Journal of Sport Rehabilitation最新文献

Although concussion management and return to play/learn decision making focuses on reducing symptoms, there is growing interest in objective physiological approaches to treatment. Clinical and technological advancements have aided concussion management; however, the scientific study of the neurophysiology of concussion has not translated into its standard of care. This expert commentary is motivated by novel clinical applications of electroencephalographic-based neurofeedback approaches (eg, quantitative electroencephalography [QEEG]) for treating traumatic brain injury and emerging research interest in its translation for treating concussion. QEEG's low-cost relative to other brain recording/imaging techniques and precedent in clinical and medical care makes it a potential tool for concussion rehabilitation. Although uncommon, licensed and certified clinicians and medical professionals are implementing QEEG neurofeedback for concussion management within their score of practice. These approaches are not widely adopted nor recommended by professional medical societies, likely because of a limited evidence base of well-designed studies with available standard protocols. Thus, the potential efficacy of QEEG neurofeedback for treating persistent symptoms or cognitive dysfunction after sports-related concussion is unknown. This commentary will update the concussion clinician-scientist on the emerging research, techniques, and disagreements pertaining to the translation of QEEG neurofeedback for concussion management, particularly in the treatment of persistent cognitive difficulties. This commentary will also introduce to readers the fundamentals of how the electroencephalogram may be acquired, measured, and implemented during QEEG neurofeedback. An evidence base of supportive findings from well-designed studies, including those that are retrospective, outcomes-based, and, ultimately, placebo/sham-controlled is recommended prior to considering more widespread adoption of QEEG neurofeedback approaches for treating persistent symptoms or cognitive deficits after sports-related concussion. We review the considerable barriers to this research and clinical implementation, and conclude with opportunities for future research, which will be necessary for establishing the quality and efficacy of QEEG neurofeedback for concussion care.

Clinical scenario: Individuals with patellofemoral pain (PFP) present with a variety of neuromuscular and psychological deficits, with the "gold-standard" for treatment being rehabilitation programs with strengthening-based exercises. While such interventions primarily target pain and function measures, it is unknown whether psychological measures such as fear-avoidance beliefs (FABs) are also affected.

Clinical question: Is rehabilitation including strengthening exercises effective in improving FABs in individuals with PFP?

Summary of key findings: Three studies met the inclusion criteria and were included in the appraisal. All studies found that rehabilitation including strengthening exercises was effective in improving FABs for physical activity, though such improvements were modest. One study found that supplementing a one-time psychological intervention to rehabilitation including strengthening exercises resulted in greater improvements in FABs than with rehabilitation including strengthening exercises alone. Two studies found associations between changes in FABs and changes in pain and/or function outcomes.

Clinical bottom line: There is consistent evidence that the incorporation of rehabilitation with strengthening exercises is effective in improving FABs in individuals with PFP, though such improvements are modest. Furthermore, supplementation with psychological interventions to rehabilitation including strengthening exercises may produce larger improvements in FABs, particularly in patients with an elevated FABs phenotype. As a result of improving FABs, patient outcomes of pain and function may be improved, though future research is needed. Therefore, at this time, we recommend that rehabilitation, including strengthening exercises with supplemental psychological interventions be prescribed for the treatment of PFP particularly in subgroups with elevated FABs, to improve patient outcomes.

Strength of recommendation: Collectively, the body of evidence included to answer the clinical question aligns with the strength of recommendation of A based on the Strength of Recommendation Taxonomy.

Context: The Buffalo Concussion Treadmill Test (BCTT) for exercise intolerance following concussion may highlight underlying autonomic dysfunction. Autonomic function at rest and with exertion may be predictive of neurocognitive performance for individuals with sports-related concussion. The purpose of this study is to explore the feasibility and utility of combining multimodal assessments with heart rate variability (HRV) measures during the BCTT for individuals with a remote history of concussion.

Design: Prospective cohort study design, pretest/posttest.

Methods: Participants included 5 males and 5 females (N = 10, age: 25.2 [3.3] y old, height: 173.2 [11.2] cm, mass: 73.4 [13.7] kg, body mass index: 24.5 [3.9], time since last concussion of 6.3 [4.5] y). All participants completed the multimodal assessment battery including: Concentration Reverse Digits (6 digits), Stroop Incongruent, and King-Devick Test under single- (seated) and dual-task conditions (walking on treadmill at 2.0 mph, 0% incline). Heart rate and HRV was collected at rest, during the BCTT, and during postexercise recovery. HRV data were processed and analyzed based on established protocols. Paired t tests were performed for pre- and postmeasurements separately for single- and dual-task tests of the multimodal assessment battery and HRV indices.

Results: During the BCTT, HRV indices reflective of peripheral nervous system activity demonstrated a significant reduction with concomitant increase in HRV indices of sympathetic nervous system activity (P < .05). Recovery in these HRV indices toward baseline was observed during postexercise recovery. Neurocognitive performance on the Stroop task significantly improved with exercise (P < .05).

