Heat tolerance testing (HTT) has been developed to assess readiness for work or exercise in the heat based on thermoregulation during exertion. Although the Israeli Defense Forces protocol has been the most widely used and referenced, other protocols and variables considered in the interpretation of the testing are emerging. Our purpose was to summarize the role of HTT after exertional heat stroke; assess the validity of HTT; and provide a review of best-practice recommendations to guide clinicians, coaches, and researchers in the performance, interpretation, and future direction of HTT. We also offer the strength of evidence for these recommendations using the Strength of Recommendation Taxonomy system.
Differences in Access to Athletic Trainers in Public Secondary Schools Based on Socioeconomic Status
Significant health care disparities exist in the United States based on socioeconomic status (SES), but the role SES has in secondary school athletes' access to athletic training services has not been examined on a national scale. To identify differences in access to athletic training services in public secondary schools based on school SES. Cross-sectional study. Database secondary analysis. Data for 3482 public high schools. Data were gathered from the Athletic Training Locations and Services (ATLAS) database, US Census Bureau, and National Center for Education Statistics. We included schools from 5 states with the highest, middle, and lowest poverty percentages (15 states total) and collected county median household income, percentage of students eligible for free or reduced-price lunch, race and ethnicity demographics, and access to athletic training services (full-time athletic trainer [AT], part-time AT only, no AT) for each school. Data were summarized in means, SDs, medians, interquartile ranges (IQRs), frequencies and proportions, 1-way analyses of variance, and Kruskal-Wallis tests. Differences were present in school SES between schools with full-time, part-time-only, and no athletic training services. Schools with greater access to athletic training services had fewer students eligible for free or reduced-price lunch (full time: 41.1% ± 22.3%, part time only: 45.8% ± 24.3%, no AT: 52.9% ± 24.9; P < .001). Similarly, county median household income was higher in schools with increased access to athletic training services (full time median [IQR]: $56 026 [$49 085–$64 557], part time only: $52 719 [$45 355–$62 105], and no AT: $49 584 [$41 094–$57 688]; P < .001). Disparities in SES were seen in access to athletic training services among a national sample of public secondary schools. Access to ATs positively influences student-athletes' health care across several measures. Pilot programs or government funds have been used previously to fund athletic training services and should be considered to ensure equitable access, regardless of school SES.Context
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The King-Devick (K-D) test is used to identify oculomotor impairment after concussion. However, the diagnostic accuracy of the K-D test over time has not been evaluated. To (1) examine the sensitivity and specificity of the K-D test at 0 to 6 hours postinjury, 24 to 48 hours postinjury, the beginning of a return-to-play (RTP) protocol (asymptomatic), unrestricted RTP, and 6 months postconcussion and (2) compare outcomes between athletes with and those without concussion across confounding factors (sex, age, sport contact level, academic year, learning disorder, attention-deficit/hyperactivity disorder, migraine history, concussion history, and test administration mode). Retrospective, cross-sectional design. Multiple institutions in the Concussion Assessment, Research and Education Consortium. A total of 320 athletes with a concussion (162 men, 158 women; age = 19.80 ± 1.41 years) were compared with 1239 total collegiate athletes without a concussion (646 men, 593 women; age = 20.31 ± 1.18 years). We calculated the K-D test time difference (in seconds) by subtracting the baseline from the most recent time. Receiver operator characteristic (ROC) curve and area under the curve (AUC) analyses were used to determine the diagnostic accuracy across time points. We identified cutoff scores and corresponding specificity at both the 80% and 70% sensitivity levels. We repeated ROC with AUC analyses using confounding factors. The K-D test predicted positive results at the 0- to 6-hour (AUC = 0.724, P < .001), 24- to 48-hour (AUC = 0.701, P < .001), RTP (AUC = 0.640, P < .001), and 6-month postconcussion (AUC = 0.615, P < .001) tim points but not at the asymptomatic time point (AUC = 0.513, P = .497). The 0- to 6-hour and 24- to 48-hour time points yielded 80% sensitivity cutoff scores of −2.6 and −3.2 seconds (ie, faster), respectively, but 46% and 41% specificity, respectively. The K-D test had a better AUC when administered using an iPad (AUC = 0.800, 95% CI = 0.747, 0.854) compared with the spiral-bound card system (AUC = 0.646, 95% CI = 0.600, 0.692; P < .001). The diagnostic accuracy of the K-D test was greatest at 0 to 6 hours and 24 to 48 hours postconcussion but declined across subsequent postconcussion time points. The AUCs did not differentiate between groups across confounding factors. Our negative cutoff scores indicated that practice effects contributed to improved performance, requiring athletes to outperform their baseline scores.Context
