Prediction of Recurrent Lateral Ankle Sprain and Ankle Pain Using Applied Care Strategies and Patient-Reported Outcomes.

CONTEXT: Lateral ankle sprain (LAS) patients often have deficient patient-reported outcomes (PROs) at return-to-activity (RTA), potentially increasing risk for recurrent LAS and ankle pain. Additionally, applied care strategies are known to correct impairments, but their ability to mitigate risk for long-term consequences remains unknown. OBJECTIVE: To determine if applied care strategies and PRO scores at RTA and 6-months post-RTA predict recurrent LAS and ankle pain 12 months after an acute LAS. DESIGN: Prospective cohort study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: We enrolled 63 individuals within one week of sustaining an acute LAS. MAIN OUTCOME MEASURES: Participants completed online surveys about their health history and recent LAS. At RTA and 6 months post-RTA, participants completed online surveys regarding demographics, applied care strategies, and patient reported outcomes (PROs): Foot and Ankle Disability Index, Identification of Functional Ankle Instability, Godin Leisure-Time Exercise Questionnaire, Short Form-8. At 12 months post-RTA, we asked participants if they sustained recurrent LAS. Chi-squares determined if recurrent LAS and ankle pain at 12-months were related to applied care strategies or ankle pain at RTA. Independent t-tests compared demographics and PROs at RTA and 6-months between participants with and without a recurrent LAS or ankle pain at 12-months. Logistic regression and area under the receiver operating characteristic (AUROC) analyses determined if demographics, applied care strategies, ankle pain at RTA, and PRO scores at RTA and 6-months predicted recurrent LAS and ankle pain at 12-months. RESULTS: Participants with a recurrent LAS had a lower walking boot use (P=0.05) and were taller than those without (P=0.03). Increased height and lack of walking boot use were predictive of recurrent LAS (P<0.01, R2=0.33, AUROC=0.81[0.68, 0.95]). CONCLUSIONS: LAS patients who are taller and do not use a walking boot might have greater risk for a recurrent LAS withing 12 months of RTA.

Influences of Athletic Trainers' Return-to-Activity Assessments for Patients With an Ankle Sprain.

CONTEXT: Athletic trainers (ATs) inconsistently apply rehabilitation-oriented assessments (ROASTs) when deciding return-to-activity readiness for patients with an ankle sprain. Facilitators and barriers that are most influential to ATs' assessment selection remain unknown. OBJECTIVE: To examine facilitators of and barriers to ATs' selection of outcome assessments when determining return-to-activity readiness for patients with an ankle sprain. DESIGN: Cross-sectional study. SETTING: Online survey. PATIENTS OR OTHER PARTICIPANTS: We sent an online survey to 10 000 clinically practicing ATs. The survey was accessed by 676 individuals, of whom 574 submitted responses (85% completion rate), and 541 respondents met the inclusion criteria. MAIN OUTCOME MEASURE(S): The survey was designed to explore facilitators and barriers influencing ATs' selection of pain; ankle-joint swelling, range of motion, arthrokinematics, and strength; balance; gait; functional capacity; physical activity level; and patient-reported outcome assessments when making return-to-activity decisions for patients after an ankle sprain. The survey asked for reasons that participants chose to use or not use each measure (eg, previous education, personal comfort, most appropriate, available or feasible, perceived value, and other). The survey contained 12 demographic items that characterized the sample of respondents and were examined as potential influences on the facilitators and barriers. Chi-square analysis was used to identify relationships among participant demographics and facilitators of or barriers to assessment selection. RESULTS: Selection of each ROAST and non-ROAST was most commonly facilitated by previous education, availability or feasibility, or perceived value. Avoidance of each ROAST was most often caused by the lack of previous education, availability or feasibility, or perceived value. The presence of facilitators and barriers was affected by various demographic variables. CONCLUSIONS: A variety of facilitators and barriers affected ATs' implementation of expert-recommended assessments when determining return-to-activity readiness in patients with an ankle sprain. Some subpopulations of ATs experienced more favorable or prohibitive conditions for assessment use.

