The Effect of Cognitive Rest as Part of Postconcussion Management for Adolescent Athletes: A Critically Appraised Topic

2017 ◽  
Vol 26 (5) ◽  
pp. 437-446 ◽  
Author(s):  
Rachel S. Johnson ◽  
Mia K. Provenzano ◽  
Larynn M. Shumaker ◽  
Tamara C. Valovich McLeod ◽  
Cailee E. Welch Bacon
Keyword(s):  
Cognitive Activity ◽  
Management Plan ◽  
Symptom Duration ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Patient Centered ◽  
Bottom Line ◽  
School Work ◽  
Centered Care ◽  
Cognitive Rest

Clinical Scenario:It is hypothesized that cognitive activity following a concussion may potentially hinder patient recovery. While the recommendation of cognitive rest is often maintained and rationalized, a causal relationship between cognitive activity and symptom duration has yet to be established.Clinical Question:Does the implementation of cognitive rest as part of the postconcussion management plan reduce the number of days until the concussed adolescent patient is symptom free compared to a postconcussion management plan that does not incorporate cognitive rest?Summary of Key Findings:A thorough literature search returned 7 possible studies; 5 studies met the inclusion criteria and were included. Three studies indicated that increased cognitive activity is associated with longer recovery from a concussion, and, therefore, supported the use of cognitive rest. One study indicated that the recommendation for cognitive rest was not significantly associated with time to concussion symptom resolution. One study indicated that strict rest, defined as 5 days of no school, work, or physical activity; might prolong symptom duration.Clinical Bottom Line:There is moderate evidence to support the prescription of moderate cognitive rest for concussed patients. Clinicians who intend on implementing cognitive rest in their concussion protocols should be aware of inconsistencies and be open-minded to alternative treatment progressions while taking into consideration each individual patient and maintaining adequate patient-centered care principles.Strength of Recommendation:Grade B evidence exists that prescription of moderate cognitive rest for concussed patients may be beneficial as a supplement to physical rest as treatment for symptom reduction in adolescents.

The Use of Breathing Exercises in the Treatment of Chronic, Nonspecific Low Back Pain

2017 ◽  
Vol 26 (5) ◽  
pp. 452-458 ◽  
Author(s):  
Barton E. Anderson ◽  
Kellie C. Huxel Bliven
Keyword(s):  
Quality Of Life ◽  
Low Back Pain ◽  
Back Pain ◽  
Lung Function ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Low Back ◽  
Bottom Line ◽  
Breathing Exercises

Clinical Scenario:Research has shown a link between poor core stability and chronic, nonspecific low back pain, with data to suggest that alterations in core muscle activation patterns, breathing patterns, lung function, and diaphragm mechanics may occur. Traditional treatment approaches for chronic, nonspecific low back pain focus on exercise and manual therapy interventions, however it is not clear whether breathing exercises are effective in treating back pain.Focused Clinical Question:In adults with chronic, nonspecific low back pain, are breathing exercises effective in reducing pain, improving respiratory function, and/or health related quality of life?Summary of Key Findings:Following a literature search, 3 studies were identified for inclusion in the review. All reviewed studies were critically appraised at level 2 evidence and reported improvements in either low back pain or quality of life following breathing program intervention.Clinical Bottom Line:Exercise programs were shown to be effective in improving lung function, reducing back pain, and improving quality of life. Breathing program frequencies ranged from daily to 2–3 times per week, with durations ranging from 4 to 8 weeks. Based on these results, athletic trainers and physical therapists caring for patients with chronic, nonspecific low back pain should consider the inclusion of breathing exercises for the treatment of back pain when such treatments align with the clinician’s own judgment and clinical expertise and the patient’s preferences and values.Strength of Recommendation:Grade B evidence exists to support the use of breathing exercises in the treatment of chronic, nonspecific low back pain.

