Clinical Question: In concussed patients, will having attention deficit hyperactivity disorder (ADHD) or learning difficulties (LD) versus not having ADHD or LD cause higher symptom severity scores or invalid baseline protocols? Clinical Bottom Line: Research supports the concept that there is a difference at baseline for individuals with ADHD and/or LD compared with those who do not.
Mindi Fisher, Ryan Tierney, Anne Russ and Jamie Mansell
Brittany M. Ingram, Melissa C. Kay, Christina B. Vander Vegt and Johna K. Register-Mihalik
Clinical Scenario: Current studies have identified body checking as the most common cause of sports-related concussion in ice hockey across all divisions and levels. As a result, many hockey organizations, particularly in youth sports, have implemented rules making body checking to the head, face, and/or neck illegal. Such a rule, in Canada, makes age 13 the first age in which individuals can engage in body checking. Despite these changes, effectiveness of their implementation on the incidence of concussion in Canadian male youth ice hockey players remains unclear. Clinical Question: What is the effect of body checking policy changes on concussion incidence in male youth ice hockey players? Summary of Key Findings: Of the 3 included studies, 2 studies reported a decrease in the incidence of concussion once a body checking policy change was implemented. The third study showed an increase; however, it is important to note that this may be due, in part, to increased awareness leading to better reporting of injuries. Clinical Bottom Line: Current evidence supports a relationship between body checking policy implementation and decreased concussion incidence; however, more research is needed to understand the long-term implications of policy change and the effects in other leagues. In addition, further data are needed to differentiate between increased concussion incidence resulting from concussion education efforts that may improve disclosure and increased concussion incidence as a direct result of policy changes. Strength of Recommendation: Grade B evidence exists that policy changes regarding body checking decrease concussion incidence in male youth ice hockey players.
Corey P. Ochs, Melissa C. Kay and Johna K. Register-Mihalik
Clinical Scenario: Collision sports are often at higher risk of concussion due to the physical nature and style of play. Typically, initial clinical recovery occurs within 7 to 10 days; however, even this time frame may result in significant time lost from play. Little has been done in previous research to analyze how individual game performance may be affected upon return to play postconcussion. Focused Clinical Question: Upon return-to-play clearance, how does sport-related concussion affect game performance of professional athletes in collision sports? Summary of Key Findings: All 3 studies included found no significant change in individual performance of professional collision-sport athletes upon returning to play from concussive injury. One of the studies indicated that there was no difference in performance for NFL athletes who did not miss a single game (returned within 7 d) and those who missed at least 1 game. One study indicated that although there was no change in performance of NFL players upon returning to play from sustained concussion, there was a decline in performance in the 2 weeks before the diagnosed injury and appearing on the injury report. The final study indicated that there was no difference in performance or style of play of NHL athletes who missed time due to concussive injury when compared with athletes who missed games for a noninjury factor. Clinical Bottom Line: There was no change in performance upon return from concussive injury suggesting that players appear to be acutely recovered from the respective concussion before returning to play. This suggests that current policies and management properly evaluate and treat concussed athletes of these professional sports. Strength of Recommendation: Grade C evidence exists that there is no change in individual game performance in professional collision-sport athletes before and after suffering a concussion.
