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Robert S. Thiebaud, Takashi Abe, Jeremy P. Loenneke, Tyler Garcia, Yohan Shirazi and Ross McArthur

Context: Blood flow restriction (BFR) increases muscle size and strength when combined with low loads, but various methods are used to produce this stimulus. It is unclear how using elastic knee wraps can impact acute muscular responses compared with using nylon cuffs, where the pressure can be standardized. Objective: Investigate how elastic knee wraps compare with nylon cuffs and high-load (HL)/low-load (LL) resistance exercise. Design: A randomized cross-over experimental design using 6 conditions combined with unilateral knee extension. Setting: Human Performance Laboratory. Participants: A total of 9 healthy participants (males = 7 and females = 2) and had an average age of 22 (4) years. Intervention: LL (30% of 1-repetition maximum [1-RM]), HL (70% 1-RM), BFR at 40% of arterial occlusion pressure (BFR-LOW), BFR at 80% of arterial occlusion pressure (BFR-HIGH), elastic knee wraps stretched by 2 in (PRACTICAL-LOW), and elastic knee wraps stretched to a new length equivalent to 85% of thigh circumference (PRACTICAL-HIGH). BFR and practical conditions used 30% 1-RM. Main Outcome Measures: Muscle thickness, maximum voluntary isometric contraction, and electromyography amplitude. Bayesian statistics evaluated differences in changes between conditions using the Bayes factor (BF10), and median and 95% credible intervals were reported from the posterior distribution. Results: Total repetitions completed were greater for BFR-LOW versus PRACTICAL-HIGH (BF10 = 3.2, 48.6 vs 44 repetitions) and greater for PRACTICAL-LOW versus BFR-HIGH (BF10 = 717, 51.8 vs 36.3 repetitions). Greater decreases in changes in maximum voluntary isometric contraction were found in PRACTICAL-HIGH versus HL (BF10 = 1035, ∼103 N) and LL (BF10 = 45, ∼66 N). No differences in changes in muscle thickness were found between LL versus PRACTICAL-LOW/PRACTICAL-HIGH conditions (BF10 = 0.32). Greater changes in electromyography amplitude were also found for BFR-LOW versus PRACTICAL-HIGH condition (BF10 = 6.13, ∼12%), but no differences were noted between the other BFR conditions. Conclusions: Overall, elastic knee wraps produce a more fatiguing stimulus than LL or HL conditions and might be used as an alternative to pneumatic cuffs that are traditionally used for BFR exercise.

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Brian W. Wiese, Kevin Miller and Eduardo Godoy

A 19-year-old African-American male Division I collegiate American football player with no prior history of shoulder injury presented with right shoulder pain after making a tackle during a game. He was initially diagnosed with a rotator cuff strain with potential underlying labral pathology. Subsequent magnetic resonance imaging arthrogram showed no labral tearing, though a Buford complex was identified. A Buford complex is a normal anatomical labral variant where the anterior labrum is absent and the middle glenohumeral ligament is “cord-like” in structure. This case was managed conservatively since surgical intervention is only recommended if there is a secondary pathology to the shoulder (e.g., type II superior labrum anterior to posterior [SLAP] lesions). Clinicians should be aware of Buford complexes because they can predispose athletes to secondary injuries and can be managed successfully with a conservative rehabilitation approach in the absence of secondary pathology.

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Timothy A. Kulpa, Jamie Mansell, Anne Russ and Ryan Tierney

Context: Patients who do not fully recover from a concussion in 7–14 days may require an impairment-based rehabilitation program. Recent evidence indicates improved outcomes with active rehabilitation compared to passive physical and cognitive rest. Clinical Question: In patients with persistent symptoms (greater than 4 weeks) following concussion, how does aerobic exercise affect postconcussion symptoms? Clinical Bottom Line: There is moderate and sufficient SORT Level B evidence to support the inclusion of subsymptom threshold (SST) exercise in the multimodal treatment plan for patients suffering from persistent symptoms after concussion. All five included studies reported moderate to very large effects ranging from d = 0.72 to d = 10.64 in reducing symptoms after the implementation of SST aerobic exercise. Additionally, two studies also identified moderate and very large effects (d = 0.77, d = 2.56) favoring aerobic exercise over stretching interventions. These results indicate that this treatment has potential clinical utility and is a viable option to reduce symptoms in patients with postconcussion syndrome and persistent symptoms following concussion.

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Fatemeh Ehsani, Rozita Hedayati, Rasool Bagheri and Shapour Jaberzadeh

Context: Chronic low back pain (CLBP) often presents with a dysfunction in deep abdominal muscles activity during standing tasks. Although some studies indicated that deep abdominal muscle activity improved during some functional tasks following stabilization exercise (SE), there is no study to evaluate the effect of SE on lateral abdominal muscles thickness during standing postural tasks. Objective: The purpose of this study was (1) to evaluate the lateral abdominal muscles thickness in the participants with CLBP while standing on a balance board and (2) to compare the effects of SE and a general exercise (GE) program on the lateral muscles thickness changes. Methods: This was a between-groups, triple-blinded randomized controlled trial design. In total, 40 females with CLBP were randomly assigned into 2 groups:  GE (control group) and supervised progressive SE (experimental group). Diagnostic ultrasound imaging was used before and after the intervention to measure lateral abdominal muscles thickness during standing on 2 different levels of platform in the Biodex Balance System. Visual analog scale and Roland–Morris Disability Questionnaire were used to evaluate changes in pain intensity and disability. Results: The results indicated significant increases in transverse abdominis muscle thickness during all standing tasks (P = .02) and significant decreases in pain intensity and disability following SE intervention (P < .001). However, the lateral abdominal muscle thicknesses were not changed after GE intervention while standing postural tasks (P > .05). The GE group revealed only significant decreases in pain intensity after intervention (P = .03). Conclusion: Supervised progressive SE improved the activity of deep abdominal muscles in standing postural tasks in the patients with CLBP.

