Association between days for concussion recovery and initial specialty clinic evaluation within 48 hours.

BACKGROUND: Researchers have highlighted the importance of early access to concussion care within one week of injury in reducing recovery times. However, a persisting question for concussion researchers is "just how early is important?" The purpose of this study was to examine differences in recovery time as predicted by the number of days elapsed since injury (DSI) to initial evaluation among patients who had access to a specialty concussion clinic within seven days. We hypothesized that DSI group membership, even within seven days, would significantly predict risk of protracted recovery (i.e., beyond 21 days). METHODS: In this archival study, retrospective data were gathered from electronic medical records between September 2020 to March 2022. Records of participants between ages 12-18, those diagnosed with a sports-related concussion based on initial clinic visit diagnosis by a medical provider and those who established care within seven days of injury at a large pediatric specialty concussion clinic were examined. Participants were divided into three DSI groups (patients seen in < 48 h: "acute", patients seen between 49 h < and < 96 h: "sub-acute", and patients seen between 97 < and < 168 h: "post-acute"). A general linear model was constructed to examine relationships between relevant concussion factors (e.g., Post Concussion Scale Score, neurodevelopmental history, psychiatric history, concussion history, migraine history, overall VOMS change score, cognitive testing, sex, age, race, and ethnicity) that were either significant in the preliminary analysis or in clinical judgement and recovery time. Adjusted odds ratios (OR) were derived from a binary logistic regression model, in which recovery time was normal (≤ 21 recovery days) or protracted (> 21 recovery days). RESULTS: A total of 856 participants were eligible. Adolescents in the acute group (M = 15.12, SD = 8.04) had shorter recovery times in days compared to those in the sub-acute (M = 17.98, SD = 10.18) and post-acute (M = 21.12, SD = 10.12; F = 26.00, p < .001) groups. Further, participants in the acute (OR = 4.16) and sub-acute (OR = 1.37) groups who accessed specialty concussion clinics within 48 h were 4 times more likely to have a normal recovery and recovered approximately 6 days faster than the post-acute care group. CONCLUSIONS: Earlier concussion care access predicted recovery times and was associated with lower risk for protracted recovery.

Physically Active Adults with Low Back Pain do not Demonstrate Altered Deadlift Mechanics: A Novel Application of Myotonometry to Estimate Inter-Muscular Load Sharing.

Background: Rehabilitation clinicians that work with physically active populations are challenged with how to safely return patients back to performing deadlift movements following low back injury. Application of reliable and valid tests and measures to quantify impairments related to low back pain (LBP) enhances clinical decision making and may affect outcomes. Myotonometry is a non-invasive method to assess muscle stiffness which has demonstrated significant associations with physical performance and musculoskeletal injury. Hypothesis/Purpose: The purpose of this study was to compare the stiffness of trunk (lumbar multifidus [LM] and longissimus thoracis [LT]) and lower extremity (vastus lateralis [VL] and biceps femoris [BF]) muscles between individuals with and without LBP during the lying, standing, and deadlifting body positions. Study Design: Cross-sectional cohort comparison. Methods: Muscle stiffness measures were collected in the VL, BF, LM, and LT muscles with participants in lying (supine and prone), standing, and the trap bar deadlift position. Separate analyses of covariance were conducted to compare absolute and relative muscle stiffness between the groups for each muscle and condition. Results: Sixty-eight participants (41 female, 21.3 years, 34 LBP) volunteered for the study. Within the deadlift condition there was a significantly greater increase in the percent-muscle stiffness change in the VL (p = .029, 21.9%) and BF (p = .024, 11.2%) muscles in the control group than in the LBP group. There were no differences in percent-muscle stiffness changes for the standing condition nor were there any absolute muscle stiffness differences between the two groups for the three conditions. Conclusion: No differences in muscle stiffness were identified in the lying, standing, or deadlifting conditions between participants with and without LBP. Differences in percent stiffness changes were noted between groups for the deadlift position, however the differences were modest and within measurement error. Future studies should investigate the utility of myotonometry as a method to identify LBP-related impairments that contribute to chronic and/or recurrent low back injury. Level of Evidence: Level 3.

Myotonometry is Capable of Reliably Obtaining Trunk and Thigh Muscle Stiffness Measures in Military Cadets During Standing and Squatting Postures.

