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Background: A validated clinical risk tool has been developed to identify pediatric and adolescent patients at risk of developing persisting symptoms after concussion, but has not been prospectively investigated within a sample of athletes seen after concussion by primary care sports medicine physicians and/or athletic trainers. Purpose: To determine whether a validated clinical risk prediction tool for persistent postconcussive symptoms (PPCSs) predicted which patients would develop PPCSs when obtained within 14 days of concussion among a multicenter sample of adolescent athletes. Study Design: Cohort study; Level of evidence, 2. Methods: Pediatric and adolescent patients (8-18 years of age) from 7 pediatric medical centers and 6 secondary school athletic training facilities who were diagnosed with a concussion and presented ≤14 days after concussion were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit and were followed until symptom resolution. Clinical risk scores (Predicting and Preventing Post-concussive Problems in Pediatrics [5P]) and total symptom severity were obtained using the Post-Concussion Symptom Inventory at the initial visit (mean, 4.9 ± 2.9 days after concussion). Participants were then compared based on symptom resolution time: PPCS group (≥28 days to symptom resolution) and no-PPCS group (<28 days). The authors assessed the odds of developing PPCSs based on the 5P risk score using a binary logistic regression model and the utility of the clinical risk prediction tool to identify total time to symptom resolution using a Cox proportional hazards model. Results: A total of 184 participants enrolled, underwent initial evaluation, and were followed until symptom resolution (mean age, 15.2 ± 2.1 years; 35% female). The mean time to symptom resolution across the entire sample was 17.6 ± 3.7 days; 16% (n = 30) of participants developed PPCS. Those in the PPCS group had significantly greater mean initial total 5P risk scores than those in the no-PPCS group (7.9 ± 1.7 vs 5.9 ± 2.3, respectively; P <.001). After adjustment for initial symptom severity, time to assessment, and assessment setting, a higher initial total 5P risk score was associated with a significantly greater odds of developing PPCSs (adjusted odds ratio, 1.49; 95% CI, 1.07-2.08; P =.019). Furthermore, a higher 5P risk score was significantly associated with longer total symptom resolution time (hazard ratio, 0.80; 95% CI, 0.74-0.88; P <.001). Conclusion: In a multicenter sample of youth athletes seen in different outpatient health care settings, the 5P risk score accurately predicted which athletes may be at risk for developing PPCSs. [ABSTRACT FROM AUTHOR]

Sport specialization, or focused participation in a single sport, is associated with an increased rate of overuse injury and burnout. Medical associations and sport organizations have published recommendations for sport specialization aimed at reducing its negative consequences. Health care providers (HCPs) are often identified as individuals who can educate athletes and parents about these important recommendations. To compare knowledge, perceptions, awareness, confidence in knowledge, and use of sport specialization recommendations among HCPs who work with pediatric athletes. Cross-sectional study. An online web-based survey was developed to assess HCPs' knowledge, perceptions, awareness, confidence in knowledge, and clinical use of sport specialization recommendations. Participants were recruited from the research survey services of 4 professional organizations. Dependent variables were responses for awareness, perceptions, confidence in knowledge, use, and barriers sections of the survey. Data were analyzed with descriptive statistics; comparisons among HCPs were made through χ2 and Kruskal-Wallis tests. The survey was completed by 770 HCPs (completion rate = 95.1%). Respondents lacked awareness specific to recommendations surrounding the maximum number of sport participation months per year (39.5%), maximum hours per week (40.7%), and maximum number of teams on which youth athletes should participate concurrently (43.9%). Physicians were the most aware of medical organization recommendations generally (48%–68.8%) and confident in their knowledge (41.5%–75.1%). All HCPs were less aware and confident in their knowledge of sport organization recommendations, with no differences among HCPs. Physicians did not perceive many barriers to the use of the recommendations, whereas athletic trainers felt that patient (39.9%) and parent (45.3%) behaviors were the greatest barriers to usage. Awareness, perceptions, and use of sport specialization recommendations varied by discipline, but most respondents believed they were associated with a decreased risk of injury. Future researchers should focus on improved education and implementation of recommendations across all roles. [ABSTRACT FROM AUTHOR]

Describe concussion education perceptions among secondary school athletic trainers and determine the relationship between education program characteristics and perceived effectiveness. Two hundred and three participants completed at least one survey item (age = 35.2 ± 9.4 years; male = 27.6%). We used descriptive statistics to describe concussion education characteristics and point out biserial correlations to determine if relationships existed between concussion education characteristics and perceived effectiveness. The most frequently used mandated concussion education programs were informational handouts created by the state interscholastic association, the Centers for Disease Control and Prevention's (CDC) Heads Up materials, and the National Federation of State High School Athletic Association's materials. The CDC's Heads Up materials, handouts created by the state interscholastic association, and in-person presentations created by respondents were the most frequent concussion educational programs utilized by respondents who indicated no specific program mandated. Educational programs that were engaging increased perceived effectiveness (n = 131, rpb = 0.31,p < 0.001). Our results highlight that materials created by state interscholastic association and the CDC's Heads Up program among others are utilized to satisfy mandates and are perceived to be moderately effective, especially when perceived to be engaging. These results can help guide future studies to examine specific educational tools and administration strategies to determine effectiveness on concussion disclosure. [ABSTRACT FROM AUTHOR]

Focused Clinical Question: Does cognitive behavioral therapy (CBT) reduce concussion symptoms among children and adolescents following mild traumatic brain injury? Clinical Bottom Line: Based on the results of this critically appraised topic, there is moderate evidence to support the use of CBT as a treatment intervention to reduce complaints of persistent concussion symptoms in children and adolescents. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the author discusses articles within the issue on topics including mental health and well-being in sports, mental health of athletes and athletic trainers, and effect of concussion on mental health.

The article describes the proper fit and maintenance of ice-hockey helmets. When one is fitting an ice-hockey helmet, the athlete's hair should be wet to simulate the sweat during a practice or game. The chin strap should be fastened and the face mask, if required, should be secured. The clinician should ensure that the helmet sits no lower than the forehead than one to two finger widths above the eyebrow. It should not move freely, slide or rotate on the head.

