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The Effect of Active Release Technique on Hamstring Extensibility: A Critically Appraised Topic

Mikala Palermo, Sierra Reich, and Mika Rives

Clinical Scenario: Hamstring extensibility plays a significant role in maintaining postural alignment essential for a functional musculoskeletal system. When hamstring extensibility is lacking, individuals are placed at a higher risk for developing various lumbar spine, pelvis, knee, and foot dysfunctions. Limited hamstring extensibility is common, occurring in as much as 40% of college students and 86% of the adult population. Therefore, it is essential to maintain hamstring extensibility, which can be aided by understanding intervention effectiveness for improving flexibility. Purpose: To critically appraise the literature on the effectiveness of Active Release Technique (ART) for the treatment of hamstring extensibility deficits. Clinical Question: What is the effect of ART in a healthy population with or without hamstring extensibility deficits? Summary of Key Findings: Three studies were included for critical appraisal. Two studies concluded a single treatment session of ART that individuals possessing limited straight leg raise range of motion experienced improved active knee extension, popliteal angle, and sit-and-reach test measures. In the third study, a single session of ART was effective at improving hamstring extensibility in males without hamstring extensibility dysfunction. Clinical Bottom Line: Based on the current level 1 and level 3 evidence, ART may be an effective treatment to produce acute increases in hamstring extensibility. Future research is still needed. Strength of Recommendation: Level B evidence exists to support the use of ART to improve hamstring extensibility in the healthy population.

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Erratum. Influence of Graft Type and Meniscal Involvement on Short-Term Outcomes Following Anterior Cruciate Ligament Reconstruction

Journal of Sport Rehabilitation

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Digital Health Literacy and Social Determinants of Health Affecting Telehealth Use by Athletic Trainers

Sujal R. Patel, Nancy A. Uriegas, Tara A. Armstrong, Ryan M. Stover, Kenneth E. Games, and Zachary K. Winkelmann

Context: While increasing telehealth use throughout sports medicine has improved patients’ access to health care, some communities may not have the same opportunities to connect with a provider. Barriers to telehealth implementation can be influenced by internal (eg, provider’s digital health literacy and resources) and external (eg, community’s social determinants of health or “SDOH”) factors. This study aimed to assess the impact of internal and external factors on telehealth use by athletic trainers (ATs). Design: Cross-sectional survey. Methods: In total, 767 ATs participated in the study. Participants (age = 39 [13] y) completed a survey containing the electronic health literacy scale and digital health literacy instrument, reported professional use of telehealth as a provider (yes/no), provided resources at their clinical site, and provided the zip code for the community they served. After data collection, the researchers extracted SDOH information using the zip code data from 2 US databases, including population density, median household income, poverty index, education level, and technology access. Chi-square or independent samples t tests were conducted to compare telehealth use by each SDOH factor. Results: In total, 62.3% (n = 478/767) of ATs reported using telehealth, and 81.6% of ATs (n = 626) had a dedicated facility to offer health care services. We identified a significant difference in digital health literacy scores between users and nonusers of telehealth (P = .013). We did not identify any significant differences between telehealth users by community type (P = .957), population density (P = .053), income (P = .462), poverty index (P = .073), and computer (P = .211) or broadband internet access (P = .295). Conclusions: Our data suggest that internal factors such as digital health literacy and clinical site resources may have contributed to an AT’s previous telehealth use in clinical practice. However, the SDOH data extracted from the community zip code where the AT provided clinical services were similar for those with and without previous telehealth use.

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Effect of Hearing Status on Concussion Knowledge and Attitudes of Collegiate Athletes