INTRODUCTION: Low back and lower extremity injuries are responsible for the highest percentage of musculoskeletal injuries in U.S. Army soldiers. Execution of common soldier tasks as well as army combat fitness test events such as the three-repetition maximum deadlift depends on healthy functioning trunk and lower extremity musculature to minimize the risk of injury. To assist with appropriate return to duty decisions following an injury, reliable and valid tests and measures must be applied by military health care providers. Myotonometry is a noninvasive method to assess muscle stiffness, which has demonstrated significant associations with physical performance and musculoskeletal injury. The aim of this study is to determine the test-retest reliability of myotonometry in lumbar spine and thigh musculature across postures (standing and squatting) that are relevant to common soldier tasks and the maximum deadlift. MATERIALS AND METHODS: Repeat muscle stiffness measures were collected in 30 Baylor University Army Cadets with 1 week between each measurement. Measures were collected in the vastus lateralis (VL), biceps femoris (BF), lumbar multifidus (LM), and longissimus thoracis (LT) muscles with participants in standing and squatting positions. Intraclass correlation coefficients (ICCs3,2) were estimated, and their 95% CIs were calculated based on a mean rating, mixed-effects model. RESULTS: The test-retest reliability (ICC3,2) of the stiffness measures was good to excellent in all muscles across the standing position (ICCs: VL = 0.94 [0.87-0.97], BF = 0.97 [0.93-0.98], LM = 0.96 [0.91-0.98], LT = 0.81 [0.59-0.91]) and was excellent in all muscles across the squatting position (ICCs: VL = 0.95 [0.89-0.98], BF = 0.94 [0.87-0.97], LM = 0.96 [0.92-0.98], LT = 0.93 [0.86-0.97]). CONCLUSION: Myotonometry can reliably acquire stiffness measures in trunk and lower extremity muscles of healthy individuals in standing and squatting postures. These results may expand the research and clinical applications of myotonometry to identify muscular deficits and track intervention effectiveness. Myotonometry should be used in future studies to investigate muscle stiffness in these body positions in populations with musculoskeletal injuries and in research investigating the performance and rehabilitative intervention effectiveness.

The Utility of Myotonometry in Musculoskeletal Rehabilitation and Human Performance Programming.

Myotonometry is a relatively novel method used to quantify the biomechanical and viscoelastic properties (stiffness, compliance, tone, elasticity, creep, and mechanical relaxation) of palpable musculotendinous structures with portable mechanical devices called myotonometers. Myotonometers obtain these measures by recording the magnitude of radial tissue deformation that occurs in response to the amount of force that is perpendicularly applied to the tissue through a device's probe. Myotonometric parameters such as stiffness and compliance have repeatedly demonstrated strong correlations with force production and muscle activation. Paradoxically, individual muscle stiffness measures have been associated with both superior athletic performance and a higher incidence of injury. This indicates optimal stiffness levels may promote athletic performance, whereas too much or too little may lead to an increased risk of injury. Authors of numerous studies suggested that myotonometry may assist practitioners in the development of performance and rehabilitation programs that improve athletic performance, mitigate injury risk, guide therapeutic interventions, and optimize return-to-activity decision-making. Thus, the purpose of our narrative review was to summarize the potential utility of myotonometry as a clinical tool that assists musculoskeletal clinicians with the diagnosis, rehabilitation, and prevention of athletic injuries.

Reliability and Validity of a Flume-Based Maximal Oxygen Uptake Swimming Test.

A mode-specific swimming protocol to assess maximal aerobic uptake (VO2maxsw) is vital to accurately evaluate swimming performance. A need exists for reliable and valid swimming protocols that assess VO2maxsw in a flume environment. The purpose was to assess: (a) reliability and (b) "performance" validity of a VO2maxsw flume protocol using the 457-m freestyle pool performance swim (PS) test as the criterion. Nineteen males (n = 9) and females (n = 10) (age, 28.5 ± 8.3 years.; height, 174.7 ± 8.2 cm; mass, 72.9 ± 12.5 kg; %body fat, 21.4 ± 5.9) performed two flume VO2maxsw tests (VO2maxswA and VO2maxswB) and one PS test [457 m (469.4 ± 94.7 s)]. For test-retest reliability (Trials A vs. B), moderately strong relationships were established for VO2maxsw (mL·kg-1·min-1)(r= 0.628, p = 0.002), O2pulse (mL O2·beat-1)(r = 0.502, p = 0.014), VEmax (L·min-1) (r = 0.671, p = 0.001), final test time (sec) (0.608, p = 0.004), and immediate post-test blood lactate (IPE (BLa)) (0.716, p = 0.001). For performance validity, moderately strong relationships (p < 0.05) were found between VO2maxswA (r =-0.648, p = 0.005), O2pulse (r= -0.623, p = 0.008), VEmax (r = -0.509 p = 0.037), and 457-m swim times. The swimming flume protocol examined is a reliable and valid assessment of VO2maxsw., and offers an alternative for military, open water, or those seeking complementary forms of training to improve swimming performance.

