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Injury Surveillance and Training Load Methods Used by Health Professionals in Tennis: An Online Multinational Survey

Diego H. Méndez, Pablo O. Policastro, and Danilo De Oliveira Silva

Context: Injury surveillance and training load monitoring are both essential for the development of preventative strategies for gradual-onset musculoskeletal injuries in elite sport. Our aim was to survey health professionals working with elite tennis players on whether and how they monitor injuries and training load. Design: A cross-sectional multinational online open-survey. Methods: The survey was developed and advertised in English, Spanish, and Portuguese languages on social media channels, a tennis academic journal, professional tennis associations, and clinical networks of the research team, from December 2020 to April 2021. Results: 72 health professionals from 27 different countries working with elite tennis players responded to the survey. Injury surveillance is performed by 94% (68/72) of the survey respondents, with only 10% (7/68) using the consensus-recommended Oslo Sports Trauma Research Center questionnaire. Most common barriers identified by health professionals to injury surveillance are time constraints (66%), lack of knowledge (43%), and technology (31%). Training load monitoring is performed by 50% (36/72) of the health professionals working with elite tennis players. Main metrics monitored are weekly differences in training load (72%) and acute:chronic workload ratio (58%). Most common reasons for training load monitoring are injury prevention (94%), training planning (81%), and player feedback (53%). Conclusions: Despite a high percentage of health professionals implementing injury surveillance metrics, most of them do not use any validated method. Only half of health professionals working with elite tennis players monitor training load. Lack of knowledge and technology were the main barriers reported for adequately monitoring injuries.

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Sports Specialization, Physical Literacy, and Physical Activity Levels in Young Adults

Chloe McKay, Johanna M. Hoch, Matthew C. Hoch, and Deirdre Dlugonski

Context: Youth sport specialization may be associated with physical literacy and physical activity in young adulthood. The purposes of this study were to compare young adult (18–25 y) physical literacy and physical activity by high school sport specialization status and to examine the relationship between current physical activity and physical literacy. Design: Retrospective, cross-sectional study design. Methods: Participants were recruited from ResearchMatch, university classes, and social media posts. Participants (N = 172; aged 22.1 [2.1] y; 80.1% female) completed the following anonymous surveys on REDCap to assess: demographics and injury history, sport specialization, physical literacy (PLAYself), and physical activity (Godin Leisure-Time Exercise Questionnaire). Results: When controlling for age, there were no statistically significant differences in physical literacy (F 2,166 = 2.02, P = .14) or moderate to vigorous physical activity (F 2,161 = 0.24, P = .79) between sport specialization groups. There was a moderate, positive relationship between physical literacy and physical activity (r = .33, P < .001). Conclusions: Young adult physical literacy and physical activity were similar regardless of youth sport specialization level. Young adult physical literacy was positively associated with physical activity. Future studies should consider physical literacy as a possible correlate of physical activity among young adults.

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The Sleep Parameters of Paralympic Athletes: Characteristics and Assessment Instruments

Isadora Grade, Henrique Andrade, Renato Guerreiro, Eduardo Stieler, Flavia R. da Silva, Hesojy G.V. da Silva, Roberto Vital, Renan A. Resende, Dawit A.P. Gonçalves, André G. Andrade, Marco T. de Mello, and Andressa Silva

Context: Sleep serves many important functions for athletes, particularly in the processes of learning, memory, recovery, and cognition. Objectives: Define the sleep parameters of Paralympic athletes and identify the instruments used to assess and monitor sleep Paralympic athletes. Evidence Acquisition: This systematic review was carried out based on the PRISMA guidelines. The survey was conducted in April 2020, the searches were carried out again in September 2021 to check whether there were new scientific publications in the area of sleep and Paralympic sport, searches were performed in the following databases: PubMed, Web of Science, Scopus, SPORTDiscus, Virtual Health Library (BIREME), and SciELO. This systematic review has included studies that investigated at least one of the following sleep parameters: total sleep time, sleep latency, sleep efficiency, number of awakenings, quality of sleep, daytime sleepiness, and chronotype; the participants were comprised of athletes with disabilities. Studies published at any time in English, Portuguese, and Spanish, were included. Evidence Synthesis: Data extraction and study selection were performed by 2 researchers independently, and a third author was consulted as necessary. The search returned a total of 407 studies. Following the screening based on exclusion and inclusion criteria, a total of 13 studies were considered. Paralympic athletes have a low amount (7.06 h) of sleep with poor quality and sleep latency (28.05 min), and 57.2% have daytime sleepiness, with the majority belonging to the indifferent chronotype (53, 5%). Moreover, 11 studies assess sleep using subjective instruments (questionnaires), and 2 studies used an objective instrument (actigraphy). Conclusions: Sleep disorders are common among Paralympic athletes, poor sleep quality and quantity, and high rates of daytime sleepiness. Subjective methods are most commonly used to assess sleep.

