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Context: Targeted and directed rehabilitation with a healthcare provider can be an effective approach in the treatment of concussion, particularly for patients with protracted recovery, high symptom reporting, cervicogenic dysfunction, musculoskeletal involvement, and/or vestibular/oculomotor dysfunction. While many environmental and intrinsic medical history factors may influence concussion recovery, little is known about whether an individual’s recovery trajectory can be influenced by the amount of time taken to receive rehabilitation. The purpose of this study was to evaluate recovery trajectories of concussion patients requiring targeted multimodal rehabilitation after a specialty concussion clinic visit within ≤3 days, 4 to 7 days, and >7 days. We also sought to evaluate risk factors for protracted recovery. Design and Methods: The study involved a retrospective chart review of 103 patients (mean age = 13.78 [2.89]; 55% female) who, after their initial specialty concussion clinic visit, received rehabilitation in ≤3 days, 4 to 7 days, and >7 days. Patients were evaluated at a pediatric specialty concussion clinic between April 2021 and December 2023, and diagnosed with concussion by a specialist (primary care sports medicine physician, nurse practitioner, and/or neuropsychologist), referred for rehabilitation via physical therapy services, completed more than one rehabilitation session, and received medical clearance to initiate the return-to-sport protocol. Groups were compared based on relevant clinical factors, Vestibular Ocular Motor Screening, neurocognitive testing (Trails B-A), Post-Concussion Symptom Scale, days from injury to concussion evaluation, days from concussion evaluation to rehabilitation, number of rehabilitation sessions, recovery days after rehabilitation, and total recovery days (ie, days from injury to medical clearance to initiate return-to-sport protocol). Data analysis included chi-square, correlations, 1-way analysis of variance, and general linear regression. Adjusted odds ratios for protracted recovery were derived from a logistic regression model. Discussion: Days from injury to concussion evaluation (P < .001), days from concussion evaluation to rehabilitation (P = .006), and Trails B-A (P = .009), were significant predictors of total recovery time among pediatric concussion patients who required multimodal rehabilitation. Risk of protracted recovery increased by 34% each day from injury to concussion evaluation a patient did not receive treatment (Nagelkerke Pseudo R ² = .45; P < .001). Previous studies have also shown that time to concussion evaluation is an important prognostic indicator of recovery. Correspondingly, prompt referral to concussion care and rehabilitation for patients with a need for multimodal rehabilitation can improve recovery outcomes.

Clinical Scenario: Individuals with patellofemoral pain (PFP) present with a variety of neuromuscular and psychological deficits, with the “gold-standard” for treatment being rehabilitation programs with strengthening-based exercises. While such interventions primarily target pain and function measures, it is unknown whether psychological measures such as fear-avoidance beliefs (FABs) are also affected. Clinical Question: Is rehabilitation including strengthening exercises effective in improving FABs in individuals with PFP? Summary of Key Findings: Three studies met the inclusion criteria and were included in the appraisal. All studies found that rehabilitation including strengthening exercises was effective in improving FABs for physical activity, though such improvements were modest. One study found that supplementing a one-time psychological intervention to rehabilitation including strengthening exercises resulted in greater improvements in FABs than with rehabilitation including strengthening exercises alone. Two studies found associations between changes in FABs and changes in pain and/or function outcomes. Clinical Bottom Line: There is consistent evidence that the incorporation of rehabilitation with strengthening exercises is effective in improving FABs in individuals with PFP, though such improvements are modest. Furthermore, supplementation with psychological interventions to rehabilitation including strengthening exercises may produce larger improvements in FABs, particularly in patients with an elevated FABs phenotype. As a result of improving FABs, patient outcomes of pain and function may be improved, though future research is needed. Therefore, at this time, we recommend that rehabilitation, including strengthening exercises with supplemental psychological interventions be prescribed for the treatment of PFP particularly in subgroups with elevated FABs, to improve patient outcomes. Strength of Recommendation: Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of A based on the Strength of Recommendation Taxonomy.