The Acute Effect of High-Intensity Resistance Training on Subsequent Firefighter Performance.

ABSTRACT: Mason, MR, Heebner, NR, Abt, JP, Bergstrom, HC, Shapiro, R, Langford, EL, and Abel, MG. The acute effect of high-intensity resistance training on subsequent firefighter performance. J Strength Cond Res 37(7): 1507-1514, 2023-High-intensity resistance training (HIRT) is commonly performed by structural firefighters on duty to enhance occupational readiness. However, exercise-induced fatigue may negatively impact subsequent occupational performance. Therefore, the purpose of this study was to assess the acute effect of HIRT on subsequent occupational physical ability in structural firefighters and to determine the time course of recovery. Seven resistance-trained male firefighters performed a timed maximal effort simulated fireground test (SFGT) in 3 randomized conditions: baseline (SFGT baseline ), 10 minutes post HIRT (SFGT 10min ), and 60 minutes post HIRT (SFGT 60min ). Work efficiency and air depletion were assessed during the SFGT. The timed HIRT session consisted of a standardized set of exercises using absolute training loads. Repeated measures analysis of variance and minimal difference (MD) analysis assessed group and individual effects between the conditions, respectively. The level of significance was set at p < 0.05. SFGT 10min completion time was greater than SFGT baseline (430 ± 137 vs. 297 ± 69 seconds, p < 0.01), with no difference between SFGT baseline and SFGT 60min (297 ± 69 vs. 326 ± 89 seconds, p = 0.08). The MD analysis indicated that all firefighters' SFGT 10min times exceeded the MD (±26.4 seconds) compared with SFGT baseline . However, 43% of firefighters still exceeded the MD at SFGT 60min . Air depletion during SFGT 10min was greater than that during SFGT baseline (2,786 ± 488 vs. 2,186 ± 276 lb·in -2 , p = 0.02), with no difference between SFGT baseline and SFGT 60min ( p = 0.25). Work efficiency during SFGT 10min was 40% lower than that during SFGT baseline ( p < 0.01), with no difference between SFGT baseline and SFGT 60min ( p = 0.25). These findings indicate that an acute bout of HIRT decreases multiple descriptors of firefighters' occupational performance 10 minutes post exercise with varied responses at 60 minutes post exercise.

Pain Early After Anterior Cruciate Ligament Reconstruction is Associated With 6-Month Loading Mechanics During Running.

BACKGROUND: Anterior cruciate ligament reconstruction (ACLR) results in persistent altered knee biomechanics, but contributing factors such as pain or patient function, leading to the altered loading, are unknown. HYPOTHESIS: Individuals with worse self-reported pain after ACLR would have poorer biomechanics during running, and poor loading mechanics would be present in the ACLR limb compared with contralateral and control limbs. STUDY DESIGN: Cohort pilot study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 20 patients after ACLR (age, 18.4 ± 2.7 years; height, 1.7 ± 0.1 m; mass, 84.2 ± 19.4 kg) completed visual analog scale and Knee Injury and Osteoarthritis Outcomes Score (KOOS) at 1 and 6 months postsurgery. At 6 months postsurgery, patients underwent biomechanical testing during running. A total of 20 control individuals also completed running biomechanical analyses. Associations between patient outcomes and biomechanics were conducted, and differences in running biomechanics between groups were analyzed. RESULTS: KOOS pain score 1 month after surgery was associated with peak ACLR knee abduction moment (R2 = 0.35;P = 0.01). At 6-months, KOOS sport score was related to peak abduction moment in the ACLR limb (R2 = 0.23; P = 0.05). For change scores, the improvement in pain scores related to ACLR limb peak knee abduction moment (R2 = 0.55; P = 0.001). The ACLR limb had lower knee excursion, extension moments, and ground-reaction forces compared with the uninvolved and control limb. The uninvolved limb also had higher ground-reaction forces compared with the ACLR limb and control limb. CONCLUSION: These results suggest that patient-reported outcomes 1 and 6 months after surgery are associated with running mechanics 6 months after ACLR. Further, the underloading present in the ACLR limb and overloading in the uninvolved limb indicates greater need for running rehabilitation after ACLR. CLINICAL RELEVANCE: Understanding pain and how it may be linked to movement dysfunction is important for improving long-term outcomes.

Gender Differences and the Influence of Body Composition on Land and Pool-Based Assessments of Anaerobic Power and Capacity.

