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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.

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.

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.

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.

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.

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.

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

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?

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

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?

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?

Context: Accurate assessment of health-related quality of life (HRQoL) is important for quality patient care. Evaluation of HRQoL typically occurs with patient self-report, but some instruments, such as the Pediatric Quality of Life Inventory (PedsQL), allow for proxy reporting. Limited information exists comparing patient and proxy reports of HRQoL after sport-related injury in adolescent athletes., Objective: To compare patient ratings and parent-proxy ratings of HRQoL in adolescent athletes who suffer musculoskeletal injuries requiring orthopedic consultation. The authors hypothesized poor agreement between patient and parent-proxy ratings of HRQoL., Design: Cross-sectional study., Setting: Orthopedic practice., Patients: Thirteen adolescent patients with a sport-related musculoskeletal injury requiring orthopedic consultation and 1 of their parents participated., Interventions: During the initial visit to the physician's office, each patient was asked to complete the PedsQL, and the patient's parent was asked to complete the parent-proxy version of the PedsQL., Main Outcome Measurements: The PedsQL is a pediatric generic outcome measure that consists of a total score and 4 subscale scores: physical, emotional, social, and school functioning. Means and standard deviations were calculated for all scores, and comparisons between patient-self report and parent-proxy ratings of HRQoL were made for the PedsQL total score and subscale scores using Pearson product-moment correlations (r)., Results: Pearson product-moment correlations showed little to fair insignificant relationships between patient self-report and parent-proxy report of the PedsQL for the total score (r = -.1) and all subscales (range r = .1 to .4)., Conclusions: Our results suggest a lack of agreement between patient and parent-proxy ratings of HRQoL, with patients rating their HRQoL lower than their parent. Patient perception of HRQoL may be more accurate than proxy report, which supports the use of patient-rated HRQoL in patient evaluation. Assessments of HRQoL made by proxies, even those close to the patient, may not represent patient health status.

Context: Recurrent headaches significantly affect health-related quality of life (HRQOL) in adults; the impact of headache on HRQOL among adolescents is unknown, and the psychometric properties of headache-specific outcomes instruments have not been adequately studied in this population., Objective: To evaluate the psychometric properties of the Headache Impact Test (HIT-6) and Pediatric Migraine Disability Assessment (PedMIDAS) in healthy adolescent athletes., Design: Descriptive survey., Setting: High school athletic training facilities during the fall sports season., Participants: 177 high school athletes (89 males and 88 females)., Interventions: A survey consisting of a demographic and concussion-history questionnaire, a graded symptom scale, the HIT-6, and the PedMIDAS. Internal consistency (α), test-retest reliability (r(s)), Bland-Altman analyses, and the Mann-Whitney U test were used to evaluate psychometric properties and age and gender differences., Main Outcome Measures: The HIT-6 and PedMIDAS item and total scores., Results: Test-retest reliability for the HIT-6 total score was r(s) = .72, and reliability of individual items ranged from r(s) = .52 to .67. The test-retest reliability for the PedMIDAS total score was r(s) = .61, and reliability of individual items ranged from r(s) = .23 to .62. Both scales demonstrated acceptable internal consistency: HIT-6 α = .89-.90 and PedMIDAS α = .71-.75., Conclusions: The authors found moderate test-retest reliability for the HIT-6 and the PedMIDAS in a healthy adolescent athlete population. Research on the applicability and utility of the HIT-6 and PedMIDAS in concussed adolescents is warranted.

