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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 denned 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? [ABSTRACT FROM AUTHOR]

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? [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: 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]

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. [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]

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]

Context: Currently, significant attention is focused on improving care for patients with concussions through legislative mandates that include educational interventions. Few researchers have examined young athletes' concussion knowledge and the factors that may influence their knowledge. Objective: To use the socioecological model to examine demographic, parental, and personal factors associated with youth athletes' knowledge of concussion. Our ultimate goal is to inform the planning and implementation of youth sport concussion-related interventions. Design: Cross-sectional survey. Setting: Gymnasium and classroom. Patients or Other Participants: North Carolina and Arizona youth athletes (n = 225; age = 8 to 15 years) active in football, boys' or girls' soccer, boys' or girls' ice hockey, or boys' or girls' lacrosse in 2012-2013. Main Outcome Measure(s): Participants completed a validated, self-administered survey. The intention and belief measures were guided by the theory of planned behavior. Perceptions of concussion and intention to seek care were examined using descriptive statistics. Athletes' concussion knowledge was modeled using linear regressions and generalized estimating equations, with child demographic and personal factors and parental knowledge and attitudes about concussion as predictors. Results: Geography, sport, parental attitudes toward concussion, and athlete age were associated with athlete knowledge in the univariable analyses (P < .10). In the multivariable model, geographic location (North Carolina versus Arizona, mean difference [MD] = 2.2, 95% confidence interval [CI] = 1.1, 3.2), sport (girls' soccer versus girls' lacrosse, MD = 2.2, 95% CI = 0.7, 3.6), more favorable parental attitudes toward concussion (MD = 1.2 for a 2-standard deviation shift; 95% CI = 0.3, 2.1), and older age (>12 years, MD = 1.6; 95% CI = 0.5, 2.6) were associated with better knowledge about concussion. Conclusions: Geographic location, sport, parental attitudes about concussion, and athlete's age influenced athletes' concussion-related perceptions, indicating the need to address multiple levels of the socioecological model when targeting youth sport interventions. Parental interventions that translate to an improved culture of youth sport by improving youth athletes' perceptions and experiences are key areas for future work. [ABSTRACT FROM AUTHOR]

Background: Little is known about the relationship between post-concussion impairments and health-related quality-of-life (HRQoL). The primary purpose of this study was to determine the relationship between traditional concussion assessments and HRQoL in adolescent athletes post-concussion. The secondary purpose was to determine the association between HRQoL deficits and time lost. Methods: In total, 1134 athletes completed a baseline assessment battery. HRQoL measures included the Pediatric Quality of Life Inventory (PedsQL), Multidimensional Fatigue Scale (MFS) and Headache Impact Test-6. In total, 122 athletes sustained a concussion and underwent follow-up testing at 3 and 10 days post-injury. Results: The strongest relationships were between symptom severity and HRQoL. For concurrent regression analyses at Day 3, PedsQL-Physical accounted for 17.9% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, PedsQL-School accounted for 15.2% and symptom severity for 7.1% of this variance. In predictive analyses, at Day 3, PedsQL-Physical accounted for 3.9% and MFS-General for 3.3% of the variance in time lost beyond that accounted for by traditional measures. At Day 10, MFS-Cognitive accounted for 12.0% of this variance. Conclusions: HRQoL appears to play a role in time lost post-concussion and should be measured in combination with traditional concussion assessments. [ABSTRACT FROM PUBLISHER]

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]

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]