD + 1, EIMD + 2, EIMD + 5, and EIMD + 9 d). We measured tensiomyography of biceps femoris and semitendinosus to calculate contraction time, the maximal displacement and the radial velocity of contraction, unilateral isometric knee flexors maximal voluntary contraction torque, and rate of torque development in first 100 milliseconds. Results: Maximal voluntary contraction torque and rate of torque development in first 100 milliseconds decreased more in CG than in EG and recovered only in EG. Biceps femoris contraction time increased only in CG (without recovery), whereas in semitendinosus contraction time increased in EG (only at EIMD + 1) and in CG (without recovery). In both muscles, tensiomyographic maximal displacement decreased in EG (in EIMD + 1 and EIMD + 2) and in CG (without recovery). Furthermore, in both muscles, radial velocity of contraction decreased in EG (from EIMD + 1 until EIMD + 5) and in CG (without recovery). Conclusion: The study shows beneficial effect of CRMRF therapy after inducing EIMD in skeletal muscle strength and contractile parameters in knee flexors.

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College Soccer Student-Athletes Demonstrate Differences in Self-Reported Athlete Health When Grouped by Match Volume

Brett S. Pexa, Justin P. Waxman, Audrey E. Westbrook, and Kevin R. Ford

Context: Physical changes following activity are well documented, but there is limited information about self-reported outcomes around competitive matches. High training volumes and poor recovery could predispose athletes to overuse injury. The purpose of this study was to identify the changes in daily athlete health measures before, during, and after the day of each match in high- and low-volume groups. Design: Prospective cohort. Methods: Fifty-five soccer athletes (age: 19.8 [1.2] y, 26 males, 29 females) provided daily measures of readiness, physical fatigue, mental stress, sleep quality, and soreness intensity match days, days 1 (D01) and 2 (D02) following matches, and standard practice days. Participants were grouped into high volume and low volume, based off the minutes played during the season. Results: Soreness increased, readiness decreased, and fatigue increased on D01 compared with match days (P < .008) in the high-volume group. Between groups, the high-volume group demonstrated higher soreness on D01 and D02, lower readiness on D01 and D02, and lower fatigue on D01, compared with the low-volume group (P < .008). Conclusions: Soccer athletes demonstrate significant changes in self-reported athlete health variables around competitive matches. These changes are similar to physical outcomes, potentially indicating that the athlete health variables may be used to track athlete recovery from competition, potentially limiting the impact of overuse injuries.