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Tamara C. Valovich McLeod, Megan N. Houston and Cailee E. Welch

Concussions resulting from sports and recreational activities are a significant concern in the pediatric population. The number of children and adolescents sustaining sport-related concussions is increasing and, as a result, legislation has been passed in all 50 states to ensure appropriate recognition and referral of pediatric athletes following concussion. The developing brain may make the diagnosis, assessment, and management of concussion more challenging for health care providers and requires the use of specific age-appropriate assessment tools. Concussion management must also include considerations for cognitive and physical rest, a collaborative concussion management team that includes medical and school personnel, and more conservative stepwise progressions for returning to school and to physical activity.

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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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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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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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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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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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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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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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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?