Understanding Youth Athlete Motivation, Training, and Activity Progression During and After the COVID-19 Sports Interruption.

Background: COVID-19 restrictions created a period of disrupted sports participation for youth athletes. The physical conditioning, sports training habits, and patterns of sports activity resumption upon returning to normal sports activity are currently unknown. Purpose/Hypothesis: This study aimed to determine the extent to which youth athletes maintained their training levels during the early stages of the COVID-19 pandemic and understand the strategies that enhanced motivation and adherence to a training regimen while in isolation. A secondary aim was to analyze how youth athletes returned to activity and identify injuries associated with prolonged sports interruption. Study Design: Observational / Survey Study. Methods: A survey designed to determine activity changes, type of organized instruction, and athlete preferences for training support were distributed by email using snowball sampling methodology to athletes 14-21 years old who were involved in competitive sports when pandemic restrictions were enacted. As sports activities resumed, a follow-up survey was distributed to the same respondents to identify feelings of preparedness, training habits, and injuries. Results: Of the155 subjects (mean age 16.1 ± 2 years, 64.5% female) that completed the initial survey, 98% reported a stoppage of in-person sports participation and 70% decreased their exercise/training volume, with 41% (n=63) reporting > 50% reduction. Most athletes (86%) received instruction from coaches, with written workouts (70%) being most common; however, most athletes (70%) preferred instructor-led, group training sessions. Of the 43 subjects that completed the follow-up survey (34% response rate), there was an increase in athletic exposures compared to mid-pandemic levels, and 25% reported sustaining a sports-related injury shortly after resuming sports activities. Conclusions: Pandemic-related sports restrictions resulted in a significant reduction in youth athlete training and conditioning. Coaches attempted to maintain training via the use of written workouts; however, athletes preferred instructor-led, group training sessions. There was a rapid resumption of sports activities, which may have contributed to the high rate of injuries in this study. Level of Evidence: 3.

Acute changes in sagittal plane kinematics while wearing a novel belt device during treadmill running.

Somatosensory feedback is used in walking retraining; however, its utility in running is less feasible due to the greater associated speeds. The purpose of this study was to examine the acute effects of wearing a novel running belt device on sagittal plane running kinematics. Ten healthy runners ran on a treadmill with and without the use of a running belt device within a repeated measures study design. Temporal-spatial characteristics and sagittal plane knee and ankle kinematics were recorded with three-dimensional motion analysis. Wilcoxon Signed-Rank Tests revealed significant decreases in centre of mass vertical displacement (z = -2.083, p = 0.003), tibial inclination at initial contact (z = -2.803, p = 0.003), and stance phase knee joint excursion (z = -2.701, p = 0.003), and greater knee flexion at initial contact (z = -2.803, p = 0.003) when the belt was donned. No differences were observed in step rate (z = -0.351, p = 0.363), foot inclination angle at initial contact (z = -2.090, p = 0.018), or peak knee flexion during stance (z = -1.172, p = 0.121). Findings suggest that donning a running belt can minimise specific high-risk biomechanical characteristics in runners with particular kinematic profiles.

Retrospective Cohort Study of Rates of Return Emergency Department Visits Among Patients Transported Home by Ambulance.

BACKGROUND: Emergency Medical Services (EMS) is an important resource that interacts with our most vulnerable patients during transport home after hospital discharge. EMS providers may be appropriately situated to support the transition of care to the home environment. OBJECTIVES: This study aimed to determine whether patients transported home by ambulance experience higher rates of return emergency department (ED) visits and readmission compared with similar patients transported home by other means. METHODS: This was a retrospective cohort study conducted at a U.S. tertiary care academic hospital. Patients aged 65 years and over transported home via ambulance after hospital discharge between January and March 2012 were included. Rates of 72-h and 30-day ED revisits and 30-day hospital readmissions were calculated. Odds ratios were calculated and revisit rates between groups were compared. RESULTS: There were 207 patients aged 65 and over transported home by ambulance. Matched controls were found for 162 patients. Compared with the matched controls, the exposed group experienced a statistically significant higher rate of 30-day ED returns (18.519% vs. 10.494%; odds ratio [OR] 1.939; p = 0.043). The exposed group also experienced a higher rate of 72-h ED returns (2.469% vs. 0.617%; OR 4.076) and 30-day readmissions (12.346% vs. 6.173%; OR 2.141), though results did not reach statistical significance. CONCLUSION: The study findings suggest that transport home via ambulance after hospital discharge could be predictive of a high risk of recidivism independent of established readmission risk factors. Programs that expand the role of EMS to include post-transport interventions may warrant further exploration.