Effects of A Single Balance Training Session on Neural Excitability in Individuals With Chronic Ankle Instability.

CONTEXT: Individuals with chronic ankle instability (CAI) demonstrate reduced spinal reflex modulation and corticospinal excitability of the soleus, which may contribute to decreased balance performance. OBJECTIVE: To determine the effects of a single session of balance training on Spinal-reflexive excitability modulation and corticospinal excitability in those with CAI. DESIGN: Randomized controlled trials. SETTING: Research laboratory. PARTICIPANTS: Thirty participants with CAI were randomly assigned to the balance training (BAL) or control (CON) group. MAIN OUTCOME MEASURES: Modulation of soleus spinal-reflexive excitability was measured by calculating relative change in normalized Hoffmann reflexes (ratio of the H-reflex to the M-wave) from prone to single-leg standing. Corticospinal excitability was assessed during single-leg stance using transcranial magnetic stimulation, outcomes of which included active motor threshold (AMT), motor evoked potential, and cortical silent period (CSP). Balance performance was measured with center of pressure velocity in anterior to posterior and medial to lateral directions. Separate 2 × 2 repeated-measures analyses of variance were employed to determine the effect of group (BAL and CON) and time (baseline and posttraining) on each dependent variable. RESULTS: There were significant group by time interactions in the modulation of soleus spinal-reflexive excitability (F1,27 = 4.763, P = .04); CSP at 100% AMT (F1,27 = 4.727, P = .04); and CSP at 120% AMT (F1,27 = 16.057, P < .01). A large effect size suggests increased modulation of spinal-reflexive excitability (d = 0.81 [0.03 to 1.54]) of the soleus in BAL compared with CON at posttest, while CSP at 100% (d = 0.95 [0.17 to 1.70]) and 120% AMT (d = 1.10 [0.29 to 1.84]) was reduced in BAL when compared with CON at posttest. CONCLUSION: After a single session of balance training, individuals with CAI initiated increases in spinal reflex modulation and corticospinal excitability of the soleus. Thus, individuals with CAI who undergo balance training exhibit positive neural adaptations that are linked to improvements in balance performance.

Cross-Education Balance Effects After Unilateral Rehabilitation in Individuals With Chronic Ankle Instability: A Systematic Review.

OBJECTIVE: To conduct a systematic review of existing literature on cross-education balance effects after unilateral training in the population with chronic ankle instability (CAI). DATA SOURCES: PubMed, SPORTDiscus, CINAHL Plus. STUDY SELECTION: To be included in the systematic review, studies were required to have been published in English, included participants with CAI, had participants undergo a unilateral therapeutic exercise for the lower extremity, and measured balance performance of the untrained lower extremity before and after the intervention. DATA EXTRACTION: The certainty of evidence in each included study was assessed via the Downs and Black checklist. A score of 24 to 28 indicated excellent or very low risk of bias; 19 to 23, good or low risk of bias; 14 to 18, fair or moderate risk of bias; and <14, poor or high risk of bias. We extracted information from each study regarding design, participant characteristics, inclusion criteria, independent and dependent variables, intervention, and results. Baseline and postintervention balance performance data for participants' untrained limbs were used to calculate the Hedges g effect sizes and 95% CIs. DATA SYNTHESIS: Our search returned 6 studies that met the inclusion criteria. The articles' risk of bias ranged from high to low (11-19). In 4 of 5 studies that examined unilateral balance training, the authors reported a cross-education effect. In the lone study that examined resistance training at the ankle joint, a cross-education effect was also present. Several cross-education effects were associated with large effect sizes. This systematic review was limited by a small number of studies that varied in methods and quality. CONCLUSIONS: Our results suggest that unilateral therapeutic exercise can improve balance performance of the untrained limb of individuals with CAI. More work is needed to determine which training protocols are most effective for generating a cross-education effect.

The Effect of Concussion History on Lower Extremity Injury Risk in College Athletes: A Systematic Review and Meta-Analysis.

