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Effects of Collagen and Exercise on Tendon Properties and Pain: A Critically Appraised Topic

Kylie S. Boldt, Bernadette L. Olson, and Ryan M. Thiele

Clinical Scenario: Achilles tendon ruptures are prevalent and devastating injuries that require the need for extensive rehabilitation. The methods for preventing these injuries vary between different exercise methods and nutritional supplementation. Although proven effective for decreasing pain and increasing tendon properties, the influence of these 2 methods in combination has not yet been evaluated. Clinical Question: Does exercise combined with collagen supplementation improve Achilles tendon structural and mechanical properties and diminish subsequent patient-reported pain compared with exercise alone in adults? Summary of Key Findings: Exercise training, including eccentric training protocols and concentric resistance training protocols, combined with collagen supplementation influence Achilles tendon properties and subsequent patient-reported pain compared with exercise alone. Clinical Bottom Line: Evidence supports that collagen along with exercise training has a significant influence on pain mitigation, augmented cross-sectional area, and tendon thickness, but may have little to no influence on tendon stiffness and microvascularity compared with exercise alone. Further research is needed to determine the effects of combined methods on various populations. Strength of Recommendation: Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of A.

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Hip Muscle Strength, Range of Motion, and Functional Performance in Young Elite Male Australian Football Players

Michael Girdwood, Benjamin F. Mentiplay, Mark J. Scholes, Joshua J. Heerey, Kay M. Crossley, Michael J.M. O’Brien, Zuzana Perraton, Anik Shawdon, and Joanne L. Kemp

Context: Hip and groin injuries are common in field sports such as football, with measurement of hip strength and range of motion (ROM) recommended for assessment of these conditions. We aimed to report hip strength, hip ROM, and functional task performance in young elite Australian football athletes. Design: Cross-sectional study. Methods: Fifty-eight newly drafted Australian Football League athletes completed hip abduction, adduction, internal rotation, external rotation, and flexion strength testing with an adjustable stabilized or hand-held dynamometer. Hip internal rotation and external rotation, bent knee fall out, and ankle dorsiflexion ROM were also measured. Players completed hop for distance, side bridge, and star excursion balance functional tests. We compared findings between the dominant and nondominant limbs. Results: We found small deficits unlikely to be clinically meaningful in the dominant limb for hip abduction and adduction strength, and a small deficit in the nondominant limb for external rotation strength and side bridge time. Athletes had lower hip internal rotation (mean difference 2.56°; 95% confidence interval, 0.87 to 4.26) and total rotation ROM (2.03°; 95% confidence interval, 0.06 to 4.01) on the dominant limb. Conclusions: There were no meaningful differences between dominant and nondominant limbs for hip strength, ROM, or functional tests. Our results may be used for benchmarking young male Australian football athletes when targeting optimal strength and returning from injury.

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Impact of Attentional Focus on Dance Performance: A Critically Appraised Topic

Kelley R. Wiese, Jatin P. Ambegaonkar, and Joel Martin

Clinical Scenario: Dancing is a demanding esthetic activity with dancers having an 85% annual injury incident rate when performing complex dance motor skills. Teachers and clinicians use a combination of external and internal attentional cues when teaching dancers motor skills and when working on rehabilitation programs with injured dancers, respectively. External attentional focus (ie, focusing on movement outcome) reportedly results in superior performance than internal attentional focus (ie, focus on body movements). Interestingly, dancers reportedly often adopt an internal focus when dancing. Still, limited literature exists examining the effects of attentional focus on dancers’ performance. Clinical Question: How does attentional focus (external or internal) impact performance in dancers? Summary of Key Findings: Four original quasi-experimental studies met inclusion criteria. In the current examination, we found mixed results about the impact of attentional focus in dancers. Specifically, using an external attentional focus resulted in better performance in 2 studies, but these findings were limited to lesser experienced dancers. Experienced dancers did not have any physical performance differences when using external or internal focus. Internal focus also did not negatively affect dancers’ performance in 2 studies. Some authors noted positive motivational effects (eg, increased perceived competence) when dancers used external focus. Clinical Bottom Line: Low-quality evidence exists supporting the notion that in less experienced dance students, external focus improves performance. In experienced dancers, the type of attentional focus did not impact performance. External focus provides positive mental effects. Thus, clinicians working with dancers can integrate individualized feedback according to dancer level, with a preference toward external focus due to positive mental effects, to design optimal training and rehabilitation programs. Strength of Recommendation: Grade B evidence exists supporting the notion that an external attentional focus improves performance in less experienced dance students and also has positive mental effects. Internal attentional focus does not impede experienced dancers’ performance.