Objectives: To describe the patient, injury, assessment and treatment characteristics, as well as return-to-play timelines and clinical findings at discharge for adolescent patients after sport-related concussion. Design: Retrospective analysis of electronic medical records. Setting: Athletic training facilities of secondary school members of the Athletic Training Practice-Based Research Network (AT-PBRN). Patients: In total, 1886 patient records were reviewed. [1204 (63.8%) male, 682 (36.2%) female, age = 15.3 ± 1.9 years, height = 169.5 ± 13.5 cm, mass = 70.3 ± 17.0 kg]. Patients were diagnosed with a concussion by an athletic trainer or team/directing physician. Interventions: None. Main Outcome Measures: Descriptive analysis of patient, injury, assessment, treatment, and participation status characteristics, as well as discharge information. Results: Injury demographic forms were completed for 1886 concussion cases. A concussion-specific evaluation form was completed for 55.9% (n = 1054) of cases. Treatment documentation was completed on 829 patients (44.0% of initial documented cases). Discharge forms were completed for 750 patients (40.0% of initial documented cases). Most cases were coded as 850.9-Concussion (85.5%, n = 642) and occurred during an in-season game (49.4%, n = 308). Time lost from competition was 24.9 ± 39.9 days. Conclusions: Most concussion cases documented in this study were not on-field emergencies, as indicated by their normal clinical examinations and the lack of immediate referral to an emergency department. However, certain aspects of the clinical examination were often not assessed during the initial evaluation. These findings describe concussion assessment and recovery in adolescents and reinforce the need for a standardized approach to concussion assessment and appropriate documentation. [ABSTRACT FROM AUTHOR]

Context: Schools that sponsor athletic programs have an obligation to provide a safe environment with appropriate policies for addressing emergencies. Objective: To describe the emergency preparedness of secondary schools in Arizona specific to emergency action plans (EAPs), cardiac arrest, concussion, and heat illness. Design: Cross-sectional study. Setting: Online survey. Patients or Other Participants: Athletic directors from 143 Arizona secondary schools (response rate= 54%). Intervention(s): A 6-section survey that included questions related to athletic trainer (AT) access, EAPs, automated external defibrillators (AEDs), concussion, heat illness, and other policies. Main Outcome Measure(s): Descriptive statistics were reported. Comparisons of responses between schools with and without AT access were conducted with Mann-Whitney U tests. Results: Most respondents (81%, n= 116) indicated their school had access to an AT, and 95% (n=125) of respondents reported their school had a written EAP. The AEDs were available at most (93%, n=121) schools. All respondents were familiar with the interscholastic concussion policy, and 98% (n= 123) indicated they had a school-specific policy. Almost all respondents (99%, n= 121) reported being familiar with the state heat-illness policy. Environmental measures were taken before practices at 48% (n= 60) of schools. Schools with access to an AT were more likely to have an EAP, venue-specific EAPs, physician approval of EAPs, AEDs, heat-illness policies, and cold-water immersion tubs and to take environmental measures. Conclusions: Whereas the majority of schools reported AT access, not all schools had adequate EAPs in place. Schools would benefit from educational opportunities regarding best practices and policy development to improve emergency preparedness. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Youth athletes may specialize in a sport of their choosing, or based on external pressures, to pursue elite status in that sport. Current evidence shows an association between highly specialized athletes and an increase in injuries as well as a connection between injury and lower health-related quality of life (HRQOL). Clinical Question: In college athletes, do early sport specialization characteristics (ie, age at specialization and degree of specialization) impact current HRQOL? Summary of Key Findings: The literature was searched for studies that investigated the age of specialization (early vs late) or degree of specialization (high, moderate, and low) and the impact on HRQOL. (1) The search returned 6 possible studies related to the clinical question. Three of the studies met the inclusion criteria and were used for this appraisal. (2) Two of the 3 included studies reported that highly specialized athletes noted lower HRQOL. (3) One study found there to be no significant difference in HRQOL between athletes who specialized early versus late but did find those who specialized early to have a greater incidence of injuries that required surgery. Clinical Bottom Line: There is moderate evidence that early sport specialization is associated with lower HRQOL compared with late sport specialization. It is important to educate athletes, parents, and coaches on the potential detriments that are associated with early sport specialization to allow stakeholders to make informed decisions regarding participation. Strength of Recommendation: Grade B evidence exists to support the idea that early, intensive sport specialization may be associated with decreased HRQOL in current college athletes. [ABSTRACT FROM AUTHOR]

Teachers play an important role in supporting students' return to school after concussion. This online cross sectional survey examined teachers' beliefs and practices regarding concussion and academic support strategies, or academic adjustments (AA). Most teachers (99.1%) agreed-to-strongly agreed concussions affect school performance, and many (71.6%) have worked with a student who received AA after concussion. Teachers who participated in concussion education and observed a decline in a student's academic performance after concussion were more familiar with and recommended AA more often. Professional development is recommended to provide teachers with practical and timely resources to enhance support for students after concussion. [ABSTRACT FROM AUTHOR]

Objective: Examine the association between self-reported concussion history and measures of concussion knowledge, attitude, and disclosure behavior. Design: Cross-sectional survey. Setting: Classroom. Participants: A convenience sample of high school athletes (n = 167; mean age = 15.7 years) from multiple sports completed a validated survey. Independent Variables: Concussion history (main predictor) was defined as the number of self-recalled concussions during participants' high school career. Main Outcome Measures: The outcomes were recalled concussion disclosure behavior (3 measures) and scales assessing both concussion knowledge and concussion attitude. Results: A greater number of previous concussions was associated with worse attitude to concussion and negative concussion disclosure behavior. For every 3 additional self-recalled concussions, there was a mean decrease of 7.2 points (range of possible scores = 14-98) in concussion attitude score (P = 0.002), a 48% decrease in the selfreported proportion of concussion events disclosed (P = 0.013), and an increased prevalence of self-reported participation in games (67%) and practices (125%) while experiencing signs and symptoms of concussion (P, 0.001). Increased concussion history did not affect concussion knowledge score (P = 0.333). Conclusions: Negative trends in concussion disclosure behavior were identified in youth athletes with a positive history of concussion. Improving disclosure in this subgroup will require targeted efforts addressing negative attitude to concussion. [ABSTRACT FROM AUTHOR]

Objective: To systematically review the literature regarding rest and return to activity after sport-related concussion. Data Sources: The search was conducted in the Cochrane Central Register of Controlled Trials, CINAHL, SPORTDiscus, Educational Resources Information Center, Ovid MEDLINE, and PubMed using terms related to concussion, mild traumatic brain injury, physical and cognitive rest, and return to activity. Study Selection: Studies were included if they were published in English; were original research; and evaluated the use of, compliance with, or effectiveness of physical or cognitive rest or provided empirical evidence supporting the graded return-to-activity progression. Data Extraction: The study design, patient or participant sample, interventions used, outcome measures, main results, and conclusions were extracted, as appropriate, from each article. Data Synthesis: Articles were categorized into groups based on their ability to address one of the primary clinical questions of interest: use of rest, rest effectiveness, compliance with recommendations, or outcome after graded return-toactivity progression. A qualitative synthesis of the results was provided, along with summary tables. Conclusions: Our main findings suggest that rest is underused by health care providers, recommendations for rest are broad and not specific to individual patients, an initial period of moderate physical and cognitive rest (eg, limited physical activity and light mental activity) may improve outcomes during the acute postinjury phase, significant variability in the use of assessment tools and compliance with recommended return-toactivity guidelines exists, and additional research is needed to empirically evaluate the effectiveness of graded return-to-activity progressions. Furthermore, there is a significant need to translate knowledge of best practices in concussion management to primary care providers. [ABSTRACT FROM AUTHOR]

