Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician’s strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP.
Kaitlyn C. Jones, Evelyn C. Tocco, Ashley N. Marshall, Tamara C. Valovich McLeod and Cailee E. Welch Bacon
Eric P. Scibek, Matthew F. Moran and Susan L. Edmond
Context: The deep squat (DS) test is a component of the functional movement screen, which is used to assess the quality of fundamental movement patterns; however, the accuracy of the DS has not been studied. The DS is a complex, total body movement pattern with evaluation required at several points along the kinematic chain. Objective: To assess the accuracy of DS scoring by an athletic trainer, physical therapist, and exercise science professional via a comparative analysis with kinematic data (KD) and to identify scoring criteria that would improve agreement between raters and KD scores. Design: Cross-sectional study. Setting: Motion analysis laboratory. Participants: A rater from each of 3 movement science disciplines rated the DS of 23 male college athletes (20.3 [1.2] y; 70.5 [3.5] kg). Interventions: Subjects were outfitted with reflective markers and asked to perform the DS. The DS performance was scored by 3 raters and kinematic analysis. Subsequently, the optimal set of criteria that minimized the difference between mode rater score and KD was determined via a Nelder–Mead simplex optimization routine. Main Outcome Measures: Intraclass correlation coefficients (ICCs) were calculated using SPSS (version 23; IBM, Armonk, NY) to determine tester agreement with the KD score and between the mode score and KD score. Results: Agreement was poor for the athletic trainer (ICC = .387), physical therapist (ICC = .298), exercise science professional (ICC = .378), and raters’ DS scores when compared with the KD. Agreement was poor for the mode score when compared with KD prior to optimization and good following optimization (ICC = .830), thereby allowing identification of specific scoring errors. Conclusions: Agreement for DS scores is poor when compared with KD; however, it may be improved with optimization of DS scoring criteria.
Jessica St Aubin, Jennifer Volberding and Jack Duffy
Clinical Question: How does early return to physical activity impact return-to-play recovery time in patients 5–30 years old after an acute concussion as compared to the current best practice of resting? Clinical Bottom Line: Based on the information gathered, there is moderate evidence to support the incorporation of light to moderate physical activity within 7 days after a concussion in order to decrease recovery time and symptoms.
Emily A. Hall, Dario Gonzalez and Rebecca M. Lopez
Clinical Question: Does the medical model of organizational structure compared to either the academic or traditional models have a greater influence on job satisfaction and quality of life in collegiate athletic trainers? Clinical Bottom Line: Based on the quality of the person-oriented evidence available, the recommendation to adopt the medical model for athletic training staff would receive a Strength of Recommendation Taxonomy (SORT) grade of B.
Adam Jones, Richard Page, Chris Brogden, Ben Langley and Matt Greig
Context: The influence of playing surface on injury risk in soccer is contentious, and contemporary technologies permit an in vivo assessment of mechanical loading on the player. Objective: To quantify the influence of playing surface on the PlayerLoad elicited during soccer-specific activity. Design: Repeated measures, field-based design. Setting: Regulation soccer pitches. Participants: Fifteen amateur soccer players (22.1 [2.4] y), injury free with ≥6 years competitive experience. Interventions: Each player completed randomized order trials of a soccer-specific field test on natural turf, astroturf, and third-generation artificial turf. GPS units were located at C7 and the mid-tibia of each leg to measure triaxial acceleration (100 Hz). Main Outcome Measures: Total accumulated PlayerLoad in each movement plane was calculated for each trial. Ratings of perceived exertion and visual analog scales assessing lower-limb muscle soreness were measured as markers of fatigue. Results: Analysis of variance revealed no significant main effect for playing surface on total PlayerLoad (P = .55), distance covered (P = .75), or postexercise measures of ratings of perceived exertion (P = .98) and visual analog scales (P = .61). There was a significant main effect for GPS location (P < .001), with lower total loading elicited at C7 than mid-tibia (P < .001), but with no difference between limbs (P = .70). There was no unit placement × surface interaction (P = .98). There was also a significant main effect for GPS location on the relative planar contributions to loading (P < .001). Relative planar contributions to loading in the anterioposterior:mediolateral:vertical planes was 25:27:48 at C7 and 34:32:34 at mid-tibia. Conclusions: PlayerLoad metrics suggest that playing surface does not influence mechanical loading during soccer-specific activity (not including tackling). Clinical reasoning should consider that PlayerLoad magnitude and axial contributions were sensitive to unit placement, highlighting opportunities in the objective monitoring of load during rehabilitation.
Stef Feijen, Angela Tate, Kevin Kuppens, Thomas Struyf, Anke Claes and Filip Struyf
Context: The latissimus dorsi plays a major role in generating the propulsive force during swimming. In addition, stiffness of this muscle may result in altered stroke biomechanics and predispose swimmers to shoulder pain. Measuring the flexibility of the latissimus dorsi can be of interest to reduce injury. However, the reliability of such measurement has not yet been investigated in competitive swimmers. Objective: To assess the within-session intrarater and interrater reliability of a passive shoulder flexion range of motion measurement for latissimus dorsi flexibility in competitive swimmers. Design: Within-session intrarater and interrater reliability. Setting: Competitive swimming clubs in Flanders, Belgium. Participants: Twenty-six competitive swimmers (15.46 [2.98] y; 16 men and 10 women). Intervention: Each rater performed 2 alternating (eg, left-right-left-right) measurements of passive shoulder flexion range of motion twice, with a 30-second rest period in between. Main Outcome Measures: The intraclass correlation coefficients were calculated to assess intrarater and interrater reliability. Results: Interrater intraclass correlation coefficient ranged from .54 (95% confidence interval [CI], −.16 to .81) to .57 (95% CI, −.24 to .85). Results for the intrarater reliability ranged from .91 (95% CI, .81 to .96) to .94 (95% CI, .87 to .97). Conclusion: Results of this study suggest that shoulder flexion range of motion in young competitive swimmers can be measured reliably by a single rater within the same session.