The Effect of Dry Needling on Patient-Reported Outcomes in Individuals With Chronic Ankle Instability: A Critically Appraised Topic

2019 ◽  
Vol 24 (5) ◽  
pp. 186-192
Author(s):  
Jennifer F. Mullins ◽  
Arthur J. Nitz ◽  
Matthew C. Hoch
Keyword(s):  
Patient Reported Outcomes ◽  
Ankle Instability ◽  
Chronic Ankle Instability ◽  
The Other ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Dry Needling ◽  
Bottom Line ◽  
Patient Reported

Clinical Scenario: Chronic ankle instability (CAI) and its associated recurrent sprains, feelings of instability, and decreased function occur in approximately 40% of individuals that suffer an ankle sprain. Despite these continued deficits, more effective treatment has yet to be established. Decreased sensorimotor function has been associated with CAI and may be amenable to dry needling treatment, thereby improving patient-reported outcomes (PROs). Focused Clinical Question: Does dry needling improve PROs in individuals with CAI? Summary of Key Findings: Two studies were identified that examined dry needling in participants with CAI. One of the two studies reported improvements in PROs (PEDro score 7/10) while the other study did not identify any changes (PEDro score 9/10). The inconsistent results were likely related to different treatment durations and follow-up timelines across the included evidence. Clinical Bottom Line: Based on the included studies, there is inconsistent evidence that dry needling can improve PROs in individuals with CAI. Strength of Recommendation: Utilizing the Strength of Recommendation Taxonomy (SORT) guidelines, level B evidence exists to recommend dry needling treatment to improve PROs for individuals with CAI.

The Effectiveness of Open Repair Versus Percutaneous Repair for an Acute Achilles Tendon Rupture

2016 ◽  
Vol 25 (4) ◽  
pp. 404-410 ◽  
Author(s):  
Heidi Krueger ◽  
Shannon David
Keyword(s):  
Achilles Tendon ◽  
Open Repair ◽  
Supporting Evidence ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Bottom Line ◽  
Physically Active ◽  
Men And Women ◽  
Percutaneous Repair ◽  
Tendon Ruptures

Clinical Scenario:There are 2 approaches available for surgical repair of the Achilles tendon: open or percutaneous. However, there is controversy over which repair is superior.Focused Clinical Question:Which type of surgery is better in providing the best overall patient outcome, open or percutaneous repair, in physically active men and women with acute Achilles tendon ruptures?Summary of Search, “Best Evidence” Appraised, and Key Findings:The literature was searched for studies of level 3 evidence or higher that investigated the effectiveness of open repair versus percutaneous repair on acute Achilles tendon ruptures in physically active men and women. The literature search resulted in 3 studies for possible inclusion. All 3 good-quality studies were included.Clinical Bottom Line:There is supporting evidence to indicate that percutaneous repair is the best option for Achilles tendon surgery when it comes to the physically active population. Percutaneous repair has faster surgery times, less risk of complications, and faster recovery times over having an open repair, although it is acknowledged that every patient has a different situation and best individual option may vary patient to patient.

The Diagnostic Accuracy of Screening Tools to Detect Eating Disorders in Female Athletes

2016 ◽  
Vol 25 (4) ◽  
pp. 395-398 ◽  
Author(s):  
Alyssa J. Wagner ◽  
Casey D. Erickson ◽  
Dayna K. Tierney ◽  
Megan N. Houston ◽  
Cailee E. Welch Bacon
Keyword(s):  
At Risk ◽  
Eating Disorders ◽  
Eating Disorder ◽  
Sensitivity And Specificity ◽  
Female Athletes ◽  
Screening Tools ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Bottom Line ◽  
Questionnaire Version

Clinical Scenario:Eating disorders in female athletes are a commonly underdiagnosed condition. Better screening tools for eating disorders in athletic females could help increase diagnosis and help athletes get the treatment they need.Focused Clinical Question:Should screening tools be used to detect eating disorders in female athletes?Summary of Key Findings:The literature was searched for studies that included information regarding the sensitivity and specificity of screening tools for eating disorders in female athletes. The search returned 5 possible articles related to the clinical question; 3 studies met the inclusion criteria (2 cross-sectional studies, 1 cohort study) and were included. All 3 studies reported sensitivity and specificity for the Athletic Milieu Direct Questionnaire version 2, the Brief Eating Disorder in Athletes Questionnaire version 2, and the Physiologic Screening Test to Detect Eating Disorders Among Female Athletes. All 3 studies found that the respective screening tool was able to accurately identify female athletes with eating disorders; however, the screening tools varied in sensitivity and specificity values.Clinical Bottom Line:There is strong evidence to support the use of screening tools to detect eating disorders in female athletes. Screening tools with higher sensitivity and specificity have demonstrated a successful outcome of determining athletes with eating disorders or at risk for developing an eating disorder.Strength of Recommendation:There is grade A evidence available to demonstrate that screening tools accurately detect female athletes at risk for eating disorders.