Primary objective: To review relevant literature regarding the effect of concussion on vestibular function, impairments, assessments and management strategies. Reasoning: Dizziness and balance impairments are common following sport-related concussion. Recommendations regarding the management of sport-related concussion suggest including tests of balance within the multifactorial assessment paradigm for concussive injuries. Analysis: The literature was searched for guidelines and original studies related to vestibular impairments following concussion, oculomotor and balance assessments and treatment or rehabilitation of vestibular impairments. The databases searched included Medline, CINAHL, Sport Discus and the Cochrane Database of Systematic Reviews through October 2013. Main outcomes and results: Dizziness following concussion occurs in ∼67-77% of cases and has been implicated as a risk factor for a prolonged recovery. Balance impairments also occur after concussion and last 3-10 days post-injury. Assessments of balance can be done using both clinical and instrumented measures with success. Vestibular rehabilitation has been shown to improve outcomes in patients with vestibular impairments, with one study demonstrating success in decreasing symptoms and increasing function following concussion. Conclusions: Best practices suggest that the assessment of vestibular function through cranial nerve, oculomotor and balance assessments are an important aspect of concussion management. Future studies should evaluate the effectiveness of vestibular rehabilitation for improving patient outcomes. [ABSTRACT FROM AUTHOR]

Objective: To determine whether jump-landing patterns, as assessed by the Landing Error Scoring System (LESS), differ based on sex and knee injury history. Design: Cross-sectional. Setting: College. Participants: Two hundred fifteen intercollegiate athletes were grouped by sex (male =116 and female = 99) and self-reported knee injury history (no = 148, mild = 31, and severe = 36). Interventions: Participants performed 3 trials of a standardized jump-landing task that were videotaped and later scored using the LESS. Main Outcome Measures: Overall, individual item, sagittal total error, and frontal total error scores of the LESS. Results: An interaction effect was reported for trunk flexion at initial ground contact. Main effects for sex indicated that males demonstrated more at-risk landing movement patterns on the sagittal plane (ie, limited trunk, knee and hip flexion at initial contact, and limited hip flexion throughout the landing), whereas females demonstrated more at-risk landing movement patterns on the frontal plane (ie, knee valgus at initial ground contact and maximum knee flexion, and more frontal plane movement throughout the landing). No main effects were reported for injury history. Conclusions: Jump-landing patterns seem to be impacted by sex but not knee injury history. Findings related to sex differences corroborate with previous laboratory-based investigations. Furthermore, findings support the clinical use of the LESS to screen for individuals who may be at risk for a lower extremity injury. Future studies should further investigate the clinical utility of the LESS, particularly its ability to predict lower extremity injuries. [ABSTRACT FROM AUTHOR]

Context: Increased rates of sport participation and sport- related injury have led to greater emphasis on and attention to medical care of student-athletes in the secondary school setting. Access to athletic training services is seen as a critical factor for delivering adequate injury prevention and medical care to student-athletes. However, few data are available regarding practice characteristics of athletic trainers (ATs) in this setting. Objective: To characterize the practices of secondary school athletic trainers (ATs). Design: Descriptive study. Setting: Web-based survey. Patients or Other Participants: A total of 17 558 ATs with current National Athletic Trainers' Association membership were identified for survey distribution. Of these, 4232 ATs indicated that they practiced in the secondary school setting, and 4045 completed some part of the survey. Main Outcome Measure(s): A Web-based survey was used to obtain demographic information about ATs and their secondary schools and characteristics of athletic training practice. Descriptive data regarding the athletic trainer's personal characteristics, secondary school characteristics, and practice patterns are reported as percentages and frequencies. Results: Most respondents were in the early stages of their careers and relatively new to the secondary school practice setting. Nearly two-thirds (62.4%; n = 2522) of respondents had 10 or fewer years of experience as secondary school ATs, 52% (n=2132) had been certified for 10 or fewer years, and 53.4% (n = 2164) had 10 or fewer years of experience in any practice setting. The majority of respondents (85%) worked in public schools with enrollment of 1000 to 1999 (35.5%) and with football (95.5%). More than half of respondents were employed directly by their school. Most respondents (50.6%) reported an athletic training budget of less than $4000. The majority of ATs performed evaluations (87.5%) on-site all of the time, with a smaller percentage providing treatments (73.3%) or rehabilitation (47.4%) services all of the time. Conclusions: This is the first study to describe secondary school athletic training that reflects national practice trends. To improve the quality of athletic training care and to support and improve current working conditions, the profession must examine how its members practice on a day-to-day basis. [ABSTRACT FROM AUTHOR]

Context: Analysis of health care service models requires the collection and evaluation of basic practice characterization data. Practice-based research networks (PBRNs) provide a framework for gathering data useful in characterizing clinical practice. Objective: To describe preliminary secondary school setting practice data from the Athletic Training Practice-Based Research Network (AT-PBRN). Design: Descriptive study. Setting: Secondary school athletic training facilities within the AT-PBRN. Patients or Other Participants: Clinicians (n = 22) and their patients (n = 2523) from the AT-PBRN. Main Outcome Measure(s): A Web-based survey was used to obtain data on clinical practice site and clinician characteristics. Patient and practice characteristics were obtained via deidentified electronic medical record data collected between September 1, 2009, and April 1, 2011. Descriptive data regarding the clinician and CPS practice characteristics are reported as percentages and frequencies. Descriptive analysis of patient encounters and practice characteristic data was performed, with the percentages and frequencies of the type of injuries recorded at initial evaluation, type of treatment received at initial evaluation, daily treatment, and daily sign-in procedures. Results: The AT-PBRN had secondary school sites in 7 states, and most athletic trainers at those sites (78.2%) had less than 5 years of experience. The secondary school sites within the AT-PBRN documented 2523 patients treated across 3140 encounters. Patients most frequently sought care for a current injury (61.3%), followed by preventive services (24.0%), and new injuries (14.7%). The most common diagnoses were ankle sprain/strain (17.9%), hip sprain/strain (12.5%), concussion (12.0%), and knee pain (2.5%). The most frequent procedures were athletic trainer evaluation (53.9%), hot- or cold-pack application (26.0%), strapping (10.3%), and therapeutic exercise (5.7%). The median number of treatments per injury was 3 (interquartile range = 2, 4; range = 2-19). Conclusions: These preliminary data describe services provided by clinicians within the AT-PBRN and demonstrate the usefulness of the PBRN model for obtaining such data. [ABSTRACT FROM AUTHOR]

Context: To improve patient care, athletic training clinicians and researchers should work together to translate research findings into clinical practice. Problems with patient care observed in clinical practice should be translated into research frameworks, where they can be studied. Practice-based research networks (PBRNs) provide a compelling model for linking clinicians and researchers so they can conduct translational research to improve patient care. Objective: To describe (1) the translational research model, (2) practice-based research as a mechanism for translating research findings into clinical practice, (3) the PBRN model and infrastructure, (4) the research potential using the PBRN model, and (5) protection of human participants in PBRN research. Description: Translational research is the process of transforming research findings into health behavior that ultimately serves the public and attempts to bridge the gap between research and clinical practice. Practice-based research represents the final step in the translational research continuum and describes research conducted by providers in clinical practices. The PBRNs are characterized by an organizational framework that transcends a single site or study and serves as the clinical research "laboratory" for conducting comparative-effectiveness studies using patient-oriented measures. The PBRN approach to research has many benefits, including enhanced generalizability of results, pooling of resources, rapid patient recruitment, and collaborative opportunities. However, multisite research also brings challenges related to the protection of human participants and institutional review board oversight. Clinical and Research Advantages: Athletic training studies frequently include relatively few participants and, consequently, are able to detect only large effects. The incidence of injury at a single site is sufficiently low that gathering enough data to adequately power a treatment study may take many years. Collaborative efforts across diverse clinical practice environments can yield larger patient samples to overcome the limitations inherent in single-site research efforts. [ABSTRACT FROM AUTHOR]

