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.
Steven Nagib and Shelley W. Linens
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.
Sergio Jiménez-Rubio, Archit Navandar, Jesús Rivilla-García and Victor Paredes-Hernández
Context: Despite the presence of various injury prevention programs, the rate of hamstring injuries and reinjuries is increasing in soccer, warranting the need for a soccer-specific rehabilitation program. Objective: To develop and validate a new, functional on-field program for the rehabilitation and readaptation of soccer players after a hamstring strain injury through a panel of experts; and determine the usefulness of the program through its application in professional soccer players. Design: A 13-item program was developed, which was validated by a panel of experts and later applied to professional soccer players. Setting: Soccer training ground. Participants: Fifteen strength and conditioning and rehabilitation fitness coaches with a professional experience of 15.40 (1.57) years in elite clubs and national teams in Europe validated the program. The program was later applied to 19 professional soccer players of the Spanish First Division (La Liga). Interventions: Once a player sustained a clinically diagnosed injury, the player would first be subject to mobilization and strengthening exercises in the gym after undergoing treatment by percutaneous needle electrolysis. The player would then complete an on-field readaptation program consisting of 13 drills arranged in a progressive manner in terms of complexity. The drills integrated various aspects of repeated sprint abilities, retraining and reeducation of biomechanical patterns, and neuromuscular control of the core and lower limbs. Main Outcome Measures: Aiken’s V for each item of the program and number of days taken by the players to return to play. Results: The experts evaluated all items of the program very highly, as seen from Aiken’s V values between 0.78 and 0.98 (0.63–0.99) for all drills, while the return to play was in 22.42 (2.32) days. Conclusion: This program has the potential to help a player suffering from a hamstring strain injury to adapt to real-match conditions in the readaptation phase through the application of sports-specific drills that were very similar to the different injury mechanisms.
Rafael Squillantini, Brielle Ringle and Julie Cavallario
Clinical Question: In patients with acute knee injuries, is there evidence to support that the lever sign test is more accurate in diagnosing an anterior cruciate ligament sprain than the Lachman test? Clinical Bottom Line: The evidence does not indicate that the lever sign test can be used in isolation in lieu of the Lachman test, but there is sufficient evidence to support adding the lever sign test to the examination of potential anterior cruciate ligament sprains.
Marcos de Noronha, Eleisha K. Lay, Madelyn R. Mcphee, George Mnatzaganian and Guilherme S. Nunes
Context: Ankle sprains are common injuries in sports, but it is unclear whether they are more likely to occur in a specific period of a sporting game. Objective: To systematically review the literature investigating when in a match ankle sprains most likely occurred. Evidence Acquisition: The databases CINAHL, EMBASE, MEDLINE, and SPORTDiscus were searched up to August 2016, with no restriction of date or language. The search targeted studies that presented data on the time of occurrence of ankle sprains during sports matches. Data from included studies were analyzed as a percentage of ankle sprain occurrence by halftime and by quarters. Meta-analyses were run using a random effects model. The quality assessment tool for quantitative studies was used to assess the article’s quality. Evidence Synthesis: The searches identified 1142 studies, and 8 were included in this review. A total of 500 ankle sprains were reported during follow-up time, which ranged from 1 to 15 years, in 5 different sports (soccer, rugby, futsal, American football, and Gaelic football). The meta-analyses, including all 8 studies, showed that the proportion of ankle sprains during the first half (0.44; 95% confidence interval [CI], 0.38–0.50) was smaller than the second half (0.56; 95% CI, 0.50–0.62). For the analyses by quarters, the proportion of ankle sprains in the first quarter (0.14; 95% CI, 0.09–0.19) was considerably smaller than the second (0.28; 95% CI, 0.24–0.32), third (0.25; 95% CI, 0.17–0.34), and fourth (0.29; 95% CI, 0.22–0.36) quarters. Conclusion: The results of this review indicate that ankle sprains are more likely to occur later in the game during the second half or during the latter minutes of the first half.
Erica S. Albertin, Emilie N. Miley, James May, Russell T. Baker and Don Reordan
Clinical Scenario: Hip osteoarthritis currently affects up to 28% of the population, and the number of affected Americans is expected to rise as the American population increases and ages. Limited hip range of motion (ROM) has been identified as a predisposing factor to hip osteoarthritis and limited patient function. Clinicians often apply therapy techniques, such as stretching and strengthening exercises, to improve hip ROM. Although traditional therapy has been recommended to improve hip ROM, the efficiency of the treatments within the literature is questionable due to lack of high-quality studies. More recently, clinicians have begun to utilize joint mobilization and the Mulligan Concept mobilization with movement techniques to increase ROM at the hip; however, there is a paucity of research on the lasting effects of mobilizations. Given the difficulties in improving ROM immediately (within a single treatment) and with long-lasting results (over the course of months), it is imperative to examine the evidence for the effectiveness of traditional therapy techniques and more novel manual therapy techniques. Focused Clinical Question: Is there evidence to suggest manual mobilizations techniques at the hip are effective at treating hip ROM limitations? Summary of Clinical Findings: 5 Randomized Controlled Studies, improved patient function and ROM with the Mulligan concept, high velocity low amplitude improved. Clinical Bottom Line: We found moderate evidence to suggest favorable outcomes following the use of hip mobilizations aimed at improving hip ROM and patient function. Strength of Recommendation: Strength of the studies identified are 1B.