The Effects of Low-Level Laser Therapy on Pain Associated With Tendinopathy: A Critically Appraised Topic

2016 ◽  
Vol 25 (1) ◽  
pp. 83-90 ◽  
Author(s):  
Andrew T. Doyle ◽  
Christine Lauber ◽  
Kendra Sabine
Keyword(s):  
Electrical Stimulation ◽  
Laser Therapy ◽  
Low Level Laser Therapy ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Bottom Line ◽  
Low Level ◽  
Moist Heat ◽  
Low Level Laser ◽  
Level Laser

Clinical Scenario:Tendinopathies plague many active individuals, causing pain and reducing sport activity by decreasing range of motion and strength. There are many modalities that have been used to treat pain associated with chronic inflammation, such as ultrasound, moist heat packs, and electrical stimulation. Low-level laser therapy (LLLT) is one such modality. Potential benefits of managing pain associated with tendinopathies have been investigated using LLLT. Cellular respiration and metabolism are thought to be increased by LLLT acting on the mitochondrial cytochromes. The effects LLLT may have on cellular activity could increase blood flow to progress the healing process by reducing the pain-spasm cycle. The purpose of this critically appraised topic is to identify the clinical effectiveness of LLLT on pain associated with tendinopathy and to identify the parameters used to achieve statistically and clinically relevant pain outcomes.Focused Clinical Question:What is the effect of LLLT on pain associated with tendinopathy?Clinical Bottom Line:Although LLLT significantly decreases pain from baseline, its use may be no better than placebo or traditional treatments such as ultrasound, moist heat packs, electrical stimulation, or therapeutic exercise to reduce pain associated with tendinopathy. Total accumulated joules across the treatment sessions may need to be taken into account as a parameter.

Can Temperate-Water Immersion Effectively Reduce Rectal Temperature in Exertional Heat Stroke? A Critically Appraised Topic

2017 ◽  
Vol 26 (5) ◽  
pp. 447-451 ◽  
Author(s):  
Tyler T. Truxton ◽  
Kevin C. Miller
Keyword(s):  
Rectal Temperature ◽  
Water Immersion ◽  
Heat Stroke ◽  
Medical Emergency ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Temperate Water ◽  
Bottom Line ◽  
Exertional Heat Stroke ◽  
Cooling Rates

Clinical Scenario:Exertional heat stroke (EHS) is a medical emergency which, if left untreated, can result in death. The standard of care for EHS patients includes confirmation of hyperthermia via rectal temperature (Trec) and then immediate cold-water immersion (CWI). While CWI is the fastest way to reduce Trec, it may be difficult to lower and maintain water bath temperature in the recommended ranges (1.7°C–15°C [35°F–59°F]) because of limited access to ice and/or the bath being exposed to high ambient temperatures for long periods of time. Determining if Trec cooling rates are acceptable (ie, >0.08°C/min) when significantly hyperthermic humans are immersed in temperate water (ie, ≥20°C [68°F]) has applications for how EHS patients are treated in the field.Clinical Question:Are Trec cooling rates acceptable (≥0.08°C/min) when significantly hyperthermic humans are immersed in temperate water?Summary of Findings:Trec cooling rates of hyperthermic humans immersed in temperate water (≥20°C [68°F]) ranged from 0.06°C/min to 0.19°C/min. The average Trec cooling rate for all examined studies was 0.11±0.06°C/min.Clinical Bottom Line:Temperature water immersion (TWI) provides acceptable (ie, >0.08°C/min) Trec cooling rates for hyperthermic humans post-exercise. However, CWI cooling rates are higher and should be used if feasible (eg, access to ice, shaded treatment areas).Strength of Recommendation:The majority of evidence (eg, Level 2 studies with PEDro scores ≥5) suggests TWI provides acceptable, though not ideal, Trec cooling. If possible, CWI should be used instead of TWI in EHS scenarios.