There is limited information about the use and perceptions of interventions postconcussion. The purpose of this study was to examine the treatment characteristics, self-reported confidence and perceptions of treatment, and barriers to treatment implementation. More than 50% of respondents utilized interventions for cervicogenic (55.5%, n = 85/153) and migraine symptoms (82.4%, n = 126/153). While respondents utilized and believed they should implement treatments, more than half referred to another healthcare professional (e.g., physical therapy, physician, psychologist) to perform treatment interventions. Finally, those in the clinic setting report having more adequate staff to perform treatments compared with high schools (p =.003). The continued use of interdisciplinary teams' postconcussion and the development of lower cost staff and resource interventions may help to increase adoption. [ABSTRACT FROM AUTHOR]

Background: To improve and standardize the sideline evaluation of sports-related concussion, the Sport Concussion Assessment Tool 2 (SCAT2) was developed. This tool assesses concussion-related signs and symptoms, cognition, balance, and coordination. This newly published assessment tool has not established representative baseline data on adolescent athletes.Hypothesis: Representative baseline SCAT2 scores in adolescent athletes will differ by gender, grade in school, and self-reported concussion history.Study Design: Descriptive epidemiology study.Methods: Interscholastic athletes were administered the SCAT2 during a preseason concussion baseline testing session. The SCAT2 total score ranges from 0 to 100 points, with lower scores indicating poorer performance. Overall, representative values were calculated using descriptive statistics. Separate independent-samples t tests, with gender and concussion history as the independent variables, and a 1-way analysis of variance, with grade as the independent variable, were conducted to assess differences in SCAT2 total score (P < .05).Results: There were 1134 high school athletes (872 male and 262 female) who participated. The SCAT2 total score across all participants was 88.3 ± 6.8 (range, 58-100); skewness was −0.86 ± 0.07, and kurtosis was 0.73 ± 0.14. Male athletes scored significantly lower on the SCAT2 total score (P = .03; 87.7 ± 6.8 vs 88.7 ± 6.8), and 9th graders (86.9 ± 6.8) scored significantly lower than 11th (88.7 ± 7.0) and 12th (89.0 ± 6.6) graders (P < .001). Athletes with a self-reported concussion history scored significantly lower on the SCAT2 total score than those with no concussion history (P < .001; 87.0 ± 6.8 vs 88.7 ± 6.5).Conclusion: These data provide representative scores on the SCAT2 in adolescent athletes and show that male athletes, 9th graders, and those with a self-reported concussion history scored significantly lower than their female, upperclassmen, or nonconcussed peers.Clinical Relevance: These results suggest that healthy adolescent athletes display variability on the SCAT2 at baseline. Therefore, clinicians should administer baseline assessments of the SCAT2 because assuming a perfect baseline score of 100 points is not appropriate in an adolescent athlete population. [ABSTRACT FROM PUBLISHER]

Abstract: There is a discrepancy between males and females in regards to lower extremity injury rates, particularly at the knee []. Gender differences in neuromuscular recruitment characteristics of the muscles that stabilize the knee are often implicated as a factor in this discrepancy. There is considerable research in the area of gender differences in regards to neuromuscular characteristics of the lower extremity in response to perturbation; however, most studies have been performed on the adult population only. Additionally, there is no consensus as to the gender differences that have been demonstrated. The purpose of this study was to compare muscular preactivation of selected lower extremity muscles (vastus medialis, rectus femoris, and medial/lateral hamstrings) in adolescent female basketball athletes, male basketball athletes, and female non-athletes in response to a drop landing. Subjects in the female non-athlete group recruited rectus femoris significantly slower than both the female athlete and male athlete groups (619.9=588.5>200.1ms prior to ground contact). The female non-athlete group also demonstrated a significantly slower vastus medialis compared to the female athlete group (127.1 vs 408.1ms), but not significantly slower than the male athlete group (127.1 vs 275.7ms). There were no differences between female athletes and male athletes for time to initial contraction of any muscle groups. No differences were found among the groups for medial or lateral hamstring activation. This study demonstrates that physical conditioning due to basketball participation appears to affect neuromuscular recruitment in adolescents and reveals a necessity to find alternate methods of training the hamstrings for improved neuromuscular capabilities to prevent injury. [Copyright &y& Elsevier]

The article aims to evaluate the concussion history of young athletes using three questions on the questions on the pre-participation screening (PPS) and a concussion symptom survey (CSS). Results show that there was little agreement among the three PPS questions, with kappa coefficients. The study concludes that identification of concussion history may depend on the phrasing of questions on the PPS. Detailed discussion of the results and information on the study's design, setting, participants, interventions and main outcome measures are provided.

Context: Establishing psychometric and measurement properties of concussion assessments is important before these assessments are used by clinicians. To date, data have been limited regarding these issues with respect to neurocognitive and postural stability testing, especially in a younger athletic population. Objective: To determine the test-retest reliability and reliable change indices of concussion assessments in athletes participating in youth sports. A secondary objective was to determine the relationship between the Standardized Assessment of Concussion (SAC) and neuropsychological assessments in young athletes. Design: We used a repeated-measures design to evaluate the test-retest reliability of the concussion assessments in young athletes. Correlations were calculated to determine the relationship between the measures. All subjects underwent 2 test sessions 60 days apart. Setting: Sports medicine laboratory and school or home environment. Patients or Other Participants: Fifty healthy young athletes between the ages of 9 and 14 years. Main Outcome Measure(s): Scores from the SAC, Balance Error Scoring System, Buschke Selective Reminding Test, Trail Making Test B, and Coding and Symbol Search subsets of the Wechsler Intelligence Scale for Children were used in the analysis. Results: Our test-retest indices for each of the 6 scores were poor to good, ranging from r = .46 to .83. Good reliability was found for the Coding and Symbol Search tests. The reliable change scores provided a way of determining a meaningful change in score for each assessment. We found a weak relationship (r < .36) between the SAC and each of the neuropsychological assessments; however, stronger relationships (r > .70) were found between certain neuropsychological measures. Conclusions: We found moderate test-retest reliability on the cognitive tests that assessed attention, concentration, and visual processing and the Balance Error Scoring System. Our results demonstrated only a weak relationship between performance on the SAC and the selected neuropsychological tests, so it is likely that these tests assess somewhat different areas of cognitive function. Our correlational findings provide more evidence for using the SAC along with a more complex neuropsychological assessment battery in the evaluation of concussion in young athletes. [ABSTRACT FROM AUTHOR]

The article discusses the postural control deficits in participants with functional ankle instability as measured by the Balance Error Scoring System (BESS), in the U.S. The study involved a between-groups design to assess postural control among participants, conducted in a university athletic training facility. The test battery of BESS requires participants to stand unsupported on two different surfaces and in different stances. Based from the results, subjects with functional ankle instability scored more errors or having poorer balance on the single stancefirm condition, tandem stancefoam condition, and total BESS score. Therefore, using the BESS, postural control deficits were identified in participants with functional ankle instability.

