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Instructions Promoting an External Focus Are More Effective for Altering Impact Forces in Female Runners

Jacy Zajac, Kelsey Redman, Emily Watkins, and Thomas Gus Almonroeder

Context: Previous studies have found that instructions promoting an external focus (EF) tend to be more effective for movement pattern retraining compared to instructions promoting an internal focus (IF), for a variety of movement tasks. However, few studies have examined how different types of instructions affect running mechanics associated with running-related injury risk. Therefore, the purpose of this study was to compare the effects of instructions promoting different attentional foci on impact forces during running. Design: Cross-sectional study. Methods: Twenty uninjured female recreational runners ran at a self-selected speed with their typical pattern (no instructions condition) on an instrumented treadmill that measured ground reaction forces. Next, they were given 2 sets of instructions intended to alter their running pattern; one promoted an IF and the other promoted an EF. Repeated-measures analysis of variance was used to compare impact peaks and loading rates across the conditions (no instructions, IF, and EF), with post hoc tests conducted in the case of a significant omnibus test. Results: There were differences among the conditions in the impact peaks (P < .001) and loading rates (P < .001). Impact peaks were lower for the IF (P = .002) and EF (P < .001) conditions compared to the no instructions condition. Loading rates were lower for the EF condition compared to the no instructions (P < .001) and IF (P < .001) conditions; there was no difference between the IF and no instructions conditions (P = .24). Conclusions: Our findings indicate that instructions promoting an EF may be more effective at reducing loading rates during running compared to instructions promoting an IF. Clinicians should consider these findings when attempting to retrain a runner’s running pattern.

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The Relationship Between Eating Disorders, Disordered Eating, and Injury in Athletes: A Critically Appraised Topic

Karrie L. Hamstra-Wright, Kellie C. Huxel Bliven, John E. Coumbe-Lilley, Eddin Djelovic, and Jahnvi Patel

Clinical Scenario: Eating disorders (EDs) and disordered eating (DE) result in numerous physical and psychological complications for female and male athletes. Besides bone-related injury, little research exists investigating what injuries EDs and/or DE contribute to. Clinical Question: Are EDs and/or DE a risk factor for injury incidence in athletes? Summary of Key Findings: We searched for prospective studies assessing EDs or DE as a risk factor for injury in female or male athletes high school age and older. Our search returned 5 studies. One study found Eds, or DE were not a risk for any type of injury in female cross-country and track-and-field athletes. Two studies found a possible relationship between EDs or DE, as one contributing factor of others, in the incidence of bone stress injuries (BSIs) in female athletes who compete in various sports. One study found female, but not male, cross-country and track-and-field athletes with a history of EDs were more at risk for stress fractures than those without a history. One study found Eds, or DE were not a risk for BSI in female runners and triathletes. Clinical Bottom Line: Large and important gaps in the literature exist investigating injuries related to EDs or DE outside of BSIs. There is low–moderate evidence that EDs and/or DE are either a sole, or contributing, risk factor for BSIs in female athletes. Strength of Recommendation: Grade B evidence exists to support the idea that EDs and/or DE are a risk factor for a specific type of injury (BSI) in female athletes only.

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Cross-Cultural Adaptation and Validation of the Persian Version of the Functional Arm Scale for Throwers

Masumeh Hessam, Mohammad Hossein Mousavi, Maryam Saadat, and Kellie C. Huxel Bliven

Background: The Functional Arm Scale for Throwers (FAST) is a reliable and valid region-specific tool designed to evaluate health-related quality of life in throwing athletes with upper-extremity injuries. The purpose of this study was to adapt, translate, and evaluate the psychometric properties of the Persian version of the Functional Arm Scale (FAST-Persian) for use in throwing athletes. Materials and Methods: The study was conducted based on 5 steps of cross-cultural adaptation including forward translation, synthesis, backward translation, expert committee review, and pretesting. The final Persian questionnaire, along with Persian versions of Disabilities of the Arm, Shoulder, and Hand and Kerlan-Jobe Orthopedic Clinic questionnaires, was completed by 177 throwing athletes for validity analysis. After 7 to 14 days, the FAST-Persian was reanswered by 80 throwers, who had no changes in this time interval. Internal consistency and test retest reliability were used to evaluate reliability of the questionnaire. Standard error of measurement and smallest detectable changes were also calculated. Construct validity was determined by correlational analysis with Disabilities of the Arm, Shoulder, and Hand and Kerlan-Jobe Orthopedic Clinic questionnaires. Dimensionality was evaluated with factor analysis. Result: Cronbachs alpha was .99, and the interclass correlation coefficient levels for total score and 5 subscales of the FAST-Persian ranged between .98 and .99. The standard error of measurement and smallest detectable changes were 3.17 and 8.80, respectively. The FAST-Persian had a high correlation with Disabilities of the Arm, Shoulder, and Hand (r = .98, P < .0001) and Kerlan-Jobe Orthopedic Clinic (r = .98, P < .0001) scores. Factor analysis revealed one factor with a total variance of 75.23%. Conclusion: The FAST-Persian is a reliable and valid measurement tool that can be used to evaluate health-related quality of life in overhead athletes and throwers.