Matthew P. Brancaleone, René R. Shingles, and Zachary A. Weber

Context: Collegiate athletes who are deaf or hard-of-hearing (D/HoH) are diagnosed with concussions at a similar rate as athletes who are hearing; however, little evidence exists on knowledge and attitudes of athletes who are D/HoH toward concussions. This study aimed to examine differences in knowledge of and attitudes toward concussions between athletes who are D/HoH and athletes who are hearing. Design: Cross-sectional research design. Methods: Of the 310 athletes who are D/HoH and 430 athletes who are hearing that were invited to participate, 90 athletes who are D/HoH, and 72 athletes who are hearing completed the survey. The Rosenbaum Concussion Knowledge and Attitudes Survey was used to quantify knowledge of and attitude toward concussions. The Rosenbaum Concussion Knowledge and Attitudes Survey consists of the concussion knowledge index (CKI) and the concussion attitudes index (CAI) subscales. Linear regressions were run to test the association of hearing status with CKI and CAI scores. Pearson correlations were performed to determine relationships between CKI and CAI for athletes who are D/HoH and athletes who are hearing. Alpha level was set a priori at P ≤ .05. Results: Athletes who are hearing demonstrated a higher CKI component score (19.58 [2.19]) compared to athletes who are D/HoH (16.14 [3.31]; P < .001). There were no statistical differences in CAI between hearing groups (hearing: 57.18 [8.73], D/HoH: 55.97 [9.92]; P = .41). There was a moderate positive correlation between CKI and CAI (r = .58) for athletes who are D/HoH, while a weak positive correlation (r = .30) for athletes who are hearing was observed. Conclusions: Athletes who are D/HoH have poorer knowledge of concussions but similar attitudes toward concussion as that of athletes who are hearing. Current concussion educational interventions are in written or spoken form which may not be inclusive to athletes who are D/HoH. Health care professionals should consider an athlete’s preferred communication mode to improve the efficiency and effectiveness of education.

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A Quasi-Randomized Clinical Trial to Compare the Effects of Suspension Versus Instability Training on Balance

José-María Blasco, Catalina Tolsada-Velasco, Irene Borja-de-Fuentes, Elena Costa-Moreno, Carmen García-Gomáriz, and David Hernández-Guillén

Context: Suspension training devices are becoming increasingly popular. Most studies analyzed the effectiveness according to diverse measures in patients with or without conditions at any age. The characteristics of suspension training are very specific and can increase instability and; therefore, enhance balance. The goal was to determine the effects of suspension training on balance by comparing it with instability training. Design: Two-arm, randomized trial. Methods: 44 young adults, aged 22.4 years old, with no musculoskeletal condition, took part. There were 2 interventions, suspension and instability training, designed with 12 sessions in 4 weeks. The primary outcome was the Y-Balance test. Other balance outcomes were the Emery and jumping sideways tests, and platform measures while standing. Results: Suspension and instability training were effective in enhancing balance in terms of the primary outcome, the Y-Balance test, with no between-group differences. Instability training enhanced the Emery test over suspension training (P = .018), but the latter was more effective in the jumping sideways test (P = .003). Neither of the training improved static balance measures. Conclusions: Training with suspension devices is effective in enhancing dynamic balance, with similar improvements to instability training. Importantly, the magnitude of change and the frequency of responders to intervention in terms of motor coordination and keeping balance in unstable conditions appear to be sensitive to the type of training.

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Closed-Loop Reflex Responses of the Lateral Ankle Musculature From Various Thresholds During a Lateral Ankle Sprain Perturbation

Jeffrey D. Simpson, Ludmila Cosio Lima, Youngil Lee, Harish Chander, and Adam C. Knight

Context: Latency is a reliable temporal metric used to evaluate sensorimotor integration of the fibularis longus (FL) and fibularis brevis (FB) during lateral ankle sprain perturbations. Currently, no clinical recommendations exist to select appropriate thresholds to evaluate the closed-loop reflex response of the lateral ankle musculature. The purpose of this study was to assess threshold value on latency of the FL and FB during an unanticipated inversion perturbation that simulates the mechanism of a lateral ankle sprain. Design: Descriptive laboratory study. Methods: Twenty healthy adults with no history of lateral ankle sprain injury completed an unanticipated single-leg drop landing onto a 25° laterally inclined force platform from a height of 30 cm. Surface electromyography recorded muscle activity data from the FL and FB during the inversion perturbation. Latency was identified at points where muscle activity exceeded 2, 5, and 10 SD above the average muscle activity 200 milliseconds prior to foot contact, and compared across threshold value using a 1-way analysis of variance (P < .05). Results: The 2 SD threshold was significantly shorter than both 5 SD and 10 SD thresholds for the FL (P < .01) and FB (P < .01). Likewise, the 5 SD threshold was significantly shorter than the 10 SD thresholds for FL (P = .004) and FB (P = .003). Conclusions: More sensitive thresholds results in a shorter closed-loop reflexive response compared to the more rigorous thresholds. We recommend that selection of the appropriate threshold to identify latency of the lateral ankle musculature should be based on the device used to simulate a lateral ankle sprain and the ankle inversion velocity produced during the ankle inversion perturbation.

