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Ashley E. Evans, Madeline Curtis, Marguerite (Meg) Montjoy and Erica Beidler

Context: The rate of sport-related concussion diagnosis has significantly increased in recent years, which has created a need for injury prevention initiatives. There have been efforts put forth by researchers and American football organizations to teach athletes how to tackle properly in order to decrease the number of subconcussive head impacts and concussions. Clinical Question: Does the implementation of a behavioral tackling intervention decrease the head impact frequency in American football players? Clinical Bottom Line: There is moderate SORT Level B evidence to support the use of behavioral tackling interventions as a means for reducing head impact frequency in football athletes. All four included studies found a significant reduction in head impacts following a behavioral tackling intervention with study findings ranging from a 26–33% reduction in impact frequency. These findings were consistent in youth, high school, and college football players and for different types of behavioral tackling interventions. Therefore, these results indicate that behavioral tackling interventions have the potential to reduce the number of head impacts sustained by American football players, which may ultimately lead to a reduction in concussion occurrence as well.

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Justin Goins

Clinical Question: What is the most optimal position to perform the prone hip extension exercise in order to improve the gluteus maximus to hamstring activation ratio? Clinical Bottom Line: There does not appear to be a specific position recommended to perform the prone hip extension exercise in order to activate the gluteus maximus over the hamstrings.

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Irfan A. Khan and Kelley Henderson

Clinical Question: What is the efficacy of myofascial release, combined with trigger point therapy, in treating pain in patients with tension-type headaches? Clinical Bottom Line: There is significant evidence to support the use of myofascial release and trigger point therapy in patients with pain from tension-type headaches.

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Daniel G. Miner, Brent A. Harper and Stephen M. Glass

Context: Current tools for sideline assessment of balance following a concussion may not be sufficiently sensitive to identify impairments, which may place athletes at risk for future injury. Quantitative field-expedient balance assessments are becoming increasingly accessible in sports medicine and may improve sensitivity to enable clinicians to more readily detect these subtle deficits. Objective: To determine the validity of the postural sway assessment on the Biodex BioSway™ compared with the gold standard NeuroCom Smart Equitest System. Design: Cross-sectional cohort study. Setting: Clinical research laboratory. Participants: Forty-nine healthy adults (29 females: 24.34 [2.45] y, height 163.65 [7.57] cm, mass 63.64 [7.94] kg; 20 males: 26.00 [3.70] y, height 180.11 [7.16] cm, mass 82.97 [12.78] kg). Intervention(s): The participants completed the modified clinical test of sensory interaction in balance on the Biodex BioSway™ with 2 additional conditions (head shake and firm surface; head shake and foam surface) and the Sensory Organization Test and Head Shake Sensory Organization Test on the NeuroCom Smart Equitest. Main Outcome Measures: Interclass correlation coefficient and Bland–Altman limits of agreement for Sway Index, equilibrium ratio, and area of 95% confidence ellipse. Results: Fair–good reliability (interclass correlation coefficient = .48–.65) was demonstrated for the stance conditions with eyes open on a firm surface. The Head Shake Sensory Interaction and Balance Test condition on a firm surface resulted in fair reliability (interclass correlation coefficient = .50–.59). The authors observed large ranges for limits of agreement across outcome measures, indicating that the systems should not be used interchangeably. Conclusions: The authors observed fair reliability between BioSway™ and NeuroCom, with better agreement between systems with the assessment of postural sway on firm/static surfaces. However, the agreement of these systems may improve by incorporating methods that mitigate the floor effect in an athletic population (eg, including a head shake condition). BioSway™ may provide a surrogate field-expedient measurement tool.

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Ghada Jouira, Selim Srihi, Fatma Ben Waer, Haithem Rebai and Sonia Sahli

Context: Athletes with intellectual disability (ID) have a high risk of injury while participating in various sports. Warm-up (WU) is the most preventive measure to reduce injuries in sports. Objective: To investigate the effects of dynamic stretching WU (DS-WU) and plyometric WU (PL-WU) on dynamic balance in athletes with ID. Design: Crossover study. Setting: Research laboratory. Participants: A total of 12 athletes with ID (age 24.5 [3.22] y, height 165.7 [8.4] cm, weight 61.5 [7.1] kg, intelligence quotient 61.1 [3.5]). Main Outcome Measures: Dynamic balance was assessed using the Star Excursion Balance Test (SEBT) at pre-WU, post-WU, and 15 minutes post-WU for both the DS-WU and the PL-WU. A 2-way analysis of variance (3 sessions × 2 WU methods) with repeated-measures was used in this study. Results: Following the DS-WU, participants demonstrated significant improvements in the SEBT composite score post-WU (89.12% [5.54%] vs 87.04% [5.35%]; P < .01) and at 15 minutes post-WU (89.55% [5.28%] vs 87.04%, P < .01) compared with pre-WU. However, no significant difference between these two post-WU scores (post-WU and 15 min post-WU) was found. For the PL-WU, participants demonstrated a significant decrease in the SEBT composite score at post-WU (85.95% [5.49%] vs 87.02% [5.73%]; P < .05); however, these scores increased significantly at 15 minutes post-WU (88.60% [5.42%] vs 87.02% [5.49%]; P < .05) compared with that at pre-WU. The SEBT composite scores are significantly higher in the DS-WU than in the PL-WU at both post-WU sessions (P < .05). Conclusion: Both DS-WU and PL-WU could improve dynamic balance and may be recommended as WUs in athletes with ID; however, particular caution should be exercised immediately after the PL-WU.

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Kyle Matsel, Claire Davies and Tim Uhl

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.

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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.