Clinical Scenario: Anxiety is a mental disorder that affects a large portion of the population and may be problematic when evaluating brain injuries such as concussion. The reliance of cognitive testing in concussion protocols call for the examination of potential cognitive alterations commonly seen in athletes with anxiety. Focused Clinical Question: Does anxiety affect neuropsychological assessments in healthy college athletes? Summary of Key Findings: Three studies were included: 1 cross-sectional study and 2 prospective cohort studies. One study examined the effect of a range of psychological issues on concussion baseline testing in college athletes. Another study examined the effect of anxiety on reaction time both before and after sport competition in college-aged athletes. The final study examined the effects of psychosocial issues on reaction time during demanding tasks in college athletes. The first study reported slower simple and complex reaction times in athletes with anxiety. The second study found that athletes with high trait anxiety have slower reaction times both before and after competition. The third study reported that demanding tasks led to increased state anxiety which slowed reaction time. Overall, all 3 studies support the adverse effect anxiety can have on cognitive testing in athletes. Clinical Bottom Line: College athletes who present with anxiety at baseline may be susceptible to decreased performance on neuropsychological assessments. Strength of Recommendation: There is level B evidence that anxiety in healthy college athletes can impact neuropsychological assessments, and level C evidence that anxiety at baseline concussion assessment impacts neuropsychological testing in college athletes.
Christopher P. Tomczyk, George Shaver, and Tamerah N. Hunt
Ryan D. Henke, Savana M. Kettner, Stephanie M. Jensen, Augustus C.K. Greife, and Christopher J. Durall
ClinicalScenario: Low-intensity aerobic exercise (LIAEX) below the threshold of symptom exacerbation has been shown to be superior to rest for resolving prolonged (>4 wk) symptoms following sport-related concussion (SRC), but the effects of LIAEX earlier than 4 weeks after SRC need to be elucidated. Focused Clinical Question: Does LIAEX within the first 4 weeks following SRC hasten symptom resolution? Summary of Key Findings: Two randomized controlled trials (RCT) and 1 nonrandomized trial involving adolescent athletes (10–19 y) were included. One RCT reported faster recovery time with LIAEX versus placebo stretching. Likewise, recovery time was faster with LIAEX versus rest in the nonrandomized trial, but not in the underpowered RCT, although effect sizes were similar between these studies (0.5 and 0.4, respectively). All 3 studies reported a reduction in concussion symptom severity with LIAEX; however, the magnitude of symptom reduction across the recovery timeline was greater in the LIAEX group than the rest group in the nonrandomized trial, but not the 2 RCTs. Importantly, no adverse effects or incidence of delayed recovery from LIAEX were reported in any of the studies. Clinical Bottom Line: LIAEX initiated within 10 days after SRC may facilitate a faster recovery time versus placebo stretching or rest, although additional clinical trials are strongly advised to verify this. Strength of Recommendation: Level 1b and 2b evidence suggests subsymptom exacerbation LIAEX may decrease Postconcussion Symptom Scale scores and hasten symptom resolution in adolescent athletes following SRC.
Erik A. Wikstrom, Cole Mueller, and Mary Spencer Cain
Context: Lateral ankle sprains (LAS) have one of the highest recurrence rates of all musculoskeletal injuries. An emphasis on rapid return to sport (RTS) following LAS likely increases reinjury risk. Unfortunately, no set of objective RTS criteria exist for LAS, forcing practitioners to rely on their own opinion of when a patient is ready to RTS. Purpose: To determine if there was consensus among published expert opinions that could help inform an initial set of RTS criteria for LAS that could be investigated in future research. Evidence Acquisition: PubMed, CINHL, and SPORTDiscus databases were searched from inception until October 2018 using a combination of keywords. Studies were included if they listed specific RTS criteria for LAS. No assessment of methodological quality was conducted because all included papers were expert opinion papers (level 5 evidence). Extracted data included the recommended domains (eg, range of motion, balance, sport-specific movement, etc) to be assessed, specific assessments for each listed domain, and thresholds (eg, 80% of the uninjured limb) to be used to determine RTS. Consensus and partial agreement were defined, a priori, as ≥75% and 50% to 75% agreement, respectively. Evidence Synthesis: Eight domains were identified within 11 included studies. Consensus was reached regarding the need to assess sport-specific movement (n = 9, 90.9%). Partial agreement was reached for the need to assess static balance (n = 7, 63.6%). The domains of pain and swelling, patient reported outcomes, range of motion, and strength were also partially agreed on (n = 6, 54.5%). No agreement was reached on specific assessments of cutoff thresholds. Conclusions: Given consensus and partial agreement results, RTS decisions following LAS should be based on sport-specific movement, static balance, patient reported outcomes, range of motion, and strength. Future research needs to determine assessments and cutoff thresholds within these domains to minimize recurrent LAS risk.