Manuel Trinidad-Fernández, Manuel González-Sánchez and Antonio I. Cuesta-Vargas
Context: Several studies have shown that the kinematics of the scapula is altered in many disorders that affect the shoulder. Description of scapular motion in the chest continues to be a scientific and clinical challenge. Objective: To check the validity and reliability of a new, minimally invasive method of tracking the internal and external rotation of the scapula using ultrasound imaging combined with the signal provided by a 3-dimensional electromagnetic sensor. Design: A cross-sectional study with a repeated-measures descriptive test–retest design was employed to evaluate this new tracking method. The new method was validated in vitro and the reliability of data over repeated measures between scapula positions was calculated in vivo. Setting: University laboratory. Participants: A total of 30 healthy men and women. Main Outcome Measure: The validation of the scapula rotation tracking using the in vitro model was calculated by Pearson correlation test between a 2-dimensional cross-correlation algorithm of the new method and another software image. The reliability of the tracking of the scapula rotation was measured using the intraclass correlation coefficient. Results: In the validation in vitro, the correlation of rotations obtained by the 2 methods was good (r = .77, P = .01). The reliability in vivo had excellent results (intraclass correlation coefficient = .88; 95% confidence interval, .82–.93) in the test–retest analysis of 8 measures. The intrarater analysis of variance test showed no significant differences between the measures (P = .85, F = 0.46). Conclusion: Ultrasound imaging combined with a motion sensor to track the scapula has been shown to be a reliable and valid method for measuring internal and external rotation during separation of the upper limb.
Barıs Seven, Gamze Cobanoglu, Deran Oskay and Nevin Atalay-Guzel
Context: The evaluation of the wrist strength and proprioception gives clinicians and researchers information about effectiveness of their rehabilitation protocol or helps diagnosis of various neuromuscular and somatosensorial disorders. Isokinetic dynamometers are considered the gold standard for these evaluations. However, the studies about test–retest reliability of isokinetic dynamometer are inadequate. Objective: The purpose of this study was to determine the test–retest reliability of isokinetic wrist strength and proprioception measurements using the Cybex isokinetic dynamometer. Design: Test–retest reliability study. Setting: University laboratory. Participants: Thirty participants were enrolled (age 23.2 [2.8] y, height 171.1  cm, weight 66.6 [11.6] kg) in this study. Intervention: Cybex isokinetic dynamometer was used for strength and proprioception measurements. Main Outcome Measures: Concentric flexion–extension strength test was performed at 90°/s angular velocity, and eccentric flexion–extension strength test was performed at 60°/s angular velocity. The proprioception of the wrist was assessed via active joint position sense. The 30° extension of the wrist, which is accepted as the functional position of the wrist, was selected as the targeted angle. The intraclass correlation coefficient (ICC2,1) method was used for test–retest analysis (P < .05). Results: The active joint position sense measurements of dominant (ICC2,1: .821) and nondominant (ICC2,1: .763) sides were found to have good test–retest reliability. Furthermore, with the exception of dominant eccentric extension strength (moderate reliability) (ICC2,1: .733), eccentric and concentric flexion (dominant: ICC2,1 = .890–.844; nondominant: ICC2,1 = .800–.898, respectively), and extension (dominant: ICC2,1 = .791 [concentric], nondominant: ICC2,1 = .791–.818, respectively) strength measurements of both sides were found to have good reliability. Conclusions: This study shows that the Cybex isokinetic dynamometer is a reliable method for measuring wrist strength and proprioception. Isokinetic dynamometers can be used clinically for diagnosis or rehabilitation in studies which contain wrist proprioception or strength measurements.
Steven Nagib and Shelley W. Linens
Clinical Scenario: Every year, millions of people suffer a concussion. A significant portion of these people experience symptoms lasting longer than 10 days and are diagnosed with postconcussion syndrome. Dizziness is the second most reported symptom associated with a concussion and may be a predictor of prolonged recovery. Clinicians are beginning to incorporate vestibular rehabilitation therapy (VRT) in their postconcussion treatment plan, in order to address the dysfunctional inner ear structures that could be causing this dizziness. Focused Clinical Question: Can VRT help postconcussion syndrome patients experiencing prolonged dizziness by improving their perceived disability? Summary of Key Findings: Three studies were included: 1 randomized control trial, 1 retrospective chart review, and 1 exploratory study. The randomized control trial compared cervical spine therapy alone to cervical spine therapy in conjunction with VRT to obtain medical clearance for sport. The chart review explored VRT as a treatment for reducing dizziness and improving balance and gait dysfunction. The exploratory study implemented VRT in conjunction with light aerobic exercise to improve perceived disability associated with dizziness postconcussion. All 3 studies found statistically significant decreases (improvements) in Dizziness Handicap Index scores. Clinical Bottom Line: There is preliminary evidence suggesting that VRT can improve perceived disability in patients with postconcussion syndrome experiencing prolonged dizziness. There is a decrease (improvement) in Dizziness Handicap Index scores across all 3 studies. VRT is a relatively safe treatment option, with no adverse reactions or case reports. Strength of Recommendation: There is level 2 and level 3 evidence supporting the use of VRT to treat patients suffering from dizziness postconcussion.