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Clinical management of sport-related concussion requires the assessment of various factors, including motor performance. The tandem gait test, a measure of postinjury motor performance, has demonstrated clinical utility but is limited by time availability and test uniformity. To assess intrasession reliability between tandem gait test trials and determine the number of trials necessary for optimal utility and feasibility in clinical decision-making after concussion. Cross-sectional study. Pediatric sport medicine clinic. Adolescent athletes who recently sustained a concussion (n = 44; age = 15.4 ± 1.8 years; 39% females) and were seen for care within 14 days (7.3 ± 3.2 days) of their injury as well as uninjured control participants (n = 73; age = 15.8 ± 1.3 years; 41% females). All individuals completed 3 single-task and 3 dual-task tandem gait trials. We collected test completion time and cognitive performance for each trial and calculated Pearson correlation coefficients between trials and intraclass correlation coefficients (ICCs) to determine intrasession reliability. We also compared performance between groups and calculated area under the curve (AUC) values to identify the ability of each trial to distinguish between groups. Both the concussion and control groups demonstrated high intrasession reliability between tandem gait trials under single- (R ≥ 0.82, ICC ≥ 0.93) and dual- (R ≥ 0.79, ICC ≥ 0.92) task conditions. The greatest group classification values were obtained from the second single-task trial (AUC = 0.89) and first dual-task trial (AUC = 0.83). Test completion time provided excellent between-groups discrimination in single- and dual-task conditions. However, cognitive performance during dual-task trials demonstrated only marginally significant clinical utility (AUC ≤ 0.67). Tandem gait assessments may only require 2 trials under single-task and 1 trial under dual-task conditions to effectively discriminate between concussion and control groups. This approach may improve the feasibility (ie, time requirement) of the test while maintaining excellent discriminatory ability.Context
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Clinical reaction-time (RT) measures are frequently used when examining patients with concussion but do not correlate with functional movement RT. We developed the Standardized Assessment of RT (StART) to emulate the rapid cognitive demands and whole-body movement needed in sport. To assess StART differences across 6 cognitive-motor combinations, examine potential demographic and health history confounders, and provide preliminary reference data for healthy collegiate student-athletes. Prospective, cross-sectional study. Clinical medicine facilities. A total of 89 student-athletes (56 [62.9%] men, 33 [37.1%] women; age = 19.5 ± 0.9 years, height = 178.2 ± 21.7 cm, mass = 80.4 ± 24 kg; no concussion history = 64 [71.9%]). Student-athletes completed health history questionnaires and StART during preseason testing. The StART consisted of 3 movements (standing, single-legged balance, and cutting) under 2 cognitive states (single task and dual task [subtracting by 6's or 7's]) for 3 trials under each condition. The StART trials were calculated as milliseconds between penlight illumination and initial movement. We used a 3 × 2 repeated-measures analysis of variance with post hoc t tests and 95% CIs to assess StART cognitive and movement differences, conducted univariable linear regressions to examine StART performance associations, and reported StART performance as percentiles. All StART conditions differed (P ≤ .03), except single-task standing versus single-task single-legged balance (P = .36). Every 1-year age increase was associated with an 18-millisecond (95% CI = 8, 27 milliseconds) slower single-task cutting RT (P < .001). Female athletes had slower single-task (15 milliseconds; 95% CI = 2, 28 milliseconds; P = .02) and dual-task (28 milliseconds; 95% CI = 2, 55 milliseconds; P = .03) standing RT than male athletes. No other demographic or health history factors were associated with any StART condition (P ≥ .056). The StART outcomes were unique across each cognitive-motor combination, suggesting minimal subtest redundancy. Only age and sex were associated with select outcomes. The StART composite scores may minimize confounding factors, but future researchers should consider age and sex when providing normative data.Context