Clinical Scenario: Patients who experience prolonged concussion symptoms can be diagnosed with postconcussion syndrome (PCS) when those symptoms persist longer than 4 weeks. Aerobic exercise protocols have been shown to be effective in improving physical and mental aspects of health. Emerging research suggests that aerobic exercise may be useful as a treatment for PCS, where exercise allows patients to feel less isolated and more active during the recovery process. Clinical Question: Is aerobic exercise more beneficial in reducing symptoms than current standard care in patients with prolonged symptoms or PCS lasting longer than 4 weeks? Summary of Key Findings: After a thorough literature search, 4 studies relevant to the clinical question were selected. Of the 4 studies, 1 study was a randomized control trial and 3 studies were case series. All 4 studies investigated aerobic exercise protocol as treatment for PCS. Three studies demonstrated a greater rate of symptom improvement from baseline assessment to follow-up after a controlled subsymptomatic aerobic exercise program. One study showed a decrease in symptoms in the aerobic exercise group compared with the full-body stretching group. Clinical Bottom Line: There is moderate evidence to support subsymptomatic aerobic exercise as a treatment of PCS; therefore, it should be considered as a clinical option for reducing PCS and prolonged concussion symptoms. A previously validated protocol, such as the Buffalo Concussion Treadmill test, Balke protocol, or rating of perceived exertion, as mentioned in this critically appraised topic, should be used to measure baseline values and treatment progression. Strength of Recommendation: Level C evidence exists that the aerobic exercise protocol is more effective than the current standard of care in treating PCS. [ABSTRACT FROM AUTHOR]

Objective:To determine a balance recovery timeline after a functional exertion protocol using the Balance Error Scoring System (BESS). Design and Setting: Five subject groups (4 test, 1 control) were tested 3 times during 1 session: once before the exertion protocol (pretest) and twice after the exertion protocol (posttest I and posttest II). Posttest I occurred at staggered intervals of 0, 5, 10, and 15 minutes, depending on experimental group assignment, and posttest II occurred at 20 minutes. Subjects:One hundred subjects (80 test, 20 control) volunteered to participate in this study. None of the subjects had a balance disorder, mild head injury, or lower extremity injury in the 6 months before testing. Measurements:We assessed balance using the BESS, assigning a score for each stance-surface condition. Results: We found a significant decrease in BESS performance after the exertion protocol in all test groups, with exertion having the greatest effect on the tandem and single-leg stance conditions. All subjects recovered by posttest II, which was administered 20 minutes after cessation of the exertion protocol. Conclusions:Athletic trainers need to be aware of the effect of exertion when administering the BESS after physical activity. Athletic trainers can expect the BESS performance of healthy athletes to return to baseline levels within 20 minutes of rest. [ABSTRACT FROM AUTHOR]

Objective: To determine the immediate effects of a wholebody fatigue protocol on performance of the Balance Error Scoring System (BESS), a postural-stability test commonly used as part of a concussion-assessment battery. Design and Setting: Subjects were assigned to a fatigue or control group and were assessed before and immediately after a 20-minute fatigue protocol or rest period. Subjects: Fourteen fatigue subjects and 13 control subjects participated in this study. All subjects were male and free of vestibular disorders, and none had suffered a mild head injury or lower extremity injury in the preceding 6 months, as described through self-report. Measurements: We measured performance on the BESS for 9 stance-surface conditions and summed each condition to obtain a total score. Using the Borg scale, we also measured ratings of perceived exertion before, during, and after the fatigue protocol or rest period. Results: We found a significant increase in total errors from pretest to posttest in the fatigue group (14.36 ± 4.73 versus 16.93 ± 4.32), a significant decrease in errors in the control group (13.32 ± 3.77 versus 11.08 ± 3.88), and a significant difference between groups on the posttest. The rating of perceived exertion scores were significantly different between the fatigue and control groups at the middle (13.29 ± 1.59 versus 6.23 ± 0.83) and end (15.86 ± 2.38 versus 6.15 ± 0.55) of the fatigue or rest period. Conclusions:The BESS error scores increased immediately after the fatigue protocol, demonstrating that balance ability diminished. Clinicians who use the BESS as part of their sideline assessment for concussion should not administer the test immediately after a concussion due to the effects of fatigue. [ABSTRACT FROM AUTHOR]

This study quantitatively assessed the mechanical reliability and validity of position, torque and velocity measurements of the Biodex System 3 isokinetic dynamometer. Trial-to-trial and day-to-day reliability were assessed during three trials on two separate days. To assess instrument validity, measurement of each variable using the Biodex System 3 dynamometer was compared to a criterion measure of position, torque and velocity. Position was assessed at 5 degrees increments across the available range of motion of the dynamometer. Torque measures were assessed isometrically by hanging six different calibrated weights from the lever arm. Velocity was assessed (30 degrees/s to 500 degrees/s) across a 70 degrees arc of motion by manually accelerating the weighted lever arm. With the exception of a systematic decrease in velocity at speeds of 300 degrees/s and higher, the Biodex System 3 performed with acceptable mechanical reliability and validity on all variables tested. [ABSTRACT FROM AUTHOR]

The article offers information on advances in concussion assessment, treatment, and management since the National Athletic Trainers' Association (NATA) published its 2014 position statement. Topics include updates to the NATA's recommendations in key areas such as education, assessment, mental health considerations, and rehabilitation management strategies.

An editorial is presented on the Growing Influence of Female Athletic Training Scholars. The article discusses that studies of health care competency address trends in return to play after concussion, concussion education and care-seeking behaviors, athlete-workload monitoring, and external biofeedback for chronic ankle injury rehabilitation; and investigations related to the vitality of the profession address work-family guilt, mentoring newly certified athletic trainers (ATs).