Consistent differences between males and females have been shown in land-based measurements of anaerobic power and capacity. However, these differences have not been investigated for a tethered 30-s maximal swimming test (TST). The purpose of this study is to explore gender differences in land and pool-based assessments of anaerobic power (Fpeak) and capacity (Fmean), as well as the influence of body composition. Thirteen males and fifteen females completed land (Wingate (WAnT)) and pool-based (TST) measures of anaerobic power and capacity previously described in the literature. Additionally, the subjects completed assessments of body composition via air displacement plethysmography. The males produced higher force than the females for Fpeak (p < 0.001) and Fmean (p = 0.008) during the TST. However, linear regression analysis determined that lean mass significantly predicted Fpeak (p = 0.002) and Fmean (p < 0.001) during the TST, while gender was no longer significant (p = 0.694 and p = 0.136, respectively). In conclusion, increases in anaerobic power and capacity (Fpeak and Fmean) may be a function of increased lean mass in males and females, warranting future research on the impact of resistance training programs on force production and swimming performance.

The Utility of Myotonometry in Musculoskeletal Rehabilitation and Human Performance Programming.

Myotonometry is a relatively novel method used to quantify the biomechanical and viscoelastic properties (stiffness, compliance, tone, elasticity, creep, mechanical relaxation) of palpable musculotendinous structures with portable mechanical devices called myotonometers. Myotonometers obtain these measures by recording the magnitude of radial tissue deformation that occurs in response to the amount of force that is perpendicularly applied to the tissue through a device's probe. Myotonometric parameters such as stiffness and compliance have repeatedly demonstrated strong correlations with force production and muscle activation. Paradoxically, individual muscle stiffness measures have been associated with both superior athletic performance and higher incidence of injury. This suggest there may be optimal stiffness levels that promotes athletic performance while too much or too little may lead to an increased risk of injury. Numerous studies suggest that myotonometry may assist practitioners in the development of performance and rehabilitation programs that improves athletic performance, mitigates injury risk, guides therapeutic interventions, and optimizes return to activity decision making. Thus, the purpose of this narrative review is to summarize the potential utility of myotonometry as a clinical tool that assists musculoskeletal clinicians with the diagnosis, rehabilitation, and prevention of athletic injuries.

Training Strategies Maintain Performance Characteristics in Marines Selected for Marine Forces Special Operations Individualized Training Course.

INTRODUCTION: Marines must complete an intensive Assessment and Selection (A&S) course before becoming a U.S. Marine Forces Special Operations Command (MARSOC) Raider. Following selection, marines are given training recommendations designed to maintain performance characteristics deemed relevant to successfully complete a rigorous 9-month Individualized Training Course (ITC). However, training strategies are individually implemented by the marine, and the time between the two courses is highly irregular, ranging between 2 months and 24 months based on operational factors related to military occupational specialty (MOS). The purpose of this study was to evaluate changes in performance between the completion of A&S and the start of ITC and to examine if the duration between courses and previous MOS influenced changes in performance. MATERIALS AND METHODS: Body fat percentage (BF%), anaerobic power (AP), anaerobic capacity (AC), aerobic capacity (VO2max), knee flexion (KF), knee extension (KE), trunk extension (TE), and trunk flexion (TF) isokinetic strength were collected on 38 marines (age: 25.1 ± 2.7 years, height: 1.77 ± 0.05 m, mass: 83.2 ± 7.7 kg, Post-A&S to ITC start: 204.1 ± 68.4 days) following A&S and directly before ITC. RESULTS: Pre-ITC students had significantly greater mass (P = .002), BF% (P = .000), and AP (P = .039). There were no significant changes in AC (P = .170), VO2max (P = .259), KF (P = .400), KE (P = .320), TE (P = .178), and TF (P = .643). There was no significant relationship between performance outcomes and time between courses and previous MOS. CONCLUSION: Current training strategies appear effective at addressing performance deficits that occur as a result of A&S, while maintaining high levels of KF, KE, TE, TF, AC, and VO2max. However, pre-ITC students still exhibited AP deficits compared to active marine raiders, so forthcoming programming may benefit from an increased emphasis on AP. Assessment of additional selectees at these timepoints, as well as students before A&S may provide valuable information to MARSOC human performance specialists to develop programing, ultimately leading to a higher ITC graduation rate, increased force readiness, and decreased financial burden forcewide.

Exploring Vestibular/Ocular and Cognitive Dysfunction as Prognostic Factors for Protracted Recovery in Sports-Related Concussion Patients Aged 8 to 12 Years.

