Clinical Scenario: Shoulder pain is a very common symptom encountered in outpatient physical therapy practice. In addition to therapeutic exercise and manual therapy interventions, trigger point dry needling (TDN) has emerged as a possible treatment option for reducing shoulder pain and improving function. Dry needling consists of inserting a thin stainless-steel filament into a myofascial trigger point with the intention of eliciting a local twitch response of the muscle. It is theorized that this twitch response results in reduced muscle tension and can aid in reduced pain and disability. To this point, multiple studies have found TDN to be effective at reducing pain and improving function in the short-term, but the long-term outcomes remain unknown. Clinical Question: Does the addition of TDN to an exercise program result in better long-term pain intensity and disability reduction in patients with shoulder pain? Summary of Findings: Improvement in long-term pain and function can be expected regardless of the addition of TDN to an evidence-based exercise program for patients with shoulder pain. Clinical Bottom Line: Either TDN or an evidence-based therapeutic exercise program elicits improved long-term pain and disability reduction in patients with shoulder pain, which suggests that clinicians can confidently use either approach with their patients. Strength of Recommendation: Strong evidence (level 2 evidence with PEDro scores >8/10) suggesting that TDN does not outperform therapeutic exercise regarding long-term pain reduction.
Kyle Matsel, Claire Davies, and Tim Uhl
Barbara Baker, Eric Koch, Kevin Vicari, and Kyle Walenta
Introduction: Sports-related concussions (SRCs) have received attention due to their prevalence in youth. An SRC results from a strong force causing neurological impairment. Recent research has recommended rehabilitation within the first week post-SRC after 24 to 48 hours of rest. The postacute phase is defined as 48 hours to 7 days post-SRC. It is imperative to evaluate the most effective mode and intensity of physical activity to reduce symptoms and improve outcomes. Methods: CINAHL, PubMed, SPORTDiscus, and Web of Science databases were used to search the terms “brain concussion” AND “exercise” and variations of these terms. The evidence level for each study was evaluated using the 2011 Oxford Center for Evidence-Based Medicine Guide. The methodological rigor of each study was evaluated using a scale adapted from Medlicott and Harris. Results: Two thousand sixty-eight records were identified. Six studies were included in this systematic review. Three studies were classified as moderately strong. The remaining 3 studies were considered weak. Five of the studies used either a cycle ergometer or a treadmill. The sixth study used walking, cycling, and swimming, as well as sports drills. All of these modes of exercise were determined to be safe. All studies utilized low- and moderate-intensity interventions, which were found to be nondetrimental and showed improved recovery time and symptom resolution. Five of the studies also incorporated components of high-intensity exercise that was also found to be nondetrimental, and they showed a positive influence on recovery time and symptom resolution. However, all activity in each of the reviewed studies started at a low level and progressed up to a higher level only as each individual client’s symptoms permitted. Discussion: Overall, this review found that various modes of activity at light-, moderate-, and high-intensity levels are efficacious and can be safely used during the postacute phase of SRC. Conclusion: Though the volume of literature at this time is limited, therapists should consider prescribing closely monitored individualized exercise programs utilizing progressive intensities when treating patients during the postacute phase of SRC.
Matthew D. Watson, George J. Davies, and Bryan L. Riemann
Context: A recent report demonstrated moderate to strong relationships between seated single-arm shot-put (SSASP) test performance and isokinetic pushing forces at varying velocities, directly supporting the SSASP test as a reflection of multijoint upper-extremity strength. Yet, no previous work appears to have assessed whether the SSASP test is more reflective of shoulder flexion or elbow extension strength. Objective: To examine the relationship between isokinetic shoulder flexion and elbow extension strength and SSASP test performance and to compare limb symmetry indices (LSI) between the 2 tests. Design: Correlational design. Setting: Biomechanics laboratory. Patients (or Other Participants): A total of 30 healthy and physically active young adults. Intervention(s): Participants completed the SSASP test and concentric isokinetic (60°/s and 180°/s) shoulder flexion and elbow extension using their dominant and nondominant arms. Main Outcome Measures: SSASP test performance and isokinetic shoulder flexion and elbow extension peak torques as well as LSI between the 2 tests. Results: Strong relationships were observed between SSASP ranges and isokinetic peak torques at each velocity for both shoulder and elbow (r ≥ .804, P < .001). While the Bland–Altman results on the LSI only demonstrated a significant bias for the shoulder (60°/s, P = .009), limits of agreement results demonstrated extremely wide intervals (32.5%–52.1%). Conclusions: The SSASP test is a multijoint upper-extremity functional performance test that is reflective of equal shoulder flexion and elbow extension contributions; however, there was large variability regarding the agreement between the SSASP LSI and isokinetic shoulder and elbow strength LSI.
