Congratulations to the winners of the 2018 Outstanding Manuscript Awards, as determined by the Editorial Board and the Editors of the Journal of Athletic Training:
The National Basketball Association (NBA; also referred to as “the league”) has established a centralized, audited electronic medical record system that has been linked with external sources to provide a platform for robust research and to allow the NBA to conduct player health and safety reviews. The system is customized and maintained by the NBA and individual teams as part of the employment records for each player and is deployed uniformly across all 30 teams in the league, thereby allowing for standardized data on injuries, illnesses, and player participation in NBA games and practices. The electronic medical record data are enriched by linkage with other league external data sources that provide additional information about injuries, players, game and practice participation, and movement. These data linkages allow for the assessment of potential injury trends, development of injury-prevention programs, and rule changes, with the ultimate goal of improving player health and wellness. The purpose of this article is to describe this NBA injury database, including the details of data collection, data linkages with external data sources, and activities related to reporter training and data quality improvement.
To evaluate sex differences in incidence rates (IRs) of anterior cruciate ligament (ACL) injury by sport type (collision, contact, limited contact, and noncontact). A systematic review was performed using the electronic databases PubMed (1969–January 20, 2017) and EBSCOhost (CINAHL, SPORTDiscus; 1969–January 20, 2017) and the search terms anterior cruciate ligament AND injury AND (incidence OR prevalence OR epidemiology). Studies were included if they provided the number of ACL injuries and the number of athlete-exposures (AEs) by sex or enough information to allow the number of ACL injuries by sex to be calculated. Studies were excluded if they were analyses of previously reported data or were not written in English. Data on sport classification, number of ACL injuries by sex, person-time in AEs for each sex, year of publication, sport, sport type, and level of play were extracted for analysis. We conducted IR and IR ratio (IRR) meta-analyses, weighted for study size and calculated. Female and male athletes had similar ACL injury IRs for the following sport types: collision (2.10/10 000 versus 1.12/10 000 AEs, IRR = 1.14, P = .63), limited contact (0.71/10 000 versus 0.29/10 000 AEs, IRR = 1.21, P = .77), and noncontact (0.36/10 000 versus 0.21/10 000 AEs, IRR = 1.49, P = .22) sports. For contact sports, female athletes had a greater risk of injury than male athletes did (1.88/10 000 versus 0.87/10 000 AEs, IRR = 3.00, P < .001). Gymnastics and obstacle-course races were outliers with respect to IR, so we created a sport category of fixed-object, high-impact rotational landing (HIRL). For this sport type, female athletes had a greater risk of ACL injury than male athletes did (4.80/10 000 versus 1.75/10 000 AEs, IRR = 5.51, P < .001), and the overall IRs of ACL injury were greater than all IRs in all other sport categories. Fixed-object HIRL sports had the highest IRs of ACL injury for both sexes. Female athletes were at greater risk of ACL injury than male athletes in contact and fixed-object HIRL sports.Objective
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The complex, high-energy nature of football puts players at risk for hip injuries. To analyze National Collegiate Athletic Association (NCAA) Injury Surveillance Program data for men's football hip injuries from 2004–2005 through 2013–2014. Descriptive epidemiologic study. National Collegiate Athletic Association football teams. Data on collegiate football players was provided by the NCAA Injury Surveillance System from 2004–2005 through 2013–2014. The incidence, risk factors, rates, and distribution of hip injuries over the 10-year period from 2004–2005 through 2013–2014 were determined. Rates and distribution of injuries were analyzed by injury type, time loss, event type, time of season, recurrence, mechanism of injury, player position, and if surgery was required. Injury rate ratios were calculated to compare rates between event types and by time of season. A total of 1618 hip injuries occurred during 3 121 380 athlete-exposures (AEs), resulting in an overall hip injury rate of 5.18 per 10 000 AEs. Adductor strains (38.63%) were the most common type, followed by hip-flexor strains (28.55%) and hip contusions (18.23%). Players were 3.56 (95% confidence interval [CI] = 3.19, 3.98) times more likely to sustain a hip injury during competitions compared with practices. They were 2.37 (95% CI = 2.15, 2.62) and 3.56 (95% CI = 2.49, 5.08) times more likely to sustain a hip injury during the preseason than in-season or the postseason, respectively. During the 10-year period, NCAA football players sustained higher rates of hip injuries during competitions and the preseason. The majority were noncontact injuries, resulted in time loss of less than 6 days, and did not require surgery. The injuries varied with player position and occurred most often to defensive backs. Muscle strains were the most frequent group of hip injuries, while adductor strains, hip-flexor strains, and hip contusions were the most common injury types.Context
