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Brendon P. McDermott, Douglas J. Casa, Susan W. Yeargin, Matthew S. Ganio, Lawrence E. Armstrong and Carl M. Maresh

Objective:

To describe the current scientific evidence of recovery and return to activity following exertional heat stroke (EHS).

Data Sources:

Information was collected using MEDLINE and SPORTDiscus databases in English using combinations of key words, exertional heat stroke, recovery, rehabilitation, residual symptoms, heat tolerance, return to activity, and heat illness.

Study Selection:

Relevant peer-reviewed, military, and published text materials were reviewed.

Data Extraction:

Inclusion criteria were based on the article’s coverage of return to activity, residual symptoms, or testing for long-term treatment. Fifty-two out of the original 554 sources met these criteria and were included in data synthesis.

Data Synthesis:

The recovery time following EHS is dependent on numerous factors, and recovery length is individually based and largely dependent on the initial care provided.

Conclusion:

Future research should focus on developing a structured return-to-activity strategy following EHS.

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Kelley D. Henderson, Sarah A. Manspeaker and Zevon Stubblefield

Key Points ▸ Diagnosis of exertional rhabdomyolysis includes a combined exam and laboratory findings. ▸ Exertional rhabdomyolysis during in-season tennis competition is rare. ▸ Return to activity following exertional rhabdomyolysis can occur swiftly OR in the middle of sport season if a progressive

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Eric Emmanuel Coris, Stephen Walz, Jeff Konin and Michele Pescasio

Context:

Heat illness is the third leading cause of death in athletics and a leading cause of morbidity and mortality in exercising athletes. Once faced with a case of heat related illness, severe or mild, the health care professional is often faced with the question of when to reactivate the athlete for competitive sport. Resuming activity without modifying risk factors could lead to recurrence of heat related illness of similar or greater severity. Also, having had heat illness in and of itself may be a risk factor for future heat related illness. The decision to return the athlete and the process of risk reduction is complex and requires input from all of the components of the team. Involving the entire sports medicine team often allows for the safest, most successful return to play strategy. Care must be taken once the athlete does begin to return to activity to allow for re-acclimatization to exercise in the heat prior to resumption particularly following a long convalescent period after more severe heat related illness.

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William M. Adams, Yuri Hosokawa, Robert A. Huggins, Stephanie M. Mazerolle and Douglas J. Casa

Context:

Evidence-based best practices for the recognition and treatment of exertional heat stroke (EHS) indicate that rectal thermometry and immediate, aggressive cooling via cold-water immersion ensure survival from this medical condition. However, little is known about the recovery, medical follow-up, and return to activity after an athlete has suffered EHS.

Objective:

To highlight the transfer of evidenced-based research into clinical practice by chronicling the treatment, recovery, and return to activity of a runner who suffered an EHS during a warm-weather road race.

Design:

Case study.

Setting:

Warm-weather road race.

Participant:

53-y-old recreationally active man.

Intervention:

A runner’s treatment, recovery, and return to activity from EHS and 2014 Falmouth Road Race performance.

Main Outcomes:

Runner’s perceptions and experiences with EHS, body temperature, heart rate, hydration status, exercise intensity.

Results:

The runner successfully completed the 2014 Falmouth Road Race without incident of EHS. Four dominant themes emerged from the data: predisposing factors, ideal treatment, lack of medical follow-up, and patient education. The first theme identified 3 predisposing factors that contributed to the runner’s EHS: hydration, sleep loss, and lack of heat acclimatization. The runner received ideal treatment using evidence-based best practices. A lack of long-term medical care following the EHS with no guidance on the runner’s return to full activity was observed. The runner knew very little about EHS before the 2013 race, which drove him to seek knowledge as to why he suffered EHS. Using this newly learned information, he successfully completed the 2014 Falmouth Road Race without incident.

Conclusions:

This case supports prior literature examining the factors that predispose individuals to EHS. Although evidence-based best practices regarding prompt recognition and treatment of EHS ensure survival, this case highlights the lack of medical follow-up and physician-guided return to activity after EHS.

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Jay R. Ebert, Anne Smith, Peter K. Edwards and Timothy R. Ackland

Context:

Matrix-induced autologous chondrocyte implantation (MACI) is an established technique for the repair of knee chondral defects. Despite the reported clinical improvement in knee pain and symptoms, little is known on the recovery of knee strength and its return to an appropriate level compared with the unaffected limb.

Objective:

To investigate the progression of isokinetic knee strength and limb symmetry after MACI.

Design:

Prospective cohort.

Setting:

Private functional rehabilitation facility.

Patients:

58 patients treated with MACI for full-thickness cartilage defects to the femoral condyles.

Intervention:

MACI and a standardized rehabilitation protocol.