Conclusion: Implementation of multimodal assessments to evaluate physiological and neurocognitive responses to exercise in individuals with history of sports-related concussion is feasible. Addition of these objective measures may decrease reliance on self-reporting of exercise-induced symptom exacerbation, enabling clinicians to identify individuals whose neurocognitive performance or physiologic response to exercise on the BCTT deviates from the expected.

Clinical scenario: The Functional Movement Screen (FMS) is used to assess movement patterns and the risk of injury of active individuals. Current studies have found positive relationships with core training and injury prevention as well as lower limb stability, which can help improve FMS scores.

Clinical question: Does the implementation of a core training program have an impact on FMS scores in healthy active adults who participate in sport?

Summary of key findings: Literature was searched for articles that included core-focused exercises and implementation of the FMS. This resulted in 25 studies being returned, only 23 of which were published in the last 10 years. Only 7 focused on the change in FMS scores after implementation of core training. Three of these studies were included in the analysis due to the specialized athlete population. All 3 studies found that using a core training program led to significantly higher FMS scores postintervention.

Clinical bottom line: There is clear evidence that core training increases FMS scores in athletes. It is important for health care providers treating athletes to consider core training to improve functional movement patterns or FMS scores in sport-specific populations.

Strength of recommendation: Overall, there are moderate to high levels of evidence that support a grade B recommendation for core training improvements on FMS scores in athletes.

Context: The single-leg hop is based solely on performance with no measure of movement quality. The purpose of this study was to (1) develop a real-time screening tool to capture single-leg functional performance and movement quality and (2) to provide preliminary validation (criterion validity) of a trained clinician's real-time movement quality assessment with 3D kinematics.

Study design: Cross-sectional.

Methods: Fifty-nine adolescent athletes volunteered (15.2 [1.1] y, 165.8 [9.2] cm, and 61.5 [13.9] kg, 51 females and 8 males). Each participant performed 3 trials of the single-leg hop on their dominant leg. A 3-dimensional inertial measurement system was used to capture knee joint kinematics. A movement quality checklist for use during a single-leg hop (movement quality single-leg hop) was developed to score biomechanical errors based on lower-extremity injury risk factors. Four criteria were developed for the checklist: (1) knee valgus, (2) foot rotation, (3) lateral trunk flexion, and (4) erect posture. An independent t test was conducted for each dependent variable (knee flexion displacement and knee abduction displacement) by each independent variable (movement category presence of (1) lateral trunk flexion, (2) knee valgus, (3) foot rotation, and (4) erect posture/sound during landing [yes or no]). The alpha level was set at α < .05 for all analyses.

Results: Knee flexion displacement was significantly decreased (P < .001, mean difference 9.40 [1.88]) and knee abduction displacement was significantly increased (P < .001, mean difference 9.41 [0.47]) for those who had knee valgus documented by the clinician. In additional, for those with visually documented erect posture/sound of landing, there was a significant decrease in knee flexion displacement (P < .001, mean difference 10.13 [2.34]).

Conclusion: The movement quality single-leg hop checklist has shown promising preliminary validation (criterion validity) for clinicians to assess movement quality. Increased knee abduction and decreased knee flexion are common risk factors associated with knee injuries and this clinician friendly real-time checklist may highlight individuals who are at risk of sustaining a knee injury.

Context: Advancements in portable load-cell technology have enabled high-quality assessment of shoulder internal (IR) and external rotation (ER) peak force (Fmax) and rate of force development (RFD). This study's purpose was to explore the reliability and differences between IR and ER Fmax and RFD in different testing positions using a novel load-cell device.

Design: A within-subjects repeated-measures design was employed to compare the intersession values and reliability of Fmax and RFD for both shoulder IR and ER across 3 positions: seated-0°, supine-0° and supine-90°.

Methods: National-level swimmers (n = 19; age = 16.8 [1.0] y) completed 3 testing occasions of each condition (combination of arm, rotation, and test position) separated by 7 to 14 days.

Results: IR superseded ER in all testing positions. The association between these positions across IR and ER was typically strong for both Fmax and RFD (r > .85, P < .001) except for IR RFD (r = .56-.73, P < .05). For sessions 2 to 3, Fmax intraclass correlation coefficient and CV (intraclass correlation coefficient = .89-.96, CV = 5.2%-8.8%) were typically within acceptable ranges, whereas RFD (intraclass correlation coefficient = .74-.90, CV = 11.5%-18.1%) often exhibited inflated error.

Conclusion: The supine (90°) position was the most consistent position across both measures. Load-cell technology can be confidently used to assess shoulder rotation Fmax in 3 different positions, whereas RFD should be used with caution without protocol refinement.

Context: In shoulder rehabilitation, exercises that reduce upper trapezius (UT) activity and optimize the trapezius muscle activation rate reduce the symptoms of shoulder pathologies. One such exercise, the lawn-mower (LM) exercise, is frequently used in scapular rehabilitation protocols due to its multijoint, multiplanar, and kinetic chain-based nature. Design/Objective: This study aimed to compare trapezius muscle activation levels and ratios during the LM exercise in standing and quadruped positions through a randomized controlled trial.

