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Michelle A. Sandrey

Clinical Question: Is there sufficient evidence to determine which low back instability tests should be incorporated into a stabilization classification exam for athletes? Clinical Bottom Line: There is moderate level 2 evidence to include, but not to use in isolation, the prone instability test along with other instability tests in a stabilization classification exam.

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Kimberly Somers, Dustin Aune, Anthony Horten, James Kim and Julia Rogers

Context: Limited ankle dorsiflexion (DF) range of motion has been correlated with decreased flexibility of the gastrocnemius/soleus complex. Decreased ankle DF range of motion can lead to an increase in lower-extremity injuries, for example, acute ankle sprains, Achilles tendinopathy. Objective: The purpose of this study was to determine whether a single application of the intervention to the gastrocnemius/soleus complex via multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques acutely improved ankle DF. Design: Subjects were assigned to groups via random card selection. Investigators provided verbal cues as needed to yield correct performance of interventions. Both interventions were performed twice for 1 minute using a dynamic walking rest of 30.48 m at a self-selected pace between interventions. Statistical analyses were completed using a 1-way analysis of variance, at α level ≤ .05. Setting: A convenience sample study. Participants: A total of 42 asymptomatic physical therapy students (18 females and 24 males) with mean age of 26.12 (4.03) years volunteered to participate. Interventions: Multidirectional self-myofascial release using a foam roller, multiplanar dynamic stretch performed in downward dog, or a combination of both techniques. Main Outcome Measures: Weight-bearing right ankle DF measurements were recorded in centimeters using a forward lunge technique (intraclass correlation coefficient = .98, .97, and .96). Results: Data analysis revealed no significant difference between the 3 groups in all pre–post measurements (P = .82). Mean (SD) measurements from pretest to posttest for myofascial release, dynamic stretching, and combination interventions were 0.479 (0.7) cm, 0.700 (0.7) cm, and 0.907 (1.4) cm, respectively. Conclusion: Until further studies are conducted, the selection of technique to increase ankle DF range of motion should be based on each individual patient’s ability, preference, and response to treatment.

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Rodrigo Rodrigues Gomes Costa, Rodrigo Luiz Carregaro and Frederico Ribeiro Neto

Context: There seems to be no consensus on which aspects better distinguish the different levels of spinal cord injury regarding body composition, strength, and functional independence. Objective: The study aimed to determine which variables better differentiate tetraplegia (TP) from paraplegia and high paraplegia (HP) from low paraplegia (LP). Design: Cross-sectional study. Setting: Rehabilitation hospital network. Patients: Forty-five men with spinal cord injury, n = 15 for each level (TP, HP, and LP) causing complete motor impairment (American Spinal Injury Association Impairment Scale: A or B) were enrolled in the study. Main Outcome Measures: The 1-maximum repetition test, functional independence measure, spinal cord independence measure, and body composition (skinfold sum, body fat percentage, and body mass index) were assessed. Discriminant analysis was carried out using the Wilks lambda method to identify which strength and functional variables can significantly discriminate subjects for injury classification (TP, HP, and LP). Results: The discriminant variable for TP versus HP was body mass index and for TP versus LP was 1-maximum repetition (P ≤ .05). There were no variables that discriminated HP versus LP. Conclusions: The discriminant variables for TP versus HP and TP versus LP were body mass index and 1-maximum repetition, respectively. The results showed that HP and LP are similar for strength and functional variables.

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Jesús Seco-Calvo, Juan Mielgo-Ayuso, César Calvo-Lobo and Alfredo Córdova

Context: Despite prior studies that have addressed the recovery effects of cold-water immersion (CWI) in different sports, there is a lack of knowledge about longitudinal studies across a full season of competition assessing these effects. Objective: To analyze the CWI effects, as a muscle recovery strategy, in professional basketball players throughout a competitive season. Design: A prospective cohort design. Setting: Elite basketball teams. Participants: A total of 28 professional male basketball players divided into 2 groups: CWI (n = 12) and control (n = 16) groups. Main Outcome Measures: Muscle metabolism serum markers were measured during the season in September—T1, November—T2, March—T3, and April—T4. Isokinetic peak torque strength and ratings of perceived exertion were measured at the beginning and at the end of the season. CWI was applied immediately after every match and after every training session before matches. Results: All serum muscular markers, except myoglobin, were higher in the CWI group than the control group (P < .05). The time course of changes in muscle markers over the season also differed between the groups (P < .05). In the CWI group, ratings of perceived exertion decreased significantly from the beginning (T1–T2) to the end (T3–T4). Isokinetic torque differed between groups at the end of the season (60°/s peak torque: P < .001 and ηp2=.884; and 180°/s peak torque: P < .001 and ηp2=.898) and had changed significantly over the season in the CWI group (P < .05). Conclusions: CWI may improve recovery from muscle damage in professional basketball players during a regular season.