Introduction: Collegiate athletes who suffer a concussion may possess prolonged impairments even after clearance for return-to-participation, which may place them at an increased risk of lower extremity injury. Objective: To conduct a systematic review and meta-analysis of studies examining risk of lower extremity musculoskeletal injury following a concussion in collegiate athletes. Methods: A literature search was performed using the following databases: PubMed, CINAHL, SPORTDiscus. The following search terms were used to identify relevant articles, ["concussion" OR "brain injury" OR "mild traumatic brain injury" OR "mTBI"] AND ["lower extremity injury" OR "musculoskeletal injury"]. Articles were included if they were published between January 2000 and July 2021 and examined collegiate athletes' risk of sustaining a lower extremity musculoskeletal injury following a concussion. Methodological quality of included studies was performed with a modified Downs and Black Checklist. The primary outcome of interest was the risk of sustaining a lower extremity musculoskeletal injury following a concussion. A random effects meta-analysis was conducted in which a summative relative risk (RR) for sustaining a lower extremity injury in athletes with and without a history of concussion was calculated. Results: Seven studies met the eligibility criteria to be included in the systematic review. There were 348 athletes in the concussion group and 482 control athletes in the included studies. Most of the studies were of good or excellent quality. Five of the seven studies were able to be included in the meta-analysis. College athletes who suffered a concussion possessed a 58% greater risk of sustaining a lower extremity musculoskeletal injury than those who did not have a history of a concussion (RR = 1.58[1.30, 1.93]). Conclusions: Lower extremity injury risk is potentially increased in college athletes following a concussion compared to those without a history of a concussion. Further research is needed to investigate the mechanism behind this increased risk. Clinical assessments throughout the concussion return-to-play protocol may need to be improved in order to detect lingering impairments caused by concussions. Level of Evidence: 1.

Assessments Used by Athletic Trainers to Decide Return-to-Activity Readiness in Patients.

CONTEXT: Patients with ankle sprains are often cared for by athletic trainers (ATs). Expert consensus was previously established for Rehabilitation-Oriented Assessments (ROASTs) that should be included in ankle sprain evaluations. However, it is unknown what methods ATs use to determine return-to-activity readiness following an ankle sprain. OBJECTIVE: Our purpose was to identify ATs' methods for determining patients' return-to-activity readiness following an ankle sprain and demographic determinants of ATs' methods. SETTING: Online survey Study Design: Cross-sectional study Level of Evidence: CEBM Level 1 Participants: We recruited 10,000 clinically practicing ATs. A total of 676 accessed the survey, 574 submitted responses (85% completion rate), and 541 respondents met inclusion criteria. MAIN OUTCOME MEASURES: We distributed an online survey to participants to ask them about their assessment of pain, swelling, range of motion, arthrokinematics, strength, balance, gait, functional capacity, physical activity level, and patient-reported outcomes in deciding return-to-activity. Descriptive statistics characterized participant demographics and frequencies of assessment measures used by ATs. Chi-square analyses identified relationships between demographics and assessment selection. RESULTS: Pain, swelling, range of motion, strength, balance, gait, and functional capacity were assessed by 76-97% of ATs. Arthrokinematics, physical activity level, and patient-reported outcomes were assessed by 25-36% of participants. When selecting specific assessment methods, ATs often did not use recommended ROASTs. ATs with higher degrees, more advance educational programs, employment in non-traditional settings, more clinical experience, and familiarity with expert consensus recommendations were more likely to use ROASTs. CONCLUSIONS: Before approving return-to-activity for patients with ankle sprains, some recommended outcomes and assessment methods are not evaluated by ATs. Practice in non-traditional settings, more advanced degrees, more clinical experience, and familiarity with expert-consensus guidelines appear to facilitate use of ROASTs.

Perceived Instability, Pain, and Psychological Factors for Prediction of Function and Disability in Individuals With Chronic Ankle Instability.