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Exposure to game conditions and previous injury are known to increase the risk of injury, but little available evidence pertains to modifiable factors that may mediate dynamic control of body segments, such as core muscle endurance and neurocognitive capabilities. To identify potentially modifiable factors associated with the occurrence of a core or lower extremity sprain or strain during participation in football. Prospective cohort study. National Collegiate Athletic Association Division I Football Bowl Subdivision football program. All team members who participated for the duration of 1 season or both of 2 consecutive seasons (n = 142). Predictors of injury occurrence were derived from analysis of preparticipation data that included the results of front plank hold (FPH) and neurocognitive tests. Receiver operating characteristic analysis was used to establish binary classifications of injury risk. Logistic regression analyses were conducted to build multivariable injury-prediction models for optimal discriminatory power. Exceptionally good discrimination between injured and noninjured participants was provided by models that included the results of the FPH and ImPACT neurocognitive tests. A high level of exposure to game conditions and injury during the preceding year magnified the effects of other risk factors. A model for identifying players with an elevated risk for injury occurrence during both of 2 consecutive seasons included FPH ≤120 seconds, verbal memory score ≤87, composite reaction time ≥560 milliseconds, and starter status. Having ≥2 of the 4 risk factors demonstrated 44% sensitivity and 91% specificity, with an odds ratio = 8.40. Core muscle endurance and neurocognitive processes may both play important roles in generating anticipatory muscle stiffness during participation in collegiate football. These factors may be particularly important for players who sustained an injury during the previous year and those who have a high level of game exposure.Context
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Bilateral Strength Asymmetries and Unilateral Strength Imbalance: Predicting Ankle Injury When Considered With Higher Body Mass in US Special Forcesa
Ankle injury is one of the most common conditions in athletics and military activities. Strength asymmetry (SA) and imbalance may represent a risk factor for injury, but past investigations have produced ambiguous conclusions. Perhaps one explanation for this ambiguity is the fact that these authors used univariate models to predict injury. To evaluate the predictive utility of SA and imbalance calculations for ankle injury in univariate and multivariate prediction models. Prospective cohort study. Laboratory. A total of 140 male US Air Force Special Forces. Baseline testing consisted of body composition, isometric strength, and aerobic and anaerobic capacity. A clinician conducted medical chart reviews 365 days posttesting to document the incidence of ankle injury. Strength asymmetries were calculated based on the equations most prevalent in the literature along with known physiological predictors of injury in the military: age, height, weight, body composition, and aerobic capacity. Simple logistic regression was conducted using each predictor, and backward stepwise logistic regression was conducted with each equation method and the physiological predictors entered initially into the model. Strength asymmetry or imbalance or both, as a univariate predictor, was not able to predict ankle injury 365 days posttesting. Body mass (P = .01) and body mass index (P = .01) significantly predicted ankle injury. Strength asymmetry or imbalance or both significantly predicted ankle injury when considered with body mass (P = .002–.008). As a univariate predictor, SA did not predict ankle injury. However, SA contributed significantly to predicting ankle injury in a multivariate model using body mass. Interpreting SA and imbalance in the presence of other physiological variables can help elucidate the risk of ankle injury.Context
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Poor quadriceps force control has been observed after anterior cruciate ligament (ACL) reconstruction but has not been examined after ACL injury. Whether adaptations within the central nervous system are contributing to these impairments is unknown. To examine quadriceps force control in individuals who had sustained a recent ACL injury and determine the associations between cortical excitability and quadriceps force control in these individuals. Cross-sectional study. Research laboratory. Eighteen individuals with a recent unilateral ACL injury (6 women, 12 men; age = 29.6 ± 8.4 years, height = 1.74 ± 0.07 m, mass = 76.0 ± 10.4 kg, time postinjury = 69.5 ± 42.5 days) and 18 uninjured individuals (6 women, 12 men; age = 29.2 ± 6.8 years, height = 1.79 ± 0.07 m, mass = 79.0 ± 8.4 kg) serving as controls participated. Quadriceps force control was quantified as the root mean square error between the quadriceps force and target force during a cyclical force-matching task. Cortical excitability was measured as the active motor threshold and cortical silent period. Outcome measures were determined bilaterally in a single testing session. Group and limb differences in quadriceps force control were assessed using mixed analyses of variance (2 × 2). Pearson product