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Frontal- and transverse-plane kinematics have been prospectively identified as risk factors for running-related injuries in females. The Running Readiness Scale (RRS) may allow for clinical evaluation of these kinematics. To determine the reliability and validity of the RRS as an assessment of frontal- and transverse-plane running kinematics. Cross-sectional study. University research laboratory. A total of 56 novice female runners (median [interquartile range] age = 34 years [26–47 years]). We collected 3-dimensional kinematics during running and RRS tasks: hopping, plank, step-ups, single-legged squats, and wall sit. Five clinicians assessed RRS performances 3 times each. Interrater and intrarater reliabilities of the total RRS score and individual tasks were calculated using the intraclass correlation coefficient and Fleiss κ, respectively. Pearson product moment correlation coefficients between peak joint angles measured during running and the same angles measured during RRS tasks were computed. Peak joint angles of high- and low-scoring participants were compared. Interrater and intrarater reliabilities of assessment of the total RRS scores were good (intraclass correlation coefficients = 0.75 and 0.80, respectively). Reliability of assessing individual tasks was moderate to almost perfect (κ = 0.58–1.00). Peak hip adduction, contralateral pelvic drop, and knee abduction during running were correlated with the same angles measured during hopping, step-ups, and single-legged squats (r = 0.537–0.939). Peak knee internal rotation during running was correlated with peak knee internal rotation during step-ups (r = 0.831). Runners who scored high on the RRS demonstrated less knee abduction during running (P ≤ .01). The RRS may effectively assess knee abduction in novice runners, but evaluation criteria or tasks may need to be modified to effectively characterize pelvic and transverse-plane knee kinematics.Context
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Rehabilitative exercises alleviate pain in patients with patellofemoral pain (PFP); however, no researchers have analyzed the cartilage response after a bout of those athletic activities in patients with PFP. To determine if a single session of rehabilitative exercises alters femoral cartilage morphology. Crossover study. Research laboratory. Twelve participants with PFP (age = 21.0 ± 2.0 years, height = 1.72 ± 0.1 m, mass = 68.7 ± 12.6 kg) and 12 matched healthy participants (age = 21.3 ± 2.8 years, height = 1.71 ± 0.1 m, mass = 65.9 ± 12.2 kg) were enrolled. Participants completed treadmill running, lower extremity strengthening exercises, and plyometric exercises for 30 minutes each. Patient-reported outcomes on the visual analog scale, Anterior Knee Pain Scale (AKPS), Knee injury and Osteoarthritis Outcome Score (KOOS), and Knee Injury and Osteoarthritis Outcome Score for Patellofemoral Pain and Osteoarthritis were collected. Femoral cartilage ultrasonographic images were obtained at 140° of knee flexion. Ultrasound images were segmented into medial and lateral images using the intercondylar notch. Medial and lateral cartilage cross-sectional area (mm2) and echo intensity (EI), defined as the average grayscale from 0 to 255, were analyzed by ImageJ software. The difference between loading conditions was calculated using repeated-measures analysis of variance. The Spearman correlation was calculated to find the association between the cartilage percentage change (Δ%) and patient-reported outcomes. Pain increased in the PFP group after all loading conditions (P values < .007). No differences were found in cartilage cross-sectional area or EI alteration between or within groups (P values > .06). The KOOS was negatively associated with the Δ% of the lateral femoral cartilage EI after plyometric loading (ρ = –0.87, P = .001), and the AKPS score was positively correlated with the Δ% of lateral femoral cartilage EI (ρ = 0.57, P = .05). Ultrasound imaging did not identify cartilaginous deformation after all loading conditions. However, because lateral cartilaginous EI changes were associated with the AKPS and KOOS score, those questionnaires may be useful for monitoring changes in femoral cartilage health.Context