CONTEXT: Chronic ankle instability (CAI) is associated with residual instability, pain, decreased function, and increased disablement. Injury-related fear has been associated with CAI, although its relationship to other impairments is unclear. The fear-avoidance model is a theoretical framework hypothesizing a relationship among pain catastrophizing, injury-related fear, chronic pain, and disability. It has been useful in understanding fear's influence in other musculoskeletal conditions but has yet to be studied in those with CAI. OBJECTIVE: To explore relationships among instability, pain catastrophizing, injury-related fear, pain, ankle function, and global disability in individuals with CAI. DESIGN: Cross-sectional study. SETTING: Anonymous online survey. PATIENTS OR OTHER PARTICIPANTS: A total of 259 people, recruited via email and social media, with a history of ankle sprain completed the survey; of those, 126 participants (age = 32.69 ± 4.38 years, females = 84.92%, highly active = 73.81%) were identified as having CAI and were included in the analysis. MAIN OUTCOME MEASURE(S): Demographics of gender identity, age, and physical activity level were recorded. Assessments used were the Identification of Functional Ankle Instability questionnaire (instability), the Pain Catastrophizing Scale (pain catastrophizing), the Tampa Scale of Kinesiophobia-11 (injury-related fear), a numeric pain rating scale and activity-based question (pain presence), the Quick Foot and Ankle Ability Measure (ankle function), and the modified Disablement in the Physically Active Scale (disability). Relationships among variables were explored through correlation and regression analyses. RESULTS: After we controlled for instability and pain, pain catastrophizing and injury-related fear were significantly related to function and disability ratings in individuals with CAI. Together, the variables predicted 48.7% (P < .001) of the variance in function and 44.2% (P < .001) of the variance in disability. CONCLUSIONS: Greater instability, pain catastrophizing, injury-related fear, and pain predicted decreased function and greater disability in those with CAI. These findings are consistent with the hypothesized relationships in the fear-avoidance model, although further investigation is needed to determine causality of these factors in the development of CAI.

Corticospinal activity during a single-leg stance in people with chronic ankle instability.

PURPOSE: The aim of the study was to determine whether corticospinal excitability and inhibition of the tibialis anterior during single-leg standing differs among individuals with chronic ankle instability (CAI), lateral ankle sprain copers, and healthy controls. METHODS: Twenty-three participants with CAI, 23 lateral ankle sprain copers, and 24 healthy control participants volunteered. Active motor threshold (AMT), normalized motor-evoked potential (MEP), and cortical silent period (CSP) were evaluated by transcranial magnetic stimulation while participants performed a single-leg standing task. RESULTS: Participants with CAI had significantly longer CSP at 100% of AMT and lower normalized MEP at 120% of AMT compared to lateral ankle sprain copers (CSP100%: p = 0.003; MEP120%: p = 0.044) and controls (CSP100%: p = 0.041; MEP120%: p = 0.006). CONCLUSION: This investigation demonstrate altered corticospinal excitability and inhibition of the tibialis anterior during single-leg standing in participants with CAI. Further research is needed to examine the effects of corticospinal maladaptations to motor control of the tibial anterior on postural control performance in those with CAI.

Injury-Related Fear in Individuals With and Without Chronic Ankle Instability: A Systematic Review.

CONTEXT: Injury-related fear has recently been recognized to exist in ankle sprain populations. It is unclear, however, if injury-related fear levels differ between those who develop chronic ankle instability (CAI) and those who do not and the best tools for assessing these differences. OBJECTIVE: The purpose of this study was to conduct a comprehensive systematic review investigating differences in injury-related fear between individuals with and without CAI. EVIDENCE ACQUISITION: Relevant studies from CINAHL Plus with full text, PubMed, and SPORTDiscus through November 2020 were included. All studies used the Tampa Scale of Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, or Athlete Fear Avoidance Questionnaire as either a descriptor or a main outcome and provided comparison data between a CAI group and ankle sprain copers (COP) or controls (CON). The authors independently assessed methodological quality using the modified Downs and Black Quality Index. Studies were then grouped by between-group comparisons including CAI and CON, CAI and COP, and COP and CON. The authors calculated Hedge g effect sizes and 95% confidence intervals to examine group differences. EVIDENCE SYNTHESIS: A total of 11 studies were included in this review. In total, 8 studies provided data for the CAI and CON comparison, 7 for CAI and COP comparisons, and 4 for COP and CON comparisons. Methodological quality scores ranged from 60.0% to 86.7%, with 2 high-, and 9 moderate-quality studies. Overall, the evidence suggests that physically active individuals with CAI report higher levels of injury-related fear when compared with both COP and CON. Although limited, ankle sprain COP do not seem to differ from CON. CONCLUSION: Available evidence emphasizes the importance of injury-related fear in individuals who develop chronicity after ankle sprain injury. The Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia are useful for the identification of injury-related fear in individuals after sustaining an ankle sprain and should be used to inform rehabilitation strategies and to monitor efficacy in fear reduction.