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The Interruption of Rehabilitation Following Anterior Cruciate Ligament Reconstruction due to COVID-19 Restrictions: Association With Return-to-Sport Testing

William H. Suits, Olivia N. Roe, Corey M. Snyder, and Luke J. Voss

Context: Among many unanticipated changes, access to rehabilitation was disrupted during the onset of the COVID-19 pandemic. It is unclear how the timing of late-stage rehabilitation following anterior cruciate ligament with surgical reconstruction (ACLR) during the initial months of the pandemic affected outcomes. The purpose of this study was to compare physical performance outcome measures in patients following ACLR prior to and following COVID-19-related restrictions. Design: Retrospective cohort study. Methods: Data from patients who underwent return-to-sport testing following ACLR were analyzed based on date. December 2018 through March of 2020 (n = 66) was defined as the baseline period, and June through October 2020 (n = 27) was defined as the surveillance period. Outcome measures included single leg hop, triple hop, single leg vertical jump, and the lower-extremity functional test (LEFT). Linear mixed models were used to compare outcome measures before and after the onset of pandemic-related restrictions, clustered by sex and sport. A 1-way analysis of variance was performed to analyze the association between the number of virtual rehabilitation visits and outcome measures for subjects in the surveillance period. Results: Subjects in the surveillance period performed significantly worse in the LEFT (+7.88 s; 95% confidence interval, 1.11 to 14.66; P = .02) and single leg vertical jump on the unaffected side (−4.32 cm; 95% confidence interval, −7.44 to −1.19, P < .01), and performed better with single leg vertical jump symmetry (+6.3%; 95% confidence interval, 1.0% to 11.5%; P = .02). There were no other statistically significant differences. There was no significant association between having virtual rehabilitation visits and any of the performance outcomes. Conclusions: There was a decline in physical performance outcome measures in patients following ACLR who did not attend regular in-person physical therapy sessions in the late-stage rehabilitation due to COVID-19-related restrictions. Other factors during this unique time period, such as access to training facilities or psychosocial stressors, may have also influenced outcomes.

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Musculoskeletal Pain, Mood, and Sports Injury in Wheelchair Power Soccer Players

Ligia Raianne da Silva Moura, Jessica Fernandez Mosqueira Gomes, Fabiana Azevedo Terra Cunha Belache, Ney Armando de Mello Meziat Filho, and Patrícia dos Santos Vigário

Context: Wheelchair Power Soccer (WPS) is the only team sport that allows the participation of people with severe physical disabilities who require the daily use of motorized wheelchairs. These individuals may live with chronic pain due to the characteristics of the disabilities and treatments, interfering with their health and limiting their participation in sports. Objectives: To investigate the prevalence of musculoskeletal pain and its relationship with mood in WPS players and to analyze the incidence of traumatic injuries during a championship. Methods: A prospective, longitudinal study was carried out on 30 WPS athletes (93.33% male) with a mean (SD) (range) age of 22.37 (9.79) (47) years. Data collection was performed during a South American WPS Championship lasting 3 days, with: investigation of the presence of musculoskeletal pain and mood through a questionnaire; investigation of the occurrence of traumatic injuries through match observation; and confirmation of the occurrence of traumatic injuries through access to medical department records. Results: About 30% (n = 9/30) of the sample presented some pain on the day of evaluation, with an intensity of 5.67 (3.35) (10) points on the visual analog scale. The most common regions of pain were the lower back (13.3%, n = 4/30), thoracic (10%; n = 3/30), and cervical (10%; n = 3/30) areas of the spine. A total of 46.7% (n = 14/30) reported pain in the month before data collection but of less intensity (2.56 [4] [10] points), the most common regions being the lower limbs (20%; n = 6/30) and cervical spine (20%; n = 6/30). Among the between-group comparisons (ie, participants with pain vs without pain), no relationship was observed between mood state and pain. No traumatic injuries were identified during the competition. Conclusion: The presence of musculoskeletal pain was common in WPS players, but it was not related to mood. As no traumatic injuries were observed during the championship, this modality seems to be safe for people with physical disabilities in general.