Context: Functional movement screen (FMS) and Y-balance test (YBT) are used to predict the risk of musculoskeletal injuries. FMS and YBT tools in relation to injury in elite female softball athletes have not been examined. Objectives: This study aims to (1) compare the differences in FMS, Y-Balance upper quarter (YBT-UQ), and lower quarter (YBT-LQ) scores between injured and noninjured group and (2) determine the ability of FMS and YBT scores to predict the odds of musculoskeletal injury in elite fast-pitch female softball athletes. Design: Prospective cohort study. Methods: Thirty-eight athletes (age = 22.9 [2.6] y, height = 170.2 [5.2] cm, mass = 65.5 [7.2] kg) completed preseason FMS and YBT assessments. Injury data were collected throughout one full season, categorized based on the location of the injury, and then recorded as a binary variable (ie, injured and noninjured groups). FMS, YBT-UQ, and YBT-LQ scores were compared between injured and noninjured groups. Binary logistic regression was used to predict the occurrence of injury among softball athletes. Results: FMS scores were significantly lower for the injured group compared with the FMS scores belonging to the noninjured group (P ≤ .001; d = 1.52). Lower FMS composite scores predicted injury (Wald_(df = 1) = 6.755; odds ratio = 0.231; P = .009; 95% confidence interval, 0.076–0.697). No between-group differences existed in YBT-UQ (P = .67; d = 0.14) and YBT-LQ (P = .16; d = 0.50) composite scores between the injured and the noninjured groups. YBT-UQ (Wald_(df = 1) = 2.300; odds ratio = 0.893; P = .129; 95% confidence interval, 0.772–1.033) and YBT-LQ (Wald_(df = 1) = 0.145; odds ratio = 1.024; P = .703; 95% confidence interval, 0.906–1.157) were not significant predictors of injury. Conclusions: FMS appears to be a valuable screening tool for assessing musculoskeletal injury risk in elite fast-pitch female softball athletes.

Context: A common component within rehabilitation recommendations for baseball pitchers is employment of an interval throwing program. However, there is a lack of a consistent set of advocated guidelines for program content and implementation for athletes at the professional and collegiate levels. Design: Cross-sectional study. Methods: A survey was developed to obtain clinician views regarding the composition and implementation of interval throwing programs for baseball pitchers. The survey was divided into demographic information and sections on criteria to begin throwing programs, frequency of throwing, soreness management, warm-up components, program components and regulation of a program, and criteria to achieve permitting live throwing. Clinicians including physicians, physical therapists, and certified athletic trainers who evaluate and treat musculoskeletal injuries among baseball pitchers at the professional-level and/or collegiate-level clinician received the survey. Responses were tabulated and compared between the professional-level clinician and collegiate-level clinician groups using chi-square analyses with statistical significance set at P ≤ .05. Results: The survey was completed by 166 clinicians (collegiate level = 81, professional-level clinician = 85). There were no statistical differences between groups for allowing warm-up throws, program regulation, maximum distance allowed, managing soreness, or criteria to achieve before permitting live throwing. Between-group differences included criteria to begin a program (≤.03), warm-up distance (P ≤ .02), nonthrowing warm-up methods (P ≤ .04), non-warm-up distance (P ≤ .01), using ratings of perceived exertion (P < .01), throwing frequency (P < .01), and program components (P ≤ .04). Conclusions: Responses appear to mirror interval throwing program designs previously reported in the literature but there are modifications and additions utilized by clinicians at different playing levels.