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Preliminary Baseline Vestibular Ocular Motor Screening Scores in Pediatric Soccer Athletes

Morgan Anderson, Christopher P. Tomczyk, Aaron J. Zynda, Alyssa Pollard-McGrandy, Megan C. Loftin, and Tracey Covassin

Context: The utility of baseline vestibular and ocular motor screening (VOMS) in high school and collegiate athletes is demonstrated throughout the literature; however, baseline VOMS data at the youth level are limited. In addition, with the recent adoption of the change scoring method, there is a need to document baseline VOMS total and change scores in a pediatric population. Objective: To document baseline VOMS total and change scores and to document the internal consistency of the VOMS in pediatric soccer athletes. We hypothesized that the VOMS would demonstrate strong internal consistency in pediatric soccer athletes. Design: Cross-sectional study. Methods: Pediatric soccer athletes (N = 110; range = 5–12 y) completed the VOMS at baseline. Descriptive statistics summarized demographic information, VOMS total scores, and VOMS change scores. Cronbach α assessed internal consistency for VOMS total scores and change scores. Results: Twenty-one (19.1%) participants had at least one total score above clinical cutoffs (≥2 on any VOMS component and ≥5 cm on average near point convergence). Forty (36.4%) participants had at least one change score above clinical cutoffs (≥1 on any VOMS component and ≥3 cm on average near point convergence). The internal consistency was strong for total scores with all VOMS components included (Cronbach α = .80) and change scores (Cronbach α = .89). Conclusions: Although results suggest VOMS items measure distinct components of the vestibular and ocular motor systems, caution should be taken when interpreting VOMS total and change scores in pediatric athletes, as overreporting symptoms is common, thereby impacting the false-positive rate.

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Spanish Cross-Cultural Adaptation and Validation of the Kerlan-Jobe Orthopaedic Clinic Shoulder and Elbow Score

Javier Bailón-Cerezo, Roy La Touche, Beatriz Sánchez-Sánchez, Irene de la Rosa-Díaz, María Torres-Lacomba, and Sergio Hernández-Sánchez

Context: There are no available questionnaires in Spanish that assess the function and performance of shoulder and elbow in overhead sports. The Kerlan-Jobe Orthopaedic Clinic (KJOC) score is a reference tool for this purpose. We aimed to cross-culturally adapt and investigate its measurement properties in Spanish overhead athletes. Design: Cross-cultural adaptation followed the steps of direct translation, back translation, comprehensibility analysis, and review by the Committee of Experts. Then, symptomatic and asymptomatic overhead athletes were invited to complete an electronic version of the Spanish adaptation (KJOC-Sp). The structural validity was evaluated through an exploratory factor analysis with principal axis factoring. Hypotheses were tested for known-groups and convergent validity, studying the correlation with the Shoulder Pain and Disability Index and the Disabilities of the Arm, Shoulder, and Hand Sports Module questionnaires in symptomatic athletes. Cronbach alpha was calculated for internal consistency and intraclass correlation coefficient (ICC)2,1 for test–retest reliability. Floor and ceiling effects and time to completion were also calculated. Results: The KJOC-Sp maintained the content of the original version and was adapted to the new population. One hundred participants (41 females and 59 males) with a mean age of 22.4 (5.9) years participated in the study of measurement properties. The factor analysis revealed a 1-factor solution. Symptomatic participants scored significantly lower than asymptomatic, with a large effect size (P < .001; r = .67). Correlations were of −.60 (P < .05) with the Shoulder and Pain Disability Index questionnaire and −0.66 (P < .05) with the Disabilities of the Arm, Shoulder, and Hand Sports Module questionnaire. Cronbach alpha was .98 (95% confidence interval, .97–.98) and the ICC2,1 was .96 (95% confidence interval .93–.98). No floor or ceiling effects were observed among the symptomatic athletes, while mean time to completion was 121 seconds. Conclusion: The KJOC-Sp is equivalent to the original score, aside from valid and reliable, without floor or ceiling effects in symptomatic athletes and with a low time consumption.