PATIENT SCENARIO: An adolescent female youth soccer athlete, with a previous concussion history, suffered a second concussion 4 wk ago. Her postconcussive symptoms are affecting her school performance and social and family life. CLINICAL OUTCOMES ASSESSMENT: Concussion is typically evaluated via symptoms, cognition, and balance. There is no specific patient-oriented outcomes measure for concussion. Clinicians can choose from a variety of generic and specific outcomes instruments aimed at assessing general health-related quality of life or various concussion symptoms and comorbidities such as headache, migraine, fatigue, mood disturbances, depression, anxiety, and concussion-related symptoms. CLINICAL DECISION MAKING: The data obtained from patient self-report instruments may not actively help clinicians make return-to-play decisions; however, these scales may be useful in providing information that may help the athlete return to school, work, and social activities. The instruments may also serve to identify issues that may lead to problems down the road, including depression or anxiety, or serve to further explore the nature of an athlete's symptoms., Clinical Bottom Line: Concussion results in numerous symptoms that have the potential to linger and has been associated with depression and anxiety. The use of outcomes scales to assess health-related quality of life and the effect of other symptoms that present with a concussion may allow clinicians to better evaluate the effects of concussion on physical, cognitive, emotional, social, school, and family issues, leading to better and more complete management.

Context: Patient-oriented outcome measures such as the Medical Outcomes Short Form (SF-36) and the Pediatric Outcomes Data Collection Instrument (PODCI) are important tools for determining the impact of events like sport-related injury on health-related quality of life (HRQoL). Unfortunately, there are no published studies using these instruments that compare adolescent athletes with their nonathlete peers, making interpretations of these measures in this population difficult., Objective: To compare HRQoL in adolescent athletes and nonathletes using 2 common instruments., Design: Cross-sectional., Setting: 7 high schools., Participants: 219 athletes and 106 nonathletes., Intervention: None., Main Outcome Measures: The SF-36 and the PODCI were completed in a counterbalanced manner during 1 session. Dependent variables included the 8 subscale and 2 composite scores of the SF-36 and the 5 subscale scores and 1 global score of the PODCI., Results: On the SF-36, athletes reported higher scores on the physical function, general health, social functioning, and mental health subscales and the mental composite score and lower scores on the bodily pain subscale than nonathletes. On the PODCI, athletes reported higher scores on the sport and physical function and happiness subscales and lower scores on the pain/comfort subscale., Conclusions: Athletes reported higher scores on a number of SF-36 and PODCI subscales related to mental, emotional, and physical well-being than nonathletes. Our findings suggest that athletic involvement may be a benefit to the overall health status of adolescents and imply that athletes may be a distinct adolescent group requiring their own normative values when using the SF-36 and PODCI.

Ankle sprains are one of the most common sport-related injuries treated by rehabilitation professionals. These injuries often result in lost participation and can lead to subsequent injury episodes. Therefore, it is important to determine appropriate means of preventing these injuries. There has recently been an increase in the popularity of balance training programs for the prevention of knee anterior cruciate ligament (ACL) injury, with some thought that starting these programs in younger athletes may be most beneficial. However, there is the potential that these types of training programs may also be beneficial for decreasing the risk of other lower extremity injuries, including ankle sprains in the adolescent athlete.

Context: Clinicians often rely on the self-report symptoms of patients in making clinical decisions; hence it is important that these scales be reliable., Objective: To determine the test-retest reliability of healthy youth in completing a graded symptom scale (GSS), modified from the Head Injury Scale Self-Report Concussion Symptoms Scale (HIS)., Design: Repeated-measures., Setting: Middle school classroom., Patients or Other Participants: 126 middle school students., Intervention: A survey consisting of a demographic and life events questionnaire and a GSS asking about symptom severity and duration., Main Outcomes Measures: Score for each symptom on the severity and duration scale and a total symptom score (TSS) and the total number of symptoms endorsed (TSE) from the severity scale. Responses on a life events questionnaire were also recorded., Results: We found excellent reliability for TSS (ICC=.93) and TSE (ICC=.88) for the severity scale. We found moderate to excellent reliability on the individual symptoms of both the severity (ICC=.65-.89) and duration (ICC=56-.96) scales., Conclusions: Healthy youth can reliably self-report symptoms using a GSS. This patient-oriented outcome measure should be incorporated into more investigations in this age group.