Anterior Cruciate Ligament Reconstruction Rehabilitation Clinical Practice Patterns: A Survey of the PRiSM Society.

BACKGROUND: Recovery after anterior cruciate ligament (ACL) reconstruction (ACLR) requires extensive postoperative rehabilitation. Although no ideal rehabilitation procedure exists, most experts recommend a fusion of time and strength and functional measures to guide decision making for activity progression during rehabilitation. This process is often directed by surgeon protocols; however, the adoption of contemporary rehabilitation recommendations among surgeons is unknown. PURPOSE: To understand the current landscape of surgeon practice as it relates to ACLR rehabilitation recommendations in adolescent athletes. STUDY DESIGN: Cross-sectional study. METHODS: An online survey was distributed among members of the Pediatric Research in Sports Medicine (PRiSM) Society in January 2017. The survey was designed to identify clinical practice patterns during 3 key transitional points of rehabilitation after ACLR: progression to jogging, modified sports activity, and unrestricted return to sports. RESULTS: Responses from 60 orthopaedic surgeons were analyzed. While 80% of surgeons agreed upon initiating jogging within a 1-month range (3-4 months postoperatively), similar levels of agreement were only captured when including a wider 4-month (4-8 months) and 6-month range (6-12 months) for modified sports activity and unrestricted return to sports, respectively. All respondents (100%) reported using knee strength as a determinant to progress to modified sports activity; however, the mode of testing varied, with most using manual muscle testing (60%), followed by isokinetic (28%) or isometric (12%) testing. Most surgeons (68%) reported using some form of functional testing to return to modified sports activity, but the mode of testing and required progression criteria varied considerably among all reported testing procedures. The use of patient-reported outcome measures was limited to 20% of the sample, and no respondents reported using fear or self-efficacy questionnaires. Upon completion of rehabilitation, 73% recommended injury prevention programs, and 50% recommended the use of a functional ACL brace. CONCLUSION: Rehabilitation progression practices in adolescent athletes are variable and become more inconsistent as the time from surgery increases. While the majority of the sample considered strength and functional testing important, the mode of testing and criteria thresholds for activity advancement varied considerably.

INTERRATER AND TEST-RETEST RELIABILITY OF THE Y BALANCE TEST IN HEALTHY, EARLY ADOLESCENT FEMALE ATHLETES.

BACKGROUND: Adolescence is the stage of development marked by peak rates of skeletal growth resulting in impaired dynamic postural control and increased injury risk, especially in female athletes. Reliable tests of dynamic postural control are needed to help identify athletes with balance deficits and assess changes in limb function after injury. PURPOSE: To estimate the interrater and test-retest (intrarater) reliability of the Y-Balance Test in a group of early adolescent females over a one-month period when administered by novice raters. METHODS: Twenty-five early adolescent females (mean age 12.7 ± 0.6 years) participated. Two physical therapy student raters, randomly selected from a pool of five, simultaneously assessed each subject's performance on the Y-Balance Test and were blinded to each other's results. Twenty-one subjects returned for a second session (mean 32.3 ± 9.6 days) and were assessed by the same two raters, blinded to previous measurements. Maximum and normalized reach distances and composite scores of the right and left limbs were collected. Intraclass correlation coefficients (ICC) were calculated for between rater and between session agreement. Measurement error and minimal detectable change values were calculated for clinical interpretation. RESULTS: Interrater reliability was excellent for all reach directions and composite scores of the right limb (ICC 0.973-0.998) and left limb (ICC 0.960-0.999) except for the day 1 left anterior reach which was good (ICC 0.811). Test-retest reliability were moderate to excellent for the right limb (ICC 0.681- 0.908) and moderate to good for left limb (ICC 0.714 - 0.811). Minimal detectable change values for the right and left limbs ranged between 2.02-3.62% and 2.77-3.63%, respectively. CONCLUSIONS: The Y-Balance Test is a reliable tool to assess dynamic balance in early adolescent females and may be utilized in a clinical setting to monitor function over a one-month time interval. Between rater differences were mainly attributed to disparities in subjective test requirements and not quantitative measures of reach distance. LEVEL OF EVIDENCE: Level 2.

Rehabilitation Practice Patterns Following Anterior Cruciate Ligament Reconstruction: A Survey of Physical Therapists.

