Evaluation of the Craniovertebral Angle in Standing versus Sitting Positions in Young Adults with and without Severe Forward Head Posture.

The purpose of this study was to examine the effects of standing versus sitting body position on the craniovertebral angle (CVA) in young adults without pathology; and to investigate whether mean differences between positional CVA measures in subjects with severe forward head posture (FHP) are distinct from age-matched controls with normal head posture. Ninety-eight young adults (68 women, 30 men) without pathology (OVERALL; n = 98) volunteered for the study; those with CVA > 53° were also included in a normal posture group (NORM; n = 14); those with CVA < 45° were also included in a severe FHP group (SEV; n = 15). CVA assessments were conducted in standing and sitting. Mean difference comparison of change in mean CVA between conditions revealed significantly (p < 0.05) higher CVA values in standing condition (OVERALL: 50.0 ± 5.2°; NORM: 56.6 ± 2.7°; SEV: 41.2 ± 3.2°) compared to sitting condition (OVERALL: 47.8 ± 5.7°; NORM: 55.9 ± 2.8°; SEV: 39.0 ± 4.0°). Mean difference comparison of between-group change in mean CVA between conditions revealed greater CVA change (p < 0.05) in the SEV group (2.2 ± 2.1°) versus the NORM group (0.8 ± 1.2°). Sitting CVA values may be lower (indicating greater FHP) than standing CVA values in young adults. Differences between standing and sitting CVA measures may be greater in young adults with severe FHP compared to peers with normal head posture. Study findings support standing as a standardized body position for CVA assessment in young adults without pathology.

The Effects of Postural Education or Corrective Exercise on the Craniovertebral Angle in Young Adults with Forward Head Posture: A Randomized Controlled Trial.

The purpose of this study was to compare the effects of three different intervention strategies, postural education (PE) and two corrective exercise programs (CEPs), on the craniovertebral angle (CVA) in young adults with forward head posture (FHP). A prospective four-arm parallel randomized controlled trial with repeated measures was performed. Seventy-nine healthy young adults (55 women, 24 men; mean age: 20.08 ± 2.19 years) with FHP were randomized into four groups: PE group, self-myofascial release + stretching group (SMRS), self-myofascial release + stretching + strengthening group (SMRSS), and a control group (CG). Participant CVA (°) was assessed before and after a 4-week intervention. Seventy-two participants completed the trial. Mean difference comparisons of within-group change in mean CVA revealed an increase in the PE (MD = 3.1, p < .01), SMRS (MD = 3.8, p < .01), and SMRSS (MD = 4.4, p < .01) groups. Mean difference comparison of between-group change in mean CVA supported greater CVA change in the SMRS and SMRSS groups compared to the CG (F(3, 68) = 5.26, p < .01, η2 = .188). All three interventions appear to be effective techniques for improving FHP in young adults, however CEPs may provide superior outcomes than PE alone. A 4-week CEP consisting of self-myofascial release + stretching may yield similar CVA enhancements as a CEP consisting of self-myofascial release + stretching + strengthening. Study findings can assist fitness professionals in designing evidence-based FHP intervention programs for young adults.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms.

OBJECTIVE: Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups. METHODS: Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults. RESULTS: All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings. CONCLUSION: Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

Evidence-Based Corrective Exercise Intervention for Forward Head Posture in Adolescents and Young Adults Without Musculoskeletal Pathology: A Critically Appraised Topic.

CLINICAL SCENARIO: Habitual overuse of cellphones is on the rise among adolescents and young adults. Those who maintain a flexed neck posture when using a cellphone for extended periods possess an elevated risk for developing forward head posture (FHP). Chronic FHP can lead to painful medical disorders affecting the head, neck, and shoulders. Both stretching and strengthening exercises are advocated interventions to address this postural abnormality; however, due to a wide range of corrective exercise programming in the literature, the decision for which exercises to prescribe for this condition can be challenging for clinicians. CLINICAL QUESTION: For adolescents and young adults without musculoskeletal pathology, what are the most frequent stretching and strengthening exercises incorporated into effective FHP intervention programs supported by current randomized control trials? SUMMARY OF KEY FINDINGS: A combined total of 5 stretches and 8 strengthening exercises were identified across 3 studies of level 1b evidence that successfully impacted FHP using a combined stretching and strengthening corrective exercise intervention. The supine chin tuck and a sternocleidomastoid stretch were utilized in all 3 studies, while scapular retraction and a pectoralis stretch were included in 2 of the 3 studies. CLINICAL BOTTOM LINE: Based on the results of this appraisal, the most frequent stretches and strengthening exercises incorporated into effective FHP intervention programs supported by current randomized control trials focused on adolescents or young adults without musculoskeletal pathology include a sternocleidomastoid stretch, pectoralis stretch, the supine chin tuck, and scapular retraction. STRENGTH OF RECOMMENDATION: There is "Good" to "Excellent" evidence from 3 level 1b randomized control trials to support the inclusion of a sternocleidomastoid stretch, pectoralis stretch, the supine chin tuck, and scapular retraction exercises into a corrective exercise program to address forward head posture.