James A. Ashton-Miller and Ronald F. Zernicke
Amy R. Barchek, Shelby E. Baez, Matthew C. Hoch, and Johanna M. Hoch
Clinical Scenario: Physical activity is vital for human health. Musculoskeletal injury may inhibit adults from participating in physical activity, and this amount may be less than adults without a history of musculoskeletal injury. Clinical Question: Do individuals with a history of ankle or knee musculoskeletal injury participate in less objectively measured physical activity compared with healthy controls? Summary of Key Findings: Four studies were included. Two studies concluded patients who have undergone an anterior cruciate ligament reconstruction (ACLR) spent less time in moderate to vigorous physical activity levels when compared with healthy controls, but still achieved the daily recommended amount of physical activity. One study determined that participants with CAI took fewer steps per day compared with the control group. The fourth study determined patients with patellofemoral pain were less physically active than healthy controls as they took fewer steps per day and spent less time participating in mild and high activity. Clinical Bottom Line: There is consistent, high quality evidence that demonstrates individuals with a history of ankle or knee musculoskeletal injury participate in less objectively measured physical activity compared with healthy individuals. Strength of Recommendation: Due to nature of study designs of the included articles in this critically appraised topic, we recommend a grade of 3B.
Dawn T. Gulick
Background: Knee disorders prevalence is estimated at more than 50% in a lifetime. There are over 250,000 anterior cruciate ligament (ACL) injuries per year in the United States. There are over 175,000 ACL reconstructions annually. This study was a double-blinded design to establish the reliability and validity of a new orthopedic device to measure linear translation of the tibia on the femur (ACL testing). Methods: A Zeiss Smartzoom microscope was used as the gold standard to assess the ability of the Mobil-Aider™ to measure linear translation. Sixty blinded measures were taken with each of 6 different devices. Results: Both the intraclass correlation and the Pearson correlation were .986. The Cronbach alpha reliability analysis was 0.992. Independent 1-sample t tests were performed on the differences between the Mobil-Aider™ and Zeiss values, and were not found to be significant (P = .42); that is, they were the same. Bland–Altman plot and a linear regression revealed no propositional bias. Finally, with 360 measures over 6 devices, the power of this study was calculated to be 100%. Discussion: This data are the first step in establishing reliability and concurrent validity of a new device. As a result of the current data, the Mobil-Aider™ device is deemed a promising orthopedic tool for use in assessing the laxity of the ACL. Additional testing needs to be performed on both healthy and injured knees. Conclusions: There is potential for the Mobil-Aider™ to contribute to the assessment of ACL injuries, but additional human testing is needed.
Salman Nazary-Moghadam, Mahyar Salavati, Ali Esteki, Behnam Akhbari, Sohrab Keyhani, and Afsaneh Zeinalzadeh
Objectives: The current study assessed the intrasession and intersession reliability of the knee flexion–extension Lyapunov exponent in patients with anterior cruciate ligament deficiency and healthy individuals. Study Design: University research laboratory. Methods: Kinematic data were collected in 14 patients with anterior cruciate ligament deficiency and 14 healthy individuals walked on a treadmill at a self-selected, low, and high speed, with and without cognitive load. The intraclass correlation coefficient, standard error of measurement, minimal metrically detectable change, and percentage of coefficient of variation were calculated to assess the reliability. Results: The knee flexion–extension Lyapunov exponent had high intrasession reliability, with intraclass correlation coefficients ranging from .83 to .98. In addition, the intersession intraclass correlation coefficient values of these measurements ranged from .35 to .85 regardless of group, gait speed, and dual tasking. In general, relative and absolute reliability were higher in the patients with anterior cruciate ligament deficiency than in the healthy individuals. Conclusions: Although knee flexion–extension Lyapunov exponent demonstrates good intrasession reliability, its low intersession reliability indicates that changes of these measurements between different days should be interpreted with caution.
