Neurocognitive and Reactive Return to Play Testing Protocol in Overhead Athletes Following Upper Extremity Injury.

The incidence of upper extremity (UE) injuries in sport, particularly with the shoulder and elbow in baseball/softball players, appears to be increasing yearly, especially in younger age athletes. Improving the objective criteria and testing methods used to determine return to play (RTP) readiness following non-operative or post-operative management of UE injuries is one aspect of the rehabilitation process that may significantly help in reducing reinjury rates. Currently, the majority of clinicians are still using post operative time frame and/or strength/range of motion as their main criteria for clearance to RTP following UE injury. This demonstrates an inadequate reflection of the actual unpredictable, dynamic environment athletes are returning to participate in. In our clinical experiences, objective testing to allow for clearance to sport participation should incorporate neurocognitive and reactive testing to promote improvements in the athlete's ability to dual task and focus/concentrate on the multi-dimensional tasks at hand. We know that neuroplastic changes occur following UE injury resulting in decreased proprioception and increased motor activation with simple UE tasks. Currently the research on UE return to play testing is limited. The purpose of this clinical commentary was to describe the utilization and provide reference values for a series of reactive neurocognitive UE tests, to assist with RTP, in high school and collegiate overhead athletes (baseball and softball) utilizing the Blaze Pod light system. The use of a more dynamic reactive testing battery may decrease the reinjury rates when an athlete is cleared for participation by measuring readiness in chaotic circumstances that are more reflective of the sporting environment the athlete is working to return to resulting in a greater sense of confidence, performance and prevention of reinjuries.

The Longitudinal Neurophysiological Adaptation of a Division I Female Lacrosse Player Following Anterior Cruciate Rupture and Repair: A Case Report.

Background: Neurophysiological adaptation following anterior cruciate ligament (ACL) rupture and repair (ACLR) is critical in establishing neural pathways during the rehabilitation process. However, there is limited objective measures available to assess neurological and physiological markers of rehabilitation. Purpose: To investigate the innovative use of quantitative electroencephalography (qEEG) to monitor the longitudinal change in brain and central nervous systems activity while measuring musculoskeletal function during an anterior cruciate ligament repair rehabilitation. Case Description: A 19 year-old, right-handed, Division I NCAA female lacrosse midfielder suffered an anterior cruciate ligament rupture, with a tear to the posterior horn of the lateral meniscus of the right knee. Arthroscopic reconstruction utilizing a hamstring autograft and a 5% lateral meniscectomy was performed. An evidence-based ACLR rehabilitation protocol was implemented while using qEEG. Outcomes: Central nervous system, brain performance and musculoskeletal functional biomarkers were monitored longitudinally at three separate time points following anterior cruciate injury: twenty-four hours post ACL rupture, one month and 10 months following ACLR surgery. Biological markers of stress, recovery, brain workload, attention and physiological arousal levels yielded elevated stress determinants in the acute stages of injury and were accompanied with noted brain alterations. Brain and musculoskeletal dysfunction longitudinally reveal a neurophysiological acute compensation and recovering accommodations from time point one to three. Biological responses to stress, brain workload, arousal, attention and brain connectivity all improved over time. Discussion: The neurophysiological responses following acute ACL rupture demonstrates significant dysfunction and asymmetries neurocognitively and physiologically. Initial qEEG assessments revealed hypoconnectivity and brain state dysregulation. Progressive enhanced brain efficiency and functional task progressions associated with ACLR rehabilitation had notable simultaneous improvements. There may be a role for monitoring CNS/brain state throughout rehabilitation and return to play. Future studies should investigate the use of qEEG and neurophysiological properties in tandem during the rehabilitation progression and return to play.

The Effects on Knee Swelling, Range of Motion and Pain using a Commercially Available Hot/Cold Contrast Device in a Rehabilitation and Sports Medicine Setting.