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Despite a call to incorporate patient-reported outcome measures (PROMs) into all aspects of health care, little is known about which instruments are best suited for a pediatric patient population with sport-related injury. The objective of this article was to perform a systematic review of the currently available evidence to determine which PROMs were used for pediatric patients with sport-related injuries and identify the associated psychometric properties and considerations for clinical utility. We conducted a literature search for articles on PROMs used in the pediatric population through electronic databases and a manual search of reference lists and authors between from inception to 2020. Articles were grouped based on the PROM(s) included, and considerations for clinical utility and psychometric properties were extracted from each article. Thirty-nine articles were included in this review, from which 22 PROMs were identified: 12 PROMs were developed specifically for the pediatric population, 4 were modified versions of an adult scale, and 6 were adult measures used in a pediatric population. Of the PROMs included in this review, the Oxford Ankle Foot Questionnaire for Children and the Pediatric Quality of Life Inventory were the most comprehensive in their development and assessment. Several outcome measures used for pediatric patients had missing or inadequate measurement properties and considerations for clinical utility, particularly in regard to readability, responsiveness, and interpretability. Clinicians and researchers should consider a measure's feasibility, acceptability, appropriateness, and psychometric properties when selecting a PROM for use with the pediatric population. [ABSTRACT FROM AUTHOR]

The article presents a cross-sectional survey on the understanding of sport-related concussion among youth sports coaches which was administered at coaches' meetings, following practices, and via mail. It has been indicated that scores on the survey instrument reflecting symptom recognition and management knowledge. This survey indicated that among youth sports coaches, coaching education was predictive of the ability to recognize signs and symptoms of sport-related concussion. signs and symptoms of sport-related concussion. However, it is necessary that several misconceptions about concussion still exist and highlighting that education regarding concussion is essential.

Reference/Citation: Koh JO, Cassidy JD, Watkinson EJ. Incidence of concussion in contact sports: a systematic review of the evidence. Brain Inj. 2003;17:901-917. Clinical Question: What is the incidence of concussion in various contact sports? Data Sources: Studies for the review were found through a MEDLINE search (1985-2000) and by gathering and reviewing older articles referenced in the searched articles. The main terms that were included in the search were brain injuries, brain concussion, and incidence. Text words that were also included were mild traumatic brain injury, concussion, incidence, injury, and head injury, along with the names of 8 contact sports (American football, boxing, ice hockey, judo, karate, tae kwon do, rugby, and soccer). Study Selection: For this review, concussion was defined as "a mild brain injury resulting from a direct blow to the head resulting in physiological changes in brain function." Cohort studies with documented incidence of concussion in athletes from 8 identified contact sports were the target of the search. All studies of male and female athletes in any of the 8 contact sports, including practices and games and regardless of level of competition, were included in the study search. Possible articles for review were identified through a 3-step screening process. Article titles were initially screened by one of the authors. If the title seemed to be relevant to the purpose of the review, the abstract of the article was then screened for inclusion/exclusion criteria as the second step. To be included, studies had to relate to the incidence of injury to the head and brain, report results relevant to concussion, involve 1 of the 8 identified contact sports, and be published between 1985 and 2000. All systematic reviews about mild traumatic brain injury (TBI) or concussion were also included. Studies were excluded if they discussed concussion due to whiplash injury or concussion associated with spinal cord injury, facial bone fracture, or soft tissue injuries; if they reported prevalence, rather than incidence, of concussion; if they addressed chronic TBI; if they comprised case reports or letters to the editor; or if they lacked a denominator to determine risk rates. Finally, relevant and unknown articles from the abstract screening were reviewed again for the inclusion and exclusion criteria by an independent, outside party. Data Extraction: A general methodologic criteria design was used to critically appraise all articles that met the inclusion and exclusion criteria. This design appraised 11 study design and reporting criteria. In order for an article to be accepted into the systematic review, it had to meet at least the 5 mandatory criteria: description of the source population, appropriate description of inclusion and exclusion criteria, verifiable results from the raw data, differentiation of the incidence of injury between practice and game settings, and adequately measured denominator of population or person-time at risk. For each individual study, the 5 mandatory criteria listed above were rated with regard to whether they were included or addressed in the paper (yes), were missing from the paper (no), or were included but not described fully or in a way characterized by sound quality (substandard ). If any of the 5 mandatory criteria were rated no, the article was not evaluated any further. Data taken from these articles included sex, types of sessions in which concussion occurred, and numbers defining incidence of concussion within a contact sport. In some studies, rates were recalculated from the raw data in order to check accuracy, or if they were not presented in the published material, rates were calculated. These rates were recalculated with the denominator presented in the original study, athletes at risk for injury or time at risk for injury.… [ABSTRACT FROM AUTHOR]

Secondary schools that offer school-sponsored athletic events should follow best-practice guidelines to provide policies that promote student health and safety. To assess emergency preparedness from the perspective of athletic administrators (AAs) in Iowa secondary schools. Cross-sectional study. Online survey. Ninety-eight AAs from Iowa completed the survey (age = 45.33 ± 10.22 years, years as an AA = 9.37 ± 8.14, years in current role = 7.72 ± 7.09). The 6-section survey contained with questions about access to athletic trainers (ATs), emergency action plans (EAPs), cardiopulmonary resuscitation (CPR), automated external defibrillators (AEDs), concussions, heat illness, and other general policies. Descriptive statistics (percentages and frequencies) were reported. Relative risk was calculated to compare schools with and those without access to ATs (P <.05). Most respondents (76.5%, n = 75/98) reported their school had access to a licensed AT. The majority had a written EAP (83.3%, n = 70/84), but fewer than half (39.2%, n = 31/79) reviewed it annually and fewer than 10% (n = 6/85) reported practicing it each year. All respondents (100%, N = 78/78) stated they had an AED on campus. All respondents (N = 77/77) indicated that they were familiar with the Iowa High School Athletic Association's (IHSAA's) concussion policy and had a concussion guideline in place. Many respondents (95.9%, n = 71/74) described being familiar with the IHSAA's heat illness policy, but more than half (62.1%, n = 41/66) noted they did not have a heat illness policy in place at their school. Most respondents indicated their school had access to ATs, followed the state-mandated concussion guidelines, and had an AED. Although participants reported having written EAPs in place, levels of annual EAP review and practice were low. These results suggest that schools would benefit from educational opportunities to improve safety policies. [ABSTRACT FROM AUTHOR]

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport. Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice. These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies. [ABSTRACT FROM AUTHOR]

Background: Identifying risk factors for prolonged recovery following concussion can assist clinicians with appropriate management strategies. It is thought that athletes who continue to participate following a hit to the head or body may take longer to recover following a concussion diagnosis. Objective: To systematically review the body of literature regarding the effect of delayed reporting and delayed presentation to medical providers on concussion recovery times. Design: Systematic review with meta-analysis. Data Sources: PubMed, Ovid Medline, SPORTDiscus, Cochrane Central Register of Controlled Trials and hand searches of reference lists. All the searches were performed in April 2020. Eligibility criteria for selected studies: Studies included an investigation of immediate versus delayed reporting or early versus late presentation following a concussion, were published in the past ten years, and were level 4 evidence or higher. Results: 12 studies were included. Patients who continued play or delayed reporting their concussion had significantly longer recovery times (standardized mean difference = 0.36 days (95%CI 0.066, 0.662) than those who immediately reported or were removed from play (p = 0.017). Expressed in raw scores, those who immediately reported recovered in 5.4 days (95% CI − 10.14, − 0.75) fewer than delayed reporters. Comparable results were found for post-concussion symptom scores (p = 0.034) with immediate reporters demonstrating lower symptom severity scores. Our qualitative synthesis found patients who presented earlier to a concussion specialist tended to recover faster than those who presented later. Conclusions: Patients who delayed reporting or continued play had longer recovery times compared to their immediately-reporting peers. Providers should ask concussion patients approximately how long they waited to report their injury, and also focus educational efforts on encouraging immediate reporting of concussion. [ABSTRACT FROM AUTHOR]