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Those with chronic ankle instability (CAI) demonstrate deleterious changes in talar cartilage composition, resulting in alterations of talar cartilage loading behavior. Common impairments associated with CAI may play a role in cartilage behavior in response to mechanical loading. To identify mechanical and sensorimotor outcomes that are linked with the magnitude of talar cartilage deformation after a static loading protocol in patients with and those without CAI. Cross-sectional study. Laboratory setting. Thirty individuals with CAI and 30 healthy individuals. After a 60-minute off-loading period, ultrasonographic images of the talar cartilage were acquired immediately before and after a 2-minute static loading protocol (single-legged stance). Talar cartilage images were obtained and manually segmented to enable calculation of medial, lateral, and overall average talar thickness. The percentage change, relative to the average baseline thickness, was used for further analysis. Mechanical (ankle joint laxity) and sensorimotor (static balance and Star Excursion Balance Test) outcomes were captured. Partial correlations were computed to determine associations between cartilage deformation magnitude and the mechanical and sensorimotor outcomes after accounting for body weight. In the CAI group, greater inversion laxity was associated with greater overall (r = −0.42, P = .03) and medial (r = −0.48, P = .01) talar cartilage deformation after a 2-minute static loading protocol. Similarly, poorer medial-lateral static balance was linked with greater overall (r = 0.47, P = .01) and lateral (r = 0.50, P = .01) talar cartilage deformation. In the control group, shorter posterolateral Star Excursion Balance Test reach distance was associated with greater lateral cartilage deformation (r = 0.42, P = .03). No other significant associations were observed. In those with CAI, inversion laxity and poor static postural control were moderately associated with greater talar cartilage deformation after a 2-minute static loading protocol. These results suggest that targeting mechanical instability and poor balance in those with CAI via intervention strategies may improve how the talar cartilage responds to static loading conditions.Context
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Although neuromuscular deficits in people with chronic ankle instability (CAI) have been identified, previous researchers have mostly investigated the activation of multiple muscles in isolation. Investigating muscle synergies in people with CAI would provide information about the coordination and control of neuromuscular activation strategies and could supply important information for understanding and rehabilitating neuromuscular deficits in this population. To assess and compare muscle synergies using nonnegative matrix factorization in people with CAI and healthy control individuals as they performed different landing-cutting tasks. Cross-sectional study. Laboratory. A total of 11 people with CAI (5 men, 6 women; age = 22 ± 3 years, height = 1.68 ± 0.11 m, mass = 69.0 ± 19.1 kg) and 11 people without CAI serving as a healthy control group (5 men, 6 women; age = 23 ± 4 years, height = 1.74 ± 0.11 m, mass = 66.8 ± 15.5 kg) participated. Muscle synergies were extracted from electromyography of the lateral gastrocnemius, medial gastrocnemius, fibularis longus, soleus, and tibialis anterior (TA) muscles during anticipated and unanticipated landing-cutting tasks. The number of synergies, activation coefficients, and muscle-specific weighting coefficients were compared between groups and across tasks. The number of muscle synergies was the same for each group and task. The CAI group exhibited greater TA weighting coefficients in synergy 1 than the control group (P = .02). In addition, both groups demonstrated greater fibularis longus (P = .03) weighting coefficients in synergy 2 during the unanticipated landing-cutting task than the anticipated landing-cutting task. These results suggest that, although both groups used neuromuscular control strategies of similar complexity or dimensionality to perform the landing-cutting tasks, the CAI group displayed different muscle-specific weightings characterized by greater emphasis on TA function in synergy 1, which may reflect an effort to increase joint stability to compensate for ankle instability.Context
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The objective of this paper is to present the case of a healthy, 19-year-old female collegiate soccer player who developed acute pulmonary edema and acute heart failure in the recovery room after hip labral arthroscopic surgery. The patient's initial diagnosis, of negative pressure pulmonary edema in direct relation to extubation, was questioned when she became hemodynamically unstable. A cardiac biopsy revealed acute pulmonary edema and heart failure secondary to viral myocarditis. The patient was treated and discharged 10 days after admission. Specific and substantiated return-to-play guidelines after a cardiac event, specifically viral myocarditis, have been sparse. The interprofessional collaboration between athletic trainers and cardiologists is a key dynamic in the clinical decision-making process of a safe return to competitive athletic participation after a cardiac event.