OBJECTIVE: To explore the prognostic ability of the vestibular/ocular motor screening (VOMS), King-Devick (K-D) Test, and C3 Logix Trails A and B to identify protracted recovery from sports-related concussion (SRC) in patients aged 8 to 12 years. DESIGN: Retrospective cohort analysis. SETTING: Specialty pediatric sports concussion clinic. PARTICIPANTS: A total of 114 youth athletes aged 8 to 12 years who were diagnosed with an SRC within 7 days of injury. INDEPENDENT VARIABLES: A positive screen on the VOMS, K-D, and C3 Logix Trails A and Trails B. Combined positive screens on multiple tests (ie, 2, 3, or all 4 positive screens of 4 possible). MAIN OUTCOME MEASURES: Recovery time in days and protracted recovery (recovery time ≥30-days) were the primary outcomes of interest. RESULTS: A positive VOMS screen was associated with 1.31 greater days to SRC recovery ( P = 0.02) than a negative VOMS screen. The K-D and C3 Logix tests were not significantly associated with recovery time, nor were any combinations of tests ( P > 0.05). The VOMS demonstrated moderate prognostic ability to predict normal recovery (negative predictive value = 80.78% [95% CI = 63.73-90.95]). Overall predictive accuracy of normal versus protracted recovery was strongest when a participant screened positive on all 4 tests (Accuracy = 76.32% [95% CI = 67.45-83.78]). CONCLUSIONS: The VOMS was associated with overall recovery time and proved to be a useful test to identify those who would experience a normal recovery time. Combining the 4 tests improved the prognostic accuracy of the protocol in predicting protracted versus normal recovery. These findings suggest that combining multiple, varied assessments of cognition and vestibular/ocular functions may better explain factors contributing to protracted recovery.

Asymmetrical Loading Patterns in Military Personnel With a History of Self-Reported Low Back Pain.

BACKGROUND: Servicemembers are required to operate at high levels despite experiencing common injuries such as chronic low back pain. Continuing high levels of activity while compensating for pain may increase the risk of musculoskeletal injuries. As such, the purpose of this project was to determine if servicemembers with chronic low back pain have reduced lower extremity performance, and if they use alternate strategies to complete a functional performance task as compared to healthy servicemembers. METHODS: Of a total of 46 male United States Marine Corps Forces Special Operations Command (MARSOC) personnel, 23 individuals who suffered from chronic low back pain (age = 28.6 ± 4.4 years, weight = 84.2 ± 6.8 kg) and 23 healthy controls (age = 27.9 ± 3.8 years, weight = 83.8 ± 7.7 kg) completed a stop jump task. In this task, three-dimensional biomechanics were measured, and lower extremity and trunk strength were assessed. RESULTS: The low back pain group exhibited higher vertical ground reaction force impulse on the dominant limb (0.26% body weight [BW]/s), compared to the nondominant limb (0.25% BW/s, p = .036). The control group demonstrated relationships between jump height and strength in both limbs (dominant: r = 0.436, p = .043; nondominant: r = 0.571, p = .006), whereas the low back pain group demonstrated relationships between jump height and dominant limb knee work (r = 0.470, p = .027) and ankle work (r = 0.447, p = .037). CONCLUSIONS: This study demonstrates that active-duty MARSOC personnel with a history of low back pain reach similar levels of jump height during a counter movement jump, as compared to those without a history of low back pain. However, the asymmetries displayed by the low back pain group suggest an alternate strategy to reaching similar jump heights as compared to healthy individuals.

Physical Therapists' Assessment of Patient Self-Efficacy for Home Exercise Programs.

BACKGROUND: Patient adherence to home exercise programs (HEPs) is low, and poor patient self-efficacy is a barrier clinicians can influence. However, little evidence suggests that clinicians assess level of patient self-efficacy before prescribing HEPs. PURPOSE: To determine the importance of patient self-efficacy to physical therapists (PTs) when addressing patient barriers, determine how PTs assess and use patient self-efficacy for HEPs, and describe the barriers facing PTs when assessing patient self-efficacy for HEPs. STUDY DESIGN: Survey. METHODS: Practicing PTs were recruited from the American Physical Therapy Association's Orthopedic Section and emailed the electronic survey. RESULTS: Email invitations were sent to 17730 potential participants, and 462 PTs completed the survey over one month. PTs rated self-efficacy as "very" to "extremely" important for patient adherence (58%, 265/454). Most (71%, 328/462) reported assessing self-efficacy before prescribing HEPs and did so through verbal discussion and observation of the patient (50% and 38% respectively). Half of respondents individualized HEPs through self-efficacy related themes. PTs not assessing self-efficacy reported not knowing how (51%, 68/134), being unsure what to do with the information (24%, 32/134), or reporting other barriers (21%, 28/134). CONCLUSIONS: Most PTs indicated that self-efficacy was important for patient adherence, but assessment strategies reported, such as verbal discussion and observation, may not be the most accurate. PTs who did not assess self-efficacy reported not knowing how or what to do with the information once collected. These findings suggest that there is a gap in knowledge related to how to evaluate self-efficacy for HEPs. Better assessment of self-efficacy may lead to more appropriate and effective implementation strategies. LEVEL OF EVIDENCE: Level II.