Background and Purpose: Contrast therapy consists of alternating thermotherapy and cryotherapy repeatedly to assist in the management of acute, subacute, and chronic musculoskeletal conditions. This has been utilized for several decades with good to excellent subjective and objective results reported for patients with swelling (acute to chronic), pain, and loss of motion. Typically, the intervention is performed by either the use of a hot and cold whirlpool or by applying hot and cold packs which can be very time consuming and labor intensive. The purpose of this study was to determine the efficacy of a single treatment of the Hyperice X system in reducing knee joint pain, swelling and stiffness in active patients and young injured athletes. A secondary purpose was to measure patient satisfaction with the use of the device. Subjects: Fifty subjects (34 males and 16 females) with a mean age of 22.2 +/- 4.9 yrs (ranging from 17 to 45 yrs of age) were recruited. Subjects presented with various types of knee pain, both non-operative and operative, secondary to ligamentous, tendinous, cartilage, muscle, and/or meniscus pathology. The subjects were in various stages of rehabilitation with six in the acute stage, 24 in subacute stage, and 20 in the chronic stage. The subjects participated in a variety of different sports at various levels of competition ranging from recreational to professional. Methods: Subjects were recruited from one of two centers: an athletic training room or an outpatient sports medicine rehabilitation center. They were evaluated for baseline pain using the visual analog scale (VAS),verbal patient satisfaction on a scale of 1-10, verbal assessment of knee tightness, knee circumference, and knee flexion range of motion. The Hyperice X was applied to the knee utilizing the contrast setting for a total of 18 minutes with three six-minute cycles, each consisting of three minutes of heat therapy and three minutes of cold therapy. The contrast therapy was applied at the initiation of the physical therapy session and all subjective and objective measures were repeated immediately post contrast treatment. Results: The VAS scores significantly improved following the treatment session with the mean score pretreatment of 2.59 and following the treatment of 1.68. Knee circumference improved for mid patella and 5 cm below mid patella, but no significant improvement was noted at the 5 cm above the patella region. Knee flexion improved from 130 degrees pre-treatment to 134 degrees post treatment. Knee extension improved from 2.72 degrees of hyperextension to 3.44 degrees, both of which were statistically significant(p<.001). Conclusion: Contrast therapy utilizing the Hyperice X device demonstrated effectiveness in affecting pain reduction, swelling, and knee ROM. A commercially available device providing contrast therapy, may enhance outcomes in athletes after even a single treatment. In addition, the device was found to be easy to use, clinically practical, and demonstrated very high subjective patient satisfaction. Level of Evidence: Level 3.

Blood Flow Restriction Training.

Muscle weakness and atrophy are common impairments after musculoskeletal injury. Blood flow restriction (BFR) training offers the ability to mitigate weakness and atrophy without overloading healing tissues. It appears to be a safe and effective approach to therapeutic exercise in sports medicine environments. This approach requires consideration of a wide range of factors, and the purpose of our article is to provide insights into proposed mechanisms of effectiveness, safety considerations, application guidelines, and clinical recommendations for BFR training after musculoskeletal injury. Whereas training with higher loads produces the most substantial increases in strength and hypertrophy, BFR training appears to be a reasonable option for bridging earlier phases of rehabilitation when higher loads may not be tolerated by the patient and later stages that are consistent with return to sport.

Physiological Monitoring Detected Changes During Women's Soccer Anterior Cruciate Ligament Injury.

A growing number of studies utilizing wearable technologies are examining the influence of the autonomic nervous system (ANS) on intense training, recovery, and injury risk. Exercise biometric (EB) data were collected on collegiate, female soccer players during a preseason camp. One player sustained an anterior cruciate ligament (ACL) injury. Baseline anthropometric and EB data were compared to non-injured, position-matched teammates. All players had similar baseline testing. The injured athlete had a higher body mass index (BMI) and slower vision reaction time (RT). On the day of her injury (DOI), relative percentage heart rate recovery (tHRR) between intense training sets was calculated. Relative percentage tHRR was much lower for the injured athlete, indicating reduced recovery between training sets immediately prior to the injury. Also on DOI, the injured athlete had a lower glomerular filtration rate (GFR). In addition to BMI and RT differences, the lower relative percentage tHRR and GFR on the DOI observed for the injured athlete may reflect an imbalanced ANS recovery, and potentially to risk factors leading to her ACL injury.

American Football Players in Preseason Training at Risk of Acute Kidney Injury Without Signs of Rhabdomyolysis.