Currently, the National Collegiate Athletic Association (NCAA) recommends written policies and procedures that outline steps to support student-athletes facing a mental health challenge and the referral processes for emergency and nonemergency mental health situations. To assess the mental health policies and procedures implemented and athletic trainers' perceived confidence in preventing, recognizing, and managing routine and crisis mental health cases across all 3 divisions of NCAA athletics. Cross-sectional survey design and chart review. Online survey. Athletic trainers with clinical responsibility at NCAA member institutions (N = 1091, 21.5% response rate). Confidence in screening, preventive patient education, and recognizing and referring athletes with routine and emergency mental health conditions (5-point Likert scale: 1 = not at all confident, 2 = hardly confident, 3 = somewhat confident, 4 = fairly confident, 5 = very confident) using a content-validated survey (Cronbach α = 0.904) and mental health policy and procedure chart review. Respondents indicated they felt fairly confident in screening (40.21%, n = 76 of 189) for risk of any mental health condition and fairly confident in implementing preventive patient education (42.11%, n = 80 of 190). They were fairly confident they could recognize (48.95%, n = 93 of 190) and refer (45.79%, n = 87 of 190) patients with routine mental health conditions. Participants were fairly confident they could recognize (46.84%, n = 89 of 190) but very confident (46.32%, n = 88 of 190) they could refer individuals with mental health emergencies. Policies lacked separate procedures for specific emergency mental health situations such as suicidal or homicidal ideation (36.1%), sexual assault (33.3%), substance abuse (19.4%), and confusional state (13.9%). Policies also lacked a plan for regular engagement of student-athletes in leadership roles (16.7%) and annual training of all student-athletes (16.7%). Although athletic trainers were generally confident in their ability to address emergency and routine mental health conditions, opportunities exist to improve policies for prevention, screening, and referral. Best-practice guidelines should be used as a guide to develop policies that foster an environment of mental health wellness.Context
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A Descriptive Analysis of Patient Outcomes and Experiences at a Student-Run Athletic Training Clinic
The prevalence of student-run clinics is rising due to educational benefits and the ability to provide cost-effective care to underserved patients. Current literature on the effect of athletic training student-run clinics on patient outcomes and experiences is limited. To explore patient-reported outcomes (PROs), patient experiences, and patient demographics in an athletic training student-run clinic. Mixed-methods study: cross-sectional survey with retrospective analysis of deidentified patient outcomes from November 2017–October 2021. Athletic training student-run clinic. A total of 388 patients from the university (ie, students and staff) and local community with a variety of musculoskeletal injuries. Participants completed a packet to provide their responses to demographic items and PRO scales: Disablement in the Physically Active Scale Short Form-8, Numeric Pain Rating Scale, Patient-Specific Functional Scale, and Global Rating of Change Scale at 3 time points. They also completed an electronic patient experience survey after their final visit to the student-run clinic. Most participants reported clinically significant improvements across all PRO scales: an average improvement of 39.1% in pain, 39.3% in function, and 43.1% in quality of life in <11 days, on average. Furthermore, they described a high level of satisfaction with care and a globally positive experience at the student-run clinic. Patients experienced clinically significant improvements in pain, function, disablement, and quality of life when receiving care from athletic training students at a student-run clinic. In addition, they indicated a high level of satisfaction with the care provided and a positive overall experience with an athletic training student-run clinic.Context