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? [ABSTRACT FROM AUTHOR]

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? [ABSTRACT FROM AUTHOR]

Clinical Scenario: It has been suggested that posterior shoulder tightness is a common contributor to shoulder impingement in overhead-throwing athletes. The incidence of shoulder pain in the general population has been reported to be as high as 27%, and as many as 74% of the patients who were seen for shoulder issues had signs of impingement. Particularly regarding physically active adults, shoulder impingement is frequent among overhead-throwing athletes and may lead to lost participation in sport, as well as other injuries including labral pathologies. Therefore, finding an effective mechanism to reduce posterior shoulder tightness in overhead athletes is important and may help prevent impingement-type injuries. Typically, posterior shoulder tightness is identified by measuring horizontal humeral adduction; although another clinical measure that is commonly used is the bilateral measurement of glenohumeral internal-rotation (IR) range of motion (ROM). It is important to note, however, that the measurement of glenohumeral IR ROM specifically aims to identify glenohumeral IR ROM deficits (GIRD). Although GIRD is believed to be a leading contributor to posterior shoulder tightness, this measure alone may not capture the full spectrum of posterior shoulder tightness. While treatment interventions to correct any ROM deficits typically include a stretching protocol to help increase IR, joint mobilizations have been found to produce greater mobility of soft tissue and capsular joints. However, it is unclear whether the combination of both joint mobilizations and a stretching protocol will produce even larger gains of ROM that will have greater longevity for the patient suffering from posterior shoulder tightness. Focused Clinical Question: Does the use of joint mobilizations combined with a stretching protocol more effectively increase glenohumeral IR ROM in adult physically active individuals who participate in overhead sports and are suffering from posterior shoulder tightness, compared with a stretching protocol alone? [ABSTRACT FROM AUTHOR]

Clinical Scenario: It has been suggested that posterior shoulder tightness is a common contributor to shoulder impingement in overhead-throwing athletes. The incidence of shoulder pain in the general population has been reported to be as high as 27%, and as many as 74% of the patients who were seen for shoulder issues had signs of impingement. Particularly regarding physically active adults, shoulder impingement is frequent among overhead-throwing athletes and may lead to lost participation in sport, as well as other injuries including labral pathologies. Therefore, finding an effective mechanism to reduce posterior shoulder tightness in overhead athletes is important and may help prevent impingement-type injuries. Typically, posterior shoulder tightness is identified by measuring horizontal humeral adduction; although another clinical measure that is commonly used is the bilateral measurement of glenohumeral internal-rotation (IR) range of motion (ROM). It is important to note, however, that the measurement of glenohumeral IR ROM specifically aims to identify glenohumeral IR ROM deficits (GIRD). Although GIRD is believed to be a leading contributor to posterior shoulder tightness, this measure alone may not capture the full spectrum of posterior shoulder tightness. While treatment interventions to correct any ROM deficits typically include a stretching protocol to help increase IR, joint mobilizations have been found to produce greater mobility of soft tissue and capsular joints. However, it is unclear whether the combination of both joint mobilizations and a stretching protocol will produce even larger gains of ROM that will have greater longevity for the patient suffering from posterior shoulder tightness. Focused Clinical Question: Does the use of joint mobilizations combined with a stretching protocol more effectively increase glenohumeral IR ROM in adult physically active individuals who participate in overhead sports and are suffering from posterior shoulder tightness, compared with a stretching protocol alone? [ABSTRACT FROM AUTHOR]

Injury or illness can affect individual perceptions of health status and health-related quality of life (HRQOL). Concussion can result in different symptoms, impairments, and functional limitations that have been found to lower HRQOL. Furthermore, concussion is known to influence the emotional and behavioral dyscontrol domains of HRQOL in pediatric populations; however, this has yet to be explored in other populations. To compare individuals with and those without a concussion history and (1) HRQOL and (2) the emotional and behavioral dyscontrol domains of HRQOL in college students. Cross-sectional study. University laboratory setting. Of a total of 252 participants (155 women; age = 19.95 ± 1.53 years), 76 (30.2%) had a history of concussion and 176 (69.8%) did not. For participants with a history of concussion, the mean time since injury was 5.29 ± 2.77 years. The Patient-Reported Outcome Measures Information System (PROMIS) Global Health, version 1.1, and Quality of Life in Neurological Disorders Emotional and Behavioral Dyscontrol Short Form (Neuro-QOL). No differences were seen between median scores in individuals with and those without a history of concussion in the PROMIS Physical Health (13.0 versus 14.0; P =.24), PROMIS Mental Health (12.0 versus 12.0; P =.99), and Neuro-QOL (16.0 versus 16.0; P =.47) scores. Additionally, when gender was controlled, the associations between a history of concussion and PROMIS Physical Health score (odds ratio [OR] = 1.04; 95% CI = 0.43, 2.52), PROMIS Mental Health score (OR = 0.66; 95% CI = 0.13, 3.25), and Neuro-QOL score (OR = 1.16; 95% CI = 0.66, 2.04) were not significant. Preliminary findings suggested that the emotional and behavioral dyscontrol domains were not influenced by a concussion history of > 1 year in college-aged participants. Future researchers should continue to explore specific HRQOL domains affected by concussion as well as the influences of prior mental health conditions and behavioral dysfunction after a subsequent injury. [ABSTRACT FROM AUTHOR]

Context: Concussions are shown to hinder multiple health dimensions, including health-related quality of life (HRQOL), suggesting a need for a whole-person approach to assessment and treatment. Patient-reported outcome measures are one method to gather the patient's perspective regarding their HRQOL. Objective: To evaluate perceived HRQOL using the Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale in patients throughout concussion recovery. Design: Prospective cohort, descriptive survey. Setting: There were 9 high school athletic training facilities. Participants: A total of 70 patients with diagnosed concussions (51 males, 7 females, 12 unreported; age = 15.7 [0.9] y, height = 174.6 [8.4] cm, mass = 72.8 [14.8] kg, grade = 10.0 [0.9] level). Interventions: Patient-Reported Outcomes Measurement Information System Pediatric-25 was administered at 3 days, 10 days postconcussion, and return to play (RTP). Main Outcome Measures: Patient-Reported Outcomes Measurement Information System Pediatric-25 subscale T scores and self-reported concussion history (yes/no). Results: A total of 70 patients completed the study. For the Pediatric-25 subscales, the severity of problems associated with Physical Function Mobility, Anxiety, Depression, Fatigue, and Pain Interference were highest 3 days postconcussion, decreasing at 10 days and RTP (all p <.05). No differences were found between days 3 and 10 for Peer Relationship scores, but improvements were identified at RTP (p <.05). Pediatric-25 subscale scores at the 3 measurements were not statistically associated with concussion history (all p >.05). Ceiling and floor effects were present in all subscales throughout each timepoint, except for Physical Function Mobility (14.7%), and pain interference (11.8%) at day 3 postinjury. Conclusions: Patients who had suffered a concussion improved from day 3 through RTP on multiple health domains as demonstrated through the Pediatric-25 subscales. These findings highlight the need for health care professionals to serially monitor HRQOL and social factors that may affect the patient postconcussion as part of a multifactorial assessment. Ceiling effects in high functioning adolescent athletes were present; thus, efforts should be made to identify appropriate scales for use in managing recovery in athletic populations. [ABSTRACT FROM AUTHOR]