Jefferson Fagundes Loss, Edgar Santiago Wagner Neto, Tatiane Borsoi de Siqueira, Aline Dill Winck, Laura Silveira de Moura and Luiz Carlos Gertz
Trunk-flexor muscle strength plays a fundamental role in athletic performance, but objective measurements are usually obtained using expensive and nonportable equipment, such as isokinetic dynamometers. The aim of this study was to assess the concurrent validity of a portable, one-dimensional, trunk-flexor muscle strength measurement system (Measurement System) that uses calibrated barbells and the reliability of the measurements obtained using the Measurement System, by conducting test–retests. As a complementary assessment, the measurements obtained during a maximum contraction test performed by a group of 15 subjects were also recorded. Four conditions were assessed: repeatability, time reproducibility, position reproducibility, and subject reproducibility. The results demonstrate that both the concurrent validity and the measured reliability (intraclass correlation coefficient > .98) of the Measurement System are acceptable. The Measurement System provides valid and reliable measures of trunk-flexor muscle strength.
Matheus Lima Oliveira, Isabela Christina Ferreira, Kariny Realino Ferreira, Gabriela Silveira-Nunes, Michelle Almeida Barbosa and Alexandre Carvalho Barbosa
Context: Strength assessment is essential to prescribe exercise in sports and rehabilitation. Low-cost valid equipment may allow continuous monitoring of training. Objective: To examine the validity of a very low-cost hanging scale by comparing differences in the measures of peak force to a laboratory grade load cell during shoulder abduction, flexion, extension, and internal and external rotations. Design: Analytical study. Participants: Thirty-two healthy subjects (18 women, age 26  y, height 172  cm, mass 69  kg, body mass index 23  kg/m2). Main Outcome Measures: The dependent variable was the maximal peak force (in kilogram-force). The independent variable was the instrument (laboratory grade load cell and hanging scale). Results: No differences were observed while comparing the results. The intraclass correlation coefficients1,1 ranged from .96 to .99, showing excellent results. The Cronbach alpha test also returned >.99 for all comparisons. The SEM ranged from 0.02 to 0.04 kgf, with an averaged SD from 0.24 to 0.38 kgf. The correlation was classified as high for all tested movements (r > .99; P < .001), with excellent adjusted coefficients of determination (.96 < r 2 < .99). Bland–Altman results showed high levels of agreement with bias ranging from 0.27 to 0.48. Conclusions: Hanging scale provides valid measures of isometric strength with similar output measures as laboratory grade load cell.
Josep C. Benítez-Martínez, Pablo Martínez-Ramírez, Fermín Valera-Garrido, Jose Casaña-Granell and Francesc Medina-Mirapeix
Context: The prevalence and negative consequences of the symptoms surrounding patellar tendinopathy constitute an important problem for sports medicine professionals. The identification of potential pain mediators is, therefore, of major interest to improve both the prevention and management of this injury. Objective: To compare the pain experienced by elite male adult basketball players and patterns of patellar tendon abnormalities. Also, to identify whether structural and vascular sonographic abnormalities (focal area of hypoechogenicity, thickening, and neovascularization [NV]) are equal in determining pain perceptions. Design: An observational study with professional basketball teams (ACB—Spanish league). Participants: A total of 73 male basketball players (mean age 26.8 y). Main Outcome Measures: Patellar tendon ultrasonography images. Pain scores were compared between the identified patterns. Multiple regression analysis was used to examine the relative importance of abnormalities. Results: Of the 146 tendons, 91 had some degree of sonographic abnormality. Three main patterns were identified: I (1 structural abnormality without NV), II (2 structural abnormalities without NV), and III (2 structural abnormalities and NV). A total of 31 tendons (21.2%) exhibited pattern I, 46 (31.5%) presented pattern II, and 13 tendons (8.9%) exhibited pattern III. The mean visual analog scale and the Victorian Institute of Sport assessment questionnaire—patellar tendon (VISA-P) scores for pattern III were significantly different (P < .05) compared with patterns I and II; however, the pain pressure threshold (PPT) scores were not. NV was significantly associated with worsened scores for all pain measures; however, the focal area of hypoechogenicity was only associated with PPT scores. Conclusion: Patterns of sonographic abnormalities, including NV, demonstrated greater pain. Although NV determined scores for the visual analog scale, VISA-P, and PPT, the presence of focal area of hypoechogenicity on its own is a determining factor for the PPT. This study suggests that the combination of 2 or more sonographic abnormalities may help explain pain variations among basketball players.
Christopher P. Tomczyk, George Shaver and Tamerah N. Hunt
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.