Tethered Swimming Test: Reliability and the Association With Swimming Performance and Land-Based Anaerobic Performance.

ABSTRACT: Nagle Zera, J, Nagle, EF, Nagai, T, Lovalekar, M, Abt, JP, and Lephart, SM. Tethered swimming test: reliability and the association with swimming performance and land-based anaerobic performance. J Strength Cond Res 35(1): 212-220, 2021-The purpose of this study was 3-fold: (a) to examine the test-retest reliability of a 30-second maximal tethered freestyle swimming test (TST), (b) to assess the validity of the TST by examining the association with sprint swimming performance, and (c) to examine the associations between a swim-specific and land-based measure of anaerobic performance. A total of 29 male and female swimmers were recruited to participate in the study. Each subject completed a Wingate Anaerobic cycling test (WAnT), 2 or 4 TST, and a 22.9 m (25 yd), 45.7 m (50 yd), and 91.4 m (100 yd) maximal freestyle performance swims (PS). Mean and peak force (Fmean and Fpeak) were recorded for both the WAnT and TST, and average swimming velocity and time were recorded for the PS. In addition, physiological and perceptual measures were recorded immediately postexercise for all tests. The results of the present investigation showed strong intersession and intrasession reliability (R = 0.821-0.975; p < 0.001) for force parameters of the TST. Moderate correlations were found between Fmean and PS time and velocity of all distances, with slightly weaker correlations between Fpeak and the 22.9 m (time and velocity) and 45.7 m (velocity) PS. Finally, moderate correlations were found for Fmean and Fpeak of the TST and WAnT. This study demonstrated that the TST is a reliable measure, with moderate association with swimming performance, producing similar physiological responses compared with free swimming. Therefore, future research should focus on investigating the potential benefits of using the TST as a regular assessment tool as a part of a competitive swimming training program to track adaptations and inform training decisions.

Altered Physical Performance Following Advanced Special Operations Tactical Training.

ABSTRACT: Winters, JD, Heebner, NR, Johnson, AK, Poploski, KM, Royer, SD, Nagai, T, Randall, CA, Abt, JP, and Lephart, SM. Altered physical performance following advanced special operations tactical training. J Strength Cond Res 35(7): 1809-1816, 2021-The purpose of this study was to determine how the unique challenges of specific military tactical training phases influence overall physical performance characteristics. Broad jump, 5-10-5, 300-yd shuttle, percent body fat (%BF), anaerobic power (AP) and anaerobic capacity (AC), maximal oxygen uptake (V̇o2max), isokinetic knee extension/flexion strength, shoulder internal/external rotation strength, and trunk extension/flexion strength were collected on 73 United States Marine Corps Forces Special Operations Command (MARSOC) students (age: 27.4 ± 3.8 years, height: 178.7 ± 6.6 cm, and body mass: 85.8 ± 9.4 kg) at the beginning of (P1), in between (P2), and at the completion of 2 distinct tactical training phases (P3). Linear mixed models were used to analyze within-subject performance changes over the 3 time points, and post hoc Bonferroni pairwise comparisons analyzed performance changes between each testing time point. There were significant changes in broad jump (p < 0.0001), 5-10-5 agility time (p < 0.001), %BF (p = 0.011), AP (p < 0.0001), V̇o2max (p = 0.001), and both right and left shoulder internal rotation strength (p = 0.004 and p = 0.015, respectively) between P1 and P2. There were also significant changes in 300-yd shuttle run time (p = 0.001), AP (p < 0.0001), AC (p < 0.0001), left knee extension strength (p = 0.006), trunk flexion strength (p < 0.0001), and left shoulder external rotation strength (0.027) between P2 and P3. Identifying the effect that specific tactical training phases may have on physical performance will allow for the development of effective phase-specific evidence-based human performance programs, reducing performance deficits and thereby reducing the risk of injury.

Development of a pain neuroscience education program for post-traumatic stress disorder and pain.