Objective To determine the impact of concussion on general, fatigue-specific, and headache-specific Health-related quality of life (HRQOL). Design Repeated measures. Setting High school athletic facilities. Patients Two hundred and fifty-nine adolescent athletes who sustained a concussion diagnosed by their athletic trainer (218 males, 41 females, age=15.9±1.2 years, grade=10.0±1.1). Interventions Participants completed the paediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), and Headache Impact Test (HIT-6) during a preseason baseline (BL) and on days 3 (D3), 10 (D10) and 30 (D30) post-concussion. Main Outcome Measures Dependent variables included: 4 PedsQL subscale scores (physical (PF), emotional (EF), social (SOF), school (SCF) functioning), 3 MFS subscale scores (general (GF), sleep (SLF), cognitive (CF) fatigue), and the HIT-6 total score. Higher scores on the HIT-6 and lower scores on the PedsQL and MFS indicate lower HRQOL. Analyses were conducted using generalised estimating equations with follow-up Bonferroni corrections. Results All omnibus tests were significant (p<0.001). Athletes reported significantly lower HRQOL on D3 than BL for PF (D3=77.8, 95% CI 75.1 to 80.4; BL=92.9, 95% CI 91.4 to 94.4), SCF (D3=78.6, 95% CI 76.3 to 80.8; BL=83.9, 95% CI 81.8 to 86.0), CF(D3=73.2, 95% CI 70.3 to 76.1; BL=82.6, 95% CI 79.9 to 85.1), GF (D3=74.9, 95% CI 72.0 to 77.9; BL=85.1, 95% CI 82.8 to 87.4) and HIT-6 (D3=51.5, 95% CI 50.3 to 52.6; BL=45.4, 95% CI 44.5 to 46.4). All D10 and D30 subscale scores were significantly higher than BL. Conclusions Concussed athletes demonstrated lower general, fatigue-specific, and headache-specific HRQOL in the immediate days post-injury. These findings corroborate reports of the symptoms experienced acutely post-concussion and align with a time when athletes are often restricted from participating in physical and cognitive activities. The effects of concussion on HRQOL appear short-lived, with recovery by 10 days postinjury. [ABSTRACT FROM AUTHOR]

Concussion symptoms are important self-reported indicators of recovery. The purpose of this study was to describe the symptom burden in the first 3 weeks postconcussion and estimate the strength of relationship between symptomatology and days postconcussion. Headache was the most commonly endorsed symptom during weeks 1 (71.1%), 2 (37.6%), and 3 (32.6%). Severity scores were negatively correlated with days postconcussion, p <.01. While headache is commonly reported following a concussion, and decreases with time, it was still endorsed 3 weeks postinjury. Clinicians should be aware that lingering symptoms may suggest a prolonged recovery that requires an active treatment approach. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Context: Athletic trainers (ATs) play a vital role in managing the care of student-athletes after a sport-related concussion, yet little is known about their specific involvement in the implementation of academic adjustments as part of the concussionmanagement plan. Objective: To explore ATs' perceived roles and responsibilities regarding the implementation of academic adjustments for concussed student-athletes. Design: Qualitative study. Setting: Individual telephone interviews. Patients or Other Participants: Sixteen ATs employed in the secondary school setting (8 women, 8 men; age = 39.6 ± 7.9 years; athletic training experience = 15.1 ± 5.6 years), representing 12 states, were interviewed. Data Collection and Analysis: One telephone interview was conducted with each participant. After the interviews were transcribed, the data were analyzed and coded into themes and categories, which were determined via consensus of a 4-person research team. To decrease researcher bias, triangulation occurred through participant member checking, the inclusion of multiple researchers, and an internal auditor. Results: Several categories related to participants' perceptions regarding their roles and responsibilities within the academicadjustments process emerged from data analysis: (1) understanding of academic adjustments, (2) perceptions of their roles in academic adjustments, (3) initiation of academic adjustments, (4) facilitation of academic adjustments, and (5) lack of a role in the academic-adjustments process. Althoughmost ATs perceived that they had a role in the initiation and facilitation of academic adjustments for concussed student-athletes, some reported they did not want a role in the process. Regardless, participants frequently suggested the need for further education. Conclusions: These findings highlight that ATs either wanted to be involved in the implementation of academic adjustments but felt further education was needed or they did not want to be involved because they felt that it was not in their area of expertise. To create a cohesive concussion-management team, it is vital that ATs understand their individual and collaborative roles in the secondary school setting. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events. [ABSTRACT FROM AUTHOR]

The article discusses research being done on evidence-based studies which examined concussions in athletes. It references the study "The Effects of Rest and Treatment Following Sport-Related Concussion: A Systematic Review of the Literature," by K. J. Schneider et al. in the 2013 issue of the "British Journal of Sports Medicine." The factors considered include criteria used in study selection, data extraction and final article selection.

To estimate scale scores for patient-reported outcome (PRO) measures that classify patients as improved or unimproved at days 3 and 10 post-concussion. Data from 187 adolescent patients who sustained a concussion (150 males, 32 females, 5 not reported) were analyzed. Patients completed the Pediatric Quality of Life Inventory (PedsQL), PedsQL Multidimensional Fatigue Scale (MFS), Headache Impact Test (HIT-6), and Global Rating of Change (GROC) on days 3 and 10 post-concussion. Dependent variables: PedsQL total score, 3 MFS subscale scores [general (MFS-GF), sleep (MFS-SLF), cognitive (MFS-CF) fatigue], and HIT-6 total score. Higher scores on PedsQL and MFS indicate better health; lower scores on HIT-6 indicate less impact on headache-related health. GROC ascertained patient-perceived magnitude of change in health status since concussion. Receiver Operating Characteristic Curve analyses estimated PRO cut-point scores that classified patients as improved or unimproved. Day 3 PRO cut-points: PedsQL total = 90; MFS-GF = 73; MSF-CF = 85; MFS-SLF = 81; and HIT-6 total = 54. Day 10 PRO cut-points: PedsQL total = 91; MFS-GF = 85; MFS-CF = 85; MFS-SLF = 90; and HIT-6 total = 51. Our results define PedsQL, MFS, and HIT-6 scores as they relate to perceived improvement following concussive injuries. Cut-point scale scores help clinicians interpret concussion PROs and make informed decisions during the management of patients with concussion. [ABSTRACT FROM AUTHOR]