Bethany L. Anderson, Rod A. Harter, and James L. Farnsworth II
Clinical Scenario: Dynamic stretching and foam rolling are commonly used by athletes to reduce injury and enhance recovery, thereby improving athletic performance. In contrast to dynamic stretching, little research has been conducted on the acute effects of foam rolling as part of the preexercise warm-up routine. Previously, when researchers implemented foam rolling with static stretching as a warm-up, some found that foam rolling slightly improved flexibility and performance outcomes. More recent research has shown that dynamic stretching is favorable to static stretching when used as a warm-up strategy. Therefore, adding foam rolling to dynamic stretching is hypothesized to create more significant improvements in flexibility and performance compared with adding foam rolling to static stretching. Focused Clinical Question: In active individuals, does foam rolling in addition to dynamic stretching lead to enhanced performance compared with dynamic stretching alone? Summary of Key Findings: Four randomized controlled trials were included. Two studies concluded that the addition of foam rolling to dynamic stretching increased vertical jump height more than dynamic stretching alone, while 2 studies found no difference between these treatment groups. Two studies concluded that the addition of foam rolling increased agility performance compared with dynamic stretching alone, while one study found no difference between treatment groups and one study did not measure agility. All 4 studies reviewed concluded that foam rolling did not improve flexibility more than dynamic stretching alone. Clinical Bottom Line: Foam rolling in conjunction with dynamic stretching may further improve an athlete’s agility and power output; however, little improvement has been observed with foam rolling in regard to athlete flexibility when compared with completing dynamic stretching programs alone. Strength of Recommendation: Inconsistent findings from 4 randomized controlled trials suggest there is Grade C evidence to support the inclusion of foam rolling in a dynamic warm-up.
Paige Guild, Monica R. Lininger, and Meghan Warren
Clinical Scenario: Female college student-athletes (SA) often experience time loss from musculoskeletal injuries to the lower extremities. This can lead to lengthy rehabilitation, expensive medical bills, and declines in health-related quality of life. Identifying at-risk athletes prior to the start of an athletic season may allow coaches or athletic trainers to prescribe an injury prevention program. Clinical Question: In female college SA, are preseason single leg hop (SLH) scores associated with identifying those at risk for lower-extremity musculoskeletal injuries? Summary of Key Findings: Five prospective cohort studies in female SA scored athletes on the SLH prior to the start of the athletic sport season. One of 5 studies found an association of SLH with injury risk. An additional 2 studies found that the SLH as part of a battery of functional performance tests was associated with injury risk in some anatomic locations (eg, thigh/knee), but not overall injury risk. Clinical Bottom Line: Methodological limitations of the reviewed studies limits a final conclusion, and there is insufficient evidence to determine if the SLH should be used as a sole functional performance test to identify at-risk female SA; it may be useful as part of a battery of functional performance tests for female college SA. Strength of Recommendation: All studies were prospective cohort studies (level 3).
Ke’La Porter, Carolina Quintana, and Matthew Hoch
Clinical Scenario: Neurocognitive performance may put individuals at a greater risk for lower-extremity musculoskeletal injuries. Research has observed the relationship between lower-extremity musculoskeletal injury and baseline neurocognitive performance; however, the understanding of this relationship is lacking. Exploring this relationship may give further insight into musculoskeletal injury and provide innovative directions for musculoskeletal injury prevention. Clinical Question: Is there a relationship between neurocognitive performance and lower-extremity biomechanics during a jumping or cutting task in healthy adult athletes? Summary of Key Findings: The literature was searched for articles that examined the relationship of a baseline neurocognitive test and a biomechanical analysis following a sports-related task. A total of 3 cross-sectional articles were included. All 3 studies concluded that poorer neurocognitive performance was associated with biomechanical faults that are linked to increased risk or rate of lower-extremity musculoskeletal injury. Clinical Bottom Line: Based on the evidence included, there is a moderate-level evidence to support the relationship between neurocognition and lower-extremity biomechanics in healthy adult athletes. Strength of Recommendation: In accordance with the van Tulder approach, there is a moderate level of evidence due to consistent findings from a combination of high- and limited-quality articles.