Main Outcome Measures:

Preoperatively and at 1, 2, and 5 y postsurgery, patients underwent a 3-repetition-maximum straight-leg raise test, as well as assessment of isokinetic knee-flexor and -extensor torque and hamstring:quadriceps (H:Q) ratios. Correlation analysis investigated the association between strength and pain, demographics, defect, and surgery characteristics. Linear-regression analysis estimated differences in strength measures between the operated and nonoperated limbs, as well as Limb Symmetry Indexes (LSI) over time.

Results:

Peak knee-extension torque improved significantly over time for both limbs but was significantly lower on the operated limb preoperatively and at 1, 2, and 5 y. Mean LSIs of 77.0%, 83.0%, and 86.5% were observed at 1, 2, and 5 y, respectively, while 53.4–72.4% of patients demonstrated an LSI ≤ 90% across the postoperative timeline. Peak knee-flexion torque was significantly lower on the operated limb preoperatively and at 1 year. H:Q ratios were significantly higher on the operated limb at all time points.

Conclusions:

While peak knee-flexion and hip-flexor strength were within normal limits, the majority of patients in this study still demonstrated an LSI for peak knee-extensor strength ≤ 90%, even at 5 y. It is unknown how this prolonged knee-extensor deficit may affect long-term graft outcome and risk of reinjury after return to activity.

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Nathan Millikan, Dustin R. Grooms, Brett Hoffman and Janet E. Simon

Context: Functional tests are limited primarily by measuring only physical performance. However, athletes often multitask, and deal with complex visual-spatial processing while being engaged in physical activity. Objective: To present the development and reliability of 4 new neurocognitive single-leg hop tests that provide more ecological validity to test sport activity demands than previous functional return to sport testing. Design: Cross-sectional. Setting: Gymnasium. Participants: Twenty-two healthy participants (9 males and 13 females; 20.9 [2.5] y, 171.2 [11.7] cm, 70.3 [11.0] kg) were recruited. Interventions: Maximum distance (physical performance) and reaction time (cognitive performance) were measured for 3 of the neurocognitive hop tests all testing a different aspect of neurocognition (single-leg central-reaction hop—reaction time to 1 central stimulus, single-leg peripheral-reaction crossover hop—reaction time between 2 peripheral stimuli, and single-leg memory triple hop—reaction to memorized stimulus with distractor stimuli). Fastest time (physical performance) and reaction time (cognitive performance) were measured for the fourth neurocognitive hop test (single-leg pursuit 6m hop—requiring visual field tracking [pursuit] and spatial navigation). Main Outcome Measures: Intraclass correlation coefficients were calculated to assess reliability of the 4 new hop tests. Additionally, Bland–Altman plots and 1-sample t tests were conducted for each single-leg neurocognitive hop to evaluate any systematic changes. Results: Intraclass correlation coefficients based on day 1 and day 2 scores ranged from .87 to .98 for both legs for physical and cognitive performance. The Bland–Altman plots and 1-sample t tests (P > .05) indicated that all 4 single-leg neurocognitive hop tests did not change systematically. Conclusions: These data provide evidence that a neurocognitive component can be added to the traditional single-leg hop tests to provide a more ecologically valid test that incorporates the integration of physical and cognitive function for return to sport. The test–retest reliability of the 4 new neurocognitive hop tests is highly reliable and does not change systematically.

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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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Robert Vallandingham, Zachary Winkelmann, Lindsey Eberman and Kenneth Games

recommendations in these areas. The charts indicated that less than half the patients were taped (n = 40/107, 37.4%) or braced (n = 13/107, 12.1%) upon return to activity. The mean time loss reported within this study was 10.0 ± 10.2 days (n = 62, 57.9%). There was a mean of 2.5 treatment categories and a mean of

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Michael Dressing, Jillian Wise, Jennifer Katzenstein and P. Patrick Mularoni

Correlations of Anxiety Scales With Return to Activity and MMAAC Test Scores Days until return to school Days until return to play MMAAC total score MMAAC total score 0.367* 0.151 — Westside test anxiety score 0.288 0.099 0.762** SCARED total anxiety −0.073 0.141 0.533** SCARED panic disorder 0.015 0.230 0

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Teddy W. Worrell

Noncompliance to rehabilitation programs presents a significant challenge to clinicians. Noncompliant athletes are at greater risk for re-injury and slower return to activity. There is a paucity of information concerning compliance to sports rehabilitation. This paper advocates the use of behavioral and cognitive techniques to facilitate achievement of rehabilitation goals. Behavioral techniques involve the use of specific short-term functional goals to achieve the long-term goal of return to activity. Cognitive techniques involve the relationship between thoughts and action, that is, if athletes are thinking negatively, they are less compliant to rehabilitation programs. Specific examples of both techniques are presented to the clinician that are proposed to increase rehabilitation goal attainment.