Roel De Ridder, Julien Lebleu, Tine Willems, Cedric De Blaiser, Christine Detrembleur and Philip Roosen
Context: Wearable sensor devices have notable advantages, such as cost-effectiveness, easy to use, and real-time feedback. Wirelessness ensures full-body motion, which is required during movement in a challenging environment such as during sports. Research on the reliability and validity of commercially available systems, however, is indispensable. Objective: To confirm the test–retest reliability and concurrent validity of a commercially available body-worn sensor—BTS G-WALK® sensor system—for spatiotemporal gait parameters with the GAITRite® walkway system as golden standard. Design: Reliability and concurrent validity study. Setting: Laboratory setting. Participants: Thirty healthy subjects. Main Outcome Measures: Spatiotemporal parameters: speed, cadence, stride length, stride duration, stance duration, swing duration, double support, and single support. Results: In terms of test–retest reliability of the BTS G-WALK® sensor system, intraclass correlation coefficient values for both the spatial and temporal parameters were excellent between consecutive measurements on the same day with intraclass correlation coefficient values ranging from .85 to .99. In terms of validity, intraclass correlation coefficient values between measurement systems showed excellent levels of agreement for speed, cadence, stride length, and stride duration (range = .88–.97), and showed poor to moderate levels of agreement (range = .12–.47) for single/double support and swing/stance duration. Bland–Altman plots showed overall percentage bias values equal to or smaller than 3% with limits of agreement ≤15% (speed, cadence, stride length, stride duration, swing duration, and stance duration). Only for single and double support, the limits of agreement were higher with, respectively, −15.4% to 19.5% and −48.0% to 51.4%. Conclusion: The BTS G-WALK® sensor system is reliable for all measured spatiotemporal parameters. In terms of validity, excellent concurrent validity was shown for speed, cadence, stride length, and stride duration. Cautious interpretation is necessary for temporal parameters based on final foot contact (stance, swing, and single/double support time).
Alissa C. Rhode, Lauren M. Lavelle and David C. Berry
Clinical Scenario: ReBound is a portable shortwave diathermy unit used to heat tissues using the same principle as induction drum shortwave diathermy. It is unclear if ReBound can vigorously (4°C) heat intramuscular tissue as efficiently as other thermal agents. Clinical Question: In adults (P), is ReBound diathermy (I) compared with other thermal agents (C) effective at increasing intramuscular tissue temperature by 4°C (O)? Summary of Key Findings: (1) Three studies were included for review, all randomized crossover studies. (2) All studies agreed ReBound does not achieve vigorous (4°C) heating effects during a 30-minute treatment to the triceps surae muscle (depth = 1 and 3 cm). (3) Studies agreed that the heat generated by ReBound dissipates slower than (P < .001) or similar to pulsed shortwave diathermy at 3 cm and faster than moist hot packs (P < .001) at 1 cm. (4) One study found that intramuscular tissue temperatures increased more with ReBound (3.69°C [1.50°C]) than moist hot packs (2.82°C [0.90°C]) at superficial depths (1 cm, d = 0.70). (5) Two studies compared ReBound with MegaPulse II pulsed shortwave diathermy at a 3 cm depth. One found that the MegaPulse II increased intramuscular tissue temperature by 4.32°C (1.79°C) compared with the ReBound’s 2.31°C (0.87°C) increase (d = 1.43). The final study reported that the MegaPulse II increased triceps surae muscle temperature by 3.47°C (0.92°C) versus ReBound at 3.08°C (1.19°C) (d = 0.37). (6) The combined results are an increase of 3.81 (1.38°C) for the MegaPulse II and 2.77 (1.12°C) for ReBound (d = 0.83). Clinical Bottom Line: Results strongly indicate that the ReBound should not be used for vigorous (4°C) heating effects in the triceps surae muscle at 1 and 3 cm. Clinicians can use ReBound when traveling or instead of moist hot packs for moderate (2°C–3°C) heating effects at deep and superficial levels (1 and 3 cm) for large treatment areas with subcutaneous fat thickness <15 mm. Strength of Recommendation: Consistent level B findings indicate that ReBound does not achieve vigorous heating effects (4°C).