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Can the Copenhagen Adduction Exercise Prevent Groin Injuries in Soccer Players? A Critically Appraised Topic

Marcos Quintana-Cepedal, Omar de la Calle, and Hugo Olmedillas

Clinical Scenario: Injuries that affect the groin region are among the most common in football players. To prevent this condition, studies have focused on strengthening the adductors, hip flexors, or abdominal muscles. Recent investigations have used an eccentric-biased exercise (Copenhagen Adduction Exercise [CAE]) that promotes functional and architectural adaptations in the muscle tissue, though its effect on injury risk reduction is unknown. Clinical Question: Can the Copenhagen Adduction Exercise prevent groin injuries in soccer players? Summary of Key Findings: The literature was searched for studies investigating the potential groin injury risk reduction effect of the CAE. (1) Three studies met the inclusion criteria and were used for this appraisal; (2) one study observed a significantly lower injury rate ratio favoring the group that used the CAE program; and (3) 2 studies found similar or higher injury rates in the intervention groups, not supporting the inclusion of the CAE as a preventative tool. Clinical Bottom Line: There is conflicting evidence that usage of the CAE is superior to not performing adductor strengthening exercises in mitigating the risk of sustaining groin injuries. Given the evidence supporting these findings, it is advisable to exercise caution when contemplating the incorporation of the CAE into training regimens aimed at preventing groin injuries. Strength of Recommendation: There is Grade B evidence to suggest that inclusion of the CAE may not be associated with reduced injury rates.

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The Effect of Staged Versus Usual Care Physiotherapy on Knee Function Following Anterior Cruciate Ligament Reconstruction

Kestrel McNeill, Hana Marmura, Melanie Werstine, Greg Alcock, Trevor Birmingham, Kevin Willits, Alan Getgood, Marie-Eve LeBel, Robert Litchfield, Dianne Bryant, and J. Robert Giffin

Context: The long duration and high cost of anterior cruciate ligament reconstruction (ACLR) rehabilitation can pose barriers to completing rehabilitation, the latter stages of which progress to demanding sport-specific exercises critical for a safe return to sport. A staged approach shifting in-person physiotherapy sessions to later months of recovery may ensure patients undergo the sport-specific portion of ACLR rehabilitation. Design/Objective: To compare postoperative outcomes of knee function in patients participating in a staged ACLR physiotherapy program to patients participating in usual care physiotherapy through a randomized controlled trial. Methods: One hundred sixty-two patients were randomized to participate in staged (n = 80) or usual care physiotherapy (n = 82) following ACLR and assessed preoperatively and postoperatively at 2 weeks, 6 weeks, 3 months, and 6 months. The staged group completed the ACLR rehabilitation protocol at home for the first 3 months, followed by usual care in-person sessions. The usual care group completed in-person sessions for their entire rehabilitation. Outcome measures included the Lower Extremity Functional Scale, International Knee Documentation Committee Questionnaire, pain, range of motion, strength, and hop testing. Results: There were no statistically significant between-group differences in measures of knee function at 6 months postoperative. Patients in the usual care group reported significantly higher International Knee Documentation Committee scores at 3 months postoperative (mean difference = 5.8; 95% confidence interval,  1.3 to 10.4; P = .01). Conclusion: A staged approach to ACLR rehabilitation does not appear to impede knee function at 6 months postoperative but may result in worse patient reported outcomes at early follow-ups.