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Psychometric Properties of a Modified Athlete Burnout Questionnaire in the Collegiate Athletics Setting

Madeline P. Casanova, Ashley J. Reeves, and Russell T. Baker

Context: Mental health is an important component of holistic care in athletic settings. Burnout is one of many factors associated with poor mental health, and clinicians should assess for these symptoms. The Athlete Burnout Questionnaire (ABQ) has been proposed as a measure of burnout in athletes; however, design concerns are prevalent within the scale, and psychometric analyses have resulted in inconsistent measurement properties, limiting the usefulness of the scale for accurate assessment of burnout in athletes. The objective of our study was to assess the factor structure of the Alternate Modified ABQ-15v2 using confirmatory factor analysis. If model fit was inadequate, a secondary purpose was to identify a psychometrically sound alternate ABQ model. Design: Observational study. Methods: Intercollegiate athletes and dancers pursuing a degree in dance (n = 614) were recruited from programs across the United States. Individuals had varied health statuses (eg, healthy, injured), scholarship support, and participated in a variety of intercollegiate sports. A confirmatory factor analysis was conducted on the modified 15-item ABQ (Alternate Modified ABQ-15v2). Exploratory factor analysis and covariance modeling of a proposed alternate 9-item scale (ABQ-9) was conducted and multigroup invariance analysis was assessed across athlete category, class standing, and student-athlete scholarship status to assess consistency of item interpretation across subgroups. Results: The Modified ABQ did not meet recommended model fit criteria. The ABQ-9 met all recommended model fit indices but was not invariant across athlete category. Conclusions: The ABQ-9 may be a viable and efficient option for assessing burnout in the collegiate athletics setting. However, further research is needed to validate the ABQ-9 in a cross-validation study.

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Hip Abductor and External Rotator Strengths Correlate With Hop Symmetry in Men Athletes 2 Years After Anterior Cruciate Ligament Reconstruction

Zakariya H. Nawasreh, Mohammad A. Yabroudi, Mohamed N. Kassas, Sharf M. Daradkeh, and Khaldoon M. Bashaireh

Context: Hip muscle strength and hop performance limb symmetries after anterior cruciate ligament reconstruction (ACLR) are not well studied. This study aimed to determine the differences in hip abductors’ (ABD) and external rotators’ (ER) muscle strength measures between limbs, and the relationship between hip ABD and ER muscle strengths and hop performance limb symmetry indices (LSIs) 2 years after ACLR. Design: Cross-sectional study. Methods: Forty (level I/II) men athletes 2 years after unilateral ACLR completed 4 single-legged hop tests and involved hip ABD and ER strength testing (maximum voluntary isometric contraction [MVIC]; isokinetic peak torque [PKTQ] at 60°, 180°, and 300°/s; and isotonic peak velocity at 75% of their MVICs). Muscle strength measures were normalized to body mass, and hop performances were reported as LSIs. Paired t test was used to determine strength differences between limbs, and the Pearson correlation coefficient was used to assess the relationship between involved hip muscle strength measures and hop performance LSIs. Results: Hip ER-MVIC (involved: 60.26 [12.01], uninvolved: 63.68 [13.17] N·m/kg) and ER eccentric PKTQ at 60°/s (involved: 32.59 [9.28]; uninvolved: 35.73 [10.50] N·m/kg) were significantly different between limbs (P ≤ .018). Single-hop LSI correlated with hip ER-PKTQ at 180°/s (r = .354) and 300°/s (r = .324, P ≤ .041), while triple-hop LSI correlated with hip ER-MVIC (r = .320), concentric ER-PKTQ at 180°/s (r = .355), eccentric ER-PKTQ at 60°/s (r = .314), and hip ABD-PKTQ at 60°/s (r = .364) and 300°/s (r = .336, P ≤ .049). Conclusions: Men athletes demonstrated symmetrical hop performance and hip muscle strengths, except for ER hip’s MVIC and isokinetic eccentric peak torque at 60°/s 2 years after ACLR. Hop performance LSIs had a few, yet positive moderate relationships with involved hip ABDs and ER strength measures. This may indicate that hip ABD and ER muscle strength measures contribute to athletes’ hop performances 2 years after ACLR. Post-ACLR rehabilitation programs might incorporate hip muscle strengthening training to improve athletes’ functional performances.