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Effect of Floss Band on Anaerobic Exercise and Muscle Tissue Oxygenation

David Marko, Patrik Vymyslický, Petr Miřátský, Petr Bahenský, Tomáš Malý, Radek Vobr, and Miroslav Krajcigr

Context: Flossing is still a relatively new technique that has yielded varied results in the research literature; therefore, it requires further investigation. Previous research has shown that thigh tissue flossing might improve performance in countermovement jump, sprint time, maximum voluntary contraction, and rate of force development. Design: The present study aims to investigate the effect of the floss band on performance during the Wingate test (30-WAT), muscle oxygen saturation (SpO2), and total hemoglobin in vastus lateralis. Methods: Twenty-two students of physical education and sport (11 men and 11 women) were randomly selected to complete either the Wingate test with the application of a floss band in warm-up or the Wingate test without the use of a floss band, followed by the alternative 24 hours apart. Results: Throughout the testing, the floss band did not affect performance values during the Wingate test (relative peak power, relative average power, and fatigue index). However, there was a medium to large effect difference during 1 minute prior to 30-WAT (PRE), during the 30-WAT, and 10-minute recovery (REC) in values of SpO2 and total hemoglobin. Use of floss band displayed a higher SpO2 during PRE, 30-WAT, and REC by ∼13.55%, d < 2; ∼19.06%, d = 0.89; and ∼8.55%, d = 0.59, respectively. Conclusion: Collectively, these findings indicate that the application of thigh flossing during warm-up has no effect on 30-WAT performance; however, SpO2 was significantly increased in all stages of testing. This could lead to potential improvement in repeated anaerobic exercise due to increased blood flow. Increased muscle oxygen saturation can also lead to improved tissue healing as oxygen supply is essential for tissue repair, wound healing, and pain management.

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The End of the Formal Rehabilitation Is Not the End of Rehabilitation: Knee Function Deficits Remain After Anterior Cruciate Ligament Reconstruction

Daniel Niederer, Matthias Keller, Max Wießmeier, Lutz Vogt, Amelie Stöhr, Karl-Friedrich Schüttler, Christian Schoepp, Wolf Petersen, Lucia Pinggera, Natalie Mengis, Julian Mehl, Matthias Krause, Maren Janko, Daniel Guenther, Tobias Engeroff, Andree Ellermann, Turgay Efe, Raymond Best, David A. Groneberg, Michael Behringer, and Thomas Stein

Objective: To rate athletes’ functional ability and return to sport (RTS) success at the end of their individual, formal, medically prescribed rehabilitation after anterior anterior cruciate ligament (ACL) reconstruction. Methods: In our prospective multicenter cohort study, 88 (42 females) adults aged 18–35 years after acute unilateral ACL rupture and subsequent hamstring grafting were included. All patients were prospectively monitored during their rehabilitation and RTS process until the end of their formal rehabilitation and RTS release. As outcome measures, functional hop and jump tests (front hop, balance hops, and drop jump screening test) and self-report outcomes (Knee Injury and Osteoarthritis Outcome Score, ACL-RTS after injury) were assessed. Literature-based cut-off values were selected to rate each performance as fulfilled or not. Results: At 7.5 months (SD 2.3 months) after surgery, the percentage of participants meeting the functional thresholds ranged from 4% (Knee Injury and Osteoarthritis Outcome Score SPORT) and over 44% (ACL-RTS after injury sum score) to 59% (Knee Injury and Osteoarthritis Outcome Score activities of all daily living) in the self-report and from 29% (Balance side hop) to 69% (normalized knee separation distance) in performance testing. Only 4% fulfilled all the cut-offs, while 45% returned to the same type and level of sport. Participants who successfully returned to their previous sport (type and level) were more likely to be “over-cut-off-performers.” Conclusions: The low share of the athletes who fulfilled the functional RTS criteria highlights the importance of continuing the rehabilitation measures after the formal completion to assess the need for and success of, inter alia, secondary-preventive therapies.