Detecting changes in postural sway.

Postural sway has been identified as a valid marker for assessing the presence of a concussion and monitoring return to activity progression. Instrumented balance assessments have shown to be more reliable in detecting postural sway. However, many sports medicine programs cannot afford to purchase a force plate system to objectively assess postural sway and changes, which may occur due to a head injury. The purpose of this study was to determine if the C3Logix™ application can detect postural sway with the same degree of accuracy as the VSR Sport™ by NeuroCom®. Forty-five Division I Lacrosse players, consisting of 27 males and 18 females, participated in this study. Participants completed the Stability Evaluation Test (SET) on the VSR Sport™ while simultaneously completing the same balance assessment via the C3Logix™ application. The balance assessment consisted of three stances (double leg, single leg, tandem stance) on two surfaces (firm & foam) for a total of six trials. A Pearson correlation was used to determine the correlation between the postural sway velocity values from the VSR Sport™ and ellipse volume values from the C3Logix™ application. Each of the stances on both the firm and foam surface was found to have a strong correlation, suggesting the C3Logix™ application is a valid alternative to postural assessments on a force plate.

The Effectiveness of Frequency-Based Resistance Training Protocols on Muscular Performance and Hypertrophy in Trained Males: A Critically Appraised Topic.

Clinical Scenario: Manipulation of exercise variables in resistance training (RT) is an important component in the development of muscular strength, power, and hypertrophy. Currently, most research centers on untrained or recreationally trained subjects. This critically appraised topic focuses on studies that center on the well-trained subject with regard to frequency of training. Clinical Question: In well-trained male subjects, is there an association between RT frequency and the development of muscular strength and hypertrophy? Summary of Key Findings: Four studies met the inclusion criteria and were included for analysis. All studies showed that lower-frequency training could elicit muscular strength and hypertrophy increases. One study suggested that a higher frequency compared with a lower frequency may provide a slight benefit to hypertrophic development. One study reported a greater level of delayed onset muscle soreness with lower frequency training. The 4 studies demonstrate support for the clinical question. Clinical Bottom Line: Current evidence suggests that lower-frequency RT produces equal to greater improvements on muscular strength and hypertrophy in comparison to higher-frequency RT when volume is equated. The evidence is particularly convincing when lower-frequency RT is associated with a total-body training protocol in well-trained male subjects. Strength of Recommendation: There is moderate-to-strong evidence to suggest that lower-frequency RT, when volume is equated, will produce equal to greater improvements on muscular strength and hypertrophy in comparison to higher-frequency RT.

Correlation of Head Impact Exposures With Vestibulo-Ocular Assessments.

CONTEXT: Managing a concussion injury should involve the incorporation of a multifaceted approach, including a vision assessment. The frontoparietal circuits and subcortical nuclei are susceptible to trauma from a concussion injury, leading to dysfunction of the vestibulo-ocular system. Research investigating the effect of cumulative subconcussive impacts on neurological function is still in its infancy, but repetitive head impacts may result in vestibular system dysfunction. This dysfunction could create visual deficits, predisposing the individual to further head trauma. OBJECTIVE: The purpose of this study was to investigate the cumulative effect of subconcussive impacts on minimum perception time, static visual acuity, gaze stability, and dynamic visual acuity scores. DESIGN: Prospective cohort. SETTING: Division I university. PATIENTS: Thirty-three Division I men's lacrosse players (age = 19.52 [1.20] y). INTERVENTION: Competitive lacrosse season. MAIN OUTCOME MEASURES: At the beginning and end of the season, the players completed a vestibulo-ocular reflex assessment, using the InVision™ system by Neurocom® to assess perception, static acuity, gaze stability, and dynamic visual acuity. Score differentials were correlated with the head impact exposure data collected via instrumented helmets. RESULTS: A significant correlation was found between change in perception scores and total number of head impacts (r = .54), and between changes in dynamic visual acuity loss scores on the rightside and maximum rotational acceleration (r = .36). No statistical differences were found between preseason and postseason vestibulo-ocular reflex variables. CONCLUSIONS: Cumulative subconcussive impacts may negatively affect vestibulo-ocular reflex scores, resulting in decreased visual performance. This decrease in vestibulo-ocular function may place the athlete at risk of sustaining additional head impacts or other injuries.

