Zachary K. Winkelmann

Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence-Based Review.

Reference/Citation: Hamstra-Wright KL, Bliven KC, Bay C. Risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. Br J Sports Med. 2015;49(6):362-369. CLINICAL QUESTION What factors put physically active individuals at risk to develop medial tibial stress syndrome (MTSS)? DATA SOURCES The authors performed a literature search of CINAHL, the Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE from each databases inception to July 2013. The following key words were used together or in combination: armed forces, athlete, conditioning, disorder predictor, exercise, medial tibial stress syndrome, militaries, MTSS, military, military personnel, physically active, predictor, recruit, risk, risk characteristic, risk factor, run, shin pain, shin splints, and vulnerability factor. STUDY SELECTION Studies were included in this systematic review based on the following criteria: original research that (1) investigated risk factors associated with MTSS, (2) compared physically active individuals with and without MTSS, (3) was printed in English, and (4) was accessible in full text in peer-reviewed journals. DATA EXTRACTION Two authors independently screened titles or abstracts (or both) of studies to identify inclusion criteria and quality. If the article met the inclusion criteria, the authors extracted demographic information, study design and duration, participant selection, MTSS diagnosis, investigated risk factors, mean difference, clinical importance, effect size, odds ratio, and any other data deemed relevant. After the data extraction was complete, the authors compared findings for accuracy and completeness. When the mean and standard deviation of a particular risk factor were reported 3 or more times, that risk factor was included in the meta-analysis. In addition, the methodologic quality was assessed with an adapted checklist developed by previous researchers. The checklist contained 5 categories: study objective, study population, outcome measurements, assessment of the outcome, and analysis and data presentation. Any disagreement between the authors was discussed and resolved by consensus. MAIN RESULTS A total of 165 papers were initially identified, and 21 original research studies were included in this systematic review. More than 100 risk factors were identified in the 21 studies. Continuous data were reported 3 or more times for risk factors of body mass index (BMI), navicular drop, ankle plantar-flexion range of motion (ROM), ankle-dorsiflexion ROM, ankle-eversion ROM, ankle-inversion ROM, quadriceps angle, hip internal-rotation ROM, and hip external-rotation ROM. As compared with the control group, significant risk factors for developing MTSS identified in the literature were (1) greater BMI (mean difference [MD] = 0.79, 95% confidence interval [CI] = 0.38, 1.20; P < .001), (2) greater navicular drop (MD = 1.9 mm, 95% CI = 0.54, 1.84 mm; P < .001), (3) greater ankle plantar-flexion ROM (MD = 5.94°, 95% CI = 3.65°, 8.24°; P < .001), and (4) greater hip external-rotation ROM (MD = 3.95°, 95% CI = 1.78°, 6.13°; P < .001). Ankle-dorsiflexion ROM (MD = -0.01°, 95% CI = -0.96, 0.93; P = .98), ankle-eversion ROM (MD = 1.17°, 95% CI = -0.02, 2.36; P = .06), ankle-inversion ROM (MD = 0.98°, 95% CI = -3.11°, 5.07°; P = .64), quadriceps angle (MD = -0.22°, 95% CI = -0.95°, 0.50°; P = .54), and hip internal-rotation ROM (MD = 0.18°, 95% CI = -5.37°, 5.73°; P = .95), were not different between individuals with MTSS and controls. CONCLUSIONS The primary factors that appeared to put a physically active individual at risk for MTSS were increased BMI, increased navicular drop, greater ankle plantar-flexion ROM, and greater hip external-rotation ROM. These primary risk factors can guide health care professionals in the prevention and treatment of MTSS.

Athletic Training Students' Knowledge of Ethical and Legal Practice with Technology and Social Media

Context: Technology, social media, and access to health care continue to grow simultaneously. There is limited research on the knowledge of athletic training students regarding the ethical and lega...