BACKGROUND: Recovery from anterior cruciate ligament reconstruction (ACLR) requires an intensive course of postoperative rehabilitation. Although guidelines outlining evidence-based rehabilitation recommendations have been published, actual practice patterns of physical therapists are unknown. OBJECTIVES: To analyze the current landscape of clinical practice as it pertains to rehabilitation progression and the use of time and objective criteria in rehabilitation following ACLR. METHODS: In this cross-sectional study, an online survey was distributed to members of the Academy of Orthopaedic Physical Therapy, the American Academy of Sports Physical Therapy, and the Private Practice Section of the American Physical Therapy Association between January and March 2017. RESULTS: The study analyzed a sample of 1074 responses. Supervised physical therapy was reported to last 5 months or less by 56% of survey respondents. The most frequent time frames for activity progression were 3 to 4 months (58%) for jogging, 4 to 5 months (50%) for modified sports activity, and 9 to 12 months (40%) for unrestricted sports participation. More than 80% of respondents reported using strength and functional measures during rehabilitation. Of those physical therapists who assessed strength, 56% used manual muscle testing as their only means of strength testing. Single-limb hop testing (89%) was the most frequently reported measure used to allow patients to begin modified sports activity following ACLR. Performance criteria for strength and functional tests varied significantly across all phases of rehabilitation. The 45% of respondents who reported using patient-reported outcome measures indicated that just under 10% of those measures involved fear or athletic confidence scales. CONCLUSION: Considerable variation in practice exists among American Physical Therapy Association members regarding rehabilitation following ACLR. This variability in practice may contribute to suboptimal outcomes and confusion among practitioners and patients. J Orthop Sports Phys Ther 2018;48(10):801-811. Epub 22 May 2018. doi:10.2519/jospt.2018.8264.

Tarsometatarsal (Lisfranc) Joint Injury in an Athlete With Persistent Foot Pain.

The patient was a 20-year-old female ultimate frisbee player who felt a "pop" in her left foot with resultant pain and bruising along the plantar aspect of her midfoot. She was seen by an orthopaedic physician, who ordered standard radiographs that were found to be unremarkable. Although initial non-weight-bearing films were normal, these findings do not rule out tarsometatarsal joint injury. Following presentation to physical therapy 4 months after the initial injury, the patient was referred to a sports medicine physician. Weight-bearing radiographs and magnetic resonance imaging were ordered and confirmed a high-grade Lisfranc ligament tear. J Orthop Sports Phys Ther 2016;46(6):494. doi:10.2519/jospt.2016.0408.

Strength and functional performance recovery after anterior cruciate ligament reconstruction in preadolescent athletes.

BACKGROUND: In the skeletally immature population, the incidence of anterior cruciate ligament (ACL) injuries and ACL reconstructions appears to be increasing. Differences in surgical techniques, physiology, and emotional maturity may alter the rehabilitation progression and impact the outcomes when compared with adults. Reports of objective strength recovery and performance-based outcome measures after pediatric ACL reconstruction (ACLR) are limited. STUDY DESIGN: Retrospective case series. LEVEL OF EVIDENCE: Level 4. METHODS: All patients that underwent all-epiphyseal ACLR from January 2008 to August 2010 were identified. Isokinetic peak quadriceps/hamstring torque values and functional performance measures in unilateral hopping tasks were extracted and compared with the noninjured limb. A limb symmetry index (LSI) of ≥90% was considered satisfactory. RESULTS: Complete data were available for 16 patients (mean age, 12.28 years; range, 8.51-14.88 years). By a mean 7 months (range, 3.02-12.56 years) postoperatively, only 9 of 16 (56%) were able to achieve a satisfactory LSI for quadriceps strength. For hamstring strength, 15 of 16 (94%) were able to achieve satisfactory LSI. By a mean of 12 months (range, 5.39-24.39 months) postoperatively, only 6 of 16 subjects (38%) were able to achieve satisfactory performance on all functional hop tests. At a mean 15.42 months (range, 8.58-24.39 months) postsurgery, only 4 of 16 (25%) subjects were able to achieve an LSI of ≥90% on all testing parameters. CONCLUSION: For some pediatric patients, significant strength and functional deficits may be present at greater than 1 year after ACLR. This population may require more prolonged rehabilitation programs to allow for adequate recovery of strength and function because of unique characteristics of normal growth and development.

The consequences of chronic pain.

Questions from patients about analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The topic addressed in this issue is untreated/undertreated chronic pain and the physical, emotional, and social consequences that can profoundly affect a patient's quality of life. Chronic pain is no longer considered a symptom; it is a disease entity itself. Anxiety and depression often coexist with chronic pain. Chronic pain is the enemy of happiness. Further, chronic pain can activate the sympathetic nervous system, leading to the fight-or-flight response.

Ziconitide.