Kellie C. Huxel Bliven
Amanda L. Ager, Dorien Borms, Magali Bernaert, Vicky Brusselle, Mazarine Claessens, Jean-Sébastien Roy, and Ann Cools
Context: Proprioception deficits contribute to persistent and recurring physical disability, particularly with shoulder disorders. Proprioceptive training is thus prescribed in clinical practice. It is unclear whether nonsurgical rehabilitation can optimize shoulder proprioception. Objectives: To summarize the available evidence of conservative rehabilitation (ie, nonsurgical) on proprioception among individuals with shoulder disorders. Evidence Acquisition: PubMed, Web of Science, and EBSCO were systematically searched, from inception until November 24, 2019. Selected articles were systematically assessed, and the methodological quality was established using the Dutch Cochrane Risk of Bias Tool and the Newcastle-Ottawa Quality Assessment Scale. The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were utilized for this review. The conservative treatments were categorized as follows: (1) conventional therapy, (2) proprioceptive training, (3) elastic kinesiology tape, and (4) other passive therapies. Evidence Synthesis: Twelve articles were included, yielding 58 healthy control shoulders and 362 shoulders affected by impingement syndrome, glenohumeral dislocations, nonspecific shoulder pain, rotator cuff dysfunction, or subluxation poststroke. The level of agreement between the evaluators was excellent (84.9%), and the studies were evaluated to be of fair to excellent quality (risk of bias: 28.5%–100%). This review suggests, with moderate evidence, that proprioceptive training (upper-body wobble board or flexible foil training) can improve proprioception in the midterm. No decisive evidence exists to suggest that conventional therapy is of added value to enhance shoulder proprioception. Conflicting evidence was found for the improvement of proprioception with the application of elastic kinesiology tape, while moderate evidence suggests that passive modalities, such as microcurrent electrical stimulation and bracing, are not effective for proprioceptive rehabilitation of the shoulder. Conclusions: Proprioceptive training demonstrates the strongest evidence for the effective rehabilitation of individuals with a shoulder proprioceptive deficit. Elastic kinesiology tape does not appear to affect the sense of shoulder proprioception. This review suggests a possible specificity of training effect with shoulder proprioception.
Kyle M. Petit and Tracey Covassin
Context: Cognitive and physical rest are commonly utilized when managing a sport-related concussion (SRC); however, emerging research now suggests that excessive rest may negatively impact recovery. Despite current research recommendations, athletic trainers (ATs) may be behind in implementing this emerging research into clinical practice. Objective: To assess college ATs’ perceptions and implementation of an emerging SRC management approach (cognitive and physical rest and activity). Design: Cross-sectional study. Setting: Survey. Participants: A total of 122 (11.8%) ATs (53.3% female; 10.8 [9.8] y experience; 8.7 [6.9] SRCs managed annually) responded to the survey, which was randomly distributed to 1000 members of the National Athletic Trainers’ Association, as well as 31 additional ATs from varying universities. Main Outcome Measures: A 5-point Likert scale assessed the ATs’ perceptions and clinical practices as they relate to specific athlete behaviors (ie, texting, sleeping). The ATs were asked about their willingness to incorporate physical activity into clinical practice. Results: Playing video games (95.9%) and practicing (93.4%) were the activities most perceived to extend SRC recovery. However, sleeping more than usual (7.4%) and increased time in a dark environment (11.5%) were viewed as less likely to extend recovery. ATs restricted practicing (98.4%) and working out (91.8%) for athletes with SRC, while sleeping more than usual (6.6%) and increased time in a dark environment (13.1%) were less restricted. About 71% of the ATs would implement light physical activity for athletes with a symptom score of 1 to 5, 31% with scores of 6 to 10, and 15% with scores of 11 to 20. About 43%, 74%, and 97% believe that light, moderate, and vigorous physical activity, while symptomatic, will extend recovery, respectively. Conclusions: The ATs were receptive to including light physical activity into their SRC management, although only in certain situations. However, most ATs’ beliefs and clinical practices did not completely align with emerging research recommendations for the management of SRCs.
Brian Catania, Travis Ross, Bradley Sandella, Bradley Bley, and Andrea DiTrani Lobacz
Context: Training and assessment of the abdominal and trunk muscles are widely used in the clinical setting. However, it is unknown what types of exercises are most effective in activation of both the global and local stabilizers in these regions. Objective: The purpose of this study was to establish the reliability of a novel clinical screening tool (sling screen) to assess the muscles of the abdomen and trunk. The second aim was to use the clinical screening tool and musculoskeletal ultrasound to compare the effects of a rotary-based exercise program that targets both the global and local muscles to the effects of a traditional exercise program on the activation of the abdominal and trunk muscles. Design: Double-blind, randomized controlled trial. Setting: Sports medicine facility. Participants and Interventions: Thirty-one healthy participants were randomly allocated to receive a single-session rotary-based or traditional “core” exercise program. Main Outcome Measures: The participants were assessed at the baseline and immediately postintervention. The primary outcome measures were muscle thickness examined by musculoskeletal ultrasound and clinical examination of muscle activation using a screening tool. The data were collected by blind assessors. Reliability and validity of a clinical screening tool (sling screen) were also assessed. Results: The analysis of the covariance tests showed a significant increase in oblique thickness for the rotary exercise group. All participants displayed a significant increase in multifidus thickness. The Wilcoxon signed-rank tests revealed a significant increase in clinical assessment scores in the rotary exercise group but not the traditional exercise group. Reliability of the sling screen ranged from moderate to good. Conclusion: This clinical trial provides evidence that a rotary-based exercise program may be more effective in producing increases in oblique muscle thickness than traditional “core” exercises in young, healthy adults. The sling screen tool was able to identify these muscle thickness changes. Future studies should investigate how these results correlate to injury risk, other populations, and also how to implement the sling screen into clinical practice.