moment correlations were performed between quadriceps force control and cortical excitability in individuals with an ACL injury. Individuals with an ACL injury exhibited greater total force-matching error with their involved (standardized mean difference [SMD] = 0.8) and uninvolved (SMD = 0.9) limbs than did controls (F1,27 = 11.347, P = .03). During the period of descending force, individuals with an ACL injury demonstrated greater error using their involved (SMD = 0.8) and uninvolved (SMD = 0.8) limbs than uninjured individuals (F1,27 = 4.941, P = .04). Greater force-matching error was not associated with any cortical excitability measures (P > .05). Quadriceps force control was impaired bilaterally after recent ACL injury but was not associated with selected measures of cortical excitability. The findings highlight a need to incorporate submaximal-force control tasks into rehabilitation and “prehabilitation,” as the deficits were present before surgery.Context
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Females have consistently higher anterior cruciate ligament (ACL) injury rates than males. The reasons for this disparity are not fully understood. Whereas ACL morphometric characteristics are associated with injury risk and females have a smaller absolute ACL size, comprehensive sex comparisons that adequately account for sex differences in body mass index (BMI) have been limited. To investigate sex differences among in vivo ACL morphometric measures before and after controlling for femoral notch width and BMI. Cross-sectional study. Laboratory. Twenty recreationally active men (age = 23.2 ± 2.9 years, height = 180.4 ± 6.7 cm, mass = 84.0 ± 10.9 kg) and 20 recreationally active women (age = 21.3 ± 2.3 years, height = 166.9 ± 7.7 cm, mass = 61.9 ± 7.2 kg) participated. Structural magnetic resonance imaging sequences were performed on the left knee. Anterior cruciate ligament volume, width, and cross-sectional area measures were obtained from T2-weighted images and normalized to femoral notch width and BMI. Femoral notch width was measured from T1-weighted images. We used independent-samples t tests to examine sex differences in absolute and normalized measures. Men had greater absolute ACL volume (1712.2 ± 356.3 versus 1200.1 ± 337.8 mm3; t38 = −4.67, P < .001) and ACL width (8.5 ± 2.3 versus 7.0 ± 1.2 mm; t38 = −2.53, P = .02) than women. The ACL volume remained greater in men than in women after controlling for femoral notch width (89.31 ± 15.63 versus 72.42 ± 16.82 mm3/mm; t38 = −3.29, P = .002) and BMI (67.13 ± 15.40 versus 54.69 ± 16.39 mm3/kg/m2; t38 = −2.47, P = .02). Whereas men had greater ACL volume and width than women, only ACL volume remained different when we accounted for femoral notch width and BMI. This suggests that ACL volume may be an appropriate measure of ACL anatomy in investigations of ACL morphometry and ACL injury risk that include sex comparisons.Context
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Constant-tension (CT) stretching has been used to reduce hamstrings passive stiffness; however, the time course of hamstrings stiffness responses during a short bout of this type of stretching and the effects on maximal and explosive strength remain unclear. To examine the time course of hamstrings passive-stiffness responses during a short, practical bout of manual straight-legged–raise (SLR) CT passive stretches and their effects on maximal and explosive strength in healthy young women. Descriptive laboratory study. Research laboratory. Eleven healthy women (age = 24 ± 4 years, height = 167 ± 4 cm, mass = 65 ± 8 kg) participated. Participants underwent four 15-second SLR CT passive stretches of the hamstrings. Hamstrings passive stiffness was calculated from the slopes of the initial (phase 1) and final (phase 2) portions of the angle-torque curves generated before and after the stretching intervention and at the beginning of each 15-second stretch. Hamstrings peak torque and rate of torque development were derived from maximal voluntary isometric contractions performed before and after the stretching intervention. The slope coefficients (collapsed across phase) for the third and fourth stretches and the poststretching assessment were lower than the prestretching assessment (P range = .004–.04), but they were not different from each other (P > .99). In addition, no differences in peak torque (t10 = −0.375, P = .72) or rate of torque development (t10 = −0.423, P = .68) were observed between prestretching and poststretching. A short bout of SLR CT passive stretching may effectively reduce hamstrings stiffness without negatively influencing maximal and explosive strength.Context