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Combined Neurocognitive and Exercise Tolerance Testing Improves Objectivity of Buffalo Concussion Treadmill Test

Daniel Miner and Brent Harper

Context: The Buffalo Concussion Treadmill Test (BCTT) is a standard assessment of exercise tolerance utilized for exercise prescription following concussion and to inform decisions regarding return to play. One limitation of the BCTT is that interpretation of test results is dependent on individuals’ self-report of symptom exacerbation with exertion. Symptoms following concussion are significantly underreported or unreported. Combining objective neurocognitive assessment with exercise tolerance testing may enable clinicians to objectively identify those requiring further assessment or rehabilitation before return to play. The purpose of this study was to investigate how performance on a neurocognitive assessment battery is affected by provocative exercise testing. Design: Prospective cohort study, pretest/posttest. Methods: A total of 30 participants included 13 women (43.3%), age 23.4 (1.93) years, height 173.56 (10) cm, weight 77.35 (16.3) kg, and 11 (36.7%) with history of concussion. All participants completed a neurocognitive assessment battery, including the Stroop Test and standardized assessments of working memory, attention, and information processing speed/accuracy in single-task (seated position) and dual-task conditions (walking on a treadmill at 2.0 miles per hour). The neurocognitive assessment battery was performed at baseline and after the standard BCTT test protocol. Results: BCTT: Average percentage of heart rate maximum (%HRmax) = 93.97% (4.8%); average maximum rating of perceived exertion = 18.6 (1.5). Time-based performance in single-task and dual-task conditions significantly improved from baseline (P < .05) following maximal exercise testing on the BCTT for the following neurocognitive assessments: concentration-reverse digits, Stroop congruent, and Stroop incongruent. Conclusions: Healthy participants demonstrated improvements across multiple domains of neurocognitive performance following the exercise tolerance testing on the BCTT. Understanding normal responses in neurocognitive performance for healthy individuals following exercise tolerance testing may allow clinicians to more objectively monitor the trajectory of recovery following sports-related concussion.

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Exercise Parameters for Postconcussion Symptom Rehabilitation: A Systematic Review

Kannan Singaravelu Jaganathan, Karen A. Sullivan, Sally Kinmond, Sara Berndt, Steve Street, Catherine Haden, Jaimi Greenslade, Katie McMahon, Gary Mitchell, and Graham Kerr

Context: Exercise rehabilitation for postconcussion symptoms (PCS) has shown some benefits in adolescent athletes; but a synthesis of evidence on exercise per se has been lacking. Objective: This systematic review aimed to determine if unimodal exercise interventions are useful to treat PCS and if so, to identify a set of clearly defined and effective exercise parameters for further research. Evidence Acquisition: Relevant health databases and clinical trial registries were searched from inception to June 2022. The searches used a combination of subject headings and keywords related to mild traumatic brain injury (mTBI), PCSs, and exercise. Two independent reviewers screened and appraised the literature. The Cochrane Collaboration’s Risk of Bias-2 tool for randomized controlled trials was used to assess methodological quality of studies. Evidence Synthesis: Seven studies were included in the review. Four studies were assessed to have a low overall risk of bias, 2 with low risk and 1 with some concerns. Participants in the studies comprised mostly adolescents with sports-related concussion. The review found exercise to be more beneficial than control conditions in 2 studies investigating acute PCS and 2 studies investigating persistent PCS. Within-group differences showing symptom improvement over time were observed in all 7 studies. In general, the review found support for programmatic exercise that commences after an initial period of rest for 24 to 48 hours. Recommendations for exercise parameters that can be explored in subsequent research include progressive aerobic exercise starting from 10 to 15 minutes at least 4 times a week, at a starting intensity of 50% HR of the subsymptom threshold, with length of program depending on recovery. Conclusion: The evidence in support of exercise rehabilitation for PCSs is moderate based on the small pool of eligible studies. Further research can be guided by the exercise parameters identified in this review.