The Effectiveness of Hyperbaric Oxygen Therapy as a Treatment for Postconcussion Symptoms

2017 ◽  
Vol 26 (3) ◽  
pp. 290-294 ◽  
Author(s):  
Jeremy R. Hawkins ◽  
Kayla E. Gonzalez ◽  
Kristin J. Heumann
Keyword(s):  
Hyperbaric Oxygen ◽  
Hyperbaric Oxygen Therapy ◽  
Oxygen Therapy ◽  
Neuropsychiatric Symptoms ◽  
Effective Means ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Postconcussion Syndrome ◽  
Bottom Line ◽  
Level 1

Clinical Scenario:Concussions are a prevalent topic in medicine. Concussion symptoms include headaches, dizziness, nausea, neuropsychiatric symptoms, and cognitive impairments, the persistence of which is referred to as postconcussion syndrome. Hyperbaric oxygen therapy (HBOT) has been proposed and evaluated as an additional treatment of these symptoms. HBOT is an innovative approach that has been considered by many but has received both criticism and acceptance.Clinical Question:Is HBOT an effective means of reducing symptoms for individuals suffering from postconcussion syndrome (persistence of symptoms for >3 mo)?Summary of Search:The literature was searched for studies that were relevant to the clinical question. Literature provided 5 level 1 studies that were relevant enough to be considered.Clinical Bottom Line:Based on the research that is available, the authors conclude that there is more evidence to refute the use of HBOT for postconcussion syndrome than to support it.Strength of Recommendation:Four studies disprove the use of HBOT; 1 study supported the use of HBOT. These 5 studies are the same level of evidence (level 1) and provide significant findings in their studies. The strength of this recommendation is a B according to the Centre for Evidence-Based Medicine.

scholarly journals Hip Strengthening Compared With Quadriceps Strengthening in Conservative Treatment of Patients With Patellofemoral Pain: A Critically Appraised Topic

2015 ◽  
Vol 20 (1) ◽  
pp. 4-12 ◽  
Author(s):  
Chyrsten L. Regelski ◽  
Brittany L. Ford ◽  
Matthew C. Hoch
Keyword(s):  
Patellofemoral Pain ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Bottom Line ◽  
Muscle Strengthening ◽  
Oral Pain ◽  
Patient Reported ◽  
Strengthening Exercises ◽  
Hip Abductor ◽  
Hip Strengthening

Clinical Scenario:Patellofemoral pain is a common injury that affects both athletic and sedentary populations. Clinicians may treat patellofemoral pain more effectively through a comprehensive understanding of the most effective exercise protocols.Clinical Question:In patients with patellofemoral pain, are hip abductor and external rotator muscle strengthening exercises more effective in reducing pain and improving patient-reported function compared with isolated quadriceps strengthening?Summary of Key Findings:A comprehensive and systematic database search was conducted for studies of level 2 evidence or higher. The search yielded 253 studies; of these studies, four randomized control trials and one comparative control trial fit the inclusion and exclusion criteria. A combination of quadriceps and hip strengthening exercises or hip strengthening exercises alone reduced pain and improved patient-reported function compared with quadriceps strengthening alone.Clinical Bottom Line:There is strong evidence to support the use of hip strengthening or hip strengthening combined with quadriceps strengthening in the treatment of patellofem-oral pain to decrease pain and improve patient reported function.Strength of Recommendation:The Strength of Recommendation Taxonomy recommends a grade of A for level 1 evidence with consistent patient-oriented findings.

