A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines.

Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.

Unique Features of the US Department of Defense Multidisciplinary Concussion Clinics.

The US Department of Defense (DoD) and the Department of Veterans Affairs (VA) actively address care needs for a subset of service members (SMs) who experience prolonged symptoms and adverse sequelae interfering with their usual level of function after sustaining mild traumatic brain injury. The development of multidisciplinary concussion clinics and implementation of several reinforcing policies within the DoD and the VA address this unique patient population. A network known as the National Intrepid Center of Excellence and Intrepid Spirit Centers and the VA, primarily support these patients through intensive outpatient programs. The VA also has an inpatient program that utilizes specialized capabilities. The features unique to several of these centers are described in this article. While providing for similar patient care needs, each clinical setting implements unique evaluation and treatment modalities to target analogous goals of return to the highest functional level possible and develop life skills to enhance health, quality of life, and readiness to perform military duties. Currently, patient-reported outcomes are being collected.

Consortium for health and military performance and American College of Sports Medicine Summit: utility of functional movement assessment in identifying musculoskeletal injury risk.

Prevention of musculoskeletal injuries (MSKI) is critical in both civilian and military populations to enhance physical performance, optimize health, and minimize health care expenses. Developing a more unified approach through addressing identified movement impairments could result in improved dynamic balance, trunk stability, and functional movement quality while potentially minimizing the risk of incurring such injuries. Although the evidence supporting the utility of injury prediction and return-to-activity readiness screening tools is encouraging, considerable additional research is needed regarding improving sensitivity, specificity, and outcomes, and especially the implementation challenges and barriers in a military setting. If selected current functional movement assessments can be administered in an efficient and cost-effective manner, utilization of the existing tools may be a beneficial first step in decreasing the burden of MSKI, with a subsequent focus on secondary and tertiary prevention via further assessments on those with prior injury history.

Training in ACSM black flag heat stress conditions: how U.S. marines do it.

Exertional heat injuries have gained public attention over the past several years, as have the means to prevent and treat them. One of the simplest preventive measures is to refrain from physical training and competition during times of increased environmental heat stress. Unfortunately, this often is not possible or desirable in certain populations. As a result of operational and training requirements, the U.S. Marine Corps and the U.S. Navy medical team have developed an effective exertional heat injury prevention strategy that relies upon education, leadership, and continuous hands-on observation. The fundamental aspects of this approach can be applied to other team sporting activities.

A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome: the Joint Undertaking to Monitor and Prevent ACL Injury (JUMP-ACL) cohort.

BACKGROUND: Patellofemoral pain syndrome is one of the most common chronic knee injuries; however, little research has been done to determine the risk factors for this injury. HYPOTHESIS: Altered lower extremity kinematics and kinetics, decreased strength, and altered postural measurements will be risk factors. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: A total of 1597 participants were enrolled in this investigation and prospectively followed from the date of their enrollment (July 2005, July 2006, or July 2007) through January 2008, a maximum of 2.5 years of follow-up. Each participant underwent baseline data collection during their pre-freshman summer at the United States Naval Academy. Baseline data collection included 3-dimensional motion analysis during a jump-landing task, 6 lower extremity isometric strength tests, and postural alignment measurements (navicular drop and Q angle). RESULTS: Risk factors for the development of patellofemoral pain syndrome included decreased knee flexion angle, decreased vertical ground-reaction force, and increased hip internal rotation angle during the jump-landing task. Additionally, decreased quadriceps and hamstring strength, increased hip external rotator strength, and increased navicular drop were risk factors for the development of patellofemoral pain syndrome. CONCLUSION: Multiple modifiable risk factors for patellofemoral pain syndrome pain have been identified in this investigation. To decrease the incidence of this chronic injury, the risk factors for patellofemoral pain syndrome need to be targeted in injury prevention programs. CLINICAL RELEVANCE: Prevention programs should focus on increasing strength of the lower extremity musculature along with instructing proper mechanics during dynamic movements to decrease the incidence of patellofemoral pain syndrome.

American College of Sports Medicine position stand. Exertional heat illness during training and competition.