Curation of a Simulation Experience by the Clinical Scholar: An Educational Technique in Postprofessional Athletic Training

Context: Postprofessional athletic training programs continue to prepare advanced-practice leaders in the profession. As part of being leaders and clinical scholars within the field, it is important that students pursing postprofessional graduate education be exposed to curriculum and instructional theory, practice, and strategies. Objective: To describe an education technique focused on the curation of a simulation assignment as part of a postprofessional athletic training course as a means to develop an appreciation of instructional strategies as a clinical scholar. Background: The postprofessional athletic training student (PP-ATS) may be working as a full-time clinician, graduate assistant, or novice educator, or as an intern within an athletic training clinic. Regardless of employment status, PP-ATSs engage with several key stakeholders, ranging from parents and legal guardians to coaching staff and professional athletic training students. The PP-ATS may be tasked to provide education to these stakeh...

Acute Effects and Perceptions of Deep Oscillation Therapy for Improving Hamstring Flexibility

CONTEXT Hamstring inflexibility is typically treated using therapeutic massage, stretching, and soft tissue mobilization. An alternative intervention is deep oscillation therapy (DOT). Currently, there is a lack of evidence to support DOTs effectiveness to improve flexibility. OBJECTIVE To explore the effectiveness of DOT to improve hamstring flexibility. DESIGN Randomized single-cohort design. SETTING Research laboratory. PARTICIPANTS Twenty-nine healthy, physically active individuals (self-reported activity of a minimum 200 min/wk). INTERVENTIONS All participants received a single session of DOT with randomization of the participants leg for the intervention. The DOT intervention parameters included a 1∶1 mode and 70% to 80% dosage at various frequencies for 28 minutes. Hamstring flexibility was assessed using passive straight leg raise for hip flexion using a digital inclinometer. Patient-reported outcomes were evaluated using the Copenhagen Hip and Groin Outcome Score and the Global Rating of Change (GRoC). MAIN OUTCOME MEASURE The independent variable was time (pre and post). The dependent variables included passive straight leg raise, the GRoC, and the participants perceptions of the intervention. Statistical analyses included a dependent t test and a Pearson correlation. RESULTS Participants reported no issues with sport, activities of daily living, or quality of life prior to beginning the intervention study on the Copenhagen Hip and Groin Outcome Score. Passive straight leg raise significantly improved post-DOT (95% confidence interval, 4.48°-7.85°, P < .001) with a mean difference of 6.17 ± 4.42° (pre-DOT = 75.43 ± 21.82° and post-DOT = 81.60 ± 23.17°). A significant moderate positive correlation was identified (r = .439, P = .02) among all participants between the GRoC and the mean change score of hamstring flexibility. Participants believed that the intervention improved their hamstring flexibility (5.41 ± 1.02 points) and was relaxing (6.21 ± 0.86). CONCLUSIONS DOT is an effective intervention to increase hamstring flexibility.

Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review

Reference:  Schiftan GS, Ross LA, Hahne AJ. The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: a systematic review and meta-analysis. J Sci Med Sport. 2015;18(3):238-244. CLINICAL QUESTION   Does the use of proprioceptive training as a sole intervention decrease the incidence of initial or recurrent ankle sprains in the athletic population? DATA SOURCES   The authors completed a comprehensive literature search of MEDLINE, CINAHL, SPORTDiscus, and Physiotherapy Evidence Database (PEDro) from inception to October 2013. The reference lists of all identified articles were manually screened to obtain additional studies. The following key words were used. Phase 1 population terms were sport*, athlet*, and a combination of the two. Phase 2 intervention terms were propriocept*, balance, neuromusc* adj5 train*, and combinations thereof. Phase 3 condition terms were ankle adj5 sprain*, sprain* adj5 ankle, and combinations thereof. STUDY SELECTION   Studies were included according to the following criteria: (1) the design was a moderate- to high-level randomized controlled trial (>4/10 on the PEDro scale), (2) the participants were physically active (regardless of previous ankle injury), (3) the intervention group received proprioceptive training only, compared with a control group that received no proprioceptive training, and (4) the rate of ankle sprains was reported as a main outcome. Search results were limited to the English language. No restrictions were placed on publication dates. DATA EXTRACTION   Two authors independently reviewed the studies for eligibility. The quality of the pertinent articles was assessed using the PEDro scale, and data were extracted to calculate the relative risk. Data extracted were number of participants, intervention, frequency, duration, follow-up period, and injury rate. MAIN RESULTS   Of the initial 345 studies screened, 7 were included in this review for a total of 3726 participants. Three analyses were conducted for proprioceptive training used (1) to prevent ankle sprains regardless of history (n = 3654), (2) to prevent recurrent ankle sprains (n = 1542), or (3) as the primary preventive measure for those without a history of ankle sprain (n = 946). Regardless of a history of ankle sprain, participants had a reduction in ankle-sprain rates (relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.55, 0.77; numbers needed to treat [NNT] = 17, 95% CI = 11, 33). For individuals with a history of ankle sprains, proprioceptive training demonstrated a reduction in repeat ankle sprains (RR = 0.64, 95% CI = 0.51, 0.81; NNT = 13, 95% CI = 7, 100). Proprioceptive training as a primary preventive measure demonstrated significant results (RR = 0.57, 95% CI = 0.34, 0.97; NNT = 33, 95% CI = 16, 1000). CONCLUSIONS   Proprioceptive training programs were effective in reducing the incidence rates of ankle sprains in the athletic population, including those with and those without a history of ankle sprains.

Optimal Screening Methods to Detect Cardiac Disorders in Athletes: An Evidence-Based Review

Reference/Citation:  Harmon KG, Zigman M, Drezner JA. The effectiveness of screening history, physical exam, and ECG to detect potentially lethal cardiac disorders in athletes: a systematic review/meta-analysis. J Electrocardiol. 2015;48(3):329-338. CLINICAL QUESTION   Which screening method should be considered best practice to detect potentially lethal cardiac disorders during the preparticipation physical examination (PE) of athletes? DATA SOURCES   The authors completed a comprehensive literature search of MEDLINE, CINAHL, Cochrane Library, Embase, Physiotherapy Evidence Database (PEDro), and SPORTDiscus from January 1996 to November 2014. The following key words were used individually and in combination: ECG, athlete, screening, pre-participation, history, and physical. A manual review of reference lists and key journals was performed to identify additional studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed for this review. STUDY SELECTION   Studies selected for this analysis involved (1) outcomes of cardiovascular screening in athletes using the history, PE, and electrocardiogram (ECG); (2) history questions and PE based on the American Heart Association recommendations and guidelines; and (3) ECGs interpreted following modern standards. The exclusion criteria were (1) articles not in English, (2) conference abstracts, and (3) clinical commentary articles. Study quality was assessed on a 7-point scale for risk of bias; a score of 7 indicated the highest quality. Articles with potential bias were excluded. DATA EXTRACTION   Data included number and sex of participants, number of true- and false-positives and negatives, type of ECG criteria used, number of cardiac abnormalities, and specific cardiac conditions. The sensitivity, specificity, false-positive rate, and positive predictive value of each screening tool were calculated and summarized using a bivariate random-effects meta-analysis model. MAIN RESULTS   Fifteen articles reporting on 47 137 athletes were fully reviewed. The overall quality of the 15 articles ranged from 5 to 7 on the 7-item assessment scale (ie, participant selection criteria, representative sample, prospective data with at least 1 positive finding, modern ECG criteria used for screening, cardiovascular screening history and PE per American Heart Association guidelines, individual test outcomes reported, and abnormal screening findings evaluated by appropriate diagnostic testing). The athletes (66% males and 34% females) were ethnically and racially diverse, were from several countries, and ranged in age from 5 to 39 years. The sensitivity and specificity of the screening methods were, respectively, ECG, 94% and 93%; history, 20% and 94%; and PE, 9% and 97%. The overall false-positive rate for ECG (6%) was less than that for history (8%) or PE (10%). The positive likelihood ratios of each screening method were 14.8 for ECG, 3.22 for history, and 2.93 for PE. The negative likelihood ratios were 0.055 for ECG, 0.85 for history, and 0.93 for PE. A total of 160 potentially lethal cardiovascular conditions were detected, for a rate of 0.3%, or 1 in 294 patients. The most common conditions were Wolff-Parkinson-White syndrome (n = 67, 42%), long QT syndrome (n = 18, 11%), hypertrophic cardiomyopathy (n = 18, 11%), dilated cardiomyopathy (n = 11, 7%), coronary artery disease or myocardial ischemia (n = 9, 6%), and arrhythmogenic right ventricular cardiomyopathy (n = 4, 3%). CONCLUSIONS   The most effective strategy to screen athletes for cardiovascular disease was ECG. This test was 5 times more sensitive than history and 10 times more sensitive than PE, and it had a higher positive likelihood ratio, lower negative likelihood ratio, and lower false-positive rate than history or PE. The 12-lead ECG interpreted using modern criteria should be considered the best practice in screening athletes for cardiovascular disease, and the use of history and PE alone as screening tools should be reevaluated.

