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  • Author: Cailee E. Welch x
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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 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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Reliability of Clinician Scoring of the Landing Error Scoring System to Assess Jump-Landing Movement Patterns

Jessica G. Markbreiter, Bronson K. Sagon, Tamara C. Valovich McLeod, and Cailee E. Welch

Clinical Scenario:

An individual’s movement patterns while landing from a jump can predispose him or her to lower-extremity injury, if performed improperly. The Landing Error Scoring System (LESS) is a clinical tool to assess jump-landing biomechanics as an individual jumps forward from a box. Improper movement patterns, which could predispose an individual to lower-extremity injuries, are scored as errors. However, because of the subjective nature of scoring errors during the task, the consistency and reliability of scoring the task are important. Since the LESS is a newer assessment tool, it is important to understand its reliability.

Focused Clinical Question:

Are clinicians reliable at scoring the LESS to assess jump-landing biomechanics of physically active individuals?

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The Diagnostic Accuracy of Screening Tools to Detect Eating Disorders in Female Athletes

Alyssa J. Wagner, Casey D. Erickson, Dayna K. Tierney, Megan N. Houston, and Cailee E. Welch Bacon

Clinical Scenario:

Eating disorders in female athletes are a commonly underdiagnosed condition. Better screening tools for eating disorders in athletic females could help increase diagnosis and help athletes get the treatment they need.

Focused Clinical Question:

Should screening tools be used to detect eating disorders in female athletes?

Summary of Key Findings:

The literature was searched for studies that included information regarding the sensitivity and specificity of screening tools for eating disorders in female athletes. The search returned 5 possible articles related to the clinical question; 3 studies met the inclusion criteria (2 cross-sectional studies, 1 cohort study) and were included. All 3 studies reported sensitivity and specificity for the Athletic Milieu Direct Questionnaire version 2, the Brief Eating Disorder in Athletes Questionnaire version 2, and the Physiologic Screening Test to Detect Eating Disorders Among Female Athletes. All 3 studies found that the respective screening tool was able to accurately identify female athletes with eating disorders; however, the screening tools varied in sensitivity and specificity values.

Clinical Bottom Line:

There is strong evidence to support the use of screening tools to detect eating disorders in female athletes. Screening tools with higher sensitivity and specificity have demonstrated a successful outcome of determining athletes with eating disorders or at risk for developing an eating disorder.

Strength of Recommendation:

There is grade A evidence available to demonstrate that screening tools accurately detect female athletes at risk for eating disorders.

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The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic

Rachel S. Johnson, Mia K. Provenzano, Larynn M. Shumaker, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario:

It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established.

Clinical Question:

Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest?

Summary of Key Findings:

A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration.

Clinical Bottom Line:

There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles.

Strength of Recommendation:

Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents.

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Kinesiophobia After Anterior Cruciate Ligament Reconstruction in Physically Active Individuals

Arika L. Cozzi, Kristina L. Dunn, Josie L. Harding, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario:

There are approximately 200,000 anterior cruciate ligament (ACL) tears reported annually in the United States. Patients who undergo ACL reconstruction followed by an aggressive rehabilitation protocol can often structurally and functionally progress to a preinjury level. Despite physical improvements with ACL-rehabilitation protocols, however, there are still a substantial number of individuals who do not return to preinjury level, particularly physically active individuals, of whom only 63% return to their full potential preinjury level. This may be due to continued pain, swelling, stiffness, and weakness in the knee. In addition, research concerning the topic of kinesiophobia (ie, fear of reinjury), which may prevent individuals from returning to their activities, has increased over the past several years. Kinesiophobia is defined as the irrational or debilitating movement of physical activity resulting in the feeling of vulnerability to painful injury or reinjury. Kinesiophobia may have a significant impact on physically active individuals, considering the proportion of patients who do not return to their sport. However, it is unknown whether kinesiophobia is associated with patients’ perceived physical-impairment levels after ACL reconstruction.

Focused Clinical Question:

Is kinesiophobia associated with self-perceived levels of knee function after ACL reconstruction?

Open access

Pain Education With Therapeutic Exercise in Chronic Nonspecific Low Back Pain Rehabilitation: A Critically Appraised Topic

Kaitlyn C. Jones, Evelyn C. Tocco, Ashley N. Marshall, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon

Clinical Scenario: Low back pain is widely prevalent in the general population as well as in athletes. Therapeutic exercise is a low-risk and effective treatment option for chronic pain that can be utilized by all rehabilitation clinicians. However, therapeutic exercise alone does not address the psychosocial aspects that are associated with chronic low back pain. Pain education is the umbrella term utilized to encompass any type of education to the patient about their chronic pain. Therapeutic exercise in combination with pain education may allow for more well-rounded and effective treatment for patients with chronic nonspecific low back pain (NS-LBP). Clinical Question: Does pain education combined with therapeutic exercise, compared with therapeutic exercise alone, improve patient pain in adults with chronic NS-LBP over a 2- to 3-month treatment period? Summary of Key Findings: A thorough literature review yielded 8 studies potentially relevant to the clinical question, and 3 studies that met the inclusion criteria were included. The 3 studies included reports that exercise therapy reduced symptoms. Two of the 3 included studies support the claim that exercise therapy reduces the symptoms of chronic NS-LBP when combined with pain education, whereas one study found no difference between pain education with therapeutic exercise. Clinical Bottom Line: There is moderate evidence to support the use of pain education along with therapeutic exercise when attempting to reduce symptoms of pain and disability in patients with chronic NS-LBP. Educational interventions should be created to educate patients about the foundation of pain, and pain education should be implemented as a part of the clinician’s strategy for the rehabilitation of patients with chronic NS-LBP. Strength of Recommendation: Grade B evidence exists to support the use of patient education with therapeutic exercise for decreasing pain in patients with chronic NS-LBP.

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Reliability of Clinician Scoring of the Functional Movement Screen to Assess Movement Patterns

Lisa M. Stobierski, Shirleeah D. Fayson, Lindsay M. Minthorn, Tamara C. Valovich McLeod, and Cailee E. Welch

Clinical Scenario:

Injuries are inevitable in the physically active population. As a part of preventive medicine, health care professionals often seek clinical tools that can be used in real time to identify factors that may predispose individuals to these injuries. The Functional Movement Screen (FMS), a clinical tool consisting of 7 individual tasks, has been reported as useful in identifying individuals in various populations that may be susceptible to musculoskeletal injuries. If factors that may predispose physically active individuals to injury could be identified before participation, clinicians may be able to develop a training plan based on FMS scores, which could potentially decrease the likelihood of injury and overall time missed from physical activities. However, in order for a screening tool to be used clinically, it must demonstrate acceptable reliability.

Focused Clinical Question:

Are clinicians reliable at scoring the FMS, in real time, to assess movement patterns of physically active individuals?