The role of subconcussive impacts on sway velocities in Division I men's lacrosse players.

Head impacts resulting in a concussion negatively affect the vestibular system, but little is known about the effect of subconcussive impacts on this system. This study's objective was to determine if subconcussive head impacts sustained over one competitive lacrosse season, effect sway velocity. Healthy Division I male lacrosse players (n = 33; aged 19.52 ± 1.20 years) wore instrumented helmets to track head impact exposures. At the beginning and end of the season the players completed an instrumented Balance Error Scoring System assessment to assess sway velocity. Score differentials were correlated to the head impact exposure data collected via instrumented helmets when averaged within participant. Paired samples t-tests revealed a post-season increase in sway velocity on the double leg stance, firm surface (p = 0.002, d = 0.59); tandem stance, firm surface (p = 0.033, d = 0.39) and double leg, foam surface (p = 0.014, d = 0.45) A significant correlation was found between change in tandem stance, firm surface sway velocities and linear acceleration (p < 0.001, r = 0.65). It appears subconcussive impacts may result in tandem stance balance deficits. Repetitive head impacts may negatively affect sway velocity, even in the absence of a diagnosed concussion injury.

Effect of Head Impact Exposures on Changes in Cognitive Testing.

BACKGROUND: Gaining a better understanding of head impact exposures may lead to better comprehension of the possible effects of repeated impact exposures not associated with clinical concussion. PURPOSE: To assess the correlation between head impacts and any differences associated with cognitive testing measurements pre- and postseason. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A total of 34 National Collegiate Athletic Association Division I men's lacrosse players wore lacrosse helmets instrumented with an accelerometer during the 2014 competitive season and were tested pre- and postseason with the Sport Concussion Assessment Tool (SCAT 3) and Concussion Vital Signs (CVS) computer-based neurocognitive tests. The number of head impacts >20g and results from the 2 cognitive tests were analyzed for differences and correlation. RESULTS: There was no significant difference between pre- and postseason SCAT 3 scores, although a significant correlation between pre- and postseason cognitive scores on the SCAT 3 and total number of impacts sustained was noted (r = -0.362, P = .035). Statistically significant improvements on half of the CVS testing components included visual reaction time (P = .037, d = 0.37), reaction time (P = .001, d = 0.65), and simple reaction time (P = .043, d = 0.37), but no correlation with head impacts was noted. CONCLUSION: This study did not find declines in SCAT 3 or CVS scores over the course of a season among athletes who sustained multiple head impacts but no clinical concussion. Thus, it could not be determined whether there was no cognitive decline among these athletes or whether there may have been subtle declines that could not be measured by the SCAT 3 or CVS.

Correlation of Head Impacts to Change in Balance Error Scoring System Scores in Division I Men's Lacrosse Players.

BACKGROUND: Investigation into the effect of cumulative subconcussive head impacts has yielded various results in the literature, with many supporting a link to neurological deficits. Little research has been conducted on men's lacrosse and associated balance deficits from head impacts. HYPOTHESES: (1) Athletes will commit more errors on the postseason Balance Error Scoring System (BESS) test. (2) There will be a positive correlation to change in BESS scores and head impact exposure data. STUDY DESIGN: Prospective longitudinal study. LEVEL OF EVIDENCE: Level 3. METHODS: Thirty-four Division I men's lacrosse players (age, 19.59 ± 1.42 years) wore helmets instrumented with a sensor to collect head impact exposure data over the course of a competitive season. Players completed a BESS test at the start and end of the competitive season. RESULTS: The number of errors from pre- to postseason increased during the double-leg stance on foam ( P < 0.001), tandem stance on foam ( P = 0.009), total number of errors on a firm surface ( P = 0.042), and total number of errors on a foam surface ( P = 0.007). There were significant correlations only between the total errors on a foam surface and linear acceleration ( P = 0.038, r = 0.36), head injury criteria ( P = 0.024, r = 0.39), and Gadd Severity Index scores ( P = 0.031, r = 0.37). CONCLUSION: Changes in the total number of errors on a foam surface may be considered a sensitive measure to detect balance deficits associated with cumulative subconcussive head impacts sustained over the course of 1 lacrosse season, as measured by average linear acceleration, head injury criteria, and Gadd Severity Index scores. If there is microtrauma to the vestibular system due to repetitive subconcussive impacts, only an assessment that highly stresses the vestibular system may be able to detect these changes. CLINICAL RELEVANCE: Cumulative subconcussive impacts may result in neurocognitive dysfunction, including balance deficits, which are associated with an increased risk for injury. The development of a strategy to reduce total number of head impacts may curb the associated sequelae. Incorporation of a modified BESS test, firm surface only, may not be recommended as it may not detect changes due to repetitive impacts over the course of a competitive season.