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The Effect of Remote Myofascial Release on Chronic Nonspecific Low Back Pain With Hamstrings Tightness

Hassan Tamartash, Farid Bahrpeyma, and Manijhe Mokhtari Dizaji

Context: Anatomy trains theory states that performing techniques in any part of the superficial myofascial backline can remotely treat other parts of this pathway. Due to the connections of different parts of the superficial backline, it is possible to influence the hamstring by performing the technique in the lumbar area. As chronic nonspecific low back pain (LBP) may lead to or be caused by hamstring tightness, remote myofascial release (MFR) techniques using the superficial backline can help improve hamstring tightness. Objective: This study aimed to evaluate the effect of remote MFR on hamstring tightness for those with chronic nonspecific LBP. Design: Single-blind, parallel design. Setting: The present study was performed at the clinical setting of Tarbiat Modares University in Iran. Methods: This study included 40 participants (20 males and 20 females) who were 40.5 (5.3) years old with chronic nonspecific LBP and hamstring tightness. Interventions: Participants were randomly divided into the lumbar MFR (remote area) and hamstring MFR groups. Participants underwent 4 sessions of MFR for 2 weeks. Main Outcome Measures: A passive knee-extension (PKE) test was used for muscle tightness evaluation 3 times. Results: Repeated-measure analysis of variance test showed that after the lumbar and hamstring MFR, the PKE was significantly reduced in both legs: lumbar MFR (right knee: from 61.04° [2.17°] to 51.01° [4.11°], P ≤ .003 and left knee: from 63.02° [3.12°] to 52.09° [2.48°], P ≤ .004) and hamstring MFR (right knee: from 62.01° [4.32°] to 50.50° [7.18°], P ≤ .001 and left knee: from 63.11° [2.56°] to 51.32° [5.31°], P ≤ .002). Least Significant Difference (LSD) post hoc test results showed that the 2 groups were not significantly different after the MFR (P ≥ .05). Also, the intraclass correlation coefficient index showed that the PKE test has excellent reliability (intraclass correlation coefficient, .910 for the right limb and .915 for the left limb). The minimal detectable change at the 95% confidence interval indicated that a change greater than or equal to 6° is required to exceed the threshold of the error PKE test, respectively. Conclusion: The present study showed that the remote MFR technique to the lumbar region demonstrated the same significant results in decreasing hamstring tightness as was noted in hamstring MFR to both limbs in patients with chronic nonspecific LBP.

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The Effect of Contralateral Knee Neuromuscular Exercises on Static and Dynamic Balance, Knee Function, and Pain in Athletes Who Underwent Anterior Cruciate Ligament Reconstruction: A Single-Blind Randomized Controlled Trial

Motahareh Karimijashni, Fahimeh Kamali Sarvestani, and Amin Kordi Yoosefinejad

Context: Contralateral training in the early stages after surgery can improve the balance of the reconstructed knee, which is impaired following anterior cruciate ligament reconstruction (ACLR). However, little is known about the neuromuscular cross exercise after ACLR. Objective: To investigate the effects of an 8-week cross exercise on balance and function of the reconstructed knee following ACLR. Design: A single-blind randomized clinical trial. Participants: Thirty athletic males who underwent ACLR were randomly divided into intervention (n = 15) and control groups (n = 15). Intervention: The intervention and control groups received a routine physiotherapy program. In addition, the intervention group performed neuromuscular exercises on the nonoperated limb. Outcome Measures: Before and 9 weeks after ACLR, dynamic and static balance, function, and pain in the reconstructed knee were measured by Star Excursion Balance Test (SEBT), stork balance stand test, balance error scoring system (BESS), Lysholm questionnaire, and visual analog scale. Data were analyzed by SPSS using 2-independent sample t test, paired t test, and analysis of covariance. Results: Between-group comparison showed that, contralateral knee neuromuscular exercises significantly increased in the reaching distance in SEBT in the anterior (P < .001), posterior (P < .001), posteromedial (P = .010), and posterolateral directions (P = .007), decreased the number of errors in 4 stance positions of BESS including single stance on the firm (P ≤ .001) and foam surface (P ≤ .001), and tandem stance on the firm (P = .028) and foam surface (P ≤ .001). It also increased the time of standing of the stork stand test (P = .044) and decreased the pain intensity (P = .014). Conclusion: Neuromuscular exercise of the nonsurgical knee could improve the dynamic and static balance, and pain in the early stages following ACLR in the surgical leg. These findings may be potentially valuable for current rehabilitation protocols.

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Volume 32 (2023): Issue 3 (Mar 2023)