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Blood Flow Restriction Therapy for Use After Extremity Fracture: A Critically Appraised Topic

Ian Robertson, Marina Lazarides, and Cody R. Butler

Clinical Scenario: Blood flow restriction (BFR) therapy has emerged as a viable treatment option to enhance clinical recovery in patients with primarily muscular injuries. However, BFR therapy has been rarely investigated in patients with osseous injuries to include extremity fracture. Focused Clinical Question: Does BFR-enhanced therapy improve clinical outcomes in patients during the acute to subacute rehabilitation period after extremity fracture? Summary of Key Findings: (1) In cases of 2 high-performing athletes with talus and osteochondral fracture of the knee, BFR was well tolerated and an effective rehabilitation regimen. (2) In 2 randomized controlled trials evaluating BFR use in patients after operative and nonoperative management of distal radius fractures, pain with activity and self-perceived function were improved in BFR-enhanced therapy as compared with a standard rehabilitation regimen. (3) Objective clinical outcomes including radiographic healing, extremity range of motion, and grip strength evaluated by the randomized controlled trials did not differ significantly between the BFR-enhanced and standard rehabilitation groups. Clinical Bottom Line: BFR-enhanced therapy may improve pain and self-perceived function of the injured extremity during the acute to subacute rehabilitation period after fracture. However, there is not yet a demonstrated benefit of BFR on hastening objective measures of clinical recovery. Large-scale clinical trials comparing BFR-enhanced rehabilitation with standard rehabilitation regimens are needed to better characterize BFR use in patients with osseous injuries. Strength of Recommendation: Two case reports and 2 randomized controlled trials provide level IIB evidence suggesting that BFR may improve pain in the acute rehabilitative stage and improve the patient’s perceived function of the injured extremity, without greater improvement in objectively measured clinical parameters as compared with a standard rehabilitation regimen.

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Is Real-Time Poolside Assessment of Upper Limb Errors in Front Crawl Swimming Technique Reliable and Equivalent to Video Analysis?

Travis R. Pollen, David Ebaugh, Jason Mohring, Dean Hutchinson, and Sheri P. Silfies

Context: Swimming technique is widely believed to influence performance, but this relationship has rarely been tested objectively using a real-time poolside assessment. Objective: To determine the (1) test–retest reliability, interrater reliability, and criterion validity (live vs video) of real-time poolside assessment of upper limb (UL) errors in front crawl (FC) swimming technique and (2) the relationship between UL errors and FC swimming performance. Design: Cross-sectional reliability, validity, and correlational study. Setting: Swim team practice at a college natatorium. Participants: Thirty-nine Division III college swimmers (21 women and 18 men, age = 19 [1] y, swimming experience = 11 [3] y). Main Outcome Measures: Seven UL errors in FC swimming technique, many of which involved unnecessary vertical and mediolateral motions, were assessed in real time from outside the pool during swim practice. Test–retest reliability, interrater reliability, and criterion validity were calculated using Cohen kappa (κ) and weighted kappa (κ w ). Swimming performance was determined by the participants’ best FC events relative to the conference records. The correlation between total UL errors and FC swimming performance was assessed with Pearson r. Results: Cohen κ and κ w were moderate for the majority of errors, with the following ranges: 0.46 to 0.90 (test–retest), −0.01 to 1.00 (interrater), and 0.36 to 0.66 (criterion validity). There was a significant correlation between total UL errors and FC swimming performance: r(24) = −.59 (P = .001, R 2 = .35). Conclusions: Reliability and validity were moderate for the majority of errors. The fewer UL errors swimmers made while practicing FC, the faster their best FC race times tended to be relative to the conference record. UL errors in FC swimming technique explained 35% of the variance in performance.