Gender Differences in Concussion Reporting Among High School Athletes.

BACKGROUND: An athlete's lack of concussion knowledge could lead to significant underreporting and injury mismanagement. To provide more effective management strategies of concussions in adolescent athletes, further examination of reporting behaviors is of critical importance. HYPOTHESIS: The hypotheses for this study were as follows: (1) Girls are more likely to report concussion, (2) girls are more likely to report future concussions after an educational intervention, and (3) a difference in rationale for not reporting concussion will be found between sexes. STUDY DESIGN: Cross-sectional, cohort design. LEVEL OF EVIDENCE: Level 3. METHODS: Survey answers were collected on 454 high school athletes (212 girls, 242 boys; mean age, 15.7 ± 1.15 years). Individual team meetings lasting approximately 30 minutes were held to collect data and provide an educational lecture. Participants were randomly provided an iClicker to submit a response to questions asked. RESULTS: Girls were more likely to report a concussion (χ(2) = 8.32, df = 3, N = 454, P = 0.040) and more likely to report future concussions after educational intervention (χ(2) = 8.54, df = 2, N = 454, P = 0.014). There were no differences between sexes regarding rationale for not reporting a concussion (χ(2) = 6.42, df = 4, N = 454, P = 0.170). CONCLUSION: There is concern these athletes still fail to understand the severity and potential sequelae of concussion injury. Both sexes cited that concussion is not a serious enough injury to warrant reporting to a medical professional. CLINICAL RELEVANCE: High school athletes recover more slowly from concussions compared with college athletes; therefore, educating this population and promoting the importance of being knowledgeable regarding concussion recognition may increase reporting prevalence.

High School Athletes' Perceptions of Concussion.

BACKGROUND: The perception high school athletes have regarding concussions may influence their injury-reporting behavior, and if their perceptions are based on incorrect or incomplete information, they may be at risk for subsequent head injuries. PURPOSE: To determine whether the recent influx of concussion information has had a positive impact on high school athletes' knowledge of concussions, to determine their perceptions regarding the severity of a concussion injury, and to determine whether receiving correct information will potentially alter their future reporting behavior. STUDY DESIGN: Cross-sectional study; Level of evidence, 4. METHODS: A total of 454 high school athletes (212 females, 242 males; mean age, 15.7 ± 1.15 years) from 6 different schools participated in an anonymous survey. The researchers met with teams individually at their high schools to collect data and provide an educational intervention regarding sports-related concussions. The survey questions assessed the athletes' personal injury histories and perceptions and knowledge of the severity of concussion injuries. RESULTS: There was a difference in the number of athletes who reported having their "bell rung" (n = 297) versus the number of athletes reporting at least 1 concussion (n = 172) (t (453) = -11.60, P = .000, d = -0.54). There was also a difference in the number of athletes who reported a history of at least 1 concussion at the beginning of the study session (n = 172) versus the number of athletes who reported at least 1 concussion at the end of the session (n = 292) (t (453) = -12.018, P = .000, d = 0.732). Fifty percent of athletes also stated that the importance of a game/event should dictate when they return to play. CONCLUSION: High school athletes continue to fail to realize when they have sustained a concussion. Additionally, athletes lack understanding regarding the severity and seriousness of a concussion. A better effort at formalized education must be made if the culture of sports is to change. CLINICAL RELEVANCE: Allied health care professionals need to continue to put forth a great effort in educating all student athletes on what a concussion is and the dangers of a concussion injury. Preseason meetings should be used as an opportunity to provide formalized education to all student athletes.

The impact of an educational intervention on college athletes' knowledge of concussions.

OBJECTIVE: The purpose of this study was to determine college athletes' knowledge regarding concussions and to determine if an educational lecture before their sport season would improve their knowledge and reporting of concussions. DESIGN: Cross-sectional study. SETTING: University classroom. PARTICIPANTS: Seventy National College Athletic Association Division II men's/women's soccer players and men's/women's basketball players. INTERVENTIONS: Educational lecture regarding the basics of concussions. MAIN OUTCOME MEASURES: Descriptive statistics, ANOVAs, and a paired sample t test determined the athletes' knowledge of concussion before and after the season and the impact of the educational intervention. RESULTS: A paired sample t test indicated that the athletes scored better on the postseason concussion knowledge assessment [t(49) = 10.34, P < 0.000, d = 1.47]. CONCLUSIONS: After an educational intervention, athletes demonstrated an improvement in their knowledge on concussions.