Lumbopelvic Stability and Trunk Muscle Contractility of Individuals with Chronic Ankle Instability.

BACKGROUND: Chronic ankle instability (CAI) results in hip neuromuscular impairments that can perpetuate dysfunction through reduced lumbopelvic stability and subsequent malpositioning of the lower body during functional movement. Lumbopelvic stability might be further impaired through changes in trunk muscular contractility. However, lumbopelvic stability and trunk muscle morphology have not been compared between individuals with and without CAI. PURPOSE: To compare lumbopelvic stability and trunk muscle contractility between individuals with and without chronic ankle instability (CAI) and determine if lumbopelvic stability and trunk muscle contractility are associated with self-reported function. STUDY DESIGN: Case-control study. METHODS: Ten individuals with CAI, 10 ankle sprain copers (COP), and 10 healthy controls (CON) participated. Diagnostic ultrasound imaging was used to assess transversus abdominis (TrA) and lumbar multifidus (LM) muscle contractility. A percent change in contraction thickness from rested to contracted conditions was calculated for each muscle. Lumbopelvic stability was assessed using unilateral hip bridge, trunk flexion endurance, Biering-Sorensen, and side plank tests. Self-reported function was measured with the Foot and Ankle Ability Measure Activity of Daily Living (FAAM-ADL) and Sport (FAAM-S) subscales. One-way ANOVAs and Cohen's d effect sizes compared scores on clinician and patient-reported outcomes between groups. Pearson product moment correlations analyzed associations between self-reported function and trunk muscle contractility and lumbopelvic stability. Significance was set a priori at P<0.05. RESULTS: COP had significantly greater TrA contractility than CAI (P<0.01, d=2.65[1.45,3.85]) and CON (P=0.03, d=1.05[0.08,1.94]). Although not statistically significant, a large effect size suggest that CAI had lower TrA contractility than CON (P=0.12, d=0.92[-0.03,1.80]). No differences existed for LM contractility or lumbopelvic stability tests. A moderate direct correlation (r=0.65, P=0.04) existed between CON's TrA contractility and FAAM-ADL scores. CONCLUSION: Deficits in TrA contractility are a novel finding among individuals with CAI. While LM contractility and lumbopelvic stability did not differ between groups, future research should continue to examine their relevance to CAI. LEVEL OF EVIDENCE: 3b.

The Effect of Footwear, Running Speed, and Location on the Validity of Two Commercially Available Inertial Measurement Units During Running.