Context: The Buffalo Concussion Treadmill Test (BCTT) for exercise intolerance following concussion may highlight underlying autonomic dysfunction. Autonomic function at rest and with exertion may be predictive of neurocognitive performance for individuals with sports-related concussion. The purpose of this study is to explore the feasibility and utility of combining multimodal assessments with heart rate variability (HRV) measures during the BCTT for individuals with a remote history of concussion. Design: Prospective cohort study design, pretest/posttest. Methods: Participants included 5 males and 5 females (N = 10, age: 25.2 [3.3] y old, height: 173.2 [11.2] cm, mass: 73.4 [13.7] kg, body mass index: 24.5 [3.9], time since last concussion of 6.3 [4.5] y). All participants completed the multimodal assessment battery including: Concentration Reverse Digits (6 digits), Stroop Incongruent, and King–Devick Test under single- (seated) and dual-task conditions (walking on treadmill at 2.0 mph, 0% incline). Heart rate and HRV was collected at rest, during the BCTT, and during postexercise recovery. HRV data were processed and analyzed based on established protocols. Paired t tests were performed for pre- and postmeasurements separately for single- and dual-task tests of the multimodal assessment battery and HRV indices. Results: During the BCTT, HRV indices reflective of peripheral nervous system activity demonstrated a significant reduction with concomitant increase in HRV indices of sympathetic nervous system activity (P < .05). Recovery in these HRV indices toward baseline was observed during postexercise recovery. Neurocognitive performance on the Stroop task significantly improved with exercise (P < .05). Conclusion: Implementation of multimodal assessments to evaluate physiological and neurocognitive responses to exercise in individuals with history of sports-related concussion is feasible. Addition of these objective measures may decrease reliance on self-reporting of exercise-induced symptom exacerbation, enabling clinicians to identify individuals whose neurocognitive performance or physiologic response to exercise on the BCTT deviates from the expected.

Context: The single-leg hop is based solely on performance with no measure of movement quality. The purpose of this study was to (1) develop a real-time screening tool to capture single-leg functional performance and movement quality and (2) to provide preliminary validation (criterion validity) of a trained clinician’s real-time movement quality assessment with 3D kinematics. Study Design: Cross-sectional. Methods: Fifty-nine adolescent athletes volunteered (15.2 [1.1] y, 165.8 [9.2] cm, and 61.5 [13.9] kg, 51 females and 8 males). Each participant performed 3 trials of the single-leg hop on their dominant leg. A 3-dimensional inertial measurement system was used to capture knee joint kinematics. A movement quality checklist for use during a single-leg hop (movement quality single-leg hop) was developed to score biomechanical errors based on lower-extremity injury risk factors. Four criteria were developed for the checklist: (1) knee valgus, (2) foot rotation, (3) lateral trunk flexion, and (4) erect posture. An independent t test was conducted for each dependent variable (knee flexion displacement and knee abduction displacement) by each independent variable (movement category presence of (1) lateral trunk flexion, (2) knee valgus, (3) foot rotation, and (4) erect posture/sound during landing [yes or no]). The alpha level was set at α < .05 for all analyses. Results: Knee flexion displacement was significantly decreased (P < .001, mean difference 9.40 [1.88]) and knee abduction displacement was significantly increased (P < .001, mean difference 9.41 [0.47]) for those who had knee valgus documented by the clinician. In additional, for those with visually documented erect posture/sound of landing, there was a significant decrease in knee flexion displacement (P < .001, mean difference 10.13 [2.34]). Conclusion: The movement quality single-leg hop checklist has shown promising preliminary validation (criterion validity) for clinicians to assess movement quality. Increased knee abduction and decreased knee flexion are common risk factors associated with knee injuries and this clinician friendly real-time checklist may highlight individuals who are at risk of sustaining a knee injury.

