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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Matthew J. Hussey, Alex E. Boron-Magulick, Tamara C. Valovich McLeod, and Cailee E. Welch Bacon
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?
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.
Bridget M. Spooner and Cailee E. Welch Bacon
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.
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.
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?
Amy M. Gibson, Gary W. Cohen, Kelly K. Boyce, Megan N. Houston, and Cailee E. Welch Bacon
Clinical Question: What personal and environmental characteristics are associated with burnout in athletic trainers, as measured by the Maslach Burnout Inventory (MBI) and Athletic Training Burnout Inventory (ATBI)? Clinical Bottom Line: There is strong evidence suggesting that personal and environmental factors are associated with burnout in athletic trainers, as measured by the MBI and ATBI. While it is difficult to identify a single contributing factor that increases the athletic trainer’s perception of burnout, athletic trainers should be aware of the characteristics associated with the condition and take appropriate action to reduce the risk of burnout.
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.
Cailee E. Welch Bacon, Nydia L. Cabra, Taryn C. Pennington, Lindsey E. Eberman, and Julie M. Cavallario
All athletic trainers (ATs) must meet regulatory standards as outlined in state practice acts. While state practice acts are similar, some variations can lead to misunderstanding or unfamiliarity with appropriate scopes of practice. We aimed to describe ATs’ perceptions regarding athletic training scope of practice. Only 29.7% of respondents correctly identified state government as the agency that defines athletic training scope of practice and 51.7% agreed their respective state practice act limits the skills they can perform. To advocate for the profession, ATs must have a primary understanding of the laws and regulations that promote ATs to work at their fullest ability.