Exertional heat illness can affect athletes during high-intensity or long-duration exercise and result in withdrawal from activity or collapse during or soon after activity. These maladies include exercise associated muscle cramping, heat exhaustion, or exertional heatstroke. While certain individuals are more prone to collapse from exhaustion in the heat (i.e., not acclimatized, using certain medications, dehydrated, or recently ill), exertional heatstroke (EHS) can affect seemingly healthy athletes even when the environment is relatively cool. EHS is defined as a rectal temperature greater than 40 degrees C accompanied by symptoms or signs of organ system failure, most frequently central nervous system dysfunction. Early recognition and rapid cooling can reduce both the morbidity and mortality associated with EHS. The clinical changes associated with EHS can be subtle and easy to miss if coaches, medical personnel, and athletes do not maintain a high level of awareness and monitor at-risk athletes closely. Fatigue and exhaustion during exercise occur more rapidly as heat stress increases and are the most common causes of withdrawal from activity in hot conditions. When athletes collapse from exhaustion in hot conditions, the term heat exhaustion is often applied. In some cases, rectal temperature is the only discernable difference between severe heat exhaustion and EHS in on-site evaluations. Heat exhaustion will generally resolve with symptomatic care and oral fluid support. Exercise associated muscle cramping can occur with exhaustive work in any temperature range, but appears to be more prevalent in hot and humid conditions. Muscle cramping usually responds to rest and replacement of fluid and salt (sodium). Prevention strategies are essential to reducing the incidence of EHS, heat exhaustion, and exercise associated muscle cramping.

Intravenous fluids post marathon : when and why?

The medical management of marathon casualties involves several potential treatment pathways. It is helpful to develop defined treatment protocols for commonly experienced conditions addressing intervention selection criteria and monitoring response to therapy. Providing intravenous (IV) fluids for runners post marathon should be scrutinised based upon the effectiveness and safety of the intervention. Commonly agreed upon indications for IV fluids are replacement for clinical dehydration and support for unconscious, hypoglycaemic or persistently hypotensive athletes. Most clinicians recommend serum sodium evaluation prior to IV initiation. IV fluid use in athletes with persistent nausea, generalised muscle cramping and to augment whole-body cooling is commonly deployed despite the paucity of supporting scientific evidence and remains an area for further study. Marathon medical support leaders should develop and disseminate guidelines to direct the administration of IV fluids at their medical aid stations.

Diagnosis and current treatment options of shoulder impingement.

A comprehensive review of shoulder impingement reveals numerous causes, contributing factors, and therapeutic options for the resolution of symptoms and return to optimal shoulder function. The clinical diagnosis of shoulder impingement is rather straightforward, but the challenge arises in identifying causative factors and directing treatment options to alleviate symptoms and restore normal function. Shoulder impingement occurs when the space between the proximal humerus and the coracoacromial arch is narrowed such that the transversing tendons, primarily the supraspinatus and to a lesser degree, the infraspinatus, are injured. As the most diagnosed shoulder ailment an understanding of shoulder anatomy, supporting musculature and function, inciting factors, and individual demands are critical in directing the appropriate treatment plan. Medications, therapeutic exercise and surgical interventions all have their place in the treatment of shoulder impingement.

Current progress in meniscal repair and postoperative rehabilitation.

The understanding and treatment of meniscal injury has evolved at a rapid pace over the past 20 years. With the realization of the meniscus as a vital structure to proper knee integrity, function, and longevity, the sports medicine and orthopedic communities have shifted the focus of conservative and surgical treatment to that of meniscal conservation. Hand-in-hand with this increased understanding, advances in surgical procedures, techniques, and equipment have followed. Likewise, postoperative rehabilitation protocols, based on an increased understanding of the meniscal physiologic response to injury, concurrent knee injury, repair technique, and patient-specific considerations, have advanced. Various surgical repair techniques have demonstrated superior results to complete and partial meniscectomy. Multiple factors including tear orientation and location, surgeon preference and experience, associated injuries, and patient goals and expectations often guide the type of surgery performed. Limitations in weight bearing, pivoting, and return to sporting activities in the rehabilitative process are currently areas of active rehabilitative research.