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Volume 32 (2023): Issue 7 (Sep 2023)

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Intrarater and Interrater Reliability and Agreement of a Method to Quantify Lower-Extremity Kinematics Using Remote Data Collection

Margaret S. Harrington, Ikeade C. Adeyinka, and Timothy A. Burkhart

Context: To assess the reliability of a remote 2D markerless motion tracking method (Kinovea) to quantify knee and hip angles during dynamic tasks. Methods: Fourteen healthy adults performed body weight squats and lateral lunges while video recording themselves at home. Knee and hip angles were quantified in the sagittal plane for the squats and in the frontal plane for the lateral lunges. Two students each performed the video analysis procedure twice, 2 weeks apart. Intraclass correlation coefficients were used to calculate the intrarater and interrater reliability for angles at maximum depth. The intrarater and interrater agreement over the joint angle–time signals were quantified using a validation metric; an acceptable agreement threshold was set at a validation metric of 0.803 or higher. Standard error of measurement (SEM) was also calculated. Results: Reliability was good to excellent (intraclass correlation coefficients = .80–.98) for all angle comparisons at maximum depth. The agreement over the entire joint angle–time signal was acceptable for all squat variables except for the interrater hip angle comparison (validation metric = 0.797). None of the lateral lunge variables met the threshold of acceptable agreement. The mean SEM across participants for all joint angle–time signal and for maximum depth was acceptable (<5°) for all measurements (SEM = 1.2°–4.9°). Conclusions: Overall, the reliability, agreement, and SEM quantified in this study support the integration of remote methods to quantify lower-extremity kinematics into research and clinical practice.

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Reliability and Concurrent Validity of Smartphone Clinometer Application for Measuring Scapular Rotations in Subjects With and Without Shoulder Pain

Varmeet Kaur, Meena Makhija, and Vandana Phadke

Context:  Clinical assessment of scapular motion is obscured by a lack of clinically accessible and feasible angular measurement tools. This study evaluates the reliability and validity of the smartphone “Clinometer” app in measuring scapular upward rotation (UR) and anteroposterior tilt. Design: Psychometric analysis. Methods: We recruited 57 participants—10 with and 47 without shoulder pain. Two physical therapists consecutively measured both scapular movements using the Clinometer app at the arm by the side (rest), 30°, 60°, 90°, and 120° of humeral elevation in the scapular plane; one therapist measured again after 2 days. For evaluating concurrent validity, we compared the Clinometer scores with those measured using an electromagnetic motion capture system in 10 healthy participants. Intraclass correlation coefficients (ICC) with standard error of measurement (SEM) and minimal detectable difference at 90% confidence intervals (MDD90) were calculated. Concurrent validity was evaluated using repeated-measures analysis of variance followed by post hoc testing with Tukey–Kramer test (P < .05). Results: We observed good intrarater reliability (ICC: UR = .76–.85, tilt = .69–.9; SEM: 2.2°–3.5°; MDD90: ∼5°–8°) and moderate to good interrater reliability (ICC: UR = .66–.78, tilt = .66–.76; SEM: 3.6°–8°; MDD90: ∼9°–18°) for both rotations. The Clinometer scores for UR were comparable to electromagnetic motion capture system at all angles except 90° (difference ∼8°); for scapular tilt, the scores were comparable only at rest and 30° elevation. Conclusion: The Clinometer app is reliable and valid for measuring scapular UR throughout and for scapular tilt at lower humeral elevation angles. The MDD90 values for scapular rotations computed in this study can be helpful in rehabilitation planning and future research.