Introduction: Most running-related injuries are believed to be caused by abrupt changes in training load, compounded by biomechanical movement patterns. Wearable technology has made it possible for runners to quantify biomechanical loads (e.g., peak positive acceleration; PPA) using commercially available inertial measurement units (IMUs). However, few devices have established criterion validity. The aim of this study was to assess the validity of two commercially available IMUs during running. Secondary aims were to determine the effect of footwear, running speed, and IMU location on PPA. Materials and Methods: Healthy runners underwent a biomechanical running analysis on an instrumented treadmill. Participants ran at their preferred speed in three footwear conditions (neutral, minimalist, and maximalist), and at three speeds (preferred, +10%, -10%) in the neutral running shoes. Four IMUs were affixed at the distal tibia (IMeasureU-Tibia), shoelaces (RunScribe and IMeasureU-Shoe), and insole (Plantiga) of the right shoe. Pearson correlations were calculated for average vertical loading rate (AVLR) and PPA at each IMU location. Results: The AVLR had a high positive association with PPA (IMeasureU-Tibia) in the neutral and maximalist (r = 0.70-0.72; p ≤ 0.001) shoes and in all running speed conditions (r = 0.71-0.83; p ≤ 0.001), but low positive association in the minimalist (r = 0.47; p < 0.05) footwear condition. Conversely, the relationship between AVLR and PPA (Plantiga) was high in the minimalist (r = 0.75; p ≤ 0.001) condition and moderate in the neutral (r = 0.50; p < 0.05) and maximalist (r = 0.57; p < 0.01) footwear. The RunScribe metrics demonstrated low to moderate positive associations (r = 0.40-0.62; p < 0.05) with AVLR across most footwear and speed conditions. Discussion: Our findings indicate that the commercially available Plantiga IMU is comparable to a tibia-mounted IMU when acting as a surrogate for AVLR. However, these results vary between different levels of footwear and running speeds. The shoe-mounted RunScribe IMU exhibited slightly lower positive associations with AVLR. In general, the relationship with AVLR improved for the RunScribe sensor at slower speeds and improved for the Plantiga and tibia-mounted IMeasureU sensors at faster speeds.

MYCOTIC PNEUMONIA AND ENCEPHALITIS IN SOUTHERN PUDU (PUDU PUDA).

This case series describes six confirmed cases of mycotic encephalitis and/or mycotic pneumonia in southern pudu (Pudu puda). One case involved a 10.5-yr-old intact female that presented with an inability to stand, eventually progressing to grand mal seizures. Magnetic resonance imaging showed a lesion within the cerebellar vermis with edema causing cerebellar herniation. The animal was euthanized based on a grave prognosis. Gross and histologic examination revealed primary central nervous system phaeohyphomycosis. Curvularia spicifera was sequenced from the cerebellar tissue. This is the first time this fungus has been reported as a primary central nervous system infection in an artiodactyl species. The remaining five cases occurred in neonates between 17 and 67 days old. Clinical signs varied widely, including facial swelling, weakness, posterior paresis, and sudden death. Antifungal therapy was initiated in three neonatal animals but was unsuccessful in each case. All neonates had active mycotic pneumonia caused by Aspergillus fumigatus or Mucor spp. at time of death; four of these animals also had disseminated disease that caused mycotic encephalitis. This case series indicates that fungal disease should be included in the differential diagnosis list of any pudu presenting for neurologic or respiratory clinical signs.

Neural excitability of lower extremity musculature in individuals with and without chronic ankle instability: A systematic review and meta-analysis.

This systematic review and meta-analysis examined differences in lower extremity neural excitability between ankles with and without chronic ankle instability (CAI). We searched the literature for studies that compared corticomotor or spinal reflexive excitability between a CAI group and controls or copers, or between limbs of a CAI group. Random effects meta-analyses calculated pooled effect sizes for each outcome. Nineteen studies were included. Meta-analyses of motor thresholds of the fibularis longus (Z = 1.17, P = 0.24) and soleus (Z = 0.47, P = 0.64) exhibited no differences between ankles with and without CAI. Pooled data indicate that ankles with CAI had reduced soleus spinal reflexive excitability (Z = 2.18, P = 0.03) and significantly less modulation of the soleus (Z = 6.96, P < 0.01) and fibularis longus (Z = 4.75, P < 0.01) spinal reflexive excitability when transitioning to more challenging stances. Pre-synaptic inhibition was facilitated in ankles with CAI (Z = 4.05, P < 0.01), but no difference in recurrent inhibition existed (Z = 1.50, P = 0.13). Soleus spinal reflexive activity is reduced in those with CAI. Reduced ability of ankles with CAI to modulate soleus and fibularis longus reflexive activity may contribute to impaired balance.

An intervention based on the health belief model led to improvements in self-efficacy towards ERIPP participation and functional performance in club sport athletes: a pilot study.