Questions from patients about analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. The topic addressed in this query is ziconotide, a novel approach to the management of severe and chronic pain prepared from snail venom, its uses and possible side effects.

Cardiac dysfunction after left permanent cerebral focal ischemia: the brain and heart connection.

BACKGROUND AND PURPOSE: Stroke can lead to cerebrogenic cardiac arrhythmias. We sought to investigate the effect of ischemic stroke on cardiac function in a mouse model of permanent middle cerebral artery occlusion (pMCAO). METHODS: Twenty-four hours after the induction of focal ischemia, cardiac function was measured in mice by endovascular catheterization of the heart. Immediately after hemodynamic measurements, mice were euthanized and brains were excised and sectioned to measure infarct volume and the severity of insular cortex injury. Myocardial damage was evaluated by hematoxylin-eosin staining. Serum and heart levels of norepinephrine (NE) were also determined. RESULTS: Cardiac dysfunction occurred in 9 out of 14 mice that underwent left pMCAO. In these 9 mice, the severity of left insular cortex lesion was greater than the mice with normal heart function. The serum and heart levels of NE were significantly higher in left pMCAO mice with heart dysfunction. Liner regression analysis indicates significant inverse correlation between the severity of left insular cortex damage and heart dysfunction. Mice that underwent right pMCAO did not exhibit cardiac dysfunction. CONCLUSIONS: This study shows that left focal cerebral ischemia can produce cardiac dysfunction, which is associated with the extent of left insular cortex damage. Furthermore, mice exhibiting cardiac dysfunction had elevated levels of NE in the serum and heart.

Asiatic acid, a pentacyclic triterpene from Centella asiatica, is neuroprotective in a mouse model of focal cerebral ischemia.

Asiatic acid, a triterpenoid derivative from Centella asiatica, has shown biological effects such as antioxidant, antiinflammatory, and protection against glutamate- or beta-amyloid-induced neurotoxicity. We investigated the neuroprotective effect of asiatic acid in a mouse model of permanent cerebral ischemia. Various doses of asiatic acid (30, 75, or 165 mg/kg) were administered orally at 1 hr pre- and 3, 10, and 20 hr postischemia, and infarct volume and behavioral deficits were evaluated at day 1 or 7 postischemia. IgG (blood-brain barrier integrity) and cytochrome c (apoptosis) immunostaining was carried out at 24 hr postischemia. The effect of asiatic acid on stress-induced cytochrome c release was examined in isolated mitochondrial fractions. Furthermore, its effects on cell viability and mitochondrial membrane potential were studied in HT-22 cells exposed to oxygen-glucose deprivation. Asiatic acid significantly reduced the infarct volume by 60% at day 1 and by 26% at day 7 postischemia and improved neurological outcome at 24 hr postischemia. Our studies also showed that the neuroprotective properties of asiatic acid might be mediated in part through decreased blood-brain barrier permeability and reduction in mitochondrial injury. The present study suggests that asiatic acid may be useful in the treatment of cerebral ischemia.

Differential neuroprotective effects of carnosine, anserine, and N-acetyl carnosine against permanent focal ischemia.

Carnosine (beta-alanyl-L-histidine) has been shown to exhibit neuroprotection in rodent models of cerebral ischemia. In the present study, we further characterized the effects of carnosine treatment in a mouse model of permanent focal cerebral ischemia and compared them with its related peptides anserine and N-acetylated carnosine. We also evaluated the efficacy of bestatin, a carnosinase inhibitor, in ameliorating ischemic brain damage. Permanent focal cerebral ischemia was induced by occlusion of the middle cerebral artery (pMCAO). Mice were subsequently randomly assigned to receive an intraperitoneal injection of vehicle (0.9% saline), carnosine, N-acetyl carnosine, anserine, bestatin alone, or bestatin with carnosine. Infarct size was examined using 2,3,5-triphenyltetrazolium chloride staining 1, 3, and 7 days following pMCAO, and neurological function was evaluated using an 18-point-based scale. Brain levels of carnosine were measured in treated mice using high-performance liquid chromatography 1 day following pMCAO. We demonstrated that treatment with carnosine, but not its analogues, was able to significantly reduce infarct volume and improve neurological function compared with those in vehicle-treated mice. These beneficial effects were maintained for 7 days post-pMCAO. In contrast, compared with the vehicle-treated group, bestatin-treated mice displayed an increase in the severity of ischemic lesion, which was prevented by the addition of carnosine. These new data further characterize the neuroprotective effects of carnosine and suggest that carnosine may be an attractive candidate for testing as a stroke therapy.