Should Cooling Vests Be Used to Treat Exertional Heatstroke? A Critically Appraised Topic

2017 ◽  
Vol 26 (3) ◽  
pp. 286-289
Author(s):  
Megan L. Keen ◽  
Kevin C. Miller
Keyword(s):  
Cold Water ◽  
Core Body Temperature ◽  
Water Immersion ◽  
Heat Stroke ◽  
Cold Water Immersion ◽  
Clinical Scenario ◽  
Clinical Question ◽  
Bottom Line ◽  
Cooling Rates ◽  
Central Nervous System Dysfunction

Clinical Scenario:Exercise performed in hot and humid environments increases core body temperature (TC). If TC exceeds 40.5°C for prolonged periods of time, exertional heat stroke (EHS) may occur. EHS is a leading cause of sudden death in athletes. Mortality and morbidity increase the longer the patient’s TC remains above 40.5°C; thus, it is imperative to initiate cooling as quickly as possible. Acceptable cooling rates in EHS situations are 0.08–0.15°C/min, while ideal cooling rates are above 0.16°C/min. Cooling vests are popular alternatives for cooling hyperthermic adults. Most vests cover the anterior and posterior torso and have varying numbers of pouches for phase-change materials (eg, gel packs); some vests only use circulating water to cool. While cooling vests offer several advantages (eg, portability), studies demonstrating their effectiveness at rapidly reducing TC in EHS scenarios are limited.Clinical Question:Are TC cooling rates acceptable (ie, >0.08°C/min) when hyperthermic humans are treated with cooling vests postexercise?Summary of Findings:No significant differences in TC cooling rates occurred between cooling vests and no cooling vests. Cooling rates across all studies were ≤0.053°C/min.Clinical Bottom Line:Cooling vests do not provide acceptable cooling rates of hyperthermic humans postexercise and should not be used to treat EHS. Instead, EHS patients should be treated with cold-water immersion within 30 min of collapse to avoid central nervous system dysfunction and organ failure.Strength of Recommendation:Strong evidence (eg, level 2 studies with PEDro scores ≥5) suggests that cooling vests do not reduce TC quickly and thus should not be used in EHS scenarios.

scholarly journals Early Controlled Exercise and Timing of Treatment Following Concussion: A Critically Appraised Topic

2020 ◽  
Vol 29 (3) ◽  
pp. 360-366 ◽  
Author(s):  
Nicholas Hattrup ◽  
Hannah Gray ◽  
Mark Krumholtz ◽  
Tamara C. Valovich McLeod
Keyword(s):  
Aerobic Exercise ◽  
Interdisciplinary Approach ◽  
Rehabilitation Program ◽  
Psychological State ◽  
Sufficient Evidence ◽  
Symptom Duration ◽  
Clinical Question ◽  
Bottom Line ◽  
Duration Of Symptoms ◽  
Symptom Intensity

Clinical Scenario: Recent systematic reviews have shown that extended rest may not be beneficial to patients following concussion. Furthermore, recent evidence has shown that patient with postconcussion syndrome benefit from an active rehabilitation program. There is currently a gap between the ability to draw conclusions to the use of aerobic exercise during the early stages of recovery along with the safety of these programs. Clinical Question: Following a concussion, does early controlled aerobic exercise, compared with either usual care or delayed exercise, improve recovery as defined by symptom duration and severity? Summary of Key Findings: After a thorough literature search, 5 studies relevant to the clinical question were selected. Of the 5 studies, 1 study was a randomized control trial, 2 studies were pilot randomized controlled trials, and 2 studies were retrospective. All 5 studies showed that implementing controlled aerobic exercise did not have an adverse effect on recovery. One study showed early aerobic exercise had a quicker return to school, and another showed a 2-day decrease in symptom duration. Clinical Bottom Line: There is sufficient evidence to suggest that early controlled aerobic exercise is safe following a concussion. Although early aerobic exercise may not always result in a decrease in symptom intensity and duration, it may help to improve the psychological state resulting from the social isolation of missing practices and school along with the cessation of exercise. Although treatments continue to be a major area of research following concussion, management should still consist of an interdisciplinary approach to individualized patient care. Strength of Recommendation: There is grade B evidence to support early controlled aerobic exercise may reduce the duration of symptoms following recovery while having little to no adverse events.

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