Clinical Scenario: The Functional Movement Screen (FMS) is used to assess movement patterns and the risk of injury of active individuals. Current studies have found positive relationships with core training and injury prevention as well as lower limb stability, which can help improve FMS scores. Clinical Question: Does the implementation of a core training program have an impact on FMS scores in healthy active adults who participate in sport? Summary of Key Findings: Literature was searched for articles that included core-focused exercises and implementation of the FMS. This resulted in 25 studies being returned, only 23 of which were published in the last 10 years. Only 7 focused on the change in FMS scores after implementation of core training. Three of these studies were included in the analysis due to the specialized athlete population. All 3 studies found that using a core training program led to significantly higher FMS scores postintervention. Clinical Bottom Line: There is clear evidence that core training increases FMS scores in athletes. It is important for health care providers treating athletes to consider core training to improve functional movement patterns or FMS scores in sport-specific populations. Strength of Recommendation: Overall, there are moderate to high levels of evidence that support a grade B recommendation for core training improvements on FMS scores in athletes.

Context: Advancements in portable load-cell technology have enabled high-quality assessment of shoulder internal (IR) and external rotation (ER) peak force (F_max) and rate of force development (RFD). This study’s purpose was to explore the reliability and differences between IR and ER F_max and RFD in different testing positions using a novel load-cell device. Design: A within-subjects repeated-measures design was employed to compare the intersession values and reliability of F_max and RFD for both shoulder IR and ER across 3 positions: seated-0°, supine-0° and supine-90°. Methods: National-level swimmers (n = 19; age = 16.8 [1.0] y) completed 3 testing occasions of each condition (combination of arm, rotation, and test position) separated by 7 to 14 days. Results: IR superseded ER in all testing positions. The association between these positions across IR and ER was typically strong for both F_max and RFD (r > .85, P < .001) except for IR RFD (r = .56–.73, P < .05). For sessions 2 to 3, F_max intraclass correlation coefficient and CV (intraclass correlation coefficient = .89–.96, CV = 5.2%–8.8%) were typically within acceptable ranges, whereas RFD (intraclass correlation coefficient = .74–.90, CV = 11.5%–18.1%) often exhibited inflated error. Conclusion: The supine (90°) position was the most consistent position across both measures. Load-cell technology can be confidently used to assess shoulder rotation F_max in 3 different positions, whereas RFD should be used with caution without protocol refinement.

Context: Interest in the effects of concurrently using neuromuscular electrical stimulation (NMES) and blood flow restriction (BFR) to improve muscle strength has risen, but limited studies and inconsistent findings have led to more questions. The 2 current projects aimed to systematically investigate how NMES waveform shape and BFR occlusion pressure acutely influence electrically elicited force (EEF) and tissue oxygen saturation (StO₂) of the knee extensors. Design: A single-session repeated-measures design was followed. Methods: EEF and StO₂ were measured in 2 different groups of 15 participants during 3 sets of NMES contractions. Ten NMES contractions per set were performed with 5 minutes of passive interset recovery. In the first project, different NMES waveforms (RUS, Russian burst-modulated alternating current; VMS, biphasic pulsed current; and VMS-Burst, burst-modulated biphasic pulsed current) were administered for each set, while BFR was applied at 60% limb occlusion pressure (LOP). During the second projet, VMS was administered, while a different BFR occlusion pressure (0% LOP, 40% LOP, and 80% LOP) was used during each set. Two-way repeated-measures analysis of variance examined if repetition and/or NMES waveform (first project) or BFR occlusion pressure (second project) significantly affected (P < .05) EEF or StO₂. Results: VMS (12% [7%] MVIF) and VMS-Burst (13% [10%] MVIF) led to higher EFF compared with RUS (6% [5%] MVIF) with 60% LOP; 80% LOP (20% [14%] MVIF) led to lower EEF compared with 0% LOP (29% [17%] MVIF) with VMS. No significant differences in StO₂ were observed between NMES waveforms or BFR occlusion pressures. Conclusions: If a clinician wanted to concurrently use NMES and BFR, the acute findings of the current projects would suggest the use of VMS or VMS-Burst with lower BFR occlusion pressure (40% LOP). However, further investigation into how these parameters would influence muscle strength subsequent to a training/rehabilitation intervention should be performed.