OBJECTIVE: This study was designed to identify changes in blood biomarkers that would indicate excessive muscle breakdown during the initial 10 days of preseason training in collegiate American football players and subsequently increase their risk of acute kidney injury (AKI). DESIGN: Prospective cohort study. SETTING: Preseason, heat acclimatization period. PARTICIPANTS: Twenty-five Division I American football players. INTERVENTION: Clinical biomarkers for muscle damage were measured during a preseason training camp. Samples were obtained before camp and approximately 5 and 10 days into camp after completion of heat acclimatization training. MAIN OUTCOMES: Creatine kinase, myoglobin, lactate dehydrogenase, and creatinine were measured. Glomerular filtration rate (GFR) was calculated. Urine was collected at each blood draw to qualitatively identify hematuria and red blood cells. RESULTS: A high percentage of athletes had an asymptomatic reduction in kidney function over the 10-day period. Ten of 23 athletes did have a significant, 31.6%, mean reduction in GFR, placing each at risk of AKI according to Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE) classification. The plasma myoglobin for the at risk of AKI group had a mean value 8× above their baseline mean on day 5 and statistically significant mean 13× higher on day 10 than baseline. The not at risk of AKI group did not have significant differences between days 0, 5, and 10. CONCLUSIONS: A relatively high percentage of athletes had an asymptomatic reduction in kidney function during the intense preseason training period. 43.4% of athletes in this study had a significant 31.6% mean reduction in GFR over the 10 days. According to RIFLE classification, this placed each athlete "at risk" of AKI.

Test and Evaluation of Heart Rate Derived Core Temperature Algorithms for Use in NCAA Division I Football Athletes.

The purpose of this study was to assess the validity of utilizing heart rate to derive an estimate of core body temperature in American Football athletes. This was evaluated by combining commercially available Zephyr Bioharness devices, which includes an embedded estimated core temperature (ECT) algorithm, and an ingestible radio frequency core temperature pill during the highest heat injury risk timepoint of the season, summer training camp. Results showed a concordance of 0.643 and 78% of all data points fell within +/-1.0 °F. When the athletes were split into Upper (>/=6.0%) and Lower (<6.0%) body composition groups, there was a statistical improvement in accuracy with the Upper Body Fat% reaching 0.834 concordance and 93% of all values falling within +/-1.0 °F of the Gold Standard. Results suggest that heart rate derived core temperature assessments are a viable tool for heat stress monitoring in American football, but more work is required to improve on accuracy based on body composition.

COVID-19 Surveillance and Competition in Sport: Utilizing Sport Science to Protect Athletes and Staff during and after the Pandemic.

The ongoing Coronavirus 2 (COVID-19) pandemic abruptly halted athletic competition and standard training practices, consequently generating great confusion surrounding when and how to safely reintroduce sports. Therefore, tangible solutions disseminated to performance staff, coaches, and athletes are warranted to ensure optimal levels of health and physical performance for all personnel during both the current social distancing standards as well as the impending return of competition despite continued risks. In this commentary, we offer strategies for utilizing technology and data tools as components of longitudinal COVID-19 surveillance based on ongoing research efforts as well as current guidance from governing bodies, while also serving the performance needs of the athletes and staff. Recommended data sources include digital symptom and well-being surveys, standardized and routine physical performance testing, sleep and sleep physiology monitoring, cognitive applications, and temperature. This system is flexible to numerous commercially available products and is designed for easy implementation that permits instant feedback provided directly to the athlete as well as their support staff for early intervention, ultimately mitigating COVID-19 risks. We will discuss multiple options, including examples of data, data visualizations and recommendations for data interpretation and communication.

Body Composition Changes over Multiple Academic Years in Female Collegiate Soccer Players.

Body composition plays a key role in overall health and sports performance and its assessment is an important part of many athletic programs. The purpose of this study was to describe longitudinal changes in body composition for collegiate female soccer players in order to provide data to inform future training and nutrition interventions for this population. A linear mixed-model (LMM) approach was used to analyze four years of pre- and post-season body composition data, including total mass, fat-free mass (FFM), fat mass, and body fat percentage (%BF) for 49 athletes. Athletes gained an average of 0.5 kg FFM during the season (p < 0.05) and increased total mass, FFM, fat mass, and %BF (2.5 kg, 1.1 kg, 1.7 kg, and 1.7%, respectively; p < 0.05) over four years. Freshmen experienced a 1.5 kg gain in total mass pre- to post-season (p < 0.05), while no changes in total mass or body composition were seen in other grade levels. Gains in %BF during the off season between Freshman and Sophomore years represented negative changes in body composition that should be addressed further. These results can help interdisciplinary athlete care teams optimize training programs in this population by understanding what changes are expected over multiple years. Normalizing these changes may also help the promotion of realistic body composition goals and the development of positive training and dietary habits.