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Erik A. Wikstrom, Kyeongtak Song, Kimmery Migel and Chris J. Hass

Aberrant loading is a mechanism by which individuals with chronic ankle instability (CAI) may negatively impact cartilage health and therefore long-term health outcomes. We aimed to quantify walking vertical ground reaction force (vGRF) component differences between those with and without CAI. Participants (n = 36) walked barefoot overground at a self-selected comfortable pace. Normalized peak vGRF, time to peak vGRF, and normalized loading rate were calculated. Higher normalized loading rates (CAI: 5.69 ± 0.62 N/BW/s; controls: 5.30 ± 0.44 N/BW/s, p = .034) and less time to peak vGRF (CAI: 1.48 ± 0.18 s; controls: 1.62 ± 0.16 s, p = .018) were observed in those with CAI. In conclusion, those with CAI demonstrate a higher normalized loading rate and less time to peak vGRF compared to controls.

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Chi-Whan Choi, Jung-Wan Koo and Yeon-Gyu Jeong

Context: The modified side-bridge exercise is designed for some special situations in which it is impossible to tolerate the compressive load on the side supported during the side bridge, such as in the older people with a hip or knee replacement and even in athletes with shoulder pain. Objectives: To examine the effects of 3 modified side-bridge exercises on the spinal stability muscles compared with traditional side-bridge (TSB) exercises for healthy men. Design: The effects of different exercises on the muscle activities of the external oblique (EO), internal oblique (IO), and quadratus lumborum (QL) during TSB exercise, both legs lift on side lying (BLLS), torso lift on a 45° bench while side lying (TLBS), and wall side bridge (WSB) were analyzed with the 1-way repeated-measures analysis of variance. Setting: This study was conducted in a university hospital laboratory. Participants: A total of 20 healthy men were recruited for this study. Interventions: The participants performed TSB, BLLS, TLBS, and WSB in a random order. Main Outcome Measures: Surface electromyography measured the muscle activity of the EO, IO, and QL. A 1-way repeated-measures analysis of variance assessed the statistical significance of the EO, IO, and QL muscle activity. When there was a significant difference, a Bonferroni adjustment was performed. Results: BLLS and TLBS showed similar effects to TSB in the EO, IO, and QL muscle activity, whereas WSB showed significantly less QL muscle activity than TSB (P < .05). Moreover, TLBS was significantly greater in the muscle activity of QL and EO than WSB (P < .05). Conclusion: BLLS and TLBS may be effective rehabilitation techniques to activate EO, IO, and QL in patients who are unable to perform TSB as spine stability exercises.

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Ryan Thomson, Danielle Carabello, Jamie Mansell and Anne Russ

Clinical Question: In retired National Football League (NFL) players, what is the prevalence of depression after sustaining concussions? Clinical Bottom Line: There is emerging evidence to support the clinical question that retired NFL players with a history of concussion may be diagnosed with depression.

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Muammer Altun

Context: Joint position sense (JPS) tests of proprioception lack ecological validity because the testing conditions are so different from the normal function that they can contribute little to understanding the role proprioception plays in daily and sporting activities. Objective: To evaluate the effect of low and high external load on the knee JPS and to investigate the relationship between maximum voluntary isometric contraction and force sense (FS). Design: Experimental study. Setting: Research laboratory. Participants: A total of 47 volunteers with no history of knee pathology. Interventions: Three active JPS tests performed with no load, low load, and high load were compared at the 45° target angle. For isometric FS test, 50% load was used. For isotonic low load and high load JPS tests, 30% and 70% loads were applied, respectively. Main Outcome Measures: To analyze obtained data set 2-way multiple analysis of variance, repeated measures of analysis of variance, paired sample t test, and the Pearson correlation coefficient were used. Results: JPS was not affected by gender (male and female) and activity levels (sedentary, recreational, and trained). Results of the repeated measure of analysis of variance demonstrated the significant main effect of loads (P = .001). Significant differences were found between no load, low load, and high load JPS (P = .001). A positive and significant correlation was found between maximum voluntary isometric contraction and FS error values (r = .41, P = .001). Conclusions: The results suggest that as the load level increases, the knee JPS improves. Knee JPS assessed under external load may be a more appropriate alternative to the nature of the sport. Those with higher muscle strength have a worse FS.

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Alexandra F. DeJong and Jay Hertel

Treadmill running analyses cannot adequately replicate outdoor running demands, and wearable sensors offer a means to overcome this clinical limitation. The purpose of this report is to describe five individual runners’ biomechanical outcomes during hill and track intervals, stroller running, and 5- and 21-K races using wearable sensors. Step rates and lengths increased while foot contact time decreased during sprints and 5-K race portions. Stroller running increased step rate, length, and pronation. Step length decreased and pronation and foot contact time increased over the 21-K race. Wearable sensors helped identify patterns in natural training environments as a basis for clinical application.

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Kami N. Thews, Zachary K. Winkelmann, Lindsey E. Eberman, Kirsten A. Potts and Kenneth E. Games

Firefighters are exposed to psychological stress while on duty that could lead to mental and behavioral illnesses that may go unreported. We surveyed firefighters to identify their perceived barriers encountered when attempting to report a mental and behavioral illness with a follow-up question related to how difficult the selected barrier was in the reporting process. A total of 314 firefighters completed the instrument, with most indicating they experienced cultural barriers such as social norms from administration and peers. The findings demonstrate an overall demand for a cultural change within the fire service for a supportive environment that encourages reporting.