Oliver Silverson, Nicole Cascia, Carolyn M. Hettrich, Matt Hoch and Tim Uhl
Clinical Scenario: Assessing movement of the scapula is an important component in the evaluation and treatment of the shoulder complex. Currently, gold-standard methods to quantify scapular movement include invasive technique, radiation, and 3D motion systems. This critically appraised topic focuses on several clinical assessment methods of quantifying scapular upward rotation with respect to their reliability and clinical utility. Clinical Question: Is there evidence for noninvasive methods that reliably assess clinical measures of scapular upward rotation in subjects with or without shoulder pathologies? Summary of Key Findings: Four studies were selected to be critically appraised. The quality appraisal of diagnostic reliability checklist was used to score the articles on methodology and consistency. Three of the 4 studies demonstrated support for the clinical question. Clinical Bottom Line: There is moderate evidence to support reliable clinical methods for measuring scapular upward rotation in subjects with or without shoulder pathology. Strength of Recommendation: There is moderate evidence to suggest there are reliable clinical measures to quantify scapular upward rotation in patients with or without shoulder pathology.
Nicole Cascia, Tim L. Uhl and Carolyn M. Hettrich
Clinical Scenario: Ulnar collateral ligament (UCL) injuries are highly prevalent in professional baseball players with the success of operative management being well known in the literature. Return to play (RTP) rates following nonoperative management of partial UCL injuries in professional baseball players are not well established in the literature. With a UCL tear being a potential career-ending injury, it is imperative that the best treatment option is provided to these throwing athletes. There is an increase in the incidence of UCL surgical rates and a lack of general agreement on nonoperative treatment of partial UCL injuries as reported by the American Shoulder and Elbow Surgeons in 2017. There is also a lack of clarity on when to initiate rehabilitation, which may be due to the limited amount of studies reporting success of RTP rates and time to RTP following conservative interventions of partial UCL injuries. Evidence on the RTP rates seen following conservative management of partial UCL tears injuries can help guide health care providers in deciding on the best treatment option for professional baseball athletes who desire to return to their athletic careers. These rates of RTP will add valuable objective input when determining if conservative management is the best choice. To determine the current evidence, inclusion criteria for the literature search consisted of RTP rates following conservative treatment in professional baseball players between inception and 2018. Clinical Question: Is there evidence for successful RTP rates in professional baseball players following conservative treatment of a UCL injury? Summary of Key Findings: Three retrospective studies met the inclusion criteria and were included. Of those, 2 reported RTP rates following a nonoperative rehabilitation program of a UCL injury, whereas 1 reported RTP rates after injection therapy in subjects who attempted a trial of conservative treatment. All 3 studies considered location and grade of UCL tear. Successful RTP rates (66%–100%) were reported in professional baseball players following nonoperative treatment of partial UCL injuries. Clinical Bottom Line: Current evidence supports high success with RTP rates up to 100% after nonoperative treatment of grade 1 UCL injuries in professional baseball players and between 66% and 94% for a grade 2 and above. Strength of Recommendation: There is level C evidence for high RTP rates following nonoperative treatment of partial UCL injuries in professional baseball players.