Methods: Eighteen healthy volunteers (mean age [SD] = 25 [5] y, 10 women and 8 men, mean body mass index [SD] = 22.91 [2.59] kg/m2) participated in the study, and surface electromyography was employed to measure trapezius muscle activity during quadruped LM (QLM) and standing LM (SLM) exercises. The data were normalized as a percentage of maximal voluntary contraction.

Results: The study revealed significantly lower UT activity (percentage of maximal voluntary contraction) during QLM compared with SLM (P < .05) in concentric and isometric phases. Conversely, QLM exhibited significantly higher activation of the middle trapezius (MT) and lower trapezius (LT) in all phases when compared with SLM (P < .05). UT/MT and UT/LT ratios were also significantly lower in all QLM phases compared with SLM (P < .05).

Conclusion: Study findings suggest that quadruped exercises reduce UT activation while promoting more balanced MT and LT muscle activation. This balance is essential for shoulder rehabilitation, especially in cases requiring minimal UT activation and maximal MT and LT activation. In cases where a balanced trapezius muscle activation pattern is required, including QLM exercises rather than SLM exercises may be more efficient.

Clinical scenario: Ballet dancers exhibit a high risk of musculoskeletal injuries with around 75% of all injuries attributed to overuse injuries. The high prevalence of chronic injuries suggests contributions caused by abnormal biomechanics in combination with repetitive stress common to ballet. Traditional sports settings implement movement screening tools including the Movement Competency Screen (MCS) and functional movement screen (FMS) to identify factors predisposing athletes to injury. However, unique training demands and movement patterns of ballet and contemporary pose challenges for fundamental movement screenings. Identifying relationships between movement screening scores and injury incidence in dancers may allow for early injury risk factors detection and injury prevention programs implementation to reduce overall injury rate.

Clinical question: Does implementation of the MCS improve prediction of injury incidence compared with use of the FMS™ in collegiate, preprofessional, and professional ballet, and contemporary dancers?

Summary of key findings: Three studies met the inclusion criteria for critical appraisal. One study utilized the MCS while the other 2 implemented the FMS™ to assess ballet and modern dancers. These studies concluded the MCS may predict injury when implemented as a preseason screening in ballet and contemporary. The FMS™ did not demonstrate predictive capability for injuries in ballet and contemporary dancers.

Clinical bottom line: While the MCS shows injury prediction potential, a dance-specific movement screening more accurately representing dance-related movement patterns may improve validity in this population. Continuation and standardization of dance injury research is imperative to understand movement compensations predisposing individuals to injury and injury prevention measures.

Recommendation: Grade B evidence suggests potential predictive ability of the MCS in identifying dance-related injury, while no association exists between the FMS™ and dance injuries. Additional research regarding dance-specific movement application to functional screenings shows potential for accurate and reliable injury prediction methods for ballet and modern dancers.

Context: Interest in the effects of concurrently using neuromuscular electrical stimulation (NMES) and blood flow restriction (BFR) to improve muscle strength has risen, but limited studies and inconsistent findings have led to more questions. The 2 current projects aimed to systematically investigate how NMES waveform shape and BFR occlusion pressure acutely influence electrically elicited force (EEF) and tissue oxygen saturation (StO2) of the knee extensors.

Design: A single-session repeated-measures design was followed.

Methods: EEF and StO2 were measured in 2 different groups of 15 participants during 3 sets of NMES contractions. Ten NMES contractions per set were performed with 5 minutes of passive interset recovery. In the first project, different NMES waveforms (RUS, Russian burst-modulated alternating current; VMS, biphasic pulsed current; and VMS-Burst, burst-modulated biphasic pulsed current) were administered for each set, while BFR was applied at 60% limb occlusion pressure (LOP). During the second projet, VMS was administered, while a different BFR occlusion pressure (0% LOP, 40% LOP, and 80% LOP) was used during each set. Two-way repeated-measures analysis of variance examined if repetition and/or NMES waveform (first project) or BFR occlusion pressure (second project) significantly affected (P < .05) EEF or StO2.

Results: VMS (12% [7%] MVIF) and VMS-Burst (13% [10%] MVIF) led to higher EFF compared with RUS (6% [5%] MVIF) with 60% LOP; 80% LOP (20% [14%] MVIF) led to lower EEF compared with 0% LOP (29% [17%] MVIF) with VMS. No significant differences in StO2 were observed between NMES waveforms or BFR occlusion pressures.

Conclusions: If a clinician wanted to concurrently use NMES and BFR, the acute findings of the current projects would suggest the use of VMS or VMS-Burst with lower BFR occlusion pressure (40% LOP). However, further investigation into how these parameters would influence muscle strength subsequent to a training/rehabilitation intervention should be performed.