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Reliability of Y Balance Test in Runners With Intellectual Disability

Ghada Jouira, Haithem Rebai, and Sonia Sahli

Context: The Y Balance Test (YBT) is a simple, reliable, cost-effective screening test. It is used to evaluate dynamic balance as well as to determine the potential risk of injury of the lower limbs. The reliability of YBT has been widely reported in the general population. However, there are no studies evaluating the reliability of YBT use in athletes with intellectual disability (ID). The aim of the study was to examine the reliability of the YBT in runners with ID. Design: A reliability study. Methods: Twelve male runners (short-distance running) with ID (age 25.1 [4.50] y, height 169.1 [4.2] cm, weight 69.5 [5.5] kg, and intelligence quotient 60.8 [2.4]). The YBT was used to measure participants’ dynamic balance in the anterior, posteromedial, and posterolateral reach directions. The analysis used the normalized values to the relative length of the lower limbs. A 1-way (trial) repeated-measures (5) analysis of variance for each direction was used. Intraclass correlation coefficient, standard error of measurement, and minimal detectable change were computed to assess the reliability of the YBT between trials. Results: After 6 practice trials, 3 out of 5 consecutive ones achieved results stabilization for all directions and both legs (P < .05). The intraclass correlation coefficient, standard error of measurement, and minimal detectable change values for all trials ranged from .76 to .87, 5% to <7%, and 11% to <15%, respectively. Conclusion : The YBT is a highly reliable tool to measure the dynamic balance of male runners with ID. Therefore, it is recommended to perform 6 practice trials and 3 measurements in these runners.

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Exploratory Examination of Knee Self-Efficacy in Individuals With a History of ACL Reconstruction and Sport-Related Concussion

Francesca M. Genoese, Aaron J. Zynda, Kayla Ford, Matthew C. Hoch, Johanna M. Hoch, Tracey Covassin, and Shelby E. Baez

Context: Knee self-efficacy and injury-related fear are associated with poor self-reported knee function and decreased physical activity (PA) after ACL reconstruction (ACLR). Limited research has explored contextual factors that may influence psychological responses in this population, such as history of sport-related concussion (SRC). After SRC, individuals may experience increased negative emotions, such as sadness and nervousness. However, it is unknown how SRC history may influence knee-self efficacy and injury-related fear in individuals with ACLR. The purpose of this study was to compare knee self-efficacy and injury-related fear in individuals after ACLR who present with and without history of SRC. Design: Cross-sectional study. Methods: Forty participants ≥1 year postunilateral ACLR were separated by history of SRC (no SRC = 29, SRC = 11). The Knee Self-Efficacy Scale (KSES) and subscales measured certainty regarding performance of daily activities (KSES-ADL), sports/leisure activities (KSES-Sport), physical activities (KSES-PA), and future knee function (KSES-Future). The Tampa Scale of Kinesiophobia-11 measured injury-related fear. Mann–Whitney U tests were used to examine between-group differences. Hedges g effect sizes and 95% confidence interval were used to examine clinically meaningful group differences. Results: Individuals with a history of ACLR and SRC demonstrated worse KSES-PA (7.5 [5.3]) compared with those without a history of SRC (8.1 [6.1], P = .03). No other statistically significant differences were observed. A medium effect size was present for the KSES-PA (0.62), KSES-ADL (0.42), KSES-Present (ADL + PA + Sport) (0.48), KSES-Total (0.53), and Tampa Scale of Kinesiophobia-11 (0.61) but must be interpreted with caution as 95% confidence interval crossed 0. Conclusions: This exploratory study indicated that individuals with a history of ACLR and SRC had worse knee self-efficacy for PA compared with those without history of SRC. Rehabilitation specialists should monitor knee self-efficacy deficits in the post-ACLR population and recognize the potential influence of cumulative injury history on rehabilitative outcomes.

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Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability

Cameron J. Powden, Rachel M. Koldenhoven, Janet E. Simon, John J. Fraser, Adam B. Rosen, Abbis Jaffri, Andrew B. Mitchell, and Christopher J. Burcal

Context: Intervention studies for chronic ankle instability (CAI) often focus on improving physical impairments of the ankle complex. However, using an impairments-focused approach may miss psychological factors that may mediate function and recovery. Patient-reported outcome (PRO) measures can be used to assess several dimensions of the health-related quality of life (HRQoL) and deliver enhanced patient-centered care. Therefore, the purpose of this investigation was to evaluate group-level improvements in HRQoL and treatment response rates following various interventions in patients with CAI. Design: Cross-sectional. Methods: Data from 7 previous studies were pooled by the chronic ankle instability outcomes network for participant-level analysis, resulting in 136 patients with CAI. Several interventions were assessed including balance training, gait biofeedback, joint mobilizations, stretching, and strengthening, with treatment volume ranging from 1 to 4 weeks. Outcome measures were PROs that assessed ankle-specific function (Foot and Ankle Ability Measure), injury-related fear (Tampa Scale of Kinesiophobia and Fear Avoidance Belief Questionnaire), and global well-being (Disablement in the Physically Active); the PROs assessed varied between studies. Preintervention to postintervention changes were evaluated using separate Wilcoxon signed-rank tests and effect sizes, and a responder analysis was conducted for each PRO. Results: Significant, moderate to large improvements were observed in PROs that assessed ankle-specific function, injury-related fear, and global well-being following intervention (P < .001). Responder rates ranged from 39.0% to 53.3%, 12.8% to 51.4%, and 37.8% for ankle specific function, injury-related fear, and global well-being, respectively. Conclusions: Various interventions can lead to positive improvements in HRQoL in patients with CAI. Treatment response rates at improving HRQoL are similar to response rates at improving impairments such as balance, further reinforcing the need for individualized treatment approaches when treating a patient with CAI.