Kenji Kanazawa, Yoshihiro Hagiwara, Takuya Sekiguchi, Ryo Fujita, Kazuaki Suzuki, Masashi Koide, Akira Ando, and Yutaka Yabe
Context: Range of motion (ROM) in the glenohumeral joint decreases with age in healthy subjects; however, the underlying mechanism remains unclear. The process of aging of the joint capsule, including the coracohumeral ligament (CHL), could affect ROM limitation. Objective: This study investigated correlations between elasticity of the CHL, evaluated by means of shear-wave elastography, and age, side dominance, and ROM in healthy individuals. Design: Experimental study. Setting: Laboratory. Subjects: Eighty-four healthy volunteers (39 men and 45 women, mean age: 42.6 y) were included. Main Outcome Measures: Subjects were divided into 3 age groups: younger (20–39 y), middle (40–59 y), and older (≥60 y) age groups. With participants in the supine position, CHL elasticity in both shoulders was evaluated in both neutral and 30° external rotation, with arms at the sides. ROM, including forward flexion, lateral elevation, external rotation, 90° abduction with external rotation, and hand behind the back were measured with participants in the standing position. Results: The CHL elastic modulus was higher in the older group than in the younger group in the neutral (78.4 kPa [SD: 37.1] and 56.6 kPa [SD: 31.7], respectively) and 30° external rotation positions (135.5 kPa [SD: 63.5] and 71.4 kPa [SD: 32.2], respectively). Negative correlations were found between the CHL elastic modulus and ROM in terms of 30° external rotation and both external rotation (R = −.59, P = .02) and 90° abduction with external rotation (R = −.71, P = .003) in the older group, with correlation coefficients increasing with age. Conclusions: Significant correlations were identified between CHL elasticity and ROM in both external rotation and 90° abduction with external rotation with increasing age. Decreased CHL elasticity was strongly associated with decreased shoulder ROM in middle-aged and older individuals.
Tobias Lundgren, Gustaf Reinebo, Markus Näslund, and Thomas Parling
Despite the growing popularity of mindfulness and acceptance-based performance enhancement methods in applied sport psychology, evidence for their efficacy is scarce. The purpose of the current study is to test the feasibility and effect of a psychological training program based on Acceptance and Commitment Training (ACT) developed for ice hockey players. A controlled group feasibility designed study was conducted and included 21 elite male ice hockey players. The ACT program consisted of four, once a week, sessions with homework assignments between sessions. The results showed significant increase in psychological flexibility for the players in the training group. The outcome was positive for all feasibility measures. Participants found the psychological training program important to them as ice hockey players and helpful in their ice hockey development. Desirably, future studies should include objective performance data as outcome measure to foster more valid evidence for performance enhancement methods in applied sport psychology.
Yasuki Sekiguchi, Erica M. Filep, Courteney L. Benjamin, Douglas J. Casa, and Lindsay J. DiStefano
Clinical Scenario: Exercise in the heat can lead to performance decrements and increase the risk of heat illness. Heat acclimation refers to the systematic and gradual increase in exercise in a controlled, laboratory environment. Increased duration and intensity of exercise in the heat positively affects physiological responses, such as higher sweat rate, plasma volume expansion, decreased heart rate, and lower internal body temperature. Many heat acclimation studies have examined the hydration status of the subjects exercising in the heat. Some of the physiological responses that are desired to elicit heat acclimation (ie, higher heart rate and internal body temperature) are exacerbated in a dehydrated state. Thus, euhydration (optimal hydration) and dehydration trials during heat acclimation induction have been conducted to determine if there are additional benefits to dehydrated exercise trials on physiological adaptations. However, there is still much debate over hydration status and its effect on heat acclimation. Clinical Question: Does dehydration affect the adaptations of plasma volume, heart rate, internal body temperature, skin temperature, and sweat rate during the induction phase of heat acclimation? Summary of Findings: There were no observed differences in plasma volume, internal body temperature, and skin temperature following heat acclimation in this critically appraised topic. One study found an increase in sweat rate and another study indicated greater changes in heart rate following heat acclimation with dehydration. Aside from these findings, all 4 trials did not observe statistically significant differences in euhydrated and dehydrated heat acclimation trials. Clinical Bottom Line: There is minimal evidence to suggest that hydration status affects heat acclimation induction. In the studies that met the inclusion criteria, there were no differences in plasma volume concentrations, internal body temperature, and skin temperature. Strength of Recommendation: Based on the Oxford Centre for Evidence-Based Medicine Scale, Level 2 evidence exists.