Introduction: Individuals with co-morbid post-traumatic stress disorder (PTSD) and pain have higher disability, pain, and pain catastrophizing beliefs than patients without PTSD. Pain neuroscience education (PNE) may be an effective tool to help those with PTSD and pain reduce maladaptive beliefs about pain. The purpose of this paper is to report the development and evaluation of a PNE curriculum for participants with PTSD and pain. Methods: After writing an initial draft of PNE for PTSD and pain, a panel of medical experts in PNE, PTSD, and rehabilitation reviewed the booklet. After addressing recommendations from the medical panel (n = 29), individuals with (n = 13) and without (n = 20) PTSD reviewed the booklet. Results: Overall, 89% of participants recommended the PNE booklet and 90% thought it would help patients with PTSD and pain. Although patients with PTSD rated the PNE booklet more critically than other participants, a particular support group (n = 4) rated the PNE booklet significantly different (p < .05) than remaining participants with PTSD (n = 9). Individuals with PTSD and pain were able to comprehend the PNE booklet at a comparable rate to an expert medical panel and participants without PTSD after adjusting for education levels (p = .12). Conclusions: Many patients with PTSD and pain avoid painful activities because they believe they are harmful. This research demonstrates that individuals with PTSD and pain can comprehend PNE that challenges these beliefs. The PNE curriculum developed by this research may provide a logical explanation for the link between PTSD symptoms and pain and should be tested for clinical effectiveness.

INFLUENCE OF LIMB DOMINANCE AND SHOULDER INJURY ON STRENGTH AND EXPLOSIVE FORCE IN US MARINES.

BACKGROUND: The specialized roles of many military personnel require specific skills and high physical demands, placing unique stresses on the shoulders and increasing risk of injury. As normal dominant/nondominant shoulder asymmetries have been established in military personnel, bilateral strength comparisons must be understood in context of daily physical demands to monitor patients' progress or readiness to return to duty. PURPOSE: This study aims to assess bilateral differences in strength and explosive force in United States Marines with a history of dominant or nondominant shoulder pathology. STUDY DESIGN: Cross-Sectional. METHODS: A total of 52 full-duty, male US Marines with a shoulder injury within the prior year participated. Bilateral isokinetic shoulder internal (IR) and external (ER) rotation strength, and peak force (Peak Force) and average rate of force production (Avg Rate) during an explosive push-up were collected. Dominant versus nondominant side data were independently examined within each group (DOM: dominant injury, NOND: nondominant injury). Comparison between DOM and NOND, as well as previously published CON (no history of shoulder injury) was also completed. RESULTS: NOND (n = 26) demonstrated significantly less IR (p < 0.001) and ER (p = 0.003) strength and Peak Force (p = 0.001) and Avg Rate (p = 0.047) on the injured side, while DOM (n = 26) demonstrated no bilateral differences in strength or push-up performance. Comparison between the three groups showed that NOND demonstrated significantly less ER strength than CON (p = 0.022). CONCLUSIONS: Military personnel demonstrate asymmetric strength patterns likely due to increased demand of the dominant shoulder. US Marines with a history of injury to the nondominant shoulder performed differently than those with a dominant side injury, presenting with both strength and push-up asymmetries. They also demonstrated significant ER strength deficits compared to CON. Common clinical practice and previous literature often compare injured and uninjured limbs or injured individuals to healthy controls, but further distinction of dominant or nondominant side may provide more accurate information needed to develop targeted treatment strategies. CLINICAL RELEVANCE: Recognizing unique occupational demands and how patients may present differently with dominant versus nondominant side shoulder injuries are important considerations for ensuring accurate assessment and effective individualized rehabilitation. LEVEL OF EVIDENCE: 3.

Military Protein Intake Related to Strength and Fat Mass Independent of Energy Intake.

INTRODUCTION: Kinetic military units operate in austere training environments and deprivation not commonly experienced by competitive athletes. Nutritional strategies to protect against decrements in performance and potential injury risk may differ for these two groups. A cross sectional analysis was conducted to determine energy and macronutrient characteristics associated with performance metrics. MATERIALS AND METHODS: 78 male subjects (age: 28.4 ± 6.0 years, height: 178.3 ± 6.7 cm, mass: 84.3 ± 9.4 kg, 8.5 ± 5.8 years of service) assigned to Marine Corps Forces Special Operations Command completed a 1-day performance assessment. Body mass, lean body mass, fat mass (FM), aerobic capacity (VO2max), lactate inflection point (LT), anaerobic power, anaerobic capacity, knee flexion strength, knee extension strength, peak knee flexion strength, and peak knee extension strength outcome values were recorded. Dietary intake was collected using automated self-administered 24-hour dietary recall (ASA24). Performance assessment scores were compared with macronutrient intake and controlled for energy intake using analysis of covariance. RESULTS: Differences in knee flexion strength, knee extension strength, peak knee flexion strength, and peak knee extension strength were significant across low (LPRO), medium (MPRO), and high (HPRO) protein intake groups (p < 0.05) with LPRO performance metrics significantly lower than both MPRO and HPRO and MPRO significantly lower than HPRO. FM was significantly higher in LPRO than MPRO or HPRO (p < 0.05). Low carbohydrate intake (LCHO) was associated with greater body mass and FM compared with high (HCHO) (p < 0.05). There was no association between fat intake and any variable. CONCLUSIONS: Increases in protein intake may have beneficial performance effects independent of total energy intake, while moderate increases in carbohydrate intake may not be sufficient to enhance physical performance in a special operations population.