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Postconcussion deficits in neurocognitive performance and postural control may persist at the time of return to sport participation. How these deficits, if present, affect athletic performance is largely unknown, with prior studies showing mixed results. To evaluate postconcussion National Hockey League player performance using advanced hockey metrics over short- (5 games), medium- (10 games), and long-term (remainder of the season) seasonal performance. Retrospective cohort study. National Hockey League players who sustained a sport-related concussion (SRC; n = 93) and returned during the same season and players (n = 51) who missed time for non–injury-related reasons. Six performance metrics were used: (1) points per 60 minutes, (2) Corsi percentage, (3) personal Fenwick shooting percentage, (4) scoring chances per 60 minutes, (5) penalty difference, and (6) PDO (not an acronym but sometimes referred to as SVSP% [save percentage shooting percentage]). Performance was compared using 2 (group) × 2 (time) repeated-measures analyses of variance for 3 time windows: (1) ±5 games, (2) ±10 games, and (3) the remainder of the season postconcussion. Alpha values were set at a conservative .01 to account for the lack of independence among dependent variables. No significant interactions were present for any of the 6 dependent variables at any of the 3 time windows. Overall, none of the secondary variables differed. Using advanced, sport-specific metrics, we found that National Hockey League players did not display worse seasonal performance during 3 postinjury time frames after they sustained an SRC. Whereas laboratory studies have identified lingering neurologic deficits after concussion, our results suggest that these deficits, if present, either do not translate to worse athletic performance or were not captured by these 44 metrics. Further, prospective efforts are needed to accurately quantify performance after SRC among professional hockey players.Context
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Evaluating Performance of National Hockey League Players After a Concussion Versus Lower Body Injury
Concussions elicit changes in brain function that may extend well beyond clinical symptom recovery. Whether these changes produce meaningful deficits outside the laboratory environment is unclear. The results of player performance postconcussion within professional sports have been mixed. To determine whether National Hockey League (NHL) players with concussions performed worse after returning to sport than players with lower body injuries or uninjured players. Cohort study. Publicly available Web sites that compiled injury and player statistics of NHL players. Male NHL players who missed games due to a concussion (n = 22), lower body injury (n = 21), or noninjury (ie, personal reason or season break; n = 13) during the 2013–2014 and 2014–2015 regular seasons. Data on concussed athletes were used to identify similar players with lower body injury and noninjury based on (1) position, (2) time loss, (3) time on the ice, and (4) team. The primary performance metric was a modified plus-minus statistic calculated by weighting the players' plus-minus metric by their team's simple rating system to account for varying team performances. Linear mixed models assessed the relationship between injury type (concussion, lower body, or noninjury) and performance (plus-minus score). We observed a quadratic effect for a time2 × group interaction (\upchi _2^2 = 8.85, P = .01). This interaction revealed that the concussion and lower body injury groups had similar patterns of an initial decrease (ie, 2 weeks after return to play), followed by an increase in performance compared with the uninjured group in weeks 5 and 6. Meanwhile, the uninjured group had an initial increase in performance. We observed no group × linear time interaction (P = .47) or overall group effect (P = .57). The NHL players in the concussion and lower body injury groups displayed similar performance impairments. Both injured cohorts experienced an initial decrease in performance at weeks 1 to 2 after return to play, followed by improved performance at weeks 5 to 6 after return to play, suggesting that the performance implications of concussion may be short lived.Context
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Little is known about how educating runners may correct common misconceptions surrounding heat safety and hydration strategies. To investigate (1) beliefs and knowledge about heat safety and hydration strategies among recreational runners and (2) the effectiveness of an educational video in optimizing performance in the heat. Cross-sectional study. Survey. A total of 2091 (25.1%) of 8319 runners registered for the 2017 Falmouth Road Race completed at least 1 of the 3 administered surveys. A 5.3-minute video and an 11-question survey regarding heat safety and hydration strategies were developed, validated, and implemented. The survey was e-mailed to registrants 9 weeks before the race (PRERACE), after they viewed the video (POSTEDU), and the afternoon of the race (POSTRACE). The total score for responses to 2 multiple choice questions and nine 5-point (response range = strongly agree to strongly disagree) Likert-scale questions. The PRERACE results showed that more than 90% of respondents recognized the importance of staying hydrated beginning the day before the planned activity, correctly identified that dark color urine is not a sign of euhydration, and believed that dehydration may increase the risk for heat syncope. Conversely, fewer than 50% of respondents knew the number of days required to achieve heat acclimatization, the role of sweat-rate calculation in optimizing one's hydration strategy, or the risk of water intoxication from drinking too much water. An improvement in survey score from PRERACE to POSTEDU was observed (mean difference = 2.00; 95% confidence interval = 1.68, 2.33; P < .001) among runners who watched the video, and 73% of the improvement in their scores was retained from POSTEDU to POSTRACE (mean difference = −0.54; 95% confidence interval = −0.86, −0.21; P < .001). The video successfully shifted runners' beliefs and knowledge to enable them to better optimize their performance in the heat.Context
