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The Current Evidence Does Not Support the Use of Electrical Stimulation to Decrease Pain and Edema and Improve Function Following a Lateral Ankle Sprain: A Critically Appraised Paper

Bridget M. Spooner and Cailee E. Welch Bacon

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Positive and Negative Factors That Influence Concussion Reporting Among Secondary-School Athletes

Melissa C. Kay, Cailee E. Welch, and Tamara C. Valovich McLeod

Clinical Scenario:

Concussions are one of the most common sport-related injuries affecting athletes participating at all levels across a variety of sports. It has been reported that up to 3.8 million concussive events occur per year that are sports-related. One significant issue with identifying concussions is that a clinical diagnosis is based on the presence of signs and symptoms, which are self-reported by the patient. In the adolescent population, injury to the brain is possible with even the slightest insult, which can affect recovery and predispose them to subsequent concussions. Recent legislative efforts have included athlete education as a means to improve concussion reporting. More specifically, all 50 US states and the District of Columbia have implemented concussion legislation that includes some type of concussion education protocol, but there is still little evidence to suggest that enhanced knowledge levels result in behavior changes, including improved concussion-reporting practices. It is unclear what factors make an adolescent athlete more or less likely to report the symptoms of a concussion.

Focused Clinical Question:

What factors positively or negatively influence secondary school athletes’ likelihood of reporting symptoms of sport-related concussions?

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The Impact of Adding an Eccentric-Exercise Component to the Rehabilitation Program of Patients With Shoulder Impingement: A Critically Appraised Topic

Alison R. Valier, Ryan S. Averett, Barton E. Anderson, and Cailee E. Welch Bacon

Clinical Scenario:

Shoulder pain is a common musculoskeletal complaint and is often associated with shoulder impingement. The annual incidence of shoulder pain is estimated to be 7% of all injuries, and is the third-most-common type of musculoskeletal pain. Initial treatment of shoulder impingement follows a conservative plan and emphasizes rehabilitation programs as opposed to surgical interventions. Shoulder rehabilitation programs commonly focus on strengthening the muscles of the shoulder complex and, more specifically, the rotator cuff. The rotator cuff is a primary dynamic stabilizer of the glenohumeral joint, using both eccentric and concentric contractions. The posterior rotator cuff, including teres minor and infraspinatus, works eccentrically to decelerate the arm during overhead throwing. Exercises to strengthen the rotator cuff and the surrounding dynamic stabilizers of the shoulder girdle vary and include activities such as internal and external rotation, full-can lifts, and rhythmic stabilizations. Traditionally, shoulder rehabilitation programs have focused on isotonic concentric contractions. Common strengthening exercises typically involve movements that result in shortening the muscle length while simultaneously loading the muscles. However, recent attention has been given to eccentric exercises, which involve lengthening of the muscle during loading, for the treatment of a variety of different tendinopathies including those of the Achilles and patellar tendons. The eccentric, or lengthening, motion is thought to be beneficial for people who are involved in activities that place eccentric stress on their shoulder, such as overhead throwers. Based on studies related to the Achilles tendon, eccentric exercise may positively influence the tendon structure by increasing collagen production and decreasing neovascularization. The changes that occur as a result of eccentric exercises may improve function, strength, and performance and decrease pain more than concentric programs, producing better patient outcomes. Although eccentric strength training has been shown to provide strength gains, there are no clear guidelines as to the inclusion of this form of exercise training in shoulder rehabilitation programs for the purposes of improving function and decreasing pain.

Focused Clinical Question:

Does adding an eccentric-exercise component to the rehabilitation program of patients with shoulder impingement improve shoulder function and/or decrease pain?

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The Diagnostic Accuracy of Clinical Diagnostic Tests for Thoracic Outlet Syndrome

Krista M. Hixson, Hannah B. Horris, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario:

Thoracic outlet syndrome is quite challenging to diagnose. Currently, there are myriad diagnostic procedures used in the diagnosis of all types of thoracic outlet syndrome. However, controversy exists over which diagnostic procedures produce accurate findings.

Clinical Question:

Can clinical diagnostic tests accurately diagnose patients presenting with symptoms of thoracic outlet syndrome?

Summary of Key Findings:

A thorough literature search returned 6 possible studies; 3 studies met the inclusion criteria and were included. Two studies supported the use of clinical diagnostic tests for the diagnosis of thoracic outlet syndrome. One study reported high false-positive rates among clinical diagnostic tests for thoracic outlet syndrome. One study reported that clinical diagnostic test findings correlate to provocative positioned magnetic resonance imaging findings.