OBJECTIVES: To determine if an intervention based on the Health Belief Model (HBM) could improve attitudes towards exercise-related injury prevention program (ERIPP) participation and functional performance in club sport participants. DESIGN: Repeated measures METHODS: Participants completed the HBM Scale (HBMS) and Theory of Planned Behavior Scale (TPBS) to assess attitudes towards ERIPP participation at three time points (pre-measure, post-measure, follow-up measure). The HBM based intervention was delivered immediately following the pre-measure containing: 1) education on ERIPPs, benefits and barriers to participating, strategies to overcome barriers, risk factors and consequences for lower extremity injuries, and strategies to prevent lower extremity injuries 2) individualized feedback on functional performance 3) demonstration and participation in the 11+. Attitudes towards injury prevention were compared using the subscales of the HBMS and TPBS at all three time points. Functional performance was compared at the pre-measure and follow-up measure. RESULTS: Significant improvements with large effect sizes were detected in individual self-efficacy from pre-test (0.73±4.48) to post-test (2.93±4.30; P=0.05; ƞ2=0.18) and pre-test to follow-up (3.20±3.49; P=0.04; ƞ2=0.20) and community led self-efficacy from pre-test (4.40±2.75) to post-test (6.07±3.43; P=0.02; ƞ2=0.24) and pre-test to follow-up (7.07±2.05; P=0.001; ƞ2=0.44). Additionally, significant improvements were found in the LESS-RT following the intervention. CONCLUSIONS: The intervention based on the HBM led to improvements in individual and community led self-efficacy indicating an enhancement in the participants' confidence in their ability to participate in an ERIPP. Future research should investigate the effectiveness of individualized interventions to improve attitudes towards and adherence to ERIPPs.

Rehabilitation Utilizing Controlled Aerobic Activity in Patients With a Concussion: A Critically Appraised Topic.

Clinical Scenario: A sport-related concussion is a common injury to the brain that may cause a variety of symptoms ranging in duration and severity. The mainstay of treatment for concussion has been rest, followed by a stepwise return to activity. This recovery process may be lengthy when symptoms persist. Aerobic exercise conducted at subsymptom and submaximal intensities has been proposed as a potential intervention for symptoms following a concussion. Therefore, the purpose of this critically appraised topic is to examine the safety of varying aerobic exercise intensities in patients with a concussion. Focused Clinical Question: Are subsymptom and submaximal exercise programs safe when implemented in a population with a symptomatic sports-related concussion when compared with traditional rest? Summary of Key Findings: Four randomized controlled trials were included for critical appraisal. The 4 studies investigated supervised and controlled aerobic exercise as early as within 1 week of with a concussion; all studies conclude that exercise is safe and may be of benefit to individuals with a concussion. Two studies support the use of submaximal exercise as a therapeutic intervention for adolescents with persistent concussion symptoms. Clinical Bottom Line: The authors conclude that controlled exercise performed within the symptom or exertion threshold of patients with concussion is safe compared with rest. It was noted that symptom changes may occur; however, the changes did not have a negative impact on long-term recovery. This research should ease concerns about prescribing physical activity when an athlete with concussion is still experiencing lingering symptoms. While specific parameters of the activity performed have not been described in detail, the individualization of each exercise program was stressed. Strength of Recommendation: Grade A.

Decreased perceived ankle and knee joint health in individuals with perceived chronic ankle instability.

PURPOSE: Abnormal movement patterns and neuromuscular impairments at the ankle are thought to contribute to ankle joint degeneration in those with chronic ankle instability. However, these impairments are not confided to the ankle; rather, proximal neuromuscular deficiencies at the knee and aberrant movement patterns, thought to be responsible for reductions in knee joint health, have also been identified. While neuromuscular impairments and self-reported functional limitations have been examined in those with chronic ankle instability, patient-generated symptoms associated with joint health of the ankle and knee have not been investigated. Therefore, the purpose was to compare perceived ankle and knee joint health in individuals with and without chronic ankle instability. METHODS: The Ankle Osteoarthritis Scale and the Knee Injury and Osteoarthritis Outcome Score assessed region-specific ankle and knee joint health. RESULTS: Participants with chronic ankle instability reported more ankle pain (P < 0.001) and disability (P < 0.001) than the control group. Chronic ankle instability individuals also reported worse knee joint health (P < 0.05). CONCLUSIONS: The increased symptomology associated with decreased ankle joint health further supports information demonstrating joint degeneration in young adults with chronic ankle instability. The decreased perceived knee joint health provides preliminary evidence of the negative impact proximal neuromuscular impairments associated with chronic ankle instability that may have on joints other than the ankle. Assessing subjective ankle and knee joint function can guide clinicians in developing individualized rehabilitation by providing them with an understanding if a patient presenting with chronic ankle instability suffers from symptoms arising from more than just the ankle. LEVEL OF EVIDENCE: Case-control, Level III.