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Acute and Overuse, Time-Loss and Non-Time-Loss Lateral Ankle Sprains and Health Care Utilization in Collegiate Student-Athletes

Cathleen N. Brown, Viktor E. Bovbjerg, Michael T. Soucy, SeokJae Choe, Michael Fredericson, and Janet E. Simon

Context: Health care utilization and the occurrence of non-time-loss (NTL) lateral ankle sprains is not well documented in collegiate athletes but could provide better estimates of injury burden and inform clinician workload. Design: Descriptive epidemiologic study. Methods: Lateral ankle sprain injury occurrence for Division I collegiate student-athletes in a conference with 32 sports representing 732 team seasons was collected during the 2018–2019 through 2020–2021 academic years. Injuries were designated as acute or overuse, and time-loss (TL) or NTL. Associated health care utilization, including athletic training services (AT services), and physician encounters were reported along with anatomical structures involved and season of occurrence. Results: A total of 1242 lateral ankle sprains were reported over the 3 years from 732 team seasons and 17,431 player seasons, resulting in 12,728 AT services and 370 physician encounters. Most lateral ankle sprains were acute-TL (59.7%), which were associated with the majority of AT services (74.1%) and physician encounters (70.0%). Acute-NTL sprains represented 37.8% of lateral ankle sprains and were associated with 22.3% of AT services and 27.0% of physician encounters. On average, there were 12.7 (5.8) AT services per acute-TL sprain and 6.0 (3.6) per acute-NTL sprain. Most sprains involved “ankle lateral ligaments” (45.6%), and very few were attributed to overuse mechanisms (2.4%). Conclusions: Lateral ligament sprains are a common injury across many sports and result in substantial health care utilization from ATs and physicians, including NTL lateral ankle sprains. Although TL injuries were the majority of sprains, a substantial proportion of sprains were NTL and accounted for a considerable proportion of health care utilization.

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Association of Proximal and Distal Factors With Lower Limb Kinematics During a Classical Ballet Jump

Anelise Moreti Cabral, Adalberto Felipe Martinez, Vitor Leme, Bruna Calazans Luz, and Fábio Viadanna Serrão

Context: Excessive dynamic lower limb misalignment may predispose ballet dancers to jump-related injuries. However, it is unknown whether proximal and distal factors influence this movement pattern. The aim of this study was to investigate whether hip abduction strength, foot alignment, and ankle dorsiflexion range of motion (ROM) are associated with peak angles of hip adduction and internal rotation and knee abduction during the preparation and landing phases of a classical ballet jump. Design: Cross-sectional study. Methods: Forty-one healthy amateur ballet dancers were included. Hip abduction strength was evaluated isometrically using a handheld dynamometer, foot alignment was determined by the shank-forefoot alignment, and weight-bearing ankle dorsiflexion ROM was measured by performing the lunge test. Peak hip and knee angles were analyzed 3-dimensionally during the preparation and landing phases of a single-leg jump. A Pearson correlation matrix was used to investigate the association of hip abduction strength, shank-forefoot alignment, and ankle dorsiflexion ROM with peak angles of hip adduction and internal rotation and knee abduction during the preparation and landing phases of the jump. Results: Greater hip abduction strength was associated with greater peak hip internal rotation angle (r = .43, P < .05), but not with peak hip adduction and knee abduction angles during the preparation phase of the jump. There were no associations of shank-forefoot alignment and ankle dorsiflexion ROM with peak hip and knee angles during the preparation (r = −.23 to .36, P > .05) and landing (r = −.20 to .24, P > .05) phases of the jump. There was no association of hip abduction strength with peak hip and knee angles during the landing phase of the jump (r = −.28 to .16, P > .05). Conclusion: Hip abductors strengthening, correction of foot misalignments, and increasing ankle dorsiflexion ROM may not prevent excessive hip and knee movements during a classical ballet single-leg jump in amateur dancers.