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Generic patient-reported outcome (PRO) instruments are designed to capture health-related quality-of-life outcomes and to determine treatment effectiveness from the patient's perspective. Multiple generic PROs are used in clinical practice, and an investigation of the psychometric properties of these instruments in a high-functioning, physically active population is important for the future use of these instruments. To determine the relationship among 3 generic PROs: the modified Disablement in the Physically Active (mDPA) Scale, the Patient-Reported Outcome Measurement Information System Physical Function (PROMIS-PF), and the Short Form 12 (SF-12) in physically active patients seeking treatment for a lower extremity health condition. Cross-sectional study. Athletic training clinical facility, physical therapy clinic. One hundred patients seeking rehabilitation services for a lower extremity health condition. All patients completed a demographic questionnaire and the 3 generic PROs at 1 time point during their rehabilitation: the mDPA-Total, mDPA-physical summary component (mDPA-PSC), mDPA-mental summary component (mDPA-MSC), the PROMIS-PF, and SF-12 mental component summary (SF-MCS) and physical component summary (SF-PCS). Separate Spearman rank (r) correlations were performed to assess the strength of the relationship among PRO instruments. The floor and ceiling effects were also examined. A strong relationship was present between the SF-12 PCS and the mDPA-Total (r = −0.65), the mDPA-PSC (r = −0.64), and the PROMIS-PF (r = 0.65). Significant moderate relationships were identified between the mDPA-MSC and the SF-12 PCS (r = −0.43) and MCS (r = −0.53). Weak relationships were noted between the mDPA-Total and SF-12 MCS (r = −0.21) and the SF-12 MCS and mDPA-PSC (r = −0.10) and PROMIS-PF (r = 0.20). The PROMIS-PF and mDPA had good convergent and divergent validity. Clinicians treating physically active patients should consider these instruments for use in clinical practice. Future researchers should examine additional psychometric properties of these instruments in physically active patients.Context
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Organizational policies for work-life balance exist, but little is known about athletic trainers' (ATs') awareness of and willingness to use them. To explore ATs' formal and informal work-life balance policies in the collegiate and university athletic training setting. Sequential mixed-methods study. Web-based survey. We sent 4673 e-mails to National Athletic Trainers' Association ATs (full-time employment for at least 1 year, nonacademic appointment); 1221 participants began our survey (access rate = 26.1%), and 783 completed the survey (64.1% completion rate). Demographics were as follows: men = 375 (48.0%) and women = 404 (51.7%); age = 36 ± 10 years; experience = 13 ± 9 years; years at current place of employment = 8 ± 8 years; and participants with children or minor dependents = 262 (33.5%). We created a 17-item instrument from an earlier qualitative study. A panel of experts (n = 3; employer, employee, and researcher) completed a content analysis. Variables of interest were confidence (scale = 1–4) and satisfaction (scale = 1–5) with policies. We used Pearson χ2 analyses to compare the effect of undergoing an orientation and the presence or absence of children on the main outcome measures. A majority of participants had experienced formal orientation through the human resources department (n = 522, 66.8%), the direct supervisor (n = 240, 30.7%), or a colleague (n = 114, 14.6%). However, many had received no orientation (n = 184, 23.6%). Those who had undergone orientation indicated greater confidence in knowing about (P < .001) and greater satisfaction with (P < .001) formal workplace policies and benefits. Those with children stated that they had greater confidence in knowing about (P < .001) and greater satisfaction with (P = .013) formal workplace policies and benefits. Those who had been oriented felt greater confidence in knowing about (P = .009) but no difference in satisfaction with (P = .060) informal workplace policies and benefits. We did not identify differences between those with and those without children regarding their confidence in knowing about (P = .653) or satisfaction with (P = .150) informal workplace policies and benefits. Athletic trainers in the collegiate and university setting were not confident in their knowledge of formal or informal work-life balance policies.Context
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Reliability and Validity of the Functional Assessment of Neurocognition in Sport (FANS): A Paradigm Shift in Post-Concussion Return-to-Sport Decision-Making
Corticospinal Excitability during Standing and Its Association with Postural Control Following Acute Lateral Ankle Sprain.
Driving After Concussion: Clinical Measures Associated with Post-concussion
The role of shoulder posture in pitching mechanics and injury risk in high school baseball pitchers
Healthcare Utilization and Provider Workload in Collegiate Student Athletes for Acute, Overuse, Time-Loss and Non-Time-Loss Injuries
JAT eISSN: 1938-162X
JAT ISSN: 1062-6050
ATEJ ISSN: 1947-380X