Use of Social or Behavioral Theories in Exercise-Related Injury Prevention Program Research: A Systematic Review.

BACKGROUND: The use of social or behavioral theories within exercise-related injury prevention program (ERIPP) research may lead to a better understanding of why adherence to the programs is low and inform the development of interventions to improve program adherence. There is a need to determine which theories have been used within the literature and at what level theory was used to further the field. OBJECTIVE: To determine which social or behavioral science theories have been incorporated within ERIPP research and assess the level at which the theories were used. The key question guiding the search was "What social or behavioral theories have been used within ERIPP research?" METHODS: A systematic review of the literature was completed with an appraisal of bias risk using a custom critical appraisal tool. An electronic search of EBSCOhost (Academic Search Complete, CINAHL, Medline, Psychology and Behavioral Sciences Collection) and PubMed was completed from inception to October 2018. Studies investigating attitudes towards ERIPP participation with the use of a social or behavioral theoretical model or framework were eligible for inclusion. RESULTS: The electronic search returned 7482 results and two articles were identified though a hand search, which resulted in ten articles meeting inclusion criteria. Four different behavioral or social theoretical models or frameworks were identified including the health action process approach model, health belief model, self-determination theory, and theory of planned behavior. Six studies utilized the theory at a B level meaning a theoretical construct was measured while four utilized the theory at the C level meaning the theory was tested. The mean critical appraisal score was 78%, indicating a majority of the studies were higher quality. CONCLUSION: There has been an increase in the use of theory within literature that is specific to ERIPP participation. Additionally, the use of theory has shifted from guiding program design to the measurement of theoretical constructs and testing of the theoretical models.

Differences in temporal gait mechanics are associated with decreased perceived ankle joint health in individuals with chronic ankle instability.

BACKGROUND: Chronic ankle instability (CAI) is associated with an increased risk of developing post-traumatic osteoarthritis (PTOA). Altered temporal gait parameters likely contribute to the early development and progression of PTOA in CAI. However, it is unknown if increased clinical symptoms of ankle PTOA influence temporal gait parameters among those with CAI. RESEARCH QUESTION: Compare temporal gait parameters and Ankle Osteoarthritis Scale (AOS) scores between individuals with and without CAI. METHODS: Thirty CAI participants and 30 healthy-controls volunteered to participate in this retrospective case-control study. Participants completed the Pain and Disability subscales of the AOS. Temporal gait parameters were assessed using a GAITRite® electronic walkway. Participants performed 5 walking trials, which were subsequently combined into a single test. Temporal variables (swing, stance, single-limb support and double-limb support) were extracted for the involved limb and normalized to percent of gait cycle (%GC). RESULTS: Participants with CAI had higher scores on the Pain (P < 0.001) and Disability (P = 0.001, d = 0.87[0.33,1.39]) subscales of the AOS. CAI individuals spent less time during swing (P = 0.022]) and single-limb support (P = 0.030) phases and more time during the double-limb support (P = 0.021) phase. Single-limb support time was moderately correlated with higher scores on the AOS pain (r=-0.416, P = 0.011) and disability (r=-0.473 P = 0.004) subscales. SIGNIFICANCE: Individuals with CAI spend varying times in each phase of the gait cycle compared to uninjured controls. Individuals with CAI may adopt this abnormal gait strategy due to increased clinical symptoms of ankle PTOA. Rehabilitation programs should focus on minimizing the symptoms of ankle PTOA to restore normal temporal gait parameters.