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Girls' high school volleyball is very popular across the United States. Prospective data are limited regarding the incidence and risk factors of time-loss (TL) and non–time-loss (NTL) injuries sustained in this population. To estimate the incidence and describe the characteristics of injuries (TL and NTL) sustained in a girls' high school volleyball season. Descriptive epidemiology study. Convenience sample of 78 high school interscholastic volleyball programs. Female high school volleyball players participating during the 2018 interscholastic season. Injury rates, proportions, and rate ratios were measured for TL and NTL injuries with 95% CIs. A total of 2072 girls enrolled in the study, and 468 participants (22.5%) sustained 549 injuries (TL = 71.6%, NTL = 28.4%) for an overall injury rate of 5.31 (95% CI = 4.89, 5.79) per 1000 athlete-exposures. The competition injury rate was greater than the practice injury rate for all injuries (injury rate ratio [IRR] = 1.19; 95% CI = 1.00, 1.41) and TL injuries (IRR = 1.31; 95% CI = 1.07, 1.60). Players with a previous musculoskeletal injury had a higher rate of TL than NTL injuries (IRR = 1.36; 95% CI = 1.12, 1.65). Ankle injuries accounted for the greatest proportion of TL injuries (n = 110, 28%), while the greatest proportion of NTL injuries occurred in the hand or fingers (n = 34, 22%). Ligament sprains accounted for 40% of TL injuries (n = 156), whereas muscle or tendon strains (n = 79, 51%) accounted for more than half of all NTL injuries. Although most injuries sustained by adolescent girls' volleyball athletes were TL in nature, nearly a third of all injuries were NTL injuries. Injury characteristics differed widely between TL and NTL injuries. Understanding the most common types and characteristics of injuries among high school volleyball players is critical for the development of effective injury-prevention programs.Context
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Shoulder pain is pervasive in swimmers of all ages. However, given the limited number of prospective studies, injury risk factors in swimmers remain uncertain. To determine the extent to which the risk factors of previous injury, poor movement competency, erroneous freestyle swimming technique, and low perceived susceptibility to sport injury were associated with noncontact musculoskeletal injury in collegiate swimmers. Prospective cohort study. College natatorium. Thirty-seven National College Athletic Association Division III swimmers (21 females, 16 males; median age = 19 years [interquartile range = 3 years], height = 175 ± 10 cm; mass = 70.0 ± 10.9 kg). Participants completed preseason questionnaires on their previous injuries and perceived susceptibility to sport injury. At the beginning of the season, they completed the Movement System Screening Tool and the Freestyle Swimming Technique Assessment. Logistic regression was used to calculate odds ratios (ORs) with 95% CIs for the association between each risk factor and injury. Eleven of the 37 participants (29.7%) sustained an injury. Univariate analyses identified 2 risk factors: previous injury (OR = 8.89 [95% CI = 1.78, 44.48]) and crossover hand positions during the freestyle entry phase (OR = 8.50 [95% CI = 1.50, 48.05]). After adjusting for previous injury, we found that a higher perceived percentage chance of injury (1 item from the Perceived Susceptibility to Sport Injury) decreased the injury odds (adjusted OR = 0.11 [95% CI = 0.02, 0.82]). Poor movement competency was not associated with injury (P > .05). Previous injury, a crossover hand-entry position in freestyle, and a low perceived percentage chance of injury were associated with increased injury odds. Ascertaining injury histories and assessing for crossover positions may help identify swimmers with an elevated injury risk and inform injury-prevention strategies.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
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
Corticospinal Excitability during Standing and Its Association with Postural Control Following Acute Lateral Ankle Sprain.
The socio-economic cost of anterior cruciate ligament injuries and lateral ankle sprains in amateur football and basketball.
JAT eISSN: 1938-162X
JAT ISSN: 1062-6050
ATEJ ISSN: 1947-380X