Using Tuning-Fork Tests in Diagnosing Fractures

REFERENCE/CITATION Mugunthan K, Doust J, Kurz B, Glasziou P. Is there sufficient evidence for tuning fork tests in diagnosing fractures? A systematic review. BMJ Open. 2014;4(8):e005238. CLINICAL QUESTION Does evidence support the use of tuning-fork tests in the diagnosis of fractures in clinical practice? DATA SOURCES The authors performed a comprehensive literature search of AMED, CAB Abstracts, CINAHL, EMBASE, MEDLINE, SPORTDiscus, and Web of Science from each databases start to November 2012. In addition, they manually searched reference lists from the initial search result to identify relevant studies. The following key words were used independently or in combination: auscultation, barford test, exp fractures, fracture, tf test, tuning fork. STUDY SELECTION Studies were eligible based on the following criteria: (1) primary studies that assessed the diagnostic accuracy of tuning forks; (2) measured against a recognized reference standard such as magnetic resonance imaging, radiography, or bone scan; and (3) the outcome was reported using pain or reduction of sound. Studies included patients of all ages in all clinical settings with no exclusion for language of publication. Studies were not eligible if they were case series, case-control studies, or narrative review papers. DATA EXTRACTION Potentially eligible studies were independently assessed by 2 researchers. All relevant articles were included and assessed for inclusion criteria and value using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool, and relevant data were extracted. The QUADAS-2 is an updated version of the original QUADAS and focuses on both the risk of bias and applicability of a study through a series of questions. A third researcher was consulted if the 2 initial reviewers did not reach consensus. Data for the primary outcome measure (accuracy of the test) were presented in a 2 × 2 contingency table to show sensitivity and specificity (using the Wilson score method) and positive and negative likelihood ratios with 95% confidence intervals. MAIN RESULTS A total of 62 citations were initially identified. Six primary studies (329 patients) were included in the review. The 6 studies assessed the accuracy of 2 tuning-fork test methods (pain induction and reduction of sound transmission). The patients ranged in age from 7 to 84 years. The prevalence of fracture in these patients ranged from 10% to 80% using a reference standard such as magnetic resonance imaging, radiography, or bone scan. The sensitivity of the tuning-fork tests was high, ranging from 75% to 92%. The specificity of the tuning-fork tests had a wide range of 18% to 94%. The positive likelihood ratios ranged from 1.1 to 16.5; the negative likelihood ratios ranged from 0.09 to 0.49. CONCLUSIONS The studies included in this review demonstrated that tuning-fork tests have some value in ruling out fractures. However, strong evidence is lacking to support the use of current tuning-fork tests to rule in a fracture in clinical practice. Similarly, the tuning-fork tests were not statistically accurate in the diagnosis of fractures for widespread clinical use. Despite the lack of strong evidence for diagnosing all fractures, tuning-fork tests may be appropriate in rural and remote settings in which access to the gold standards for diagnosis of fractures is limited.