Management and Treatment of Concussions via Tele-Concussion in a Pediatric Setting: Methodological Approach and Descriptive Analysis.

BACKGROUND: Approximately 2 million children in the United States sustain a concussion annually, resulting in an economic impact as high as US $20 billion. Patients who receive treatment at concussion specialty clinics, versus primary care, experience faster recovery, thereby reducing patient burden and subsequent medical-related costs. Accessibility to specialty clinics is typically limited by the availability of in-office visits. This is particularly relevant in light of the severe acute respiratory syndrome coronavirus 2 pandemic and subsequent guidance to eliminate all non-medically necessary in-clinic visits. Telehealth has been used to effectively deliver in-clinic care across several disciplines including psychiatry, psychology, and neuropsychology. However, a model of telehealth delivered concussion assessment, treatment, and management has not been established. OBJECTIVE: The purposes of this paper are to describe a pediatric concussion specialty clinic's experiences in delivering telehealth concussion services and to provide preliminary descriptive data on a sample of pediatric telehealth patients with concussions. METHODS: The specialty pediatric concussion clinic described here began providing telehealth services in 2019 and is part of the largest and fastest-growing telehealth hospital network in the United States. The clinical care process will be described, including accessing the telehealth platform, assessment during the initial appointment, injury management including communication with relevant patient stakeholders (eg, parent or guardians, athletic trainers), dissemination of rehabilitation exercises, and nature of follow-up visits. Descriptive data will include patient demographics, the radius of care, the time between the date of injury and initial visit, the average number of follow-up visits, and days until medically cleared for return-to-learn and return-to-play. RESULTS: The analytic sample included 18 patients with concussions who were seen for all of their visits via telehealth between August 2019 and April 2020. The mean age of the sample was 14.5 (SD 2.5) years. The radius of care was a median of 17 (IQR 11.0-31.0) miles from the clinic with a median time between injury and the first visit of 21 (IQR 6.0-41.5) days. The mean number of visits was 2.2 (SD 0.8) with a median days between visits of 5.4 (IQR 3.0-9.3) to manage and treat the concussion. Of the 18 patients, 55.6% (n=10) were medically cleared for return-to-learn or -play in a median of 15.5 (IQR 11.0-29.0) days. CONCLUSIONS: Limited access to health care is a well-understood barrier for receiving quality care. Subsequently, there are increasing demands for flexibility in delivering concussion services remotely and in-clinic. This is the first paper to provide a clinically relevant framework for the assessment, management, and treatment of acute concussion via telehealth in a pediatric population.

The Self-Efficacy for Home Exercise Programs Scale: Development and Psychometric Properties.

BACKGROUND: The Self-Efficacy for Home Exercise Programs Scale (SEHEPS) was developed to help clinicians evaluate patients' self-efficacy for performing prescribed home exercise programs. Prior to clinical adoption, the scale's psychometric properties need to be examined. OBJECTIVE: To determine the psychometric properties of the SEHEPS. METHODS: Eighty-one patients (32 men, 49 women; mean ± SD age, 42 ± 17 years) with varying musculoskeletal conditions participated in this cohort study. Patients were given a home exercise program at the initial physical therapy visit and completed the SEHEPS and a modified Self-Efficacy for Exercise (SEE) scale. The SEHEPS is a 12-item patient-reported questionnaire designed to assess self-efficacy for prescribed home exercise. Patients rated their confidence on a 7-point scale that ranged from 0 (not confident) to 6 (very confident). Total scores ranged from 0 (low self-efficacy) to 72 (high self-efficacy). We assessed the internal consistency of the SEHEPS using Cronbach's alpha and its test-retest reliability using an intraclass correlation coefficient. Convergent validity between the SEHEPS and SEE scale was evaluated with a Spearman correlation. RESULTS: High internal consistency (α = .96) and good test-retest reliability (intraclass correlation coefficient = 0.88; SEM, 4; minimal detectable change at the 95% confidence level, 12) were demonstrated. The SEHEPS was strongly correlated with the SEE scale (ρ = 0.83, P<.01), indicating strong convergent validity. CONCLUSION: The SEHEPS demonstrates excellent internal consistency and convergent validity with the SEE scale. Overall, the SEHEPS is a clinically useful tool to evaluate a patient's self-efficacy in home-based musculoskeletal exercise programs. This scale can be used prior to prescribing a home exercise program for patients with musculoskeletal conditions. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2019;49(9):647-655. Epub 10 Jul 2019. doi:10.2519/jospt.2019.8779.