Clinical Bottom Line:

There is moderate evidence to support the use of the Halstead maneuver (also known as the costoclavicular maneuver or exaggerated military brace test), Wright’s test, Cyriax Release test, and supraclavicular pressure test to have good diagnostic accuracy for the provocation of symptoms in patients presenting with upper extremity pathology. However, these clinical diagnostic tests do not appear to allow for the differential diagnosis of thoracic outlet syndrome exclusively. The use of the Adson’s test and Roos test should be discontinued for the differential diagnosis of thoracic outlet syndrome.

Strength of Recommendation:

Grade B evidence exists to support the accuracy of the Halstead maneuver, Wright’s test, Cyriax Release test, and supraclavicular pressure test for the diagnosis of upper extremity pathology in general. Grade C evidence exists for the use of these clinical diagnostic tests to exclusively diagnose thoracic outlet syndrome.

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The Comparison of Instrument-Assisted Soft Tissue Mobilization and Self-Stretch Measures to Increase Shoulder Range of Motion in Overhead Athletes: A Critically Appraised Topic

Matthew J. Hussey, Alex E. Boron-Magulick, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario: Shoulder range of motion (ROM) in throwing athletes relies on a balance of mobility and stability to maintain proper function and health that, if disrupted, can lead to shoulder injury. There have been several studies that address the relationship between ROM deficits and overhead injuries; however, it may be unclear to clinicians which interventions are most effective for increasing ROM in the glenohumeral joints of overhead athletes. Clinical Question: In overhead athletes who have deficient shoulder ROM, is instrument-assisted soft tissue mobilization (IASTM) more effective at acutely increasing ROM over the course of a patient’s treatment when compared with self-stretching? Summary of Key Findings: A thorough literature review yielded 3 studies relevant to the clinical question, and all 3 studies were included. Two articles found a significant increase in acute ROM when compared with a self-stretch measure. All 3 articles showed increases in internal rotation and horizontal adduction, and 1 study reported an increase in total arc of shoulder ROM. Clinical Bottom Line: There is moderate evidence to support the use of IASTM to acutely increase ROM in the glenohumeral joint of overhead athletes. Clinicians should be aware of the variability with recommended treatment times; however, positive results have been seen with treatments lasting 5 to 6 minutes per treatment region. There is no consensus for treatment intensity, and certain IASTM tools require certification. Strength of Recommendation: Grade B evidence exists that IASTM is more effective at increasing shoulder ROM (ie, internal rotation, horizontal adduction, external rotation, total arc of motion) in overhead athletes than self-stretching measures.

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The Functional Movement Screen’s Ability to Detect Changes in Movement Patterns After a Training Intervention

Lindsay M. Minthorn, Shirleeah D. Fayson, Lisa M. Stobierski, Cailee E. Welch, and Barton E. Anderson

Clinical Scenario:

Appropriate movement patterns during sports and physical activities are important for both athletic performance and injury prevention. The assessment of movement dysfunction can assist clinicians in implementing appropriate rehabilitation programs after injury, as well as developing injury-prevention plans. No gold standard test exists for the evaluation of movement capacity; however, the Functional Movement Screen (FMS) has been recommended as a tool to screen for movement-pattern limitations and side-to-side movement asymmetries. Limited research has suggested that movement limitations and asymmetries may be linked to increased risk for injury. While this line of research is continuing to evolve, the use of the FMS to measure movement capacity and the development of intervention programs to improve movement patterns has become popular. Recently, additional research examining changes in movement patterns after standardized intervention programs has emerged.

Clinical Question:

Does an individualized training program improve movement patterns in adults who participate in high-intensity activities?

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Critically Appraised Papers and Topics Part 1: Use in Clinical Practice

Cailee E. Welch, Mariel K. Yakuboff, and Meredith J. Madden

Edited by Michael G. Dolan

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Critically Appraised Papers and Topics Part 2: How to Read and Interpret a CAP

Cailee E. Welch, Mariel K. Yakuboff, and Meredith J. Madden

Edited by Michael G. Dolan

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Treatment of Medial Tibial Stress Syndrome: A Critical Review

Kyle K. Winters, Nicholas Kostishak, Tamara Valovich McLeod, and Cailee E. Welch

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A Biomechanical Analysis of Barefoot versus Shod Distance Running

Kelsey J. Picha, Michelle L. Weber, and Cailee E. Welch

Edited by Michael G. Dolan