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Theresa L. Miyashita and Paul A. Ullucci

Context: Managing a concussion injury should involve the incorporation of a multifaceted approach, including a vision assessment. The frontoparietal circuits and subcortical nuclei are susceptible to trauma from a concussion injury, leading to dysfunction of the vestibulo-ocular system. Research investigating the effect of cumulative subconcussive impacts on neurological function is still in its infancy, but repetitive head impacts may result in vestibular system dysfunction. This dysfunction could create visual deficits, predisposing the individual to further head trauma. Objective: The purpose of this study was to investigate the cumulative effect of subconcussive impacts on minimum perception time, static visual acuity, gaze stability, and dynamic visual acuity scores. Design: Prospective cohort. Setting: Division I university. Patients: Thirty-three Division I men’s lacrosse players (age = 19.52 [1.20] y). Intervention: Competitive lacrosse season. Main Outcome Measures: At the beginning and end of the season, the players completed a vestibulo-ocular reflex assessment, using the InVision system by Neurocom® to assess perception, static acuity, gaze stability, and dynamic visual acuity. Score differentials were correlated with the head impact exposure data collected via instrumented helmets. Results: A significant correlation was found between change in perception scores and total number of head impacts (r = .54), and between changes in dynamic visual acuity loss scores on the rightside and maximum rotational acceleration (r = .36). No statistical differences were found between preseason and postseason vestibulo-ocular reflex variables. Conclusions: Cumulative subconcussive impacts may negatively affect vestibulo-ocular reflex scores, resulting in decreased visual performance. This decrease in vestibulo-ocular function may place the athlete at risk of sustaining additional head impacts or other injuries.

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Jessica Ross and Peter D. MacIntyre

Flow is a desirable state of consciousness and absorption in an optimally challenging activity. Prior research has investigated individual differences in flow. The present study investigates flow by contrasting physical versus mental activities, using a mixed-methods, sequential explanatory design. The sample from the quantitative phase included 205 undergraduate university students assessed on measures of personality, difficulties in emotion regulation, and flow. The big-five traits intellect and conscientiousness, as well as the emotion regulation subscale “lack of emotional clarity” predicted flow during mental activities, but unexpectedly no variables significantly predicted physical flow activities. The second phase used semi-structured interviews with 10 participants. Analyses of the interviews helped further explain the statistical findings, revealing four main themes: role of stress, source of guilt, presence of others, and satisfaction and fulfillment. We conclude that flow is especially relevant in physical activities which have advantages over mental activities in opportunities to experience flow.

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Kailin C. Parker, Rachel R. Shelton and Rebecca M. Lopez

Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient’s core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14–0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.

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Abbis H. Jaffri, Thomas M. Newman, Brent I. Smith, Giampietro L. Vairo, Craig R. Denegar, William E. Buckley and Sayers J. Miller

Context: The Dynamic Leap Balance Test (DLBT) is a new dynamic balance task that requires serial changes in base of support with alternating limb support and recovery of dynamic stability, as compared with the Y modification of the Star Excursion Balance Test (Y-SEBT), which assesses dynamic stability over an unchanging base of support. Objectives: To assess the dynamic balance performance in 2 different types of dynamic balance tasks, the DLBT and the SEBT, in subjects with unilateral chronic ankle instability (CAI) when compared with matched controls. The authors hypothesized that the DLBT score would significantly differ between the CAI involved and uninvolved limbs (contralateral and healthy matched) and demonstrate a modest (r = .50) association with the SEBT scores. Design: Case-control. Setting: Controlled laboratory. Participants: A total of 36 physically active adults, 18 with history of unilateral CAI and 18 without history of ankle injury, were enrolled in the study. CAI subjects were identified using the Identification of Functional Ankle Instability questionnaire. Interventions: The DLBT and the SEBT were performed in a randomized order on a randomly selected limb in CAI and healthy subjects. Main Outcome Measures: Time taken to complete the DLBT and the reach distances performed on the SEBT were compared between the CAI and the healthy subjects. Results: There were no statistically significant differences (P < .05) in SEBT reach distances between groups. The DLBT time was greater (P < .01) for unstable ankles compared with the stable ankle. The authors found no correlation (P > .05) between DLBT time and any of the SEBT reach distances suggesting that the DLBT provides unique information in the assessment of patients with CAI. Conclusion: The DLBT challenges the ability to maintain postural control in CAI subjects differently than the SEBT. There is a need of more dynamic balance assessment tools that are functional and clinically relevant.

Open access

Nicholas Hattrup, Hannah Gray, Mark Krumholtz and Tamara C. Valovich McLeod

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.

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Blair Mills, Brad Mayo, Francisco Tavares and Matthew Driller

Context: Given the relatively novel technique of tissue flossing is currently lacking in the research literature despite some positive findings in preliminary studies, the modality clearly requires further research. Current evidence suggests that band flossing results in performance improvements and may also be an effective method in injury prevention. Objective: Previous research has shown that tissue flossing may result in increased ankle range of motion, jump, and sprinting performance in recreational athletes. The present study aims to extend on this research, within an elite athlete sample. Design: Counterbalanced, cross-over design with experimental and control trials, separated by 1 week. Setting: University laboratory. Participants: Fourteen professional male rugby union athletes (mean [SD]: age 23.9 [2.7] y). Intervention: Application of a floss band to both ankles (FLOSS) for 2 minutes or without flossing of the ankle joints (CON) on 2 separate occasions. Main Outcome Measures: A weight-bearing lunge test, a countermovement jump test, and a 20-m sprint test at pre and at 5 and 30 minutes post application of the floss band or control. Results: There were no statistically significant interactions between treatment (FLOSS/CON) and time for any of the measured variables (P > .05). Effect size analysis revealed small benefits for FLOSS in comparison with CON for countermovement performance 5 minutes post (d = 0.28) and for 10-m (d = −0.45) and 15-m (d = −0.24) sprint time 30 minutes post. Conclusion: Findings from the current study suggest minimal benefits of tissue flossing when applied to the ankle joint in elite athletes for up to 30 minutes following their application.